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The history of Aarhus began as a fortified Viking settlement founded in the 8th Songles and with the first written records stemming from the bishopric seated here from at least The city was founded on the northern citied of a fjord at Fuji oriental massage Charlotte Lund natural harbour and the primary driver of growth was for centuries seaborne trade in agricultural products.
In the 19th century it was occupied twice by German troops during the Schleswig Wars but avoided destruction. As the industrial revolution took hold, the city grew to become the second-largest in the country by the 20th century. Today, Aarhus is at the cultural and economic core of the region and the largest centre for trade, services and industry in Jutland.
The city ranks as the 92nd largest city in Singles in tri cities Aabenraa European Unionand as number among world cities. It is also a top conference city in the world.
Major Danish companies have based their headquarters here and people commute for work and leisure from a wide area in Region Midtjylland.
Being the Danish city with the youngest demographics, with 48, inhabitants aged under 18, [2] Aarhus is also the second fastest growing Danish city, with an average growth of 4, people per annum since Aarhus is known for its musical history. In the s, many jazz clubs sprang up around the city, fuelled by the young population. By the s, the music scene diversified into rock and other genres. Some Danish cities resisted the new spelling of their names, notably Aalborg and Aabenraa. The renaming Where are the hookers in Flong into effect on 1 January Whichever spelling local authorities choose, most newspapers and public institutions will accept it.
It is notable that the "Aa" spelling has been in use the longest.
In the buildings and adjoining archaeological layers, everyday utensils like combs, jewellery and basic multi-purpose Professional dating websites Herning from approximately the year have been. The centre of Aarhus was once a pagan burial site until Aarhus's first church, Holy Trinity Church, a timber structure, was built upon it during the Sintles of FrodeKing of Jutland, around The rampart was later reinforced by Harald Bluetoothand together with the town's geographical placement, this Aabfnraa that Aros was an important trade and military centre.
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There are strong indications of a former royal residence from the Viking Age in Vibya few kilometres south of the Aarhus city centre. The bishopric of Aarhus dates back Aaberaa at least when Adam of Bremen reported the bishop Reginbrand attended the synod of Ingelheim in Germany. The growing influence of the Church during the Middle Ages gradually turned Aarhus, with its bishopric, into a prosperous religious Best escort agencies Viborg.
The charter is the first official recognition of the town as a regional Mature Skive bbw and is by some considered Aarhus's birth certificate. The official Old Ringsted grannies religious status spurred growth so in the defensive earthen ramparts, ringing the town since the Viking age, were abandoned to accommodate citkes.
Parts of the ramparts are still in existence today and can be experienced as steep slopes at ln riverside and they have also survived in some place names of the inner city, including the streets of Volden The Rampart and Graven The Moat.
Inoctroi was imposed in larger Danish cities which changed the layout and face of Aarhus over the following decades. Wooden city walls were erected to prevent smuggling, with gates and toll Aabenfaa on the major thoroughfares, Mejlgade and Studsgade.
The city Sing,es funnelled most traffic through a few streets where merchant quarters were built. Following the Napoleonic warsDenmark lost Norway and was excluded from international trade for some years which caused a recession for Aarhus's trade-based economy that lasted until the s.


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Me who browse the forums and read stuff knows that the 2nd Azerite Power is defense and won't be suggested by AMR unless it has some kind of speed buff.
My suggestion is to add a tooltip over an empty 2nd Azerite Power that reads "This is purely defense options, take the one to your liking and play style." or something similar. Maybe even add a question mark icon over it.


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GES Extends Reopening for Shs 3 Students to Sunday, August 25
The Ghana Education Service (GES) has rescheduled the reopening date for third-year Senior High School (SHS) students from Monday, August 19 to Sunday, August 25, 2019.
GES extends reopening for SHS 3 students to Sunday, August 25
A statement issued on Friday and signed by the Director-General of the GES, Prof Kwasi Opoku Amankwa, said the new date was arrived at after a joint meeting of stakeholders involving management of the GES, Conference of Heads of Assisted Secondary Schools (CHASS), Association of Principals of Technical Institutions (APTI) and the Labour Unions in the Pre-Tertiary Education Service.
READ ALSO: We Won't Go Back to School on 25th August – SHS Teachers
It explained that it was expected that the new date would enable parents and students, teachers and education workers to prepare adequately for the reopening of the new academic year.
"It was concluded that the reopening of schools for SHS 3 on the 19th of August, 2019, be shifted to Sunday, 25th August, 2019," the statement said.
READ ALSO: We Have Not Scrapped Bece, Disregard Rumours – Ges
"This means that form 3 students are to report for the 1st Semester 2019/2020 academic year on Sunday, 25th August 2019 for academic work to begin on Monday, 26th August 2019," it added.


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Panera Asiago Bagel Nutrition
Calorie count of Panera Bread Blueberry Bagel. When you won't locate various low calorie, less fat, or perhaps low carbohydrate puddings, one or two addresses can be bought in "mini" sizes and can end up being an alternative.. To kit additional healthy proteins with your hoagie, choose Whole Grain breads, that aggregates six grms every cut.
While many products at a restaurant are available in huge servings, you could have the choice of obtaining a half-order which could decrease the calorie consumption of the food. You may also mix-and-match diverse what to produce a delicious meal—or several, getting out of the relationship with left over spots to shut down and collect at a later time.
Consuming 50–100 grms each day
Evaluating the vitamins and minerals of the foods will help you better determine what meals works, or perhaps against you. When there is a issue with bagels, it can the typical deli kleines, rundes br?tchen may possess approximately three hundred and fifty calorie consumption and 55 to sixty grms of carbohydrates—equal in carbs to 3 or perhaps 4 pieces of breads.
In the event that you're sense just a little uninspired with barbequed poultry, Panera's containers provide you with various other healthy proteins alternatives just like cage-free ova and edamame. Every single pan can be underneath 380 unhealthy calories and includes below 15g of excess fat, despite the fact that full-sized meals can be bigger in salt and sugars than any other selections.
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Allow me to share 18 balanced food to have within this diet plan. A ketogenic diet plan is quite frequently used to cut back seizures in individuals with epilepsy. Yet , it includes already been connected to a variety of more benefits, which include weight-loss, much better blood glucose control, and possibly a much healthier cardiovascular system. Second, you'll need to skip out on the medial side, considering that the alternatives happen to be loaf of bread, debris or perhaps a great apple—all that contain glucose and cabohydrate supply.
Reduced carb
weight loss plans assist you to lose fat
To kit additional healthy proteins with your hoagie, match up with Whole Grain loaf of bread, that aggregates 6th grms every piece. As you may anticipate in the chain's identity, recently cooked loaf of bread can be Panera's claims to celebrity. You won't locate virtually any specifically low carbohydrate alternatives over the food handling business menu, but once you want a platform for the purpose of creating a healthy and balanced hoagie, there are several alternatives to find. In line with the provider's web page, their 2000th coffeehouse exposed in 2016.
- Meaning taking on fruits, fruit and vegetables, fiber rich foods, and hard working liver with your every day diet plan.
- You can also mix-and-match numerous what to produce a delicious meal—or several, getting out of the relationship with left over spots to shut down and collect at a later time.
- While many products at a restaurant are available in huge servings, you could have the choice of obtaining a half-order which could decrease the calorie consumption of the food.
- Minimizing oily food whilst raising proteins is actually a method to consume healthful whilst living a proper way of life.
Panera Asiago Bagel Nutrition. You require regarding 75 fewer calorie consumption each day every single 10 years in your life, generally. Odds are in case you didn't realize that, you might have recently been consuming in method that isn't commensurate with natural fact or maybe the fact of the way of life.


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BLC Expands Accredited Testing Portfolio
'BLC' is a name you can trust in the leather testing arena. As a measurement of BLC's technical capabilities, we ensure our testing services are accredited by the United Kingdom Accreditation Service (UKAS), the national accreditation body to the ISO 17025 standard. All accreditations provide verification of BLC's technical competence and integrity as an industry leading UK-based test house. BLC is a UKAS accredited testing laboratory, reference no. 0076.
