text:
#4. Daniel Jackson (Stargate series)
An archaeologist's job is to learn from the civilizations who built ancient relics. Daniel Jackson has an actual portal to that civilization, and he's still less helpful for learning about the past than a bottle of absinthe to the head. Granted the civilization he's studying happen to be bloodthirsty slavers out to murder him, but the peace-loving pygmies of the Pa'ci'fist forest would attack Daniel on sight just to make sure he didn't destroy every historical record of their existence.
He also graduated from the world's only joint Ancient Cultures/Phys Ed program
The closest Stargate comes to real archaeology is resurrecting a relic from the ancient "80s period" by bringing back MacGuyver. And just like all sci-fi military resurrection experiments, it creates an evil opposite: instead of using ordinary objects to create non-lethal weapons, Colonel O'Neill (MacGuyver) uses lethal weapons to destroy extraordinary objects. And he's just part of the anti-precious items squad Jackson leads to the galaxy's most incredible finds. All together, the team put more priceless relics in danger than 57 Jackie Chans going undercover as the Smithsonian museum security detail.
His other archaeological assistants are Teal'C, a giant soldier whose first act was to use a walking stick to blow up an ancient building, and Carter, a brilliant scientist from the University Of Science Means Setting Things To Overload.
Not one incredibly world-changing relic has survived more than 30 minutes exposure to Jackson and Co.'s anti-archaeology field. He'd do less damage to history if he threw an atomic warhead into a DeLorean, since that would only blow things up once.
#3. Professor Hershel Layton (Professor Layton series)
The first problem is that Professor Layton can't so much as check his watch without taking 20 minutes to solve it. Faced with an actual mystery based on a forgotten people, the only place he'd be able to write his results is in the cold ashes of the heat death of the universe.
Ah, a bus timetable! Luke, fetch my supercomputer and five different colors of pen!
The second is that any conclusion he reached would be laughed out as ludicrous by Scientologist Birthers. So far his "mysteries" have been revealed to be an entire town of clockwork robots, a group hallucination the size and population of Transylvania, and an entire fake London built in a giant cave below London. Even one of Layton's "discoveries" would have Benjamin Gates calling bullshit, and he's legally forbidden from using that word.
On the plus side? Professor Layton beats National Treasure in pulse-pounding action.
#2. Everyone (The Mummy series)
In The Mummy, the movie-archaeologists jobs of knowing things andkilling things" are split between two characters: Brendan Fraser took care of the action, back in the brief period when he could headline a movie, and Evelyn Carnahan takes care the academic training, in that "she can read." And she'll screw even this elementary skill up so bad it kills people.
She's clearly not comfortable with the responsibility.
They steal the Book of the Dead from an accredited academic who has it in the first place to prevent idiots meddling with it -- he's essentially what Benjamin Gates wants to be: a treasure protector. However in The Mummy, our protagonists promptly ignore his desperate warnings, making this the first archaeologist movie that doesn't even try to hide the fact that you're accidentally cheering for the bad guys. The ancient evil is unleashed when Evelyn reads aloud from the book in the City of the Dead in the dead of the night, which works exactly as well as you'd expect. She wasn't even trying to summon something good, or researching, she was just reading the book to see what it said. Yes, this does mean that the nightmarish murder-thing's killing spree of plagues is all because the good guys' "smart" character can't read with her mouth closed.
She's clearly not comfortable with the responsibility.
#1. Lara Croft
Lara Croft has made a career out of bringing horny 12-year-old boys and guns into ancient ruins -- the two worst things to bring into a tomb outside of fire and corpse solvent. Her defining features were created by mistake in 1996, when a programming error gave her character model 150 percent extra chestage and before the coder could fix it a marketing executive dive-tackled him screaming, "STOP HIM THIS IS A BESTSELLER NOW!"
... thus giving birth to the now common origami fetish.
Creating new objects through accidental use of modern technology vs. recovering old ones made through dedicated old technology = exact opposite of archaeology.
However, this article isn't about her flaws as a character, but as an archaeologist, a profession that game designers gave her because muddy-brown textures are easy to draw, jumping puzzles are easy to design and wild animals are way easier to program than real enemies. Wait, her enemies are animals? We suppose turning modern species into relics by rendering them extinct sort of counts as archaeology.
And this counts as a dialogue on race relations.
To give you an idea of Croft's archaeology chops, the Wikipedia plot summary of her movies contain sentences such as "Since the device resembles a clock, Croft consults a clock expert," and "the Cradle of Life is in a valley where its forests are filled with shadow monsters." But her most baffling decision is having to leap across deadly spaces, and constantly make do without any of the normal tools any of the other archaeologists on this list seem to carry around with them. Why doesn't she have a grappling hook, or at least a whip to help swing across the gaping chasms? Because where the hell is she going to store that?
She's already got these two ... guns.
Luke also reports on Lenin's Amazing Exploding Ass, how to deal with scumbag lawyers, the Rise and Fall of Call of Duty and many more wonderful things.
You can learn about more people who are bad at their jobs in our new book.
Or check out 8 Classic Movie Robots That Actually Suck at Their Job and 4 Reasons Terminators Suck At Their Jobs.


text:
Find us on:
Browse Sections
Young children need to go to the doctor or nurse for a "well-child visit" 7 times between the ages of 1 and 4.
A well-child visit is when you take your child to the doctor for a full checkup to make sure she is healthy and developing normally. This is different from other visits for sickness or injury.
At a well-child visit, the doctor or nurse can help catch any problems early, when they may be easier to treat. You will also have a chance to ask questions about things like your child's behavior, eating habits, and sleeping habits.
To make the most of your child's visit:
What about cost?Thanks to the Affordable Care Act, insurance plans must cover well-child visits. Depending on your insurance, your child may be able to get well-child checkups at no cost to you. Check with your insurance company to learn more.
How often do I need to take my child for well-child visits?Young children grow quickly, so they need to visit the doctor or nurse regularly to make sure they are healthy and developing normally.
Children ages 1 to 4 need to see the doctor or nurse when they are:
If you are worried about your child's health, don't wait until the next scheduled visit – call the doctor or nurse right away.
How do I know if my child is growing and developing on schedule?Your child's doctor or nurse can help you identify "developmental milestones," the new skills that children usually develop by a certain age. These include physical, mental, language, and social skills.
Each child grows and develops differently. For example, some children will take longer to start talking than others. Learn more about child development.
At each visit, the doctor or nurse will look for some basic developmental milestones to see if your child is developing on schedule. This is an important part of the well-child visit.
By age 12 months, most kids:
Check out this complete list of developmental milestones for kids age 1.
By age 15 months, most kids:
By age 18 months, most kids:
Check out this complete list of developmental milestones for kids age 18 months.
By age 24 months (2 years), most kids:
Check out this complete list of developmental milestones for kids age 24 months.
By age 30 months, most kids:
By age 3 years, most kids:
Check out this complete list of developmental milestones for kids age 3 years.
By age 4 years, most kids:
Check out this complete list of developmental milestones for kids age 4 years.
Take these steps to help you and your child get the most out of well-child visits.
Gather important information.Take any medical records you have to the appointment, including a record of shots your child has received.
Make a list of any important changes in your child's life since the last doctor's visit, like:
Use this tool to keep track of your child's family health history.
Make a list of questions you want to ask the doctor.Before the well-child visit, write down 3 to 5 questions you have. This visit is a great time to ask the doctor or nurse any questions about:
Here are some questions you may want to ask:
Take a notepad and write down the answers so you remember them later.
Before your child's visit, talk with others who also care for your child, like a grandparent or babysitter. They may be able to help you think of questions to ask the doctor or nurse.
Ask what to do if your child gets sick. Make sure you know how to get in touch with a doctor or nurse when the office is closed. Ask how to get hold of the doctor on call – or if there's a nurse information service you can call at night or during the weekend.
Know what to expect.During each well-child visit, the doctor or nurse will ask you questions about your child, do a physical exam, and update your child's medical history. You'll also be able to ask your questions and discuss any problems you may be having.
The doctor or nurse will ask questions about your child.The doctor or nurse may ask about:
Your answers to questions like these will help the doctor or nurse make sure your child is healthy and developing normally.
See what else the doctor may ask when your child is:
The doctor or nurse will also check your child's body.To check your child's body, the doctor or nurse will:
Content last updated on: July 30, 2015
Reviewer Information
Find More Resources

