text:
Radiation Oncology/Palliation/Bone metastases

Palliation of Spine and Bone Metastases

 * ''For spinal cord compression, please see: spinal cord compression
 * For specific tumor types, see also: Renal cell
 * ''For spinal cord tolerance, please see Spine NTCP

Guidelines

 * ASTRO; 2011 PMID 21277118 -- "Palliative Radiotherapy for Bone Metastases: An ASTRO Evidence-Based Guideline." (Lutz S, Int J Radiat Oncol Biol Phys. 2011 Jan 27. [Epub ahead of print])

 * Society of Nuclear Medicine; 2003 PDF Guidelines link -- "Palliative Treatment for Painful Bone Metastases" (version 3.0)

 * International Spine Radiosurgery Consortium consensus guidelines for target volume definition in spinal stereotactic radiosurgery. PMID 22608954-- (Cox BW Int J Radiat Oncol Biol Phys. 2012 Aug 1. [Epub ahead of print])
 * Describes target delineation of the CTV and created the "SSS" (Spratt Six Segmentation) to unify communication regarding the location of involvement of spinal tumors/metastases.

Open Reduction Internal Fixation (ORIF)

 * Mayo Clinic; 2004 PMID 15289695 -- "Management of pathologic fractures of the proximal femur: state of the art." (Jacofsky DJ, J Orthop Trauma. 2004 Aug;18(7):459-69.)
 * Review of surgical techniques
 * Radiation therapy recommendation: RT should follow ORIF, typically 2-4 weeks later. Typical schedule 30/10 though British Association of Surgical Oncologists guideline recommends 20/5

Long Bones

 * Mirels Criteria
 * 1989 PMID 2684463 -- "Metastatic disease in long bones: a proposed scoring system for diagnosing impending pathologic fractures" (Mirels H, Clin Orthop Relat Res. 1989;249:256–264.)
 * PMID Article
 * Score >8 suggests benefit from pinning

 * '''Harrington's criteria
 * 1986 PMID 3819423 -- "Impending pathologic fractures from metastatic malignancy: evaluation and management." (Harrington KD, Instr Course Lect. 1986;35:357-81.)

Vertebral body

 * Spinal Instability Neoplastic Score (SINS)
 * 2010 PMID 20562730 -- "A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group." (Fisher CG, Spine (Phila Pa 1976). 2010 Oct 15;35(22):E1221-9. doi: 10.1097/BRS.0b013e3181e16ae2)
 * Potentially unstable lesions ≥ 7; unstable lesions ≥ 13
 * Surgical consultation recommended for lesions ≥ 7

 * 2014 PMID 24594004 -- "Reliability of the Spinal Instability Neoplastic Score (SINS) among radiation oncologists: an assessment of instability secondary to spinal metastases." (Fisher CG, Radiat Oncol. 2014 Mar 4;9:69. doi: 10.1186/1748-717X-9-69.)
 * Survey. 33 radiation oncologists, 10 sites, 30 cases.
 * Outcome: Interobserver variability 0.76, intra-observer variability 0.80. All unstable cases were rated as appropriately
 * Conclusion: Among radiation oncologists, SINS is highly reliable, reproducible and valid assessment tool

 * CT-based algorithm
 * Harvard; 2009 PMID 19996215 -- "Noninvasive Prediction of Fracture Risk in Patients with Metastatic Cancer to the Spine." (Snyder BD, Clin Cancer Res. 2009 Dec 15;15(24):7676-7683.)
 * Retrospective. 94 women, CT scans. Load-bearing capacity, axial rigidity, bending rigidity calculated, and normalized by BMI. Vertebral fracture risk calculated
 * Outcome: 11 fractures occurred in 10 patients. Structural parameters 100% sensitive; 55-70% specific to predict fracture risk
 * Conclusion: CTRA is as sensitive and more specific than current radiographic criteria

Palliative RT Endpoints

 * Bone Metastases Consensus Working Party; 2002 PMID 12242115 -- "International consensus on palliative radiotherapy endpoints for future clinical trials in bone metastases." (Chow E, Radiother Oncol. 2002 Sep;64(3):275-80.)
 * Pain assessment: 11 point scale (0-10), should relate to worst and average pain over prior 3 days
 * Narcotic use: should be converted to daily oral morphine equivalent
 * Endpoints:
 * Partial response: reduction of 2 or more points (0-10 point scale) without analgesic increase OR analgesic reduction of 25% in daily morphine equivalent without increase in pain
 * Pain progression: increase in pain score 2 or more points with stable analgesic use OR increase of 25% in daily morphine equivalent with pain stable or 1 point above baseline

External Beam Asymptomatic

 * Memorial Sloan Kettering (2018 - 2021) -- RT to asymptomatic high risk sites vs standard of care
 * Outcome 2024 PMID -- "Prophylactic Radiation Therapy Versus Standard of Care for Patients With High-Risk Asymptomatic Bone Metastases: A Multicenter, Randomized Phase II Clinical Trial" (Gillespie EF, J Clin Oncol. 2024 Jan 1;42(1):38-46. doi: 10.1200/JCO.23.00753. Epub 2023 Sep 25.)
 * Multicenter Phase II. 73 patients. Adult, widely metastatic solid tumors. Arm 1) standard of care (systemic therapy or observation) vs Arm 2) prophylactic RT. Lung 27%, breast 24%, prostate 22%
 * Outcome: Skeletal events RT 2% vs OBS 29% (SS). Fewer hospitalizations (SS). Improved overall survival HR 0.49, SS.
 * Conclusion: Prophylactic radiation lowered skeletal events, hospitalization, and improved survival

Overview

 * A UK trial reported in 1986 was the first to randomize patients to RT 8/1 vs. 30/10. While there was no difference in pain relief at 12 weeks, the trial was criticized for low compliance and short follow-up
 * A follow-on UK trial revealed that RT 8/1 has higher rate of clinical response than RT 4/1
 * Several other trials have confirmed equivalent safety and efficacy of 8 Gy x1 compared with multi-fraction regimens, including RTOG 97-14
 * All trials show a higher re-treatment rate for 8/1 fractionation (~25% vs. ~10% for multifraction regimens), but some of this may be for other reasons than pain level prior to re-irradiation
 * Cochrane review (2004) found overall pain response ~60%, complete pain response ~33%, with no difference between single fraction and multifraction regimens. The composite retreatment rate was higher for single fraction 21% vs. 7%. Conclusion was that single fraction is effective
 * Based on the Dutch Bone Metastasis Study, patient who live <12 weeks do particularly poorly after RT. Only half respond (and that means their pain score decreases from 7 to 5 on 11 point scale), and most die in pain even in the presence of analgesics. Patients who live >12 weeks do better, with 78% responders

Meta-analyses

 * University of Toronto, 2007 - PMID 17416863 — "Palliative Radiotherapy Trials for Bone Metastases: A Systematic Review." Chow E et al. J Clin Oncol. 2007 Apr 10;25(11):1423-1436.
 * Single-fraction vs multiple fraction RT. Updates previous meta-analysis. Literature review.
 * Conclusion: Overall response and complete response same in single fraction (8/1) and multi-fraction treatments. Retreatment rate higher with single fraction

 * Cochrane Review, 2004 PMID 15106258 -- "Palliation of metastatic bone pain: single fraction versus multifraction radiotherapy - a systematic review of the randomised trials." (Wai MS, Cochrane Database Syst Rev. 2004;(2):CD004721.)
 * Pooled meta-analysis. 11 trials, 3435 patients. Any primary site, but mainly prostate, breast, and lung
 * Pain response: single fraction 60% vs. multifraction 59% (NS). Complete response 34% vs. 32% (NS). Single fraction higher re-treatment 21% vs. 7% (SS)
 * Pathologic fracture: single fraction 3% vs. 1.5%
 * Conclusion: Single fraction as effective as multiple fractions at relieving pain. Higher re-treatment and higher rate of pathologic fracture in the single fraction arm

 * McMaster University, 2003 PMID 12573746 -- "Meta-analysis of dose-fractionation radiotherapy trials for the palliation of painful bone metastases." (Wu JS, Int J Radiat Oncol Biol Phys. 2003 Mar 1;55(3):594-605.)
 * 16 trials,
 * Conclusion: No significant difference in complete and overall pain relief between single and multifraction palliative RT for bone metastases. More frequent re-irradiation rate in the lower dose arms.

Randomized

 * RTOG 97-14 (1998-2002) -- RT short (8/1) vs. RT long (30/10)
 * Randomized. 898 patients. Prostate or breast cancer. Weight-bearing 56%, C-spine 5%, T-spine 19%, L-spine 27%, cord compression not allowed. Life expectancy >3 months, KPS >=40 Arm 1) RT 8/1 vs. Arm 2) 30/10. Primary outcome pain relief at 3 months
 * Outcome; 2005 PMID 15928300 -- "Randomized trial of short- versus long-course radiotherapy for palliation of painful bone metastases." (Hartsell WF, J Natl Cancer Inst. 2005 Jun 1;97(11):798-804.)
 * Outcome: 3-month complete pain relief 8/1 15% vs. 30/10 18% (NS); partial 50% vs. 48% (NS); stable 26% vs 24%; progressive 9% vs 10%. Comparable narcotic relief. Retreatment rate 18% vs. 9% (p<.001)
 * Toxicity: acute 8/1 10% vs. 30/10 17% (SS); late toxicity rare
 * Conclusion: Both regimens equivalent for pain control and narcotic relief at 3 months. 8/1 less acute toxicity but higher retreatment
 * Single males; 2006 PMID 16814950 — "Continuing evidence for poorer treatment outcomes for single male patients: retreatment data from RTOG 97-14." Konski A et al. Int J Radiat Oncol Biol Phys. 2006 Sep 1;66(1):229-33.
 * Retreatment (within the original RT portal) at 36 months: 8/1 18% vs 30/10 9% (SS) No difference in retreatment rate between arms for unmarried males, but difference was seen in all other groups.
 * Conclusion: Patients receiving 8 Gy in a single fraction had significantly higher retreatment rates compared with patients receiving 30 Gy in 10 fractions.
 * Economic analysis; 2009 PMID 19546803 -- "Economic analysis of radiation therapy oncology group 97-14: multiple versus single fraction radiation treatment of patients with bone metastases." (Konski A, Am J Clin Oncol. 2009 Aug;32(4):423-8.)
 * Markov model using information from the trial. Cost modeled using Medicare RVU rates
 * Outcome: Mean cost 8 Gy group $998 vs 30 Gy group $2316. QALY survival 7.3 months vs 9.5 months. ICER $6973/QALY
 * Conclusion: Single fraction was the less expensive and more cost-effective treatment

 * Norway/Sweden (1998-2000) -- short RT (8/1) vs. long RT (30/10)
 * Randomized. Stopped early due to comparable outcomes on interim analysis. 376/1000 patients. Bone metastases (spine 38%, pelvis 35%, extremity 20%) resulting in clinically important pain, KPS >40, life expectancy >6 weeks. Spinal cord compression excluded. Arm 1) RT 8/1 vs. 30/10. Target known mets with 2-3 cm margin, for spinal lesions 1 VB above/below. Prophylactic corticosteroids not used. Primary outcome pain relief over 28 weeks (82% questionnaire compliance)
 * 2006 PMID 16793154 -- "Prospective randomised multicenter trial on single fraction radiotherapy (8 Gy x 1) versus multiple fractions (3 Gy x 10) in the treatment of painful bone metastases." (Kaasa S, Radiother Oncol. 2006 Jun;79(3):278-84.) F/U 18 months
 * Outcome: No difference in pain intensity, global QoL, fatigue, or opioid/non-opioid analgesics. (NS). Median O/S 8 Gy 9.6 months vs. 30 Gy 7.9 months (NS)
 * Conclusion: Similar benefit. Recommend single fraction 8 Gy as standard

 * TROG 96.05 PMID 15878101 -- "Randomized trial of 8 Gy in 1 versus 20 Gy in 5 fractions of radiotherapy for neuropathic pain due to bone metastases (Trans-Tasman Radiation Oncology Group, TROG 96.05)." (Roos DE, Radiother Oncol. 2005 Apr;75(1):54-63. Epub 2004 Oct 28.)
 * Phase III. 272 patients. Bone mets, known primary, no change in therapy x6 weeks, no cord compression. Lung 31%, prostate 29%, breast 8%
 * Randomized to 8 Gy/1 fx vs. 20 Gy/5 fxs in 15 centers
 * Response rate: 53% vs. 61% (p=NS); TTF 2.4 mo vs. 3.7 mo (p=0.056)
 * Conclusion : "8/1 was not shown to be as effective as 20/5, nor was it statistically significantly worse. Outcomes were generally poorer for 8/1, although the quantitative differences were relatively small."