BLC have significantly expanded their accredited testing portfolio to include 23 new methods in leather testing, textile and upholstery testing and chemical compliance testing. Newly accredited tests include:
Leather Tests
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Chemical Compliance Tests
View BLC's latest schedule of accreditation on the UKAS website.
Do you want fast and reliable results you can trust?
Contact BLC for your product testing needs via email to firstname.lastname@example.com or telephone their UK-based test house directly on +44 (0)1604 679999.
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The team worked with over 200 companies in the leather, textile, and chemical industries on achieving better chemical...
Deforestation is one of the most high-profile challenges for the leather industry. Understand how supply chain mapping can...
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Showing all 4 results
To'ak chocolates. Known as the most exclusive and at the same time most expensive chocolate bars in the world. Made entirely in Ecuador.
Fortunately for people like us who don't have hundreds of euros ready for a chocolate bar, they now also have the 'Signature' line. The same chocolate, but without all the bells and whistles, wooden packaging and accompanying artwork. Still pricey, also within the world of better chocolates. But they have passed our test sessions well, so we are happy to offer them.
Available soon: To be available by the end of January 2019 at the latest.


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This idea has been merged into another idea. To comment or vote on this idea, please visit ACU-I-1556 Time tracking for 1099 Subcontractor.
A number of companies hire contractors to do work and enter hours, however, there is no 1099 option for employees. It only exists for Vendors. It would be ideal to have either employees attached to a Vendor account or for an employee to have 1099 capabilities.
The cost would still be allocated to the project, but the payment would come from a generated bill.
Currently we are manually creating an AP Bill based on the hours entered into the system. The ideal solution would be to use the employee class. If Employee Class = Contractor then time card will generate an AP Bill as opposed to flowing through the timecard allocation process.
From where do you actually pay out the contractors? How do you record the payment in your GL?
The numbers would come based on the Employee Cost and Hours Entered into time cards.
The 1099 data is calculated based on Accounts Payable Bills that were entered. You can't create AP bills for employees. If we allow printing 1099 for employees, from where would you suggest gathering the numbers?


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If you were denied a car loan, but you still need a car, it's time to start saving for one. Building a cash reserve might be tough if your budget is already stretched thin, but money-saving tips will help you to make the process less painful.
Start tracking all your expenses.
As they say, "money likes to be counted." If you don't know where your money goes to, you don't know what expenses to cut. So the next step will be:
Temporarily cut some of your expenses.
Eating out can be expensive – try to eat homemade food. It will not only save you some money, but home-made food is much healthier. Take a break from the gym. You can still workout at home or take a run in the park. As a bonus, you will get more vitamin D (according to Nutrition Research, there is 41.6% deficiency of Vitamin D in US adults.) Consider public transit, where possible, and save on gas.
Consider debt consolidation
If you have credit card debts, talk to your bank or credit union and discuss options of debt consolidations with lower interest rates. If you were successful in that, put aside the amount you saved towards your next car purchase.
Change Providers
According to Mission Fed CU, "switching providers often come with saving on your bill as well as extra incentives."
Keep the change
Keep the change is one of the tip #DebtFreeDays from SchoolsFirst FCU, "keep your spare change and use [SchoolsFirst's] free coin machines to turn them into cash […]"
When you save enough to buy a car with your cash, call Autoland LLC (800) 234-6999, and we will help you to find the best car for your budget.
P.S. Consider buying one of the top most affordable new cars.
The content provided in this blog consists of the opinions and ideas of the author alone and should be used for informational purposes only. Autoland LLC disclaims any liability for decisions you make based on the information provided. References to any specific commercial products, processes, or services, or the use of any trade, firm, or corporation name in this article by Autoland LLC is for the information and convenience of its readers and does not constitute an endorsement, control or warranty by Autoland LLC.


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Take advantage of this fully furnished villa in the serene neighborhood of Deer Creek with a large two-car garage. This prominent property is located in the pristine and quiet gated community of Palmer Ranch. The home is 10 minutes away from Siesta Key beach and only 2 minutes to the popular Legacy Trails which includes 22 miles of biking trails. There is also a lovely full-sized outdoor community pool and walking trails within Deer Creek community. You are sure to find yourself relaxing and relishing your time at this tranquil location.
Listing courtesy of BERKSHIRE HATHAWAY HOMESERVICES FLORIDA REALTY. Selling Office: COLDWELL BANKER RES R E.
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Dewi, Ratna Sari (2015) PERBEDAAN HASIL BELAJAR KIMIA SISWA MENGGUNAKAN MODEL PEMBELAJARAN TGT (TEAMS GAMES TOURNAMENT) DENGAN MEDIA MIND MAPPING DAN MOLYMOOD PADA POKOK BAHASAN HIDROKARBON. Jurnal Title, 07 (01). ---.
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This research was purpose to know the effect of TGT (Team Games Tournament) learning model with Molymood to student chemistry learning outcomes on teaching Hydrocarbon. The type of this research is quasy-experiment using random group pretest-posttest design. The 2 class of X students of some SMA Negeri in Medan used as a sample, a class was teach by TGT model using mind mapping media and another with molymood media. The research data analysed using two side T-test. The research result show that there is a differences of student learning outcomes between student teach using TGT model with mind mapping media accompanying molymood media. It shows that the student teaching by TGT model using molymood give increasing learning output approx 70.9%, while TGT model with mind mapping media 54.2%
|Item Type:
|Teams Games Tournaments (TGT); Mind Mapping; Molymood; Hydrocarbon
|Q Science > QD Chemistry
Q Science > QD Chemistry > QD450 Physical and theoretical chemistry
|Program Pasca Sarjana > Pendidikan Kimia
|Depositing User:
|Mr Renaldi Syafaruddin Akbar
|Date Deposited:
|07 Apr 2016 07:41
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Purpose: P-glycoprotein is an efflux pump for many drugs including doxorubicin and paclitaxel. This study evaluated the coadministration of these drugs with the P-glycoprotein inhibitor valspodar (PSC 833) with the aim of determining: (a) maximum tolerated doses (MTDs) of doxorubicin followed by paclitaxel (DP); (b) the MTD of DP combined with PSC 833 (DPV), without and with filgrastim (G-CSF); and (c) the pharmacokinetic interactions of PSC 833 with doxorubicin and paclitaxel.
Experimental Design: For the first cycle, patients received doxorubicin as a 15-min infusion followed by paclitaxel as a 1-h infusion. For the second cycle, patients received reduced doses of DP with PSC 833 at 5 mg/kg p.o., four times a day for 12 doses.
Results: Thirty-three patients with various refractory malignancies were enrolled and assessable. The MTD of DP without PSC 833 was 35 mg/m2 doxorubicin and 150 mg/m2 paclitaxel. The MTD of DPV without G-CSF was 12.5 mg/m2 doxorubicin and 70 mg/m2 paclitaxel. The dose-limiting toxicity for both DP and DPV was neutropenia without thrombocytopenia. With G-CSF, the MTD for DPV was 20 mg/m2 doxorubicin and 90 mg/m2 paclitaxel. No grade 4 nonhematological toxicities were observed. Five partial and two minor tumor remissions were observed. Paired pharmacokinetics with and without PSC 833 revealed substantial drug interactions with both doxorubicin and paclitaxel.
Conclusions: PSC 833 can be administered safely with doxorubicin and paclitaxel. The pharmacokinetic profiles of these drugs are significantly affected by PSC 833, requiring ∼60% dose reductions for equivalent degrees of myelosuppression.
