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If you downloaded a version that is either a lot older or a lot newer than this guide, it is a good idea to read the guide included in your downloaded version instead of the version you're reading right now. You can find the Compilation Guide in the directory


                doc/manual

You can download a released version of openMSX from the releases page on GitHub . The latest version is probably the best one. This guide assumes that you are using the latest release.

After downloading, type the following in a UNIX or MinGW Shell (in your start menu), or use another decompression tool:

in which


                VERSION

is the openMSX version you downloaded, or use the file name you saved the tar.gz file with. The directory that is created by uncompressing the


                tar.gz

file is called the top of the source tree .

Getting a Git clone means you use Git to retrieve the latest version of the source code of openMSX. This means you will need to install a Git client. This package is usually named

git

. There are graphical front-ends for Git, but this guide will tell you how to use Git from the command line. More information about Git can be found on the Git Documentation site.

In this line you specified where you want to retrieve the files from (host name of the Git server), what project you want to retrieve ( openMSX in this case), what module you want to get ( openMSX.git in this case, which is the module that contains the sources of the main openMSX program) and what directory it should be cloned to (we chose openMSX in this example).

When compiling openMSX on Windows with GCC, it's often convenient to use


                C:\MinGW\msys\1.0\home\<username>\openMSX

as the target directory, as this is easy to reach from your MinGW Shell - it's your MinGW home directory.

For this to work smoothly, without having to type your password all the time, it's probably a good idea to read the GitHub docs about SSH keys .

The Git command creates a directory called


                openMSX

for you in the current directory (or in the directory you specified in TortoiseGit). This directory is what we call in this manual the top of the source tree . In addition to the openMSX code, you will see a hidden Git administration directory called


                .git

. Do not mess with it (nor move contents of this directory around), otherwise Git will get confused.

Moderator:Welcome to Medical Breakthroughs from Penn Medicine, advancing medicine through precision diagnostics and novel therapies. Your host is Dr. Lee Freedman.

Dr. Lee Freedman:Oropharyngeal cancer makes up a growing proportion of head and neck malignancies. To some extent, this has been associated with the increase in infection of the oropharynx by oncogenic strains of the Human Papillomavirus, or HPV. Transoral Robotic Surgery, or TORS has allowed for minimally invasive surgery for HPV-related and non-HPV-related oropharyngeal cancer. I am your host, Dr. Lee Freedman and with me today is Dr. Gregory Weinstein, Professor and Vice Chair and the Director of the Division of Head and Neck Surgery. He is also the Co-Director of the Center for Head and Neck Cancer in the Department of Otorhinolaryngology, Head and Neck Surgery at the University of Pennsylvania.

Dr. Weinstein, welcome to the program.

Dr. Gregory Weinstein:Thanks very much.

Dr. Lee Freedman:Why do we not start very basically with the question, what exactly is TORS?

Dr. Gregory Weinstein:TORS is Transoral Robotic Surgery. Back in 2004, my colleague Bert O’Malley and I began research applying the da Vinci surgical robotic system, which is made by Intuitive Surgical, to tumors and lesions of the throat.

So what TORS is, is it allows the three arms of the robot to be put into the mouth and allows us to resect cancers or benign lesions or benign tumors that, in the past, was required a rather extensive operation to remove, or an alternate nonsurgical treatment, such as radiation or chemoradiation, which in some cases, is not as effective as surgery and so this is what transoral robotic surgery is..Dr. Lee Freedman:So the advantage seems to be that it’s much less invasive when you compare it to a traditional surgery?

Dr. Gregory Weinstein:Exactly and these little tools that are at the end of the robotic arms, move exactly like your hands do. So essentially, what it is, you can consider it like miniaturization of your hands and working in the mouth in tight spots that we normally would have trouble getting to

In 2009, the FDA cleared transoral robotic surgery for T1 and T2 malignancies and benign tumors of the throat and last year, the FDA cleared removal of benign tongue-based lesions.