 * Dutch Bone Metastasis Study (1996-1998) -- short RT (8/1) vs long RT (24/6)
 * Randomized. 1171 patients. Painful bone metastases, spinal cord compression excluded, C-spine excluded (T/L-spine 37%, pelvis 29%, femur 16%, other 18%). Primary endpoint pain. Median F/U 4 months
 * 1999 PMID 10577695 -- "The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study." (Steenland E, Radiother Oncol. 1999 Aug;52(2):101-9.)
 * Outcome: Response 71% (breast 76%, prostate 78%, NSCLC 60%), complete response 35%. No difference in pain relief at 3 months, 12 months. No difference in time-to-progression. Median OS 7 months (NS); breast CA 16 months vs. NSCLC 3 months.
 * Retreatment: overall 16%; 8/1 25% vs. 24/6 7% (SS), on further analysis higher recurrence pain score in 24/6 group before retreatment
 * Toxicity: No difference in acute toxicity; double the rate of subsequent pathologic fractures in the single fraction arm
 * Conclusion: Equality of 8/1 vs 24/6, provided 4x more retreatments accepted. Equality holds in long-term survivors
 * Last 12 weeks; 2010 PMID 20225326 -- "Efficacy of radiotherapy for painful bone metastases during the last 12 weeks of life: results from the Dutch Bone Metastasis Study." (Meeuse JJ, Cancer. 2010 Mar 11. [Epub ahead of print])
 * Subset analysis. 274 patients who died within 12 weeks after randomization. Patient classified as responders (decrease in initial pain intensity score by 2 of 11 points without analgesic increase, or decrease in analgesics without increase in pain. Used )
 * Outcome: Response 8/1 53% vs 24/6 56% (NS); median time-to-response 2 weeks (1-9) in both groups. In responders, pain score decreased from 7/11 to 5/11 by death. In non-responders, no change. 60% of patients never reached below pain score 5 until death (regardless of RT and medication use). Compared with patients who lived >12 weeks, response percentage for patients who lived <12 weeks was poor 45% vs 78% (SS)
 * Conclusion: Pain responded in ~50% of patients with short survival, regardless of fractional schema. Single fraction should be preferred, and additional palliative measure remain essential

 * UK/NZ (1992-1997) -- short RT (8/1) vs. long RT (20/5 or 30/10)
 * Randomized. 761 patients. Painful skeletal metastases (pelvis/hip 28%, L-spine 20%, ribs 11%, T-spine 9%, femur 6%, C-spine 3%, other 22%). Arm 1) RT 8/1 vs. Arm 2) RT 20/5 or 30/10. Primary endpoint pain relief.
 * 1999 PMID 10577696 -- "8 Gy single fraction radiotherapy for the treatment of metastatic skeletal pain: randomised comparison with a multifraction schedule over 12 months of patient follow-up. Bone Pain Trial Working Party." ([No authors listed], Radiother Oncol. 1999 Aug;52(2):111-21.) Full 12 month follow-up available in 30%.
 * Outcome: No difference in time-to-improvement, time-to-complete pain relief, or class of analgesics (NS). Complete response (no pain, no increase in pain meds) 58%. Retreatment 8/1 23% vs. long-RT 10% (SS) but on further analysis likely due to greater readiness to reatreat rather than need due to pain outcome
 * Toxicity: No difference in nausea (56% vs. 65%), vomiting (30% vs. 32%), spinal cord compression, or pathological fracture
 * Conclusion: No difference in safety or efficacy; pain relief durable over 12-month follow up. 8 Gy single fraction is the treatment of choice

 * Germany, 1996 - PMID 8985030, — "Rapid course radiation therapy vs. more standard treatment: a randomized trial for bone metastases." Niewald M et al. Int J Radiat Oncol Biol Phys. 1996 Dec 1;36(5):1085-9.
 * Randomized to 20 Gy / 5 fractions vs 30 Gy / 15 fractions
 * Slight trend favoring 30 Gy in frequency of pain relief and recalcification. No significant differences in frequency, duration of pain relief, pathologic fractures, or survival.

 * UK -- short RT (4/1) vs short RT (8/1)
 * Randomized. 270 patients. Painful bone metastases. Arm 1) RT 4/1 vs. Arm 2) RT 8/1. Compliance with questionnaire 72% at 4 weeks
 * 1992 PMID 1372126 -- "A prospective randomised trial of 4 Gy or 8 Gy single doses in the treatment of metastatic bone pain." (Hoskin PJ, Radiother Oncol. 1992 Feb;23(2):74-8.)
 * Outcome: 4-week response 4 Gy 44% vs. 8 Gy 69% (SS); but no difference in complete response or duration of response
 * Conclusion: 8 Gy higher probability of pain relief, but 4 Gy can be effective

 * UK -- short RT (8/1) vs long RT (30/10)
 * Randomized. 288 patients with metastatic bone pain. Arm 1) RT 8/1 vs. Arm 2) RT 30/10. Questionnaire compliance 31% beyond 12 weeks
 * 1986 PMID 3775071 -- "Prospective randomised trial of single and multifraction radiotherapy schedules in the treatment of painful bony metastases." (Price P, Radiother Oncol. 1986 Aug;6(4):247-55.)
 * Outcome: No difference in speed of onset, duration of pain relief at 12 weeks. Pain relief independent of histology. Reirradiation more likely with 8/1 schedule but increased analgesic use in 30/10

 * RTOG 74-02 -- Solitary 40.5/15 vs. 20/5; Multiple 30/10 vs. 15/5 vs. 20/5 vs. 25/5
 * Randomized. Pts with solitary lesions randomized to 270 cGy x 15 (40.5 Gy) or 400 x 5 (20 Gy). Pts with multiple lesions randomized to 300 x 10 (30 Gy), 300 x 5 (15 Gy), 400 x 5 (20 Gy), or 500 x 5 (25 Gy, blocking cord after 20 Gy).
 * 1982 PMID 6178497 — "The palliation of symptomatic osseous metastases: final results of the Study by the Radiation Therapy Oncology Group." Tong D et al. Cancer. 1982 Sep 1;50(5):893-9.
 * Outcome: 90% with some relief of pain. 54% had eventual complete pain relief. No difference between radiotherapy regimens in pain relief. No difference among regimens in promptness of pain relief, except there was an association between the dose and the promptness to complete pain relief (fastest in 15 Gy, slowest in 25 Gy group); no difference in the duration of pain relief.
 * Conclusion: No difference between regimens
 * 1985 PMID 2579716, 1985 — "Reanalysis of the RTOG study of the palliation of symptomatic osseous metastasis." Blitzer PH et al. Cancer. 1985 Apr 1;55(7):1468-72.
 * Higher number of fractions (40.5/15 and 30/10) found related to complete relief of pain.

Kyphoplasty + RT

 * Pittsburgh, 2005 PMID 15771398 -- Combination kyphoplasty and spinal radiosurgery: a new treatment paradigm for pathological fractures. (Gerszten PC, Neurosurg Focus. 2005 Mar 15;18(3):e8.)
 * 26 patients with pathologic fractures secondary to tumor treated with Kyphoplasty followed by single fraction (16-20 Gy) RT
 * Conclusion : "A combined kyphoplasty and spinal radiosurgery treatment paradigm was found to be safe and clinically effective for patients with pathological fractures without significant spinal canal compromise. This technique combines two minimally invasive surgical procedures, thereby avoiding the morbidity associated with open surgery while providing immediate fracture fixation as well as a single-fraction tumoricidal radiation dose."

Hemibody radiation
Fractionated hemibody RT:
 * RTOG 88-22 (1989-93) - PMID 8823257, 1996 — "A phase I/II study to evaluate the effect of fractionated hemibody irradiation in the treatment of osseous metastases--RTOG 88-22." Scarantino CW et al. Int J Radiat Oncol Biol Phys. 1996 Aug 1;36(1):37-48.
 * 142 pts. Phase I/II, dose escalation. Pts w/ painful bone mets (single or multiple) confined to one hemibody (upper/mid/lower) from breast or prostate ca.
 * Treatment of local painful site (local RT) followed by hemibody. Escalation of hemibody RT dose, 2.5 Gy/fx to 4-8 fx (10 - 20 Gy). Hemibody began within 3 days of local RT, and the local RT portal was shielded during hemibody RT. Lung shielding to keep lung dose to 6 Gy. Liver and kidney limited to 15 Gy.
 * Dose-limiting toxicity at 17.5 Gy (hematologic toxicity). Time to new disease in the hemibody field: 19% at 1 yr, no difference between arms; no difference in retreatment rates.
 * Conclusion: Comparing this study to single fraction study (RTOG 82-06), there was a reduction of 36% of new disease with the fractionated technique. No difference in survival.

Single-fraction hemibody RT:
 * RTOG 82-06 - 8 Gy
 * 499 pts. Received 300x10 local radiation to the painful site, then randomized to hemibody RT (8 Gy/1) or observation.
 * PMID 1374061, 1992 — "A report of RTOG 8206: a phase III study of whether the addition of single dose hemibody irradiation to standard fractionated local field irradiation is more effective than local field irradiation alone in the treatment of symptomatic osseous metastases." Poulter CA et al. Int J Radiat Oncol Biol Phys. 1992;23(1):207-14.
 * Disease progression at 1 yr: 35% (local+HBI) vs 46% (local only); new disease in hemibody: 50% vs 68%; median time to new disease in hemibody: 12.6 m vs 6.3 m.

 * RTOG 78-10 (1978-81)
 * 168 pts (129 evaluable). Doses: 600-800 rad (upper half body), 800-1000 rad (lower and middle). Dose rate 15-45 rad/min. Used comprehensive premedication program (IV hydration, antiemetics, steroids) for pts receiving upper half RT; antiemetics only for mid or lower half. 10 pts received treatment to both body halves (sequentially).
 * PMID 2423225, 1986 — "Single-dose half-body irradiation for palliation of multiple bone metastases from solid tumors. Final Radiation Therapy Oncology Group report." Salazar OM et al. Cancer. 1986 Jul 1;58(1):29-36.
 * Pain relief in 73%; 20% with complete relief. No dose response seen: optimum response at the lower doses tested (600 for UHBI, 800 for LHBI and MBI). Time to pain relief - 50% within 48 hrs, 80% within 1 week, 95% in 2 wks.
 * PMID 6169699 (No abstract), 1981 — "Single-dose half-body irradiation for the palliation of multiple bone metastases from solid tumors: a preliminary report." Salazar OM et al. Int J Radiat Oncol Biol Phys. 1981 Jun;7(6):773-81.
 * Conclusion: rapid pain relief. Safest dose appears to be 600 (upper) and 800 (lower/mid). Compared with conventional RT (a la RTOG 74-02), overall pain relief and duration of pain relief are similar, but HBI achieved pain relief much sooner (complete pain relief within 2 weeks vs many months), 4 times lower recurrence of pain in the radiated fields (54% vs 13%)

Reviews:
 * PMID 2579726, 1985 — "Systemic hemibody irradiation for overt and occult metastases." Rubin P et al. Cancer. 1985 May 1;55(9 Suppl):2210-21.

SBRT

 * University of Toronto; 2023 PMID 36309076 -- "Dose-Escalated 2-Fraction Spine Stereotactic Body Radiation Therapy: 28 Gy Versus 24 Gy in 2 Daily Fractions" (Zeng KL, Int J Radiat Oncol Biol Phys. 2023 Mar 1;115(3):686-695. doi: 10.1016/j.ijrobp.2022.09.076. Epub 2022 Oct 26.)
 * Retrospective. 947 vertebral body segments, 482 patients. Comparison of 28 Gy (301 segments) vs 24 Gy (646 segments) in 2 fractions SBRT. Median f/u 24 months.
 * Outcome: 28 Gy - 6-mo LF 3%, 1-year LF 5%, 2-year LF 11% vs 24 Gy 6%, 12%, 18% (SS). Higher risk of failure in 24 Gy group, paraspinal extension, epidural extension
 * Toxicity: Vertebral compression fracture 5%, 8%, and 11%, and similar between cohorts. Higher risk in spinal malalignment, pre-existing VCF, junctional spine location, and higher V90 dose
 * Conclusion: Dose escalation to 28 Gy in 2 fractions improved local control, similar risk of vertebral fracture.