P-gp3 is a transmembrane efflux pump for many drugs including anticancer agents such as Vinca alkaloids, anthracyclines, taxanes, and epipodophyllotoxins (1) . Encoded by the MDR1 gene (2) , this multidrug transporter is highly expressed in many clinically resistant tumors at diagnosis and/or relapse. Expression of MDR1 is an adverse prognostic factor in several cancers (3, 4, 5, 6, 7, 8, 9, 10) , which suggests that P-gp-mediated drug resistance may contribute to a significant portion of treatment failures (11, 12, 13) . Several noncytotoxic drugs such as verapamil, phenothiazines, and cyclosporines have been shown to modulate this mechanism of MDR by inhibition of P-gp function (14, 15, 16, 17, 18, 19, 20, 21, 22) .
PSC 833 is a nonimmunosuppressive, nonnephrotoxic analogue of cyclosporine and is ∼2- to 10-fold more potent than cyclosporine in its ability to inhibit P-gp (23, 24) . PSC 833 alters the pharmacokinetics of etoposide causing a decrease in CL, doubling of plasma t1/2, and an increase in the dose-normalized plasma AUC (25, 26, 27) . Significant pharmacokinetic effects are also observed when PSC 833 is given in combination with paclitaxel (28) or doxorubicin (29, 30) . These effects are in part a consequence of inhibition by PSC 833 of endogenous P-gp, which is expressed at high levels in the biliary canaliculi, renal tubules, and intestinal lumen. The drug interactions necessitate dose reductions of the chemotherapeutic agents to avoid excessive toxicity. The P-gp substrates doxorubicin and paclitaxel have recently been used in combination, particularly in breast cancer (31, 32, 33, 34, 35) . We report here results of a Phase I study, in which we assessed the effect of PSC 833 on the MTD, pharmacokinetics, and pharmacodynamics of doxorubicin in combination with paclitaxel.
Patient Selection
Patients were eligible if they had a pathological confirmation of incurable malignancy and had measurable disease. No chemotherapy for 3 weeks prior to study entry (6 weeks for nitrosoureas) or no radiation therapy for 4 weeks prior to study entry was permitted. Patients were required to have an Eastern Cooperative Oncology Group performance status 0–2 and an anticipated survival of >3 months. Adequate renal function (creatinine < 1.5 mg/dl) and hepatic function (serum bilirubin, <1.0 mg/dL, serum aspartate amino transferase <3 × upper limit of normal) was required. Normal bone marrow function was required as indicated by white blood count greater than 3,500 per mm3 and platelet count greater than 100,000 per mm3. Prior doxorubicin treatment was allowed but could not exceed a cumulative dose of 300 mg/m2. LVEF was required to be ≥45% at rest by radionuclide ventriculogram. Patients with active central nervous system metastases were excluded. The protocol was approved by the Panel on Medical Human Subjects of Stanford University.
Chemotherapy Administration
To obtain paired pharmacokinetic sampling data, patients were hospitalized in the Clinical Research Center of Stanford University Medical Center. Approximately 30 min prior to chemotherapy, all of the patients received i.v. premedication with dexamethasone 20 mg, famotidine 20 mg, and diphenhydramine 25 mg to prevent hypersensitivity reactions to paclitaxel, as well as an antiemetic (ondansetron 10 mg i.v.) prior to the administration of doxorubicin.
Patients received doxorubicin by i.v. 15-min infusion, followed by paclitaxel 1 h i.v. infusion, for the first cycle. Three weeks later, patients received reduced doses of doxorubicin and paclitaxel (as described below) in combination with PSC 833. PSC 833 (provided by Novartis Pharmaceuticals Corporation, East Hanover, New Jersey) was administered at 5 mg/kg p.o. four times daily for a total of 12 doses using the liquid formulation. If significant toxicity particular to PSC 833 occurred (i.e., grade 3 ataxia), the PSC 833 dose was reduced to 4 mg/kg. Chemotherapy was administered on day 2, after the fifth or sixth dose of PSC 833.
Patients continued to receive this combination of doxorubicin, paclitaxel, and PSC 833 every 3 to 4 weeks, with assessment of toxicity and tumor response. In the absence of grade 3 or 4 neutropenia, or other grade 3 toxicity, the dosage of chemotherapy was increased stepwise, to ensure that the patient was receiving a therapeutic dose. If grade 3 or 4 neutropenia occurred the doses remained fixed for that patient. If grade 3 or 4 toxicity occurred (excluding neutropenia, hyperbilirubinemia, and nausea/vomiting), the patient was removed from the study or treated at a lower dose of chemotherapy, as agreed on by patient and investigator. On documentation of disease progression, or StD after six cycles of the combination treatment, the patient was removed from the study.
Study Design
Separate dose escalation cohorts were planned for cycle 1 (DP) versus cycle 2 (DPV), as further described. If one patient among the first three in a cohort developed grade 3 or 4 toxicity (excluding neutropenia, hyperbilirubinemia, and nausea/vomiting), the cohort was expanded to six. If two of these six patients developed grade 3 or 4 toxicity (exclusions as noted above), this represented dose-limiting toxicity, and the maximal tolerated dose was defined as the next lower dose level.
Because grade 4 neutropenia represents a significant risk to patients, but is no longer usually considered a dose-limiting toxicity, we decided that a >50% incidence of grade 4 neutropenia was unacceptable, even if there were no other dose-limiting toxicities in the cohort. Grade 4 neutropenia was, therefore, handled as follows. If any of the three patients in a cohort of three had grade 4 neutropenia, the cohort was expanded from three to six. If one to three of six patients in a cohort of six had grade 4 neutropenia, without fever, the next cohort was enrolled and treated at the next dose level. If 4 of 6 patients had grade 4 neutropenia, the cohort was expanded to 8 or 10 patients (see cohort I of DP and cohort III of DPV).
Once the maximally tolerated dose of doxorubicin and paclitaxel (DP) with PSC 833 was determined, we proceeded to establish the maximally tolerated dose with G-CSF (Neupogen; Amgen, Thousand Oaks, CA) support. Patients were treated at the maximally tolerated dose of DP for one cycle, and then, on cycle 2, received doxorubicin, paclitaxel, and PSC 833 (DPV) with G-CSF support, at one dose level higher than that previously established as the maximally tolerated dose without G-CSF support. This was based on our finding that the dose-limiting toxicity with DPV is neutropenia. Patients were enrolled in cohorts of three, until the maximally tolerated dose was determined.
Dose levels (all doses are in mg/m2) were as follows. The initial starting doses for DP alone were 40 and 175 mg/m2 and for DPV were 10 and 70 mg/m2, respectively. Because of dose-limiting neutropenia observed in the first cohort of patients receiving DP (40/175), the second cohort was treated at a lower dose level of 35/150, respectively. For DPV, dose escalation entailed doses of 12.5/70 and then 15/80.
Dose escalation by cohort and determination of the MTD was based on dose-limiting toxicities observed during the first cycle of DP or DPV, respectively. After cycle 2, a patient whose nadir showed only grade 1 or 2 neutropenia received a higher dose of chemotherapy, with the increase according to the scheme presented above to ensure that patients were not undertreated.
Assessment of Toxicities and Antitumor Response
Quantitative hematological and nonhematological toxicities were assessed by the common toxicity criteria of the National Cancer Institute (36) . Patients were monitored closely and nadir counts checked on days 11 and 15. Imaging studies were performed after every two cycles of treatment.
Although antitumor efficacy was not a primary objective of the study, tumor response rate and time to progression were recorded. Partial remission was defined as a 50% reduction in the sum of products of the two largest perpendicular diameters of all of the measurable lesions for at least 4 weeks and with no new lesion or progression of assessable disease. Minor response was defined as partial regression of disease of <50%. StD was any measurement not fulfilling the criteria for response or progression and lasting at least 4 months. Tumor progression was defined as a 25% or greater increase in tumor size measured as the bidimensional product of perpendicular diameters. The time to progression was measured from the time of first study drug administration to documented progressive disease.
