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Radiation Oncology/Skin care

Gels/Creams

 * ALOCANE Plus - Physician Dispensed Only. Active ingredients Lidocaine HCL 4% and Benzalkonium Chloride 0.13%. (Topical Anesthetic/Anti-Microbial Gel used for Radiation Dermatitis. Packaged in 3.5mL single dose foil packs and 50 count pro-packs). Manufacturer: Quest Products
 * Alra Therapy Lotion. Non-Rx; comes in 4 oz. bottle; used in hospitals over 15 years [needs citation]. Manufacturer: Alra.com
 * Remedy Skin Repair Cream Remedy Advanced Skin Care
 * Elta creme Website
 * Glucan Professional Moisturizing Cream - comes in a tube, does not erase skin marks. Manufacturer: Brennen Medical
 * Glucan Pro 3000 - comes in a jar, acts as a better barrier but erases skin marks. Manufacturer: Brennen Medical
 * Silvadene cream
 * Herb to Soothe™ Botanical Cream. Herbal remedy delivers multi-target approach to healing skin.  Manufacturer:  Unitech Medical
 * Udder cream
 * AloePlex Gel. Non-Rx. (Apply to involved skin TID. Supplied as: 3 oz tubes. One month supply = 3-6 tubes). Manufacturer: MPM Medical
 * RadiaPlex Gel. (Apply to involved skin TID. Supplied as: 3 oz tubes. One month supply = 3-6 tubes). Manufacturer: MPM Medical
 * Biafine. Rx. Active ingredient trolamine. (Use TID for radiation dermatitis. supplied as 45g and 90g tubes). Website
 * Studies: See RTOG 99-13 (H&N, PMID 16648511 ), RTOG 97-13 (Breast, PMID 11121627), PMID 11516855 (Phase II, breast)
 * Aquaphor. Eucerin website
 * Xclair. Includes hyaluronic acid. Xclair website
 * Miaderm Radiation Relief. Includes Calendula, hyaluronic acid, and aloe vera. Manufacturer: Miaderm.com

Barriers

 * Remedy Nutrashield Remedy Advanced Skin Care
 * Remedy Calazime Protectant Paste Remedy Advanced Skin Care
 * Remedy Dimethicone Mositure Barrier Remedy Advanced Skin Care
 * Remedy Clear Aid Remedy Advanced Skin Care
 * Vigilon
 * OraMagic Patch (see under Head and Neck care)
 * CoolMagic Gel Sheet. Provides a soothing, cooling effect. (Supplied as: 3.75"x3.75", 6"x8", 8"x12". 10 per box.) Manufacturer: MPM Medical

Skin Fibrosis

 * Montpellier; 2008 (France) PMID 18211604 -- "A randomized, prospective study using the LPG((R)) technique in treating radiation-induced skin fibrosis: clinical and profilometric analysis." (Bourgeois JF, Skin Res Technol. 2008 Feb;14(1):71-6.)
 * Randomized. 20 women, s/p BCS + RT 6-16 months prior. Arm 1) LPG((R)) massage vs. Arm 2) observation
 * Outcome: LPG massage improved erythema, decreased pain and pruritus, decreased feeling of induration, and improved skin softness
 * Conclusion: Improvement after clinical signs after LPG massage

Acute Dermatitis

 * Acute dermatitis was described as early as 1924, and was initially used to guide dosimetry
 * Severe skin reactions typically happen where skin rubs together (e.g. inframammary fold, neck, groin, perineum) or where there are dosimetric hotspots. The hotspots may be deeply subcutaneous, as described by Pignol in their breast IMRT trial correspondence (PMID 18591570)
 * The prevalence of moist desquamation is 30-50%, and may be as high as 60% in patients treated for nasopharyngeal cancer
 * Risk factors include smoking, use of bolus, and concurrent chemotherapy
 * For many decades, skin washing during RT was forbidden. Randomized evidence showed that skin washing is not harmful, and may be beneficial
 * A number of randomized studies evaluated prophylactic use of creams and lotions, but none were overwhelmingly positive
 * It is probably reasonable to use moisturizing creams such as Aloe Vera or Aquaphor (these were the most commonly used products in RTOG 97-13) in Grade I-II dermatitis. For Grade III-IV dermatitis, use of non-adherent absorbent dressings may be considered
 * Hydrogel dressing have resulted in prolonged healing time, with no benefit for symptomatic relief, and should not be used
 * For breast irradiation, axillary deodorant use is comparable in toxicity to no use, and should not be discouraged
 * For cranial irradiation, routine hair washing does not influence development of skin toxicity, and probably should not be discouraged

Axillary deodorant

 * Quebec; 2009 PMID 19327906 -- "Use of axillary deodorant and effect on acute skin toxicity during radiotherapy for breast cancer: a prospective randomized noninferiority trial." (Theberge V, Int J Radiat Oncol Biol Phys. 2009 Nov 15;75(4):1048-52. Epub 2009 Mar 26.)
 * Randomized, non-inferiority trial. 84 patients with breast RT. Arm 1) deodorant use vs. Arm 2) no deodorant.
 * Outcome: Grade 2 axilla dermatitis deodorant 23% vs. no deodorant 30% (NS); Grade 2 breast dermatitis 30% vs. 34% (NS); no Grade 3+ dermatitis. Sweating deodorant 18% vs no deodorant 39% (SS)
 * Conclusion: No evidence to prohibit deodorant use during breast RT

APP cream

 * St. Jude's; 2007 PMID 18093332 -- "A phase III trial comparing an anionic phospholipid-based cream and aloe vera-based gel in the prevention of radiation dermatitis in pediatric patients." (Merchant TE, Radiat Oncol. 2007 Dec 19;2:45.)
 * Randomized. 45 patients, irradiated to at least 23.4 Gy (mean 34 Gy), age >3 years. Two creams applied to each patient by nursing staff, site randomly chosen prior to treatment. Arm 1) anionic polar phospholipid (APP) based cream (made by Ocular Research of Boston, Boston, MA) vs. Arm 2) aloe vera-based cream
 * Outcome: Grouped scores better for APP cream. Dryness and peely skin also better for APP cream
 * Conclusion: APP cream is more effective than aloe-vera based gel

Hydrogel (moist) dressing

 * Edinburgh; 2007 (UK) PMID 17363185 -- "Randomized comparison of dry dressings versus hydrogel in management of radiation-induced moist desquamation." (Macmillan MS, Int J Radiat Oncol Biol Phys. 2007 Jul 1;68(3):864-72. Epub 2007 Mar 23.)
 * Randomized. 357 patients with breast (63%), H&N (30%) or anorectal CA. Arm 1) simple dry dressings vs. Arm 2) hydrogel (Intrasite). Started using from onset of moist desquammation. Prevalence of moist desquammation 28%, mean 32 days after starting treatment
 * Outcome: Time-to-healing significantly worse. No impact on subjective symptoms (pain, burning, sleep). Compliance significantly better with hydrogel dressing (93% vs. 63%)
 * Conclusion: Hydrogel dressing are worse than dry dressings, with prolonged healing time

 * Prince of Wales; 2000 (Hong Kong) PMID 10851773 -- "The effects of hydrocolloid dressing and gentian violet on radiation-induced moist desquamation wound healing." (Mak SS, Cancer Nurs. 2000 Jun;23(3):220-9.)
 * Randomized. 39 patients, 60 moist desquamation wounds. Arm 1) hydrocolloid (moist) dressing vs. Arm 2) gentian violet (control).
 * Outcome: No difference between the groups; substantially worse patient satisfaction with gentian violet due to discoloration and drying
 * Conclusion: No difference; patients should decide which they prefer

XClair

 * Rome; 2006 PMID 16980242 -- "A double-blind, vehicle-controlled clinical study to evaluate the efficacy of MAS065D (XClair), a hyaluronic acid-based formulation, in the management of radiation-induced dermatitis." (Primavera G, Cutan Ocul Toxicol. 2006;25(3):165-71.)
 * Randomized. Patients with BCA. Arm 1) control vs. Arm 2) Xclair
 * Outcome: Xclair significantly better for radiation dermatitis and erythema. No difference in pain and itch. Both patients and investigators preferred Xclair
 * Conclusion: Xclair can be an effective option for managing radiation dermatitis

Beclomethasone Spray

 * Ratan Hospital; 2006 (India) PMID 17192690 -- "Prophylactic beclomethasone spray to the skin during postoperative radiotherapy of carcinoma breast: a prospective randomized study." (Shukla PN, Indian J Cancer. 2006 Oct-Dec;43(4):180-4.)
 * Randomized. 60 patients with BCA treated with 50/25, randomized to beclomethasone spray to irradiated axilla vs. observation
 * Wet desquammation: beclomethasone spray 13% vs. observation 37% (SS)
 * Conclusion: topical steroid during RT reduces risk of wet desquammation

Calendula

 * Lyon; 2004 (France)(1999-2001) PMID 15084618 -- "Phase III randomized trial of Calendula officinalis compared with trolamine for the prevention of acute dermatitis during irradiation for breast cancer." (Pommier P, J Clin Oncol. 2004 Apr 15;22(8):1447-53.)
 * Randomized. 254 patients with BCA. Arm 1) Biafine (control) vs. Arm 2) calendula.
 * Outcome: Grade 2+ acute dermatitis calendula 41% vs. Biafine 63% (SS); also less frequent interruption of RT. Calendula more difficult to apply but self-assessed satisfaction greater
 * Conclusion: Calendula highly effective for prevention of acute Grade 2+ dermatitis

Theta-Cream

 * Munich; 2004 (Germany)(2002) PMID 15127162 -- "Thêta-Cream versus Bepanthol lotion in breast cancer patients under radiotherapy. A new prophylactic agent in skin care?" (Roper B, Strahlenther Onkol. 2004 May;180(5):315-22.)
 * Randomized. 20 patients with BCA. Arm 1) Theta-Cream vs. Arm 2) Bepanthol lotion (control). Evaluated by modified RTOG criteria and photography
 * Outcome: No difference between groups. Theta-Cream trend to worse skin markings, and mild itchiness
 * Conclusion: Theta-Cream not better, more expensive, and trend to worse outcome

Nonadherent Dressings

 * Prince of Wales; 2005 (Hong Kong)(2001-2003) PMID 16330964 -- "A comparison of wound treatments in nasopharyngeal cancer patients receiving radiation therapy." (Mak SS, Cancer Nurs. 2005 Nov-Dec;28(6):436-45.)
 * Randomized. 146 patients with nasopharyngeal CA, who developed moist desquammation. Arm 1) nonadherent absorbent dressings vs. Arm 2) gentian violet (control). Daily cleansing with 0.9% saline. Evaluated wound healing, presence of infectin, social isolation, sleep, neck mobility
 * Outcome: No difference in any outcome; trend to higher wound pain with gentian violet
 * Conclusion: Nonadherent absorbent dressing can be considered for moist desquamation

