I have loved to write for as long as I can remember. I soon found I had been right about not earning loads of money writing fiction, but I love it. What writing advice do you have for aspiring authors? I think you have to be a reader in order to write. Not just for pleasure, but to observe how other authors craft their books. The other thing is that you must know the basics of spelling, punctuation and grammar before you try to write anything, and certainly before you try to publish anything.
Bringing the past alive is a fascinating job, so I might pursue that. How long does it usually take you to write the first draft of a book? About two months for the first draft and then a couple of weeks tweaking and editing. I also have a beta reader who does an excellent job of weeding out my British terminology.
How has your environment or upbringing impacted your writing? Both my series are set in my hometown of Seattle, so there are a lot of local references and locations. I once had someone buy a book on the spot after he learned one of the scenes took place about yards from where we were. Describe what your ideal writing space looks like. My ideal writing space would be a private office in Seattle overlooking Lake Washington or Puget Sound, furnished with a solid wall of books, a comfy chair to sit and write in and an endless supply of coffee.
Reality is somewhat different. Why should a potential reader buy your book s? I think my books appeal to a broad spectrum of readers, basically anyone who likes a light-hearted, fast-paced whodunnit with interesting characters and a lot of humor. We also advocate the use of sealant glues over coil embolization in response to concerns over stapler misfire. Imperative to adequate embolization is the understanding of segment IV collateral flow, and the need for selective embolization of this segment to provide adequate contralateral growth.
An adequate period of observation, generally of 4—6 weeks, is also required to allow the fullest extent of hepatic hypertrophy. Five patients in the second-era group underwent PVE and four of them went on to receive bile duct excision with concurrent lobectomy and hepaticojejunostomy. In the first era of our study period, these patients would not have been deemed surgical candidates based on inadequate future liver remnant. In the future, PVE is certain to play an increasingly important role in the preoperative preparation of patients with Klatskin's tumour.http://boudoirsposa.ru/includes/21.php
Surgical resection for hilar cholangiocarcinoma: experience improves resectability
The final controversy refers to preoperative biliary instrumentation. Several studies have cautioned that the use of preoperative biliary drainage is associated with an increase in the incidence of postoperative infection, whereas other reports have indicated improvement in the post-resection liver remnant. Early in the series, it was our policy to continue biliary drainage for 6—8 weeks.
In more recent patients, we have limited the period of drainage to 1—2 weeks preoperatively. In regard to a technical aspect, stenting also provides a clear plane for dissection and leads to localized fibrosis in the stented biliary radicle. In the present series, stenting represents another factor contributing to the higher resection rates achieved in the second-era patient group.
Furthermore, fibrosis of the duct provides better purchase for a subsequent biliary enteric anastamosis. Renewed attempts at liver transplantation in hilar cholangiocarcinoma have been met with newfound enthusiasm. Unfortunately, although numerous patients are screened, only a minority are actually eligible for transplantation. Despite the role of chemotherapy in the neoadjuvant protocol for transplantation, no solid clinical evidence exists for the postoperative administration of chemotherapy in patients undergoing resection for hilar cholangiocarcinoma.
Some series have demonstrated modest improvements in survival, 46 , 47 but this benefit has never been demonstrated clearly in a large prospective trial. Over the last two decades, the treatment of hilar cholangiocarcinoma has continued to rest firmly on the same cornerstone: Clear benefit has been observed with the use of an aggressive approach to surgical resection, including concomitant hepatectomy. More uncertain is the use of portal vein resection or pancreatoduodenectomy to achieve tumour-free margins.
Advances in interventional radiology, and in percutaneous transhepatic biliary drainage, PVE, anaesthesia and critical care techniques have made the achievement of a higher percentage of R0 resections feasible. However, even when negative margins cannot be achieved, there is still a survival benefit to patients who undergo surgical resection of all gross disease. Despite the renewed hope that other modalities such as transplantation and adjuvant chemoradiotherapy or chemophotodynamic therapy will prove feasible, aggressive resection remains the principal treatment for hilar cholangiocarcinoma.
The major limitations of this study refer to its retrospective nature and the fact that it was confined to patients who had been referred for surgical evaluation. The number of patients who are not referred for surgery is substantial and probably constitutes the majority of patients with hilar cholangiocarcinoma.