Cardiac function was monitored in all of the patients. All of the patients had a baseline radionuclide ventriculogram (MUGA) at rest to determine the LVEF. Patients had a repeat study after every two cycles of treatment once the doxorubicin cumulative dose reached 300 mg/m2. Patients were taken off study if there was a >10% decrease in the absolute LVEF or a decline in the resting ejection fraction to ≤45%.
Cerebellar ataxia has previously been shown to be a limiting toxicity for PSC 833 (12) . This toxicity was graded as follows: grade 1, slight subjective sense of incoordination, without difficulty in walking and a normal exam; grade 2, definite subjective incoordination on walking but able to walk without assistance and, on physical examination, broad-based gait and/or mild dysdiadochokinesis and difficulty walking heel to toe; grade 3, unable to walk without assistance from another person or a walker and, on examination, a markedly abnormal gait and inability to walk heel to toe; grade 4, unable to walk with assistance.
For grade 3 or 4 ataxia, the PSC 833 dose was reduced to 4 mg/kg, and the patient was observed closely for resolution of toxicity. If grade 3 ataxia still persisted, one PSC 833 dose was held, and the patient restarted at 4 mg/kg. If grade 3 ataxia still persisted, the PSC 833 dose was further reduced to 3 mg/kg.
Pharmacokinetic Studies of Doxorubicin, Paclitaxel, and PSC 833
Pharmacokinetic studies of doxorubicin and paclitaxel were performed on 25 patients during their first cycle of doxorubicin and paclitaxel alone, and subsequently during their first cycle with PSC 833. Plasma and urine levels of these drugs were analyzed. Samples of venous blood (2 ml, one pediatric green top tube) were drawn and patients asked to collect all of the urine for 48 h after the initiation of the chemotherapy infusions, in 24-h aliquots. These samples were analyzed for doxorubicin, paclitaxel, and their respective metabolites by HPLC. For the first doxorubicin and paclitaxel cycle, blood samples were drawn just prior to the chemotherapy infusion, and then 0.5, 1, 2, 3, 4, 6, 8, 12, 18, 24, 36, and 48 h after initiation of the paclitaxel infusion.
Venous sampling during the combined treatment with PSC 833 was similar to that for the chemotherapy alone with the addition of limited sampling for peak and trough PSC 833 values. Whole blood PSC 833 concentrations were determined using the ANAWA whole blood RIA kit for PSC 833 (ANAWA laboratories AG 8602; Zurich, Switzerland).
Doxorubicin Assay.
Doxorubicin and its major metabolite doxorubicinol were analyzed by reverse-phase HPLC using modifications to prior methods (37) . Concentrations were calculated using peak area ratios of doxorubicin or doxorubicinol to internal standard in relation to the standard curve. The coefficient of determinations (r2) for all of the standard curves was >0.95. The lower limit of quantitation was 2 nm, and the interday and intraday coefficients of variation were <5.0%.
Paclitaxel Assay.
Paclitaxel was analyzed by reverse-phase HPLC using modifications to a prior method (38) . Retention time of 6-OH-paclitaxel was determined using a supernatant of human liver microsomes containing metabolized paclitaxel (39) . Retention times were: 6-OH-paclitaxel (6.5 min), cephalomannine (9.1 min), and paclitaxel (10.9 min). Concentrations were calculated as peak area ratios of paclitaxel or metabolite:internal standard relative to the standard curve. The coefficients of determination (r2) for standard curves were >0.95. The lower limit of quantitation was 0.01 μm, and the interday and intraday coefficients of variation were <8.0%.
Pharmacokinetic Analyses
Standard, noncompartmental pharmacokinetic calculations of parameters from doxorubicin and paclitaxel concentration-time data were performed using the XLPHARM M-IND program (Dr. V. K. Piotrovskij, VKPharmacokinetics, Turnhout, Belgium) implemented on Microsoft Excel (version 5.0, Microsoft Corporation, Redmond, WA; Ref. 40 ). The AUC was normalized for differences in the delivered dose by dividing the AUC by the dose administered in mg/m2. Volume of distribution at steady state (Vss) and clearance were derived from traditional noncompartmental equations in which: where T is the duration of the infusion, clearance is the dose divided by the plasma AUC, and AUMC is the area under the first moment curve. The peripheral volume of distribution (Vp) was calculated by subtracting the central volume of distribution (Vc) from Vss. The MRT was calculated using the equation: where T is the duration of drug administration. Time above threshold concentrations for paclitaxel (>0.05 or >0.025 μm) were determined by simulating the decay of a terminal first-order time point concentration (C) over a range of time points (Cp1–Cp2), using the derived terminal elimination rate constant (Kz) value, fitted to the equation: using Scientist 2.0 (MicroMath Scientific Software, Salt Lake City, UT).
Statistical Considerations
Pharmacokinetic data were tested using the Wilk-Shapiro statistic and were found to be abnormally distributed (41) . Differences in pharmacokinetic data and parameters between the doxorubicin or paclitaxel groups in the absence and presence of treatment with PSC 833 were compared using the Wilcoxon signed rank test. The a priori level of significance was P = 0.05 (two-sided).
Patient Characteristics
Thirty-nine patients with advanced cancers were entered into the trial between June 1995 and June 1998. Six were excluded from this report because they did not receive DPV because of progressive disease (n = 3), toxicity (n = 2), or patient's choice (n = 1). The demographic characteristics of the 33 assessable patients are shown in Table 1⇓ . Disease categories of these patients were: ovarian cancer (n = 15), lung cancer (n = 7), sarcoma (n = 3), and 1 each for germ cell, fallopian tube, breast, colon, neuroectodermal, peritoneal, vaginal, and thymic cancers. The median age was 53 years (range, 33–76 years). The patients were pretreated with a mean of 3.4 regimens (excluding hormonal and radiation therapy) prior to study entry. There were 25 women and 8 men, reflecting the relatively large number of patients with ovarian cancers.
Determination of MTD
Doxorubicin and Paclitaxel without PSC 833.
The toxicities for the two dose levels of DP alone are shown in Tables 2⇓ and 3⇓ . Seven patients were entered on the starting dose of 40 and 175 mg/m2, and six of seven experienced grade 4 neutropenia. Although there were no cases of fever with neutropenia at this dose level, the high rate of grade 4 neutropenia was considered unacceptable without the use of G-CSF. The next dose level was reduced to 35 and 150 mg/m2, and this was defined as the MTD because 5 of 10 patients had grade 4 neutropenia with 2 of 10 also experiencing fever. Subsequently, 16 more patients were entered at this dose level. Overall at this dose, 12 of 26 patients had grade 4 neutropenia and 11 of 26 had grade 3 neutropenia. Five of these 26 patients had fever associated with the neutropenia.
Doxorubicin and Paclitaxel with PSC 833.
The toxicities observed for DPV without and with G-CSF are presented in Tables 4⇓ and 5⇓ . The MTD of this combination was 12.5 mg/m2 doxorubicin and 70 mg/m2 paclitaxel with three of six patients experiencing grade 4 neutropenia, and two with both fever and neutropenia (Table 4)⇓ . No significant thrombocytopenia (platelets <100,000/mm3) was noted in cohorts I through III. It is evident from Tables 2⇓ and 4⇓ that cohort I of DP produced a degree of myelosuppression very similar to that of cohort III of DPV, with mean neutrophil nadir counts of 290 and 350/mm3, respectively. Likewise, cohort II of DP was similar in myelosuppression to cohort II of DPV (Tables 2⇓ and 4⇓ ), with mean neutrophil nadir counts of 930 and 1,000/mm3, respectively.
The next twelve patients (cohorts IV and V) were treated with escalating dose of DPV with G-CSF support. DPV was well tolerated by six patients at doxorubicin 20 mg/m2 and paclitaxel 80 mg/m2 with one (of six) grade 3 and one (of six) grade 4 thrombocytopenia without evidence of bleeding. Only one grade 4 neutropenia was observed. The use of G-CSF resulted in higher nadir counts (mean/median 2,000/mm3) compared with the earlier cohorts. Six patients were treated at the next dose level of 20/90 (cohort V) and this dose defined the MTD because two of six patients had grade 4 neutropenia with fever and two of six patients experienced grade 3 or 4 thrombocytopenia, with a total of three of the six patients experiencing dose-limiting toxicities (Table 4)⇓ .