Aloe Vera

 * Miami; 2001 PMID 11338761 -- "The effect of aloe vera gel/mild soap versus mild soap alone in preventing skin reactions in patients undergoing radiation therapy." (Olsen DL, Oncol Nurs Forum. 2001 Apr;28(3):543-7.)
 * Randomized. Arm 1) skin clense with mild unscented soap vs. Arm 2) soap + aloe very multiple times daily.
 * Outcome: No difference if dose <27 Gy; for dose >27 Gy, longer time-to-skin change soap 3 weeks vs. soap + aloe 5 weeks
 * Conclusion: Protective effect for adding aloe to soap

 * NCCTG; 1996 (1990-1991, 1992-1993) PMID 8892458 -- "Phase III double-blind evaluation of an aloe vera gel as a prophylactic agent for radiation-induced skin toxicity." (Williams MS, Int J Radiat Oncol Biol Phys. 1996 Sep 1;36(2):345-9.Related Articles, Links
 * Randomized. Breast cancer patients. Two separate randomizations: Trial 1 (n=194): Arm 1) aloe vera gel vs. Arm 2) placebo gel. After negative result, Trial 2 (n=108): Arm 1) aloe vera gel vs. Arm 2) no treatment. Minimum RT dose 50 Gy. Gel applied BID on starting RT. Skin dermatitis scored weekly by patients and health-care providers
 * Outcome: Trial 1: no difference between aloe vera gel and placebo. Trial 2: no difference between aloe vera gel and no treatment
 * Conclusion: Aloe vera gel (and placebo gel) do not protect against radiation-induced dermatitis

Biafine

 * RTOG 99-13; 2006 (2000-2002) PMID 16648511 -- "Phase III Trial of an emulsion containing trolamine for the prevention of radiation dermatitis in patients with advanced squamous cell carcinoma of the head and neck: results of Radiation Therapy Oncology Group Trial 99-13." (Elliott EA, J Clin Oncol. 2006 May 1;24(13):2092-7.)
 * Randomized, 3 arms. 547 patients with locally advanced H&N cancers. RT >=50 Gy. Arm 1) prophylactic trolamin emulsion TID starting 1st day of RT vs. Arm 2) interventional trolamine emulsion once symptomatic vs. Arm 3) declared institutional management (14 different products: Aquaphor 39%, gel 24%, cream 16%, corticosteroid 11%, other 10%)
 * Outcome: Grade 2+ radiation dermatitis prophylactic arm 79% vs. interventional arm 77% vs. institutional management 79% (NS)
 * Conclusion: No advantage for use of trolamin (Biafine) in reducing RT dermatitis over local standard of care

 * Beilinson; 2001 (Israel) PMID 11182045 -- "Topical Biafine and Lipiderm for the prevention of radiation dermatitis: a randomized prospective trial." (Fenig E, Oncol Rep. 2001 Mar-Apr;8(2):305-9.)
 * Randomized. 74 patients with BCA. Arm 1) Biafine vs. Arm 2) Lipiderm vs. Arm 3) no treatment. Ointments started 10 days prior to RT, applied BID. Endpoints evaluated were maximal skin toxicity, gaps in RT, impression of patients, subjective skin reaction, RN score and MD score.
 * Outcome: No difference in all endpoints among all 3 groups
 * Conclusion: Neither Biafine nor Lipiderm have a radioprotective effect

 * RTOG 97-13; 2000 (1998) PMID 11121627 -- "Randomized phase III study comparing Best Supportive Care to Biafine as a prophylactic agent for radiation-induced skin toxicity for women undergoing breast irradiation: Radiation Therapy Oncology Group (RTOG) 97-13." (Fisher J, nt J Radiat Oncol Biol Phys. 2000 Dec 1;48(5):1307-10.)
 * Randomized. 172 patients with BCA. Arm 1) Biafine vs. Arm 2) best supportive care (typically Aquaphor or Aloe Vera). Biafine applied TID, starting after first treatment.
 * Outcome: No difference. RTOG 0 Biafene 9% vs. BCS 7%; RTOG 1 50% vs. 58%; RTOG 2 41% vs. 32%; RTOG 3 0% vs. 3% (NS).
 * Large breast size: Biafine better. RTOG 0 Biafene 52% vs. BCS 10%; RTOG 1 48% vs. 80%; RTOG 2 0% vs. 10%
 * Conclusion: No overall difference between Biafine and best supportive care

Hyaluronic Acid

 * Switzerland; 1997 PMID 9106924 -- "Double-blind, randomized clinical study comparing hyaluronic acid cream to placebo in patients treated with radiotherapy." (Liguori V, Radiother Oncol. 1997 Feb;42(2):155-61.)
 * Randomized. 134 patients with H&N, breast, or pelvic CA. Arm 1) hyaluronic acid cream vs. Arm 2) placebo. mean RT dose 62 Gy
 * Outcome: acute radio-epithelitis significantly lower with hyaluronic acid. Both patient and physician preference for hyaluronic acid. No difference in tolerance
 * Conclusion: Prophylacit hyaluronic acid reduces high grade dermatitis

Dexpanthenol (Bepanthen)

 * Norwegian Radium Hospital; 1996 PMID 9023388 -- "Skin treatment with bepanthen cream versus no cream during radiotherapy--a randomized controlled trial." (Lokkevik E, Acta Oncol. 1996;35(8):1021-6.)
 * Randomized. 79 patients, breast (n=63) and H&N (n=16). Arm 1) dexpanthenol cream vs. Arm 2) nothing. Applied on parts of treatment field for each patient.
 * Outcome: No difference by EORTC/RTOG grade or itching/pain
 * Conclusion: No clinically important benefit for using Bepanthen cream

Sucralfate cream

 * Dundee; 2004 (UK) PMID 15542162 -- "Does aqueous or sucralfate cream affect the severity of erythematous radiation skin reactions? A randomised controlled trial." (Wells M, Radiother Oncol. 2004 Nov;73(2):153-62.)
 * Randomized, 3 arms. 357 patients with H&N, breast, or anorectal CA. Arm 1) aqueous cream vs. Arm 2) sucralfate cream vs. Arm 3) no creme. Start first day of RT. Wash using unperfumed soap
 * Outcome: No difference among 3 groups. Predictors smoking, higher BMI, concurrent chemo, or bolus
 * Conclusion: No benefit for prophylactic aqueous or sucralfate cream

 * Helsinki; 1994 PMID 8204277 -- "Skin protection by sucralfate cream during electron beam therapy." (Maiche A, Acta Oncol. 1994;33(2):201-3.)
 * Randomized. 50 patients with BCA, receiving PMRT electrons to chest wall. Arm 1) sucralfate cream vs. Arm 2) base cream
 * Outcome: Significant prevention of acute dermatitis; significantly faster recover of skin
 * Conclusion: Sucralfate cream significantly better than base cream

Skin powder

 * Tuebingen; 2002 PMID 12122788 -- "Intraindividual comparison of two different skin care conceptions in patients undergoing radiotherapy of the head-and-neck region. Creme or powder?" (Schreck U, Strahlenther Onkol. 2002 Jun;178(6):321-9.)
 * Randomized. 12 patients with H&N. Arm 1) creme vs. Arm 2) powder. Each patient would treat 1/2 neck with creme and other half with powder.
 * Outcome: No difference
 * Conclusion: No difference between cream and powder

Vitamin C

 * CNS Cancer Consortium; 1993 PMID 8514538 -- "A double-blind, randomized, prospective trial to evaluate topical vitamin C solution for the prevention of radiation dermatitis. CNS Cancer Consortium." (Halperin EC, Int J Radiat Oncol Biol Phys. 1993 Jun 15;26(3):413-6.)
 * Randomized. 65 patients with primary/metastatic brain tumors. Arm 1) topical ascorbic acid solution vs. Arm 2) control. All patients both treatments; applied on one vs. other side of head.
 * Outcome: No difference in patient preference, or toxicity score
 * Conclusion: No benefit for ascorbic acid

Chamomile cream

 * Helsinki; 1991 PMID 2036252 -- "Effect of chamomile cream and almond ointment on acute radiation skin reaction." (Maiche AG, Acta Oncol. 1991;30(3):395-6.)

Corticosteroids

 * Uppsala; 2001 (Sweden) PMID 11369066 -- "Potent corticosteroid cream (mometasone furoate) significantly reduces acute radiation dermatitis: results from a double-blind, randomized study." (Bostrom A, Radiother Oncol. 2001 Jun;59(3):257-65.)
 * Randomized. 49 patients with BCA. Arm 1) mometasone furoate cream (moderately potent) vs. Arm 2) emollient cream. Applied twice/week until 12th fraction, then daily. Both groups non-blinded emollient cream daily
 * Outcome: MMF decreased acute radiation dermatitis (SS); no difference in pigmentation
 * Conclusion: Adding MMF to emollient is more effective than emollient alone

 * Penn State; 1982 PMID 7079509 -- "Prophylaxis of radiation dermatitis with a topical cortisone cream." (Potera ME, Radiology. 1982 Jun;143(3):775-7.)
 * Randomized. 19 patients (H&N, chest wall, abdomen). Arm 1) 0.2% hydrocortisone valerate vs. Arm 2) placebo. Applied hydrocortisone to 1/2 treatment field and placebo to other 1/2, starting 2 weeks after initiating RT. RT dose 27.4-62.8 Gy
 * Outcome: No difference in acute skin response, or dermatitis symptoms. No difference in late effects
 * Conclusion: No benefit for prophylactic 0.2% hydrocortisone

 * Sweden; 1967 PMID 4864308 -- "Topical treatment of radiation dermatitis with bethamethasone-17-valerate, vaseline and eucerine--a double-blind comparison." (Bjornberg A, Clin Radiol. 1967 Oct;18(4):463-4.)

 * Germany; 1959 PMID 13659285 -- "[Radiation reaction of the skin in the use of glucocorticoids.]" [Article in German] (Huter KA, Strahlentherapie. 1959 Mar;108(3):475-7.)

Hair Washing

 * Royal Marsden; 2000 (UK) PMID 10699472 -- "Advice on hair and scalp care during cranial radiotherapy: a prospective randomized trial." (Westbury C, Radiother Oncol. 2000 Feb;54(2):109-16.)
 * Randomized. 109 patients undergoing cranial RT. Arm 1) no hair washing vs. Arm 2) routine hair washing. Recorded diary card showed lower frequency in Arm 1
 * Outcome: No difference in acute skin reactions
 * Conclusion: Normal hair washing does not increase adverse skin reactions

Skin Washing

 * Quebec; 2001 (Canada) PMID 11230896 -- "The impact of skin washing with water and soap during breast irradiation: a randomized study." (Roy I, Radiother Oncol. 2001 Mar;58(3):333-9.)
 * Randomized. 99 patients with BCA. Arm 1) no washing vs. Arm 2) washing with water/soap.
 * Outcome: Moist desquamation no washing 33% vs. washing 14%. Median scores for pain, itching, burning higher in no washing group though (NS)
 * Conclusion: Washing irradiated skin during RT should not be discouraged

 * Clatterbridge; 1992 (UK) PMID 1554631 -- "Can patients wash during radiotherapy to the breast or chest wall? A randomized controlled trial." (Campbell IR, Clin Oncol (R Coll Radiol). 1992 Mar;4(2):78-82.)
 * Randomized, 3 arms. 99 patients with BCA, some treated with bolus. Arm 1) not washing vs. Arm 2) washing with water alone vs. Arm 3) washing with soap and water.
 * Outcome: Subjective and objective measurements less in the two groups randomized to washing, regardless of bolus
 * Conclusion: Washing of skin should be encouraged in low skin doses

title: Radiation Oncology/Skin care


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Cookbook:Molasses

| Basic foodstuffs | Sweeteners

Molasses is a flavorsome liquid sweetener.

