text:
Handbook of Genetic Counseling/Klinefelter Syndrome

Klinefelter Syndrome

Introduction

 * The most common sex chromosome abnormality
 * The most common cause of male hypogonadism and infertility
 * Characterized by the addition of at least one extra X chromosome to a 46,XY male karyotype
 * Most descriptions refer to 47,XXY karyotype
 * Over 50% of males with Klinefelter syndrome have 47,XXY karyotype
 * Those with mosaicism or other chromosome complements may have different prognosis
 * Presentation and prognosis are quite variable
 * In 1942, Dr. Klinefelter described testicular dysgenesis (defective development), elevated urinary gonadotropins (hormones that stimulate the gonads) microorchidism (small testes), eunuchoidism (deficient hormone production by the testes), azoospermia (no spermatozoa in the semen), and gynecomastia (enlargement of breast tissue)
 * The clinical features are not present until mid to late adolescence, so it is technically correct to refer to fetuses, newborns, and children as having 47,XXY
 * Reserve the term Klinefelter syndrome for affected adolescents and adults

Diagnosis

 * Most are identified by a karyotype as part of a work-up for infertility or by prenatal diagnosis detected by amniocentesis performed for other indications

Incidence

 * Estimated to be 1/500 to 1/1000 male births
 * But many are probably never diagnosed

Clinical Manifestations

 * Lifespan is normal
 * Development
 * By adolescence, most boys are at or above the 80th percentile for height
 * There is a tendency toward slightly delayed motor and language milestones
 * 2/3 of boys with 47,XXY are delayed in walking
 * Key language milestones may be delayed in up to 50% affected but are often within normal limits
 * Sensorimotor integration problems may arise by age 6-7 years
 * May include hypotonia, apraxia, primitive reflex tension, and problems with bilateral coordination and visual perceptual motor integration
 * On average, intellectual skills are slightly diminished and learning problems are increased, but this varies widely
 * Cognitive difficulties are largely limited to the area of verbal skills
 * Reading skills are the area of academic progress that can be most problematic for boys with 47,XXY
 * Often boys are unable to demonstrate success in physical achievements as compared to male peers
 * Behavior
 * Tend to be shy, nonassertive, and immature
 * Language difficulties contribute to the reluctance for interpersonal interactions
 * Aggressive behavior can occur due to prolonged frustration but are not characteristic of this group
 * Some investigators have reported an increased occurrence of ADHD but others have not
 * Adolescent males are often reluctant to speak freely and lack confidence
 * Some may experience serious psychological distress due to limited athletic and academic success and continued learning difficulties
 * There are few reports on the adult adaptation of men with 47,XXY
 * Sexual functioning is typically normal, although sexual drive is often low if supplemental testosterone therapy is not utilized
 * There is no evidence for increased aberrant sexual behavior
 * There is normal gender orientation
 * Endocrine
 * Sexual development is normal in infancy and during childhood
 * There is an adolescent elevation of testosterone that begins to plateau around age 14 years, then serum levels remain in the low to low normal adult range
 * By mid-puberty, boys have FSH and LH levels 5-10 times the normal range
 * Due to endocrine changes, testicular growth is arrested
 * Testicular volume and size is decreased
 * The number of Leydig cells (testosterone-secreting cells) is decreased
 * Gynecomastia is seen in about 15% of cases
 * Increased breast tissue is common in adolescent males, but it may not always regress in some adolescents with 47,XXY
 * Supplemental testosterone does not usually prevent or diminish gynecomastia but simple mastectomy can be performed
 * Facial hair, axillary hair, and pubic hair all increase during puberty, but this may occur to a lesser degree than in 46,XY males
 * Hair pattern is male
 * Older literature described fat distribution as being female, but this is not true
 * Infertility
 * Sexual function is normal, but ejaculate contains no sperm
 * A few cases of fertility have been reported in the literature, but it is thought that cryptic mosaicism may be present in some of the men
 * Men on testosterone therapy will not attain fertility
 * Intracytoplasmic sperm injection (ICSI)
 * Some men with 47,XXY have been shown to have a few sperm in their testes, even when no sperm are present in ejaculate
 * After testosterone therapy and testicular biopsy, sperm have been recovered and utilized in the ICSI procedure to achieve pregnancy and birth
 * Preimplantation/prenatal diagnosis is necessary to rule out chromosomal aneuploidy
 * The process of testicular sperm extraction, ICSI, and preimplantation diagnosis is not routinely offered at this time
 * For most 47,XXY males, the most realistic prospects for fatherhood are by utilization of artificial insemination by donor or adoption
 * Neoplasia
 * There is a 1% lifetime risk for developing extragonadal germ cell tumors, usually in the mediastinum
 * For unknown reasons, Klinefelter syndrome is a predisposing factor to the aberrant migration of primordial germ cells
 * Affected males may present with respiratory symptoms due to the mass size
 * Some cases of precocious puberty in boys with 47,XXY have been caused by germ cell tumors that secrete hCG.
 * The ages of susceptibility are early adolescence to age 30
 * Increased risk of breast cancer, probably up to 3% lifetime risk
 * This is a 20-fold increase over the normal male population
 * This risk does not warrant routine screening
 * Immunologic
 * Adults are at a slightly increased risk for certain autoimmune disorders
 * Such as systemic lupus erythematosis, diabetes mellitus, and thyroid disorders
 * It has been suggested that sex hormones may be involved in the pathogenesis of autoimmune diseases
 * Cardiovascular
 * Mitral valve prolapse has been reported but a baseline cardiac echo is NOT warranted
 * There is a risk for cardiovascular disease associated with elevated cholesterol levels
 * Chronic leg ulcers are seen in approximately 6-13% of patients

Management

 * Adolescents and adults with Klinefelter syndrome are unable to produce normal quantities of testosterone, so supplemental testosterone can maintain levels in the normal range
 * This enables them to stimulate and maintain androgen-dependent processes
 * In many cases, it promotes increased sense of well-being
 * Helps to maintain secondary sex characteristics including facial and body hair
 * Can increase and maintain muscle mass and promote weight gain
 * Can increase energy and sex drive and lower cholesterol levels
 * Can stimulate bone mineralization and prevent loss of bone mass which can lead to osteoporosis
 * Testosterone therapy is usually considered in mid to late adolescence because serum testosterone levels do not plateau until about age 14 years in most affected males
 * Therapy can begin as early as age 12 however
 * Serum testosterone levels should be carefully monitored during the initiation process
 * Excess testosterone can lead to inappropriate sexual behavior
 * There are some reports of aggressiveness when higher concentrations are administered
 * Intramuscular injections of testosterone enanthate or cypionate have been the most common method of testosterone replacement
 * The standard adult dose is 200mg every 10-14 days
 * In an adolescent, the initial dose is considerable lower, usually 100mg every 4 weeks
 * Because this method does not mimic normal physiologic production, there may be fluctuations in mood and physical functioning
 * Usually injected into deep muscle in the thighs or buttocks
 * Because testosterone ether is dissolved in an oil base, the injections can be slow and painful
 * Transdermal testosterone patches can provide a more normal physiological availability of testosterone
 * Patches are replaced every 24 hours
 * Scrotal patch is effective in postpubertal males, but adolescents in one study were resistant to daily application to their genitalia
 * A nonscrotal patch can be worn on the thighs, abdomen, trunk, or upper arm
 * Side effects are rare but include: acne, leg edema, breast tenderness, and local skin reactions
 * Oral testosterone is not generally available in the U.S.
 * New formulations of testosterone currently being investigated include implantable pellets, sublingual tablets, and long-lasting injections

Differential Diagnosis

 * Karyotype analysis may be indicated with the following features:
 * Learning disabilities, language difficulties, attention deficits, psychosocial problems, small testes, infertility
 * Kallman syndrome
 * Characterized by hypogonadotrophic hypogonadism and anosmia (loss of the sense of smell)

Etiology

 * Nondisjunction of the sex chromosomes during the first or second meiotic division of gametogenesis in either parent causes chromosomal aneuploidy
 * The extra X chromosome is contributed only slightly more frequently by the mother than the father
 * There are no apparent differences in phenotype or imprinting effects
 * AMA is slightly associated with the extra X chromosome; there is no paternal age effect
 * There are no predisposing or preventative factors
 * This is important for parents to understand

Other Male X Chromosome Aneuploidy

 * Few cases of variants of 47,XXY have been followed prospectively so the natural history is not known
 * Most information is from case reports of abnormal individuals
 * This ascertainment bias could mean that individuals with a variation of the 47,XXY karyotype are actually more mildly affected than reported here
 * Mosaicism
 * 46,XY/47,XXY mosaicism is the most common form of 47,XXY mosaicism
 * The normal cell line modifies the risk for developmental delay
 * Fertility may be possible
 * Testosterone supplementation is probably not indicated
 * 48,XXYY
 * The most common variant of Klinefelter syndrome
 * Similar physical phenotype to 47,XXY, but males are taller and have disproportionately longer lower extremities
 * IQ is typically reduced and ranges from 60 to 80; however, at least 10% of reported cases had IQs ranging from 80 to 111
 * Speech and motor delays are common, and behavior may be shy or impulsive and aggressive
 * Hypergonadotrophic hypogonadism is similar to that in males with 47,XXY and testosterone treatment is the same
 * Genitalia may be small
 * 48,XXXY (3 X chromosomes)
 * Results from the addition of an extra X to a 47,XXY karyotype
 * A more abnormal phenotype including facial anomalies such as hypertelorism, epicanthic folds, simplified ears, and mild prognathism (projection of the jaw beyond the forehead)
 * Tall stature is common
 * May be skeletal anomalies such as clinodactyly, elbow abnormalities, and radioulnar synostosis
 * Generally, there is mild to moderate mental retardation (IQ=40-60)
 * Behavior is usually passive and cooperative
 * Genitalia may be small, and gynecomastia is frequently reported
 * 49,XXXXY (4 X chromosomes)
 * This is the most severe variant of Klinefelter syndrome
 * Abnormal facial features include hypertelorism, epicanthic folds, broad nasal bridge, low-set and malformed ears and prognathism
 * Cardiac defects, usually patent ductus arteriosus, are present in 15-20% of cases
 * Males have short stature, short, broad neck, narrow thorax, radioulnar synostosis, and hyperextensible joints
 * Genitalia are hypoplastic
 * Cryptorchidism (failure of testes to descend) is often present at birth
 * Range of mental retardation is broad (IQ is generally 20 to 70)
 * Speech and motor sills are severely impaired
 * Behavior ranges from placid to aggressive
 * 46,XX males
 * Males who have clinical features of Klinefelter syndrome but normal female karyotype
 * Occurs in about 1 in 20,000 male births
 * Clinical features
 * Shorter than males with 47,XXY, and extremities are not disproportionately long
 * Genitalia are usually normal male, but there is an increased risk for hypospadias or ambiguous genitalia
 * Testes are small and azoospermia is present
 * IQ is generally higher than with 47,XXY males, and the risk for learning disabilities and behavior problems is lower
 * Over 90% have a portion of Yp containing the SRY gene translocated to the paternally derived X chromosome
 * This material is no always cytogenetically visible, but can be detected by FISH
 * The remaining 10% are thought to be the result of an autosomal or X chromosome mutation
 * These males are more likely to have genital abnormalities

