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The most common use is for people with sleep apnea pregnancy 6-8 weeks buy cheap femara 2.5mg on-line, characterized by snoring and lack of oxygen during sleep menopause bleeding symptoms buy cheap femara. Sleep apnea is linked to high blood pressure menstrual after menopause order femara 2.5 mg online, stroke and cardiovascular disease menstruation odors as you get older cheap 2.5mg femara free shipping, memory problems, weight gain, impotency and headaches. For reasons that are not completely clear, sleep apnea is significantly more common to people with spinal cord injuries, especially those with quadriplegia, among whom an estimated 25-40 percent have the condition. It may also be that certain medications (baclofen, for example, is known to slow down breathing) affect sleep patterns. People with higher cervical injuries who rely upon neck and upper chest muscles to help with breathing may be susceptible to sleep apnea because these muscles are inac tive during deep sleep. Tracheostomy care: There are many potential complications related to trache ostomy tubes, including the inability to speak or swallow normally. Certain tracheostomy tubes are designed to direct air upward during exhalation and thus permit speech during regular, periodic intervals. The tube is a foreign body in the neck, and thus has the potential of introducing organisms that would ordinarily be stopped by natural defense mechanisms in the nose and mouth. Cleaning and dressing of the tracheostomy site daily is an important preventive measure. Weaning (removing ventilator support): In general, those with complete neurologic injuries at C2 and above have no diaphragmatic function and require a ventilator. Those with complete injuries at C3 or C4 may have diaphragmatic function and usually have the potential for weaning. People with complete injuries at C5 and below have intact diaphragmatic function and may at first require a ventilator; they are usually able to wean. Weaning is important because it reduces the risk of some health issues related to tracheostomy, and also because weaned individuals generally require much less paid assisted care. Respira tory muscle training can improve respiratory muscle performance but may also dramati cally reduce respiratory infections. There are a number of commercially available hand held devices for inspiratory muscle training. Features a newsletter, articles from healthcare professionals and venturesome vent users. John Bach, says it has removed dozens of tracheostomy tubes from vent users and taught many to breathe without ventilators. Limited mobility coupled with impaired sensation can lead to pressure sores or ulcers, which can be a devastating complication. It protects the underlying cells against air, water, foreign substances and bacteria. Pressure injuries, also called pressure sores, pressure ulcers, bed sores, decubiti or decubitus ulcers, range in severity from mild (minor skin reddening) to severe (deep craters that can infect all the way to muscle and bone). Unrelieved pressure on the skin squeezes tiny blood vessels, which supply the skin with nutrients and oxygen. When skin is starved of blood for too long, tissue dies and a pressure ulcer forms. Sliding around in a bed or chair can cause blood vessels to stretch or bend, leading to pressure ulcers. An abrasion can occur when a persons skin is pulled across a surface instead of lifted. Other causes of pressure injuries are braces or hard objects that put pressure on the skin. Skin damage from pressure usually begins on the body where the bones are close to the skin surface, such as the hip. If there is a hard surface on the outside, too, the skin is pinched off from circulation. Because the rate of circulation is reduced by paralysis to begin with, less oxygen is available to the skin, lowering the skins resistance. If the pressure is not removed, a blister or scab may form—this means that the tissue underneath is dying. Frequently, this dead tissue is small on the skin surface, but damaged tissue may extend deep to the bone. Explore causes: check out mattress, seat cushion, transfer procedures and turning techniques. What to do: Follow steps in Stage One but cleanse wound with water or saline solution and dry carefully. Signs of Trouble: the sore is getting bigger; the sore starts to smell bad or the drainage becomes greenish in color. Stage Three: Skin has broken down further, into the second layer of skin, through the dermis into the subcutaneous fat tissue. You must see a care provider at this point; this is getting serious and may need special cleaning or debriding agents. Healing: this occurs when the sore gets smaller, when pinkish skin forms along the edges of the sore. Bleeding might occur but take this as a good sign: circulation is back and that helps healing. Only when the sore is completely healed—when the top layer of skin is unbroken and normal looking. Build up gradually over periods of a few days to allow skin pressure tolerance to build. A pressure injury can mean several weeks or even months of hospitalization or bed rest in order for the sore to heal. All of this can cost thousands of dollars and mean valuable time away from work, school or family. Clearly, his death was related to pressure sores; to be sure, Reeve had been battling more than one skin sore and had even experienced life-threatening sepsis just weeks before he died. But according to people who were with him on his last day, Reeve did not appear to have symptoms that would red-fag recurrent sepsis (he did not exhibit fever, chills, fatigue, malaise, anxiety, confusion). According