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ISSN (on-line): 1806-3756 | ISSN (printed): 1806-3713
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International collaboration among medical societies is an effective way to boost Latin American production of articles on tuberculosis
A colaboração internacional entre sociedades médicas é uma forma eficaz de aumentar a produção de artigos sobre tuberculose na América Latina
Giovanni Battista Migliori1,a, Rosella Centis1,b, Lia D'Ambrosio2,c, Denise Rossato Silva3,d, Adrian Rendon4,e
J Bras Pneumol.2019;45(2):e20180420-e20180420Abstract PDF PT PDF EN Portuguese Text Appendix
Objective: Most studies of tuberculosis originate from high-income countries with a low incidence of tuberculosis. A review of the scientific production on tuberculosis in Latin American countries, most of which are low- or middle-income countries (some with high or intermediate tuberculosis incidence rates), would improve the understanding of public health challenges, clinical needs, and research priorities. The aims of this systematic review were to determine what has been published recently in Latin America, to identify the leading authors involved, and to quantify the impact of international collaborations. Methods: We used PubMed to identify relevant manuscripts on pulmonary tuberculosis (PTB), drug-resistant tuberculosis (DR-TB), or multidrug-resistant tuberculosis (MDR-TB), published between 2013 and 2018. We selected only studies conducted in countries with an annual tuberculosis incidence of ≥ 10,000 reported cases and an annual MDR-TB incidence of ≥ 300 estimated cases, including Brazil, Peru, Mexico, Colombia, and Argentina. Articles were stratified by country, type, and topic. Results: We identified as eligible 395 studies on PTB and 188 studies on DR/MDR-TB-of which 96.4% and 96.8%, respectively, were original studies; 35.5% and 32.4%, respectively, had an epidemiological focus; and 52.7% and 36.2%, respectively, were conducted in Brazil. The recent Latin American Thoracic Association/European Respiratory Society/Brazilian Thoracic Association collaborative project boosted the production of high-quality articles on PTB and DR/MDR-TB in Latin America. Conclusions: Most of the recent Latin American studies on tuberculosis were conducted in Brazil, Mexico, or Peru. Collaboration among medical societies facilitates the production of scientific papers on tuberculosis. Such initiatives are in support of the World Health Organization call for intensified research and innovation in tuberculosis.
Clinical characteristics and evolution of non-HIV-infected immunocompromised patients with an in-hospital diagnosis of tuberculosis
Características clínicas e evolução de pacientes imunocomprometidos não HIV com diagnóstico intra-hospitalar de tuberculose
Denise Rossato Silva, Diego Millán Menegotto, Luis Fernando Schulz, Marcelo Basso Gazzana, Paulo de Tarso Roth Dalcin
J Bras Pneumol.2010;36(4):-Abstract PDF PT PDF EN Portuguese Text
Objective: To investigate the characteristics of and risk factors for mortality among non-HIV-infected immunocompromised patients with an in-hospital diagnosis of tuberculosis. Methods: This was a two-year, retrospective cohort study of patients with an in-hospital diagnosis of tuberculosis. The predictive factors for mortality were evaluated. Results: During the study period, 337 hospitalized patients were diagnosed with tuberculosis, and 61 of those patients presented with immunosuppression that was unrelated to HIV infection. Extrapulmonary tuberculosis was found in 47.5% of cases. In the latter group, the in-hospital mortality rate was 21.3%, and the mortality rate after discharge was 18.8%. One-year survival was significantly higher among the immunocompetent patients than among the HIV patients (p = 0.008) and the non-HIV-infected immunocompromised patients (p = 0.015), although there was no such difference between the two latter groups (p = 0.848). Among the non-HIV-infected immunocompromised patients, the only factor statistically associated with mortality was the need for mechanical ventilation. Among the patients over 60 years of age, fibrosis/atelectasis on chest X-rays and dyspnea were more common, whereas fever and consolidations were less common. Fever was also less common among the patients with neoplasms. The time from admission to the initiation of treatment was significant longer in patients over 60 years of age, as well as in those with diabetes and those with end-stage renal disease. Weight loss was least common in patients with diabetes and in those using corticosteroids. Conclusions: The lower prevalence of classic symptoms, the occurrence of extrapulmonary tuberculosis, the delayed initiation of treatment, and the high mortality rate reflect the diagnostic and therapeutic challenges of tuberculosis in non-HIV-infected immunocompromised patients.
Doença de Kikuchi-Fujimoto
Rogério Gastal Xavier, Denise Rossato Silva, Mauro Waldemar Keiserman, Maria Francisca Torres Lopes
J Bras Pneumol.2008;34(12):1074-1078Abstract PDF PT PDF EN Portuguese Text
Kikuchi-Fujimoto disease is characterized by fever and lymphadenopathy, usually localized in the cervical region. This disease principally affects young females. It can be confused with lymphoma, adenocarcinoma metastasis and tuberculosis. We report two cases of Kikuchi‑Fujimoto disease. In the first case, a 28-year-old female had been treated for tuberculosis one year prior and presented with a clinical and histological profile consistent with Kikuchi-Fujimoto disease. The second patient, a 58-year-old female, initially received treatment for Wegener's granulomatosis and, subsequently, for tuberculosis. Histopathological examination followed by immunohistochemical analysis confirmed the diagnosis of Kikuchi-Fujimoto disease in both cases. After the definitive diagnosis had been made, both patients were treated symptomatically, and both presented clinical improvement within one month. Subsequently, the latter patient developed systemic lupus erythematosus.
