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## Ethics approval and consent to participate
The study was conducted in accordance with the ethical principles of the Declaration of Helsinki (2013). Ethical approval was obtained from Sakhiya Skin Clinic, Surat, Gujarat, India. (Approval No: 2023/06). Consent forms were signed by patient. He was informed that he had the right to withdraw from the study at any time without any consequences. All pictures reported in this case- report study belong to Sakhiya Skin Clinic, Surat- 395003, Gujarat, India.
## Consent for publication
Not applicable
## Competing interest
The authors declare that they have no competing interests.
## Open Access
This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated.
## Author Details
1Department of Dermatology, Sakhiya Skin Clinic, Surat, Gujarat, India. 2Department of Medical Writing, Sakhiya Skin Clinic, Surat, Gujarat, India
## Article Info
Received: 21 April 2023 Accepted: 03 June 2023 Published: 07 June 2023
## References
1. Grando SA. Pemphigus autoimmunity: hypotheses and realities. Autoimmunity. 2012 Feb;45(1):7-35. doi 10.3109/08916934.2011.606444.
2. Lever WF, Schaumburg-Lever G. Immunosuppressants and prednisone in pemphigus vulgaris: therapeutic results obtained in 63 patients between 1961 and 1975. Arch Dermatol. 1977 Sep;113(9):1236-41. doi: 10.1001/archderm.1977.01640090084013.
3. Pasricha JS, Gupta R. Pulse therapy with dexamethasonecyclophosphamide in pemphigus. Indian J Dermatol Venereol Leprol. 1984; 50:199-203.
4. Bystryn JC, Steinman NM. The adjuvant therapy of pemphigus. An update. Arch Dermatol. 1996 Sep;132(2):203-12.
5. Heizmann M, Itin P, Wernli M, Borradori L, Bargetzi MJ. Successful treatment of paraneoplastic pemphigus in follicular NHL with rituximab: report of a case and review of treatment for paraneoplastic pemphigus in NHL and CLL. Am J Hematol. Feb 2001;66(2):142-4. doi: 10.1002/1096-8652(200102)66:2<142::AID-AJH1032>3.0.CO;2-0.
6. Food and Drug Administration. Rituxan label; 2012 [cited Feb 2, 2021]. Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2012 /103705s5373lbl.pdf.
7. Belgi AS, Azeez M, Hoyle C, Williams REA. Response of pemphigus vulgaris to anti-CD20 antibody therapy (rituximab) may be delayed. Clin Exp Dermatol. 2006 Jan;31(1):143. doi: 10.1111/j.1365-2230.2005.01941.x.
8. Schmidt E, Seitz CS, Benoit S, Bröcker EB, Goebeler M. Rituximab in autoimmune bullous diseases: mixed responses and adverse effects. Br J Dermatol. 2007 Feb;156(2):352-6. doi: 10.1111/j.1365-2133.2006.07646.x.
9. Barrera MV, Mendiola MV, Bosch RJ, Herrera E. Prolonged treatment with rituximab in patients with refractory pemphigus vulgaris. J Dermatol Treat. 2007 Jan;18(5):312-4. doi 10.1080/09546630701323988.
10. Faurschou A, Gniadecki R. Two courses of rituximab (anti-CD20 monoclonal antibody) for recalcitrant pemphigus vulgaris. Int J Dermatol. 2008 Mar;47(3):292-4. doi: 10.1111/j.1365-4632.2008.03423.x.
11. Craythorne EE, Mufti G, DuVivier AW. Rituximab used as a first-line single agent in the treatment of pemphigus vulgaris. J Am Acad Dermatol. 2011 Nov;65(5):1064-5. doi: 10.1016/j.jaad.2010.06.033.
12. Horvath B, Huizinga J, Pas HH, Mulder AB, Jonkman MF. Low-dose rituximab is effective in pemphigus. Br J Dermatol. 2012 Feb;166(2):405-12. doi: 10.1111/j.1365-2133.2011.10663.x.
13. Craythorne E, Du Vivier A, Mufti GJ, Warnakulasuriya S. Rituximab for the treatment of corticosteroid—refractory pemphigus vulgaris with oral and skin manifestations. J Oral Pathol Med. 2011 Sep;40(8):616-20. doi: 10.1111/j.1600-0714.2011.01017.x.
14. Kim JH, Kim YH, Kim MR, Kim SC. Clinical efficacy of different doses of rituximab in the treatment of pemphigus: a retrospective study of 27 patients. Br J Dermatol. 2011Sep;165(3):646-51. doi: 10.1111/j.1365-2133.2011.10411.x.
15. Kasperkiewicz M, Shimanovich I, Ludwig RJ, Rose C, Zillikens D, Schmidt E. Rituximab for treatment-refractory pemphigus and pemphigoid: a case series of 17 patients. J Am Acad Dermatol. 2011 Sep;65(3):552-8. doi 10.1016/j.jaad.2010.07.032
16. Investor update. Basel; June 12, 2019. [cited Feb 5, 2021]. Available from: https://www.roche.com/investors/updates/inv-update2019-06-12.htm.
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# APPLICATIONS
For more than a century, Xylem's pump technologies and solutions have satisfied customers all over the world. The e- SH pump continues that tradition, with higher efficiencies and proven performance. Here are just a few of the markets and applications in which we're helping customers solve their water and fluid management challenges.
Water intake- Water transfer and circulation- Pressure boosting- Process cooling and heating- Fluid transfer and transport- Produced water transfer and boosting- Boiler feed booster
## PUMPED FLUIDS
- Groundwater- Potable water- Process water- Gray/used water- Heat transfer fluids- Produced water
## SPECIFICATIONS
<table><tr><td>Maximum flow</td><td>1,140 gpm</td></tr><tr><td>Maximum head</td><td>464 ft. TDH</td></tr><tr><td>Maximum working pressure</td><td>230 psi</td></tr><tr><td>Maximum temperature</td><td>250 °F</td></tr><tr><td>Hydraulic performance</td><td>compliant with ANSI/HI 14.6 Grade 2B</td></tr><tr><td>Suction and discharge flanges</td><td>1" - 4" ANSI class 150 flanges</td></tr><tr><td>Motor</td><td>Standard 60 HZ NEMA premium efficient motors</td></tr></table>

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to tumor necrosis factor alpha (TNF- \(\alpha\) ) inhibitors. Rituximab is off- label and used for various autoimmune disorders including, PV due to potential therapeutic effects in the modulation of pathogenic B cells [5]. We report a case of generalized PV, treated with rituximab.
## Case presentation
A 39- year- old male patient who lives in Surat, Gujarat, was referred with a 3- month history of painful ulcerated lesions in the oral cavity. On enquiring about the patient's history, we came to know that initially, the patient had difficulty chewing food and the severity increased gradually. The ulcerations caused considerable discomfort, affecting his normal oral functions. Subsequently, fluid- filled lesions developed involving the scalp, trunk, limbs, and axilla. Lesions were increasing in size and number and had little tendency to heal. Blisters were flaccid and burst on their own to form erosions within 2- 3 days. Medical and family history was non- contributory. No history of fever, joint pain, malaise, and photosensitivity. He had weak oral hygiene due to the bad habit of taking betel quid with tobacco five times a day and smoking seven bids per day for the past 12 years. Further, he consumes two- quarters of alcohol on an alternative day for the last 12 years. History of any drug intake before the appearance of lesions was also absent. Intraoral examination revealed that approximately \(1.0 \times 1.5\) dimensions ulceration lesions were present on the buccal mucosa. Dermatological examination revealed multiple vesicular lesions ranging from \(0.3 \times 0.3\) to 1.5 \(\times 1.5\) involving the face, trunk, upper limbs, and dorsum of the penis (Figure 1a- i).

<center>Figure 1: Showing (a) ulcerative lesions present on the buccal mucosa (b) multiple vesicular lesions present on the face (c) multiple vesicular lesions with erosion present on the lower neck (d) multiple vesicular lesions present on the umbilicus (e) multiple vesicular lesions with erosion present on the upper limb (f) multiple vesicular lesions with erosion present on the back (g) multiple vesicular lesions with erosion on the axilla (h) flaccid blister lesions on the scalp (i) multiple vesicular lesions present on the dorsum of the penis. </center>
There was a positive Nikolsky sign and a bulla spread sign. The clinical manifestations of oral ulcers, flaccid bullae, and positive Nikolsky sign hinted at the provisional diagnosis of PV. Mucous membrane pemphigoid, bullous lichen planus, paraneoplastic pemphigus, chronic ulcerative stomatitis, recurrent herpes lesions in immunocompromised patients, and erythema multiforme were the potential differential diagnosis of this condition. Regarding this, a biopsy was performed from a new vesicle to confirm the diagnosis. Histopathological examination revealed an intraepidermal suprasabial acantholytic blister. Several acantholytic cells and neutrophils could be seen in the blister. The floor of the blister showed a tombstone pattern with occasional acantholytic cells. A moderately dense superficial perivascular mixed infiltrate was present in the dermis. Mild spongiosis with neutrophils was present at the periphery of the blister (Figure 2).

<center>Figure 2: Photomicrograph showing acantholysis of the keratinocytes, tombstone appearance, epithelium exhibiting spongiosis, and superficial perivascular mixed infiltrate (H & E stain, \(\times 5\) ). </center>
The hematological test had all findings within standard limits and, routine urine examination was unremarkable. In accordance with these findings, the definite diagnosis of PV was made and the treatment with oral cefuroxime (500mg twice a day) and oral prednisolone (20mg twice a day) with azathioprine (50mg twice a day) was started. Topical antibiotics and triamcinolone gel are advised for local application in the oral cavity. The dose of oral prednisolone was gradually tapered to 20mg, 10mg, 5mg, and 2.5mg (twice a day) every 30 days. The patient was maintained on the same dose of azathioprine (50mg twice a day) for one year. With the given therapy, complete remission was not achieved. Also, azathioprine was discontinued due to an elevated level of liver enzymes. Hence, the patient was shifted to rituximab therapy. The patient was initially given three doses of rituximab 1 gm each on days 1, 15, and 45. As premedication, ceftriaxone 1gm intravenously, hydrocortisone 100mg intravenously, paracetamol 650mg stat orally, and pheniramine maleate 2cc stat intravenously were given, sequentially on the day of infusion. After 30 minutes of these premedications rituximab (1gm) intravenously in 500ml of normal saline was given slowly over six to eight hours. The last dosage of rituximab was given after 3 months. A administration of rituximab lead to decrease Dsg 3 antibody levels which in turn resulted in the complete remission of the skin lesions within the next year (Figure 3a- g).
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# MAKE YOUR SYSTEM EVEN MORE EFFICIENT
To build and operate an efficient water system, you need both the right products and experts who know the application. Aquavar® IPC and Hydrovar® controllers have been designed by Xylem's engineers with these things in mind. The Aquavar® IPC or Hydrovar® variable speed controller provide built in pump protection controls and monitoring to help you optimize pump operations and increase energy savings up to 70% (vs. fixed speed) while reducing installation time.

SPECIFICATIONS
<table><tr><td>Indoor enclosures</td><td>IP20 Open, TYPE 1, TYPE 12</td></tr><tr><td>Outdoor enclosures</td><td>TYPE 3R, TYPE 4X</td></tr><tr><td>Input supply</td><td>1.5-600 hp (frame A-D) wall or base mounted</td></tr><tr><td>Ambient<br>temperature</td><td>\(14^{\circ }F-113^{\circ }F(-10^{\circ }C-45^{\circ }C)\) Higher temperatures can be achieved by derating the output amperage of<br>the drive 10% for up to \(122^{\circ }F(50^{\circ }C)\)</td></tr><tr><td>Communication</td><td>Modbus® RTU, Metasys N2, FLN, and BACnet standard<br>Others available with option cards</td></tr><tr><td>Altitudes</td><td>At altitudes from 0 to 1,000 meters<br>(0 to 3,300 ft)<br>Nameplate rated current is available<br>Derate for altitudes above 1,000<br>(3,300 ft) with a maximum operating<br>altitude of 3,000 m (9,900 ft)<br>Consult factory for applications above 3,000 m (9,900 ft)</td></tr><tr><td>Relative humidity</td><td>Lower than 95% without condensation</td></tr><tr><td>Electrical -<br>input power</td><td>3 phase 380 V to 480 V ±10%<br>1 phase 200 V to 240 V ±10%<br>3 phase 200 V to 240 V ±10%<br>3 phase 525 V to 600 V ±10%<br>Frequency 50 or 60 Hz, ±2 Hz</td></tr><tr><td>Electrical -<br>output power</td><td>3 phase from 0 to V supply</td></tr></table>
# AQUAVAR® IPC VARIABLE SPEED CONTROLLER
# FEATURES
·Easier start-up and programming with Start-Up Genie
·Wide range of standard and permanent magnet motors with power up to 600 hp
·Multi-pump configuration for up to four (4) pumps - no need for programmable logic controller (PLC)
·Remote commissioning and monitoring with USB connectivity and software
·Two wire multi-pump connection for faster installation
·Hand on, off, and auto-on buttons available for easy pump operation at the keypad. No toggling between local and remote operation
·System redundancy with multi-master control in case of drive failure
·BACnet and Modbus as a standard for seamless BMS integration
·Submersible and above ground applications
·Wide range of voltage and enclosure options
·True 208 V coverage
·Dedicated single phase input
·Remote commissioning and monitoring with USB connectivity and software
·In-panel or handheld keypad with backlit display
·Alarm Log for last 5 alarms and maintenance events
·EMC/RFI filters and dual DC-link reactors to reduce drive noise emissions and interference
·I/O expansion cards, factory installed or field configured
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# A case report on generalized pemphigus vulgaris treated with rituximaba
J agdish J adavbhai Sakhiya \(^{1\ast}\) , Dhruv J agdish Sakhiya \(^{1}\) , J ashmine Mukeshbhai Gandhi \(^{1}\) , Feral Ravi Daruwala \(^{2}\)
## Abstract
Background: Pemphigus vulgaris has an obscure etiology; the presence of autoantibodies is coherent with an autoimmune disease. Rituximab a monoclonal antibody that specifically targets the CD20 antigen of B lymphocytes, has arisen as a novel treatment approach for pemphigus vulgaris.
Case presentation: A 39- year- old male patient presented with a three- month history of mouth ulcers, poor oral hygiene accompanied with heavy tobacco smoking and alcohol consumption. He was diagnosed with pemphigus vulgaris. The disease gradually progressed to involve other body parts. The patient had shown partial improvement after conventional therapy (oral cefuroxime, oral prednisolone with azathioprine) and was later on successfully treated with rituximab. After 90 days of follow- up, no future recurrence was observed.
Conclusion: With this case, the authors would like to aware other clinicians of the potential use of rituximab in treating pemphigus vulgaris, especially when the conventional therapy fails.
Keywords: Autoantibodies; Pemphigus, Rituximab, Oral Hygiene, Ulceration, Tobacco Smoking, Alcohol consumption, India
## Background
The term pemphigus implies a group of autoimmune, mucocutaneous blistering diseases, in which the keratinocyte antigens are the target of the autoantibodies, prompting acantholysis and the formation of blisters. Main variants of pemphigus include pemphigus vulgaris (PV) and pemphigus foliaceus (PF). PV is the most common subtype and represents well over \(80\%\) of cases. As being a serious and potentially lifethreatening condition, early treatment is of utmost importance [1]. The advent of corticosteroids in the amelioration of pemphigus has dramatically changed the outlook of this perpetually disastrous disease; thus, corticosteroids have become the cornerstone of pemphigus therapy. One case reported favorable outcomes with combined therapy of highdose corticosteroids and other immunosuppressants. However, such a high dose of corticosteroids can cause serious adverse events such as several metabolic problems, global reduction of
immune system efficacy, antecedent risk of serious infections, and mortality [2]. To overcome these long- term events, Pasricha and Gupta introduced dexamethasone cyclophosphamide pulse (DCP) therapy in 1984 [3]. Later on, DCP and oral corticosteroids with or without adjuvant immunosuppressants (azathioprine, cyclophosphamide, mycophenolate mofetil, and cyclosporine) have emerged as the backbone of pemphigus treatment, however, they are associated with the high death rate in pemphigus [4]. With these conventional treatments, some patients fail to improve or some have contraindications for their usage, or some encounter relapse. Hence, advanced research has continuously been going on for finding newer molecules in pemphigus. In 2001, Heizmann et al. [5] first used rituximab for the therapy of autoimmune bullous diseases. He reported a case of paraneoplastic pemphigus favorably managed with rituximab, since then there was a drastic development in the pemphigus treatment era. Rituximab chimeric monoclonal antibody selectively acts on the CD20 expressing B cells, which are known to secrete auto- antibodies targeting the epidermal desmogleins (DSG). It has been used nearly in one million patients for treating lymphoma worldwide. Recently, rituximab has been approved for rheumatoid arthritis that is unresponsive
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thyroid gland by an adequate regimen (e.g., perchlorate 1,000 mg given at least \(30\mathrm{min}\) prior to injection) to prevent possible thyroid uptake of free radioactive iodine.
## Information Pertinent to Performance of the Procedure
- Patient history with particular focus on previous surgery and/or radiation therapy as well as current and past neurological or psychiatric status.- History of diabetes, fasting state.- Information regarding recent morphological imaging studies (CT, MRI).- Current medication and when last taken, especially psychotropic pharmaceuticals. These may influence regional metabolic rate of glucose (rCMRGI).- Patient's ability to lie still for \(20 - 40\mathrm{min}\) for PET to \(\sim 1\mathrm{h}\) for SPECT.
