PURPOSE: The goal of this study is to determine whether the magnitude of overlap between planning target volume (PTV) and rectum (Rectumoverlap) or PTV and bladder (Bladderoverlap) in prostate cancer volumetric-modulated arc therapy (VMAT) is predictive of the dose-volume relationships achieved after optimization, and to identify predictive equations and cutoff values using these overlap volumes beyond which the Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) dose-volume constraints are unlikely to be met. MATERIALS AND METHODS: Fifty-seven patients with prostate cancer underwent VMAT planning using identical optimization conditions and normalization. The PTV (for the 50.4 Gy primary plan and 30.6 Gy boost plan) included 5 to 10 mm margins around the prostate and seminal vesicles. Pearson correlations, linear regression analyses, and receiver operating characteristic (ROC) curves were used to correlate the percentage overlap with dose-volume parameters. RESULTS: The percentage Rectumoverlap and Bladderoverlap correlated with sparing of that organ but minimally impacted other dose-volume parameters, predicted the primary plan rectum V45 and bladder V50 with R(2) = 0.78 and R(2) = 0.83, respectively, and predicted the boost plan rectum V30 and bladder V30 with R(2) = 0.53 and R(2) = 0.81, respectively. The optimal cutoff value of boost Rectumoverlap to predict rectum V75 >15% was 3.5% (sensitivity 100%, specificity 94%, p < 0.01), and the optimal cutoff value of boost Bladderoverlap to predict bladder V80 >10% was 5.0% (sensitivity 83%, specificity 100%, p < 0.01). CONCLUSION: The degree of overlap between PTV and bladder or rectum can be used to accurately guide physicians on the use of interventions to limit the extent of the overlap region prior to optimization.
Humans ; Linear Models ; Organs at Risk* ; Prostate* ; Prostatic Neoplasms* ; Radiation Injuries ; Radiotherapy Planning, Computer-Assisted ; Radiotherapy, Intensity-Modulated* ; Rectum ; ROC Curve ; Seminal Vesicles ; Sensitivity and Specificity ; Urinary Bladder

Thyroid nodules are very common and found in up to 68% of the general U.S. population on ultrasound. Although thyroidectomy has long been the mainstay of treatment for malignant and symptomatic benign thyroid nodules, various interventional ablative techniques have emerged in the last couple of decades as alternative non-surgical treatment options. Globally, the most widely adopted technique has been ultrasound-guided radiofrequency ablation (RFA). RFA of thyroid nodules was first performed in 2002, and there has been an expanding body of evidence since 2006 showing that RFA and other interventional ablative techniques are effective treatments for benign solid thyroid nodules, toxic adenomas, and thyroid cysts. More recently, evidence has emerged that these techniques may be effective treatment for low-risk thyroid cancer and recurrent disease. Despite these findings, the United States has been slow to adopt these techniques, with only a single publication on RFA more than a decade after the first series was published. EM Rogers’ Diffusion of Innovation Theory provides us the appropriate lens to carefully analyze the process of adoption of RFA for thyroid nodules-to understand where we are currently, as well as, the important next steps that must be accomplished in order for RFA and other ablative techniques to be successfully adopted into the management algorithm of thyroid nodules in the United States.

PURPOSE: The aim of this study was to clarify the relationship between the autonomic nervous system and attention deficit hyperactivity disorder (ADHD) rating scales and to evaluate the usefulness of heart rate variability (HRV) as a psychophysiological biomarker for ADHD. MATERIALS AND METHODS: Subjects were recruited from outpatients in the Department of Child and Adolescent Psychiatry at the Korea University Medical Center from August 2007 to December 2010. Subjects received methylphenidate. Time- and frequency-domain analyses of HRV, the Korean ADHD rating scale (K-ARS), and computerized ADHD diagnostic system were evaluated before treatment. After a 12-week period of medication administration, we repeated the HRV measurements and K-ARS rating. RESULTS: Eighty-six subjects were initially enrolled and 37 participants completed the 12-week treatment and HRV measurements subsequent to the treatment. Significant correlations were found between the K-ARS inattention score and some HRV parameters. All of the HRV parameters, except the standard deviations of the normal-to-normal interval, very low frequency, and low frequency to high frequency, showed a significant positive correlation between baseline and endpoint measures in completers. High frequency (HF) and the square root of the mean squared differences of successive normal-to-normal intervals (RMSSD), which are related to parasympathetic vagal tone, showed significant decreases from baseline to endpoint. CONCLUSION: The HRV test was shown to be reproducible. The decrease in HF and RMSSD suggests that parasympathetic dominance in ADHD can be altered by methylphenidate treatment. It also shows the possibility that HRV parameters can be used as psychophysiological markers in the treatment of ADHD.
Adolescent ; Attention/drug effects/*physiology ; Attention Deficit Disorder with Hyperactivity/diagnosis/*drug therapy ; Autonomic Nervous System/physiopathology ; Biomarkers ; Central Nervous System Stimulants/pharmacology/*therapeutic use ; Child ; Female ; Heart Rate/*drug effects/physiology ; Humans ; Male ; Methylphenidate/pharmacology/*therapeutic use ; Prospective Studies ; Republic of Korea ; Treatment Outcome