subset: commoncrawl


text:
6 Animals That Can Get You High
Most human beings are inexplicably drawn to at least some measure of mind-altering substances, from your grandmother sipping her soothingly-caffeinated tea to the dude in Under Armour sweatpants puking out rivers of beer in front of your apartment building at seven o'clock on a Sunday morning.
However, only the few, the visionaries, look at passing wildlife and think, "Hey, I wonder if that creature can get me wasted? Let's lick it and find out."
The sad part? Those guys are often rewarded for their efforts, by animals like...
#6. Giraffes
The Arabic-speaking Humr people of Sudan are strictly forbidden to partake in any plant-based intoxicant such as alcohol or cannabis, which is a bizarrely specific restriction reminiscent of the Transportation Security Administration's express identification of nunchucks as a prohibited item on airplanes. However, as long as only plant-based toxins are forbidden, we're seeing a loophole big enough for B.J. McKay to drive through.
You can't see it, but Bear has nunchucks.
Umm Nyolokh is a made from the liver and bone marrow of giraffes, a compound believed to contain traces of DMT and other psychoactive components. The primary effect of Umm Nyolokh is the hallucinations it reportedly causes, which stupendously are hallucinations of giraffes. As whimsical as this sounds, seeing the animal that you just killed to get high sounds like it could make for some pretty terrifying trips.
Among the Humr people, the purpose of taking Umm Nyolokh is that the visions supposedly reveal the location of more giraffes that can be hunted. At first glance this seems like a very vision-quest type thing to do; a spiritual extension of a people living harmoniously with nature. But like the 80s drug PSA starring the stock broker who "does more coke, so he can make more money, so he can buy more coke," the tribesman probably take that extra hit of Umm Nylokh so they can locate more giraffes, so they can make more Umm Nyolokh, so they can locate more giraffes. It's a vicious cycle, and one that we'd imagine has to make for some much more confused hunting and gathering.
"Shit, are you the giraffe I just killed and made drugs from, or the giraffe I'm about to kill and make drugs from?"
It's really no more harmonious than taking your stereo to Cash Converters so you can buy a couple grams of heroin, though admittedly less African wildlife is involved.
#5. Salamanders
For those who missed a few classes of third grade Biology, salamanders are those amphibians that look like lizards as part of a desperate natural ploy to stop getting thrown out of reptilian country clubs. Salamanders also have the charming characteristic of oozing mucous from pores in their skin, protecting them from drying out in the air and providing lubrication while in the water.
Geraldo shares this trait.
In many species this doubles as a defense mechanism, as the mucous is both highly toxic and completely fucking disgusting.
You're right with us if you're thinking right now you'd rather keep these things as far away from your mouth as possible. However, a Slovenian folk recipe for salamander brandy calls for throwing live salamanders into a fermenting pot of fruit.
The salamander, in an attempt not to absorb ethanol into its sensitive skin, will exude the toxic mucous until its ooze-glands are spent and it dies, because the one thing missing from our fruit bowl is a rotting dead amphibian.
"Wow... that's a lot of blood."
The resulting salamander brandy has euphoric, hallucinogenic and aphrodisiac effects to the point that it is said that after drinking it, users may suddenly develop spontaneous new fetishes--which could be for anything at all--and then act them out on something completely different in their boner-driven salamander juice confusion.
So, the evening of a typical salamander brandy drinker may progress from pizza and TV, to cracking open a salamander brandy, to developing the insatiable urge to peniscerate a dishwasher, to mistaking a cat for a dishwasher, to mistaking Tom Sizemore for a cat, to having sex with Tom Sizemore.
#4. Cobras
The cobra, or naja, family of snakes are renowned for deadliness and are one of the only non-Australian species to regularly show up on "deadliest snake" lists. And for good reason; the venom of the cobra contains several separate active components, including a powerful neurotoxin and a compound that attacks the respiratory system. Essentially, a cobra bite will suffocate you and rape your brain. Obviously it was just a matter of time until someone tried to do some on purpose, to get high.
Some of the proteins in cobra venom effectively block acetylcholine receptors in the brain, producing a state referred to by science as "spaced the fuck out, man." Iranian-American, new age author, Jamshid Hosseini described his experience with a drink made from tea, milk and cobra venom whilst traveling with Hare Krishna and Hindu monks:
"Oh, my God, why did I do this? I'm a fool. This is the stupidest thing I ever did."
- Jamshid Hosseini
He then went on to re-experience his childhood before embarking on a cosmic journey through time.
Hosseini barely survived the cobra tea party, and recommends that those seeking spiritual enlightenment substitute meditation for almost dying from deadly snake venom. Still, his experiences haven't deterred our eastern brothers, as many Asian cultures have been bottling "snake wine" for years, jamming cobras into bottles of rice wine and straight grain alcohol to dilute them into the mixture.
Not pictured: snake-related agony
Spiking alcohol (which is a poison) with cobra venom (which is a poison) is the type of trailblazing genius that painted the Sistine Chapel and brought The Flintstones to prime time television, so knock back another cold glass of death juice in the name of progress.
Also, there's sometimes scorpions in it, which adds a delightful bouquet of more poison.


text:
$util.date("MMMM d, yyyy",$topLevel.timeZone)
Coach Bill Self and KU basketball players spoke to the media Thursday. The Jayhawks answered questions about Friday's tournament game against Michigan.
Click Here to access the online Public Inspection File
Viewers with disabilities can get assistance accessing this station's FCC Public Inspection File by contacting the station with the information listed below. Questions or concerns relating to the accessibility of the FCC's online public file system should be directed to the FCC at 888-225-5322, 888-835-5322 (TTY), or email@example.com.


text:
Tachometer, 6K, 4" For Inboard & I/O's - Faria
This item is found in the following Product Families
Faria Euro Instruments
Upgrade your boat's dashboard with wide range of instruments from Faria. Each instrument features a black dial with bold white numerals. And, …
Faria Euro Black Series - Ammeter, 2"
Perimeter-lighted black dial with bold white graphics, black aluminum bezel, and flat glass lens.
These easily readable and rugged instruments in the Euro series feature bold, bright white numerals against a non-glare background. Sculpted bright white pointers and low profile European style black bezels contribute to maximum readability.
This product ships in 1 business day.
Add to Cart and enter your Postal Code to determine the shipping charges and estimated delivery date.
Most products and orders leave our warehouse in 1 business day. However, select items may take more processing time. Alaska and Hawaii orders please add 1 additional warehouse processing day.
Standard Shipping Policies


text:
Let $A\subset\{0,1\}^\omega$ be a measurable set (w.r.t. the usual borel sigma algebra) which does not depend on any even coordinate (that is, if $x\in A$ and $x$ and $y$ agree except on a finite number of even coordinates, then $y\in A$).
Is it true that $A$ belongs to the sigma-algebra generated by all the odd coordinates + the tail sigma algebra?
To clarify: the tail sigma algebra consists of all the events which do not depend on any coordinate.
It seems to me that this should be some easy/well known measure theory fact/counterexample, but perhaps I'm wrong? Suggestions on where to look for an answer would be welcome.
Note that it is well known the this statement is false if the ground space would be $[0,1]^\omega$.


text:
- Text Size:
- ASmall Text
- AMedium Text
- ALarge Text
A robbery suspect made things easier for police officers trying to identify him.
Cincinnati police said two men robbed a pizza delivery driver at knifepoint on Sept. 25, punching and choking the victim before taking his wallet.
But in the process, police said, one of the robbers dropped his own wallet and left it behind.
Officers used information in that wallet to identify Cortez Sloan, 19, and arrested him Wednesday.
Officers are still looking for the other robber.
The views expressed are not those of this site, this station or its affiliated companies. By posting your comments you agree to accept our terms of use.blog comments powered by Disqus


text:
Africa (sub-Saharan)
Africa (sub-Saharan)
Recent Activity
Land is the basis of nearly all economic activities from farming to financial speculation on cotton production — in and along the periphery of an internationally protected park that spans parts of Benin, Burkina Faso, and Niger. Recognized as the "W" Transboundary Biosphere Reserve in 2002, this vast territory and surrounding areas are experiencing a land-management crisis in which seasonal and long-term migration has played a major role. This article examines these challenges through the use of reflexive maps, which capture data relating not only to migrants' paths and motivations, but also the social values and knowledge that they carry with them.
Recent Activity
This report analyzes prenatal behaviors and birth outcomes of Black immigrant mothers, and finds that Black immigrant mothers are less likely to give birth to preterm or low-birth-weight infants than U.S.-born Black women, but more likely to experience these birth outcomes than other immigrant and U.S.-born women.
This practical handbook highlights policies and programs that can magnify the resources, both human and financial, that emigrants and their descendants contribute to development. It gives concrete examples of policies and programs that have been effective, and pulls out both useful lessons and common challenges associated with the topics at hand.
Ce manuel pratique et simple d'utilisation à l'usage des décideurs et des praticiens fait le point des mesures les plus récentes prises par les pouvoirs publics en direction des diasporas. La question qui se pose aux responsables politiques n'est pas tant de savoir si les diasporas peuvent être utiles à leur pays d'origine, mais comment elles le sont et quels types de politiques et de programmes publics sont à même de favoriser ces relations.
Este manual ofrece a los formuladores de políticas y especialistas una guía accesible y práctica sobre las iniciativas gubernamentales referentes a la diáspora. Este manual contiene un menú, seleccionado cuidadosamente, de opciones normativas y programáticas viables basadas en experiencias reales en distintas partes del mundo.
This report finds that the 813,000 U.S. children under the age of 10 who have Black immigrant parents from Africa or the Caribbean generally fall in the middle of multiple well-being indicators, faring less well than Asian and white children but better than their native-born Black and Hispanic peers. Citizenship status, English proficiency, parental characteristics, poverty, housing, and access to social supports are examined.
The impact of climate change as a driver of human migration is expected by many to dwarf all others. Still, certain frequently repeated forecasts of the number of people who stand to be displaced by climate change are not informed by a complete understanding of migration dynamics, as this report explains.


text:
The title is mostly the question. Is it good to give everyone in the group the chance to be the GM, or should the best do the job always for best play experience?
Sign up
- Anybody can ask a question
- Anybody can answer
- The best answers are voted up and rise to the top
The GM/Player roles are not symmetrical
In my experience, not everyone is suited, desires, or even likes to GM. The work required to show-up and play your character is almost always less than preparing to GM - reviewing rules [changes], creating worlds/encounters, prepping session materials, cross-checking player-submissions, etc. Even "lazy GMs" usually do more prep than their players - it is a side effect of the many-to-one nature of the game.
It's not for the timid. - so no one should be compelled to take on the role.
Finding out requires trying out
On the other hand, there are many folks who might be great GMs, if they only get the chance.
Earth Needs More GMs! Watching a great GM can be intimidating to prospective ones. Offering the rotation to everyone at the table is an excellent means to encourage trying the role on for size. And, as suggested by the question - allowing other game systems to be introduced as well can help with the fear of being compared to other GMs stigma.
"Hey! I don't know if I can do it justice, but I just read about this new system: XXX - and if you guys want, I'll try to run it for a one-shot next week..."
I think this is really up to each individual group. From what I have seen on this site some groups share GM load by campaign and other groups play different simultaneous campaigns with different GMs.
My group has kept to one consistent GM for our main campaign. However, myself and one other member of our group have started our own campaigns with the same group of people. We still play in our usual time and just give our regular GM time off to be a normal player.
This has the advantage of giving the main adventure the consistency of a single GM, but it also gives the GM a break and allows him to step into the player role. It also gives the players who want it the opportunity to get behind the screen and GM.
A gaming group is like a sports team. Like that team, you have a variety of concerns you need to balance.
Is everyone having fun/are we excelling?
If everyone's having fun, that's good. Sometimes GMs get burned out and don't want to GM, which means everyone's not having fun. Sometimes one or more of the GMs suck, in which case everyone's not having fun. Sometimes someone wants to GM but they are getting told "no, this other person is the GM," in which case they're not having fun. These factors vary from group to group and vary over time within the group, so you need to know how much people are enjoying the game(s) and their role(s). Talk about it.
But "are we having fun right this minute" isn't the only gauge...
Are we planning for the future; is our group healthy?
Having one GM, like just having one pitcher, can be a problem when that one GM leaves/graduates/has a falling out/burns out/gets married/etc. You want a deeper roster. So in many cases, you will want to let the person who's not your "best" GM do the job so that they get better. You will want to let valued members GM, even if they're not the best, because they are happy and will stay with the group if they get to GM once in a blue moon.
You have to plan for long term happiness, too.
GM Rotation Example
In my old gaming group in Memphis, TN, we had me as primary GM for years and one other guy who GMed some. When D&D 3e came out we all bought the books and I bought the first crop of 6 adventures that came out (mostly third party - hooray OGL!). I said, "I'll run the first one, but I'm as new to this game as anyone. I know some of you have GMed and some never have. But what do you all think about everyone taking a turn GMing in this initial round?" They all agreed and so inside the same campaign with the same characters, we rotated GMing from adventure to adventure. Some folks had never GMed; others had. The experience was extremely positive for everyone.
Once we had done that, we were very happy we had, and though some people went back to just being players, more chipped in to GM over time and even started side groups to run other campaigns; it helped turn the group into one gaming group into a network of related gaming groups. My group here in Austin is the same kind of way; nearly everyone GMs sometimes and as a result it's not one six person group, it's a group of maybe 4 or more loosely affiliated games. This provides a lot of flexibility in terms of player recruitment, game choice, etc.
I've played in a longterm campaign with 1 DM, and another group where everyone DMs.
Benefits of many DMs:
Benefits of a single DM:
Disadvantages of Multiple DMs:
Disadvantages of Single DM:
In the final analysis, I think it comes down to a Coke/Pepsi kind of thing. I personally really like the many-DM approach my current group uses, but I do miss some of the long-term character development that single DM campaigns allow for. It is also somewhat frustrating when you've thought up some sort of wonderful campaign and are amped up about it, only to find it sit on a shelf for a year while you wait in line.
Our group has one primary DM who "owns" the campaign, but other people take turns as well running story arcs that are a part of the overall campaign. Basically, the primary plot belongs to our main DM, but from time to time, others of us have run arcs which belong to the same world, but which usually occur in other parts of the campaign world and only have a minor to moderate interaction or influence on the main campaign plotline. It's worked quite well for us. We've been playing the same campaign for nearly 15 years now.
When we do one-offs with other rules, such as an annual Call of Cthulhu session or two around Halloween and occasional runs with other rules systems then it's usually run by someone other than the primary DM.
I've been a DM for as long as I've been role playing. More often then not, I'm the DM for our games. The reasons vary from desire to creativity to just wanting to run the game. But it gets taxing and tiring and after a while, a DM will burn out. I'm not saying that the players should have to sit and take a break for a few weeks/months, but it helps a lot if you have different people to run games. This way, you don't get a DM to burn out or run out a material. I know I have more than once in the last 12 years. I think it's a very good idea, but note that it's not for everyone.