## Precautions and Conscious Sedation
- Continuous supervision of the patients during the whole scanning procedure is necessary. This is especially important for patients with tumor associated seizures.- In uncooperative patients, it may be worthwhile to apply conscious sedation (e.g., by a short acting benzodiazepine such as i.v., midazolam). For FDG, administration should take place at least \(20\mathrm{min}\) after tracer injection, preferably starting only a few minutes before data acquisition.- Appropriate monitoring (pulse-oxymetry) should be performed to recognize the possibility of cardiopulmonary depression and appropriate antidote/emergency backup should be foreseen. Doses of sedation should be reduced in elderly patients.
## Radiopharmaceutical
## Radiopharmaceutical
- \([^{18}\mathrm{F}]\mathrm{Fluoro-2-deoxyglucose}\) (FDG).
- \(3 - [^{123}\mathrm{I}]\mathrm{Iodo - \alpha - methyl - L - tyrosine}\) (IMT).
- [Methyl- \(^{11}\mathrm{C}]\) L-methionine (MET).
- \(O - (2 - [^{18}\mathrm{F}]\mathrm{Fluoroethyl}) - \mathrm{L}\) -tyrosine (FET).
## Recommended Dosage
The dose recommendations for FDG, MET, and FET mentioned here are valid for full ring dedicated PET- cameras with BGO- crystals in 3D- mode.
- FDG: in adults, \(125 - 250\mathrm{MBq}\) (typically \(150\mathrm{MBq}\) ) in 3D-mode. In children, \(2 - 4\mathrm{MBq / kg}\) in 3D-mode with a minimum of \(10\mathrm{MBq}\) in newborn infants.
- IMT: \(100 - 400\mathrm{MBq}\) (typically \(185\mathrm{MBq}\) ).
- MET: \(200 - 250\mathrm{MBq}\) .
- FET: \(200 - 250\mathrm{MBq}\) .
The administered dose may increase using 2D- mode and vary for other systems according to differences in sensitivity. For the radiolabeled amino acids, the activity to be administered to children should be a fraction of the adult activity calculated from body weight according to the factors given by the EANM Pediatric Task Group.
## Radiation Dosimetry (Table 2.1)
## Radiation Dosimetry of Brain Transmission Scans
Based on transmission scans of \(10\mathrm{min}\) and CT- based scans of \(5 - 10\mathrm{s}\) , the effective doses per scan are: \(20 - 30\mu \mathrm{Sv}\) for Germanium- based transmission, \(\sim 20\mu \mathrm{Sv}\) for low- dose high- speed CT, and between \(220\) and \(450\mu \mathrm{Sv}\) for high- quality CT.
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# LOAD INDUCED CHANGES IN COLLAGEN FIBRE ARCHITECTURE IN ARTERIES CHARACTERISED BY SMALL ANGLE LIGHT SCATTERING
Gaul, R.1,2, Lally, C.1,2 1Trinity Centre for Bioengineering, Trinity College Dublin, Dublin, Ireland. 2School of Engineering, Trinity College Dublin, Dublin, Ireland. email: rgau@tcd.ie
## INTRODUCTION
The structural strength of arteries is governed by reinforcing collagen fibres present in the vessel wall. Although healthy vessels are capable of fibre remodelling, unhealthy fibre remodelling patterns may be associated with disease [1]. A greater understanding of the remodelling of these fibres may provide greater insight into arteries at risk of disease and how arterial repair may be induced.
Small angle light scattering (SALS) is a technique which has previously been used to determine the structure of thin, highly organised tissue structures, such as bovine pericardium and porcine aortic valve tissue [2].
The aim of the present study is to design and develop a fully automated SALS system capable of determining the changes in arterial fibre architecture in response to strain.
## MATERIALS AND METHODS
An in- house SALS system has been developed making use of an unpolarised 5mW HeNe laser \((\lambda = 632.8 \mathrm{nm})\) and two focusing lenses in order to pass light through a tissue sample held in an automated sample positioner. The sample positioner incorporates two stepper motors controlled by LabVIEW to allow movement of the sample in the x and y plane with a resolution of \(5 \mu \mathrm{m}\) . The sample is interrogated sequentially in \(250 \times 250 \mu \mathrm{m}\) regions. The resulting scattered light pattern is recorded by a CMOS camera and analysed through a custom Matlab code to determine predominant collagen fibre directions.
To validate the system, testing was conducted on test plates with known printed configurations. Once validated, SALS testing was carried out on flat porcine carotid artery wall sections fixed at different stretch ratios. Carotid artery samples were fixed and processed using a standard histological tissue sectioning protocol. Validation of the results was achieved through histological staining of the sections.
## RESULTS
Figure 1a displays the collagen fibre directions in an unstretched carotid artery section, as predicted by SALS, overlaid on picrosirius red stained histological images. Figure 1b shows the reorganisation of the constituent collagen fibres under circumferential stretch \((\lambda = 1.25)\) .
Collagen fibre patterns in the artery were also obtained through the thickness of the artery wall using SALS, for both strained and unstrained configurations.

<center>Figure 1 Fibre orientation as determined by SALS overlaid on histological carotid wall images. a) unstretched \((\lambda = 1)\) and b) stretched circumferentially \((\lambda = 1.25)\) . </center>
## DISCUSSION
Results shown in Figure 1 highlight the dependence of fibre orientation on the levels of stretch experienced by the artery wall. A clear realignment of collagen fibres in the direction of loading is visible from Figure 1a and 1b. Although these results are widely known and shown in literature, this is the first time they have been resolved through SALS.
Although SALS is limited to thin samples, time consuming staining protocols are not required for fibre characterisation. The speed, accuracy and ease of use of this system make it a powerful system for providing insights into the response of arterial tissue to load.
Future work aims to fully identify load induced tissue changes in healthy and diseased arterial tissue using SALS.
## REFERENCES
[1] Creane et al., Biomech Model Mechanobiol., 10: 831- 843, 2011[2] Billiar, K., and Sacks, M., J. Biomech. 30: 753- 7 56, 1997
## ACKNOWLEDGEMENTS
This research was part funded by Science Foundation Ireland (SFI/13/ERC/B2775) and the Irish Research Council (GOIPG/2014/515).
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http://www.springer.com/978- 90- 481- 8664- 8
Methods of Cancer Diagnosis, Therapy, and PrognosisBrain CancerHayat, M.A. (Ed.)2011, XLVI, 394 p., HardcoverISBN: 978- 90- 481- 8664- 8
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The parametric equations for a projectile with constant gravity g:
\[x = \nu_{0}t\cos \theta +x_{0}\]
\[y = -\frac{1}{2} gt^{2} + \nu_{0}t\sin \theta +y_{0}\]
ex. A shell is fired from ground level with an initial speed of 768 ft/sec. at an angle of \(30^{\circ}\) . Find:
1. \(\vec{r} (t)\)
2. the maximum altitude attained
3. the range of the shell
4. the speed on impact
5. the horizontal distance when \(y = 2240\) ft.
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purpose of attenuation correction. The scanning parameters may vary according to the type of CT scanner. Usually the tube voltage is set at \(140\mathrm{kV}\) , which permits the conversion of the Hounsfield units into attenuation coefficients at \(511\mathrm{keV}\) . The CT scan can be performed after the injection of FDG and has the advantage to significantly reduce the total scan time (usual duration is \(< 10\mathrm{s}\) ). However, the dose of the CT scan to the patient can be reduced by lowering the tube current (see radiation dosimetry above) if anatomical information is not needed. When performing PET- CT of the brain it is recommended to check for movements between the CT and the PET sessions, which might produce artefacts in the attenuation correction.
- Emission scan. As semiquantitative estimates of tumor-to-background uptake ratios are typically used, it is recommended to use a standardized acquisition protocol with a fixed time for start of acquisition to make the data of different patients or repeated scans comparable. If data are acquired in 3-D mode, appropriate scatter correction is mandatory. The duration of emission image acquisition should be related to the minimum required number of counts. For FDG, typically data are acquired over 15-30 min aiming to collect 50-200 million counts. Even though shorter acquisition times can still be used for diagnostic pattern evaluation (Chen et al. 2005), a minimum of 15 min in 3D mode is advocated. For MET and FET typically data are acquired for 20 min (20-40 min p.i.), often supplemented by dynamic data starting directly with tracer injection.
## IMT Single Photon Emission Tomography
- Multiple detectors (triple or dual head) or other dedicated SPECT cameras for brain imaging should be used for acquisition. Single detector units cannot generally be recommended. They may only be used if scan time is prolonged appropriately, a dose in the upper suggested range is applied, and meticulous care is taken to produce high-quality images.
- LEHR or LEUHR parallel-hole collimators are the mostly available collimator sets for brain imaging. All purpose collimators are not suitable. The use of medium energy collimators could be advantageous; however, usually they are hampered by a low sensitivity. They may only be used if acceptable count rates are obtained. If available, collimator sets specifically adapted to the characteristics of \(^{123}\mathrm{I}\) may be used. Fanbeam collimators may be generally preferred over parallel-hole collimators due to the advantageous trade-off between resolution and count rate capability. The acquisition parameters are summarized in Table 2.2.
TABLE 2.2. Acquisition parameters for IMT-SPECT
<table><tr><td>- Rotational radius: smallest possible with appropriate patient safeguard</td></tr><tr><td>- Matrix: 128 × 128</td></tr><tr><td>- Angular sampling: ≤3° (360° rotation)</td></tr><tr><td>- Zoom: acquisition pixel size should be 1/3–1/2 of the expected resolution; therefore it may be necessary to use a hardware zoom to achieve an appropriate pixel size</td></tr><tr><td>- Acquisition mode: Step and shoot mode is predominantly used. Continuous mode acquisition may provide shorter total scan time, reduce mechanical wear to the system and improve patient comfort</td></tr><tr><td>- Total scan time: depending on the imaging device, typical scan time for a triple head camera is about 30–50 min (e.g., 120 projections; 40 projections per head; 60 s/projection)</td></tr></table>
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Do: An electron in a TV tube is beamed horizontally at a speed of 5 x \(10^{6}\) m/sec. toward the face of the tube 40 cm away. To determine how far the electron drops before it hits, which equation would be used?
a. \(y = -4.9t^{2}\) b. \(y = -4.9t^{2} - 5x10^{6}t\) c. \(5x10^{6}t = 4\) d. \(5x10^{6}t = 40\)
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# Stanford

# Brett Babin
Postdoctoral Research Fellow, Pathology - Curriculum Vitae available Online
## Bio
## BIO
Brett received his B.S. in Chemical Engineering from the University of Massachusetts Amherst in 2009. There he worked in the lab of Dr. Neil Forbes developing microfluidic devices to study the interactions between bacteria and in vitro tumor models. He earned his Ph.D. in Chemical Engineering from the California Institute of Technology in 2016 where he worked with Dr. Dave Tirrell and Dr. Dianne Newman. His thesis focused on the development and application of a method for time- and cell- selective proteomic analysis in bacteria. He used this approach to study protein synthesis by the opportunistic pathogen Pseudomonas aeruginosa under dormancy and biofilm growth conditions. Brett joined the Bogyo lab at Stanford in the fall of 2016. His current focus is on the roles of serine hydrolases in the physiology of pathogenic bacteria.
## HONORS AND AWARDS
HONORS AND AWARDS- A. P. Giannini Postdoctoral Fellowship, A. P. Giannini Foundation (2018)- Microbiology and Immunology Postdoctoral Fellowship, Stanford School of Medicine (2018)- Dean's Fellowship, Stanford School of Medicine (2017)
## PROFESSIONAL EDUCATION
PROFESSIONAL EDUCATION- Bachelor of Science, University of Massachusetts Amherst (2009)- Doctor of Philosophy, California Institute of Technology (2016)
## STANFORD ADVISORS
STANFORD ADVISORS- Matthew Bogyo, Postdoctoral Faculty Sponsor
## Research & Scholarship
## LAB AFFILIATIONS
Matthew Bogyo, Bogyo Lab (9/1/2016)
## Publications
## PUBLICATIONS
- Activity-based protein profiling in bacteria: Applications for identification of therapeutic targets and characterization of microbial communities. Current opinion in chemical biologyKeller, L. J., Babin, B. M., Lakemeyer, M., Bogyo, M. 2019; 54: 45-53
- Leveraging Peptide Substrate Libraries to Design Inhibitors of Bacterial L on Protease ACS CHEMICAL BIOLOGY
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Babin, B. M., Kasperkiewicz, P., Janiszewski, T., Yoo, E., Drag, M., Bogyo, M. 2019; 14 (11): 2453- 62
- The dormancy-specific regulator, SutA, is intrinsically disordered and modulates transcription initiation in Pseudomonas aeruginosa. Molecular microbiologyBergkessel, M., Babin, B. M., VanderVelde, D., Sweredoski, M. J., Moradian, A., Eggleston-Rangel, R., Hess, S., Tirrell, D. A., Artsimovitch, I., Newman, D. K. 2019
- Covalent Modifiers of Botulinum Neurotoxin Counteract Toxin Persistence ACS CHEMICAL BIOLOGYGarland, M., Babin, B. M., Miyashita, S., Loscher, S., Shen, Y., Dong, M., Bogyo, M. 2019; 14 (1): 76-87
- Selective Proteomic Analysis of Antibiotic-Tolerant Cellular Subpopulations in Pseudomonas aeruginosa Biofilms. mBioBabin, B. M., Atangcho, L., van Eldijk, M. B., Sweredoski, M. J., Moradian, A., Hess, S., Tolker-Nielsen, T., Newman, D. K., Tirrell, D. A. 2017; 8 (5)
- SutA is a bacterial transcription factor expressed during slow growth in Pseudomonas aeruginosa PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA Babin, B. M., Bergkessel, M., Sweredoski, M. J., Moradian, A., Hess, S., Newman, D. K., Tirrell, D. A. 2016; 113 (5): E597-E605
- In situ visualization of newly synthesized proteins in environmental microbes using amino acid tagging and click chemistry ENVIRONMENTAL MICROBIOLOGYHatzenpichler, R., Scheller, S., Tavormina, P. L., Babin, B. M., Tirrell, D. A., Orphan, V. J. 2014; 16 (8): 2568-2590
Hatzenpichler, R., Scheller, S., Tavormina, P. L., Babin, B. M., Tirrell, D. A., Orphan, V. J. 2014; 16 (8): 2568-2590
- State-selective Metabolic Labeling of Cellular Proteins ACS CHEMICAL BIOLOGY
Ngo, J. T., Babin, B. M., Champion, J. A., Schuman, E. M., Tirrell, D. A.
2012; 7 (8): 1326- 1330
- Noninvasive characterization of in situ forming implants using diagnostic ultrasound JOURNAL OF CONTROLLED RELEASE
Solorio, L., Babin, B. M., Patel, R. B., Mach, J., Azar, N., Exner, A. A.
2010; 143 (2): 183- 190
- A multipurpose microfluidic device designed to mimic microenvironmental gradients and develop targeted cancer therapeutics LAB ON A CHIP Walsh, C. L., Babin, B. M., Kasinskas, R. W., Foster, J. A., McGarry, M. J., Forbes, N. S. 2009; 9 (4): 545-554
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Chapter 4. SepINRIA: Multiple sclerosis brain MRI visualization, comparison and analyze Software
Software functionality: SepINRIA has different functionality which can be loaded from a single main window:
- Lesion Segmentation Edition: Manual or semi-automatic segmentation of MS lesions (e.g. a segmentation realized by an expert). Segmentations can be saved and visualized in 2D or 3D. Lesion number and lesion volume can be computed and print.- Automatic Lesion Segmentation: Automatic segmentation of MS lesions from four MRI sequences (Dual Spin Echo T2-PD, T1, T2-FLAIR).- Images or Segmentation Comparison: Quantitative comparisons of two images registered to assess evolution and comparison between a segmentation (e.g. automatic segmentation) and a segmentation of reference (segmentation of an expert): by computation of the difference image or by visualizing them in the same window (side to side or image fusion).- Brain Atrophy Evaluation: Manual and automatic evaluation of the brain atrophy. Linear measurements computation of the brain, lateral ventricle and third ventricle width are available in the manual mode. And evolution of the BPF in function of the exam dates can be perform in the automatic mode.
### 4.2 Structure based on C++
This section describes concisely dependencies of the software and also its structure by providing a simplify UML scheme of the code architecture.
#### 4.2.1 Software dependencies
SepINRIA is based on several C++ libraries (C.f. Figure 4.2). ITK \(^2\) and MIPS \(^3\) contain both image processing tools. The first one can be downloaded on Internet and is especially used for image conversion. Whereas the second one is inner to the Asclepios team (algorithms presented in chapter 3 can be found in this library).

<center>FIGURE 4.1 - Used libraries and framework in SepINRIA </center>
The display is supported by the libraries VTK \(^4\) and vtkINRIA3D \(^5\) (C.f. Figure A.1) while the user graphical interface is based on wxWidgets \(^6\) . Finally, the general framework (structure
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## CPE 495. Cooperative Education Experience. 12 units
CR/NC Term Typically Offered: F,W,SP,SU Prerequisite: Sophomore standing and consent of instructor.
Full- time work experience in business, industry, government, and other areas of student career interest. Positions are paid and usually require relocation and registration in course for two consecutive quarters. A more fully developed formal report and evaluation by work supervisor required. Credit/No Credit grading only. No major credit allowed; total credit limited to 24 units.
## CPE 515. Computer Architecture. 4 units
Term Typically Offered: TBD Prerequisite: CPE 315 and graduate standing, or consent of instructor.
Comparative study and design of multiprocessor, dataflow, RISC, high level language and other new computer architectures. VLSI processor design techniques. 3 seminars, 1 laboratory. Crosslisted as CPE/CSC 515.
