Medulloblastoma is the most common malignant pediatric brain tumor. It arises from early brain development cells and is treated aggressively with surgery, chemotherapy, and craniospinal radiation. Despite treatment, 30% of patients eventually die from the disease and survivors face significant long-term side effects. Current treatment involves risk-adapted radiation doses and chemotherapy based on clinical trials. Newer treatment approaches aim to reduce radiation doses and side effects through techniques like proton therapy.
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
This is a made easy summary of ICRU 89 guidelines for gynecological brachytherapy. Extra practical questions for MD/DNB Radiotherapy exams are also attached.
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
EBCTCG METAANALYSIS
INDICATION OF POST OP RADIOTHERAPY
Immobilization devices
Conventional planning
Alignment of the Tangential Beam with the Chest Wall Contour
Doses To Heart & Lung By Tangential Fields
The vmat vs other recent radiotherapy techniquesM'dee Phechudi
VMAT is a new type of intensity-modulated radiation therapy (IMRT) treatment technique that uses the same hardware (i.e. a digital linear accelerator) as used for IMRT or conformal treatment, but delivers the radiotherapy treatment using a rotational or arc geometry rather than several static beams.
This technique uses continuous modulation (i.e. moving the collimator leaves) of the multileaf collimator (MLC) fields, continuous change of the fluence rate (the intensity of the X rays) and gantry rotation speed across a single or multiple 360 degree rotations
EBCTCG METAANALYSIS
INDICATION OF POST OP RADIOTHERAPY
Immobilization devices
Conventional planning
Alignment of the Tangential Beam with the Chest Wall Contour
Doses To Heart & Lung By Tangential Fields
The vmat vs other recent radiotherapy techniquesM'dee Phechudi
VMAT is a new type of intensity-modulated radiation therapy (IMRT) treatment technique that uses the same hardware (i.e. a digital linear accelerator) as used for IMRT or conformal treatment, but delivers the radiotherapy treatment using a rotational or arc geometry rather than several static beams.
This technique uses continuous modulation (i.e. moving the collimator leaves) of the multileaf collimator (MLC) fields, continuous change of the fluence rate (the intensity of the X rays) and gantry rotation speed across a single or multiple 360 degree rotations
Management of cacrinoma cervix: Techniques of radiotherapy (2D conventional, 3D Conformal radiotherapy (3DCRT) and IMRT with a review of various contouring guidelines.
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
2. • Medulloblastoma is the most common malignant (WHO grade IV)
brain tumor of childhood
• It is an embryonal lesion arising from progenitor cell populations
present during early brain development.
• Medulloblastoma is currently treated with maximal safe resection,
chemotherapy, and craniospinal radiation.
• Despite such aggressive therapy, 30% of patients eventually succumb
to this disease
• Survivors cope with the long-term side effects of treatment that have
significant impacts on their quality of life.
8. Risk adaptive management
• Average risk –
• Conventional dose: 30–36 Gy CSI and boosting the primary brain site to
54–55.8 Gy with or without adjuvant chemotherapy ( usually not given)
Or
• Reduced dose: May consider reduced dose radiation
• 23.4 Gy/14# CSI with concurrent weekly Vincristine (1.5mg/m2) and
boosting the primary brain site to 54–55.8 Gy
• f/b Adj chemotherapy 6 cycles of ( Vincristine (1.5mg/m2) ,Cisplatin
(75mg/m2) , Lomustine ( 75mg/m2) or Cyclophosphomide (75mg/m2)
9. Risk adaptive management
• High risk –
• 35-36GY/21# with weekly vincristine or carboplatin(35mg/m2 for 15
days) and boosting primary brain site to 54–55.8 Gy
• f/b Adj chemotherapy 8 cycles of ( Vincristine (1.5mg/m2) ,Cisplatin
(75mg/m2) , Lomustine ( 75mg/m2 )
• Omission of vincristine during radiotherapy phase of therapy or dose
modification may be required for adults because they do not tolerate
this regimen as well.