 * Pittsburgh; 2007 PMID 17224814 -- "Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution." (Gerszten PC, Spine. 2007 Jan 15;32(2):193-9.)
 * Prospective cohort study. 500 cases of spinal metastases (cervical 15%, thoracic 42%, lumbar 22%, sacral 20%), treated with radiosurgery. Maximum dose 12.5-25 Gy (mean 20 Gy). Prior EBRT 69% (typically 30/10 or 35/14)
 * Outcome: Long-term pain control 86%; at least some improvement in neurologic function in 85% (30/35)
 * conclusion: Radiosurgery has potential to improve long-term palliation

 * MD Anderson
 * Phase I/II study. 63 patients with 74 spinal mets. SBRT 30 Gy in 5 fractions @ 6 Gy/fraction. Spinal cord max dose 10 Gy.
 * 2007 PMID 17688054 "Phase I/II study of stereotactic body radiotherapy for spinal metastasis and its pattern of failure." (Chang EL, J Neurosurg Spine. 2007 Aug;7(2):151-60.). Median F/U 1.8 years
 * Outcome: Actuarial 1-year PFS 84%. Failure mostly 1) recurrence in adjacent bone, or 2) recurrence in epidural space
 * Toxicity: no neuropathy or myelopathy; Grade 3 GI (n=1), Grade 3 dysphagia (n=1), Grade 3 chest pain (n=1). No late Grade 3-4 toxicity
 * Conclusion: Safe and effective
 * 2004 PMID 15275711 -- "Phase I clinical evaluation of near-simultaneous computed tomographic image-guided stereotactic body radiotherapy for spinal metastases." (Chang EL, Int J Radiat Oncol Biol Phys. 2004 Aug 1;59(5):1288-94.)
 * Phase I. 15 patients. Median F/U 9 months
 * Toxicity: none
 * Conclusion: Technically feasible
 * 2003 PMID 14529763 -- "Near simultaneous computed tomography image-guided stereotactic spinal radiotherapy: an emerging paradigm for achieving true stereotaxy." (Shiu AS, Int J Radiat Oncol Biol Phys. 2003 Nov 1;57(3):605-13.)
 * Description of treatment technique

 * Memorial Sloan Kettering; 2005 PMID 15850902 -- "Multifractionated image-guided and stereotactic intensity-modulated radiotherapy of paraspinal tumors: a preliminary report." (Yamada Y, Int J Radiat Oncol Biol Phys. 2005 May 1;62(1):53-61.)
 * Retrospective. 35 patients (21 metastases, 20 previously irradiated). Treated with paraspinal IMRT. Prior median dose 30/10. Retreatment dose median 20/5 (20-30 Gy). If no prior RT, median dose 70 Gy. Median F/U 11 months
 * Outcome: Palliation 90%; LC for primary tumors 81% vs. mets 75%
 * Toxicity: No radiation-induced myelopathy or radiculopathy
 * Conclusion: Stereotactic IGRT allows delivery of high doses to close proximity of spinal cord

 * Heidelberg; 2003 (1997-2001) PMID 12504049 -- "Clinical results of retreatment of vertebral bone metastases by stereotactic conformal radiotherapy and intensity-modulated radiotherapy." (Milker-Zabel S, Int J Radiat Oncol Biol Phys. 2003 Jan 1;55(1):162-7.)
 * Retrospective. 18 patients, 19 recurrent spinal metastases. Treated with 3D-CRT (n=5) or IMRT (n=14). Prior conventional RT (median 38 Gy). Median time-to-recurrence 18 months. Median retreatment 39.6 Gy (spinal cord dose limited to ~60-65% of Rx dose) @2 Gy/fraction. Median F/U 12 months.
 * Outcome: LC 95%, significant pain relief 81%, neurologic improvement 42%. Tumor size unchanged 84%, 1 local progression 9 months after RT.
 * Toxicity: No significant late toxicity
 * Conclusion: Fractionated 3DCRT and IMRT safe and effective for re-treatment

Review
 * MD Anderson; 2008 PMID 18514775 -- "Stereotactic body radiosurgery for spinal metastases: a critical review." (Sahgal A, Int J Radiat Oncol Biol Phys. 2008 Jul 1;71(3):652-65.)

 * MSKCC, 2007 PMID 17762734 -- "A Review of Image-Guided Intensity-Modulated Radiotherapy for Spinal Tumors." (Yamada Y, Neurosurgery. 61(2):226-235, August 2007.)
 * Review of IGRT for spinal tumors, including hypofractionated and SBRT approaches

Unsealed Sources

 * ''Please see the Unsealed sources page for more information

Kyphoplasty

 * Cancer Patient Fracture Evaluation (CAFE) (2005-2008) -- kyphoplasty vs non-surgical management
 * Randomized. 134 patients, 1-3 painful vertebral compression fractures. Arm 1) kyphoplasty vs Arm 2) non-surgical management. Primary endpoint Roland-Morris disability questionnaire (RDQ) at 1 month
 * 2010 PMID not yet available -- "Using DOIBalloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial" (Berenson J, The Lancet Oncology, Early Online Publication, 17 February 2011doi:10.1016/S1470-2045(11)70008-0)
 * Outcome: RDQ disability score pre-treatment to post-treatment change: vertebroplasty 17.6 to 9.1 (-8.3 points) vs non-surgical management 18.2 to 18.0 (-0.1 points) (SS)
 * Conclusion: Kyphoplasty effective and safe for painful vertebral compression fractures

Re-treatment

 * See also: Radiation_Oncology/Palliation/Spinal_Cord_Compression for re-treatment of spinal metastases.

Meta-analysis:
 * Netherlands; 2012 (1985-2000) PMID 22300568 -- "Effectiveness of Reirradiation for Painful Bone Metastases: A Systematic Review and Meta-Analysis." (Huisman M, Int J Radiat Oncol Biol Phys. 2012 Sep 1;84(1):8-14.)
 * 7 articles included in the meta-analysis. 527 pts treated with reirradiation. Initial dose 4-8 Gy x 1. Most patients retreated with single fraction again. Pain response was achieved after reirradiation in 58%. Location: spine in 36%.
 * Conclusion: "Reirradiation of painful bone metastases is effective in terms of pain relief for a small majority of patients; approximately 40% of patients do not benefit from reirradiation. Although the validity of results is limited, this meta-analysis provides a comprehensive overview and the most quantitative estimate of reirradiation effectiveness to date."


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Radiation Oncology/Palliation/Brain Metastases

Brain Metastases

 * Official Guidelines
 * Overview
 * Surgery
 * Whole Brain RT
 * Stereotactic Radiosurgery
 * Brain Metastases Randomized Evidence

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


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Radiation Oncology/Palliation/Spinal Cord Compression

Spinal Cord Compression

 * ''Please also see the bone metastasis page, which includes spine metastases without cord compression
 * ''Please also see summary of randomized evidence
 * ''Please also see the spine dose tolerance page

Epidemiology

 * Estimated >20,000 cases in US per year, in ~10% patients
 * Most common breast (~30%), NSCLC (~17%), prostate (~14%)
 * Clinical presentation
 * Back pain (90%), frequently for weeks
 * Weakness (80%)
 * Sensory deficits (50-80%)
 * Autonomic dysfunction (40-60%)
 * Definition (Princess Margaret, see PMID 15774794)
 * Radiographic features: Compression of dural sac and its contents (spinal cord and/or cauda equina) by an extradural tumor mass. Minimum radiographic evidence is indentation of the theca at the level of clinical features
 * Clinical features: Any or all of the following: pain (local or radicular), weakness, sensory disturbance, and/or evidence of sphincter dysfunction.
 * Anatomically, compression can be intramedullary, leptomeningeal, or extradural
 * Pathophysiology of extradural compression includes several mechanisms
 * Continued growth of bone met into epidural space
 * Blockage of neural foramina by a paraspinal mass
 * Destruction of vertebral bone, causing a collapse and displacement of bony fragments into epidural space
 * Vascular obstruction of epidural venous plexus, leading to cord edema, ischemia, and ultimately permanent damage
 * History (adapted from Perez, 4th):
 * When did the pain begin?
 * When last walking independently?
 * Why come to hospital today?
 * Fever or weight loss?
 * Last void?
 * Physical exam (adapted from Perez, 4th):
 * KPS?
 * Raise legs against gravity?
 * Hands sensation compared with feet sensation?
 * Reflexes (ankle, knee, elbow, wrist)?
 * Workup: MRI (sensitivity 93%, specificity 97%, accuracy 95%)
 * Predictive factors: time to development of motor deficits, favorable histology
 * Median OS ~3 months
 * If ambulatory after treatment, median OS ~7 months
 * If non-ambulatory after treatment, median OS ~1.5 months
 * Approximately 30% can survive >1 year

Prognosis
Ambulatory Status:
 * Multi-national; 2008 PMID 18436390 -- "A Score Predicting Posttreatment Ambulatory Status in Patients Irradiated for Metastatic Spinal Cord Compression." (Rades D, Int J Radiat Oncol Biol Phys. 2008 Apr 22. [Epub ahead of print])
 * Scoring system. 2096 met spinal cord compression patients. Factors: primary tumor type, interval between tumor diagnosis and MSCC, visceral mets, motor function before RT, time to develop motor deficits. Total score 21-44. Outcome modeled: ambulatory status
 * Outcome: Post-RT ambulatory rate if score <=28 6%, 29-31 44%, 32-34 70%, 35-37 86%, >=38 98%. 6-month OS 6%, 31%, 42%, 61%, 93%
 * Conclusion: For patients with score <=28, suggest short course RT. For patients with score 29-37, suggest surgery + RT. For patients with score >=38 RT alone provides excellent results

 * Multi-national; 2011 PMID 20605351 -- "Validation of a score predicting post-treatment ambulatory status after radiotherapy for metastatic spinal cord compression." (Rades D, Int J Radiat Oncol Biol Phys. 2011 Apr 1;79(5):1503-6.)
 * 653 patients (treated with RT alone) prospective trial for validation of 2008 retrospective study with 2096 patients reported above. Same scoring system as 2008 with simplified three instead of five groups for post treatment ambulatory status. RT alone groups were compared with another group of 104 patients treated with surgery followed by RT.
 * Outcome: Post-RT ambulatory rate for score ≤28 (Group I)=10.6%, 29-37 (Group II)=70.9%, ≥38 (Group III)=98.5%. 6-month OS 11.3%, 46.4%, and 92.0%. Addition of laminectomy (n=41) did not add statistically significant (SS) benefit compared to RT alone. SS benefit with laminectomy plus stabilization (n=63) followed by RT when all groups combined (P=0.04), with non-SS trend in Group II (P=0.23, possibly due to only 31 patients in the group).
 * Conclusion: For patients with score ≤28, suggest short course RT for palliation of pain. For patients with score 29-37, consider adding laminectomy plus stabilization to RT. For patients with score ≥38 RT alone provides excellent results

 * Hannover; 2002 (1998-2000) PMID 12095565 -- "Final results of a prospective study of the prognostic value of the time to develop motor deficits before irradiation in metastatic spinal cord compression. (Rades D, Int J Radiat Oncol Biol Phys. 2002 Jul 15;53(4):975-9.)
 * Prospective. 98 patients. No surgery, dexamethasone 32-40 mg/qd. 3 subgroups based on time of motor deficit development prior to RT: Group A (1-7 days, n=31), Group B (8-14 days, n=31), and Group C (>14 days, n=36). Groups balanced. RT started as soon as possible, 30/10 or 37.5/15 or 40/20, using PA field
 * Outcome: Initial ambulatory rate A 48% vs. B 55% vs. C 56%. Post-treatment ambulatory rate 35% vs. 55% vs. 86%. This held at 6 weeks (SS), 12 weeks (SS), and trend at 24 weeks (p=0.07). Deterioration worst in Group A (10% improved, 42% stabilized, 48% worse)
 * Predictors: time-to-develop motor deficit (slower better), type of tumor (favorable=myeloma, lymphoma, SCLC, testicular better), pretreatment ambulation (ambulation better)
 * Conclusion: Functional outcome better with slower development of motor deficits before RT

Survival:
 * 2010 PMID 20564129 -- "Validation and simplification of a score predicting survival in patients irradiated for metastatic spinal cord compression." (Rades D, Cancer. 2010 Aug 1;116(15):3670-3.)
 * Based on: PMID 17948910 (2008, Rades D) ("The first score predicting overall survival in patients with metastatic spinal cord compression.")
 * 439 pts treated with RT alone.

