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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Int J Radiat Oncol Biol Phys. Author manuscript; available in PMC 2012 May 8.
Published in final edited form as:
PMCID: PMC3347884

Phase I Trial of Pelvic Nodal Dose Escalation with Hypofractionated IMRT for High Risk Prostate Cancer

Toxicity concerns have limited pelvic nodal prescriptions to doses that may be suboptimal for controlling microscopic disease. In a prospective trial, we tested whether image-guided IMRT can safely deliver escalated nodal doses while treating the prostate with hypofractionated radiotherapy in 5–1/2 weeks.

Methods and Materials

Pelvic nodal and prostatic image-guided IMRT was delivered to 53 NCCN high risk patients to a nodal dose of 56 Gy in 2 Gy fractions with concomitant treatment of the prostate to 70 Gy in 28 fractions of 2.5 Gy, and 50 of 53 patients received androgen deprivation for a median duration of 12 months.

The median follow-up was 25.4 months (range 4.2–57.2). No early grade 3 (Gr3) RTOG or CTCAE v.3.0 GU or GI toxicities were seen. The cumulative actuarial incidence of Gr2 early GU toxicity (primarily alpha blocker initiation) was 38%. The rate was 32% for Gr2 early GI toxicity. None of the dose-volume descriptors correlated with GU toxicity, and only the volume of bowel receiving ≥30 Gy correlated with early GI toxicity (p=0.029). Maximum late grades 1,2 and 3 GU toxicities were seen in in 30%, 25% and 2%, respectively. Maximum late grade 1 and 2 GI toxicities were seen in 30% and 8% (rectal bleeding requiring cautery), respectively. The estimated 3-year biochemical control (nadir + 2) was 81.2 ± 6.6%. No patient manifested pelvic nodal failure, while two experienced para-aortic nodal failure outside the field. The 6 other clinical failures were distant only.

Pelvic IMRT nodal dose escalation to 56 Gy was delivered concurrently with 70 Gy of hypofractionated prostate radiotherapy in a convenient, resource-efficient and well-tolerated 28 fraction schedule. Pelvic nodal dose escalation may be an option in any future exploration of potential benefits of pelvic radiation therapy in high-risk prostate cancer patients.

Keywords: Pelvic Lymph Node Dose Escalation, Bowel Displacement Board, Rectal Balloon, Hypofractionated Radiation Therapy, Image-Guided Prostate IMRT

The clinical benefit of pelvic nodal irradiation for prostate cancer has been difficult to establish and is uncertain. While progression free survival benefit has been reported in RTOG 94-13 at 5 year follow-up (1), an update of this study (2) and other other trials as well (3, 4). have either shown only trends or have failed to demonstrate benefit using doses of 45–50.4 Gy. Salvage radiation data indicate improved biochemical control with increasing doses to the 66–70 Gy range when targeting microscopic disease in the prostatic fossa (5, 6), but prescribed pelvic nodal doses have been limited by toxicity concerns. Beyond well-known difficulties in reliably selecting patients at high risk for nodal involvement, one hypothesis for such uncertain benefit from pelvic radiotherapy is that contemporary doses from 45–50.4 Gy are suboptimal for controlling microscopic disease.

Advances and techniques such as intensity modulated radiation therapy (IMRT), bowel displacement techniques (7), and bladder filling can better facilitate limiting the dose to small bowel while treating pelvic nodal basins. When using conventional fractionation for the pelvic nodes and the prostate, two separate 3D conformal or IMRT plans must be generated; however, one IMRT plan may direct the entire treatment if hypofractionated radiotherapy is delivered to the prostate gland via a simultaneous integrated boost. Early evidence also suggests that hypofractionated radiotherapy may confer some additional advantage by increasing the therapeutic ratio due to a hypothesized low α/β ratio for prostate cancer (8).

We therefore tested whether image-guided IMRT can safely deliver escalated nodal doses while treating the prostate simultaneously with a hypofractionated schedule. We present a dose-volume analysis of toxicities and preliminary biochemical control estimates in 53 high pelvic nodal risk patients treated to a nodal dose of 56 Gy in 2 Gy fractions with concomitant treatment of the prostate to 70 Gy in 2.5 Gy fractions, with the entire treatment delivered in 28 fractions.

Methods and Materials

Patients with high risk prostate adenocarcinoma with prediction of ≥ 10% pelvic lymph node involvement (9) were eligible for treatment on this phase I prospective protocol, approved by the institutional review board of the University of Wisconsin Hospital. In addition, any patient with radiographic evidence of pelvic lymph node involvement but absence of distal metastases could be enrolled on the protocol. All patients had no evidence of distal metastases on bone scan and CT of the abdomen and pelvis. Any patient with a history of pelvic radiotherapy or prior malignancy diagnosed within the past 5 years other than non-melanoma skin cancer was ineligible. Patients on full-dose anticoagulation or clopidogrel were ineligible, although patients taking aspirin could be enrolled. A total of 53 patients were enrolled.

Neoadjuvant, concurrent and adjuvant adcrogen deprivation therapy (ADT) using an LHRH agonist without concurrent anti-androgen therapy was delivered to all except 9 patients for between 6 and 24 month. Six patients refused androgen deprivation therapy or requested early termination, while 3 others received between 25 and 28 months of ADT. The resultant median duration of ADT was 12 months (Table 1).

Table 1
Patient characteristics.

