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Effects of Radiotherapy on oral tissues PDF
Effects of Radiotherapy on oral tissues
Radiation is defined as the transmission of energy through space and matter. Matter is anything that occupies space and has inertia. It has mass and can exert force or be acted on by a force. Matter occurs in three states-solid, liquid, and gas-and may be divided into elements and compounds.
Radiation occur in two forms
Particulate Radiation-Particulate radiation consists of atomic nuclei or subatomic particles moving at high velocity. Alpha particles,beta particles and cathode rays are examples of particulate radiation.
Electromagnetic Radiation-Electromagnetic radiation is the propagation of energy through space accompanied by electric and magnetic force fields.Eg: X-rays,Gamma rays
Electromagnetic radiation is generated when velocity of electrically charged particle is altered.both ionizing and non ionizing radiation is present in the electromagnetic spectrum.
Radiation Biology
Radiation biology is the study of the effects of ionizing radiation on the biological systems. The initial interaction between ionizing radiation and matter occurs at the level of the electron within the first 10-13 second after exposure. These changes result in modification of biologic molecules within the ensuing seconds to hours. In turn, the molecular changes may lead to alterations in cells and organisms that persist for hours, decades, and possibly even generations. If enough cells are killed in an individual, it may cause injury or death. If cells are modified, such changes may lead to cancer or disorders in the descendents of the exposed individual.
Biologic effects of ionizing radiation may be divided into two broad categories:
Deterministic effects
Stochastic effects
Deterministic effects are those effects in which the severity of response is proportional to the dose. These effects, usually cell killing, occur in all people when the dose is large enough. Deterministic effects have a dose threshold below which the response is not seen. Examples of deterministic effects include oral changes after radiation therapy.
Stochastic effects are those for which the probability of the occurrence of change, rather than its severity, is dose dependent. Stochastic effects are all or none: either a person has or does not have the condition. For example radiation induced cancer is stochastic effect, because greater exposure of a person or population to radiaton increases the probability of cancer but not its severity. Stochastic effect are believed are not to have dose thresholds.
Radiation therapy, or radiotherapy also called radiation oncology, and sometimes abbreviated to XRT, is the medical use of ionizing radiation as part of cancer treatment to control malignant cells (not to be confused with radiology, the use of radiation in medical imaging and diagnosis). Radiotherapy may be used for curative or adjuvant treatment. It is used as palliative treatment (where cure is not possible and the aim is for local disease control or symptomatic relief) or as therapeutic treatment (where the therapy has survival benefit and it can be curative). Total body irradiation (TBI) is a radiotherapy technique used to prepare the body to receive a bone marrow transplant.
Radiotherapy has several applications in non-malignant conditions, such as the treatment of trigeminal neuralgia, severe thyroid eye disease, pterygium, pigmented villonodular synovitis, prevention of keloid scar growth, and prevention of heterotopic ossification. The use of radiotherapy in non-malignant conditions is limited partly by worries about the risk of radiation-induced cancers.
Radiotherapy is used for the treatment of malignant cancer, and may used as a primary or adjuvant modality. It is also common to combine radiotherapy with surgery, chemotherapy, hormone therapy or some mixture of the three. Most common cancer types can be treated with radiotherapy in some way. The precise treatment intent (curative, adjuvant, neoadjuvant, therapeutic, or palliative) will depend on the tumour type, location, and stage, as well as the general health of the patient.
Radiation therapy is commonly applied to the cancerous tumour. The radiation fields may also include the draining lymph nodes if they are clinically or radiologically involved with tumour, or if there is thought to be a risk of subclinical malignant spread. It is necessary to include a margin of normal tissue around the tumour to allow for uncertainties in daily set-up and internal tumour motion. These uncertainties can be caused by internal movement (for example, respiration and bladder filling) and movement of external skin marks relative to the tumour position.
To spare normal tissues (such as skin or organs which radiation must pass through in order to treat the tumour), shaped radiation beams are aimed from several angles of exposure to intersect at the tumour, providing a much larger absorbed dose there than in the surrounding, healthy tissue.
Brachytherapy, in which a radiation source is placed inside or next to the area requiring treatment, is another form of radiation therapy that minimizes exposure to healthy tissue during procedures to treat cancers of the breast, prostate and other organs.
Radiation therapy works by damaging the DNA of cells. The damage is caused by a photon, electron, proton, neutron, or ion beam directly or indirectly ionizing the atoms which make up the DNA chain. Indirect ionization happens as a result of the ionization of water, forming free radicals, notably hydroxyl radicals, which then damage the DNA. In the most common forms of radiation therapy, most of the radiation effect is through free radicals. Because cells have mechanisms for repairing DNA damage, breaking the DNA on both strands proves to be the most significant technique in modifying cell characteristics. Because cancer cells generally are undifferentiated and stem cell-like, they reproduce more, and have a diminished ability to repair sub-lethal damage compared to most healthy differentiated cells. The DNA damage is inherited through cell division, accumulating damage to the cancer cells, causing them to die or reproduce more slowly.
One of the major limitations of radiotherapy is that the cells of solid tumours become deficient in oxygen. Solid tumours can outgrow their blood supply, causing a low-oxygen state known as hypoxia. Oxygen is a potent radiosensitizer, increasing the effectiveness of a given dose of radiation by forming DNA-damaging free radicals. Tumour cells in a hypoxic environment may be as much as 2 to 3 times more resistant to radiation damage than those in a normal oxygen environment. Much research has been devoted to overcoming this problem including the use of high pressure oxygen tanks, blood substitutes that carry increased oxygen, hypoxic cell radiosensitizers such as misonidazole and metronidazole, and hypoxic cytotoxins, such as tirapazamine. There is also interest in the fact that high-LET (linear energy transfer) particles such as carbon or neon ions may have an antitumour effect which is less dependent of tumour oxygen because these particles act mostly via direct damage.
The amount of radiation used in radiation therapy is measured in gray (Gy), and varies depending on the type and stage of cancer being treated. For curative cases, the typical dose for a solid epithelial tumor ranges from 60 to 80 Gy, while lymphomas are treated with 20 to 40 Gy. Preventative (adjuvant) doses are typically around 45 – 60 Gy in 1.8 – 2 Gy fractions.
Fractionation
The total dose is fractionated (spread out over time) for several important reasons. Fractionation allows normal cells time to recover, while tumor cells are generally less efficient in repair between fractions. Fractionation also allows tumor cells that were in a relatively radio-resistant phase of the cell cycle during one treatment to cycle into a sensitive phase of the cycle before the next fraction is given. Similarly, tumor cells that were chronically or acutely hypoxic (and therefore more radioresistant) may reoxygenate between fractions, improving the tumor cell kill. Fractionation regimes are individualised between different radiotherapy centres and even between individual doctors. In North America, Australia, and Europe, the typical fractionation schedule for adults is 1.8 to 2 Gy per day, five days a week. In some cancer types, prolongation of the fraction schedule over too long can allow for the tumor to begin repopulating, and for these tumor types, including head-and-neck and cervical squamous cell cancers, radiation treatment is preferably completed within a certain amount of time. For children, a typical fraction size may be 1.5 to 1.8 Gy per day, as smaller fraction sizes are associated with reduced incidence and severity of late-onset side effects in normal tissues.
Types of Radiotherapy
· Conventional external beam radiotherapy-Conventional external beam radiotherapy (2DXRT) is delivered via two-dimensional beams using linear accelerator machines. 2DXRT mainly consists of a single beam of radiation delivered to the patient from several directions: often front or back, and both sides.
· Stereotactic radiation-Stereotactic radiation is a specialized type of external beam radiation therapy. It uses focused radiation beams targeting a well-defined tumor using extremely detailed imaging scans. Radiation oncologists perform stereotactic treatments, often with the help of a neurosurgeon for tumors in the brain or spine.
· Virtual simulation, 3-dimensional conformal radiotherapy, and intensity-modulated radiotherapy-The planning of radiotherapy treatment has been revolutionized by the ability to delineate tumors and adjacent normal structures in three dimensions using specialized CT and/or MRI scanners and planning software.
· Particle therapy-In particle therapy (Proton therapy), energetic ionizing particles (protons or carbon ions) are directed at the target tumor.
Brachytherapy-Brachytherapy (internal radiotherapy) is delivered by placing radiation source(s) inside or next to the area requiring treatment. Brachytherapy is commonly used as an effective treatment for cervical,prostate,breast, and skin cancer and can also be used to treat tumours in many other body sites.
Radioisotope therapy-Systemic radioisotope therapy is a form of targeted therapy. Targeting can be due to the chemical properties of the isotope such as radioiodine which is specifically absorbed by the thyroid gland a thousandfold better than other bodily organs
Side effects of Radiotherapy
Radiation therapy is in itself painless. Many low-dose palliative treatments (for example, radiotherapy to bony metastases) cause minimal or no side effects, although short-term pain flare up can be experienced in the days following treatment due to oedema compressing nerves in the treated area. Treatment to higher doses causes varying side effects during treatment (acute side effects), in the months or years following treatment (long-term side effects), or after re-treatment (cumulative side effects). The nature, severity, and longevity of side effects depends on the organs that receive the radiation, the treatment itself (type of radiation, dose, fractionation, concurrent chemotherapy), and the patient.
Most side effects are predictable and expected. Side effects from radiation are usually limited to the area of the patient's body that is under treatment. One of the aims of modern radiotherapy is to reduce side effects to a minimum, and to help the patient to understand and to deal with those side effects which are unavoidable.
The main side effects reported are fatigue and skin irritation, like a mild to moderate sun burn. The fatigue often sets in during the middle of a course of treatment and can last for weeks after treatment ends. The skin irritation will also go away, but it may not be as elastic as it was before. Patients should ask their radiation oncologist or radiation oncology nurse about possible products and medications that can help with side effects.
Acute and Subacute Complications of Radiation Therapy
Acute reactions are those which arise during or shortly after radiation therapy and resolve within ninety days post-therapy.
Mucositis
One of the first symptoms of radiation complications is mucositis ,which occurs 12- 17 days after the initiation of therapy. Mucosal inflammation varies with dosage, target size and duration of therapy. Oral mucositis can present as patchy mild erythema to frank confluent ulceration. Chemotherapeutic agents such as 5FU, procarbazine, methotrexate, etc., may increase the severity of these symptoms. Currently, there are no drugs available to prevent mucositis, and it is imperative to distinguish these lesions from those caused by infections. Cultures may be needed to differentiate between fungal, bacterial and viral lesions versus those secondary to radiation effects.
Prevention, on the part of the Radiation Oncologist is essential to minimizing excessive morbidity of the oral mucosa
This is accomplished by designing portals that limit the exposure to tissues not at risk for tumor reoccurrence. When interstitial implants are a part of a treatment protocol, soft tissues of the oropharynx are at greater risk for developing soft tissue ulcerations. Mucosa thickness, another important predictor of exaggerated tissue response, should be considered. The anterior commisures of the mouth and the medial surface of the angle of the mandible are sites which contain very thin mucosa and would benefit from field blocks if possible.
Lack of saliva and damaged taste buds may alter the sensation of taste during radiotherapy. Often, patients complain that many foods taste excessively salty which may reduce the motivation for adequate oral intake. In response to their altered taste sensation, patients tend to compensate by increasing their intake of sugar. Counseling should be provided to avoid this behavior due to the increased risk of dental caries. However, altered taste sensorium is a transient phenomenon since the taste buds recover in two to four months post therapy.
Mechanisms of damage to the Oral Mucosa
The mucosa joins the skin and the lining of the digestive tract to form a barrier against microorganisms that protects the deeper organs and tissues.The oropharyngeal mucosa, covered by nonstratified squamous epithelium, is composed of endothelium and connective tissue. Stem cells, which form the basement membrane of the endothelium in the oropharyngeal cavity, replicate and differentiate to form layers of mucosal cells that compose the lining.