Dr. Lee Freedman:I would imagine this is a skill that needs to be developed. What is the process of learning this technique and how many surgeons across the country are adept at this?

Dr. Gregory Weinstein:So back in 2009, after FDA clearance, it was necessary to do what we call postgraduate surgical training. Postgraduate surgical training means that practicing surgeons who are out there, this is new technology and the new approach, need a way to learn these techniques so that they can, if they choose to, apply them in their practices.

So we began a training program at the University of Pennsylvania, which is done in conjunction with the robotics company and what the training approach has done, is it allows surgeons to get online training on the web and then, inadamant training done in computer packages that are in the console of the robot that they do back at their home hospital. Then, they visit the University of Pennsylvania, spend about eight hours doing a pig lab where they deal with live tissues.

Then the next day, they do have a day of cadaver work with either Bert O’Malley or myself and then, they observe cases the following day in the operating room and watch what we’re doing and the OR set up and how we use the instruments and how we do the cases. Then, finally, they go back proctorships for these surgeons in their first couple of cases.

So it’s been an approach that has yielded, I think since 2009, over 250 trainings of individual surgeons. Prior to that, we had surgeons coming from around the world, about 50 surgeons, so about 300 surgeons have been trained at the University of Pennsylvania. We’re the primary training program in the world for this technology and now, several thousand TORS cases are done annually, worldwide.

Dr. Lee Freedman:Oh, that’s fascinating, so a very broad-reaching training program involving many modalities, all based, really, out of your program at the University of Pennsylvania?

Dr. Gregory Weinstein:That would be accurate.

Dr. Lee Freedman:I imagine that this technique results in much lower morbidity. It’s been five, six years since it’s been approved, do we have efficacy measures for this versus more standard treatments?

Dr. Gregory Weinstein:Well, to get FDA clearance, essentially what we did was, we compared the results… I’ll backup for second. Back in 2006, we felt that it was important to get others doing research in transoral robotic surgery. We set up a training program, that was a research training program for 12 surgeons from around the country and this included surgeons from Mayo Clinic, University of Alabama, MD Anderson and Mt. Sinai in New York, from numerous institutions around the country and then, we gave them our research protocol, showed them how to do the surgeries that we were doing back in 2006 and then, encouraged them to do research at all these institutions began research programs.

Ultimately, we pooled the data from the University of Pennsylvania in 2009, the University of Alabama and the Mayo Clinic and with one of my colleagues, Chris Holsinger who was at MD Anderson, now is at Stanford as a Data Safety Manager.

The data from our work was given to the FDA and basically, it compared to historical findings in the literature for standard surgery and for radiation and chemoradiation and was found that on and oncologic level, it was at least equivalent, or better than many modalities and on a functional level, was again, equivalent or better.

If we look specifically oropharyngeal cancer, because oropharyngeal cancer, there has been an epidemic of HPV-related oropharyngeal cancers in the United States and this has been really the home that TORS has found. It really is an excellent treatment modality for tonsil cancer and tongue-based cancer.

If you look at that specifically, the cure rates that have been published in the literature for HPV-related cancers, are over 95 percent using transoral robotic surgery and the key issue is, functional outcomes.

In other words, can the patient still swallow and speak well and the functional outcomes have been outstanding, as well, with a very low, what we call, PEG dependency, when patients can’t swallow after an aggressive treatment in their throat, they have to have a stomach tube and the PEG dependency rates have been on the order of less than one percent, or two percent and the same for tracheostomy rates, which is, in some patients, because of swelling, would need that.

Now, when you look at the alternative treatment for oropharyngeal cancer, it’s high-dose chemotherapy and radiation, typically, cisplatin-based chemotherapy. New technology doesn’t get developed, it doesn’t get accepted, it doesn’t get adopted by the community, unless the thing it’s replacing has problems.