Molasses is produced during the manufacture of sugar. Sugarcane juice is boiled down to crystallize out the sugar it contains. The remaining liquid is light molasses. Light molasses may be processed again to produce more sugar and the less-sweet dark molasses, which in turn may be processed yet again to produce blackstrap molasses. Darker molasses are also stronger in flavor and higher in vitamins and minerals, such as calcium, magnesium, iron, and potassium. Molasses may be sulfured to preserve it; this adds a bad taste though.

When the sugarcane juice is boiled less, with no sugar being removed, the result is cane syrup. Unusually dark cane syrup is often sold as molasses. It can be considered a sort of extra-light molasses, with a milder flavor than true molasses.

Dark treacle is a common substitution for molasses. Since brown sugar is made from sugar with molasses added, brown sugar can be a substitute if plain sugar can be removed from the recipe. One cup of dark brown sugar contains one cup of sugar plus 2 to 8 tablespoons (1/8 to 1/2 cup) of molasses.

Recipes using molasses include

 * Barbecue sauce
 * Hermits
 * Molasses cookies

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

title: Cookbook:Molasses


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Cookbook:Treacle

| Basic foodstuffs

Treacle is a general term for liquid sweeteners produced in the sugar refining process. Black treacle is equivalent to molasses. Light treacle is approximately equivalent to cane syrup and golden syrup. If a recipe specifies neither black nor light treacle, you may wish to assume that the recipe calls for a mixture or that it uses molasses with some sugar added back in.

title: Cookbook:Treacle


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Cookbook:Cane Syrup

| Basic foodstuffs | Sweeteners

Cane syrup is a pale golden liquid sweetener or syrup. It is the sugarcane analog to maple syrup.

Production
The sugarcane is first mashed and strained to extract the liquid cane juice. The juice is then boiled down until concentrated and sweet, stopping shy of crystallizing and extracting the sucrose sugar. This is similar to the process used to make maple syrup, though cane syrup needs more skimming than maple syrup does to prevent cloudiness.

Characteristics
Cane syrup is light golden with a slight caramelized flavor. Unusually thick and dark cane syrup may be sold as molasses—however, cane syrup is usually sweeter than true molasses, since molasses is a later byproduct post-sugar extraction. Still, cane syrup is less sweet than pure granulated sugar.

Use
Cane syrup may be used as a sweetener in various beverages, cooking, and baking, especially those traditional to the American South. It can replace maple syrup for use as a breakfast topping.

Substitution
Several common substitutions exist, though they all have different characteristics that will impact the final product. Maple syrup is the best analog for cane syrup in terms of sweetness, texture, and sugar composition—however, maple syrup's characteristic flavor profile may not be desired. Golden syrup and corn syrup have a more similar flavor profile to that of cane syrup, but they are much thicker and have a different sugar profile (higher in glucose and fructose), which can slightly impact the final texture if used in baked goods. The same is true of light treacle.

title: Cookbook:Cane Syrup


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Cookbook:Golden Syrup

| Basic foodstuffs | Sweeteners

Golden syrup is a moderately thick cane syrup.

Light treacle is often an exact substitute, but may include light molasses.

Substitute with dark corn syrup, light molasses, cane syrup or maple syrup. A more exact substitution can be had by boiling down cane syrup, diluting true light molasses and adding sugar, or diluting a so-called "molasses" that has not had sugar extracted from it.

title: Cookbook:Golden Syrup


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Systems Theory/Cybernetics

What is Cybernetics?
There are many different definitions of Cybernetics and many individuals who have influenced the direction of Cybernetics. Cybernetics takes as its domain the discovery or design and application of principles of regulation and communication. Cybernetics treats ways of behaving and not things. Cybernetics does not ask "what is this thing?" but "what does it do?" and "what can it do?" However, questions may also be posed concerning "how it does what it does" which is reflected in higher orders of cybernetics. Because numerous systems in the living, technological and social world may be understood in this way, Cybernetics is a combination of many traditional disciplines. The concepts which Cyberneticians develop thus form a metadisciplinary language through which we may better understand and modify complex systems.

History
Deriving from the Greek word for steersman (kybernetes), Cybernetics was first introduced by the mathematician Wiener, as the science of communication and control in the animal and the machine (to which we now might add: in society and in individual human beings). It grew out of Shannon's information theory, which was designed to optimize the transfer of information through communication channels (e.g. telephone lines), and the feedback concept used in engineering control systems. A more philosophical definition, suggested in 1958 by Louis Couffignal, one of the pioneers of Cybernetics in the 1930s, considers Cybernetics as "the art of assuring efficiency of action". Cybernetics in General Systems Theory is defined as the study of control within a system, typically using combinations of feedback loops. This can be within machines or living structures. First order Cybernetics relates to closed systems, second order includes the observer perspective and third order looks to how these co evolve. Cybernetics and systems theory study basically the same problem, that of organization independent of the substrate in which it is embodied. Insofar as it is meaningful to make a distinction between the two approaches, we might say that systems theory has focused more on the structure of systems and their models, whereas Cybernetics has focused on how systems function, that is to say how they control their actions, how they communicate with other systems or with their own components. Since structure and function of a system cannot be understood in separation, it is clear that systems theory and Cybernetics should be viewed as two facets of a single approach.

Cybernetics Contributions
The early contributions of Cybernetics were mainly technological, and gave rise to communication technology, feedback control devices, automation of production processes and computers. Another tradition, which emerged from human and social concerns, emphasizes epistemology, how we come to know, and explores theories of self-reference to understand such phenomena as identity, autonomy, and purpose. Some Cyberneticians seek to create a more humane world, while others seek merely to understand how people and their environment have co-evolved. Some Cyberneticians are interested in systems as we observe them, others in systems that do the observing. Some try to develop methods for modelling the relationships among measurable variables. Others seek to understand the dialogue that occurs between models or theories and social systems. Early efforts sought to define and apply principles by which systems may be controlled. More recently, Cyberneticians try to understand how systems describe themselves, control themselves, and organize themselves. Despite its short history, Cybernetics has developed a concern with a wide range of processes involving people as active organizers, as autonomous, and as sharing communicators, responsible individuals. Interest moved soon to numerous sciences, applying Cybernetics to processes of cognition, to such practical pursuits such as psychiatry, family therapy, the development of information and decision systems, government, management, and to efforts to understand complex forms of social organization including communication and computer networks.

Pillars of Cybernetics
Cybernetics theories tend to rest on four basic pillars: circularity, variety, process and observation. Circularity occurs in its earliest theories of circular causation or feedback, later in theories of recursion and of iteration in computing and now involving self-reference in cognitive organization and in autonomous systems of production. This circular form enables Cybernetics to explain systems from within, making no recurse to higher principles or a priori purposes, expressing no preferences for hierarchy. Variety is fundamental to its communication, information and control theories and emphasises multiplicity, alternatives, differences, choices, networks, and intelligence rather than force and singular necessity. Almost all Cybernetic theories involve process and change, from its notion of information, as the difference between two states of uncertainty, to theories of adaptation, evolution and growth processes. A feature of Cybernetics is that it explains such processes in terms of the organization of the system manifesting it, e.g., the circular causality of feedback loops is taken to account for processes of regulation and a system's effort to maintain equilibrium or to reach a goal. Observation including decision making is the process underlying Cybernetic theories of information processing and computing. By extending theories of self-reference to processes of observation including cognition and other manifestations of intelligence, Cybernetics has been applied to itself and is developing an epistemology of systems involving their observers (second-order Cybernetics) qualitatively unlike the earlier interest in the ontology of systems which are observed from the outside (first-order cybernetics).

Focus
While as a meta-theory, the principles and ideas of Cybernetics and Systems Science are intended to be applicable to anything, the "interesting" objects of study that Cybernetics and Systems Science tends to focus on are complex systems such as organisms, ecologies, minds, societies, and machines. Cybernetics and Systems Science regards these systems as complex, multi-dimensional networks of information systems. Cybernetics presumes that there are underlying laws and principles which can be used to unify the understanding of such seemingly disparate types of systems. The characteristics of these systems directly affect the nature of cybernetic theory, resulting in serious challenges to traditional methodology. Some of these characteristics are complexity, mutuality, complementarity, evolvability, constructivity and reflexivity (for additional information consult the appendix). The domain of computing applications has grown so rapidly that labelling anything that uses a computer as "cybernetic" is more obscuring than enlightening. Therefore we would limit the label "cybernetic technology" to those information processing and transmitting tools that somehow increase the general purpose "intelligence" of the user, that is to say the control the user has over information and communication.

The systemic and the analytic approaches are more complementary than opposed, yet neither one is reducible to the other. The analytic approach seeks to reduce a system to its basic elements in order to study in detail and understand the types of interaction that exist between them. By modifying one variable at a time, it tries to conclude general laws that will enable one to predict the properties of a system under very different conditions. To make this forecast possible, the laws of the additivity of elementary properties must be invoked. This is the case in homogeneous systems, those composed of analogous elements and having weak interactions among them. Here the laws of statistics readily apply, enabling one to understand the behaviour of the multitude of disorganized complexity. The laws of the additivity of elementary properties do not apply in very complex systems composed of a large diversity of elements linked together by strong interactions. These systems must be approached by methods such as those which the systemic approach groups together. The purpose of the new methods is to consider a system in its complexity, its totality, and its own dynamics. Through simulation one can "animate" a system and observe in real time the effects of the different kinds of relations among its elements. The study of this behavior leads in time to the determination of rules that can modify the system or design other systems.

Resources and Further Reading

 * PERSPECTIVES ON THE HISTORY OF THE CYBERNETICS MOVEMENT: THE PATH TO CURRENT RESEARCH THROUGH THE CONTRIBUTIONS OF NORBERT WIENER, WARREN McCULLOCH, AND JOHN VON NEUMANN, Rav, Yehuda (Cybernetics & Systems; Dec2002, Vol. 33 Issue 8, p779, 26p)
 * THE ORIGINS AND PURPOSES OF SEVERAL TRADITIONS IN SYSTEMS THEORY AND CYBERNETICS, Umpleby, Stuart A. & Dent, Eric B., Cybernetics & Systems; Mar1999, Vol. 30 Issue 2, p79, 25p
 * CYBERNETIC THEORY DOES NOT EXPLAIN FAMILY AND COUPLE PROCESS: SYSTEMS THEORY AND DIALECTICAL METATHEORY, Moyer, Alfred J., American Journal of Family Therapy; Fall94, Vol. 22 Issue 3, p273, 9p
 * Major systems theories throughout the world, Bahg, Chang-Gen, Behavioral Science; Apr90, Vol. 35 Issue 2, p79, 29p, 5 diagrams, 2 graphs
 * http://www.asc-cybernetics.org/foundations/definitions.htm
 * http://www.worldtrans.org/whole/wholedefs.html
 * http://www.worldtrans.org/whole.html
 * http://web.mit.edu/sdg/www/
 * http://www.well.com/user/dooley/systems.html
 * http://ssie.binghamton.edu/
 * http://carbon.cudenver.edu/~mryder/itc_data/complexity.html
 * http://histm2.free.fr/H.Couffign.htm
 * http://www.calresco.org/glossary.htm
 * http://pespmc1.vub.ac.be/CYBSWHAT.html
 * http://www.hfr.org.uk/cybernetics-pages/origins.htm
 * http://pespmc1.vub.ac.be/ASC/CYBERNETICS.html
 * http://pespmc1.vub.ac.be/ANALSYST.html

title: Systems Theory/Cybernetics


text:
Talk:US History/Bush Clinton

What do John McCain and George W. Bush have to do with George H.W. Bush? Nothing. This is opinion, and irrelevant to a summary history of this President. Also, The comments describing the Presidential campaign are irrelevant, and a matter of [partisan] opinion. A textbook should relay only historical facts. Similarly, "longest peacetime expansion", regarding President Clinton, is hotly debated.