The oropharyngeal mucosa has a very high cell turnover rate. These self-renewing cells live for approximately 3 to 5 days, resulting in replacement of the lining every 7 to 14 days.This rapid course of cellular proliferation and constant epithelial replacement renders the mucosa vulnerable to the cytotoxic effects of radiation. The atrophic changes in the epithelium of the oral membrane usually occur at a total dose level of 1600 to 2200 cGy when radiation is administered at a rate of 200 cGy per day.
Acute mucositis is the result of hypoplasia and destruction of the squamous epithelium, sterilization of mucosal stem cells, inhibited proliferation of transit cells, and absence of cell regeneration. Oral mucositis is compounded by high-dose radiation to tooth-bearing bone that results in hypoxia and reduces the vascular supply to the bone and soft tissues, causing vascular thromboses and fibrosis. Head and neck irradiation not only can cause ulcerative oral mucositis clinically similar to that caused by high-dose chemotherapy, but also can induce damage that results in permanent dysfunction of the vasculature, connective tissue, salivary glands, muscle, and bone.
Many untested topical oral preparations can reduce symptoms of oral mucositis. Efficacy and safety of these agents has not been established. Currently accepted elixirs include a combination of Benadryl, Kaopectate, MOM, antacids, sucralfate, corticosteroids, dyclonine, and viscous lidocaine. If pain is severe enough to limit eating, systemic analgesia should be considered. Extremes in mucosal inflammation which demonstrate confluent lesions may warrant a treatment break to allow tissues to continue therapy. However, cessation in treatment can be dangerous by allowing rapid repopulation of tumor cells during breaks in therapy. Commercial mouth rinses should be avoided. The alcohol and phenols contained in these preparations may further dehydrate the mucosa causing further pain. Chlorhexidine should be continued during radiation therapy and may be diluted for tolerance.
Local and total body irradiation may irreversibly affect the production and quality of saliva in the major and minor salivary glands. Doses as low as 20 Gy will result in clinically noticeable changes such as sparse thick ropy saliva. In particular, if the parotid glands are in a field which received 40Gy or over, permanent dysfunction of the salivary glands should be expected and discussed with the patient prior to treatment. Concomitant administration of medications which are known to induce xerostomia (i.e. psychotropics, antiemitics, antihistamines, and thousands of other commonly prescribed medications.) should be carefully considered.
The diagnosis of xerostomia is based on subjective impressions by the patient and the clinician. Dry mouth may affect speech, taste, nutrition and the patients ability to wear a prosthesis. Saliva also contains antimicrobial compounds (i.e. sIgA, and mucins) which reduce pathogenic bacteria and decrease the risk of infection in the oropharynx . However, saliva's most important role lies in its ability to mechanically cleanse the teeth and soft tissues. Therefore, with radiation induced xerostomia it is common for this to lead to an increased incidence of caries, especially in the cervical portion of the clinical crown at the cementoenamel junction. Similarly, the change in salivary content and quantity also leads to an increased incidence of candidiasis and periodontal disease.
Mechanism of Salivary Glands damage
Ionizing radiation to the regions of the oral mucosa causes not only specific histologic and physiologic changes, but also structural and functional alterations in the underlying supportive tissues including the salivary glands and bones. Saliva and mucus produced by the salivary glands protect the mucous membranes and teeth, lubricate the food bolus, and facilitate eating and speaking. Saliva has additional protective roles in the regulation of acidity and in antimicrobial defense through the action of immunoglobulin and nonimmunoglobulin glycoproteins.
Salivary secretions decrease dramatically in the irradiated field, especially when that field includes the parotid and submandibular glands.Acinar and ductal cells in the salivary glands degenerate, and the normal cellular arrangement is replaced by ductal remnants and loose fibrous connective tissue that is infiltrated moderately with lymphocytes and plasma cells.
Generally, there is a direct relation between the changes in saliva and the extent of glandular changes. The decline in saliva reflects radiation-provoked inflammatory and degenerative changes in the acinar cells of the salivary glands. A decrease in free-flowing saliva is followed by the accumulation of sticky mucus because the acini of the serous glands are affected more than the acini of the mucus glands.
The severity of xerostomia is related directly to the dosage of radiation. At a total dose of approximately 3000 cGy, damage to the salivary glands occurs and causes viscous saliva. Radiation-induced xerostomia is rapid in onset, with a decrease in saliva greater than 50% after 1 week of RT at an approximate total dose of 2000 cGy, and a decline in saliva greater than 75% after 6 weeks of RT at a total dose of 6000 cGy. With a dose less than 6000 cGy, changes in the salivary glands, including edema and inflammation, are reversible. When the dose exceeds 6000 cGy, changes may be permanent, with fibrosis and glandular degeneration. Xerostomia is progressive, persistent, and irreversible, producing a reduction in saliva output greater than 95% 3 years after RT.
The sensitivity of the various salivary glands located in different areas of the mouth is related to this initial shift in saliva quality. For example, the change initially affects the parotid glands more than the mucous glands. The result is an abundance of thick mucus. In addition, if the irradiated portals are located over the parotid and submandibular glands, xerostomia eventually becomes severe. Because of the diminished lubricating ability of the saliva, patients often lose all desire for food, which intensifies the vicious cycle of nutritional deficiency. Bäckström et al reported that patients with a low saliva secretion rate produced by RT had a significant decrease in daily caloric intake.
Changes in Saliva Quality
The changes in saliva quality associated with RT include a decline in the production of glycoproteins and a decrease in salivary pH. Radiation therapy-induced damage to the salivary glands decreases the production of antibodies and antibacterial agents and limits the binding ability of large salivary glycoproteins (eg, immunoglobulin A) to the surface of the oral mucosa. Glycoproteins reduce the adhesion of microorganisms to the oral mucosa and serve as a protective barrier for the superficial cells in the oral cavity. The absence of the glycoproteins' protective properties renders the epithelial cells more vulnerable to irritation and trauma.
Normally, the saliva maintains the homeostasis of the acid-base balance that inhibits some opportunistic infections. The pH of saliva, which normally is between 6.8 and 7.0, may fall below 5.5 during RT. Alterations in the various components of saliva and decreased salivary flow inhibit the protective effects of saliva. Therefore, mucositis often is aggravated by infectious ulceration.
Management for xerostomia is directed at several levels. First, addressing the patients chief complaint of chronic dry mouth, treatment is generally palliative–utilizing artificial saliva, carrying water bottles for periodic mouth moistening. Salivary substitutes are available in two types. All contain electrolytes commonly found in saliva including those normally used for remineralization and should be used in dentate patients. The other solutions contain dextrans which should be reserved for edentulous patients so as not to raise the caries index. Sialogogues (pilocarpine) may also be used to stimulate saliva formation if residual salivary tissue remains. These drugs alleviate many of the problems encountered during therapy.
However, the critical aspect in managing head and neck irradiated patients with xerostomia is controlling the risks for oral diseases. Therefore, initiation of meticulous oral hygiene regimens including topical fluoride trays , chlorhexidine rinses, and regular dental hygiene therapy sessions are required. In addition, dietary advice is recommended to reduce the intake of carogenic foods.
Another acute effect commonly associated with mucositis is oral candidiasis. Colonization of the yeast on damaged tissue can intensify the symptomatic effects of radiation on the mucosa.
The practitioner should be aware of the multiple presentation of candida including pseudomembranous (removable white plaques with an erythematous base), chronic hyperplastic (leukoplakia like plaques that do not wipe away), and chronic cheilitis. These infections should be eliminated to decrease mucositis and the chance of distant gastrointestinal infections.
Management of patients with oral pharyngeal candidasis include both topical and systemic approaches. Historically, nystatin topical solution have been used with mixed efficacy. Patients involved in this therapy should be advised that the solution must be refrigerated at all times or the solution will become inactivated. Other topical solutions include clotrimazole troche which is recommended for edentulous patients and angular cheilitis. However, this medication should be avoided by the dentulous patient for caries control, due to its high sugar content. Currently, the best medication for oral or systemic candidiasis is Diflucan. The treatment regimen includes a 200mg loading dose the first day, followed by a 100mg /day dose for the remaining thirteen days. However, it is imperative that the physician obtain liver function tests prior to initiation of treatment because of the potential toxic side effects on the liver.
Local infections can lead to sialadenitis, periodonditis, abscesses, pericoronitis, or other causes of ulceration. Emperic treatment with antibiotics are usually adequate; however, periodontal lesions usually need additional debridement. The oral cavity may be the portal of entry for systemic infections. Therefore, chlorhexadine rinses should be considered for these patients.
Gingival bleeding may be the first sign of thrombocytopenia. The patients' ability to accomplish adequate oral hygiene may be limited. In these instances flossing may have to be discontinued . Again chlorhexadine rinses may be required to reduce pathogens found in plaque.
Chronic Complications of Radiation Therapy
Osteoradionecrosis
Certainly one of the most devastating complication of radiation therapy to the head and neck is the development of osteonecrosis of the mandible. Long term effects of radiation therapy on osseous and soft tissues is soft tissue fibrosis and ischemia, which may never resolve. The main mechanism of osseous involvement is injury which occurs to the small vasculature of the Haversian canals and the periosteal tissue. Fortunately, osteonecrosis is a relatively uncommon complication, with an incidence ranging from less than two percent to as high as 10%. This range in incidence varies with total dose administered to the mandible. (i.e. greater than 70 Gy yielding the larger number)
Another compounding factor is location of the primary tumor. If the lesion is large and is situated at the floor of mouth the rate of osteonecrosis more than doubles to 25%. Due to the decrease in healing capacity of the tissues from decreases in blood supply, infections to the jaw are devastating. The major etiologies are extraction of failed dentition after radiation therapy. Therefore, posterior mandibular teeth may be planned for extraction if more than 6,000 rads are expected in that field.
Great importance should be placed on pretreatment evaluation of all remaining dentition. Any questionable teeth that cannot be adequately maintained for years should be extracted. A period of two weeks prior to radiation therapy is advised for adequate healing of extraction sites. All preprosthetic surgery required, should be performed prior to the initiation of radiation therapy.
Occasionally systemic antibiotics will be required if osteoradionecrosis develops. Technically it is not an infection of bone but rather a nonhealing hypoxic wound. Systemic antibiotics are of limited value to the mandible itself due to the decreased vasculature and subsequent poor drug delivery to the site. However, in secondary infections they may have a role in preventing the spread of infection. No attempt should be made initially to obtain primary soft tissue closure of bone, since most wounds less than 1 cm or less will heal in weeks to months without surgical intervention other than removing sequestrum. For large defects in the jaw, surgery will be required with osseous and soft tissue reconstruction with the aide of preoperative and postoperative hyperbaric oxygen.
The role of hyperbaric oxygen has greatly enhanced the ability to reconstruct patients with osteoradionecrosis with large boney and soft tissue defects. However, the cost is tremendous and access to treatment is limited. Additionally it is felt that patients with active malignancies should not be exposed to HBO for fear that it can accelerate the repopulation process. The mechanism of action appears to be supporting neovascularization within tissues ,increasing the oxygen tension . The protocol is 20 pre- surgical hyperbaric oxygen (HBO) sessions, each consisting of 90 minutes of 2.4 atm of absolute pressure/day x five days /week. After the reconstructive surgery, an additional ten treatments is prescribed to ensure adequate vascularization of the grafted bone and soft tissue.
Soft Tissue Necrosis
The primary etiologies for this type of chronic complication are due to excessive doses delivered to the tissues via interstitial implants or secondary to soft tissue irritation from an inadequate fitting prosthesis. If the patient can tolerate being edentulous, it is recommended for the first six months post-therapy to allow for adequate healing and remodeling of bone. Occasionally it is required to administer HBO and antibiotics to alleviate the necrotic tissue.
Trismus
This condition is secondary to fibrosis which occurs in the muscles of mastication after being within the field of radiation. Best management is to encourage physical therapy during and after the radiation is administered. This feature can also be an important factor for adequate oral hygiene if the patient is unable to open the mouth for proper dental care.