The most frequent toxicity for both DP and DPV was hematological as shown in Tables 2⇓ and 4⇓ . Grade 4 neutropenia was observed in 18 of 33 patients treated with DP alone and 12 of 20 patients treated with DPV. Fever with neutropenia was observed in 5 of 33 patients on DP and 5 of 20 treated with DPV. Two patients developed fever and neutropenia despite prophylactic G-CSF in cohort V, Table 4⇓ . Significant thrombocytopenia (<50,000/mm3) was seen in two of six patients in cohort IV and in three of six patients in cohort V.
Nonhematological toxicities (grades 2 and 3) for DP alone are shown in Table 3⇓ and for DPV in Table 5⇓ . No grade 4 toxicities were observed. Transient reversible hyperbilirubinemia was an anticipated side effect of PSC 833 (41) and was seen in 15 of 33 patients. One patient developed a cardiac arrhythmia that required treatment. Other reversible side effects observed were nausea/vomiting (n = 5 for DP; n = 8 for DPV), constipation (n = 1 for DP; n = 8 for DPV), fatigue (n = 6 for DP; n = 7 for DPV), and skin rash (n = 2 for DP and n = 1 for DPV).
Cerebellar neurotoxicity attributed to PSC 833 (42) is shown in Table 6⇓ for each of the cohorts studied. In 9 patients, PSC 833 produced significant (grade 3), but rapidly reversible, ataxia requiring dose reduction of PSC 833 to 4 mg/kg in eight patients and to 3 mg/kg in two patients. Only two of these nine patients had peak PSC 833 blood levels >3000 ng/ml (7020 and 4310 ng/ml, respectively)
Antitumor Responses
Five partial responses were noted among 33 assessable patients (non-small cell lung, 12, 6, and 4 months; ovarian cancer, 5 months; and fallopian tube cancer, 11 months), as well as two minor responses (ovarian cancer, 6 months; mediastinal germ cell tumor, 4 months). Six patients had StD (three ovarian cancers and one sarcoma for 4 months, two non-small cell lung cancers for 6 and 9 months, respectively).
Pharmacokinetic Evaluations
The median peak whole blood PSC 833 level in 15 patients evaluated was 3090 ng/ml (range, 1460–7020 ng/ml) with a median trough level of 3400 ng/ml (1460–5500 ng/ml). Paired pharmacokinetic analyses with and without PSC 833 were performed in 18 courses of doxorubicin and in 16 courses of paclitaxel. PSC 833 resulted in substantial drug interaction with both doxorubicin and paclitaxel. In the 18 patients with pharmacokinetic analyses of doxorubicin, an average dose reduction of 65% resulted in an actual doxorubicin AUC decline of 35% during PSC 833 treatment. This was primarily a reflection of a 57% reduction in doxorubicin peak concentration at the end of drug administration. However, PSC 833 treatment resulted in an 86% increase in the dose-normalized AUC of doxorubicin, which correlated with a 44% decrease in CL, a 77% increase in the terminal phase t1/2 and an 84% increase in MRT (Table 7)⇓ . Despite the lower actual AUC values, the longer t1/2 and MRT values indicate that coadministration with PSC 833 results in a prolonged low-level exposure to the drug as illustrated in the concentration-time profile for a patient receiving doxorubicin ± PSC 833 in Fig. 1⇓ . PSC 833 had a greater effect on doxorubicinol AUC, causing an increase of 259% for this metabolite.
In 16 patients with pharmacokinetic analyses of paclitaxel, coadministration of PSC 833 treatment resulted in a 158% increase in paclitaxel Vss, a 213% increase in (Vp), a 96% increase in the terminal phase t1/2, and a 31% increase in time >0.025 mm concentration (Table 8)⇓ . There was no apparent effect on the AUC of paclitaxel. However, the longer t1/2 and MRT values indicate that PSC 833 prolongs the duration of exposure to paclitaxel as illustrated in the typical concentration-time profile for a patient receiving paclitaxel with and without PSC 833 in Fig. 2⇓ . PSC 833 had a greater effect on 6-OH-paclitaxel, causing a 222% increase in the AUC of this metabolite.
MDR1 gene expression is seen in a variety of malignancies, both at initial diagnosis and at time of relapse (1, 12) , and is one of the mechanisms implicated in clinical drug resistance. Modulation of MDR with inhibitors of P-gp may improve the efficacy of chemotherapy (12 , 22) . Doxorubicin and paclitaxel are substrates of P-gp (the protein encoded by the MDR1 gene) and are active agents in many solid tumors. Therefore, modulation of resistance to these drugs is an attractive concept. A large number of clinical trials of reversal of MDR have been undertaken with drugs that are relatively weak P-gp inhibitors, often producing limiting toxicities at doses below those necessary to inhibit MDR (11, 12) . PSC 833 is 2- to 10-fold more potent than its parent compound cyclosporine for modulating MDR in vitro and in vivo (23, 24) . In this study, target levels of PSC 833 capable of MDR1 modulation (>1000 ng/ml) were achieved in all of the 15 patients thus evaluated.
On the basis of our previous experience and those of others using these agents, we anticipated significant pharmacokinetic interactions between PSC 833 and the MDR-related agents, and, therefore, used lower initial doses of doxorubicin and paclitaxel when given with PSC 833 (26 , 29 , 30 , 43) . The MTD of DP alone was 35 mg/m2 and 150 mg/m2 respectively. The addition of PSC 833 to DP resulted in substantial hematological toxicity even at the lowered doses, and, as a result, the MTD of the combination was 12.5 mg/m2 doxorubicin and 70 mg/m2 paclitaxel. This degree of dose reduction is not surprising. Previous studies with paclitaxel or doxorubicin when administered as single agents combined with cyclosporine or PSC 833 also produced marked alterations in pharmacokinetics, necessitating 50 and 60% dose reductions, respectively (12 , 28, 29, 30) . With the addition of G-CSF, we were able to escalate doses of doxorubicin only marginally because of thrombocytopenia. The MTD of the combination with G-CSF support was 20 mg/m2 doxorubicin and 90 mg/m2 paclitaxel.
The addition of PSC 833 significantly prolonged the plasma t1/2 and MRT of both doxorubicin and paclitaxel. The observed increase in myelosuppression when PSC 833 was combined with doxorubicin and paclitaxel is most likely related to these pharmacokinetic effects. The pharmacokinetic interactions of these drugs are consistent with clinical, laboratory, and animal model observations (26 , 44, 45) and corroborate the need for dose reduction of doxorubicin and paclitaxel when they are combined with PSC 833.
Previously, Gianni et al. (46) reported a correlation of the degree of neutropenia to the duration of paclitaxel concentration above 0.05 μm. In paired analyses, we found no difference in time above 0.05 μm of paclitaxel for DP alone versus DPV, despite the fact that the dose of paclitaxel was 2-fold higher in the DP cycle. The prolongation of the elimination phase of paclitaxel by PSC 833 was manifested by a significant increase in time above 0.025 μm for paclitaxel in the DPV cycle. These effects of PSC 833 on the disposition and distribution of paclitaxel are likely to have contributed to the relatively high myelosuppression seen with the low dose of doxorubicin and paclitaxel in DPV.
There was a marked effect of PSC 833 on the disposition of the major metabolites doxorubicinol and 6-OH-paclitaxel. This is consistent with our previous observations with cyclosporine and doxorubicin in humans (47) and with in vitro studies of paclitaxel and cyclosporine (39) . However, the clinical importance of the interaction between PSC 833 and the metabolites is likely to be less than for the parental drugs, because these metabolites are markedly less cytotoxic in vitro (48, 49) .
