To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
To report a single-institution experience of intensity-modulated radiotherapy (IMRT) and RapidArc treatment plans for the patients treated with low grade mucoepidermoid carcinoma (MEC) of the salivary gland while sparing the organs at risk (OARs) within tolerance limits.
Material and Methods:
Twenty-five patients with MEC were selected to develop and analyse the treatment plans using both of the techniques. Dose distributions were calculated using Eclipse treatment planning system (Varian Medical Systems, Palo Alto, CA). Plans were generated to deliver the dose of 6000 cGy in 30 fractions. For IMRT, seven angle plans were used and for RapidArc, two half arcs were used with the same 6 MV photon beam. Quality of treatment plans was evaluated by using parameters such as, coverage, conformity index (CI), homogeneity index (HI), gradient index (GI), unified dosimetry index (UDI), dose volume histogram, delivery time and OARs sparing for IMRT and RapidArc plans.
The analysis revealed that IMRT and RapidArc coverages are 0·90 and 0·94, respectively; CIs are 1·15 and 1·10, respectively; HIs are 1·12 and 1·07, respectively; GIs are 0·94 and 0·98, respectively. Average UDI values for RapidArc and IMRT are 1·09 and 1·11, respectively. Integral dose comparison shows better OAR sparing for RapidArc. RapidArc plans have the shorter beam on time (45%) in comparison with IMRT plans.
Planning constraints were achieved in both techniques. However, RapidArc showed better quality treatment plan, OARs sparing and shorter delivery time as compared to IMRT.
The coronavirus disease 2019 (COVID-19) pandemic has led to significant strain on front-line healthcare workers.
In this multicentre study, we compared the psychological outcomes during the COVID-19 pandemic in various countries in the Asia-Pacific region and identified factors associated with adverse psychological outcomes.
From 29 April to 4 June 2020, the study recruited healthcare workers from major healthcare institutions in five countries in the Asia-Pacific region. A self-administrated survey that collected information on prior medical conditions, presence of symptoms, and scores on the Depression Anxiety Stress Scales and the Impact of Events Scale-Revised were used. The prevalence of depression, anxiety, stress and post-traumatic stress disorder (PTSD) relating to COVID-19 was compared, and multivariable logistic regression identified independent factors associated with adverse psychological outcomes within each country.
A total of 1146 participants from India, Indonesia, Singapore, Malaysia and Vietnam were studied. Despite having the lowest volume of cases, Vietnam displayed the highest prevalence of PTSD. In contrast, Singapore reported the highest case volume, but had a lower prevalence of depression and anxiety. In the multivariable analysis, we found that non-medically trained personnel, the presence of physical symptoms and presence of prior medical conditions were independent predictors across the participating countries.
This study highlights that the varied prevalence of psychological adversity among healthcare workers is independent of the burden of COVID-19 cases within each country. Early psychological interventions may be beneficial for the vulnerable groups of healthcare workers with presence of physical symptoms, prior medical conditions and those who are not medically trained.
Reports of psychiatric morbidity associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection tend to be limited by geography and patients’ clinical status. Representative samples are needed to inform service planning and research.
To describe the psychiatric morbidity associated with SARS-CoV-2 infection (confirmed by real-time polymerase chain reaction) in referrals to a consultation-liaison psychiatry service in Qatar.
Retrospective review of 50 consecutive referrals.
Most patients were male. Median age was 39.5 years. Thirty-one patients were symptomatic (upper respiratory tract symptoms or pneumonia) for coronavirus disease 2019 (COVID-19) and 19 were asymptomatic (no characteristic physical symptoms of COVID-19 infection). Seventeen patients (34%) had a past psychiatric history including eight with bipolar I disorder or psychosis, all of whom relapsed. Thirty patients (60%) had physical comorbidity. The principal psychiatric diagnoses made by the consultation-liaison team were delirium (n = 13), psychosis (n = 9), acute stress reaction (n = 8), anxiety disorder (n = 8), depression (n = 8) and mania (n = 8). Delirium was confined to the COVID-19 symptomatic group (the exception being one asymptomatic patient with concurrent physical illness). The other psychiatric diagnoses spanned the symptomatic and asymptomatic patients with COVID. One patient with COVID-19 pneumonia experienced an ischaemic stroke. Approximately half the patients with mania and psychosis had no past psychiatric history. Three patients self-harmed. The commonest psychiatric symptoms were sleep disturbance (70%), anxiety (64%), agitation (50%), depressed mood (42%) and irritability (36%).
