This document describes the case of a 52-year-old male who presented with vomiting and was found to have a pituitary adenoma. An MRI showed a 2.3x1.6 cm dumbbell shaped lesion in the sella turcica extending suprasellarly and compressing the optic chiasm. The patient underwent endoscopic transphenoidal resection, with near total excision. Post-op MRI showed residual tissue in the right and left sides of the sella. The patient was planned for stereotactic radiotherapy with 25Gy in 5 fractions to treat the residual tumor. Target and organ at risk volumes were delineated on planning MRI and CT scans. Treatment planning was performed to optimize dose distribution and minimize
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.
Techniques for Inguinal/Groin IrradiationAjeet Gandhi
Inguinal radiotherapy delivery is many a times a complex dosimetric uncertainty and we need to judiciously choose the technique for best patient outcome
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.
Techniques for Inguinal/Groin IrradiationAjeet Gandhi
Inguinal radiotherapy delivery is many a times a complex dosimetric uncertainty and we need to judiciously choose the technique for best patient outcome
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
1. ROSE CASE
STEREOTAXY FOR PITUITARY ADENOMA
RADIATION ONCOLOGY
SIMULATION TO EXECUTION
DR KANHU CHARAN PATRO
MD,DNB[RADIATION ONCOLOGY],MBA,FAROI,PDCR,CEPC
2. HISTORY
• 52 year male with no co morbidities
• Had complaints of vomiting on July 2020 – Projectile
type
• Associated with reeling sensation of head and
involuntary movements involving all four limbs
• Not associated with headache/ blurring of vision
• Admitted in hospital and evaluated
3. MRI Scan - Preop
SEQUENCES FINDINGS
MRI 1. 2.3 × 1.6 × 1.6 cm
2. Dumbbell shaped
3. Altered intensity lesion in sellar region
4. Extending into Suprasellar location
5. Pituitary gland not separated from lesion
6. Optic chiasm – compressed & superiorly
displaced
7. Doubtful B/L Parasellar extension (R>L) with
encasement of cavernous segment B/L ICA
(R>L)
CE MRI 1. Peripheral rim enhancement with irregular
non enhancing area within the matrix of
lesion - Necrosis
13. MRI PROTOCOL
• MRI POST OP CONTRAST
• FSPGR-ANATOMY
• FATSAT T1- PACKING MATERIAL DISTINGUISH
• DELAYED CONTRAST- NORMAL PTUITARY DISTINGUISH
• T2- TO SEE CAVERNOUS SINUS INVOLVEMNET
• 1MM
• NO GAP
• NO TILT
• 512 X 512 MATRIX
• NEUTRAL NECK
• FOV SHOULD INCLUDE BODY CONTOUR NOSE, EYE AND
SKULL
19. PREOP POSTOP
VISUAL ACUITY LEFT Normal Normal
VISUAL ACUITY RIGHT Normal Normal
VISUAL FIELD LEFT Near normal 100%
VISUAL FIELD RIGHT Near normal 100%
Visual assessment
23. MRI - POSTOP
SEQUENCES FINDINGS
T1 & T2 1. Residual pituitary tissue
2. 16×11×7mm on Right side
3. 12×8×8mm on Left side
4. Bridging soft tissue is seen along
the floor of sella
5. B/L Cavernous sinus – normal
6. Optic chiasm – 4mm away from
tumor
31. • Contour the residual as GTV
• Be relax at caudal site and lateral side
• Do not include cavernous sinuses unless involved
• Differentiate from packing material
• CTV- Unnecessary unless it is an aggressive
adenoma with potential areas of microscopic
infiltration
• PTV – 1mm to GTV
2/26/2021 31
TARGET DELINEATION
32. • While SCRT is suitable for the treatment of all
pituitary tumours, irrespective of size, shape
or proximity to critical normal tissue
structures,
• SRS is only suitable for treatment of small
tumours away from the optic chiasm
2/26/2021 32
SCRT VS SRS
33. FSRT FOR PITUITARY
• Stereotactic radiotherapy originally referred to radiotherapy
treatment delivered to an intracranial target lesion that was located
by stereotactic means in a patient immobilised in a neurosurgical
stereotactic head frame. The improved patient immobilisation,
more accurate
• Tumour target localisation using cross-sectional image for treatment
planning, and high precision radiation treatment delivery to the
tumour target, enabled a reduction in the margins around the
radiotherapy target volume (the GTV to PTV margin), therefore
achieving greater sparing of surrounding normal tissues than can be
obtained with standard CRT techniques
2/26/2021 33
34. SCRT VS SRT
• While SCRT is suitable for the treatment of all