At simulation, patients were placed in the prone position in a bowel displacement custom mold (belly board) (7). The bladder was filled with 200 ml of diluted contrast after placement of a Foley catheter. A rectal balloon (Radiadyne™, Houston, TX) was subsequently placed to reduce prostatic motion and displace the posterior rectal wall from higher dose regions. Intravenous contrast was administered before 2.5 mm axial CT images were obtained. Linear accelerator step-and-shoot IMRT treatment plans (n=5) were created using the Pinnacle treatment-planning system (Philips Medical Systems, Andover, MA), while TomoTherapy treated patients (n=48) were planned using its associated treatment planning system (TomoTherapy, Inc., Middleton, Wisconsin).

Treatment consisted of 56 Gy delivered to pelvic lymph node basins with simultaneous integrated hypofractionated treatment to the prostate gland to 70 Gy, all delivered in 28 fractions over 5.5 weeks. The prostate was outlined on the planning CT scan, and a 5 mm expansion was added in all dimensions to generate the planning target volume (PTV), except that the posterior expansion was limited to 3 mm. The seminal vesicle bases were treated to 70 Gy, and the treating physician could elect to assign the superior seminal vesicles to either 56 Gy or 70 Gy depending on risk of involvement.

The nodal target volume was initially defined by a method of conformal avoidance described previously (10). Briefly, conformal avoidance target volumes were determined by including tissues normally included in the standard four field beam arrangement; however, small bowel, rectum, and bladder were contoured as avoidance structures. The superior border of the four-field was the L5-S1 interspace, and the inferior border was the ischial tuberosities. The AP and PA fields defined the lateral extent of the volume. Field edges were lateral to the SI joints and the obturator foramina and otherwise remained 2 cm outside the pelvic rim. The posterior border was behind the bony sacrum as inferiorly as S3 for coverage of presacral nodes, and the rectum was split below S3. The anterior block was defined by a line 1 cm anteriosuperior to an imaginary line from the sacral prominence to the superior pubic symphysis, allowing at least a 1.5 cm margin anterior to the common and external iliac vessels. The conformal avoidance nodal target volume was then contoured as the structure formed by the intersection of all four beams minus the small bowel, sigmoid colon, rectum, and bladder. Posteriorly, the contours were edited so that no volume extended more than 1 cm into the sacrum. Inferiorly, the contours were edited to not fall below the ischium. The space directly anterior to the bladder was also eliminated.

Over time, the nodal PTV was modified consistent with the Radiation Therapy Oncology Group’s consensus recommendations (11). The nodal target volume was created using vessel-based knowledge of lymph node drainage with inclusion of internal iliac, external iliac, obturator, presacral and distal common iliac nodes. The pelvic lymph node PTV began at the L5/S1 interspace at the level of the distal common iliac and proximal presacral lymph nodes. The presacral lymph nodes were included from S1 through S3, with the posterior border placed at the anterior sacrum and anterior border approximately 10 mm anterior to the anterior sacral bone. The external iliac artery and vein served as the reference for delineation of the external iliac basin, and a margin of 10 mm was allowed around the vessels to define the PTV. The external iliac PTV extended from the bifurcation of the common iliac vessels to the top of the femoral heads, which serve as the bony landmark for the inguinal ligament. The internal iliac vessels were contoured with a 10 mm expansion and both the internal and external iliac contours were connected on each slice, carving out bowel, bladder, and bone. The region between the expanded internal and external iliac vessels allowed for inclusion of the obturator nodes, and this volume was contoured to the top of the pubic symphysis. Bowel, bladder, and bone were carved out of the nodal PTV region.

Patients were followed at 1 month upon completion, every 3 months for one year post-treatment, every 4 months during years 2–3, every 6 months during years 4–5, and then annually. PSA values were obtained at each visit, along with assessments for toxicity. CT and bone scans during follow-up were not routinely performed, but only carried out in the context of rising PSA’s. Toxicity was graded per the NCI-CTC v.3.0 grading criteria Biochemical control was measured using the “nadir + 2” definition (12). Freedom from clinical failure accounted for any clinical recurrence including locoregional or distant recurrence, but death from other causes was censored. PSA failure alone was not considered an event in the actuarial analysis of freedom from clinical failure.

Early toxicities were defined as those occurring during or within 3 months of completing radiation therapy. The association between grade of early effects and dose-volume descriptors was tested using Spearman’s rank correlation coefficient. The Cox Proportional Hazards model was used to test associations between late effects and dose-volume descriptors. Two-tailed P values less than .05 were considered statistically significant. All data were examined using SPSS (version 16.0, SPSS, Inc, Chicago, IL).

Between August 2004 and September 2008, a total of 53 patients were treated. Fifty patients received androgen deprivation for a median duration of 12 months (range 3–28 months), with three patients not so treated due to patient refusal. Patient characteristics are detailed in Table 1. The dosimetric parameters achieved using IMRT to spare organs at risk are detailed in Table 2. Median follow-up was 25.4 months (range 4.2–57.2 months).

Table 2
Dosimetric parameters achieved with IMRT planning.

