Ethical Issues related to the Physician Sunshine Act Coursework

Ethical Issues related to the Physician Sunshine Act - Coursework Example or design of clinical trials or development of medical devices should be encouraged since they help in the enhancement of the existing technology for the benefit of patients. By gaining the ability of accessing information regarding their physicians’ financial relationships with pharmaceutical companies, the public will be greatly informed regarding possible conflict of interest as well as protect them from potentially injurious doctor-industry relationships. In addition, patients will get a better grasp of when and whether associations with manufacturers manipulate the physician’s decisions (Twomey &Jennings, 2014). Exceptions such as gifts of less than $10, educational materials for patient distribution and product samples are important and serve to pass new products to the market in addition to assisting in education and research. Provision of free gifts or food makes the message being delivered more palatable as well as to be more favorably received by the

Introducing Sheltered Instruction Essay Example | Topics and Well Written Essays - 1250 words

Introducing Sheltered Instruction - Essay Example According to the research carried out by National Clearinghouse for English Language Acquisition, (2002), it is known that each year proportion of non- English speaking students is increasing at more rate than actual number. And many states are not up to that level to deliver language and other services that these immigrant students actually need. As per the work by Moss & Puma (1995), Ruiz-de-Velasco (2000) & Fix and Waggoner (1999), these students have less grades and high dropout rate as compared to US-born students in spite of having high attendance rate. It is evident from these studies that most schools are not satisfying the requirement of educating linguistically and culturally diverse students. To achieve high levels of educational standards and accommodate the requirement of 'No Child Left Behind Act (2001)', federal and state governments expect all students to have adjusted national and state assessments. English learners enter U.S schools with wide range of language profi ciencies and subject matter knowledge, based on their background, socioeconomic status, age of arrival and personal experiences. To succeed students with varieties of criteria the teacher development, program design, curriculum and materials, and instructional and assessment practices should be modified. This paper will address especially strategies for improving teacher development and instructional practices. Many standards have been ... High-stake test has been adopted in many states as result of 'No Child Left Behind Act (2001)'. This was benefited to English learning students as teachers and schools concentrated on overall progress, including LEP students, so as to reach benchmarks laid. In spite of these many adaptation, students exit before they become proficient in academic English due to several reasons. First reason is being standardized test designed for US born students, EL students at beginning level found it difficult to meet criteria as they can not read, write or speak English fluently. Thus program failed to confirm that EL students learn academic content primarily, with learning English. Second reason for failure of high-stack tests was lack of certified ESL and bilingual teachers. To compensate this shortage, principals started hiring less-qualified teachers, using substitutes, canceling courses, increasing class size, or asking teachers to teach outside their field of preparation. The Sheltered Instruction Approach and SIOP model The growth in numbers of students learning English as an additional language and the shortage of qualified ESL and bilingual teachers raised the need of sheltered content instruction approach. "sheltered instruction is an approach that can extend the time students have for getting language support services while giving them a jump-start on the content subjects they will need for graduation" (Echevarria, 2004, p.10). It is not a set of instruction techniques need to added or replaced by teacher's original techniques, but an approach that complements those methods and strategies. Sheltered Instruction Observation Protocol (SIOP) model has been designed for flexibility and confirmed with wide range of classroom

Transience And Eternity In The Elegy Theology Religion Essay

Transience And Eternity In The Elegy Theology Religion Essay Old English poetry can be divided into two main types: heroic poetry and Christian poetry. Christianity, as the most widely spread religion, is present in most literary works, including some of the heroic poems, although heroic poetry is considered separate from Christian poetry. There are many analogies to Christian themes in the poetry of the Old English period, since religion played a major part in peoples lives at the time. The Seafarer is an Old English poem which was recorded in the Exeter book, or Codex Exoniensis, a collection of Old English poetry, including The Wanderer and The Descent into Hell, which dates back to the tenth century. It is a poem which describes the lonely, full of hardship and suffering life of the seaman. It can be logically divided into two parts. The first is a typical elegy the speaker remembers his dismal life at sea, which he has chosen to the disturbing life on land. He knows he is alone, and he constantly has this internal conflict about choosing the sea to the land. The second part is more moralistic, or didactic. The speaker talks about the transience of wealth and fame on Earth, and how nobody will manage to outwit death and God, no matter how glorious a life they have led. Eventually all people will die, life will end for everyone at a certain point, and no amount of money will help them avoid their fate. In the beginning of the poem the seafarer makes a song about his travels and experiences at sea. He begins grimly with a description of the troublesome times and lonely life while hes sailing. This is a life which common people in the city know nothing about. They are safe on the land while the seaman risks his life at sea. The weather is cold and stormy, the terrible tossing of waves rock the ship, the seaman will soon freeze. He has to endure the fierce storms, the snow and the hail. The beginning of the poem is not only a description of a fierce weather. It is a description of the inner state of mind of the seaman the inner struggles and conflicts he has. He is not homesick, but he realizes he is alone in the sea. His troubles are represented as being caused by the sea, but in reality the sea only represents what is already inside him, in his soul. The seafarer feels grim sorrow at heart. He is unable to feel any pleasure from the surroundings; he does not enjoy it because of the darkness in his soul and heart. There are moments in which he holds life at sea in contempt. Yet there is something which draws him back to the sea. He can choose the safe life on land, at home, where there are his fellow men, possibly his family, and where food and warmth are ensured. However, he feels this constant urge to travel, to go back to the sea. The sea is mysterious it is wide and infinite; it holds many secrets; it offers a different lifestyle it draws one away from everything familiar and safe, and throws them into a new, different world the world of danger, uncertainty, constant change; a world with no boundaries or limits. This is what the seafarer seeks, this is why he constantly returns to the dangerous travels he needs