A wide range of psychiatric morbidity is associated with SARS-CoV-2 infection and is seen in symptomatic and asymptomatic individuals. Cases of psychosis and mania represented relapses in people with schizophrenia and bipolar disorder and also new onset cases.
Radiative-magnetohydrodynamic (RMHD) equations along with a full set of Maxwell's equations are followed to formulate the charged surface waves at the interface of an incompressible, radiative, magnetized dusty plasma and vacuum, while assuming that the characteristic wave frequency is much smaller than the ion gyrofrequency, having an equilibrium background state. It is found that the separation of charges on the surface is followed by thermal motion, which further leads to a negative pressure gradient normal to the surface, hence the plasma–vacuum interface is under tension due to two different types of oppositely directed pressures. The dusty plasma RMHD set of equations admits a linear dispersion relation of surface Jeans instability of an incompressible dusty plasma, which exhibits a strong coupling between the electron surface charge and dust surface mass densities and we conclude that the surface densities of both electrons and dust as well as the dust inertia play major roles in the gravitational collapse of the surface of astrophysical objects such as stars, galaxies etc. Further, the growth rate of radiative surface waves is found to be function of both the temperature inhomogeneity, appearing due to thermal radiation heat flux, as well as the thermal radiation pressure. The present findings of charged surface waves may seek application at the astroscales.
To determine if a global mid-upper arm circumference (MUAC) cut-off can be established to classify underweight in adults (men and non-pregnant women).
We conducted an individual participant data meta-analysis (IPDMA) to explore the sensitivity (SENS) and specificity (SPEC) of various MUAC cut-offs for identifying underweight among adults (defined as BMI < 18·5 kg/m2). Measures of diagnostic accuracy were determined every 0·5 cm across MUAC values from 19·0 to 26·5 cm. A bivariate random effects model was used to jointly estimate SENS and SPEC while accounting for heterogeneity between studies. Various subgroup analyses were performed.
Twenty datasets from Africa, South Asia, Southeast Asia, North America and South America were included.
All eligible participants from the original datasets were included.
The total sample size was 13 835. Mean age was 32·6 years and 65 % of participants were female. Mean MUAC was 25·7 cm, and 28 % of all participants had low BMI (<18·5 kg/m2). The area under the receiver operating characteristic curve for the pooled dataset was 0·91 (range across studies 0·61–0·98). Results showed that MUAC cut-offs in the range of ≤23·5 to ≤25·0 cm could serve as an appropriate screening indicator for underweight.
MUAC is highly discriminatory in its ability to distinguish adults with BMI above and below 18·5 kg/m2. This IPDMA is the first step towards determining a global MUAC cut-off for adults. Validation studies are needed to determine whether the proposed MUAC cut-off of 24 cm is associated with poor functional outcomes.
Garra gotyla is an indigenous coldwater fish of the cyprinid family and has wide geographical distribution in India as well as in other countries of Asia and Africa. Induced breeding in G. gotyla was carried out successfully for the first time and an attempt has been made to document developmental stages chronologically from the first minute of fertilization, through all stages of embryonic development until the fifth day post hatching. This experiment was carried out at 22–24°C water temperature at the Directorate of Coldwater Fisheries Research, Bhimtal, India. During the breeding trial, the fertilization rate was observed as 70–75% and hatching rate was 85–90%. The mature fertilized ova were measured as 0.8–1.0 mm in diameter and the perivitelline membrane became thick soon after fertilization and formation of the germ pole. The periods taken for complete developmental stages were recorded; cleavage stage 111 min (min post fertilization (pf)), blastulation stage 580 min (pf), neurulation and segmentation 1250 min (pf) and hatching was completed after 1420 min. The sac fry was measured as 3 mm in length and took almost 3 days for complete absorption of the yolk content. The major structural and differential changes observed are in head, tail, fins, alimentary canal, rudiments of each organ and appearance of melanophore pigmentation in the whole body. The 5-day-old larvae were measured as 6 mm in length with almost every organ fully differentiated. The present study will be utilized for large-scale production of fingerlings for stock enhancement in rivers, lakes and possibilities of genetic improvement and manipulation at the embryonic stage.