pituitary tumours, irrespective of size, shape
or proximity to critical normal tissue
structures,
• SRS is only suitable for treatment of small
tumours away from the optic chiasm
2/26/2021 34
37. Tumor board decision
• After group discussion with neurosurgeon,
radiation oncologist and patient, board
decided to plan for stereotactic radiotherapy
• Patient was explained about complications
and outcome of each procedure
38. Patient discussion
• Discussed about RT comparing with re-surgery
• Discussed about the procedure
• Discussed about visual preservation
• Discussed about follow up imaging ,hormonal and
visual evaluation
• Discussed about tumor response
• Discussed about need of surgery in future
• Discussed about need of RERT in future
• Discussed about post radiotherapy cyst formation
• Discussed about post radiotherapy hypopituitarism and
need of hormonal replacement
43. • 1mm slice
• Contrast
• Vertex to neck
• With fraxion
Planning CT
44. MRI protocol
• T1/T2/FLAIR sequence- Usual sequence
• 3D FSPGR sequence- Normal anatomy
• FATSAT sequence- Differentiate packing material
• 512x 512 matrix
• 1mm slice
• No gap
• No tilt
• Neutral neck
• FOV should include body contour nose, eye and skull
54. SL NO PARAMETER VALUE
1 D MAX 31.49Gy
2 D95% 27.38Gy
3 D100% 24.61Gy
4 V95% 100%
5 V25 Gy[V100%] 99.96%
6 V110% 94.20%
7 V120% 19.28
8 V130% 0
1. Prescription Isodose level is usually not 100% PD covering 100% PTV
2. Often 95% PD covering 95% PTV or higher
3. Or 100% PD covering 95% PTV or higher.
Michael Torrens,/J Neurosurg (Suppl 2)/2014
PTV coverage index
55. • FORMULA
• VOLUME OF PRESCRIPTION ISODOSE/PTV VOLUME
• 4.956/4.161=1.19
• DESIRABLE=1
[Sonja Petkovska
Proceedings of the Second
Conference on Medical Physics
and Biomedical Engineering]
RTOG conformity index
56. • FORMULA
(VOLUME OF PRESCRIPTION ISODOSE IN AREA OF INTEREST)2
PTV VOLUME X VOLUME OF PRESCRIPTION ISODOSE
• 4.474x4.474/4.161X4.956=0.97
• IDEAL= > 0.85. AND <1
Michael Torrens,/J Neurosurg (Suppl 2)/2014
Paddick conformity index
57. • FORMULA
• MAXIMUM DOSE/PRESCRIPTION DOSE
• 31.49Gy/25Gy=1.25
• DESIRABLE = 1.1-1.3
HOMOGENITY index
58. • Dose fall off observation is very much needed in this
evaluation under headings
• Gradient index
• Difference between various isodose lines
• e.g between 80% and 60%- ideal- <2mm
• Between 80% and 40%- ideal- < 8mm
• For that reason we have to calculate equivalent
radius
Dose fall off
59. • To evaluate dose gradient we have to find out
difference between radius of various isodose line
• But none is iso spherical
• We have to find out equivalent radius from formula
• First find out the specified isodose volume
• Then calculate the radius
• V=4/3 πr3
• r= (3V/4π)1/3
Equivalent radius
61. • FORMULA
– Difference of equivalent radius of prescription
isodose and equivalent radius of 50% isodose
• 1.62mm-1.06mm=0.56mm
• It should be between 0.3 to 0.9
Gradient index
62. • BETWEEN 80% AND 60%- IDEAL-<2mm
• HERE1.49--1.27= 0.21mm
• BETWEEN 80% AND 40%- IDEAL- <8mm
– HERE1.8--1.27= 0.53mm
EORTC-22952-26001
Distance between various isodose lines
66. • MECHANICAL ISOCENTER CHECK
– WINSTON LUTZ TEST
• POINT DOSE VERIFICATION
• TOLERANCE-1MM
Travis R. Denton/JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS/2015
QA part
70. PREMEDICATION
• TAB. DEXAMETHASONE 8MG THRICE DAILY
STARTING DAY BEFORE
• TAB. ONDANSETRON 8MG THRICE DAILY
STARTING DAY BEFORE
• TAB. PAN 4O ONCE DAILY STARTING DAY
BEFORE
• DIABETES CARE IF
Pre medication-optional
71. • TAPER THE STEROID OVER A WEEK
• ANTI EMETICS
• PPI
Post medication-optional
81. NORMAL PITUITARY- MRI PICTURES
The adenohypophysis is isointense & the
neurohypophysis is hyperintense- T1 PLANE
Sagittal postcontrast T1shows normal
diffuse enhancement of the gland
2/26/2021 81
82. PITUITARY MICROADENOMA- MRI PICTURES
LEFT PART PITUITARY GLAND. WITHIN THE GLAND, A
FOCAL AREA OF HYPOINTENSITY IS SEEN IN T1 PLANE
Microadenoma remains hypointense while the
remainder of the gland enhances IN T1 CONT
2/26/2021 82
83. DELAYED IMAGE
2/26/2021 83
1. Imaging more than 30 minutes after intravenous contrast also
may help detect Microadenomas, which then appear as focal
hyperintense lesions relative to the surrounding gland.
