Ex voto longen
woensdag 30 januari 2013
6 AFFAIRS
The 1st Affair
A married man was having an affair with his secretary.
One day they went to her place and made love all afternoon.
Exhausted, they fell asleep and woke up at 8 PM.
The man hurriedly dressed and told his lover to take his shoes outside and rub them in the grass and dirt.
He put on his shoes and drove home.
'Where have you been?' his wife demanded. 'I can't lie to you,' he replied,
I'm having an affair with my secretary. We had sex all afternoon.'
She looked down at his shoes and said: 'You lying bastard! You've been playing golf!'
The 2nd Affair
A middle-aged couple had two beautiful daughters but always talked about having a son.
They decided to try one last time for the son they always wanted.
The wife got pregnant and delivered a healthy baby boy.
The joyful father rushed to the nursery to see his new son.
He was horrified at the ugliest child he had ever seen.
He told his wife: 'There's no way I can be the father of this baby.
Look at the two beautiful daughters I fathered! Have you been fooling around behind my back?'
The wife smiled sweetly and replied: 'No, not this time!'
The 3rd Affair
A mortician was working late one night.
He examined the body of Mr. Schwartz, about to be cremated, and made a startling discovery. Schwartz had the largest private part he had ever seen!
'I'm sorry Mr. Schwartz,' the mortician commented, 'I can't allow you to be cremated with such an impressive private part. It must be saved for posterity.'
So, he removed it, stuffed it into his briefcase, and took it home.
'I have something to show you won't believe,' he said to his wife, opening his briefcase.
'My God!' the wife exclaimed, 'Schwartz is dead!'
The 4th Affair
A woman was in bed with her lover when she heard her husband opening the front door..
'Hurry,' she said, 'stand in the corner.' She rubbed baby oil all over him, then dusted him with talcum powder. 'Don't move until I tell you,' she said. 'Pretend you're a statue.'
'What's this?' the husband inquired as he entered the room.
'Oh it's a statue,' she replied. 'The Smiths bought one and I liked it so I got one for us, too.'
No more was said, not even when they went to bed..
Around 2 AM the husband got up, went to the kitchen and returned with a sandwich and a beer.
'Here,' he said to the statue, 'have this. I stood like that for two days at the Smiths and nobody offered me a damned thing.'
The 5th Affair
A man walked into a cafe, went to the bar and ordered a beer.
'Certainly, Sir, that'll be one cent.' 'One Cent?' the man exclaimed.
He glanced at the menu and asked: 'How much for a nice juicy steak and a bottle of wine?'
'A nickel,' the barman replied. 'A nickel?' exclaimed the man. 'Where's the guy who owns this place?'
The bartender replied: 'Upstairs, with my wife.'
The man asked: 'What's he doing upstairs with your wife?'
The bartender replied: 'The same thing I'm doing to his business down here.'
The 6th & Best Affair
Jake was dying His wife sat at the bedside.
He looked up and said weakly: 'I have something I must confess.'
'There's no need to, 'his wife replied.
'No,' he insisted, 'I want to die in peace. I slept with your sister, your best friend, her best friend, and your mother!'
'I know,' she replied. 'Now just rest and let the poison work.'
maandag 28 januari 2013
Your Duck is Dead!!
A woman brought a very limp duck into a veterinary surgeon. As she laid her pet on the table, the vet
pulled out his stethoscope and listened to the bird's chest.
After a moment or two, the vet shook his head and sadly said, "I'm sorry, your duck, Cuddles, has
passed away."
The distressed woman wailed, "Are you sure?" "Yes, I am sure. Your duck is dead," replied the
vet..
"How can you be so sure?" she protested. "I mean you haven't done any testing on him or anything.
He might just be in a coma or something."
The vet rolled his eyes, turned around and left the room. He returned a few minutes later with a black
Labrador Retriever. As the duck's owner looked on in amazement, the dog stood on his hind legs, put his
front paws on the examination table and sniffed the duck from top to bottom. He then looked up at the
vet with sad eyes and shook his head.
The vet patted the dog on the head and took it out of the room. A few minutes later he returned with
a cat. The cat jumped on the table and also delicately sniffed the bird from head to foot. The cat sat back
on its haunches, shook its head, meowed softly and strolled out of the room.
The vet looked at the woman and said, "I'm sorry, but as I said, this is most definitely, 100% certifiably,
a dead duck."
The vet turned to his computer terminal, hit a few keys and produced a bill, which he handed to the woman..