10. Medulloblastoma in infants
• Risks of neurocognitive decline associated with the use of
radiotherapy in infants and very young children
• Localized medulloblastoma : 5 cycles of cisplatin, vincristine,
etoposide, and cyclophosphamide - followed by a single high-dose
myeloablative chemotherapy regimen of thiotepa, carboplatin, and
etoposide
• Disseminated disease- intraventricular/thecal methotrexate is also
added
13. Patient positioning
Prone Position :
• Advantage :
• Direct visualisation of the field junctions
• Good alignment of spine
• Disadvantage
• Uncomfortable, and large scope for patient
movement
• Difficult for anaesthetic procedures
Prone Position :
• Advantage :
• More comfortable
• Better reproducibility
• Safer for general anaesthesia
• Disadvantage
• Direct visualisation of spinal field not
possible
Head position
Extended : most commonly used – allows the mandible to move out of the spinal field
Flexed : probably straighten he cervical spine – more homogenous dose distribution
14.
15. Simulation
• Concern 1
• Divergence of upper border of spinal field in case of single spinal field (and inter divergence of
spinal fields in case of 2 spinal filed )
• Concern 2
• Divergence of both cranial fields
• Solution
• Spinal field simulated first
• 2 spinal fields if the length is >36 cm
• Upper border at low neck
• Lower border at termination of thecal sac or S2 which ever is lower
• In case of 2 spinal; fields , junction at L2/L3
16. Spinal field simulation
• Patient is aligned with alignment laser system
• Thoracic spine field is simulated first
• The upper border is above the shoulder but without exiting through the mouth .
• The upper border of thoracic field is marked on the lateral aspect of neck also to show the divergence ( to
match with brain field )
• The superior beam should reach to the L1-L2 space to avoid junctions over the inferior part of the spinal cord
• Lumbar spine also simulated , enough to include sacral nerve and roots .
• Inferior border at S3 because the dural sac ends at S2
• Posterior field ( PA )radiographs are taken for both fields
• A lateral radiograph is also obtained with lead wire marking the sagittal dorsal contour of the patient to see
depth of spinal cord . ( reference point is kept at anterior border of body )( thecal sac border )
• Field width should be adjusted so that the lateral field borders are at least 1 cm lateral to the lateral edge of
each ipsilateral pedicle
• Caudal end of the craniospinal field needs to be widened by 1.2 to 1.8 cm to encompass the increase in
distance between nerve root exits as
17. Carinal + cervical spinal field simulation
• The patient is fixed in a prone position with the head ideally
aligned and the neck as straight as possible.
• Eyelid markers are necessary
• Parallel-opposed large lateral fields are simulated with the central
ray in the pineal region
• The collimator should be angled to accommodate the superior
diverging spine field
• Blocks are drawn on the radiograph so that the irradiated volume
includes
• the olfactory groove (cribriform plate),
• the orbits 3 cm posterior to the eyelid markers (2 cm if gantry is angled),
• the middle cranial fossa plus a >1-cm margin, and
• the posterior halves of the odontoid process and the included cervical
vertebral bodies
Anterior block border is approximately
0.5 cm inferior to the projection of the cribriform plate,
3 cm posterior to the ipsilateral eyelid surface and
0.5 cm inferior to the middle cranial fossa floor, and
approximately bisects the cervical vertebral bodies
18. Field selection
• Cranial fields : two parallel opposing lateral fields
• Spinal fields :
• Conventional SSD : Two fields
• Extended SSD : One field may be enough
19. Problem in field matching
• Cranial and spinal field divergence
• Using half beam block technique
• Using collimator couch rotation
technique
• Using planned gaps
• Spinal field divergence
• Gap is given as per calculated formula
• Abutting fields treated with double
junction technique (spinal shift
technique )
• Gap feathering technique
20. Solution for Cranial and spinal field divergence
• Divergence of spinal field into the cranial field is overcome with
collimator rotation
• Divergence of carinal field into spinal field is overcome with couch
rotation( foot end move towards gantry )
• Both this rotations are performed during cranial field treatment
21.
22.
23.