2. Encasement of the intercavernous internal carotid artery by
adenoma greater than or equal to 67% was concluded to be a
specific sign of a cavernous sinus invasion in one study.
3. Fat packed in the surgical defect appears hyperintense on T1-
weighted sequences and requires the use of fat-saturated
sequences to distinguish contrast enhancement from packing
material
84. PITUITARY MACROADENOMA- MRI PICTURES
There is a well defined round lesion noted in
the pituitary fossa, the lesion is homogeneous
and isodense on T1
There is a well defined homogeneously
enhancing lesion in the pituitary fossa on
Sagittal T1 C+ suggestive of pituitary adenoma
2/26/2021 84
91. DOCTORS
• DR P S BHATTACHARYA
• DR C R KUNDU
• DR V K REDDY
• DR SAJAL KAKKAR
PHYSICISTS
• MR A C PRABU
• MR A SRINU
• MR PRASAD
• DR ANIL KUMAR
TECHNOLOGIST TEAM
Acknowledgments
92. FOLLOW UP
• 3 MONTHLY FIRST 2 YEARS THEN 6 MONTHLY
• HORMONAL CHECK UP FOR NORMALIZATION
• HORMONAL CHECK UP FOR INSUFFICIENCY
• OPHTHALMIC EVALUATION FOR RECOVERY
• OPHTHALMIC EVALUATION FOR NEURITIS
2/26/2021 92
93. FOLLOW UP IMAGING
• BASELINE EVALUATION AT 3 MONTH OF POST
RADIATION
• MRI PREFERRED
• FURTHER IMAGING AT SYMPTOMATIC
PROGRESSION
2/26/2021 93
95. OPTIC NEUROPATHY
• Usual radiotherapy doses are 45 to 50Gy range.
• This dose is below the tolerance of optic pathway
including optic chiasm.
• It allows for the treatment of pituitary adenomas
of all sizes, including large tumors with
suprasellar extension frequently encasing or in
close proximity to the optic apparatus.
• The toxicity of fractionated external beam RT is
low, with a 1.5% risk of radiation-induced optic
neuropathy
• 0.2% risk of necrosis of normal brain structures
2/26/2021 95
96. PITUITARY INSUFFICIENCY
The most frequent late morbidity of radiation
is hypopituitarism likely to be primarily the
result of hypothalamic injury, although
direct effect on the pituitary gland cannot be
excluded.
In patients who have normal pituitary
function around the time of RT, hormone
replacement therapy is required in 20% to
40% at 10 years
2/26/2021 96
97. A. The 10-year PFS reported in seven large series
of conventional external beam RT for pituitary
adenoma is 80% to 94% .
B. In the largest series of 411 patients, the 10-
year PFS was 94% at 10 years and 89% at 20
years
2/26/2021 97
98. CONTROL AFTER STEREOTAXY
Patients with GH–producing pituitary adenomas should not
undergo further radiation therapy or surgery for at least 5
years after radiosurgery because GH and IGF-I levels
continue to normalize over that interval
2/26/2021 98