text:
Speech-Language Pathology/Stuttering/Stress-Related Changes

Under stress, people's voices change. They tense their speech-production muscles, increasing their vocal pitch. They try to talk faster. They repeat words or phrases. They add interjections, such as "uh." These are normal dysfluencies. A study found that under stress, non-stutterers went from 0% to 4% dysfluencies, for the simple task of saying colors. Stutterers went from 1% to 9%.

The "conventional wisdom" is that stutterers are always nervous or stressed out. Many psychological studies have proven that this isn't true. But stress has an important role in stuttering.

This next fact is so obvious that you've probably never thought about how important it is. All stutterers can talk fluently. In relaxed, low-stress situations we can say any sound or word fluently. If you're a severe stutterer, there might not be many such situations. But there are some.

In other situations we stutter. How many paraplegics do you know who can walk in some situations, but not other situations? Or people who are blind with certain people, but not with other people? None that I've ever known.

Think about this. Our brains are capable of producing fluent speech. We have all the speech motor programs necessary to produce any speech sound, fluently.

We also have speech motor programs for producing dysfluent sounds. Stutterers have two sets of open-loop speech motor programs. Our brains select one or the other set of speech motor programs, depending on environmental cues—where we are or whom we're talking to.

This is like a person who grew up summers in Massachusetts and winters in Georgia. Such a person would have a set of speech motor programs to speak with a New England accent. And this person would have a set of speech motor programs to speak with a Southern accent. When she's in Massachusetts, hearing people speak with New England accents, her brain automatically selects the New England accent speech motor programs. In Georgia, her brain selects Southern accent speech motor programs.

You always have choices for handling stressful situations. Some choices trigger your brain to automatically select dysfluent speech motor programs. Other choices trigger your brain to select fluent speech motor programs. This chapter will teach you to make choices for handling stress that automatically select fluent, relaxed speech. You'll feel relaxed and speak confidently even when non-stutterers are stressed out.

Are Responses to Stress Psychological?

According to "conventional wisdom," stuttering is a psychological disorder because stutterers generally speak fluently in low-stress situations, and stutter in high-stress situations.

But many responses to stress are physical. E.g., "fight or flight" increased heart rate. Stress is considered to be a factor in the development of physical disorders, such as heart disease, and a primary factor in gastrointestinal disorders. Why is stuttering considered to be a psychological disorder, but stomach ulcers are considered to be a physical disorder?

This chapter presents how stuttering is a response to stress, and then presents psychological treatments for better handling stress. Although the presented treatments are psychological, I object to referring to responses to stress as psychological responses. You can treat responses to stress physically, such as with medications or using an anti-stuttering device. I've put those treatments into other chapters. Perhaps more than the other factors, responses to stress show that the factors that contribute to stuttering are complex and interconnected.

Stuttering Reduces Stress

Systolic blood pressure is an indicator of stress. Stuttering reduced stutterers' blood pressure 10%. In contrast, fluent speech, chewing gum, and sitting quietly each reduced blood pressure about 2%.

You're thinking, "No way. Stuttering doesn't relax me. Stuttering doesn't feel like a massage and warm bath."

But think about it. Stutterers are, on average, disfluent on 10% of syllables. We say 90% of syllables fluently. But we don't say one hundred syllables fluently, and then finish a conversation with ten dysfluencies. Stuttering usually occurs on the first sound of the first word, in a stressful situation. I.e., your stress builds up as you anticipate speaking. You stutter, and this releases stress. You then say several syllables fluently.

You then stutter on another syllable, then say several more syllables fluently. Usually your speech improves over the course of the conversation, and your last few sentences are your most fluent.

If your blood pressure were monitored in such a conversation, it might look like this (this is speculative, not based on research):

Stuttering Reducing Stress

Your stress increases as you anticipate speaking. You block on the first syllable. This reduces your stress, and you speak fluently. Your stress builds up again, and you stutter again. This reduces your stress, and the cycle repeats until you're speaking fluently at the end of the conversation.

Stuttering Isn't a Good Response to Stress

Stuttering doesn't change the stressful situation. E.g., a highway patrol officer pulls you over for speeding. Stuttering won't make the officer think you weren't speeding.

Stuttering might make the situation worse. E.g., the highway patrol officer mistakes your stuttering for methamphetamine addiction. He handcuffs you and searches your car. This stresses you more, and you stutter more.

Stuttering and stress are a vicious cycle. Stuttering reduces your stress for a few seconds, but then causes more stress. You get stuck in the cycle, unable to break free.

Another study measured listeners' systolic blood pressure. Listening to stuttering made listeners feel stress. The listeners' increased stress may in turn increase the stutterer's stress. Again, stuttering and stress start a vicious cycle.

This chapter will show you that you have other choices for handling stress, instead of stuttering. These other choices reduce stress, instead of throwing you into an endless cycle.

Distraction and Placebos

The "experts" believe that "Distraction methods can be used to eliminate stuttering temporarily." But if distraction worked, stutterers would work a Rubik's cube or play a pocket video game whenever they wanted to talk fluently.

Two studies tried to distract stutterers from stuttering. In the first study, stutterers stepped on and off a 10-inch platform while reading out loud. In the second study, stutterers manually tracked an irregular line on a rotating drum while speaking. Neither distraction was able to reduce stuttering.

Distraction can cause stuttering. Stutterers often say that they can use therapy skills in a clinical environment, but the distractions of normal conversations make fluent speech difficult.

An "expert" wrote, "if a stutterer were to forget that he was a stutterer, he would have no further difficulty with his speech." Another "expert" wrote, "our beliefs about stuttering seem to be one of the main factors in stuttering severity."

Placebos are pills without medications, or, more generally, an inactive, nonspecific medical treatment that alters the beliefs of a patient. A study found that placebos did not reduce stuttering. Another study also found that placebos had no effect on stuttering—but the placebos caused terrible side effects! Reported placebo side effects included constipation, sexual dysfunction, dizziness, sweating, and tremors. The placebo was six times more powerful than the medication in the study, in producing side effects.

This raises an interesting question. Placebos are effective treatments for almost every disease and symptom:

Study after study showed that, for virtually any disease, a substantial portion of symptoms—roughly one-third, by most estimates—would improve when patients were given a placebo treatment with no pharmacological activity. Patients simply believed that the treatment would help them, and somehow, it did.

…for a wide range of afflictions, including pain, high blood pressure, asthma and cough, roughly 30 to 40 percent of patients experience relief after taking a placebo…placebos seem to be most reliably effective for afflictions in which stress directly affects the symptoms…pain, asthma and moderate high blood pressure can become worse when the patient is upset…placebos may work in part by lessening the apprehension associated with the disease [because] the immune system falters under stressful conditions.

Stuttering may be the only disorder that placebos have no effect upon! I.e., stuttering isn't affected by belief, and stutterers can't be "psyched" into fluency. In contrast, heart disease, asthma, etc. appear to be physical diseases but are actually in large part psychological. Could stuttering—long believed to be psychological—actually have no psychological component?

Good Stress, Bad Stress

We experience many forms of stress. Some forms of stress reduce stuttering. Other forms of stress increase stuttering. Still other forms of stress have no effect on stuttering.

Adrenaline and Fluency-Enhancing Stress

In World War Two, a severe stutterer regularly spoke fluently for mortar communication during combat.

One night, a person physically threatened me for several hours. I've never been so fluent in my life! My voice was calm and relaxed as I tried to get the person to calm down.

Noradrenaline and adrenaline compete with dopamine for the binding sites on D4 receptors, and when bound, act as agonists. At the same time, through feedback inhibition, norepinephrine inhibits tyrosine hydroxylase, which in turn inhibits the production of dopamine. Because dopamine in the striatal system increases stuttering (see Genes and Neurotransmitters, and adrenaline blocks dopamine, "fight or flight" situations that increase adrenaline reduce stuttering.

Stutterers report that when the adrenaline wears off, their stuttering increases.

Physiological Stress

Physical activities such as running or bicycling elevate heart rate, blood pressure, etc. Dropping a rock on your foot is another form of physiological stress.

Exercise makes you breath harder, with your diaphragm. If your stuttering involves disordered breathing you may stutter more when exercising. On the other hand, if your speech-language pathologist trained you to speak with diaphragmatic breathing, exercise may improve your fluency.

In general, physiological stress has no effect on stuttering.

Progressive relaxation trains you to relax all of your muscles, starting with your toes and ending with your facial muscles. Progressive relaxation has minimal effect on stuttering. Relaxation exercises only reduce stuttering when the focus is on relaxation speech production muscles (respiration, vocal folds, and the lips, jaw, and tongue articulators).

Cognitive Stress

Hearing or seeing several things at once, especially if the events contradict each other (cognitive dissonance), increases stuttering.

For example, I can't stand talking to a person who's watching television. Or a person who's playing guitar, or picks up the phone to make a call while I'm trying to talk to him. I have a cousin who watches TV, plays guitar, and makes telephone calls, all at the same time, when I to talk to him. He thinks he's making efficient use of his time, but he wastes my time.

Listeners should give their full attention to stutterers. Turning away to do something else, even if you say, "I'm still listening," will increase the individual's stuttering.

If a listener won't give you his or her full attention, consider whether the conversation matters to you. If not, walk away. Don't consider whether what you're saying is important to the listener. It's obviously not.

Time Pressure

Time pressure increases stuttering. At the beginning of this chapter I mentioned a study in which subjects were told to say colors. At first, "red" was written in red on a computer monitor. The screens came faster and faster, to increase time pressure.

Next, cognitive stress was added. E.g., the word "red" was written in yellow on a computer monitor. The subjects had to say "yellow," not "red."

These results were dramatic. Non-stutterers went from 0% dysfluent words, to 2% disfluencies with time pressure, then to 4% with time pressure and cognitive stress.

Stutterers went from 1% stuttered words, to 3% with time pressure, to 9% with time pressure and cognitive stress.

Telling a stutterer to talk faster will have the opposite effect. Instead, tell stutterers to take all the time they need.

Use time pressure to your advantage by limiting what you say. Tell most people to make a five-minute speech and they ramble on for ten minutes, without getting to the point. If you're asked to make a five-minute speech, get to the point in one minute, without the rambling. What you think is one minute will actually take two or three minutes, and then adding in stuttering will make it five minutes. Even when I stuttered severely I had professors compliment my presentations.

Pragmatic Speech

Pragmatic speech is intended to cause another person to do a speciﬁc action. This might be telling a co-worker how to send a fax. Don't say, "Let me do it for you."

More stressful is asking someone to do something you want, when you're afraid that the person will say no. E.g., asking your boss for a raise, or asking an attractive person out on a date, or telling your housemate to wash the dishes. The listener is relatively powerful, and you're in a position of relative weakness.

To reduce stress, we usually try to make the question look casual. You "just happen" to run into the attractive person at the health club, and you "just happen" to have tickets to a show in your pocket, and you "casually" ask for a date. Or you wait until you've just landed a big sale for the company, and "jokingly" tell your boss that you deserve a raise.