The formulation of paclitaxel contains cremophor EL, which has been shown to cause alterations in the pharmacokinetics of the doxorubicin (50 , 51 , 52) . In this study, because the paclitaxel dose was lowered with PSC 833, the decreased amount of cremophor EL would have had minimal effects during the PSC 833 cycle.
Recently, Gianni et al. (53) , using a schedule of administration similar the one in our study, i.e., a bolus of doxorubicin, followed 15 min later with a 3-h infusion of paclitaxel, found a modest interaction when doxorubicin administration preceded paclitaxel. These effects were observed during the β t1/2 phase with no significant change in the terminal (γ) t1/2, which suggests that the observed changes could be attributable to alterations in pharmacokinetics when the paclitaxel vehicle, cremophor EL, was at its maximal concentrations. In contrast, we found significant increase in dose-normalized AUC (86%) and terminal elimination t1/2 (77%), as well as other parameters (Table 7)⇓ . Similar findings were observed with the major metabolite doxorubicinol. These data support the contention that cremophor EL did not contribute significantly to the observed effects on doxorubicin pharmacokinetics.
Paclitaxel was well tolerated as a 1-h infusion as has been reported previously (54) . The main toxicity of both DP and DPV was hematological (Tables 2⇓ and 4⇓ ). PSC 833 caused a reversible grade 3 ataxia in nine patients, which required dose reduction to 4 mg/kg in eight patients, and 3 mg/kg in two patients. The mechanism of the cerebellar toxicity of PSC 833 is unknown, but is probably not related directly to inhibition of P-gp, because some other inhibitors of P-gp including cyclosporine do not cause ataxia, and P-gp knockout mice are not ataxic (55) . The transient hyperbilirubinemia produced by PSC 833 is similar to that of high-dose cyclosporine (42) and is likely attributable to inhibition of the canalicular multispecific organic anion transporter (cMOAT/MRP2; Refs. 56 , 57 ), and/or other transporters of bilirubin and bilirubin glucuronide in the biliary canaliculi.
Tumor regression was observed in 7 of 33 patients and another 6 patients had stabilization of disease for at least 4 months. The design of this study did not allow us to assess what role MDR modulation may have played in these responding patients. Whether these responses are attributable to reversal of MDR1 or intrinsic sensitivity to doxorubicin and paclitaxel cannot be determined from the design of this Phase I trial. Moreover, treatment of P-gp-negative tumors with inhibitors of P-gp may result in clinical benefit by preventing the development of MDR. This has been demonstrated in a laboratory model of a human sarcoma cell line, in which PSC 833 reduced the mutation rate for doxorubicin resistance significantly, and suppressed the activation of MDR1 (58) . These findings suggest that treatment of drug-sensitive, P-gp-negative malignancies with effective MDR modulation may suppress the emergence of resistant MDR1 positive subclones and result in improved outcome (1 , 14) .
In conclusion, PSC 833 can be administered safely in combination with doxorubicin and paclitaxel with appropriate dose modification of the cytotoxic drugs. PSC 833 significantly increases the paclitaxel and doxorubicin exposure secondary to decreased clearance, accounting for the need to reduce doses ∼2-fold to achieve equivalent myelosuppression. Additional Phase II/III studies are required to determine the clinical role of this intriguing combination.
We gratefully acknowledge the excellent contributions of Jenny Villena and Steven Johnson for HPLC analyses and Beverly Kelley for secretarial support throughout this project. These studies would not have been possible without the dedicated work of the nurses and staff of the General Clinical Research Area and the Oncology Day Care Center at Stanford. We also thank our colleagues in the Oncology Division, Stanford University School of Medicine, and the physicians who have referred patients to this and related clinical trials.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
↵1 Supported in part by NIH Grants R01 CA 52168 (to B. I. S.) and M01 RR 00070 (to General Clinical Research Center, Stanford University School of Medicine) and by Novartis Pharmaceutical Corporation. Dr. Sikic is a paid consultant for Novartis Pharmaceuticals and Bristol-Myers Squibb Corporations. This work was presented in part at the Annual Meeting of the American Society of Clinical Oncology in Los Angeles, CA, May 1998.
↵2 To whom requests for reprints should be addressed, at Stanford University School of Medicine, Oncology Division, 269 Campus Drive CCSR-1105, Stanford, CA 94305-5151. Phone: (650) 725-6427; Fax: (650) 736-1454; E-mail: brandy{at}stanford.edu
↵3 The abbreviations used are: P-gp, P-glycoprotein; MDR, multidrug resistance; PSC 833, valspodar; MTD, maximum tolerated dose; DP, doxorubicin followed by paclitaxel; DPV, DP combined with PSC 833; G-CSF, filgrastim; AUC, area under the curve; StD, stable disease; LVEF, left ventricular ejection fraction; HPLC, high-performance liquid chromatography; MRT, mean residence time.
- Received October 17, 2000.
- Revision received January 22, 2001.
- Accepted January 25, 2001.


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Armando Ramírez creates the figure from a spark plug. Leaning over his racing bike, a cyclist pedals furiously. Screws, wire and metal bits left from a die cutter are also used, while the bicycle features parts from a pulley. Ramírez does not give his sculptures a fine polished finish, therefore smudges and scratches may be present.
- Recycled material
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Comment on 31.8.1805
I.e. Baron Herman Schubart, who, like the previous year had invited Thorvaldsen to spend the summer at his country house Montenero near Leghorn. At the beginning of August, Thorvaldsen had decided to go there, cf. Schubart's letter dated 8.8.1805. See the Thorvaldsen Chronology for more references to this visit.
Last updated 04.12.2017


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[ñ Balloon Toons: Zoe and Robot, Let's Pretend || Ü PDF Download by ✓ Ryan Sias] Ryan Sias
This is fun to read aloud, especially if you re willing to do a robot voice Zoe s friend Robot just can t seem to get the hang of her pretend mountain climbing expedition What can she do Just keep trying, Zoe, it s all going to work out After digging through the Austin Public Library catalog for awesome picture books about robots and coming up with very little that interested me, and NO female characters in sight, I really appreciated this one My son was six when we read this, but we could have [...]
Zoe, a young girl, asks Robot, her large robot, to go mountain climbing with her But when she leads Robot to the mountain, all Robot can see is a pile of pillows Zoe realizes she must teach her Robot how to pretend.Zoe tries several ways to teach Robot, but nothing seems to help Then, almost spontaneously, Robot begins to speak of a pillow as a fluffy cloud and Zoe and Robot are happy.The book is a graphic novel, with simple text and bright illustrations Ta daa Welcome to Mt Pillow, says Zoe Rob [...]
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Zoe struggles mightily to get her friend Robot to play with her She quickly learns that his mechanical mind is too literal for make believe, or is it Another great comic book for beginning readers The illustrations are fabulous and the story does a fantastic job of showing what one child can do with just their imagination.
I won this book from one of the first reads giveaways This was a very cute book to read to my toddler She enjoyed the pictures, and that the little girl was able to get the robot to pretend in the end The author also sent some coloring pages and little postcards along with the book too My daughter likes the book, and has asked me to read it a few times It s a win
My daughter and I found this on A Mighty girl s list of graphic novels We decided to order it and make it a part of our bookshelf We are glad we did This is a terrific book about pretending and friendship My daughter had me read it three times in one night and we are ready to read it again We love this book.
Grades K 1 Robot can t pretend He takes everything too literally When Zoe wants to climb a mountain , all robot can see is a pile of pillows So Zoe decides to try and teach robot how to use imagination Very simple graphic novel that is fun to read.
This is a great book It has become one of my daughter s favorites to read The comic book style is appealing and the content is enjoyable and gives us a great reminder to play pretend with our kids
I love this early reader graphic novel series Zoe wants to pretend but Robot doesn t know how to pretendhe is a robot After many attempts at helping Robot pretend, Zoe is just about to give up but then something surprising happens.