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Including these patients would provide a better estimate of the true resectability rate. Furthermore, it is possible that changes in referral patterns may play a role in the increased rate of resectability seen in the more recent era of the study. National Center for Biotechnology Information , U. Author information Article notes Copyright and License information Disclaimer. Received Jul 25; Accepted Oct This article has been cited by other articles in PMC. Abstract Objectives In hilar cholangiocarcinoma, resection provides the only opportunity for longterm survival.
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Methods We conducted a retrospective analysis of consecutive hilar cholangiocarcinoma patients presenting over an year period. Results Of the patients in the cohort, Conclusions Although R0 resection can be achieved in only a minority of patients, these patients have a reasonable chance of longterm survival.
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Introduction Early experiences with hilar cholangiocarcinoma, or Klatskin's tumour, were often discouraging. Materials and methods From January to December , consecutive patients with hilar cholangiocarcinoma underwent surgical exploration at the University of Louisville or the University of Cincinnati. Results Patient presentation Of the consecutive patients evaluated for hilar cholangiocarcinoma, the majority were White males. Table 1 Patient characteristics and comparison by era. Open in a separate window.
Diagnostic imaging and preoperative staging Of the patients in whom preoperative brushings were performed, cytology was positive in 39 Operative morbidity and mortality A total of patients were explored for potential resection. Resection and operative margins Univariate analysis revealed era first vs. Table 2 Univariate analysis of factors affecting resection. Table 3 Univariate analysis of factors affecting the ability to achieve margin-negative resection. R1 R0 P -value Age, years, median range 63 21—88 64 27—88 0.
Survival Rates of 1-, 3- and 5-year survival in the first 55 patients were Table 4 Survival rates over 1, 3 and 5 years and median survival. Survival P -value 1-year 3-year 5-year Median, months All patients Table 5 Multivariate Cox proportional hazards analysis of survival. Discussion Historically, hilar cholangiocarcinoma has been considered as a uniformly lethal disease in which expectations for 5-year survival are low. Conclusions Over the last two decades, the treatment of hilar cholangiocarcinoma has continued to rest firmly on the same cornerstone: Conflicts of interest None declared.
Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis. An unusual tumour with distinctive clinical and pathological features. Sclerosing carcinoma of the major intrahepatic bile ducts. Carcinoma of the extrahepatic biliary tract. Carcinoma of the hepatic hilus. Surgical management and the case for resection. Surgical management of carcinoma of the junction of the main hepatic ducts.
Jarnagin WR, Shoup M. Surgical management of cholangiocarcinoma. Survival and an overview of decision-making in patients with cholangiocarcinoma. Hepatobiliary Pancreat Dis Int. Proximal bile duct cancer. Aggressive surgical resection for hilar cholangiocarcinoma: Audit of a single centre's experience. Surgical management of hilar cholangiocarcinoma: HPB Oxford ; 7: Resection of hilar cholangiocarcinoma: Forty consecutive resections of hilar cholangiocarcinoma with no postoperative mortality and no positive ductal margins: You told me a very interesting story about yourself and what made you start writing.
Would you be willing to share that here? I had worked as a journalist for years, so I had been writing for a long time, but in , I went to stay with my mother for two months after she had a minor stroke. I was climbing the walls with boredom, so I decided to write a mystery novel, setting it in a small research laboratory like the one where my parents had both worked. I had spent a lot of time there during my childhood, so I knew how it functioned and thought there would be a reasonable amount of material for plots.
There are now ten novels and four short stories in that series, and the Zukie books are a spin-off of those. Not only would I get a trip to Florida out of it, but I love his books and his off-the-wall sense of humor. I like my mysteries to have some humor, and this one certainly does, although the downbeat, cliff-hanger ending seems out of sync with the rest of the book. Since there are two more books in the series, I assume Charlie finds a way out of his predicament by the time the second one starts.
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Cynthia, thank you again for taking the time to talk to me and share some of your wisdom with all of us. Best of luck to you with your newest Zukie Merlino Mystery. What made you decide to go with self-publishing rather than traditional?
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