text:
by Melissa Brunner
With Earth Day recently passed, we received an update Thursday on Shawnee County's efforts to provide curbside recycling service. They plan to launch in January, and should be bringing Commissioners a request for a conditional use permit in the weeks ahead. It would allow construction to get underway on a facility to process the recyclables.
I took a trip to our breakroom after I read that information to find a coworker flipping aluminum cans out of a trash can and into the aluminum can recycling bin we have placed there. He joked that, apparantly, some people still hate the environment. But we got to talking about how a little inconvenience can keep us from doing something we don't necessarily oppose. Case in point - the city of Topeka recently put a recycling bin right next to the trash can under each workers desk. They've already seen a huge reduction in trash. It's not that they didn't have office recycling before - it's just that you might have to walk down the hall to put your materials in the recycling bin.
You might chalk it up to the same human nature that has you circling the parking lot to find the closest spot. Is it really that tough for most of us to walk a few extra steps to get inside the store? Is it really that tough to walk your aluminum can to the bin down the hall? Not really, but it sure might save a few seconds!
It's the train of thought that has had Shawnee County Refuse Director Steve Bolton so passionate about bringing curbside recycling to Shawnee County. Sure, the county has drop off bins all around town, but If it's there anyway - right at your doorstep - you might be more inclined to use it.
What do you think? Does a little inconvenience keep you from recycling (I admit - I wouldn't dream of putting an aluminum can in the trash at home, but a few have ended up in the can under my desk!)? What advice do you have to make it more of a habit?


text:
Nasdaq Faces Facebook Fine
Exchange Group in Talks With SEC on $5 Million Penalty Over Botched IPO
Nasdaq OMX Group's NDAQ -0.16 % missteps during last year's debut of Facebook Inc. FB -0.85 % shares cost Wall Street an estimated $500 million. In the end, U.S. securities regulators may end up fining the exchange group 1% of that.
Nasdaq is in preliminary talks with the Securities and Exchange Commission over a potential settlement related to its botched handling of Facebook's much-anticipated offering, according to people with knowledge of the discussions.
While a settlement agreement isn't assured, the two sides are discussing a monetary penalty of about $5 million, people involved with the discussions said. In addition, Nasdaq has offered to compensate customers $62 million for losses stemming from Facebook IPO trades.
Securities laws and Nasdaq's own rules have helped limit the exchange group's expenses from the technical glitches. Nevertheless, Wall Street's collective losses from the IPO, and the blow it dealt to investors' confidence, have colored the perception of Nasdaq's potential costs.
"Why should the banks and brokers be left holding the bag for Nasdaq's snafus?" said Scott Saks, a lawyer at Paul Hastings LLP who handles corporate listings, and who isn't involved in discussions about Nasdaq's compensation proposal.
Nasdaq executives have been eager to put behind them an eight-month investigation into the miscues from the May 18 IPO. If the SEC monetary penalty happens, it would be only the second time the regulator has fined a stock exchange.
In September, the New York Stock Exchange's parent company agreed to pay $5 million to settle SEC allegations it provided market data to some customers ahead of others, giving clients of customized feeds an edge. NYSE Euronext, the Big Board's parent, neither admitted nor denied the allegations. It said the timing issues stemmed from "technology issues, not from intentional wrongdoing by the exchange or any of its personnel."
In Nasdaq's discussions with the SEC, issues include Nasdaq's alleged lack of controls over its systems, sanctions the agency might demand, and steps Nasdaq will be required to take to prevent future errors, people close to the discussions said.
SEC investigators have continued to ask Nasdaq for information in recent weeks, boosting expectations that any agreement could still be weeks, if not months, away. An agency spokesman declined to comment.
A Nasdaq spokesman said the company is working closely with the SEC to resolve issues related to the Facebook IPO.
"We continue to believe we acted appropriately and in the best interests of investors under challenging circumstances," the spokesman said.
The day of Facebook's IPO, Nasdaq's systems got caught in a loop while lining up orders before the social-networking company's shares started trading. The opening of trading in Facebook shares was stalled by half an hour. For almost three hours more, Nasdaq failed to send order confirmations to brokers, causing uncertainty about who held what positions.
The widespread confusion fueled a market-wide debate over the soundness of computer-driven trading that has come to dominate markets. The industry's technology leaps are credited for lowering costs but also criticized for complicating markets.
Nasdaq isn't the only one to catch heat from the Facebook IPO. Bankers at Morgan Stanley MS -0.45 % and other Wall Street firms have drawn criticism for their handling of a deal that initially priced Facebook shares at $38, stinging investors who then saw them fall sharply in value. The shares lately have been trading at between $25 and $33 since late last year.
Nasdaq executives had hoped by January to have SEC approval for the company's proposal to pay customers a total of $62 million for losses. But the process has dragged on in part due to staff turnover throughout the SEC.
The debate over who's liable for Facebook IPO losses also has highlighted the special status U.S. exchanges enjoy as market regulators as well as for-profit businesses with paying customers. That status affords exchanges protection from many legal actions. Regulators are grappling with a growing cry from Wall Street firms who say the system needs to change, and hold up the Facebook debacle as exhibit A.
The quandary for regulators and lawmakers is complicated, though, said Michael Zuppone, who chairs Paul Hastings's capital-markets practice.
If exchanges' liabilities aren't capped, effectively they would need insurance against the risk of massive losses. "It's a trade-off," Mr. Zuppone said, and changes would likely raise trading costs and the cost of capital for companies.
Nasdaq executives have said that the company has no obligation to make up for losses stemming from the Facebook IPO. A spokesman said Tuesday that the company's voluntary proposal is "supported by many members."
At the same time, Nasdaq executives hope that resolving the payout questions will lay to rest a source of tension between the company and some of its biggest customers. Nasdaq wants customers to waive their right to sue the company as part of a compensation agreement.
Write to Jenny Strasburg at email@example.com and Jean Eaglesham at email@example.com


text:
- Home
- Find a Cabin
Any Questions? Please call us at 1-800-235-2661!
Search by Availability
Search by Bedrooms
Showcased Cabin
Private and luxurious, this cabin offers the finest in smoky mountain views. this beautifu…
Learn More.
- Specials
- Things to Do
- About Us & Policies
- Blog
- Contact Us


text:
WEIRTON - Shelby Wade, the daughter of Lonnie and Christine Wade of Colliers, recently completed and donated 20 "Birthday in a Box" packages to C.H.A.N.G.E. Inc.
Wade wrapped and decorated 20 boxes with everything a child would need to have a birthday party. The boxes were made for children aged 5 to 16 with 10 boxes for boys, and 10 boxes for girls. Each box contained a box of cake mix, icing, party plates, birthday candles, balloons and a present for the child.
The boxes were presented to C.H.A.N.G.E. Inc. to be given to children struggling with domestic violence issues who are staying in their shelter. This allows the children to feel they are not forgotten on their birthday, and it takes the burden away for a parent who may not be able to provide their child with a birthday party and a present.
"This project wouldn't have been possible without all the donations I received from local businesses," said Wade. "Every business I talked to was more than willing to help in any way they could."
Participating local businesses include K-Mart, Ted's Plaza Pharmacy, Shop 'N Save, Kroger, Suzanne's Hallmark, Dollar Tree and Wal-Mart.
October was domestic violence awareness month and C.H.A.N.G.E.'s last birthday box was given away a day before Shelby donated the 20 "Birthday in a Box" packages she put together.
"Families come to the Lighthouse at all hours, and we worry about providing the basic essentials," said Judy Raveaux, chief executive officer.
"When birthdays occur during their stay, it's a welcomed blessing to select a box for the child celebrating that special day. Shelby needs to be commended for such a worthwhile project, and we are honored to be a recipient of her Birthday In a Box Project," Raveaux said.
Wade, a Brooke High School senior, completed this project as part of her senior honors project.
The honors program consists of students with a minimum cumulative GPA of 3.55 who have taken honors and Advanced Placement classes, and students who complete a senior project that is approved by the honors program committee. Students who meet these requirements will graduate with honors.