Resources

 * Understanding Klinefelter Syndrome, A Guide for XXY Males and Their Families, by Robert Bock (1993), National Institute of Health
 * Available free of charge by calling 301-496-5133

 * Klinefelter Syndrome, For Boys Only, A Supplement, by Diane Plumridge, Christine Barkost, and Stephen La Franchi (1982) :Oregon Health Sciences Center
 * Available for $1.25 at P.O. Box 574, Portland, OR 97207

 * Klinefelter Syndrome and Associates
 * Online at www.genetic.org
 * Mailing address: 11 Keats Court, Coto de Caza, CA 92679
 * Phone: (888)999-9428


text:
Handbook of Genetic Counseling/Lupron Exposure

Lupron Exposure

Contracting

 * Introductions and small talk
 * Confirm referring physician
 * Assess understanding of the reason for the referral to genetics
 * What concerns or questions do you have that you would like to discuss today?
 * Outline session agenda
 * Medical and family history questions
 * Some of the possible effects that lupron can have on the pregnancy
 * Options available to you
 * Discussion of concerns and questions

Elicit Medical History

 * Confirm LMP: __________
 * EDC: __________
 * Today's gestational age: __________
 * Have you had an ultrasound?
 * Date of ultrasound: __________
 * Results of ultrasound: __________
 * How has the pregnancy been going so far?
 * When did you first find out you were pregnant
 * What medications are you taking?
 * Amount and frequency of each.
 * When did you start taking each?
 * Do you have any other medical problems?
 * Any complications with the pregnancy

Elicit Family History
(3 generations)
 * Anyone had: multiple SAB, SB, early deaths or babies that required surgery as infants?
 * Anyone born with birth defects such as cleft lip or palate, spina bifida, or heart problems
 * MR/LD
 * Has anyone in family had cancer (dx. <50) or chronic illnesses (heart disease, diabetes)
 * Anyone with muscle weakness or muscular dystrophy
 * Anyone with bleeding disorders
 * Anyone with any other genetic disorders such as cystic fibrosis, PKU, etc.

Discuss possible side effects of taking lupron at time of conceptions

 * All pregnancies are at a 3-5% risk of birth defects or mental retardation
 * There may be an increase in risks to the fetus when a woman is on lupron at conception.
 * HOWEVER, this doesn't mean that the baby will be born with a problem, it just means that we know that based on your special circumstances, your pregnancy may be at an increased risk for miscarriage or maybe even a birth defect
 * The reasons we believe there might be an increased risk are based on a small number of women who were exposed to lupron during pregnancy as well as animal studies
 * We can tell you what has been reported, but the numbers are too small to make any real conclusions
 * 125 women who were exposed to lupron at the time of pregnancy have been identified and reported as of Feb 2002
 * 35 of them miscarried (28%), one was terminated for trisomy 18, three were ectopic pregnancies (2.4%)
 * 2 of the 125 infants had congenital anomalies which included bilateral inguinal hernia and other atretic kidney (positive family history for atretic kidney)
 * 14 were still ongoing pregnancies and 71 had babies with no malformations or health problems
 * 6 children (around age 7) who were exposed to lupron or a similar medication (GnRH agonist).
 * 1 had a cleft palate
 * 1 had a seizure disorder
 * 3 had ADHD
 * HOWEVER this is a very small number of children and is not enough to base any conclusions on
 * Also, it was unclear how they were defining ADHD because they all had normal psychological tests
 * Most of the studies regarding the risks that lupron poses for a pregnancy have been done on rabbits and rats.
 * These studies are often not directly related to effects and risks for humans because these animals are different enough that drugs can have a different effect on them when compared to a human fetus.
 * Increased fetal mortality and decreased fetal weights in rabbits when given 1/30th and 1/3rd the human dose and for rats at 1/3rd the human dose
 * Although not all agree with the interpretation, studies on rabbits suggest that there may be an increase in some birth defects, which include hydrocephalus or vertebral anomalies (dose related at 1/300th, 1/30th and 1/3rd the human dose)
 * Rats showed no increase in birth defects
 * We therefore don't really have a lot of conclusive information, but the main concern would seem to be an increased risk for pregnancy loss.
 * This increase in fetal mortality is likely due to alterations in hormonal levels brought about by the drug (estrogen and progestin levels reduced to levels within the menopausal range)

Options

 * Level II ultrasound -- performed at 18 -20 weeks
 * Done by an experienced technician
 * Can detect many birth defects
 * Developing organs will be looked at in detail
 * Can often detect abnormalities in the formation of the limbs, spine, heart, and brain
 * U/S is good to make us suspicious of some birth defects but it can't tell us everything
 * We won't know if there is mental deficiency by u/s
 * Also, u/s is dependent upon cooperation of the baby. Sometimes we just can't get a great view and may not be able to see everything we are looking for
 * But it can usually provide some reassurance to see that organs and body parts have formed properly

Maternal Serum Marker Screening
(Unrelated to any risks due to exposure there is a blood test that is routinely offered to all pregnant women)
 * MSAFP at about 16-18 weeks
 * Screening performed on a sample of your blood
 * Can provide an indication that a fetus may be at a higher or lower risk than the general population to have an ONTD, but it will not tell us for certain if there is a neural tube defect
 * Detects about 80-90% of ONTD's (so it can miss some)
 * Will also tell if fetus is at an increased risk above your age-related risk for a chromosome abnormality
 * Blood test can also look at other markers in the blood and determine if there may be an increased risk for two chromosomal abnormalities (for which you are not at an increased risk for based on your history of seizures and medications)

Psychosocial Considerations

 * Guilt over doing something that may cause birth defects
 * Anxiety because we don't know what to expect
 * Was this a planned pregnancy and is she excited to be pregnant or was this unexpected
 * Any other health concerns or circumstances that would make this a difficult pregnancy
 * Assess support system and coping strategies

Follow-up

 * Questions?
 * Schedule level II ultrasound

Lupron Facts

 * GnRH - agonist - mimicks GnRH, but is more potent
 * Considered category X drug (meaning benefits to women don't outweigh potential risk to fetus and it is contraindicated for women who could potentially get pregnant)
 * Not known if transfers to human milk, but structure makes this unlikely
 * No breast feeding data are available
 * Triggers release of LH and FSH (hormones that stimulate ovary in preparation for ovulation)
 * First taken then any LH and FSH stored in pituitary is released, but further production and release is blocked
 * When LH and FSH blocked, ovarian follicle and egg don't grow and less estrogen produced by ovary
 * Initial release of FSH and LH may cause one last cycle before suppressing ovarian activity
 * Should therefore use backup protection during the first month of treatment
 * Lupron is used in preparation for infertility treatments and when it is used in this fashion before conception there has been no increased risk of fetal anomalies reported to be associated with the infertility treatment.

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/


text:
Handbook of Genetic Counseling/Zellweger Syndrome

Zellweger Syndrome

Genetic Etiology

 * Mode of inheritance: Autosomal recessive with non-allelic heterogeneity.
 * Chromosome location: 2p15, 1q22, 12p13.3, 7q21-q22, 6q23-q24
 * Molecular genetics: Phenotype caused by mutation in any of several genes involved: in peroxisome biogenesis (peroxi-1, -2, -3, -5, -6, or -12).
 * Peroxisomes are subcellular organelles that play a role in lipid metabolism--these are absent

Incidence and Carrier Frequency

 * Incidence is 1 in 40,000. Males and females are affected equally.

Clinical Features

 * Craniofacial Features
 * Flat occiput and face
 * Anteverted nares
 * Epicanthal folds
 * Brushfield spots
 * High forehead
 * Large fontanels
 * Shallow orbits
 * Ocular Features
 * Cataracts
 * Hypoplastic optic disk
 * Auditory Features
 * Abnormal helices
 * Deafness
 * Neurological Features
 * Early developmental delay
 * Seizures
 * Brain migrational abnormalities
 * MR in survivors
 * Brain malformations including microgyria, heteropias, subependymal cysts, astrocytosis and gliosis, hypoplastic corpus callosum, hypoplastic olfactory lobes
 * Extremities
 * Single palmar creases
 * Joint contractures
 * Stippled epiphyses
 * Camptodactyly
 * Cardiovascular Features
 * Cardiac septal defects
 * PDA
 * Other Features
 * Hepatomegaly
 * Postnatal growth deficiency and low birth weight
 * Poor suck
 * Albuminuria and cysts of glomeruli in kidneys
 * Elevated serum iron level and evidence of excess iron storage
 * Absent liver peroxisomes

Age of Onset, Natural History, Life Span

 * Most babies are born breech and exhibit failure to thrive. Some developed icterus and bloody stool.
 * Vast majority of children die within the first year of life. Those who survive have profound mental retardation. Average life span is 12-13 weeks.

Testing

 * Diagnosis is made through DNA testing.
 * Increase in plasma and fibroblasts of very-long-chain fatty acids and lack of dihydroxyacetone phosphate acyltransferase (DHAP-AT) are biochemical markers for this syndrome

Surveillance, Management, and Treatment Options

 * Multidisciplinary early intervention
 * Oral administration of plasmalogens
 * Restricted phytanic acid intake
 * OT, PT, hearing aids, nutrition
 * Skeletal surveys (X-rays, CT and MRI)
 * Renal and abdominal ultrasounds

Differential Diagnoses

 * Down syndrome is the most common


text:
Handbook of Genetic Counseling/XXX Syndrome

XXX Syndrome

Introduction

 * Greet family and acknowledge prior contact.

Contracting

 * Discuss the reason for referral - amniocentesis results.
 * Express empathy over what a surprise the diagnosis was for the family.
 * Assess their main questions and concerns and find out what they hope to gain from the session.
 * Find out how much reading/research they have done on XXX Syndrome and assess the degree of their knowledge about heredity and genetics.
 * Explain our intent to address their concerns and questions about Triple X. Explain that we will share information about the syndrome, discuss the test results, how the syndrome is caused, recurrence risks, problems associated with Triple X, and medical management.

