text:
Index of content:
Volume 42 (2015)
Volume 41 (2014)
Volume 40 (2013)
Volume 39 (2012)
Volume 38 (2011)
Volume 37 (2010)
Volume 36 (2009)
Volume 35 (2008)
Volume 34 (2007)
Volume 33 (2006)
Volume 32 (2005)
Volume 31 (2004)
Volume 30 (2003)
Volume 29 (2002)
Volume 28 (2001)
Volume 27 (2000)
Volume 26 (1999)
Volume 25 (1998)
Volume 24 (1997)
Volume 23 (1996)
Volume 22 (1995)
Volume 21 (1994)
Volume 20 (1993)
Volume 19 (1992)
Volume 18 (1991)
Volume 17 (1990)
Volume 16 (1989)
Volume 15 (1988)
Volume 14 (1987)
Volume 13 (1986)
Volume 12 (1985)
Volume 11 (1984)
Volume 10 (1983)
Volume 9 (1982)
Volume 8 (1981)
Volume 7 (1980)
Volume 6 (1979)
Volume 5 (1978)
Volume 4 (1977)
Volume 3 (1976)
Volume 2 (1975)
Volume 1 (1974)
Volume 33, Issue 6, June 2006
- Joint Imaging/Therapy Moderated Poster Session: Exhibit Hall F
- Moderated Poster ‐ Area 2 (Joint): Modeling of Intra‐Fraction Organ Motion
SU‐DD‐A2‐01: On the Accuracy of a Moving Average Algorithm for Tracking Respiratory Motion During Radiation Therapy Treatment Delivery33(2006); http://dx.doi.org/10.1118/1.2240135View Description Hide Description
Introduction:Real‐time motion tracking (RTT) treatmentdelivery has several advantages toward the improvement of accuracy for radiotherapy. However, currently there are certain limitations to this technique. The purpose of this study was to investigate an alternative treatment scenario using a moving average algorithm (MA) for treatment which could potentially be approaching the accuracy of RTT. Method: A comparison was performed between three different treatment scenarios.
(3) Static beam delivery(SB) .
Where Xest (t) and Xact (t) are the estimated and actual position at time t, n in seconds is the averaging period (5–25 seconds range). The data used for this analysis was 331 respiration‐motion traces from 24 lung‐cancer patients acquired using three different breathing types (free breathing(FB), audio coaching(A) and audio‐visual biofeedback(AV)). The metrics used for comparison were the group systematic error(M), the standard deviation(SD) of the systematic error(Σ), and the root mean square of the random error(σ). The averaging period was varied to study the effect on the various metrics. Margins were calculated using the formula by Stroom et al.(IJROBP 1999;43(4)) Results: M and Σ are negligible for both MA[M ∈ (−0.01,0), Σ ∈ (0,0.01)] and RTT[ M ∈ (0), Σ ∈ (0)] compared to SB[ M ∈ (−0.15,−0.02), Σ ∈ (0.05–0.20)]. MA(0.48–0.54) has a slightly reduced σ than SB(0.53–0.57). Negligible improvements were found by varying the average periods for M and Σ . σ was found to be insensitive to the different averaging periods(0.53–0.56 for A). From the margin calculations FB is most affected by the different treatment scenarios. (All values in cm). Conclusions: MA has accuracy advantages over SB and practical advantages over RTT. MA significantly reduces M and Σ compared with SB. MA and SB require less margins for AV than that for FB and A. The margins required for RTT are independent of breathing training type. There is a group systematic error caused by intrafraction motion during FB.
SU‐DD‐A2‐02: Variability of Waveforms and Probability Distributions in External Respiratory‐Surrogate Marker Data33(2006); http://dx.doi.org/10.1118/1.2240136View Description Hide Description
Purpose: To investigate intra‐ and inter‐fractional, inter‐subject variability in the motion patterns of external respiratory‐surrogate markers. A strong correlation between the motion of external markers and internal targets has been previously reported. Method and Materials: Varian real‐time position management (RPM) system is used clinically to monitor external marker motion. We analyzed over 450 RPM datasets (traces) from 186 4D‐CT, and 6 gated radiotherapy subjects (mean length: 235 seconds). Aperiodic (long‐term) motion components were subtracted by applying high‐pass filtering to Fourier transform of the data. Probability distribution functions (PDF) of the marker position were constructed, and variability bounds were calculated for the realized distributions. Trace‐average waveforms (TAW) were constructed from cumulative PDF, calculated separately for leading and trailing edges of motion cycles within the trace. Results: Inter‐ and intra‐fractional variability of PDF were reduced where the aperiodic motion components were subtracted from the data. The distribution of aperiodic shifts was approximately Gaussian over multiple fractions. Comparison between the data from various subjects showed that the PDF (when normalized to the mean amplitude of individual traces) was remarkably stable, indicating rather limited inter‐fractional and inter‐subject variability. While intra‐fractional variability of PDF appeared to be typically larger than either inter‐fraction or inter‐subject, as a wide variety of waveforms were realized within each trace. Conclusion: The marker position PDF and its variability bounds, constructed based on a single trace (e.g., pre‐treatment 4D‐CT), may serve as a conservative estimate of the expected variability in the PDF realized during a fractionated treatment. This information can be used in robust optimization of treatment planning for moving targets. The TAW may potentially be useful in subject classification by "respiratory personality", and prediction of the realized PDF for a given expected uncertainty in the trace extrema positions (full exhale and inhale). Supported in part by the NCI grant 5P01‐CA21239‐25.
SU‐DD‐A2‐03: Assessment of Four‐Dimensional CT Image Acquisition Quality33(2006); http://dx.doi.org/10.1118/1.2240137View Description Hide Description
The purpose of the present work is to develop and validate a series of tests to assess the quality of four‐dimensional (4D) computed tomography(CT)imaging as applied to radiation treatment planning. Using a commercial motion phantom and two programmable moving platforms with a CT phantom, we acquired 4D CT datasets on two commercial multislice helical CT scanners using different approaches to 4D CTimage reconstruction. 4D CTimagedata sets were obtained as the platform moves in different patterns designed to simulate various breathing patterns. Known inserts were contoured and statistics were generated to evaluate properties important to radiation therapy, namely phase‐binning accuracy, geometric accuracy, volume accuracy, and CT number accuracy. Phase‐binning accuracy varied by as much as 5% for a 4D procedure in which images were reconstructed, then binned, but exhibited no variation for a 4D procedure in which projections were binned prior to reconstruction. Geometric distortion was found to be small as was volume error. Partial volume effects in the direction perpendicular to the axial planes of reconstruction affected volume accuracy, however. CT numbers were reproduced accurately, but 4D images exhibited significantly more noise than static CTimages. Characterization of such properties can be used to better understand and optimize the various parameters that affect 4D CTimage acquisition.
SU‐DD‐A2‐04: A Simple Method to Reconstruct a Representative Mid‐Ventilation CT Scan From 4D Respiration Correlated CT Scans for Radiotherapy Treatment Planning of Lung Cancer Patients33(2006); http://dx.doi.org/10.1118/1.2240138View Description Hide Description
Purpose: Four‐dimensional (4D) imaging techniques can be used to obtain (respiration) artifact‐free CTimages of the thorax. However, its use in radiotherapy is limited since clinical treatment planning systems are currently not able to use the full 4D data. The purpose of this study was to reconstruct a representative single 3D CT scan from the 4D data set (with tumor closest to the mean position) for use in radiotherapy planning of lungtumors to enable reduction of treatment error margins. Method and Materials: After acquisition of the 4D CT scan (10 frames), the tumor is manually segmented (roughly) in the first frame and automatically (gray‐value) registered to the tumor in the subsequent frames. This gives the motion of the tumor during the respiratory cycle in 3D. Subsequently, from the cranio‐caudal (CC) tumor motion curve, the mean tumor position and its corresponding mid‐ventilation (MV) time‐percentage are calculated. The CT scan for planning is reconstructed at this time‐percentage. As indication of the merit of this concept, its effect on margins from CTV to PTV and on the PTV volume was calculated covering respiratory motion, respiratory baseline variation and setup errors (systematic and random). Results: Based on 13 patients, the worst tumor position accuracy (with respect to the mean tumor position) in the mid‐ventilation CT scan occurred in the anterior‐posterior direction: −0.7±0.8 mm (due to hysteresis). For these patients, the errors in conventional free‐breathing CT were estimated to be 0±3.4 mm (CC) and 0±1.4 mm (AP). The mid‐ventilation concept resulted in margin reduction up to 45% and a PTV volume reduction up to 35%. Conclusion: The mid‐ventilation concept, based on tumor motion, is a simple method to obtain an artifact‐free CT scan with smaller systematic errors compared to conventional CT scans. Significant reduction of the PTV volume can be achieved.
SU‐DD‐A2‐05: Impact of Fiducial Marker Placement for the Purpose of Phase Definition of the Respiratory Cycle for 4D‐CT Image Reconstruction33(2006); http://dx.doi.org/10.1118/1.2240140View Description Hide Description
Purpose: Most 4D‐CT acquisition methods rely on an externally measurable quantity proportional to the breathing cycle (e.g. chest wall excursion), for 4D‐CT image reconstruction. Typically, the position of a single reflective marker placed on the patient's chest is monitored. The marker location is often chosen primarily to maximize the measurable motion irrespective of proximity to tumor location. We examine the behavior of motion of multiple markers, at different locations, placed on the patient surface during 4D‐CT acquisition and evaluate the impact of marker location on respiratory cycle phase definition for 4D‐CT reconstruction and its subsequent application to radiotherapy planning. Method and Materials: An infrared guided positioning system (iGPS), capable of tracking multiple reflective fiducials in 3 dimensions, has been adapted to provide respiratory phase information for 4D‐CT reconstruction. Data for 3‐5 marker positions, placed at different locations on the patients chest, from 10 patients receiving 4D‐CT was examined. Results: For most patients (9/10) motion of 3–5 markers is reasonably well synchronized suggesting no significant effect of the fiducial location. For one patient, we observed a marker on the abdomen switch from being completely in‐phase to being completely out of phase relative to a marker on the center of the chest. This dramatically illustrates that the phase of a specific external marker may not correspond to the motion, external or internal, near the volume of interest. Conclusions: The position of a fiducial marker may affect not only the amplitude of motion but also the observed phase for some patients. The importance of this phase shift depends on how the resulting 4D‐CT is ultimately applied to radiotherapy planning. In particular, if specific phases (e.g. extremes) are selected for radiotherapy target definition, special attention should be paid to the location of the fiducial marker and its role in image reconstruction.