The reason we did this research, particularly on oropharyngeal cancer, was that the standard high-dose chemoradiation is way too intense, by treatment, with significant side effects and the side effects include, a long-term risk of a permanent stomach tube of about 10 percent in the best of hands, if you look at the literature.

Then, in terms of cure rate, we, right now, when we look at this, we say that chemoradiation, that HPV-related cancer is highly curable with chemoradiation, but in fact, if you look at the existing data, if you look at the patients and it’s been done, looking at ROTG patients, for instance.

If a patient is a nonsmoker, then, regardless of the stage of the HPV-related cancer, they have about a 93 percent overall survival at three years. If they have a 10-pack year smoking history and they have more than one lymph node in the neck, the cure rate drops down to 67 percent. Then, if they’re not HPV-related, the cure rates from chemoradiation at three years are about 47 percent. That’s disease-free survival.

Now, if you look at TORS, regardless of HPV status, or smoking status, we published this data recently in Head To Neck Journal, it’s over a 95 percent cure rate regardless of whether they were smokers, or numbers of lymph nodes and so forth. So the home that TORS has found, is as an alternative to high-dose chemoradiation.

Dr. Lee Freedman:Very impressive. If you’re just tuning in, you’re listening Medical Breakthroughs from Penn Medicine on ReachMD. I’m your host Dr. Lee Freedman and I’m speaking with Dr. Gregory Weinstein, Professor and Vice Chair and the Director of the Division of Head and Neck Surgery at the University of Pennsylvania.

Dr. Weinstein, let’s turn to HPV, what is the connection with HPV and oropharyngeal cancer?

Dr. Gregory Weinstein:There’s a number of HPV-related viruses. The one that causes head and neck cancer tends to be HPV 16 and HPV 18, but mostly HPV 16. If you look at the CDC website, 50 million Americans have been exposed HPV virus.

Now, normally what happens with the virus, it gets integrated into the cell and takes over the DNA mechanism, reproduces itself as viral capsid, destroys the cell and then is dispersed and is infectious and moves on.

Well, with HPV and this kind of oncologic virus, in some patients, the virus gets integrated into the DNA of the cell and automatically turns itself off from replicating and then, resides there, not being infectious, because really, the infectious point appears to be about six months to a year and then, it’s not longer infectious, but in some patients, it’s integrated itself into the DNA and then, kind of resides there for decades and then, several decades later, anywhere from 20 to 40 years later, these cancers start to show up.

This is the same virus that causes cervical cancer, but unlike in women, we don’t have a Pap Smear yet or early detection method for finding these cancers. So the way these cancers tend to be found is when the patient develops a lymph node in the neck because they tend to be silent and relatively small in the throat.So really, the way they’re showing up is by a lymph node, which automatically makes it stage 3 and stage 4, but still is very highly curable because the primary sites are mostly T1 and T2, they’re perfectly amenable to transoral robotic surgery.

Dr. Lee Freedman:And when we say de-intensification for this type of process, what does that mean?

Dr. Gregory Weinstein:So, you know, it’s very interesting, you know the Pub Med database, which has 24 million entries, it’s our Google, right, doctors Google for looking up articles, if you put the word de-intensification into Pub Med, 26 articles come up, that was about a few weeks ago when I was checking before the lecture I gave, I was just curious, 20 out of the 26 articles are related to high-dose chemoradiation for oropharyngeal cancer. It boggles the mind. There are 24 million entries and the only treatment that is considered so intense that the term de-intensification pulls up almost all the articles is high-dose chemoradiation for oropharyngeal cancer.

So what our goal is, is to try and de-intensify the amount of radiation we’re giving to people and less chemotherapy because high-dose radiation has to be given in a wide field when you haven’t done the surgery, with high doses and has to be given in conjunction with chemotherapy, which also increases the toxicity in the throat.

Then, the delicate muscles of swallowing can be damaged so that patients can have real difficulty swallowing long-term. So when we say de-intensification, but we mean is, do the surgery, they heal, they do very well, then, we want to decrease the radiation dose for the primary site into the neck, avoid chemotherapy in about 40% of patients and then, decrease the total dosage and field size that we do at the primary site said this de-intensifies the treatment.