## CPE 521. Computer Systems. 4 units
Term Typically Offered: SP Prerequisite: CPE/EE 329 or CPE/EE 336, or equivalent, and graduate standing or consent of instructor.
Organization of modern general purpose, high speed digital computer systems. Design of arithmetic units, control units, memories and memory subsystems. Cost, power and speed trade- offs in the design of such systems. 3 seminars, 1 laboratory. Crosslisted as CPE/EE 521.
## CPE 522. Advanced Real-Time Operating Systems Design. 4 units
Term Typically Offered: W Prerequisite: CPE/EE 439.
Define and implement a microcontroller- based Real- Time Operating System (RTOS). Advanced real- time concepts, kernel structure, task and time management, various intertask communication constructs including semaphores, queues and mailboxes. Scheduler design, memory management and shared resource management in a resource- constrained microcontroller environment. 3 seminars, 1 laboratory. Crosslisted as CPE/EE 522.
## CPE 523. Digital Systems Design. 4 units
Term Typically Offered: F Prerequisite: CPE/EE 329 or CPE/EE 336, and graduate standing.
Full- custom design and analysis of digital circuits using full CMOS, pass- transistor and dynamic circuit topologies. Transistor sizing for minimizing power consumption, delay and other design criteria. 3 seminars, 1 laboratory. Crosslisted as CPE/EE 523.
## CPE 564. Computer Networks: Research Topics. 4 units
Term Typically Offered: TBD Prerequisite: CSC/CPE 464 and graduate standing, or consent of instructor.
Exploration of advanced topics in emerging computer networking technologies; focus on leading edge computer network research topics. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 564.
## CPE 569. Distributed Computing. 4 units
Term Typically Offered: TBD Prerequisite: CSC 141 or CSC 348; and CPE/CSC 357; or graduate standing and consent of instructor.
Principles and practices in distributed computing: interprocess communications, group communications, client- server model, distributed objects, message queue system, distributed services, mobile agents, object space, Internet protocols. Distributed algorithms: consensus protocols, global state protocols. Fault tolerance: classification of faults, replication. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 569.
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# The Arab Family in Kuwait: Size and Structure (1)
Recent studies dealing with family status in the Arab world are few and sometimes contradictory. While some researchers, such as Dr. Madeeha Naser (1972), assume that \(75\%\) of Iraqi families belong to the extended type grouping three generations living under one roof(2), Dr. Sana Khawli's investigation, condensed in Al- Raida (no. 9, vol. II, p. 15), leads her to conclude that the Arab family is evolving into a non- isolated nuclear family.
Some researchers adopt a middle course by recognizing the existence of differences between country and town regarding family type and affirming that the extended family exists in a larger proportion in the country than in town and city. Good, another sociologist, asserts that for economic and other reasons, the extended family has not been the rule in Arab countries. Peterson says that demographic factors have prevented the extensive spread of the extended family in Egypt and that the large family of six members or more formed \(40\%\) of Egyptian families since the beginning of the twentieth century.
A study prepared by Dr. Fahd al- Thaqeb aims to show that even if economic and demographic conditions should favor the spread of the extended family, as is the case in Kuwait, this family type is bound to remain a minority.
This study is based on statistics derived from interviews between 1965 and 1970 with a random sample of Kuwaiti families representing various social levels.
## Family Size
Between 1965 and 1970, the majority of families in Kuwait were made up of six or more members per family. This proportion decreased among university graduates from \(67.4\%\) in 1965 to \(56.9\%\) in 1970. The data reveal that the number of family members tends to decrease in proportion with the cultural, economic and social status of the family. For example, while \(33\%\) of family heads with secondary education have limited the number of their families to five or less, only \(12\%\) of illiterate family heads have adhered to this number.
Large- sized families are characteristic of higher middle and lower middle classes. Small- sized families of 1- 5 members exist at the rate of \(38\%\) in less privileged classes, while \(72\%\) of the lower middle class are made up of eight or more each.
## Family Structure
Three family types have been singled out: the nuclear, the quasi- extended and the extended family. The first
(1) Condensed from Dr. Fahd Al-Thaqeb, "Size and Structure of the Arab and Kuwaiti Family," Journal of Social Sciences, No 12, Year IV, July 1976 (Arabic), pp. 81-91.
(2) Ibid. p. 81.
comprises the parents and children; the third includes two or more families living in the same house, joined by blood ties. The quasi- extended family is a small sized extended family.
In Kuwait, the nuclear family forms \(59.2\%\) , the quasi- extended \(18.4\%\) , and the extended family \(22.4\%\) .
The size of the family is not a sound indicator of its type, though it may have some connection with it. It was found that only \(26\%\) of the nuclear families interviewed were made up of six members each, while \(70\%\) of them had 6- 12 members per unit.
The study has shown that the nuclear family, while it is not the ideal type, is most common among urban, educated, young people and among the middle class. This type is less common in lower and lower middle class. About \(31\%\) of families of the lower class are quasi- extended while in the upper socio- economic group, the quasi- extended type reaches only \(15\%\) .
The proportion of the extended family type is higher among illiterate groups: \(30\%\) for illiterate against \(17\%\) for university people.
## Age of Respondents
The family type differed according to the age of people interviewed. Around \(50\%\) of the young lived in nuclear families. Many of them lived in quasi- nuclear ones and did not break communication with their relatives. The ages of \(65\%\) of nuclear family people ranged between 30 and 39 years, while the highest proportion of the extended family type existed among those who were 50 years of age or above.
## Conclusion
The majority of families forming the random sample of this survey belonged to the nuclear family type. The extended family, though it should be favored by social and demographic conditions in a country like Kuwait, is likely to form a minority.
The data show a steady increase in the average number of family members during the last few years. In 1957 the average was 6.8 per family; in 1965 it rose to 7.3; and in 1970, to 7.6. The rise is due to improved economic and demographic conditions in Kuwait. Also, the proportion of families numbering 6 or more each, rose from \(66.4\%\) in 1965 to \(70.2\%\) in 1970.
The family size is also an indicator of the fertility rate and bears no relation to family structure. It is noteworthy that extended families joining together three generations formed only \(17\%\) of the bulk of extended families. This result coincides with Good's theory that traditional, extended families have been and remain a minority in the Arab world.
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## CPE 422. Network and Web Security. 4 units
Term Typically Offered: W Prerequisite:CPE 464.
Introduction to network and web security, including denial of service, botnets, access control, routing attacks, transport layer attacks, tunneling mechanisms, VPNs, IDS, firewalls, penetration testing, key distribution, browser security, social network security, email security, jamming, and wireless security. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 422.
## CPE 428. Computer Vision. 4 units
Term Typically Offered: W Prerequisite:CPE/CSC 357 or EE 328 or ME 305.
Introduction to the concepts of 2D and 3D computer vision: low- level image processing methods such as filtering and edge detection; feature extraction; segmentation and clustering; stereo vision; appearance- based and model- based algorithms. 3 lectures, 1 laboratory. Crosslisted as CPE/ EE 428.
## CPE 431. Programming Languages II. 4 units
Term Typically Offered: SP Prerequisite: CSC 430.
Language principles and design issues: bindings, conversion, parameter passing, and dynamic semantics. Language implementation: intermediate code representation, memory management, code optimization, and code generation. Functional programming languages. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 431.
## CPE 432. Digital Control Systems. 3 units
Term Typically Offered: F Prerequisite: EE 302 & EE 342. Concurrent: CPE/EE 472. Recommended: Prior background in discrete time systems, for example EE 328, EE 368.
Theory and applications of digital computers in linear control systems. Discrete time methods are used in analysis and design studies. Digital control systems are synthesized. 3 lectures. Crosslisted as CPE/EE 432.
## CPE 439. Introduction to Real-Time Operating Systems. 4 units
Term Typically Offered: F Prerequisite:CPE/EE 329 or CPE/EE 336.
Theory, design and implementation of real- time operating system- based embedded systems. Scheduling algorithms, operating system resources, peripheral device interfacing and embedded system architecture. Resource management issues in a resource- limited (microcontroller- based) environment. 3 lectures, 1 laboratory. Crosslisted as CPE/EE 439.
## CPE 441. Computer-Aided Design of VLSI Devices. 4 units
Term Typically Offered: F Prerequisite: EE 307 and EE 347. Recommended: EE 308 and EE 348, for students interested in analog design.
Design of VLSI circuits using state- of- the- art CAD software. Design issues and algorithms related to design using CAD. Full custom design through automated design and a major multi- week chip design project in lab. 3 lectures, 1 laboratory. Crosslisted as CPE 441/EE 431.
## CPE 450. Capstone II. 3 units
Term Typically Offered: W Prerequisite:CPE 350.
Team- based design, construction and deployment of an embedded system that includes a custom- built computer. Technical management of product development teams. Technical documentation, configuration management, quality assurance, integration and systems testing. Professionalism. 1 lecture, 2 laboratories.
## CPE 453. Introduction to Operating Systems. 4 units
Term Typically Offered: F, W, SP Prerequisite: CSC/CPE 357, and CSC/CPE 225 or CPE/EE 229 or CPE/EE 233.
Introduction to sequential and multiprogramming operating systems; kernel calls, interrupt service mechanisms, scheduling, files and protection mechanisms, conventional machine attributes that apply to operating system implementation, virtual memory management, and I/O control systems. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 453.
## CPE 454. Implementation of Operating Systems. 4 units
Term Typically Offered: TBD Prerequisite: CSC/CPE 453.
Design and implementation of multiprogramming kernels, systems programming methodology, interprocess communications, synchronization, device drivers and network access methods. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 454.
## CPE 458. Current Topics in Computer Systems. 4 units
Term Typically Offered: TBD Prerequisite: CSC/CPE 357.
Selected aspects of design, implementation and analysis of networks, advanced operating and distributed systems. Topics may include process management, virtual memory, process communication, context switching, file system designs, persistent objects, process and data migration, load balancing, security and networks. The Schedule of Classes will list topic selected. Total credit limited to 8 units. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 458.
## CPE 461. Senior Project I. 3 units
Term Typically Offered: F,W,SP,SU Prerequisite:CPE 350.
Selection and completion of an individual or team project in laboratory environment. Project results are presented in a formal report. 3 laboratories.
## CPE 462. Senior Project II. 2 units
Term Typically Offered: F,W,SP,SU Prerequisite:CPE 450.
Selection and completion of an individual or team project in laboratory environment. Project results are presented in a formal report. 2 laboratories.
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univariate logistic regression analysis was performed, applying 24 baseline demographics and disease characteristics. Significant \((p< 0.1)\) variables in univariate were included in multivariate models. Last, multivariate models were selected based on model fit statistics (Akaike information criterion and \(\mathrm{r}^2\) ) and clinical significance. Adjusted OR and \(95\%\) CIs for selected baseline variables were calculated.
## RESULTS
Overall, 334 patients were randomised to treatment and received adalimumab+MTX \((n = 171)\) or MTX alone \((n = 163)\) and 148 \((86.5\%)\) and 128 \((78.5\%)\) patients completed the double- blind portion of the study, respectively (figure 1). Demographics and baseline characteristics were well matched between treatment groups (table 1). The mean RA disease duration was 0.3 years, and the majority of patients had \(\geq 1\) erosion at baseline and high disease activity. The mean MTX dose during the 26- week study was \(6.2\pm 0.8\mathrm{mg / week}\) in the adalimumab+MTX group and \(6.6\pm 0.6\mathrm{mg / week}\) in the MTX alone group \((p< 0.001)\) . After 26 weeks of treatment, \(34.5\%\) (59/171) of adalimumab+MTX patients were receiving MTX 8 mg/week versus \(65.0\%\) (106/163) of MTX alone patients \((p< 0.001)\) .
## Radiographic progression
Treatment with adalimumab+MTX significantly inhibited radiographic progression (figure 2A) at week 26 versus MTX alone (mean change \(\pm \mathrm{SD}\) , \(1.5\pm 6.1\) vs \(2.4\pm 3.2\) , respectively; \(p< 0.001\) ). Results were confirmed by an LE analysis (figure 2A). Changes in radiographic progression during 26 weeks of treatment were also assessed by a cumulative probability plot of \(\Delta \mathrm{mTSS}\) (figure 2B). Fewer adalimumab+MTX patients exhibited radiographic progression \((\Delta \mathrm{mTSS} > 0.5)\) , with \(62.0\%\) (106/171) of patients showing no radiographic progression versus \(35.4\%\) (57/161) of MTX alone patients \((p< 0.001)\) . Furthermore, only \(14.0\%\) (24/171) of adalimumab+MTX patients exhibited clinically relevant radiographic progression \((\Delta \mathrm{mTSS} > 3)\) versus \(37.3\%\) (60/161) of MTX alone patients \((p< 0.001)\) . In addition, a significantly higher percentage of adalimumab+MTX patients did not experience worsening \((\leq 0.5)\) in erosion score (73.7% (126/171)) versus MTX alone patients (42.2% (68/161); \(p< 0.001\) ). In patients who lacked baseline erosive damage, the continued absence of erosions was reported in more adalimumab+MTX patients versus MTX alone patients (9/9 vs 2/6 patients, respectively; \(p = 0.01\) ).
## Clinical response
A significantly higher percentage of adalimumab+MTX patients achieved ACR responses versus MTX alone patients at each assessment (figure 3A- C). Significant differences between treatment groups, observed as early as week 2, were maintained through week 26. At week 26, a significantly larger percentage of adalimumab+MTX patients versus MTX alone patients achieved ACR20, ACR50 and ACR70 (figure 3A- C) and ACR90 (12.9% vs \(5.5\%\) ; \(p = 0.02\) ) responses. Significant differences in favour of adalimumab+MTX were also observed from week 2 to 26 for DAS28- ESR, DAS28- CRP, SDAI and CDAI (see online supplementary figure 1A- D). A larger percentage of adalimumab+MTX patients than MTX alone patients demonstrated good or moderate European League Against Rheumatism responses (figure 3D) and were in states of low disease activity or remission after 26 weeks of treatment (figure 3E). Furthermore, a significantly larger percentage of adalimumab+MTX patients versus MTX alone patients satisfied Boolean remission criteria (19.3% vs \(8.6\%\) , \(p = 0.007\) ). Adalimumab+MTX achieved a 1.8-
Table 1 Demographics and baseline characteristics
<table><tr><td>Parameter*</td><td>Adalimumab+MTX (n=171)</td><td>MTX (n=163)</td></tr><tr><td>Age±SD (year)</td><td>54.0±13.1</td><td>54.0±13.2</td></tr><tr><td>Females (n (%))</td><td>144 (84.2)</td><td>128 (78.5)</td></tr><tr><td>RA duration±SD (year)</td><td>0.3±0.4</td><td>0.3±0.4</td></tr><tr><td>Weight±SD (kg)</td><td>54.4±9.7</td><td>56.1±12.3</td></tr><tr><td>Previous DMARD use (n (%))</td><td>74 (43.3)</td><td>87 (53.4)</td></tr><tr><td>1 DMARD</td><td>57 (33.3)</td><td>69 (42.3)</td></tr><tr><td>2 DMARDs</td><td>17 (9.9)</td><td>18 (11.0)</td></tr><tr><td>Corticosteroid use at baseline (n (%))</td><td>58 (33.9)</td><td>49 (30.1)</td></tr><tr><td>RF positive (n (%))</td><td>146 (85.4)</td><td>136 (83.4)</td></tr><tr><td>Mean titre±SD (IU/ml)</td><td>154.5±202.3</td><td>163.7±362.8</td></tr><tr><td>Anti-CCP positive (n (%))</td><td>145 (84.8)</td><td>136 (83.4)</td></tr><tr><td>Mean titre±SD (IU/ml)</td><td>386.2±694.2</td><td>241.3±367.2</td></tr><tr><td>ESR (mm/h)</td><td>59.9±30.1</td><td>61.8±29.0</td></tr><tr><td>CRP (mg/dl)</td><td>2.9±3.0</td><td>3.1±3.3</td></tr><tr><td>Swollen joint count (n±SD)</td><td></td><td></td></tr><tr><td>0-28</td><td>11.5±4.7</td><td>11.8±5.3</td></tr><tr><td>0-66</td><td>16.5±6.2</td><td>17.3±7.7</td></tr><tr><td>Tender joint count (n±SD)</td><td></td><td></td></tr><tr><td>0-28</td><td>13.2±5.8</td><td>13.2±6.1</td></tr><tr><td>0-68</td><td>20.7±9.4</td><td>21.1±10.2</td></tr><tr><td>mTSS</td><td>13.6±22.3</td><td>13.6±17.4</td></tr><tr><td>Erosion score</td><td>7.5±11.6</td><td>7.3±9.2</td></tr><tr><td>Joint space narrowing score</td><td>6.2±11.4</td><td>6.2±9.4</td></tr><tr><td>DAS28-ESR</td><td>6.6±0.9</td><td>6.6±1.0</td></tr><tr><td>DAS28-CRP</td><td>5.8±1.0</td><td>5.9±1.0</td></tr><tr><td>HAQ-DI score</td><td>1.1±0.7</td><td>1.3±0.8</td></tr><tr><td>SDAI score</td><td>40.7±12.0</td><td>41.4±13.8</td></tr><tr><td>CDAI score</td><td>37.8±10.9</td><td>38.3±12.4</td></tr><tr><td>Physician's global assessment of disease activity±SD (mm)</td><td>65.8±18.4</td><td>66.2±18.8</td></tr><tr><td>Patient's global assessment of disease activity±SD (mm)</td><td>64.1±24.8</td><td>66.4±23.7</td></tr></table>
\\*Data are mean±SD unless otherwise indicated. CCP, cyclic citrullinated peptide; CDAI, clinical disease activity index; CRP, C reactive protein; DAS28-CRP, disease activity score using a 28-joint count and CRP level; DAS28-ESR, disease activity score using a 28-joint count and ESR; DMARD, disease-modifying antirheumatic drug; ESR, erythrocyte sedimentation rate; HAQ-DI, Health Assessment Questionnaire disability index; mTSS, modified total Sharp score; MTX, methotrexate; RA, rheumatoid arthritis; RF, rheumatoid factor; SDAI, simplified disease activity index.
to 2.2- fold increase in the percentage of patients achieving clinical remission, across all definitions of clinical remission evaluated, versus MTX alone.
