By Y. Curtis. Rose-Hulman Institute of Technology.
Bernd Sebastian Kamps Full Power versus Standby | 31 * * * That’s it! You have • a suitable language manual with audio files and order uroxatral with paypal, ideally buy generic uroxatral 10mg online, a translation and word lists 2 • Ear Memory You know how to • cut an audio files into snippets • browse saved snippets with the arrow buttons ‘1►’ and ‘1◄’ • use Full Power mode and Standby mode • activate the repeat mode and the continuous repeat mode Important Please note that you need to “cut” an audio into snippets only once because all snippets are automatically saved buy 10mg uroxatral mastercard. For all following sessions uroxatral 10mg low cost, stop using the AB button; instead, use only the middle- sized arrow buttons ‘1►’ and ‘1◄’. If you want to do AB exercises without saving the 2 snippets, go first into Ear Memory’s simple mode by long-clicking the folder button. Before going on to your next stop – the preliminary and final exams – remember your final target: understanding every single word and guess the correct spelling without reading the text, with eyes closed. Depending on your sustainable daily Power Listening, decrypting a one-hour audio will take you two to four months. Preliminary Exams Remember the ‘island uplift’ image. Like tectonic uplift, understanding a new language is a slow process: first a word, then a couple of words and half sentences; finally, complete sentences and then a whole text! Over the coming weeks you’ll reach your target of understanding every single word with eyes closed. While this process may seem to be slow, in reality your brain is working at full throttle and executing acrobatic feats. Not only will you learn more than 1000 new words within a few months, you will also reduce the ‘time-to- response’ between hearing a word and understanding its meaning, from several seconds to less than 0. As a matter of fact, the knowledge of words can vary widely, from low, moderate, elevated, high to perfect. The definitions: 5 seconds Low Low probability of usefulness 3 seconds Moderate Moderate probability of usefulness 1 second Elevated Elevated probability of usefulness 0. As a novice it may take you up to 5 or 10 seconds before finding a foreign language equivalent of corkscrew (German: Korkenzieher; French: tire-bouchon; Italian: cavatappo; Portuguese: saca-rolhas; Spanish: sacacorchos; Russian: штопор). Months and dozens of bottles later, you’ll do it in Ear2Memory 2016 34 | Ear2Memory. That’s a spectacular improvement of more than one order of magnitude, courtesy of your brain, the most complicated structure in the known universe. First, at the beginner’s level, after cutting the audio with the AB button into snippets of suitable length of generally 2 to 4 seconds, you’ll use the Arrow buttons ‘1►’ and ‘1◄’ to browse the snippets and repeat them until you clearly remember which sound corresponds to which word; what the words mean; and what the correct spelling is. You’ll probably stay at the beginner’s level for a few weeks, repeating the ‘Arrow Session’ for every audio at intervals that would ideally be no longer than 5 days. At the intermediate level you don’t need the translation anymore because you know the text by heart. Now do your first preliminary test: close your eyes before playing the next snippet and listen. If you don’t, open your eyes again and read the sentence several times. You can do this preliminary test in different ways: 1. Use the Arrow buttons to browse the snippets and listen to each snippet the number of times you need. Long-click the Repeat button (the second above the AB button) and set the number of loops to 3. Then (single-)click the Repeat button and listen without reading. Getting a triple shot Bernd Sebastian Kamps Preliminary Exams | 35 will allow you to understand most snippets word by word. Long-click the Shuffle button (right button above the AB button) and set the number of loops to 3. Then click the Shuffle button and listen without reading. Later reduce the number of loops to 2 in both the repeat and the shuffle mode. With only two opportunities, understanding is more challenging. First, check the word lists of your language manual regularly because you cannot understand 