SU‐DD‐A2‐06: The Effect of Respiratory Rate and Radiation Timing On Dose Coverage in Dynamic Breast IMRT33(2006); http://dx.doi.org/10.1118/1.2240141View Description Hide Description
Purpose:IMRT has been shown to be capable of delivering plans with desirable homogeneous dose distribution for breast cancertreatment. However, the dose distribution may be influenced by interplay between dynamic MLC and respiratory motion. The purpose of this study was to investigate the impact of respiratory rate and radiation timing on the dose distribution of breast dynamic IMRT.Method and Materials: Using similar setup configuration, a helical CT and 4DCT image sets for six breast cancer patients were collected and contoured. Dynamic IMRT plans were designed using the helical CTimages. The planned MLC sequence was segmented according to the respiratory phases with a series of respiratory rates (7.5–30/min) and radiation timing (evenly distributed in respiratory cycles). The segmented dynamic MLC sequences were applied to the radiation fields on the corresponding 4DCT phases. A program was developed to calculate the cumulative dose distribution from all the phases. Results: For normal breathing rates (15–20/min), the dose coverage didn't change significantly regardless of radiation starting time. The change of target V90 was less than 2%. However, for extremely slow respiratory rates (7.5–10/min), the dose distribution and V90 changed significantly depending on the radiation timing. The change of target V90 was more than 10%. There was no significant dose coverage change for the underlying heart regardless respiratory rate or radiation timing. Conclusions: For breast patients treated with dynamic IMRT, if the respiratory rate of the patient is within the "normal" range then the impact of such respiration on dose coverage of the target was found to be statistically insignificant. However, the dose distribution may change significantly when patient has a slow breathing rate. Respiratory gating may be required to obtain satisfactory dose coverage for such cases. There was no significant dose distribution change for heart regardless respiratory rate or radiation timing.
- Moderated Poster ‐ Area 3 (Joint): Tomographic Imaging for Therapy Localization
SU‐DD‐A3‐01: Kernel Classification for Assessing Inter‐Fraction Motion in IGRT33(2006); http://dx.doi.org/10.1118/1.2240143View Description Hide Description
Purpose: To develop a method that identifies an IGRTimaging session as either normal or problematic based solely on the amount of right‐left, anterior‐posterior, and superior‐inferior repositioning of the patient over the treatment session. Methods and Materials: A retrospective data set containing over 1100 anterior‐posterior, right‐left lateral, and superior‐inferior patient shift values for 29 prostate patients was examined using a non‐parametric kernel regression classification method to determine if a patient was "normal" or "problematic." The treatment sessions were grouped as either being "normal", or affected because they were "overweight", or had "rectal filling", or were both "overweight and had rectal filling". In kernel regression, constants are fitted using a locally weighted criterion. The basis of kernel regression is to estimate a response using a weighted average of points, in a training set, which are local to the query point. A bandwidth is used to determine the definition of local. Leave one out cross validation (LOOCV) was used to select the optimal bandwidth and also evaluate the technique's performance. Results: The method correctly classified 24 of the 29 patients using their respective shift data sets, with four of the misclassifications occurring when the technique correctly identified non‐normal datasets, but assigned them to the wrong problem group. Only one patient was classified as normal incorrectly. Conclusion: Using readily accessible shift data, the kernel regression classification method was able to correctly identify the cause behind IGRT positioning problems for individual prostate patients. This technique is fully automated and can be implemented on a treatment planning computer to determine the reason a patient is having positioning errors early during treatment.
SU‐DD‐A3‐02: Evaluation of Helical Tomotherapy Megavoltage CT System for Daily Automatic Patient Setup Correction and Manual Prostate Gland Motion Correction33(2006); http://dx.doi.org/10.1118/1.2240144View Description Hide Description
Purpose: To evaluate the efficacy of helical tomotherapy megavoltage CT system (MVCT), and to study patient setup uncertainty and inter‐fractional internal organ motion for prostate cancer patients during the course of external beam treatment. Method and Materials: 34 prostate cancer patients that received definitive helical tomotherapy treatments were included in this study. MVCT images were registered with planning CTimages using automatic bone registration followed by manual registration based on soft tissue match. Patient setup corrections and internal organ motion corrections in the medial‐lateral (ML), superior‐inferior (SI), anterior‐posterior (AP) directions, and rotations around the longitudinal axis were obtained from 1345 daily MVCT image registrations.Results: The mean and standard deviation of patient setup corrections were 3.1±7.3 mm in the ML direction, −0.8±4.9 in the SI direction, −0.2±6.4 in the AP direction, and 0.8±1.3° for rotations around the longitudinal axis. The mean and standard deviation of internal organ motion corrections were −0.1±0.8 mm in the ML direction, −0.1±0.7 mm in the SI direction, and 0.0±1.9 mm in the AP direction. The fraction of manual registrations that did not have adjustment in the ML, SI, or AP direction was 84%, 95%, and 71%, respectively. The prostate motion variability did not change during the course of treatment. Conclusion: Patient setup uncertainty dominated target position uncertainty. Helical tomotherapy MVCT system was effective in correcting patient setup errors and internal organ motions in the ML and AP directions, but provided limited soft tissue resolution in the SI direction.
SU‐DD‐A3‐03: A Dose‐Guided Adaptive Therapy Process for Treatment Evaluation and Correction33(2006); http://dx.doi.org/10.1118/1.2240145View Description Hide Description
Purpose: To develop an adaptive therapy process for off‐line radiotherapy evaluation and modification. Method and Materials: An adaptive therapy process was developed to analyze and adjust a patient treatment. This included:
Daily Online Processes
• Daily CTimaging
• Patient repositioning
Weekly Offline Processes
• Automatic dose recalculation on each daily image
• Automatic deformable registration of each image with the planning image
• Automatic deformation‐based recontouring of each image
• Automatic deformation‐based dose accumulation
• Cumulative plan evaluation
• Replanning, as needed
The on‐line imaging and repositioning was performed with the TomoTherapy MVCT system and integrated registration software. The off‐line processes were performed on a standalone workstation.
Head and neck cases were studied with this process. Cumulated doses were typically analyzed at the end of each week, and modifications were performed mid‐course. Remaining treatments were then performed with the adapted plan. Results: It was found that CT‐guided soft‐tissue positioning alone did not protect against dosimetric changes due to patient weight loss. Without plan adaptation, the right parotid gland would have received a dose of 10 Gy above the plan, due to its medial motion towards the target region. However, since mid‐course adaptive replanning was used, the dose was only 2.5 Gy above the original plan. The use of an additional plan adaptation could have further reduced this discrepancy. Conclusion: An adaptive therapy process was developed for off‐line contouring, dose recalculation, dose accumulation, and replanning. This process was applied to clinical head and neck patients to evaluate on‐going treatments, adjust plans, and retrospectively assess the results. This process reduced unexpected parotid dose for these patients. This process also indicated that ability to recalculate to accumulate doses on daily CTimages is important for addressing systematic errors, such as anatomical changes, that may arise during a treatment.
Supported by TomoTherapy, Inc.
SU‐DD‐A3‐04: Quantitative Evaluation of Cone Beam Digital Tomosynthesis (CBDT) for Image‐Guided Radiation Therapy33(2006); http://dx.doi.org/10.1118/1.2240146View Description Hide Description
Purpose: Cone beam digital tomosynthesis (CBDT) is a new imaging technique proposed by us recently as a rapid approach for creating cross sectional images of a patient in the radiotherapytreatment room. Similar to the cone beam computed tomography(CBCT) approach, the CBDT uses an X‐ray source and an X‐ray detector on a Linac to acquire projection data by rotation around the patient. Unlike CBCT, CBDT utilizes partial scans, typically in the range of 20–60 degrees of gantry arc. The purposes of this work are (1) to evaluate quantitatively the image quality of CBDT in terms of signal‐to‐noise ratio and spatial resolution; (2) to demonstrate that we can use CBDT to image soft tissue targets, e.g., the prostate. Method and Materials: An experimental CBDT system has been built on a Linac with a recently developed flat‐panel detector. A number of phantoms including a spatial resolution phantom, two contrast‐detail phantoms and a custom‐made anthropomorphic pelvic phantom (CIRS Inc.) were used in the evaluation. CBDT phantom images have been generated and analyzed for different degrees of gantry arc and compared to those from CBCT.Results: Quantitative results on signal‐to‐noise ratio and spatial resolution have been obtained for different degrees of gantry arc. Compared to CBCT, CBDT has a worse spatial resolution in the direction perpendicular to the planes of reconstruction but a better resolution in the parallel direction. The image quality of CBDT is acceptable in the planes most relevant to the treatment. It has been shown that the prostate is visible on CBDT reconstructed images of the pelvic phantom. Conclusion: This work indicates that the CBDT approach can be a viable and rapid tomographical imaging technique for treatment verification in radiotherapy.Conflict of Interest: This work was partially supported by Siemens Medical Solutions, Inc.