But then you stutter, belying that this "casual" conversation is stressful for you. Your listener recognizes your weak position and, if he or she has an ego problem, enjoys manipulating you. A powerful person with an ego problem manipulating you is a pretty good description of stress. Instead, use other ways to reduce stress. First, don't make a big effort to set up a "casual"-seeming situation. The more effort you make, the more stress you'll feel that it's "now or never" to get a positive response.

Next, use Winston Churchill's strategy of preparing your points in advance ("I deserve a raise for three reasons…"), anticipating your listener's objections, and preparing responses to those objections. Then use slow speech to explain each point. Pause between points. Use the pause to check that your breathing and vocal folds are relaxed. You'll sound confident and in control.

Lastly, be willing to walk away. Is it the end of the world if your housemate doesn't wash the dishes, or you don't get a date? Visualize what you'll do and how you'll feel if the answer is no.

Be an Anti-Mirror

People tend to mirror each others' speech patterns. A person speaks fast to you, so you talk fast. A listener jumps in before you finish your sentences, so you interrupt her sentences. A person gets angry at you, so you raise your voice and get emotional.

All of those speech patterns increase stuttering. Instead, be an anti-mirror. The faster people speak to you, the slower you talk. Instead of interrupting, wait for the other person to finish speaking, then count to three before you start to talk. If a person expresses anger, make your voice quieter, slower, and less emotional.

Embarrassment and Uncertainty

We fear embarrassment. E.g., I'm about to call you Josh, when I think, "Wait, his name is Joel."

This fear is multiplied when we're speaking to more than one person—saying something embarrassing in front of an audience of a thousand people is more embarrassing than in front of one person.

Lack of feedback increases our fears of embarrassment. I.e., when speaking on television we can't observe the reactions of listeners. You could say something stupid and never know it. You try to remember and analyze the last thing you said while you're saying something else.

If you say something embarrassing, make a joke out of it. E.g., I was waiting for a woman I'd never met. She said she'd arrive at 6pm. At 6:05pm a woman parked in front of my house. I went out and said, "You must be Ariana." She didn't say anything so I said it again. She responded that she wasn't Ariana. I said, "Oh my God, I'm so embarrassed," in a humorous way.

Then there's always the "at my advanced age I can't remember names." That's funny whether you're 90 or 19.

That sounds obvious, but there's a subtle point in there. Acknowledging embarrassment ends embarrassment.

Establishing Status

We communicate status largely via speech. We feel anxiety when status is ambiguous.

E.g., you find a large, muscular hoodlum sitting on your car. Do you speak with firm authority, ordering the hoodlum off your car? Do you choose a friendly, buddy-buddy tone of equality? Do you meekly ask if the hoodlum could let you have your car back?

Stuttering doesn't necessarily communicate low status. Embarrassment and anxiety about stuttering communicates low status. Calmly stuttering, while looking the hoodlum in the eye, establishes that you're not afraid to stutter and you're not afraid of the hoodlum.

Moral Stress

You did something wrong. You didn't realize it was wrong at the time, but now you're suspected of this minor crime. You make up a lie to eliminate the suspicion. But your lie is caught. Now you're in real trouble.

I'm not going to preach whether "honesty is the best policy" or whether lying your way out of situations sometimes works. What I'll tell you is how to use stuttering to appear to be telling the truth. Interrogations start with "baseline" questions such as your name. But every stutterer blocks on their name! Get into some good dysfluencies on your name. Imagine yourself hooked up to a lie detector machine. Make the needle swing into the red.

Then when you're asked the real question, pause, relax your breathing and your vocal folds, and slowly and fluently tell your story—truthfully or otherwise. A lie detector machine will indicate that you're telling the truth. A human listener will do the same.

Categorize Stress to React Rationally

Movies show characters in stressful situations. When watching movies, name the type of stress a character experiences. Soon you should feel an inner voice say "moral stress," or "time pressure" when watching movies.

Then the same light bulb will switch on in your mind when watching people in daily life. When the light bulb switches on in situations stressful to you, you're on your way to eliminating this type of stress.

Stress causes you to react emotionally, not rationally. When reacting emotionally, you react one way. Different people have different emotional reactions, depending on their personality type. E.g., one person might react with outward anger, when another person reacts with inward shame. That doesn't matter. What matters is the automatic, single response to all stressful situations.

Shifting out of an emotion and into "neutral" enables you to see other possible responses, and select the best response. The light bulb switching on enables you to switch gears.

References

 * 1) Caruso, A., et al. "Adults Who Stutter: Responses to Cognitive Stress." Journal of Speech and Hearing Research, 37, 746-754, August 1994.
 * 2) Perkins, W., Dabul, B. "The Effects of Stuttering on Systolic Blood Pressure." Journal of Speech & Hearing Research, Vol. 16, No. 4, December 1973.
 * 3) Schwartz, Martin. Personal correspondence.
 * 4) Kuehn, Donald (1994). Official correspondence from the National Institute of Deafness and Communication Disorders (NIDCD).
 * 5) Bloodstein, Oliver (1995) A Handbook On Stuttering, 5th edition, San Diego: Singular Press.
 * 6) Bloodstein, Oliver (1996) "Stuttering as an Anticipatory Struggle Reaction," in R. F. Curlee & G. M. Siegel, Nature and Treatment of Stuttering: New Directions. Boston: Allyn&Bacon.
 * 7) Neiders, Gunars. Stutt-x e-mail correspondence, December 18, 1997.
 * 8) Prins, D., Madelkorn, T., Cerf, A. "Principal and Differential Effects of Haloperidol and Placebo Treatments Upon Speech Disfluencies in Stutterers."  Journal of Speech & Hearing Research, 23, 614-629, September 1980.
 * 9) Stager, Ludlow, Gordon, Cotelingam, and Rapoport. "Fluency Changes in Persons Who Stutter Following a Double Blind Trial of Clomipramine and Desipramine," Journal of Speech and Hearing Research, June 1995.
 * 10) Goleman, Daniel, and Joel Gurin. Mind/Body Medicine, Consumer Reports Books, 1993.
 * 11) Brown, Walter A. "The Placebo Effect."  Scientific American, January 1998, 90-96.
 * 12) Bloodstein, Oliver (1995) A Handbook On Stuttering, 5th edition, San Diego: Singular Press.
 * 13) Newman-Tancredi, Adrian. "Noradrenaline and adrenaline are high affinity agonists at dopamine D4 receptors." European Journal of Pharmacology 319 (1997) 379-383. 101511,274@compuserve@com. Valerie Audinot-Bouchez, Alain Gobert, Mark J. Millan, Department of Psychopharmacology, Institut de Recherches, 125 Chemin de Ronde, 78290 Croissy-sur-Seine (Paris), France.
 * 14) Bloodstein, Oliver (1995) A Handbook On Stuttering, 5th edition, San Diego: Singular Press.
 * 15) Caruso, A., et al. "Adults Who Stutter: Responses to Cognitive Stress." Journal of Speech and Hearing Research, 37, 746-754, August 1994.


text:
Traditional Chinese Medicine/Man Jing Zi

Name Means:
 * Man-to spread
 * Jing-Brambles/thorns
 * Zi-Seeds

English Name:
 * Vitex fruit

Chinese Name:
 * 蔓荆子 (Pinyin: màn jīng zĭ)

Latin Name:
 * Fructus Viticis

Taste & Temperature:
 * ../Xin-Spicy/
 * ../Ku-Bitter/
 * ../Liang-Cool/

Channels:
 * Foot Tai Yang of Urinary Bladder
 * Foot Jue Yin of Liver
 * Foot Yang Ming of Stomach

Actions & Indications:
 * disperses Wind-Heat (Spicy & Cool)
 * clears head & eyes
 * drains Damp & expels Wind

Contraindication:
 * Qi & Yin deficiency causing excessive sweating

Caution:
 * Yin deficiency syndrome
 * Blood deficiency
 * chronic skin infection
 * headache or eye problem due to Blood or Yin deficiency
 * Stomach Qi deficiency

Antagonize:
 * ../Wu Tou/
 * ../Shi Gao/

Dosage:
 * 2-4 qian (6-12 grams)

back to:
 * ../Xin Liang Jie Biao/
 * ../TCM Materia Medica/

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


text:
False Friends of the Slavist/Map zьrno

zьrno

title: False Friends of the Slavist/Map zьrno


text:
Wikibooks:WikiProject Macintosh/Guidelines

=Tone= Mac books are written for users with little to moderate computer experience, probably at home or on the client side of a large network. Therefore, Mac books should aim to be very light and relaxed. The way language is used should make reading a Mac book a fun activity in itself. Jokes should be subtle and not over-used. And above all, nothing should be done at the expense of clarity. A reader should be able to absorb everything with one read-through of the book. Repeat key concepts from section to section (in parentheses, perhaps) as a reminder.

=Lingusitic Conventions= For the sake of consistency, follow these linguistic conventions:

 * Use American spelling in all Mac WikiBooks.
 * Use the serial comma.
 * Avoid using elipses (...) to end sentences.

=Structure= The organizational "tree" of a Mac WikiBook looks like this:

 * Main Page
 * Parts (optional)
 * Chapters, Appendices, and Glossaries
 * Sub-Chapters (optional)

Nest each one inside the one "bigger" than it.

A Word on Parts
Parts are used only in books covering suites of Applications. Instead of linking to chapters on the main page, these books link to parts. Each part is like a book in itself, containing an introduction and a table of contents linking to the part's own chapters and appendices.

A perfect example of a book that uses "parts" is the iLife book. Each application gets its own part, and therefore its own table of contents and glossary. This vastly simplifies getting around the iLife book.

A Word on Sub-Chapters
Sub-chapters complexify things. Avoid using them if possible, but put them in if a chapter becomes huge and unwieldy on one page (such as a chapter that explains every single application in Mac OS X Tiger). Please do not put sub-chapters inside sub-chapters.

Main Page
Each WikiBook's must have a main page. This starts off with an Introduction section. The Introduction has, in this order:

 * 1) A section about the product(s) described in the WikiBook
 * 2) A section about the WikiBook itself, exlpaining what one is for new users and what the WikiBook does and does not cover
 * * Include the obligatory "assumes knowledge of Mac OS X Tiger message".
 * 1) A section about how to use the WikiBook
 * *Nesting of Menu commands and files (copy verbatim from another WikiBook, if you'd like)
 * *Clarification of confusingly similar words (e.g. windows vs. Windows) and interchangable words (e.g. application and program)
 * *Explanation of each kind of Info Box or other special template used in the WikiBook.

The second section of the Main Page must is the table of contents, with links to all chapters, appendices, and glossaries. Coding tables of contents can be confusing. Follow this format exactly:

# Chapter 1
 * Chapter 1 description
 * 1) Chapter 2
 * Chapter 2 description
 * 1) Chapter 3
 * Chapter 3 description
 * 1) Appendices
 * Appendix A
 * Appendix A description
 * Appendix B
 * Appendix B description
 * 1) Glossary
 * Glossary description

For an example of a perfect table of contents, see the Mac OS X Tiger WikiBook.

=No Advertising!= It's legitimate and helpful to mention an application (Freeware, Shareware, Open Source, or Regular), brand of hardware, or website, but this wikibook shouldn't be a platform for advertising, nor should any tutorial contained in it ever rely on a non-Apple product.