text:
HUNTSVILLE (November 15, 2012)-Texas inmate Preston Hughes, 46, was executed Thursday night in Huntsville for the stabbing deaths of a teenage girl and her 3-year-old cousin 24 years ago in Houston.
Hughes insisted he was innocent in the deaths of Shandra Charles, 15, and her cousin, Marcell Taylor, who were found lying on a path behind a Houston restaurant.
Taylor was dead and Charles was gravely wounded and near death after the attack in a wooded field.
Charles told an officer at the scene, "Preston tried to tape me."
Tests later confirmed that she had been raped.
Both she and her cousin were stabbed in the chest and neck and their aortas and jugular veins were severed, authorities said.
Police went to a nearby apartment complex at the end of the dirt path and found Hughes, who was the only person named Preston among the residents.
Officers found the girl's eyeglasses in the apartment and evidence of blood on Hughes' clothing.
Hughes later provided two written statements in which he admitted he stabbed both the boy and the girl.
He was probation for sexual assault of a child at the time of the murders.
Hughes and his attorneys filed numerous motions in the courts to block the execution, which was delayed Thursday evening because of pending appeals, although the U.S. Supreme Court refused earlier to review the case.
It was the second execution of the week.
Wednesday evening Ramon Hernandez, 41, was executed for the 2002 robbery, rape and murder of a 37-year-old woman in San Antonio.


text:
Sexual intimacy is an important part of life. For people with diabetes, it's necessary to pay close attention to issues concerning their sexual health. That's because damage to the nerves or blood vessels caused by diabetes can interfere with sexual function. Certain medications used to treat diabetes-related complications can also affect sexual health. By discussing these issues with your health care provider, you can continue to enjoy this part of your life.
According to the American Diabetes Association, diabetes can damage the blood vessels and nerves of the penis. This damage can lead to erectile dysfunction (ED), the inability to get or sustain an erection. Diabetes also increases the risk for low testosterone and depression, both of which can contribute to ED. In addition, ED may be a side effect from certain medications used to treat high blood pressure and heartburn resulting from gastroparesis--a diabetes-related stomach condition. Men with diabetes are three times more likely than those without it to have ED. They also tend to develop the problem at a younger age.
When ED is linked to nerve damage caused by diabetes, treatment options include pills, medicine inserted into the penis, a vacuum tube and pump, or surgery to implant a device inside the penis. Surgery can also be done to repair blood vessels in the area.
The National Institute of Diabetes and Digestive and Kidney Diseases reports that diabetes can cause nerve damage and reduced blood flow in the vagina that can lead to dryness. This, in turn, can cause discomfort during sexual activity. Depression may also interfere with sexual desire and also make it difficult to discuss sexual concerns with your partner or health care provider. Vaginal lubricant creams may help with dryness. Your provider might recommend changes in position or Kegel exercises to strengthen muscles in the pelvic area to enhance sexual arousal.
If you feel uncomfortable talking about problems with your sexual health, remember that your health care provider has helped many people with diabetes resolve these issues. He or she can also recommend treatment options for depression. If you're not sure how to talk about these issues, try saying that you have a personal question you'd like to ask. Together, you and your provider can find a solution.


text:
Honors chorus concert planned for March 2
Published: Friday, February 22, 2013 at 1:23 p.m.
Last Modified: Friday, February 22, 2013 at 1:23 p.m.
The Carolina Concert Choir of Hendersonville, N.C., is sponsoring the third annual all-county high school honors chorus concert at 3 p.m. March 2 in the Hendersonville High School Auditorium.
The Honors Chorus is composed of choral music students from Henderson County's public high schools, as well as high school students from private schools and home schools. The choral program will include music by Morten Lauridsen, Eric Whitacre, Bob Chilcott and a spiritual arranged by Moses Hogan. The public is invited.
The chorus is directed by Dr. Michael Lancaster, director of choral activities at Western Carolina University. Katherine Price is accompanist, with Amy Lovinger, violinist. The Honors Chorus is an outreach program of The Carolina Concert Choir, an all-auditioned group of singers, performing choral music for 34 years in Western North Carolina. The Carolina Concert Choir is directed by Bradford Gee.
Tickets are $5 and may be purchased at the door before the concert or from area high school choral music students.
Reader comments posted to this article may be published in our print edition. All rights reserved. This copyrighted material may not be re-published without permission. Links are encouraged.


text:
Manage Subscriptions
Log Out
Log In
A Redding police officer turns cars away at Shasta High School because of the lock down.
No email address was supplied by
To complete your registration on this site, please supply an address.
Please confirm or modify the email address to which you will have subscription offers sent.
For a more personalized experience, please supply the following optional information.


text:
Genetic testing now allows personalized treatment. Find out more.
Search for a doctor by name or specialty. Search now.
Our patients have amazing accounts of hope and resilience. Read their stories.
Your gifts help us push the boundaries of cancer treatment. Ways to Give
Our services are available to all UC San Diego Health patients. Our payment options include insurance (copays may apply), cash, or low-fee or no-fee options.
See Appointments and Locations for more information.
Psychiatrists and Psychologists
Psychiatrists and psychologists play a key role in supporting patients, family members, and caregivers through the stressor of cancer and its treatment. We specifically focus on patients who developed mental health issues as a result of their cancer, and those whose preexisting mental health conditions are impacting their ability to engage in treatment.
We typically provide services during the course of direct cancer care within one year of completing disease-specific treatment, and lasting for up to 12 sessions (or one year).
These services can include:
Official Web Site of the University of California, San Diego.