SU‐DD‐A3‐05: Evaluation of Respiration‐Correlated Digital Tomosynthesis for Soft Tissue Visualization33(2006); http://dx.doi.org/10.1118/1.2240147View Description Hide Description
Purpose: To find optimal parameters for digital tomosynthesis (DTS) image acquisition, assess DTS imaging for soft tissue visualization and patient positioning, and determine if DTS can be acquired fast enough to avoid blur caused by the respiratory motion Methods and Materials: We have used Varian gantry‐mounted kV on‐board imaging system to acquire DTS images as well as reference cone‐beam CT(CBCT) scans. An external respiratory monitor system recorded patient respiration together with the x‐ray on/off signal during imaging for retrospective sorting of projections based on respiration phase. DTS reconstruction used backprojection followed by a deblur. For a lung tumor subject to the respiratory motion we also reconstructed DTS images during a short time interval (∼ 1 s = 6° arc at 1 rpm) around the end‐exhalation.
Results: Phantom studies indicate that image quality increases with DTS arc length; however, longer arc lengths cause image blur and degradation. Optimal DTS arc length is 10–20.° Patient studies also indicate that at approximately 15° arc length image quality, as judged visually, is the best. For longer arcs image blur increases, while for shorter arcs out of plane objects become more pronounced. For all arc lengths tumor visualization was possible. Both manual and automatic 2D registrations of DTS and CBCT were possible in most cases. For short (6°) or long (30°) arc lengths manual registration became more challenging and automatic registration less precise, but still possible. Registration of a respiratory correlated DTS image over a 6,° non‐optimal arc, was possible. Conclusions: DTS is capable of soft tissue and bone visualization and can be an efficient imaging modality for image‐guided radiotherapy. DTS can be acquired, with some tradeoff in image quality, during a ∼1s time interval, allowing reduction of respiratory motion artefacts. Conflict of interest: Research sponsored by NCI Grant P01‐CA59017 and Varian Medical Systems.
SU‐DD‐A3‐06: Assessment of Lung Tumor and Diaphragm Motion Using Cone‐Beam CT and 4DCT33(2006); http://dx.doi.org/10.1118/1.2240148View Description Hide Description
Purpose: To determine the variability in diaphragm and tumor motion assessed at planning and for each treatment fraction for patients with inoperable early stage non‐small cell lungcancertreated using stereotactic body radiation therapy(SBRT).Method and Materials: Six patients with upper lobe lungtumors were treated using SBRT. For each patient, tumor motion was assessed initially using fluoroscopy on a conventional simulator. The subsequent scanning session involved a helical scan and a four‐dimensional CT (4DCT) scan to assess tumor motion at the inspiration and expiration phases of breathing. Each of the three treatments was performed under on‐line cone‐beam computed tomography(CBCT)image guidance. Similarly to 4DCT, the projections for the CBCT scans were sorted based on an internal surrogate of the breathing cycle to provide volumetric datasets at the inspiration and expiration phases of breathing for each treatment fraction. Results: For five of the six patients treated,lungtumor and diaphragm motion measured on the treatment unit using CBCT was consistent with the tumor motion measured by 4DCT at planning. However, for the sixth patient, diaphragm motion, and to a lesser extent tumor motion, was markedly different between planning and the three treatment fractions. For this patient, the average tumor motion difference observed between 4DCT and projection‐sorted CBCT scans was 4.5 mm (A/P) and the average diaphragm motion difference was 12.0 mm (A/P) and 9.5 mm (S/I), respectively. Conclusion: Our study has shown that the relative motion and position of the tumor at the time of treatment may not match that of the planning scan. Application of breathing motion data acquired at scanning time to modulate or gate radiation therapy may not be suitable for all patients. Conflict of Interest: Princess Margaret Hospital is part of the Elekta Synergy Consortium. The research is supported, in part, by Elekta Inc.
- Moderated Poster ‐ Area 2 (Joint): Correction Strategies
SU‐EE‐A2‐01: Minimizing Residual Target Motion for Imaging Guided IMRT Delivery33(2006); http://dx.doi.org/10.1118/1.2240178View Description Hide Description
Purpose:IMRT delivery could be affected by residual target motion, the intrafractional target uncertainties resulting from motion that follows image‐guided procedures such as dual x‐ray image acquisitions with patient positional corrections. This study investigates the 6D spatial characteristics of residual target motion and a method for minimizing potential IMRT delivery errors. Method and Materials: A recursive dose painting algorithm was developed to reorder MLC segments, so that most segments were delivered repetitively at a fraction of its prescribed MU. The rationale is that there could be residual target motion that would cause significant delivery errors, so to "paint" the target voxels recursively in small dose segments instead of painting the whole area once with a larger dose segment, could produce a more accurate delivery. The residual target motions used were determined from implanted spine fiducials detected using the dual x‐ray images taken every 10–20 seconds during treatment (Cyberknife, Accuray). Six‐degree of freedom spatial characteristics of the residual target uncertainties were extracted. These residual motions were then fed into the recursive dose painting method for dose evaluation. Results: The residual target motion study showed that although the average was less than 3 mm during the whole delivery, there existed large irregularities in distributions in both rotational and translational directions. For most cases, there were also systematic motion errors of 0.5–1 mm and large spurious motions, sometimes of 5 mm or more. When using the actual error‐time curves, the recursive delivery significantly reduced dose variations caused by such errors (by as much as 27%). For the majority of cases studied, a cycle of three to six repetitive dose paintings was found sufficient to achieve such improvements. Conclusion: Residual target motion is irregularly distributed as treatment time progresses. Recursive dose painting provides a solution to decrease the dose errors caused by such uncertainties.
SU‐EE‐A2‐02: Feasibility of Tracking Head Position Under An Obscuring Immobilization Mask Using a Bite Block and a 3‐D Surface Imaging System33(2006); http://dx.doi.org/10.1118/1.2240186View Description Hide Description
Purpose: To assess the accuracy and feasibility of measuring head motion under a thermoplastic immobilization mask when using a 3‐D surface imaging system. Materials and Methods: Small dome‐shaped objects were arranged asymmetrically on a styrofoam platform that was attached to a bite block system. The assembly was mounted on the couch of a linear accelerator to a micromanipulator with slow motion controls. This arrangement is operationally similar to a bite block affixed to the maxilla of a intracranial radiation therapy patient. The micromanipulator allowed for motions with six degrees of freedom. We were able to achieve sub‐millimeter translational adjustments of the bite block assembly and angulation. The platform and objects were "tracked" with the AlignRT® 3‐D surface imaging system (VisionRT, London, UK) in order to compare mechanical translational and rotational movements of known magnitude with the changes reported by the AlignRT system. While translational motions are only reported with millimeter resolution on the computer control screen, we obtained the system records sub‐millimeter from stored data file records. Results: Translational agreement between the micromanipulator and the AlignRT system was 0.1±0.1 mm in all three axes. Rotational agreement was within 0.5 degrees for pitch and roll. Agreement for yaw was not determined, however the display for couch rotation is 0.1 degree and has a stability of ±0.1 degrees. Conclusion: The AlignRT surface imaging system has superior accuracy that is sufficient for stereotactic radiosurgery guidance using a bite block as we have designed the experiment. Combining a bite block similar to what we designed with the AlignRT 3‐D system shows promise in monitoring head position under an occluding immobilization mask.
SU‐EE‐A2‐03: Evaluation of Auto‐Segmentation Tools for the Target Definition for the Treatment of Lung Cancer33(2006); http://dx.doi.org/10.1118/1.2240194View Description Hide Description
Purpose: With the advent of more sophisticated image devices in the treatment room, image guided radiotherapy(IGRT) and adaptive radiotherapy(ART) have become distinct possibilities. IGRT and ART techniques in their various stages have been implemented in clinics. One of the ART techniques using the daily acquired CTimages involves re‐planning due to the target shape variation during the treatment. Lungcancer volumes of some cases are observed to undergo significant changes where re‐planning is a necessity. To be able to define target efficiently can help the treatment flow significantly. This study evaluates various auto or semi‐auto contouring tools either commercially available or under development for their accuracy and ease of use. Method and Materials: Three methods are included in the study. Two are commercially available (Focal,CMS): auto threshold (of gray level); and auto Segmentation where gray level, the edges and prior shape information are used. The third method is the ITK‐SNAP program that uses a powerful level set(snake) segmentation algorithm to segment anatomical structures in three dimensions. Results: Ten image sets from helical and cone beam CTs are included in the study. The acceptable contours are defined as those with distance to agreement to those drawn by radiation oncologists less than 3 mm. For target volume surrounded by normal lung, the percentage slices of contours that do not need manual adjustment are 41–62%, 23–39%, 62–78% for threshold, auto‐segmentation and SNAP respectively. For cone beam CT, these numbers are approximately 10% lower. SNAP can also be used for target volume with no clear boundary, although the percentage success is much lower. Conclusion: More sophisticated auto‐segmentation tools need to be available routinely with more flexibility for users to adjust algorithm parameters in order for them to be useful for routine clinical ART purposes.
SU‐EE‐A2‐04: A Method of Online MLC Aperture Adjustment for Treatment of Patients with Set Up Variations33(2006); http://dx.doi.org/10.1118/1.2240215View Description Hide Description
Purpose: To investigate MLC aperture adjustments to compensate patient setup variations, replacing couch shift methods for precision treatment delivery. Method and Materials: Patient setup variations can be described by 3‐D translational shifts. A scheme of adjusting MLC apertures to compensate for translational displacements of the patient has been developed. Patient shift information, such as provided by commercial image matching software, establishes the aperture shift vector. The projection of this vector into and orthogonal to the BEV plane was used to determine the displacement vector and divergence for the aperture. Modified beam apertures were generated and MLC leaf positions were determined through a polynomialinterpolation.