Steroids

 * If clinical suspicion is high, should be administered even before radiographic diagnosis. They can be rapidly discontinued if necessary
 * A randomized trial showed improved ambulation with administration of steroids over no steroids, with a dose of 96 mg QD
 * Loading and maintenance dose are not well established. A small randomized trial showed statistical equivalence between dexamethasone 100 mg IV and dexamethasone 10 mg, although there was a suggestion of clinical benefit for the higher dose
 * Very high doses (~100 mg QD) can result in significant toxicity, and are typically not used now. One ought to be cautious in patients with diabetes mellitus, HTN, and peptic ulcer disease
 * A recommended regimen (Perez 5th ed) is dexamethasone 10 mg IV loading dose, then dexamethasone 4-6 mg every 6-8 hours. Patients should also be started on proton pump inhibitor for the duration of dexamethasone based on PPI date in NSAIDs and GI prophylaxis
 * A Phase II trial suggests that for patients with good motor function, corticosteroids may not be necessary, as long as they are counseled about development of symptoms

 * Perugia; 1996 (Italy)(1991-1993) PMID 8610645 -- "Radiotherapy without steroids in selected metastatic spinal cord compression patients. A phase II trial." (Maranzano E, Am J Clin Oncol. 1996 Apr;19(2):179-83.)
 * Phase II. 20 patients with spinal cord compression, no neurologic deficit (radiculopathy allowed), no massive invasion of spine on MRI/CT. Walking deficits in 4 patients (2 radiculopathy, 2 back pain). No steroids given RT 30/10
 * Outcome: 100% ambulatory at completion. Median OS 14 months
 * Conclusion: RT without steroids is feasible in patients with good motor function and avoids toxicity

 * Copenhagen -- 96 mg dexamethasone vs. control
 * Randomized. 57 patients with spinal cord compression. Arm 1) high-dose dexamethasone (IV bolus 96mg, then 96 mg x3 days, then 10 day taper) vs. Arm 2) no steroids
 * 1994 PMID 8142159 -- "Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomised trial." (Sorensen S, Eur J Cancer. 1994;30A(1):22-7.)
 * Outcome: Gait function dexamethasone 81% vs. control 63%, 6-months later 59% vs. 33%. Median OS no difference
 * Toxicity: Significant side effects 11%
 * Conclusion: High-dose glucocorticoid therapy should be given as adjunct

 * Norwegian Radium Hospital; 1992 PMID 1560260 -- "High incidence of serious side effects of high-dose dexamethasone treatment in patients with epidural spinal cord compression." (Heimdal K, J Neurooncol. 1992 Feb;12(2):141-4.)
 * Retrospective. 28 consecutive patients, treated with high-dose dexamethasone (96 mg IV, taper in 14 days).
 * Toxicity: 29% side-effects, 14% serious (1 fatal ulcer, 1 rectal bleeding, 1 GI perforation, 1 sigmoid perforation)
 * Conclusion: High incidence of side effects, now use dexamethasone 16 mg daily, taper in 14 days

 * Rotterdam -- bolus 10 mg IV vs. bolus 100 mg IV
 * Randomized. 37 patients with cord compression. Arm 1) Dexamethasone bolus 10 mg IV vs. Arm 2) dexamethasone bolus 100 mg IV. Both followed by dexamethasone 16 mg daily
 * 1989 PMID 2771077 -- "Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression." (Vecht CJ, Neurology. 1989 Sep;39(9):1255-7.)
 * Outcome: Improved neurologic status: moderate 8% vs. high 25% (NS). Overall no difference in pain, ambulation, or bladder function
 * Conclusion: No difference
 * Comment: Small trial, and clinically significant difference (8% vs. 25%) if real

Surgery + RT vs. RT alone

 * Surgery is indicated when there is spinal instability or bony retropulsion causing the cord compression. This is a consensus opinion, without literature support (see PMID 15774794)
 * Surgery may also be indicated in patients with symptomatic cord compression, with paralysis <2 days based on the Patchell trial. However, there is significant morbidity associated with the operation, and the trade-offs need to be considered. Laminectomy doesn't appear as beneficial

 * Bluegrass Neuro-Oncology Consortium (1992-2002) -- Decompression + RT vs. RT alone
 * Randomized. Stopped early after meeting stopping rule. 101/200 patients, paraplegia <=48 hours. Spinal cord compression from mets (excluded radiosensitive histologies, CNS primary). Decadron 100 mg, then 24 mg Q6. Arm 1) Surgery + RT vs. Arm 2) RT alone. 32 unable to walk (16 vs. 16). RT 30/10, field 8cm wide and one VB above/below lesion. RT started within 14 days post-op, or within 24 hrs of randomization. Endpoint ability to walk.
 * 2005 PMID 16112300 -- "Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial." (Patchell RA, Lancet. 2005 Aug 20-26;366(9486):643-8.)
 * Ability to walk: surgery + RT 84% vs. RT alone 57% (SS). Length of response: 122 days vs. 13 days (SS). No improvement: surgery + RT 19% vs. RT alone 62% (SS)
 * If ambulatory: Ability to walk 94% vs. 74% (SS); duration of response 153 days vs. 54 days (SS)
 * If non-ambulatory: Ability to walk 62% vs. 19% (SS); duration of response 59 days vs. 0 days (SS)
 * Cross-over: ambulatory patients treated with RT alone and failed, then treated with surgery: 30% able to walk
 * Continence: surgery + RT 156 days vs. RT alone 17 days (SS); OS 126 days vs. 100 days (SS)
 * Conclusion: Direct decompression + RT better than RT alone, even for patients who are ambulatory
 * Comment: RT alone arm results significantly worse than what would have been expected based on other prospective RT trials; took 10 yrs to accrue 101 pts, suggesting results apply to only a minority of cord compression pts; non-neurologic morbidity higher in RT alone group, suggesting insufficient stratification factors used

 * Germany (2000-2009)
 * 2010 PMID 20606090 --"Matched Pair Analysis Comparing Surgery Followed By Radiotherapy and Radiotherapy Alone for Metastatic Spinal Cord Compression'' (Rades D, J Clin Oncol. 2010 Aug 1;28(22):3597-604)
 * Matched pair analysis of 108 pts receiving surgery+ steroids + RT for metastastic cord compression vs 216 pts (1:2 match) from database of 2300 pts treated w/ RT alone. Matched for 11 potential prognostic factors. Included pts w/ multiple involved vertebrae, myeloma/lymphoma, non-ambulatory pts.
 * Outcomes (RT alone vs surg RT--no p values significant)
 * Ambulatory Post-Treatment: 68% vs 69%
 * Regained Ambulation: 26% vs 30%
 * 1 yr local control: 91% vs 90%
 * 1 yr OS: 40% vs 47%
 * Complications: None > CTCAE gr. 1 vs 11% sig bleed, postop pneumonia, PE
 * Conclusion: Endpts after RT alone similar to surg+ RT. A new RCT is justified.

 * Upstate, New York -- Laminectomy +RT vs. RT alone
 * 1980 PMID 7441333 -- "Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy." (Young RF, J Neurosurg. 1980 Dec;53(6):741-8.)
 * Randomized. 29 patients, metastatic spinal cord compression. Arm 1) laminectomy + RT vs. Arm 2) RT alone. Post-op RT started within 7 days, 30/10, +/- one VB using single PA field at 5 cm depth. RT alone 12/3 followed by 18/7, started within 1-2 after myelogram. Decadron IV 12 mg loading, then 4 mg Q6.
 * Outcome: No difference in pain relief (88% vs. 92%), improved ambulation (45% vs. 54%), or sphincter function. Mean survival 6 months vs. 5 months (NS).
 * Conclusion: Results are suggestive but not conclusive due to limited size and design defects

RT Dose

 * There does not appear to be any difference among the various dose-fractionation regimens
 * In the US, RT 30/10 is considered standard of care, and shorter fractionation schedules (20/5 or 8/1) are typically reserved for those with progressive disease refractory to systemic chemotherapy and are typically avoided in newly diagnosed patients who are chemotherapy-naive (Perez 5th ed)
 * German multi-institutional randomized trial showed 20/5 schema is not inferior to 30/10 schema, in patients with poor/intermediate survival

 * SCORE-2 / ARO 2009/01 -- epidural spinal cord compression, 20/5 vs 30/10
 * Randomized. 203 patients with metastatic spinal cord compression, lower extremity motor deficits. Evaluated by neurosurgeon. Poor or intermediate prognosis (score <=38 points on scoring system (above)). Diagnosis confirmed by MRI. Arm 1) 4 Gy x 5 fractions vs Arm 2) 3 Gy x 10 fractions. 3D-conformal ~70%, rest PA or AP/PA fields. Primary end point motor deficits at 1 month
 * Results, 2016 PMID 26729431 -- Radiotherapy With 4 Gy × 5 Versus 3 Gy × 10 for Metastatic Epidural Spinal Cord Compression: Final Results of the SCORE-2 Trial (ARO 2009/01)." (Rades D, J Clin Oncol. 2016 Feb 20;34(6):597-602. doi: 10.1200/JCO.2015.64.0862. Epub 2016 Jan 4.)
 * Outcome: 1 month response rate 4x5 87% vs 3x10 90% (NS). Improvement 38% vs 44% (NS), stable function 49% vs 45%, further deterioration 13% vs 10% (NS for all). Ambulatory rate 72% vs 78% (NS). 6-month LC 75% vs 82% (NS)
 * Conclusion: Short course RT with 4 Gy x 5 was not inferior to 3 Gy x 10 in these patients

 * Germany / Netherlands; 2008 (2006-2008) PMID 18539406 -- "Preliminary Results of Spinal Cord Compression Recurrence Evaluation (Score-1) Study Comparing Short-Course Versus Long-Course Radiotherapy for Local Control of Malignant Epidural Spinal Cord Compression." (Rades D, Int J Radiat Oncol Biol Phys. 2008 Jun 6. [Epub ahead of print])
 * Prospective, 2 arm. 231 patients with spinal cord compression. Arm 1) Short RT (8/1, 20/5) or Arm 2) Long RT (30/10, 37.5/15, or 40/20). Randomization not possible as different schedules used for logistical reasons in different countries. Primary endpoint PFS (lack of progressive motor deficits or in-field recurrence)
 * Outcome: 12 month PFS short RT 55% vs. long RT 72% (SS); LC 61% vs. 77% (SS); OS 25% vs. 32% (NS). Improvement in motor function 28% vs. 30% (NS)
 * Conclusion: Short and long course RT similar functional outcome and OS. However, long course RT significantly better for PFS and LC

 * Multi-national (1992-2003)
 * NSCLC; 2006 PMID 16580192 -- "Defining the appropriate radiotherapy regimen for metastatic spinal cord compression in non-small cell lung cancer patients." (Rades D, Eur J Cancer. 2006 May;42(8):1052-6.)
 * Retrospective. 252 NSCLC patients with SCC compression. Treated with short (8/1 or 20/5) or long (30/10, 37.5/15, or 40/20) RT. Improvement in motor function 14%, no change 54%, deterioration 32%
 * Oucome: function affected by time of motor deficit before RT (>14 days better). No impact of RT regimen. In short RT group, no difference between 8/1 and 20/5
 * Conclusion: recommend 8 Gy x 1
 * Multiple myeloma; 2006 PMID 16413695 -- "Short-course radiotherapy is not optimal for spinal cord compression due to myeloma." (Rades D, Int J Radiat Oncol Biol Phys. 2006 Apr 1;64(5):1452-7.)
 * Retrospective. 172 patients. Treated with short (8/1 or 20/5) or long (30/10, 37.5/15, or 40/20) RT
 * Outcome: Improvement in 52%; in nonambulatory 47% regained ability to walk. Improvement more frequent after long-course RT 76% vs. 40% (SS) at 1 year, 83% vs. 54% (SS) at 2 years. Similar outcome among the different long fractionation schemes
 * Conclusion: Long-course RT preferable for myeloma patients; 30/10 appropriate
 * Fractionation; 2005 PMID 15908648 -- "Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression." (Rades D, J Clin Oncol. 2005 May 20;23(15):3366-75.)
 * Retrospective. 1304 patients with spinal cord compression. Treated with 8/1, 20/5, 30/10, 37.5/15, 40/20
 * Outcome: motor function improved in ~30%, ambulatory rates ~70%. RT schedule not associated with outcome. Recurrence rates: 8/1 24%, 20/5 26%, 30/10 14%, 37.5/15 9%, 40/20 7% (SS); no difference between 8/1 and 20/5, and no difference between 30/10, 37.5/15, and 40/20
 * Toxicity: acute mild (Grade I only), no late toxicity
 * Conclusion: Similar functional outcome. Recommend 8/1 in expected poor survival, and 30/10 in expected good survival

 * Germany / Netherlands; 2005 (1999-2003) - PMID 15890595 — "Comparison of 1 x 8 Gy and 10 x 3 Gy for functional outcome in patients with metastatic spinal cord compression." Rades D et al. Int J Radiat Oncol Biol Phys. 2005 Jun 1;62(2):514-8.
 * Retrospective. 96 pts treated 1 x 8 Gy (in Amsterdam) compared with 108 pts treated with 10 x 3 Gy (in Germany). Evaluated ambulatory status and motor function
 * No difference in outcome between the two radiation regimens. 1 x 8 Gy should be considered in poor prognosis patients.