-then edit it

title: Talk:US History/Bush Clinton


text:
Wikijunior:Big Cats/Leopard

The leopard is the champion athlete of the cat world. Most big cats can pull with five times as much force as the same weight of human athletes. The leopard can pull seven times as hard. It would take three Olympic class weightlifters merely to achieve a draw at tug of war with one 100 pound leopard. This amazing strength is demonstrated when a successful hunter scrambles up the side of a tree with a full grown antelope in its jaws to eat in peace.

The leopard gets its name from the ancient Greek words for "lion" (leon) and "panther" (pard).

Where do leopards live?
Leopards live in the Middle East, parts of Asia, and Africa. This means they live in more places than any other big cat. Leopards spend a lot of time in trees, often sleeping draped over a branch. They will even pull entire prey animals up into the branches where they can eat without having to fight off other predators trying to steal their food.

What do leopards look like?
Leopards are usually 6.5-10 feet (2-3 m) long, including 23-43 inches (58-110cm) of tail, and weigh about the same as a human or a large dog, 65-155 pounds (30-70 kg). They stand 17.5–30.5 inches (43-78 cm) tall. Female leopards are usually only two-thirds the size of male leopards.

A leopard's coat is short and sleek. Depending on where it lives, a leopard's coat can be a pale straw color, grey, gold-ish, or black. All leopards have black spots. Because the fur in a leopard's spots is thicker and more coarse, they can be felt as well as seen.

Black leopards are sometimes called panthers, and they were once thought to be a separate species. Though they are all black, they still have the black spots that leopards are famous for. On black leopards, these spots are only slightly darker than the surrounding fur, but under very bright light, they stand out from the lighter, somewhat purplish, background fur.

What do leopards eat, and how do they catch their prey?
Leopards tend to eat antelopes and similarly sized herd animals. They avoid the larger herbivores, such as water buffalo, because the larger beasts can only be safely captured by groups of animals that hunt in teams, such as lions. Leopards also eat smaller animals including rodents, rabbits, and even large insects. Some have been known to eat Nile crocodiles, which are powerful reptiles!

They are known to kill and eat dogs, so those persons who bring a dog into leopard country are advised to cage the dog so that it does not become food for leopards.

Fun facts
But don't ask for a pet leopard. A little house cat or a dog of any size is far safer.
 * In captivity, leopards are the most temperamental of the large cats and can be difficult to handle. While they can be affectionate, they cause an unusually large number of animal-related injuries among caretakers in zoos, circuses, and animal care centers.
 * It is built like and acts much like a house cat, so anyone fascinated by the big cats might as well have a house cat that behaves much the same as a leopard -- except that a house cat can't hurt you a lot when it scratches or bites.
 * One of the funniest movies ever made was one called Bringing Up Baby. It is old -- it was made in 1939 and it is in black-and-white -- and it stars a leopard named "Baby" that creates problems for the great human movie stars Cary Grant and Katherine Hepburn. (If you don't know who Cary Grant and Katherine Hepburn are, then ask an adult over 50. Those were two of the greatest movie stars ever).

For more information
Next Topic: Jaguars
 * Wikipedia: Leopard
 * The Cyber Zoomobile http://home.globalcrossing.net/~brendel/leopard.htm
 * Big Cats Online http://dspace.dial.pipex.com/agarman/bco/fact2.htm
 * Leopards at the San Diego Zoo http://www.sandiegozoo.org/animalbytes/t-leopard.html

ca:Viquijúnior:Grans felins/Lleopard Wikijunior Großkatzen/ Leopard zh:Wikijunior:大猫/豹

title: Wikijunior:Big Cats/Leopard


text:
Entomology

Entomology is the scientific study of insects. Insects have many kinds of interactions with humans and other forms of life on earth, so it is an important specialty within biology; unlike many other fields of biology, entomologists include both persons studying insects for their own sake, and those employed by commercial concerns interested in the control of insects (usually pest species). This divides the field into basic and applied entomology.

Because of this divide, any given university might put their department of entomology in either the biology department (with an emphasis on basic entomology) or in the agriculture department (with an emphasis on applied entomology. Despite this difference, today many entomology groups study both basic and applied aspects of the science.

The definition of entomology, especially as far as entomology departments is concerned, is sometimes widened to include the study of other terrestrial arthropods, such as spiders, scorpions, and ticks (the arachnids).

title: Entomology


text:
Geometry/Five Postulates of Euclidean Geometry

Postulates in geometry is very similar to axioms, self-evident truths, and beliefs in logic, political philosophy, and personal decision-making. The five postulates of Euclidean Geometry define the basic rules governing the creation and extension of geometric figures with ruler and compass. Together with the five axioms (or "common notions") and twenty-three definitions at the beginning of Euclid's Elements, they form the basis for the extensive proofs given in this masterful compilation of ancient Greek geometric knowledge. They are as follows:

 * 1) A straight line segment may be drawn from any given point to any other.
 * 2) A straight line may be extended to any finite length.
 * 3) A circle may be described with any given point as its center and any distance as its radius.
 * 4) All right angles are congruent.
 * 5) If a straight line intersects two other straight lines, and so makes the two interior angles on one side of it together less than two right angles, then the other straight lines will meet at a point if extended far enough on the side on which the angles are less than two right angles.

Postulate 5, the so-called Parallel Postulate was the source of much annoyance, probably even to Euclid, as it is not a simple, concise statement, as are the other four. Mathematicians, and really most of us, value simplicity arising from simplicity, with the long complicated proofs, equations, and calculations needed for rigorous certainty done behind the scenes, and to have such a long sentence amidst such other straightforward, intuitive statements seems awkward. As a result, many mathematicians over the centuries have tried to prove the results of the Elements without using the Parallel Postulate, but to no avail. However, in the past two centuries, assorted non-Euclidean geometries have been derived based on using the first four Euclidean postulates together with various negations of the fifth.


text:
User talk:61.242.178.238

— Brim 18:09, 23 Feb 2005 (UTC)

title: User talk:61.242.178.238


text:
IB Cultural Anthropology/The Course

Overview
This volume serves as a textbook for the IB Cultural Anthropology Course. The text acts as review for the material to reinforce the knowledge needed to do well on the IB Examination. The course will be divided into thirteen chapters. These chapters are, in turn, divided into sections.

It should be noted that this book correlates to the standard level course. The higher level course requires more ethnography and has a larger theory component.

Chapters

 * The Nature of Anthropology
 * The Nature of Culture

title: IB Cultural Anthropology/The Course


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Web Development/What is a backend?

Back-end development references a client server architecture common in ecommerce. Client side tends to have a strong user interface skill and the server side a strong API skill. But they overlap.

A backend developer could just be focused on a database and providing an API to it or on a server language like PHP and those mentioned so far and provide an API to it. Their work would need to be accessible to many other back end applications such as the database developer example and more to many front end applications. For example today many web backends service not only desktop and mobile web front ends but also device apps and even desktop apps. So the back end developer will not know how all of those front ends work but provide a server side interface such as a REST interface for those multiple front end technologies to access such as a login. Server developer can also make user interfaces that are probably less robust for administrative access to their code, functionality and data.

A front end developer in a client server architecture could be an app developer such as with Android, iOS or Windows and even be a specialist in one of those working with the UI libraries available in those OSs. They could be a desktop developer such as MacOS or Windows or Linux working with the UI libraries available in those OSs. Pretty much everyone on client side have knowledge of HTML CSS as that shows up even in native apps. User interface developers often have skills at building and using APIs. For example the Javascript angular.js MVC or the iOS MVC and the javascript JQuery API. In this sense a front end developer could be working with data API once it arrives on the client side and have less to do with the actual look and feel aspect of the front end.

In all cases an overlap in skills is a good to have for communication among the team and debugging client server apps. I always joke that the UI person takes the blame for anything that seems to go wrong because it is the cover to the book. In resolving the problem sometimes the UI person needs to clearly understand the surface interface language or at least the API of the server side to help isolate the problem solving effort. Same goes for the server side developers. However they are at the disadvantage because they could be serving many different client side technologies. So they often fall back to their own testing of the API hooks to isolate and remove themselves from the problem solving issues. But you can see the communication not only person to person on a professional team basis but mores on data transmission, the structure and tagging of the data is improved when both sides have a good understanding of their respective technologies to the extend of the data.

The backend to a website is pretty much everything the user can't see. Generally, this means the programming that generates pages that the user views, creating the "server-side" content of the site. This could be scripts, directives, databases, and other automated functions the server performs.

Back-end development includes the server implementation and it more on the logical interaction of data, how it is stored, and transmitted. Back-end developers typically work with programming languages such as PHP, Python, Go, and new Javascript libraries like Node.

title: Web Development/What is a backend?


text:
Web Development/The rationale of concepts: being careful

One of the most important tasks for a web developer before any work is begun on the page is the conception stage. After a concept has been developed, it is important that the developer thinks of his or her website in realistic terms.

For example, if a database will be necessary, consider how much space an entry will take up, and how many entries there will be total. Think of the hardware requirements of your site. Think, using what knowledge of programming and backend you may already have (or consulting a professional), if what you are trying to do will even be possible.

Most importantly, keep in mind the limitations of your human resources. You should have an idea of what size operation you're going to be running: money, men, etc. You don't want to stretch your people too thin. If you think it may be necessary to scale down your project to make it more realistic from a human resources point, then do it. It's better to be overcautious than to work your men and yourself into the ground.

Also, mind your capital and other resources. In Section 3.1, What's needed to develop a website?, we'll be covering this more in-depth. For now, just use common sense. One person didn't make Amazon.com on one dime in one day.


text:
User:Mike.laub

http://ideastockexchange.com/

title: User:Mike.laub


text:
IB Cultural Anthropology/The Nature of Culture

This chapter attempts to define culture and describe some general characteristics.

Sections

 * Definitions of Culture
 * Characteristics of Culture
 * Levels of Culture
 * Enculturation
 * Adaptation
 * Functionalism
 * Rights


text:
IB Cultural Anthropology/The Nature of Culture/Definitions of Culture

In order to meet the goal of cultural anthropology- understanding culture- there first must be a working definition of culture. There are, however, almost as many definitions of culture as there are anthropology texts. Though there is no single, accepted definition, there are several characteristics that most definitions agree upon from which one can draw a general idea as to what the concept of culture is.

