 why you can’t accomplish what you want or says that you can’t do it. Gather your thoughts back, gather your energy back. Gather your strengths back and then direct it only at the manifestations that you want, towards your true will and genuinely let go of the things that you cannot control. Let go of what happens in between. Give up control to that. To things that your can’t make happen like someone’s reaction to something, or a person’s thoughts on something or even exactly what would happen tomorrow. You can only hold an intention or manifestation as to what would happen and then everything that occurs will happen for that to be fulfilled. So “I want to be happy tomorrow and I don’t want to go to church” would be my intention and manifestation and then maybe someone calls or something happens that would make what I want not happen but I didn’t really TRY to control exactly how that would happen because I can’t. Do not add more problems to yourself or worry about petty things or the things that you have absolutely no control over. There’s absolutely no point worrying about that.
The tower reversed: now is the time to make changes to avoid disaster. This moment when a foundation has been build when you are open and receptive and seeing your shadow. And that’s why you were asked to deal with your fears and anxieties and your limiting beliefs because it could causes a crisis later on. It could still come back and cause unnecessary hassles. Like your hurt inner child coming out to play when you are about to make an important life decision. Take away the clutter! Defucking clutter. Take a look at your habits or the things you are doing now or your goals that doesn’t contribute to what you want in the future. Otherwise, try new things, let new things in.
The world reversed: if you are having a little issue breaking free from this old patterns, perhaps try celebrating yourself accomplishments. Celebrate how far that you have come. Celebrate the little things. Gratitude. Thank yourself. Love yourself. Pump yourself up. Realize that you deserve so so much more. Because a limiting belief that you hold is that you aren’t good enough for someone or something, or to have something. Imposter syndrome. What you have is not enough. You have nothing to offer. Woe is me. And that way, by comparing yourself to others, you begin to see the difference in where you are and then that causes a sort of reinforcement of beliefs that “yes, see, we are in such different places and doing different things and they are growing faster than me” and then you don’t see that you are just learning different lessons and having different experiences. Your progress is best measured against your past. Against, like I said before, what you have accomplished and where you came from. Compare your growth from last year till now. From your former thoughts and from where you have been or what you have done. You can only compare yourself from you to you.
Cd20 Expression and Effects on Outcome of Relapsed/Refractory Diffuse Large B Cell Lymphoma after Treatment with Rituximab

Introduction: Down regulation of CD20 expression has been reported in diffuse large B cell lymphoma (DLBCL)). Therefore, it is important to determine whether chemotherapy with rituximab induces CD20 down regulation and effects survival. Objectives: To determine the incidence of down regulation of CD20 expression in relapsed DLBCL after treatment with rituximab and to compare outcomes and assess pattern of relapse between CD20 negative and CD20 positive cases. Methodology: We retrospectively reviewed patients with relapsed DLBCL who received rituximab in the first line setting at Aga Khan University Hospital between January 2007 and December 2014. Data were recorded on predesigned questionnaires, with variables including demographics, details regarding date of diagnosis and relapse, histology, staging, international prognostic index, treatment and outcomes at initial diagnosis and at relapse. The Chi square test was applied to determine statistical significance between categorical variables. Survival curves were generated by the Kaplan–Meier method. Results: A total of 54 patients with relapsed DLBCL were included in our study, 38 (70 %) males and 16(30%) females. Some 23 (43%) patients were at stage IV at the time of diagnosis and 34 (63%) had B symptoms. The most frequent R-IPI at diagnosis was II in 24 (44%) patients. Only 6 (11%) did not show CD20 expression on re-biopsy for relapsed/refractory disease, 2 with CD20 negative DLBCL responding to second line chemotherapy. A complete response after salvage chemotherapy was noted in 16 (29.6%) cases with relapsed/refractory DLBCL. Seven (13%) patients underwent an autologous bone marrow transplant as consolidation after second line treatment. Median overall survival was 18 months in CD20 positive vs. 13 months in CD20 negative patients. Conclusion: This study demonstrated that a small percentage of patients treated with rituximab lose their CD20 expression at the time of relapse. However, it is unclear whether this is associated with an inferior outcome.