Acute Toxicity

Acute GU toxicities were grade 0 in 6 (11%), grade 1 in 27 (51%), and grade 2 in 20 patients (38%). All grade 2 GU toxicities involved initiation of either alpha blocker or anti-cholinergic medications. Pearson and Spearman’s correlations were performed for correlation of GU toxicity with absolute volume and percent of bladder receiving ≥ 45 Gy, ≥ 60 Gy, and ≥ 70 Gy. Early GU toxicity demonstrated no statistical correlation with these dosimetric parameters. Acute GI toxicities were grade 0 in 9 (17%), grade 1 in 27 (51%), and grade 2 in 17 patients (32%). Grade 2 GI toxicities related to increased bowel frequency requiring anti-diarrheal medications. Pearson and Spearman’s correlations were performed for correlation of GI toxicity with absolute volume and percent small bowel receiving ≥ 30 Gy, ≥ 40 Gy, ≥ 45 Gy, ≥ 50 Gy, and ≥ 60 Gy as well as absolute volume and percent rectum receiving ≥ 50 Gy, ≥ 60 Gy, and ≥ 70 Gy. Early GI toxicity demonstrated statistically significant correlation only with the absolute volume of small bowel receiving ≥ 30 Gy (r=0.322, p=0.029; ρ =0.335, p=0.023). Mean weight loss during treatment was 0.6% (range 0–6.4%). No patient developed grade 3 or greater acute toxicity.

Late Toxicity

Maximum late GU toxicities were grade 0 in 23 (43%), grade 1 in 16 (30%), grade 2 in 13 (25%), and grade 3 in 1 patient (2%). The single late grade 3 GU toxicity occurred in a patient who developed urinary retention 7 months after completion of radiotherapy, requiring Foley catheter placement for 26 days with acute renal failure. His obstruction subsequently resolved with alpha-blocker maintenance, and his renal function normalized. As shown in Figure 1, the prevalence of late GU toxicity ≥ grade 2 was lower than 20% over the duration of follow-up. Maximum late GI toxicities were grade 0 in 33 (62%), grade 1 in 16 (30%), and grade 2 in 4 patients (8%). The prevalence of late GI toxicity ≥ grade 2 was lower than 10% over the duration of follow-up, as demonstrated in Figure 2. All late grade 2 GI toxicities consisted of rectal bleeding requiring no more than 2 argon laser procedures. There was no statistical correlation of the dosimetric parameters included in Table 2 with late GU or late GI toxicity.

Figure 1
Prevalence of genitourinary toxicity following initiation of radiotherapy.
Figure 2
Prevalence of gastrointestinal toxicity following initiation of radiotherapy.

Patterns of Failure

The preliminary biochemical control estimate using the nadir + 2 definition was 81.2% at 3 years (95% CI: 74.6%–87.8%), as shown in Figure 3. At a median follow-up of 25.4 months, three deaths have occurred, all from other malignancies including pancreatic cancer, bladder cancer, and multiple myeloma. No patient developed pelvic nodal failure, although two patients manifested peri-aortic nodal failure outside the treatment volumes. One of the patients with peri-aortic nodal failure had pre-treatment radiographic evidence of pelvic nodal metastases (clinical stage T3b N1 M0); he manifested concurrent seminal vesicle failure in a region of initial disease but had no evidence of pelvic nodal failure. The other 3 patients with N1 disease have not clinically failed. There were no additional local failures detected either by digital rectal exam or by imaging. Six patients developed bone metastases. The estimated freedom from clinical failure at 3 years was 83.1% (95% CI: 76.7%–89.5%).

Figure 3
Biochemical control using the nadir + 2 definition of PSA failure.

Pelvic nodal irradiation, delivered with various schedules of androgen deprivation therapy, has been the historic standard for locally advanced prostate cancer (1316). The two minimum requirements for clinical benefit from pelvic radiotherapy are the selection of patients at sufficiently high risk for nodal metastatic involvement and the safe delivery of radiation doses sufficiently high to sterilize nodal metastases.

There are a number of models that estimate the risk of pelvic nodal involvement (1721), many of which may underestimate such risk, given their reliance on nodal pathology from limited rather than extended lymph node dissections. Extended pelvic lymph node dissections have revealed that nodal involvement is often not contiguous (22, 23), whereas limited lymphadenectomy usually results in sampling of only obturator and external iliac lymph nodes. Higher rates of nodal positivity have been reported with extended lymph node dissections compared to historical standard node dissections (23, 24), leading some to recommend extended dissection including internal iliac, external iliac, obturator, and presacral regions in patients with clinical parameters that place them at higher risk (2226). While one randomized trial failed to demonstrate increased nodal positivity when comparing extended to standard dissection, the study included largely low risk patients, and only 6.5% of all patients were found to have pathologically involved nodes (27).

Conversely, there is evidence for model overestimation as well. An analysis of the Surveillance, Epidemiology, and End Results Registry (SEER) 2004 database suggested that the Roach formula overestimates pelvic lymph node risk by a factor of 16 for patients with Roach score ≤ 10%, 7 for Roach score 10–20%, and 2.5 for Roach score > 20%. This analysis, however, was based on a population of almost exclusively cT1/2 patients who had a median of only 5 nodes surgically removed, and the overall rate of involved nodes was only 3.29% (28).

Thus, failure of randomized trials to demonstrate long-term efficacy of nodal irradiation (24) could relate, in some part, to the inability to select and study patients at sufficiently high risk of harboring nodal metastases. Lymphotropic nanoparticle enhanced MRI is one approach that may offer potential to better select patients at risk for nodal metastases. MRI with lymphotropic superparamagnetic nanoparticles has in one study demonstrated an overall sensitivity of 90.5% and specificity of 90.4% on a node-by-node basis for detection of nodal metastases (29). This diagnostic tool, should it ever become widely available, could, in addition to facilitating a decision regarding pelvic radiation, also help to identify patients better treated with pelvic nodal and prostate irradiation rather than prostatectomy. Specifically, Heesakkers et al. reported that 41% of patients with histologically confirmed nodes detected by MR lymphography had nodal metastases in areas outside of the region of routine pelvic lymph node dissection; additionally, 41% of patients had positive nodes both inside and outside the routine dissection area (30).