to Dana Reeve, the more likely cause of death was a reaction to an antibiotic Reeve was given for a developing infection (he had a history of drug sensitivity). Reeve chose to live his life fully and well, and as much as possible on his own terms. Skin wound treatment by any means is complicated by hard-to-treat infec tions, spasticity, additional pressure and even the psychological makeup of the person (pressure injuries have been linked to low self-esteem and impulsive behavior). It is an oversimplification to say pressure sores are always prevent able but thats almost true; with vigilant care and good overall hygiene, skin integrity can be maintained. A wide variety of pressure-relieving support surfaces, including special beds, mattresses, mattress overlays or seat cushions are available to support your body in bed or in a chair. Heres an example of a product to help people who cant turn at night and who may not have an attendant to do it for them: Freedom Bed is an automatic lateral rotation system that quietly turns through a 60-degree range of rotation; Drink plenty of fluids; a healing wound or sore can lose more than a quart of water each day. Note: Beer and wine do not count; alcohol actually causes you to lose water or become dehydrated. Being too thin causes you to lose the padding between your bones and your skin and makes it possible for even small amounts of pressure to break down the skin. It may occur in associa tion with spinal cord injury, multiple sclerosis, cerebral palsy, or brain trauma. Symptoms may include increased muscle tone, rapid muscle contractions, exaggerated deep tendon reflexes, muscle spasms, scissoring (involuntary crossing of the legs) and fixed joints. Paralysis Resource Guide | 114 2 When an individual is first injured, muscles are weak and flexible because of whats called spinal shock: the bodys reflexes are absent below the level of injury; this condition usually lasts for a few weeks or several months. Spasticity is usually caused by damage to the portion of the brain or spinal cord that controls voluntary movement. Since the normal flow of nerve messages to below the level of injury is interrupted, those messages may not reach the reflex control center of the brain. Because the spinal cord is not as efficient as the brain, the signals that are sent back to the site of the sensation are often over-exaggerated in an overactive muscle response or spastic hypertonia: an uncontrollable “jerking” movement, stiffening or straightening of muscles, shock-like contractions of a muscle or group of muscles, and abnormal tone in the muscles. The most common muscles that spasm are those that bend the elbow (flexor) or extend the leg (extensor). These reflexes usually occur as a result of an automatic response to painful sensations. While spasticity can interfere with rehabilitation or daily living activities, it is not always a bad thing.

The beneficial effect and efficacy of irradiation declined with time and manifested with late recurrences menstruation tissue buy femara 2.5mg on line. The analysis included 1942 patients in twelve controlled trials (four randomized controlled and eight nonrandomized controlled trials) breast cancer 0-9 buy cheap femara on-line. At a follow-up of 24 to 36 months breast cancer charms buy 2.5 mg femara fast delivery, there continued to be no significant difference in cardiac death (p = 0 womens health doctors cheap 2.5 mg femara with mastercard. At intermediate follow-up, brachytherapy reduced the rate of revascularization, binary restenosis, and late loss compared to balloon angioplasty and selective bare-metal stents alone. The authors assessed the comparative effectiveness of brachytherapy and the two radiation sources. Five randomized controlled trials that compared brachytherapy to placebo in 1310 patients were reviewed. There was considerable between-study variance, and diabetes was found to be a significant factor in this variance. Intracoronary brachytherapy was effective compared to placebo at mid-term follow up. Brachytherapy has also been evaluated as a method of primary prevention of restenosis after stent implantation for de novo lesions 3. It is considered to be a safe short-term method of restoring patency although repeat intervention will be eventually medically necessary. This study confirmed the safety and usefulness of the procedure in a high risk population. Thirty-one patients (33 stenoses) were randomized to stent implantation (control group), and 30 patients (31 stenoses) were randomized to brachytherapy and stented angioplasty. The incidence of stent thrombosis was slightly higher in the brachytherapy group (10%) than in the control group (6. The occurrence of additional ischemic events in both groups equalized the long term clinical outcomes. The authors stated that intracoronary beta radiation at the time of stent implantation only transiently prevents excessive neointimal proliferation that leads to stenosis recurrence in the first year after treatment. The Page 10 of 311 late catch-up phenomenon, along with the natural progression of the atherosclerotic disease in other segments, is responsible for the loss of the clinical benefit of brachytherapy in the long term. Eighty-nine diabetic patients (106 lesions) were randomly assigned to treatment with beta radiation or placebo treatment. Binary restenosis rates were significantly lower in the brachytherapy group in all subsegments. The authors concluded that, in diabetic patients with de novo coronary lesions, intracoronary radiation after stent implantation significantly reduced restenosis. This