The duck's owner, still in shock, took the bill. "$150!" she cried, "$150 just to tell me my duck is dead!"
The vet shrugged, "I'm sorry. If you had just taken my word for it, the bill would have been $20, but with the
Lab Report and the Cat Scan, it's now $150."
pulled out his stethoscope and listened to the bird's chest.
After a moment or two, the vet shook his head and sadly said, "I'm sorry, your duck, Cuddles, has
passed away."
The distressed woman wailed, "Are you sure?" "Yes, I am sure. Your duck is dead," replied the
vet..
"How can you be so sure?" she protested. "I mean you haven't done any testing on him or anything.
He might just be in a coma or something."
The vet rolled his eyes, turned around and left the room. He returned a few minutes later with a black
Labrador Retriever. As the duck's owner looked on in amazement, the dog stood on his hind legs, put his
front paws on the examination table and sniffed the duck from top to bottom. He then looked up at the
vet with sad eyes and shook his head.
The vet patted the dog on the head and took it out of the room. A few minutes later he returned with
a cat. The cat jumped on the table and also delicately sniffed the bird from head to foot. The cat sat back
on its haunches, shook its head, meowed softly and strolled out of the room.
The vet looked at the woman and said, "I'm sorry, but as I said, this is most definitely, 100% certifiably,
a dead duck."
The vet turned to his computer terminal, hit a few keys and produced a bill, which he handed to the woman..
The duck's owner, still in shock, took the bill. "$150!" she cried, "$150 just to tell me my duck is dead!"
The vet shrugged, "I'm sorry. If you had just taken my word for it, the bill would have been $20, but with the
Lab Report and the Cat Scan, it's now $150."
dinsdag 15 januari 2013
Lung cancer screening recommended
The updated guidelines on lung cancer screening released by the American
Cancer Society (ACS) conclude that there is sufficient evidence for screening
with low-dose computed tomography (LDCT) in certain high-risk individuals.
The guidelines were published online January 11 in CA: A Cancer Journal for Clinicians. They are an update of interim guidelines issued in 2010, and are based on a systematic review published last year (JAMA. 2012; 307:2418-2429).
The ACS recommends screening for lung cancer for people 55 to 74 years with a history of smoking (at least a 30-pack-year history), in those who currently smoke, and in those who quit smoking in the previous 15 years.
The LCDT screen is performed annually, and the ACS emphasizes that people should be encouraged to join an organized screening program with expertise in lung cancer and multidisciplinary teams "wherever possible."
"The adoption of lung cancer screening could save many lives," Richard Wender, MD, from Thomas Jefferson University Medical College in Philadelphia, Pennsylvania, and colleagues state in the guidelines, citing evidence from the National Lung Cancer Screening Trial (NLST).
"At this time, there is sufficient evidence to support screening provided that the patient has undergone a thorough discussion of the benefits, limitations, and risks, and can be screened in a setting with experience in lung cancer screening," they add.
The National Comprehensive Cancer Network was the first to recommend annual screening with LCDT for certain populations (in 2011); the American Lung Association followed in 2012.
The American College of Radiology has announced that it is preparing its own set of guidelines to ensure that CT lung cancer screening is performed using "proper personnel, equipment, protocols, and follow-up."
Issues of Concern
Despite the official guidelines and enthusiasm from some medical centers, there has been reticence from some lung cancer experts, who are concerned that many details need to be resolved before national screening programs are implemented.
The ACS acknowledges some of these concerns in its guidelines, and notes that high-quality lung cancer screening in the United States "poses many challenges." Whether or not the benefit from screening observed in the NLST will be seen in community-based screening for lung cancer "could be influenced by many factors, and the answer awaits the results of further observations and research," Dr. Wender and colleagues write.
On the positive side, screening could detect lung cancer at an earlier stage and therefore save lives; on the negative side are limitations and potential harms, including the "relatively high" level of false-positive findings and the resultant anxiety and need for additional invasive tests (such as lung biopsy). In the NSTL, 96.4% of the postive screening results in the LDCT group and 94.5% in the radiography (control) group were false-positive results.
In addition, there is "a legitimate concern" that some smokers will view the chance to undergo screening as an excuse to continue smoking, Dr. Wender and colleagues note. They emphasize that "vigorous smoking cessation efforts must accompany LDCT screening for adults who are current smokers."
Another issue concerns payment. Currently, very few government or private insurance programs provide coverage for the initial LDCT for lung cancer screening.
Advice to Clinicians
The ACS guidelines outline specific recommendations for clinicians.