It doesn’t have collateral damage to the swallowing muscles, so that’s really important because these cancers, which by the way, essentially are caused by normal sexual behavior, these cancers tend to occur in 40 to 60 year age group. They tend to be healthy people that are physically fit and are very health conscious, frequently have either quit smoking in the distant past, or don’t smoke at all. It’s a real, what happened here, I did everything right. I was eating right. I’m exercising, an otherwise healthy people.

Now, if you take that group of patients and then, you give them an incredibly intense treatment that damages their swallowing function, it really has a negative impact on quality of life and they have a lot of living to do because it’s a highly curable cancer. The goal is to de-intensify. Now, there’s other ways that are being looked at to de-intensify with other chemotherapy and radiation regimens, but TORS is FDA cleared, 20 percent of patients avoid radiation entirely. This is a viable method for providing the de-intensification for our patients.

Dr. Lee Freedman:Absolutely. From what you said, the efficacy is excellent and you avoid all the morbidity of those other very intense treatments.

Dr. Gregory Weinstein:Well, not necessarily all the morbidity because 80 percent of patients are still getting radiation, but you decrease the morbidity.

Dr. Lee Freedman:I stand corrected, you decrease it. Absolutely. Now, as we look ahead Dr. Weinstein, what do you see for the future of TORS?

Dr. Gregory Weinstein:Well, right now, there’s a couple things going on. There’s a number of trials around the world looking at even further de-intensification. There’s an NCI-funded trial from ECOG, the Eastern Cooperative Oncology Group. I’m the Director of Surgical Quality on that study.

What that study is looking at is patients go through transoral surgery, primarily, transoral robotic surgery and then, if they’re kind of intermediate group, they get randomized between 5,000 versus 6,000 rounds, which is an opportunity to lower the dose. Typically, when patients have extra capsular spread, or cancer spread outside the lymph node, which is discovered when we remove the lymph nodes, as part of this surgical paradigm, they typically get chemo and radiation.

In our study, National Multi Institutional Trial, we are avoiding chemotherapy in the groups that have minimal extra capsular spread. So this is a way of de-intensifying treatment. There’s an in-house study at the University of Pennsylvania where we are also not radiating the primary site at all, if patients don’t have any high-risk features. So they go for the surgery and if they have neck indications for radiation, which is multiple positive lymph nodes, or cancer spreading outside the node, then, they would get radiation or chemoradiation, but we would block out the primary site entirely.

We know this is safe because we published data showing that in patients who don’t get radiation at all after transoral robotic surgery, the risk of recurrence at the primary site is only about two percent.

In our cohort that didn’t get radiated, the cure rate is incredibly high with a two to four percent recurrence rate, we saved radiation. Remember, radiation can only be given to one body part per lifetime, generally speaking. Sometimes, we re-radiate, but as a last resort.

So now, if we’ve kept radiation on the side, if they are even that small group that does recur, we can still use radiation or chemoradiation if we choose to, so that group does particularly well. This is another study that’s being done. There are new iterations of the robot that are coming out.

The first robot we began with was called a da Vinci Standard. I mean, that’s the equivalent, back in 1991 when I arrived at Penn and the computer program was DOS. Then, we moved our way up to the first Windows program, which is a da Vinci S and now, there’s the SI and the XI, which isn’t used for transoral robotic surgery, but on the horizon is the da Vinci SP, which is a single port system in which small tools come out of one inch and a half port and give an even better access to the throat. So these are all exciting things on the horizon.

Dr. Lee Freedman:Well, I very much want to thank Dr. Gregory Weinstein for educating us about transoral robotic surgery, relatively new technique, developed at Penn Medicine that has equal or improved efficacy over standard approaches and the ability to drastically reduce morbidity from other types of treatments that patients with this problem have negated in the past.