Definition
The first respected definition of culture was written by Sir Edward Tylor. He stated that culture is "that complex whole that includes knowledge, belief, art, morals, law, custom and any other capabilities and habits acquired by man as a member of a society." In short, everything one does is a product of culture. However, culture is not only the behavior of an individual, but also the thought processes and perceptions of the world of an individual. A scientist, for example, might view a flower blooming in a radically different way from an artist. In addition to thought processes, culture needs to be able to be transmitted from generation to generation. Thus, culture must be something that can be learned. Essentially, we can for the purpose of this course state the basic definition of culture as:

The patterns of thought and behavior that are transmitted by a society that can be used to predict the actions of members of that culture

Tacit & Explicit Culture
This definition of culture pervades throughout the lives of its members- sometimes explicitly, sometimes in subtler forms. Explicitly, one knows that in American culture, forks go to the left of the plate and knives to the right. When setting the table, one might have to think to oneself to which side each utensil goes. More tacit culture, however, is the knowledge of which foods to use which utensils. One just ‘knows’ to eat a salad with a fork and soup with a spoon. One wouldn’t need to hesitate to decide as one might when setting the table. The more apparent aspects of one’s culture that a member can consciously identify are said to be part of the explicit culture. Subconscious and unconscious aspects of one’s culture are said to be part of the tacit culture.

Ideal & Real Culture
In defining culture, one also needs to make a distinction between ideal and real culture. One might find, in creating a model of the rules a society follows, it is much easier to create a model based on the ideal culture. In the Yanomamo, for example, a model for marriage patterns would be very simple based on ideal culture- one should marry one’s cross cousin! However, the Yanomamo don’t live ideally, and neither does any other culture. The kinship status of some members may arbitrarily change so that they will be “cross-cousins” and therefore eligible marriage partners. Creating a model of this real culture is much uglier, but is the reality of the situation. In studying cultures anthropologically, one must take into account both the ideal and real versions of a culture.

Back to The Nature of Culture


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IB Cultural Anthropology/The Nature of Culture/Characteristics of Culture

As one might expect, all cultures must share several characteristics if “culture” is to be differentiated from other forms of behavior. These similarities between all cultures are surprisingly few. The ultimate goal of cultural anthropology is to determine which characteristics all cultures share in common.

Society
Firstly, all culture must take place through a medium of a group of people, known as a society. Even extinct (e.g. Greek or Roman) or imagined (e.g. science-fiction novels) cultures have societies to transmit the culture (even if the societies, too, are dead or fictional). As culture cannot exist without a society, a human society cannot exist without culture. Other animals, such as bees or ants, congregate into societies, yet these animals do not exhibit culture. Yet no human society is without culture. The functionalist school of anthropological thought attempts to explain why culture is so vital to human societies.

Cultural Integration
It is vital to the study of cultural anthropology that the anthropologist take cultural integration into account. All aspects of culture relate to one another, so an analysis of a culture must be done holistically. Changes to one seemingly unimportant part of a particular culture can reverberate throughout the entire culture and affect even the most unrelated aspects.

It would be a difficult science if the anthropologist were to only examine the whole culture, however. In order to properly gain ample data, the anthropologist will typically divide the culture into arbitrary categories. For example, the anthropologist might study eating patterns, kinship, and warfare. However, the study is not finished after the data has been collected. The anthropologist then needs to describe how these ostensibly unrelated categories affect each other. Anthropology is thus a holistic science.

Tsembaga
A standard example of the integration of a culture is that of the Tsembaga of Papua New Guinea. Upon analysis, one sees that wealth, kinship, warfare, and food are all interrelated though one would think that one would hardly have anything to do with the next.

In the Tsembaga culture, pigs are a symbol of power and wealth. Thus, if a man wants to be powerful, he must own many pigs. However, in order to own that many pigs, he needs to feed the pigs with yams. But only Tsembaga women are allowed to grow yams. So if a man wants to be powerful, he must have many wives, which introduces a marriage system of polygamy.

One will notice, however, that this system will only hold itself for so long- in a polygamous society there usually needs to be less men than women. Otherwise, unsuccessful men become disgruntled and the culture comes into crisis. Also, if one has many wives, the pigs will become well-fed and fertile. After some time there will be too many pigs- the yams will all go to the pigs and the humans won’t have any left over to survive. To avoid this problem, the Tsembaga then attempt to gain more land for growing yams- but their neighbors own that land. Thus, the two groups war against each other. Men die in the process and the unequal male-female ratio is retained. After the war ends there is a great celebration. To celebrate the end of a war, the Tsembaga sacrifice huge numbers of pigs.

Thus, the initial conditions are restored and through the integration of these various aspects the culture is able to persist. Had the anthropologist studied only one of these traits of the culture, say marriage patterns, the anthropologist would have been unable to determine how the Tsembaga are able to retain an unequal male-female ratio and thus be capable of supporting polygamy.

Symbolism
Humans are abstract creatures, and culture takes advantage of that. In this culture, for example, people work ferociously in order to gain small bits of green paper. While this paper has little practical value, the society attaches symbolic value to it to make it represent wealth. Likewise, people may hold positions of power and be called a “boss,” “chief,” or “president.” In each of these cases, there is no significant physical difference between a “boss” and a “subordinate.” The title and position are symbols of one’s power over another.

The symbol most fundamental to culture is that of language. Physically, language is just sound waves being created and modified in various ways by the mouth and throat. However, our minds and culture attaches meaning to particular sound waves so that humans can communicate much more sophisticatedly than animals. Indeed, the same is true for written language. To a Chinese speaker, these lines would have no meaning. However, English speakers are able to attach meaning to these lines so the concept of anthropology can be effectively transmitted. One will spend hours attempting to commit these lines to memory. Then, one can successfully take the IB examination, create more random lines and receive a number in exchange for the hours of work. Culture is fraught with symbolism.

Back to The Nature of Culture


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IB Cultural Anthropology/The Nature of Culture/Levels of Culture

Culture exists at various levels and changes to varying degrees between these levels. One can generalize these levels to be:

 * International
 * National
 * Subcultures
 * Individual

International
General cultural traits often extend beyond borders. Much of Latin America, for example, shares the same overall culture. Similarly, The US and Canada share many cultural standards. International culture tends to be very broad, however, and one will find a wide range of variation between the culture of, for example, Peru and Brazil. International culture is the most general classification of culture.

National
For the most part, the people within a nation tend to have the same general cultural characteristics. Americans, for example, tend to value individual freedom over extensive family ties. These national cultural traits, however, are almost as weak as international cultural traits. Indeed, one could often find groups of people who share more in common with a group of people in another country than in their own. This tends to be the case in areas where borders were arbitrarily drawn for political reasons. (E.g. Africa or the Middle East.)

Subcultures
Within any given culture (especially a large culture), one would be likely to find subcultures. In America, for example, the various economic classes form their own subcultures. Middle class families, for example, tend to emphasize individualism and happiness, whereas lower class families tend to emphasize obedience more. Both groups are still very much a part of the American culture; however, it is the distinction that can be made between them that makes them subcultures.

Occasionally a subculture might have to practice its culture secretly. During the early 1960s, for example, homosexuality was illegal, so homosexual cultures needed to maintain secrecy. Jewish culture during the 1930s in Nazi Germany is another example. Such subcultures are called clandestine cultures.

Individual Variation
Culture is different for every member, and any study of culture must take into account those differences. Men and women tend to view their culture differently due to different places in society, and likewise a chief is likely to view the culture differently than a peasant. Despite these differences, the actual variation relative to another culture is negligibly small.

Pluralistic Societies
Societies in which multiple cultures enhabit the same geographic and political region are called pluralistic societies. The United States is a weakly pluralistic society- there is a great deal of individual variation and a high number of subcultures. However, for the most part, these sub cultures maintain most of the values of the nation as a whole. More strongly pluralistic societies can be found in, for example, Bosnia. Often violence erupts in strongly pluralistic societies because members of different cultures cannot understand each other and conflict arises when they don't operate by the same rules.

Back to The Nature of Culture


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IB Cultural Anthropology/The Nature of Culture/Enculturation

Definition
If a culture is to survive, it must find a way to pass itself through generations. All cultures do this through enculturation- the transmission of cultural knowledge to children. As children grow up, they learn the accepted behaviors of their society. However, enculturation is not simply the learning of accepted behaviors. Any animal can be conditioned to perform certain behaviors, yet these animals are not being encultured. When one is encultured, one not only learns proper behaviors, but the proper way of perceiving the world.

Yanomamo vs. Semai Enculturation
A Yanomamo boy, for example, will learn certain behaviors as he grows up. He will learn to begin fighting whenever he gets angry. Yet, not only will he learn to fight, he will also begin to perceive fighting and “fierceness” as a noble and valiant behavior. A Semai boy, on the other hand, will not only learn radically different behavior, but will gain a radically different perception of the world. The Semai boy will learn to never express his anger or lash out in violence. After time, however, he will not only never physically express anger, but he will not view anger as a prized trait and so will rarely get angry.

Back to The Nature of Culture


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IB Cultural Anthropology/The Nature of Culture/Adaptation

On their own, humans are not very good at surviving. Humans have weak muscles relative to their size and even the few they have are not very agile. They lack a strong hide and do not have much fur. In fact, humans are physically inferior to nearly every other species on the planet. The evolutionary trait that humans have grown to compensate for this physical weakness is culture. Culture provides humans with the knowledge of how to survive in their environment. Methods for food-getting and creating shelter are purely cultural traits- humans are not born with this knowledge.

Because environments change over time, the culture living in that environment, too, must change over time. Because cultures must constantly adapt to meet the changing needs of societies, cultures are dynamic systems. Anthropologists often take this into account and periodically update ethnographies with an extra chapter dedicated to changes in the culture since the ethnography was written.

Back to The Nature of Culture


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IB Cultural Anthropology/The Nature of Culture/Functionalism

The Functionalist school of anthropological thought was created by Alfred Radcliffe-Brown. The doctrine of functionalism states that all cultural traits arise as human adaptations to survive in a particular environment. So, any trait can be analyzed to find a function related to the survival of the individual or society.

Individual
Culture must meet the survival needs of the individual and of the society. Needs of the individual are:

 * Method for getting food
 * This is perhaps the most important function of culture. Without a method of getting food, social structure falls apart.
 * Tools
 * This is often related to the other survival needs, but is necessary nevertheless.
 * Safety
 * Relations to other humans
 * Medical Needs
 * Fear / Stress

Society
Needs of the society are:

 * Reproduction
 * Children also need to be socialized
 * Production and distribution of resources
 * Maintenance of order
 * Gossip is predominantly used in preliterate societies

Institutions
To accomplish these needs of both individual and society cultures generally have certain institutions (among others):

 * Kinship
 * Government
 * Law
 * Economy
 * Religion

Above all, a culture must motivate humans to survive. Cultures must provide humans with a meaning in life at some level that wills them to put the effort into survival. Without this fundamental motivation, humans would not perform the work needed to continue their existence and the culture would become extinct.