=Book, Not Encyclopedia= Remember that Mac WikiBooks are books, not encyclopedias. Keep a casual tone. This book is supposed to be the Mac OS X user's best friend, not a dry encyclopedia of information.

=Images= Put in color screenshots, product images, and diagrams in important places. Use them when necessary, but never frivolously, so the pages can load over a dial-up connection. Also make sure the screenshots do not show any "haxies", themes, etc. Keep the screens uncluttered and familiar to the average user (for instance, use bundled Apple wallpaper, don't over-customize toolbars, and don't show any alternative icons). Also, when talking about a window or a menu, the screenshot should not include anything else. As a rule, full screenshots should be 830px wide.

Screenshots should be centered except when impractical, always appear as thumbnails, and be labeled in this format: "Fig. 1 - Here is a caption, which is "dry" (not funny or interesting) and does not contain instructions."

=Tables= Tables should be used whenever appropriate.
 * Table width should be set to 830px
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 * Tables should be labeled in this fashion "Table 1. This is a simple caption."

=Info Boxes= Use Info Boxes whenever they make sense. Use the following templates:

=WikiProject Templates= These templates should be used to display affiliation with the Macintosh WikiProject.

 * Template:WP Mac Module - Use this template at the top of all module's talk pages.
 * Template:WP Mac Cleanup - Place this template at the top of all bad modules and their talk pages.


text:
Wikibooks:WikiProject Macintosh/Advanced Guidelines

Advanced WikiBooks follow different guidelines than regular Mac WikiBooks. Only guidelines that are different appear below; all others are the same as their non-advanced counterparts.

=Tone= Advanced Mac WikiBooks should have the same tone as a regular Mac WikiBook, but with fewer jokes, a slightly more dense style, and less repetition. Clarity is even more important as concepts get more and more complicated, and a lack of clarity is the fatal flaw for most books pertaining to this subject matter.

=Templates=
 * Use Template:WP Mac Adv Module on talk pages for Advanced WikiBooks.
 * Use Template:WP Mac Adv Cleanup on Advanced modules that need cleanup.


text:
Traditional Chinese Medicine/Chai Hu

Name Means:
 * Chai-Firewood
 * Hu-Beard

English Name:
 * bupleurum
 * hare's ear root
 * thorowax root

Chinese Name:
 * 柴胡 (Pinyin: chái hú)

Latin Name:
 * Radix Bupleuri

Taste & Temperature:
 * ../Xin-Spicy/
 * ../Ku-Bitter/
 * ../Liang-Cool/

Channels:
 * Foot Jue Yin of Liver
 * Foot Shao Yang of Gall Bladder
 * Hand Jue Yin of Pericardium
 * Hand Shao Yang of San Jiao

Actions & Indications:
 * disperse Wind-Heat (Spicy & Cool)
 * raise Yang Qi
 * Middle Jiao Qi sinking
 * resolve Shao Yang disorders & reduce fever
 * soothe Liver Qi

Contraindication:
 * Qi & Yin deficiency causing excessive sweating
 * Yin deficiency couch
 * Liver Fire ascending to head
 * can occasionally cause Nausea or Vomiting

Caution:
 * Yin syndrome
 * Blood deficiency
 * chronic skin infection

Dosage:
 * 1-4 qian (3-12 grams)

back to:
 * ../Xin Liang Jie Biao/
 * ../TCM Materia Medica/

title: Traditional Chinese Medicine/Chai Hu


text:
False Friends of the Slavist/Map vermę

verme

title: False Friends of the Slavist/Map vermę


text:
Traditional Chinese Medicine/Sheng Ma

Name Means:
 * Sheng-Ascending
 * Ma-Hemp

English Name:
 * cimicifuga rhizome
 * bugbane rhizome
 * black cohosh rhizome

Chinese Name:
 * 升麻 (Pinyin: shēng má)

Latin Name:
 * Rhizoma Cimicifugae

Taste & Temperature:
 * ../Xin-Spicy/
 * ../Gan-Sweet/
 * ../Liang-Cool/

Channels:
 * Hand Tai Yin of Lung
 * Hand Yang Ming of Large Intestine
 * Foot Tai Yin of Spleen
 * Foot Yang Ming of Stomach

Actions & Indications:
 * disperse Wind-Heat (Spicy & Cool)
 * raise Yang Qi
 * lower or sink the qi in the Middle Jiao
 * clear heat & detoxify
 * release rashes

Contraindication:
 * Qi & Yin deficiency causing excessive sweating
 * Yin deficiency with Heat
 * upper excess & lower deficiency
 * fully-erupted measles
 * difficulty in breathing

Caution:
 * Yin deficiency
 * Blood deficiency
 * chronic skin infection

Dosage:
 * .5-3 qian (1.5-9 grams)

back to:
 * ../Xin Liang Jie Biao/
 * ../TCM Materia Medica/

title: Traditional Chinese Medicine/Sheng Ma


text:
Traditional Chinese Medicine/Ge Gen

Name Means:
 * Ge-Coarse grass linen
 * Gen-Root

English Name:
 * kudzu root
 * pueraria

Chinese Name:
 * 葛根 (Pinyin: gé gēn)

Latin Name:
 * Radix Puerariae

Taste & Temperature:
 * ../Xin-Spicy/
 * ../Gan-Sweet/
 * ../Liang-Cool/

Channels:
 * Foot Tai Yin of Spleen
 * Foot Yang Ming of Stomach

Actions & Indications:
 * disperse Wind-Heat (Spicy & Cool)
 * raise Yang Qi
 * diarrhea
 * release muscles & clear heat
 * nourish fluids & alleviate thirst
 * treat hypertension
 * treat heart and brain diseases due to lack of blood circulation

Contraindication:
 * Qi & Yin deficiency causing excessive sweating

Caution:
 * Yin deficiency
 * Blood deficiency
 * chronic skin infection

Dosage:
 * 2-4 qian (6-12 grams)

title: Traditional Chinese Medicine/Ge Gen


text:
False Friends of the Slavist/Map za

za

title: False Friends of the Slavist/Map za


text:
Traditional Chinese Medicine/Dan Dou Chi

Name Means:
 * Dan-plain/insipid/tasteless
 * Dou-bean/soyabean
 * Chi-imperial orders

English Name:
 * prepared soybean

Chinese Name:

 * 淡豆敕 (Pinyin: dàn dòu chì)

Latin Name:

 * Semen Praeparatum Sojae

Taste & Temperature:
 * ../Gan-Sweet/
 * slightly ../Ku-Bitter/
 * ../Han-Cold/ or ../Wen-Warm/

Channels:
 * Hand Tai Yin of Lung
 * Foot Yang Ming of Stomach

Actions & Indications:
 * disperse Wind-Heat (Spicy & Cool)
 * alleviate irritability

Contraindication:
 * Qi & Yin deficiency causing excessive sweating

Caution:
 * Yin deficiency
 * Blood deficiency
 * chronic skin infection
 * nursing mother, inhibits lactation

Preparations:
 * Qing Dou Chi w/:
 * ../Sang Ye/
 * Qing Hao (青蒿 / wormwood)
 * Wen Dou Chi w/:
 * ../Ma Huang/
 * ../Zi Su Ye/

Dosage:
 * 2-5 qian (6-15 grams)

back to:
 * ../Xin Liang Jie Biao/
 * ../TCM Materia Medica/


text:
Traditional Chinese Medicine/Fu Ping

Name Means:
 * Fu-Float
 * Ping-Duckweed

English Name:
 * spirodela
 * duckweed

Chinese Name:
 * 浮萍 (Pinyin: fú píng)

Latin Name:
 * Herba Lemnae Seu Spirodelae

Taste & Temperature:
 * ../Xin-Spicy/
 * ../Han-Cold/

Channels:
 * Foot Tai Yang of Urinary Bladder
 * Hand Tai Yin of Lung

Actions & Indications:
 * disperse Wind-Heat (Spicy & Cool)

Contraindication:
 * Qi & Yin deficiency causing excessive sweating

Caution:
 * Yin syndrome
 * Blood deficiency
 * chronic skin infection

back to:
 * ../Xin Liang Jie Biao/
 * ../TCM Materia Medica/

title: Traditional Chinese Medicine/Fu Ping


text:
XML - Managing Data Exchange/RSS/RSS on Firefox

Add Live Bookmark by Icon
Firefox's Live Bookmarks is one application of RSS. Here we are going to tell you how to use Firefox browser as your RSS reader. There are basically two different ways for user to feed RSS into Firefox. The first and easiest way is to add the feed directly.

 * When browsing a website with RSS feed, there will be a small icon showed on window.
 * For Firefox version 1.5.0.1, a small icon will show on the right side of the URL location.
 * The icon will change depending on the theme of your Firefox browser. The icon showed here is the default icon of Firefox.
 * For different version of Firefox, the location of the icon might be different. In prior versions, the icon might be at lower-right corner of the window.

 * Users click on the icon.
 * A dialog window will show up.
 * Choose the location to put the Live Bookmark. Then click OK.
 * Live Bookmark will show on the bookmark bar.
 * When clicking on the icon, it will update to the latest news automatically.
 * When you click on one topic, it will open one new window connecting to the website of the content.

Another Way to Feed RSS

 * Click on the Bookmark tag and choose Manage Bookmarks.

 * In Bookmarks Manager, choose File -> New Live Bookmark.
 * Copy the RSS site (an URL of a xml file) of the website you want.

 * Paste the RSS link into Feed Location attribute.

 * The Live Bookmark will show up at your Bookmarks.


text:
User:JBogdan

"Pro-Public Domain"

Users and visitors may consider my textual contributions as public domain. If you have anything you want to say you may mention it on my talk page.

If you want to reach me faster, try my talk page on Wikipedia: w:User:JBogdan

I am also JBogdan there.

Eventually I will add these userboxes (if they exist!): This user recycles and frequently drives 55mph on freeways to get good gas ecomomy, and prefers to obey speed limits. This user does not have a TV and enjoys not having it. This user is a also a member of Wikipedia, Wikiversity, and Wikimedia Commons.

title: User:JBogdan


text:
Talk:Learning the vi Editor/Vim

I just started using vim. I've been trying to setup my _vimrc file in windows, and have found it frustrating. All I want to do for now is set a few environment variables, tabstop, wrap, expandtab. But when I create a file with these settings, the text hilighting and other default settings are erased. I think this document should show how to create a _vimrc file that leaves all default settings and allows you to add just your changes. Golden Eternity 23:09, 19 March 2006 (UTC)Golden_Eternity

 * While this a Book not a Forum I still give you a hint: Prehaps there is a syntax error in your _vimrc - this might prevent the system from reading succesive setups. Help in Fixes:

 * Try  - this will read the file without the need to restart.
 * Use  after start - this will show last 10 errormessages and there should not be any after a fresh start ;-).

 * --Krischik T 07:24, 20 March 2006 (UTC) (Note to self: add hints to main page)

 * (My guess) Maybe you are deactivating "vimrc_example.vim". This file comes with Vim and has many useful defaults. If you create a _vimrc, you should :source vimrc_example.vim or copy the parts of it that interest you. -- anonymous

Merge Proboposal
See Talk:Vim_Tipbook...