clinical benefit was reduced, however, by the frequent occurrence of new thrombosis. The guideline also states that a prolonged intake of clopidogrel for one year after radiation is necessary. Brachytherapy for treatment of in-stent restenosis of a saphenous vein bypass graft is considered as a Class 1B recommendation. Class I indicates evidence and/or general agreement that a given diagnostic procedure/treatment is beneficial, useful and effective. Level of evidence A indicates that data is derived from multiple randomized clinical trials or meta analyses, while level of evidence B indicates data is derived from a single randomized clinical trial or large non-randomized studies (Silber et al. Intracoronary brachytherapy was shown to be an effective treatment for in-stent restenosis of native coronary arteries or saphenous vein grafts. Brachytherapy procedures have decreased in frequency, however, and drug-eluting stents have emerged as the treatment of choice in the majority of cases. Brachytherapy may still play a role in the treatment of in-stent restenosis in selected patients, however. Three-year follow-up after intracoronary gamma radiation therapy for in stent restenosis. Long-term efficacy of intracoronary irradiation in inhibiting in-stent restenosis. Comparative efficacy of -irradiation for treatment of in-stent restenosis in saphenous vein graft versus native coronary artery in-stent restenosis: an intravascular ultrasound study. Intravascular ultrasound analysis of the impact of gamma radiation therapy on the treatment of saphenous vein graft in-stent restenosis. Angiographic and three-dimensional intravascular ultrasound analysis of combined intracoronary beta radiation and self-expanding stent implantation in human coronary arteries. Intracoronary -irradiation for the treatment of de novo lesions: 5-year clinical follow-up of the BetAce randomized trial. Five-year clinical follow-up after intracoronary radiation: results of a randomized clinical trial. Localized intracoronary gamma-radiation therapy to inhibit the recurrence of restenosis after stenting. A meta-analysis of randomised controlled trials assessing drug-eluting stents and vascular brachytherapy in the treatment of coronary artery in-stent restenosis. Randomized trial of 90Sr/90Y -radiation versus placebo control for treatment of in-stent restenosis. Three-year follow-up after intravascular -radiation for in-stent restenosis in saphenous vein grafts. Evolution of angiographic restenosis rate and late lumen loss after intracoronary beta radiation for in-stent restenotic lesions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Two-year clinical follow-up of 90Sr/90 Y radiation versus placebo control for the treatment of in-stent restenosis. Randomized blinded clinical trial of intracoronary brachytherapy with 90Sr/Y beta-radiation for the prevention of restenosis after stent implantation in native coronary arteries in diabetic patients. A meta-analysis of randomized controlled trials of intracoronary gamma and beta-radiation therapy for in-stent restenosis. Endoluminal beta-radiation therapy for the prevention of coronary restenosis after balloon angioplasty. Intravascular gamma radiation for in-stent restenosis in saphenous-vein bypass grafts. Five-year follow-up after intracoronary gamma radiation therapy for in-stent restenosis. Comparison between drug-eluting stents and beta-radiation for the treatment of diffuse in-stent restenosis: clinical and angiographic outcomes. The use of hyperthermia and concurrent radiation therapy treatment is medically necessary for any of the following: A. Recurrent cervical lymph nodes from head and neck cancer Treatment of the above conditions will be approved in the absence of both of the following: D. Metastatic disease for which chemotherapy or hormonal therapy is being given concurrently or planned E. Evidence of tumor recurrence exceeding 4 cm in depth When hyperthermia is indicated, no more than 10 hyperthermia treatments delivered twice weekly at 72-hour intervals should be utilized. Later review of the negative findings disclosed that the critical temperature necessary for hyperthermic cell death, 42 to 43 degrees centigrade (C), was either poorly measured or poorly maintained in these studies. Point measurements rather than volume mapping of thermal gradients were relied upon in planning these hyperthermia studies. Research from Duke University, Northwestern University, University of Southern California, Stanford University, Washington University, as well as centers in Holland, Germany, Norway, Austria, Italy, and Switzerland have contributed substantially to the emergence of hyperthermia as a useful treatment modality when combined with radiation therapy. It states, “Local hyperthermia is covered under Medicare when used in conjunction with radiation therapy for the treatment of primary or metastatic cutaneous or subcutaneous superficial malignancies. This is the only approval for deep heating, and only actual costs incurred in the research may be billed. The standard recommended treatment regimen for use with radiation therapy is a “…total of 10 hyperthermia treatments delivered two times per week at 72-hour intervals, with each heat treatment preceded or followed by a standard prescribed dose of ionizing radiation within 30 minutes of the heat treatment. There are three clinical sites in which randomized studies have documented the benefit of hyperthermia given in conjunction with radiotherapy. Melanoma – 134 metastatic or recurrent lesions of malignant melanoma in 70 patients were randomly assigned to receive radiation therapy (three fractions of 8 or 9 Gy over 8 days) alone or followed by hyperthermia (43 degrees C for 60 minutes). Beneficial local effect was 28% for radiation alone, and 46% for combined treatment. Breast – Five randomized trials were combined to report the benefit of combined treatment for superficial localized breast cancer. The control rate for radiation therapy alone was 41%, while that for combined treatment was 59%.