100% of a spoken script if you do not know 100% of the words. Second, preparing exams is easier when you do it with friends. If you have friends or family who want to learn the 2 same language, present them with the Ear Memory Power Listening Program and explain the benefits to them. In Bernd Sebastian Kamps Preliminary Exams | 37 particular, teach them how to use a worksheet to document their progress. Describe the extraordinary feeling of conquering, one after the other, ‘islands of total understanding’. After a few preliminary tests with the repeat and shuffle mode (see previous chapter), you’ll be ready for the final exam of your first audio file. Play the audio normally (without repeating the snippets), close your eyes and listen until the end. Question: Have you, yes or no, understood every single word? If you have, you have conquered your first island of total understanding! This is an exceptional achievement because it doesn’t happen often in a lifetime. As you will remember it forever, celebrate it with champagne! If you are younger, especially if you are in your twenties, you might need a few sessions less. Please don’t stop at your first experience of ‘total understanding’. Give you brain time to strengthen the connections (synapses) between the brain cells involved (neurons). Copy the audio file into a separate playlist on your smartphone. Over the coming weeks, the playlist will grow longer with more newly ‘conquered audio territories’. Make it a habit to listen to the playlist while you are in your car, on public transport, during other activities (cooking, jogging, etc. We have known people who used language audio files as ‘sleeping pills’ to fall asleep faster! I had no previous experience of Russian: no language course, no trip to Russia. The total audio time of the manual (Russisch mit System, Langenscheidt 2015, 18 lessons) was 43 minutes. My daily average of Power Listening was one hour and 22 minutes. The ‘discoveries’ of the ‘first islands of total understanding’ are marked in blue. Further Ear Memory Uses 2 Here, we have presented the power of Ear Memory. In addition to language learning, the app may be used in 2 numerous heterogenous settings. First, Ear Memory can be employed in areas of study that require the acquisition of huge numbers of new words; these include areas as different as medicine, law and economics. Second, 2 Ear Memory might be helpful during rehearsal of oral presentations (songs and poems at school, shows at colleges, scientific demonstrations at conferences, etc. It has not escaped our notice that the specific mechanism of Power Listening & Power Reading immediately suggests a possible benefit in the rehabilitation of stroke patients with memory deficits. Phase II + III How shall you continue your language project after this Phase I?
MSD has announced that they will stop the manufacture and distribution by December 2015 generic 10 mg uroxatral fast delivery. Drug Profiles 683 Cidofovir Manufacturer: Gilead Sciences order uroxatral line. Indications and trade name: CMV retinitis in patients without renal dysfunction uroxatral 10 mg low cost, mainly in cases of resistance/contraindications to gancyclovir or foscavir generic 10mg uroxatral otc. Some experts use cidofovir for PML (off-label use), although efficacy is uncertain. Side effects: renal failure, which can occur even after 1 dose of cidofovir. Less fre- quent: neutropenia, dyspnea, alopecia, decreased intraocular pressure, iritis, uveitis. Fever, chills, headache, rash, nausea and vomiting are usually caused by probenecid and should subside within 12 hours. Complaints may be lessened with food intake, antipyretics, or antiemetics. Warnings: renal function (serum creatinine, electrolytes, proteinuria) should be checked before each dose of cidofovir. Cidofovir is always contraindicated at serum creatinine levels >1. Cidofovir should be given according to the following scheme: –3 h 2 g probenecid (4 tablets of 500 mg), prior to that 20-30 drops metamizole plus 50 mg prednisolone –3 to –1 h 1000-2000 ml 0. Probenecid has drug interactions with acetaminophen, acyclovir, angiotensin con- verting enzyme inhibitors, aminosalicylic acid, barbiturates, benzodiazepines, bumetanide, clofibrate, methotrexate, famotidine, furosemide