the challenge of the hard life at sea; he needs the struggles either physical or emotional. His journey in the sea is not only a journey on the physical level. It represents the journey which his soul takes on the path to God. He has to go through hardship and struggles; he has to fight with the difficulties which God sends him; he has t o welcome the challenges of the sea as challenges which God sends to test his soul. He is sailing in the sea which suggests that he is going forward. His soul is, symbolically, about to walk the path which leads to God, passing through severe trials. His kinsmen, who live on land, stay where they are, they havent moved from their place not only physically, but figuratively as well their souls have not taken the path to God, but they simply enjoy the transient goods in life while they have them. They live a stable, secure life with no dangers or trials. They strive for the goods and the glory which earthly life offers, and never think of their spirituality and morality. They dont realize that everything on Earth is fleeting and that life as they know it wealthy, glorious and bountiful will only last until their death and not in the afterlife when their souls will meet God. This is a light transition to the second part of the poem which is a moral criticism of the people, especially the rich, who rely on their wealth and glory only. They may lead a sinful life, they may oppress the weaker or the poor people, but their deeds are the only thing which will accompany them in the afterlife, not gold or money, not friends and kinsmen. There is a similar concept in the English morality play Everyman, in which wealth and fellow men abandon Everyman on his journey to death, and only good deeds stay with him until the end. There is the Christian influence, which is present in almost every piece of work in the medieval literature. According to the Christian religion God is the only truly eternal and lasting thing in the Universe. The speaker strongly criticizes the sinful life of common men instead of living a good, honorable and humble life, they only rely on wealth and bounty, and they think these earthly goods will help them or benefit them in some way in the afterlife. They never challenge their souls, and they never even pray to God. The speaker tries to imply that the rich need to change their lifestyle but he realizes that they will not, because they do not understand how their sins and idleness will only harm them later. They dont realize that wealth is transient and they will not be able to take it with them after death. God will not take in mind how powerful a man was on Earth or how much money did he possess, but will only consider his good and brave deeds and his sins. Life in Heaven is eternal and Heaven is a sort of reward for leading a faithful, honorable life. The seafarer claims that earthly happiness will not endure. He mentions that age comes upon him eventually, which suggests that glorious life is only there for some time and then one gradually loses everything they possess, including their vitality, and outer things like their friends and kinsmen. The way one spends their life on Earth determines where they will spend their afterlife. The speaker urges people to think carefully what afterlife they would like to have and then decide what the right path to there is. He tries to explain to them that they will all be equal after death, no matter how wealthy some were and how poor the others were on Earth. Moreover, they all are equal even now in Gods eyes. It does not make a difference to God whether one is rich or poor; whether one is famous or not. What will differentiate them after death is how they led their life, what they did and what their deeds led to. This is the point at which some will be sent to Heaven and others will be sent to Hell. Afterlife will be eternal, that is why people have to think now how they want to spend it. The seaman has given up on all earthly goods and bounty because he has realized that they are not important, they will be lost in time and in the end nothing will remain, only memories of the glorious days and consequences from the deeds, good or bad. The Seafarer is not only a poem about life and death. It concerns transience in life and eternity as a concept mainly in the afterlife. It suggests that life on its own has no other meaning but to praise God and to prove that one is noble enough to go to Heaven. Moreover, life is a test for the soul whether it has to be sent to Heaven or to Hell. Life after death is what really matters, because it will be for eternity, in contrast to life on Earth which lasts only a few decades. The concept of eternity is important for the moral to reach the common people. If the common man does not fear God, or does not at least consider what will happen to him after his death, he will not try to live a better, noble life, but he will only keep in mind his earthly matters, and this will lead him to impious, even ignoble deeds. Thus The Seafarer can be considered a moral poem which teaches man how to live and how to save his soul, so that he deserves afterlife in Heaven.

tupac :: essays research papers

Tupac Shakur was a black African American rapper who lived his life with poverty, violence and drugs. The songs â€Å"â€Å"Hellrazor†Ã¢â‚¬ , â€Å"Me and My Girlfriend† and the poem â€Å"In the Event of my Demise† reflect the tragedy and pain which was Tupac’s life. All his poetry relies on vivid imagery and violent language to create a very realistic picture of how terrible life can be living in the ghettos of America. The song â€Å"Hellrazor† is a very dramatic song which tells the story of a young black African American male trying to make his way into becoming a â€Å"Gangsta† as he has no other way to support himself. The theme of change is reflected in this song. The song doesn’t really have a straight flowing structure. It rhymes in places but there is no pattern to it. For example: it rhymes in the 1st two lines: -   Ã‚  Ã‚  Ã‚  Ã‚  Ã¢â‚¬Å"Born heartless and mean muggin†   Ã‚  Ã‚  Ã‚  Ã‚  Ã¢â‚¬Å"At 16 on the scene watching fiends buggin† But after that it doesn’t rhyme for further 8 lines. That leaves a very dramatic effort because it reflects the tension and the violence of this song. The song has some very harsh and effective similes. For example: - â€Å"When a nigga gettin' richer, they come to get ya† â€Å"It is like a motherfuckin' trap and they wonder why it's hard being black†. This simile works very well because it uses some really strong emotions and the theme of racism to get the message through. Also the use of very strong language leaves a lasting image on the listener. The song uses plenty of Gangsta slang. Some examples include: - Gat, Loc, 5-0.   Ã‚  Ã‚  Ã‚  Ã‚  This is a very memorable song because it is so emotional and tragic. The most vivid lines come when he raps about how a little girl who was killed by a gun. Lines such as:   Ã‚  Ã‚  Ã‚  Ã‚  Ã¢â‚¬Å"Dear Lord, if you hear me tell me why?†   Ã‚  Ã‚  Ã‚  Ã‚  Ã¢â‚¬Å"Little girl like Natasha had to die†   Ã‚  Ã‚  Ã‚  Ã‚  Ã¢â‚¬Å"She neva got go see the bullet, just heard the shot†   Ã‚  Ã‚  Ã‚  Ã‚  Ã¢â‚¬Å"Her little body couldn't take it, she shook and dropped† This part of the song is very dramatic because of his reference to god and by the way he said that she didn’t even see the bullet coming. It is very hard to forget this song because of its strong language and powerful imagery of the girl being murdered. The song â€Å" Me and my Girlfriend† is a very complicated song. The message that Tupac is trying to get through is not what you see written down on the piece of paper.