Elicit Medical History

 * Maternal and paternal age
 * Ethnicity
 * Consanguinity
 * Chronic illnesses

Elicit Family History

 * Construct pedigree
 * Identify possible risks

Pregnancy History

 * Review information from intake.
 * G (# of pregnancies), P (# of live births), SAb, EAb
 * Exposures/medical complications (infection, fever, rash, medication, smoking, alcohol, recreational drugs, x-rays, bleeding)

Genetics of XXX Syndrome

 * 47, XXX karyotype
 * Inheritance pattern: chromosomal abnormality caused by non-disjunction (possible correlation to advanced maternal age)
 * Prevalence: 1 in 1,000 females
 * Recurrence risk: less than 1%

Natural History and Clinical Features of XXX Syndrome

 * At birth, girls with Triple X show no physical stigmata and are normally developed. The infants may have a lower than normal birth weight.
 * These girls are described as being quiet and passive babies with a lower assertive age during childhood.
 * They are usually delayed in motor, speech, and psychosocial development with delayed emotional maturation.
 * Tall stature (at the 80th percentile by adolescence, with an average adult height of 172 cm).
 * Comparatively low weight in comparison to height.
 * Lower head circumference (25th - 35th percentile)
 * Back problems may develop due to weak musculature.
 * Lower IQ (average is approximately 90) - however, mental retardation is very rare. May have learning difficulties in school that require outside help.
 * Normal puberty and average onset of menstruation.
 * Fertile, with the possibility of early menopause.
 * No increased risk of disease or mental illness.

Diagnosis and Testing of XXX Syndrome

 * Diagnosis by amniocentesis, CVS, or chromosome testing.
 * Recurrence risk of less than 1%.
 * There is a theoretical increased risk of X aneuploidy for the children of women with Triple X, however, this has not been shown in practice. A less than 1% risk figure is quoted, but genetic counseling is suggested to explain the possibility of prenatal diagnosis if desired.

Management

 * Early intervention programs with mental, social, and motor stimulation are suggested to help prevent possible developmental delay.
 * Speech therapy is recommended to counteract speech delays.
 * Participation in team sports and group activities is suggested to improve motor skills and psychosocial adaptation.
 * Schools should provide special education or resource help for learning difficulties.

Psychosocial Issues

 * Self-fulfilling prophecy leading to a behavior problem
 * Should they tell their pediatrician?
 * Should they tell their daughter's teachers?
 * Should they tell their daughter?

Resources

 * The Turner Center
 * Psychiatric Hospital Aarhus
 * Skovagervej 2 DK-8240
 * Risskov Denmark
 * www.aaa.dk/turner/engelsk

 * Klinefelter Syndrome and Associates
 * PO Box 119
 * Roseville, CA 95678-0119
 * (916) 773-2999
 * www.genetic.org

 * Website on Triple X Syndrome
 * www.triplo-x.org

 * Website with family stories
 * www.voicenet.com/~markr/triple.html


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text:
Handbook of Genetic Counseling/Waardenburg Syndrome

Waardenburg Syndrome

Contracting

 * Introductions, acknowledge any prior contact
 * Assess main concerns of patient
 * Why are they visiting Genetics today?
 * What do they hope to gain from the session?
 * Assess knowledge of diagnosis -- any questions?
 * How has *** been since his last hospital visit?
 * Overview of today's session
 * Restate patient's concerns
 * Medical history, family history, physical exam, genetics, recurrence risk, testing options and limitations

Pediatric Intake

 * Pregnancy and Medical History
 * Developmental History
 * Family History
 * cousin and uncle with white forelocks?
 * premature greying
 * different colored eyes

Etiology

 * WT1: PAX3 gene on chromosome 2 (2q35)
 * codes for DNA binding transcription factors expressed in the early embryo
 * WS2: MITF gene mutations (3p14.1-p12.3) have been described in 10-20%
 * MITF gene mutations have also been identified in patients with the Tietz syndrome (deafness with uniform hypopigmentation)
 * WT3: caused by mutations in the PAX3 gene (2q35)
 * WT4: caused by mutations in the endothelin-3 gene (20q13.2-q13.3), endothelin receptor B gene (13q22), and SOX10 gene (22q13)

Incidence and Carrier Frequency

 * autosomal dominant inheritance
 * majority of probands have an affected parent, though may be undiagnosed
 * minority of probands do not have an affected parent and are assumed to have a de novo mutation
 * risk to siblings of proband = 50% if parent affected
 * risk to offspring of proband = 50%
 * Type I incidence: 1:20,000 to 1:40,000
 * comprises about 3% of congenitally deaf children
 * Type IV has autosomal recessive inheritance

Clinical Features

 * Type I
 * variable phenotype
 * sesorineural hearing loss
 * congenital, non-progressive, uni- or bilateral
 * most common type is profound bilateral
 * white forelock
 * may be present at birth or appear later
 * may become normally pigmented over time
 * eyebrows and eyelashes may also be hypopigmented
 * leukoderma
 * white skin patches, frequently on the face, trunk, or limbs
 * often have hyperpigmented borders
 * spina bifida and cleft lip and palate have been described in multiple families
 * Type 2
 * if the average W index across a family is less than 1.95, the diagnosis is WS2
 * sensorineural hearing loss and heterochromia iridum are the two most characteristic features of WS2
 * Type 3 (Klein-Waardenburg Syndrome)
 * individuals have a combination of typical WS1 features and hypoplasia or contractures of the limb muscles or joints, carpal bone fusion, or syndactyly
 * Type 4
 * Individuals having a rare combination of pigmentary abnormalities, hearing loss, and Hirschsprung disease

Natural History

 * does not affect lifespan or intelligence

Testing

 * Clinical Diagnosis
 * An individual must have two major or one major plus two minor criteria to be considered affected by WT1**
 * Major Criteria
 * Congenital sensorineural hearing loss
 * White forelock, hair hypopigmentation
 * Pigmentation abnormality of the iris
 * Complete heterochromia iridum (eyes of different color)
 * Partial/segmental heterochromia (two different colors in same iris, typically brown and blue)
 * Hypoplastic blue irides, or brilliant blue irides
 * Dystopia canthorum, W index >1.95*
 * Affected first-degree relative
 * Minor Criteria
 * Skin hypopigmentation (congenital leukoderma)
 * Synophyrys/medial eyebrow flare
 * Broad/high nasal root, prominent columella
 * Hypoplastic alae nasi
 * Premature gray hair (before age 30 years)
 * W index: The measurements necessary to calculate the W index (in mm) are as follows:
 * inner canthal distance (a), interpupillary distance (b), and outer canthal distance (c).
 * Calculate X = 2a - (0.2119c + 3.909)/c
 * Calculate Y = 2a - (0.2479b + 3.909)/b
 * Calculate W = X + Y + a/b
 * An abnormal W index result is >1.95.

 * When ICD (a) and OCD (c) are the only measurements available, IPD (b) can be calculated according to the formula: [(c - a)/2] + a. This can be used when IPD (b) is already known to compare measured and calculated values.

 * Molecular genetic testing
 * available by sequencing the PAX3 gene (chromosomal locus 2q35)
 * can be used to confirm the diagnosis in atypical cases
 * primarily used for genetic counseling of at-risk family members
 * detects over 90% of disease-causing mutations
 * most mutations are unique
 * available clinically
 * Prenatal testing
 * available for pregnancies at 50% risk in which a parent has been identified as having a PAX3 mutation
 * performed on fetal cells obtained by CVS or amniocentesis
 * can determine whether or not the fetus has inherited the PAX3 mutation, but it cannot determine the clinical manifestations nor their severity
 * not available for families who have not had molecular genetic testing of the PAX3 gene or do not have a PAX3 gene mutation

Management and Treatment

 * folic acid supplementation in pregnancy is recommended for women at increased risk of having a child with WS1, given the possibly increased risk of neural tube defects in association with WS1
 * congenital hearing loss can be identified through universal screening of newborns
 * management of hearing loss
 * as a minimum, all children with a risk for hereditary hearing loss should receive screening audiometry
 * the team evaluating and treating the deaf individual should consist of an otolaryngologist with expertise in the management of early childhood otologic disorders, an audiologist experienced in the assessment of hearing loss in children, a clinical geneticist, and a pediatrician
 * the expertise of an educator of the Deaf, a neurologist, and a pediatric ophthalmologist may also be required
 * sequential audiologic examinations are essential to document the stability or progression of the hearing loss and to identify and treat superimposed hearing losses, such as middle ear effusion
 * an important part of the evaluation is determining the appropriate habilitation option
 * possibilities include hearing aids, vibrotactile devices, and cochlear implantation
 * cochlear implantation can be considered in children over 12 months of age with severe-to-profound hearing loss

Psychosocial Issues

 * guilt issues with the affected parent
 * individual education plan
 * school support/signer

Support Groups and Resources

 * American Society for Deaf Children
 * PO Box 3355
 * Gettysburg, PA 17325
 * Phone: 717-334-7922 (business V/TTY); 800-942-ASDC (parent hotline)
 * Fax: 717-334-8808
 * Email: ASDC1@aol.com
 * www.deafchildren.org

 * National Association of the Deaf
 * 814 Thayer
 * Silver Spring, MD 20910-4500
 * Phone: 301-587-1788 (voice); 301-587-1789 (TTY)
 * Fax: 301-587-1791
 * Email: NADinfo@nad.org
 * www.nad.org

 * National Vitiligo Foundation
 * 611 S Fleishel Ave
 * Tyler, TX 75701
 * Phone: 903-531-0074
 * Email: vitiligo@Trimofran.org
 * www.vitiligofoundation.org

 * National Organization for Albinism and Hypopigmentation
 * PO Box 959
 * East Hempstead, NH 03826-0959
 * Phone: 603-887-2310; 800-473-2310
 * Email: noah@albinism.org
 * www.albinism.org

 * NCBI Genes and Disease Webpage
 * www.ncbi.nlm.nih.gov/disease/Waard.html

 * Hereditary Hearing Loss Home Page
 * Additional information on Waardenburg syndrome
 * www.uia.ac.be/dnalab/hhh


text:
A-level Mathematics/OCR/S1

What is statistics?
Statistics is the scientific approach to numerical information. Statistical development has shown that many aspects of progress depend upon the correct analysis of numerical information - particularly in science, economics and business. Please post all questions to A-level Mathematics/Discussion.

Contents

 * 1) /Collection of data/
 * 2) /Representation of data/
 * 3) /Probability/
 * 4) /Discrete Random Variables/
 * 5) /Bivariate Data/

title: A-level Mathematics/OCR/S1


text:
User:Author~enwikibooks

I am an avid teacher, student, read and writer of sorts.

title: User:Author~enwikibooks


text:
Cookbook:Soy Protein Bread

The use of soy protein in this recipe increases the bread's natural flavor. This bread is very easy to prepare.