Dosimetric plan comparisons were made within Pinnacle 7.6c. Static field and segmented IMRT patient plans were investigated for pelvic as well as head and neck sites. Arbitrary shift vectors ranging from 3 mm up to 30 mm have been investigated. Non‐integral MLC leaf width shifts parallel to the leaf bank face to characterize leaf width effects. Results: Conformal plans show dose variations from the original plan of up to 3% in the pelvis for shifts of up to 30 mm. Dose coverage of the PTV was maintained except in the superior‐inferior direction, where coverage in the last 3 mm of target fell as low as 92% of the prescribed dose. Results for prostate and oropharynx IMRT plans showed little increase in maximum critical structure doses, and small increases in mean doses. DVH's for IMRT plans confirmed minimal impact on critical structure doses. Conclusion: An alternative method of on‐line adaptive treatment delivery has been explored which eliminates the need to adjust the patient position. This can potentially increase treatment accuracy and efficiency through minimizing patient disturbances and reducing the time between imaging and treatment.
SU‐EE‐A2‐05: Direct Aperture Optimization for On‐Line Adaptive Radiation Therapy33(2006); http://dx.doi.org/10.1118/1.2240220View Description Hide Description
Purpose: To investigate a novel technique for on‐line adaptive radiation therapy(ART) that uses direct aperture optimization (DAO) Methods and Materials: A model simulating the geometry of a prostate case was created. The prostate, rectum and bladder are represented by an ellipsoid, cylinder and sphere, respectively (the dimensions and positions of these structures are based on patient image data). This configuration represented the "original geometry" and was used to create the original IMRT treatment plan. The plan was created using an in‐house DAO system with seven beams (40, 80, 110, 250, 280, 310, 355 gantry angles) and six apertures per beam. Four different "deformed geometries" were created by systematically deforming the original geometry to various degrees (0.25, 0.50, 0.75 and 1.00 cm maximum deformations of rectum and prostate). For each deformed geometry, a new treatment plan was created by modifying (adapting) the original treatment plan using DAO. The quality of the resulting plans, together with the optimization time efficiency of the plan adaptation, was used to assess the suitability of DAO for on‐line ART. The effects of altering different DAO parameters were investigated by varying the maximum leaf step size, maximum aperture weight change and optimization cooling schedule. Results: The plans created by adapting the original treatment plan met the imposed dose constraints for all four deformed geometries. Adapting the original treatment plan was much faster than performing a completely new re‐optimization. Furthermore, by appropriately limiting selective DAO parameters the convergence to an acceptable plan was significantly accelerated. The optimal choice of DAO parameter limits was correlated to the degree of geometry deformation. Conclusion: This study demonstrated that DAO is highly suitable for online ART. The treatment plan adaptation was efficient and the resulting plans met the imposed dose constraints.
SU‐EE‐A2‐06: Benefit of 3D Image‐Guided Stereotactic Localization in the Hypofractionated Treatment of Lung Cancer33(2006); http://dx.doi.org/10.1118/1.2240225View Description Hide Description
Purpose: To investigated the benefit of image‐guided stereotactic localization for lungcancer patients treated with hypofractionated radiotherapy.Materials & Methods: A stereotactic body localizer (SBL) was used for patient immobilization, image registration among multi‐phase CT simulation, and image‐guided stereotactic localization. The simulation scans consist of 3 sets of CTimages taken during free breathing and 2 breath‐holding scans (at maximum inhalation and exhalation). Target delineation was performed on all 3 sets of images and the combination of the targets forms a composite gross‐target volume (GTV). Treatment planning was performed on the planning‐target volume (PTV) using 3 mm margin to account for the presumed reliability of the CT localization. Prior to each treatment, a localization CT scan using a CT‐on‐rails was obtained. Couch shifts were made based on the changes of the stereotactic coordinates of three pre‐selected bony landmarks. In this retrospective treatmentdose verification, we performed image fusion between the simulation CT scan and each pre‐treatment CT scan to obtain the same target and critical structure information. The same treatment plans were re‐loaded onto each pre‐treatment CT scan with their respective stereotactic coordinate system. The changes in dose distributions were assessed by dose‐volume histograms of the PTV and the critical structures before and after isocenter corrections which were prompted by image guided stereotactic localization. We compared D95, D99, and V95 for the PTV and GTV, and V20and V30 for the ipsilateral lung.Results: Our retrospective study for 10 patients with 40 dose reconstructions showed that the average D95, D99, and V95 of the PTVs are 92.1%, 88.1%, and 95.8% of the planned values before isocenter corrections. With the corrections, these values are all improved to 100% of the planned values. Conclusions: 3D image guidance is crucial for stereotactic radiotherapy of lungtumors when small margins are used.
- Moderated Poster ‐ Area 3 (Joint): Molecular Imaging & Image Registration / Fusion
SU‐EE‐A3‐01: A Novel Filtering Approach for Local PET Verification of Proton Radiotherapy33(2006); http://dx.doi.org/10.1118/1.2240226View Description Hide Description
Purpose:Protonradiotherapy activates positron emitters in tissue, which can be imaged with PET. However, the resulting PET image is not directly proportional to the delivered dose. We are investigating the spatial relationship between the dose distribution and its PET image without reverting to Monte Carlo methods. The first goal is to validate the proton range in the patient, and ultimately to reconstruct the spatial distribution of the actually delivered dose from its PET image.Method and Materials: The relationship between the protondose and its PET image can be described mathematically as a convolution (filtering). We derive the convolution kernel analytically. This filter is unique for a given activation channel, independent of beam energy and specific absorber. The straightforward application of the method to determine the PET signal by locally filtering the planned dose distribution was validated through comparisons with Monte Carlo calculations and measured PET data in homogeneous and inhomogeneous media. The challenging inversion of the relationship, determining the dose from the PET signal, was initially explored for a simplified mono‐energetic case in a homogeneous absorber. Results: Activity depth profiles obtained with the convolution approach agreed with measured and Monte Carlo data within 1 mm in depth. In terms of absolute intensity, the agreement was within 1.5% between filtered and simulated profiles and 10% between filtered and measured data in the distal region. Attempts to recover the dose distribution from its PET image through a de‐convolution yielded promising results for idealized data but were strongly noise dependent. Conclusion: We have derived the spatial relationship between dose and positron activation and demonstrated the possibility to obtain the PET image measured after proton treatment by locally filtering the planned dose distribution. The inverse approach, i.e., direct dose quantification from the measured PET, seems possible but is very sensitive to noise.
SU‐EE‐A3‐02: The Potential of FDG‐PET in Delineating the Lumpectomy Cavity for Partial Breast Irradiation Patients33(2006); http://dx.doi.org/10.1118/1.2240227View Description Hide Description
Purpose: To investigate the potential of FDG‐PET imaging for delineating the surgical cavity in post‐operative partial breast irradiation patients. Method and Materials: A DCIS breast cancer patient was imaged with a GE Discovery ST PET‐CT scanner approximately 2 weeks post lumpectomy. Following the treatment planningCT, a single‐bed (15 cm) FDG‐PET scan was dynamically acquired in 5‐sec intervals over 15 mins. The raw PET data was combined to form bins ranging from 30 sec to 15 min. These data were reconstructed by the GEscanner through an iterative OSEM algorithm, and hardware fused to the treatment planningCT. The value of PET in visualizing the lumpectomy cavity border was investigated through visual comparisons of fused PET‐CT images, the evolution of PET intensity for various breast points, and signal‐to‐noise measurements across the lesion. Results: The PETimage showed clear signal enhancement near the lumpectomy cavity. This enhancement formed a ring in each axial slice, matching the locations of surgical clips. Enhancement was also apparent where the cavity border was difficult to evaluate by CT density or clips alone. The ring presented a significantly higher SUV than other breast tissue (2.2 vs. <1.4), while the region inside the ring had a lower SUV than the (presumably benign) glandular tissue in the same breast (1.2 vs. 1.4). The SUV values were transient below 5 min, but remained stable thereafter. Conclusion: FDG‐PET may provide useful information for delineating lumpectomy cavity borders by elucidating regions of enhanced radiotracer uptake due to inflammation. The hypointense PET volume enclosed by the high activity ring may represent fluid and non‐viable tissue stemming from post‐surgical changes, explaining its lower FDG uptake and further supporting the suggestion that the ring corresponds to the cavity border itself. On current hardware, five‐minute scans were required to achieve stable SUVs.


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EAST PROVIDENCE ŌĆō A Rhode Island State Police investigation has found no sufficient facts or probable cause to back up allegations that two members of the City Council unlawfully influenced City Manager Peter Graczykowski to place Police Chief Joseph Tavares on paid administrative leave in return for a new employment contract for Graczkowski.
ŌĆ£Over the past several weeks, several individuals were interviewed pertaining to the allegations and those interviews failed to reveal sufficient facts to meet the probable cause standard required to bring forth a criminal charge,ŌĆØ State Police Deputy Supt. Michael J. Winquist said Monday.
Among the individuals investigators wanted to interview, only City Council members Thomas A. Rose Jr. and Christine A. Rossi ŌĆö the two councilors linked to the allegations ŌĆö exercised their right to counsel and ŌĆ£did not fully cooperate with the investigation,ŌĆØ Winquist said.
Rose could not be reached for comment on Thursday, but Rossi spoke publicly, saying the investigation ŌĆ£didnŌĆÖt report anything because there was nothing to report.ŌĆØ
ŌĆ£I did nothing wrong and this was nothing but smoke and mirrors,ŌĆØ she said.
Rossi disagrees with the state policeŌĆÖs assertion that she was not ŌĆ£fully cooperativeŌĆØ during the investigation.
ŌĆ£I met with them for over 40 minutes,ŌĆØ said Rossi, adding the only thing she didnŌĆÖt agree to do was give a taped statement without her legal counsel present.