A significantly larger decrease from baseline in mean HAQ- DI score, indicative of an improvement in physical function, was observed for adalimumab+MTX patients versus MTX alone patients at week 26 \((- 0.6\pm 0.6\) vs \(- 0.4\pm 0.6\) ; \(\mathrm{p< 0.001}\) ). Although the significant difference between the two groups was small (0.2 units), the percentage of patients achieving normal functionality (HAQ- DI score \(< 0.5\) ) after 26 weeks of treatment was also significantly higher with adalimumab+MTX (figure 3F).
## Factors associated with the absence of radiographic progression or with clinical remission
Disease activity or function baseline variables generally were associated with the absence of radiographic progression \((\mathrm{AmTSS}\leq 0.5)\) and with clinical remission (DAS28- ESR \(< 2.6\) ) in both treatment groups (see online supplementary text and online supplementary table 1).
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## CPE 101. Fundamentals of Computer Science. 4 units
CPE 101. Fundamentals of Computer Science. 4 unitsTerm Typically Offered: F, W, SPPrerequisite: Completion of ELM requirement, and passing score on MAPE or MATH 117 with a grade of C- or better or MATH 118 with a grade of C- or better, or consent of instructor.
Basic principles of algorithmic problem solving and programming using methods of top- down design, stepwise refinement and procedural abstraction. Basic control structures, data types, and input/output. Introduction to the software development process: design, implementation, testing and documentation. The syntax and semantics of a modern programming language. Credit not available for students who have taken CSC/CPE 108. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 101.
## CPE 105. Fundamentals of Computer Science I Supplemental Instruction. 1 unit
CR/NC Term Typically Offered: TBD Concurrent: CPE/CSC 101.
Facilitated study and discussion of fundamental concepts of computer science and familiarization with programming environments. Credit/No Credit grading only. 1 laboratory. Crosslisted as CPE/CSC 105.
## CPE 108. Accelerated Introduction to Computer Science. 4 units
CPE 108. Accelerated Introduction to Computer Science. 4 unitsTerm Typically Offered: TBDPrerequisite: MATH 118 (or equivalent) with a grade of C- or better, significant experience in computer programming, and consent of instructor.
Accelerated introduction to basic principles of algorithmic and objectoriented problem solving and programming. Introduction to programming language concepts including control structures, data types, classes, and inheritance. Program design principles. Use and implementation of algorithms (searching, sorting, recursion) and data structures (lists, stacks, and queues). Intended for students with experience in algorithmic problem solving and using basic control structures and data types in a modern programming language (CPE/CSC 101), but who are not ready for CPE/CSC 202. Not open to students with credit in CPE/CSC 102 or CPE/CSC 202. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 108.
## CPE 123. Introduction to Computing. 4 units
Term Typically Offered: FPrerequisite: Basic computer literacy.
Use of a supportive software development environment to design, develop, and test applications in a selected topic domain that demonstrates the potential of careers in computing. An introduction to computing and to the selected topic domain. The Schedule of Classes will list topic selected. No programming experience required. Not for students with credit in CPE/CSC 103 or CPE/CSC 203. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 123.
## CPE 133. Digital Design. 4 units
CPE 133. Digital Design. 4 unitsTerm Typically Offered: F, W, SP, SUPrerequisite: An orientation course in student's major (EE 111 & EE 151 for EE students, CPE 100 for CPE students), CPE/CSC 101.
Number systems, Boolean algebra, Boolean functions, and function minimization. Analysis and design of combinational and sequential logic circuits. Hardware Description Language (HDL) concepts and applications digital design and synthesis in Programmable Logic Devices (PLDs). Not open to students with credit in CPE/EE 129. Course may be offered in classroom- based or online format. 3 lectures, 1 laboratory. Crosslisted as CPE/EE 133.
## CPE 200. Special Problems for Undergraduates. 1-2 units
CPE 200. Special Problems for Undergraduates. 1- 2 unitsTerm Typically Offered: F, W, SP, SUpPrerequisite: Consent of instructor.
Individual investigation, research, studies, or surveys of selected problems. Total credit limited to 4 units, with a maximum of 2 units per quarter.
## CPE 202. Data Structures. 4 units
CPE 202. Data Structures. 4 unitsTerm Typically Offered: F, W, SPPrerequisite: CPE/CSC 101 with a grade of C- or better; MATH 141 or MATH 221 with a grade of C- or better; or consent of instructor.
Introduction to data structures and analysis of algorithms. Abstract datatypes. Specification and implementation of advanced data structures. Theoretical and empirical analysis of recursive and iterative algorithms. Software performance evaluation and testing techniques. Not open to students with credit in CSC/CPE 108. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 202. Formerly CPE/CSC 103.
## CPE 203. Project-Based Object-Oriented Programming and Design. 4 units
CPE 203. Project- Based Object- Oriented Programming and Design. 4 unitsTerm Typically Offered: F, W, SPPrerequisite: CPE/CSC 202 with a grade of C- or better or consent of instructor.
Object- oriented programming and design with applications to project construction. Introduction to class design, interfaces, inheritance, generics, exceptions, streams, and testing. 3 lectures, 1 laboratory. Crosslisted as CPE/CSC 203. Formerly CPE/CSC 102.
## CPE 233. Computer Design and Assembly Language Programming. 4 units
CPE 233. Computer Design and Assembly Language Programming. 4 unitsTerm Typically Offered: F, W, SPPrerequisite: CPE/EE 133.
Design and implementation of digital computer circuits via CAD tools for programmable logic devices (PLDs). Basic computer design with its datapath components and control unit. Introduction to assembly language programming of an off- the- shelf RISC- based microcontroller. Not open to students with credit in CPE/EE 229. 3 lectures, 1 laboratory. Crosslisted as CPE/EE 233.
## CPE 290. Selected Topics. 1-4 units
CPE 290. Selected Topics. 1- 4 unitsTerm Typically Offered: TBDPrerequisite: Open to undergraduate students and consent of instructor.
Directed group study of selected topics. The Schedule of Classes will list title selected. Total credit limited to 8 units. 1 to 4 lectures.
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longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995;38:44- 8. 22 Fries JF, Spitz P, Kraines RG, et al. Measurement of patient outcome in arthritis. Arthritis Rheum 1980;23:137- 45. 23 Smolen JS, Breedveld FC, Schiff MH, et al. A simplified disease activity index for rheumatoid arthritis for use in clinical practice. Rheumatology (Oxford) 2003;42:244- 57. 24 Aletaha D, Nell VPK, Stamm T, et al. Acute phase reactants add little to composite disease activity indices for rheumatoid arthritis: validation of a clinical activity score. Arthritis Res Ther 2005;7:R796- 806. 25 van Gestel AM, Prevoo MLL, van't Hof MA, et al. Development and validation of the European League Against Rheumatism response criteria for rheumatoid arthritis. Comparison with the preliminary American College of Rheumatology and the World
Health Organization/International League Against Rheumatism criteria. Arthritis Rheum 1996;39:34- 40. 26 Wells G, Becker J- C, Teng J, et al. Validation of the 28- joint Disease Activity Score (DAS28) and European League Against Rheumatism response criteria based on C- reactive protein against disease progression in patients with rheumatoid arthritis, and comparison with the DAS28 based on erythrocyte sedimentation rate. Ann Rheum Dis 2009;68:954- 60. 27 Felson DT, Smolen JS, Wells G, et al. American College of Rheumatology/European League Against Rheumatism provisional definition of remission in rheumatoid arthritis for clinical trials. Ann Rheum Dis 2011;70:404- 13. 28 Aletaha D, Smolen J. The Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI): a review of their usefulness and validity in rheumatoid arthritis. Clin Exp Rheumatol 2005;23(5 suppl 39):S100- 8.
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<table><tr><td>Nature<br>Classification</td><td>Case<br>Number</td><td>Date/Time<br>Reported</td><td>Date/Time<br>Occurred</td><td>General<br>Location</td><td>Brief Statement</td><td>Disposition</td><td>Officer</td></tr><tr><td>Agency Assist</td><td>18-013896</td><td>5/9/18;1911</td><td>5/9/18;1911-<br>5/9/18;1951</td><td>Rockbridge<br>County</td><td>Assisted RBSO with<br>vehicle pursuit</td><td>Inactive</td><td>Schriver</td></tr><tr><td>Property Damage</td><td>18-013642</td><td>5/7/18;1030</td><td>5/7/18;1230</td><td>South Institute<br>Hill lot</td><td>Accident with minor<br>vehicle damage<br>reported</td><td>Inactive</td><td>Panebianco</td></tr><tr><td>Larceny</td><td>18-013788</td><td>5/8/18;2330</td><td>12/1/17;0730-<br>12/12/17;2349</td><td>VMI Barracks</td><td>Cadet reported items<br>missing from trunk<br>room</td><td>Active</td><td>Falls</td></tr><tr><td>Warrant Service</td><td>18-014144</td><td>5/11/18;1920</td><td>5/11/18;1920-<br>5/11/18;1920</td><td>BOQ</td><td>Witness subpoena<br>served on officer</td><td>Inactive</td><td>Beagan</td></tr><tr><td>Burglar Alarm</td><td>18-014153</td><td>5/12/18;0525</td><td>5/12/18;0525-<br>5/12/18;0527</td><td>Davidson-<br>Tucker House</td><td>Alarm malfunction</td><td>Inactive</td><td>Beagan</td></tr><tr><td>Traffic Accident</td><td>18-014205</td><td>5/12/18;1734</td><td>5/12/18;1734-<br>5/12/18;1821</td><td>Paulette Hall<br>lot</td><td>Minor accident</td><td>Inactive</td><td>Patterson</td></tr><tr><td>Underage<br>Possession</td><td>18-014251</td><td>5/13/18;0110</td><td>5/13/18;0110-<br>5/11/18;0125</td><td>VMI Barracks</td><td>Underage cadet</td><td>Cleared by<br>arrest</td><td>Beagan</td></tr><tr><td>Vehicle Trespass</td><td>18-014252</td><td>5/13/18;0030</td><td>5/13/18;0030-<br>5/13/18;0130</td><td>VMI Barracks</td><td>Unauthorized use of<br>state vehicle</td><td>Inactive</td><td>Falls</td></tr><tr><td>Property Damage</td><td>18-014279</td><td>5/13/18;1145</td><td>5/13/18;1255</td><td>VMI Barracks</td><td>Padlock assembly<br>damaged</td><td>Inactive</td><td>Panebianco</td></tr><tr><td>Larceny</td><td>18-014485</td><td>5/15/18;0046</td><td>5/14/18;2000-<br>5/15/18;0030</td><td>VMI Barracks</td><td>Cadet reported<br>uniform item missing</td><td>Inactive</td><td>Schriver</td></tr><tr><td>Burglar Alarm</td><td>18-014721</td><td>5/16/18;2049</td><td>5/16/18;2049-<br>5/16/18;2100</td><td>JM Hall</td><td>Alarm malfunction</td><td>Inactive</td><td>Patterson</td></tr><tr><td>Burglar Alarm</td><td>18-014731</td><td>5/16/18;2232</td><td>5/16/18;2232-<br>5/16/18;2250</td><td>JM Hall</td><td>Alarm malfunction</td><td>Inactive</td><td>Patterson</td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td></td><td></td><td></td><td></td><td rowspan="2"></td><td rowspan="2"></td><td rowspan="2"></td><td rowspan="2"></td></tr><tr><td></td><td></td><td></td><td></td></tr></table>
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of anti- TNF- \(\alpha\) and MTX combination therapy in patients with early RA and high disease activity.
## Author affiliations
\(^{1}\) Division of Rheumatology, Department of Internal Medicine, School of Medicine, Keio University, Shinjuku- ku, Tokyo, Japan \(^{2}\) Institute of Rheumatology, Tokyo Women's Medical University, Shinjuku- ku, Tokyo, Japan \(^{3}\) Department of Orthopedic Surgery, Nagoya University Graduate School and School of Medicine, Showa- ku, Nagoya, Japan \(^{4}\) Department of Medicine and Rheumatology, Graduate School of Tokyo Medical and Dental University, Bunkyo- ku, Tokyo, Japan \(^{5}\) Division of Rheumatology and Hematology, Department of Medicine, Sapporo City General Hospital, Chuo- ku, Sapporo, Japan \(^{6}\) Matsubara Mayflower Hospital, Kato- shi, Hyogo, Japan \(^{7}\) Uchida Clinic of Rheumatic Diseases, Sumida- ku, Tokyo, Japan \(^{8}\) Eisai Co, Ltd., Bunkyo- ku, Tokyo, Japan \(^{9}\) Abbott GmbH & Co KG, Ludwigshafen, Germany \(^{10}\) Abbott Laboratories, Abbott Park, Illinois, USA \(^{11}\) The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Yahatanishi- ku, Kitakyushu, Japan
Acknowledgements The authors would like to thank all the patients, investigators and support staff who participated in the study, Soura Santra, PhD, formally of Abbott, who provided statistical support, and Mary Beth C. Moncrief, PhD, of MedThink SciCom, for editorial assistance in the writing of this manuscript; this assistance was funded by Abbott.
Contributors All the authors evaluated the study results, interpreted the data and suggested additional analyses. All authors contributed to the development and critical review of manuscript and approved the final version.
Funding This study was supported by Abbott Japan Co (Tokyo, Japan) and Eisai Co (Tokyo, Japan).
Competing interests TT has received consulting fees, speaking fees, honoraria and/ or research grant support from Abbott Japan Co; Astellas Pharma Inc; Astra- Zeneca K.K.; Bristol- Myers Squibb; Chugai Pharmaceutical Co; Daiichi- Sankyo Co; Eisai Co; Janssen Pharmaceutical K.K.; Mitsubishi Tanabe Pharma Corporation; Pfizer Japan Inc; and Takeda Pharmaceutical Co. HY has received research grants from Abbott Japan Co; Bristol- Myers Squibb; Chugai Pharmaceutical Co; Eisai Co; Janssen Pharmaceutical K.K.; Mitsubishi Tanabe Pharma Corporation; Otsuka Pharmaceutical Co; Pfizer Japan Inc; Takeda Industrial Pharmaceutical Co; and UCB Japan Co, and speakers honoraria/ consulting fees from Abbott Japan Co; Bristol- Myers Squibb; Chugai Pharmaceutical Co; Eisai Co; Janssen Pharmaceutical K.K.; Mitsubishi Tanabe Pharma Corporation; Otsuka Pharmaceutical Co; Pfizer Japan Inc; Takeda Pharmaceutical Co; and UCB Japan Co. NI has received research grants from Astellas Pharmaceutical; Chugai Pharmaceutical Co; Eisai Co; and Mitsubishi Tanabe Pharmaceutical Co. NM has received research grants from Abbott Japan Co; Astellas Pharmaceutical; Banyu Pharmaceutical; Chugai Pharmaceutical Co; Daiichi Sankyo Pharmaceutical Co; Eisai Co; Janssen Pharmaceuticals; Mitsubishi Tanabe Pharma Corporation; Takeda Pharmaceutical Co; and Teijin Limited. MM has received research grants from Abbott Japan Co; Eli Lilly Japan K.K.; GlaxoSmithKline K.K.; Pfizer Japan Inc; Bristol- Myers Squibb; and Otsuka Pharmaceutical Co, and received compensation for work on this manuscript from Abbott Japan Co. TM has received research grants from Chugai Pharmaceutical Co; Bristol- Myers Squibb; Nippon Kayaku Co; Otsuka Pharmaceutical Co; Takeda Pharmaceutical Co; Eli Lilly Japan K.K.; Eli Lilly and Company; Astellas Pharma Inc; Pfizer Japan Inc; AstraZeneca K.K.; and Santen Pharmaceutical Co, and received compensation for work on this manuscript from Abbott Japan Co. SU has received research grants from Abbott Japan Co, and received compensation for work on this manuscript from Abbott Japan Co. HA is an employee of Eisai Co, Tokyo, Japan. HK is an employee of Abbott GmbH and Co KG, Ludwigshafen, Germany, and may hold Abbott stock or options. VA is an employee of Abbott Laboratories, Abbott Park, Illinois, USA, and may hold Abbott stock or options. YT has received consulting fees, speaking fees and/or honoraria from Mitsubishi Tanabe Pharma Corporation; Abbott Japan Co; Eisai Co; Chugai Pharmaceutical Co; Janssen Pharmaceutical K.K.; Santen Pharmaceutical Co; Pfizer Japan Inc; Astellas Pharma Inc; Daiichi- Sankyo Co; GlaxoSmithKline K.K.; Astra- Zeneca; Otsuka Pharmaceutical Co; Actelion Pharmaceuticals Japan; Eli Lilly Japan K.K.; Nippon Kayaku Co; UCB Japan Co; Quintiles Transnational Japan Co; Ono Pharmaceutical Co; and Novartis Pharma K.K. YT has received research grants from Bristol- Myers Squibb; MSD K.K.; Chugai Pharmaceutical Co; Mitsubishi Tanabe Pharma Corporation; Astellas Pharma Inc; Abbott Japan Co; Eisai Co; and Janssen Pharmaceutical K.K.
