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By: A. Gnar, M.B. B.CH. B.A.O., Ph.D.
Deputy Director, University of Nebraska College of Medicine
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Recommendation in case of early progression In case progressive disease is diagnosed and the commencement of radiotherapy shall still be deferred, the recommended chemotherapy is the use of Cisplatin/Vincristin and Cyclophosphamide/Vincristin as in the case of allergy. Radiotherapy When adjuvant treatment is indicated, radiotherapy can be the first line treatment in case of a small residuum amenable to stereotactic or conformal irradiation. Older children, who upon indication for non-surgical therapy will receive external beam radiotherapy, will be irradiated with 54 Gy tumor dose conventionally fractionated at 1, 8 Gy given on five days per week. The specific aims of the radiotherapy study are a maximal sparing of organs at risk by applying highly focussed radiotherapy with modern planning and technical equipment (see section 15. In case, that it is necessary to give radiotherapy to younger children, it is recommended to contact the national study chairmen for radiotherapy details. A trial of prior chemotherapy could be considered to reduce the volume of a larger tumor. Qualitative changes of contrast enhancement will be described and correlated with response. Treatment of Pure Optic Nerve Tumors Where there is symptomatic or progressive tumor associated with demonstrable visual deterioration, and there is a strong need to initiate treatment to control symptoms and attempt to preserve vision, highly focussed radiotherapy should be considered. Children receiving chemotherapy for an isolated optic nerve glioma will not be eligible for randomization, yet. Thus, the treatment strategy for low-grade gliomas has to incorporate recommendations for second (and third) line treatment approaches. In each case the possibilities for a meaningful surgical intervention should be checked, as well. Progression during chemotherapy (early progression) in an older child ( 8 years) In case of progression at the first evaluation at week 24 or later during consolidation in a child older than 8 years, it should be assessed, if radiotherapy can be applied as second line therapy. Progression following the end of chemotherapy For children, who experience tumor progression following the end of therapy, several points have to be considered: age: Children still in the young age group, in whom radiotherapy should be further postponed, should receive second line chemotherapy. Children still in the young age group, in whom highly focussed radiotherapy appears possible, can go on to receive radiotherapy. Progression following radiotherapy For all children, who have received radiotherapy as their first treatment, chemotherapy is the first option in case of tumor progression. They will not be randomized and receive standard induction and consolidation with Vincristin and Carboplatin. They should not be irradiated unless chemotherapy and surgery options have failed. Preconditions to be stratified into this patient group: Tumor location: All tumor locations Histology: Low grade glioma according to section 9. Histologic diagnosis is primarily made by the local pathologist, yet central pathologic review is strongly recommended. Neuroradiologic criteria have to be fulfilled for all children not biopsied and central neuroradiologic review has to be obtained. Age eligibility: For patients with Neurofibromatosis age should not be used as a criteria for primary treatment stratification, since the restrictions for the use of primary radiotherapy apply to all ages.
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Agonists at the glycine site may be full (glycine, D-serine, and D-alanine) or partial (D-cycloserine). Cycloserine is an agonist at low concentrations and an antagonist at high concentrations. Histamine 731 Histamine, derived from L-histidine, is released from mast cells and causes vasodilation and activation of smooth muscle as well as gastric acid secretion. H1 blockers include diphenhydramine (Benadryl) which can be used to treat drug induced Parkinsonism or acute dystonia, or it can be employed for its hypnotic and anti-motion sickness 732 properties. Based on animal studies suggesting that depletion of histamine affects short-term memories, researchers are examining the possibility of using H3 autoreceptor antagonists in patients with memory problems. Release of substance P, which is inhibited by opiates, is associated with intense pain. Capsaicin, found in chili peppers, depletes substance P in nerve sensory terminals. Neuropeptides There are small proteins consisting of anything from two to dozens of amino acids. They are only deactivated outside the cell (by proteolysis), and have a long duration of action, their effects often persisting after they are degraded. Release of such peptides with serotonin appears to depend on an increase in electrical stimulation. These chemicals have been studied as possible antipsychotic agents, although with inconsistent results. Not surprisingly, therefore, cholecystokinin antagonists have also been looked at as potential anxiolytics. The mainly hypothalamic peptide melanin-concentrating hormone is important for feeding and energy balance because melanin-concentrating hormone knockout mice are thin, eat little and have increased rates of metabolic activity. Purine receptors Receptors for purines such as adenosine are divided into P1 and P2. When injected into the paraventricular nucleus, neuropeptide Y increases intake of food and water. Tyramine is formed in foodstuffs by decarboxylation of tyrosine during aging, ripening or decay. Side effects are mainly due to increased brain dopamine levels and include dyskinesia and nausea that may respond to dosage adjustment. Mode of action of antidepressants: a critique We tend to apply rationale for how a drug works after its benefits are noticed.