Introduction
Addition of rituximab to induction chemotherapy in DLBCL has improved prognosis, specially bcl2 positive and non-germinal center subtype of DLBCL (Fenske et al., 2009). Response rates with single agent rituximab in DLBCL at initial diagnosis is approximately 30-35% (Davis et al., 1999;Kewalramani et al., 2004). Combination of rituximab with chemotherapy has improved complete response rates to 75%-80% (Gisselbrecht et al., 2010). Unfortunately, 30-40 % patients relapse after complete response and 10% are refractory to standard anthracycline based regimen ( Raut and Chakrabarti, 2014). At relapse, retreatment with chemo immunotherapy shows a response rate of 55% when compared to 28% when treated with regimens without rituximab (Raut and Chakrabarti, 2014;Jiang et al., 2013).

Materials and Methods
This is a retrospective cohort study. After exemption approval from hospital ethical review committee medical records of patients with relapsed/refractory DLBCL who received treatment at Aga Khan University hospital (AKUH) were reviewed from January 2007 and December 2014. We included only those patients who had received rituximab as part of the first line therapy and had pathological assessment at the time of relapse. Patients who did not have adequate biopsy specimen for review at the time of relapse and those who didn't receive second line treatment and followup at AKUH were excluded from the study.
Primary objective of the study was to determine the incidence of CD20 expression in patients with relapsed DLBCL who were previously exposed to rituximab. The secondary objectives included disease characteristics, disease free survival and overall survival of CD20 positive and CD20 negative relapsed DLBCL. For our analysis disease free survival was defined as any recurrence after completion of definitive treatment and overall survival was defined as time from initial diagnosis until death from any cause. Patients were followed from the time of initial diagnosis till last follow up if alive or till death.
Statistical analysis: SPSS version 19 was used for statistical analysis. Descriptive statistics were calculated with the help of mean standard deviation and for categorical variables, frequencies and percentages were used. Chi square test was applied to determine statistical significance between categorical variables. Survival curves were calculated by Kaplan-Meier curve. P<0.05 was considered to be statistically significant and P<0.1 showed trend toward significance.

Patient characteristics at initial diagnosis
Fifty four patients were included in the analysis. Among them, 38 (70%) were male and 16 (30%) were female. The mean age at diagnosis was 55.3+/-16.7 years (range, 22-91 years). 34 (63%) patients presented with B symptoms. Most common stage was stage IV in 23(43%) patients. 70% of the patients had low-high intermediate prognosis as classified by Revised International Prognostic Index (R-IPI). (Table 1) The most frequently prescribed first line chemo regimen was R-CHOP in 44 (81.5%) patients. 8 (14.8%) patients received R-CVP and 2 (3.7%) patients were treated with R-EPOCH. 26(48%) patients also received intrathecal chemotherapy for central nervous system prophylaxis. 26(48.1%) showed complete response at end of treatment evaluation. Among 26 patients who showed complete response, 17(31.4%) had low RIPI.

Patient characteristics at relapse
26 patients relapsed after first line therapy. Median time interval between last dose of rituximab and re-biopsy at the time of radiographic disease relapse was 11(6-96) months. At relapse, 2 (3.7%) patients were CD20 negative and 24 patients remained CD20 positive as determined by immunohistochemistry (IHC). PAX-5 was then performed on CD20 negative samples and found to be positive in 1/2 patients. There was no statistically significant difference in the expression on ki67 between the biopsy specimens taken at initial diagnosis and relapse. The most common site of relapse in CD20 negative patients was gastrointestinal tract in both patients. In CD20 positive patients, lymph nodal relapse was most frequently documented in 11 (46%) patients followed by gastrointestinal tract in 4(16.6%) patients. DHAP/R-DHAP was prescribed in 11(45.6%), ICE/R-ICE in 6 (25%) and others in 7(29.4%) patients. Complete response (CR) to salvage chemotherapy was documented by imaging studies in 13 (50%) patients out of which 12 patients were CD20 positive and 1 patient was CD 20 negative. DHAP/RDHAP was the was the most successful regimen, with a CR documented in 8/13(61%) (P-0.11). 5 patients