Suggestions for the Edentulous Patients
Proper fitting of prostheses is essential, discrepancies can result in ulcers which may lead to osteoradionecrosis. New dentures should be constructed only after adequate healing time; in the interim, soft tissue liners may be used. Chlorhexidine two times a day until salivary function returns can be used to keep the mouth clean. Salivary analogues may also be used to increase retention of the dentures.
Candida is often a problem and antifungals should be used. These drugs may be added into tissue conditioners or placed where needed. Dentures should be removed and cleaned every night. At first sign of discomfort, the denture should be removed, adjusted or relined. It is extremely important not to have soft tissue ulcerations, because the risk of osteoradionecrosis is a life-long threat.
Other effects of radiotherapy to Head and Neck region
Radiation induced dental caries
As mentioned earlier, radiation may permanently alter the quality and quantity of salivary flow. Saliva plays an integral role in the prevention of dental caries. Without its protective action, the cariogenic oral bacteria are permitted to colonize the teeth unchecked. In the absence of a strict and meticulous preventive hygiene regimen, rampant caries typically results. Carious lesions may begin to appear within three months of radiation therapy and proceed rapidly to devastate the dentition. The key to managing this problem is prevention. As will be discussed later, a regimen of strict oral hygiene, daily fluoride application, carbohydrate restriction and frequent dental follow up are essential.
Abnormal Development of the Dentition
Tooth development begins at four months in utero and continues until early adolescence when the permanent teeth complete their formation. As with many other tissues, radiation has the potential to interfere with normal growth and maturation of the developing dentition. The severity of malformation is dependent on the stage of development at which the teeth are irradiated and the total dose received. Abnormal development in humans has been observed with a total dose as low as 400 cGy.1 Dental abnormalities include crown and root dwarfism, root shortening, incomplete calcification, abnormal curvature of the roots, delayed or arrested eruption, and ankylosis of primary teeth. Shortened roots may lead to inadequate anchorage of the teeth in the supporting bone with subsequent loosening , increased susceptibility and involvement with periodontal disease, and early tooth loss. Ankylosis of primary teeth as well as delayed or abnormal eruption of permanent teeth may lead to significant malocclusion. These problems may require substantial efforts by the general dentist in conjunction with other specialists to restore adequate form and function to the dentition.
Abnormal Facial Development
In the same vein as disturbed dental development, the structures of the facial complex, which are also actively developing in the child, may also be adversely affected by radiation therapy. These changes are secondary to radiation effects on cartilagenous growth centers. These areas are located, for the mandible, in the condyles, and for the maxilla, in the sutural growth centers. Higher radiation doses on the order of 6000-7000 cGy are associated with disturbances of facial growth and associated malformations. The child with these growth disturbances may develop micrognathia, maxillary deficiency, retrognathia, skeletal and dental malocclusion as well as other abnormalities in the facial complex. The management of those long term survivors who manifest these complications involves a team approach involving the dentist, orthodontist, oral and maxillofacial surgeon as part of rehabilitation.
Oral changes following Radiotherapy to paediatric patient
The advent of chemotherapy and radiotherapy as treatment modalities for pediatric malignancies has produced a significant increase in cure rates for many of these cancers. However, along with the increased success of treatment with these modalities comes a potential for multiple organ system morbidity that may last the lifetime of the patient. These modalities have found their niche in the treatment of head and neck cancers, and as such, many of these pediatric patients will survive into adulthood. With this increased survival there is an increased potential to develop significant long term complications within the treatment fields. It is therefore imperative that the health care team be familiar with not only the potential complications of therapy, but also their prevention, recognition and management.
Oral complications of radiotherapy are usually the result of the direct effects of radiation on the oral tissues. The tissues most frequently affected are the mucosa, salivary glands and mineralized tissues.
Possible Changes That You May See In Your Child's Mouth During Radiation Therapy
Early changes
Mucositis: This is a reaction of the skin inside the mouth to radiation. It typically occurs within the first two weeks of treatment. Your child's mouth will become reddened and quite sore. There may even develop ulcerations throughout the mouth with severe discomfort. This reaction usually resolves completely 2-3 weeks after the cessation of therapy. The soreness of the mouth may make it difficult for your child to speak, swallow or eat. However, it is very important that your child continue to take fluid and food to maintain hydration and nutrition for proper healing. Your doctor or dentist may be able to prescribe anesthetic mouth rinses to soothe the soreness and make eating and drinking easier.
Dry Mouth: If the glands that produce saliva have been included in the area to be treated, your child may develop a dry mouth. Depending on the degree of involvement of the glands, the dry mouth may be mild to severe, and may partially return or be permanent. This too may be uncomfortable for your child and make eating difficult. It may be necessary to take frequent sips of fluids (such as water or milk) with each bite of food, as well as take smaller bites, in order to properly moisten and allow easier swallowing. There are man made saliva substitutes available that may ease the discomfort of a dry mouth and make eating and speech easier.
Late changes
Tooth Decay: Saliva is an important part of the body's mechanism for preventing tooth decay. As mentioned above, radiation therapy can cause a permanent decrease in the amount of saliva produced. This, in turn, can lead to an increased rate of tooth decay in your child's mouth. It is therefore very important to follow your dentist's recommendations on oral hygiene during radiation therapy. Brushing and flossing of the teeth to remove plaque and tartar is crucial to minimizing the risk of severe tooth decay and early tooth loss. Fluoride tooth paste should be used with a soft tooth brush. In addition, fluoride gels in custom trays supplied by your dentist should be used daily according to your dentist's recommendations. Any cavities or tooth aches should be brought to the attention of your dentist right away to avoid unnecessary loss of teeth due to decay. Finally, it is very important to keep your regularly scheduled check up appointments with your dentist so that any problems or concerns may be addressed.
Abnormal Eruption of Adult Teeth:Radiation therapy that involves the head and neck has affects on the developing adult teeth that lie within the jawbone. These affects include delayed eruption (the teeth will come into the mouth later than normal), eruption of teeth in an abnormal alignment (teeth may be crooked), or fusion of the baby teeth in the jaw bone preventing the adult teeth from erupting. These abnormalities can also be corrected, most times, with orthodontics and/or oral surgery.
Abnormal Facial Development:Radiation can also effect the areas of active growth, called growth centers, in the jaws and facial region. If these areas are in the area being treated by radiation, it is possible that future growth of the jaws and/or face may be delayed or disturbed. This altered growth may result in a small jaw with a poor bite, or an altered facial appearance later in life. However, many of the resultant deformities can be adequately corrected through a combination of orthodontic and/or oral surgical procedures.
Difficulty Opening the Mouth:The muscles that open and close the mouth may lie within the area to be treated with radiation. If so, they may be affected and undergo changes which make it difficult to open the mouth, called trismus. This may require a substantial amount of time to occur, even after treatment has stopped, and may develop gradually, making it difficult to notice. This is another reason to make sure you keep your follow up visits with your radiation oncologist and dentist even though treatment may be completed.
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Score and Sound: The Unsung Heroes Behind the Scenes
November 23, 2009 07:29 | By Bob Bayless
Every year about this time, the Oscar nominations are made. Music, of all the crafts, is possibly the most subjective category to judge, especially for an award of this magnitude. The daunting task of deciding what is worthy of contention goes to the composers, music editors and music supervisors who are Academy members.
"Movies are so different that sometimes the score is relied upon to make the transitions and fill all the emotional moments from scene to scene," says Kenny Hall. Hall was nominated for a MPSE Golden Reel Award for his music editing on Disney's animated feature film, Mulan. For over 20 years, he worked as composer Jerry Goldsmith's music editor. He now holds "The Art of Music Editing" chair at USC.
"Other scores, such as Slumdog Millionaire, become an integral part of the sound design," reveals Hall. "As a score, I never thought it was anything really terrific, but I thought as part of the sound design, the combination of that score and effects were magical."
Hall continues, "Many times a score that resonates with me is a very simple melody that has developed throughout the whole picture, and I feel it made the film totally emotionally satisfying to the audience in the end."
Rolfe Kent
Rolfe Kent, Golden Globe nominee for his score for Sideways and composer of this year's releases, The Men Who Stare at Goats and Up in the Air, talked about what constitutes an Oscar-worthy score, "The music has to make a significant impact on the film. If it does it in a particularly original way, that can be 'ear catching.' To me that's creativity! Creativity is what I'm most interested in. If someone has come up with really surprising or emotionally effecting juxtapositions, and made a significant, dramatic impact in the process, then that's what is going to attract my attention."
Hall shared his belief that some pictures don't offer great opportunities for a score. "If the scene plays well, and you're looking for a place to play the music, then it doesn't need it!" Sometimes scores in certain films, or music in other films is forced in, just to "move it along," but then the picture never breathes. There are so many variables; it just depends on the film.
"I've noticed that some people make a point of getting stars to play on their scores, and while I applaud the involvement of great talent, that doesn't mean much to me," adds Kent. "It's really about the filmmaking and the role of the composer as filmmaker—anything that is a genuine contribution to creative filmmaking. After all, the academy is about filmmaking. Filmmaking is our only interest and the focus of what we're looking at. It doesn't matter who played it. What matters is the ideas, and how they contribute to the film."
"The music has to make a significant impact on the film. If it does it in a particularly original way, that can be 'ear catching.' To me that's creativity! Creativity is what I'm most interested in." – Rolfe Kent
The Best Song is of course another kettle of fish due to the commercialization factor. A popular song influences the decision-making process. Hall comments, "There have been some songs that won Academy Awards because of some popularity factor. I'm not going to name names, but many times a song won because the picture was popular, or the performance was popular. Songs are an odd animal. Not that many songs are nominated. Often the song has nothing to do with the picture. It tends to be a song in the middle of the picture. I think they have changed the rules this year. I believe that now the song has to be part of the last scene, which then plays into the end credits. That way they can be qualified. I hate the idea that you can now have a song that begins with the end credits."
"For songs it would definitely be an involvement in the film," says Kent. "I assume the existence of the song category comes from back in the day when there were a lot of musicals in the '30s or '40s. It strikes me that the song should be very relevant to the film, and ideally, should actually be in the film. I've always loved when the theme is used in the score as well. Admittedly, that doesn't happen too often these days, but that's something that makes a lot of sense to me. It clearly indicates that the song is integral to the whole filmmaking process."
Hall adds, "The whole approach to music for film, is a subjective thing for many people, but I think the great scores, many of which have never won an Oscar because of the popularity factor of the Academy Awards, will hopefully be re-examined someday to really get their full credit for the picture. Many pictures come to my mind. One that I worked on was Patton. It was a three-hour movie. It had thirty minutes of music in it, but how important those few cues were, is unbelievable!"
According to Hall, "In the nomination process, I always go with the films where the score did not draw attention to itself, and yet was so wonderfully supportive to the story and to the emotion of the characters."
Although Hall has an excellent home theater setup and receives all the screeners, he realizes the value of seeing a movie as it was intended to be seen—with an audience. That is the best way to judge whether or not a score is having the desired emotional effect. You can feel the emotion with an audience, but you might miss it if viewed alone. That, of course, is why they tried to outlaw screeners and CDs of the score a few years back, but unfortunately, not everyone has the time, or the dedication to view every contender with an audience. I applaud those who do, especially for this category.