Toxicity related dose limitations may also have decreased the ability to demonstrate a clinical benefit from pelvic radiation therapy. Pelvic nodal doses of 45–46.8 Gy have not demonstrated consistent benefit in randomized trials compared with treatment to only the prostate (24). In most other malignant diseases, a dose of 45 Gy would be considered suboptimal to sterilize microscopic disease in the absence of chemotherapy. Head and neck squamous cell carcinomas are typically regarded as radiocurable, and the draining neck lymphatics are often treated to 54 Gy using conventional fractionation, with or without chemotherapy (31). Furthermore, there is evidence for dose response in prostate cancer not only in the definitive setting but also for presumptive microscopic disease in the post-prostatectomy setting. King et al. reported 5-year biochemical control of 25% for a prostate bed dose of 60 Gy compared to 58% for a dose of 70 Gy (p<0.0001) (6). A subsequent analysis of salvage trials reported a gain in tumor control probability per additional gray within the steep portion of the probability curve of 3.8%/Gy (5). By this measure, the increase in dose in our study from the 45–50.4 Gy range to 56 Gy could result in significantly increased rates of sterilization of microscopic nodal disease. Unknown at this point is the potential dose modifying effect that concurrent androgen deprivation therapy might have on dose response.

The escalation of nodal dose to 56 Gy in our series does not appear to increase either acute or late GU or GI toxicity when compared to preliminary toxicity reporting from a series from the University of Colorado delivering 50.4 Gy to the nodal basin concurrently with 70 Gy to the prostate in 28 fractions (33). Interestingly, the median volume of small bowel receiving ≥ 45 Gy in our study was only 116.9 cc, below the recommended limit of 195 cc from the recent QUANTEC (Quantitative Analyses of Normal Tissue Effects in the Clinic) series when the entire peritoneal potential space of bowel is included (34). Thirteen patients in our series marginally exceed the 195 cc limit (maximum 549cc), but only 2 of these 13 developed grade 2 acute GI toxicities, neither of whom subsequently experienced scorable late GI toxicity. As indicated earlier, none of the dose-volume descriptors correlated with early GU toxicity, and only the volume of bowel receiving ≥ 30 Gy correlated with early GI toxicity (p=0.029).

Potential differences in patient characteristics and the preliminary nature of the biochemical control estimates of our study preclude detailed comparisons between these results and those of other studies that involved high risk patients treated with androgen deprivation and pelvic radiotherapy. However, with a median of 12 months of androgen deprivation therapy, this study’s estimated 3 year biochemical disease free survival of 81.2% ± 6.6%, does appear consistent with the RTOG 9413 reported 4-year biochemical control rate of 70% with 4 months of neoadjuvant/concurrent androgen deprivation (2). and with the RTOG 9202 reported 5-year biochemical control rate of 66.6% with 28 months total androgen deprivation (38).

The hypofractionated regimen of 70 Gy in 28 fractions of 2.5 Gy delivered to the prostate in this present trial is familiar and potentially attractive. This is both because prostate hypofractionated radiotherapy has been hypothesized to enjoy a radiobiological advantage over conventional fractionation (8, 39), and because it is the fractionation regimen used both by Cleveland Clinic’s well tolerated and effective study of prostate only radiotherapy in 770 patients (39) and by the experimental arm of ongoing RTOG trial 0415.

Pelvic nodal IMRT dose escalation to 56 Gy delivered concurrently with 70 Gy of hypofractionated prostate radiotherapy in 28 fractions over 5–1/2 weeks is a resource-efficient, convenient and well-tolerated regimen that produces acceptable preliminary biochemical control rates. No in-field pelvic nodal failures have been observed to date despite 2 peri-aortic failures outside the treatment volume. While the benefits of pelvic nodal irradiation using conventional 45–50.4 Gy doses remain unproven, pelvic nodal dose escalation combined with better tools for patient selection could provide a new avenue for exploring its potential benefits.

Conflicts of Interest Notification: The authors have no conflicts of interest to disclose.

This work was presented at the 2010 American Radium Society Annual Meeting. Grant Support by NCI–R01CA106835

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Liz Moriondo 4.12.17

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Liz Moriondo opens up her mouth to sing, and out comes a blend of Shania Twain’s breathy perfection and Bonnie Raitt’s sensual, bluesy grit. If you listen closely enough, you can still hear the Ozark Mountains of her native Missouri where she first started singing in front of audiences at the age of 3. As all of us know, it ... Read More

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Braden Baugh is an independent country artist native to Nashville, TN. While in high school he started writing music but also had a passion for sports. After playing golf for a couple of years in college, he decided to move back home to Hendersonville, TN where he started working with industry professionals on creating the best country music possible. After years of playing and writing he is set to release his debut EP on January 15, 2016. His classic country influences shine through on these 4 songs he plans on traveling the states to make sure everyone gets a chance to listen.

