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Finally, the benefit of maintenance therapy, especially in the low-risk category, is still a matter of debate. French investigators initially reported superior overall survival (OS) for patients receiving maintenance therapy with low-dose chemotherapy, ATRA or combined ATRA and chemotherapy [ 38 ]. This survival benefit was confirmed by a large US North Intergroup randomized trial for patients receiving ATRA maintenance after obtaining CR with ATRA plus chemotherapy regimens [ 45 ]. On the contrary, a GIMEMA study randomizing patients in molecular CR (mCR) to maintenance therapy with ATRA alone, ATRA plus low-dose chemotherapy or no maintenance, reported no significant differences in outcomes among the four groups [ 46 ]. Similarly, Japanese investigators by the JALSG reported no improvement in disease-free survival (DFS) for patients in mCR receiving intensified maintenance chemotherapy after induction and three intensive consolidation courses [ 47 ]. Despite the high cure rates, the toxicity profile of ATRA plus chemotherapy regimens includes severe hematologic toxicity with deaths in remission together with occurrence of secondary myeloid neoplasms in 2%–3% of cases [ 48 ].

In 2004, Chinese investigators from Shanghai reported a randomized trial with 61 newly diagnosed APL patients treated with ATO or ATRA or the combination of the two drugs for induction therapy [ 49 ]. CR rates were similar in the three arms ranging from 90% to 95.2%, but the median time to achieve CR was shorter in the combination arm (25.5 days) compared with the single-agent arm (40.5 days in the ATRA group and 31 days in the ATO group). After induction, all patients received chemotherapy. None of the patients treated with the ATRA–ATO combination relapsed, whereas 26% and 11% patients relapsed in the ATRA and ATO groups, respectively, with a median DFS of 13, 16 and 20 months for ATRA, ATO and combination groups, respectively. In a long-term update of the study, the estimated 5-year event-free survival (EFS) and OS rates for patients treated with ATRA–ATO were 89.2% and 91.7%, respectively [ 49 ]. The role of ATO as a consolidation therapy added to conventional ATRA plus chemotherapy was investigated in a randomized trial conducted by United States and Canadian investigators [ 50 ]. In this study, 481 newly diagnosed patients were randomly assigned to receive induction with ATRA, cytarabine and daunorubicin followed by two consolidation courses with ATRA and daunorubicin or to the same induction and consolidation and two 25-day cycles of ATO administered after induction therapy. Patients receiving ATO showed significantly better 3-year EFS compared with those receiving ATRA plus chemotherapy (80% versus 63%) as well as superior 3-year OS (86% versus 81%) and 3-year DFS (90% versus 70%) [ 50 ]. More recently, the Australasian group reported the results of the APML4 trial, combining anthracycline chemotherapy, ATO and ATRA for remission induction therapy, followed by two consolidation cycles with ATO–ATRA without further chemotherapy [ 51 ]. Compared with a previous study from the same group (APML3), this regimen resulted in improved survival outcomes, with 2-year freedom from relapse (FFR), failure-free survival and OS of 97.5%, 88% and 93%, respectively. A recent update of this study with a follow-up of 4.2 years showed 5-year FFR of 95% (95% CI 89–98), DFS of 95% as well as EFS of 90% and OS of 94% [ 51 ].

“There are female Infantry and Armor Soldiers, in training now, with assignments to Fort Carson, Fort Campbell and Fort Bliss. These Soldiers will start arriving at the additional installations as soon as April 2018,” Army spokesman Paul Boyce told Moneyish.

The Army has opened three new combat posts to women. (U.S. Army)

The first class of female infantry officers completed training at Fort Benning, Georgia, in fall 2016. The first 18 women to complete infantry basic training graduated in spring 2017. And then last November, six women earned their Expert Infantrymen Badges at Fort Bragg. The EIB test entailed 30 basic infantry skills and tasks that had to be completed with less than three errors, and these six women were among the 287 soldiers who passed the test out of 1,007 initial contenders.