redpajama_set_name: RedPajamaCommonCrawl


text:
<?php

declare(strict_types=1);

namespace Nelmio\Alice\FileLocator;

use Nelmio\Alice\FileLocatorInterface;
use Nelmio\Alice\NotCallableTrait;

class FakeFileLocator implements FileLocatorInterface
{
    use NotCallableTrait;

    public function locate(string $name, string $currentPath = null): string
    {
        $this->__call(__FUNCTION__, func_get_args());
    }
}

redpajama_set_name: RedPajamaGithub


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A professional college admissions counselor in Bergen County NJ such as Pearl Glassman is going to know how to help you determine which is the best one for your career. Beginning your college search with the basics will help you identify the colleges that will best suit you personally and academically. Everyone has unique requirements and values, and what is important to you may not mean as much to someone else. Take location, for example. You may not want to be 100 miles from home. This means that schools on the other side of the globe are simply off the table. School size, cost and other basic college criteria are the same. While athletics may be the top priority to one person, Greek life may be the first priority to someone else. By identifying your requirements early on, you're capable of eliminating hundreds of schools and focus on the things which will make your school a ideal fit. The actual cost of the college is an enormous factor. When parents' sons or daughters are looking for a college for them, this is something that they're thinking about a great deal. If you'd like to reduce prices, there is a wide variety of ways to do so. Not all colleges and universities have come with the same price. Financial aid, scholarships and work-study programs are provided by most schools. This is apart from student loans. Part of college counseling is having someone assist you in finding the best financial alternative. Are you in need of advice for college in Old Tappan NJ from a counselor you are able to depend on? All you need to do is contact Pearl Glassman.
Talk to one of our specialists today when you're not sure why you need college admissions counseling in Bergen County NJ or you have not been certain where to find a college admissions counselor.