They advise that clinicians review the smoking history of all patients 55 to 74 years of age to identify those who are in relatively good health but who have a history of smoking (at least 30-pack-year) and currently smoke or have quit smoking in the previous 15 years.
Having identified these individuals, clinicians who have access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening. This should include a discussion about potential benefits and harms, limitations, and for current smokers should include counseling on smoking cessation.
The guidelines emphasize that clinicians should not discuss lung cancer screening with individuals who do not meet the above requirements.
"Wherever possible, individuals who choose to undergo lung screening should enter an organized screening program at an institution with expertise in LCDT screening, with access to a multidisciplinary team skilled in evaluation, diagnosis, and treatment of abnormal lung lesions, " the guidelines advise.
They recommend that "if an organized, experienced screening program is not accessible, but the patient strongly wishes to be screened, they should be referred to a center that performs a reasonably high volume of lung CT scans, diagnostic tests, and lung cancer surgeries."
"If such a setting is not available, and the patient is not willing or able to travel to such a setting, the risks of cancer screening may be substantially higher than the observed risks associated with screening in the NSTL, and screening is not recommended," according to the guidelines.
CA Cancer J Clin. Published online January 10, 2013. Full text
The guidelines were published online January 11 in CA: A Cancer Journal for Clinicians. They are an update of interim guidelines issued in 2010, and are based on a systematic review published last year (JAMA. 2012; 307:2418-2429).
The ACS recommends screening for lung cancer for people 55 to 74 years with a history of smoking (at least a 30-pack-year history), in those who currently smoke, and in those who quit smoking in the previous 15 years.
The LCDT screen is performed annually, and the ACS emphasizes that people should be encouraged to join an organized screening program with expertise in lung cancer and multidisciplinary teams "wherever possible."
"The adoption of lung cancer screening could save many lives," Richard Wender, MD, from Thomas Jefferson University Medical College in Philadelphia, Pennsylvania, and colleagues state in the guidelines, citing evidence from the National Lung Cancer Screening Trial (NLST).
"At this time, there is sufficient evidence to support screening provided that the patient has undergone a thorough discussion of the benefits, limitations, and risks, and can be screened in a setting with experience in lung cancer screening," they add.
The National Comprehensive Cancer Network was the first to recommend annual screening with LCDT for certain populations (in 2011); the American Lung Association followed in 2012.
The American College of Radiology has announced that it is preparing its own set of guidelines to ensure that CT lung cancer screening is performed using "proper personnel, equipment, protocols, and follow-up."
Issues of Concern
Despite the official guidelines and enthusiasm from some medical centers, there has been reticence from some lung cancer experts, who are concerned that many details need to be resolved before national screening programs are implemented.
The ACS acknowledges some of these concerns in its guidelines, and notes that high-quality lung cancer screening in the United States "poses many challenges." Whether or not the benefit from screening observed in the NLST will be seen in community-based screening for lung cancer "could be influenced by many factors, and the answer awaits the results of further observations and research," Dr. Wender and colleagues write.
On the positive side, screening could detect lung cancer at an earlier stage and therefore save lives; on the negative side are limitations and potential harms, including the "relatively high" level of false-positive findings and the resultant anxiety and need for additional invasive tests (such as lung biopsy). In the NSTL, 96.4% of the postive screening results in the LDCT group and 94.5% in the radiography (control) group were false-positive results.
In addition, there is "a legitimate concern" that some smokers will view the chance to undergo screening as an excuse to continue smoking, Dr. Wender and colleagues note. They emphasize that "vigorous smoking cessation efforts must accompany LDCT screening for adults who are current smokers."
Another issue concerns payment. Currently, very few government or private insurance programs provide coverage for the initial LDCT for lung cancer screening.
Advice to Clinicians
The ACS guidelines outline specific recommendations for clinicians.
They advise that clinicians review the smoking history of all patients 55 to 74 years of age to identify those who are in relatively good health but who have a history of smoking (at least 30-pack-year) and currently smoke or have quit smoking in the previous 15 years.
Having identified these individuals, clinicians who have access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening. This should include a discussion about potential benefits and harms, limitations, and for current smokers should include counseling on smoking cessation.
The guidelines emphasize that clinicians should not discuss lung cancer screening with individuals who do not meet the above requirements.
"Wherever possible, individuals who choose to undergo lung screening should enter an organized screening program at an institution with expertise in LCDT screening, with access to a multidisciplinary team skilled in evaluation, diagnosis, and treatment of abnormal lung lesions, " the guidelines advise.