Ingredients

 * 30 g (1 oz) fresh yeast
 * 2 eggs
 * 1 cup vegetable oil
 * 3 cups warm milk
 * 1 tbsp white granulated sugar
 * 1 tbsp salt
 * 1 cup texturized soy protein
 * 8 cups all-purpose flour

Procedure

 * 1) Heat the milk until it is about to boil, then add the salt and the soy protein. Mix it for the salt to be well dissolved. Let it rest until is warm again.
 * 2) Put the milk and the rest of the ingredients, including the yeast, in blender. Mix it for a few seconds until it is homogeneous.
 * 3) Pour the mixture into a bowl and start mixing in the flour to keep the bread homogeneous all the time.
 * 4) Work the bread with your hands all the time, always keeping it smooth. You may have to add some extra flour while you work with it. Keep doing this until the bread stops being sticky.
 * 5) Let it rest for about 25 minutes at a warm place.
 * 6) Separate out several small balls of bread of about 1 inches (2.5 cm) in diameter and half that in height.
 * 7) Put the breads on a baking tray with some distance between them and leave them for another 15 minutes.
 * 8) Preheat the oven to about 200°C and put the tray in the middle of the oven.
 * 9) Let them bake for about 20 minutes.

Notes, tips, and variations

 * You may increase the amount of oil by ½ cup to make it more moist and increase its lifetime.
 * You may add minced provolone into the mixture (not filling) to give it a delicious subtle taste of cheese. You may of course fill it as well.
 * You may cook it in different shapes than the small buns.

title: Cookbook:Soy Protein Bread


text:
User talk:Manilow~enwikibooks

i love lucia:|

Your account will be renamed
Hello,

The developer team at Wikimedia is making some changes to how accounts work, as part of our on-going efforts to provide new and better tools for our users like cross-wiki notifications. These changes will mean you have the same account name everywhere. This will let us give you new features that will help you edit and discuss better, and allow more flexible user permissions for tools. One of the side-effects of this is that user accounts will now have to be unique across all 900 Wikimedia wikis. See the announcement for more information.

Unfortunately, your account clashes with another account also called Manilow. To make sure that both of you can use all Wikimedia projects in future, we have reserved the name Manilow~enwikibooks that only you will have. If you like it, you don't have to do anything. If you do not like it, you can pick out a different name.

Your account will still work as before, and you will be credited for all your edits made so far, but you will have to use the new account name when you log in.

Sorry for the inconvenience.

Yours, Keegan Peterzell Community Liaison, Wikimedia Foundation 23:28, 17 March 2015 (UTC)

Renamed
 This account has been renamed as part of single-user login finalisation. If you own this account you can |log in using your previous username and password for more information. If you do not like this account's new name, you can choose your own using this form after logging in: . -- Keegan (WMF) (talk) 05:14, 19 April 2015 (UTC)

title: User talk:Manilow~enwikibooks


text:
User:Neva~enwikibooks

Translator and journalist from Bulgaria.

Здрасти,

Би ли гласувала за Българската уикикнига също и на Collaboration of the Month/January 2006 voting тъй като са я преместили там. Благодаря ти. --Vanka5 19:27, 29 December 2005 (UTC)

title: User:Neva~enwikibooks


text:
User:Axezz~enwikibooks

I have yet to edit Wikibooks but they will come. Here are though some interesting projects: transwiki, Wikiversity and related projects.

Newsletter - Languages - Philosophy - Staff lounge - Transwiki - VfD - Boilerplates - Help desk

Wikijunior: Ancient Civilizations – Big Cats – Bugs – Dinosaurs – The Elements – How Things Work – Human Body – Kings and Queens of England – Languages – The Solar System – South America – World War II About Wikijunior >>

{| cellspacing=3
 * - valign="top"
 * width="50%" style="border-style:solid;border-width:1px;padding:1em;padding-top:0;"|

Featured text

 * width="50%" style="border-style:solid;border-width:1px;padding:1em;padding-top:0;"|

The Wikimedia Foundation is a non-profit organization that depends on donations to operate. If you find Wikibooks or other projects hosted by the Wikimedia Foundation useful, please consider making a donation. Donations are used primarily for purchasing server equipment and launching new projects.
 * }

title: User:Axezz~enwikibooks


text: User talk:24.98.247.225

title: User talk:24.98.247.225


text:
User talk:85.31.137.11

Please stop adding nonsense to Wikibooks. It is considered vandalism. If you would like to experiment, use the sandbox. Thank you.

March 2011
We welcome and appreciate your contributions, but some of your recent edits had to be undone. Please see What is Wikibooks? to learn more about what contributions are beneficial to Wikibooks. Please be aware that some edits can be considered vandalism, use the sandbox for any test edits you would like to make, and read the welcome page to learn more about contributing constructively to this project. Thank you. QU TalkQu 12:18, 9 March 2011 (UTC)

Block Notice
You cannot edit for 1 week due to disruptive editing. You are welcome to contribute constructively when editing privileges are restored. You may appeal this action with a reasonable argument by adding the text below. Jomegat (discuss • contribs) 14:41, 10 March 2011 (UTC)

May 2011
You cannot edit for 1 month due to your persistent vandalism. You are welcome to contribute constructively when editing privileges are restored. You may appeal this action with a reasonable argument by adding the text below. QU TalkQu 13:11, 16 May 2011 (UTC)

Block Notice
You cannot edit for 6 months due to persistent vandalism. You are welcome to contribute constructively when editing privileges are restored. You may appeal this action with a reasonable argument by adding the text below. Jomegat (discuss • contribs) 11:19, 23 September 2011 (UTC)

title: User talk:85.31.137.11


text: User talk:67.87.54.196

title: User talk:67.87.54.196


text:
User talk:84.176.250.152

Please stop adding nonsense to Wikibooks. It is considered vandalism. If you would like to experiment, use the sandbox. Thank you.

title: User talk:84.176.250.152


text:
User talk:70.50.239.224

blocked as open proxy --Derbeth talk 14:47, 7 December 2005 (UTC)

title: User talk:70.50.239.224


text: User talk:216.110.116.139

title: User talk:216.110.116.139


text: User talk:81.30.217.171

title: User talk:81.30.217.171


text:
Radiation Oncology/Liver/Liver Mets

Overview

 * Liver is the second most frequently metastatic organ, after lymph nodes
 * Rich dual vascular supply and cell-promoting humoral factors
 * In US/Europe, liver mets are much more frequent than primary liver tumors
 * Primaries most commonly going to liver:
 * Adults: the eye, colon, stomach, pancreas, breast, and lung
 * Children: neuroblastoma, Wilms tumor, and leukemia
 * Seeding: 77% both lobes, 10% single lesions. Multiple mets often vary in size, suggesting seeding from primary in waves
 * Imaging: With an equivalent specificity, PET is the most sensitive (vs. U/S, CT, MRI)
 * Treatment options:
 * Surgery
 * Transcatheter arterial chemoembolization (TACE)
 * Ablation (Cryoablation, Microwave ablation, EtOH ablation, RF ablation, Laser ablation
 * RT historically not used due to low median liver tolerance, but now increasing interest with conformal therapy and stereotactic radiotherapy
 * Survival:
 * Colorectal primary: resection can offer cure, 5-year survival 20-40%
 * Breast, lung, pancreas primary: poor due to usually widespread metastatic disease outside of liver

Treatment
Most studies include both mets and primary liver cancer; for now they are kept together. Please see the Liver/Treatment page.

Surgery

 * MSKCC; 2007 (1985-1994) PMID 17925551 -- "Actual 10-year survival after resection of colorectal liver metastases defines cure." (Tomlinson JS, J Clin Oncol. 2007 Oct 10;25(29):4575-80.)
 * Retrospective. 612 consecutive patients, 102 10-year survivors
 * Outcome: If survive 10 years, 97% DSS; if survive 5 years, 66% DSS
 * Initial factors: 50% N+, 39% >1 met, 35% tumor size >5cm, 25% bilobar mets, 7% synchronous disease
 * Conclusion: Almost 20% cure in well-selected patients with CRC liver mets

title: Radiation Oncology/Liver/Liver Mets


text:
Radiation Oncology/Liver/HCC

Hepatocellular carcinoma

Epidemiology

 * 6th most common cancer in the world. 14.7 per 100,000 men and 4.9 per 100,000 women.  3 to 1 ratio male to female.  Highest risk areas are East and Southeast Asia and Sub-Saharan Africa.
 * In North America, only 1-3 per 100,000 people. Incidence is increasing due to hepatitis virus.
 * Death rate equal to (or exceeds!) the incidence. There are more deaths than new cases because of the poor outcome and because metastatic disease to the liver is mistakenly attributed to liver cancer in statistics.

Risk

 * Roughly 80% of HCC is attributable to either HBV or HCV, of which HBV accounts for ~55% and HCV 25%
 * Persistent HBV infection: 100x-250x risk
 * Chronic HCV and cirrhosis: 100x
 * Ethanol is carcinogenic. Higher risk of HCC than in non-alcohol-drinkers with HCV.
 * Other chemicals: alfatoxin B, nitrites, hydrocarbons, solvents, organochlorine pesticides, primary metals, polychlorinated biphenyls

Prevention

 * Treatment of HCV with interferon alpha decreases risk of developing HCC

Clinical presentation
Asymptomatic in early stages. Detected with AFP and ultrasound in patients with liver disease. Many patients are asymptomatic even in advanced stages. The majority of symptoms are from liver disease itself. Tumor-related symptoms are palpable mass in abdomen, acute onset pain from hemorrhage, dull pain, abdominal fullness, low grade fever, obstructive jaundice, and splenomegaly.

Biology

 * Rapid doubling time of 41 days

Workup

 * Triphasic CT scan is most sensitive imaging modality (more than MRI). Since AFP has a 10-15% false positive rate and may be elevated in HCC, intrahepatic cholangiocarcinoma (ICC), or some colon metastases, since 2005, the AASLD has recommended the triphasic CT scan as the distinguishing test of choice for radiologic diagnosis of HCC.
 * Metastases are rare at presentation
 * Indocyanine green (IDG) 15-minute retention rate for determining eligibility for resection

Child Pugh Score Table

Child Pugh Class Designation

Current staging
AJCC 7th Edition (2009) Note: Staging applies only to hepatocellular carcinoma (no longer includes intrahepatic bile ducts)

Primary Tumor:
 * T1 - Solitary tumor without vascular invasion
 * T2 - Solitary tumor with vascular invasion or multiple tumors none more than 5 cm
 * T3
 * T3a - Multiple tumors more than 5 cm
 * T3b - Tumor of any size involving a major branch of the portal vein or hepatic vein
 * T4 - Tumor with direct invasion of adjacent organs, other than the gallbladder, or with perforation of visceral periteonum

Regional Lymph Nodes:
 * N0 - no
 * N1 - yes
 * Regional nodes include: hepatic artery, portal vein, hilar, hepatoduodenal ligament, inferior phrenic, caval lymph nodes

Distant Metastases:
 * M0 - none
 * M1 - yes

Stage Grouping:
 * Stage I: T1 N0 M0
 * Stage II: T2 N0 M0
 * Stage IIIA: T3a N0 M0
 * Stage IIIB: T3b N0 M0
 * Stage IIIC: T4 N0 M0
 * Stage IVA: N1
 * Stage IVB: M1

Older staging editions
AJCC 6th Edition (2002) Note: staging was also used for intrahepatic bile ducts

 * T1 - Solitary, <= 2cm, without vascular invasion
 * T2 - Solitary <= 2cm with vascular invasion; multiple, limited to one lobe, <= 2cm, without vascular invasion; solitary, >2 cm, without vascular invasion
 * T3 - Solitary, >2cm, with vascular invasion; multiple, one lobe, <= 2cm, with vascular invasion; multiple, one lobe, any more than 2cm
 * T4 - Multiple tumors, involving more than one lobe; invasion of a major branch of portal or hepatic veins; invasion of adjacent organs other than gallbladder; perforation of visceral peritoneum

 * Stage I: T1 N0 M0
 * Stage II: T2 N0 M0
 * Stage IIIA: T3 N0 M0
 * Stage IIIB: T1-3 N0 M0
 * Stage IVA: T4
 * Stage IVB: M1

Prognosis

 * Fibrolamellar variant has a better prognosis

Treatment
Most studies include both mets and primary liver cancer; for now they are kept together. Please see the main Liver page.