WESSON, Miss. (AP) — American flags hung from every pole and business in the small Mississippi town of Wesson as the remains of a 23-year-old sailor headed to his last resting place Wednesday, 75 years to the day after he was killed at Pearl Harbor.
Fireman 1st Class Jim H. Johnston was buried with full military honors in his hometown. He was one of 429 crewmen killed on the USS Oklahoma when it was attacked by Japanese aircraft on Dec. 7, 1941. The attack triggered the entry of the United States into World War II.
Local media report Johnston's remains were disinterred last year in hopes of identifying them through modern scientific methods, and were returned to Johnston's family on Tuesday.
In October 1949, a military board ruled that many of the remains from the Oklahoma, including Johnson's, were non-recoverable.
The Riverwood Family Funeral Service was contacted by the Navy to make the arrangements and owners offered their services free of charge.
About 250 local residents gathered around the family plot at the Wesson Cemetery as Johnston was buried next to his parents.
Gov. Phil Bryant attended the graveside service and thanked Johnston and all of the Mississippians killed in World War II for their service.
Frank Springs, Johnston's nephew from Lucedale, Mississippi, was one of the family members attending the service. He spoke briefly thanking others for attending.


The pain of gallstones for four years must have been excruciating for Mary Wiggins of Indianapolis.
Over 150 years ago, with little to no fanfare, medical history was made in Indianapolis.
The patient was Mary Wiggins, a 31-year-old seamstress who was forced to quit work because the mass in her abdomen had grown since she first noticed it four years prior.
Dr. John S. Bobbs consulted and was confident it was not an ovarian tumor as many had suspected. He also didn't know what it could be.
Indianapolis had no surgical hospital at the time, no sterile operating rooms and no trained nurses.
On June 15, 1867, Wiggins was taken to a room on the third floor over the Vinton & Kiefer druggist at the southwest corner of Meridian and Pearl streets, where L.S. Ayres would be constructed some 38 years later.
Wiggins was placed under chloroform anesthesia. When Bobbs cut into the lower abdomen, he found a translucent mass about five inches long and two inches in diameter. He cut the sac and "several solid bodies about the size of ordinary rifle bullets" fell out, he wrote. Only after removing the stones and the fluid could he identify the sac as the gallbladder.
Bobbs left the gallbladder in place believing it could not be removed. Wiggins was stitched up and left under the care of an English woman for a six-week recovery.
Bobbs had successfully performed the first cholecystotomy: the removal of gallstones. It wasn't until 15 years later that the first cholecystectomy, the removal of the gallbladder was performed.
Though Bobbs' groundbreaking operation was witnessed by eight other doctors, he waited a year to make his work public.
Twelve years after her operation, Mary Wiggins married John Burnsworth and moved to McCordsville. She died in 1913 at the age of 77, nearly 46 years after her history-making operation.
Bobbs, who died in 1870, also had been a brigade surgeon during the Civil War and medical director for the state of Indiana. Upon his death, Bobbs left an endowment to establish Indianapolis' first dispensary.
If you find yourself walking past the Napolese restaurant on Meridian Street, south of Washington (the former L.S. Ayres annex), you'll find a plaque dedicated to Bobbs and Wiggins that reads: "Here in 1867 Dr. John Stough Bobbs performed the first successful removal of gall stones in man." Nevermind that it was a woman.


text:
Victory for NJ Free Speech - Targum Says (paraphrasing) #NoNJS4001
The editors of NJ Daily Targum struck a major blow to efforts led by NJ Senator Sweeney to usher in a wave of repression against students and faculty at public universities and public schools. Sweeney has sponsored a proposed bill that would target anti-war and pro Palestinian activism - anyone that criticizes Israel - for sanction and possibly even criminal charges. The Rutgers Daily Targum - in its long held tradition of being a bastion of advocacy for free speech has stated today, November 25, clearly and unequivocally - opposition to the bill even calling upon students to actively engage in work to stop it!
I have to admit that over my long years I had tussled with Targum reporters and editors - as a political activist at Rutgers in the 70's and 80s. I might have thought that they made me personally and activists in general look silly upon occasion. (I was doing street theatre in a horse costume on College Avenue once - long story.) In their minds maybe we were looking foolish - and you never know - we all stumble here and there. But The Daily Targum as long as is I can remember has always been a bastion for free speech - and today they once again ring that bell!
This is a clarion call for all the state newspapers (many have already denounced this attack on free speech) to reiterate their opposition and especially all of the campus newspapers across the state of New Jersey need to read today's Targum editorial - and come out swinging with your own defense to inform the students on ALL OF THE CAMPUSES of NJ about these dangers! That is a most important impact that the Targum editorial can have.
But we all need to take the link to the editorial and tweet it to Assembly and Senators as well as to news outlets - especially campus - throughout NJ, the US and world!
As the Targum states:
"First, nationalities and ethnicities are completely separate matters — something this bill seems to feign ignorance of. Regardless of your personal opinions on Israel, criticizing a government's policies is not the same as criticizing a race, religion nor ethnicity.
Through this bill, legislators have effectively made collectivized verbal critiques against Israel's government a hate crime, which is damaging by any metric. No institution, whether it be a government, an activist group, a religion or a philosophy, has the right to be above criticism.
The bill's vague language makes it especially dangerous. While the intention of the bill is to squash anti-Semitism at public universities, a section of the bill defined an aspect of anti-Semitism as "applying a double standard to Israel."
What exactly a "double standard" means in this case is unclear. Can we not criticize one side of an issue unless we criticize the other as well? That is not how critique works — it is completely possible to key in on one issue without focusing on every single injustice occurring in the world at once.
With the loose language used in this bill, it is quite transparent that lawmakers plan to use it to limit free speech for student media, activist groups and on-campus talk in general.
Looking at the bigger picture here, any attempt to legislate speech must be either critically examined or outright fought. It is acceptable to outlaw genuinely endangering speech, but this is firmly not one of those cases.
Silencing criticism is not acceptable. Attempting to shut down activism and protest is a violation of our fundamental duty outlined in the Bill of Rights."
Role of All Marxists Leninist Union in Raising Alarm on NJ S4001 at Rutgers
The dangers of this bill were brought to the attention of the Rutgers community at the AMLU meeting at Scott Hall, on September 12, in a panel discussion hosted by All Marxist Leninist Union that was broadcast live on Facebook by NJ Revolution Radio. The event was coordinated between AMLU and #NJAntiWarAgenda with participation "as individuals" of members of American Muslims for Palesine.
AMLU also brought it to the attention of the Rutgers campus through an op-ed that the Daily Targum ran on October 29. 2019.
The AMLU op-ed excerpted below detailed some of the activities among university and high school students opposing the proposed repressive law.
"The anti-war and anti-imperialist struggle would most certainly be crippled, as U.S.-Israeli imperialism is undeniably a global force at the center of many destructive wars and conflicts across the world.
The ability of groups to form coalitions among the anti-imperialist Left would be strictly limited under the bill in such a way that our liberties of free assembly would be curtailed.
The NJ S4001 Bill, if passed, would persecute any group or individual in educational institutions like high schools and universities who would be "delegitimizing Israel by denying the Jewish people their right to self-determination and denying Israel the right to exist."
That . .. . bill, in the end, would prohibit Students for Justice for Palestine (SJP) and Boycott, Divest and Sanctions (BDS) clubs and speakers on campus and thus restrict their right to speak and protest against Israel's war crimes. . . .
But we are not alone in our opposition to this bill. A statement from the Rutgers campus group Anakbayan Rutgers stated, "We must unwaveringly say that fighting for the basic rights to life, land, water, and democracy for Palestinians through boycott or any other means is not a crime, and it is not anti-semitic. The passage of this unjust bill would fly in the face of both academic freedom and freedom of dissent, and more primarily the Palestinian people and their just struggle for liberation."
Meanwhile, high school students concerned about their rights to advocate in the public schools have started a petition which stated in part: "We are opposing NJ bills S4001 and A5755 introduced by Sen. (Stephen) Sweeney (D-N.J.) and Assemblywoman (Annette) Quijano *. This proposed law dangerously conflates criticism of Israel with Antisemitism. It would punish legitimate dissent of U.S. foreign policy and its support for Israel. We support student rights to free speech in and out of school, (and to) criticize American foreign policy."
Protesting US backed Bolivia coup
Members of AMLU were recently instrumental leading a protest on College Avenue (Rutgers, New Brunswick) to condemn the US supported murderous right wing coup against the legitimately elected president of Bolivia Evo Morales. See report. Israel exports its products of violence, counter insurgency expertise, its cyber hack and surveillance products to fascist regimes all over Latin America so it is important for the effort to oppose US intervention and war in Latin America to protect our rights to criticize Israel's direct role in these deadly policies.
There is more news today on the attempt to repress and criminalize solidarity and anti-war voices in NJ. A volunteer lobbyist, requesting anonymity given the current repressive political climate was in Trenton talking to Assembly members. The lobbyist stated that most Assembly members they met are opposed and some who were originally supportive are now opposed.
Ironically though, one assembly member, Gary Schaer, who has a significant Arab constituency as he represents Passaic, NJ, with a concentration of Arab voters, is a strong supporter of the repressive bill. It is ironic because his constituency will be impacted as members in the community support the victims of violence in the Middle East, including Palestinian victims of Israeli violence. The lobbyist stated that we need to stay strong to defeat this bill and that he was told that a similar bill could be introduced - even if this one is defeated. The lobbyist urges everyone to stick to the fight!
AMLU and the Daily Targum were in harmony on a major point in each of the two op-eds - the need for student action. As AMLU stated, "We invite you to join the New Jersey Committee to Protect Dissent to protect the rights of students and faculty to discuss and criticize U.S. foreign policy and to support the struggles of the Palestinian people."
For their part, the Targum editors urge: "Truly any campus group that believes in free speech as a blood right must recruit support to fight this issue, and all Rutgers students — those who stand on either or neither side of the Israeli-Palestinian dispute — must be willing to join in this fight. We all attend a public school and thus would be heavily impacted by this excuse of a bill. We must send the message to our legislators that although we are public, we do not exist to be hammered under the thumb of our lawmakers."
As part of #NJAntWarAgenda - if you are interested in stipended anti imperialist and pro student rights (especially regarding this kind of bill) for campus organizign - text 908-881-5275.
Open letter to faculty unions includes links to Palestine Legal and CAIR opposition to this bill.
· Assembly women Annette Quijano no longer appears as co-sponsor of A5755
@SenSweeney @daily_targum Blasts NJS4001 - Sweeney's attack on free speech rights! GO TARGUM!
Sweeney: WITHDRAW NJ S4001 NOW!#StopNJS4001 #StopNJA5755https://t.co/kb2jgpr5ff
— Bob Witanek (@bwitanek) November 26, 2019
Huge Will n for free speech.Of course it is bizzare to have to fight for this freedom.We will fight their next tool of oppression as well.Happy Thanksgiving comrades.BDS!!!✌✌✌
Mark Lesko November 26, 2019 at 6:43 AM
This is a critical fight. I am all in.
Victory for NJ Free Speech - Targum Says (paraphra...
NJ Says "NO MORE COUPS!" - Comite Bolivia NJ Forme...