## Patient consent Obtained.
Ethics approval An institutional review board approved the study at each site.
Provenance and peer review Not commissioned; externally peer reviewed.
Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is properly cited and the use is non- commercial. See: http://creativecommons.org/licenses/by- nc/3.0/
## REFERENCES
1 Filipovic I, Walker D, Forster F, et al. Quantifying the economic burden of productivity loss in rheumatoid arthritis. Rheumatology (Oxford) 2011; 50:1083- 90. 2 Scott DL, Wolfe F, Huizinga TWJ. Rheumatoid arthritis. Lancet 2010;376:1094- 108. 3 Takeuchi T. Revolutionary change in rheumatoid arthritis management with biological therapy. Keio J Med 2011;60:75- 81. 4 Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease- modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008;59:762- 84. 5 Smolen JS, Alethaa D, Bijlsma JW, et al. For the T2T Expert Committee. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 2010;69:631- 7. 6 Breedveld FC, Weisman MH, Kavanaugh AF, et al. For the PREMIER Investigators. The PREMIER study: a multicenter, randomized, double- blind clinical trial of combination therapy with adalimumab plus methotrexate versus methotrexate alone or adalimumab alone in patients with early, aggressive rheumatoid arthritis who had not had previous methotrexate treatment. Arthritis Rheum 2006;54:26- 37. 7 van der Heijde D, Breedveld FC, Kavanaugh A, et al. Disease activity, physical function, and radiographic progression after longterm therapy with adalimumab plus methotrexate: 5- year results of PREMIER. J Rheumatol 2010;37:2237- 46. 8 Weinblatt ME, Keystone EC, Furst DE, et al. Adalimumab, a fully human anti- tumor necrosis factor \(\alpha\) monoclonal antibody, for the treatment of rheumatoid arthritis in patients taking concomitant methotrexate: the ARMadalimumab trial. Arthritis Rheum 2003;48:35- 45. 9 van de Putte LBA, Atkins C, Malaise M, et al. Efficacy and safety of adalimumab as monotherapy in patients with rheumatoid arthritis for whom previous disease modifying antirheumatic drug treatment has failed. Ann Rheum Dis 2004;63:508- 16. 10 Keystone EC, Kavanaugh AF, Sharp JT, et al. Radiographic, clinical, and functional outcomes of treatment with adalimumab (a human anti- tumor necrosis factor monoclonal antibody) in patients with active rheumatoid arthritis receiving concomitant methotrexate therapy: a randomized, placebo- controlled, 52- week trial. Arthritis Rheum 2004;50:1400- 11. 11 Furst DE, Schiff MH, Fleischmann RM, et al. Adalimumab, a fully human anti- tumor necrosis factor- alpha monoclonal antibody, and concomitant standard antirheumatic therapy for the treatment of rheumatoid arthritis: results of STAR (Safety Trial of Adalimumab in Rheumatoid Arthritis). J Rheumatol 2003;30:2563- 71. 12 Kavanaugh A, Fleischmann RM, Emery P, et al. Clinical, functional and radiographic consequences of achieving stable low disease activity and remission with adalimumab plus methotrexate or methotrexate alone in early rheumatoid arthritis: 26- week results from the randomised, controlled OPTIMA study. Ann Rheum Dis 2013;72:64- 71. 13 Takeuchi T, Kameda H. The Japanese experience with biologic therapies for rheumatoid arthritis. Nat Rev Rheumatol 2010;6:644- 52. 14 Miyasaka N, The CHANGE Study Investigators. Clinical investigation in highly disease- affected rheumatoid arthritis patients in Japan with adalimumab applying standard and general evaluation: the CHANGE study. Mod Rheumatol 2008;18:252- 62. 15 Takeuchi T, Tanaka Y, Kaneko Y, et al. Effectiveness and safety of adalimumab in Japanese patients with rheumatoid arthritis: retrospective analyses of data collected during the first year of adalimumab treatment in routine clinical practice (HARMONY study). Mod Rheumatol 2012;22:327- 38. 16 Koike T, Hariagi M, Ishiguro N, et al. Safety and effectiveness of adalimumab in Japanese rheumatoid arthritis patients: postmarketing surveillance report of the first 3,000 patients. Mod Rheumatol 2012;22:498- 508. 17 Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31:315- 24. 18 Felson DT, Anderson JJ, Boers M, et al. American College of Rheumatology. Preliminary definition of improvement in rheumatoid arthritis. Arthritis Rheum 1995;38:727- 35. 19 Felson DT, Anderson JJ, Lange ML, et al. Should improvement in rheumatoid arthritis clinical trials be defined as fifty percent or seventy percent improvement in core set measures, rather than twenty percent? Arthritis Rheum 1998;41:1564- 70. 20 Fransen J, Creemers MCW, van Riel PLCM. Remission in rheumatoid arthritis: agreement of the disease activity score (DAS28) with the ARA preliminary remission criteria. Rheumatology (Oxford) 2004;43:1252- 5. 21 Prevoo ML, van't Hof MA, Kuper HH, et al. Modified disease activity scores that include twenty- eight- joint counts. Development and validation in a prospective
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Extracted from the minutes of the October 13, 2010, meeting of the Committee on Instruction posted on the CoC web page.
## Adding Time Limit for Degree Completion for Students who Stop Out-
S. Shannon recommended that the addition of a time limit, and listing it in the catalog, for students who leave a program and then return back after years to finish their degrees under their original curriculum. There should be a set time limit as to how long the student can count courses toward the original degree. It was determined that 10 years would be a appropriate time limit. This would close off the option to graduate from their original program if more than 10 years have passed... Motion was approved
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# SECTION VII: TRANSPORTATION
Local transportation for the participating teams shall be the responsibility of the participating institutions.
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# Sample Dashboard Report
<table><tr><td>Item</td><td>Accounting (based on June 30, 2015 ASC 715 report)</td><td>Funding (based on July 1, 2015 valuation report)</td></tr><tr><td>Service Cost (cost of benefits earned)</td><td>N/A – plan frozen</td><td>N/A – plan frozen</td></tr><tr><td>Expense/Minimum Required Contribution</td><td>$63,881</td><td>$0</td></tr><tr><td>Projected Benefit Obligation (PBO)</td><td>$15,498,295</td><td>N/A</td></tr><tr><td>Accumulated Benefit Obligation (ABO)/Funding Target Assets</td><td>$15,498,295</td><td>$11,876,067</td></tr><tr><td>Balance Sheet Liability</td><td>$11,888,246</td><td>$12,025,120 (AVA)</td></tr><tr><td>AOCI Balance (offset to retained earnings; represents items not yet reflected in P&amp;L; mainly net losses; amortized over future periods; key items for settlement charges and/or curtailment)</td><td>$7,690,218</td><td>N/A</td></tr><tr><td>Cash into Plan</td><td>$548,000 (cash basis)</td><td>$321,000 (accrual basis)</td></tr><tr><td>Cash out of Plan</td><td>$628,690+$99,236 (expenses)</td><td>$628,690+$99,236 (expenses)</td></tr><tr><td>Liability by Group:</td><td></td><td></td></tr><tr><td>Actives</td><td>$ 4,326,586</td><td>$ 3,046,932</td></tr><tr><td>Retired</td><td>6,791,034</td><td>5,791,017</td></tr><tr><td>Terminated Vested</td><td>4,380,675</td><td>3,038,118</td></tr><tr><td>Total</td><td>$15,498,295</td><td>$11,876,067</td></tr><tr><td>PBGC Premiums</td><td>$95,928</td><td>$95,928</td></tr><tr><td>Demographics:</td><td></td><td></td></tr><tr><td>Actives</td><td>152</td><td>152</td></tr><tr><td>Retired</td><td>168</td><td>168</td></tr><tr><td>Terminated Vested</td><td>152</td><td>152</td></tr><tr><td>Total</td><td>472</td><td>472</td></tr><tr><td>Discount Rate/Effective Rate</td><td>4.30% (BOY)/4.25% (EOY)</td><td>6.28%</td></tr></table>
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## SECTION VI: SCHEDULE OF EVENTS
## Friday
FridayCourse preparation.Course walk- through with NCAA site representative.Course review and practice by participants.Packet pick- up.Mandatory coaches meeting.
## Saturday
SaturdayCourse preparation.Course review and practice by participants.Women's race - race start time to be determined.\*Men's race - race start time to be determined.\*Post- competition recognition ceremony.
\*The men's race will go first in even years, the women's race will go first in odd years. Start times are subject to the approval of the track and field and cross country committee.
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# Spectrum of Pension Risk Management Options

\* As of July 9, 2015, IRS Notice 2015- 49 prohibits sponsors from adopting lump sum windows for participants who currently receive annuity payments.
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# SECTION VIII: VOLUNTEER NEEDS
Approximately 75- 150 volunteers on competition day will be needed for assignments, including course safety, finish chute, concessions, parking, media and merchandise sales.
The prospective host that is bidding on this championship agrees to all terms and conditions as outlined above in this Championship Bid Specifications Agreement. We agree to comply with all the requirements listed in this document and to administer the designated championship in accordance with the policies of the NCAA and the applicable NCAA sports committee. Prospective hosts that agree with all the requirements listed in this document for the designated championship shall signify agreement by selecting "Yes" below.
YES NO NO with Exception
Prospective hosts who do not agree with all requirements in this document shall select either "No" or "No with Exception" and declare any issues and/or exceptions regarding the aforementioned terms. Please note: any proposed revisions to the language in this document must be specified in the bidding portal to be considered.
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"{\"figure_id\": \"sample_00028_fig01\", \"label\": \"image\", \"bounding_box_pixels\": {\"x1\": 146, \"y1\": 71, \"x2\": 1123, \"y2\": 328}, \"description\": null}"
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# Terminated Vested Lump Sums (continued)
## Plan Sponsors Have Many Factors to Consider When Implementing a Lump Sum Program
Plan funded status- Pension expense- Settlement accounting- Administration- Communication challenges- Participant reaction- Paternalism- Mortality tables (known through 2016)- PBGC premium increases
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radiosensitizes only PC- 3M (Fig. 6A) cells, which express low levels of EGFR protein, but not DU- 145 (Fig. 6B), which over- express EGFR (Fig. 6C).

<center>Figure 6. SR48692 radiosensitizes human prostate cancer cells expressing low levels of EGFR (A, PC-3M) but not prostate cancer cells overexpressing EGFR (B, DU-145).(C) Expression of EGFR in normal (RWPE-1) and PC cell lines (LNCaP, C4-2, DU-145, PC-3 and PC-3M). </center>
In summary, our data show that SR48692 selectively sensitizes PC cells to ionizing radiation. Our results also show that NT stimulation (a) activates a novel EGFR/Src/Stat5b signaling pathway and enhances PC cell proliferation and (b) stabilizes the androgen receptor (AR) through EGFR/Src - dependent phosphorylation; both of which can be inhibited by SR48692. Activation of the EGFR, Src and AR pathway(s) has been implicated, not only in the development of androgen- independent disease, but also in tumor metastasis, especially in bones. Future research, planned for the third and final year of this project, will concentrate on animal studies (completing Task 2 and 3), the role(s) of neuroendocrine cell secretions (Task 1c), and will finalize studies on molecular mechanisms of SR48692 radiosensitizing activity (Task 4). In addition, Cetuximab (C- 225/Erbitux, ImClone), a clinically used EGFR inhibitor, will be used to study the role of EGFR in SR- induced radiosensitization. We speculate that inhibitors, such as Cetuximab or Dasatinib (Bristol- Myers- Squibb; a Src family inhibitor), will significantly improve experimental radiotherapy outcome and could establish the basis for future combined treatment therapy in humans.
## KEY RESEARCH ACCOMPLISHMENTS
- We have demonstrated that radiosensitizing activity of SR48692 depends on the expression of NTR1 receptor in prostate cells. This establishes the foundation of cancer-specificity of SR48692 radiosensitizing activity.- We have demonstrated that radiosensitizing activity of SR48692 is not dependent on androgen receptor (AR) expression levels in prostate cells. However, SR48692 blocks neurotensin-induced AR phosphorylation/stabilization. Therefore, blocking NTR1 receptor could provide additional benefits to anti-tumor therapy.- We have demonstrated that the radiosensitizing activity of SR48692 is affected by the EGFR receptor levels in prostate cells.
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## ABSTRACT
Introduzione. Lo studio del sonno, grazie all’introduzione di moderne tecniche di neurofisiopatologia, ha rivelato l’esistenza di disturbi respiratori notturni intimamente associati a maggiore morbilità e mortalità cardiovascolare. Tra di essi spicca per la multifattorialità della genesi e per le strette connessioni con molte patologie cardio e cerebro-vascolari, endocrine e dismetaboliche, la Sindrome delle Apnee Ostruttive del Sonno (OSAS), in cui l’infermiere può esercitare, in ogni fase (diagnostica, terapeutica e di follow-up) le proprie funzioni assistenziali con ampi livelli di autonomia sia a livello relazionale che educativo. Obiettivo. Sviluppare un programma educativo multidisciplinare per soggetti affetti da disturbi respiratori durante il sonno, sulla base dei dati raccolti nella SOC di Pneumologia dell’Ospedale Cardinal Massaia dell’ASL 19 di Asti, riassumendo le indicazioni in un opuscolo-guida per il paziente. Metodi. Analisi descrittiva e inferenziale su una casistica di soggetti afferenti alla SOC di Pneumologia dell’ASL 19 di Asti affetti da OSAS, in terapia con ventilazione non-invasiva (CPAP), nel periodo 2003 - 2006. Analisi dei bisogni di salute secondo i modelli funzionali di salute di Gordon. Risultati. I bisogni della popolazione studiata emersi dall’analisi epidemiologica riguardano l’alimentazione, l’attività fisica, il sonno, la gestione della salute e la percezione di sé. Vengono presentati gli obiettivi terapeutici, utilizzando i modelli concettuali di riferimento, e il metodo educativo, scelto con il metodo PICO. Le indicazioni sono riassunte in un opuscolo informativo per il paziente. Conclusioni. L’autonomia professionale dell’infermiere consente un approccio terapeutico rivolto all’educazione comportamentale del portatore di bisogni di salute con l’obiettivo di ristabilire un equilibrio psico-fisico e favorire l’adattamento sociale secondo modelli funzionali di salute. L’efficacia di questo programma educativo per soggetti affetti da disturbi respiratori nel sonno dovrà essere valutata in successivi studi a lungo termine. PAROLE CHIAVE: Disturbi respiratori sonno-correlati, sindrome delle apnee ostruttive nel sonno, CPAP, nursing, educazione terapeutica.
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# Table of Contents
Introduction 4Body 4Key Research Accomplishments 7Reportable Outcomes 8Conclusion 8
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## ABSTRACT
Introduction: Thanks to the introduction of modern neurophysiopathology techniques, the sleep investigations revealed the existence of nighttime breathing problems associated with cardiovascular morbidity and mortality rates. The Obstructive Sleep Apnoea Syndrome (OSAS) may be linked to pathologies such as cardio and cerebrovascular disorders, endocrine and metabolic disorders due to various factors and genesis. Nursing consists of assisting the patient autonomously during the diagnostic, therapeutic and follow- up phases; supporting and relating with the patient which is all part of the educational programme.
Objective: To develop a multidisciplinary educational programme for all those patients who suffer from sleep apnoea syndrome, based on the data collected in the Pneumology Unit at the Hospital Cardinal Massaia (ASL 19 in Asti), summarizing the indications in an educational pamphlet for the patient.
Methods: Case history and inferential analyses were carried out on patients suffering from OSAS at the Pneumology Unit (ASL 19 in Asti), while in treatment with non- invasive ventilation therapy (CPAP) during 2003- 2006. Analysis was performed based on Gordon's functional health models regarding patients' needs.
Results: The studies have demonstrated that the primary needs of the population are concerned with nutrition, physical activity, sleep patterns, health management and self- perception. Both the therapeutic objectives, based on the functional health models, and the educational method adopting the PICO system, have been proposed. The recognised indications and tips have been summarized in a pamphlet for the patient.
Conclusions: Nursing therapeutic approach can promote the patient's health status, both psycho- physical and social health. The efficacy of this behavioural education programme for patients with sleep apnoea disorders will have to be assessed by carrying out long- term studies and tests.
KEY WORDS: Sleep- disorder, respiratory disorders, breathing, obstructive sleep apnoea syndrome, CPAP, nursing, therapeutic education.
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Award Number: W81XWH- 08- 1- 0114
TITLE: Mechanisms of Radiosensitization by the Neurotensin Receptor Antagonist SR48692 in Prostate Cancer Models
PRINCIPAL INVESTIGATOR: Jaroslaw Dziegielewski, Ph.D.
CONTRACTING ORGANIZATION: University of Virginia Charlottesville, VA 22904
REPORT DATE: April 2010
TYPE OF REPORT: Annual
PREPARED FOR: U.S. Army Medical Research and Materiel Command Fort Detrick, Maryland 21702- 5012
DISTRIBUTION STATEMENT:
- Approved for public release; distribution unlimited
The views, opinions and/or findings contained in this report are those of the author(s) and should not be construed as an official Department of the Army position, policy or decision unless so designated by other documentation.