and theophylline. Clarithromycin Manufacturer and trade names: diverse manufacturers, therefore several trade names, such as Clarithromycin-CT, Klacid, Mavid Indications: prophylaxis and treatment of MAC disease. Clarithromycin is a component of the following (selection): • Mavid film-coated tablets, 500 mg • Klacid film-coated tablets, 250 mg 684 Drugs Dosage: with MAC 500 mg BID, both for primary prophylaxis and for maintenance therapy. For respi- ratory tract infections 250 mg BID will suffice. Side effects: mainly gastrointestinal complaints such as nausea, vomiting, abdomi- nal discomfort and diarrhea; in addition, allergic skin reactions, headache, elevated transaminases, alkaline phosphates and bilirubin. Interactions, warnings: no concurrent treatment with rifampin, carbamazepine, cisapride, terfenadine, pimozide and other macrolide antibiotics such as erythro- mycin or azithromycin. Lopinavir and ritonavir increase clarithromycin levels. If administered concurrently, oral treatments with clarithromycin and AZT should be taken 1–2 hours apart. Comments: macrolide antibiotic with a shorter half-life than azithromycin. Clindamycin Manufacturer and trade names: diverse manufacturers, therefore several trade names, such as Aclinda, Clindabeta, Clindamycin-ratiopharm, Sobelin. Indications: for HIV-infected patients, mainly cerebral toxoplasmosis. Also for serious infections by anaerobes, staphylococci (because of good tissue and bone penetration also used in dentistry). Dosage: 600 mg IV QID or 600 mg oral QID (always with pyrimethamine and leucovorin). In renal failure, reduce dose to a quarter or a third of the normal dose. Allergies are also frequent and often require discontinuation. In cases of infection with Clostridium difficile “Pseudo- membranous colitis”, the clinical spectrum ranges from mild watery stool to severe diarrhea with blood and mucous, leukocytosis, fever and severe abdominal cramps which may progress to peritonitis, shock and toxic megacolon. Warnings: clindamycin is contraindicated in inflammatory bowel disease and antibi- otic-induced colitis. Caution with reduced hepatic or renal function and in asthma. With occurrence of diarrhea on clindamycin, discontinue and give metronidazole (or vancomycin). Comments: still used in patients with cerebral toxoplasmosis. Indications and trade names: HIV infection, as a pharmacoenhancing drug in com- bination with elvitegravir, atazanavir and darunavir. No dose adjustment in patients with renal insufficiency. However, combination with tenofovir is not recommended in patients who have an estimated creatinine clearance below 70 mL/min. Drug Profiles 685 Side effects: increase of serum creatinine (often less than 0. In combination with atazanavir, the risk for hyperbilirubinemia seems to be higher than with ritonavir. Interactions, warnings: cobicistat is a potent inhibitor of CYP3A which acts as a boosting agent. Among many others, carbamazepine, sildenafil, rifampicin, ergotamines, lovastatin and simvastatin are contraindicated. Do not combine with efavirenz, nevirapine, etravirine and PIs other than atazanavir or darunavir. Comments: cobicistat is approved as a boosting agent for elvitegravir, atazanavir and darunavir. For detailed information see page: 91, 102 Combivir Manufacturers: ViiV Healthcare. Indications and trade name: HIV infection, as a component in combined therapy for ART naïve or pretreated patients. In cases of reduced renal function (creatinine clearance below 50 ml/min) and anemia, Combivir should be replaced with the individual drugs to allow for adjustment of 3TC and AZT doses. Comments: the first fixed-dose combination in HIV medicine (1998). While it is prescribed less, it remains an alterna- tive in certain circumstances. For detailed information see page: 77 Complera (Europe: Eviplera) Manufacturer: Gilead Sciences and Janssen-Cilag. Indications and trade name: adult treatment-naïve patients with HIV RNA less than or equal to 100,000 copies/mL, and in virologically suppressed adult patients on a stable antiretroviral regimen in order to replace their current regimen. Nutritional drinks are not enough for proper absorption. In cases of reduced renal function (cre- atinine clearance below 50 