 * Italy (1998-2002) -- 16/2 (over 1 week) vs. 15/3 + 15/5 (over 2 weeks)
 * Randomized. 300 patients, short life expectancy (<=6 months), with metastatic spinal cord compression. Dexamethasone 8 mg IV BID, taper after end of RT. Arm 1) Short-course RT (8 Gy x 2 over 7 days) vs Arm 2) Split-course RT (5 Gy x 3, 4 day break, 3 Gy x 5). RT 2 VBs above and below.
 * 2005 PMID 15738534 — "Short-Course Versus Split-Course Radiotherapy in Metastatic Spinal Cord Compression: Results of a Phase III, Randomized, Multicenter Trial." (Maranzano E et al. J Clin Oncol. 2005 May 20;23(15):3308-10.)
 * Outcome: Pain relief short 56% vs long 59% (NS), ambulation 68% vs. 71% (NS), bladder function 90% vs. 89% (NS). Median OS 4 months. Recurrence 2%, all in short course
 * Toxicity: Grade 1-2 dysphagia 14%, Grade 1-2 diarrhea 7%
 * Conclusion: Both regimens effective, short-course more convenient for patients

 * "Always on a Friday", Netherlands, 2001 (1987-97)
 * PMID 11321668 — "Always on a Friday? Time pattern of referral for spinal cord compression." Poortmans P et al. Acta Oncol. 2001;40(1):88-91.
 * 443 pts treated for spinal cord compression. 30% of referrals took place on Fridays.

Specific tumor types
Myeloma:
 * For more information on treatment of spinal cord compression, see Radiation Oncology/Multiple myeloma.

Re-treatment

 * Please also see spine NTCP page; Radiation_Oncology/Palliation/Bone_metastases

 * Multi-national; 2008 (1995-2007) PMID 18642349 -- "Prognostic factors for functional outcome and survival after reirradiation for in-field recurrences of metastatic spinal cord compression." (Rades D, Cancer. 2008 Jul 18. [Epub ahead of print])
 * Retrospective. 124 patients re-irradiated for MSCC in-field recurrence, C-spine excluded. First RT 8/1 or 20/5 or 30/10 or 37.5/15 or 40/20 depending on medical center. All stable/improved after first RT. All motor deficits at time of Re-RT, 69% ambulatory. Second RT 8/1 (38%), 15/5 (23%), 20/5 (24%), 21/7 (2%), 20/10-24/12 (9%). Cummulative BED(a/b=2) 77.5-143 Gy, 92% <=120 Gy. Median F/U 11 months
 * Outcome: Motor function improved 36%, stable 50%, deteriorated 14%. Predictors for motor function: effect of 1st RT, ECOG PS, time-to-motor deficits, visceral mets. Re-RT dose or cumulative BED no impact on function or OS
 * Late toxicity: No radiation myelopathy observed
 * Conclusion: Spinal irradiation appears effective and safe when cumulative BED <120 Gy (a/b=2, corresponds to 60 Gy in 2 Gy/fx). Single fraction reasonable if poor estimated survival

 * Hamburg, 2005 (Germany)(1995-2003) PMID 16170487 -- "[Effectiveness and toxicity of reirradiation (Re-RT) for metastatic spinal cord compression (MSCC)]" - [Article in German] (Rades D, Strahlenther Onkol. 2005 Sep;181(9):595-600.)
 * Retrospective. 74 patients re-irradiated in-field. Median F/U 9 months
 * Outcome: Improved motor function in 39%; no impact of RT schedule, cumulative EQD2, or time between treatments
 * Toxicity: no radiation myelopathy. Cumulative EQD2 (using a/b=2) 39-40 in n=21, 49-50 in n=41, 56-60 in n=6, and >60 in n=6
 * Conclusion: Re-RT effective for in-field recurrence of cord compression

 * Knoxville, TN; 2005 PMID 16125871 -- "Evaluation of image-guided helical tomotherapy for the retreatment of spinal metastasis." (Mahan SL, Int J Radiat Oncol Biol Phys. 2005 Dec 1;63(5):1576-83. Epub 2005 Aug 26.)
 * Retrospective. 8 patients with spinal cord compression after prior RT (30/10 - 45/25 Gy). Tomotherapy technique. Retreatment dose 20-30 Gy in 2-2.5 Gy/fx. Cummulative spinal cord Dmax limit 50 Gy. Dose gradient 10%/mm. Mean F/U 15 months
 * Outcome: 100% LC. Complete pain relief 6/8, partial pain relief 2/8
 * Complications: None
 * Conclusion: Tomotherapy

Guidelines and Standards

 * Johns Hopkins; 2008 PMID 18688056 -- "Evidence-based standards for cancer pain management." (Dy SM, J Clin Oncol. 2008 Aug 10;26(23):3879-85.)
 * Literature review, then expert panel. Metastatic bone pain and spinal cord compression
 * Spinal cord compression: MRI imaging. Corticosteroids. Start definitive treatment (surgery or RT) within 24 hours

 * Toronto; 2005 PMID 15774794 -- "Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiative's Neuro-Oncology Disease Site Group." (Loblaw DA, J Clin Oncol. 2005 Mar 20;23(9):2028-37.)
 * Minimize treatment delay. MRI imaging. High dose dexamethasone effective, but significant toxicity. Patients who are ambulatory do not need dexamethasone, but should be educated about the symptoms of spinal cord compression
 * Treatment for patients with MSCC should consider pretreatment ambulatory status, comorbidities, technical surgical factors, the presence of bony compression and spinal instability, potential surgical complications, potential RT reactions, and patient preferences.

 * Toronto; 1998 PMID 9552073 -- "Emergency treatment of malignant extradural spinal cord compression: an evidence-based guideline." (Loblaw DA, J Clin Oncol. 1998 Apr;16(4):1613-24.)


text:
Talk:FHSST Physics/Contributors

awsome kob guys I like what I've read so far--65.24.68.237 09:47, 12 Jun 2005 (UTC)

title: Talk:FHSST Physics/Contributors


text:
Talk:Electronics/Op-Amps

Reorganisation
Ok firstly this page is very confusing. So this is what I'm going to do. Firstly I'm going to remove ideas of coupling, oscillators, and offsets until the ideal op-amp is discussed.

Firstly oscillators because that clouds the use of Op Amps. They are first and foremost signal amplifiers. Secondly coupling because this is also a more advanced idea to real amplifier circuit and Op Amp have high CMRR, common mode rejection ratios which means coupling is generally unnecessary. Where as a real Common Emitter amplifier, for instance doesn't. Which means it is not neccesary. Lastly offsets, If this is your first sight of an Op Amp then how would know of or dream up an offset.

That which was removed is below. - IknowNothing

Oscillator When positive feedback occurs in an Op-Amp/Transistor it becomes an oscillator. Unless, of course, it becomes a Comparator.

Coupling ways of allowing an AC signal to go from on stage to another without changing the bias of the 2 stages.

Diode. DC voltage drop. When AC passes only allows half the waveform through. This is useful for constructing a power supply.

Capacitive coupling. DC does not pass through capacitors, but AC does. At low frequencies capacitors have high impedance, and at high frequencies capacitors have low impedance.

Transformer coupling. Inductor based. AC does not pass through inductors, but DC does. Low impedance at low frequencies and high impedance at high frequencies.

My next move is to move any comments of what an Op Amp is physically constructed from until a discussion of real op amps. Since it just clouds the issue. - IknowNothing

Notation
I have changed $$G_{openloop}$$ to $$A_{vo}$$ and use $$A_f$$ for closed loop gain. - IknowNothing

Interested Contributor.
In am interested in contributing information on the "operational amplifier" used in a differential configuration. In particular, the case in which the input is a "floating voltage source" (i.e. magnetic readhead). This topology would be a variant of the difference amplifier whose input is typically two individual voltage sources each referenced to ground.

Do you think there might be any interest in this topic? - hgmjr

Yes. I don't quite understand what distinguishes the two cases you mention. I suspect I'm not the only one. What about the Instrumentation amplifier? Is that one of the two cases, or is that a third case? --DavidCary 21:52, 17 October 2005 (UTC)

merge
Since Circuit Theory:Op Amps Electronics/Op-Amps talk about exactly the same thing, should we merge them? --DavidCary 23:00, 17 October 2005 (UTC)

 * There is going to be alot of cross-talk between the Electronics and Circuit Theory books, although the later are being prepared specifically to tend to a different audience then the former. Also, I am working on creating an entire "curriculum" of sorts in Electrical Engineering, and I want to make sure that there is a firm foundation in place on these subjects before more advanced books on the topic get written.

 * I will admit that Op-Amps specifically do not play a particularly central role in the Circuit Theory book, or in the EE curriculum at large, and would conceed that perhaps the Op-Amp page in particular would not adversely affect the project if it were merged (or even removed entirely) from the Circuit Theory book. Other pages however, i would fight the motion whole-heartedly. --Whiteknight T C E 14:33, 19 October 2005 (UTC)

I don't know how you came to that conclusion. I'm an EE and I can tell you that the introductory circuit analysis courses that EEs take INCLUDES op-amps. It's a very basic part of the curriculum. What's the difference between the audiences between circuit theory and electronics? I don't see any. 70.18.253.241 22:09, 19 October 2005 (UTC)

 * Well, I'm an EE as well, and we learned about Op Amps one week, and the subject never once came up again. I was under the impression that it simply wasnt that big a deal considering the little treatment of it that I recieved in my education. I certainly don't think that there is enough material on Op Amps to span 2 books, so I wont bother trying to make that happen. Also, I came to the conclusion that the two books are focused towards different audiences for a number of reasons that I have enumerated (so far without opposition) in a number of places, including my user page, and the Circuit Theory talk page. --Whiteknight T C E 02:37, 20 October 2005 (UTC)

I read your criteria and it appears the electronics book version does treat it like a black box for the most part, which would fit your criteria. I really can't see you justify dropping it all together, I find it strange that your curriculum barely covered it, but I wouldn't exclude it just because yours didn't. They're an integral part of introductory circuit theory classes for a reason, and I think it'd be best not to question the judgement of such a unaninmously implemented program  without some better justification than "well I personally didn't use it much after that." Your use page says you're a ECE (as opposed to just EE), so perhaps the exra digital slant is why you don't have as much experience with them? Njyoder 22:05, 21 October 2005 (UTC)

 * My only point is that if there is talk that the material is being covered adequately well in two books, and if the Circuit Theory book cannot cover the material any better then the Electronics book, then there probably isnt much reason to have it covered in 2 separate books. If the concensus is to merge then, we will merge the pages. --Whiteknight T C E 01:37, 24 October 2005 (UTC)

ooooo

It seems to me that this is a hardware/software problem. Keep both modules, with

QUITTNER 142.150.49.166 20:46, 22 November 2005 (UTC)
 * Electronics:Op-Amps describing the hardware aspect. Which Op-Amps are available, construction and price differences, which to use why (with mathematics for hardware by itself), max/min. statistics/ratings, their construction, even, maybe, different bases available, temperature range for use, for storage.
 * Circuit Theory/Op Amps describing how to use them, the various applications (with applicable circuit-based mathematics).
 * Links to other pages of WIKIBOOKS, and WIKIPEDIA, aiming for minimum duplication. Think of the many users who are not at all interested in the theory, only in what to do and how to do it quickly and at minimum cost.

ooooo

The challenge
(a copy of Talk:Circuit_Idea/Simple_Op-amp_Summer_Design)

David Cary wrote:

................................................

TI manufactures several 24-bit ADCs. All of their data sheets recommend using the OPA1632 "fully differential amplifier". (No surprise that it is also manufactured by TI).

A " fully differential amplifier" is very different from a " difference amplifier" or a "instrumentation amplifier".

Can Dieter's procedure be applied to a fully differential amplifier? At first glance, I'm guessing that there's one minor and one major change: If that process looks good, please move it to Electronics/Op-Amps. (Should we mention fully differential amplifiers on this Circuit Idea/Simple Op-amp Summer Design page? ) --DavidCary 23:15, 5 November 2007 (UTC)
 * Use equal feedback resistors Rf, one from the + output to the - input, and one from the - output to the + input. Connect the "common" input to the appropriate voltage source. (minor change to the " difference amplifier" )
 * The sum of the gains = zero in a properly-designed fully differential amplifier circuit. (Right? major change)
 * Calculate resistor values for each input, using Ri = Rf / |desired gain|.
 * For inputs with positive gain, connect the calculated resistor value between that input and the + input on the amplifier.
 * For inputs with negative gain, connect the calculated resistor value between that input and the - input on the amplifier.
 * If all your inputs are differential pairs, then the sum of all the gains is now zero. Done. Otherwise add a ground resistor to bring the total gain to zero.