Contents?
Why does this page have two tables of contents, one at the top and one in the page?

title: Talk:Learning the vi Editor/Vim


text:
French/Lessons/To be

French has six different types of pronouns: the 1st, 2nd, and 3rd person singular and the 1st, 2nd, and 3rd person plural.

 * Tu and vous
 * This is an important difference between French and English. English no longer distinguishes between the singular and the plural, formal version of you, although thou used to be the informal singular version up to the Mid-nineteenth Century. In French, it is culturally important to know when to use and when to use.
 * Vous is the plural form of you. This is somewhat equivalent to you all, you guys, all of you, except that it does not carry any familiarity when used with the plural. You'd use it to address your friends as well as when talking to the government at a press conference. Vous is also used to refer to single individuals to show respect, to be polite or to be neutral. It is used when talking to someone who is important, someone who is older than you are, or someone with whom you are unfamiliar. This is known as Vouvoiement.
 * Conversely, tu is the singular and informal form of vous (you) in French. It is commonly used when referring to a friend or a family member, and is also used between children or when addressing a child. If it is used when speaking to a stranger, it can be taken as disrespect. This is known as Tutoiement. As a rule of thumb, use tu only when you would call that person by his first name, otherwise use vous. French speaking people will make it known when they would like you to refer to them by tu. In French speaking Canada, the use of the singular tu is used everywhere, and can be considered a cultural difference from that of Europe and Africa. You can use the vous in Canada, but it won't affect your respect.

 * Il, elle, and on
 * French pronouns carry meanings that do not exist in English pronouns. The pronoun it does not exist in French. Il replaces all masculine nouns, even those that are not human; the same is true with elle and feminine nouns.
 * The French third person on has several meanings, but most closely matches the now archaic English one. While in English, sentences with one as the subject sound old-fashioned, their French equivalents are quite acceptable. In everyday language, on is used, instead of nous, to express we; the verb is always used in the 3rd person singular.

 * Ils and elles
 * While the third person plural they has no gender in English, the French equivalents ils and elles do. However, when pronounced, they normally sound the same as il and elle, so distinguishing the difference requires understanding of the various conjugations of the verbs following the pronoun. Also, if a group of people consists of both males and females, the male form is used, even with a majority of females; however, this sensibly yields to overwhelming majority: given a group of only one male to thousands of females, the female form would be used.

A verb is a word that describes an action or mental or physical state.

 * Tenses and moods : French verbs can be formed in four moods, each of which express a unique feeling. Each mood has a varying number of tenses, which indicate the time when an action takes place. The conjugations in the present tense of the indicative mood, the present indicative, is discussed in the next section. There is one conjugation for each of the six subject pronouns.

 * Infinitives : The infinitive form is the basic form of a verb. It does not refer to a particular tense, person or subject. The infinitive form of the verb is often used to identify it. In English, the infinitive form is to ___. In French, the infinitive is one word. For example, parler translates to to speak, finir translates to to finish, and aller translates to to go.

 * Conjugation : French verbs conjugate; they take different shapes depending on the subject. English verbs only have one conjugation; that is the third person singular (I see, you see, he/she sees, we see, they see). The only exception is the verb to be (I am; (thou art); you are; he/she is; we are; they are). Most French verbs will conjugate into many different forms. Most verbs are regular, which means that they conjugate in the same way. The most common verbs, however, are irregular.

Être translates as to be in English. As in most languages, it is an irregular verb, and is not conjugated like any other verb.

Used as a noun, means the being or the creature. Likewise, the phrase means the human being.

Expressing agreement
Tu es d’accord ou pas ?, Tu es d’accord ?, literally meaning You are of agreement?, or simply is used informally to ask whether someone agrees with you.

To respond positively, you say Oui, je suis d'accord. or simply D'accord:

D'accord corresponds to the English okay.

When stating your nationality or job, it is not necessary to include the article:

This is an exception to the normal rule.

There is both a masculine and a feminine form of saying your nationality—for males and females respectively:

Nationalities are not capitalized as often in French as they are in English. If you are referring to a person, as in an Arab person or a Chinese person, the French equivalent is un Arabe or un Chinois. However, if you are referring to the Arabic language or Chinese language, the French would not capitalize: l'arabe, le chinois. If the nationality is used as an adjective, it is normally left uncapitalized: un livre chinois, un tapis arabe.

The preposition means from:

De becomes d' before a vowel, due to elision:

The definite article is included with countries:

The contraction is used in place of de le:

Likewise, the contraction is used in place of de les:

De also has other translations, which depend on context. For example, it is used to indicate an amount:

The preposition means at or in:

The contraction is used in place of à le:

Likewise, the contraction is used in place of à les.

À also has other translations, which depend on context. For example, when used with, à means to:

title: French/Lessons/To be


text:
Traditional Chinese Medicine/Mu Zei

Name Means:
 * Mu-Wood
 * Zei-Thief

English Name:
 * equisetum
 * scouring rush
 * shave grass

Chinese Name:
 * 木贼 (Pinyin: mù zéi)

Latin Name:
 * Herba Equiseti Hiemalis

Taste & Temperature:
 * ../Gan-Sweet/
 * ../Ku-Bitter/
 * ../Ping-Neutral/

Channels:
 * Hand Tai Yin of Lung
 * Foot Jue Yin of Liver

Actions & Indications:
 * disperse Wind-Heat (Spicy & Cool)
 * brighten eyes, remove visual obstruction
 * clear heat & stop bleeding

Contraindication:
 * Qi & Yin deficiency causing excessive sweating

Caution:
 * Yin syndrome
 * Blood deficiency
 * chronic skin infection
 * frequent urination
 * depleted fluids
 * Qi deficiency

Dosage:
 * 1-3 qian (3-9 grams)

back to:
 * ../Xin Liang Jie Biao/
 * ../TCM Materia Medica/

title: Traditional Chinese Medicine/Mu Zei


text:
Proteomics/Protein Identification - Mass Spectrometry

Introduction
Mass spectrometry is a technique in which gas phase molecules are ionized and their mass-to-charge ratio is measured by observing acceleration differences of ions when an electric field is applied. Lighter ions will accelerate faster and be detected first. If the mass is measured with precision then the composition of the molecule can be identified. In the case of proteins, the sequence can be identified. Most samples submitted to mass Spectrometry are a mixture of compounds. A spectrum is acquired to give the mass-to-charge ratio of all compounds in the sample. Mass spectrometry is also known as 'mass spec' or MS for short. Mass spectrometry throws light on molecular mechanisms within cellular systems. It is used for identifying proteins, functional interactions, and it further allows for determination of subunits. Other molecules in cells such as lipid components can also be defined.
 * Mass Spectrometry Overview

A mass spectrometer is composed of several different parts: a source that ionizes the sample, the analyzer that separates the ions based on mass-to-charge ratio, a detector that "sees" the ions, and a data system to process and analyze the results. You can also measure relative abundance of an ion using mass spectrometry. Different compounds have differential ionization capabilities and therefore intensity of your ion is not a direct correlation to concentration.

Mass spectrometry can be a high throughput analytical method due to the ability for a mass spectrum to be measured rapidly and with minimal sample handling as compared to gel methods.

It is an analytical method which has a variety of uses outside of proteomics, such as isotope and dating, trace gas analysis, atomic location mapping, pollutant detection, and space exploration

 * History of Mass Spectrometry

The history of this technique finds its roots in the first studies of gas excitation in a charged environment, more than 100 years ago. This pioneering work led to the identification of two isotopes of neon (neon-20 and neon-22) via mass to charge ration discrimination by J.J Thomson in 1913. Over the next fifty years the fundamental basis of the technique was further developed. After the coupling of gas chromatography to Mass Spectroscopy in 1959 by researches at Dow Chemical, the full potential of the technique as a highly accurate, quantitative method for exploring compounds was realized, spurring a wave of developments which continue to the present day. The precision of mass spectrometry led to the discovery of isotopes.

The technique of mass spectrometry is a valuable tool in the field of proteomics. It can be used to identify proteins through variations of mass spectrometry techniques. The most common first approach to proteomics is a bottom-up approach in which the protein is digested by a protease, such a trypsin, and the peptides are then analyzed by peptide mass fingerprinting, collision-induced dissociation, tandem MS, and electron capture dissociation. Once the peptides masses have been determined the mass list can be sent to a database, such as MASCOT, where the list is compared to the masses of all known peptides. If enough peptides match that of a known protein you can identify your protein. If the masses of your peptides do not match a known protein you can sequence your peptide by de novo sequencing using MS/MS methods; where you isolate your peptide and break it along the peptide bond backbone forming y and b ions from which you can determine the sequence. The advantages of the bottom-up approach are that the small size of tryptic peptide ions is easy to handle biochemically than entire protein ions because of their relatively small masses that are easier to be determine. Beside bottom-up approach, another approach is top-down. In top-down approach, the complete proteins are directly analyzed by using mass spectrometer without solution digestion as bottom-up does. The advantages of the top-down approach are that it can sometime provide the complete coverage of the protein. But since whole proteins are hard to handle biochemically compared to small peptide pieces, it makes top-down approach difficult to analyze.
 * Implications of Mass Spectrometry for Proteomics Applications

Another use of mass spectrometry in proteomics is protein quantification. By labeling proteins with stable heavier isotopes you can in turn determine the relative abundance of proteins. Companies now produce kits, such as iTRAQ (Applied Biosystems), in order to do this at a high-throughput level.

One of the most powerful ways to identify a biological molecule is to determine its molecular mass together with the masses of its component building blocks after fragmentation. There are two dominant methods for doing this. The first is electrospray ionization (ESI), in which the ions of interest are formed from solution by applying a high electric field. This is done by applying a high electric field to the tip of a capillary, from which the solution will pass through. The sample will be sprayed into the electric field along with a flow of nitrogen to promote desolvation. Droplets will form and will evaporate in a vacuumed area. This causes an increase in charge on the droplets and the ions are now said to be multiply charged. These multiply charged ions can now enter the analyzer. ESI is a method of choice because of the following properties: (1)The "softness" of the phase conversion process allows very fragile molecules to be ionized intact and even in some non-covalent interactions to be preserved for MS analysis. (2)The eluting fractions through liquid chromatography can then be sprayed into the mass spectrometer, allowing for the further analysis of mixtures. (3)The production of multiply charged ions allow for the measurement of high-mass biopolymers. Multiple charges on the molecule will reduce its mass to charge ratio when compared to a single charged molecule. Multiple charges on a molecule also allows for improved fragmentation which in turn allows for a better determination of structure. The second is matrix-assisted laser desorption/ionization (MALDI) in which the molecular ions of interest are formed by pulses of laser light impacting on the sample isolated within an excess of matrix molecules. This enables the determination of masses of large biomolecules and synthetic polymers greater than 200,000 Daltons without degradation of the molecule of interest. The advantages of MALDI are its robustness, high speed, and relative immunity to contaminants and biochemical buffers.