“This historic achievement is a reminder of the great things we can achieve when women are seen and treated as equals and given the same chance to contribute to their country,” Sen. Tammy Duckworth, a combat veteran, Womens Lace Yoke Blouse Simply Be Clearance Exclusive Buy Cheap Pay With Paypal Discount Largest Supplier Free Shipping Prices Pictures B0h4xslo7a

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THIS IS AN IMPORTANT MESSAGE FROM ME: No matter how many people think otherwise, Jehovah’s Witnesses really is God’s visible organization. The wrath of Jehovah God really is upon the Mormon Church of Satan, no matter how many people think otherwise. The stock market really is going to crash, worldwide , no matter how many people think otherwise. No matter how many people think otherwise, Caroline Kennedy will be elected President in the year 2020; Jim Turner of Texas will be elected Vice President; Robert Kennedy Jr. will be nominated and confirmed U.S. Attorney General; Robert Mueller will be nominated and confirmed Director of the FBI. No power on earth has the power to prevent this prophetic message that I write from becoming reality, not even these four people themselves. I write under inspiration from and with authority from , God, the true God, Jehovah. cc all Mormon barristers

THIS IS AN IMPORTANT MESSAGE FROM ME: No power on earth has the power to prevent this prophetic message that I write from becoming reality, not even these four people themselves.

THIS IS ANOTHER IMPORTANT MESSAGE FROM ME: Mayor Warren Wilhelm aka Bill de Blasio is the clean-up man, if the Mormon Church of Satan/CIA succeed in their planned nuclear bomb attack on the Hudson River. His administration is already prepared to hold tribunals and immediately execute some of the “troublemakers” (30,000 bananas; nationwide: 30,000 guillotines, )

Partial List of Scapegoats, if the Mormon Church of Satan/CIA succeed in their nuclear bomb attack on the Hudson River:

Of patients presenting to hospital with CAP, up to 10% will require critical care admission.

Streptococcus pneumoniae continues as the most common infective pathogen.

Staphylococcus aureus, Legionella , and gram-negative pathogens are increasingly frequent causative pathogens.

Combined viral and bacterial infections may induce a more severe spectrum of disease.

Severe community-acquired pneumonia (CAP) remains a frequent reason for admission to hospital. It is the most common cause of septic shock requiring escalation to treatment within an intensive care unit (ICU). Despite earlier recognition and recent advances in supportive care, severe CAP is still associated with substantial morbidity and mortality, more often seen in the elderly and those with considerable comorbidities.


CAP is defined as an acute infection of the pulmonary parenchyma, with symptom onset in the community. Diagnosis can still be made within 48 h of hospital admission to meet criteria for a community-acquired infection. Severe CAP is defined as a pneumonia requiring supportive therapy within a critical care environment, that is associated with a higher mortality rate. Severe CAP is frequently a multisystem disease and patients will often present with multiple organ failure.

The annual incidence of CAP is 1.6–10.6 per 1000 adult population in Europe. 1 Between 1.2% and 10% of patients requiring hospital admission to treat CAP will require ICU admission. The incidence of CAP increases with age, and more than 90% of deaths related to severe pneumonia occur in patients over the age of 70. The 28 day mortality rate in patients admitted to critical care is ∼17%, which increases to 24.4% in those requiring invasive mechanical ventilation and 28.8% in those that develop septic shock. 1 Mortality rates in younger patients are more influenced by the severity of the infection rather than the presence of comorbidities. Even in the absence of comorbidities, severe CAP is associated with excess mortality over subsequent years among survivors independent of age.

CAP classically presents with a triad of infective signs (fever, leucocytosis), clinical signs and symptoms (sputum production, tachypnoea, cough, pleuritic chest pain), and a new or changed infiltrate as observed on radiography, for which there is no other explanation except infection. However, these clinical signs and symptoms may not be universally seen or present typically, particularly in the elderly or immunosuppressed. Diagnosis of CAP may be clouded or complicated by underlying disease states that affect cardiorespiratory function and by atypical or subacute presentations of infection.

Pneumonia develops when the defensive mechanisms within the lung become overwhelmed by a pathogen which has been either inhaled or aspirated. This is more likely to occur with more virulent pathogens and in patients with reduced host defences. Pathogens responsible for CAP are varied and wide-ranging in their capacity to cause severe disease and extra-pulmonary features (Table 1 ). The predominant pathogen throughout all age groups remains Streptococcus pneumoniae. Legionella , gram-negative bacilli, influenzae species, and Staphylococcus aureus are becoming increasingly common causes of severe CAP requiring critical care admission in comparison with CAP managed outside of critical care units. The frequency of other less prevalent causes of CAP such as Chlamydophilia psittaci , Coxiella burnetii , and Mycoplasma pneumoniae varies according to epidemiological setting and in part on the diagnostic techniques that are used. No causative organism is identified in up to 36% of cases of severe CAP.

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