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<table><tr><td>ART 3314</td><td>Issues in Contemporary Art*</td></tr><tr><td>ART 2314/ENGL<br>2340/GNED<br>2340/MUSC<br>2340/THTR 2340</td><td>Creative Thinking and the Artistic Process</td></tr><tr><td>BAT 2301/ECON<br>2320</td><td>Statistics for Business and Economics</td></tr><tr><td>BUSN 3335</td><td>Entrepreneurship and Venture Planning*</td></tr><tr><td>ENTR 2190</td><td>Exploring Entrepreneurship Opportunities*</td></tr><tr><td>ENTR 3340</td><td>Innovation, Design and Entrepreneurship*</td></tr><tr><td>ENTR 3341</td><td>Entrepreneurial Planning and Strategies*</td></tr><tr><td>MKTG 2301</td><td>Principles of Marketing</td></tr><tr><td>MKTG 3382</td><td>Integrated Marketing Communications *</td></tr><tr><td>MUSC 4321</td><td>Applied Music Pedagogy</td></tr><tr><td>SPMT 3316</td><td>Leadership for Sport Professionals</td></tr><tr><td>THTR 3342</td><td>Stage Management</td></tr><tr><td>THTR 3343</td><td>Arts Management</td></tr></table>
*This course has at least one prerequisite.
**Excluding PHIL 3-90, PHIL 3-91, and PHIL 4-90.**
# Distribution Requirement:
No more than six (6) of the elective credit hours used to satisfy the minor requirements may come from any one department. Additionally, ALE minors who are also pursuing any major in the School of Business may not use any Business course other than MGMT 2301 to fulfill this minor.
# Certification
The Arts, Letters, and Enterprise Certification gives students an opportunity to build knowledge while also gaining practical experience in an internship off campus. This path requires fewer hours than the Minor. ALE Certification is especially suited for students pursuing a degree in clinical sciences, engineering sciences, social sciences, or those interested in non-profit management. It requires completion of at least 12 credit hours, as listed below, plus a supervised internship of one-semester duration or the equivalent.
Students may not receive both an ALE minor and certification.
The program offers a certification as a supplement to traditional majors and minors. Students earn the certification by:
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ADMINISTRATIVE WITHDRAWAL: A basic requirement of this course is that you will participate in all class meetings and conscientiously complete all required course activities and/or assignments. Keep in touch with me if you are unable to attend, participate, or complete an assignment on time. If you miss more than half of the required activities within the first \(25\%\) of the course without contacting me, you may be administratively withdrawn from this course. Administrative withdrawal may have academic, financial, and financial aid implications. Administrative withdrawal will take place after the full refund period, and if you are administratively withdrawn from the course you will not be eligible for a tuition refund. If you have questions about the administrative withdrawal policy at any point during the semester, please contact your instructor.
LAST WITHDRAW DATE: Last day to withdraw with automatic grade of W is Sunday, October 21, 2018. Requires advisor approval via the late drop/add classes link in One.IU. UCOL students or Engineering/Technology freshmen must see advisor by 5:00PM on the prior Friday. In person transactions must be processed by 5:00P on the prior Friday (October 19, 2018).
Beginning October 22, 2018, drops will be approved only in serious, extenuating circumstances and requires the approval of the student's advisor, instructor, Chair or Associate Chair in Mathematics, and the School of Science Dean's Office. If you stop attending class without officially withdrawing by the last withdraw date, your grade will be an F for the course. If you find it necessary to withdraw from the course, we encourage you to first talk to your instructor or to your advisor so that they can assist you in deciding what alternative options best fit your needs. Students should read carefully the withdraw information found on the Registrar's website (registrar.iupui.edu) under the Academic Calendar.
INCOMPLETES: A grade of "Incomplete" (I) will only be given in accordance with the Department of Mathematical Sciences Grade of Incomplete Policy. An incomplete (grade of I) is only allowed for special circumstances: the student must have a passing grade in \(75\%\) of the course work. Specifically, students must be passing at the \(3 / 4\) mark of the session to qualify for assigning an incomplete. The instructor must agree that an incomplete is appropriate and it must be approved by the Associate Chair of the Department of Mathematical Sciences.
IUPUI POLICY ON DISABILITY ACCOMMODATIONS Students needing accommodations because of disability will need to register with Adaptive Educational Services (AES) and complete the appropriate forms issued by AES before accommodations will be given. The AES office is located in Taylor Hall, UC 100. You can also reach the office by calling 317- 274- 3241.
IUPUI POLICY ON RELIGIOUS HOLIDAYS IUPUI respects the right of all students to observe their religious holidays and will make reasonable accommodation, upon request, for such observances. Students seeking accommodation for religious observances MUST submit a request in writing to the course instructor by the end of the second week of the semester and should use the Request for Course Accommodation Due to Religious Observance Form. More information on the IUPUI Policy on Religious Holidays is available here: registrar.iupui.edu/religious.html. Failure to comply with the university policy will result in no accommodations given later in the semester.
IUPUI POLICY ON ACADEMIC INTEGRITY: The IU Code of Student Rights, Responsibilities, and Conduct states that students must uphold and maintain academic and professional honesty and integrity; the code defines academic misconduct as any activity that tends to undermine the academic integrity of the institution. Students engaging in academic misconduct may therefore receive penalties from their course instructor and disciplinary action from the university. Policies against academic misconduct apply to all course-, department-, school-, and university- related activities. Academic misconduct may involve human, hard- copy, or electronic resources and includes but is not limited to the following: cheating, fabrication, plagiarism, interference, violation of course rules, and facilitating academic dishonesty. For definitions of these activities, visit studentcode.iu.edu/responsibilities/academic- misconduct.html. Additional information about the rights and responsibilities of IU students is available at studentcode.iu.edu/.
STUDENT ENGAGEMENT ROSTER: This semester your instructor will be using the Student Engagement Roster (SER) to provide real- time feedback on your performance in this course. Periodically throughout the semester the instructor will be entering data on factors such as your class attendance, participation, and success with coursework, among other things. This information will provide feedback on how you are faring in the course and offer you suggestions on how you might be able to improve your performance. Students can view their submitted SER data through the One.IU tile, Student Engagement Roster (Student).
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<table><tr><td>ENGL 3335</td><td>Rhetorical Analysis*</td></tr><tr><td>FREN 3305</td><td>Introduction to French Literature I*</td></tr><tr><td>FREN 3306</td><td>Introduction to French Literature II*</td></tr><tr><td>FREN 4304</td><td>Topics in French Literature of the Eighteenth Century*</td></tr><tr><td>FREN 4305</td><td>Topics in French Literature of the Nineteenth Century*</td></tr><tr><td>MUSC 3341</td><td>Music History 1: Ancient Greece to Mozart*</td></tr><tr><td>MUSC 3342</td><td>Music History 2: Classical Era to the Present*</td></tr><tr><td>PHIL</td><td>All upper division courses**</td></tr><tr><td>PLSI 3352</td><td>Civil Rights and Liberties</td></tr><tr><td>PLSI 3361</td><td>Classical Political Thought</td></tr><tr><td>PSYC 2401</td><td>Statistics and Research Methods</td></tr><tr><td>PSYC 3451</td><td>Clinical Psychology*</td></tr><tr><td>RELI 1320</td><td>Ethical Issues in Religious Perspective</td></tr><tr><td>RELI</td><td>All upper division courses*</td></tr><tr><td>SPAN 3321</td><td>Spanish Cinema*</td></tr></table>
# Principles of Organizations and Communities
<table><tr><td>BUSN/HCOM<br>3362</td><td>Organizational Communication</td></tr><tr><td>HCOM 1300</td><td>Theories of Communication</td></tr><tr><td>HCOM 1333</td><td>Public Speaking</td></tr><tr><td>HCOM 2304</td><td>Interpersonal Communication</td></tr><tr><td>HCOM 3360</td><td>Communicating in Small Groups and Teams</td></tr><tr><td>HCOM 3364</td><td>Communication and Effective Leadership</td></tr><tr><td>PLSI 3303</td><td>Elections and Campaigns*</td></tr><tr><td>THTR 1343</td><td>Improvisation</td></tr></table>
# APPLICATIONS
<table><tr><td>ALE 3301</td><td>Grant Writing and Fundraising*</td></tr><tr><td>ALE 4-90</td><td>Internship</td></tr><tr><td>ART 1410</td><td>Design</td></tr></table>
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# MATH 15400 Trigonometry Fall 2018 Course Policy
\*\*See instructor for section-specific course materials\*\*
INSTRUCTOR: OFFICE: E-MAIL:
OFFICE PHONE: OFFICE HOURS:
A working knowledge of the concepts of college algebra and trigonometry is essential for all parts of science, engineering, and technology. Many other courses, (e.g. business, economics, health sciences, and more), will require you to apply the mathematical tools you learn in your college algebra and trigonometry courses, so keep in mind that success in future courses may depend heavily on your ability to apply the material from MATH 15400.
OFFICIAL IUPUI COURSE DESCRIPTION: MATH 15400 Trigonometry (3 cr.) P: MATH 15300 (with a minimum grade of C). MATH 15300- 15400 is a two- semester version of MATH 15900. Not open to students with credit in MATH 15900. This course covers college- level trigonometry and, together with MATH 15300, provides preparation for MATH 16500, MATH 22100, and MATH 23100.
MORE ON PREREQUISITES: It is assumed that you have recently mastered the material of MATH 15300 (College Algebra) with a grade of C or better within the last year. If this is not the case then you should talk to your instructor as soon as possible to decide if this is the correct class for you. The main reason people have difficulty with MATH 15400 is because of insufficient background. Again, if you are not sure if this is the right class for you, talk to your instructor early. It is not difficult to determine which class you should be in.
TEXTBOOK: The correct textbook for all sections of MATH 15400 is, Algebra and Trigonometry with Analytic Geometry, Classic 12th Edition, by Swokowski and Cole, with Enhanced WebAssign Access Card, ISBN: 9781305525849, Loose- leaf 3- ring textbook, Cengage Publisher. There are over a dozen different editions and formats of this textbook so it is important that you get the correct one. The required textbook may be purchased at the IUPUI Barnes & Noble Bookstore.
## IUPUI DEPARTMENT OF MATHEMATICAL SCIENCES CALCULATOR POLICY:
In all developmental and introductory courses at IUPUI numbered below MATH 16500, the only technology that can be used on in- class, closed- book assessments (quizzes, tests, final exam) is the Texas Instruments TI- 30XA scientific calculator. In all calculus and calculus- related courses at IUPUI with numbers MATH 16500 or above, no calculators or other forms of technology can be used on in- class, closed- books assessments (quizzes, tests, final) For math/stat courses with numbers above MATH 26600, it is up to the instructor's discretion as to what forms of technology may be used on in- class, closed- book assessments.
MORE ON CALCULATOR POLICY: The TI- 30XA is the only calculator allowed on quizzes and exams. No other calculator is allowed in the classroom. It does not matter what you were allowed to use in your previous math course. Bring your TI- 30XA scientific calculator with you to every class period. The calculator slide cover must be removed and put away when taking an exam or quiz.
ATTENDANCE: Attendance is required of all students without exception. A student absent from class bears full responsibility for all material covered in class. Quizzes will be given at the beginning of class, so please be on time. If you anticipate having to leave class early, please let your instructor know before the beginning of class. Regular attendance is crucial for success in this course.
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point in having a dialogue between realists and constructivists, and there would be no such thing as "realist- constructivism."
point in having a dialogue between realists and constructivists, and there would be no such thing as "realist- constructivism."How then can a constructivist argue consistently that power cannot be transcended in politics? An obvious candidate is the post- structural and relational argument that power inheres in social practices, and that the (re)production of stable social relations is always a result of strategic (but not always rational) social action. In short, power, by definition, is always present and implicated in any social formation. Although this may seem like a natural- necessity claim to some readers, it is not. Power is assumed to take different forms under different sociopolitical circumstances, and these forms are part of the analysis—not "givens" that structure reality in immutable ways. Barkin's (2003:327) tactical decision to avoid discussing "postmodern constructivism," because it "is generally more accepting of the centrality of power in politics," prevents him from formulating this more compelling answer. This is ironic, given that Barkin (2003:338) winds up having to refer to "critical" notions of power to flesh out his proposed research program.
## Implications
Our alternative framework is illustrated in Figure 1. Once we recognize that "realist- constructivism" necessarily involves post- structural and critical understandings of power, we can better elucidate the points of dialogue and contention between the four ideal- type approaches delineated above. At a basic level, our mapping suggests that liberal- constructivists and realists have minimal grounds for agreement, as do realist- constructivists and liberals. The most fruitful places for dialogue occur along the horizontal and vertical connections between the ideal- type positions, rather than along the diagonals, because it is there that we find both points of agreement and disagreement.
For example, the growing Habermasian turn in liberal- constructivism involves claims that, to the degree that contextual factors (such as institutional design) approximate Habermas's notion of an "ideal speech condition," power can be displaced from interactions in world politics. Although realists find this proposition simply absurd—on the grounds that anarchy makes such conditions impossible to find—

<center>FIG. 1. Alternative Framework </center>
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FINAL EXAM: The common departmental final exam will be on Friday, December 7, 2018, from 6:00P- 8:00P. The location will be announced later. The final exam is a departmental comprehensive exam. It will be worth 200 points, i.e., it will be weighted the same as two in- class exams. Be sure that you do not have a conflict (work, personal, or class) with the time and date of the common departmental final exam. No make- ups will be given except for the following documented situations: 1) IUPUI sponsored event, for example athletic competition, 2) Military training or deployment, and 3) Jury duty. Documentation must be provided in advance. More information about the common departmental final exam (practice problems, practice finals, etc.) can be found on the Mathematics Department's course web pages (math.iupui.edu/math/undergraduate/courses). The IUPUI departmental final exam schedule can be found at: registrar.iupui.edu/accal.html.
REMINDER: To receive credit for quiz and exam problems you must show all your work. Check your answers carefully before submitting your quiz/exam. Problems involving units must have the units represented on the answer to receive full credit. Keep all returned graded quizzes and exams until after you receive your final course grade.
GRADING: To perform well in this course you must not only understand the mathematical concepts, you must be able to use them correctly in solving problems. Accurate computations go together with understanding the method. MATH 15300- 15400 is a prerequisite for MATH 16500- 16600, Analytic Geometry and Calculus I & II, MATH 17100, Multidimensional Mathematics, MATH 22100- 22200, Calculus for Technology I & II, MATH 23100- 23200, Calculus for Life Sciences I & II and all physics courses. It is important to get into the habit (the earlier the better) of checking your work before submitting it to be evaluated by someone else. You will find this habit to be very valuable in your later courses.
GRADES: Your letter grade for the course will be determined from your total scores which will be computed as follows. Exam scores and/or the final course grades may be adjusted.
<table><tr><td>TOTAL POSSIBLE POINTS</td><td></td><td>GRADES</td></tr><tr><td>Best 3 out of 4 in-class exams</td><td>300</td><td>540-600 A's</td></tr><tr><td>Quizzes</td><td>100</td><td>480-539 B's</td></tr><tr><td>Final exam</td><td>200</td><td>420-479 C's</td></tr><tr><td>Total</td><td>600</td><td>360-419 D's</td></tr><tr><td></td><td></td><td>0 - 359 F</td></tr></table>
Pluses and minuses will be awarded on the final grades as follows:
90- 92% A-, 93- 96% A, 97% and above A+ 80- 82% B-, 83- 86% B, 87- 89% B+ 70- 72% C-, 73- 76% C, 77- 79% C+ 60- 62% D-, 63- 66% D, 67- 69% D+ 0- 59% F
IUPUI CAMPUS- WIDE POLICES: Students are expected to read carefully the IUPUI policies concerning attendance, academics, and conduct. Students are expected read the university policies within the few days of classes as some policies have early deadlines. Information on university campus- wide course policies related to attendance (Aadministrative Withdrawal, Disabilities, Emergency Withdrawal, Military Service, Religious Holidays), academic policies (Auditing a class, Final Exam Scheduling, Grade Replacement, Grade Forgiveness, and Pass/Fail Option), and conduct (Academic Integrity, Academic Misconduct, and Code of Conduct) and related policies can be accessed in Canvas under the "Syllabus Supplement", "Campus Course Policies" and "IUPUI Academic and Student Support Services" links.
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honor requires the preservation of society and its members. The frequency of war in such worlds will vary according to its perceived destructiveness, the robustness of regional society, and the nature of external threats. Fear will become the dominant motive if regional or international society weakens or dissipates, or threats from the outside are perceived as severe. Realism is most appropriate in this kind of world. Thucydides (1996:6.8- 27) documented in his Sicilian Debate how deterrence cannot keep the peace in these conditions, and how resulting wars are likely to be more general and destructive.
Social scientists have paradigms that capture two of the three generic motives identified by the Greeks. Liberalism is rooted in appetite; realism is rooted in fear. No paradigm is based on honor, although it is an important motive at every level of social interaction. Even wealth, as Thorstein Veblen (1898) noted, is often sought, not as an end, but as a means of achieving standing and self- esteem. The clash between liberalism and realism turns on the extent to which international relations is distinct from domestic politics because the former lacks a Leviathan. Many realists assert that international relations is a self- help system in which states must rely on their military capabilities to protect themselves. Many liberals contend that the dense network of institutions and profitable exchanges that bind together the developed economies of the world have enabled them to escape the security dilemma and get on with the business of generating wealth.
Even if liberals are right, this does not mean that power is no longer central to pluralistic security communities. Developed states and influential interest groups will always have clashing preferences, and the outcomes of these disputes will be influenced by their relative power. At the same time, in security communities constraints exist on the kinds of power that can be brought to bear: military threats and economic sanctions (beyond those allowed by trade treaties) are beyond the pale. Losers are expected to comply even in the absence of mechanisms of enforcement. Liberals explain self- restraint and compliance in terms of institutions and the strategic reasoning they promote. But such behavior is for the most part normative and an expression of the partially collective identities that relevant actors have formed. These identities have created a sense of obligation—something qualitatively different from compliance based on self- interest and strategic reasoning (Finne- more and Toope 2001; Reus- Smit 2003). They have also made compliance more palatable by restraining actors from seeking outcomes that deny others benefits or expectations of benefits in the future. This is why the more unilateral behavior of the Bush administration—whose leading luminaries do not share these collective identities and wisdom—has aroused such vocal opposition from the United States' closest allies.