ŌĆ£IŌĆÖm a hairdresser and even I know thatŌĆÖs not a good idea,ŌĆØ she said.
State police released their findings following a three-month investigation called for by the state-appointed Budget Commission, which had requested state police intervention into alleged improprieties and irregularities in the police department unrelated to the police chiefŌĆÖs job performance.
Tavares, the cityŌĆÖs chief of police for the past three-and-half years, was placed on leave on April 15 while an internal investigation was conducted by Human Resources Director Kathleen Waterbury. The findings of the investigation were later turned over to the Budget Commission, which reinstated Tavares in May after its review of the findings found no wrongdoing on the chiefŌĆÖs part.
At the same time, the commission assigned a State Police investigator to determine if any criminal statutes had been violated when the chief was placed on leave, specifically whether any member of the City Council interfered with or influenced Graczykowski in the Tavares matter.
The city charter expressly prohibits members of the City Council from interfering with the city manager regarding appointments and removals of employees serving the city in an administrative capacity.
As part of the investigation, the Budget Commission had also requested that State Police investigate allegations of an improperly administered promotional exam, as well as other internal matters.
ŌĆ£These issues were determined to be administrative in nature and referred back to Chief Tavares for review by his professional standards unit,ŌĆØ Winquist said.
TavaresŌĆÖ attorney, Thomas J. McAndrew, said in May that on the day the chief was placed on leave, Graczkowski tried to get Tavares to sign a separation agreement intended to force him to involuntarily resign.
Tavares was named chief in 2009, succeeding former Police Chief Hubert Paquette. Before coming to East Providence, Tavares was chief of police in Warwick.
McAndrew has said that it is his belief that the entire incident involving the chief was fueled by ŌĆ£malcontentsŌĆØ within the Police Department and ŌĆ£political shenanigansŌĆØ by some current and former members of the City Council who want Tavares gone.
ŌĆ£There were a number of disgruntled police officers who applied for and were not selected for the chiefŌĆÖs position, much to their dismay,ŌĆØ he said. ŌĆ£However, they have continued their unrelenting assault against this man of honesty and integrity over the past three years to the point where they have now involved current and former members of the City Council who have fought vigorously to have him fired.ŌĆØ
McAndrew said when Tavares was placed on leave there was no mention of an internal probe or investigation.
ŌĆ£There was no mention of any charges at the time he was placed on leave, but there was a separation agreement that was intended to force him to involuntarily resign as chief of police,ŌĆØ McAndrew said. ŌĆ£The alleged investigation, taken in context of what happened to the chief on April 15, falls far short of the city managerŌĆÖs representations and far short of due process.ŌĆØ
McAndrew called the entire episode ŌĆ£a frontal attackŌĆØ on the chief, saying the decision to place Tavares on leave came within days after the Budget Commission relinquished control back to the city
ŌĆ£My belief is that some members of the City Council put pressure on Mr. Graczykowski and that there may have been the perception that he wouldnŌĆÖt have his contract renewed if he didnŌĆÖt take action against the chief,ŌĆØ McAndrew said.
Graczykowski issued a public statement yesterday on the investigation, saying he wasnŌĆÖt surprised by its conclusions.
ŌĆ£As expected, both the city officials and hard working officers of the East Providence Police Department have been cleared of any wrongdoing in this matter,ŌĆØ he said.
(Follow Joseph Fitzgerald on Twitter @jofitz7)

subset: commoncrawl


text:
Hi all,
I have a problem and needed some help.
I have a server (windows 2003) with iis6 and php 4.4.4, and an internal Web site that connects to a sql 2008 database. The site works perfectly, I can make it through queries to the database sql.
The site works on windows 2003 server with iis6, php 4.4.4, and uses the ISAPI with mssql.
The problem is that the server is old, and I need to install the site database + sql + iis the new server.
The new server is a Windows 2008, IIS7, and the version of php 4.4.4 does not work on windows 2008.
I have to install everything, migrate the database, install the php and IIS7.
Migrate the database and install II7, is not the problem, the problem is in php.
IIS7 does not accept mssql and the site is all done in php 4.4.4. How can I put the site on IIS7 without problems.
I've tried to put the site there, but I can not connect to the database.
I can run php info, no problem. I can run the main page of login, but when I put the data, user and password, it does not turn on.
I'll have to change some PHP programming?
I do not know much about php, so any help is needed.
2003 The server does not use apache or mysql. He has installed SQL Server 2008, iis6 and php 4.4.4 only. Since it is internal Web site, do not need apache.
Thank you.


text:
Golf Rules in Action DVDGolf Rules in Action explains and demonstrates the basic Rules of the game.
Golf Rules IllustratedA clear, detailed, illustrated explanation of the Rules of Golf.
A Guide to the Rules on Clubs and BallsGuidelines to interpret the Rules relating to the design and manufacture of golf clubs and balls.
Birds and Golf CoursesThis book provides guidance on how to support bird populations through effective management of the roughs and out of play areas.
The GolfersThis book examines in detail the historical background to the painting 'The Golfers'.
Ian Woosnam admits he will be a proud Welshman when his country hosts The Senior Open Championship Presented by Rolex for the first time this month, and the former World Number One is hoping to produce a performance befitting the special occasion.
Wales' greatest golfer will undoubtedly have the home support on his side when Royal Porthcawl Golf Club welcomes the world's leading senior stars, including Bernhard Langer, Miguel Angel Jiménez, Colin Montgomerie and Tom Watson, from July 24-27.
The 2006 European Ryder Cup captain, who won two European Tour titles on home soil, narrowly missed out on capturing the Wales Senior Open at Royal Porthcawl in 2009 and last year, finishing tied third on both occasions.
He is now hoping the Welsh fans can inspire him to be in contention once again as the Bridgend links becomes the 12th different venue to host The Senior Open Championship.
"It's the first time we've ever had a Senior Major in Wales, so it's pretty special for the country and obviously I'd love to play well," said Woosnam.
"I'm very proud that The Senior Open is coming to Wales. We do have courses in Wales that can cope with The Senior Open and big tournaments.
"We had The Ryder Cup in Wales in 2010 and we've had the Welsh Open over the years, so this will keep Wales on the map. For a lot of the American players, it will be the first time they have been to Wales, so hopefully they will get the chance to see what we have to offer.
"I'm hoping we get some big crowds to come out and support us. It will be interesting to see how the course is set up. If the weather is fine, you can shoot five, six under par, like I did last year, but if the wind blows, level par is a good one. So it really all depends on the conditions we get.
"Some of the American players have been asking me about the course when I've been playing over there. I've told them to be prepared for a tough test and to get their low ball out if the wind blows.
"I do know the course well so that could be an advantage to me, but then I also know where the trouble is too."
Woosnam's glittering collection of global titles already includes a Major Championship following his victory in the 1991 Masters Tournament, and he is planning to hone his game on some of Wales' famous links courses as he attempts to become only the second player from the country to win The Senior Open Championship, after Brian Huggett 16 years ago.
"I didn't play too well at Royal Birkdale last year, so hopefully I will get off to a good start this year and be up there," said Woosnam, who in 2008 became the first former European Tour Number One to win the Senior Tour Order of Merit. "I'm going to spend a few days in Wales before we go to Royal Porthcawl and play some of the courses to get some sea links practice. I'll go to Aberdovey and Harlech, then maybe Tenby as I've never been there. We've got some great courses so it will be nice to spend some time playing them."
Woosnam will be also using his homecoming to help unearth the next generation of Welsh talent as part of the Valleys Golf initiative involving local schoolchildren, which will take place the day before the start of The Senior Open Championship.
Tickets are now on sale to see Woosnam and many more of golf's most iconic names in action at Royal Porthcawl.
Any One Day tickets for the biggest Senior golf championship in Europe are priced at £30, while season tickets, which include the Official Practice Day on Wednesday, July 23, are only £80. Practice day entry on July 23 only is £15.
Under-16s are admitted free of charge, while car parking is located on site close to the course and is also free. Anyone wishing to sample the golf and also the facilities within Porthcawl town centre will be able to hop on and hop off an open top double decker bus which will run daily between a number of locations around the town and the golf course.
For adults and kids alike, there is plenty of fun to be found in the Activity Zone located in the Tented Village at Royal Porthcawl Golf Club. There is an opportunity to enjoy the facilities within the Village and participate in a number of activities including free PGA golf lessons supported by The R&A in the Swing Zone while Golf Development Wales will be on site to lend their support to the activities.
Also, the public will be invited to attempt a range of challenges, both authentic and with a simulator, such as trying to hole in one or hole a bunker shot – all for the cost of a minimum £2 donation towards the Championship's two Official Charities, Age Cymru and Tenovus.
Additionally, hospitality packages for the four official days of championship play are selling out fast. Friday is already sold out and Sunday is filling up quickly so act now to purchase an outstanding day out at Royal Porthcawl, for just £99 plus VAT.
The Senior Open Hospitality package will be located within our tented village which is located close to the 18th green and includes admission ticket, parking, breakfast, two-course lunch with wine, programme and drawsheet and guaranteed seat in the 18th green grandstand.
Tickets for The 2014 Senior Open Championship Presented by Rolex at Royal Porthcawl can be bought online via www.senioropengolf.com or by calling +44 (0)800 0232557, with details of the hospitality packages also available.


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* This is the Professional Version. *
Advance Directives
Advance directives are legal documents that extend a person's control over health care decisions in the event that the person becomes incapacitated. They are called advance directives because they communicate preferences before incapacitation occurs. There are 2 primary types:
Every state in the US recognizes these documents and encourages their use as a simple legal tool by which people can express their wishes and have them honored. However, formal advance directives are not the only means of expressing such wishes. Both common law and constitutional principles direct that any authentic expression of patients' wishes should be honored if within the scope of generally accepted medical standards.