text:
Intensity Modulated Radiation Therapy: An Introduction for Patients and Clinicians - Part II: Treatment Delivery and Clinical Applications
Please use for reference only.
Last Modified: August 21, 2002
Authors: Jason Lee MD,1 Indra J. Das PhD,1 Shiao Y. Woo MD,2
Walter Grant PhD,2 Bin S. Teh MD,2 J. Kam Chiu MD,2
E. Brian Butler MD2
Affiliations: Abramson Cancer Center of the University of Pennsylvania1 Department of Radiation Oncology, The Methodist Hospital, Baylor College of Medicine2
4. Delivery of IMRT
Implementation of IMRT
Treatment systems for IMRT have become available with the introduction of multileaf collimators (MLC). Instead of rectangular collimator jaws found in early radiation treatment units, an MLC consists of multiple narrow leaves which are under computer control and allow custom-shaped beam apertures without fabricated blocks. The width of the leaves on a typical MLC projects between 5 mm to 12.5 mm at isocenter, depending on the manufacturer. The characteristics of MLC depends on the manufacturers' design, and has been extensively reported. (15-17) During IMRT delivery, the leaves of the MLC are adjusted while the beam is on to modify the fluence of radiation across the portal. The treatment portal is broken into smaller deliverable portals, called beamlets, which can be delivery by the MLC. The physical equivalent of MLC-based IMRT would involve the fabrication of a custom-milled lead alloy block of varying thickness to match the fluence profile necessary for each portal -- a very cumbersome task.
The implementation of IMRT may be performed using two distinct methods: multiple fixed gantry positions or a rotating gantry. With fixed gantry therapy, multiple beam angle and table configurations are chosen which should optimize radiation delivery. For example, for prostate cancer, the beam may enter from anterior, LAO, LPO, RAO, and RPO directions. A greater number of gantry positions increases the flexibility of dose modulation and improves dose distributions up to a certain point. With a rotation gantry technique, treatment is delivered from multiple arc rotations.
1. Fixed Gantry, "Sliding Window:" At each gantry position, opposing leaves of the MLC are operated in dynamic mode (ie, in motion while the radiation is on) at a certain speed and distance to produce a portion of the beam aperture. A number of algorithms have been developed to convert the fluence profile into an MLC motion sequence. A hypothetical example of beam intensity profiles for an LAO portal used in prostate cancer is shown in Figure 4-1. The use of this technique for prostate cancer has been popularized at Memorial Sloan Kettering Cancer Center (New York, NY). (18)
Figure 4-1: Schematic of beam intensity profiles of an LAO field for prostate cancer
2. Fixed Gantry, "Multisegment:" For each gantry position, the portal is divided into multiple "segments" with individual monitor unit settings. While the radiation intensity for each segment is constant, the confluence of the segments produce the modulated fluence profile. Verification of the dose for each stationary segment is possible. At the University of Michigan Medical Center (Ann Arbor, MI), treatment for head and neck cancer consists of five gantry angles and one to four segments at each gantry position. (19)
3. Rotating Gantry, "Sequential Arc:" With the sequential arc technique, the treatment is delivered in multiple axial slices. Each slice of the target region is treated with a thin-slit MLC during gantry rotation. After each rotation, the patient is moved in the horizontal direction so the next slice can be treated. The Peacock system is a form of this technique and has been successfully used at various institutions including the Methodist Hospital (Houston, TX) for brain, head and neck, and prostate cancer patients. (20) This process can be time-consuming since only one slice is treated at a time.
4. Rotating Gantry, "Intensity-Modulated Arc Therapy:" A stationary patient may be treated by a full-field MLC portal with a series of superimposed intensity-modulated arcs. Each arc treats a certain "segment" of the beam profile, and cumulative dose deposit fluence from all the arcs form the desired dose-distribution. (21) This is sometimes known as "double-dynamic" MLC IMRT, since both the gantry and MLC leaves are in motion.
5. Rotating Gantry, "Tomotherapy:" A generalization of a sequential arc technique is known as tomotherapy, where both the gantry and patient are in motion, much like a helical CT scanner. (22) This technique is under development at the University of Wisconsin (Madison, WI). A CT scanner on the same gantry would allow real-time dose verification. This application is a fusion of two technologies- CT and linear accelerators.
Commercially Available Treatment Systems
Since the introduction of the first IMRT system in 1994, a number of commercial systems have become available. This report discusses a few of these products below, but by no means is this a comprehensive review.
1. Peacock (NOMOS Corporation, Sewickley, PA)
The first FDA-approved IMRT system known as the Peacock was introduced in 1994 and is in wide clinical use today. Over 1,000 patients have been treated with the Peacock system at The Methodist Hospital (Houston, TX). The Peacock takes advantage of the sequential arc technique of IMRT. (23) The Peacock delivers radiation through a special collimator device called the Multileaf Intensity Modulating Collimator (MIMiC) which attaches to the gantry head of a standard linear accelerator (Figure 4-7). The MIMiC has opposing rows of 20 tungsten leaves, each of which projects to a 1 ? 1 cm2 field at isocenter in the open position (Figure 4-8). The MIMiC is also known as a binary system, which allows only a 1 ? 1 cm2 pixel by each leaf. A single arc with the MIMiC treats a 2 cm length; longer fields are treated with sequential arcs with precision linear indexing of the couch. The leaves of the MIMiC are pneumatically-driven by computer control while the gantry is rotating, thereby creating the desired intensity-modulated pattern. For each individual patient, the information for gantry and leaf position is stored on a 3.5 inch floppy disk and inserted into the on-board computer of the MIMiC for treatment. During gantry motion, the pneumatic positioning of the MIMiC leaves produces loud "clack-clack-clack" sounds [Audio], and patients are offered ear plugs to reduce this noise.
Figure 4-7: Peacock attachment on linear accelerator
Figure 4-8: MIMiC collimator unit accelerator
The information for gantry and leaf position is obtained from the inverse treatment planning computer, after the dose-distribution has been approved by the radiation oncologist. The Peacock delivers radiation through sequential 270o arcs via a portal approximately 20 ? 2 cm or 20 ? 4 cm. For every 5o segment (total 54 segments) of the arc, the radiation intensity can be varied through each of the 40 leafs in 10% increments from completely closed (0%) to completely open (100%). The leaf intensity pattern is generated by the inverse planning computer, which uses an optimization algorithm known as "simulated annealing" to conform to the dose-constraints set by the treating physician. The result of this spatially nonuniform radiation exposure is a highly conformal and relatively uniform dose administration to the target.
2. Varian Medical Systems, Inc. (Palo Alto, CA)
The linear accelerators produced by Varian and other manufacturers use full-field MLC to deliver IMRT, rather than sequential arcs as in the Peacock system. The premium MLC marketed by Varian contains 60 pairs of leaves, forming a full 40 ? 40 cm field. The central leaves measure 5 mm at isocenter and can be moved with a precision of 0.2 mm, thereby creating the high resolution beam apertures necessary for precision IMRT. With Varian's inverse treatment planning software, this equipment is suitable for "step and shoot" or "sliding window" IMRT. Varian equipment and software have undergone extensive development, testing, and clinical use at Stanford University, Memorial Sloan Kettering Medical Center, the Medical College of Virginia, and other academic centers.
The inverse treatment system (HeliosTM) uses a sophistated optimization algorithm that provides plans for varying beam energies and coplanar or noncoplanar configurations. The optimization process considers beamlets measuring 2.5 ? 5-10 mm, depending on leaf width, and typically 30 voxels per cm3 for target and normal tissue regions. The dose calculation algorithm factors in head scatter and leaf transmission when generating the leaf motion sequences. The result is highly accurate radiation delivery compared with the calculated dose distributions.
3. Other Inverse Planning Systems
The MLC and IMRT planning system are separate entities and can be obtained separately. Most MLC's constructed today are designed to take advantage of IMRT. A number of inverse planning systems are available from companies with existing 3D-CRT planning software. NOMOS, makers of the Peacock, has developed the CORVUS system which uses dose-volume constraint specifications and can drive both the MIMiC and full-field MLC's. PLATO Complete (Nucletron Corporation, Columbia, MD) and Helax-TMS 5.0 (MDS Nordion, Ontario, Canada) are other inverse planning/IMRT systems which have gained 510(k) clearance by the FDA for marketing in the U.S. Newer software incorporates sophisticated models which can calculate effects of head scatter, thus producing more accurate dose distributions, particularly in low-dose off-axis regions. The treatment plans generated by these packages can be delivered by MLC-equipped linear accelerators.
Quality Assurance
A concern with computer-controlled treatment is the validation of the radiation delivery especially when using beamlets; in other words, are the tumor and surrounding tissues receiving the planned dose? Verification of dosimetry is basically a comparison of measured versus calculated dose for a particular plan. With conventional radiation therapy, a well-aligned portal film and a dosimeter measurement are generally sufficient reassurance. In IMRT, there is no practical method to verify spatial dose-intensity gradients with the patient in place. A number of potential obstacles are present in IMRT which may result in a deviation from the planned dose: 1) patient setup and organ motion; 2) couch movement in sequential arc therapy; 3) accuracy of leaf movement on dynamic MLC; and 4) radiation leakage through MLC leaves and beam characteristics from longer beam-on times. Aslo for segmented treatment, the radiation is delivered in beamlets for a very short time. This raises serious issues regarding dose linearity as described by Das et al. (24 ) Several techniques have been devised which can validate that the intended dose-distributions are, in fact, being delivered.
1. "Square Box" Phantom: Assessing the changes in optical density of radiographic film when exposed to ionizing radiation is a familiar method of measuring dose. A square box phantom holds multiple sheets of film at regular spacing, and is then irradiated with the IMRT plan. The film densities are measured with an optical scanner and compared with predicted planar dose distributions for the phantom. Alternatively, the phantom can be fitted with a matrix of individual dosimeters (TLD or diodes) to obtain direct dose measurements. (25) For prostate cancer treatment verification, the phantom can be covered with a tissue-equivalent shell to more closely approximate the contour of a human pelvis (Figure 4-9).
Figure 4-9: Pelvic film phantom
2. Anthropomorphic Phantom: Unlike square phantoms, a humanoid phantom has the advantage of performing quality assurance in targets shaped and similar to treated patients. An anthropomorphic phantom known as RANDO® (The Phantom Laboratory, Salem, NY) has been created which corresponds to the average male and female body shapes and densities. RANDO® can accomodate film and individual dosimeters, though there is less freedom with placement and film must be shaped to fit. One study comparing the patient-optimized plans calculated for the humanoid phantom and the measured dose distributions in the phantom revealed that dose discrepancies do occur, but most are less than 3%. (26)
3. Electronic Portal Dose Imaging (EPID): Many newer linear accelerators can be equipped with an on-line electronic portal imaging device. By operating this device in a manner which integrates the captured radiation over the entire beam area, the resultant portal image could be compared with a computer-constructed portal dose image. This system would have to account for the degradation in image quality with longer distances from the radiation source and the effect of scattered dose. Additional problems include the inhomogeneity present in the patient's body, whereas calculations are performed as a homogeneous phantom.
4. BANGTM (MGS Research Inc., Guilford, CT) Gel Imaging: This is a newer dosimetry system where a special gel compound known as BANGTM is exposed to IMRT or stereotactic treatment. The ionizing radiation produces a polymerization reaction in the gel which can be imaged by MRI. A full 3D dose distribution can be obtained, with a resolution as small as a few cubic millimeters. (27) The need to obtain an MRI scan for the gel limits the practicality of this method; however, an optical measuring system is under development.
During the early commissioning of an IMRT system, quality assurance procedures for each new patient are advisable to verify proper dose delivery. Additionally, the precision of linear couch movement in sequential arc IMRT, as in Peacock treatment, requires inspection as table indexing errors as little as 1 mm can lead to dose inhomogeneity of 10%. (11) A facility may elect to perform quality assurance measures for individual patient plans on a less frequent basis once additional experience and a higher comfort level is gained with IMRT.
5. Clinical Uses of IMRT
The potential clinical applications of IMRT are broad and continue to expand. While IMRT is feasible for any disease site treated with conventional radiation therapy (with the exception of total body irradiation), IMRT has been implemented where benefits are most likely to occur. IMRT is particularly well-suited for curative treatment of intracranial tumors, head and neck tumors, and prostate tumors, where target location is fairly stable, normal tissue toxicity is of major concern, and a dose-response has been shown for local control.
New radiation therapy technology can be evaluated by various "levels" of evidence, similar to the safety, efficacy, and effectiveness data required for pharmaceuticals. The first level is whether IMRT can produce the desired dose distributions, and the evidence from the discussion above would support this. The second level is whether IMRT is safe for patients, particularly in the setting of dose escalation. The third level is whether IMRT can result in cure or local control of tumors, and lastly, whether IMRT is superior in terms of cure rates and toxicity compared with conventional technology. Studies on IMRT for various clinical sites are reviewed briefly below.
CNS Tumors