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease with synovitis and extra-articular systemic involvement. Chronic RA treatment is challenging and represents a major health burden worldwide. Recent insights regarding RA pathogenesis have led to novel therapeutic agents, especially biologics. Furthermore, accumulating experience and new clinical studies have helped to inform updated recommendations for treatment of RA. Recently, treatment guidelines from the American College of Rheumatology were released. Here, we review these guidelines and their application to daily practice.

Epigenetics is defined as an inheritable effect that influences gene activity, but does not involve a change in DNA sequence. Epigenetic gene regulation has an essential role in determining individual gene function and activity in each specific cell type. Epigenetics includes four predominant mechanisms: DNA methylation, histone modification, nucleosome positioning and microRNA (miRNA). These mechanisms influence gene expression, cell differentiation, proliferation, DNA repair and replication. Epigenetic modifications are far more sensitive to environmental stimuli than DNA sequence alterations. Candidate gene approaches have identified a small set of genes that undergo epigenetic changes, such as aberrant DNA demethylation, histone modification, as well as regulation by miRNA in rheumatic diseases. It is well known that T cells from patients with SLE or RA, as well as synovial fibroblasts from individuals with RA, have sequences undergoing DNA hypomethylation and/or histone modifications. In addition, miRNA regulates the gene expression by pairing with its target mRNAs and is often deregulated in systemic rheumatic diseases. High-throughput approaches are necessary for screening the epigenetic alterations, and it is essential to screen the specific tissue and cell types that are relevant to the disease pathogenesis. Identification of cell-specific targets of the epigenetic deregulation in rheumatic disorders will provide clinical markers for the diagnosis, disease progression and response to therapy. Our understanding of epigenetics is in its infancy. New generation of pharmaceuticals, which manipulate the epigenome to the switch targeted genes on or off are under investigation. The new field of repairing or optimizing the epigenome through epigenetic modifier and/or diet is wide open.
Autoimmune Diseases ; Base Sequence ; Biomarkers ; Cell Differentiation ; Diet ; Disease Progression ; DNA ; DNA Methylation ; DNA Repair ; Epigenomics ; Fibroblasts ; Gene Expression ; Histone Code ; Histones ; Humans ; Mass Screening ; MicroRNAs ; Nucleosomes ; Rheumatic Diseases ; RNA, Messenger ; T-Lymphocytes

This new classification system redefines the current paradigm of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and ankylosing spondylitis (AS), by focusing on the features of the disease at earlier stages. The new classification criteria of RA was devised to facilitate early diagnosis. They include the use of positive anti-cyclic citrullinated peptide antibody test and the presence of the increased level of acute phase reactants such as erythrocyte sedimentation rate and c-reactive protein. As compared to the old criteria in which only plain radiography was used to determine the joint damage, ultrasound can be regarded as a valuable tool for examining the extent of synovitis in the new criteria. In terms of SLE, immunologic criteria were intensified in the new classification criteria. They include hypocomplementemia as a single criterion and the presence of anti beta2GPI antibody is considered to meet the antiphopholipid antibody criterion. The new concept of neuropsychiatric lupus is applied as well. The most recent classification criteria for AS were provided by Assessment of Spondyloarthritis International Society. They cover the whole spectrum of axial spondyloarthritis (SpA) and peripheral SpA and use magnetic resonance imaging as an important tool to assess early sacroiliac changes. In addition, they emphasize the presence of HLA-B27 gene as an important criterion. In order to prevent the undesirable organ damages, it is crucial to diagnose rheumatic diseases at early stages according to these new classification criteria and to start an early aggressive treatment. The accurate diagnosis and early targeted therapies will contribute to the improved quality of life and increased overall survival of the patients with rheumatic diseases.
Acute-Phase Proteins ; Arthritis, Rheumatoid ; Blood Sedimentation ; C-Reactive Protein ; Early Diagnosis ; HLA-B27 Antigen ; Humans ; Joints ; Korea ; Lupus Erythematosus, Systemic ; Magnetic Resonance Imaging ; Quality of Life ; Rare Diseases ; Rheumatic Diseases ; Spondylitis, Ankylosing ; Synovitis