mL/min), Complera should be avoided. For side effects, see sections on tenofovir (caution with renal function, Fanconi syndrome), rilpivirine and FTC. Interactions, warnings: for interactions, see also sections on tenofovir, rilpivirine and FTC. Complera should not be coadministered with the following drugs, as sig- nificant decreases in rilpivirine plasma concentrations may occur due to CYP3A enzyme induction or gastric pH increase: carbamazepine, phenytoin, rifabutin, rifampin, proton pump inhibitors (PPIs), St. In patients with HIV-1 RNA greater than 100,000 copies/mL, the virologic failure rate conferred a higher rate of overall treatment resistance and cross-resistance to NNRTIs compared to Atripla. Should not be used in highly viremic patients, due to high resistance rates. This well-tolerated FDC can be difficult to take because of its food requirement and drug interactions. For detailed information see page: 190 Co-trimoxazole (trimethoprim-sulfamethoxazole) Manufacturer and trade names: diverse manufacturers, therefore several trade names, such as Cotrim-ratiopharm, Cotrimstada, Eusaprim. Indications: prophylaxis and treatment of Pneumocystis pneumonia (PCP). Prophylaxis and treatment (second-line) of cerebral toxoplasmosis. Also for other infections, for example urinary tract infections. As PCP therapy: 5 mg/kg (based on TMP) orally or IV q 8 h x 21 days, therefore usually 5 to 6 ampules each 80/400 mg TID. With reduced renal function, use half-dose with creatinine clearance of 15 to 50 ml/min. High intravenous doses also cause myelotoxicity (anemia, neu- tropenia), nausea, vomiting, headache, raised transaminases.
More variability in consolidation and maintenance may affect PFS when drastically cheap uroxatral 10mg on-line, some physicians are even ﬂoating the idea of the death comparing early ASCT versus late approaches cheap uroxatral 10mg without prescription, these 2 studies will of ASCT based on the results of the CRd regimen without intensive solve many issues regarding the role of systematic frontline ASCT therapy despite the studies not being randomized purchase generic uroxatral on line. Preliminary randomized data favor early ASCT plus novel agents over novel agents alone In the future buy uroxatral 10mg visa, biology might help in the treatment At the end of 2014, only few data from prospective and retrospec- decision tive trials are available to solve the outstanding issue of early versus Our understanding of the biology of MM has increased markedly late ASCT. At the 2010 ASH annual meeting, Siegel et al reported over the last years. Systematic cytogenetic evaluations in clinical important results of the outcome of len/dex followed by early ASCT trials have revealed critical adverse prognostic factors, including in the ECOG E4A03 study. Upon completing 4 cycles of therapy, patients had the are progressing toward a consensus regarding the deﬁnition of option of proceeding to ASCT or continuing on the assigned high-risk disease,35,38 few cooperative groups are currently able to therapy. In this post hoc, retrospective analysis of patients younger propose a risk-adapted strategy incorporating frontline ASCT based than 65 years and including only those surviving the ﬁrst 4 cycles of on well-deﬁned initial biological and/or clinical characteristics. This therapy, OS at 3 years was 94% with early ASCT and 78% in is particularly true outside of clinical trials, when patients are treated patients continuing protocol therapy. Although a direct comparison on a routine basis in the “real-life” setting. Additional correlative between patients undergoing early ASCT and those who did not was studies including genomic and cytogenetic analyses are being not possible because the assignment to early ASCT versus no early performed in the 2 ongoing prospective EMN2 and IFM/DFCI 2009 ASCT was not randomized, the survival with ASCT at 3 years trials comparing upfront versus delayed ASCT mentioned, with the 252 American Society of Hematology speciﬁc goal of deﬁning subgroups of patients who may beneﬁt or an advisory committee and has consulted for Celgene and from the different therapeutic approaches to develop a valuable Janssen. Off-label drug use: Induction with novel agents for the risk-adapted strategy. In