Just over a month ago, an article by Josh Rosenberg, me, Leigh Graves Wolf, and Matt Koehler appeared in the Journal of Computers in Mathematics and Science Teaching. This is—perhaps obviously—a continuation of some of our previous work on Twitter hashtags in graduate education, but this piece took a particular look at social media use, including Twitter, within the MSU Urban STEM fellowship program that recently wrapped up. Following the #MSUrbanSTEM hashtag on Twitter was one of the highlights of following Twitter hashtags related to MSU's Master of Arts in Educational Technology program, so we jumped at the opportunity to contribute to a special issue focused on the MSU Urban STEM.
The article can be found here, if you're interested.


Facebook algorithm has once again changed but not in favour of brands.
Agencies and brands will now have to invest in Facebook to reach the same audiences they did previously, this includes paying for a range of adverts and spending time creating appealing adverts that people will be interested in. With more and more businesses turning to adverts to reach users there is now a lot more competition which in turn has the potential to make Facebook advertising much more expensive with brands fighting for space on a users Newsfeed.
In the last quarter alone Facebook ad rates have risen by 35% due to brands noticing this change with a decline in organic reach.
What does this mean for brands using Facebook?
There will now have to be a lot more planning and clever execution when developing Facebook campaigns that go deeper into campaign execution, optimisation and media planning, and a lot more focus on reporting and analytics to see what works and what doesn't on a campaign by campaign basis.
For marketers it's now a case of needing to be better media planners, which businesses can get the most engaging and organic content that users are interested in. Marketers need to understand how to plan and execute great social media campaigns.
This big change from Facebook could actually be to do with how it has stated many times that it's not a news organisation but rather a social media network with a big emphasis on eradicating 'Fake News' from users News Feeds. It makes it easier to combat this problem with less and less users seeing these updates. This algorithm change is potentially taking Facebook back to the days of wall posts and status updates.
However, for those users who still want to see the content posted from their favourite brands and publishers all is not lost. There are options under the News Feed tab on Facebook that will allow users to prioritise the pages and friends whose posts they are most interested in. So there is some flexibility in still having your brand's content seen but it relies on the users actually choosing your brand.


text:
Helwer victim of a leaner style of government
In Brandon SunPublish Date May 12, 2016 shaun
Republished from the Brandon Sun print edition May 7, 2016
Reg Helwer applauds his team following a convincing win April 19, 2016 (Brandon Sun)
You kind of have to feel for Brandon West MLA Reg Helwer. One of the loyalists of Brian Pallister's members over the last four years, Helwer found himself in the audience last Tuesday as opposed to being on stage when the new Progressive Conservative cabinet was sworn in at the Canadian Museum for Human Rights.
To be fair to the new premier, he did state there was little to no guarantees for the city, or our MLAs going into this election. With that said, there was a substantial swath of armchair politicos who believed the member from Brandon West was a clear-cut choice for a number of potential portfolios in government. Helwer has proven likable, energetic and hardworking as a member of the legislature, and without a doubt the fact he was not chosen has to sting a bit, and rightfully so.
Pallister's plan all along was to shrink the size of cabinet by one-third if elected, and Tuesday's reveal reiterated the fact that he was poised to do just that by working on a leaner, efficiency-based style of government.
Manitobans would be hard-pressed to argue with the new premier looking to trim portfolios in the province, and aside from the standard political opposition to the move, his choice to reduce the cabinet does make sense.
If Pallister was truly going to "find efficiencies" in the province, the fact he looked at his own house first hopefully indicates that his ideals are built on those aforementioned efficiencies, and not the slash-happy politics the NDP warned Manitobans against.
Where the challenge lies now for our city is whether we will have enough engagement for Brandon-specific interests at the cabinet table without an MLA present.
This city has far too many necessary projects in the works currently and in the near future to be positioned without a voice at the table.
And as much as the PC party faithful in the area attempted to downplay the absence, without Helwer or Brandon East MLA Len Isleifson in ministerial positions, it will set our city back.
Moving forward, both of our MLAs face a stiff challenge to engage the cabinet to "work for Brandon," as former Brandon East NDP MLA Drew Caldwell liked to say.
Helwer has his job cut out for him as Brandon's new elder statesman and member of the government as opposed to opposition.
Meanwhile, Isleifson will be tasked to set the tone for his constituency and also attempting to connect with new cabinet colleagues on projects specific to our city.
To be fair, the region wasn't completely shut out, as multi-term MLA Cliff Cullen (Spruce Woods) will serve as the de facto Westman representative in cabinet. With Cullen's appointment, he joins a number of rural reps filling key positions for the premier. Seven rural members have been tasked with portfolios in government, and the fact Pallister chose to look beyond the borders of Winnipeg speaks to his base, but frankly our city deserved more as the second-biggest centre in this province.
The other small sliver of hope comes from the idea the premier himself identifies as an adopted Brandonite due to the time he spent here while attending Brandon University. As much as we will embrace our adopted son, to be entirely honest this city has changed a great deal since Pallister graced the hallowed halls of his alma mater.
Our challenges are legitimate and somewhat unique in this province. We are Manitoba's finest example of community stuck between the needs of a big city while dealing with the supports of a small town, and a place at the cabinet table would have hopefully continued the mindset of building Brandon, to again coin a term of Isliefson's predecessor.
It may sound a bit like sour grapes, but to have no representation for our city only reiterates the belief of that second-city mentality Brandonites so often rail against. This was a golden opportunity to show that the "sky was blue" in Brandon and Pallister missed that opportunity by not allowing a voice.
It is a government in its infancy, so some leeway can be given, but Helwer and Isleifson deserved better than was handed out this past week. It would have been nice to have that representation again and our city would have improved as a result of that representation.
Now we are left to bet on the future and hope when a shuffle happens that the premier decides to recognize this city and our needs by offering us a seat at his cabinet table.
Parking key to boosting Keystone revenue?
Bokhari's departure signals rough waters for Grits
Restoring nationial image more than a dream
October 24, 2015 shaun
ISIL strategy risky but right move for Grits
Measuring progress more than just mega projects
March 12, 2016 shaun