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The effects have been most thoroughly studied in Taiwan but there is considerable evidence from studies on populations in other countries as well breast cancer chemotherapy 2.5 mg femara. Increased risks of lung and bladder cancer and of arsenic-associated skin lesions have been reported to be associated with ingestion of drinking-water at concentrations 50 µg arsenic/litre women's health diet plan buy femara 2.5mg without prescription. Their evaluation of the effects of arsenic on humans was summarized as follows: the main adverse effects reported to be associated with long-term ingestion of inorganic arsenic by humans are cancer ximena herrera women's health order femara 2.5mg online, skin lesions menstruation cycle pregnancy purchase femara with a mastercard, developmental effects, cardiovascular disease, neurotoxicity and diabetes. The classification of arsenic as a carcinogen was originally based on evidence of skin cancers. Studies in Taiwan, China, and other regions where high exposures to arsenic in drinking-water occurred have confirmed the relationship. Significant associations between exposure to high levels of ingested arsenic in drinking-water and bladder cancer have been observed in ecological studies from Chile, Argentina and Taiwan, China, and cohort studies in Taiwan, China. In studies from Chile, Argentina and Taiwan, China, exposure to arsenic at high concentrations in drinking-water has been shown to be associated with lung cancer. Again, when smokers and non-smokers were compared, the associations were stronger in the smokers. Nutritional status of exposed populations has been observed to influence cancer risk. The evidence for an association with cancers at other sites, including prostate, liver and kidney, is less conclusive. Epidemiological studies in different regions of the world have consistently demonstrated a strong association between long-term inorganic arsenic ingestion and skin lesions, typically in the form of hyperkeratosis, hyperpigmentation or hypopigmentation. Observations of skin lesions following low chronic exposure have suggested that these characteristic dermal changes are sensitive indications of the toxic effects of inorganic arsenic. Available epidemiological studies indicate a positive relationship between high concentrations of inorganic arsenic in drinking-water and sensitive end-points for peripheral and central neurotoxicity. There is some evidence that exposure of children to inorganic arsenic in areas with elevated arsenic concentrations (>50 µg/l) in drinking-water produces effects on cognitive performance, but so far this is not conclusive. The association between blackfoot disease and inorganic arsenic exposure has been confirmed by many studies, but blackfoot disease has been reported primarily in an area along the south-western coast of Taiwan, China, where arsenic contamination in well water is very high (170–880 µg/l). Except for blackfoot disease, the reported associations between inorganic arsenic exposure and cardiovascular disease prevalence/mortality and other cardiovascular end-points currently do not provide sufficient evidence of causality and are not considered pivotal for the assessment. Studies conducted in Bangladesh and Taiwan, China, indicated an extra risk of diabetes among high-exposure populations. In addition, recent findings suggest that in utero arsenic exposure impaired child thymic development and that enhanced morbidity and immunosuppression might occur. However, as a result of limitations in the studies, the relationship between arsenic exposure and these outcomes remains uncertain. For this evaluation, studies were preferred that included documentation of exposure from drinking-water both at higher concentrations (e. This was in order to assess effects across a broad gradient of exposure and to avoid extrapolation below the observed range in the dose–response modelling. For skin cancer, three of the four most recent studies of low-level exposure utilized toenail arsenic as a biomarker of exposure; however, the relationship between toenail arsenic and total dietary exposure to inorganic arsenic remains uncertain. Further, as arsenic-related skin lesions may be a possible precursor to skin cancer and have been reported at lower concentrations of arsenic in drinking-water compared with skin cancer, the Committee considered the data for skin lesions to be a more sensitive adverse effect than skin cancer. Thus, pivotal data were identified from epidemiological studies reporting a positive association with arsenic exposure and these effects. However, the great majority of exposure occurs through naturally contaminated groundwater, through drinking-water, water used in food preparation and water used to irrigate food crops, particularly rice. It is technically feasible to achieve arsenic concentrations of 5 µg/l or lower using any of several possible treatment methods. However, this requires careful process optimization and control, and a more reasonable expectation is that 10 µg/l should be achievable by conventional treatment (e. The ideal solution is to use alternative sources of water that are low in arsenic. However, it is