An advance directive cannot be completed after a patient becomes mentally incapacitated and, in most states, it does not become effective until after incapacity has been determined. If no advance directive has been prepared, an authorized surrogate (see Consent and Surrogate Decision Making) must be identified or appointed to make health care decisions.
Living will
A living will is a limited document that expresses a person's preferences for end-of-life health care (it is called a "living" will because it is in effect while the person is still alive). In many states, the document is more formally called a medical directive to doctors or a declaration. State laws vary greatly regarding scope and applicability of living wills.
A living will allows people to express preferences for the amount and nature of their health care, from no interventions to maximum treatment. Detailed treatment preferences are desirable because they provide more specific guidance to practitioners. However, living wills completed long before a person experiences a life-limiting disorder have not usually been very helpful because, among other reasons, many people change their preferences as their circumstances change. A living will cannot compel health care practitioners to provide health care that is medically or ethically unwarranted.
To be legally valid, a living will must comply with state law. Some states require that living wills be written in a fairly standardized way. Others are more flexible, permitting any language as long as the document is appropriately signed and witnessed. In most states, a health care practitioner involved in the patient's care cannot be a witness. A document that does not comply with state law requirements for statutory living wills may still serve as reliable evidence of a patient's wishes if it appears to be an authentic expression of the patient's wishes.
Living wills go into effect when people are no longer able to make their own health care decisions or a medical condition specified in the directive—typically a terminal condition, permanent vegetative state, or the end-stage of a chronic condition—is diagnosed. Often, state law provides a process for confirming and documenting the loss of decisional capacity and the medical condition.
Durable power of attorney for health care
In this document, one person (the principal) names another person (the agent, proxy, or health care representative) to make decisions about health care and only health care. In most states, these documents become legally effective when the principal loses clinical capacity to make health care decisions. Some states recognize immediately effective durable powers of attorney for health care, but as a practical matter, the principal retains decision-making authority until incapacity regardless, so there is little practical difference. Like the living will, the durable power of attorney for health care may be referred to by different terms in different states.
People who have both a living will and a durable power of attorney for health care should stipulate which should be followed if the documents seem to conflict. Because predicting future circumstances in all of their complexity is impossible and because the durable power of attorney for health care designates a decision maker who can respond to all manner of here-and-now circumstances, whereas a living will states specific preferences regarding specific situations, a durable power of attorney is far more practical and flexible than a living will. The agent is granted the power to discuss medical alternatives with the physicians and make decisions if an accident or illness incapacitates the person. In most states, a health care practitioner providing care for the patient cannot serve as agent for health care matters. The durable power of attorney for health care can include a living will provision or any other specific instructions but, preferably, should do so only as guidance for the agent, rather than as a binding instruction.
The durable power of attorney for health care typically names an alternate or successor in case the first-named person is unable or unwilling to serve as agent. Two or more people may be named to serve together (jointly) or alone (severally), although reliance on multiple concurrent agents can be problematic. A jointly held power requires that all agents agree and act together. In this arrangement, all named agents must be contacted and must agree on every decision; thus, any disagreement results in a stalemate until it is resolved by the agents or the courts. A severally held power may be more functional because it allows any named agent to act alone. However, agents in this arrangement can also disagree, and, if irreconcilable, the courts may have to become involved.
The use of the durable power of attorney for health care is valuable for adults of all ages. It is especially critical for unmarried couples, same-sex partners, friends, or other individuals who are considered legally unrelated and who wish to grant each other the legal authority to make health care decisions and to ensure rights of visitation and access to medical information.
Ideally, physicians should obtain a copy of a patient's living will and durable power of attorney for health care, review the contents with the patient while the patient is still capable, and make it part of the medical record. A copy of the durable power of attorney for health care should also be given to the patient's appointed agent and another copy placed with important papers. The patient's attorney should hold a copy of all documents. An increasing number of states offer optional electronic registries for recording advance directives.
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* This is a professional Version *


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By Scott Warrington and Dennis Klager
Carpet cleaners frequently inquire about how and where they may dump their waste water. This may be out of concern for the environment or simply a desire to avoid fines and other legal problems. There is no one answer that is right in every situation. A solution that is right in one part of your service area may not be allowed in another location you service.
During past decades of truckmount cleaning and water extraction, one typical procedure was to open the dump valve and empty the water onto the driveway and into the street, ending up in the storm drain.
The storm drain is the opening out on the street that clears away water during a "storm". This water goes to our lakes and streams, usually with no filtering. Whatever is in the wastewater ends up in a river or lake. This is NOT the sewer system.
I have witnessed cleaners who open a valve and dump dirty water while driving down a highway or city street.
When automatic pump outs came along, technicians could place a discharge hose in the flower bed or on the lawn and dump wastewater onto the ground.
What has happened, in some cities, response to dumping on driveways and city streets has been met by the city or local municipality imposing fines and even criminal charges. In Houston, it can be a substantial fine plus criminal charges.
Local jurisdictions – states, counties, and cities – are all able to enact regulations that control how wastewater is managed. These regulations are often adopted from guidelines and licensing requirements set out by the U.S. Environmental Protection Agency (EPA). Whatever the specific details, the goals are to keep drinking water safe, minimize impact on the environment especially aquatic life, and to avoid creating problems with the wastewater treatment facilities.
We will examine the potential issues and some possible solutions for different situations.
Septic Systems
What are the potential issues when wastewater is discharged into septic lines or a septic field? Number one is the volume of water. Septic tanks and fields are built to handle the expected volume of discharge from the home or other facility that feeds it, plus limited extra capacity as margin for error.
Waste material must spend sufficient time in the septic system before it is ready to percolate through the ground and reach aquifers or drinking water. The addition of an extra 100 gallons of water to the systems may push waste matter through the system too fast.
An additional concern is how the waste material affects the bacteria working to digest organic matter in the septic system. Excessively high or low pH or the addition of a quantity of solvents can slow or stop the action of the bacteria necessary to breakdown waste material.
It may be acceptable to dispose of limited quantities of wastewater from carpet cleaning in a septic field through a drain or commode. But this would be unacceptable for large volumes of water or if the waste includes significant volume of solvents.
Sewer / Waste Treatment Facilities
Known as publically owned treatment works (POTW), most communities will have a wastewater treatment plant that incorporates a series of processes to remove pollutants from wastewater. These plants are designed to treat organic materials not hazardous chemicals. Even household cleaners, beauty products, medicine, and lawn care products should not be disposed of in public sewer lines.[1] Are there potential issues for the cleaner who wants to discharge into a sewer that leads to a POTW? Yes, there are several.[2]
Foremost are synthetic fibers and other non-soluble solids. During the cleaning process, especially with cut-pile carpet and staple fibers, there will be some shedding of fibers. These fibers along with paper clips, staples and other miscellaneous solids will enter the wastewater. They can contribute to clogging of pipes. They don't breakdown in a system that is designed to eliminate organic solids. They must be filtered out at some point.
The easiest way to accomplish that is by a simple prefilter added to your vacuum line before the waste tank.
A second concern is solvents. More stringent regulation of solvents used in cleaning, has resulted in volatile solvents that would easily evaporate with low vapor pressure or non-volatile solvents that evaporate slowly if at all. This reduces solvent vapors in the breathing air space, but more solvents end up in the wastewater. Yes, these solvents are usually diluted with large volumes of water; however sophisticated equipment can detect amounts in parts per billion. This increased awareness of the presence of solvents has heightened concerns. Small amounts of solvents are still permitted in most jurisdictions, but if quantities of paint, oil and grease removers, graffiti removers and similar solvents are used, it may be necessary to dispose of the waste as hazardous waste.
The pH of the wastewater is also a concern. Highly alkaline or highly acidic waste can interfere with the chemistry used at the treatment plant. The pH of your wastewater should be between 5.5 and 9.0. In practice, this is seldom a problem since any cleaning products are highly diluted with water.
The run-off of fertilizers containing phosphates into streams, rivers, lakes and other bodies of water encourages the growth of aquatic plants. Plants use the oxygen dissolved in the water leaving less oxygen for fish. This can result in fish kills. The process is known as eutrophication. The problem is mainly from agriculture, but regulations limit the amount of phosphates that can be in cleaning products including laundry detergents and carpet cleaning presprays. There may also be rules on how much if any phosphate can be dumped where it will drain into a body of water.
There may also be concerns about pesticides. Although disinfectants have been classified as pesticides, carpet cleaners do not use pesticides in the regular course of cleaning. Any pesticides in the recovered water were cleaned out of the carpet after being applied by a pest control company or the home-owner themselves.
Disposal Options
Emptying the waste tank where the water can run to a storm drain is not approved in any situation. Draining to gutters, paved streets, parking lots and similar would fall into this category.
If some areas, especially where water is a scarce commodity, pre-filtered water may be dumped onto ground. However, water should not be discharged where it can reach a stream, creek, river, lake or other body of surface water. In situations where water can be drained onto the ground, it should be a minimum of 75' from any body of water. The discharge should not be on top of a septic field nor within 35' of any drinking water well.
Surface draining should not be done repeatedly in the same location, even if it is your own property. Quantities over 150 gallons should be discharged onto the ground at one location.
Pumping pre-filtered wastewater to a drain or commode that leads to a sanitary sewer system and treatment facility is acceptable in every location as long as you have the property owner's permission. These sewer lines may also be reached through a clean-out opening in the yard if one is present. Look for white PVC cap to locate a clean-out.
Some recreational vehicle parks may allow you to dump into their system where RV holding tanks are emptied. There is usually a fee and should only be done with the permission of the operator of the facility. Some car wash facilities may allow you to dump filtered water. However, this can put a strain on some recovery systems. Do so only with permission from the owner.