Bronchodilator effect on maximal breath-hold time in patients with obstructive lung disease
Efeito do broncodilatador no tempo de apneia voluntária máxima em pacientes com distúrbios ventilatórios obstrutivos
Raqueli Biscayno Viecili, Paulo Roberto Stefani Sanches, Denise Rossato Silva, Danton Pereira da Silva, André Frota Muller, Sergio Saldanha Menna Barreto
J Bras Pneumol.2011;37(6):745-751Abstract PDF PT PDF EN Portuguese Text
Objective: To identify the role of bronchodilators in the maximal breath-hold time in patients with obstructive lung disease (OLD). Methods: We conducted a case-control study including patients with OLD and a control group. Spirometric tests were performed prior to and after the use of a bronchodilator, as were breath-hold tests, using an electronic microprocessor and a pneumotachograph as a flow transducer. Respiratory flow curves were displayed in real time on a portable computer. The maximal breath-hold times at end-inspiratory volume and at end-expiratory volume (BHTmaxVEI and BHTmaxVEE, respectively) were determined from the acquired signal. Results: A total of 35 patients with OLD and 16 controls were included. Prior to the use of a bronchodilator, the BHTmaxVEI was significantly lower in the OLD group than in the control group (22.27 ± 11.81 s vs. 31.45 ± 15.73 s; p = 0.025), although there was no significant difference between the two groups in terms of the post-bronchodilator values (24.94 ± 12.89 s vs. 31.67 ± 17.53 s). In contrast, BHTmaxVEE values were significantly lower in the OLD group than in the control group, in the pre- and post-bronchodilator tests (16.88 ± 6.58 s vs. 22.09 ± 7.95 s; p = 0.017; and 21.22 ± 9.37 s vs. 28.53 ± 12.46 s; p = 0.024, respectively). Conclusions: Our results provide additional evidence of the clinical usefulness of the breath-hold test in the assessment of pulmonary function and add to the existing knowledge regarding the role of the bronchodilator in this test.
Eliminating tuberculosis in Latin America: making it the point
Eliminação da tuberculose na América Latina: considerações
Raquel Duarte1,2,3,a, Denise Rossato Silva4,b, Adrian Rendon5,c, Tatiana Galvẫo Alves6,d, Marcelo Fouad Rabahi7,e, Rosella Centis8,f, Afrânio Kritski9,g, Giovanni Battista Migliori8,h
J Bras Pneumol.2018;44(2):73-76PDF PT PDF EN Portuguese Text
Septic pulmonary embolism secondary to jugular thrombophlebitis: a case of Lemierre's syndrome
Embolia pulmonar séptica secundária à tromboflebite jugular: um caso de síndrome de Lemierre
Denise Rossato Silva, Marcelo Basso Gazzana, Ricardo Albaneze, Paulo de Tarso Roth Dalcin, Josi Vidart, Nei Gulcó
J Bras Pneumol.2008;34(12):1079-1083Abstract PDF PT PDF EN Portuguese Text
Abstract Lemierre's syndrome is characterized by acute oropharyngeal infection, complicated by internal jugular venous thrombosis secondary to septic thrombophlebitis, and by metastatic infections in various distant organs-most commonly in the lungs. We report a case of Lemierre's syndrome in a 56-year-old female who presented with right-sided neck mass and fever. Right internal jugular venous thrombosis was demonstrated on an ultrasound. A computed tomography scan of the chest revealed multiple opacities throughout both lungs. An open surgical biopsy was performed due to suspicion of pulmonary metastases. Anatomopathological examination revealed septic emboli in lung parenchyma. Retrospectively, the patient reported a history of pharyngitis two weeks prior to hospitalization. After the diagnosis had been made, the patient was treated with broad-spectrum antibiotics (cefuroxime for 7 days and azithromycin for 5 days; subsequently, because fever persisted, cefepime for 7 days). One month later, a computed tomography scan of the chest revealed resolution of the opacities.
Risk factors for tuberculosis: diabetes, smoking, alcohol use, and the use of other drugs
Fatores de risco para tuberculose: diabetes, tabagismo, álcool e uso de outras drogas
Denise Rossato Silva1,a, Marcela Muñoz-Torrico2,b, Raquel Duarte3,4,c, Tatiana Galvão5,d, Eduardo Henrique Bonini6,7,e, Flávio Ferlin Arbex6,f, Marcos Abdo Arbex6,g, Valéria Maria Augusto8,h, Marcelo Fouad Rabahi9,i, Fernanda Carvalho de Queiroz Mello10,j
J Bras Pneumol.2018;44(2):145-152Abstract PDF PT PDF EN Portuguese Text
Tuberculosis continues to be a major public health problem. Although efforts to control the epidemic have reduced mortality and incidence, there are several predisposing factors that should be modified in order to reduce the burden of the disease. This review article will address some of the risk factors associated with tuberculosis infection and active tuberculosis, including diabetes, smoking, alcohol use, and the use of other drugs, all of which can also contribute to poor tuberculosis treatment results. Tuberculosis can also lead to complications in the course and management of other diseases, such as diabetes. It is therefore important to identify these comorbidities in tuberculosis patients in order to ensure adequate management of both conditions.