24. Spinal field divergence
1. Abutting fields treated double junction technique ( spinal shift
technique )
2. Filed gap technique : will result in cold spots above and hot spots in
the deeper tissue ( Gap given as per formula )
3. Feathering of gap can smoothen out dose gradient
25. Double junction technique
• Method to ensure dose homogeneity without need for gaps
• Described by Johnson and Kepka ( 1982)
• Principle: an overlapping segment is treated with two different fields
on alternate days
• The junction is therefore automatically feathered on alternate days
• Receives homogenous dose 50% of time and receives junctional dose
in remaining 50% of time ( from the other 2nd field ) .
• No cold spots are generated , actually no overlap is taking place
28. Gap feathering
• Feathering refers to movement of the junctions of the two fields
• Purpose : reduce overdose ( due to overlap )
• Reduce underdose ( due to gap)
Allows a longer segment of cord to be exposed to more homogenous
dose
• Feathering also reduces impact of setup errors
• As the treatment progress the under and over dose gets spread over
a greater area of the spinal cord allowing more homogenous dose
distribution
29. • Usually shifted by 1 to2 cm at
each shift
• Done every few fractions (5 or
7)
• Either in cranially or caudal
direction ( so set up easy )
• If to be shifted cranially all
borders are shifted cranially .
• Lower border of lower field is a
constant
32. • CT simulation is necessary to ensure
adequate coverage of the CTV in the
subfrontal region at the cribriform plate
• CT simulation is also helpful in identifying the
lateral aspect of CTV for the spine field that
includes the extensions of the meninges
along the nerve roots to the lateral aspects
of the spinal ganglia
33. Imaging techniques
• A planning CT scan is obtained using 1–2.5 mm slice thickness from
the vertex to the lower border of C3 vertebrae
• 2–5 mm slice thickness from the lower border of C3 vertebrae to the
upper part of the femur (2–2.5 mm for younger children).
34. CTV cranial
• Cranial CTV: includes brain with entire frontal lobe and cribriform plate.
The geometric edge of the shielding should extend at least 0.5 cm inferiorly
below the cribriform plate and at least 1 cm elsewhere below the base of
the skull
• Firstly, the inner table of the skull is outlined using bony window settings
(suggested CT Window/level: 1500–2000/300–350).
• Secondly, ensure that the cribriform plate, the most inferior parts of the
temporal lobes, and the whole pituitary fossa, which contains CSF are
included in the CTVcranial.
• Thirdly, the CTVcranial is modified to include the extension of CSF within
the dural sheath of cranial nerves
35. CTV Spinal
• The CTVspinal should include the entire subarachnoid
space to encompass the extensions along the nerve
roots laterally
• Inferior border of Spinal CTV must be determined by
imaging the lower limit of the thecal sac on a spinal
MRI; inferior treatment field border should be set 1 cm
below this
• The lower border of the spinal CTV should include the
lower border of the thecal sac, which can be as high as
L5 or as low as S3
36.
37. Planning target volume (PTV)
• The PTV margin should be based on departmental data.
• Most institutions add a 3–5 mm margin to CTVcranial and a 5–8 mm
margin to CTVspinal
38. Treatment Planning and Delivery
• Using modern tools for treatment planning and delivery, it is possible to
greatly simplify the technique and substantially reduce planning and
delivery times
• In general, photons in the 6- to 10-MV range provide satisfactory coverage
of the PTV
• Electrons are used in some centres to treat the spinal axis because of
improved dose calculation algorithms and even electron dose modulation
techniques
• Treatment planning and delivery methods such as intensity modulated
radiation therapy (IMRT) together with daily image verification allow for
improved dosimetry with photons with clinically relevant dose reductions
39. New Treatment Modalities for CSI
• Protons provide a dose distribution for CSI that cannot be achieved by
even the most sophisticated photon beam treatment planning
• With significant reduction in low dose exposure outside the target
volume
• There may be significant benefits from reduced irradiation of the
heart and organs anterior to the spine
• Currently, an increasing number of children requiring craniospinal
radiotherapy are treated by proton therapy