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Phase I feasibility trial of stereotactic body radiation therapy for primary hepatocellular carcinoma. Charged particle therapy versus photon therapy for patients with hepatocellular carcinoma: A systematic review and meta-analysis. Randomized clinical trial comparing proton beam radiation therapy with transarterial chemoembolization for hepatocellular carcinoma: results of an interim analysis. Consider referral to surgeon with hepatobiliary expertise and consider intraoperative photography. Other Clinical Presentations Note: All recommendations are category 2A unless otherwise indicated. Neoadjuvant chemotherapy regimens include: gemcitabine/cisplatin, gemcitabine/oxaliplatin, gemcitabine/ capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin, 5-fluorouracil/oxaliplatin, 5-fluorouracil/cisplatin, and the single agents gemcitabine, capecitabine, and 5-fluorouracil. Oncologist 2008;13:415-423) gThere are limited clinical trial data to define a standard regimen or definitive benefit. Neoadjuvant chemotherapy regimens include: gemcitabine/cisplatin, gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/ oxaliplatin, 5-fluorouracil/oxaliplatin, 5-fluorouracil/cisplatin, and the single agents gemcitabine, capecitabine, and 5-fluorouracil. Other Clinical oConsider biliary drainage for patients with jaundice prior to instituting chemotherapy. If there is a suspicious mass, a biopsy is not necessary as this can result in peritoneal dissemination. If the diagnosis is not clear, frozen section biopsies can be considered in selected cases before proceeding with defnitive resection. Consider pathologic re-review by a hepatobiliary pathology expert and/or speak to surgeon to check for completeness of cholecystectomy, signs of disseminated disease, location of tumor, and any other pertinent information. Review the pathology report for T stage, cystic duct margin status, and other margins. Higher yields may be seen in patients with T3 or higher tumors, poorly diferentiated tumors, or with a margin-positive cholecystectomy. Diagnostic laparoscopy should also be considered in patients with 1 any suspicion of metastatic disease on imaging that is not amenable to percutaneous biopsy. Routine resection of the bile duct for lymphadenectomy has been 2,3 shown to increase morbidity without convincing evidence for improved survival. Is port site resection necessary in the surgical management of gallbladder cancer. Jaundice predicts advanced disease and early mortality in patients with gallbladder cancer. Ablative radiotherapy doses lead to a substantial prolongation of survival in patients with inoperable intrahepatic cholangiocarcinoma: a retrospective dose response analysis. The choice of treatment modality may depend on extent/location of disease and institutional capabilities. Adjuvant therapy in the treatment of biliary tract cancer: a systemic review and meta-analysis.
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Sinusoidal spaces lined by endothelial cells and filled with blood, Kupffer Zone 2 Blood cells and stellate cells. No interface activity like on the right inflammation is hepatocytes), very irregular (projections extending contained with the portal tract. Interface Hepatitis Definitions Injury can lead to fatty metamorphosis of the hepatocytes. Know specifically because of how it applies to Reyes syndrome and fatty liver of pregnancy. Macrovesicular Microvesicular Steatosis Steatosis Definitions Various forms of injury. Left: balloon cells and Mallory bodies are the histological hallmark of steatohepatitis. Balloon Cells with Acidophil Body Mallory Bodies (Councilman Body) Cholestasis Hepatocytes form bile. This can occur either within the hepatocytes (L) or within the canalicular spaces (R). Ballooning degeneration and steatosis) Intracellular accumulations: fatty change, steatosis, iron accumulation Inflammation. Influx of acute or chronic inflammatory cells involving the portal tracts, interface and/or lobules. Vascular Abnormalities Resulting in ischemia Which can lead to hepatocyte and/or biliary injury. Regeneration/Fibrosis Serum Markers for Hepatic Injury How is the liver doing in this patient? Direct: conjugated only Plasma membrane enzymes Serum alkaline phosphatase Can also look at membrane enzymes. Infectious Most common form of injury viral hepatitis Viral Hepatitis Others. Portal tract with Chronic (at least 6 months): can still have ongoing inflammatory cells. Extends beyond limiting plate, causing active injury (portal, interface, or lobular hepatitis) with hepatocellular injury. Normal Hepatitis B hepatocytes: very granular Can present acutely or subclinically. Excessive ethanol consumption: one of the leading causes of liver disease th Alcohol abuse is the 5 leading cause of death in the U.