Idiopathic pulmonary fibrosis and emphysema in smokers
Fibrose pulmonar idiopática simultânea a enfisema em pacientes tabagistas
Denise Rossato Silva, Marcelo Basso Gazzana, Sérgio Saldanha Menna Barreto, Marli Maria Knorst
J Bras Pneumol.2008;34(10):779-786Abstract PDF PT PDF EN Portuguese Text
Objective: To describe the clinical and functional findings recently reported in the medical literature for patients diagnosed with emphysema involving the upper lobes and idiopathic pulmonary fibrosis (IPF) involving the lower lobes. Methods: Eleven patients with emphysema and IPF were identified retrospectively. All of the patients underwent high-resolution computed tomography of the lung and pulmonary function tests. Results: Of the 11 patients, 8 were male and 3 were female. The mean age was 70.7 ± 7.2 years (range, 61-86 years). All of the patients were smokers (mean smoking history, 61.5 ± 43.5 pack-years). The mean values of forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and FEV1/FVC were 72.1 ± 12.7%, 68.2 ± 11.9% and 74.4 ± 10.8, respectively. Lung volumes were normal in 7 patients. A restrictive pattern was observed in 3 patients, and hyperinflation was present in one. The diffusing capacity was moderatelyto- severely reduced in all of the patients (mean, 27.7% ± 12.9% of predicted). Ten of the 11 patients performed the six-minute walk test. The mean distance covered was 358.4 ± 143.1 m, and 9 of the 10 patients presented desaturation ≥ 4%. Echocardiographic findings suggestive of pulmonary hypertension were present in 4 patients (mean systolic pulmonary artery pressure, 61.8 mmHg; range, 36-84 mmHg). Conclusions: The concomitant presence of emphysema and IPF causes characteristic changes on pulmonary function tests. The most significant finding is a discrepancy between diffusing capacity and spirometry results.
Global TB Network: working together to eliminate tuberculosis
Global TB Network: trabalhando juntos para eliminar a tuberculose
Denise Rossato Silva1,a, Adrian Rendon2,b, Jan-Willem Alffenaar3,c, Jeremiah Muhwa Chakaya4,5,d, Giovanni Sotgiu6,e, Susanna Esposito7,f, Giovanni Battista Migliori8,g
J Bras Pneumol.2018;44(5):347-349PDF PT PDF EN Portuguese Text
Pulmonary arterial hypertension and thyroid disease
Hipertensão arterial pulmonar e doenças da tireoide
Denise Rossato Silva, Marcelo Basso Gazzana, Ângela Beatriz John, Débora Rodrigues Siqueira, Ana Luiza Silva Maia, Sérgio Saldanha Menna Barreto
J Bras Pneumol.2009;35(2):179-185Abstract PDF PT PDF EN Portuguese Text
Recent studies have suggested an association between pulmonary arterial hypertension (PAH) and thyroid diseases (hypothyroidism and hyperthyroidism). This combination has a good prognosis, because the increase in the pulmonary artery pressure is usually slight and reverses after the treatment of the thyroid disease. Although the exact mechanism involved in the pathogenesis of this combination has not yet been established, it has been hypothesized that thyroid hormones and autoimmunity have a direct influence. Due to the high prevalence of thyroid disease in patients with PAH, thyroid function tests should be considered in the investigation of every patient with PAH. In this review, we describe the prevalence of PAH in patients with thyroid diseases and the prevalence of thyroid disease in patients with PAH, as well as addressing the principal effects that thyroid diseases have on the respiratory system. In addition, we report the treatment effects in patients with these diseases.
Latent tuberculosis infection in patients with rheumatic diseases
Infecção latente por tuberculose em pacientes com doenças reumatológicas
Camila Anton1,2,a, Felipe Dominguez Machado1,2,b, Jorge Mario Ahumada Ramirez1,2,c, Rafaela Manzoni Bernardi1,2,d, Penélope Esther Palominos3,e, Claiton Viegas Brenol3,f, Fernanda Carvalho de Queiroz Mello4,g, Denise Rossato Silva1,2,h
J Bras Pneumol.2019;45(2):e20190023-e20190023Abstract PDF PT PDF EN Portuguese Text
Most people infected by Mycobacterium tuberculosis (Mtb) do not have any signs or disease symptoms, a condition known as latent tuberculosis infection (LTBI). The introduction of biological agents, mainly tumor necrosis factor (TNF) inhibitors, for the treatment of immune-mediated diseases such as Rheumatoid Arthritis (RA) and other rheumatic diseases, increased the risk of reactivation of LTBI, leading to development of active TB. Thus, this review will approach the aspects related to LTBI in patients with rheumatologic diseases, especially those using iTNF drugs. For this purpose it will be considered the definition and prevalence of LTBI, mechanisms associated with diseases and medications in use, criteria for screening, diagnosis and treatment. Considering that reactivation of LTBI accounts for a large proportion of the incidence of active TB, adequate diagnosis and treatment are crucial, especially in high-risk groups such as patients with rheumatologic diseases.
New and repurposed drugs to treat multidrug- and extensively drug-resistant tuberculosis
Novos fármacos e fármacos repropostos para o tratamento da tuberculose multirresistente e extensivamente resistente
Denise Rossato Silva1,a, Margareth Dalcolmo2,b, Simon Tiberi3,c, Marcos Abdo Arbex4,5,d, Marcela Munoz-Torrico6,e, Raquel Duarte7,8,9,f, Lia D'Ambrosio10,11,g, Dina Visca12,h, Adrian Rendon13,i, Mina Gaga14,j, Alimuddin Zumla15,k, Giovanni Battista Migliori10,l
J Bras Pneumol.2018;44(2):153-460Abstract PDF PT PDF EN Portuguese Text
Multidrug-resistant and extensively drug-resistant tuberculosis (MDR-TB and XDR-TB, respectively) continue to represent a challenge for clinicians and public health authorities. Unfortunately, although there have been encouraging reports of higher success rates, the overall rate of favorable outcomes of M/XDR-TB treatment is only 54%, or much lower when the spectrum of drug resistance is beyond that of XDR-TB. Treating M/XDR-TB continues to be a difficult task, because of the high incidence of adverse events, the long duration of treatment, the high cost of the regimens used, and the drain on health care resources. Various trials and studies have recently been undertaken (some already published and others ongoing), all aimed at improving outcomes of M/XDR-TB treatment by changing the overall approach, shortening treatment duration, and developing a universal regimen. The objective of this review was to summarize what has been achieved to date, as far as new and repurposed drugs are concerned, with a special focus on delamanid, bedaquiline, pretomanid, clofazimine, carbapenems, and linezolid. After more than 40 years of neglect, greater attention has recently been paid to the need for new drugs to fight the "white plague", and promising results are being reported.
