A unified mixed-integer programming model for simultaneous fluence weight and aperture optimization in VMAT, tomotherapy, and cyberknife

All rights reserved. In this paper, we propose and study a unified mixed-integer programming model that simultaneously optimizes fluence weights and multi-leaf collimator (MLC) apertures in the treatment planning optimization of VMAT, Tomotherapy, and CyberKnife. The contribution of our model is threefold: (i) Our model optimizes the fluence and MLC apertures simultaneously for a given set of control points. (ii) Our model can incorporate all volume limits or dose upper bounds for organs at risk (OAR) and dose lower bound limits for planning target volumes (PTV) as hard constraints, but it can also relax either of these constraint sets in a Lagrangian fashion and keep the other set as hard constraints. (iii) For faster solutions, we propose several heuristic methods based on the MIP model, as well as a meta-heuristic approach. The meta-heuristic is very efficient in practice, being able to generate dose- and machinery-feasible solutions for problem instances of clinical scale, e.g., obtaining feasible treatment plans to cases with 180 control points, 6750 sample voxels and 18,000 beamlets in 470 seconds, or cases with 72 control points, 8000 sample voxels and 28,800 beamlets in 352 seconds. With discretization and down-sampling of voxels, our method is capable of tackling a treatment field of 8000-64,000cm3, depending on the ratio of critical structure versus unspecified tissues.

Insulin sensitivity not modulated 24 to 78 h after acute resistance exercise in type 2 diabetes patients

Background
The aim of this study was to describe the clinical characteristics, causative pathogens, clinical management and outcomes of patients presenting to a tertiary adult Australian intensive care unit (ICU) with a diagnosis of necrotizing fasciitis (NF).
Methods
This retrospective observational study was conducted in a 19-bed, level III, adult ICU in a 450-bed tertiary, regional hospital. Clinical databases were accessed for patients diagnosed with NF and admitted to The Geelong Hospital ICU between 1 February 2000 and 1 June 2011. Information on severity of sepsis, surgical procedures and microbiological results were collected.
Results
Twenty patients with NF were identified. The median age was 52.5 years and 38% were female. The overall mortality rate was 8.3%. Common co-morbidities were diabetes (21%) and heart failure (17%), although 50% of patients had no co-morbidities. Group A Streptococcus was the identified pathogen in 11 (46%) patients, and Streptococcus milleri group in 5 (21%) patients. Hyperbaric oxygen therapy was not used in the majority of patients. The initial antibiotics administered were active against subsequently cultured bacteria in 83% of patients. Median time to surgical debridement was 20 h. Diagnosis and management was delayed in the nosocomial group.
Conclusions
This study reports physiological data, aetiology and therapeutic interventions in NF for an adult tertiary hospital. We demonstrate one of the lowest reported mortality rates, with early surgical debridement being achieved in the majority of patients. The main delay was found to be in the diagnosis of NF.