What Makes a Good City?

What makes a good city ?There are far to many to enumerate but here are a few: A secure water supply and sanitation system. A solid economy. A transportation network on every level. A strong tax base. Good to great schools. Better then Good police protection. Affordable housing, A built in arts and culture environment, Affordable medical, social services, sanitation and fire protection. A community spirit, a Love Thy Neighbor attitude.The ideal cityBuild housing, construct infrastructure like roads and plumbing, provide public services like electricity and garbage collection, coordinate commerce, provide recreational facilities such as parks, stadiums and museums, and facilitate transport.What makes a perfect city ?A good transport system, low traffic, lots of money, beaches and rivers, big CBD. High Helth and good education system plus near to oter big cities.Ideal CityCORRECTION OF THE ESSAY : â€Å"Imagine the Ideal City† The city of my dreams is neither too big nor too sma ll. (Jenna) It is clean, there aren’t any cigarette butts, chewing gums, papers or dog dirt on the floor.( Angà ©lique /Marjorie) It is Green, ecological (Stà ©phanie): there are less traffic and pollution because people use alternative means of transport (Gamzà ©/ Maria) and the cars run with solar energy. The houses are equipped with solar panels too to protect the Earth (Fanny/Stephanie) People recycle their wastes (Gamze ) The environment is respected (Jenna) &the scenery is pleasant because the huge sky scrappers & tower blocks have been replaced by detached houses. (Marjorie/Sabrina)The city is built with recycled materials to fight global warming (Fanny) In this ideal town People are happy & safe, they can have walks in the streets & gardens even at night. The pavements are large enough for parents with buggies and accessible for  disabled people (Vanessa). Car Parks are free (Maria). You can borrow free bikes or take a stylish cheap taxi. (Anthony) Drivers respec t pedestrians and don’t insult other drivers. Everybody is civilised & smiles (Angà ©lique/ Sabrina) You can go shopping in low cost stores (Angà ©lique). There are many activities & services for everyone: for children and elderly people . Drama groups and artists perform in the street and a music festival regularly takes place for everyone’s Greatest pleasure. (Fanny)Criminals & delinquents are supervised by cameras. In case of a problem the police or the firemen are there immediately (Vanessa) No Poverty in this ideal town.There aren’t any homeless & beggars. Charities accommodate them in decent buildings. Students no longer sleep in cars or squats. (Marjorie /Mrs Lombrana) The rents are not excessively high, everybody can afford buying a home.

Follicular And Mantle Cell Lymphomas Health And Social Care Essay

follicular lymphoma 2nd most common type of lymphoma in United States ; diagnosticians able to name PL with less information and more duplicability than any other type of lymphoma ; FLs vary in character ; cutaneal ( follicle centre cell ) lymphomas normally curable with local therapy ; duodenal and paediatric -both rare indolent diseases ; make good with minimum therapy ; by and large non do of decease in affected patients Grade 3 follicular lymphoma: presently defined by figure of big ( blast ) cells per high-power field ( HPF ) ; method tolerably accurate in FL, and most consistent ; grade 1, & lt ; 5 big cells per HPF, grade 2, 5 to 15 per HPF, and grade 3, & gt ; 15 per HPF ; duplicability survey — -diagnosis of FL by diagnosticians & gt ; 90 % consistent, but well less accurate in finding class: class 3 FL farther classified as 3A ( big cleaved cells ) and 3B ( blast cells ) ; nevertheless, limited truth in finding class may bespeak limited duplicability in separating 3A from 3B ; distinctniess of class 3B ( Sloan-Kettering survey ) — -maximum standardised consumption ( [ SUV ] of fluorodeoxy glucose on antielectron emanation imaging [ PET ] ) in class 3 FL more similar to SUV in patients with diffuse similar to SUV in patients with diffuse big B cell lymphoma ( DLBCL ) than grade 1 or 2 FL ; Harris survey — per centum of Ki-67 stain-positive cells increased With increasing class of FL, with grade 3 FL staining near to degrees seen in DLBCL ; several surveies showed that some patients with FL grade 3 treated with cyclophosphamide, doxorubicin, Oncovin ( oncotic ) and Pediapred ( CHOP ) or CHOP like regimens had response to therapy similar to that of patients with DLBCL ; ability to bring around this group justifies handling all patients with grade 3 FL with regimens used to handle DLBCL.Low-grade FL: multiple effectual interventions available ( best one as yet unknown ) : ticker and wait – lupus erythematosus favored ; single-a gent Leukeran or cyclophosphamide — no longer used ( most patients treated with combination therapy ) ; local radiation therapy ( RT ) — used in patients with localised disease: total-body irradiation — out of favour ; patient Immunity and FL ( Rosenberg survey ) — showed self-generated slirinkage of FL in many patients ; multiple surveies show patients with fewer macrophages have better endurance than patients with high degrees ( may explicate shrinking without intervention ) ; vaccinum survey — -without intervention ) ; vaccinum survey — subset of patients who made antibodies had duplicating of progression-free endurance ( PFS ; suggests possibility of use of _relationship between FL and environment ) ; Gallic survey – inauspicious consequence of high macrophage