The role of the Brazilian Tuberculosis Research Network in national and international efforts to eliminate tuberculosis
O papel da Rede Brasileira de Pesquisas em Tuberculose nos esforços nacionais e internacionais para a eliminação da tuberculose
Afranio Kritski1,a, Margareth Pretti Dalcolmo2,b, Fernanda Carvalho Queiroz Mello3,c, Anna Cristina Calçada Carvalho4,d, Denise Rossato Silva5,e, Martha Maria de Oliveira6,f, Julio Croda7,8,g
J Bras Pneumol.2018;44(2):77-81PDF PT PDF EN Portuguese Text
Epidemiological aspects of respiratory symptoms treated in the emergency room of a tertiary care hospital
Perfil epidemiológico dos atendimentos de emergência por sintomas respiratórios emum hospital terciário
Denise Rossato Silva, Vinícius Pellegrini Viana, Alice Mânica Müller, Ana Cláudia Coelho,Gracieli Nadalon Deponti, Fernando Pohlmann Livi, Paulo de Tarso Roth Dalcin
J Bras Pneumol.2013;39(2):164-172Abstract PDF PT PDF EN Portuguese Text
Objective: To evaluate the prevalence of respiratory symptoms as the motive for emergency room visits by adult and pediatric patients, describing the major clinical syndromes diagnosed and the outcomes of the patients. Methods: A cross-sectional study conducted in the emergency room of a tertiary care university hospital. Between November of 2008 and November of 2009, we reviewed the total number of emergency room visits per day. Children and adults who presented with at least one respiratory symptom were included in the study. The electronic medical records were reviewed, and the major characteristics of the patients were recorded. Results: During the study period, there were 37,059 emergency room visits, of which 11,953 (32.3%) were motivated by respiratory symptoms. The prevalence of emergency room visits due to respiratory symptoms was 28.7% and 38.9% among adults and children, respectively. In adults, the rates of hospitalization and mortality were 21.2% and 2.7%, respectively, compared with 11.9% and 0.3%, respectively, in children. Among the adults, the time from symptom onset to emergency room visit correlated positively with the need for hospitalization (p < 0.0001), the length of the hospital stay (p < 0.0001), and the mortality rate (p = 0.028). Conclusions: We found a high prevalence of respiratory symptoms as the motive for emergency room visits by adult and pediatric patients. Our results could inform decisions regarding the planning of prevention measures. Further epidemiological studies are needed in order to clarify the risk factors for severe respiratory symptoms.
Série tuberculose
Denise Rossato Silva1,a, Fernanda Carvalho de Queiroz Mello2,b, Afrânio Kritski3,c, Margareth Dalcolmo4,d, Alimuddin Zumla5,e, Giovanni Battista Migliori6
J Bras Pneumol.2018;44(2):71-72PDF PT PDF EN Portuguese Text
Série tuberculose 2019
Denise Rossato Silva1,a, Giovanni Battista Migliori2,b, Fernanda Carvalho de Queiroz Mello3,c
J Bras Pneumol.2019;45(2):e20190064-e20190064PDF PT PDF EN Portuguese Text
Managing severe tuberculosis and its sequelae: from intensive care to surgery and rehabilitation
Tratamento da tuberculose grave e suas sequelas: da terapia intensiva à cirurgia e reabilitação
Simon Tiberi1,2,a, Marcela Muñoz Torrico3,b, Ananna Rahman1,c, Maria Krutikov1,d, Dina Visca4,e, Denise Rossato Silva5,f, Heinke Kunst2,g, Giovanni Battista Migliori4,h
J Bras Pneumol.2019;45(2):e20180324-e20180324Abstract PDF PT PDF EN Portuguese Text
Multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) continue to challenge physicians and public health specialists. Global treatment outcomes continue to be unsatisfactory, positive outcomes being achieved in only 54% of patients. Overall outcomes are even worse in patients infected with highly resistant strains. Treating MDR-/XDR-TB is difficult because of frequent adverse events, the long duration of drug regimens, the high costs of second-line drugs, chronic post-infectious sequelae, and loss of organ function. Ongoing research efforts (studies and trials) have various aims: increasing the rates of treatment success; understanding the potentialities of new and repurposed drugs; shortening the treatment duration; and reducing the rates of adverse events. It is hoped that better access to rapid diagnostics, increased awareness, and treatments that are more effective will reduce the rate of complications and of lung function impairment. This article aims to discuss the management of severe tuberculosis (defined as that which is potentially life threatening, requiring higher levels of care) and its sequelae, from intensive care to the postoperative period, rehabilitation, and recovery. We also discuss the nonpharmacological interventions available to manage chronic sequelae and improve patient quality of life. Because the majority of MDR-/XDR-TB cases evolve to lung function impairment (typically obstructive but occasionally restrictive), impaired quality of life, and low performance status (as measured by walk tests or other metrics), other interventions (e.g., smoking cessation, pulmonary rehabilitation, vaccination/prevention of secondary bacterial infections/exacerbations, complemented by psychological and nutritional support) are required.
