Developing the Role of Radiotherapy for Inoperable Gastric Cancer

Gastric cancer (GC) is a leading cause of mortality worldwide, resulting in 4,000 deaths per year in the UK. Surgical resection is the only cure, but 60-70% of patients are unsuitable for surgery, for whom palliative treatment is limited to systemic anti-cancer therapy and/or low-dose radiotherapy on occurrence of local symptoms. Poor outcomes highlight the urgent need for novel treatment strategies. Therefore, this thesis explores whether radiotherapy could have a role in the management of non-metastatic, inoperable GC. Firstly, a retrospective service evaluation explores treatment patterns and outcomes in South West Wales, to inform potential sample size for future trials. A systematic review of definitive, pre-operative and high-dose palliative radiotherapy evaluates efficacy, safety, dose/fractionation schedules and techniques in use. A survey of UK oesophago-gastric clinical oncologists explores current opinion, practice, and appetite for future trials. During a study of interobserver variability (IOV) in gastric tumour volume delineation (TVD) using computed tomography and magnetic resonance imaging (MRI), conformity indices are analysed, and qualitative and quantitative effect of MRI evaluated. Finally, comparison of two pre-operative radiotherapy protocols evaluates user-experience and analyses the volumetric and dosimetric advantages of each. The results demonstrate a largely non-randomised evidence base supporting the efficacy and safety of gastric radiotherapy, but optimal dose/fractionation remains unknown and technique varies. The survey demonstrates infrequent use of gastric radiotherapy in the UK, due to limited evidence and toxicity concerns, but support for a future UK trial is high. Clinician confidence in TVD is low, further demonstrated by considerable IOV in delineation of gastric tumour volumes. The addition of MRI improves subjective TVD experience, though impact on IOV is conflicting. Dosimetric analysis of pre-operative protocols demonstrates substantial dose to organs-at-risk following elective nodal irradiation. The findings of this thesis have informed the development of the first UK trial of gastric radiotherapy, GastroSCOPE

Parental Involvement Typologies in Rural Community Schools: A Qualitative Investigation.

There are a number of pressing issues facing today\u27s educational society. Among the most controversial is the research and information surrounding the perceived positive or negative effects of parental involvement and barriers that restrict parental involvement. The purpose of this study was to examine 6 parental involvement typologies and their use and existence in 3 East Tennessee elementary schools. The Epstein (1987) typologies were used to classify parent involvement modalities. Parents who had a child enrolled in the 3rd, 4th, or 5th grade during the 2007-2008 school year were interviewed. The interviews followed an open-ended interview guide and the research is qualitative in nature. Research findings in this study were consistent with findings from a number of previous parental involvement studies. Research participants displayed an appreciation for the educational process and voiced strong opinions on parenting, communication, volunteering, decision-making, learning at home, and collaboration with the community. Barriers to parental involvement practices were addressed as were suggestions for improved parental involvement opportunities and modalities

Assets and Needs Assessment of Senior Residents in the West Bloomington Neighborhood

The experience and process of aging has become a prominent topic of discussion nationwide and Central Illinois is no exception, due to the rapid growth within the senior population in the area. The 60 and over population of Illinois is projected to grow by 87% during the next 30 years (The Maturing of Illinois). An initiative has been developed to evaluate how prepared local communities are for older adults by conducting needs assessments, which can also serve as vital tools for those who plan and provide human services in communities. Often community leaders will form policies and allocate limited resources based on assumptions about the needs of the senior population and outdated information (Parsons and Higley 1995). This report is part of a larger needs assessment that will serve as a resource for community leaders to use in future policies and projects that will involve senior West Bloomington residents. This report examines needs of the senior population of West Bloomington as well as how organizations provide for those needs as evaluated by the senior population themselves. Based on our findings and recognizing the limitations of the study, we make recommendations for action and future research

Estimation of the Prevalence of Undiagnosed and Diagnosed HIV in an Urban Emergency Department

To estimate the prevalence of undiagnosed HIV, the prevalence of diagnosed HIV, and proportion of HIV that is undiagnosed in populations with similar demographics as the Universal Screening for HIV in the Emergency Room (USHER) Trial and the Brigham and Women's Hospital (BWH) Emergency Department (ED) in Boston, MA. We also sought to estimate these quantities within demographic and risk behavior subgroups.We used data from the USHER Trial, which was a randomized clinical trial of HIV screening conducted in the BWH ED. Since eligible participants were HIV-free at time of enrollment, we were able to calculate the prevalence of undiagnosed HIV. We used data from the Massachusetts Department of Public Health (MA/DPH) to estimate the prevalence of diagnosed HIV since the MA/DPH records the number of persons within MA who are HIV-positive. We calculated the proportion of HIV that is undiagnosed using these estimates of the prevalence of undiagnosed and diagnosed HIV. Estimates were stratified by age, sex, race/ethnicity, history of testing, and risk behaviors.The overall expected prevalence of diagnosed HIV in a population similar to those presenting to the BWH ED was 0.71% (95% CI: 0.63%, 0.78%). The prevalence of undiagnosed HIV was estimated at 0.22% (95% CI: 0.10%, 0.42%) and resultant overall prevalence was 0.93%. The proportion of HIV-infection that is undiagnosed in this ED-based setting was estimated to be 23.7% (95% CI: 11.6%, 34.9%) of total HIV-infections.Despite different methodology, our estimate of the proportion of HIV that is undiagnosed in an ED-setting was similar to previous estimates based on national surveillance data. Universal routine testing programs in EDs should use these data to help plan their yield of HIV detection

Favouritism: exploring the 'uncontrolled' spaces of the leadership experience

In this paper, we argue that a focus on favouritism magnifies a central ethical ambiguity in leadership, both conceptually and in practice. The social process of favouritism can even go unnoticed, or misrecognised if it does not manifest in a form in which it can be either included or excluded from what is (collectively interpreted as) leadership. The leadership literature presents a tension between what is an embodied and relational account of the ethical, on the one hand, and a more dispassionate organisational ‘justice’ emphasis, on the other hand. We conducted 23 semi-structured interviews in eight consultancy companies, four multinationals and four internationals. There were ethical issues at play in the way interviewees thought about favouritism in leadership episodes. This emerged in the fact that they were concerned with visibility and conduct before engaging in favouritism. Our findings illustrate a bricolage of ethical justifications for favouritism, namely utilitarian, justice, and relational. Such findings suggest the ethical ambiguity that lies at the heart of leadership as a concept and a practice