degrees eliminated in patients treated with rituximab ( RTX ; suggests changing microenvironment as possible mechanism of action of interventions, including autologous root cell organ transplant [ ASCT ] ) ; ASCT non considered intervention for FL until late ( despite informations ) ASCT as salvage therapy: Chemotherapy, Unpurged and Purged ( CUP ) test – patients randomized to CHOP chemotherapy ( CTX ) entirely, or ASCT ( with or without purged marrow ) plus CHOP, in patients who had failed on Leukeran or other CTX ; patients in both organ transplant weaponries had important advantage in PFS and overall endurance ( OS ) ; survey indicates ASCT effectual therapy before RTX ; consequences decline after insistent intervention ; 3 of 4 upfront ASCT surveies in patients with FL show extremely important advantage in PFS ( no agvantage in OS ) , but upfront ASCT non done in United States ; St. Bart's/Dana Farber and UNMC informations — – of patients Farber and UNMC informations — of patients treated with ASCT ( pre-RTX, largely grades 1 and 2 ) , somewhat & lt ; 50 % had 10-yr freedom from disease patterned advance Possible functions of RTX in FL: remedy of FL ( rid ofing demand for organ transplant ) -Stanford survey update, UNMC survey, and Surveillance, Epidemiology and End Results ( SEER ) data show betterment in FL endurance over past 3 decennaries ; RTX of import subscriber to alter ( although other factors possible ) ; Cochrane meta-analysis — patients given RTX in initial therapy had extremely important survival advantage ; UNMC informations analysis suggests patients with low-grade FL and initial intervention with RTX had superior endurance, compared to patients having RTX at other times or non at all ; Primary RTX and Maintenance ( PRIMA ) survey – care RTX increased opportunity of continued remittal by 20 % ; consequence larger in patients with complete response ( CR ) than in those with partial response ( PR ) ; Swiss survey — demonstrated survival advantage with merely 4 extra doses of RTX ; analysis of PET informations from PRIMA survey — negative findings on PET seen in 92 % of patients with true CR ; one-third of patients with unsure CR PET-positive ; 20 % of patients with progressive disease 20 % of patients with progressive disease PET-negative ; PET negativeness best forecaster of result ; RTX improves endurance of FL, but unclear Whether it cures high proportion of patients with low-grade FL, ASCT after RTX therapy: Spanish survey and Collaborative Trial in Relapse Aggressive Lymphoma ( CORAL ) — — – patients with DLBCL treated with RTX before ASCT # 50 % more likely to be cured than patients with no RTX ; perchance due to bring around rate of patients after RTX therapy ( ie, patients still necessitating ASCT after RTX probably had more immune disease ) ; German surveies – patients witlt FL randomized to ASCT V care with interferon ( IFN ) af ter initiation with CHOP ; patients who got CHOP plus RTX ( R-CHOP ) and ASCT had somewhat better endurance than patients on IFN ; patients without RTX had much better endurance with ASCT than with IFN ; Cleveland study – no important difference in endurance after ASCT betweett patients with relapsed FL who had received RTX in past and those who had non In vivo purge: no direct informations available on effects on ASCT results ; UNMC informations — patients treated with monoclonal antibodies ( MAB ) and RTX earlier cell aggregation had better results after ASCT ( ill-defined how much betterment due toMAB V RTX ) ; Gallic survey – patients treated with MAB for salvage therapy had better results ; other surveies -majority of patients had no tumour cells ( per polymerase concatenation reaction [ PCR ] ) after RTX Post-transplantation care: small informations available ; several surveies showed important proportions of patients had delayed neutropenia or hypoganimma gloibulinemia if treated with RTX after ASCT ; no inerease in mortality seen with RTX, but it gives no advantage ( and increases trouble for patients ) ‘Conclusions: public-service corporation of RTX in FL remains ill-defined ; ASCT remains best tratment in younger healthier patients for relapsed FL ; best given after first intervention failure ; vivo purging perchance of import ; unproved Whether it has maior consequence on results ; value of post-transplantation RTX uncertain ; talker recommends handling rate 3 FL per protocols for DLBCL Questions and replies: consequence of length of i ¬?rst remittal on recommendations for ASCT – in other diseases ( e.g, Hodgkin lymphoma ) , patients do less good with brief initial remittal and ASCT, but likely better than with alternate likely better than with alternate therapies ; if patient immature and healthy, talker would still offer ASCT ; talker would discourse ASCT with immature healthy patients who have had really long or really brief remittals ; PET as tool to place faineant class 3 FL — unknown if patients with low SUVmaX should hold different intervention ; differences in diagnosing of class 3 FL add complexness to determination for intervention ; upfront allotransplantantation for FL — -best intervention to eliminate FL ; limited by 20 % to 30 % freshman mortality ( mortality decreases with age of patient ) Minimal Residual Disease in Follicular and Mantle Cell Lymphoma: -Foundation: CHRISTINE POTT, MD. absence of residuary lymphoma mass on imagination and bone marrow biopsy ( low sensitiveness ) referred to as clinical remittal ; analysis of minimum residuary disease ( MRD ) below clinical remittal reveals