The prevalence of dementia is rising in low-resource countries, where specialist memory services are almost non-existent. The COVID-19 pandemic has created opportunities for innovative remote healthcare. Research shows a lack of dementia literacy and help-seeking behaviour for memory-related problems among older adults in South Asian countries. This paper proposes a remote memory service model and virtual dementia training in South Asian countries, called Memory First Aid (MFA). MFA offers help to a person experiencing memory difficulties until appropriate professional help is received. The MFA course is a 12-h webinar-based package consisting of four weekly modules. It covers dementia awareness and clinical features. The aim is to develop a non-medical workforce able to screen and assess older people with suspected dementia.
Anesthesiologists are likely to face pediatric disaster victims both in the developed world and in developing countries, as children are a significant percentage of the global population. Although many challenges in taking care of children in disasters, especially in resource-poor countries, are like the ones described elsewhere in this book, pediatric disaster preparedness involves some unique considerations. The following provides a brief overview of essential equipment, training, and resuscitation as applicable to the anesthesiologist caring for a child in a disaster.
A comparative study was performed about the plan parameters and quality indices between volumetric arc therapy (VMAT) and intensity-modulated radiotherapy (IMRT) for the treatment of high-risk prostate cancer patients. The aim of this retrospective study was to compare the two methods of external beam radiotherapy IMRT and VMAT in terms of plan quality and efficacy.
Material and method:
Fifteen high-risk prostate patients were planned for radiotherapy using 6 MV photon. Three dose levels were contoured having Planning Tumour Volume 1 (PTV1 = 48 Gy), Planning Tumour Volume 2 (PTV2 = 57.6 Gy) and Planning Tumour Volume 3 (PTV3 = 60 Gy). Setup margins were given using the CHIP trial method. The prescribed PTV3 dose was 60 Gy in 20 fractions which is biologically equivalent to 74 Gy in 37 fractions using α/β = 3. In case of IMRT, seven fixed beam angles 30, 60, 105, 180, 255, 300 and 330 were used and the dose was optimised using the sliding window method. In case of rapid arc technique, one or two full arcs were used for dose optimisation while keeping all the dose constraints and other planning parameters same used in IMRT. The plan evaluation parameters and Organ at risks (OARs) doses were calculated using a dose volume histogram (DVH).
The average D2, D5, D95 and PTVmean for PTV3 were 61.22, 61.13, 58.12, 60.00 Gy and 62.41 62.24 59.53 61.12 Gy for IMRT and VMAT, respectively. The averages V60 for bladder and V30 for rectum were 22.81, 25 and 67, 65% for IMRT and VMAT, respectively. The average homogeneity index (HI), conformity index (CI) and gradient index (GI) were 1.04, 1.4833, 14.79 and 1.04, 1.704, 7.89 for IMRT and VMAT, respectively.
VMAT takes less dose-delivery time and lesser number of monitoring units than IMRT, thus it compensates the intrafractional movements during dose delivery. The Dose GI in VMAT was much better than IMRT. This indicates sharper dose fall off near the normal tissue. No other major differences were observed in terms of plan evaluation parameters between IMRT and VMAT techniques. So, we conclude that VMAT technique is more efficient than IMRT in terms of plan quality and dose delivery.
Four Western countries (Greece, Ireland, Italy and Portugal) with strong Orthodox and Catholic traditions have been associated with the underreporting of death by suicide, and underreported suicides are sometimes found among deaths recorded as ‘undetermined’ or ‘accidental’.
This population-based study tests whether there are any significant difference in patterns of suicides, undetermined deaths and accidental deaths between these four Western countries and 21 predominately Islamic countries.