text:
How we got here: from labs working solo to a learning network.
By Bas Leurs, Lead Learning Designer, Accelerator Lab Network
By the time UNDP launched its Accelerator Lab Network in 2019, the organization had been working in the social and public innovation space for quite some time. So it doesn't come as a surprise that "labs" form the unit of action for UNDP's Accelerator Lab network.
But how did we get here? How did we move from single labs working solo to a network of labs? In this blogpost I will take a non-exhaustive look at the origins and history of social and public innovation labs, their networks and the role of labs in UNDP's innovation journey.
The birth of public innovation labs
Social and public innovation labs — or simply "labs" — come in many different shapes and forms. Usually they are a team, or an organizational unit, that is tasked with innovation aiming to improve how a government works to deliver greater public value.
Across the world we see, among other things, that policy issues are becoming increasingly more interconnected and complex, that the gap between governments and citizens is widening, and budgets are constantly being cut. Solving problems "as we have always been doing" — while expecting different results — simply doesn't cut it.
Labs have a mandate to challenge and question how things are done, as well as suggest, test and rehearse new ways of working, introducing new skills and mindsets to an organisation.
They create a safe space for experimentation and change by exploring alternative futures, identifying emerging problem spaces, working on specific issues that require new forms of collaboration or partnerships (e.g. between departments and with the private sector), enabling co-creation processes that directly involve citizens in the policy cycle or service design process, and/or by building capacity around a specific technology or innovation method.
Public and social innovation labs have been around for about 20 years now. Kennisland (The Netherlands), Nesta (UK), Sitra (Finland) and MindLab (Denmark) are often seen as one of the first.
Particularly MindLab's journey reached an almost iconic status. MindLab demonstrated that it was possible to embed an entirely different logic and way of working, grounded in social science and design, in the heart of the Danish government. This has inspired many other governments and innovators to set up labs as well.
Having a multidisciplinary team of scientists, policy makers and designers, stimulated a culture of action and reflection that helped MindLab to test, improve and codify their practice continuously. Their generosity to share their expertise and support newcomers has created a vast legacy. And even though MindLab had to close its doors after sixteen years recently, its legacy lives on.
In the early days there were few such labs, but we now find public innovation labs in every corner of the world. There are hundreds and perhaps thousands of them working at the federal, regional or local level. Usually they have the word "lab" in their name while there are also many teams and initiatives that don't carry that lab-badge but do operate as one.
Various events, conferences and meetups: Lab retreat after the LabWorks conference at Nesta (London, 2015); informal meeting with GovLab, Nesta, La 27e Région and MindLab (Copenhagen, 2015); Design for Europe symposium by La 27e Région (Paris, 2015); Estado Futuro conference by Laboratorio de Gobierno (Santiago, 2016); States of Change faculty meeting at Nesta (London, 2016); Edge of Government pavilion by MBRCGI at the World Government Summit (Dubai, 2017)
Over the past ten to fifteen years, the practice of public innovation labs has matured. Various awards, conferences, events (e.g. Nesta's LabWorks, MBRCGI's Edge of Government, OECD's Innovation in Government) and numerous smaller meetups, have served as crucial platforms for connecting lab practitioners, from different parts of the world, including newcomers as well as seasoned experts. Also, a prolific body of knowledge has been produced and disseminated through various newsletters, publications, blogs, toolkits, playbooks, guides (see e.g. Nesta's or OPSI's compendium of tools) and learning programmes.
Over time these activities have contributed to the establishment of an active and loosely organised global community of practice, pushing the field of public innovation forward, advancing its methods, spreading its tools and skills and building legitimacy by demonstrating tangible results.
UNDP's Innovation Journey (2012–2016)
At some point in time, while the need for doing innovation in a large bureaucracy like UNDP became inevitable, the notion of a lab also started to get traction in the development sector. For UNDP, that journey started around 2012, with some first innovation projects "under the radar". Innovation got a formal position in UNDP with the Budva Declaration in November 2013. Since then, various innovation labs have been set up within UNDP or with governments in Moldova, Armenia, North Macedonia, Bangladesh, Sri Lanka, Egypt, to name a few.
The rise of innovation networks
Several people running labs, or their governing agencies, realised at a certain moment that they needed to connect with a wider ecosystem to mobilise talent, build capacity and create impact at scale. Over the past five years or so, we have seen various national and international networks of public innovators emerge.
The National Meeting of Chile's Innovadores Publicos (Santiago, December 2017)
Take for example, at a federal or state level, Taiwan's network of innovation officers, Chile's Innovadores Publicos, Victoria's (Australia) Innovation Network or Canada's Free Agents. The size and zeal of these networks show there is an appetite among public servants for doing things differently.
At the same time we have also seen some global networks of public innovators emerge: some are initiated as bottom up like One Team Gov or as a start-up like apolitical, and others are curated by inter- or non-governmental organisations like Nesta's States of Change, OECD's OPSI Network, or the UN's Innovation Network.
These networks have generally been helpful in advancing and spreading the practice of public innovation, but so far none of them have set an agenda and executed on it to address the world's most pressing issues we find around the 2030 Agenda for Sustainable Development — issues that affect the livelihoods and lives of billions of people.
Istanbul Innovation Days 2017
Planting the seeds for UNDP's Accelerator Lab Network….
This absence of concerted effort was addressed during the Istanbul Innovation Days in 2017: How can labs operate at a much larger scale, creating more impact? At this conference, UNDP, Nesta and a cohort of innovation practitioners critically reflected on the practice of public and development labs and their impact.
Labs as a single change agent normally don't operate beyond their remit or political mandate and are, for that reason, struggling to address complex challenges like youth unemployment, corruption, waste management, or transnational issues like immigration, terrorism and climate change. In order to address these challenges, we needed to re-imagine the lab as a concept as well as its practice.
The suggested way forward was a collective approach and to
"…build a movement that needs new political capital and a very different set of alliances — as well as possibly new skills and competencies — to address the step change in the type of challenges governments are facing that underline a class of issues underpinning the Sustainable Development Goals."
Although this was easier said than done, the seed for building a movement — a collective where the whole is bigger than the sum of its parts — was planted.
In the summer of 2018, when Millie Begovic, the driving force behind the Istanbul Innovation Days, met with UNDP's Administrator Achim Steiner, the opportunity arose to bring this vision of a movement to life.
The Administrator had observed that a lot of innovation was happening at UNDP, but often at the fringes of the day and not in a joined-up way. Likewise he also noticed that many of the programmes in UNDP with momentum, energy and new partners often occurred somewhere around a lab-like space. And even though some argued at that time that we may had well reached "peak labs", as some notable labs like MindLab and Mexico's Laboratorio Para la Ciudad had just closed their doors, the Administrator wanted to learn from these experiences. Thus he set out an audacious plan to launch a global learning network of 60 labs, all at once, in a staggering six months.
Building on the previous experience that UNDP had with innovation, but with no precedent in terms of scale and ambition, the network is one of a kind. A large-scale experiment that is intended to create a "shock to the system", the Accelerator Labs reimagine how development is done and accelerate progress on the 2030 Agenda by a globally integrated learning approach.
Common innovation sense would advise anyone with such a plan to go for a staged implementation: starting for example with 5 labs, then add 10, 15 and 30 more, while feeding the learnings from previous cohorts into the next. Yet it is March 2020 now, and we already have all 60 Accelerator Labs up and running and creating a systemic shock inside this large public sector development organization.
Given the short timeline and the sheer scale, it certainly has not been an easy ride, but we are learning at speed from all the 60 labs and their partners on emerging or the most pressing developing challenges. Depopulation, plastic waste, informal economy, youth unemployment are some of the issues the labs are exploring.
For this year we focus on embedding, spreading and learning within and beyond the network. We'll be embedding the accelerated learning cycle into lab practice and into UNDP as an organisation. We will be exploring how to spread the solutions, insights, and ways of working with partners. And we will be setting up a sensory network using machines and humans learning together to follow the emergence of what the network is learning.
Special thanks to Giulio Quaggiotto, Millie Begovic and Jesper Christiansen for their input and feedback.
Is the Business Ecosystem a Toy for Big Companies?
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Verda to Take Industry by Storm | To Launch with Ontario's "Click and Collect" Model for Legal…
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GiD Report#178 — The WSJ's FB investigation and Gary Gensler's Senate testimony
GlobaliD in GlobaliD
Week 12: Ranking Five Video Streaming Services
Braeden Gee
Airbnb to begin collecting Colorado taxes for hosts
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Tesla Dominance: what happens when customers realize there is a better way
Imperfect Exchange
Silicon Valley firm starts blacklist of venture capitalists accused of harassing women
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Telephone, Email, Skype, Facebook — What Are the Most Popular Contact Channels in Customer Service?
parlamind in Service first.


text:
Q: how to register an existing delta table to hive We are using spark for reading/writing data in delta format stored in HDFS (Databricks Delta table version 0.5.0).
We would like to utilize the power of Hive to interact with the delta tables.
How can we register an existing data in delta format from a path on HDFS to Hive?
Please note that currently we are running spark (2.4.0) on cloudera platform (CDH 6.3.3)

A: The only way I can do this so far is by registering it as an unmanaged table. The most significant difference, as far as I can tell, is that if you drop an unmanaged table, it does not drop the underlying data.