Tuberculosis in hospitalized patients: clinical characteristics of patients receiving treatment within the first 24 h after admission
Tuberculose em pacientes hospitalizados: características clínicas dos pacientes que iniciaram tratamento nas primeiras 24 h de permanência hospitalar
Denise Rossato Silva, Larissa Pozzebon da Silva, Paulo de Tarso Roth Dalcin
J Bras Pneumol.2014;40(3):279-285Abstract PDF PT PDF EN Portuguese Text
Objective: To evaluate clinical characteristics and outcomes in patients hospitalized for tuberculosis, comparing those in whom tuberculosis treatment was started within the first 24 h after admission with those who did not. Methods: This was a retrospective cohort study involving new tuberculosis cases in patients aged ≥ 18 years who were hospitalized after seeking treatment in the emergency room. Results: We included 305 hospitalized patients, of whom 67 (22.0%) received tuberculosis treatment within the first 24 h after admission (≤24h group) and 238 (88.0%) did not (>24h group). Initiation of tuberculosis treatment within the first 24 h after admission was associated with being female (OR = 1.99; 95% CI: 1.06-3.74; p = 0.032) and with an AFB-positive spontaneous sputum smear (OR = 4.19; 95% CI: 1.94-9.00; p < 0.001). In the ≤24h and >24h groups, respectively, the ICU admission rate was 22.4% and 15.5% (p = 0.258); mechanical ventilation was used in 22.4% and 13.9% (p = 0.133); in-hospital mortality was 22.4% and 14.7% (p = 0.189); and a cure was achieved in 44.8% and 52.5% (p = 0.326). Conclusions: Although tuberculosis treatment was initiated promptly in a considerable proportion of the inpatients evaluated, the rates of in-hospital mortality, ICU admission, and mechanical ventilation use remained high. Strategies for the control of tuberculosis in primary care should consider that patients who seek medical attention at hospitals arrive too late and with advanced disease. It is therefore necessary to implement active surveillance measures in the community for earlier diagnosis and treatment.
Severe tuberculosis requiring ICU admission
Tuberculose grave com necessidade de internação em UTI
Denise Rossato Silva, Marcelo Basso Gazzana, Paulo de Tarso Roth Dalcin
J Bras Pneumol.2012;38(3):386-394Abstract PDF PT PDF EN Portuguese Text
Tuberculosis is a curable disease that can evolve to severe forms, requiring the treatment of the patients in an ICU, especially if there is a delay in the diagnosis or if it affects elderly patients, those on dialysis, or those with HIV infection or other states of immunosuppression, as well as in cases of multidrug resistant disease. Knowledge of the radiological presentation of the cases can help diagnose these severe forms, as can the introduction of new tests, such as the early detection of the etiological agent by PCR and chest CT, which favors the early initiation of treatment. In addition, the use of regimens without isoniazid and rifampin, as well as uncertain enteral absorption and low serum concentrations of antituberculosis drugs, can reduce the efficacy of treatment. For such patients, the prognosis is generally poor and mortality rates are high.
Pulmonary tuberculosis and lung cancer: simultaneous and sequential occurrence
Tuberculose pulmonar e câncer de pulmão: ocorrência simultânea ou sequencial
Denise Rossato Silva, Dirceu Felipe Valentini Junior, Alice Mânica Müller, Carlos Podalirio Borges de Almeida, Paulo de Tarso Roth Dalcin
J Bras Pneumol.2013;39(4):-Abstract PDF PT PDF EN Portuguese Text
Objective: Lung cancer (LC) is the leading cause of cancer-related death and represents a major public health problem worldwide. Another major cause of morbidity and mortality, especially in developing countries, is tuberculosis. The simultaneous or sequential occurrence of pulmonary tuberculosis and LC in the same patient has been reported in various case series and case-control studies. The objective of this study was to describe the characteristics of patients developing tuberculosis and LC, either simultaneously or sequentially. Methods: This was a cross-sectional study based on the review of medical charts. Results: The study involved 24 patients diagnosed with tuberculosis and LC between 2009 and 2012. The diagnoses of tuberculosis and LC occurred simultaneously in 10 patients, whereas tuberculosis was diagnosed prior to LC in 14. The median time between the two diagnoses was 5 years (interquartile range: 1-30 years). Fourteen patients (58.3%) were male, 20 (83.3%) were White, and 22 (91.7%) were smokers or former smokers. The most common histological type was adenocarcinoma, identified in 14 cases (58.3%), followed by epidermoid carcinoma, identified in 6 (25.0%). Seven patients (29.2%) presented with distant metastases at diagnosis; of those 7 patients, 5 (71%) were diagnosed with LC and tuberculosis simultaneously. Conclusions: In the present study, most of the patients with tuberculosis and LC were smokers or former smokers, and tuberculosis was diagnosed either before or simultaneously with LC. Non-small cell lung cancer, especially adenocarcinoma, was the most common histological type.
Tuberculose: onde estamos?
Fernanda Carvalho de Queiroz Mello1,a, Denise Rossato Silva2,b, Margareth Pretti Dalcolmo3,c
J Bras Pneumol.2018;44(2):82-82PDF PT PDF EN Portuguese Text
Copyright 2020 - Brazilian Thoracic Association


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Malaysia: Workers report poor working conditions & low wages at Karex factories
A report alleged that workers in Karex factories were "liviing in cramped and undignified conditions" and in "damp and unhygienic dormitories.
Karex released a statement saying that it "does no believe that forced labour or modern slavery is currently occuring at our factories". Further, it earlier committed that it would hire "an independent firm specialising in ethical trade, human rights, labour standards" to carry out a "full social analysis".
The same report identified some of Karex's major buyers and these entities have released statements, which were included in the report.
Business & Human Rights Resource Centre reached out to USAID to also get their response-- this is linked below.Get RSS feed of these results
All components of this story
USAID response to allegations against Karex
Author: USAID
Note: Business & Human Rights Resource Centre reached out to USAID as regards the allegations against Karex. Its response is found below.
We want to assure you that USAID takes these allegations very seriously and referred the information to the Office of Inspector General.
USAID directed the implementing partner to prepare a risk mitigation plan to ensure that alternate suppliers and products are available and registered to support continuity of supply to USAID programs and partners. As of February 2019, no new orders have been placed with Karex.