................................................

 * David, I would like to congratulate you on your success; you have managed to revise and enrich the Daisy's (Dieter's) theorem! By the way, do you have a dog:)?

 * Two monts ago, a arrived to a similar conclusion that only unbalanced (asymmetric) differential amplifying circuits obey Daisy's theorem (see the old version of Simple_Op-amp_Summer_Design). If they were single-ended circuits, the sum of the input gains would constitute K; if they were balanced (symmetric) differential amplifying circuits (like the basic 4-resistor FDA circuit), the sum of the input gains would be 0. Only, Dieter didn't share my assertion and removed my insertion:(

 * Well, let's try to record these changes hoping that Dieter will miss out on them:). For a start, I have scattered the examples illustrating the quick design procedure. Circuit-fantasist 17:35, 16 November 2007 (UTC)

 * Shadow's design procedure only applies to Voltage feedback op-amps. It does not apply to Current mode op-amps, nor to video amps. Please keep the name. This is Shadow's procedure.
 * It's not a trick. The procedure only applies to the General Summing Amplifier.  The gain equation is derived via VSA analysis and simplified for large op-amp gain.
 * Don't confuse this aproach with the comedy of error approach typically used in electronics. Djhk 18:13, 7 November 2007

 * Fully differential amplifiers were popular as video amps in the past; also popular inside ICs due to noise concerns.

 * You need a 4wire interface model.
 * Look up common mode and differential signals.
 * In telephony these are longitudinal and metallic signals.

 * I have rarely seen this discussed in Electronics.
 * The techniques are well known in telephony, but not publicly discussed.
 * The TI paper is a crude introduction.

 * If you're interested look for SLIC circuits.
 * Professional audio uses 3wire interfaces. The concepts are hidden by transformers.

 * In summary, this is a special topic. You need to learn some of basics.
 * Speculation is not good. Makes everyone look like fools. Drop the topic. Djhk  10:02, 22 November 2007

 * Djhk, I do not yet understand why the sum of the input gains of a fully differential amplifier is one instead zero. Please, elucidate me. Circuit-fantasist 18:59, 23 November 2007 (UTC)

 * The key to Daisy's theorem is the word ALL. Whenever you draw an incomplete circuit, the gain sum is indeterminate. Before submitting any circuit, test it. Build it on a simulator or better build the circuit. Keep the trash out of the wiki. Don't mention Daisy when speculating. Djhk

 * Djhk, I do not yet understand why the sum is 1. Please, log in before writing comments and finish them with ~ (these four tildes will be replaced by your user name and the current date).
 * What do you think about the sketch below? Are there virtual grounds at the two FDA's inputs? Circuit-fantasist 08:56, 24 November 2007 (UTC)

 * "The sum of the gains = zero in a properly-designed fully differential amplifier circuit". Wrong! Daisy's theorem states that the sum of ALL gains is equal to one. This applies to the +out node, the -out node, or any other node. If we add two sets of gains, each of which has a sum of +1, how do we get a sum of zero. Is 1+1 = 0 ? Djhk 20:59, 24 November 2007

 * Djhk, look at equation 11 at page 10 of this TI article about FDA. For simplicity, assume R1 = R2 = R3 = R4 and Uocm = 0. Then, VOUT+ = 0.5VIN+ - 0.5VIN-; the sum of gains is 0.5 - 0.5 = 0. Or look at equation 13 at the same page: VOUT- = - 0.5VIN+ + 0.5VIN-; the sum of gains is again - 0.5 + 0.5 = 0. These calculations corroborate the speculation that the sum of the gains in a FDA is zero. Circuit-fantasist 17:37, 25 November 2007 (UTC)

 * Daisy's theorem applies to linear circuits. Any single voltage in a linear circuit can be expressed as a sum of gains times inputs. If ALL inputs are included in the equation, then the sum of the gains is equal to one. Taking two gains and adding them may result in any value. In your example the gains refer to different nodes. Write the linear equations for each output, include ALL inputs and you will find that the gains in each equation add to one.
 * Djhk 03:15, 3 December 2007 (UTC)

Presenting FDA in a more attractive way

Here is an idea for a more attractive circuit presentation in a case, if you want to discuss this nice circuit. Let's outline roughly the circuit operation.

To apply a differential input signal means to change the two input voltages to the same extent but to opposite directions. For example, let's choose a typical case when, in the beginning the two input voltages are zero. As a result, the FDA has set its output voltages zero as well; no currents flow through the circuit.

Then, we decrease simultaneously the upper voltage VIN- under the ground and the lower voltage VIN+ above the ground. At the first moment, the FDA is "surprised" and does not react to this "intervention" (its output voltages VOUT- and VOUT+ remain zero). As a result, the FDA's input voltages become V- = - R2/(R1 + R2) and V+ = R4/(R3 + R4).

After a while, the FDA "recovers" and, observing continously its input voltages, begins changing its output voltages: VOUT- to the positive rail VCC and VOUT- to the negative rail VEE. The FDA stops when it manages to zero (approximately) its input voltages (to make its inputs virtual grounds). By the way, there is another virtual ground point here - the middle point inside of the flying load RL.

It is interesting that, in contrast to the ordinary op-amp differential amplifier, here both the power supplies produce currents flowing through the negative feedback resistors and the flying load. In this case, the (+) FDA's output "blows" a current while the (-) FDA's output "sucks" a current. If R1 = R3 and R2 = R4, the (-) FDA's output (or, maybe it is more correctly to say an "input") "sucks" all the current of the (+) FDA's output. Am I right?

It is interesting as well to draw more pictures when we vary other circuit quantities:
 * add a constant common-mode input voltage to the varying differential input voltage,
 * vary only VIN1 or VIN2 (converting a single-ended signal to a differential one),
 * move simultaneously the sliders of the two potentiometers R1-R2 and R3-R4 (changing the circuit gain),
 * vary the common-mode input voltage while the differential input voltage stays constant,
 * vary the voltage VOCM (not shown on the figure above) that controls the output common-mode voltage (keeping differential and input voltage constant), etc. Circuit-fantasist 16:15, 24 November 2007 (UTC)

 * Still a fantasy. Can we get a schematic? How about a simulation? Djhk 22:57, 24 November 2007 (UTC)

title: Talk:Electronics/Op-Amps


text:
Afrikaans

An English Course on the Afrikaans Language

{| width="100%" cellpadding="15" cellspacing="3"
 * bgcolor="#DEE7F5" width="50%" valign="top"|
 * bgcolor="#DEE7F5" width="50%" valign="top"|

Getting Started

 * Afrikaans ~ English –  (Cover page)
 * /Introduction/ [[File:100%.svg]] - Covers: History of the language, comparison to other languages, course philosophy
 * /Pronunciation/ [[File:75%.svg]] - Covers: Pronunciation of all vowels, diphthongs, consonants and stress.

Lessons

 * Lesson One [[File:100%.svg]] - Covers: Similarities, Articles, Subject and Object Pronouns, Greetings, and the Infinitive and Present Tenses.
 * Lesson Two [[File:100%.svg]] - Covers: Plurals, Sentence Structure, the Past and Future Tenses, "om te wees" and "om te hê", and Possessors.
 * Lesson Three [[File:100%.svg]] - Covers: Plurals Cont., the Infinitive Modifier, Determiners, and Phrases, "I love/like" and "I need".
 * Lesson Four [[File:100%.svg]] - Covers: Auxiliaries and General Word Order
 * Lesson Five [[File:00%.svg]]
 * Lesson Six[[File:25%.svg]]
 * Lessons Seven[[File:25%.svg]]
 * Lesson Eight[[File:25%.svg]]

 * width="30%" bgcolor="#BECFEB" valign="top"|

Vocabulary

 * By Category:
 * Animals / Diere - Mammals, Birds, Reptiles, Amphibians, Insects
 * Astronomy / Sterrekunde - Planets, Phenomena
 * Body / Liggaam - Parts
 * Buildings / Geboue - Types and Purposes
 * Clothing / Klere - Types, Accessories and Jewellery
 * Countries / Lande - Names and Peoples
 * Colours / Kleure - Names and Intensive Forms
 * Family / Familie - Close and Removed
 * Food / Kos - Types and Ingredients
 * Games / Spele - Types and Pieces
 * Holidays / Vakansiedae - Types
 * House / Huis - Rooms, Furniture and Appliances
 * Occupations / Beroepe - Occupations and Workers
 * Sports / Sport - Types, Participators and Gear
 * Weather / Weer - Seasons, Temperature
 * By Location:
 * Beach / Strand
 * Farm / Plaas
 * Office / Kantoor
 * Post Office / Poskantoor
 * Restaurant / Restourant
 * School / Skool
 * Supermarket / Supermark
 * University / Universiteit
 * By Grammar:
 * Phrasebook
 * Common Adjectives
 * Common Verbs
 * Conjunctions
 * Quantifiers
 * Prepositions
 * Irregular Plurals
 * width="20%" height="80%" bgcolor="#BECFEB" valign="top"|

Resources

 * Newspapers In Afrikaans
 * Common phrases

The Project

 * Contributors
 * Users
 * Project History
 * Current Development

Authors' Workbench

 * Syllabus
 * Lesson Structure
 * Layout Guide
 * How To...
 * Page Log
 * Project Notebook
 * }
 * }

title: Afrikaans


text:
User:Korrigan

See my page on Meta.

title: User:Korrigan


text:
Puzzles/Subdivisions

 * Subdividing a triangle
 * Subdividing a cornerstone

title: Puzzles/Subdivisions


text:
Puzzles/Subdivisions/Subdividing a cornerstone

Can you subdivide the following outline into four identical pieces (if you consider the border to be a straight line and '|'s and '__'s to be the same length)?

- ---

Alternatively you can think of the above figure to be a square of size 4 units from which the upper right corner, a square of size 1, has been discarded.

solution


text:
User:Stephen Staines

From Ireland. Speaks Irish and English with intermediate French. Currently doing my Leaving Certificate Exam (hArdteistemeireachta) to go to college to study French and Spanish. Can't wait!

title: User:Stephen Staines


text:
Template:Computer software bookshelf

 Computer software  G ENERAL G UIDES  – Choosing The Right File Format – How To Search – Using AsUnit – ERP Internals — S OFTWARE G UIDES  – Using Firefox – Microsoft SQL Server – Gmail – Using GNOME – Microsoft Excel Programming Recipes – Microsoft Office – OpenOffice.org – Paint.NET – Using PHPEclipse – Pro Engineer – The GIMP – Learning the vi Editor – Question Writer 3 Manual — O PERATING S YSTEM G UIDES  – Aros – Operating System Design – How To Backup Operating Systems – Guide to UNIX – Mac OS X Tiger – UNIX Computing Security — L INUX  – Knowing Knoppix – Linux For Newbies – Linux Guide — W INDOWS  – Basic Computing Using Windows – Computers for Beginners — F REE AND OPEN SOURCE SOFTWARE (FOSS) BOOKS  – FOSS Licensing – FOSS Government Policy – FOSS Education – FOSS A General Introduction – FOSS Localization – FOSS Open Standards

All Computer software books...

title: Template:Computer software bookshelf


text:
LPI Linux Certification/Use RPM and YUM package management

Red Hat Package Manager is a powerful package manager, which can be used to build, install, query, verify, update, and erase individual software packages. A package consists of an archive of files and meta-data used to install and erase the archive files. The meta-data includes helper scripts, file attributes, and descriptive information about the package. Packages come in two varieties: binary packages, used to encapsulate software to be installed, and source packages, containing the source code and recipe necessary to produce binary packages.

Detailed Objective
(LPIC-1 Version 5.0)

Weight: 3

Description: Candidates should be able to perform package management using RPM, YUM and Zypper.

Key Knowledge Areas:
 * Install, re-install, upgrade and remove packages using RPM, YUM and Zypper.
 * Obtain information on RPM packages such as version, status, dependencies, integrity and signatures.
 * Determine what files a package provides, as well as find which package a specific file comes from.
 * Awareness of.

The following is a partial list of the used files, terms and utilities:

Red Hat Package Manager
Some Linux distribution uses rpm the “Red Hat Package Manager” for all its distribution software. RPM maintains a detailed database of all software installed in the system.

To install a RPM package, do:

rpm -i [package].rpm

The package will be installed only if the dependency are met and there is no conflict with another package. To upgrade a package, do:

rpm -U [package].rpm

The files of the old package version will be removed and replaced by the new files. To remove a RPM package, do:

rpm -e [package].rpm

The package will be removed only if no other package depends on it.