Because of the stability of the cranium and the sensitivity of numerous intracranial structures, much of the early IMRT activity focused on brain and head and neck tumors. IMRT has been used for malignant and benign tumors, and in adult and pediatric populations. Table 5-1 lists the major avoidance structures such as the orbits, optic nerve and chiasm, brainstem, and temporal lobes, along with suggested dose limits. Brain lesions may be large, irregular, and solitary, or smaller and multiple. IMRT can address both situations. The dosimetry using Peacock-based IMRT and stereotactic radiosurgical techniques for various clinical scenarios is often comparable. Peacock and LINAC-based stereotactic plans were compared for simulated intracranial targets using RTOG criteria of homogeneity (how uniform the dose is over the target) index and conformality (how well dose is limited to the target) index. (28) For regular-shaped lesions, they were similar, but for large irregular lesions >4 cm, the Peacock plan was actually more conformal and homogeneous.
Figure 5-1: Peacock isodose curves for a suprasellar mass
For lesions that have been traditionally treated with conventional radiation therapy, IMRT may result in reduced morbidity by virtue of its ability to avoid surrounding normal tissues. Examples include craniopharyngiomas and pituitary adenomas which are adjacent to temporal lobes, optic nerve, and optic chiasm. An axial isodose distribution using Peacock for a suprasellar lesion (red) is shown in Figure 5-1, and demonstrates the inward deviation of the isodose curves near these critical structures (optic chiasm and brainstem in green).
For high-grade gliomas, little progress has been made in improving cure rates for the past several years. Relatively few studies have reported the experience using 3D-CRT or IMRT for these brain tumors. Some centers are investigating dose-escalation beyond the current standard dose of 60 Gy. At the University of Michigan, doses of 90 Gy have been delivered to glioblastoma multiforme patients and escalation continues. (5) At the Methodist Hospital (Houston, TX), a protocol is investigating the safety and efficacy of accelerated IMRT given as daily fractions of 5 Gy to GTV and 2 Gy to CTV over 10 fractions.
|Normal Structure
|Dose Threshold (cGy)
|Normal Structure
|Dose Threshold (cGy)
|Ipsilateral Parotid Gland
|Spinal Cord
|Contralateral Parotid Gland
|Optic Nerves/Chiasm
|Lacrimal Gland
|Temporal Lobes
Table 5-1: Radiation Thresholds for Head and Neck and Intracranial Tumor Treatment
Head and Neck Tumors
Many of the immobilization and avoidance issues for brain tumors also apply to head and neck cancers. In addition, there is great interest in sparing parotid gland salivary function and preventing xerostomia (dry mouth), a common complication from conventional irradiation of head and neck cancers. The geometry of head and neck cancers is often complex, and efforts are also directed towards reducing dose to adjacent structures such as the mandible and spinal cord. Typical dose-limits to critical structures are shown in Table 5-1. As the results from clinical studies emerge, it will be important to ensure that the reduction in high-dose volumes does not compromise locoregional control.
Figure 5-2 shows an isodose curve of a nasopharynx cancer that has extended to the right oropharynx and upper neck nodes. The gross visible tumor (highlighted in red) on CT scan has a concave shape surrounding the spinal cord, a common situation in advanced head and neck cancer and typical challenge for radiation oncologists. The Peacock plan is able to direct high-dose regions away from the spinal cord, mandible, and opposite parotid gland, while maintaining dose-uniformity across the gross tumor and subclinical regions at risk (highlighted in purple). Furthermore, this treatment plan simplifies matters as it obviates the need for matching electron boosts once spinal tolerance has been exceeded.
Figure 5-2: Peacock plan for nasopharynx cancer
Parotid-sparing radiation therapy for head and neck cancer has been investigated by the University of Michigan using 3D-CRT and more recently, IMRT. (29) IMRT is implemented using multisegmented static fields, with the contralateral parotid gland as an avoidance structure. A comparison of treatment plans versus reconstructed conventional three-field plans in 15 patients showed better target dose conformity and a dose-reduction in contralateral parotid of about two-thirds. Salivary flow was measured in 88 patients before and after conformal parotid-sparing radiation therapy. By limiting the mean dose received by the parotid gland to less than 26 Gy, salivary flow was preserved in the majority of cases, whereas high doses resulted in little recovery of salivary production. Compared with standard irradiation, patients reported less dry mouth with conformal parotid-sparing techniques. (19) In a recent study of patterns of failure following conformal irradiation, the 2-year local control was 79%, with none recurring near the contralateral parotid gland. However, 4 of 58 patients experienced relapses in the superior neck and retropharyngeal nodes near the ipsilateral parotid, stimulating the investigators to increase doses to these regions. (30)
IMRT has the capability of incorporating boost treatment simultaneously within larger field irradiation. (31,32) This technique of head and neck radiation may provide a higher biologically equivalent dose while reducing treatment time and maintaining acute toxicity at acceptable levels. These techniques are further discussed below.
Locoregional recurrence in head and neck cancer is not an uncommon situation. Management options for these patients tend to be limited and designed with palliative intent. Because of normal tissue tolerance, conventional re-irradiation is often not possible, and studies have reported on stereotactic techniques, hyperfractionated radiation, and brachytherapy. At the Methodist Hospital, ten patients with recurrent disease (previous doses 50-67 Gy) underwent Peacock-based IMRT for an additional 16-66 Gy. All patients achieved palliation of local symptoms, and half of the patients have had no progression of local disease. (20)
Prostate Cancer
Radiation therapy has a long history in the treatment of prostate cancer. A series of technological advances in the past 20 years have improved the targeting of the prostate and shielding of rectum and bladder. This has lead radiation oncologists to embark on dose-escalation trials for prostate cancer in attempt to improve tumor control. (33) However, higher doses can induce more rectal and bladder toxicity. IMRT has been used for prostate cancer over the past several years to allow dose-escalation without equivalent increase in toxicity. Because of the narrow prescribing margins (often <10 mm) between target and organs at risk (rectum and bladder), novel immobilization and location methods are necessary. One approach is the insertion of a rectal balloon filled with air which presses the prostate against the pubis, and stabilizes the gland during therapy. Other methods include transabdominal ultrasound location of the prostate gland, or placement of metal seeds within the gland to serve as internal fiducial markers.
Memorial Sloan Kettering Cancer Center has been conducting a dose-escalation study for prostate cancer since the late 1980's. Their initial treatment plan consisted of six static 3D-planned coplanar fields, and a boost above 72 Gy was performed with 6-8 lateral and posterior-lateral fields. An IMRT-based plan using the "sliding window" method was developed for the boost, and quickly became the technique for the entire course of therapy. (18,34) The dose-distributions produced by IMRT were even superior to those produced by a 6-field 3D-CRT technique. The preliminary results of this trial using conventional 3D-CRT are encouraging, and support further dose-escalation.35 In 743 patients, the probability of a PSA nadir to 1.0 ng/ml or less and the probability of PSA control were higher in the higher dose arms. Among the selected patients who underwent post-treatment biopsies, fewer patients in the highest dose arm (81 Gy) were positive for tumor cells. In addition, grade 3 rectal and urinary toxicity was <1% for all patients, a risk similar to or less than that associated with conventional doses.
|Dose Level
|Patients Treated
|Patients Biopsied
|Negative for Tumor Cells
|Tumor Cells with Radiation Effect
|Positive for Tumor Cells
|66.6 Gy
|70.2 Gy
|75.6 Gy
|81.0 Gy
Table 5-2: Biopsy Results in Prostate Cancer Dose-Escalation Trial
An alternative to dose-escalation is accelerated treatment with IMRT. Investigators at the Cleveland Clinic have tested the safety and efficacy of hypofractionated IMRT to 70 Gy in 28 fractions. (36) This has the advantage of shorter treatment times (5.5 weeks for 70 Gy vs. 9 weeks for 81 Gy), with similar biologic effect. Fifty-one patients were treated with 5 static intensity-modulated fields generated by CORVUS inverse planning. Approximately 70% of patients experienced grade 1 acute rectal and bladder toxicity, and up to 20% experienced grade 2 toxicity, which is more frequent than that generally seen with conventional fractionation. If this proves to be an effective and tolerable regimen, the shortened duration of treatment may enhance patient convenience.
Prostate cancer patients are treated with the Peacock system at the Methodist Hospital (Houston, TX). A typical isodose plan for a prostate patient is shown in Figure 5-3. Patients are prescribed 70 Gy in 35 fractions to the periphery of the prostate gland and seminal vesicles. This corresponds to a mean dose to the prostate and seminal vesicles of approximately 76 Gy and 74 Gy respectively, and less than 35 Gy to the bladder and rectum. A toxicity analysis was performed on 50 patients and compared with conventionally-treated patients (Table 5-3). Although this is a retrospective comparison, there is a suggestion that patients treated with IMRT may have less acute toxicity. (37)
Figure 5-3: Peacock plan for prostate cancer
|GU Toxicity by RTOG Grade
|GI Toxicity by RTOG Grade
|6-Field Conformal
Table 5-3: Acute Radiation Toxicity in Prostate Cancer Treatment
There has been recent interest in using IMRT for tangential treatment of breast cancer patients. The goals of breast IMRT are twofold: 1) reduce dose to the ipsilateral lung, contralateral breast, and if left-sided, heart and coronary vessels; and 2) for institutions who treat the internal mammary nodal (IMN) chain, incorporate IMNs while maintaining dose-limits on normal structures. A dosimetric study was performed at Memorial Sloan Kettering Cancer Center, using IMRT implemented with the sliding window technique. (38) Doses to critical normal structures, including the contralateral breast and coronary arteries represented by the left anterior cardiac wall, were significantly reduced.
A second study compared conventional tangential irradiation with static field IMRT in 20 breast patients. (39) The method of intensity modulation involved an initial field prescribed to approximately 90% of the presscribed dose, and a second segment of radiation which supplemented underdosed regions of the breast. Dose homogeneity across the breast could be improved from the "hot spots" of 22% seen with conventional therapy. More importantly, the 90% of the IMN chain received 4500 cGy, whereas 50% of the IMN chain received 3500 cGy with conventional planning, without increased dose to the underlying normal organs.
Simultaneous Boost Therapy
Standard radiation fractionation schemes deliver higher doses to areas of greatest disease burden; i.e., gross tumor receives 60-70 Gy and subclinical regions receive 45-50 Gy. This has conventionally been performed with successive phases of radiation, the first delivering lower doses to larger volumes and subsequent phases directed at smaller target volumes. In head and neck cancer, this scheme is known as "shrinking field" technique, and may involve several conedowns. Tumor control in head and neck cancer is also related to length of treatment time, with protracted courses resulting in lower control rates. (40) Accelerated fractionation with twice-a-day radiation has been proposed to counteract repopulation of tumor clonogens, and shown to be superior compared with standard fractionation using a concomitant boost technique in a randomized trial. (41)
IMRT has the ability to incorporate a concomitant boost volume within larger volume treatment. This technique is known as a simultaneous integrated boost (SIB) or simultaneous modulated accelerated radiation therapy (SMART). (31) For a typical head and neck case, the gross tumor at the primary and nodal sites may be designated target 1, and prescribed 220-250 cGy per day. The surrounding subclinical regions adjacent to the primary tumor and regional nodes may be designated target 2, and prescribed 180-200 cGy per day. Radiobiologically, the resultant dose-fractionation is likely to be similar to a typical dose of 7000 cGy in 7 weeks. A comparison of the standard fractionation, accelerated fractionation, and the SMART boost is shown in Table 5-4.
|Total Dose (cGy)
|Overall Duration
|Standard fractionation
|200 cGy x 35 fractions QD
|7 weeks
|Hyperfractionated Radiotherapy
|120 cGy x fractions BID
|6 weeks + 1 day
|Accelerated Fractionation
MGH Split Course
200 cGy x 35 fractions QD 7/wk
|5 weeks
6 weeks
12 days
16 days
|Concomitant Boost (MDACC)
|180 cGy x 30 fractions QAM
150 cGy x 12 fractions QPM
|6 weeks
|SMART Boost
|240 cGy x 25 fractions (GTV)
200 cGy x 25 fractions (CTV)
|5 weeks
|CAIR = continuous accelerated radiation therapy; MGH = Massachusetts General Hospital; CHART = continuous hyperfractionated accelerated radiation therapy; CHARTWEL = CHART weekend-less; MDACC = M.D. Anderson Cancer Center; SMART = simultaneous modulated accelerated radiation therapy
Table 5-4: Accelerated Fractionation Schemas
The potential advantages of an integrated boost are that a single plan can be used for the entire treatment, and fractionation to gross disease is accelerated. In addition, the dose distribution is more conformal, since the boost fields do not "violate" previously treated regions that were intended to receive subclinical doses. The downside is that this treatment can be more toxic, as the daily dose to mucosal regions is higher.
The experience with the SMART boost in the first 20 Peacock-treated head and neck patients was recently reported. (31) Gross tumor and subclinical disease are commonly prescribed 240 cGy and 200 cGy per day, respectively, or 6000 cGy over 5 weeks to gross disease. The mean doses to target regions are higher- 6440 and 5440 cGy. Grade 3 mucosal toxicity was observe in 80% of patients, resulting in the need for IV fluids or tube feeding in many patients. Late toxicity has not been observed, as the mean doses to critical structures have been kept well below tolerance. Local disease has been controlled in 90% of patients, although two patients developed lung metastases.
6. Implementation of IMRT versus Conventional Technology
Manpower Issues