USAID requires all implementing partners to comply with the U.S. Government's Federal Acquisition Regulation, "Combating Trafficking in Persons." Further procurement through USAID implementing partners may be considered after Karex demonstrates compliance with federal acquisition regulations via independent third-party validation.
USAID is committed to ending human trafficking. Since 2001, USAID has supported Counter-Trafficking in Persons programs in over 71 countries.
Malaysia: Condom supplier to NHS and British retailers accused of 'shameful' working conditions & labour abuses
Author: Nicola Smith, The Telegraph
"Revealed: Condom supplier to NHS and British high street accused of 'shameful' working conditions", 23 January 2019
...The Telegraph talked to 22 Nepali and Bangladeshi employees of Karex's condom... factories [in Malaysia]... workers were living in cramped and undignified conditions... in damp and unhygienic dormitories...
Karex produces five billion condoms a year, accounting for roughly 15 per cent of the world market... [It's] website... video claims the firm is "helping humanity one condom at a time". It describes itself as a "champion social responsibility and sustainability".
Karex owns... Pasante Healthcare Ltd... which distributes its products in the UK... [C]lients include Tesco, Boots, Superdrug and Costco [and the NHS]. Globally Karex boasts a "clientele of... retailers in over 130 countries". These... included... Reckitt Benkiser, the owner of Durex, and Global Protection Corp...
Karex said...it "does not believe that forced labour or modern slavery is currently occurring at our factories". However... the Karex CEO, said the company... would hire "an independent firm specialising in ethical trade, human rights, labour standards" to carry out a "full social analysis" within 45 days. A committee of management and employees would also be created...
All those interviewed... said they would struggle to survive without daily overtime... The workers financial woes are compounded by fees demanded by recruitment firms and brokers in their home countries, which leave them in debt bondage for much of their first year of employment.
...An NHS Supply Chain spokesperson said: "We take all allegations concerning labour standard abuses very seriously and have contacted the supplier about this matter."...
Superdrug said... [i]t's most recent audit was conducted last week. "We have temporarily suspended all orders with the Karex Group however we have had an urgent call with our supplier to discuss the findings from our [recent] audit and these do not raise concerns"...
Tesco said it had also visited the factory last week and... had identified "a number of serious concerns". It added: "We immediately suspended Tesco production at the site pending further investigation..."
Reckitt Benkiser, owner of Durex, said... it had a "zero tolerance" policy on human rights abuses. "We audited this Karex facility in 2018 and have been in active dialogue with the company to implement necessary corrective actions,"...
Global Protection Corp said: "We are taking this very seriously, and are already working with Karex to investigate."
Boots had not replied at the time of going to press and USAID could not respond because of the US government shutdown.
- Related stories: Malaysia: Workers report poor working conditions & low wages at Karex factories
- Related in-depth areas: Beyond Social Auditing
- Related companies: Boots (now Alliance Boots) Costco Global Protection Corp (part of Karex) Karex Reckitt Benckiser Superdrug (part of Hutchison Whampoa) Tesco


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text: House Bill 1069 House Bill 1069 ARCHIVE (2000) Latest Information DIGEST OF HB1069 (Updated January 25, 2000 5:46 PM - DI 96) Sport utility vehicles in highway funding. Specifies that, for purposes of highway funding and the motor vehicle laws, a van, sport utility vehicle, or other motor vehicle is a passenger motor vehicle and not a truck if it is designed primarily for carrying passengers. Replaces the term "passenger car" with "passenger motor vehicle" in the allocation formula for the local road and street account in order to include van and sport utility vehicle registrations in the formula. Current Status:In Committee - first House Latest Printing (PDF) Action ListIntroduced Bill (PDF) Fiscal Impact Statement(s): >1(PDF) House Committee Reports Filed Committee Reports: >1069-1, >1069-1(PDF) Passed Committee Reports: >1069-1, >1069-1(PDF) House Amendments Senate Committee Reports Senate Amendments Conference Committee Reports


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The intrigues which have accompanied the race for the Senate Presidency have left the ruling party in the country, the All Progressives Congress (APC) in a state of disarray for long time.
However, there seem to be some sort of respite from the whole brouhaha as the President who had been quiet for a long time has finally made a timely intervention.
Before we analyse the sagacity of the President, let us go back to the genesis of the problem so that we can get a better understanding of what led to the issues in the first place, and what this recent development entails.
It had begun in 2015, after the All Progressives Congress (APC) swept the polls across the country in virtually all the elections. The positions of the National Assembly were not left out of the political tsunami as the APC produced the majority in both chambers of the Assembly.
Top shots in the party went on to hand-pick certain candidates to serve as the Senate President and Speaker of the House of Reps. That was where the root of every issue that was to bedevil the ruling party – as far as the National Assembly was concerned – began.
In 2015, the APC seem were not really prepared for power as it was the first time another party would be taking over from the Peoples Democratic Party, PDP, at the Federal Level. The events that followed the victory of the party in the elections showed that a serious problem was lurking in the horizon.
The party had touted Senator Ahmed Lawan for the position of Senate Presidency, while Hon. Femi Gbajabiamila was positioned to serve as Speaker of the House of Reps. This however, did not see the light of day as Senator Bukola Saraki, a member of the APC then, connived with his loyalists in the party and members of the opposition, PDP, to emerge as Senate President.
In the process, a Senator from the opposition, Ike Ekweremadu, emerged as the Deputy Senate President, which had never occurred in the history of the country.
In like manner, Yakubu Dogara, who was a member of the APC as well, connived with PDP House Members who gave him their bloc vote and enabled him to defeat the anointed candidate of the APC, Femi Gbajabiamila, in the Speakership race.
Fast forward to 2019, this same problem reared its head once more, after the ruling party again emerged victorious at the polls.