Korean Americans (KAs) with psychiatric service needs underutilizes the mainstream mental health services in United States (US). Barriers to mental health service access among KAs reflect their unique heritage and culture. More than two-thirds of KAs identify themselves as Christians, and Korean clergy have influential roles in daily lives of vast majority of KAs. By working with the Korean clergy, a small voluntary organization such as the Association of Korean American Psychiatrists could provide invaluable assistance in removing the barriers to mental health services for KAs.
Asian Americans* ; Clergy ; Emigrants and Immigrants* ; Emigration and Immigration ; Humans ; Mental Health Services* ; Psychiatry ; United States

No abstract available.
Cervical Vertebrae/*injuries ; Humans ; Male ; Middle Aged ; Neck Pain/*etiology ; Spinal Fractures/*diagnosis ; Spondylitis, Ankylosing/*complications

Since the time of its inception within facial anatomy, wide variability in the terminology as well as the location and extent of retaining ligaments has resulted in confusion over nomenclature. Confusion over nomenclature also arises with regard to the subcutaneous ligamentous attachments, and in the anatomic location and extent described, particularly for zygomatic and masseteric ligaments. Certain historical terms—McGregor's patch, the platysma auricular ligament, parotid cutaneous ligament, platysma auricular fascia, temporoparotid fasica (Lore's fascia), anterior platysma-cutaneous ligament, and platysma cutaneous ligament—delineate retaining ligaments of related anatomic structures that have been conceptualized in various ways. Confusion around the masseteric cutaneous ligaments arises from inconsistencies in their reported locations in the literature because the size and location of the parotid gland varies so much, and this affects the relationship between the parotid gland and the fascia of the masseter muscle. For the zygomatic ligaments, there is disagreement over how far they extend, with descriptions varying over whether they extend medially beyond the zygomaticus minor muscle. Even the ‘main’ zygomatic ligament's denotation may vary depending on which subcutaneous plane is used as a reference for naming it. Recent popularity in procedures using threads or injectables has required not only an accurate understanding of the nomenclature of retaining ligaments, but also of their location and extent. The authors have here summarized each retaining ligament with a survey of the different nomenclature that has been introduced by different authors within the most commonly cited published papers.
Cheek* ; Fascia ; Ligaments* ; Masseter Muscle ; Parotid Gland ; Rejuvenation

OBJECTIVE: In this study we utilized the Surveillance, Epidemiology and End-Results (SEER) registry to identify risk factors for lymphatic spread and determine the incidence of pelvic and para-aortic lymph node metastases in patients with uterine papillary serous carcinoma (UPSC) and uterine clear cell carcinoma (UCCC) who underwent complete surgical staging and lymph node dissection. METHODS: Nine hundred seventy-two eligible patients diagnosed between 1998 to 2009 with International Federation of Gynecology and Obstetrics (FIGO) 1988 stage IA-IVA UPSC (n=685) or UCCC (n=287) were identified for analysis. Binomial logistic regression was used to determine risk factors for lymph node metastasis, with the incidence of pelvic and para-aortic lymph node metastases reported for each FIGO primary tumor stage. The Cox proportional hazards regression model was used to determine factors associated with overall survival. RESULTS: FIGO primary tumor stage was the only independent risk factor for lymph node metastasis (p<0.01). The incidence of pelvis-only and para-aortic lymph node involvement according to the FIGO primary tumor stage were as follows: IA (2.3%/3.8%), IB (7.5%/5.2%), IC (22.5%/16.9%), IIA (20.8%/13.2%), IIB (25.7%/14.9%), and III/IV (25.7%/24.3%). Prognostic factors for overall survival included lymph node involvement (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.09 to 1.85; p<0.01), patient age >60 years (HR, 1.70; 95% CI, 1.21 to 2.41; p<0.01), and advanced FIGO primary tumor stage (p<0.01). Tumor grade, histologic subtype, and patient race did not predict for either lymph node metastasis or overall survival. CONCLUSION: There is a high incidence of both pelvic and para-aortic lymph node metastases for FIGO stages IC and above uterine papillary serous and clear cell carcinomas, suggesting a potential role for lymph node-directed therapy for these patients.
Adenocarcinoma, Clear Cell/epidemiology/pathology/*secondary/surgery ; Adult ; Aged ; Aged, 80 and over ; Aorta, Abdominal ; Cystadenocarcinoma, Papillary/epidemiology/pathology/*secondary/surgery ; Cystadenocarcinoma, Serous/epidemiology/pathology/*secondary/surgery ; Female ; Humans ; Incidence ; Kaplan-Meier Estimate ; Lymph Node Excision ; Lymphatic Metastasis ; Middle Aged ; Neoplasm Grading ; Neoplasm Staging ; Pelvis ; SEER Program ; United States/epidemiology ; Uterine Neoplasms/*epidemiology/pathology/surgery