A type of mass spectrometer often used with MALD is TOF or Time of Flight mass spectrometry. This enables fast and accurate molar mass determination along with sequencing repeated units and recognizing polymer additives and impurities. This technique is based on an ultraviolet absorbing matrix where the matrix and polymer are mixed together along with excess matrix and a solvent to prevent aggregation of the polymer. This mixture is then placed on the tip of a probe; then the solvent is removed while under vacuum conditions. This creates co-crystallized polymer molecules that are dispersed homogeneously within the matrix. A pulsing laser beam is set to an appropriate frequency and energy is shot to the matrix, which becomes partially vaporized. In turn the homogeneously dispersed polymer within the matrix is carried into the vapor phase and becomes charged. To obtain a superb signal-to-noise ratio, multiple laser shots are executed. The shapes of the peaks are improved and the molar masses determined are more accurate. Fianlly, in the TOF analyzer the molecules from a sample are imparted identical translational kinetic energies because of the electrical potential energy difference. These ionic molecules travel down an evacuated tube with no electrical field and of the same distance. The smallest ions arrive first at the detector, which produces a signal for each ion. The cumulative data from multiple laser shots yield a TOF mass spectrum, which translates the detector signal into a function of time, which in turn can be used to calculate the mass of the ion.

In addition to these ionization techniques, highly powerful mass analyzers have been developed. These analyzers measure the mass/charge ratio of intact ionized biomolecules, as well as their fragmentation spectra, with high accuracy and high speed. The measurement of fragmentation spectra is called tandem MS or MS/MS. In conjunction with single stage MS (with intact precursor ions) tandem MS can be utilized to help elucidate a protein since the problem of elucidation will reduce to assembling the puzzle pieces of the fragmented protein.


text:
Radiation Oncology/Peds/Brain tumors

Pediatric Brain Tumors
 * Craniopharyngioma
 * Germ cell tumors
 * Ependymoma
 * Optic Pathway Glioma
 * Pilocytic Astrocytoma
 * Medulloblastoma
 * CNS PNET
 * Pineal Gland tumors
 * Atypical Teratoid Rhabdoid Tumor (AT/RT)
 * Retinoblastoma

title: Radiation Oncology/Peds/Brain tumors


text:
Radiation Oncology/Peds/Germ cell

> Radiation Oncology/Peds/Brain tumors

 * Subpage: CNS Germinoma

Epidemiology
Rare. 1% of all CNS tumors.

Pathology

 * Germinomas - 60% of intracranial germ cell tumors
 * Histologically identical to testicular germinoma.

Workup
Secreting germinomas may secrete AFP and B-HCG in serum and CSF. MRI of brain and spine.

title: Radiation Oncology/Peds/Germ cell


text:
Speech-Language Pathology/Stuttering/Measurement of Stuttering

Measuring stuttering is notoriously difficult. You can measure several aspects of stuttering:

 Frequency of disfluencies. I.e., disfluencies per hundred words or syllables. The "average" stutterer is dysfluent on 10 percent of words. People who don't stutter are disfluent on about 2% of words. Duration of disfluencies. The "average" disfluency lasts about 1 second. Speaking rate, or word per minute. The average speaking rate for people who don't stutter is 167 words per minute (Darley, 1940). The average speaking rate for stutterers is 123 words per minute. The average stutterer speaks about 25% slower than the average non-stutterer. Types of disfluencies. Wendell Johnson developed eight categories of disfluencies in 1959. The first three are common to both stutterers and non-stutterers. The last five are stuttering disfluencies.  Interjections ("uh," "er"). Revisions ("I was - I am going"). Incomplete phrases.
Part-word repetitions ("ba-ba-ba-baseball").

Word repetitions.

Phrase repetitions ("I was I was going").

Broken words ("I was g - (pause) - oing home").

Prolonged sounds.

Psychological effects.

The preferred test questionnaire for measuring stuttering is the "Stuttering Severity Instrument for Children and Adults," 3rd edition, by Glyndon Riley.

A study by Young in 1961 found that ordinary listeners judged stuttering to be "severe" when there were part-word repetitions, prolongations, broken words, and a new category, "undue stress or tension." But many speech samples were judged "severe" with relatively few of these disfluencies, suggesting that there are yet more, unidentified types of stuttering disfluencies.

There are many electronic instruments that can measure aspects of stuttering. See "Instrumentation For The Assessment And Treatment Of Stuttering", by Klaas Bakker (1996) and "Automatic Recognition of Dysfluencies" (Howell, 1997).

Problems Measuring Stuttering

Differences between judges. Different people listening to the same tape will hear different numbers of disfluencies, even if they are trained speech pathologists.

Counting normal disfluencies. Everyone has normal disfluencies. Does having lots of normal disfluencies make a person a stutterer? Or is stuttering something different? Should normal disfluencies be counted as stuttering?

Children vs. adults. Children stutter in different ways than adults: some disfluencies are normal for children but are abnormal in adults.

Hidden stuttering. Some stutterers can substitute words and appear to never stutter.

Speaking conditions. Some stutterers can read out loud perfectly fluently. Others stutter most severely when reading. Some stutterers are most fluent in conversation. Others are most disfluent. Some are most fluent in stressful situations, on telephones, etc., while others are the opposite. You can't judge how severely a person stutters from a single speaking situation.

Internal or psychological stuttering is difficult to quantify. For many stutterers the internal effects of stuttering are greater than their physical symptoms. Several stuttering therapies focus on improving the self-esteem and overall communication skills of stutterers, with little or no attention to improving physical fluency.

 Different people stutter in different ways, and each person has multiple ways of stuttering. There is no single behavior common to all stuttering. Be skeptical when anyone claims that a therapy reduced stuttering 85%, etc. Ask how stuttering was measured, under what conditions, etc.


text:
Speech-Language Pathology/Stuttering/Teenage Stuttering

"I am a mother of a stuttering thirteen-year-old boy. Stuttering really had never bothered him until this year. It is very frustrating for him to talk on the phone. His friends call all the time but he has refrained from talking on the phone because his stuttering seems to get worse. My husband and I have noticed him withdrawing from his peers. We have always had an active role with his stuttering. He has been to a lot of speech-language pathologists and we have also tried the CAFET [biofeedback computer] system. This was helping him. Unfortunately the closest center was more than two hours away. After one year it was too stressful on him missing too much school. Because of this we had to stop. Since then he has wanted nothing to do with speech-language pathologists."

Parents of teenagers who stutter tell similar stories:

 The teenager has been seeing his school's speech-language pathologists for five or even ten years. His speech isn't improving. He wants to discontinue speech therapy. He's fluent in the speech-language pathologist's office, but stutters everywhere else. The parents have taken him to other speech clinics, without success. He used to have good speech attitudes, saying whatever he wanted. Now he fears and avoids certain words or speaking situations. His social behavior has changed. He's withdrawing from social contacts.

Previously he saw himself as being like most other kids, doing the same things as other kids. School-age boys' social activities, e.g., baseball, don't demand much talking. Now he thinks of himself as a stutterer, different from other teenagers. Teenagers' social activities, e.g., dating or getting an after-school job, are harder for a stutterer.

Your teenager is an adult, in terms of stuttering. He should be doing adult stuttering therapy. This can include:

 Psychological stuttering therapy, training fluent speech (physical) skills. A support group for teenagers who stutter.

An intensive speech therapy program or a summer camp for teenagers who stutter. (Google "speech camp for teens who stutter.")

Develop a Passion
In the chapter Famous People Who Stutter, you'll learn that many celebrities developed their talents during high school as a result of stuttering. E.g.,

James Earl Jones, Bruce Willis, and Nicholas Brendan overcame stuttering through acting.

Carly Simon developed her skills as a singer and a songwriter because she couldn't talk about her feelings.

When a teenager feels passion for an activity, he or she can focus with greater intensity than adults. Your job, as a parent, is to help your teenager focus on a speech-positive activity, instead of focusing on video games or memorizing Black Sabbath lyrics.

Help your teenager become passionately involved in activities that require talking, improve his fluency, and develop his social skills. Such activities include:

Singing.

Acting.

Sports.

Debating.

Foreign languages.

Organizing a teenage stuttering support group.

A science project about stuttering.

Involve Peers in Speech Therapy
Are your teenage clients less than enthusiastic about speech therapy? Well, duh, if you're a speech-language pathologist then you're at least 25! You might even be over 30! Why would a teenage want to talk to someone your age?

Instead, have a teenage stutterer bring a friend to speech therapy. He'll talk to his friend about skateboarding or video games or other stuff you're clueless about. Better yet, you can train the friend to give your client a subtle reminder when he needs to slow down or get back on-target.

Or role-play the teenager asking a peer out on a date. He can ask her for her telephone number by saying that his speech therapist wants him to practice making telephone calls. I used to do something like this: I met a girlfriend by telling her that my speech therapist wanted me to introduce myself to strangers.

Paramount in teenagers' minds is connecting to peers (other teenagers), e.g., being seen as "cool" by their classmates. Use speech therapy as way to connect to peers and your teenager will want to do speech therapy. E.g., instead of (thinking of himself as) being seen as a boy who stutters, help your teenager think of himself as a boy who's not afraid to ask girls for their telephone numbers and ask them out on dates.

Learn American Sign Language
''I took four years of German in high school and college. The classes were taught in a conversational style. Being unable to talk, I learned nothing. No one suggested that I study American Sign Language instead. I could have been 100% fluent in that! Being good at something would have improved my self-esteem. In contrast, I felt like the stupidest person in the German classes. And if I learned sign language I would've made friends in the deaf community, or maybe worked part-time as a sign language interpreter.''--Thomas David Kehoe 02:12, 28 March 2006 (UTC)


text:
Speech-Language Pathology/Stuttering/School-Age Stuttering

Ask your child whether he or she likes school. In first and second grade, girls see school as where they socialize with their friends, via quiet verbal communication and cooperation. In contrast, boys see school as where they're told not to play with their friends, via physical interaction such as running around or showing off their physical abilities. This difference makes school more stressful for boys, with effects on their speech.

Why Do More Boys Than Girls Stutter?
Among preschoolers, boys who stutter outnumber girls who stutter about two to one, or less.

But more girls recover fluent speech, and more boys don't. By fifth grade the ratio is about four boys who stutter to one girl who stutters. This ratio remains into adulthood.

Why boys are more likely to stutter, and less likely to recover, isn't certain. Boys generally have more diseases and disorders, for reasons having to do with the Y chromosome. Boys generally have more speech disorders because girls are better at speech and language, and especially at using speech and language for social purposes. Speech and language are more stressful for boys, so boys prefer to interact physically.

At five for girls and seven for boys, children's brains go through a massive adrenaline shift. After this shift, the child is able to socialize with other children in groups. Before this age, playing with more than one or two friends can be a stressful experience.

''This was apparent to me at my nephew's sixth birthday party. One of his presents was a slinky. I showed his friends how to make the slinky walk down stairs. Three girls sat together at the top of the stairs and took turns. One girl could easily make the slinky walk down the stairs. This was harder for the second girl, but she could do it. The third girl couldn't do it at all. But they cooperated and encouraged each other. Two boys wanted to try it. But they couldn't get to top of the stairs without wrestling each other and falling back down the stairs. I wouldn't allow wrestling on the stairs, so they'd run around the living room chasing each other. Then they'd come back to play with the slinky, but start wrestling on the stairs again.''--Thomas David Kehoe 02:10, 28 March 2006 (UTC)

At five, girls are ready to start school. Boys are wild animals until seven. School can be stressful for boys who aren't ready for school. The most stressful part of school for boys may be the communication demands. Girls are using communication to make friends. Girls' communication skills and social skills develop together. In contrast, boys may not be ready to socialize with 25 other children, in a building with hundreds of other children. Some children are in school and day care for twelve hours, without time to relax or to be alone—that'd stress me out!