 * HCC (hepatocellular carcinoma) tumors can be classified as resectable (can be removed by an operation) and unresectable (cannot be removed by an operation). Only 10-15% of cases can be effectively treated with surgical resection.
 * Surgical resection with 2-cm margin of liver for T1-3 N0. Minimum of 1-cm is recommended but literature is mixed on the exact margin required.
 * For unresectable, chemoembolization, intraarterial infusional chemo, cryosurgery, ethanol injection, radioimmunotherapy, conformal radiotherapy, radiofrequency ablation.
 * For stage IV, chemotherapy, but low response rates.

 * The radionuclide 131-Lipiodol treatment is believed to offer a significant reduction in recurrence rate for resectable HCC. A 1999 Lancet study by WY Lau et al (PMID 10459961) report an improvement in the 3-year survival rate from 46.3% (control group) to 86.4% (treatment group).  This treatment is not yet approved in the United States, but it is in Phase III clinical trials in Singapore and can be administered in Hong Kong.

SBRT

 * Princess Margaret (2003-2006)
 * Phase I. 41 patients, unresectable HCC (n=31) or IHC (n=10). SBRT 6 fractions; dose dependent on NTCP calculations. Toxicity risk escalated from 5% to 10% and 20%. Median tumor size 173 mL (9-1913 mL); had to have >=800 mL uninvolved liver; Child-Pugh A liver function. Median dose 36.0 Gy (24.0 - 54.0 Gy). CTV=GTV+8mm, PTV=CTV+5mm or more
 * 2008 PMID 18172187 -- "Phase I Study of Individualized Stereotactic Body Radiotherapy for Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma." (Tse RV, J Clin Oncol. 2008 Jan 2 [Epub ahead of print]). Medium F/U 1.5 years
 * 3 month toxicity: No dose-limiting toxicity or RILD; 24% Grade 3 liver enzymes, no Grade 4/5; 23% experienced progression to Child-Pugh B liver function. Late toxicity 2 patients (6%): 1 patient dead from GI bleed from tumor-duodenal connection, 1 patient SBO requiring surgery.
 * Outcome: median OS HCC 11.7 months, IHC 15.0 months
 * Conclusion: Individualized 6-fraction SBRT safe
 * 2006 PMID 16982550 -- "Individualized image guided iso-NTCP based liver cancer SBRT." (Dawson LA, Acta Oncol. 2006;45(7):856-64.)
 * Phase I/II. 79 patients with HCC (33), IHC (12) or liver mets (34).
 * RT: prescription based on NTCP to maintain given risk of RILD to max 60/6 (median dose 36.6/6)

 * Hokkaido; 2007 (2001-2004) PMID 17869660 -- "Intercepting radiotherapy using a real-time tumor-tracking radiotherapy system for highly selected patients with hepatocellular carcinoma unresectable with other modalities." (Taguchi H, Int J Radiat Oncol Biol Phys. 2007 Oct 1;69(2):376-80.)
 * Retrospective. 18 HCC tumors, 15 patients. Real-time tumor tracking with implanted 2.0 mm fiducial marker. Median dose 48/8 (median BED 76.8 Gy). Mean F/U 1.7 years
 * Outcome: 2-year OS 39%, LC 83% (92% with re-irradiation)
 * Toxicity: 1 Grade 3 transient gastric ulcer, 2 transient LFT elevation
 * Conclusion: Fiducial marker-guided RT effective at delivering focal high dose

TACE and RT

 * Meta-analysis; 2008 PMID 19042048 -- "Transcatheter arterial chemoembolization in combination with radiotherapy for unresectable hepatocellular carcinoma: A systematic review and meta-analysis." (Meng MB, Radiother Oncol. 2008 Nov 28. [Epub ahead of print])
 * Meta-analysis. 17 trials and 1476 patients, 5 RCT.
 * Conclusion: TACE + RT is more therapeutically beneficial than TACE alone

Survival

 * Unresectable: less than 10% 5-year survival
 * Resectable: 5-year survival 50-73% stage I, 30-56% stage II, 10-29% stage III, 10% stage IV.

Radioemobolization

 * SIRveNIB; 2018 (2010 - 2016) PMID 29498924 -- "SIRveNIB: Selective Internal Radiation Therapy Versus Sorafenib in Asia-Pacific Patients With Hepatocellular Carcinoma." (Chow PKH, J Clin Oncol. 2018 Jul 1;36(19):1913-1921. doi: 10.1200/JCO.2017.76.0892. Epub 2018 Mar 2.
 * Randomized, 11 countries. 360 patients, locally advanced HCC. Arm 1) Radioemolization Y90 (mean activity 1.8 GBq); 29% did not receive assigned therapy vs Arm 2) sorafenib; 9% did not receive assigned therapy
 * Outcome: Median OS RE 8.8 months vs sorafenib 10.0 months (NS). Median PFS 5.8 month vs 5.1 months (NS)
 * Toxicity: Grade 3+ RE 28% vs sorafenib 51% (SS). Most common G3 toxicity ascites ~3%. Radiation hepatitis 1.5%
 * Conclusion: No difference in OS, but improved toxicity profile of radioembolization

Patterns of failure

 * Local tumor recurrence and intrahepatic recurrence are the predominant sites of failure.

Fibrolamellar Carcinoma

 * Considered a variant of HCC comprising < 1%; however, evidence suggests it is uniquely distinct in both epidemiology and better prognosis
 * Associated with cirrhosis in <10% patients, typically presents in a background of normal liver function and histologic architecture
 * 50-60% solitary, rest satellite lesions next to primary mass; rarely diffuse involvement
 * Surgery (hepatic resection/transplant) is primary treatment alternative
 * Radiotherapy
 * Hopkins 1985-90 PMID 10025374 -- Metastatic nonresectable fibrolamellar hepatoma: prognostic features and natural history. (1999 Epstein BE, Am J Clin Oncol. 1999 Feb;22(1):22-8.)
 * Retrospective. 17 patients with met disease. Matched control analysis with HCC patients
 * Median survival: 14 months vs. 7.7 months (p<0.001)

title: Radiation Oncology/Liver/HCC


text:
Linear Algebra/Orthogonality

< Linear algebra

Cauchy-Schwarz inequality
The Cauchy-Schwarz inequality states that the magnitude of the inner product of two vectors is less than or equal to the product of the vector norms, or: $$| \langle x,y \rangle | \le  \| x \| \| y \| $$.

Definition
For any vectors $$x$$ and $$y$$ in an inner product space $$V$$, we say $$x$$ is orthogonal to $$y$$, and denote it by $$x \bot y$$, if $$\langle x,y \rangle =0$$.

How to orthogonalize a basis
Suppose to be on a vector space V with a scalar product (not necessarily positive-definite), Problem: Construct an orthonormal basis of V starting by a random basis { v1, ... }. Solution: Gram-Schmidt for non isotropic vectors, otherwise choose v_i + v_j and reiterate.

title: Linear Algebra/Orthogonality


title: User:Pm5~enwikibooks


text:
Software Engineers Handbook/Language Dictionary/PHP

PHP
, which stands for 'PHP: Hypertext Preprocessor', is an open source scripting language. It can be embedded in HTML, similar to how JSP.

Type
PHP is a little hard to classify. The creators declare that it's a web development scripting language and, well, it is. Though it's largely procedural and has slowly gone towards being an object oriented language (PHP 5). So, really PHP can be what you want it to be. Though note, it's an interpreted language, which can be compiled down some. PHP.net's introduction pages

Execution Entry Point
PHP is generally accessed from a webserver processing an html page with some php in it, or a php file.

In an html file:

Or you can create an entire php file by enclosing the entire thing in the <? and ?>. The general trend is to call these files .php files for files that render something like html and .inc files for library files.

General Syntax
Variables contain a '$' in front of them and do not need to be declared. Lines end with a semicolon, like in C. As with most web development scripting languages, there are a few global variables, like $_SESSION and $_POST, $_GET, and $_REQUEST.

A general assignment goes like this:

Comments
// this is an inline comment. Everything after the // is a comment. Block comments are specified by a starting /* and ending */ They can span multiple lines.

Php contains phpdoc - where you can create an html manual from comments before the function declaration. They look like this:

There's a few other @ types you can use here. Sources of how to generate phpdocs are needed. More to come.

Variable Declarations
declare i as an integer $i = 1;

Or: $str = 'string';

There's no datatype declaration required, so you can change a variables datatype though assigning it to something else:

$foo = 1; $foo = 'string';

One stumbling block with this is that you need to know how to concat strings versus adding values.

For concating strings you can use the "." or ".=". If you want to add values use "+" or "+=".

If you do this: $foo = 'string'; $foo += ' is cool';

You'll end up with some number verus "string is cool", as you've added strings and not concatinated them.

Method Declaration/Implementation
Function declaration:

You can default parameters like this:

You don't need to declare any return value.

When you declare a function to use with in a class, it looks just the same as the one shown above, with the only difference is with it being physically located inside a class boundary.

Scope
All variables have a single scope in PHP. If it's in a function, then it has local scope. If it's outside a function, then it has global scope.

You can create a global variable in two ways. The first way is by putting it outside a function. The second way is to declare it this way:

global $foo;

This makes it available from anywhere.

To access a global value from inside a function you need to declare that you're using it, otherwise php thinks it's completely different from the global variable.

YES:

NO:

PHP will create the $foo inside of the function and not associate it with the global $foo. The two $foo's are completely different entities in the "NO" example.

$bar is local and its scope is limited to the function.

PHP has excellent documentation on scoping available.