Constructivist approaches take identity formation as their principal puzzle, and therefore they constitute our first line of inquiry into international relations. Constructivism does not have to be wedded to liberalism—as Barkin notes—or to any substantive paradigm. By describing identities, constructivism tells us which of them is likely to provide the most analytical leverage in a given system. As the Greeks recognized, actors in all worlds are motivated by some combination of interest, honor, and fear. Thus, no one paradigm ever suffices. We need to know which motive or motives predominate in a system or epoch and the extent to which they are constrained by reason. If balance prevails, fear will be minimal—just as it will be foremost under conditions of imbalance, that is, conditions in which nomos has broken down and rapacious actors ignore institutions or attempt to exploit them to advance their parochial goals. World politics is a composite of regional systems, each of which may be characterized by a different mix of identities and motives. Thus, realism, liberalism, constructivism, and a paradigm based on honor will all tell us something important. A more comprehensive understanding of international relations—and especially of the ways in which systems evolve and transform themselves—will require a synergistic, cross- paradigm approach.
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<center>Fig (3): Bulk density and total porosity as affected by different tillage practices. </center>
## Infiltration rate (IR)
The values of basic infiltration rate (IR) of soil as affected by different treatments are presented in Table (3). Data show that, basic infiltration rate values after each season are increased in the treated soils, where as, the values of basic IR under subsoliling and/or moling varied from 0.9 to 1.66 cm/h while, under open drainage they ranged from 0.39 to 0.59 cm/h. This may be due to the subsurface tillage gave the top soil layer a chance to dry and permitted for shrinkage and formation of water passage ways which allowed a rather easier movement of water into mole or subsoil line. Similar results were obtained by Abdel- Mawgoud et al., (2003 and 2006). Basic IR in all seasons is in somewhat higher with subsoil+mole than that with subsoil or mole treatment. Also, no obvious different between basic IR values under both subsoil and mole treatments. Data also clear that, mean values of basic IR are lower after rice crop than after sugar beet crop by 41.81, 35.13, 46.31 and 38.42 % for open drainage, subsoil+open drainage, mole+open drainage and subsoil+mole+open drains, respectively. Basic IR after first season is superior to after the third season from treatments installation.
Table (3): Basic infiltration rate (cm/h) after the first, second and third seasons from treatments executed.
<table><tr><td rowspan="2">Treatments</td><td colspan="2">First season</td><td colspan="2">second season</td><td colspan="2">third season</td><td colspan="2">Means</td></tr><tr><td>Rice</td><td>Sugar beet</td><td>Rice</td><td>Sugar beet</td><td>Rice</td><td>Sugar beet</td><td>Rice</td><td>Sugar beet</td></tr><tr><td>Open drainage</td><td>0.39</td><td>0.52</td><td>0.39</td><td>0.59</td><td>0.41</td><td>0.58</td><td>0.397</td><td>0.563</td></tr><tr><td>Subsoil+open drains</td><td>1.21</td><td>1.56</td><td>1.05</td><td>1.48</td><td>1.02</td><td>1.39</td><td>1.093</td><td>1.477</td></tr><tr><td>Mole + open drains</td><td>1.11</td><td>1.59</td><td>1.08</td><td>1.51</td><td>0.9</td><td>1.42</td><td>1.030</td><td>1.507</td></tr><tr><td>Subsoil+mole+open drains</td><td>1.22</td><td>1.66</td><td>1.11</td><td>1.55</td><td>1.05</td><td>1.47</td><td>1.127</td><td>1.56</td></tr></table>
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and utopianism. Barkin also argued that the problem with contemporary constructivism is that it has been dominated by liberalism and idealism; it would therefore benefit from a healthy infusion of realism. Much of Barkin's essay is aimed at showing that mainstream constructivism is, or can be, broadly compatible with classical realist theory.
Barkin is right that mainstream US constructivism is liberal and idealist. In this respect, his article serves as an important overarching statement of a position implicitly taken by a growing number of constructivist scholars. However, Barkin underplays the real and substantial differences between a commitment to understanding the social world as a product of contingent social interactions, on the one hand, and a commitment to understanding the social world as a result of natural necessity, on the other. These divergent commitments are assumptions about how politics works—assumptions that place constructivism in opposition to both liberal and realist approaches to contemporary international relations.
By ignoring these distinctions, Barkin's arguments amount to a call for a "constructivist realism"—a realism that takes norms and ideas seriously as objects of analysis—rather than a "realist- constructivism"—a constructivism that involves a self- consistent set of arguments about why power cannot be, in any way, transcended in international politics. The latter approach represents the key space in the field occupied by realist- constructivism, and it provides a better basis for promoting both a dialogue within constructivism and a dialogue between constructivism and realism.
## Delineating Realist-Constructivism
Where would a properly understood realist- constructivism fit into the disputes between the so- called "isms" in US international relations? One way to map its location is to consider two principal issues: (1) the degree to which international relations are socially constructed, and (2) the degree to which power can be transcended in world politics.
## Social Constructivism
According to Barkin (2003:326), constructivism's "defining feature ... is a focus on the social construction of international politics." This means that constructivists maintain that "what actors do in international relations, the interests they hold, and the structures within which they operate are defined by social norms and ideas, rather than by objective or material conditions." It is based on this latter formulation that Barkin (2003:338) contends that constructivism is a set of research methods rather than a paradigm in "the way that realism and liberalism and, for that matter, Marxism are."
But Barkin's assertion contradicts his definition of constructivism as a focus on the social construction of international politics. As Ian Hacking (1999:6) argues, the core of social construction is the claim that some phenomenon "X need not have existed, or need not be at all as it is. X, or X as it is at present, is not determined by the nature of things; it is not inevitable." Constructivism is inherently about the way politics operates; it entails claims that any given set of political relationships stem, not from natural necessity, but from contingent combinations of social agency (Tilly 1995; Jackson and Nexon 2002). Although constructivists have a far more indeterminate view of how international politics work than realists or liberals, that indeterminacy does not make constructivism merely a set of analytical tools.
Most IR theories involve some level of commitment to the proposition that international politics are socially constructed. Almost no theorist believes that international political outcomes are the inevitable consequence of the nature of things rather than subject to historical and agentic contingency (Guzzini 2000).
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# IMPROVING SOME PROPERTIES OF HEAVY CLAY SALT AFFECTED SOIL AS A RESULT OF DIFFERENT SUBSURFACE TILLAGE.
Antar, S. A. \*; A. S. El- Henawy. \*\* and A. A. E. Atwa \* \* Soils, Water and Environment Res. Inst., Agric. Res. Center, Egypt. \*\* Soils dept., Fac. of Agric., Kafrelsheikh Univ., Egypt.
## ABSTRACT
A field experiment was conducted at North Nile Delta, Egypt (Islah- Perempal Region, Motobus District, Kafer El- Shiek Governorate), to evaluate the effect of subsoliling and mole drains with open drainage on improving some soil properties and yields of rice and sugar beet crops as well as raising the efficiency of the open drainage system.
Results indicate that, subsurface tillage operations with open surface drainage lowered the water table level, after all growing seasons. The mean values of water table levels are 59.5, 59.5 and 62.3 cm with subsoliling, mole drain and subsoliling +mole, respectively while, it is 44.3 cm with the control (open drainage). Water table level is lower after sugar beet than after rice.
Soil salinity and sodicity in the topsoil, were reduced after subsoliling and moling installation. The reductions of salinity, after three years from experiment installation were 86.71, 96.81 and 98.76% for subsoliling, moling and subsoliling +moling, respectively over the control. The corresponding values of ESP decreases were 83.93, 83.20 and 119.40%, respectively. Ratio of \(\mathrm{Ca^{++} / TSS}\) in the topsoil (0- 60cm) was increased in the treated soils.
Subsoliling and/or moling seemed to be more effective on reducing soil bulk density especially in the surface layer (0- 30cm). Subsoliling and/or moling treatments were superior in enhancing soil porosity. Basic infiltration rate (BIR) was increased with subsoliling and/or moling (from 0.9 to 1.66 cm/h) while, it was ranged from 0.39 to 0.59 cm/h with the control (open drainage). Data also cleared that, BIR after rice crop season was lower than that after sugar beet crop season.
The saturation percent, field capacity and wilting point values are lower in the treated soils than untreated soils. Subsoliling and/or moling realized increases in quickly and slowly drainable pores (QDP and SDP) and higher decrease in fine capillary pores (FCP) than open drains. Mean values of QDP, SDP and FCP% in the soil depth of 0- 60cm, are 8.71, 12.93 and 32.35%, respectively with open drainage. The corresponding values are 10.66, 16.57 and 23.80%, respectively with subsoliling and 11.56, 16.35 and 23.52%, respectively with moling and 12.52, 18.84 and 20.87%, respectively with subsoliling +moling.
Rice and sugar beet yields are related to the salinity contents in soil. The yields increased when the EC decreased as affected by subsoliling and/or moling. Rice and sugar beet yields are higher under subsoliling and/or moling than with open drains in all growing seasons. Rice grain yield is higher under subsoliling tillage, moling and subsoliling +moling by 37.19, 38.43, and 34.30%, respectively, than the control. The corresponding values of sugar beet yield are 5.31, 4.65 and 7.65 ton/fed., respectively.
Keywords: Drainage, mole drains, Subsoliling, Clay soil, Rice, sugar beet.
## INTRODUCTION
In Egypt, northern part of the Nile Delta represents a large area of heavy clay soils with shallow open drainage which are low permeability that might have a low productivity. These soils are always threatened by a shallow
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Entered on Docket September 4, 2015
Below is the Order of the Court.

Brian D. Lynch U.S. Bankruptcy Judge (Dated as of Entered on Docket date above)
# UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF WASHINGTON
In re:
Extending Terms of Executive Committee and Appointment of Executive Committee Member for The Honorable Thomas T. Glover Mediation Program
General Order No. 2015- 2
The term limits of the Executive Committee of The Thomas T. Glover Mediation Program, established under Local Bankruptcy Rule 9043- 2, hamper the Committee's ability to maintain consistent and effective leadership. The Court has reviewed the Executive Committee's request for a change in the governance structure and supports a modification to the term limits.
Committee member Christopher Alston has been appointed as a bankruptcy judge in the district and can no longer serve as a Program mediator. The Committee has recommended a new individual to be appointed to fill Mr. Alston's position.
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## REFERENCES
Abdel- Mawgoud A.S.A (2004). Sobsoliling to conserve rootzone stratum of heavy clay soil. Minufiya J. Agric. Res. Vol. 29 No. 6: 1456- 1478. Abdel- Mawgoud A.S.A., M. B. El Shewikh, A. N. Abdel- Aal and M.I.I. Abdel- Khalik (2003). Open drainage and moiling for desalinization of Salty Clay Soils of Northeastern Egypt. Presented at the 9th International Drainage Workshop, September 10 - 13, 2003, Utrecht, The Netherlands. Abdel- Mawgoud A.S.A, A.A.S. Gendy and S.A. Ramadan (2006). Improving root zone environment and production of a salty clay soil using subsoiling and gypsum application. Assiut J. of Agri. Sci., 37, 2: 147- 164. Amer, M. H. (1999). Effect of tillage operations on some soil physical properties and water relations of corn. Egypt J. Appl. Sci., 14 (6):354- 365. Campbell, D.J. (1994). Determination and use of bulk density in relation to soil compaction. In Soane and Ouwerk (Eds). Soil compaction in crop production. Elsevier, London and Amsterdam. David Hopkins, Colac (2002). Managing wet soils: mole drainage. WWW.dse. Vic. Gov. De Leenher, L. and M. De Boodt (1965). Soil physics. Intre. Training Center for Post Graduate Soil Scientists, Gent., pp. 126- 135. Garcia, G. (1978). Soil water Engineering Laboratory Manual. Colorado State Univ. Dept. of Agric. and Chemical Engineering. Fortcollins, Colorado. Jodi Dej ong, H. (2004). Can subsoliling increase crop yields in Minnesota? Agric. World Wide Correspondent. Meredith Corporation. Lickacz, J. (1993). Management of solonetzic soils. Agdex 518- 8. Revised, Edmonton, Alberta, Canada. Moukhtar M. M., Madiha H. El- Hakim, A, S.A. Abdel- Mawgoud, A. I. N. Abdel- Aal, M. B. El Shewikh and M.I.I. Abdel- Khalik (2003b). Drainage and role of mole drains for heavy clay soils under saline watertable, Egypt. Paper No 078. Presented at the 9th International Drainage Workshop, September 10 - 13, 2003, Utrecht, The Netherlands. Moukhtar M. M., Aly I.N.Abdel- Aal, M.A.B.EI- Sheikh and M.I.I. Abdel- Khalik (2002a). The Role of Mole Drainage in Degradation Soils Under Saline Ground water Table, Egypt The Second International Conference on Sustainable Agriculture for Food, Energy and Industry September 8- 13, Beijing, China. Moukhtar, M. M., E. M. El- Hadidy, M.Y.S. El- Arquan And M.A.B. El- Shewikh (2002b). Soil Amelioration Technique of Cover Drainage Combined Subsoiling for Saline- Sodic Clay in North Egypt. XVth World Congress of the International Commission of Agricultural Engineering (CIGR) on J uly 28- 31 - 2002, Chicago, USA. Moukhtar, M.M., M.Y.S. El- Arquan, E.M. El- Hadidy and M.A.B. El- Shewikh (2003a). Amelioration of salt affected soils in north Dakhlia Governorate through application of tile drainage and subsoiling. J. Agric. Sci. Mansoura Univ., Special Issue, Sci. Symp. On Problems of soils and waters in Dakhlia and Damietta Governorate. March 18.
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Now, therefore, it is hereby ORDERED:
1. That each member of the Executive Committee shall be selected to a term of at least 3 years, renewable for an additional 2 years, at the discretion of the Chief Bankruptcy J udge.
2. The following attorneys are members of the Executive Committee for the Program with terms of service as set forth below. J erry Stehlik is appointed to fill the Committee position vacated by J udge Alston:
Larry Ream, chair Term expires December 1, 2015 Gloria Nagler Term expires December 1, 2015 Diana Carey Term expires December 1, 2016 Kathleen Shoemaker Term expires December 1, 2016 J erry N. Stehlik Term expires December 1, 2017
###End of Order###
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The AGGLOM vector includes several variables to assess whether it is access or proximity to agglomeration economies that are driving the results. First, for nonmetropolitan counties, we include the county's own population and the population of the nearest metropolitan area. For metropolitan counties, we include the overall metropolitan area population. Then to more accurately account for spillovers over distance, the AGGLOM also includes several spatial distance measures to reflect proximity to metropolitan areas differentiated by their status in the hierarchy. Partridge et al. (2008a, 2008b, 2009) found these distance measures to be highly associated with job and population growth as well as wages and housing values dating back to the mid- \(20^{\mathrm{th}}\) Century. For a county that is part of a metropolitan area, the first distance is from the population- weighted center of the county to the population- weighted center of the metropolitan area. Inside a metropolitan area, the influence of longer distances would largely reflect any offsetting effects of agglomeration or congestion effects. For a nonmetropolitan county, the variable is the distance from the county center to the center of the nearest metropolitan area.
Beyond the nearest metropolitan area, we also include the incremental distances to larger higher- tiered metropolitan areas to reflect added spillovers from higher- ordered cities. They reflect the incremental or marginal costs to reach each higher- tiered (larger) metropolitan areas. First, are incremental (or additional) distances to reach metropolitan areas of at least 250,000, and then at least 500,000, and finally over 1.5 million population. The largest category generally reflects national and top- tier regional cities. There may be measurement error bias when using straight- line distance rather than travel time, but this classic measurement error would bias the distance
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## Critical Values Reporting QT10
Critical Values Reporting QT10Laboratories commonly refer to critical values as results requiring immediate notification to the physician or caregiver for necessary patient evaluation or treatment. Regulations from agencies and accreditors such as the CMS, The Joint Commission, and the CAP (GEN.20316, COM.30000) mandate that laboratories develop and implement an alert system for critical values. Use this monitor to document compliance with your laboratory's alert plan.
## Objective
ObjectiveEvaluate the documentation of successful critical values reporting in the general laboratory for inpatients (including discharged inpatients) and outpatients.
## Data Collection
Data CollectionOn a monthly basis, participants will evaluate 120 inpatient, 20 discharged inpatient, and 120 outpatient critical values. Data collection will include general chemistry, hematology, and coagulation analytes on the critical values list. Retrospectively, participants will record the total number of critical values monitored and the number with documentation of successful notification. In addition, participants will provide the number of critical values that were not communicated within three hours, the number of failed notifications due to laboratory oversight, and the number of successful notifications to licensed caregivers. This monitor will exclude critical values for cardiac markers, drugs of abuse, therapeutic drug levels, urinalysis, blood gases, point- of- care tests, and tests performed at reference laboratories.
## Performance Indicators
Performance Indicators- Total critical values reporting rate (\%)- Inpatient critical values reporting rate (\%)- Discharged inpatient critical values reporting rate (\%)- Outpatient critical values reporting rate (\%)- Failed notification (<3 hours) rate (\%)
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shares described in Appendix Table 1. We also account for the average of median household incomes in nearby counties to account for nearby markets. State fixed effects account for state- specific factors including tax and expenditure policies, regulatory differences, geographic location with respect to coasts, and settlement period.