I really love the Balloon Toons series graphic novels for beginning readers This one, as all of this series that I have read, have humor, are child friendly, and simple yet interesting readers Zoe teaches Robot how to pretend not something Robots can do
This was a cute book about imagining things For the robot it is difficult As we become adults it is harder to imagine This book shows us how important it is to imagine.
Cute, simple comic style story for primary kids about friendship and imagination.
I would have probably only given 3 or 4 stars, but since Chris made me read it 4 times in a row the 5 star rating is earned Using a robot voice is strongly encouraged.
In this book, Zoe tries to teach Robot how to pretend The illustrations, story, and even the fonts are great fun
reviewing for Good Comics for Kids
Super cute, and will be a good addition to the collection, but I don t feel like I can use for a PreK K robot lesson after I just got through explaining how robots are different from humans.
Cute book


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It was my first mission as an orthopedic surgeon for MSF to Teme hospital, Port Harcourt, Nigeria. The flutter of excitement was perceptible because it was my first mission as well as the fact that I was travelling to a distant country about which I knew very little.
I arrived in Paris after an overnight flight from New Delhi and managed to reach the MSF office by the Paris metro despite having to struggle with carrying my luggage to different platforms while changing at stations that lacked escalators and had only stairs – a lesson to travel light next time.
After tiring overnight international travel, the wait at the MSF office for the briefing was an avoidable hassle. Around noon someone informed me I had a briefing session in the afternoon. I pushed my luggage and myself to the nearby hotel and prepared myself.
The swift afternoon briefing session was conducted by Dr Patrick and Mr Ali, and I got to know something about the place I was going to for my first mission.
The next day, after a hasty breakfast, I reached Charles De Gaulle airport and, to my utter dismay, found it submerged under a deluge of travellers and total confusion all around. Only after significant struggle and patience could I get my boarding pass for the flight to Abuja.
On reaching Abuja I found that Air France had forgotten to load my luggage at Paris. I filled in some forms to claim my luggage once it arrived and then had to push off to the MSF office sans baggage.
I reached the MSF office in Abuja and was greeted by friendly staff and then sent off to the expat house for an overnight stay. Early next morning I left for the airport after a quick briefing session with the medical coordinator. The local Nigerian flight with Arik air was inordinately late, but somehow I reached Port Harcourt by evening. There I was first taken to Teme hospital and had a briefing session with the field coordinator. Later in the evening I reached the expat house.
The expat house is a nice, spacious building in an imposing residential area of Port Harcourt and has many independent rooms. I had a choice of the available empty rooms which had some basic furniture and beds. The expat house is formed by two different houses, one behind the other, and there are plenty of rooms available, offering washing and laundry facilities, for a constantly changing group of expats. My luggage finally arrived three days later, training me to manage without clean clothes.
A normal day starts early and, after a self-made breakfast, all expats leave for Teme hospital at 7.30 am. Normally the surgical team is the first to leave and the other members soon follow. It's a 15-minute drive to the hospital through the heart of the busy city – no expats are allowed to go alone, so driving to and from the hospital is the only way to look at the city and its colourful, vibrant people.
Rounds begin from the emergency room where the local doctors who manage the emergencies fill in the surgical team on all the cases dealt with and admitted the previous night. The board is usually full and usually has seven to ten emergencies per night.
After completing the rounds in the wards, at around 9 am the surgeons move to the operating theatre to start the operations. There are two operating theatres and normally fresh orthopedic fixations are taken to OT1 while general surgical cases are taken to OT2. Both the operating theatres are air-conditioned and equipped with smooth-running Boyle's apparatus; there is also a C-arm in OT1. The orthopaedic's armamentarium has an excellent exfix with carbon rods. Intramedullary femur nailing is done with a sign nail (which is a solid nail) and has to be done open with distal locking using an external jig. DHS set and implants are available for Intertrochanteric fractures. Simple plates are available for plating long bones. Tibia and humerus fractures are treated conservatively except in cases of non-union, as per MSF protocol. Locking plates are not available – hence distal femur fractures and other intra-articular fractures pose a dilemma for operating surgeons and mostly have to be managed conservatively.
Plenty of really bad open road-side injuries (as well as gunshot and machetewounds and fractures) keep the surgeons busy all day long; occasionally there are night emergencies with type lllC injuries which the orthopaedic surgeon might be required to manage. The variety of cases is huge and all the surgeons are likely to have their operative skills tested. Having tackled some very difficult and bad cases does, in the end, give a sense of unmatched joy.
Lunch is brought to the hospital from the expat house and everybody has it at their convenience. The day ends late for the surgical team: the first car back home is at 5 pm, the next at 5.30 pm and the last at 6.30 pm. The surgical team usually manages to be in the last car or has to avail the facilities of a special car if it's late in the night.
Back home everybody has dinner in their own time and, after some chitchatting, it's time to go to sleep and prepare for a busy next day. There is TV with cable connection in the house for those who enjoy watching TV. The exercise enthusiasts have a jogger installed in the house and enjoy workout sessions. The expats have one shared laptop with internet connection in the house for their emails etc.
All expats have a mobile for the purpose of communicating with each other and the hospital. Mobile recharge coupons are freely available near the house in the supermarket as well as in front of the hospital gate. One can buy items for personal use from the everyday supermarket near the house. Expats are allowed to go for a walk on a specified route around the house. There is also a restaurant with a swimming pool, called 'Blue Elephant', nearby for the expats to go on Sunday afternoons. The cook is on leave on Sundays so everyone has to fend for themselves for their lunch and dinner.
On Sunday mornings only the medical team leaves for the hospital at 9.30 am. No routine cases are posted in the operating theatre on Sundays, but serious injuries from Saturday night have to be dealt with that afternoon. There is a handicraft market near the hospital where one can buy Nigerian artifacts for souvenirs.
Teme hospital has two local orthopaedic surgeons – Dr Sidney and Dr Charles – who help the expat orthopaedic surgeons in their work. Both surgeons are experienced and able and should be consulted for any difficult cases and some surgical problems. Nigerian patients are averse to amputations and hence the local surgeons should always be consulted before attempting any amputation – however necessary or imminent it might seem.
The operating theatre staff comprises many able and efficient nurses, including Peace, Margaret and Lemmy.
Time simply flies at this mission which, in a real sense, is a Mecca of orthopaedics – all orthopaedic surgeons would love to visit and work here.
Though tiring, it was an immensely professionally enjoyable mission. It ended on 18 August and I returned to New Delhi via Abuja and Paris after a series of debriefing sessions.
– Rajeev Tanwar


text:
From: Australia
Individual account
03/02/2020 - 04/05/2020
My name is Victoria Rose, an Australian woman who backpacked solo on an Aged Pension throughout Europe, Turkey and Asia Pacific for 18 months in 2018/2019. I'm now back home in Australia and intend to stay here for most of 2020.
As a LiveStream Strategist and Conversational Marketer specialising in Chatbots, I work with businesses to create a powerful on-line presence that grows and accelerates their Global footprint, to make the difference they want to make in the world.
As a best selling author (How to Make The Rest of Your Life The Best of Your Life: Tough Love For Smart Single Women Over 60) I'm travelling throughout Europe, Turkey and beyond as I write my second book.
I was born a traveller. Half a century ago as an 18 year old, I travelled solo to the UK for a 2-year working holiday.
Even at that age, living the culture of the country was more important than mixing with overseas Australians.
And here I am again, wanting to live the culture of the people and not be a tourist.
PLEASE take the time to read this full profile.
When you do, you will know whether or not I am a good fit for your situation.
You will know whether or not we go to the next step of having a video chat to see if we are a match.
2019/2020 Workaway gigs included teaching conversational English to 64 classes of middle school students in Italy.
As a trainer (for nearly three decades) people often comment on how clearly I speak.
Which translates into easy to understand.
I spent the month of March in France working with a 58 year old French woman to launch her new business on Social Media. And that was fun.