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Partial-reinforcement schedules are determined by whether the reward is presented on the basis of the time that elapses between rewards (interval) or on the basis of the number of responses that the organism engages in (ratio), and by whether the reinforcement occurs on a regular (fixed) or unpredictable (variable) schedule. Insight is the sudden understanding of the components of a problem that makes the solution apparent, and latent learning refers to learning that is not reinforced and not demonstrated until there is motivation to do so. Learning by observing the behavior of others and the consequences of those behaviors is known as observational learning. Learning theories can and have been applied to change behaviors in many areas of everyday life. Some advertising uses classical conditioning to associate a pleasant response with a product. Thompson studied her rapist throughout the incident with great determination to memorize his face. Thompson went to the police that same day to create a sketch of her attacker, relying on what she believed was her detailed memory. Consumed by guilt, Thompson sought out Cotton when he was released [1] from prison, and they have since become friends (Innocence Project, n. Picking Cotton: A Memoir of Injustice and Redemption Although Jennifer Thompson was positive that it was Ronald Cotton who had raped her, her memory was inaccurate. Jennifer Thompson is not the only person to have been fooled by her memory of events. And in more than three-quarters of these cases, the cause of [2] the innocent people being falsely convicted was erroneous eyewitness testimony (Wells, Memon, & Penrod, 2006). The two subjects of this chapter are memory, defined as the ability to store and retrieve information over time, and cognition, defined as the processes of acquiring and using knowledge. The cognitive approach became the most important school of psychology during the 1960s, and the field of psychology has remained in large part cognitive since that time. The cognitive school was influenced in large part by the development of the electronic computer, and although the differences between computers and the human mind are vast, cognitive psychologists have used the computer as a model for understanding the workings of the mind. In computers, information can be accessed only if one knows the exact location of the memory. In the brain, information can be accessed through spreading activation from closely related concepts. Although this is changing as new computers are developed, most computers are primarily serial?they finish one task before they start another. In the brain, the processes of short-term memory and long-term memory are distinct. In the brain (but not in computers) existing memory is used to interpret and store incoming information, and retrieving information from memory changes the memory itself. The brain is estimated to have 25,000,000,000,000,000 (25 million billion) interactions among axons, dendrites, neurons, and neurotransmitters, and that doesn?t include the approximately 1 trillion glial cells that may also be important for information processing and memory. Although cognitive psychology began in earnest at about the same time that the electronic computer was first being developed, and although cognitive psychologists have frequently used the computer as a model for understanding how the brain operates, research in cognitive neuroscience has revealed many important differences between brains [3] and computers.
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Why or how would it have occurred at the precise point of the beginning of history in Sumeria? The Law of Time defines this mechanistic organizing principle as the basis of the 12:60 artificial timing frequency (irregular twelve-month calendar combined with mechanical sixty-minute hour). Therefore, it was at this point at the beginning of history that artificial time and its progeny, mechanization, were actually registered as a thought form and thus became embedded in the as-yet-unconscious noosphere. Or, was it already embedded in the noosphere to be triggered at this precise point and if so, why and how? The point is that history, as it has evolved as the mainstream of civilization from Sumeria to the World Trade Center, has always been driven by the organizing principle of artificial time. It is artificial time that separates history from prehistory-and, as we shall see, from post-history as well. For the very purpose of the thirteen baktun Wave Harmonic of history is to encompass and coordinate the cycle of artificial time. In the higher knowledge of the Mayan understanding, it provided the perfect measure of the cycle of artificial time. From the perspective of the actual noospheric timing, which operates according to the natural 13:20 cosmic timing frequency, history is none other than a manifestation of artificial time. If the mathematical basis of mechanized time, and hence of mechanization, was already established at the beginning of history, then the end of history is the end of artificial, mechanized 12:60 time. The Lawof Time in Human Affairs Time codes and encompasses the whole of the cycle of artificial time through the thirteen baktun Wave Harmonic of history. What is important to grasp is that the entire cycle of artificial time was alreadyperceived by the Mayans as a phenomenon that could not endure more than the length of the cycle of thirteen baktuns. It was the result of a phenomenological experiment of living according to the synchronic cycles of the Mayan time science. After the death of my son in 1987, my wife and I began in earnest to follow the cycles encoded in the Mayan calendar: 13 day, 20-day, 52-day and 260-day cycles. Once I resigned my academic position in early 1989, we were swept by a wave of time that took us from the Rocky Mountains to Southern California to the Hawaiian Islands in the middle of the Pacific Ocean. There, in relative isolation from the rest of the world, we plunged into our experiment. Before we had truly settled in, the time wave took us to Switzerland, where on December 10, 1989, in the Museum of Time in Geneva, we were able to put our phenomenological experiment to the test-although we did not consciously realize at the time that we were doing so. There in the Museum of Time, essentially surrounded by examples of the his tory of the clock and mechanization, and because our perceptions had been altered by our living so completely by the various timing cycles encoded in the Mayan cal endar system, we were able to spontaneously perceive the existence of two timing frequencies. The natural frequency-the one we had been living-we understood instinctively to be the 13:20 timing frequency. The other frequency-the one en shrined in this Museum of Time-we understood to be the artificial 12:60 timing frequency. This realization of artificial time was rooted in the evident proof that the clock is based on the twelve-part division of a flat circle, a spatial plane that clearly has nothing to do with the dynamics of time. It is a manifest error, but one that humanity has taken for granted and endowed with all of the characteristics of "truth.