Language: English Italian. Metastases in the upper and middle neck levels I-II-III-V are generally attributed to head and neck cancers, whereas the lower neck level IV involvement is often associated with primaries below the clavicles. Diagnostic procedures include a careful clinical evaluation and a fiberoptic endoscopic examination of the head and neck mucosa, biopsies from all suspicious sites or blindly from the sites of possible origin of the primary, computerized tomography scan, and magnetic resonance.
The most frequent histological finding is Squamous Cell Carcinoma, particularly when the upper neck is involved. Thoracic, and abdominal primaries especially from lung, oesophagus, stomach, ovary or pancreas should be sought in the case of adenocarcinoma and involvement of the lower neck.
Therapeutic approaches include surgery neck dissectionwith or without post-operative radiotherapy, radiotherapy alone and radiotherapy followed by surgery as reported by several guide-lines. In early stages N1neck dissection and radiotherapy seem to have similar efficacy, whereas more advanced cases N2, N3 require combined approaches.
The extent of radiotherapy irradiation of bilateral neck and mucosa versus ipsilateral neck radiotherapy remains debatable. A potential benefit from extensive radiotherapy should be weighed against its acute and late morbidity and difficulties in re-irradiation in the case of subsequent primary emergence.
The role of other methods, such as chemotherapy and hyperthermia, remains to be determined. Il ruolo di altre metodiche quali la chemioterapia e la ipertermia sono ancora oggetto di studio. Carcinoma of unknown primary site CUP represents a heterogeneous group of malignancies presenting with lymph node or distant metastases, for which diagnostic work-up fails to identify the site of origin 1. Moreover, due to progress in immunopathology, more individualized histology-based therapeutic options have recently become available 1 — 3.
A substantial fraction of CUP patients includes cases with cervical lymph node metastases from unknown primary 4 5. Squamous cell carcinoma SCC is the most common histotype, followed by adenocarcinoma, undifferentiated carcinoma and other malignancies for example, lymphoma and melanoma 6 — 9. Patients with cervical metastases other than SCC follow different treatment guidelines and have different prognosis 10 — The management of cervical lymph node metastases from unknown primary remains a therapeutic challenge.
Randomized trials are lacking. As far as concerns SCC, since they are characterized by loco-regional progression and relatively low risk of distant metastases, the priority is given to loco-regional control.
Therefore, local modalities including surgery and radiotherapy remain cornerstones of treatment. Recently, the role of combined chemo-radiotherapy after surgery of Head and neck SCC with nodal metastases has been stressed 13 — Treatment of other malignancies depends on the histotype and site of origin.
Published retrospective series include heterogeneous patient populations with different histotypes, i. However, the recent publication of several relatively large series of patients allows for some conclusions to be drawn 7 16 26 — References were supplemented with relevant citations from older literature, from the reference list of retrieved papers, and from the official guidelines of the European Institute of Oncology and of several Scientific Societies found surfing the web 30 — Papers were selected on the basis of their relevance to the topic.
Data presented in abstract form or non-English language articles were included wherever they added significant information. In the Danish national study, the annual incidence of cervical metastases of SCC from unknown primary was 0. In the same period, the number of new head and neck cancers has increased, suggesting that the proportion of CUP cases has diminished In large series, the median nodal size was 5 cm range cm 38 and there is an apparent prevalence of N2 cases 6 24 25 28 Metastases in the upper and middle neck are generally attributed to cancers of the head and neck region, whereas metastases limited to the lower neck supraclavicular area are often associated with primary malignancies below the clavicles 8 22 36 Many patients with exclusive low neck involvement are managed with palliative approaches Mean age at diagnosis varied in some series from 55 to 65 years, and younger median age in some series may partially be explained by the inclusion of undifferentiated tumours 6 7 21 25 27 28 35 39 — Coupled with at least 48 months of relevant work experience, successful completion of the final level yields a charter membership.
While the first two levels revolved around basic financial knowledge, investment valuation comprehension, and the application of both, the CFA Level III exam focuses on portfolio management and wealth planning. The format of the exam, which is only offered in June, is a mix of item set questions similar to Level II and essay type questions. Like the other exams, the Level III exam is also conducted in two parts: the morning and afternoon sessions. In the morning session, there are 10 to 15 essay-type questions.
Each question consists of multiple parts such as A, B, C, etc. These questions may provide you with a situation and ask you to develop your own recommendation or solution. In the afternoon session, there will be 10 item sets. Each item set consists of a case statement followed by six multiple-choice questions. As mentioned earlier, the focus of the exam is on portfolio management and wealth planning, but it also covers seven topics that are grouped into two other areas, namely, Ethical and Professional Standards and Asset Classes.