Conditional Statements
There's the typical if/else statements:

Braces can be removed as long as there's only a single statement after the condition:

Another valid way to write an if statement is like this:

$bar = (($foo == true) ? 'test' : 'not test');

The first two are a bit easier to read.

There's also a case/switch conditional:

Please visit php's structure page for more information and alternate ways conditions can be written.

Looping Statements
PHP includes the traditional loops - a for loop, while and do while. There's a foreach loop as well.

For:

PHP has a special foreach loop that's useful for dealing with arrays:

While:

or

Do while:

Please visit php's loop page for more information on loops and alternative ways of writing them.

Output Statements
Here's how to print out 'Hello World!' in PHP.

echo 'Hello World!';

When you want to include a PHP variable inside the string you need to use double quotes, as PHP will not parse the data between single quotes, it will just print it out.

$foo = 'bar'; echo "foo$foo";

// prints out foobar;

It's good to use single quotes when there's no variables in the string as it saves processing time.

Error Handling/Recovery

Containers
PHP has an array as a native data type. To use:

Arrays in PHP are very powerful and useful. They can be used like a hash, as in the first and third example - you can use index's and strings into the arrays. You don't necessarily need to declare the array, though it's a good practice. Also, you can just write two brackets, as in $foo[], to signify that you want the data to go into the next index, as in example 2.

Algorithms

Garbage collection

Physical Structure

Tips

Web References
There's a great PHP library at php.net. This has the manual there as well as library pages - so it's probably appropriate for any user who's familiar with programming to some degree. You'll definitely need this page as a reference for the libraries.

Books and Articles


text:
User talk:Skymath

Do not perform copy and paste moves.
Please do not perform copy and paste moves. Use the page move tab to rename pages. That's what it is for. I've done a history merge to clean up the mess. But I leave it to you to check that the current version of the article is the latest version (which is sometimes not the case after history merges) and revert to the correct version if it is not. Uncle G 17:43, 7 December 2005 (UTC)
 * Unfortunately, your cleaning has made "Climate Change" and "Climate change" both be redirect pages, which lead no where. I will use the revert method that I found in the help section to revert "Climate Change" back to it's previous form. Thanks for the advice though. I wanted to use move, but there was some trouble because "Climate Change" was already a page (empty though, and possibly made by me). Probably there is a simple way to deal with that situation, but I thought cutting and pasting was the most straight forward way, especially considering the very small number of pages linking to Climate C/change right now. Skymath 20:57, 7 December 2005 (UTC)

title: User talk:Skymath


text:
Radiation Oncology/Antibodies

 * Liver

title: Radiation Oncology/Antibodies


text: User talk:86.2.43.231

title: User talk:86.2.43.231


text:
PHP vs ColdFusion/Editors

Picking the right editor is essential for web designers. Here we will cover some of the pros and cons of working with certain editors.

Studio 8
Studio is a software suite from Adobe Systems that includes Dreamweaver, Flash, and Fireworks 8, in addition to Contribute 3 and FlashPaper 2.

Cost: $900 US

Pros
 * Easy to Use: Simple, some more complicated functions in Flash, but no coding necessary.
 * Standards Compliant: Complies with W3C

Frontpage 2003
Frontpage is a very neat and handy utility. It offers people to create websites who know zero HTML.

Cost: $199 US

Pros
 * Easy to use: Anyone who can use word, can use Frontpage.
 * Projects: You can create projects and Frontpage will automatically re-link documents when filesystem changes occur.

Cons
 * Doesn't play nice: Frontpage has a tendency to re-write your document to structure code. This usually wipes out PHP code in the document.
 * Overly Re-writes: I dont know how many times i've looked at code by Frontpage to only see a plethora of CSS styles. Can get annoying if you are used to a certain way of coding.
 * Poor Design: Code is non-W3C complient and hard to use.
 * Lack of Support: No longer supported by Microsoft.

Notepad
Notepad requires you to know pretty much every aspect of HTML, however a wise choice for people who dont like to be told how to code.

Cost: Free

Pros
 * Runs fast: No matter what the system (Windows), notepad always performs.
 * No Re-writes: Notepad doesn't re-write anything, because it can't.

Cons
 * No Projects: No way to manage your documents without external applications or by manually re-writing.
 * No Indent Holding: Notepad does not keep your indents, making you tab in over and over.

title: PHP vs ColdFusion/Editors


text:
Biochemistry/Metabolism

Biochemistry

<< Enzymes | DNA and RNA >>

What is life? What makes life work? Life is not static; it is defined by activity. A cell has to perform certain tasks to stay alive. This activity has to be powered by fuel; the fuel is converted into energy, to keep the cell running, building blocks for new biomolecules, and waste products. This process is called metabolism.

ATP as an intermediate energy carrier
We have already seen how ATP is a universal "energy currency" in the cell, and how its high-energy phosphate can store and release this energy efficiently. But ATP is only a short-term energy storage; a hard-working human can use up to one pound of ATP per minute. How can that be?

The answer lies in the medium- and long-term energy storage molecules, notably phosphoenol pyruvate (PEP), acetyl phosphate, and creatine phosphate. Each of these molecules carries a phosphate group with an ever higher transfer potential than that of ATP. ATP is continuously regenerated by transferring phosphate groups from these molecules to ADP. For example, the reaction of creatine phosphate is Creatine phosphate + ADP + H+ ⇋ ATP + creatine a reaction which is catalyzed by the creatine kinase, and highly in favor of the "ATP side" of the equation.

Electron carriers
Most of the energy of eucaryotic lifeforms derives from oxidating fuel molecules, that is, the transfer of electrons from fuel molecules to oxygen. The fuel molecules are oxidized, while the oxygen is reduced. A rather radical form of oxidation is fire, which oxidizes its fuel directly with oxygen. As spontaneous combustion one ones cells is rather unpleasant, the electrons are carried through several steps from the fuel molecules to the final electron acceptor, oxygen. The flow of electrons causes a proton gradient in the mitochondrial membranes, which in turn is used by the enzyme ATPase (or proton pump) to generate ATP. This process, utilizing anelectron transport chain, is called oxidative phosphorylation.

The electron carrier molecules of choice are NADH and FADH2. They are pyridine nucleotides (also called flavions).

Both molecules are also for biosyntheses that require reducing power. Especially a variant of NADH, NADPH, is used for this purpose.

With all these high-energy bonds and electron-carrying molecules around, one would expect to see wild, uncontrolled chemical reactions occurring in the cell. However, the opposite is the case: Without a catalyst, ATP is quite slow to hydrolize and give its phosphate group to water. Also, all three electron-carrying molecules, NADH, NADPH, and FADH2, are slow to react with O2 without a catalyst.

Cancer Cell Metabolism
Glutamine addiction: a new therapeutic target in cancer

The Warburg observation that cancer cells use up an unusually high level of glucose and produce more lactic acid has been around since the 1920’s. It wasn’t noted till 1955 by Eagle, that cancer cells also use up a high level of the amino acid glutamine. In the article, Glutamine addiction: a new therapeutic target in cancer, Wise and Thompson highlight the role glutamine plays in cancer cell growth, protein translation, anaplerosis, and macromolecular synthesis.

Glutamine is the chief donor of nitrogen to cancer cells for the cells to multiply. When glutamine gives up its amide, it is converted into glutamic acid, which is the main nitrogen donor for nonessential amino acid synthesis. This amino acid biosynthesis makes glutamine a main ingredient for the cancer cells’ need for protein translation. Stemming off of biosynthesis is Myc, a basic protein that binds 11 of the genes involved in nucleotide biosynthesis. Myc activation is a commonly observed in cancer and is identified as the driving force behind the spread of lymphomas and small cell lung cancer. Myc facilitates glutamine consumption and supports the change of glutamine into glutamic acid, and finally into lactic acid. This satisfies the Warburg observation of the unusual lactic acid production of cancer cells.

The target of rapamycine (TOR) controls many cell functions such as cell growth, reproduction, motility, and protein synthesis. The “master regulator of protein translation, the mammalian target of rapamycin complex (TOR), is responsive to glutamine levels” (Wise and Thompson, 2010). This was initially discovered in yeast, where TOR activation was found to be dependent on glutamine levels.

The article also describes how glutamine adds to macromolecular (DNA, RNA, and proteins) synthesis by producing NADPH (nicotinamide adenide dinucleotide phosphate, a reducing agent in anabolic reactions) and providing the cancer cell with a substrate source which refills the mitochondrial carbon pool (anaplerosis). This refilling of the carbon pool is necessary for the synthesis of proteins, lipids, and nucleotides.

All of these facts relating glutamine importance to cancer cells may be a potential target in altering cancer cell metabolism. However, it is still unknown if this is a viable target for the treatment of cancer. Ideas include suppressing the glutamine uptake, TOR activation, or the anaplerosis of the cancer cells. Using an enzyme to lower blood glutamine levels is another possible method.

title: Biochemistry/Metabolism


text:
Water Resources Directory/USA/Education

Environmental Engineering (Pollution Control)

 * Cornell University -

Environmental Sciences

 * University of North Carolina (UNC) at Chapel Hill

Hydrology

 * Cornell University -

Water Resources Management
(Top five programs are numbered.)

1. Cornell University - Environmental & Water Resources Systems program in School of Civil and Environmental Engineering
 * Master of Engineering (1 year with 30 semester hours plus a design project)
 * Master of Science (2 years with 24 semester hours plus a research thesis)
 * PhD (about 5 years with research and dissertation)
 * Note: also has graduate programs in Hydrology and in Environmental Engineering

2. Duke University - Master of Environmental Management (48 credit units) with specialized tracks of study:
 * Coastal Environmental Management (CEM)
 * Conservation Science and Policy (CSP)
 * Environmental Economics and Policy (EEP)
 * Ecosystem Science and Management (ESM)
 * Energy and Environment (EE)
 * Environmental Health and Security (EHS)
 * Forest Resource Management (FRM)
 * Global Environmental Change (GEC)
 * Water and Air Resources (WAR)

3. Colorado State University - M.E. Civil Engineering with water resources focus
 * 30 semester hours with some distance learning courses, no thesis.

 * Harvard University - Center for the Environment
 * Environmental Science and Public Policy - "founded on the premise that the ability to form rational judgments concerning many of the complex challenges confronting society today involving the environment requires both an understanding of the underlying scientific and technical issues and an appreciation for the relevant economic, political, legal, historical, and ethical dimensions."