Again, Dr. Weinstein, thank you so much.

Dr. Gregory Weinstein:You’re very welcome. Thank you.

Moderator:You’ve been listening to Medical Breakthroughs from Penn Medicine. To download this podcast, or to access others in the series, please visit www.reachmd.com/Penn and visit Penn Physician link an exclusive program that helps referring physicians connect with Penn. Here, you can find education resources, information about our expedited referral process and communication tools. To learn more, visit www.pennmedicine.org/physicianlink. Thank you for listening.

Oropharyngeal cancer is part of a growing proportion of head and neck malignancies. This has also been associated with the increase in infection of the oropharynx by oncogenic strains of the human papillomavirus (HPV). And, transoral robotic surgery, or TORS, has allowed for minimally invasive surgery for HPV-related and non-HPV-related oropharyngeal cancer. To discuss this topic and much more, host Dr. Lee Freedman welcomes Dr. Gregory Weinstein, Professor and Vice Chair and the Director of the Division of Head and Neck Surgery. He is also the Co-Director of The Center for Head and Neck Cancer in The Department of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania.

The better your site structure, the better your chance of higher ranking in the search engines. Every website has some “structure.” It might be a rigorous and streamlined structure, or it may be a disorganized jumble of pages. If you are intentional and careful with your site structure, you will create a site that achieves search excellence.

In this article, I share some of the best advice on creating a powerful site structure. The tips below will help you create a site that appeals to users, gets crawled and indexed by spiders, and delivers the best SERP listings and rankings possible.

Why Structure Matters

As I’ve worked with hundreds of clients over the years, I’ve been surprised at how often site structure is overlooked. On the one hand, it’s one of the most crucial aspects of a site’s SEO performance, but on the other hand, few webmasters and owners understand what it means to have a site structure that enhances SEO.

I’m going to share a few of the reasons why site structure is so crucial, and then get into the how-to of developing your own SEO-friendly site structure.

A good site structure means a great user experience.

When you take away the colors, the fonts, the kerning, the graphics, the images, and the white space, good site design is really about a great structure.

The human mind craves cognitive equilibrium — being able to put pieces logically together, finding things where they’re expected, and locating what they are seeking. Thus, a strong and logical site structure is cognitively satisfying to users.

As you know, the more appealing your site to users, the more appealing it is to search engines, too. Google’s algorithm uses information from searchers to rank your site. If your site has poor CTRs and low dwell time, it will not perform well in the SERPs. By contrast, when a user finds a site that they like — i.e. a site with great structure — they don’t bounce and they stay longer. An accurate site structure can reduce bounce rate and improve dwell time, both of which will lead to improved rankings.

A good site structure provides your site with sitelinks.

Sitelinks are a listing format in the SERPs that show your site’s main page along with several internal links indented below. You’ve seen them before.

Sitelinks are a huge SEO advantage. They increase the navigability of your site, point users to the most relevant information, increase your brand’s reputation, improve user trust, help you dominate SERPs, increase clickthrough rate, and shorten the conversion funnel. Basically, sitelinks are awesome.

But how do you get sitelinks? You don’t simply go to Google Webmaster Tools and fill in a few fields on a form. You can’t issue a sitelink request. Instead, Google’s algorithm automatically awards websites with sitelinks. And they do so based on great site structure.

If you have a poor site structure, it’s very likely that your site will never receive site links. The absence of sitelinks could be costing your site more targeted traffic, higher CTR, and increased conversions.

A good structure means better crawling.

Web crawlers like Googlebot crawl a website’s structure. Their goal is to index the content in order to return it in search results. The better your site structure, the easier the crawlers can access and index the content.

Crawler’s don’t automatically discover on your website. Google even admits, “[there are] pages on your site we might not…discover,” or “URLs that may not be discoverable by Google’s normal crawling process.” (That’s one of the reasons why Sitemaps are necessary.) However, crawlers will have a far easier time accessing, crawling, indexing, and returning the pages of a site with strong structure.