The following table provides weighting of these topics and broad areas for the exam:. As is evident from the table, the Ethics and Professional Standards gets as much importance as in the other levels of the exam. The investment tools are not tested separately, except economics, which is a part of the portfolio management and wealth planning section for level III.
The majority of the exam revolves around portfolio management and asset classes in the portfolio context. The Code of Ethics section will most likely be an item set in the afternoon session. However, GIPS could be tested either as an essay question in the morning session or as an item set in the afternoon session. The exam tests your knowledge on all of the major asset classes, including alternative investments, derivatives, equity investments, and fixed-income investments.
However, the focus is now on the portfolio management aspects of these investments. For example, a whole session is dedicated to the management of active and passive fixed-income portfolios, covering investment objectives, benchmarking, return analysis, portfolio immunization strategies, relative value analysis, and so on. The syllabus also covers strategies used in international and emerging markets and how derivatives are used to manage interest rate and credit risks in fixed-income portfolios.
The second asset class is equity securities, which are an essential component of most investment portfolios and crucial for the portfolio's success. The discussion here surrounds equity investment strategies, evaluation of equity fund managers and equity indexes. The syllabus also discusses the corporate governance issues related to conflicts between managers and shareholders that erode value and have a direct impact on equity portfolio managers. Finally, there is a discussion on measuring and managing portfolios in international and emerging markets.
The section on alternative investments primarily discusses the alternative investment classes and how derivative instruments such as swaps, futures, and forwards are used to manage some alternative investments. This comprises the largest portion of the exam and will account for at least points out of the possible points. Portfolio management concepts will dominate both the morning and afternoon sessions. The syllabus is very comprehensive and introduces new concepts such as behavioral finance, which forms the basis for financial decision making.
Risk management concepts, covering tools and techniques for measuring and managing risk are also discussed.
Apart from these, you are likely to be tested on questions related to individual and institutional wealth.The verb is from Middle English levelenfrom the noun. Definition from Wiktionary, the free dictionary. This table isn't quite level ; see how this marble rolls off it? Just under the ceiling there were three lunette windows, heavily barred and blacked out in the normal way by centuries of grime. Their bases were on a level with the pavement outside, a narrow way which was several feet lower than the road behind the house.
We tried to hang the pictures so that the bottom of the frames were level with the dark line in the wallpaper. His pulse has been level for 12 hours.
His voice has been unchanged. It has been level for 12 hours. He kept a level head under stress. The translations below need to be checked and inserted above into the appropriate translation tables, removing any numbers. Numbers do not necessarily match those in definitions.
Hand me the level so I can tell if this is correctly installed. By the end of the day, we'd dug down to the level of the old basement floor.
Thrown on her own resources and almost penniless, she maintained herself and paid the rent of a wretched room near the hospital by working as a charwoman, sempstress, anything. In a moment she had dropped to the level of a casual labourer. The sound level is much too high; this hurts my ears. We've reached a new level of success. She achieved a high level of distinction. It took me weeks to get to level seven. Watch out for the next level ; the bad guys there are really overpowered. My half-orc barbarian reached fifth level before he was squashed by a troll.
Take the elevator and get off at the promenade level. You can level the table by turning the pads that screw into the feet.
The hurricane leveled the forest.
I levelled after defeating the dragon. He levelled an accusation of fraud at the directors.20 april 2017 Attack Defense Stamina 15/15/15 No Hitmontop!
The hunter levels the gun before taking a shot. This could get ugly.
European Qualifications Framework
Do you have a gun? Namespaces Entry Discussion. Views Read Edit History.Its face and chest are covered in white feathers with two, three-pointed crests above its eyes. Black markings surround its circular eyes, and it has a light yellow beak and feet. There is a single white spot on its stomach.
Its feet have two digits each. Delibird is omnivorous. It carries food bundled up in its tail. It normally gives stored food to its chicks, but has been known to share its food with humans stranded on icy mountains. Delibird's signature movePresentallows it to carry special items in its tail that may cause damage or heal its opponent. In a flock, the Delibird with the largest tail is its leader.
Delibird tends to live in mountainous regionsmaking its nests over sharp cliffs; one notable area of the world is around Mt. Eventually, Delibird was unable to tail the Team Rocket trio ever since they moved to the Hoenn region. Ash's Totodile shot it clear out of the sky with a Water Gun -propelled snowball while it was delivering presents. In Battling The Generation Gap! Multiple Delibird appeared in Diancie and the Cocoon of Destruction.
In Battling on the Wing! However, Gold was able to knock it out with Polibo 's Perish Song. It is likely to be the same Delibird used by his alias.
A Delibird appeared in GDZ67under the ownership of a monk. Aspects of Delibird's appearance appear to come from the rockhopper penguin. However, its red-and-white color scheme, its ability to give presents, and the appearance of carrying its sack-like tail is likely to have been derived from Santa Claus and possibly the white stork.