important that this does not result in risk substitution—for example, if the alternative water source, although low in arsenic, increases exposure to waterborne pathogens and results in acute gastrointestinal infections, which are a major source of mortality and morbidity in many parts of the world (Howard, 2003). This is important for most alternative water sources other than water from tube wells. Screening for arsenic and other possible chemical contaminants of concern that can cause problems with health or acceptability, including fluoride, nitrate, iron and manganese, is also important to ensure that new sources are acceptable. Occasional screening may also be required after a source is established to ensure that it remains safe. Where there are large urban supplies, resources are often available to treat water to remove arsenic or to exploit alternative low-arsenic sources, such as surface water that can be treated to avoid microbiological and other hazards. These low-arsenic sources can be used to blend with higher-arsenic sources to lower the concentration to acceptable levels while still retaining the resource. Many of the major problems lie in rural areas, where there are many small supplies, sometimes down to the household level. At this level, water availability and financial and technical resources are all limited. There are several available approaches, but there is a basic requirement for education. In particular, there is a need to understand the risks of high arsenic exposure and the sources of arsenic exposure, including the uptake of arsenic by crops from irrigation water and the uptake of arsenic into food from cooking water. A number of approaches have been successfully used in rural areas, including source substitution and the use of both high and low-arsenic sources blended together. These sources may be used to provide drinking-water and cooking water or to provide water for irrigation. High-arsenic water can still be used for bathing and clothes washing or other requirements that do not result in contamination of food. However, it is important to remember that there may be other contaminants present as well as arsenic, and so it is important to determine whether other contaminants of concern are present. This requires significant technical support to ensure that low arsenic levels are known and can be exploited without other problems arising. Deeper groundwater aquifers can be used to develop community water supplies, which generally succeed where there is community involvement in their establishment and operation; • removal of arsenic by low-cost village or household treatment systems, usually using absorptive media, such as elemental iron, iron or aluminium oxides and carbon. Many household treatment systems in Bangladesh and West Bengal, India, may fail prematurely because of high levels of phosphate, which competes with inorganic arsenic species for adsorption, in the water. In areas where there is observable arsenicosis, there is usually no problem in persuading the local population to follow arsenic mitigation measures, even though they often require significant extra effort. Involvement of individuals and communities in the planning, implementation and management of the mitigation strategy is a key factor for successful intervention. Studies in Bangladesh have shown that most rural households prefer sharing of uncontaminated wells or filtration of low arsenic surface water through sand to treatment of groundwater (Howard, 2003; Johnston, Hanchett & Khan, 2010). Where arsenic levels are lower and the adverse effects of arsenic exposure are less obvious, there will be a much greater requirement for education in order for mitigation measures to be carried out effectively over an extended time period. Although there is a substantial database on the association between both internal and skin cancers and the consumption of arsenic in drinking-water, there remains considerable uncertainty over the actual risks at low concentrations. The actual numbers, indicated by these estimated risks, would be very difficult to detect by current epidemiological methods. It remains possible that the estimates of cancer risk associated with various arsenic intakes are overestimates. The concentration of arsenic in drinking-water below which no effects can be observed remains to be determined, and there is an urgent need for identification of the mechanism by which arsenic causes cancer, which appears to be the most sensitive toxicity end-point. The practical quantification limit for arsenic is in the region of 1–10 µg/l, and removal of arsenic to concentrations below 10 µg/l is difficult in many circumstances. In view of the practical difficulties in removing arsenic from drinking-water, particularly from small supplies, and the practical quantification limit for arsenic, the guideline value of 10 µg/l is retained as a goal and designated as provisional. In these circumstances, there is a possibility that adverse effects could occur as a result of exposure to inorganic arsenic from water and food, but these would be at a low incidence that would be difficult to detect in epidemiological studies. Therefore, given that, in many countries, even the provisional guideline value may not be attainable, it is retained on the basis of treatment performance and analytical achievability with the proviso that every effort should be made to keep concentrations as low as reasonably possible. Carmignani M, Boscolo P, Castellino N (1985) Metabolic fate and cardiovascular effects of arsenic in rats and rabbits chronically exposed to trivalent and pentavalent arsenic.