different dynamicss of lymphoma ( may specify those who will get worse, and those with remedy or who will get worse, and those with remedy or long-run remittal ) ; MRD techniques — extremely sensitive and loosely applicable ; may assist clinicians understand disease dynamicss on molecular degree ; allow polish of clinical presenting Benefits of MRD analysis: provides possible alternate parametric quantity for clinical response ; integrates biologic Features of tumour ; rei ¬Ã¢â‚¬Å¡ects pharmacogenetic traits and dose strength achieved in single patients ; identifies prognostic subgroups in B cell lymphoma ; independent predictive factor ; of import tool for indivtdualizing intervention Assessment of MRD ) : cytogenetics and fluorescent unmoved hybridisation ( FISH ) non sufficiently sensitive ( more utile for initial diagnosing and appraisal of malignant lymphoma ) ; flow cytometry and PCR chief methods ; i ¬Ã¢â‚¬Å¡ow cytometry — loosely applicable, fast, and provides quantitative consequences ; nevertheless, malignant lymphoma has partly unstable markers ( non reproducible in many patients ) ; in FL, sensitivenesss vary harmo nizing to benign hematogones ; consensus PCR — easy, rapid to perform.inexpensive, and stable, but non quantitative ; has low sensitiveness ; immunogen-based allele-specii ¬?c PCR — most advanced method ; sensitive, with- most advanced method ; sensitive, with quantitative consequences ; specific and extremely consistent ; nevertheless, labour-intensive and expenslve.PCR markers: irnntunoflobttlin cistrons — -heavy concatenation ( IgH ) an visible radiation concatenation ( IgK ) ; applicable in B cell non-Hodgkin lymphoma, chronic lymphocytic leukaemia, and acute leukaemia ; T cell receptor cistrons — – potentially available for T non-Hodgkin lymphomas and acute lymphoblastic leukaemia ; chromosomal translocations — T ( 1/14 ; 18 ) for FL ; T ( 11 ; 14 ) fer mantle cell lymphoma ( MCL ) ; translocations serve as marks in # 80 % of B cell lymphomas, in 60 % to 70 % of FL, and 30 % to 40 % af MCL ; these techniques quantify MRD in # 80 % of patients ; imrnunoglobulin heavy-chain venue – mast loosely applicable marker, rearrangement of V, D, and ] H parts in normal development of B cells ; sequence in this junctional part Acts of the Apostless as ‘DNA ‘ i ¬?ngerprint of cell ( identifiable by consensus PCR ) ; monoclonal rearrangement in lymphoma identified by gene-scan form with monoclonal extremum ; sequencing of monoclonal rearrangement allows allele-specific primer design to aim single patient ‘s sequence ; translocation marks — – T ( 14,18 ) breaktpoints in marks — T ( 14,18 ) breakpoints in different locations in cistron ; can measure # 70 % of patients with major breakpoint part ; assay developed by Biomed 2 Group usage to measure other countries ; translocations act as molecular markers ( eg, t [ 11 ; 14 ] ) Prognostic relevancy of MRD: shown in early surveies ; betterment in curative options led to increase in surveies look intoing MRD as alternate parametric quantity for forecast ; FL surveies — showed accomplishment of molecular remittal associated with improved forecast, irrespective of whether patients received ASCT, CTX, or rituximab Floridas: Lopez-Guillermo survey — – showed accomplishment of molecular remittal possible with standard-dose CTX without antibodies ; failure-free endurance significantly better in patients who achieve both clinical and molecular remittal ; Italian survey — -PCR negativeness associated with improved forecast in patients treated with CHOP entirely or R-CHOP ; Gribben survey — updated consequences show patients with sustained MRD negativeness ( by PCR ) after ASCT have continued long-run endurance ; recent Italian survey ( .2008 ) — – PCR negativeness most of import predictive factor both in patients treated with R- factor both in patients treated with R-CHOP and those who received RTX plus high-dose consecutive CTX ; outcomes improved with molecular remittal MCL: fewer surveies available ; several surveies conclude MRD has no predictive consequence in MCL ; relevancy seen after debut of RTX and ASCT ; monocentric survey — – patients consecutive monitored for MRD after R-CHOP, root cell mobilisation with dexaBEAM ( dexatnethasone_ carmustine [ BCNU ] , etoposide, cytarabine [ Ara-C ] and Alkeran ) before ASCT ; MRD ) negativeness associated with longer PFS ( 92 minute, vs 24 minute in MRD~positive patients ) and OS ; European web tests – MRD analysis done in patients under and & gt ; 65 year of age after initiation with immuno-CTX ; patients accomplishing clinical and molecular remittal have significantly longer continuance of response, irrespective of whether MRD achieved in blood or hone marrow ; molecular response after initiation superior predictive factor, compared to Mantle Cell International Prognostic Index ( MIPI ) mark and accomplishment of clinical response.Summary: PCR identifies low- and poor-risk groups in FL and MCL ; PCR holds true in multivariate analysis and is true in multivariate analysis and is independent of pretherapeutic hazard factors ; MRD negativeness achievable without ASCT Timing of MRD appraisal in FL: available surveies show relevant clip points for obtaining predictive informations ; German Lymphoma Study Group test – rating at diagnosing allowed presentation of association between low degree of go arounding lymphoma cells and molecular response ; MRRD dynamicss during initiation ( after 4 intervention rhythms ) showed that patients with rapid decrease of go arounding lymphoma