If your five- or six-year-old son stutters, and you don't think he's ready for school (e.g., he vomits or wets his pants at school), consider keeping him home another year, or look into a co-op school where a parent can attend school with him, or let him attend school but don't put him in daycare for another six hours each day.

SLPs vs. Parents vs. Computers
A large study found that speech-language pathologists training parents to do speech therapy with their children was more effective than the speech-language pathologists doing therapy with the children. The study also found that computer-based stuttering therapy, with minimal involvement from speech-language pathologists, was the most effective treatment of all.

A study of 98 children, 9 to 14 years old, compared three types of stuttering therapy. The three types of therapy were:

 Intensive "smooth speech" fluency shaping trained relaxed, diaphragmatic breathing; a slow speaking rate with prolonged vowels; gentle onsets and offsets (loudness contour); soft articulation contacts; and pauses between phrases. The children did this therapy in a speech clinic for 35 hours over one week. Home-based "smooth speech." This was similar to the first group, but parents were included, and encouraged to continue therapy at home. Therapy was done in a speech clinic for six hours once a week for four weeks (24 hours total). Electromyographic biofeedback. The children used an EMG biofeedback computer system about six hours a day for one week (30 hours total). The EMG system monitored the child's speech-production muscle activity. The children were instructed to tense and then relax their speech-production muscles. The goal was to develop awareness and control of these muscles. The children then worked through a hierarchy from simple words to conversations, while keeping their speech-production muscles relaxed. After mastering this while watching the computer display, the children did the exercises with the computer monitoring but not displaying their muscle activity. The speech pathologists did relatively little with the children: "Constant clinician presence was not necessary as the computer provided feedback as to whether the child was performing the skills correctly."

A fourth (control) group didn't receive any stuttering therapy.

At the end of each therapy program, all three therapies reduced stuttering below 1% on average. The control group had no improvement in fluency.

One year after the therapy program, the percentage of children with disfluency rates under 2% were:

 48% of the children from the clinician-based program. 63% of the children from the parent-based program. 71% of the children from the computer-based program.

The results for children with disfluency rates under 1% were even more striking:

10% of the children from the clinician-based program.

37% of the children from the "parent-based" program.

44% of the children from the computer-based program.

 I.e., the computers were most effective, the parents next most effective, and the speech-language pathologists were least effective in the long term. At the 1% disfluency level, the computers and the parents were about four times more effective than the speech-language pathologists.

Four years later, all three groups had average stuttering reductions between 76% and 79%. This may have been due to the more dysfluent children receiving additional speech therapy.

Motivation for Speech Therapy
The father of a ten-year-old stutterer wanted to do everything to help his son. On the advice of his son's speech-language pathologist, the father bought a top-of-the-line electronic stuttering therapy device. The speech-language pathologist trained the father to use the device. The father worked with his son thirty minutes every evening.

After two months, the father returned the device for a refund. The son was 100% fluent when practicing with the device. The kid had no interest in using slow, relaxed speech the rest of the day. Stuttering didn't stop the boy from playing baseball or doing other things boys do. In the world of seven- to twelve-year-old boys, talking isn't an important activity.

But your seven- to twelve-year-old son's good self-esteem can be a double-edged sword. It's hard to get school-age boys motivated to do speech therapy. This makes it more important that parents do speech therapy with their child in every conversation. Ask your child's speech-language pathologist what your child should be doing (e.g., slow speech with stretched vowels). Have your child use therapy skills on every sentence he says to you. Be your child's therapy helper.

Advice for Parents, by Magdalene Lima, SLP

I am a speech-language pathologist in private practice and formerly a public school therapist for nine years. My suggestions to parents of children with speech problems are:

Do some research in these areas. Check out the communication disorders websites.

Go to your school speech-language pathologist with what you know and ask her what she thinks. The best approach is to treat her as the professional she is in a non-critical way with the attitude that you just want to understand all the treatments available for your son. Offer to help get information to her if she doesn't have it. Let her know you understand the position she is in and that you are on her team. This will get you much further in getting the appropriate services for your child than fighting your school.

If your insurance covers it or you have the funds, find a good private pediatric speech and languageclinic in your area and AT LEAST have an evaluation done. Just that information alone could really help the school SLP. If you can afford private therapy, get it. The main difference in service is that your child will receive individual therapy with a clinician that has the time and resources needed to provide the highest quality therapy.

As a former school speech-language pathologist, my skills and knowledge didn't suddenly change when I switched over to private practice. The setting changed, and that makes a huge difference. I now serve 30 clients rather than 75, I see them all individually, and I am paid more than in the schools. In the hours I don't see clients, I am busy researching, giving parent support, writing regular and detailed reports, and planning innovative therapy rather than going to bus duty, lunch duty, hall duty, faculty meetings that don't really apply to me and filling out massive amounts of government-required paperwork.

Is The Problem Ability or Setting?

Now to those of you who think the worst of the public school speech-language pathologist: I'd like you to stand in her shoes for a minute. In the last three years of my public school experience my caseload became unmanageable. I had 75 students, including a severely and profoundly handicapped class, four autistic students and all other students in speech from grades K-5 at that school. I begged, cried and pleaded for help from my supervisors. I KNEW I could not provide the quality of service each and every one of these students and their families deserved. However, the answer was always: get creative, we don't have money in the budget. Please understand, in my situation, it was not a lack of caring, lack of skill or ability—there was absolutely nothing I could do. I became angry and frustrated at our administration. Why didn't they provide the training, time, personnel and support we needed to provide services to these students?

Speech Pathology: A Growing and Diverse Field

The disorders in our field and the therapies that have now been developed have become extremely specialized. In the schools I was expected by parents to be an expert in the following fields: stuttering, swallowing disorders, voice disorders, articulation disorders including tongue thrust, cleft palate, phonological process disorders as well as motor speech disorders, autism and PDD, traumatic brain injury, ADHD, language and learning disabilities, hearing impairments and social and pragmatic communication disorders. Excuse me, do you realize that just as physicians receive a basic foundation in medicine, so do speech-language pathologists receive a basic foundation in all of the above disorders. You graduate from college and through your experience and personal growth and research, you become an expert in a few areas. It would be virtually impossible for one person to have the time and energy it would take to become an expert in all those areas!

This is why our field is moving towards specialty certifications. What will public schools do then? I guess they will have to hire the specialists that their individual students require.

Many and Varied Problems in the Schools

More and more our district began hiring speech assistants (speech practitioners who are not required to meet the standards of education, clinical practicum and experience needed to be fully certified and licensed) to handle huge caseloads with minimal supervision from licensed speech-language pathologists. There is a shortage of qualified speech language pathologists willing to go into public school therapy when there are much more lucrative and attractive positions available in other settings. As I talked with administrators, I soon became aware of the pressure being applied to them from the state, parents and other agencies to meet all these educational requirements. For every parent who complains there is not enough money to provide quality special education services in the school, there is another parent complaining that their gifted and talented child is not being given the education THEY deserve because of all the money being poured into special education programs. Or what about the parents of children in sports programs, they have THEIR list of complaints. Everyone thinks that their cause is totally justified because they are arguing for their children, and nothing can convince anyone that their child doesn't deserve the best.

I left the public school system to go into private practice and now my problem is solved—I love my work and I'm giving quality services to clients with fantastic results! However, what's your solution? My final and personal resolution to this whole issue, is that in many cases—not all, but many—I truly feel that schools are doing the very best they can with the resources available to them to provide the services that our children need. However, sometimes, parents are right, it's not enough. So what are we going to do? Is every parent in America with a complaint going to file suit against the local school district? If this happens, our schools will begin focusing on preventing lawsuits rather than on how best to serve and educate our children.

Work With Your Administration/Educators

Sometimes all it takes is going to an administrator, such as the Director of Special Education, and pleading your case. Also give your specific suggestions at your child's IEP meeting. You'd better have some research and documentation to back up the necessity of your suggestions. The attitude and manner in which you present yourself is of utmost importance, if they perceive you are willing to make compromises and work with them they will be more willing to stick their neck out for you. Suggest specific things such as the district paying for an outside assessment, or hiring a consultant temporarily who can lend their expertise to your child's case. Get over any intimidation you feel in asserting yourself with these people, they are just people with children and jobs and stresses just like you. What they say to you is never written in stone.

Conclusion

I'm not saying you shouldn't fight extreme injustice or abuse. I'm saying it's a huge system with a lot of variables involved. The fight is societal and governmental—usually not your local educational facility. Become involved politically in your state with your speech and hearing association—they always have a branch that is lobbying for legislation to improve speech services in the schools. Meanwhile, you have a child that has needs for quality services in the area of speech pathology, do the best you can to get that service, whether it be private therapy through insurance or private pay, or school therapy, don't stop looking until you find what you need.

YOU take responsibility to research, learn things for yourself and communicate with those who affect your child's education.


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XML - Managing Data Exchange/The one-to-many relationship/Exercises

Chapter
To return to the chapter, follow this link: One-to-many relationship

1. Museum information

 * a. Create an XML schema to describe a museum (use elements of the museum entity defined in the last chapter, and add to it a country element). Specify a set of acceptable values as a country and its calendar with date, opening time, and closing time.
 * b. Using the schema, create an XML document and populate it with data for two museums with at least 5 different dates in the calendar for one museum and 7 different dates for the other museum.

2. Currency codes for tourist guides

 * a. Help the guides by creating a valid and well-formed XML schema describing currency codes (e.g. EUR for Euros). The currency code element should consist of three characters. Along that the country's name (e.g. Germany) and the name of the currency (e.g. Euros) should be included. Create a XML document in which some currency codes are listed.

3. The spa finder
* the information found for each spa - NAME,OWNER, PHONE, CITY, STATE, ADDRESS, STARTED IN, TYPE OF SPA * the information found for each service - SERVICE, DESCRIPTION, PRICE * the information found for each offering of a service - DAYS, TIMES, PRACTITIONER, FLOOR, ROOM
 * a. the XML schema - the Spa Finder lists many spas, each spa serves many activities, and each activity is offered at many days and times by different practitioners.
 * Extra- you could use enumeration for the SERVICE, listing some pre-determined services (ie. European Facial, Avocado Facial, Hot Stone Massage, Reflexology, Accupressure, Yoga, TaiChi).

 * b. the XML document - fill in the data for 3 spas with at least 3 services each and at least 2 offerings of each service.

4. Movie Database

 * Create an XML schema to depict a relationship between movie genres, movies, and actors/actresses.
 * Choose two genres (drama, horror, action, etc.), two movies in each, and several actors/actresses from each.
 * Using the schema, create a document and populate it with the chosen information.
 * Create an XML stylesheet to present the data for easier readability. Reference the stylesheet in the document.