World Health Organization age-standardised death rates per million population were used to compare suicide rates with combined undetermined death and accidental death (UnD+AccD) rates, from which odds ratios were calculated. Substantial odds ratios (OR > 2.0) were taken as indicative of likely underreporting of suicides. The Islamic countries come from four different historico-cultural regions, described as: less-traditional Islamic countries; former USSR countries; Gulf Arab states; and Middle Eastern and North African countries. χ2-tests were used to determine any significant differences between the Western comparator countries and the Islamic regions.
For the Western comparator countries, the average suicide rate was 66 per million population, the average undetermined death rate 56 per million and the average accidental death rate 58 per million, yielding a suicide:UnD+AccD odds ratio (OR) of 1.73. The average values for the other three groups were as follows. Less-traditional Islamic countries: suicide rate, 31 per million; UnD+AccD rate, 101 per million; suicide:UnD+AccD OR = 3.3. Former USSR countries: suicide rate, 61 per million; UnD+AccD rate, 221 per million; suicide:UnD+AccD OR = 3.6. Gulf Arab states: suicide rate, 10 per million; UnD+AccD rate, 76 per million; suicide:UnD+AccD OR = 8.6. Middle Eastern and North African countries: suicide rate, 6 per million; UnD+AccD rate, 151 per million; suicide:UnD+AccD OR = 25.2. The patterns of these mortalities in the Islamic countries was significantly different from Western comparator countries.
The results indicate underreporting of suicides in Islamic countries. This might inadvertently lead to reduced access to mental health preventive services in both Western and Islamic countries.
Social anxiety is common among adolescents in Pakistan and is associated with low self-esteem. Among the recommended treatments, cognitive behavioural therapy (CBT) is effective, and self-help approaches are encouraged.
To determine the effectiveness of culturally adapted CBT-based guided self-help (CACBT-GSH) intervention, using a manual ‘Khushi aur Khatoon’, for treating social anxiety when added to treatment as usual (TAU) compared with TAU only.
A total of 76 adolescents with social anxiety aged 13–16 years from six schools in Multan, Pakistan were recruited into this randomized controlled trial. Participants were divided into intervention and control groups in a 1:1 ratio. Social anxiety, self-esteem and fear of negative evaluation were assessed through the Liebowtiz Social Anxiety Scale for children and adolescents, the Rosenberg Self-Esteem Scale and the Brief Fear of Negative Evaluation, respectively, at baseline and at the end of the study. Guided self-help using culturally adapted CBT (CACBT)-based self-help manual (eight sessions, one session per week) was provided to the intervention group. The effect of the CACBT-GSH intervention was analysed with ANCOVA.
There was a statistically significant difference between the intervention and the control groups in favour of intervention. Participants in the intervention group showed reduced symptoms of social anxiety (p < .001), fear of negative evaluation (p < .001) and enhanced self-esteem (p < .001).
The study demonstrated the effectiveness of CACBT-based guided self-help intervention in treating social anxiety and addressing the symptoms associated with it.
Short duration cotton (Gossypium hirsutum L.) cultivar may be more profitable for the growers, as it will have shortened critical growth window for drought, heat and insect pests. Therefore, in the present research work, two cotton advance lines IUB-71 and IUB-73 along with an approved cotton cultivar IUB-13 were tested under four different sowing dates i.e. S1 (25th April), S2 (10th May), S3 (25th May) and S4 (10th June) in 2017 and 2018 under field condition. Field layout was RCBD factorial with four sowing dates as one factor and three cotton genotypes as another factor with three replications. Data were recorded for plant height, total number of nodes, bolls per plant, seed cotton yield (SCY), above ground fresh biomass (AGFB) and harvest index (HI). An overall decreasing trend with increasing sowing dates was observed in all the traits except HI that relatively increased in all the three genotypes. Within each sowing date, a higher value for each trait was observed for genotype IUB-73 except for AGFB might be due to higher reproductive allocation. It is concluded that IUB-73 due to superior SCY and HI specifically under late planting is best fit for short cotton seasons with reduced critical window for cotton management.