cells have high chance of clinical remittal, compared to patients with slow response ; PFS with molecular remittal significantly greater than that with clinical remittal entirely ; postremission clip point of import if MRD used as foster parametric quantity ; multivariate analysis shows MRD ) better predictive factor than RTX treatnient, ASCT, or pretherapeiitic FL International Prognostic index ( FLIPI ) hazard factors ; extra informations analysis showed MRD position helps to define patients with different forecasts independent of clinical remittal position ; sustained MRD position — — forecast significantly better in patients with sustained molecular patients witch sustained molecular response in first twelvemonth after ASCT or intervention with interferon, compared to patients who developed MRD positiveness within first twelvemonth after ASCT or during care therapy.Timing of MRD appraisal in MCL: predictive relevancy shown after initiation and in postremission period ; increasing MRD ) degrees predict backsliding ; aged patients who stay in molecular remittal on care intervention have significantly longer continuance of response.Who should have MRD ) intervention: no current application of MRD ) to patients non enrolled in clinical tests Decisions: accomplishment of molecular remittal appropriate curative end for new clinical tests and interventions ; MRD appears executable for steering intervention, cut downing costs, and diminishing side effects ; identifies patient subgroups with durable remittals ; MRD allows individua lized hazard appraisal and intervention Future functions of MRD: rating of new intervention theoretical accounts and substances: designation of non respondents _for possible early intervention intensification ; way of care intervention ; usage in pre-emptive therapies ; orienting intervention to single hazard proi ¬?les.Mentions:1. Auto organ transplant for patients with Follicular Lymohoma in the epoch of rituximab: -JAMES O.ARMITAGE, MD.2. Minimal Residual Disease in Follicular and Mantle Cell Lymphoma: -Foundation: CHRISTIANE POTT, MD.Auto organ transplant for patients with Follicular Lymohoma in the epoch of rituximab: -JAMES O.ARMITAGE MD:2ND SubjectRENAL ISSUESAbstractionThe ends of this plan are to better the surgical and medical direction of locally advanced nephritic cell carcinoma and to avoid complications during public presentation of transdermal nephrolithotomy ( PNL ) . After hearing and absorbing this plan, the clinician will be better able to: 1. Surgically pull of f locally atlvancetl nephritic cell malignant neoplastic disease by separating between the demand for extremist V partial nephrectomy and acknowledging the indicants for lymphadenectomy. 2. Choose the most apprepriate drugs, based 0n their meachanisms of action, for the medical intervention of nephritic malignant neoplastic disease. 3. Sumarize the current position of neoadjuvant and accessory intervention ef nephritic malignant neoplastic disease. 4. Better his or her surgical technique for PNL. 5. Acknowledge the possible complications of PNL and their intervention, including hemorrhage, hurts to next variety meats, hypotension, infection, and delayed bleeding.Surgical direction of locally advanced nephritic cell carcinoma: – STEVEN C. CAMPBELL, MD, PhD:Background: 10 % to 20 % of all kidney malignant neoplastic disease ; strong informations run uping combination of surgery and systemic intervention best ; systemic intervention both neo adjuvant and adjuvant ; dei ¬?nitio n of locally advanced — kidney malignant neoplastic disease widening into adrenal secretory organs, venous system, regional nodes, or next variety meats ; T3a, T3b, T3c, T4, or node positive but MO ; divergent pathology — – lymphoma { see biopsy ) ; adrenocortical malignant neoplastic disease ( endocrinologist rating ) ; sarcoma ; transitional cell Carcinoma ( cystoscopy ) Preoperative steps: complete bowl readying because hemi colectomy may be required ; obtain consent for splenectomy, distal pancreaticlotomy, and partial hepatectomy ; in instance these processs necessary to obtain negative borders ; little per centum require preoperative embolization to minimise blood loss ; co-ordinate with vascular, Cardiovascular, and hepatic sawboness. Surgery: venous engagement — for degree 1 thrombi, topographic point Stansky clinch ; level 2 thrombi require consecutive clamping inferior vein cava ( lVC ) below, contralatera nephritic vena, and IVC above ; for degree 3, mobilise liver to obtain entree to retrohepatic IVC and clamp above and below tumour ; exposure — critically of import ; chevron scratch most common ; little per centum need thoracoabdominal incisien ; as necessary to let for en block deletion ( cardinal ) Lymphadenectomy: lymph node dissection controversial ; for lymphadenectomy, usage same templet as for testicle malignant neoplastic disease ; European organisation fo research and intervention of malignant neoplastic disease ( EORTC ) survey — showed no difference in complications or endurance between extremist nephrectomy with lymphadenectomy and extremist nephrectomy without lymph node dissection ; study criticized because extent 0f lymph node dissection non good defined and analyze groups may hold had low hazard for lymph node engagement ( ascertainment prejudice ) ; Mayo clinic survey — & gt ; 1600 patients ; showed 5 parametric quantities prognostic of increased likeliness of lymph node engagement, 1 ) atomic class 3 or 4, 2 ) sarcomatoid constituent, 3 ) really big 4 ) locally