Another option is to create a dump site at your office location. This may be as simple as a small concrete basin and filter that drains into the public sewer through a cleanout connection at your shop or office. The company I worked for did this. We even made a public invitation to other cleaning companies to use our approved dump site in lieu of emptying their waste tanks in a ditch beside the road. No other company ever took us up on the offer, but our concern for the environment did generate some favorable publicity.
If the source of the wastewater is extraction from a water loss, category 1 and 2 water can be handled in a similar fashion to wastewater from carpet cleaning. Category 3 water should only be disposed of through a sewer system that leads to a waste treatment facility (POTW).
Another major issue can be a company doing a sewer backup cleanup. Let's say the sewer serving the whole cul-de-sac is backed up. What do you do with the extracted sewage? According to the IICRC S500, it must be hauled to a licensed wastewater treatment plant or other appropriate facility in accordance with local regulations.
You could call a septic tank cleaning company or licensed waste hauler to do this. Just be sure, whatever you do is legal and safe.
One of our carpet cleaning trucks was leaking a little water, in our parking lot, due to not being completely emptied after a job. The local village officials came to our office, to inform us if it was still leaking tomorrow, we would be fined.
Make sure you know the laws in your area. It can be very expensive getting caught using the storm drain to dump your water. In some locations the "whistle-blower" who reports illegal dumping may get a reward based on fines you pay. That can be a strong incentive for someone to be watching how you handle the wastewater. PLUS, depending on what you are using to clean, it may not be good for our lakes and streams!
Make some phone calls. Don't guess. Know your local laws!
[1] What Can You Do to Protect Local Waterways? From the United States Environmental Protection Agency.
[2] Portions of this article is based on "Recommended Guidelines for Waste Water Disposal" Updated September 2012 by The Society of Cleaning and Restoration Technicians.
Try your local car wash, a readily available easy to use clean out site. The Clean Water Act requires professional car washes to route car wash wastewater to water treatment facilities or to state-approved drainage facilities designed to protect the environment. Fresh water is readily available to clean out the rest of that stinky van, and a mechanism for "payment" is already in place.
A local car wash can be very convenient. However, be sure to get permission from the owner / operator of the car wash before dumping your waste water. Water collected at a car wash must often be treated or handled specially. It would not be fair to "dump" your problem on another business owner.
For waste water disposal, you should Separate the liquid waste water from the solid waste particles in the waste water using a strainer. Solid waste particles, such as hair, can clog drains. Use a bucket to collect the liquid as it goes through the strainer.
You are correct, as the article states the foremost concern is to remove solids including carpet fibers.
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Prepare for robodrop.
By Tim Colwill on March 13, 2014 at 4:08 pm
Respawn's Vince Zampella has just tweeted news that every Australian Titanfall player will want to hear: Australian servers are happening, and it could be as soon as tomorrow.
"Aussie servers coming online, starting Friday morning and building capacity each day!," said Zampella. "Combined EA/MS/Respawn effort to make it happen!"
Very exciting stuff. We'll have more for you as soon as we get a chance to test it.
You can use the following bbCode
[i], [b], [img], [quote], [url href="http://www.google.com/"]Google[/url]
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Jersey City, NJ (PRWEB) August 22, 2013
AvePoint, the leader in governance, compliance, and management solutions for social enterprise collaboration platforms, announced today that it has once again made Inc. magazine's Inc. 500|5000, an exclusive ranking of the nation's fastest-growing private companies. It is the fourth straight year that AvePoint has made the Inc. 500|5000, joining brands such as Intuit, Zappos, Under Armour, Microsoft and Jamba Juice on the 2013 edition.
"It's a tremendous honor and accomplishment for AvePoint to be named to the Inc. 500|5000 for the fourth consecutive year," said Dr. Tianyi (TJ) Jiang, AvePoint Co-CEO and Co-Founder. "We have continued to invest heavily in every aspect of our business as we strive to deliver the best products and services in the industry while continuing to expand our market presence on a global scale. This recognition is verification that our strategy is working, and we are humbled to receive this honor once again in 2013."
Inc. magazine has welcomed the fastest-growing companies in America into this exclusive club for 32 years, and in 2013, the Inc. 500|5000 was harder to get into than ever. Organizations were ranked according to percentage revenue growth when comparing 2009 to 2012, with the minimum revenue requirement increased in 2012 to twenty times that of 2009.
"Not all the companies in the Inc. 500|5000 are in glamorous industries, but in their fields they are as famous as household name companies simply by virtue of being great at what they do. They are the hidden champions of job growth and innovation, the real muscle of the American economy," says Inc. magazine Editor Eric Schurenberg.
AvePoint has helped more than 10,000 organizations across 63 c
|Source: PRWeb
Copyright©2012 Vocus, Inc.
All rights reserved


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Child 'still helping others' through the Joseph Thomas Memorial Foundation Triathlon
Information on the Joseph Thomas Memorial Foundation can be found at its website, www.Josephthomasfoundation.org.
The web page includes applications for those needing help, and a list of sponsors.
Also, those interested can email John Thomas, father of Joseph, at firstname.lastname@example.com.
Family and friends came out to Prime Time Family Entertainment Center on Saturday for the sixth annual Joseph Thomas Memorial Triathlon, named in honor of the 6-year-old who died in 2007.
Joseph's father, John Thomas, along with others ensure Joseph is remembered with a fundraising triathlon in his name to help medically fragile children. Sponsors and friends used the occasion to come together for a day of fun and fellowship for young people.
Thomas said Joseph was born with dwarfish and had autism, a cleft plate and tracheal difficulties.
"His short life did not keep him from influencing others," Thomas said. "I still see nurses who attended to him when he was in the hospital." He said the nurses remembered Joseph's infectious smile even when he was so sick and near death.
Thomas and his late wife, Erin, started the foundation to raise money for fragile children with special needs. Among the numerous sponsors are H-E-B., the Abilene Reporter-News, Dean Baird Insurance, Prime Time, and others who contribute to the event.
The triathlon was free to participants, and kids could bowl and play skee ball or miniature golf. And that was the triathlon — not the traditional running, swimming and biking ordeal.
Joseph's grandparents, Danny and Roenna Thomas, along with his great-grandparents, Leon and Zenita Gardner, came from Sylvester to help with the event.
"We raised about $20,000 to help buy equipment such as special chairs, braces, walkers and other supplies for children," Roenna Thomas said.
"This event means a lot to me," Zenita Gardner said. "It means that Joseph is still helping others."
John Thomas' daughter, Emma, 13, a student at Wylie Middle School, has dwarfism. She has medical problems and has temporarily lost her voice. That did not keep her from enjoying the day.
Asked about her favorite time of the school day, Emma smiled and put her hand to her mouth as if eating.
"She likes lunchtime," Roenna Thomas said and laughed.
Breanna Hodges, 11, pushed her walker up to the bowling lane, picked up a ball and, using special equipment, knocked most of the pins down.
"I think I got a spare," she said with a big smile. She has undergone numerous surgeries; her last one was in Dallas last summer.
"This is wonderful that all the kids can be together today and remember Joseph Thomas," said Breanna's mother, Fransuelle Hodges.
Jase Brown Leddy, 23, Abilene, also was bowling.
"It is a lot of fun," he said as his mom and dad, Jim and Arlene Leddy, watched.
"I am excited that the young people get a chance to participate and help raise funds for the Joseph Thomas Foundation," Arlene Leddy said.
John Thomas said the event was a great success and he praised the sponsors and friends for their help.
"Joseph is still making a difference in others even though he has passed," Thomas said. "It means a lot to me to see that Joseph is still helping others."
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Southwestern Vermont Medical Center's Cancer Program Accredited with Commendation
BENNINGTON — Patients seeking the best in cancer care look for programs accredited by the Commission on Cancer (CoC) of the American College of Surgeons (ACoS). The cancer program at Southwestern Vermont Medical Center (SVMC) recently received renewed accreditation with commendation. Applying for and maintaining this accreditation is a voluntary commitment that ensures the patients to have access to the full scope of services required to diagnose, treat, rehabilitate, and support patients and their families.
"The accreditation shows that our cancer program is dedicated to providing top quality care to our patients," stated Dr. Orion Howard, medical director of the cancer center. "Our cancer program continues to offer comprehensive cancer care services that are close to home."
To qualify for accreditation, cancer programs must pass a rigorous examination of 36 standards. These standards pertain to quality and thoroughness of cancer care. CoC accreditation ensures that cancer care is comprehensive. To be approved, cancer programs must include prevention, early diagnosis, pretreatment evaluation, staging, optimal treatment, and rehabilitation. In addition, they must provide checks for the return of disease, support services, and end-of-life care. Approved programs also must demonstrate that surgeons, medical and radiation oncologists, diagnostic radiologists, pathologists, and other cancer specialists communicate regularly about patient care.
The Accreditation Program, a component of the CoC, sets quality-of-care standards for cancer programs and reviews the programs to ensure they conform to those standards. Accreditation by the CoC is given only to those facilities that have voluntarily committed to providing the highest level of quality cancer care and that undergo a rigorous evaluation process and review of their performance. To maintain accreditation, facilities with CoC-accredited cancer programs must undergo an on-site review every three years.
The cancer program provides patients access to clinical trials. Through them, patients have access to the very latest treatments. Southwestern Vermont Regional Cancer Center works with the National Cancer Institute and drug companies to offer hundreds of trials. Many are the same treatments found at major cancer centers throughout the country.
"To receive commendation on top of our accreditation places the cancer center among the best community cancer programs in New England," stated Thomas Dee, President and CEO of Southwestern Vermont Health Care. "This sets us at a level of expertise that not all cancer centers can offer."
As part of Southwestern Vermont Health Care's not-for-profit family, Southwestern Vermont Regional Cancer Center is supported in part by the generosity of donors. To make a donation, call Southwestern Vermont Health Care at (802) 447-5017.