The implementation of IMRT can be a complex and tedious task, even for radiation oncology facilities with 3D-CRT already in use. Dynamic MLC must be installed either on existing linear accelerators if feasible or as a package with a new accelerator purchase. If a CT-simulator is not present, a mechanism for obtaining patient CT imaging data must be available. Additionally, MRI images are helpful and image fusion software should be available. Planning of IMRT and control of dynamic MLC requires new computer software and a thorough understanding of the planning and treatment process by physics staff. Quality assurance measures must be adopted to ensure IMRT dose delivery is accurate. At Memorial Sloan-Kettering Cancer Center, a full 14-step procedure had been in place once an optimized IMRT plan had been developed.18 Based on prior experience gained over the past several years, a facility should be able to commission an IMRT system in a 3-4 month period. (42)
The planning of IMRT requires a paradigm shift for dosimetrists and physicians. For facilities without existing 3D-CRT planning, the task of image segmentation, or tumor and normal structure contouring, will need to be incorporated into the planning process. While some software may perform some of these tasks automatically or nearly so, the time requirement for contouring alone may take between 30 minutes or more than a hour, depending on the site of disease, organs at risk, and number of CT slices. Instead of manually testing beam arrangements and weightings, physicians will need to formulate tumor dose goals and normal structure dose-volume constraints, and allow computers to achieve the solution. For some common tumor sites such as the prostate gland, relatively standardized IMRT solutions are in place, thus streamlining the dosimetry operation.
For radiation therapists, additional training will be required regarding precision patient setup, new immobilization devices, and use of new hardware and software. While computer-controlled MLC has obviated the need for fabrication of blocks and for the therapist to enter the treatment room between fields to change blocks, treatment times may not be shorter and are, for some tumor sites, often longer. At the Methodist Hospital (Houston, TX), the total treatment time of a typical prostate cancer patient with three table indices on a Peacock system is 15 to 20 minutes. (43) Even with sliding window technique and IMAT, the treatment time is between 20 and 40 minutes. For a head and neck patient with 5 to 7 table indices and sometimes an additional conventional field for low neck irradiation, the treatment time can be substantially longer. However, initial and boost fields can be combined into a single plan, and supplemental electron fields are often unnecessary. With more automated equipment, higher dose rate accelerators, and greater experience, patient throughput is likely to improve.
Financial Considerations
The costs of any new radiation treatment relate to the fixed costs of medical equipment, the resources required to provide the treatment, and the patient-related costs of travel and self-care during a course of therapy. In addition, downstream costs related to the potential morbidity and treatment for cancer recurrences may require consideration if these differ among treatment options. (44) Depending on the facility, acquisition of a 3D planning system and an MLC device may represent a substantial investment. These costs differ depending on the manufacturer and existing equipment setup, and this discussion is beyond the scope of this review. Patient-related indirect costs are similar for prostate cancer treatment, unless dose-escalation is pursued and additional treatment time is required. For head and neck cancer, the incorporation of a SMART boost saves patients 2 weeks of treatment time, without the need for twice-a-day visits.
In one economic study, the Medicare allowable charges for conventional treatment and IMRT were compared for prostate cancer and head and neck cancer. (43) As shown in Table 6-1, the charges for IMRT for prostate cancer were about 33% higher than conventional therapy. For head and neck cancer, the charges with a SMART boost were 20% lower than conventional therapy, and 33% less than twice-a-day treatment. The charge formulas will fluctuate across various radiation oncology facilities, but this elementary analysis demonstrates IMRT need not be drastically more expensive than conventional treatment.
|Radiation Schedule
|Professional Charges
|Technical Charges
|Total Medicare Allowable Charges
|Prostate Cancer
Conventional Radiation
|Head and Neck Cancer
Concomitant Boost Radiation
Accelerated Fractionation
SMART Boost
|IMRT = intensity-modulated radiation therapy; SMART = simultaneous modulated accelerated radiation therapy
Table 6-1: Medicare Allowable Charges for Various Radiation Schedules43
Limitations of IMRT
3D-CRT and IMRT are certainly major advances in the physical delivery of radiation therapy to a target. This technology is relatively new and still being perfected. IMRT is an inefficient method of delivering radiation, since a large number of radiation monitor units are wasted in the process of achieving the desired beam fluence. In the Peacock system, a single arc can deliver 240 cGy to a target at a dose rate of 300 cGy/min. Higher fraction sizes would require repetitive arcs at the same table index, or a higher output accelerator. Efficiency of dose delivery at the present time is only 5 to 10%, whereas over 90% of output is wasted.
As a result of the increased monitor units required for IMRT, it is possible that radiation scatter and whole-body doses will increase. The dose at 10 cm from the target was measured at 2.5% of the prescribed dose. (45) In order to produce the conformal dose distributions while sparing critical surrounding organs, IMRT spreads out dose to noncritical normal tissue. The volume of normal tissue receiving low levels of radiation dose can be significantly higher than with conventional radiation therapy. The biologic effects of widespread scattered and low dose radiation are not well understood and require more study. At the same time, dose inhomogeneity within the target volume may expand as a consequence of normal tissue avoidance, and this effect on tumor control should be evaluated carefully. (46)
There are a number of issues related to human and tumor biology which IMRT is unable to overcome. IMRT is poorly suited for tumors in moving organs, such as the lung or adjacent sites whose positions vary with respiration. A number of techniques are being explored to compensate for respiratory motion, but these are far from routine use. Even the small movement that may occur in the prostate as a result of bladder or rectal content can result in significant deviations from desired dose deposition given the ever slimmer margins prescribed. Inhomogeneity corrections also play an important role in inverse planning and delivery. Currrently, all plans are done using a homogeneous phantom. An additional problem is related to defining the target, as the borders of many cancers are difficult to distinguish from normal tissue, even with CT images or MRI co-registration. (47) No imaging study can detect microscopic infiltration of cancer cells, and close attention must be paid to whether marginal or out-of-field recurrences may result from higher doses to tighter margins. Lastly, the assumption that higher doses of radiation beyond conventional doses of 60 to 70 Gy leads to better tumor control has been confirmed for prostate cancer, (48) but for few other cancers. Doses as high as 80 or 90 Gy have been unable to control gliomas, (5) so more radiation and elaborate dose-distributions will clearly be insufficient for certain cancers.
Will more patients be cured with IMRT? Higher tumor doses may be feasible while limiting normal tissue toxicity which, in theory, may improve local control of disease. Ultimately, the improved local control and reduction in radiation morbidity should result in better patient outcomes. Unfortunately there has been a relative paucity of rigorous scientific data to support the clinical benefits of IMRT; evaluation of the safety and efficacy of IMRT has been largely based on short-term comparison with historical data from conventionally treated patients. However, the early experience has been very encouraging, and many academic centers continue to push this technology to even further limits.
IMRT is a promising treatment technique for a variety of clinical situations. The implementation of IMRT relies on concepts of inverse treatment planning and computer-controlled modulation of radiation intensity. Issues regarding commissioning and quality assurance of IMRT systems have been addressed. Dosimetric studies have demonstrated improvements in conformality to target regions, and the crucial ability to avoid organs at risk for radiation injury. Clinical studies have demonstrated a reduction in acute and long-term morbidity, particularly with rectal and bladder toxicity from prostate irradiation and xerostomia. 3D-CRT and IMRT may allow safe dose-escalation with potential improvement in local control. Early results in tumor control with IMRT are encouraging; however, more long-term data are needed to confirm these benefits over conventional radiation therapy.
AcknowledgmentsThe authors thank the radiation therapists, dosimetrists, and staff at the Baylor College of Medicine Methodist Hospital for their kind assistance with the preparation of this review.
Teh BS, Woo SY, Butler EB. Intensity modulated radiation therapy (IMRT): a new promising technology in radiation oncology. The Oncologist 1999;4:433-442.
Yu CX. Intensity-modulated arc therapy with dynamic multileaf collimation: an alternative to tomotherapy. Phys Med Biol 1995;40:1435-1449.
Mackie TR, Balog J, Ruchala K, et al. Tomotherapy. Sem Radiat Oncol 1999;9(1):108-117.
Carol MP. PeacockÔ : a system for planning and rotational delivery of intensity-modulated field. Int J Imaging Systems Tech 1995;6:56-61.
Das IJ, Kase JR, Tello VM. Dosimetric accuracy at low monitor unit settings. Br J Radiol 1991;64:808-811.
Low DA, Gerber RL, Mutic S, Purdy JA. Phantoms for IMRT dose distribution measurement and treatment verification. Int J Radiat Oncol Biol Phys 1998;40(5):1231-5.
Tsai JS, Wazer DE, Ling MN, et al. Dosimetric verification of the dynamic intensity-modulated radiation therapy of 92 patients. Int J Radiat Oncol Biol Phys 1998;40(5):1213-30.
Low DA, Dempsey JF, Venkatesan R, et al. Evaluation of polymer gels and MRI as a 3-D dosimeter for intensity-modulated radiation therapy. Med Phys 1999;26(8):1542-51.
Woo SY, Grant WH 3rd, Bellezza D, et al. A comparison of intensity modulated conformal therapy with a conventional external beam stereotactic radiosurgery system for the treatment of single and multiple intracranial lesions. Int J Radiat Oncol Biol Phys 1996;35(3):593-7.
Eisbruch A, Dawson LA, Kim HM, et al. Conformal and intensity modulated irradiation of head and neck cancer: the potential for improved target irradiation, salivary gland function, and quality of life. Acta Otorhinolaryngol Belg 1999;53(3):271-5.
Dawson LA, Anzai Y, Marsh L, et al. Patterns of local-regional recurrence following parotid-sparing conformal and segmental intensity-modulated radiotherapy for head and neck cancer. Int J Radiat Oncol Biol Phys 2000;46(5):1117-26.
Butler EB, Teh BS, Grant WH III, et al. SMART (simultaneous modulated accelerated radiation therapy) boost: a new accelerated fractionation schedule for the treatment of head and neck cancer with intensity modulated radiotherapy. Int J Radiat Oncol Biol Phys 1999;45(1):21-32.
Wu Q, Manning M, Schmidt-Ullrich R, Mohan R. The potential for sparing of parotids and escalation of biologically effective bose with intensity-modulated radiation treatments of head and neck cancers: a treatment design study. Int J Radiat Oncol Biol Phys 2000;46(1):195.
Zelefsky MJ, Leibel SA, Kutcher GJ, Fuks Z. Three-dimensional conformal radiotherapy and dose escalation: where do we stand? Semin Radiat Oncol 1998;8(2):107-14.
Ling CC, Burman C, Chui CS, et al. Conformal radiation treatment of prostate cancer using inversely-planned intensity-modulated photon beams produced with dynamic multileaf collimation. Int J Radiat Oncol Biol Phys 1996 Jul 1;35(4):721-30.
Zelefsky MJ, Leibel SA, Gaudin PB, et al. Dose escalation with three-dimensional conformal radiation therapy affects the outcome in prostate cancer. Int J Radiat Oncol Biol 1998;41(3):491-500.
Mohan DS, Kupelian PA, Willoughby TR. Short-course intensity-modulated radiotherapy for localized prostate cancer with daily transabdominal ultrasound localization of the prostate gland. Int J Radiat Oncol Biol Phys 2000;46(3):575-80.
Teh BS, Uhl BM, Augspurger ME, et al. Intensity modulated radiotherapy (IMRT) for localized prostate cancer: preliminary results of acute toxicity compared to conventional and six field approach (abstr). Int J Radiat Oncol Biol Phys 1998;42(Suppl. 1):219.
Hong L, Hunt M, Chui C, et al. Intensity-modulated tangential breast irradiation of the intact breast. Int J Radiat Oncol Biol Phys 1999;44(5):1155-64.
Lo Y-C, Yasuda G, Fitzgerald TJ, Urie MM. Intensity modulation for breast treatment using static multi-leaf collimators. Int J Radiat Oncol Biol Phys 2000;46(1):187-194.
Robertson C, Roberston A, Hendry JH, et al. Similar decreases in local tumor control are calculated for treatment protraction and for interruptions in the radiotherapy of carcinoma of the larynx in four centers. Int J Radiat Oncol Biol Phys 1998;40:319-329.
Fu KK, Pajak TJ, Spencer SA, et al. A Radiation Therapy Oncology Group (RTOG) phase III randomized study to compare hyperfractionation and two variants of accelerated fractionation to standard fractionation radiotherapy for head and neck squamous cell carcinomas: preliminary results of RTOG 9003 [Abstract]. Int J Radiat Oncol Biol Phys 1999;45(3 Suppl.):145.
Grant WH III. Commissioning and quality assurance of an IMRT system. In: Sternick ES (ed): The Theory and Practice of Intensity Modulated Radiation Therapy. Madison, WI: Advanced Medical Publishing, 1997, pp 121-126.
Grant WH III, Woo SY. Clinical and financial issues for intensity-modulated radiation therapy delivery. Sem Radiat Oncol 1999;9(1):99-1107.
Perez CA, Michalski J, Ballard S, et al. Cost benefit of emerging technology in localized carcinoma of the prostate. Int J Radiat Oncol Biol Phys 1997;39(4):875-883.
Mutic S, Low DA. Whole-body dose from tomotherapy delivery. Int J Radiat Oncol Biol Phys 1998;42:229-232.
Goitein M, Niemierko A. Intensity modulated therapy and inhomogeneous dose to the tumor: a note of caution. Int J Radiat Oncol Biol Phys 1996;36(2):519-522.
Glatstein E. Dr. Strange (high) tech or how I learned to stop worrying and love my MLC/3D treatment planning, stereotactic linac. Int J Radiat Oncol Biol Phys 1999;45(5):1097-101.
Pollack A, Zagars GK, Smith LG, et al. Preliminary results of a randomized dose-escalation study comparing 70 Gy to 78 Gy for the treatment of prostate cancer [Abstract]. Int J Radiat Oncol Biol Phys 1999;45(3 Suppl.):146.
I wish u knew... Getting through cancer treatment: tips from an oncology nurseby Timothy J. Hampshire
January 09, 2013
3 Great Reasons To Have Gratitude On Your Cancer Teamby Marlys Johnson
July 25, 2016