At a parley with lawmaker-elects and the President almost immediately after results were declared, the National Chairman of the All Progressives Congress (APC) announced that the party had settled for both Ahmed Lawan and Femi Gbajabiamila to head the National Assembly.
This had left some of the lawmaker-elects on the platform of the ruling party in dismay, as they had claimed that there was no consultations with them before the choice was made, with some saying that they had intentions to run for these positions as well.
Thus the problem which had knocked the dreams of the party in 2015 was reborn. Two prominent Senators in the fold of the party, Senator Ali Ndume and Senator Danjuma Goje, had indicated their interest in running for Senate Presidency, with both vowing not to step down for Senator Ahmed Lawan, the anointed candidate of the party.
As if the defiance of both Senators was not enough, the National Leader of the All Progressives Congress (APC), Bola Tinubu had said that anybody who is refusing to tow the line of the party will be dealt with. The National Chairman of the party had also said that the decision of the party was final, and that the APC would not share any of its power with the opposition PDP.
This had further infuriated the dissenting law makers as they vowed not to allow an imposition on the National Assembly as it was supposed to be an independent arm of government.
Vice President, Yemi Osinbajo had even held a meeting with Senator Ali Ndume who had been the most vocal on his aspirations. Ndume however, at the end of the meeting had said no one could tell him to step down from the Senate Presidency race, as he had made his intentions known to both the President and the National Leader of the party even before coming out to declare, and that none of them had told him to step down.
It was looking like the 2015 experience was bound to occur all over again, with the PDP fancying their chances after they were awarded three additional seats in the Senate, swelling the number of senators in their ranks to 44.
Something had to be done, and fast, as the President had lamented on the frosty relationship he had with the past leadership of the National Assembly.
This prompted the President to call for a meeting with the Senator who was rumoured to be the choice of the opposition party, PDP, for Senate President, Senator Danjuma Goje.
The meeting turned out to be productive as the Governor of Kaduna State, Nasir el-Rufai, announced that Senator Goje had dropped his aspirations and had declared his support for Lawan.
In his own words, while explaining his decision, Senator Goje said the following:
"Instead, I am supporting the party's position thereby endorsing the candidature of Sen. Lawan.
"I am not compelled to step down; I have been winning my elections many times from local government to House of Assembly to National Assembly to governorship and I was also a minister.
"To say that I have been threatened to support somebody, no. I am supporting Lawan based on my own conviction that I am doing the right thing for our country, for our president.''
This move is a very deft one as the PDP will have to go back to the drawing board to decide on who they will now pit up against the choice of the APC in the National Leadership tussle.
What is more? The PDP will currently be in a state of disarray as the time left for the opposition party to strategise and perfect their plans is very limited – barely one week.
With this show of political maturity, the President and his party, the APC may have just proven that they are now ready for business, as the coast seems clear for the party to finally see its wish come true, after a four year delay.
Do you agree with this assertion? Let us know with your comments in the comment section below.


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I had built confidence in myself, I was perfectly content with my body and was happy to express my sexuality through suggestive dance. Its census showed [21] that the ratio of girls to boys under the age of 6 years old has dropped even during the past decade, from girls for every boys in to girls for every boys in Gender feminists also consider traditional feminine traits gentleness, modesty, humility, sacrifice, supportiveness, empathy, compassion, tenderness, nurturance, intuitiveness, sensitivity, unselfishness morally superior to the traditional masculine traits of courage, strong will, ambition, independence,assertiveness, initiative, rationality and emotional control. Mary Cassatt painted many famous Impressionist works that idealize the innocence of girls and the mother-daughter bond, for example her work Children on the Beach. The bed was even greater than the last. You got it!
Cute Latina Students Giving Head
Kandy, on another occasion, had asked me if I liked a particular music group. I remember thinking how odd that was at the time. Lizzy wasn't sure all the girls would come, since they were being assembled at my house, but they did. When they got there I directed them to the den, where there were two couches and some chairs.
Lizzy hadn't told them anything about why they were there, but I had set up a computer linked to the 55" flat screen TV on the wall. I had also gone back to the tumblr site, once I got home, and downloaded all ten of the pictures the girls had taken. I put them into a Power Point presentation on a constant loop, and had it running with the TV off. Once all the girls were there, were comfortably seated, and had something to drink, I began speaking.
That's what you are all here to do today She was the confident overconfident one, and a natural leader. There was stunned silence at first, then gasps, and then mutters. I clearly heard one female voice say "What the fuck? I bent to the laptop and minimized Power Point. I had a tumblr site up on the web browser.
That's the one I had on the screen. I saw Sam looking at the address bar, and the name of the site. Somehow, I knew I was busted. That's the mistake you were talking about. Nicole and Lou Anne turned on Samantha. It took another half hour, and moving to ten more sites before it sank in that they were a hell of a lot more visible to the world than they thought they'd been.
Finally Sam said "So what do we do? You're going to work to try to repair the damage. I won't go into details, but what I had the girls do was each take a list of five websites that had reblogged their pictures, and write to each of them, identifying the photos by file name and claiming copyright infringement. The site, assuming the operator cared, was then required to remove that picture from the blog.
Once they had contacted their initial five websites, each girl fanned out from there, finding more and more sites that had posted their pictures. It took them well into the school year until they began having a hard time finding their pictures anywhere. I got to know all of them really well in the process, because there were a number of working sessions at my house, where they could delve into things without fear of a parent finding them staring at page after page of naughty pictures.
You might say fate had lent a hand. I now had four "girlfriends" of a sort.
Mature Wives Nude TumblrWe didn't go out on dates, and there were no make-out sessions or anything like that. But we were all very comfortable in each other's presence. Twice I had seen a little casual kiss passed between the girls as they took a break from working on trying to fix their foolishness.