redpajama_set_name: RedPajamaStackExchange


text:
End Of World: French Village Ready For Doomsday
Posted on December 21, 2012, by admin in Featured post
The tiny village of Bugarach has drawn global attention – and media – because some believe it will survive the Mayan apocalypse.
5:02am UK, Friday 21 December 2012
FRANCE-TOURISM-ESOTERIC
Video: Village Shut As 'End Of World Nigh'
By Robert Nisbet, Europe Correspondent
A tiny village in the Pyrenees has been sealed off as police try to prevent an invasion by those seeking salvation from a predicted apocalypse.
The jagged mountain which dwarfs Bugarach is said to contain aliens, who plan to board a spacecraft and flee the Earth before the end of the world.
There are those, admittedly in a minority, who believe the ETs may take some humans for the ride, allowing them to perpetuate humanity.
About 500 gendarmes have blocked roads and paths leading to the mountain to prevent an unsightly, or even dangerous, stampede.
Pyrenean Village Of BugarachPolice have blocked access to the mountain
Potholes in the mountain have also been sealed, to prevent anyone trying to find any alien life in its depths.
The mountain has long been imbued with mystical powers, so many in the village are sympathetic to new-age philosophies.
The local baker Dominic Lemmens told Sky News: "Many people from this village see something in the sky, but they won't speak (about it).
"I say, 'Did you see yesterday the light on the peak,' He says, 'No' – and I see an old guy from the village smile."
Pyrenean Village Of BugarachThe village is nestled at the foothills of the Pyrenees
At a local cafe, the owner has stored dozens of clips of UFOs he said were spotted flying to and from the mountain.
Patrice Etienne believes it merits further investigation, but doubts whether today's prediction has anything to do with an alien shuttle bus.
He told me that the object could even be from another dimension.
"When we see the object go into the mountain it disappears. There is no door, no opening."
"A lot of people are coming back from the mountain saying they heard strange noises like an earthquake, or they had a problem with their camera or their mobile phone.
"So they don't know what it is."
Pyrenean Village Of BugarachMedia from all over the world have descended on the tiny village
The prediction of the Earth's imminent demise comes from the end today of the 13th baktun, a period in the Mayan civilisation's "long calendar", which lasts 392 solar years.
While some believe it signals a new beginning, others predict it will mean the end of days.
Sharing the same day as the winter solstice has led one in 10 people to worry about some sort of event, according to a Reuters worldwide poll.
In Bugarach they will be pleased when the invasion of accredited journalists finally leaves, whether it be on a plane, a spacecraft, or in a fiery meteor shower.


text:
package org.infinispan.cdi;

import org.infinispan.cdi.util.logging.Log;
import org.infinispan.configuration.cache.Configuration;
import org.infinispan.manager.DefaultCacheManager;
import org.infinispan.manager.EmbeddedCacheManager;
import org.infinispan.util.logging.LogFactory;
import org.jboss.solder.bean.defaultbean.DefaultBean;

import javax.enterprise.context.ApplicationScoped;
import javax.enterprise.inject.Disposes;
import javax.enterprise.inject.Instance;
import javax.enterprise.inject.Produces;

/**
 *
The default {@link EmbeddedCacheManager} producer.

 *
 *
The cache manager produced by default is an instance of {@link DefaultCacheManager} initialized with the default
 * configuration produced by the {@link DefaultEmbeddedCacheConfigurationProducer}. The default cache manager can be
 * overridden by creating a producer which produces the new default cache manager. The cache manager produced must have
 * the scope {@link ApplicationScoped} and the {@linkplain javax.enterprise.inject.Default Default} qualifier.

 *
 * @author Kevin Pollet <kevin.pollet@serli.com> (C) 2011 SERLI
 */
public class DefaultEmbeddedCacheManagerProducer {

   private static final Log log = LogFactory.getLog(DefaultEmbeddedCacheManagerProducer.class, Log.class);

   /**
    * Produces the default embedded cache manager.
    *
    * @param providedDefaultEmbeddedCacheManager the provided default embedded cache manager.
    * @param defaultConfiguration the default configuration produced by the {@link DefaultEmbeddedCacheConfigurationProducer}.
    * @return the default embedded cache manager used by the application.
    */
   @Produces
   @ApplicationScoped
   @DefaultBean(EmbeddedCacheManager.class)
   public EmbeddedCacheManager getDefaultEmbeddedCacheManager(@OverrideDefault Instance<EmbeddedCacheManager> providedDefaultEmbeddedCacheManager, Configuration defaultConfiguration) {
      if (!providedDefaultEmbeddedCacheManager.isUnsatisfied()) {
         log.tracef("Default embedded cache manager overridden by '%s'", providedDefaultEmbeddedCacheManager);
         return providedDefaultEmbeddedCacheManager.get();
      }
      return new DefaultCacheManager(defaultConfiguration);
   }

   /**
    * Stops the default embedded cache manager when the corresponding instance is released.
    *
    * @param defaultEmbeddedCacheManager the default embedded cache manager.
    */
   private void stopCacheManager(@Disposes EmbeddedCacheManager defaultEmbeddedCacheManager) {
      defaultEmbeddedCacheManager.stop();
   }
}


text:
Hollis (Alasca)
Hollis (Oklahoma)
4084 Hollis

Desambiguações de topônimos

redpajama_set_name: RedPajamaWikipedia


text:
Biological Activity Reveals Major Step Forward In Bringing Back The Woolly Mammoth
Jocelyne LeBlanc March 15, 2019
When researchers from Japan and Russia transplanted cell nuclei from a woolly mammoth from the Siberian permafrost into mice eggs, they noticed biological activity. This puts them a major step forward in bringing the animal back from extinction.
In 2010, the remains of a woolly mammoth calf named Yuka was found in the Sakha Republic of Russia's Far East that they believe was around 28,000 years old. They removed the cell nuclei from the remains and transplanted them in the eggs of mice and that's when they saw the early stages of cell division.
They took nuclei from muscle cells that were in fairly good condition in order to find out if they could function after being transplanted. Since cells contain DNA, just prior to dividing, they form chromosomes that end up getting pulled from spindle fibers.
The team of researchers put 24 cell nuclei into mice eggs and noticed that in 21 of the eggs, proteins that create chromosomes gathered around the cell nuclei. And in 5 of those 21 eggs, the proteins that create the spindle had also begun to form. Unfortunately, none of them ended up with full cell division and they believe it was probably because of damage to the DNA.
Satoshi Kurosaka from the Institute of Advanced Technology at Kindai University in Japan and who was also involved with the research, said, "We hope to find a mammoth that has been better preserved."
Even though the cells were unable to fully divide, it's still a major step forward in bringing back the extinct animal. What they hope to eventually accomplish is to transplant the cell nucleus of a woolly mammoth into the egg of an elephant in order to fertilize the egg with the genes of the animal. At that point, they would transplant the fertilized egg into the uterus of an elephant in hopes of giving birth to a mammoth.
The woolly mammoth lived during the last ice age and may have died off due to warmer weather which changed their food supply. They are believed to have been around the same size as an African elephant but their ears were smaller in size than those of elephants we see today. Their smaller ears could have been because of the cold climate which kept them closer to their heads in order to stay warm. Their tusks, however, were around 15 feet long and were used for digging into the deep snow and for fighting. They were herbivores that mostly fed on grass but they also ate flowers and plants.
Although researchers still have a ways to go in bringing the woolly mammoth back, this new research gives new hope that someday soon we may see a once-extinct animal brought back to new life.
Tags animal extinction biology de-extinction ice age mammoth extinction Mice Siberia woolly mammoth
Jocelyne LeBlanc works full time as a writer and is also an author with two books currently published. She has written articles for several online websites, and had an article published in a Canadian magazine on the most haunted locations in Atlantic Canada. She has a fascination with the paranormal and ghost stories, especially those that included haunted houses. In her spare time, she loves reading, watching movies, making crafts, and watching hockey.
The Village of People Who Consume Arsenic and Don't Die
Comet 67P Contains the Building Blocks of Life
Paul Seaburn May 31, 2016
Five-Legged Lamb, Five-Mouth Calf and Sheep-Eating Cow
Beware of the Killer Sponges


text:
Q: unsupported operand type(s) for -: 'str' and 'int' in python Can anyone please help me understand where I am going wrong?
import os
import numpy as np
import pandas as pd
ctr_x = []
tl_list = []

df = pd.read_csv('ring_1_05_sam.csv')
ctr_x = df.iloc[8:12, 0:1]
ctr_y = df.iloc[8:12, 1:2]
ctr_x = (ctr_x.to_string(index=False, header=False))
ctr_y = (ctr_y.to_string(index=False, header=False))
tl_list.append((str(ctr_x - 30),str(ctr_y - 30)))

print(tl_list)

I get an error:
Traceback (most recent call last):
File "annotation.py", line 9, in <module>
tl_list.append((str(ctr_x - 30),str(ctr_y - 30)))
TypeError: unsupported operand type(s) for -: 'str' and 'int'

As mentioned in comments:
I am trying to subtract each value by 30 and store in tl_list[].

A:
I am trying to subtract each value by 30 and store in tl_list[].

String conversion is distracting and unnecessary. You also don't need to explicitly instantiate and append to lists. Use pd.Series.tolist instead:
res_x = (df.iloc[8:12, 0] - 30).tolist()
res_y = (df.iloc[8:12, 1] - 30).tolist()

res = [res_x, res_y]

Or combine your operations and use np.ndarray.tolist:
res = (df.iloc[8:12, 0:2] - 30).values.tolist()

A: Disclaimer: The solutions below haven't been tested yet.
Edit:
You can do
ctr_x = df.iloc[8:12, 0:1] - 30   ## subtracts each element by 30
ctr_y = df.iloc[8:12, 1:2] - 30   ## ditto
ctr_x = (ctr_x.to_string(index=False, header=False))
ctr_y = (ctr_y.to_string(index=False, header=False))
tl_list.append((ctr_x, ctr_y))    ## appends [tuple of] string[s]

Old Answer:
ctr_x = (ctr_x.to_string(index=False, header=False))

This will line will make ctr_x a string, so it has type str.
This bit causes the error:
ctr_x - 30

Why? Simply said, because you can't subtract from a string (aka, you can't use the minus operand). Instead, you might use
int(ctr_x) - 30

This casts ctr_x as an integer first, which then allows you to use the minus operand.

Some side-notes:
You declared ctr_x = [] near the top of your code, but don't seem to be using any list functionalities with it.