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The authors state “Significant proportions of patients in both groups still experienced moderate to severe symptoms during the chronic phase women's health diet cleanse discount 2.5 mg femara otc. Acute side effects included grade 3 dermatitis womens health videos buy femara line, mucositis womens health half marathon buy femara 2.5 mg low cost, and dysphagia which occurred in 23 pregnancy 8 weeks 1 day buy femara 2.5mg lowest price, 29 and 12 patients respectively. Sixteen patients (32%) required evaluation in an emergency room during treatment with 10 subsequently requiring hospitalization primarily due to dehydration and pain from mucositis. The authors conclude that “…our findings demonstrate the feasibility and proof of principle of advanced proton therapy techniques delivering simultaneous integrated boost plans…thus laying the ground work for a direct head-to-head comparison study. It was noted that patients receiving a G-tube during radiotherapy had significantly longer history of smoking, greater comorbidity, more advanced disease, greater need for bilateral treatment, higher use of induction chemotherapy and concurrent chemotherapy, and a longer duration of treatment. With regards to toxicity, there were no differences in acute toxicity by technique. Sites of treatment included the larynx (1), nasopharynx (5), paranasal sinus (2) and oropharynx (1). At a median follow up of 27 months, four patients (44%) achieved a complete response, four achieved a partial response without disease progression and one developed local progression. With respect to toxicity, four patients experienced grade 3 acute toxicities and one developed a grade 4 toxicity (blindness in the treated eye). This heterogeneous group of patients included 19 receiving treatment at initial diagnosis and seven receiving treatment at recurrence (six of whom had prior radiation and three of whom had pulmonary metastases). Twenty were treated after surgery with 18 of these exhibiting positive margins or gross residual disease. Longer follow-up is needed to gauge the durability of disease control and to monitor for late toxicities of therapy. Sites of treatment included lacrimal gland or sac (5), paranasal sinus (4), parotid gland (4), submandibular gland (2) and buccal mucosa (1). Median dose delivered was 60 Gy with 12 patients receiving concurrent chemotherapy. Four patients developed acute grade 3 toxicity and one patient experienced a grade 4 toxicity (blindness). An additional patient developed asymptomatic frontal lobe necrosis 18 months after treatment completion with near resolution at 24 months. The authors conclude that “Intensity-modulated proton therapy demonstrated comparable efficacy and safety when compared to other radiation modalities including other proton therapy delivery techniques. One additional patient refused radiation and chemotherapy after surgery but received stereotactic radiosurgery at the time of recurrence. Patients had stage T1N0 (1), T2N0 (6), T3N0 (1) or T4N0 (3), all without metastases. Primary sites included the lacrimal gland (7), lacrimal sac/nasolacrimal duct (10) or eyelid (3). Seven patients experienced acute grade 3 while 9 patients developed chronic grade 3 ocular or eyelid function toxicity. Bivariate analysis revealed that a dose of 36 Gy or less to the ipsilateral cornea was associated with grade 3 chronic ocular toxicity (p = 0. The authors conclude that these findings “…suggest that adjuvant proton therapy can be delivered successfully after orbit-sparing surgery for epithelial tumors of the orbit and ocular adnexa. The authors conclude “Reirradiation with proton therapy, with or without chemotherapy, provided reasonable locoregional disease control, toxicity profiles, and survival outcomes for an advanced-stage and heavily pretreated population. Additional data are needed to identify which patients are most likely to benefit from Page 58 of 311 aggressive efforts to achieve local disease control and to evaluate the potential benefit of proton therapy relative to other modalities of reirradiation. In a study of 60 patients receiving proton beam therapy for reirradiation, Phan et al. All plans were calculated to 55 Gy in 25 fractions with equivalent constraints and normalized to prescription dose. Protons also increased generalized equivalent uniform dose to duodenum and stomach, however these differences were small (< 5% and 10%, respectively; p < 0. Doses to other organs at risk were within institutional constraints and placed no obvious limitations on treatment planning. The authors concluded that protons are able to reduce the treated volume receiving low-intermediate doses, however the clinical