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General Motors Is Recalling Nearly 60,000 Malibu Sedans

Posted Nov 16, 2013

General Motors is recalling almost 15,000 2013 Chevrolet Malibu sedans to check for faulty wiring harnesses that could cause fires.  General Motors is also recalling 44,406 2014 Malibus sedans to check an issue that could cause defrosters to malfunction.  2013 Malibus have an option to be equipped with optional power front seats and GM said the wiring harness could wear against the seat frame, which could result in sparking, melted wiring, smoke, etc.

GM is aware of two fires in unattended vehicles.  No crashes or injuries are related to the condition.  This recall covers 14,909 vehicles in the U.S., 13 in Canada, and 7 in Mexico.

The 2014 Malibus may have issues with the heating, ventilation and air conditioning (HVAC) system.  If the defroster is not working, then the drivers may not be able to clear the windshield.  No crashes, injuries, or complaints were made due to the condition.  This recall covers 42,696 vehicles in the U.S., 1,034 in Canada and 676 in Mexico.

[Source: Reuters]


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Books That Turned Into Blockbusters

The Da Vinci Code

The Da Vinci Code is a 2003 mystery-detective novel by Dan Brown. It follows symbologist Robert Langdon and cryptologist Sophie Neveu after a murder in the Louvre Museum in Paris, when they become involved in a battle between the Priory of Sion and Opus Dei over the possibility of Jesus Christ having been married to Mary Magdalene. The novel explores an alternative religious history, whose central plot point is that the Merovingian kings of France were descended from the bloodline of Jesus Christ and Mary Magdalene. The Da Vinci Code provoked a popular interest in speculation concerning the Holy Grail legend and Mary Magdalene’s role in the history of Christianity. The book has, however, been extensively denounced by many Christian denominations as an attack on the Roman Catholic Church. The novel nonetheless became a worldwide bestseller  that sold 80 million copies as of 2009 and has been translated into 44 languages.


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Anti-vandal Series
Yarramundi, Hawkesbury
Hawkesbury Council recently completed an upgrade of a recreation reserve west of Richmond at Yarramundi Reserve. The brief was for a three booth toilet building, the architecture to match an existing single plane roofed shade structure. There was no sewer or water services available on site.
Hawkesbury City Council
An anti-vandal restrrom with Single Plane Roof and CWT system was our recommendation for this project. To satisfy AS1428.1(2009) , BCA and the Premises Standard, the booth configuration was:
  • 1 x AS1428.1 (2009) Accessible booth
  • 2 x AS1428.1 (2009) Ambulant booths
  • 1 x External hand wash basin
  • 1 x Hand wash basin in accessible booth

The CAB 3 Stainless+Concrete construction system delivers a robust building fit for purpose at these remote vandal prone sites. The single plane roof was designed using Versiclad EPS roof panel. Colorbond Custom Orb roof, Micraline Colorbond underside. To match the nearby shade structure, Merbau horizontal battening was specified for the infill zone above the door walls to the underside of the roof structure ceiling. The CAB3 was melded with a CWT 10000 Collection well system, including GAS ground anchor, PVS passive ventilation system, and an ASS Anti Surcharge system for a flood prone area. The CWT system came with the CWT Management Kit, incorporating a site specific Management Plan.

A water supply to service the hand wash basins was catered for by a FWT 3000, Fresh Water Tank. This is an elevated concrete water tank ensuring adequate flows to the sink taps, all plumbing hidden from view for vandal attack management and water replenishing plumbing allowing for a water cart to top up the tank through a camlock arrangement solved. These collection wells can be positioned almost totally underground, negating the need for elevated ramp access for disabled access. These ramps are a common site on existing toilets using proprietary components.


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Product Spotlight: TAYST joins the PurPod100 Team

Tayst Coffee

Tayst Coffee Makes a Splash Shipping Compostable Single Serve Coffee to Homes and Offices

Tayst Coffee’s new subscription service is delivering quality sustainably-sourced single serve coffees to homes and offices across America.

The new coffee line is the brainchild of successful entrepreneurs and longtime friends, Craig Handleman and Greg Byrnes, who saw a new opportunity in the fastest growing segment of the coffee industry – single serve cup coffee.

The over 12 billion K-Cups sold last year were enough to circle the globe a dozen times, bombarding landfills. ‘If we can get just 1% of coffee drinkers to replace their plastic cup solutions with the high-quality coffee in our Tayst pods, we could reduce waste and divert up to 100 million pods away from landfills,’ challenges Byrnes.

Tayst is the first U.S. retailer to make use of PurPod100(TM) in its full coffee line up, the only certified 100% compostable single serve cups designed to work in most Keurig brewers. Testing shows they break down in as little as five weeks in the large-scale composting operations that many local governments and private waste services offer. Composting returns valuable nutrients to the Earth’s soil, making the pods a key part of Tayst’™s goal of being a zero footprint company, from product to packaging.

The quality of the coffee and the environmental benefits of the new pod are matched by Tayst’s convenient online shopping process. The easy-to-use, intelligent subscription platform offers direct-to-consumer and office shipments – no middleman required. This formula cuts packaging and transportation to and from warehouses and retail outlets. Tayst Coffee is delivered in beautiful, personalized Earth-friendly and 100% post-recycled and/or compostable packaging.

Eco-smart, delicious and easy. Tayst is changing the way the world does coffee, one serving at a time.

About Tayst:
Challenging the $100 billion coffee industry, Tayst Coffee packages sustainably sourced Amazing Coffee into the world’s first 100% Compostable pods. Earth-friendly packaging brings you your coffee fix on a monthly subscription.