Actually, both Radcliff-Brown and Malinowski are credited with fuctionalism. Radcliff-Brown developed a branch called structural-functionalism.

Radcliffe-Brown vs. Malinowski
Two interpretations of the functionalist school of thought exist: that of Radcliffe-Brown, and that of Malinowski. Alfred Radcliffe-Brown is associated with Structural Functionalism arguing that all of culture serves to support the social structure of the group. The needs of the group must first be met before the needs of the individual can be addressed. Bronislaw Malinowski, however, is associated with Psychological Functionalism which states that all behaviors primarily support the needs of the individual. Any support to the social structure as a whole merely grows out of those behaviors that are advantageous to an individual.

Analysis
In both interpretations, functionalists analyze culture in three categories:

 * Structure
 * Function
 * Organization

Structure
The structure of a culture is a general description of the culture itself. It consists of the rules and principles that govern behavior and thought. Institutions of the culture such as the kinship or economic system are described under the structure of the culture. The structure of a culture is what allows social order to exist. Structure is what maintains relationships among individuals and groups.

Function
The function of various cultural traits could be described closely, but not quite correctly as the ‘purpose.’ Function is the way that the structure of a culture serves individual and group needs. Function often describes the integration of a culture by relating one trait of a culture indirectly involved with survival to another one more directly involved with survival.

Often cultures might have the same institution, yet for different reasons. Functionalism is well suited for analyzing these cultures because it provides clear reasons as to why subtle differences between the two structures exist. Functionalism becomes cumbersome, however, in analyzing cultures in which the function is the same but the structure is radically different. In other words, functionalism cannot provide for variation between cultures.

Organization
A culture often provides an individual with several choices of behavior in a given situation. These choices are called one’s agency. Agency can be thought of as a restricted free will. One has a range of choice, but these choices are strongly constrained by the bounds of one’s culture. Regardless of the actual situation or choices, however, the agency will always promote self-interest and the interest of the group.

Back to The Nature of Culture


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IB Cultural Anthropology/The Nature of Culture/Rights

The anthropological doctrine of cultural relativism discussed previously has the potential for a wide range of abuse. Seemingly any behavior would be permissible under the guise of “cultural differences.” Some offences are too strong to bear under any culture, however, so cultural relativism is tempered by human rights.

Human Rights
Human rights are those rights vested in any individual:

 * Right to speak freely
 * Right to hold personal religious beliefs
 * Right to not be murdered
 * Right to not be enslaved
 * Right to not be imprisoned without charges

These rights transcend culture and governments and are inalienable to any human. However, because of the universal nature of these rights, several that we consider to be ‘inalienable’ are not considered at all by other cultures. These problem human rights are gender equality, political equality, and economic equality. While we may marvel at the gender inequality throughout the world, we would be horrified to practice economic equality and share our wealth with those around us.

Cultural Rights
Not only do humans have rights, but cultures have rights as well. These are vested in groups, not individuals:

 * Right to preserve culture
 * Right to raise children in that culture
 * Right to the culture’s language
 * Right to not be deprived of economic base
 * Right to self-determination
 * Right to home rule
 * Right to religious freedom

These rights are similar to human rights and are just as important- without a culture humans cannot survive anyway, so human rights would become worthless.

Intellectual Property Rights
Today, problems arise with intellectual property rights. Cultures often like to decide for themselves which icons are allowed to be used by others as an attempt to preserve a cultural base. Christians, for example, would not often encourage the sale of a paint-by-number Jesus figurine. The problem arises when deciding who exactly “owns” the idea since cultures themselves cannot own anything in our culture.

Back to The Nature of Culture


text:
Talk:IB Music

 * Links Volume
 * Volume about the exam itself

-Splat

Naming policy
To avoid confusion concerning which pages belong to this book, all pages names should start with "IB Music". This would require moving the "Introduction to IB Music" and "Contributors to IB Music" pages. I might try moving the pages later. --Kernigh 04:54, 21 March 2006 (UTC)

title: Talk:IB Music


text:
Talk:IB Cultural Anthropology

 * Add a links volume
 * Add back links to the top of longer sections
 * Perhaps a link could be added back to the IB Texts homepage. (Maybe in the links volume).

-Splat

Added a link back to the IB homepage, but I was wondering as to the necessity of your IB Cultural Anthropology/Contributors section. If anyone looks at the page history, I'm certain they'd be able to figure out who did all the work. Just a question...

Akademix 00:26, 23 May 2007 (UTC)

title: Talk:IB Cultural Anthropology


text:
Web Development/Why do people develop web pages?

People develop web pages for two main reasons: personal and professional. This book deals mostly with the latter: a medium to large-sized operation designed to generate income.

Personal

Many people have set up websites to serve their personal interests. There are a huge number of reasons people do this, from sharing information about themselves, to preaching their beliefs, to putting up a resume to be hired or sometimes people publish virtual journals called "blogs".

Often a number of people collaborate on a website, like a forum, product review, or a blog. That is nonlimited to, social media, podcasts, coding projects, gaming mods, bookmarking sties, social news, media sharing pages, microblogging, social knowledge, and sharing economy websites as well. But, since these sites are not designed for the specific purpose of generating revenue, they are still personal sites.

Professional
Many businesses (perhaps all someday) have web pages. Some are created simply to get the word out about their business: phone number, address, etc., to increase traffic to its physical location.

Many other companies have websites designed to bring in more income. They act as virtual storefronts, shipping to your doorstep or allowing you to pick up goods in person. This book deals with the development of a professional website created to promote your business.


text:
Introduction to Philosophy/Ancient Political Philosophy

< Introduction to Philosophy

Ancient Political Philosophy, whose major representatives are Socrates, Plato, and Aristotle, is an inquiry into the nexus of arete (excellence, virtue) and politics. In other words, it emphasizes the connection between ethics as the care of the soul and politics as the care of the polis (city, state).

Perhaps the most important work of ancient political philsophy is Plato's Republic, a dialogue in which Socrates discusses the ideal city-state with other guests at the house of his friend Cephalus. This dialogue is the source of the idea that the state should be ruled by philosopher-kings, a specially trained class which has demonstrated their ability through a lifetime of musical, philosophical, military, and political training. It is also notable for its criticism of democracy: despite the modern enthusiasm for democracy and the democracy present in Athens at the time of its writing, Socrates lists democracy as the second worst of the four non-ideal forms of government. Another well-known work is Aristotle's Politics.


text:
Radiation Oncology/Cervix/Brachytherapy

Intracavitary brachytherapy
Three systems:
 * Paris system
 * Stockholm system
 * Manchester system
 * Madison system (HDR)

Manchester system

 * Point A dose definitions:
 * Allegedly, Point A corresponds to the paracervical triangle in the medial edge of the broad ligament where the uterine vessels cross the ureter
 * Original definition: draw a line connecting the superior aspects of the vaginal ovoids and measuring 2 cm superior along the tandem and then 2 cm perpendicular to this. (weakness: failure of localization radiographs to show the surface of the ovoids' caps)
 * Revised definition #1: 2 cm above the external cervical os and 2 cm lateral to midline
 * Revised definition #2 (1953, Tod & Meredith): 2 cm above the distal end of the lowest source in the tandem and 2 cm lateral to the tandem
 * Common variation: use flange at cervical os

 * Point B - 5 cm lateral from the midline at the same level as Point A

The Manchester applicators consisted of a rubber tandem and two ellipsoid "ovoids" with diameters 2, 2.5, and 3 cm. No shielding in ovoids, so needed generous packing anteriorly and posteriorly. Used radium. Used 17.5, 20, and 22.5 mg Ra for the small, medium, and large ovoids, respectively.

Designed such that:
 * Point A dose rate was approximately 0.53 Gy/hr for all allowed applicator loadings
 * Vaginal contribution to Point A was limited to 40% of the total dose
 * The rectal dose should be 80% or less of the Point A dose

Prescribed 80 Gy to point A in two applications, total of 144 hours, in the absence of external beam.

Weakness: wide variation in Point A in respect to the ovoids. Point A often occurs in a high-gradient region of the isodose distribution. Therefore, minor differences in position can result in large differences in dose.

References:
 * No PMID - M. Tod and W. Meredith, A dosage system for use in the treatment of cancer of the uterine cervix. Br J Radiol 11 (1938), pp. 809–824.
 * Revised (1953) - PMID 13042092 — "M. Tod and W. Meredith, Treatment of cancer of the cervix uteri—a revised “Manchester method.”. Br J Radiol 26 (1953), pp. 252–257.

Fletcher applicator
Derives from the Manchester system. Added internal shielding in the colpostats. Afterloading ability. Colpostat has 2 cm diameter that can be increased to 2.5 or 3 cm by the addition of plastic caps. Minicolpostats are 1.6 cm and have a flat inner surface and have no shielding. Use 15, 20, and 25 mg Ra for small, medium, and large colpostats; use 10 for the minis. Tandems are available in three curvatures. Flange on the tandem avoids slippage past the cervical os, and a keel helps keep it from rotating. A yoke attaches the tandem and colpostats to maintain proper position. Loading of the tandem is 20 - 10 - 10 mgRaEq with Cs-137.

Plastic Fletcher applicators are available to be compatible with CT simulation or MRI.

The Madison system (University of Wisconsin)

 * PMID 1526873, 1992 — "High dose rate intracavitary brachytherapy for carcinoma of the cervix: the Madison system: I. Clinical and radiobiological considerations." Stitt JA et al. Int J Radiat Oncol Biol Phys. 1992;24(2):335-48.
 * PMID 1526874, 1992 — "High dose rate intracavitary brachytherapy for carcinoma of the cervix: the Madison system: II. Procedural and physical considerations." Thomadsen BR et al. Int J Radiat Oncol Biol Phys. 1992;24(2):349-57.

American Brachytherapy Society (ABS)
Recommend prescribing to Point H - Draw a line connecting the mid-dwell positions of the ovoids and find the point this line intersects the tandem. Follow 2 cm superior (along the tandem) plus the radius of the ovoids, then 2 cm perpendicular to the tandem. Note: This is basically 2 cm above the top of the ovoids.

 * ABS General Principles for locally advanced carcinoma of the cervix. (2012) PMID: 22265436 — "American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part I: general principles." Viswanathan et al. Brachytherapy. 2012 Jan-Feb; 11(1):33-46.

 * ABS HDR guidelines. (2012) PMID: 22265437 — "American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part II: high-dose-rate brachytherapy." Viswanathan et al. Brachytherapy. 2012 Jan-Feb; 11(1):47-52.

 * ABS LDR and Pulsed-dose rate guidelines. (2012) - PMID: 22265438 — "American Brachytherapy Society Consensus Guidelines for locally advanced carcinoma of the cervix. Part III: low-dose-rate and pulsed-dose-rate brachytherapy." Lee et al. Brachytherapy. 2012 Jan-Feb; 11(1)53-7.