As a new business, we started from scratch on her branding: creating her logo, name (registered the domain name) built her Facebook business page, created videos, mapped out her marketing strategy, built her channel on YouTube, interviewed her on my weekly TV livestream show, mentored her to Go Live with her very first Livestream on Facebook and created her intro video for use on all the platforms she now owned.
April 2019 saw me in Spain working with a chef to promote and build her cooking holidays on social media and beyond.
Building her business included much of the assets already mentioned as well as videoing a 3-part cooking series and uploading to her platforms.
May in Albania working with a Women's Centre supporting women and girls of domestic violence. This was achieved by growing their presence on social media, helping staff with their English language skills and helping out in their restaurant.
July and August in York, UK working with a couple to grow their businesses using my specialist social media skills. Then September saw me in Worcestershire UK, looking after a Tibetan Terrier and supporting the owner with building her Facebook business.
Oct/Nov in Thailand with the most amazing internet speed so I can continue to build my online business to support businesses with building their own ChatBot.
I'm obsessed with ChatBots and if you're in business, you should be too.
I'd be more than happy to show you why :)
IMPORTANT: My first Workaway experience was NOT good.
The hosts misrepresented what their offer was. Not only was their home filthy, it was NOT an eco farm and the deplorable conditions they expected volunteers to live in (and they lived in) were not acceptable.
BTW, I'm an ex-soldier with the Australian Army Reserves, so have lived in some bleak and isolated conditions.
Nothing as bad as this Workaway experience.
They told me other Workaways had turned up but left on the same day. And I could see exactly why.
Finally, their listing was taken down by the Workaway Team.
It is not fair to Workaways to waste their time and other Workaway opportunities by not honestly presenting the situation.
PLEASE KNOW: I will not accept any Workaway placing if the Host has not agreed to a video chat. Sound fair?
Leadership Trainer. Help with learning English.
Social Media: Get your business seen on social media using Live Streaming, building effective Facebook Business Pages and building your own Messenger ChatBot.
I can show you how to Go Live on Facebook, Youtube, Instagram, Periscope and soon ... LinkedIn ... and have fun.
How to write a book. Time management Skills. Well experienced in creating promotional videos for businesses - intros and outros my speciality.
English: Fluent
Driver's licence
Special dietary requirements


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This is the story of an optimization effort around a gated content landing page (that is, a landing page that requires email signup before the download can start) for a B2B tech company in the cybersecurity arena. Unfortunately, its name must be kept undisclosed. When marketers work on optimizing a landing page (which is quite… Read more »Continue reading
The 7 deadliest startup marketing sins that we all keep making
One website that most startups hate to visit but probably should is The Startup Graveyard. There, you'll encounter the ghosts of startup-past, including their different reasons for failure. Business-related reasons, marketing included, appear on this website more often than not. You're probably thinking, making mistakes doesn't always equal failure, and you'd be right. We've all… Read more »Continue reading
B2B Startups, here's how to select a marketing automation system – and a list of mistakes to avoid
If I had a nickel for every time I heard someone put all their chips on a single marketing automation SaaS solution… As a startup marketer in an agency, I constantly talk to clients about if, when, and which marketing automation to implement. There are two main points that usually come up in these discussions: … Read more »Continue reading
Young B2B Startups and PR agencies, friends or foes? Here's how & when they should collaborate
Startup entrepreneurs take on one of the biggest missions you can think of: trying to make something out of nothing. To succeed, they have to turn ideas into products, skeptics into investors, prospects into ambassadors… you get the idea. This is a super difficult journey in which founders need all the help they can get.… Read more »Continue reading
Is There Really a Difference between Growth Hacking & Traditional Marketing?
Well, it's complicated… A lot of people, not to say marketers, whom I know and respect keep asking me what on earth the difference between growth hacking and just plain marketing is. It sometimes feels like growth hacking is a term made up by marketers to describe…well… marketing. Yes, at first glance it's hard to… Read more »Continue reading


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1455772682 – Building a Medical Vocabulary: with Spanish Translations, 9e (Leonard, Building a Medical Vocabulary)
1455772682 – Building a Medical Vocabulary: with Spanish Translations, 9e (Leonard, Building a Medical Vocabulary) by Peggy C. Leonard BA MT MEd
1455772682 –
The language of medicine may be complex, but learning it doesn't have to be. Using short, easy-to-understand segments followed immediately by programmed exercises, Building a Medical Vocabulary: With Spanish Translations, 9th Edition starts with medical terms that you may already know and builds your knowledge by adding new combining forms, prefixes, and suffixes. An Evolve companion website reinforces your understanding with interactive games, animations, audio pronunciations, and more. Organizing medical terms by body system, this text provides the building blocks for effective communication in the health care environment.
- Easy-to-understand, conversational writing style makes reading and absorbing the material enjoyable.
- Programmed Learning sections allow you to actively participate in learning and get instant feedback on your progress.
- An Evolve companion website reinforces learning with audio pronunciations, interactive games, exercises, animations, flash cards, and more.
- Thorough explanation of terms enhances understanding by presenting vocabulary in the context of medical settings.
- Moderate level of A&P coverage provides the background that you need to understand body systems in the context of medical terminology.
- Health Care Reports and case studies allow you to apply your knowledge to job-like situations.
- Spanish translations cover common Spanish terminology that you are likely to encounter in the clinical environment.
- Be Careful with These caution boxes highlight important distinctions between terms that are similar in spelling and/or pronunciation.
- Comprehensive end-of-chapter reviews allow you to measure your learning against chapter objectives.
- The Joint Commission official Do Not Use list of error-prone abbreviations alert you to abbreviations that should not be used in the clinical setting.
- Bookmark pronunciation guide makes it easy to find pronunciations and may also be used to cover the answer column while working the programmed learning sections of the text.
- Glossary/Index makes it easy to find words and their definitions, and is great for final exam review.
- NEW Special Sense Organs chapter is dedicated to coverage of the eye, ear, and other special senses.
- NEW! List of key terms with pronunciations in each chapter provides a helpful review that coordinates with audio files on the Evolve companion website.
- NEW ICD and CPT information includes ICD and CPT terminology.
View editions and Prices!
Category: Dictionaries & Terminology
Binding: Paperback
Author: Peggy C. Leonard BA MT MEd
Pub Date: 10/27/2014
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I will miss seeing your mom when I take Megan to work! My condolences to your family, Caren!
To my dear Aunt Ina , you were a very loving and considerate and caring person . I allways looked forward to coming to Illinois in the summer knowing I was going to be spending time with my Second mom ! My loving vacation mom ❤ Also spending so much time in her kitchen and getting our hair washed in the kitchen sink and eating till we couldn't eat no more . And as Bill said making the ice cream and just sitting under the huge tree and listening to my Dad and uncle Red talk about their childhood and the trouble they used to get into. And also playing Marbles with Cathy and Caren . So much fun and loving memories and couldn't wait til the next summer! With love to Connie, Carla , Cathy and Caren and the rest of the loving family. ❤. Robert
So many great memories of Aunt Ina from when we visited every summer as kids: sitting around the kitchen trimming green beans for canning, sitting under the great oaks between grandma's house and Uncle Red and Aunt Ina's while knocking back cold ice tea or lemonade, picking bushels of tomatoes and setting them out to ripen a bit more on the pump, and making ice cream with the hand churn. These are just a few of the oh so many wonderful memories I'll cherish forever of Aunt Ina. I am grateful to have had great lady in my life; she made my world and that of everyone she met brighter, kinder, gentler and just simply better with her never-ending cheerfulness, her quick smile, the twinkle in her eye, and her indefatigable generosity.
All my love to Connie, Carla, Caren, Cathy and all the rest the family. Hugs and kisses, Will Traylor
Our deepest sympathies
Nancy looked forward to the day when Ina would come to the house and catch up on all "gossip". Nancy and Ina and all the rest of the family are feeling no pain now. The lockwood family sends their heartfelt condolences


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