the United States, 2 groups are currently treatment of frontline multiple myeloma. The Little Rock group in Arkansas proposes the application of different therapeutic options depending on the results obtained with gene-expression proﬁling. The second Hospital Hoˆtel-Dieu, Place Ricordeau, 44093 Nantes, France; group, at the Mayo Clinic in Rochester, Minnesota, is proposing the Phone: 33-240-083271; Fax: 33-240-083250; e-mail: mSMART (Mayo Stratiﬁcation for Myeloma and Risk-adapted philippe. Therapy) algorithm, a single-center consensus opinion taking into account genetically deﬁned risk status, including cytogenetics, 39 References gene-expression proﬁling, and plasma-cell-labeling index. A prospective, randomized classiﬁcation allows for the deﬁnition of 3 risk groups, high, trial of autologous bone marrow transplantation and chemotherapy in intermediate, and standard, which determine the treatment ap- multiple myeloma. The high- and intermediate-risk groups are routinely 1996;335(2):91-97. High-dose chemotherapy with stem cells after 4 cycles of induction is proposed, but ASCT is not hematopoietic stem-cell rescue for multiple myeloma. Approach to the treatment of best possible options to patients, but this will not solve the issue of multiple myeloma: A clash of philosophies. Current trends in supported by the whole myeloma community. Nevertheless, at the autologous stem cell transplantation for myeloma in the era of novel current time, such a tailored approach based on the results of large therapies. High-dose therapy and and biological feature, as well as taking into account the “dynamic” autologous peripheral blood stem cell transplantation in multiple prognostic factor that is the response to initial therapy,6 is not myeloma: upfront or rescue treatment? Results of a multicenter sequential randomized trial. GIMEMA Italian Myeloma Unlike the case with acute leukemia, in 2014, we have not yet Network. Bortezomib with thalidomide plus dexamethasone compared reached the point of a risk-adapted strategy in MM. Moreover, the with thalidomide plus dexamethasone as induction therapy before, and conclusions of the 2 most important prospective clinical trials aimed consolidation therapy after, double autologous stem-cell transplantation at comparing frontline versus late ASCT in the context of novel- in newly diagnosed multiple myeloma: a randomised phase 3 study. Therefore, the optimal approach to the treatment of 8. Bortezomib plus dexametha- MM is still to propose the most effective treatment for all patients, sone versus reduced-dose bortezomib, thalidomide plus dexamethasone as induction treatment before autologous stem cell transplantation regardless of risk status and including the so-called ”good risk” in newly diagnosed multiple myeloma. Programa para el Estudio y la mortality rate of less than 2%, which is lower than that reported by Terape´utica de las Hemopatías Malignas/Grupo Espan˜ol de Mieloma physicians favoring continuous upfront therapy without ASCT, (PETHEMA/GEM) group. Superiority of bortezomib, thalidomide, and based for example on the lenalidomide-dexamethasone combina- dexamethasone (VTD) as induction pretransplantation therapy in mul- tion. Similarly, the argument of cost does not support the use of tiple myeloma: a randomized phase 3 PETHEMA/GEM study. Randomized, multicenter, phase including for example lenalidomide and carﬁlzomib. It was recently 2 study (EVOLUTION) of combinations of bortezomib, dexametha- suggested that early ASCT could potentially be a relatively cost- sone, cyclophosphamide, and lenalidomide in previously untreated effective treatment option compared with a delayed approach. Recent numbers from both the EBMT41 and Center for International 11. International Myeloma Blood and Marrow Transplant Research (CIBMTR)42 registries Working Group. International Myeloma Working Group consensus clearly indicate that MM remains by far the principal indication for approach to the treatment of multiple myeloma patients who are ASCT in the United States and Europe and that an increasing candidates for autologous stem cell transplantation. Multiple myeloma: ESMO 2011), illustrating the profound importance of the technique for the clinical practice guidelines for