advanced tumour phase, and 5 ] tumour mortification ; seek to find ; parametric quantities preoperatively ( when possible ‘ ) , perform intraoperative frozen subdivision of lymph node, so make up one's mind if lymph node dissection needed ; talker ‘s attack — normally performs lymph node, dissection on younger patients but non on ; older frail patients ; forecast for node-positive malignant neoplastic disease — hapless ; 0 % to 20 % 5-yr endurance ; bulky lymph nodes may be worse prognostically than metastatic: disease ; patients with stray venous engagement have 40 % to 50 % remedy rates ; most T3a patients do good, but at higher hazard than patients with organ-confined disease ; other predictive considerations – histology ; border position ; tumour class ; algorithms availalale for anticipation of result. Medical Management of Locally advanced Renal Cell Carcinoma: -BRIAN I.RINI, MD.Mechanism of action of drugs for nephritic malignant neoplastic disease: mammalian mark of rapamycin ( mTOR ) inhibitors — these involve tract that regulates cell proliferation and metamorphosis in response to enviromental factors, associating cell growing factor receptor signaling via phosphatidylinositol-3-kinase ( Pl-3K ) to cell growing, proliferation, and an-giogenesis ; these drugs have non been studied as neoadjuvants or adjuvants ; vascular endothelial growing factor ( VEGF ) inhibitors -more relevant curative tract ; VEGF is cardinal regulator of physiologic angiogenesis ; more drugs available against VEGF, and they by and large have greater consequence ; bulk of nephritic cell carcinomas characterized laic mutant of V0n Hippel-Lindau ( VHL ) tumour suppresser cistron, ensuing it accretion of hypoxia-inducing factor ( HIF ) ; HIF is critical written text factor that leads to activation of m any mark genes.including VEGF ; VEGF is go arounding protein that binds to endotheliel cells and leads to permeableness, migration, and proliferation of tumour blood vas cells ; inhibitors of VEGF tract include little molecules that inhibitVEGF receptor and agents such as bevacizumab, sunitinib, and sorafenib. Neoadjuvant surveies: retrospective experience — 17 patients with kidney malignant neoplastic disease with primary tumour in topographic point ; intervention with sunitinib produced 30 % average volume decrease in tumour size ; growing curves show most decrease occurs in first 2 to 4 rhythms of intervention, so i ¬Ã¢â‚¬Å¡at period, so growing sketchs. Prospective test: patients with biopsy-proven kidney malignant neoplastic disease and unresectable priamary tumours ; treated with suntinib for 4 wk on drug and 2 wk off ; worsened clinically while off drug for 2 wk ; hence. intervention changed to uninterrupted dosing ; histology preponderantly clear cell carcinoma but non entirely, and most had metastatic disease ; about tierce of patients converted to resectable position ; & gt ; 70 % had somee tumour shrinking ; shrinking averaged 19 % ( # 1.5 % centimeter ) ; greatest consequence on clear cell carcinoma. Goal of neoadjuvant therapy: to bring forth cytoreduction of tumour ; avoiding high morbidity of extremist nephrectomy and leting intervention with partial nephrectomy. Safety: neoadjuvant therapy does non adversely affect surgical result ; in MD Andersen survey of # 6O patients who received targeted therapy ( largely bevacizumab ) so underwent cytoreductive neph1'ectonty, damage of superficial wotind mending 20 times more common in those who received targeted therapy than in matched controls ; so far ( & gt ; 100 patients ) , no big safety signals, eg, hemorrhage, coagulating. Accessory therapy: United States test of 1900 patients presently in advancement ; postnephrectomy patients randomized to 1 year of sunitinib, sorafenib, or placebo ; efficaciousness informations still several old ages off. Drumhead: -aggressive surgical direction basis of intervention for locally advanced kidney malignant neoplastic disease ; neoadjuvant VEGF-targeted intervention may take to enhanced feasibleness of resection in same patients ; stillinvestigational: no effectual adjuvant intervention for kidney malignant neoplastic disease at present.How to Avoid Cemplications While executing Transdermal Nephrolithotomy: — -MARSHALL L.STOLLER, MD. Background: key to success in transdermal nephrolithotomy ( PNL ) is for endourologist to derive appropriate entree ; make non trust on radiotherapist to execute ; appropriate landmarks are 2 i ¬?ngerbreadths sidelong from paraspinous.muscle and 2 finger's breadths below 12th rib ; 9 in 10 times puncture site in Petit ‘s trigon ; place patient prone with thorax blosters and articulatio genuss flexed ; utilize general. anaesthesia in instance of demand to entree airway ; extradural does non work { excessively hard to change over to general anaesthesia if desperately necessary ) ; radiologists puncture straight up and down, aiming nephritic pelvic girdle, but this does non enable urologist to make transdermal prcedure ; urine return dues non vouch entree to allow calyx. Nephrostomy tube entree: usage echography to assist direct needle ; purpose pelt posteriur calyx ; Technique for lower pole puncture: follow landmarks described above, , purpose for midaxillary line, progress acerate leaf, and draw C- arm toward you ; if needle below intended mark on x-ray, needle non steep plenty ; if needle above intended mark, travel deeper Technique for upper pole puncture: travel C- arm off from you ( indicates deepness and how far to progress acerate leaf ) coni ¬?rming entry: return