significance of this remains to be determined. No patient demonstrated any grade 3 toxicity during treatment or during follow up. Chemotherapy was well-tolerated with a median of 99% of the prescribed doses delivered. Median follow up was 14 months for all patients and 23 months for surviving patients. No patient experienced a grade 3 or greater toxicity during treatment or follow up. Grade 2 toxicity was limited to a single patient Page 60 of 311 experiencing grade 2 fatigue. Of the remaining 50 patients, only 78% had surgery, with 16% found to be unresectable, 4% diagnosed with metastases prior to surgery, and 2% diagnosed with cholangiocarcinoma instead of pancreatic cancer. Six of 37 eligible resected patients (16%) experienced locoregional recurrence, while 73% developed distant metastases. The authors concluded that short-course proton-based chemoradiation is well tolerated and is associated with favorable local control in resectable pancreatic cancer (although 16% local failure after surgery and radiation, particularly with such limited follow up and early deaths, is not particularly favorable). Advanced immobilization techniques, such as the use of breath hold gating or targeting with implanted fiducial markers, were not used in this series, and the dose of 67. However, there was no statistical significance between the two groups regarding the median time to progression (15. No grade 3 or higher toxicity was seen while maintaining a median overall survival of 19. This especially pertains to targets in the thorax and upper abdomen, including the pancreas, which move as a result of diaphragmatic excursion (Mori and Chen 2008; Mori, Wolfgang, and Lu et al. Because the diaphragm moves during respiration, this results in changes to the tissues in the beam path, which can cause significant interplay effects and dose uncertainty. This could result in unanticipated overdose of normal tissues or under dose of target volumes. Therefore, direct comparative studies will be helpful to determine the relative safety and efficacy of protons relative to customary photon radiation. In addition, there are concerns about proton beam dose distributions in the setting of organ and respiratory motion and tissue differences and interfaces, as are seen in this location. Until such data is published and until there is clear data documenting the clinical outcomes of proton beam therapy in the treatment of cancer of the pancreas, proton beam therapy remains unproven. However, it must be recognized that use of anterior/posterior fields whether 2D or 3D are the very technique which has been the subject of these reports. They found a 19% increase in secondary primary malignancies in seminoma patients exposed to radiation therapy as compared to the general population including pancreas, non-bladder urothelial, bladder, thyroid, and others. An accompanying editorial in the journal noted an increased incidence of seminoma during the last 4 decades with improved survival, which makes the issue of radiation-induced malignancies of increasing concern. They identified risks of lung, bladder, pancreas, stomach, and other organs, noting that secondary primary cancers are a leading cause of death in men with a history of testicular cancer. Patients treated with radiation therapy had the highest risk of developing cancer especially when treated at a young age. Among organs treated in a radiation field, stomach, large bowel, pancreas, and bladder stood out for the development of a later cancer. Given these findings, radiation is no longer used in early seminoma but there remains a population of patients with more advanced disease that may benefit. Although this population of patients is relatively small as 80% of seminoma, totaling approximately 8600 cases a year, is diagnosed in Stage I, the relative doses of radiation and increased field sizes pose a problem. The use of protons brings a distinct advantage in lowering radiation dosed to the population at risk. Therefore, there is concern that this patient population has a longer duration of survival, allowing sufficient time for very late side effects of radiation for curative treatment to emerge and affect quality of life. However, the doses of radiation that are typically delivered for lymphoma are low or moderate compared to most solid tumors, and these doses often do not approach the established tolerance doses for organs at risk in the treated volume. None of these studies has demonstrated a difference in clinical outcomes related to this dosimetric reduction. Much of the experience has been in the pediatric population, and whether extrapolation of this to adult patients is appropriate is not clear.

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