Risk for emotional and behavioural problems are known to be high among children of depressed mothers, but little is known about the impact of antenatal and postnatal depression on the physical health of the infant. Our one-year prospective follow-up study of 320 mothers and their infants in rural Rawalpindi, Pakistan, shows that infants of antenatally depressed mothers have poorer growth than controls. The relative risk for being underweight (weight-for-age z-score < -2SD) is 4.0 (95%CI 2.1-7.7) at 6 months and 2.6 (95% CI 1.7-4.1) at 12 months, while the risks for stunting (length-for-age z-score < –2SD) is 4.4 (95%CI 1.7-11.4) at 6 months and 2.5 (95% CI 1.6-4.0) at 12 months. Relative risk for ≥5 diarrhoeal episodes per year is 2.4 (95% CI 1.7-3.3). Chronic depression carries a greater risk for poor outcome than episodic depression. The associations remain significant after adjustment for confounders by multivariate analyses. It is concluded that preventive and treatment strategies for maternal depression could benefit not only the mother's well-being but also the infant's physical health and development.
To assess volume variations in target site due to changes in bladder filling and rectal content including air bubbles during simultaneous-integrated boost intensity-modulated radiotherapy (SIB-IMRT) of patients suffering from squamous cell carcinoma of uterine cervix.
Materials and methods:
A total of ten patients of squamous cell carcinoma of uterine cervix were enrolled in this analysis. All patients were planned to undergo SIB-IMRT using 10 MV beam. Planning target volume of the tumour (PTVtumour) and PTVnodal were prescribed with 5,040 and 4,500 cGy doses, respectively. During planning, PTVtumour V95%, PTVnodal V95% and organs at risk (OARs) (bladder, rectum, femoral heads and small bowel) volumes were measured from initial CT planning scans taken with full bladder. CT scans were acquired once in a week over a treatment period of 5·5 weeks. Intra-treatment scans with full bladder were then fused with the planning scans to determine variations in the target volume and the OAR volume. Changes in radiation dose to the PTVtumour and the PTVnodal were also assessed by comparing intra-treatment scans with the planning (first) scans.
All patients showed intra-treatment bladder volume larger than the planning bladder volume. Difference between planning bladder and intra-treatment bladder volumes ranged from 4·5 to 49%. Rectal volume varied from 17 to 60 cc. A wide variation between planning and intra-treatment air volumes was found in most of the patients. When comparing initial and inter-fraction air volumes, the maximum difference was 366·67%. Due to bladder and rectal volume variations, PTVtumour V95% and PTVnodal V95% doses did not remain constant throughout the treatment. The maximum discrepancy between intra-treatment PTVtumour dose and planning PTVtumour dose was 12·15%. The maximum difference between planning and inter-fraction PTV V95% was 48·28%. PTVnodal dose observed from scan taken in last week of treatment was 12·87% less than planning PTVnodal dose analysed from planning CT scan. Maximum difference in planning and inter-fraction PTVnodal V95% was 57·78%.
Inconsistent bladder and rectal volumes had a significant impact on target volume and dosage during an entire course of SIB-IMRT. For radiotherapy of gynaecological malignancies, data on variations in PTV should be acquired on daily basis to target radiation dose to the tumour site with accuracy.
A spoofing attack on a global navigation satellite system (GNSS) receiver is a threat to a significant community of GNSS users due to the high stakes involved. This paper investigates the use of slope based metrics for the detection of spoofing. The formulation of slope based metrics involves monitoring correlators along with tracking correlators in the receiver's channel, which are slaved to the prompt tracking correlator. In this study, using some candidate metrics, detectors have been formed through the analysis of simulated spoofing attacks. A theoretical variance of each metric has also been calculated as a reference for the threshold. A threshold is estimated using the measured variance from the clean signals, for specific false alarm rate. By using the measured threshold, detectors are formed based on slope metrics. These detectors have been tested using TEXBAT data. The results show that the differential slope metrics have good performance. The results have also been compared with some other techniques of spoofing detection.