Answers
To view the answers, follow this link: answers


text:
Speech-Language Pathology/Stuttering/Mentally Retarded Stuttering

Oliver Bloodstein wrote in his book A Handbook on Stuttering of "ample evidence" that stuttering is especially prevalent among persons with mental disabilities. Stuttering seems to be especially common among persons with Down Syndrome. There is some debate about this, as the stuttering symptoms among the developmentally-delayed can be different from stuttering in adults of normal intelligence.

Developmentally-delayed individuals tend to have other speech and language problems as well. A speech pathologist treating a mentally-retarded person will probably use more than just stuttering therapies. There are books devoted to this, such as Communication Strategies for People with Developmental Disabilities: Issues for Theory and Practice, edited by Ken Linfoot, Ph.D. (1995, Baltimore: Brookes Publishing Company, $33, 800/638-3775).

Eugene Cooper suggests that "reducing the number of abstract concepts the clinician uses" is paramount in treating mentally-retarded stutterers. He also emphasizes that therapy should focus on helping mentally-retarded stutterers "identify and express their feelings and attitudes about the problem." Too often, speech pathologists act as if mentally-retarded persons lack feelings and emotions, as well as intelligence. Cooper also writes that the stutterer should be "capable of verbalizing the goal of the procedure and their desire to achieve that goal" (Cooper, 1986)- good advice with any stutterer.

If the person likes to play video games, you may want to try some of the speech therapy computer games.


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Speech-Language Pathology/Stuttering/Fluency Shaping

Fluency shaping therapy trains stutterers to speak fluently with relaxed breathing, vocal folds, and articulation (lips, jaw, and tongue).

This chapter is divided into sections:

 * Motor Learning and Control

 * Fluency Shaping Overview

 * Fluency Shaping Techniques

 * Fluency Shaping Programs

 * Computers and Electronics for Fluency Shaping

 * Efficacy Studies

 * Beyond Fluency Shaping

 * Zen in the Art of Stuttering

 * Fluency Shaping Critiques—This section is for criticisms of fluency shaping therapies.

 * Personal Experiences with Fluency Shaping Therapy—Add your experiences here.

History of Fluency Shaping Therapy
William Perkins and Richard Curlee developed the first fluency shaping programs. Einer Boberg (ISTAR), Bruce Ryan (Monterey Fluency Program), George Shames and Cheri Florence (Stutter-Free Speech), and Ronald Webster (Hollins) have developed other programs.

External Links:

 * ISTAR
 * Hollins


text:
User talk:138.23.89.187

Hey thanks for your edit at Alkenes, check out this existing page: Organic Chemistry/Alkenes. Maybe you can work on what has been started there. Let me know if you need any help --Karl Wick 01:58, 20 March 2006 (UTC)

title: User talk:138.23.89.187


text:
Radiation Oncology/Peds/CNS PNET

> Radiation Oncology/Peds/Brain tumors

Supratentorial PNETs
 * Account for <5% of pediatric CNS tumors
 * Patients typically present with symptoms related to increased ICP
 * Embryonal tumor composed of undifferentiated/poorly differentiated neuroepithelial cells, which can differentiate along neuronal, astrocytic, ependymal, muscular, or melanotic lines
 * Distinct neuronal differentiation = cerebral neuroblastoma
 * Ganglion cells present = ganglioneuroblastoma
 * Arising in pineal region = pineoblastoma
 * Typically more aggressive nature compared to medulloblastoma (infratentorial PNET), with rapid progression
 * German HIT trials: 3-year PFS ST-PNET PFS 49% vs standard-risk medulloblastoma 78% on same protocol
 * CCG 921 trial: 5-year PFS ST-PNET M0 53% vs. medulloblastoma M0 71%; M+ 29% vs. 52% on same protocol
 * Different genetic alterations in ST PNET vs. medulloblastoma
 * May occur anywhere in the CNS
 * Historically treated on same protocols as medulloblastoma; treatment strategy now comparable to high-risk medulloblastoma
 * Historically, POG has viewed PNET and medulloblastoma as different entities, while CCG was reporting them together
 * Based on German HIT 87/92 trials, RT cannot be eliminated in young (<3 years) patients, even with intense chemotherapy, and delay should be <6 months. Similarly, in CCG and POG protocols, infants treated with only chemotherapy tended to progress and die of the disease

Poor prognostic factors:
 * Disseminated disease at diagnosis (M+)
 * Young age <3
 * Non-cerebellar (medulloblastoma), non-pineal (pineoblastoma) primary

Studies

 * CCG 99701 (Ongoing)
 * Phase I/II. Feasibility of concurrent/maintenance chemotherapy. Central primitive embryonic tumors (PNET, ATRT, Medulloblastoma, Ependymoblastoma, Medullomyoblastoma, Spongioblastoma, Medulloepithelioma, Neuroblastoma, Pineoblastoma). No M4 disease. RT CSI 36/20 followed by tumor boost to 53-58.6 Gy in 1.8 Gy/fx, with concurrent carboplatin/ vincristine, followed by maintenance vincristine/ cyclophosphamide or cisplatin/ vincristine/ cyclophosphamide

 * HIT-SKK87 and HIT-SKK92 (1987-1992, 1992-1997)
 * HIT-SKK87: Low-risk (complete resection, M0) and age <2.5 received maintenance chemo only until RT at 3 years or progression. High-risk (subtotal resction, M+) and age 2.5-3 induction chemo / maintence chemo until RT at 3 years or progression
 * HIT-SKK92: Post-op chemo x3 cycles first, then if CR no RT. If PR and <18 months, then more chemo, if PR and >18 months, then RT.
 * RT given as CSI 35.2/22 Gy + 20/10 Gy boost; if no residual disease, reduced to CSI 24 Gy + PF boost to 55 Gy
 * 2006 PMID 16575007 -- "Role of radiotherapy in supratentorial primitive neuroectodermal tumor in young children: results of the German HIT-SKK87 and HIT-SKK92 trials." (Timmermann B, J Clin Oncol. 2006 Apr 1;24(10):1554-60.)
 * Total 29 children enrolled on both. No RT given in 15 children.
 * 3-year outcomes: OS 17% and PFS 15%. RT only positive predictive factor
 * Conclusion: Outcomes unsatisfactory. Omission of RT jeopardizes survival, even when intensive chemo given. Suggest limiting delay of RT to maximum 6 months

 * German HIT 88/89 and HIT 91 (1991-97)
 * Pilot (HIT 88/89) followed by randomized (HIT 91). Trial enrolled pts with supratentorial PNET, medulloblastoma, and anaplastic ependymomas. All treated with extensive resection. In HIT 88/89, pts treated postoperatively with chemo x2 cycles (Ifosfamide, etoposide, MTX, cisplatin, cytarabine) -> RT (CSI 35.2 Gy + PF boost 20 Gy). In HIT 91, randomized to 1) immediate RT (35.2 + 20) followed by maintenance chemo x8 cycles (CCNU, cisplatin, vincristine), or 2) chemo -> RT (same as HIT 88/89).
 * ST PNET subset, 2002 PMID 11821469, 2002 — "Role of radiotherapy in the treatment of supratentorial primitive neuroectodermal tumors in childhood: results of the prospective German brain tumor trials HIT 88/89 and 91." (Timmermann M et al. J Clin Oncol. 2002 Feb 1;20(3):842-9.)
 * Subset analysis of 63 children with ST PNET. 67% incomplete resection. 7 children RT to tumor site only, 2 children no RT, 15 children major RT violations. Median F/U 2.6 years
 * 3-yr OS 48.4%. Progression in 38 pts, LR in 27 pts. 3-year PFS correct RT 49% vs. major protocol violation RT 7%
 * Conclusion: Preirradiation chemo increases risk of recurrence. Volume should encompass whole CNS to 35 Gy with boost to at least 54 Gy

 * Pilot HIT 88/89 PMID 9743957 -- "Preradiation chemotherapy of children and young adults with malignant brain tumors: results of the German pilot trial HIT'88/'89." (Kuhl J, Klin Padiatr. 1998 Jul-Aug;210(4):227-33.)
 * RT delayed median 23 weeks
 * 5-year OS: medulloblastoma 57%, ependymoma 62%, malignant glioma 36%, ST PNET 30%
 * Conclusion: Well tolerated and efficacious. Based on this, HIT 91 developed

 * CCG 921 (1986-1992)
 * Randomized. 427 children <21 years, with medulloblastoma, pineoblastoma, ependymoblastoma, central neuroblastoma, PNET, or malignant ependymoma, with unfavorable features. For ST-PNET required M+ staging. Children age >1.5 years (n=328) received post-op CSI with Arm A) vincristine, lomustine, prednisone vs. Arm B) 8-in-1 (cisplatin, procarbazine, lomustine, vincristine, cyclophosphamide, methylprednisolone, hydroxyurea, cytarabine). RT: age >3 received CSI 36 Gy, boost to 50.4-54 Gy spine mets and 54 Gy primary brain site; age <3 received CSI 23.4 Gy with boost to 45 Gy. Children age <1.5 years (n=99) were not randomized and received only Arm B
 * Infants failures; 2005 PMID 16007595 -- "Patterns of treatment failure in infants with primitive neuroectodermal tumors who were treated on CCG-921: a phase III combined modality study." (Hong TS, Pediatr Blood Cancer. 2005 Oct 15;45(5):676-82.)
 * Infant (<1.5 years) subset of 65 patients (19 supratentorial, 46 posterior fossa.)
 * Outcome: 5-year relapse rate M0 64% vs. M+ 71%. ST-PNET subset M0 64% vs. M+ 100%. Relapses within 2 years
 * Conclusion: despite aggresive chemo, infents have high rates of treatment failure
 * Older kids failures; 2004 PMID 15337557 -- "Patterns of failure in supratentorial primitive neuroectodermal tumors treated in Children's Cancer Group Study 921, a phase III combined modality study." (Hong TS, Int J Radiat Oncol Biol Phys. 2004 Sep 1;60(1):204-13.)
 * ST-PNET subset of 44 patients, age >1.5 years. Compared to medulloblastoma treated on same protocol
 * Outcome: 3-year PFS M0 53% vs. M+ 14% (SS); 5-year relapse rate 47% vs. 71%. Worse relapse rate compared to medulloblastoma: M0 47% vs. 29%, M+ 71% vs. 48%
 * Pattern of failure: M0 11% in spine; M+ 43% in spine
 * Time-course: 80% within 2 years
 * Conclusion: High rate of failure, M+ patients doing particularly poorly
 * 3-years; 1995 PMID 7602359 -- "Prognostic factors and treatment results for supratentorial primitive neuroectodermal tumors in children using radiation and chemotherapy: a Childrens Cancer Group randomized trial." (Cohen BH, J Clin Oncol. 1995 Jul;13(7):1687-96.)
 * ST-PNET subset of 55 patients, age >1.5 years.
 * Outcome: 3-year OS 57%, PFS 45%; pineal PNET better at 73% and 61% (SS); stage M0 PFS 50% vs. M+ 0%. No difference between chemo arms
 * Toxicity: 8-in-1 arm worse
 * Conclusion: No difference between chemo arms; M0 and pineal site better outcome
 * Infants; 1994 PMID 8040673 — "Survival of infants with primitive neuroectodermal tumors or malignant ependymomas of the CNS treated with eight drugs in 1 day: a report from the Childrens Cancer Group." (Geyer JR et al. J Clin Oncol. 1994 Aug;12(8):1607-15.)
 * Infant (<1.5 year) subset of 82 children (46 posterior fossa, 15 ependymoma, 11 nonpineal ST-PNET, 8 pineoblastoma, 2 ATRT. Received Arm B only (8-in-1), RT omitted in most cases
 * 3-year PFS: ST PNET 55% vs. medullo 22% vs. ependymoma 22% vs. pineoblastoma 0%. Median time-to-progression 6 months
 * Conclusion: OS is poor, a subset remained disease-free with chemo only
 * Comment: Results inferior compared to Baby POG, probably due to less intensive chemo, but ~20% long-term survivors with chemo only