of piss ; injection of retrograde methylene blue ; transition of i ¬Ã¢â‚¬Å¡oppy tip guidewire ( if needle in anterior calyx, K- wire does non progress beyond calyx into nephritic pelvic girdle ) ; ultrasonographic verification: injection of dilute contrast. Avoiding shed blooding complications: occur as consequence of progressing sheath excessively far ; distend piece of land merely to roll uping system ; go forth sheath somewhat outside roll uping system ; progressing excessively far cracks infundibulum. Other complications: pulsatile bloody outflow, rapid venous drainage into vena cava, fecal matters, air, gall ; inconsequential if recognized before dilation ; merely draw needle out and make another puncture ; make non necessitate to halt instance. Localization: text editions recommend taking for most inferior calyx ; survey of computed imaging ( CT ) from 100 patients showed 42 patients had 2 lower pole calyces and 59 had 3 lower pole calyces ; most median calyx will be anterior 93 % to 95 % of clip ; lower pole entree should be directed to most sidelong calyx ; if entree into posterior calyx non achieved, successful PNL non probably, because angle of anterior confronting calyx excessively short. Dilation: do non come in roll uping system, but attack every bit near as possible to roll uping systern ; rock should non be seeable on initial entry ( should he & gt ; 0.25 centimeter beyond ) ; guidewires – guarantee length adequate ; denominate working wires and safety wires: hydrophilic guidewires go in easy but besides fall out easy ; J & gt ; tipped guidewires do non punch roll uping system ; safety – urologist should have on lead spectacless to protect eyesfrom radiation and from sprinkling. Tips on technique: puncture easier in patients with history of PNL because kidney fixed ; in PNL-naive patients, kidney moves off from progressing tip { disconnected gesture required ) ; talker uses 18-gauge acerate leafs ( non 25~gauge ) ; uses really small fluoroscopy ; every bit long as wire moves back and Forth, exchange catheter can be advanced ; to minimise radiation, i ¬Ã¢â‚¬Å¡uoroscopy used merely when near roll uping? system ; catheter can be made less stiff by dunking it into microwaved saline or madestiffer by dunking it into ice slush. Amplatz system jobs: misidentify to progress Amplats sheath beyond cone ( likely to do hemorrhage ) ; go forth sheath outside roll uping system ( it will work its manner in during lithotripsy ) ; ldnked Dotter catheter ; fascial dilator unmatched with sheath ; inadequately advanced fascial sheath ; buried sheath in corpulent patients ( place sutura on terminal of sheath to ease retrieval ) ; balloon — – used merely in United provinces ( pneumatic lithoclast used in other states less expensive guarantee equal skin scratch ; as ballon dilates radially, it shortens lorigitudinally Complicating hurts: -bowel — set up separate drainage ( intestine separated from urinary system ) ; dual J and Foley catheters placed ; skin scratch enlarged and penrose drain placed ; patient placed on ternary antibiotics and low-roughage diet ; alert waiting ; bulk of hurts digressive ( non through-and-through ) , so colostomy non necessary ; postprocedural hemorrhagic — find whether due to hemorrhagic or infected daze ; temperature unreliiable ; organic structure temperature should be & gt ; 3S % ; temperature of 36A ° to 37A °C indicates possible sepsis ; infective complications — -appropriate antibiotic ; fulminant disease may be related to high endotoxin concentrations: low- force per unit area irrigation system ; hypothermia may confound diagnosing of urosepsis ; ticker for peripheral vasoconstriction bespeaking haemorrhagic daze V peripheral vasodilation bespeaking infected daze ; hurts to next variety meats — lung ( look into post procedural c hest X- beam ) ; incidence of pleural hurts # 12 % ( increases with supracostal puncture ) ; expression for pnettiuothorait or hydrothoralsi ( look for clear cost phrenic Angier on chest X ray ; intervention individualized ; see chest tubing ) ; liver † or spleen hurts ; vascular hurts ; delayed bleeding — in talker ‘s pattern, occurs in 1A °/o of instances ; disconnected brisk shed blooding due to pseudo aneurism ; occurs 6 wk after process ; dainty by ace selective angioembolizatien ( microcoils ) ; hazards include arterial dissection, nontarget embolization, and contrast-induced kidney disease ; highest hazard in diabetics Drain: nephrostomy tubes Council-tip: easy to rewire Endopyelotomy tubing: 14 Gallic to 8 Gallic ; can be hard to put Circle nephrostomy tubing: 2 entree piece of lands ; good for drawn-out drainage ; less likely to be dislodged.Foley balloon catheter: cut tip off ( like Councill catheter ) Pull-string: Cope-like tubings ; turn and draw out at same clip to avoid laceration of infundibulum. Malecot tubing: entrapment can happen in little nephritic pelvic girdle due to strong collagen span that forms through i ¬Ã¢â‚¬Å¡anges of tubing ; tissue must be cut in order to retreat entrapped tubing. Tract closing: tubeless — talker sees no advantage ; with or without dual J catheter ; styptic: agents and i ¬?brin sealers ( eg, FloSeal, Tisseel ) ; may restrict tract bleeding ; preplace occlusion balloon in roll uping system ; cauterant may diminish hemorrhage ; skin closing — better decorative consequence without Skin closing ; nephrostomy tubing — with or without skin suturas ; easy dislodged ; when tubing removed, do certain sutura comes with it ; place more than one nephrostomy tubing if necessary.