European Society for Therapeutic Radiation Oncology (ESTRO)

 * ESTRO
 * 2006 PMID 16403584 -- "Recommendations from gynaecological (GYN) GEC ESTRO working group (II): concepts and terms in 3D image-based treatment planning in cervix cancer brachytherapy-3D dose volume parameters and aspects of 3D image-based anatomy, radiation physics, radiobiology." (Potter R, Radiother Oncol. 2006 Jan;78(1):67-77. Epub 2006 Jan 5.)
 * Recommendations for 3D dose-volume parameters
 * 2005 PMID 15763303 -- "Recommendations from Gynaecological (GYN) GEC-ESTRO Working Group (I): concepts and terms in 3D image based 3D treatment planning in cervix cancer brachytherapy with emphasis on MRI assessment of GTV and CTV." (Haie-Meder C, Radiother Oncol. 2005 Mar;74(3):235-45.)
 * Specification of image-guided GTV and CTV

Good Insertion Characteristics

 * AP View
 * Tandem midline, unrotated
 * Tandem midway between colpostats
 * Keel (flange) in close proximity to gold seed markers
 * Colpostats high in the fornices along cervix, ideally ~1/3 above flange
 * Lateral View
 * Tandem bisects the colpostat
 * Sufficient anterior and posterior packing
 * Foley balloon firmly tugged down

Interstitial brachytherapy

 * UC Irvine; 2013 (1996-2009) PMID 22763030 -- "Outcomes of high-dose-rate interstitial brachytherapy in the treatment of locally advanced cervical cancer: long-term results." (Pinn-Bingham M, Int J Radiat Oncol Biol Phys. 2013 Mar 1;85(3):714-20. doi: 10.1016/j.ijrobp.2012.05.033. Epub 2012 Jul 3.)
 * Retrospective. 116 patients, cervical cancer (91% Stage IIB-IVA). Combination EBRT 50.4 with 2 interstitial implants HDR 36 Gy. Interstitial hyperthermia in 61%. Concurrent chemotherapy 81%
 * Outcome: LRC 85%. 3-year DFS Stage IB 59%, II 67%, Stage III 71%, Stage IVA 57%. 5-year DFS 60%, OS 44%
 * Toxicity: acute and late toxicities acceptable
 * Conclusion: Locally advanced cervical cancer can achieve excellent outcomes with HDR interstitial brachytherapy

LDR
Dose Prescriptions
 * Point A
 * Early stage disease (nonbulky Stage I-II): 80-85 Gy
 * Advanced stage disease (bulky or Stage IIIB): 85-90 Gy
 * Pelvic Sidewall - LDR equivalent of 50-55 Gy (early stage) or 55-60 Gy (advanced stage)
 * Early stage disease (nonbulky Stage I-II): 50-55 Gy
 * Advanced stage disease (bulky or Stage IIIB): 55-60 Gy

 * ABS LDR (2002) - PMID 11777620 — "The American Brachytherapy Society recommendations for low-dose-rate brachytherapy for carcinoma of the cervix." Nag S et al. Int J Radiat Oncol Biol Phys. 2002 Jan 1;52(1):33-48.

 * ABS LDR and Pulsed-dose rate guidelines. (2012) - PMID: 22265438 — "American Brachytherapy Society Consensus Guidelines for locally advanced carcinoma of the cervix. Part III: low-dose-rate and pulsed-dose-rate brachytherapy." Lee et al. Brachytherapy. 2012 Jan-Feb; 11(1)53-7.

Equivalent doses

 * Taiwan (1996) - PMID 8631555 — "Determination of the appropriate fraction number and size of the HDR brachytherapy for cervical cancer." Liu WS et al. Gynecol Oncol. 1996 Feb;60(2):295-300.

 * Detroit (1991) - PMID 1938550 — "Comparison of high and low dose rate remote afterloading for cervix cancer and the importance of fractionation." Orton CG et al. Int J Radiat Oncol Biol Phys. 1991 Nov;21(6):1425-34.
 * Analysis of 17,000 cervix cancer pts in 56 institutions using HDR.
 * Conversion of dose from LDR to HDR, use dose factor of 0.54.

Calculation tools:
 * Medical University of Vienna
 * link at: http://www.americanbrachytherapy.org/guidelines/index.cfm
 * direct link to Excel spreadsheet:
 * Spreadsheet #1: (LQ spread sheet) Instructions
 * Spreadsheet #2: (Reporting GYN HDR BT sheet) Instructions

Radiobiology
BED for HDR and LDR:
 * HDR: $$\mbox{BED} = N*d\left (1+\frac{d}{\alpha/\beta}\right )$$
 * LDR: $$\mbox{BED} = N*R*t\left [1 + \frac{2R}{\mu*(\alpha/\beta)}*\left (1 - \frac{1-e^{-\mu t}}{\mu*t}\right ) \right ]$$

Where N = number of fractions, d = dose per fraction, R = dose rate, t = treatment time (i.e. duration), μ = sublethal damage repair constant, and α/β = characteristic parameter of the cell survival curve from the linear quadratic model.

(from ABS, PMID 10924990) Problem: What dose/fraction of HDR delivered in six fractions will be equivalent in terms of tumor control to 60 Gy delivered to Point A at 0.55 Gy h−1?

Solution: Assume α/β (tumor) = 10 Gy, μ (tumor) = 0.46 h−1.

Then: BED (LDR) = 60[1 + (2 × 0.55)/(0.46 × 10)] = 74.3

Equating this to the BED for 6 HDR fractions with dose/fraction d gives:

74.3 = 6d(1 + d/10)

Solving this quadratic equation for d gives: d = 7.20 Gy.

Conclusion: 6 fractions of 7.20 Gy with HDR is equivalent in terms of tumor control to 60 Gy delivered at 0.55 Gy h−1.

Other references:
 * PMID 10661360 (2000) — "A simple method of obtaining equivalent doses for use in HDR brachytherapy." Nag S et al. Int J Radiat Oncol Biol Phys. 2000 Jan 15;46(2):507-13.

Clinical Comparison

 * Meta-analysis; 2010 PMID 20614461 -- "High dose rate versus low dose rate intracavity brachytherapy for locally advanced uterine cervix cancer. (Wang X, Cochrane Database Syst Rev. 2010 Jul 7;(7):CD007563. doi: 10.1002/14651858.CD007563.pub2.)
 * Cochrane review. 4 studies, 1265 patients.
 * Outcome: no difference in 3-, 5-, and 10-year OS or DSS. No difference for local control, locoregional recurrence, or distant metastases
 * Toxicity: No difference for bladder or rectosigmoid toxicity, increased risk for small bowel (RR 3.4, p=0.04)
 * Conclusion: Due to potential advantages of HDR, we recommend HDR for all clinical stages of cervix cancer

 * India, 1994 (1986-89) - PMID 8276647 — "Low dose rate vs. high dose rate brachytherapy in the treatment of carcinoma of the uterine cervix: a clinical trial." Patel FD et al. Int J Radiat Oncol Biol Phys. 1994 Jan 15;28(2):335-41.
 * 482 pts. Randomized two groups (Group I - early stage, brachy only. Group II - EBRT + BT) to HDR vs LDR.
 * 5-yr LC 79.7% (LDR) vs 75.8% (HDR). OS: Stage I - 73% vs 78%, Stage II - 62% and 64%, Stage III - 50% and 43. Rectal complications lower for HDR (19.9% vs 6.4%)

ABS Guidelines

 * HDR (2000) - PMID 10924990 — "The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for carcinoma of the cervix." Nag S et al. Int J Radiat Oncol Biol Phys. 2000 Aug 1;48(1):201-11.
 * General recommendations
 * Brachytherapy must be included as a component of radiation therapy for cervical carcinoma
 * Good applicator placement must be achieved
 * Relative dose of EBRT vs. BT depends on tumor volume, ability to displace bladder and rectum, tumor regression during EBRT, and institutional preference
 * Total treatment duration should be <8 weeks
 * HDR should be interdigitated with EBRT, such that EBRT is not given on day of BT. If vaginal geometry is optimal, start BT during week #3 and give BT once per week. If tumor volume doesn't allow this, perform 2 BT implants per week after completion of EBRT to stay within 8 week treatment duration limit
 * External Beam RT
 * HDR fraction size and number depends on EBRT dose (see table below), though individual HDR fraction size should be <7.5 Gy/fx due to concerns about late toxicity
 * There is no consensus about midline blocks. If used, should be 4-5cm wide and should not extend to the top of the pelvic field if used at <40 Gy. Care must be taken not to shield common illiac and presecral nodes.
 * Midline block position should be reassessed after each implant
 * Chemotherapy
 * Chemotherapy should be administered concurrently with EBRT, but not with BT
 * Insertion technique
 * Multiple insertions should be used to allow progressive volume reduction and thus more effective disease coverage
 * Optimum applicator placement is critical, and should be done with ultrasound and fluoroscopic guidance
 * Appropriate applicator must be chosen for disease geometry: standard ovoids, ring, or Henschke applicator
 * If an applicator cannot be accommodated, interstitial implant should be used
 * Conscious sedation should be used whenever possible; patient discomfort can lead to suboptimal packing
 * Cervical markers should be placed for identification of cervical position and to determine relationship of vaginal applicators to the cervix
 * Bladder and rectum should be displaced away from the applicators
 * External fixation devices (e.g. perineal bar or clamp/base plate) should be used to prevent movement
 * Good quality radiographs should be obtained for treatment planning and dosimetry with each insertion
 * Every effort should be made to minimize patient and applicator movement
 * Dose specification
 * Ideally, dose should be prescribed to individual patient's treatment volume, but there is insufficient information in the literature to establish a better delineated target than Point A
 * ABS recommends prescribing to Point H defined as point of intersection of mid-dwell positions of the ovoids with the tandem. Then move superiorly radius of the ovoids (to top of ovoids) + 2 cm, and then 2 cm perpendicularly
 * Dose optimization
 * Achieving good dose distribution requires both good dose insertion and dose optimization
 * Tandem optimization: start 1 cm inferiorly to the superior-most dwell position. Finish 1 cm superior to the surface of the vaginal appliance. Optimization points should fall no further than 1 cm apart along the tandem, and in both lateral directions
 * Vaginal optimization should fall at the vaginal surface or specified depth (usually 0.5 cm), and should fall in both lateral directions as not to interfere with tandem optimization
 * Dose calculations to organs at risk
 * ICRU 38 does not consistently specify location of maximum dose to the organs
 * True dose delivered should be calculated using soft tissue (CT or MRI) planning if available
 * Nominal rectal and bladder points can be used as per ICRU definitions, and should receive <80% of dose to Point H. Absolute dose should be LDR-equivalent <75 Gy for rectum and <80 Gy for bladder
 * Regional lymph nodes: BT component is small compared to EBRT dose, but should be calculated. ICRU 38 Pelvic Wall Point specification should be used. Manchester Point B should not be used
 * Dose recommendations
 * See table below as a guide
 * Point A: LDR equivalent of 80-85 Gy (early stage disease, nonbulky Stage I-II) or 85-90 Gy (advanced stage, Stage IIIB or > 4 cm).
 * Pelvic Sidewall: LDR equivalent of 50-55 Gy (early stage) or 55-60 Gy (advanced stage)
 * Physical dose delivered will be less for HDR than for LDR due to dose-rate effect
 * Quality assurance
 * AAPM TG 59 recommendations should be followed
 * Interstitial brachytherapy
 * Recommended for clinical situations when geometry for intracavitary BT is suboptimal (e.g. bulky lesions, narrow vaginal apex, inability to enter the cervical os, extension to the lateral parametria or pelvic sidewall, and lower vaginal extension)
 * Please see the manuscript for further recommendations

Suggested doses in combination with EBRT:

 * ABS HDR guidelines. (2012) PMID: 22265437 — "American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part II: high-dose-rate brachytherapy." Viswanathan et al. Brachytherapy. 2012 Jan-Feb; 11(1):47-52.