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According to Klein, we can handle loss better if we succeeded in childhood in relating to others, especially mother, as a whole person and were accepting of mixed feelings of love and anger. Lieberman(1983) holds that morbid grief may develop and become life threatening if bereavement is concealed from a patient and not discussed soon after the loss. Blame may be aimed at the self or projected onto ambulance men, doctors, or elsewhere. Anorexia, preoccupation, declines in efficiency and constant going over the past are the order of the day. Normally, with the aid of defence mechanisms, recovery takes place over some months. Factors associated with maladaptive grief in families include poor or unsupportive communication, disengagement and stifling of emotional expression, excessive guilt or anger, blaming or fighting with other members, inability to resolve normal daily family conflicts, inflexible roles, and persisting dependence on the lost person. In other words, anything that avoids, distorts, or prolongs grief augers badly for the future. Of particular interest is the case of a woman who lactated as part of an anniversary reaction to the delivery of her stillborn child. The defences employed include: searching by the bereaved; denial of the loss; talking about the loss ad infinitum; intellectualisation (talks without facing the associated feelings); identification with the deceased (dressing or talking like him, identical symptoms to those suffered by the deceased, etc. C Murray Parkes studied bereaved psychiatric patients and devised his famous division of bereavement reactions into grief and modified grief and non-specific reactions. Grief and modified grief: typical or usual grief (see above) follows fairly predictable course over a period of months, culminating in a return of interest in the affairs of the world. Chronic grief is a magnified reaction spread over a long period of time, and the person may have guilt, self-blame, identification symptoms and/or aggressive or delinquent behavior. In the very young or very old, inhibited grief is manifested by symbolic expression. In a 13 month follow up almost one in ten subjects showed chronic grief but none had delayed or absent grief. The intellectually disabled respond to loss, often for the only person who understands them, with behavior or neurotic problems. They may be kept back from the funeral or placed in an institution with unfamiliar surroundings, often facing strangers for the first time, when their carers die. Young and Papadatou(2000) state that children should be encouraged (but not pressured) to attend funerals, be supported by trusted elders, and be given an opportunity to see and touch the deceased.
Syndromes
- Cancer
- What other symptoms do you have?
- Faster than normal heart rate
- Pale color of the arm or leg (pallor)
- Persistent vomiting
- Other diseases of the arteries
- You lie on your stomach. If you have a transplanted kidney, you lie on your back.
- Not notice angina, the chest pain that warns of heart disease and heart attack
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Later Western studies of homosexual practices (Johnson ea, 2001; Jorm ea, 2002) found prevalence rates for males and females of 1-2. Too many studies have been confounded by recruitment in gay bars, and such results are unlikely to be typical of the wider population. Males who are raped by anal intercourse may be particularly upset if they experience erection and even ejaculation, not realising that this is a physiological response to pressure on the prostate. In women having menstrual periods, the late luteal phase occurs between ovulation and menstruation onset. In women without periods (including those who had the uterus removed) the timing of phases may need measurement of reproductive hormones. Ulrichs was fired as a legal adviser to a Hanoverian district court when it became known that he was homosexual. In 1914 the German homosexual psychiatrist, Magnus Hirschfeld (1868-1935) added his voice to the third sex idea. The determinants of sexual orientation and the timing of its development are poorly understood, and they are not necessarily the same in each sex. Most effeminate boys grow up to be heterosexual in orientation, and tomboyish behaviour in girls is less likely to cause parental concern. Psychoanalytic explanations for lesbianism have included a rejecting, emotionally distant mother and a powerful, frightening father. A minority of psychotherapists may still occasionally view homosexuality in a client as a pathology requiring treatment. Awareness of homosexuality can surface at widely different ages for different people. Cultures discriminating against gays and bisexuals may account, at least in part, for reports of high levels of mental disorder (especially in males: Fergusson ea, 2005) in these people. There are interpretative problems with twin research, and adoption studies are rare. Two small groups of neurones in the human hypothalamus show sexual dimorphism (inter-sex differences), being nearly twice as large in men as in women. Most adolescents who engage in homosexual behaviour will become heterosexual adults. Those who are stalked by people of the same sex as themselves get less consideration from law enforcement agencies that victims of opposite gender stalking. Increased risk for hepatitis B indicates multiple partners rather than individual sexual practices.
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