To experience Tayst Coffee visit


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Friends & Neighbor's Program for Weatherization

WINTER IS HERE!!! If we've learned anything from the start of the cold weather season it's that Buffalo NY really is the City of Good Neighbors. That's why we have the Friends and Neighbors program for weatherization. Sometimes, things are best done together. Learn more


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Wednesday, September 11, 2013

i already posted one that is similar to this one, but it was addressed to me. the whole postmark theme is so much fun. there is a font at that is just postmarks.

and here is one that is old seals

there are lots more
but, i'll let you all surf on your own

and here is one from stella :-) [kudos on your penmanship, stella]

 both of these envelopes use lines as the main design element. they are good examples of how much fun you can have with just one or two elements....lines and color. the top one has some shapes, too.

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Emilia Clarke

Terminator Genisys 2015 Movie Online
Movie Streaming
Terminator Genisys 2015 Movie Online
Watch Terminator Genisys 2015 Full Movie Online Free Download Putlockers Terminator Genisys ~ The 12 months is 2029. John Connor, chief of the resistance continues the battle in opposition to the machines. At the Los Angeles offensive, John's fears of the unknown future start to emerge when TECOM spies reveal a brand new plot by SkyNet that may assault him from each ...

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Watch Chesapeake Gold (2009) | Putlocker Movies HD

Chesapeake Gold (2009)

posted by admin, July 2, 2015 @ 1:08 am

Movie: Chesapeake Gold

  • Director: Ted Roach
  • Stars: Tommy Leggett, Travis Croxton, Ryan Croxton, David Chamberlain, Luke Breza, Donald Merritt, Mark Deklin
  • Release Date: February 16, 2009
  • Run Time: 10 min
  • Genre: Documentary, Short

Oysters were once so plentiful in the Chesapeake Bay that sailors feared running aground on the huge, reef-like beds that rose out of the water. Today however, over-harvesting and disease have pushed the native Virginia oyster to the brink of disappearing from these troubled waters forever. Fighting to save both the Chesapeake\’s native oyster population, and in turn, their own way of life, a new generation of water-men and scientists has embraced the practice of sustainable oyster farming, or aquaculture, to not only save their industry, but also to clean up the Bay at large. The Chesapeake is dying, and many here believe that the humble oyster may be one of its unlikely saviors.

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Time: 3:00
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Grid #7750 by Think!!!

  • Once you begin the grid you will have three minutes to complete it.
  • Clicking on squares selects them
  • Clicking on a selected square unselects it.
  • Try to select four items that are linked together, but remember that there may be red-herrings
  • Once you have eliminated two groups of 4 you will only have three lives to select the final group


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Contact Us

Looney Grandparents In Clifton Park Give Over $15,000 To Fake Grandchild – crazy old man

This is the same exact reason we took your car keys away Grandpa, you just can’t be trusted with things of any value! Recently I saw a story from the Times Union regarding a money transfer scam that targeted elderly folks in Saratoga County. The scam consisted of an unknown caller contacting old people and posing as their grandchild. The “grandchild” would then make up some sob story about how they were stuck in the Cayman Islands and needed money for bail. So far the scammers have claimed nearly $15,700 from unsuspecting hollow headed seniors.

This is just one of the million reasons I do not want to make it past the age of 64. I feel like it has got to be all downhill from then. I watched both of my Grandparents slip slowly into insanity with Alzheimer’s and I failed to see how that could have been enjoyable for them. Sure the bonus of forgetting how to tie your shows or turn of the stove is you get to meet new people over and over and each day is a new and exciting adventure. However, getting old just plan sucks. Your bones start to weaken, your joints don’t move, you need a steady diet of beano and above all you get taken advantage of by young no good whippier snappers for over $15,000!

Clearly I am doomed to catch this horrific dieses as I grow older as it is in my blood. And if the hereditary genes don’t kick in then certainly getting kicked in the head as much as I do in the professional wrestling ring will take its toll. Either way I get from point A to point crazy I have a system to beat it. I plant on cashing out around age 64. This will be the age I stop caring about my body and health. I drink occasionally but not excessively. I also workout and eat healthy keeping me self healthier then your average Peacock. But when I hit 64 it is game on, bring on the hard liquor at 9am hand me that pot brownie, let’s go bungee jumping from a leer jet and why not throw in a hot shot or two for lunch. If I’m going out I’m going out with a bang.

“How did Grandpa Dalton pass away? Oh he was out ridding great white sharks bare back when a couple of Orcas who were up to no good started making trouble in his neighborhood (Ocean).” Now that’s a story worth telling the next generation about, not some lame “sorry Timmy you can’t go to college because Grandpa gave away your inheritance to some Jack-Hole in the Cayman Islands”.

NEXT Grandparents Get Freaky

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Test Coverage Outlines

This is a presentation I gave at a local test meet up group called VanQ

PDF version of slides: Test Coverage Outlines

Test Coverage Outlines are just elaborate spreadsheets. They were originally inspired by Jonathan Kohl, as part of exploratory testing training at Sophos. A colleague, (Jose Artiga), and I built on the initial inspiration and came up with the first version of the test coverage outline. This was then adopted by the teams at Sophos, and of course refined through use and practice.