The emergence of advanced radiotherapy techniques, such as intensity-modulated radiotherapy (IMRT), brachytherapy, conformal radiotherapy, magnetic resonance-guided radiotherapy (MRgRT), stereotactic synchrotron radiotherapy (SSRT) and microbeam radiotherapy (MRT), has increased the importance of the verification of volumetric dose distribution. The verification of dose distribution is usually done by 2D films and 3D gel dosimeters, but PRESAGE® due to its affordability, reproducibility, precision, accuracy, unique dosimetric and physical properties is considered as an effective candidate in providing 3D dose data. PRESAGE® is insensitive to oxygen contamination, machinable and can be molded to a variety of shapes and sizes. It is absorbing rather than scattering light which facilitates high-accuracy readout by optical computed tomography (OP-CT). This review focuses on the feasibility of using PRESAGE® in various complicated radiotherapy techniques by comparing its measured doses with 2D films and treatment planning system (TPS) calculated doses.
Tuberous sclerosis complex is a rare genetic disorder leading to the growth of hamartomas in multiple organs, including cardiac rhabdomyomas. Children with symptomatic cardiac rhabdomyoma require frequent admissions to intensive care units, have major complications, namely, arrhythmias, cardiac outflow tract obstruction and heart failure, affecting the quality of life and taking on high healthcare cost. Currently, there is no standard pharmacological treatment for this condition, and the management includes a conservative approach and supportive care. Everolimus has shown positive effects on subependymal giant cell astrocytomas, renal angiomyolipoma and refractory seizures associated with tuberous sclerosis complex. However, evidence supporting efficacy in symptomatic cardiac rhabdomyoma is limited to case reports. The ORACLE trial is the first randomised clinical trial assessing the efficacy of everolimus as a specific therapy for symptomatic cardiac rhabdomyoma.
ORACLE is a phase II, prospective, randomised, placebo-controlled, double-blind, multicentre protocol trial. A total of 40 children with symptomatic cardiac rhabdomyoma secondary to tuberous sclerosis complex will be randomised to receive oral everolimus or placebo for 3 months. The primary outcome is 50% or more reduction in the tumour size related to baseline. As secondary outcomes we include the presence of arrhythmias, pericardial effusion, intracardiac obstruction, adverse events, progression of tumour reduction and effect on heart failure.
ORACLE protocol addresses a relevant unmet need in children with tuberous sclerosis complex and cardiac rhabdomyoma. The results of the trial will potentially support the first evidence-based therapy for this condition.
The aim of this work was to study the acceptability of plans prepared for prostate patients treated by volumetric modulated arc therapy (VMAT) with the vision to evaluate the quality of plans and test pre-treatment quality assurance (QA).
VMAT plans of 35 patients, planned on the Eclipse Treatment Planning System (Aria 15), were included in the study. Plan acceptability was checked using statistical analysis, which includes homogeneity index, radical and median homogeneity index, coverage and uniformity index. Dose–volume histograms (DVH) of the plans were also studied to check prescribed dose (PD), Dmax, Dmin, D5 and D95. Portal dosimetry was also done by gamma analysis using 3%/3 mm criterion. SD and mean SD error were also calculated and analysed.
Statistical analysis showed a mean HI of 1·054, coverage 0·959, UI 1·055, mDHI 0·962 and rDHI 0·866. SD of HI, coverage, UI, mDHI and rDHI was 0·019, 0·019, 0·014, 0·013 and 0·030, respectively. From the DVHs, mean of D5, D95, Dmin and Dmax was calculated at 6,252·9, 5,757·4, 6,413·3 and 5,657·7 cGy, respectively, with a prescribed dose of 6,000 cGy. According to gamma analysis, area gamma < 1 was 99·12% with a tolerance limit of 95%, maximum gamma was 1·466 with a tolerance limit of 3·5, average gamma was 0·388 with a tolerance limit of 0·5, area gamma > 1·2 was 0·242% with a tolerance limit of 0·5%, maximum dose difference was 0·6 with a tolerance limit of 1·0 and average dose difference was 0·029 with a tolerance limit of 0·2.
All three computations showed the results to be within acceptable limits. VMAT possesses a unique feature of delivering the whole treatment with only two rotations of the gantry. VMAT has an improved efficiency of delivery for equivalent dosimetric quality.