RPM Queries
With the -q option you can query the RPM database or display information about package file.

There are several switches that you can use: rpm -q -i apache
 * -i: to get package information

$ rpm -q -l pciutils /sbin/lspci /sbin/setpci /usr/share/doc/package/pciutils ... /usr/share/pci.ids
 * -l: To get a file list of a package.

$ rpm -q -f /sbin/lspci pciutils-2.1.9-58
 * -f file: Query which package a file belongs to.

 * -s: File list with status information.
 * -d: list only documentation files.
 * -a: List all the installed packages.

If you want to display information about package file you can specify filename using -p switch: rpm -q -i -p [package].rpm

RPM Commands
To get general information on a package or program, use rpmlocate.

rpmlocate ipcs -q -i apache

Searching for ipcs in rpm db:

util-linux-2.11n-75: /usr/bin/ipcs /usr/share/man/man8/ipcs.8.gz

To list all the installed packages, use rpmqpack:

rpmqpack

Alternatively use: rpm -qa

Source Installation
The RPM source files have generally the format package.src.rpm and can be installed the same way as binaries. The directories where they will be installed from /usr/src/packages are:

 * SOURCES: For the original sources.
 * SPECS: For the .spec file that controls the build process.
 * BUILD: All the sources are built in this directory.
 * RPMS: Where the complete binary packages are stored.
 * SRPMS: The sources.

To install the source of a package, do:

$ rpm -i mypack.src.rpm

The source files will be stored in the /usr/src/packages in directories SPEC and SOURCES. To compile the sources, do:

$ rpm -ba /usr/src/packages/SPECS/mypack.spec

The result of the compilation will be stored in the BUILD directory

Exercises

 * Exercises results

 * 1) Is the apache package installed?
 * 2) In which package are the files /bin/ls, /usr/sbin/tcpdump, and /sbin/ifconfig?
 * 3) From the floppy disk install the pci utilities and grub packages. Build the binaries and try to execute them. The sources should be in the /usr/src/packages/BINARY directory.


text: Radiation Oncology/Palliation/RTOG Palliation


text:
Neurology and Neurosurgery/Symptoms and Signs in Neurology

Signs and Symptoms of Neurological Disorders:

Alzheimer's Disease:
 * Forgetfullness
 * Dementia

Schizophrenia:
 * Hears internal voices
 * Delusions
 * Hallucinations
 * False personal beliefs
 * Disorganized speech


text:
Radiation Oncology/RTOG Trials/8822

RTOG 88-22 (PROSTATE, BREAST, PALLIATION)
 * Title: Phase I/II Study of Fractionated Hemibody Irradiation to Treat Osseous Metastases in Patients with Primaries of the Breast or Prostate
 * Objective:
 * (1) Determine the hematologic and acute nonhematologic toxicity of fractionated hemibody irradiation in the treatment of osseous metastases in patients with primaries of the breast or prostate.
 * (2) Establish the maximum tolerated dose of fractionated hemibody irradiation in this patient population.
 * (3) Study the delay of new metastases and the progression of existing asymptomatic metastases as a function of the treatment field.
 * NCI_Protocol: Fractionated hemibody irradiation plus local-field irradiation with electron beams
 * 30 Gy in 10 fraction followed by escalating doses of HBI (2.5 Gy/fx):
 * Arm 1: HBI 10.0 Gy
 * Arm 2: HBI 12.5 Gy
 * Arm 3: HBI 15.0 Gy
 * Arm 4: HBI 17.5 Gy
 * Arm 5: HBI 20.0 Gy
 * Eligibility:Primary breast or prostate CA, no spinal compression, pain/narcotic score 2
 * Enrolled: 144 patients
 * Publications:
 * PMID 8823257 -- A phase I/II study to evaluate the effect of fractionated hemibody irradiation in the treatment of osseous metastases--RTOG 88-22. (Scarantino CW, IJRBOP 1996). Conclusion: "The maximum tolerated dose of fractionated (2.50 Gy) HBI was found to be 17.5 Gy. The major dose limiting toxicity was hematological (thromboleukopenia). There was not a significant dose response effect on occult disease (appearance of new disease) or in the requirement for additional treatment, although certain trends were noted for the higher doses. When only patients completing assigned HBI from RTOG 82-06 and 88-22 were compared, there was no difference in the time to new disease or additional treatment in the treated field. Based on the investigative parameters of this study, single high-dose HBI was as effective as fractionated HBI. The incorporation of cytokines, to ameliorate hematological toxicity, should allow for the delivery of higher doses of fractionated HBI and sequential HBI as a means of delivering systemic irradiation."
 * Scarantino C, Caplan R, Rotman M, et al.: A phase I/II study to evalutate the effect of fractionated hemibody irradiation in the treatment of osseous bone metastases-RTOG 88-22. Int J Radiat Oncol Biol Phys 32(suppl 1): A52, 167, 1995.

title: Radiation Oncology/RTOG Trials/8822


text:
What You Should Know About Medicines/Capsule

A capsule contains medication, normally within a small container that is digested by the body. Rarely, a capsule may not be digested, and you will see it in the toilet after you use the restroom.

Time release capsule should not crushed or chewed, which may result in a drug overdose. These capsules are made to be taken once a day, and release a small amount of drug over 24 hours. Crushing, chewing, or opening a time-release capsule destroys it, and will make you receive the medication for one day in only a few minutes. In some situations, this can kill a person.

Examples of capsules: Nexium, zidovudine


text:
What You Should Know About Medicines/Liquid suspension

A suspension is a liquid with small pieces of drug. The drug is not complete dissolved in the solution. Whenever you take a suspension, you should always shake (or stir) it so that you receive the right amount of drug every time you take it. Otherwise, you may receive too little drug in the beginning, and too much drug in the end

Examples of Suspensions: Amoxicillin suspension, Insulin


text:
Cookbook:Bigos (Polish Cabbage Meat Stew)

Bigos is considered the Polish national dish by many. For more information see Wikipedia's article on Bigos.

Ingredients

 * 2.5 kg fresh cabbage
 * 2 kg fermented cabbage (sauerkraut)
 * 500 g pork or venison
 * 250 g sausage
 * 250 g bacon
 * Fresh or dried mushrooms
 * Whole black pepper
 * Salt
 * Bay leaf

Procedure

 * 1) Chop the cabbage, add pepper and salt, a part of the mushrooms and bay leaf, and cook until soft (about 2–3 hours).
 * 2) Chop the bacon and let it melt in a frying pan.
 * 3) Fry the chopped meat and sausage in the bacon grease.
 * 4) If necessary, drain excess water from the stewed cabbage and add the fried meat, bacon, and sausage along with the grease out of the pan. Stew everything as long as possible—the longer, the better (sometimes it is done for 3 hours a day in 3 following days, or even longer).
 * 5) When ready, the dish should be a thick mash that does not "leak" water on the plate; it should be mildly sour and have a strong flavour of smoked bacon.

Notes, tips, and variations

 * There are countless variations of this basic recipe. According to some, the amount of meat should be equal to the amount of cabbage; others prefer to use only fermented cabbage as in German sauerkraut.
 * A very particular feature of this dish is that it can be safely stored even for a few days without refrigerating. This is why bigos used to be a common soldiers' dish.

Kochbuch/ Bigos Livre de cuisine/Bigos Książka kucharska/Bigos


text:
Radiation Oncology/RTOG Trials/8206

RTOG 82-06 (PALLIATION)
 * Title: Phase III Comparison of Local Field Irradiation with and without Single-Dose Hemibody Irradiation for Control of Symptomatic Bony Metastases
 * Objectives:
 * (1) Determine whether the addition of a single dose of hemibody irradiation to standard fractionated local field irradiation has a beneficial effect in terms of delaying the development of new metastases and delaying the progression of existing asymptomatic metastases in cancer patients with painful osseous metastases.
 * (2) Assess tumor response by evaluation of measurable lesions in different sites in patients treated with local field irradiation vs. local field plus hemibody irradiation.
 * (3) Document the morbidity of hemibody irradiation added to a standard fractionated therapy schedule.
 * NCI_Protocol:
 * Arm 1: 30 Gy
 * Arm 2: 30 Gy + 8 Gy hemibody irradiation
 * Enrolled: 499 patients
 * Conclusion:
 * PMID 1374061 -- A report of RTOG 8206: a phase III study of whether the addition of single dose hemibody irradiation to standard fractionated local field irradiation is more effective than local field irradiation alone in the treatment of symptomatic osseous metastases. (Poulter CA, IJRBOP 1992). Conclusion: This clinical trial demonstrates that HBI has the potential to be used to treat systemic and occult metastases, particularly if both halves of the body can be treated.
 * Publications:
 * PMID 8823257 -- A phase I/II study to evaluate the effect of fractionated hemibody irradiation in the treatment of osseous metastases--RTOG 88-22. (Scarantino, IJRBOP 1996). Conclusion: "The maximum tolerated dose of fractionated (2.50 Gy) HBI was found to be 17.5 Gy. The major dose limiting toxicity was hematological (thromboleukopenia). There was not a significant dose response effect on occult disease (appearance of new disease) or in the requirement for additional treatment, although certain trends were noted for the higher doses. When only patients completing assigned HBI from RTOG 82-06 and 88-22 were compared, there was no difference in the time to new disease or additional treatment in the treated field. Based on the investigative parameters of this study, single high-dose HBI was as effective as fractionated HBI. The incorporation of cytokines, to ameliorate hematological toxicity, should allow for the delivery of higher doses of fractionated HBI and sequential HBI as a means of delivering systemic irradiation."
 * PMID 7679040 -- Irradiation in relapsing carcinoma of the prostate. (Perez CA, Cancer 1993). Review. Conclusion: The role of irradiation in the treatment of spinal cord compression is discussed. Significant improvement of neurologic function has been reported in 36-60% of the patients, depending on severity of deficit and promptness in instituting emergency treatment.
 * Poulter, C., Cosmatos, D., Rubin, P., Urtasun, R., Cooper, J., Kuske, R., Hornback, N., Coughlin, C., Weigensberg, I. and Rotman, M.: A Report of RTOG 82-06: A Phase III Study of Whether the Addition of Single Dose Hemibody Irradiation to Standard Fractionated Local Field Irradiation is More Effective Than Local Field Irradiation Alone in the Treatment of Symptomatic Osseous Mets. Int J Radiat Oncol Biol Phys, 23(1):207-214, 1992.

title: Radiation Oncology/RTOG Trials/8206


text:
Pharmacology

Written by volunteers and editors at Wikibooks, A Wikimedia Foundation Project

Pharmacology is the study of drugs. So in this book we will learn what happens when we absorb drugs.

Medical Disclaimer
This book is aimed at undergraduates or even high-school students with an interest in pharmacology.

Contents
I. Introduction II. Pharmacodynamics
 * Definition of Pharmacology
 * /Overview of Pharmacology/

 * Agonists and antagonists
 * Types of receptors

III. Pharmacokinetics

 * Absorption
 * Distribution
 * Metabolism
 * Excretion

IV. Pharmacology in a Professional and Social Context V. Drugs for pain
 * History of Pharmacology
 * Sociocultural Aspects
 * Drug administration (Law)
 * Ethics
 * Addiction

 * NSAIDs: Non-Steroidal Anti-Inflammatory Drugs
 * Opioids
 * Paracetamol or acetaminophen

VI. Drugs acting on the cardiovascular system VII. Drugs acting on the respiratory system
 * ACE inhibitors
 * Alpha1 blockers
 * Alpha 2 agonists
 * Angiotensin receptor blockers
 * Antiarrythmics
 * Anticoagulants
 * Antipyretics
 * Beta blockers
 * Calcium Channel Blockers
 * Diuretics
 * Antihyperlipidemic agents

 * Beta agonists
 * Muscarinic antagonists
 * Theophylline
 * Inhaled corticosteroids
 * Leukotriene antagonists
 * Cough Suppressants
 * Decongestants
 * Antitussives

VIII. Drugs acting on the gastrointestinal system

 * Antiemetics
 * 5-aminosalicylates
 * Antacids
 * Proton pump inhibitors
 * H2 receptor antagonists

IX. Drugs acting on the endocrine system

 * Steroids
 * Thyroid Medications

X. Drugs acting on the nervous system

 * Antiparkinsonian drugs
 * Antiepileptics

XI. Drugs acting on the mind

 * Antidepressants
 * Anxiolytics
 * Antipsychotics
 * Mood-stabilizers

XII. Drugs for bacterial infection

 * Antibiotics
 * Beta lactams
 * Polymyxins
 * Macrolides and 50S ribosome inhibitors
 * Fluoroquinolones
 * Tetracyclines
 * Aminoglycosides
 * Quinolones
 * Rifampicin
 * Nitroimidazole
 * Sulfonamides and trimethoprim

XIII. Drugs for other infections

 * Antivirals
 * Antifungals
 * Antiprotozoal and antihelminthics

XIV. Drugs for cancer

 * Alkylating agents
 * Antimetabolites
 * Mitotic inhibitors
 * Antibodies
 * Small molecule inhibitors

farmacologia Pharmakologie und Toxikologie 薬理学 Farmacologie

title: Pharmacology


text:
Pharmacology/Definition

' Pharmacology ' (from Greek φάρμακον, pharmakon, "drug"; and -λογία, -logia, "the study of") is a branch in science concerned with the effects of drugs on living organisms (pharmacodynamics) and the effects of living organisms with drugs (pharmacokinetics). This subject embodies drug composition and properties, interactions, toxicology, therapy, and medicinal uses such as application and antipathogenic capabilities. Pharmacology is subdivided into two categories as mentioned above, pharmacodynamics and pharmacokinetics. Pharmacodynamics deals with chemical interactions with body/cell receptors. Pharmacokinetics, on the other hand, deals with the four stages of chemicals passing through the body: absorption, distribution, metabolism and excretion.