Water Resources Planning
USACE Short Courses for Planners (Reference):

 * Planning Orientation Workshop
 * Planning Process Workshop
 * Plan Formulation Workshop
 * Environmental Considerations in Planning
 * Economic Analysis in Planning
 * Hydrologic & Hydraulic Considerations in Planning
 * Public Involvement and Teaming in Planning

USEPA Short Courses
 * Catalog of Watershed Courses

Homeowners

 * Drinking Water Quality

title: Water Resources Directory/USA/Education


text:
User talk:BigCow~enwikibooks

Late welcome
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I just saw your red linked talk page and couldn't resist. -- LV (Dark Mark) 18:35, 7 December 2005 (UTC)

Thank's for the welcome, he who must not be named. I still haven't been welcomed on Wikipedia yet for some reason, probably because I already had people talking on my talk page, but it's nice to be recognized. I've been working on some of the game guides here, and a lot of the articles on wikipedia itself.--BigCow 17:55, 9 December 2005 (UTC)

 * Your own personalised welcome is awaiting you at WP. Cheers. -- LV (Dark Mark) 21:39, 13 December 2005 (UTC)

Your account will be renamed
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The developer team at Wikimedia is making some changes to how accounts work, as part of our on-going efforts to provide new and better tools for our users like cross-wiki notifications. These changes will mean you have the same account name everywhere. This will let us give you new features that will help you edit and discuss better, and allow more flexible user permissions for tools. One of the side-effects of this is that user accounts will now have to be unique across all 900 Wikimedia wikis. See the announcement for more information.

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Yours, Keegan Peterzell Community Liaison, Wikimedia Foundation 23:02, 17 March 2015 (UTC)

Renamed
 This account has been renamed as part of single-user login finalisation. If you own this account you can |log in using your previous username and password for more information. If you do not like this account's new name, you can choose your own using this form after logging in: . -- Keegan (WMF) (talk) 04:39, 19 April 2015 (UTC)

title: User talk:BigCow~enwikibooks


text:
User talk:Jamiejamie

Hello and welcome to Wikibooks!

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You will find more resources in Community Portal. If you want to ask a question, visit the Study help desk, the Staff lounge, or ask me personally on my talk page.

Good luck! -- LV (Dark Mark) 18:48, 7 December 2005 (UTC)

title: User talk:Jamiejamie


text:
User talk:Bethany

Hello and welcome to Wikibooks!

Here are some tips to help you get started:
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You will find more resources in Community Portal. If you want to ask a question, visit the Study help desk, the Staff lounge, or ask me personally on my talk page.

Good luck! -- LV (Dark Mark) 19:18, 7 December 2005 (UTC)

title: User talk:Bethany


text:
User talk:Sim man~enwikibooks

Hello and welcome to Wikibooks!

Here are some tips to help you get started:
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You will find more resources in Community Portal. If you want to ask a question, visit the Study help desk, the Staff lounge, or ask me personally on my talk page.

Good luck! -- LV (Dark Mark) 20:11, 7 December 2005 (UTC)

Your account will be renamed
Hello,

The developer team at Wikimedia is making some changes to how accounts work, as part of our on-going efforts to provide new and better tools for our users like cross-wiki notifications. These changes will mean you have the same account name everywhere. This will let us give you new features that will help you edit and discuss better, and allow more flexible user permissions for tools. One of the side-effects of this is that user accounts will now have to be unique across all 900 Wikimedia wikis. See the announcement for more information.

Unfortunately, your account clashes with another account also called Sim man. To make sure that both of you can use all Wikimedia projects in future, we have reserved the name Sim man~enwikibooks that only you will have. If you like it, you don't have to do anything. If you do not like it, you can pick out a different name.

Your account will still work as before, and you will be credited for all your edits made so far, but you will have to use the new account name when you log in.

Sorry for the inconvenience.

Yours, Keegan Peterzell Community Liaison, Wikimedia Foundation 23:41, 17 March 2015 (UTC)

Renamed
 This account has been renamed as part of single-user login finalisation. If you own this account you can |log in using your previous username and password for more information. If you do not like this account's new name, you can choose your own using this form after logging in: . -- Keegan (WMF) (talk) 05:29, 19 April 2015 (UTC)

title: User talk:Sim man~enwikibooks


text:
User talk:24.149.184.245

Welcome to Wikibooks, collection of open-content textbooks! You don't have to log in to read or edit articles on Wikibooks, but creating an account is quick, free and non-intrusive, requires no personal information, and gives you many benefits, including:
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We hope that you choose to become a Wikibooks and create an account. We hope you enjoy your time here on Wikibooks as a Wikibookian! -- LV (Dark Mark) 21:14, 7 December 2005 (UTC)

title: User talk:24.149.184.245


text:
People's Tactics/Scenario Editor/Events

The most important aspects about editing events in the People’s Tactics editor are the “Show this event #” and “UPDATE” buttons. To view or edit an event, enter the number of the event into the “Events:” box and click “Show this event #”. Make changes by entering information into the boxes below and then click “UPDATE” to store the data. If you do not click “UPDATE”, your changes will be lost, along with your faith in humanity. You have been warned!

When the event type is changed, the parameters will not appear in the “DATA” and “DATASTRING” areas. First click “UPDATE” to store the fact that you’ve changed the event type, then click “Show this event #” to update the display.

ALL events in People’s Tactics MUST be accompanied by a message dialog. This means that the event will NOT occur if “SHOWALL”, “SHOWREG1” or “SHOWREG2” are left at 0 or if “SHOW STORY” is left blank.

Event parameters are entered in the “DATA” and “DATASTRING” areas. To change the value of a “DATA” parameter, put the number of the parameter in the “at#” box and the value you want to change it to in the “Val#” box and click the adjacent “OK”. To change the value of a “DATASTRING” parameter, put the number of the parameter in the “Dat#” box and the value you want to change it to in the “Str” box and click the adjacent “OK”.

Triggers
Triggers can be used by themselves or in conjunction with other triggers. If used in conjunction with other triggers, BOTH (or ALL) must be satisfied for the event to occur.

> TURN
If the turn number is greater than or equal to this number, the event will happen.

< TURN
If the turn number is less than or equal to this number, the event will happen.

X,Y=OWNER
If the hex defined by the X and Y coordinates is owned by the regime number X,Y=OWNER, then the event will happen. The regime number corresponds to “Edit Regimes and Peoples” window.

GAMEWINNER
If the regime number of the winner of the scenario is equal to this value, the event will happen. The event will happen the turn after the turn when victory is declared on the start screen, due to the way events work. The event will be displayed every subsequent turn (counter to expectations), unless specified otherwise using the ONLY ONCE? trigger modifier. The regime number corresponds to “Edit Regimes and Peoples” window.

NOT GAMEWINNER
If the regime number of the loser of the scenario is equal to this value, the event will happen. The event will happen the turn after the turn when victory is declared on the start screen, due to the way events work. The event will be displayed every subsequent turn (counter to expectations), unless specified otherwise using the ONLY ONCE? trigger modifier. The regime number corresponds to “Edit Regimes and Peoples” window.

RANDOM100
This trigger is probability based, a percent chance that the event will happen. If set to 1, there is a 1% chance of this event happening each turn, if set to 100, the event will happen each turn.

ONLY ONCE?
This is not a trigger, but a modifier that, if set to 1, will ensure the event only occurs once.

BOOKVAR => #
If the bookvar specified by BOOKVAR # has a value greater than or equal to this number, the event will happen. This will not work as a trigger if left at 0 (i.e. you can't test to see whether the bookvar value is greater than or equal to 0).

BOOKVAR =< #
If the bookvar specified by BOOKVAR # has a value less than or equal to this number, the event will happen. This will not work as a trigger if left at 0 (i.e. you can't test to see whether the bookvar value is less than or equal to 0).

IFAIREGIME
If the regime corresponding to this number is controlled by the AI, the event will happen. The regime number corresponds to “Edit Regimes and Peoples” window.

IFPEACEWITH
If the regime corresponding to this number is at peace with the regime corresonding to the number in SHOWREG1, the event will happen. The regime number corresponds to “Edit Regimes and Peoples” window. SHOWALL can be set at the same time as SHOWREG1, enabling the trigger to work and the message to be displayed to all players.

IFWARWITH
If the regime corresponding to this number is at war with the regime corresonding to the number in SHOWREG1, the event will happen. The regime number corresponds to “Edit Regimes and Peoples” window. SHOWALL can be set at the same time as SHOWREG1, enabling the trigger to work and the message to be displayed to all players.

DIPLASTTURN
If this value is not '0' then IFWARWITH and IFPEACEWITH are only checked if the the EVENTSHOWREGIME regime went to peace or war the last turn with the specified IFWARWITH and IFPEACEWITH regime (this way you can react to declaration of war or peace the turn after this was done).

Events
There are 8 types of event available in the People’s Tactics editor:

Show story
This is the simplest of the People’s Tactics events. When the triggers are met, a dialog box is displayed showing text and a picture. This kind of event can add plot depth to a game, so for example if the trigger is a city being in enemy hands, the message may say something like “Our front line city has fallen, we are all doomed”.

To use this kind of event: set the trigger and leave “THEN EVENT TYP” at 0. “SHOW SPRITE #” should be set to the number of the image you want to accompany the text. In the default game, these are numbered 2001 to 2009 and can be perused using the “Sprites” tab of the “Edit Scenario and Rules” window or by looking in PT/default/type, where they are numbered event1.bmp to event9.bmp (the 2000 is added by the editor). “SHOW SPRITE” may be left blank, resulting in a grey space next to the dialog text.

The event dialog can be shown to all regimes, one regime or two regimes. To show the event dialog to all regimes, set “SHOWALL” to 1. To show the event dialog to just one regime, set “SHOWREG1” to the number of the regime desired. The regimes are numbered according to their number in the “Edit Regimes and Peoples” window. To show the event dialog to two regimes, set “SHOWREG1” to the number of the first regime and “SHOWREG2” to the number of the second regime. It is possible to show the event to just one regime by filling in just “SHOWREG2”, but there is no benefit in doing it this way.

Enter the text you want to be displayed to the player in the “SHOW STORY” box. The character limit on what will be displayed is about 730, including spaces, but this will depend on the text. It is possible to put more text into the “SHOW STORY” box than will be displayed in the dialog, so make sure you playtest.

New formation
The new formation event does exactly what it says on the tin: it makes a new formation. To use this kind of event: set the trigger and set “THEN EVENT TYP” to 1. Set the relevant parts of the show story event. Click “UPDATE”, then “Show this event #”.