diagnosis, treatment and follow-up. Bortezomib-based versus nonbortezomib-based induction treatment before autologous stem-cell Disclosures transplantation in patients with previously untreated multiple myeloma: Conﬂict-of-interest disclosures: P. Bortezomib-thalidomide- sone as a frontline treatment for multiple myeloma. Phase II clinical and correlative tion in patients with newly diagnosed multiple myeloma. Bortezomib consolidation negativity in newly diagnosed multiple myeloma (MM) patients [ab- after autologous stem cell transplantation in multiple myeloma: a Nordic stract]. Strategies for induction, autologous hematopoi- tion therapy in patients with newly diagnosed multiple myeloma. Early versus delayed autologous Hematol Educ Program. MM)/PETHEMA (Programa para el Estudio de la Terape´utica en 32. Outcome with lenalidomide Hemopatías Malignas) Cooperative Study Groups. Multiparameter ﬂow plus dexamethasone followed by early autologous stem cell transplanta- cytometric remission is the most relevant prognostic factor for multiple tion in the ECOG E4A03 randomized clinical trial [abstract]. Blood myeloma patients who undergo autologous stem cell transplantation. Major tumor shrinking and lenalidomide signiﬁcantly improved survival of young newly diagnosed persistent molecular remissions after consolidation with bortezomib, multiple myeloma patients [abstract]. Blood (ASH Annual Meeting thalidomide, and dexamethasone in patients with autografted myeloma. Minimal residual disease cyclophosphamide-lenalidomide-dexamethasone and lenalidomide- assessed by multiparameter ﬂow cytometry in multiple myeloma: prednisone maintenance vs lenalidomide alone in newly diagnosed impact on outcome in the Medical Research Council Myeloma IX myeloma patients [abstract]. Combining ﬂuorescent in Group consensus statement regarding the current status of allogeneic situ hybridization data with ISS staging improves risk assessment in stem-cell transplantation for multiple myeloma. Gene-expression signature of stem-cell transplantation for multiple myeloma. Prediction of survival in Lenalidomide maintenance after stem-cell transplantation for multiple myeloma. Sonneveld P, Schmidt-Wolf IG, van der Holt B, et al. Bortezomib and chromosomal instability signatures in high-risk patients and hyper- induction and maintenance treatment in patients with newly diagnosed diploid signatures in low-risk patients: a study of the Intergroupe multiple myeloma: results of the randomized phase III HOVON-65/ Francophone du Mye´lome. Improvement in long-term LDH and t(4;14) and/or del(17p) identiﬁes patients with multiple outcomes with successive total therapy trials for multiple myeloma: are myeloma (MM) treated with front-line autologous stem cell transplanta- patients now being cured? Management of newly diagnosed tion as induction and consolidation followed by lenalidomide mainte- symptomatic multiple myeloma: updated mayo stratiﬁcation of my- nance in multiple myeloma patients: a phase II study of the Intergroupe eloma and risk-adapted therapy (mSMART) consensus guidelines 2013. Lenalidomide plus early versus late autologous stem cell transplantation in multiple high-dose dexamethasone versus lenalidomide plus low-dose dexameth- myeloma. Passweg JR, Baldomero H, Bregni M, et al, for the European Group for open-label randomised controlled trial. Current use and outcome of hematopoietic stem nosed multiple myeloma. Green1,2 1Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute, Department of Haematology, University of Cambridge, Cambridge, United Kingdom; and 2Department of Haematology, Addenbrooke’s Hospital, Cambridge, United Kingdom Our understanding of the genetic basis of the Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) has moved forward at a staggering pace over the last decade. With the discoveries of underlying mutations in JAK2, MPL, and, most recently, calreticulin (CALR), that together account for 90% of patients with MPNs, these conditions are now among the best characterized of hematological malignancies. While JAK-STAT pathway activation has been shown to be central to the pathogenesis of the MPN phenotype, the mechanism by which mutant CALR alters cellular function to result in myeloid proliferation remains unclear.