(slide 8) Simple spreadsheets to help;

  • Structure & simplify your test planning
  • Inspire & structure your test design
  • Be test professionals and not just test execution machines
  • Collaborate on testing
  • Show clear and concise status at any point in your testing
  • Discuss risk in terms of planned vs actual coverage

(slide 9) An example coverage outline

  • Each white background row is a test idea – a simple sentence or few words to convey an idea you want to cover by testing
  • Try to keep these simple like a heuristic that acts as a guide rather than a step by step procedure

(slide 10) Divide your test ideas up into sections

  • Example shows this as the black lines with white text
  • You can do this by functional area, test focus, heuristic etc (whatever makes sense for you in your context)

(slide 11) Divide your test ideas up into sheets

  • Again divide into functional area per sheet or perhaps copy your sheet to provide same/similar coverage against different builds or versions of your software

(slide 12) Configurations – show your coverage against different configurations

  • Example given is a common one – browsers and OS, but could equally be versions of HW, SW, Mobile device etc

(slide 13) Test types/levels – show your coverage at different test levels or different testing types

  • Matrix your test ideas against different test levels, for example unit tests, integration tests, automated UI tests, manual tests, exploratory tests
  • Even if you are not familiar with the unit tests you can suggest the developers gain some coverage of the test ideas with unit tests and fill out the column with you

(slide 14) Prioritise your test ideas

  • I use simple (high, medium, low) priority levels to organise, sort and filter test ideas by priority
  • Make sure you are executing/covering in priority order

(slide 15) Prioritise your configurations

  • I use a simple left to right prioritisation for configurations, i.e. the highest priority configuration to cover is the left most column

(slides 16 & 17) Use colour and conditional formatting

  • I use simple colours and conditional formatting to make updates easy and to show status and priority clearly
  • Make sure you also use a colour (I use x and grey) to indicate coverage that you are consciously not planning to cover

(slide 18) I use mind maps as a visual test design/planning aid

(slide 19) Start by outlining your test idea areas, use the outline to inspire your test ideas

  • I sometimes use heuristics to structure and inspire my testing, for example using a quality criteria heuristic like usability or performance I can think about test ideas that come under each of those ares
  • Creating templates (see examples) for common types of testing focus can help inspire testers as well as providing some base or consistent tests

(slide 20) Using test ideas rather than detailed test cases

  • enables and encourages variation, exploration and more ‘brain engaged’ testing
  • thus avoiding the pesticide paradox [Boris Bezier]

(slide 21) Collaboration

  • Using google docs or similar enables you to easily collaborate in real time with other testers/colleagues
  • Some of the easiest ways in which you can organise and facilitate collaboration is to allocate a config column, test area or even tabs
  • You can see who is accessing/updating the sheet and can see status of tests others are covering in real time too

(slide 22) Use colour to provide very easy and quick to read status

  • You can just look at a tab and immediately see if you have any fails or blocked tests

(slide 23) Colour coding also makes it easy to see coverage in terms of planned vs actual

Example Coverage Outlines

Feel free to copy and adapt these for you own purposes, hopefully these will inspire you to refine the outlines and share your ideas back with me and others;

Learning from the mistakes our customers care about

5 question marks

5 whys

As mentioned in a previous post I keep a close watch on customer defects. These are the issues that a customer cared about enough (or was sufficiently annoyed by) to contact us and tell us about them.
I am focusing on the issues here, not the feature requests or the how do I’s, though both can be also regarded as defects in ‘failing to understand or predict the customers needs’ or ‘failing to deliver an intuitive product’ respectively.

Being a big fan of prevention is better than cure, I like to investigate the customer issues and perform a root cause analysis or 5 whys on the reasons each issue escaped our attention.
Yes, I refer to customer reported issues as escaped defects, since they escaped our detection. It doesn’t matter how many stages in your pipeline or how may automated tests at different levels, or even how good the teams are, there will be some issues that escape our attention.
Technically, I also regard issues discovered late in our pipeline, after story acceptance and as part of our release process, as escapes too, as well as any issues we happen to find in production (before a customer reports them).

There are lots of quotes around learning from failure, and being doomed to repeat your mistakes if you fail to do so. I believe, along with many others, that true learning only comes from failure and understanding the reasons for it. However, we should take care to not make the same mistake twice as this indicates a failure to learn. So the reason for analysing these escaped defects is not to apportion blame or point fingers, it is instead to learn how we can prevent a similar class of issue in future. The preference here being to prevent the class of issue from ever being coded again. If that proves to be more expensive than the cost of impact of the issues then at least being able to prevent the class of issue escaping our attention again.

I was introduced to Lean software development techniques via Mary and Tom Poppendick  which led me to learn more about The Toyota Way where I learnt the 5 whys technique. Prior to this I had been using other root causing techniques or simply using my QA ability to ask difficult but relevant questions to achieve the learning and expose the actions.
The 5 whys technique is just so simple that it makes it easy for anyone to participate as well as facilitate, meaning that anyone can do this – you don’t need to be a QA or have a background in problem solving or root cause analysis techniques.

So, what does it look like? Well here is an example with some edits to remove any proprietary details (note 5 is simply a guide, you can use more or less whys);

Problem statement: Service proxy was updated in C# provider code but not in consumer code

Why didn’t we catch this?

  • tests run in the consumer pipeline were not sufficient to expose the issue
  • tests were not full contract tests – nothing testing the contract between producer and consumer
  • no communication between the producer and consumer teams on any changes made to the interface

Why didn’t the consumer pipeline tests expose the issue?