Delibird may have also been inspired by puffinswhich are penguin -like birds that still have the ability to fly. Delibird is a combination of delivery and bird. Pronouncing Delibird with the same inflection as delivered yields a very similar sound, with the "b" and "v" being the only variation between the two words.Thank you for visiting nature.
A Nature Research Journal. Recent improvements in mRNA vaccines act to increase protein translation, modulate innate and adaptive immunogenicity and improve delivery. Diverse approaches to mRNA cancer vaccines, including dendritic cell vaccines and various types of directly injectable mRNA, have been employed in numerous cancer clinical trials, with some promising results showing antigen-specific T cell responses and prolonged disease-free survival in some cases.
Therapeutic considerations and challenges include scaling up good manufacturing practice GMP production, establishing regulations, further documenting safety and increasing efficacy. Important future directions of research will be to compare and elucidate the immune pathways activated by various mRNA vaccine platforms, to improve current approaches based on these mechanisms and to initiate new clinical trials against additional disease targets.
However, their application has until recently been restricted by the instability and inefficient in vivo delivery of mRNA. Recent technological advances have now largely overcome these issues, and multiple mRNA vaccine platforms against infectious diseases and several types of cancer have demonstrated encouraging results in both animal models and humans. This Review provides a detailed overview of mRNA vaccines and considers future directions and challenges in advancing this promising vaccine platform to widespread therapeutic use.
Vaccines prevent many millions of illnesses and save numerous lives every year 1. As a result of widespread vaccine use, the smallpox virus has been completely eradicated and the incidence of polio, measles and other childhood diseases has been drastically reduced around the world 2.
Conventional vaccine approaches, such as live attenuated and inactivated pathogens and subunit vaccines, provide durable protection against a variety of dangerous diseases 3.
Despite this success, there remain major hurdles to vaccine development against a variety of infectious pathogens, especially those better able to evade the adaptive immune response 4. Moreover, for most emerging virus vaccines, the main obstacle is not the effectiveness of conventional approaches but the need for more rapid development and large-scale deployment.
Finally, conventional vaccine approaches may not be applicable to non-infectious diseases, such as cancer. The development of more potent and versatile vaccine platforms is therefore urgently needed. Nucleic acid therapeutics have emerged as promising alternatives to conventional vaccine approaches.If your doctor sees a suspicious mole during an exam, the next step is a skin biopsy.
If that reveals melanomaa pathologist will perform tests to determine how advanced the disease is—a process called staging. In addition, the thickness of the tumor is measured and assigned what's called a Breslow number.
This figure has been found to be significant when coming up with a patient's prognosis. Once the stage and the Breslow number have been accurately determined, your doctor can effectively plan your treatment.
Each letter of this name stands for a different aspect of a tumor's characteristics:. Once TNM factors have been identified, the cancer is given a number from 0 to IV— and sometimes a letter, from A to C—with higher numbers meaning the cancer is more advanced. Another measurement, called the Clark level, is no longer used as it has been deemed too subjective. As the melanoma becomes thicker, it has a greater chance of spreading.
First reported by Alexander Breslow, MD, inthe Breslow thickness is defined as the total vertical height of the melanoma, from the very top called the granular layer to the area of deepest penetration in the skin. An instrument called an ocular micrometer is used to measure the thickness of the excised removed tumor. Five-year survival rates can be determined by Breslow thickness. While melanoma can be a frightening diagnosis, more and more effective treatments are available, even for late-stage cancers.
Accurate staging will result in receiving the most effective treatment possible. Get our printable guide for your next doctor's appointment to help you ask the right questions. Limiting processed foods and red meats can help ward off cancer risk. These recipes focus on antioxidant-rich foods to better protect you and your loved ones. Sign up and get your guide! National Cancer Institute. Melanoma staging schemes. Updated Melanoma Molecular Map Project.Calling 1, Points Slow 0 1 Sp.
Ultra Moon An Ultra Beast that lives in a different world, it cackles wildly as it sprays its opponents with poison from the needles on its head. This lowers their Attack stat. This may also lower their Sp. Def stat. This move's power is doubled if the target is poisoned. This harshly lowers its Attack stat. This lowers the Attack, Sp. Atk, and Speed stats of a poisoned target. This sharply raises the user's Sp. Atk stat. This may also poison the target.
Its poison damage worsens every turn. TM09 Venoshock 65 10 -- The user drenches the target in a special poisonous liquid. TM17 Protect -- -- 10 -- Enables the user to evade all attacks. Its chance of failing rises if it is used in succession. TM21 Frustration?? TM27 Return?? TM34 Sludge Wave 95 10 10 The user strikes everything around it by swamping the area with a giant sludge wave. This may also poison those hit. TM36 Sludge Bomb 90 10 30 Unsanitary sludge is hurled at the target.