A good site structure is at the very core of good SEO — optimizing for the crawlers.

To sum up, your site’s organization paves the way for SEO success. In fact, it could be argued, that without a good site structure, you will never have SEO success. Strong site structure gives your site an unbreakable SEO foundation that will provide you with vast amounts of organic search.

Six Steps to Creating Site Structure

Now, I’ll tell you how to create this kind of site structure.

1. Plan out a hierarchy before you develop your website.

If you’re starting a website from scratch, you’re in a great position to plan out site structure for the best SEO possible. Even before you start creating pages in a CMS, plan out your structure. You can do it on a whiteboard, a spreadsheet program (Excel, Google Drive Spreadsheets), most word processors, or something like Visio or OmniGraffle.

A “hierarchy” is nothing more than a way to organize your information — something that is simple and makes sense. Your hierarchy will also become your navigation and your URL structure, so everything important begins here.

Generally, a site hierarchy looks like this:

There are a few features of hierarchy that you should keep in mind.

A site hierarchy is the beginning point for a great site structure.

2. Create a URL structure that follows your navigation hierarchy.

The second main element in developing strong site structure is your URL structure. If you’ve logically thought through your hierarchy, this shouldn’t be too difficult. Your URL structure follows your hierarchy.

So, let’s say your hierarchy looks like this:

The URL structure for the Chinatown location would look like this:

www.kimsrestaurant.com/locations/chinatown

Your URL structure will be organized according to your site hierarchy. This means, obviously, that your URLs will have real words (not symbols) and appropriate keyword coverage.

3. Create your site navigation in HTML or CSS.

When you create your navigation, keep the coding simple. HTML and CSS are your safest approach. Coding in JavaScript, Flash, and Ajax will limit the crawler’s ability to cover your site’s well-thought out navigation and hierarchy.

4. Use a shallow depth navigation structure.

Your navigation structure will obviously follow your site hierarchy. Make sure that pages, especially important ones, aren’t buried too deep within the site. Shallow sites work better, both from a usability and crawler perspective, as noted in this Search Engine Journal article:

5. Create a header that lists your main navigation pages.

Your top header should list out your main pages. That’s it. My website, Neilpatel.com uses a very simple top navigational header with three subcategories. This accomplishes everything I need.

Adding any other menu elements apart from your main categories can become distracting and unnecessary. If you’ve designed a parallax site, be sure to provide a persistent header menu that displays through each scrolling phase.

While dropdown menus using CSS effects or disappearing menus may provide a unique or intriguing user experience, they do not enhance SEO. I advise against them. I also advise against using an image-based navigational structure. Text links with appropriate anchors provide the strongest form of SEO.

If you have a footer with menu links, be sure to duplicate the main links of your top navigational menu in your footer navigation menu. Changing the order of links or adding additional category listing will complicate the user experience.

6. Develop a comprehensive internal linking structure.

Internal linking puts meat on the bones of a logical site hierarchy. Moz’s article on internal links lists three reasons why they are important:

Each of these is directly tied to creating a tight-knit and well-integrated site structure.

There’s no need to get complicated with internal linking. The basic idea is that every page on your website should have some link and some link another page on the website. Your navigation should accomplish internal linking to the main categories and subcategory pages, but you should also make sure that leaf-level pages have internal linking as well.

Internal linking tells the search engines what pages are important, and how to get there. The more internal linking you have across all pages, the better.

Conclusion

Site structure is a product of careful thinking, intentional design, and accurate organization. The best time to develop a strong site stricture is before you create your site. However, if you’re redesigning your site, you can rework the design and reorganize some navigational elements to improve structural SEO.

There are a lot of things to keep in mind when optimizing your site for search engines. Site structure is one of the most important, but one of the most-overlooked optimization methods. If you have a great site structure, then great SEO will follow.

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The Use of TORS for HPV-Related Oropharynx Cancer