 * Image-guided brachytherapy working group
 * 2004 PMID 15519788 — "Proposed guidelines for image-based intracavitary brachytherapy for cervical carcinoma: Report from Image-Guided Brachytherapy Working Group." Nag et al. Int J Radiat Oncol Biol Phys. 2004 Nov 15;60(4):1160-72.

HDR Implant Steps

 * Perform preliminary bimanual examination for geometry while patient undergoing EBRT
 * Induce anesthesia (consider general, conscious sedation, or spinal)
 * Consider antibiotic coverage (e.g. Ancef 1 gram)
 * Place in lithotomy position
 * Examination under anesthesia to assess geometry for implant
 * If not, abort and consider interstitial implant
 * Prep with betadine and drape (consider "urine cather" to catch stray instruments)
 * Place Foley with 7 cc diluted contrast (2 ml contrast + 5 ml saline)
 * Fill bladder with saline, using 4-5 big syringes (200-300 ml)
 * Open vagina with right angle retractors; weighted speculum may tear friable vaginal mucosa after concurrent chemo-RT
 * Use tenaculum to grasp anterior lip of cervix, and maintain tension
 * Place 2-3 gold seeds ~5mm into cervix (on x-ray, they will be ~1cm superior to the inferior-most aspect of the cervix)
 * Use sound to estimate cervix depth, under ultrasound guidance to avoid perforation
 * Once sound is in fundus, grasp exposed portion with a clamp at the cervix, and measure the sound to estimate depth
 * Most common location for perforation is posterior endocervix or lower uterine segment
 * Dilate cervix
 * Leave dilator in place until ready for tandem, to prevent cervical spasm
 * Consider Smit sleeve (frequently 60 mm sleeve)
 * Insert tandem under ultrasound guidance
 * Choose length and angle of tandem based on sound information
 * If uterus is retroverted, place tandem to follow the cavity and then gently rotate into anterior position to antervert
 * Remove tenaculum
 * Insert ovoids or ring
 * Lubricating them may help insertion
 * Choose largest size that will fit to take advantage of inverse square; however, too large an ovoid may be displaced inferiorly, away from the tumor
 * May need ovoids of 2 different sizes if the tumor is asymmetrical
 * Typically insert right ovoid, then left ovoid, then lock in place
 * If built-in tungsten shields, may provide ~15% dose reduction to the anterior rectal wall
 * Verify stable implant placement with ultrasound
 * Empty bladder, but keep Foley in place
 * Pack anteriorly and posteriorly to ovoids
 * Typically 1 inch gauze is used, with DeBakey forceps and/or fingers
 * Use lubrication (e.g. premarin cream, surgilube) on the gauze
 * Aim for floor and ceiling, but not cephalad to ovoids, so the cervix isn't displaced
 * Posterior packing initially to preferentially spare rectum
 * Place a stitch in the gauze at the end, to facilitate removal
 * Films in O.R. to evaluate implant quality (see above)
 * If admitting, consider:
 * Activity: bed rest
 * Nursing:
 * Foley to gravity
 * Compression devices to bilateral lower extremities
 * Incentive spirometry to bedside; use 10x/hr while awake
 * Head of bed at or below 30 degrees
 * Diet: clear, advance to low residue as tolerated
 * IVF: NS @ 75 ml/hr
 * Meds:
 * Lovenox 40 mq QD or heparin 5000 units SC Q8
 * Pain management (PCA pump or coverage for breakthrough pain)
 * Lomotil 1 tab Q6
 * Restoril 15 mg Qhs
 * Pepcid 20 mg PO BID
 * Patient's routine medications
 * Send to radiation oncology when stable
 * Dictate OP note (e.g. Ms X was taken to the operating room, where she was place under (general, spinal) anesthesia. (ABX) was given. The bladder was filled with sterile saline solution and the uterus was evaluated by ultrasound. The tandem was inserted under ultrasound guidance. The ovoids were placed under direct visualization. The placement of the implant was verfied with ultrasound. Vaginal vault was secured with gauze packing. (There were no complications). The patient was taken to the recovery room in a stable condition.)
 * CT sim
 * Insert dummy sources
 * Consider rectal tube with 20-30 ml barium contrast

Clinical Evidence

 * Osaka (Japan)(1983-1989) -- HDR fractional dose 7.5 Gy/fx vs. 6.0 Gy/fx
 * Randomized. 165 patients with cervix adenoCA, Stage IA-IV. Treated with 2 separated dose schedules depending on stage. Arm 1) EBRT + BT using 7.5 Gy/fx (either 37.5/5 or 30/4 or 22.5/3) vs. Arm 2) EBRT + BT using 6.0 Gy/fx (either 36/6 or 30/5 or 18/3).
 * 5-years; 1994 PMID 7974179 -- "A prospective randomized study concerning the point A dose in high-dose rate intracavitary therapy for carcinoma of the uterine cervix. The final results." (Chatani M, Strahlenther Onkol. 1994 Nov;170(11):636-42.)
 * Outcome: 5-year CSS: Stage I 100% vs. 100%, Stage II 82% vs. 85%, Stage III 62% vs. 52%, Stage IV 22% vs. 31% (all NS). No difference in LRF or DM
 * Toxicity: No difference
 * Conclusion: No difference between the two treatment schedules; small number of fractions at 7.5 Gy/fx may be advantageous due to short duration

Dose limits

 * Points specified in ICRU Report 38
 * Please see the ICRU report page on more detail about definitions
 * Bladder point - on the surface of a Foley balloon filled with 7 cc of contrast; located at center of balloon on AP film, posterior surface of the balloon on a line through midballoon on lateral film
 * Rectum point - 0.5 cm posterior to the posterior vaginal wall at the level of the bisection of the T&O. May also use barium + air contrast in rectum
 * Vaginal mucosa - at surface of ovoids
 * Pelvic sidewall, and external, common, and para-aortic LN points should be reported according to ICRU defintions

 * Medical University of Vienna
 * Late side effects; 2011 PMID 20385450 -- "Dose-volume histogram parameters and late side effects in magnetic resonance image-guided adaptive cervical cancer brachytherapy." (Georg P, Int J Radiat Oncol Biol Phys. 2011 Feb 1;79(2):356-62. Epub 2010 Apr 10.)
 * Retrospective. 141 patients, EBRT and IGBT, +/- chemotherapy. DVH parameters D2cc, D1cc, D0.1cc for rectum, sigmoid, and bladder, as well ICRU rectum and bladder point doses calculated and converted to EQD2. Median F/U 4.2 years
 * Outcome: 5-year toxicity rectum 12%, sigmoid 3%, bladder 23%. Mean D2cc rectum 65 Gy (+/- 12 Gy), sigmoid 62 Gy (+/- 12 Gy), and bladder 95 Gy (+/- 22 Gy).
 * Conclusion: D2cc and D1cc have good predictive value for rectal toxicity. Recommend rectum D2cc max 75 Gy, sigmoid no recommendation, bladder D2cc max 100 Gy
 * Vaginal toxicity; 2010 PMID 20561694 -- "Dose volume parameter D2cc does not correlate with vaginal side effects in individual patients with cervical cancer treated within a defined treatment protocol with very high brachytherapy doses." (Fidarova EF, Radiother Oncol. 2010 Oct;97(1):76-9. Epub 2010 Jun 17.)
 * Vaginal D2cc did not correlate with presence or grade of side effects

Acute complications

 * PMID 10725629 (1960-1992) - "Perioperative and postoperative complications of intracavitary radiation for FIGO stage I-III carcinoma of the cervix." Jhingran A et al.  Int J Radiat Oncol Biol Phys. 2000; 46 (5):1177-83
 * Retrospective. 7662 intracavitary procedures in 4043 patients for FIGO I-III cervical CA
 * 2.8% uterine perforation rate, 14% have fever >101 C during at least 1 admission, 0.1% fatal thromboembolism rate. Perforation did not affect DSS in stage I, II, but did lead to worse prognosis in stage III.

Late complications

 * PMID 7635768, 1995 (1960-89) — "Time course and incidence of late complications in patients treated with radiation therapy for FIGO stage IB carcinoma of the uterine cervix." Eifel PJ et al. Int J Radiat Oncol Biol Phys. 1995 Jul 30;32(5):1289-300.
 * Retrospective. 1784 pts, FIGO stage IB. Grade 3 or higher complications occurred in 7.7% at 3 yrs and 9.3% at 10 yrs. After 10 yrs, 0.34% per year, so at 20 yrs, 14.4% risk. Risk of rectal complications was the greatest, more than urinary complications.
 * Conclusion: low risk of major complications using brachytherapy.

Miscellaneous

 * Patterns of care study (2005, 1996-99) - PMID 16099599 — "Patterns of brachytherapy practice for patients with carcinoma of the cervix (1996-1999): a patterns of care study." Erickson B et al. Int J Radiat Oncol Biol Phys. 2005 Nov 15;63(4):1083-92.

title: Radiation Oncology/Cervix/Brachytherapy


text:
Entomology/What are insects?

Insects
Insects are animals with three body segments (the word insect means "segmented"): the head, the abdomen, and the thorax. Insects have, typically, three pairs of legs located on the abdomen; however, there are exceptions, such as brush-footed butterflies.

Insects belong to the taxonomic class Insecta, which is just one class of Phylum Arthropoda. The arthropods also includes Crustacea (crabs, lobsters, etc.), Arachnida (spiders, mites, etc.), and Myriapoda (Centipedes and Millipedes). The class Insecta is closely related to the class Entognatha (Collembola, Diplura, and Protura), which is usually included in the study of entomology. Both Insecta and Entognatha are within the subphylum Hexapoda.

Insects have a wide range of life cycles, but there are some basic similarities. They almost all begin as eggs, which vary widely in shape and size. Then insects undergo a period of growth. Some then undergo a metamorphosis ("huge change"), into an adult form.

Insects such as silverfish (order Zygentoma) do not undergo metamorphosis at all — they grow directly from hatching to their full size, and molt several times as a mature adult.

Some Insects, such as true bugs (order Hemiptera) and grasshoppers (order Orthoptera), undergo an incomplete metamorphosis. When they hatch from eggs they are called nymphs. These nymphs will eventually grow into their final adult form. They do not molt after that.

Insects such as butterflies, moths, and flies undergo a complete metamorphosis. When they hatch from eggs, they are called larvae. Once they have grown through several periods called instars, they become pupae (in butterflies it's called a chrysalis). Eventually, an adult, or imago phase, will emerge from the pupa.

Insects are very successful organisms. They exist in every type of terrestrial habitat, including some flies native to Antarctica. Insects also vary widely in shape, size, colour, etc. There are currently well over 900 thousand named species of insect, and estimates place the total number of species between 2 and 30 million.

title: Entomology/What are insects?