 * Baby POG I (1986-90)
 * Prospective. 198 children < 3 yrs (132 < 2 yrs, 66 age 2-3 yrs), bx proven malignant brain tumors (low-grade astro excluded), treated with maximal surgery, postop chemo (CTX/VCR followed by cis/etopo) for 2 yrs (if age < 2 at dx) or 1 yr (age 2-3) or until disease progression, followed by RT.
 * Histologies: medulloblastoma 31%, ependymoma 24%, PNET 18%, malignant glioma 9%, brain-stem glioma 7%, other 9%. 27% M+. GTR in 38% of cases.
 * RT for medullo, PNETs, anaplastic ependymoma, or subarachnoid seeding CSI 35.2 Gy + boost to primary to 54 Gy. RT for ependymoma, gliomas local to 54 Gy. If no residual disease after chemo, reduced RT to CSI 24 Gy and primary site 50 Gy. Infants <2 years 90% of dose
 * 1993 PMID 8388548 -- "Postoperative chemotherapy and delayed radiation in children less than three years of age with malignant brain tumors." (Duffner et al., N Engl J Med.  1993; 328(24):1725-31)
 * Response rate: best in medulloblastoma, glioma, ependymoma. Poor/no response in brain-stem gliomas and embryonal tumors
 * CR to chemo PFS comparable those with GTR PFS
 * Conclusion: Chemo effective in infancy. If GTF, chemo alone provided excellent control. No clinically important neurotoxicity. However, cannot recommend for embryonal tumors
 * 10-years, 1999 PMID 11554387 — "The treatment of malignant brain tumors in infants and very young children: an update of the Pediatric Oncology Group experience." (Duffner PK et al. Neuro-oncol. 1999 Apr;1(2):152-61.)
 * ST PNET (17 children): 5-year OS 27%. Failures early
 * 3-year survival: GTR 100% vs. STR 11%
 * Conclusion: Some children may have prolonged survival

title: Radiation Oncology/Peds/CNS PNET


text:
French/Cover

version 2024–July–29 of French Language By WikiBooks

The current, editable version of this book is available online in the open-content textbooks collection, at

Permission is granted to copy, distribute and/or modify this document under the terms of the GNU Free Documentation License, Version 1.2 or any later version published by the Free Software Foundation; with no Invariant Sections, no Front-Cover Texts, and no Back-Cover Texts. A copy of the license is included in the section entitled "GNU Free Documentation License."

= Attributions and Licenses = This wikibook was written by several Wikibooks contributors.

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title: French/Cover


text:
Radiation Oncology/CNS/Ependymoma

Epidemiology

 * 5-10% of pediatric brain tumors
 * Primarily in infants and children <5 years
 * Approximately 200 pediatric cases per year in USA

Location

 * Glial tumors that arise from ependymal lining of the ventricular system
 * May occur anywhere in the ventricular system or spinal canal
 * 90% are in the brain
 * 1/3 supratentorial
 * 2/3 infratentorial, many arising from the 4th ventricle
 * Up to 50% may infiltrate into the brainstem
 * 10% in the spine
 * Myxopapillary ependymomas are found almost exclusively in the conus and filum terminale and are the most common spinal tumors in this location.
 * Location differs with age:
 * In young children: 90% intracranial, typically roof of 4th ventricle
 * In adolescents/adults: 75% spinal canal

Patterns of spread

 * Spread is primarily local
 * In 50% of pts with posterior fossa tumors, a "tongue" of tumor may extend through the foramen magnum well into the cervical region
 * Risk of leptomeningeal seeding is 5-10%

Presentation

 * Since majority occur in 4th ventricle, symptoms are related to obstruction and subsequently increased intracranial pressure
 * In spinal ependymomas, presentation is typically with sensory deficits (compared with astrocytomas, which tend to present with pain and motor symptoms)

Workup

 * MRI of brain and spine: typically well-circumscribed, with displacement rather than invasion of brain parenchyma
 * CSF cytology

Pathology

 * Myxopapillary ependymoma (WHO grade I)
 * Subependymoma (WHO grade I)
 * Ependymoma (WHO grade II)
 * Cellular
 * Papillary
 * Clear cell
 * Tanycytic
 * Anaplastic ependymoma (WHO grade III)

Treatment Overview

 * No randomized studies
 * Surgery is primary management
 * Adjuvant RT is considered standard of care, although highly selected series report good outcomes with surgery alone
 * Because recurrences tend to be local, RT is typically GTV plus 1-1.5 cm margin (per Perez, 4th edition)
 * 5-year OS 50-65%, PFS 25-45%
 * Recurrences typically local; median time to failure 1-2 years. About 20% isolated distant recurrences

Surgery

 * Extent of surgery most important predictor of outcome
 * 5-year OS with GTR: 70-80%
 * 5-year OS with STR: 25-45%
 * Gross total resection (GTR) achievable depending on location, overall 30-50%:
 * Supratentorial lesions: GTR ~80%
 * Infratentorial lesions: GTR "lower" rate (per Perez, 4th edition), BNI rate 70%
 * Spinal lesions: GTR close to 100%

 * Barrow Neurological Institute; 2005 (1983-2002) PMID 15871504 -- "Is gross-total resection sufficient treatment for posterior fossa ependymomas?" (Rogers L, J Neurosurg. 2005 Apr;102(4):629-36.)
 * Retrospective. Posterior fossas ependymomas, no subependymomas or CNS dissemination. GTR in 71%. RT in 13/32 GTR and 12/13 STR. RT fields CSI + boost (n=6), rest posterior fossa or localized fields. Median F/U 5.5 years
 * Local control: Median LC: GTR alone 6.6 years vs. GTR+RT not yet reached; 10-year LC: GTR alone 50% vs. GTR+RT 100% (SS) vs. STR+RT 36% (SS), GTR alone comparable to STR+RT
 * 10-year OS: GTR alone 67% vs. GTR+RT 83% vs. STR+RT 43% (all NS)
 * Conclusion: Adjuvant RT significantly improves control after GTR

 * BI Medical Center, NYC; 1998 PMID 9755311 -- "Treatment of intracranial ependymoma by surgery alone." (Hukin J, Pediatr Neurosurg. 1998 Jul;29(1):40-5.)
 * Prospective. 10 patients. Children >3 years, s/p GTR
 * Outcome: 7 free of disease, 3 recurred (2 salvaged with surgery and RT). No deaths. Overall median PFS 4 years, and OS 4.2 years
 * Conclusion: Deferral of RT after GTR of supratentorial ependymoma safe; recurrence salvageable

Radiation
Role of post-operative RT:
 * Historically, ependymoma was believed to disseminate throughout the neuraxis, and CSI became the standard management approach
 * However, more recent retrospective studies have shown that failure is primarily local in >90%
 * Benefit for post-operative RT is based on retrospective studies. 5-yr EFS 45% vs 0% and 51-70% vs 13% PFS.

Dose response: Evidence of a dose response above 45-50 Gy.

RT volume: No evidence of need for extended-field or craniospinal radiation. CTV margin around resection cavity is generally 1 cm.

Hyperfractionation: In one study (POG 9132), HF RT produced better event-free survival for pts with incomplete resection. Dose was 69.6 Gy at 1.2 Gy BID.

Subependymoma

 * Uncommon variant of ependymal tumors
 * Histologically clusters of ependymal cells in an astrocyte-based matrix
 * Clinically slow growing, with extremely low Ki-67
 * Many discovered incidentally at autopsy
 * Clinically symptomatic tumors present with CSF obstruction
 * Gross total resection alone frequently leads to cure, but perioperative mortality can be high
 * Role of adjuvant RT is not clear

Anaplastic Ependymoma

 * HIT-SKK87 and HIT-SKK92 (1987-1992, 1992-1997)
 * HIT-SKK87: Low-risk (complete resection, M0) and age <2.5 received maintenance chemo only until RT at 3 years or progression. High-risk (subtotal resction, M+) and age 2.5-3 induction chemo / maintence chemo until RT at 3 years or progression
 * HIT-SKK92: Post-op chemo x3 cycles first, then if CR no RT. If PR and <18 months, then more chemo, if PR and >18 months, then RT.
 * RT given as CSI 35.2/22 Gy + 20/10 Gy boost; if no residual disease, reduced to CSI 24 Gy + PF boost to 55 Gy
 * 2005 PMID 16300848 -- "Role of radiotherapy in anaplastic ependymoma in children under age of 3 years: results of the prospective German brain tumor trials HIT-SKK 87 and 92." (Timmermann B, Radiother Oncol. 2005 Dec;77(3):278-85.)
 * Total 34 children enrolled. No RT given in 13 children, preventive RT in 9, salvage RT in 12
 * 3-year outcomes: PFS 27%, OS 56%. Positive predictive factors: higher age, M0, GTR, RT. If no RT, only 3/13 survived
 * Conclusion: Delaying RT jeopardized survival. Predominant failure primary tumor site; RT of neuraxis should be omitted in localized disease

Spine Ependymoma

 * Rare tumors
 * Gross total resection (~50%) leads to long-term control in >90%
 * Subtotal resection can recur in 50-70% without adjuvant therapy; with adjuvant RT local control 60-100%
 * RT dose seems to show a threshold effect, with worse control <45 Gy. However, radiation myelopathy becomes concerning >55 Gy, and with pediatric patients possibly as low as 40 Gy
 * Field size is unclear, but commonly is +/- 2 vertebral bodies. In sacrum, need to cover nerve roots, so inferior edge at S4/S5 and lateral edges to SI joints

 * Kaiser Permanente; 2007 (USA) PMID 17689025 -- "Outcomes in treatment for intradural spinal cord ependymomas." (Volpp PB, Int J Radiat Oncol Biol Phys. 2007 Nov 15;69(4):1199-204. Epub 2007 Aug 6.)
 * Retrospective. 23 patients (17 surgery alone, 5 surgery + RT, surgery + RT + chemo). Mean RT dose 45 Gy
 * Outcome: 9-year OS 64%, LC 96%
 * Recurrences: surgery alone: 12% recurred (1/17 locally, 1/17 distally). CMT 33% recurrence (both out-of-field)
 * Conclusion: En block total resection primary treatment, RT reserved for unfavorable characteristics (residual tumor, anaplastic features, piecemeal resection)

Reviews

 * PMID 15049020, 2004 — "Review of radiotherapy dose and volume for intracranial ependymoma." Taylor RE. Pediatr Blood Cancer. 2004 May;42(5):457-60.

title: Radiation Oncology/CNS/Ependymoma