Pharmacology is not to be confused with pharmacy. Pharmacy is a professional field in medicine concerned with preparation and distribution of medicine. Pharmacology is the study of the interaction and effects between chemicals and biological systems and vice versa.

title: Pharmacology/Definition


text:
User:Koepke~enwikibooks

Current Projects (IRL):

 * Developing an original full-adder using no IC's. (basic diodes, transistors only)
 * Developing a web based; turn based strategy game based on Civilization 2
 * Attempting to figure out how the hell google maps can utilize your arrow keys to move the map around in the way it does.

title: User:Koepke~enwikibooks


text:
Radiation Oncology/RTOG Trials/7810

RTOG 78-10 (PALLIATION)
 * Title: Phase I/II Study of Half-Body Radiotherapy for Multiple Osseous Metastases
 * Objectives:
 * (1) Evaluate the frequency and the duration of pain relief as a function of the dose schedules proposed.
 * (2) Assess tumor and response by evaluation of measurable lesions in different sites.
 * (3) Determine the normal tissue tolerance and toxicity following single exposure doses of irradiation, particularly focusing on the dose-limiting organs: bone marrow, lung, kidney, liver, brain, spinal cord, small bowel and heart, both in terms of acute and late reactions and damage.
 * (4) Study the natural history of progression of disseminated cancer, particularly the osseous lesions, and develop a useful staging system for evaluation of disseminated disease.
 * NCI_Protocol: Dose escalation of hemibody irradiation
 * Enrolled: 168 patients
 * Conclusion:
 * PMID 2423225 -- Single-dose half-body irradiation for palliation of multiple bone metastases from solid tumors. Final Radiation Therapy Oncology Group report. (Salazar OM, Cancer 1986). Conclusion: "HBI achieves pain relief sooner and with less evidence of pain recurrence in the irradiated area than conventionally treated patients. The most effective and safest of the HBI doses tested were 600 rad for the upper HBI and 800 rad for the lower or mid-HBI."
 * Publications:
 * PMID 6178497 -- The palliation of symptomatic osseous metastases: final results of the Study by the Radiation Therapy Oncology Group. (Tong D, Cancer 1982). Review.
 * PMID 6169699 -- Single-dose half-body irradiation for the palliation of multiple bone metastases from solid tumors: a preliminary report. (Salazar OM, IJRBOP 1981). No abstract.

title: Radiation Oncology/RTOG Trials/7810


text:
Card Games/Hearts

Hearts is a card game of trick-taking, played with a standard 52-card poker deck, that bears some resemblance to Spades and Bridge.

Requirements

 * three to five players; four is ideal
 * a standard 52-card deck of playing cards — a bridge-size deck is best for holding 13 cards, but a poker deck may also be used.
 * a method for scorekeeping

Contents

 * Rules of Hearts and Common Variations
 * Game Strategy
 * Game Situations

title: Card Games/Hearts


text:
Playful Organizing

Organisation saves time. For material items, if an object is always in the same place, you can access it a lot faster than if you have to look for it. For goal-setting and time management, it makes life simpler and reduces stress and confusion.

Getting Started

 * /This is Not Life or Death/
 * /Creating Your Ground Rules/
 * /Formulating Vision/
 * /Setting Objectives/

Making it Fun

 * /Color/
 * /Games/
 * /Silliness/
 * /Music/

Making it Work

 * /Timebox/
 * /Containers/
 * /Integrating Technology/
 * /Other Tools/

Support

 * /Invite a Friend/
 * /Invite the Family/
 * /Hire a Professional Organizer/

Checking in with Yourself

 * /Time Management Technique/
 * /Learning Technique/

Staying Interested

 * /Writing Your Own Book/

title: Playful Organizing


text:
Playful Organizing/Hire a Professional Organizer

Decide what You Want

Example

 * Non-judgmental guidance

Explore your priorities

Example

 * Creating something new in the moment

Tasks

 * Organizing and filing papers
 * Purge files regularly
 * Update address book


text:
Talk:Urdu

A Plan for the Module
This module needs a plan if it is to become a useful resource for people wishing to learn Urdu. Here's a proposal to get us started; I can't go much further than this, but I'm sure someone else out there can.

Also, a template would make it easier to navigate from one page to the next, from exercise to answer key, and from section to section. --Skoosh 22:32, 12 Jun 2005 (UTC)

Getting started

 * Introducing Urdu
 * Relationship to Hindi, Farsi, Arabic
 * History and literature
 * Writing and Pronunciation
 * Aspirated consonants
 * Retroflex consonants
 * Romanization
 * Nastaliq script

Basic Urdu

 * Salam, ap kaise hen? : Greetings and small talk
 * Voh kya he? : Asking and answering
 * tu, tum aur ap : Formality and politeness
 * Giving and getting directions
 * Buying and selling
 * Telling time

Elementary Urdu

 * Past tense
 * Future tense
 * Describing activities and storytelling
 * Counterfactuals

Formal Description

 * Grammar
 * Nouns
 * Verbs
 * Pronouns
 * Adjectives
 * Verb conjugation
 * Vocabulary
 * Nouns
 * Verbs
 * Adjectives
 * Phrases and Idioms

title: Talk:Urdu


text:
Cookbook:Ossobuco Alla Milanese

| Cuisine of Italy | Meat

Ossobuco, when loosely translated from Italian, means hollowed bone; a reference to the large piece of marrow in the center of the veal shank bone. It's a Milanese speciality of veal shanks cooked in meat broth and flavored with white wine. Slowly braised, this relatively tough, yet flavorful cut of meat becomes meltingly tender, and the connective tissues and marrow dissolve into the sauce, making it rich and creamy.

The shank is a relatively cheap cut of veal which is readily available in most good supermarkets and butcher shops. Look for meaty hind-shanks cut from the top of the thigh with a high proportion of meat to bone. Each piece should be about five inches across and one-inch to one-and-a-half inches thick.

This dish probably had its origins in a Milanese farmhouse during the late nineteenth century and most likely did not originally include tomatoes, a New World vegetable. Ossobuco first became popular in the osterie of Milan, which were neighborhood restaurants of Italy's large cities. These catered to the neighborhood's local residents but rarely if ever to tourists and foreigners.

Traditional ossobuco was prepared with cinnamon, allspice, bay leaf and gremolata and today is called ossobuco in bianco (ossobuco in white sauce). The modern version has, by and large, replaced the older one. This new version includes tomatoes and mirepoix: carrot, celery and onion, flavored with herbs but no gremolata (although hybrid versions exist which include both tomato and gremolata). Risotto alla milanese is traditionally served with ossobuco, but goes well with polenta or mashed potatoes.

Ingredients

 * 4 slices veal hind shank, about 2.5–4 centimeters (1–1½ inches) thick
 * 1 medium onion, chopped fine
 * 3 ribs celery with leaves, chopped fine
 * 1 medium carrot, chopped fine
 * 2 cloves garlic, minced
 * 3 tablespoons butter
 * 4 tablespoons vegetable oil
 * 240 ml (1 cup) dry white wine or white vermouth
 * About 480 ml (2 cups) meat broth
 * 3 tablespoons tomato paste
 * 6 anchovy fillets, mashed
 * ½ teaspoon dried thyme
 * 2–3 bay leaves
 * 2 strips lemon peel
 * Salt
 * Fresh ground pepper
 * Flour

Procedure

 * 1) Preheat oven to.
 * 2) If the butcher has not done so, tie the shanks around the middle with kitchen twine; this will keep them from falling apart during cooking.
 * 3) Choose a heavy, covered roasting pan or Dutch oven which will just accommodate the veal shanks in one layer. Put the butter, two tablespoons of the oil, the onions, celery and carrots in the pan and sweat over medium heat until the vegetables have wilted—about 8 minutes. Add the garlic and lemon peel and sweat until they're fragrant, about 2 minutes more. Remove from the heat.
 * 4) Meanwhile, heat the remaining oil in a skillet until it is near the smoking point. Lightly flour the veal shanks and slip them into the oil. Richly brown the shanks on both of the cut sides, then place them in the roasting pan on top of the vegetables.
 * 5) Place the wine in the skillet and boil until reduced by one-half, deglazing the bottom of the pan. Pour this over the veal shanks.
 * 6) Heat the beef broth to a boil in the skillet, whisking in the tomato paste and anchovies. Add this to the veal shanks, along with the herbs, several grindings of pepper, and a large pinch of salt. The liquid should cover three quarters of the shanks. If not, add extra water.
 * 7) Bring the pot to a simmer, cover, and place in the oven. Cook for approximately 2 hours, turning and basting the shanks every half hour. If you notice that the cooking liquids have nearly evaporated, add hot water, about one half cup at a time. The veal is done when it is fork tender and falling from the bone.
 * 8) Transfer the shanks to a platter, remove the strings, and cover to keep warm. If the sauce seems watery, as is probable, place the pan on the stove top over high heat and reduce the cooking liquid until the sauce has a thick, creamy consistency. Pour the sauce over the shanks and serve.

Notes, tips, and variations

 * There are variations to this dish that use other animal shanks, including turkey and venison shanks.
 * The recipe calls for anchovies, which enrich the finished sauce without adding a fishy flavor. Don't omit them, even if you don't like anchovies.
 * Traditionally, the cooking sauce is finished with a mixture of garlic, lemon zest and parsley called gremolata. It adds a burst of freshness to the finished dish. Gremolata consists of the grated zest of one lemon, one finely minced clove of garlic, and one tablespoon of finely chopped parsley. Add this mixture to the sauce at the end of the cooking, as it's being reduced.
 * Ossobuco is almost always served with risotto. It's one of the few examples of Italian cooking where a starch is served with the main course. One may, for a change, substitute orzo or ancini de pepe cooked in meat broth and finished with butter and parmesan cheese.

title: Cookbook:Ossobuco Alla Milanese


text:
User talk:Cyberroadie

Hi,

I see that you have done some "fixes" to the documentation - thank you! I urge you to contribute to the Mambo Open Source-book in any way you can, so please write content and start articles if you want to. I am very glad to see people enhance the documentation! --User:August 23:47, 12 Jun 2005 (UTC)

title: User talk:Cyberroadie


text:
Cookbook:Chocolate Fudge

| Confections | Fudge

Chocolate fudge is a traditional, rich candy, especially around the holidays in the United States.

Ingredients

 * 2 ½ cups (550 g / 1.2 lb) white granulated sugar
 * ½ cup (125 g / 4.4 oz) margarine or butter
 * ⅔ cup (160 ml / 5.4 oz) evaporated milk
 * 1 jar (7 oz / 200 g) marshmallow creme
 * 2 cups (160 g / 5.6 oz) semi sweet chocolate chips
 * ¾ cup (75 g / 2.6 oz) chopped walnuts
 * 1 tsp vanilla

Procedure

 * 1) Line a 9 in square or 13 by pan with foil so that foil extends over sides of pan; butter foil.
 * 2) In large saucepan, combine sugar, margarine, and evaporated milk. Bring to a boil over medium heat, stirring constantly.
 * 3) After 5 minutes of constant stirring, remove saucepan from heat.
 * 4) Add marshmallow creme and chocolate chips; blend until smooth. Stir in walnuts and vanilla.
 * 5) Pour into buttered, foil-lined pan. Cool to room temperature.
 * 6) Score fudge into 36–48 squares. Refrigerate until firm.
 * 7) Remove fudge from pan by lifting foil; remove foil from sides of fudge. Using large knife, cut through scored lines. Store in refrigerator.

title: Cookbook:Chocolate Fudge