## 4. Empirical Results
Table 1 reports descriptive statistics for the dependent and independent variables. Tables 2 and 3 respectively report the metropolitan and nonmetropolitan regression results for overall high- tech employment growth and for corresponding non- high- tech categories: overall total employment growth, manufacturing employment growth, and private services employment growth. \(^{11}\) For each industry category, the first column of results report a parsimonious model that does not include the demographic variables including educational attainment, total population, age, and racial/ethnic population shares. These more parsimonious models help us assess whether multicollinearity is greatly affecting the results and whether there is demographic self- sorting (such as whether college- educated workers self- sort into places they expect to have better long- term employment prospects). \(^{12}\)
### 4.1 High-Technology vs Aggregate Industry Categories
Comparing the parsimonious model results to the base model results in both Tables 2 and 3 suggests that the results are relatively stable. One exception is that the magnitude of the regression coefficient for the log of initial employment generally becomes much more negative in the parsimonious model. For example, the magnitude of the coefficient approximately doubled in the overall high- technology employment and overall total employment cases. Thus, there is some evidence of a correlation between the initial demographic composition and the initial industry employment. Nonetheless, given that the results did not significantly change, we focus on the more fully- specified base models.
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## Satisfaction With Outpatient Specimen Collection QT7
Specimen collection is one of the few areas of laboratory medicine that involves direct outpatient contact. As a result, patient satisfaction with this service is a vital indicator of quality laboratory performance. The CAP's Laboratory Accreditation Program requires measurement of patient satisfaction with laboratory services (GEN.20335). Use this monitor to help meet this requirement.
## Objective
Assess patient satisfaction with outpatient phlebotomy services by measuring patients' assessment of waiting time, discomfort level, courteous treatment, and overall satisfaction.
## Data Collection
On a monthly basis, participants will provide copies of a standardized questionnaire to a minimum of 25 outpatients (maximum of 99 outpatients) using predetermined data collection criteria. This monitor includes any outpatient undergoing venipuncture. This monitor excludes patients seen in the emergency department, ambulatory surgery area, urgent care facility, chest pain center, 23- hour short- stay facility, employee health department, outpatient health screening fair/promotion, dialysis center, nursing home, or extended care facility.
## Performance Indicators
Overall patient satisfaction score Patients "more than satisfied" \((\%)\)
## Stat Test Turnaround Time Outliers QT8
The stat test turnaround time (TAT) outlier rate, expressed as a percentage of tests missing target reporting times, is a measure of outcomes that evaluates how well the laboratory meets patient and clinician needs. This monitor helps meet CAP Checklist requirement GEN.20316, "The QM program includes monitoring key indicators of quality in the preanalytic, analytic, and postanalytic phases."
## Objective
Monitor the frequency that stat test TAT intervals exceed institutional stat test TAT expectations.
## Data Collection
Before beginning data collection, participants will establish a specimen receipt- to- report deadline for emergency department (ED) stat potassium tests. On six predetermined days per month, participants will monitor the TAT of up to 10 randomly selected ED stat potassium tests on each of three, eight- hour shifts (up to 180 tests per month) and track the number of ED stat potassium results reported later than the established reporting deadline. This monitor includes stat potassium tests ordered as part of a panel and excludes stat potassium levels that are requested on body fluids other than blood, as part of timed or protocol studies, or after the specimen arrives in the laboratory.
## Performance Indicator
## Performance Breakdowns
Stat test TAT outlier rate \((\%)\)
Breakdown of outliers by shift \((\%)\) Breakdown of outliers by day of week \((\%)\)
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regression coefficients toward zero, suggesting a larger distance effect than we report.
The EDUC vector controls for human capital and includes variables for the initial 1990 percent of the population 25 years or older that has (1) at least a high school degree but no further education, (2) some college/university but no degree, (3) Associates Degree but no further degree, and (4) at least a Bachelors degree. We expect that a greater share with a Bachelors degree to be positively linked to high- technology growth. But for assembly- line positions in manufacturing there may be a need for workers with medium skill or education levels. Likewise, to account for knowledge spillovers from research- intensive universities, we include a dummy variable for being located within 100 miles of a Carnegie Classification research- intensive university including major Land Grant universities. We also tried a dummy for being located within 50 miles, but the results were virtually identical.
Akin to the within- industry knowledge spillovers accounted for by the surrounding county industry employment, we also include the average share of the population with at least a Bachelors degree in the nearest 5 counties. \(^{10}\) Greater human capital in nearby regions may have spillovers or allow the focal county to be more innovative or technologically progressive through a greater ease in adopting innovation spillovers (Rodriguez- Pose and Crescenzi, 2008). Neighboring county educational attainment may also have labor market impacts because it may increase the available labor supply for local firms in the focal county through commuting. Alternatively, it may reduce local employment growth because high- technology firms would rather locate in the neighboring county due to better access to an educated workforce.
Natural AMENITIES are measured using a 1 to 7 scale developed by the U.S. Department of Agriculture (see Appendix Table 2). This variable assesses the hypothesis that high- technology workers may be more footloose than other workers and that these firms may be better able to locate in areas preferred by its workforce. The X vector controls for other factors that potentially influence growth including population- age composition shares and race and ethnic population
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## Q-TRACKS Clinical Pathology Monitors
## Patient Identification Accuracy QT1
In order to report accurate laboratory results and meet The Joint Commission National Patient Safety Goal #1: "Identify patients correctly," institutions must properly identify patients. Since most laboratories perform testing away from the patient, patient identification, and labeling of specimens and coordination with test requisitions must be performed accurately and completely. By continuously monitoring for wristband errors, participants can promptly identify and correct problems that may interfere with patient care services.
## Objectives
Assess the incidence of wristband errors within individual institutions, compare performance between participating institutions, and identify improvement opportunities.
## Data Collection
On six predetermined days per month, participants will monitor patient wristband identification for all phlebotomies performed at their institution. Phlebotomists will tally the total number of wristbands checked, the number of errors found, and the types of wristband error. This monitor includes all routinely wristbanded patients. Include emergency department patients only if the emergency department routinely applies wristbands to these patients.
## Performance Indicator
Wristband error rate \((\%)\)
## Performance Breakdown
Breakdown of wristband error types \((\%)\)
## Blood Culture Contamination QT2
Despite advances in blood culture practices and technology, false- positive blood culture results due to contaminants continue to be a critical problem. Blood culture contamination rate, the primary indicator of preanalytic performance in microbiology, is associated with increased length of hospital stay, additional expense, and the administration of unnecessary antibiotics. The CAP and other accrediting organizations require you to monitor and evaluate key indicators of quality for improvement opportunities. Use this monitor to help meet this requirement.
## Objective
Determine the rate of blood culture contamination using standardized criteria for classifying contaminants.
## Data Collection
On a monthly basis, participants will tabulate the total number of blood cultures processed and the total number of contaminated blood cultures. Blood cultures from neonatal patients are tabulated separately. For the purposes of this study, participants will consider a blood culture to be contaminated if they find one or more of the following organisms in only one of a series of blood culture specimens: Coagulase- negative Staphylococcus; Micrococcus; Alpha- hemolytic viridans group streptococci; Propionibacterium acnes; Corynebacterium sp. (diphtheroids); or Bacillus sp. Participants have the option to monitor institution- specific subgroups, for example, a specific department or patient population.
## Performance Indicators
Neonatal contamination rate \((\%)\) Other contamination rate \((\%)\) Overall contamination rate \((\%)\)
Look for your input forms approximately three weeks prior to the quarter.
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hanced knowledge is now available regarding the wide range of actions of estrogens on the cardiovascular system, even in male tissues. These developments suggest that it may be appropriate to reassess the adverse findings of the Coronary Drug Project. To pursue this, we have investigated the cardiovascular effects of low- dose estrogen supplementation in a group of men rendered hypogonadal as a result of treatment for prostatic cancer, thereby reducing endogenous estrogen production. In a small, randomized, placebo- controlled study, we have examined the effects of 8 weeks of estrogen supplementation on a number of surrogate cardiovascular end points, including lipid levels, blood pressure, and forearm vascular reactivity.
## Methods
## Subjects
We studied 12 men rendered hypogonadal by surgical or pharmacological treatment for prostatic cancer. We excluded patients with clinical evidence of cardiovascular disease (or on cardiovascular drugs) or severe renal, hepatic, respiratory, or hematologic conditions. The study was approved by the Alfred Hospital Human Ethics Committee. All subjects gave written fully informed consent.
## Study Design
The study followed a randomized, double- blind, placebo- controlled design. Subjects were randomly assigned to 8 weeks of estrogen supplementation with estradiol valerate (Progynova, Schering) 1 mg daily \(\mathrm{(n = 7)}\) ; mean age, \(68.4 \pm 2.6\) years) or placebo \(\mathrm{(n = 5)}\) ; mean age, \(69.2 \pm 2.8\) years). Hemodynamic and forearm vascular studies were performed twice, 8 weeks apart. Subjects were unaware of treatments received. All measurements were made by investigators blinded to the treatment. On each study day, subjects underwent the following procedures: arterial cannulation, blood sampling, assessment of forearm vascular reactivity, and measurement of hormones and other variables.
## Arterial Cannulation
Subjects rested supine throughout each study in a quiet, temperature- controlled room, \((22^{\circ}\mathrm{C})\) . The left brachial artery was cannulated with a 21- gauge, 5- cm catheter (Cook) for intra- arterial blood pressure measurement (Spacelabs Inc), drug infusions, and arterial blood sampling. Heart rate was monitored by electrocardiography. Subjects rested for 30 minutes before commencement of the study.
## Blood Sampling
Blood was taken on each occasion for measurement of urea, electrolytes, glucose, total cholesterol, triglycerides, HDL cholesterol, liver function, full blood count, estradiol, testosterone, andstenedione, dehydroepiandrosterone, sex hormone- binding globulin, follicle- stimulating hormone (FSH), and luteinizing hormone (LH).
## Assessment of Forearm Vascular Reactivity
Forearm vascular responsiveness was assessed by venous occlusion plethysmography with a sealed alloy- filled gallium and indium double- stranded strain gauge (Medasonic). Hand blood flow was excluded via a wrist cuff \((200\mathrm{mmHg})\) ; venous occlusion pressure was \(50\mathrm{mmHg}\) . Basal blood flow was obtained as an average of 3 measurements. Drugs were infused via an infusion pump at 2 mL/min.
A cyclicholine (BDH Chemicals) was infused at 9.25, 18.5, and 37 \(\mu \mathrm{g / min}\) ; norepinephrine at 25, 50 and \(100\mathrm{ng / min}\) ; and angiotensin (Ang) II at 8, 16, and \(32\mathrm{ng / min}\) , each dose for 2 minutes to allow blood flow to reach steady state. Basal NO release was assessed by intra- arterial infusion of \(\mathrm{N^{6}}\) - monomethyl- L- arginine (L- NMMA) (Calbiochem- Novabiochem) at 1, 2, and \(4\mu \mathrm{mol / min}\) , each dose for 5 minutes. Finally, sodium nitroprusside (David Bull Laboratories)
TABLE 1. Baseline Characteristics of Subjects Randomized to Estrogen \((n = 7)\) and Placebo \((n = 5)\)
<table><tr><td>Treatment Group</td><td>Age, y</td><td>Weight, kg</td><td>BMI, kg/m²</td><td>Systolic BP, mm Hg</td><td>Diastolic BP, mm Hg</td></tr><tr><td>Estrogen</td><td>68.4 ± 2.1</td><td>72.4 ± 4.5</td><td>27.2 ± 2.0</td><td>136 ± 1</td><td>87 ± 1</td></tr><tr><td>Placebo</td><td>69.2 ± 2.8</td><td>70.8 ± 4.9</td><td>27.6 ± 2.3</td><td>134 ± 1</td><td>86 ± 2</td></tr></table>
BMI indicates body mass index; BP, blood pressure.
was infused at \(1.6\mu \mathrm{g / min}\) for 2 minutes. The peak response was determined as the average of 3 consecutive steady state measurements. A 15- minute rest period between interventions was sufficient for flow to return to resting levels.
## Measurement of Hormones and Other Variables
Estradiol and other hormones, namely, total testosterone, andstenedione, FSH, LH, and sex hormone- binding globulin were measured by specific radioimmunoassay. The intra- assay coefficient of variation for estradiol was \(9\%\) \((n = 32)\) and sensitivity 30 pmol/L. Total cholesterol, triglycerides, HDL cholesterol, and glucose were also measured.
## Calculations and Statistical Analysis
Results are expressed as mean \(\pm\) SEM. Vascular reactivity doseresponse curves were compared by 2- way repeated- measures ANOVA. Other data were compared by Student's t test. In cases in which multiple comparisons were made, the Bonferroni correction was applied. The null hypothesis was rejected at \(P< 0.05\)
## Results
There were no significant adverse effects reported in any of the subjects. Only 1 subject experienced symptoms likely to be associated with estrogen treatment: mild, persistent breast tenderness. The other subjects were unable to tell whether they were receiving active treatment or placebo.
## Baseline Characteristics
Baseline characteristics are shown in Tables 1 and 2. There were no differences between the estrogen- and placebo- treated groups with respect to age, body mass index, systolic or diastolic blood pressure, or baseline plasma levels of estradiol, total testosterone, andstenedione, sex hormone- binding globulin, LH, total cholesterol, triglycerides, HDL cholesterol, hemoglobin, or glucose. FSH was higher in the placebo group as a result of very high levels in 1 individual. Testosterone levels were very low in both estrogen- and placebo- treated groups, consistent with their hypogonadal status.
## Effect of Estradiol on Serum and Plasma Measurements
As expected, estrogen levels increased with estrogen treatment, FSH levels fell, and androgen levels showed no change. HDL levels increased significantly with estrogen treatment, but total cholesterol and triglyceride levels were constant (Table 2). Glucose levels were unchanged with estrogen treatment. There were no significant differences in the placebo group. No changes were observed in renal function, liver function, or any hematologic parameters.
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The argument for coordination via a stronger central government in the Federalist Papers are directly opposed to "states rights" radicalism and devolution of powers to local control; these coordination arguments turn on recognition of certain collective action problems in supermajority requirements. The need for coordinative power for states to be justifiable limits the kinds of opt- outs they can accept.
Most American founders were committed to a "republican" conception of democracy as deliberation about the common good, which supports the notion public goods arising from judgments that are not preferences independent of others' preferences. This view is incompatible with Hobbesian egoism, which leads to pure majoritarian theories with their problematic implications (slave constitutions, secession at will, voting in a dictator, etc). These are the same problems at the collective level that inalienable liberty rules out at the individual level. Hobbesian libertarians thus find themselves with Senator Douglas.
There are limits to inequality in access to material resources as outcomes of past transactions by contract (even when these are procedurally just, and incorporate starting conditions that assure fair opportunity to earn merits) that are necessary for rights to participate in deliberative democracy to be secured (compare Rawls' argument in Political Liberalism for the "fair value of political liberties").
To be implemented, a conception of fair opportunity requires some way of defining an equal opportunity education system, which must at minimum develop motivation as well as talents - - consistent with the recognition that individual free choice may prevent both. Here again we see how much influence culture and forms of social capital have.
Pace Spencer, there is no way to specify "the" maximal set of (negative) liberties that are compatible with equal liberties of the same scope for all, any further extension of which would either (a) limit the extent of some other liberty in the set, or (b) interfere with the liberty of someone else (or both).
Condition (a) makes sense only if we focus on the positive use of some liberty as a power to bring about some result (as Narveson tries to); and even then, there may be several different sets of liberties that would count as maximal according to condition (a). Condition (b) requires that we have a natural (premoral) sense of "interference" in terms of which we could then define the set of liberties that it is morally wrong to violate. But there is no such non- normative notion of "interference" that can do this job.
Theories of property rights tracing to legitimate initial acquisition (such as Nozick's) become useless given an almost endless history of past injustices indirectly affecting present (and future) persons, most of which cannot be ascertained accurately or corrected without other costs to the stability of expectations that is necessary for autonomy and economic growth (e.g. according to Hayek). Thought experiments imply that the only morally acceptable way to correct such effects of past injustices sufficiently is to set a new minimum standard of access to the goods necessary to be productive for each new generation, or minimum levels of diversity in holdings to prevent extreme concentrations of wealth, and accept the redistributions this requires in the name of setting a new baseline that all can accept as wiping the slate.
This point about past misappropriations of property is part of a larger set of ways that people's sense of responsibilities is affected by past unchosen burdens and benefits coming from the history of the culture in which they live and its many assets and liabilities - - which will help give concrete shape to any actual political effort to establish starting- position fairness according to some more abstract ideal.
Well- being cannot be measured solely in terms of satisfaction of preferences because of the problem of adaptive preferences, which none of the libertarian theories canvassed can solve (in contrast to objective ethical judgment accounts). Nor can well- being be measured solely in terms of holding commonly needed goods, because these are not equivalent to the basic capabilities involved in the fulfillment of the human telos. Even on a fairly minimal conception (e.g. Sen's), this telos involves not only personal autonomy and "individuality" in Mill's sense, but also social relationships such as friendships, deep memberships, and chances for creative work aimed at inherently worthwhile products or long- term ends. These points explain some minimal forms of paternalism that are widely accepted, though rejected by libertarians.
It generates confusion to speak of a government being morally neutral on a matter when decision about it is left up to individual choice (and thus to market dynamics). The decision to leave some matter up to individual choice expresses a judgment that (a) the chooseable options are not moral wrongs of a kind that cannot be legally tolerated - - perhaps because they violate rights of others, and (b) that aggregate effects of such choices will shape the incentives of everyone who has to choose on the same matter in ways that
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