They recommend that "if an organized, experienced screening program is not accessible, but the patient strongly wishes to be screened, they should be referred to a center that performs a reasonably high volume of lung CT scans, diagnostic tests, and lung cancer surgeries."
"If such a setting is not available, and the patient is not willing or able to travel to such a setting, the risks of cancer screening may be substantially higher than the observed risks associated with screening in the NSTL, and screening is not recommended," according to the guidelines.
CA Cancer J Clin. Published online January 10, 2013. Full text
woensdag 9 januari 2013
Xolair, niet alleen voor astma
Xolair: Not Just for Asthma
Introduction
Humanized monoclonal IgG anti-IgE is an effective biologic agent that has been in use for more than a decade to treat atopic asthma. The effect of omalizumab (Xolair®) IgE reduction alone from might explain why it alleviates respiratory allergy, but omalizumab has also been found to be effective for a range of other conditions through its other mechanisms of action.
For example, after just 3 months of treatment, the reduction in functional IgE leads to a more than 95% downregulation of the IgE receptor. [1]This is seen in mast cells, basophils, and dendritic cells, which can explain the attenuation of the IgE-mediated response to allergens. The decreased antigen processing also results in less antigen presentation to Th2 cells -- hence, less cytokine stimulation of eosinophils. The clinical implications of this immunomodulation were highlighted in an excellent article by Sanchez and colleagues, [1] which should be read by clinicians as a classic bench-to-bedside review.
Omalizumab and Chronic Urticaria
Although the most frequent adverse effect of omalizumab administration is urticaria that did not dissuade some from using this drug to treat chronic idiopathic urticaria -- with success. Numerous case reports (as well as this author's experience) [2] support the efficacy of Xolair in chronic idiopathic urticaria. There are, however, no controlled trials to back these findings. Nonetheless, patients with various forms of urticaria, including autoimmune and idiopathic varieties of chronic urticaria as well as physical urticarias (cold, solar, and delayed pressure), have been reported to respond to omalizumab. Many of the studies were case reports, but a study of 12 patients with urticaria found that 7 of them responded within 4 months of treatment with omalizumab. [3] The mechanism of action in these cases is proposed to be the effect of omalizumab on basophil and mast cell survival rather than its effect on IgE, which was low in some cases.
Atopic Dermatitis
At the opposite end of the total serum IgE spectrum are many patients with eczema, whose serum IgE level often exceeds 1000 kU/L -- greater than the threshold for Xolair dosing. A few cases of response to omalizumab monotherapy have been reported, but the only blinded, placebo-controlled trial was very small and did not yield positive results. [4]
Idiopathic Anaphylaxis and Mastocytosis
IgE and the IgE receptor have been implicated in the pathogenesis of idiopathic anaphylaxis. Successful treatment of idiopathic anaphylaxis with omalizumab has been reported and is now the subject of an National Institutes of Health study. Although the mechanism of anaphylaxis is different than that of idiopathic anaphylaxis, mastocytosis-related anaphylaxis has also responded to Xolair in a few cases.
Omalizumab and Food Allergy
Patients receiving omalizumab for asthma have noted increased tolerance of foods that had previously caused IgE-mediated reactions. Controlled trials with food challenges have yet to be done. Studies of Xolair and eosinophilic gastrointestinal diseases are now under way.
Nonatopic Conditions
Omalizumab has worked as both monotherapy and as rescue therapy in refractory cases of Churg-Strauss syndrome. The impact of anti-IgE on allergic bronchopulmonary aspergillosis is unclear. Although it reduces total and Aspergillus-specific IgE levels, omalizumab has not been shown to improve clinical outcomes. Serum IgE is a marker of allergic bronchopulmonary aspergillosis activity, but if blocking IgE does not help then it would seem to only hinder monitoring of the disease state. Of note, a patient with Menière disease and mastocytosis experienced improvement in both conditions when treated with Xolair.
Conclusion
Over time, additional clinical applications for omalizumab will be identified. For less common conditions, it will be hard to conduct the proper trials to gain US Food and Drug Administration approval. The greatest obstacle may be cost of the drug. Some insurers will pay for Xolair on a case-by-case basis for chronic urticaria. And Genentech's Xolair Access Solutions has also been very supportive of doctors and patients who are unable to obtain coverage for nonasthmatic conditions.
Latest in Allergy & Clinical Immunology
Medscape Allergy & Immunology © 2013 WebMD, LLC
Cite this article: Xolair: Not Just for Asthma. Medscape. Jan 04, 2013.
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