text:
Follow Us On: Facebook Twitter YouTube
Washington, D.C.—The U.S. House of Representatives will take up a measure today (H.R. 359) that, if passed, will place elections more squarely in the hands of corporate interests by repealing the presidential campaign financing system, according to a leading national watchdog group, Public Campaign Action Fund. Republican lawmakers pushing the repeal claim they are doing so to save money, but a review of earmarks secured by the lawmakers pushing the change suggest they would have saved more by starting with their own legislative pork.
Full report at www.campaignmoney.org/danlungren
Public Campaign Action Fund
1133 19th Street, NW Suite #900 | Washington, DC 20036
email@example.com | (P) 202.640-5600 | (F) 202.640.5601


text:
CHARLESTON - The Ohio Valley will be well-represented Thursday when the West Virginia State Tennis Championships begin.
Coonskin Park is playing host to the Class AA-A event this year. There, local netters will compete in all but one event.
Wheeling Central has seven qualifiers, including six on the boys' side. Oak Glen's girls will have six playing, while Madonna has three participants.
Article Photos
OFF TO CHARLESTON — Madonna's Matt Conforti, Ali?Welch, and Nick Conforti are set to compete at the West Virginia State Tennis Championships.
-- Contributed
Madonna has a small, but strong, contingent led by brothers Nick and Matt Conforti.
Nick and Matt both won regional titles at No. 1 and No. 2 Singles, respectively. Then, they teammed up to claim the No. 1 Doubles title.
It was the third straight season the Confortis won regional crowns. Nick, a senior, enters state tournament play with a 22-0 mark.
Fact Box
Thursday's Schedule
Class AAA
(at Kanawha City Community Tennis Center)
No. 1 Singles
Blazer (JM) vs. Tubert (Hunt), 9 a.m.
No. 1 Doubles
Hunley-Baranski (WP) vs. Clay-Campbell (Hurr), 2:30 p.m.
No. 1 Singles
Pauley (JM) vs. Mercer (Hunt), 8 a.m.
Class AA-A
(at Coonskin Park)
No. 1 Singles
Haley (WC) vs. Flanagan (Will), 9 a.m.
N.Conforti (WM) vs. Starkey (Scott), 10 a.m.
No. 2 Singles
Szeligo vs. Leo (Will), noon
M.Conforti (WM) vs. Makani (Pburg)/Witt (WyE) winner, TBD
No. 3 Singles
Schmidt (WC) vs. Culicerto (WyE), 4 p.m.
No. 1 Doubles
Haley-Szeligo (WC) vs. Meade-Reynolds (HSJ), 5 p.m.
No. 1 Singles
Capito (WC) vs. Williams (Chap), 8 a.m.
Spurlock (OG) vs. Hamilton (CC), 9 a.m.
No. 2 Singles
Welch (WM) vs. Mobley (Poca), 11 a.m.
No. 3 Singles
Sayre (OG) vs. Stephens (L-R), 3 p.m.
No. 1 Doubles
Spurlock-Juszczak (OG) vs. Williams-Justice (Chap), 5 p.m.
Ali Welch, runner up at regionals, will compete for the Blue Dons at No. 2 Singles.
The Golden Bears girls are in every event but No. 2 Singles.
''We're matched up with Charleston Catholic quite a bit and Charleston Catholic is always good,'' Oak Glen coach Ken Keller said. ''So, we'll just do our best and have a good time. They are all very excited to go down.''
Keller didn't know if the six qualifiers was the most in school history, but it is a recent high for the school, which plays its matches at the courts at Mountaineer.
''We really appreciate them letting us use them,'' Keller said.
Hailey Spurlock has, in essence, taken on a leadership role for the Golden Bears as she is the only player on the team with state tournament experience. She played at No. 3 Singles and will compete for the No. 1 Singles crown this year.
Abbi Sayre and Madison Juszczak will compete at No. 3 and No. 4 Singles, respectively. In doubles, the Golden Bears will be represented by the duos of Spurlock and Juzczak (No. 1), Sayre and Anna Crawford (No. 2) and Lauren Pizzurro and Madison Hill (No. 3).
The Maroon Knights boys are coming off a Region One championship where titles in three events were secured. Powerhouse Charleston Catholic has won the last seven state crowns, but Central coach Peggy Dailer is eager to see how things play out.
''I've seen the draw and a couple of guys will run into some tough competition right off the bat,'' she said. ''But they'll be up to the challenge.
''They always give 100 percent no matter who they play.''
Jonathan Haley, a junior, is in the hunt at No. 1 Singles, one year after competing at No. 3 Singles. Senior Brett Szeligo will compete at No. 2 Singles, with Region One champ Gus Schmidt, in the mix at No. 3 Singles.
Haley and Szeligo will team up at No. 1 Doubles, while Schmidt and Daniel Lee join forces at No. 2 Doubles.
''They've had a wonderful year with only two losses,'' Dailer said. ''So we're looking for good things out of them.''
Ben Gordon and Billy Teufel will represent Central at No. 3 Doubles.
''Charleston Catholic is always tough,'' Dailer said when describing the tournament field. ''Bluefield, Huntington St. Joe, they are all very strong teams.
''But so are we.''
Wheeling Central boasts one girls' entrant, but she's a strong one in Joanna Capito.
''Joanna has a good draw, I think,'' Dailer said of the junior.
Capito won the regional title at No. 1 Singles last week and earned all-state honors the last two years.
''She's determined to become an all-stater for the third time,'' Dailer said. ''She works very hard in practice all the time.''
Across the river at the Kanawha City Community Tennis Center, Class AAA action will take place.
Wheeling Park and John Marshall both have two qualifiers.
John Marshall is sending two players to state in Hayden Blazer and Alaina Pauley. Both will compete at No. 1 Singles.
Wheeling Park will be represented by the No. 1 Doubles duo of Shaun Hunley and Mitch Baranski.


text:
Recently I was surprised to discover that no exact solution for the position of a planet as a function of time exists. I am referring to the two-body problem in a gravitational field where Newtons law of gravity holds.
Well known are proofs that the planet will move in an ellipse, Keplers laws can be derived fairly easy etc., but for the exact position of the planet on the ellipse as a function of time, no formula exists, only numerical approximations.
Is this correct?
Can anybody elaborate on the deeper reason(s) that this relatively simple case cannot be solved?