The following parameters area available in the “DATA” area:

1) X – the x coordinate where the formation will be created 2) Y - the y coordinate where the formation will be created 3) No function, so leave blank 4) THEATER – the type of formation, (0 for land, 1 for sea and 2 for air 5) READINESS – the readiness of the formation, ranging from 10 to 100 6) XP – the experience of the formation, ranging from 25 to 150 7) GEN SPRITE – the sprite of the officer for the formation - in the default game these are numbered 1 to 75 and can be browsed in PT/default/officer or the “Sprites” tab of the “Edit Scenario and Rules” window, where they are numbered 1801 to 1875 8) GEN LAND – the land value of the officer of the formation, ranging from 1 to 9 9) GEN AIR – the air value of the officer of the formation, ranging from 1 to 9 10) GEN SEA – the sea value of the officer of the formation, ranging from 1 to 9 11) GEN RETREAT – the retreat value of the officer of the formation, ranging from 0 to 100 (0 has a lower chance of retreating, 100 has a higher chance of retreating) 12) GEN FAME – the fame value of the officer of the formation, ranging from 0 to infinity (according to the official manual, although exercise caution with putting fame values at greater than 25) 13) REGIME OF UNIT – the regime of the unit, using the numbering of the “Edit Regimes and Peoples” window 14) OVERRIDE ENM HEX – if this is set to 0, the unit will not be placed on enemy territory, if this is set to 1 it will and will change ownership of the hex. 15) to 19) No function, so leave blank 20) INFTYP – the type of infantry the formation contains, using the numberings of the “Edit unttypes” window 21) INFQTY - the amount of infantry 22) MOBTYP – the type of mobile the formation contains, using the numberings of the “Edit unttypes” window 23) MOBQTY - the amount of mobile 24) ARTTYP - the type of artillery the formation contains, using the numberings of the “Edit unttypes” window 25) ARTQTY - the amount of artillery 26) ARMTYP - the type of armour the formation contains, using the numberings of the “Edit unttypes” window 27) ARMQTY - the amount of armour

The following parameters area available in the “DATASTRING” area:

1) NAME OF FORM – the name of the formation 2) NAME OF GEN – the name of the formation’s officer. If this is set to “random” the name of the officer will be generated in the normal way.

If the destination hex for the new formation is already full (i.e. 3 formations) then the formation will be place on neighbouring hex, unless these are all full. If the destination hex is enemy controlled, the “OVERRIDE ENM HEX” is set to 1 AND the hex contains an enemy unit, the formation will be placed on a neighbouring hex unless these also contain enemy units or are full.

If the event is not executable it will try next turn again if the trigger conditions still apply that turn.

Political Point Grant
This event changes the amount of political points of a regime. To use this kind of event: set the trigger and set “THEN EVENT TYP” to 2. Set the relevant parts of the show story event. Click “UPDATE”, then “Show this event #”. The following parameters area available in the “DATA” area:

1) REGIME 2 # - the regime number of the regime to change the political points of, using the numbering of the “Edit Regimes and Peoples” window 2) PP MUT 2 +/- - amount to change the political points by, this can be negative. If the resulting amount of political points is negative, the amount of political points will be set to 0.

Change Bookvar
Bookvars are variables where numbers can be stored. There are 200 bookvars available. The value of a bookvar can be used as a trigger and changed by an event.

To use this kind of event: set the trigger and set “THEN EVENT TYP” to 3. Set the relevant parts of the show story event. Click “UPDATE”, then “Show this event #”. The following parameters area available in the “DATA” area:

1) BOOKVAR 1 # - the number of the first bookvar to change, ranging from 1 to 200 2) VAR1 MUT +/- - the amount to change the first bookvar by, this can be negative 3) BOOKVAR 2 # - the number of the second bookvar to change, ranging from 1 to 200 4) VAR2 MUT +/- - the amount to change the second bookvar by, this can be negative 5) BOOKVAR 3 # - the number of the third bookvar to change, ranging from 1 to 200 6) VAR 3 OVERRIDE – the number to change the value of the third bookvar to 7) BOOKVAR 4 # - the number of the fourth bookvar to change, ranging from 1 to 200 6) VAR 3 OVERRIDE – the number to change the value of the fourth bookvar to

There are effectively two ways to use the change bookvar event: VAR1 MUT +/- modifies the existing bookvar value, whilst VAR 3 OVERRIDE sets the bookvar value regardless of its previous value. The modification of the existing value might be useful for counting how many cities are taken, whilst setting the value might be useful for resetting a count to 0.

Choice
This is perhaps the most complicated and most powerful event available to the scenario designer. With this event, the dialog box displayed to the player has up to five buttons on it. Clicking these buttons can change different bookvars and hence different outcomes.

To use this kind of event: set the trigger and set “THEN EVENT TYP” to 4. Set the relevant parts of the show story event. Click “UPDATE”, then “Show this event #”.

The following parameters area available in the “DATA” area:

1) CHOICE 1 BOOKVAR # - the first bookvar to change if choice 1 is selected 2) CHOICE 2 BOOKVAR # - the first bookvar to change if choice 2 is selected 3) CHOICE 3 BOOKVAR # - the first bookvar to change if choice 3 is selected 4) CHOICE 4 BOOKVAR # - the first bookvar to change if choice 4 is selected 5) CHOICE 5 BOOKVAR # - the first bookvar to change if choice 5 is selected

6) CHOICE 1 MUT +/- - the amount to change the first bookvar by if choice 1 is selected 7) CHOICE 2 MUT +/- - the amount to change the first bookvar by if choice 2 is selected 8) CHOICE 3 MUT +/- - the amount to change the first bookvar by if choice 3 is selected 9) CHOICE 4 MUT +/- - the amount to change the first bookvar by if choice 4 is selected 10) CHOICE 5 MUT +/- - the amount to change the first bookvar by if choice 5 is selected

11) CHOICE 1 BOOKVAR #2 - the second bookvar to change if choice 1 is selected 12) CHOICE 2 BOOKVAR #2 - the second bookvar to change if choice 2 is selected 13) CHOICE 3 BOOKVAR #2 - the second bookvar to change if choice 3 is selected 14) CHOICE 4 BOOKVAR #2 - the second bookvar to change if choice 4 is selected 15) CHOICE 5 BOOKVAR #2 - the second bookvar to change if choice 5 is selected

16) CHOICE 1 MUT2 +/- - the amount to change the second bookvar by if choice 1 is selected 17) CHOICE 2 MUT2 +/- - the amount to change the second bookvar by if choice 2 is selected 18) CHOICE 3 MUT2 +/- - the amount to change the second bookvar by if choice 3 is selected 19) CHOICE 4 MUT2 +/- - the amount to change the second bookvar by if choice 4 is selected 20) CHOICE 5 MUT2 +/- - the amount to change the second bookvar by if choice 5 is selected

The following parameters area available in the “DATASTRING” area:

1) CHOICE1 – the button label for the first choice 2) CHOICE1 – the button label for the second choice 3) CHOICE1 – the button label for the third choice 4) CHOICE1 – the button label for the fourth choice 5) CHOICE1 – the button label for the fifth choice

Load next campaign scenario
This event is an essential part of a campaign scenario. When this event is triggered, the next scenario file is loaded, so this event should be associated with the victory condition.

To use this kind of event: set the trigger and set “THEN EVENT TYP” to 5. Set the relevant parts of the show story event. Click “UPDATE”, then “Show this event #”.

The following parameters area available in the “DATASTRING” area:

1) FILE TO LOAD – this is the filename of the file to load

Change Diplomatic relations
This event changes the diplomatic relations between two regimes and sets the cost, in political points, for the player to change it.

To use this kind of event: set the trigger and set “THEN EVENT TYP” to 6. Set the relevant parts of the show story event. Click “UPDATE”, then “Show this event #”.

1) REG1 – first regime to change the diplomatic relation of, using the numbering of the “Edit Regimes and Peoples” window 2) REG2 – second regime to change the diplomatic relation of, using the numbering of the “Edit Regimes and Peoples” window 3) NEWDIPREL – relationship to change the regime to, 0 for war, 1 for peace 4) NEWCHANGCOST – the cost to change the new relationship, ranging from 0 to 999

Regimes will not be able to change their relationship in the turn that a change diplomatic relations event occurs. This event can be used to modify the cost of changing the relationship without actually changing the relationship making it easier/harder to declare war/make peace.

Set Gamewinner To
This event makes a particular regime the winner of the scenario. This should be used with a victory condition as the trigger (e.g. capturing the enemy capital city).

To use this kind of event: set the trigger and set “THEN EVENT TYP” to 7. Set the relevant parts of the show story event. Click “UPDATE”, then “Show this event #”.

The following parameters area available in the “DATA” area:

1) SET GAMEWINNER TO – the number of the regime to make the winner, using the numbering of the “Edit Regimes and Peoples” window

title: People's Tactics/Scenario Editor/Events


text:
Climate Change/Press Cuttings

=Climate Change in the News=
 * Article about 2005 Atlantic hurricanes and global warming
 * AP article about a study saying Alaskan permafrost may melt, enhancing global warming by releasing greenhouse gases from the soil.
 * James Hansen's op-ed in International Herald Tribune, title "It's not too late"
 * Lindzen's April '06 op-ed in Wall Street Journal
 * Lindzen's July '06 op-ed in Wall Street Journal, trying to attack An Inconvenient Truth by Al Gore
 * Oreskes' response to Lindzen and others, from July '06, published in Los Angeles Times
 * Peter Doran responds to global warming deniers in the New York Times in July '06
 * World Emissions of Carbon Dioxide Outpace Worst-Case Scenario
 * |US Carbon Emissions Hit 20-Year Low
 * Pentagon Unveils Plan For Military's Response To Climate Change
 * Study: Past Climate Change Was Caused by Ocean, Not Just the Atmosphere
 * Climate Ark - continuous updates
 * Google News - search for climate change
 * UK climate meeting calls for action - Nature.com, 3rd Feb 2005, strap line: "Researchers discuss 'dangerous' change as global-warming fears grow."
 * Landfall Nears For Strongest Hurricane In Recorded History
 * El Niño Is Going to Starve a Lot of Fish
 * Carbon Pollution Touched 800,000 Year Record in 2016, WMO Says - slashdot.org, October 30, 2017.
 * Tourism Representative Blames Scientists for Downturn in Great Barrier Reef Visits - SoylentNews, January 14, 2018.
 * 2017 was among the warmest years on record, according to new data released by NASA and the National Oceanic Atmospheric Administration. - slashdot.org, January 18, 2018.
 * Global Warming Predictions May Now Be a Lot Less Uncertain - slashdot.org, January 18, 2018.
 * Earth's Carbon Dioxide Levels Reach Highest Point In 800,000 Years - slashdot.org, May 06, 2018.
 * Invisible Scum on Sea Cuts CO2 Exchange With Air 'By Up To 50%' - slashdot.org, May 28, 2018.
 * Coastal Megacity Karachi Is Running Out of Water - slashdot.org, May 28, 2018.

title: Climate Change/Press Cuttings


text:
User:RedDragonAkai~enwikibooks

Working on putting together a text book for a Signals, Systems, and Transforms class.

my Sandbox

--RedDragonAkai 14:11, 8 December 2005 (UTC)

School is kicking my butt....

title: User:RedDragonAkai~enwikibooks


text:
User talk:70.254.188.230

Please do not remove content from Wikibooks. It is considered vandalism. If you continue, you may be blocked. Thank you. -- LV (Dark Mark) 22:28, 7 December 2005 (UTC)

title: User talk:70.254.188.230