  • because the test only exercised the simplest possible scenario which did not get affected by the change (sec call returned minimum possible data)

Why were the contract tests insufficient?

  • contract testing is not very well understood by all teams concerned
  • tests were not reviewed by anyone except developers

Why wasn’t there communication between teams?

  • the producer of the service does not know who is consuming that service
  • tests didn’t relay information of endpoint changes
  • consumer tests were still passing (green)

Why didn’t the tests relay information of endpoint changes?

  • there were no tests asserting or checking the stability of the interface
  • the consumer was coded to de-serialise the entire response when really it only needed to check for ‘success’

Why was the consumer coded to de-serialise the entire response rather than just parse the value of interest?

  • because it was deemed easier to use a standard pattern to de-serialise entire response rather than write code to specifically look for just the value of interest

Some example actions that were taken as a result of this;

  1. Provide training in contract testing patterns
  2. Producer to add tests to notify producer team of interface change (trigger for investigation or communication of change)
  3. Consumer to provide contract tests for producer to run in producer pipeline to alert of breaking changes for consumer
  4. Audit all cross team interfaces/dependencies to negotiate and add any missing contract tests


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QCBS Students

June Yee Tsun Po

McGill University
Ph.D. candidate

Supervisor: Gordon Hickey
Start: 2012-09-03
End: 2017-04-01
Personal page

How do Women Smallholder Farmers' Access to Land Resources Relate to Food Security in Semi-arid Regions of Kenya
Expanding opportunities and empowering women and girls have been key to reducing child mortality and achieved greater socio-ecological progress in development programs in recent decades. Improving sustainable agriculture by targeting small-scale farmers, particularly women, this interdisciplinary research project explores how women smallholder farmers’ participation in agricultural decisions, access land resources within local institutional structures and relationships, and how greater contextual factors in the local communities and regional counties relate to children’s nutritional growth and household food security. Smallholder farmers are the major producers of food in most developing countries. The term ‘smallholder’ refers to their limited resource endowments such as land, agricultural inputs, and access to markets and institutions. These low endowments hinder their coping capacity when facing stress such as unfavourable rain seasons, population pressure, food price volatility. Women experience further constraints in their access to productive factors, including land, technology and credit in developing areas. Women have tenuous customarily entitlement to cultivate farms of their husbands or fathers. Yet previous literature has suggested that improved access to land resources by women enhances household food security in several rural regions. To our knowledge, there is a lacuna of empirical evidence relating women’s access to land resources to childhood nutritional growth as an important indicator of household food security in semi-arid agrarian societies. This study aims to understand how women, as cooks and care-providers in the family, are also key actors in improving food and nutritional security when they gain better access to land resources in the semi-arid midlands of Kenya.

1- Respiratory disease associated with solid biomass fuel exposure in rural women and children: systematic review and meta-analysis
Po, J. Y. T., J. M. FitzGerald, C. Carlsten
2011 Thorax

2- Mortality Burden and Socioeconomic Status in India
June Y. T. Po, S. V. Subramanian
2011 PLoS ONE

3- An RNAi screen of the RRM-domain proteins of Trypanosoma brucei
Wurst, Martin, Ana Robles, June Po, Van-Duc Luu, Stefanie Brems, Mari Marentije, Savrina Stoitsova, Luis Quijada, Jörg Hoheisel, Mhairi Stewart, Claudia Hartmann, Christine Clayton
2009 Molecular and Biochemical Parasitology

4- Control of mRNA degradation in trypanosomes
Clayton, Christine, Angela Schwede, Mhairi Stewart, Ana Robles, Corinna Benz, June Po, Martin Wurst, Rafael Quieroz, Stuart Archer
2008 Biochemical Society Transactions


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Partnerships & Initiatives

The QIO Program works in concert with both national and community-based partners and administers its own CMS-led initiatives to promote quality improvement locally and nationwide.

The work of QIOs supports efforts led by the U.S. Department of Health & Human Services (HHS), the Centers for Disease Control and Prevention (CDC), the Centers for Medicare & Medicaid Services (CMS), and other organizations and federal agencies that operate on a national level to improve the quality of U.S. health care.

Locally, community groups can strengthen their impact on health care quality improvement by partnering with their region’s Quality Innovation Network-QIO (QIN-QIO). Through these collaborations, your local organization advocates the unique voices of your members or constituents while helping shape health care improvement at the community level. By working with your regional QIN-QIO, your organization has the opportunity to connect locally to national programs in which the QIO Program is a partner, as well as CMS initiatives driven by QIN-QIOs. As a result, you will gain access to tools and education that can deepen your portfolio of services, help you meet organizational goals, connect you with other organizations that share your mission, and help you change how your community receives health care. Partnering with QIN-QIOs will allow you to make a difference in your own community while contributing to national health quality goals that benefit all Americans.

BFCC-QIOs are a part of the QIO Program dedicated to improving health quality through the Medicare case review process. BFCC-QIOs help Medicare beneficiaries who have a complaint about clinical quality or want to appeal a health care provider’s decision to discharge them from the hospital or discontinue other types of services.

Throughout this case review process, BFCC-QIOs serve as a guide for beneficiaries, their families and providers to ensure that Medicare beneficiary needs are met. Continually working with beneficiaries allows concerns to be shared to help identify how the health care system can better meet the needs of other patients and assists BFCC-QIOs to seek opportunities for quality improvement across a variety of health service providers.

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Puzzle pieces