Southwestern Vermont Health Care is a non-profit community health system made up of Southwestern Vermont Medical Center, Southwestern Vermont Regional Cancer Center, the Centers for Living and Rehabilitation, the VNA & Hospice of SVHC, the SVMC Northshire Campus, the SVMC Deerfield Valley Campus, and other medical practices. As a non-profit, SVHC exists solely for the benefit of the communities it serves and depends on donations of all sizes to help it achieve its reputation for excellence and provide care for all who seek it regardless of their ability to pay.
Photo caption: A dedicated oncology team, including the cancer center medical director, Dr. Orion Howard (center) meet to review and discuss patient files to evaluate each patient's specific situation and progress. The team routinely meets as part of the voluntary commitment for accreditation in providing quality cancer care to patients.


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Martin, who is 27 and from Main Street, Kesh, is accused of wilfully neglecting and allowing the death of her daughter Millie Martin, while her 33-year-old former partner Barry 'Budgie' McCarney of Woodview Crescent, Trillick, denies murdering and sexually and physically abusing her.
Their Dungannon Crown Court trial heard that initially police questioned Millie's mother, not as a suspect, but as a witness, following the child's death from severe head injuries on December 11, 2009.
Martin admitted to detectives that she had loved McCarney, and agreed with them that there was "nothing more important than your child's life".
When asked was there "anyone you would cover for", Martin replied: "Definitely not ....definitely not", particularly where Millie was concerned.
Millie, she told detectives, "was my life and still is".
She was directly asked about McCarney, and "would you do anything for him?"
Martin answered with an emphatic: "No."
She said her relationship with McCarney was "good" and described him as "sound", but maintained that Millie came first and that she "would not think twice" about questioning McCarney or anyone she suspected of harming her.
Martin explained that she had just "loved, loved every minute" of being a mother and bringing Millie up, and while at times it could be difficult it was "rewarding though".
Earlier the court heard that Martin had told police that when she put Millie to bed for the last time, she was "all right".
"I put her to bed and gave her a kiss and a hug and she was all right," Martin told police during a video-taped interview.
Later she added: "I gave her a kiss and a cuddle and down she goes....she is sleepy....she was still all right."
The jury of nine men and three women have already heard that shortly afterwards, Martin went out to buy a KitKat, and by the time she returned home, Millie was already being rushed to hospital.
She said she was "away literally minutes" and returned to find their home empty, and then she noticed she had "a missed call" on her mobile before it rang and it was McCarney telling her: "Quick .... quick get to the hospital ..... the child's not breathing."
"I just got into hysterics," she told detectives.
Later she described that when given the devastating news that Millie may have been "tampered with", she was "physically sick to the core".
Martin said she "couldn't believe it", and because she had no explanation for any possible sexual assault, "that's how I couldn't believe it".
Martin told police that in the days leading up to her death Millie, who loved nothing more than "getting cuddles", was her usual self, "dancing, running, walking around and stuff".
However, that last morning she was still drowsy when she wakened and her mother "just thought she was tired".
Both mother and toddler then went to her grandmother's, and while she also did not think Millie was well, put it down to the possible onslaught of flu.
According to Martin, Millie then went through a cycle of one moment "picking-up" and the next appearing sleepy and drowsy again, and vice-versa.
However, Martin also revealed that at times Millie was off her food, and she worried about her so she put her on a course of multi-vitamins.
On the evening Millie was rushed to hospital by McCarney, the child had been alone in their Glebe Park home in Enniskillen with him twice, first when Martin went to a local chip shop, and then when she went out to buy KitKat.
Martin told police when she went to the chip shop she left Millie sitting on McCarney's knee on an armchair.
Afterwards, while she ate her chips, Millie played on the floor with an empty burger box.
Martin said that normally Millie was given her supper before being washed, changed and put to bed, but because she was unwell, she only took her bottle and had her nappy changed.
Asked by police if she had noticed anything around Millie's genital area when her nappy was being changed, Martin said there was nothing to cause her any worry.
The case continues.


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Model Kate Upton joins cover star Kristen Stewart in the Spring Preview edition of V magazine, looking gorgeously retro and clothed in the likes of Balenciaga, Marc Jacobs, and Louis Vuitton. The camera follows Upton on an illicit afternoon affair at a hotel with a boyish companion (culminating in a rebuke from none other than the maid) in an attempt to embody Spanish filmmaker Luis Bunuel's "bored, bourgeois beauty," says the magazine.
Upton confessed in Vogue UK this month that she has trouble with the less-than-ample undergarments provided on photoshoots for her enviable physique, but from the looks of this editorial — which features Upton and model Liam Dean in rumpled sheets, tousled hair, and various states of undress — stylist Julia von Boehm has figured it out. Her much-discussed decolletage appears well-supported, and Upton gives Christina Hendricks a run for her money in the sultry 60's vixen department.
Upton was shot by photographer Sebastian Faena (the two worked together for the very naked cover of Muse magazine last spring as well), with hair and makeup by Didier Malige and Jeannine Lobell, respectively. Click through the pictures below for a better look.
Image title
this is some kind of spaceship or something.


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Rosacea is a chronic skin condition that makes your face turn red. It may also cause swelling and skin sores that look like acne.
Alternative Names
Acne rosacea
The cause is not known. You may be more likely to have this if you are
- Age 30-50
- Fair-skinned
- A woman (men will often have more severe symptoms)
Rosacea involves swelling of the blood vessels just under the skin. It may be associated with other skin disorders (acne vulgaris, seborrhea) or eye disorders (blepharitis, keratitis).
- Redness of the face
- Blushing or flushing easily
- A lot of spider-like blood vessels (telangiectasia) of the face
- Red nose (called a bulbous nose)
- Acne-like skin sores that may ooze or crust
- Burning or stinging feeling in the face
- Irritated, bloodshot, watery eyes
Exams and Tests
Your health care provider can often diagnose rosacea by doing a physical exam and asking questions about your medical history.
There is no known cure for rosacea.
Your health care provider will help you identify the things that make your symptoms worse. These are called triggers. Triggers vary from person to person. Avoiding your triggers may help you prevent or reduce flare-ups.
Some things you can do to help ease or prevent symptoms include:
- Avoid sun exposure. Use sunscreen every day.
- Avoid a lot of activity in hot weather.
- Try to reduce stress. Try deep breathing, yoga, or other relaxation techniques.
- Limit spicy foods, alcohol, and hot beverages.
Other triggers may include wind, hot baths, cold weather, specific skin products, exercise, or other factors.
- Antibiotics taken by mouth (such as tetracycline, minocycline, or doxycycline) or applied to the skin (such as metronidazole) may control acne-like skin problems.
- Other medicines (isoretinol or Accutane), which are similar to vitamin A, are stronger drugs that your health care provider might consider.
- Rosacea is not acne and will not improve with over-the-counter acne treatment.
In very bad cases, laser surgery may help reduce the redness. Surgery to remove some swollen nose tissue may also improve your appearance.
Outlook (Prognosis)
Rosacea is a harmless condition, but it may cause you to be self-conscious or embarrassed. It cannot be cured, but may be controlled with treatment.
Possible Complications
- Lasting changes in appearance (for example, a red, swollen nose)
- Lower self-esteem
Habif TP. Acne, rosacea, and related disorders. In: Habif TP, ed. Clinical Dermatology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 7.
Goldgar C, Keahey DJ, Houchins J. Treatment Options for Acne Rosacea. Am Fam Phys. 2009 Sep;80(5).
van Zuuren EJ, Kramer S, Carter B, Graber MA, Fedorowicz Z. Interventions for rosacea. Cochrane Database Syst Rev. 2011;(3);CD003262. DOI: 10.1002/14651858.CD003262.pub4.
Last reviewed 8/29/2013 by Linda J. Vorvick, MD, Medical Director and Director of Didactic Curriculum, MEDEX Northwest Division of Physician Assistant Studies, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington. Also reviewed by David Zieve, MD, MHA, Bethanne Black, and the A.D.A.M. Editorial team.
- The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.
- A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions.
- Call 911 for all medical emergencies.
- Links to other sites are provided for information only -- they do not constitute endorsements of those other sites.
©1997 - A.D.A.M., Inc.Any duplication or distribution of the information contained herein is strictly prohibited.


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Fowler Sims, Linda
Director, Career Services and Outreach
- Room: 121B
- Telephone: 313-596-0232
•J.D., Vanderbilt University
• B.A., Early Childhood Education, University of Michigan
After graduation from the University of Michigan, Ms. Sims taught kindergarten in the Inkster Public School system. She returned to Detroit after earning her J.D. from Vanderbilt to clerk for the Honorable Anna Diggs Taylor, United States District Court for the Eastern District of Michigan. Following a two-year clerkship, she worked at the University of Michigan Law School in the offices of student services and admissions. She continued in law school academia at Wayne State University Law School as Assistant Dean for Recruitment and Admissions. While at Wayne State, Ms. Sims served as a Trustee for the Women Lawyers Association of Michigan and the Board of Advisors for the American Institute for Paralegal Studies. Ms. Sims left Wayne State to serve as the inaugural Associate Dean for Student Services at North Carolina Central University School of Law in Durham, North Carolina. In this position, she was in charge of Admissions, Career Services, Student Affairs, and Financial Aid. After five years, Ms. Sims returned home to Michigan to join the Career Services team at UDM School of Law as the Employer Outreach Specialist. In 2013, she became the Director of Career Services and Outreach. In that capacity, she helps create programs for the students that lead to employment opportunities, serves as the lead judicial clerkship advisor, and counsels students pursuing public interest careers.
Ms. Sims has served on numerous panels throughout the country and is a member of the State Bar of Michigan; Delta Sigma Theta Sorority, Incorporated; the Boys and Girls Club of Durham; and Phi Alpha Delta International Legal Fraternity.


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