They knew they could never get them all off the net, but the goal was to get all the newer reblogging down, so that only the old, musty, dusty sites might have an errant photo or two on them, old photos that hopefully few would see, and even fewer would decide to keep. And fate dipped into my life in another way too. Monica met number four. She didn't know he was number four at the time, of course.
In fact, she decided to resist making him number four. In fact, when he started talking marriage, she suggested they take a week between Thanksgiving and Christmas, and do a "trial run at things" at a ski lodge in Vermont. That went really well, and led to him becoming number four, but that doesn't matter here. What matters here is that she asked me to let Lizzy stay with me for that week.
And while Lizzy stayed with me Remember that offhand comment I made? The one where I said the girls should have gotten naked with me instead of plastering their pictures all over the internet? Well I'd forgotten it. She had, in fact, told the girls about it.
So imagine the scene: We had eaten, and Nicole had brought a movie they all wanted to watch on my 55" flat screen, where they had seen themselves, naked, cavorting at a slumber party. I was told to put the chosen DVD in the blue ray player while they all went to "put on their jammies. Now imagine my astonishment as Lizzy, dressed only in those same rainbow knee socks, and followed by a bevy of very naked, very beautiful young women, danced into the room and basically mobbed my chair.
I was covered in naked girls. They were giggling and shrieking and soft and warm and I confess, my hands did not behave themselves. But lest you think this tale has slipped off into the fantasy realm, I won't try to con you into thinking all those girls let me fuck them. No, sadly, it wasn't that way.
Or not so sadly, perhaps. The fact was that, while they had all had crushes on me, Nicole and Lou Ann both had boyfriends now. And Sam was in limbo. She had almost gone to meet her tumblr man, but then had discovered he had lied to her. That, and the amount of work she'd had to do to try to get her naked body off the internet had made her a little put off with men at the moment.
She went along with the plan to reward me by getting naked for me in person, but the truth of the matter was that she was more comfortable with the girls she had loved when she was younger, and who had loved her back, while they experimented with feelings and touches and tongues in pussies. She wasn't a true lesbian. None of them were. They just trusted and loved each other, and that always makes for pretty good sex.
So I did get mauled by naked teenagers, who did have a good time, I'll admit. After all, how often in your life do you get to do something like that and everybody present think it's a great idea? But eventually they got off of me, leaving only Lizzy on my lap.
She held out her hand. Well, Lizzy had her knee socks on, of course, but they did nothing to make her look clothed. I stumbled out, wanting to turn around and look at the three of them one last time. I was pretty sure the next time I saw them they'd have clothes on again. But I didn't, which was good, because I got to see Lizzy's bouncing bottom as each half rose and fell as she walked in front of me, pulling me deeper into the house.
I know this was a stupid question, under the circumstances, but I had to keep talking, or else I might just explode into confetti. When we got there, she had me stand by the door. Then she ran and leapt onto the bed, landing on her stomach. Her knees bent, and she took the weight of her upper body on her elbows.
There was no television, and no game controller, but the pose was obvious. She looked back over her shoulder again. If I didn't know better, I'd think there is a secret class in school where very naughty teachers help little girls learn how to seduce, or entice a man. I don't know the name of the class, but it has the word "teasing" in it.
And Lizzy got an A in that class. She waited until she saw my eyes go between her legs, and spread them a little further as I stared at the same moist looking pussy lips she had accidentally sent me in that email. Then she rolled over onto pillows she had already put in place, to lie back. She pulled her heels up by her butt and let her knees fall apart as her hands went to her big, soft breasts and began mauling them while her fingers moved to squeeze her nipples.
A single finger began going in circles, and I knew her clit was at the center of that little circle. I tore at my clothes and showed her what she had done to me already. It had been a long time for me too. I went and stood right by the bed, staring down at her. I'm desperately tired of being a virgin," she whispered back.
I wasn't sure I'd ever actually met a virgin. It had played through my head ten thousand times. She was even dressed like my fantasy! And in that fantasy I partook of her body in stages, starting with little nibbling kisses that moved from her lush lips to her neck and shoulders, and around her breasts until her straining pink nipples demanded to be suckled.
And after that had given her an orgasm, my dream lips moved down, over her flat belly to the juncture of her legs, where only girls had licked and sucked before me. In my fantasy, it was a good 45 minutes or more before my nasty old uncle penis slipped between her pussy lips and plunged into her body.
That was my fantasy, but if you'll recall how this whole story started, you'll know I don't lie. I fell on her like a ravening wolf. She squealed and flopped and thank goodness she was already excited and well lubed, because I fisted my cock and tried to kill the poor girl with it. I had no control whatsoever, and I took her like a ravening beast. I also spurted within a minute.
The only saving grace was that when I did spurt, her body was finally asserting some control over her mind, which had been somewhat shocked by events thus far. It seems her own fantasy wasn't anything like what happened either. But I was so excited that I couldn't even resort to the normal in and out motions normally associated with having sex.
The fact is that all that in and out movement does is stimulate things, and if things are stimulated enough, it isn't even needed. Talk to somebody who has learned how to do Tantric Sex. Sometimes they don't even move at all while they have sex! And in our case, we were already stimulated enough, which was why, as I spurted and tried to drive my entire body inside her vaginal canal, my pubic bone crushed her helpless clitty and an orgasm crushed her like my body was trying to.
It turns out that orgasm wasn't quite what her fantasy had thought it would be either. It was a lot better. The heels in those rainbow socks started beating a tattoo on my buttocks, which only made me keep grinding against her. And the sounds she made at that point in time instructed my balls to keep pumping, whether there was anything left to pump out or not.
It was interesting, because the intercourse only lasted a minute Finally she fell back, limp and exhausted. I still marvel how two minutes of sex can leave a person as drained as a five mile sprint. I turned my head as I fell on top of my poor niece. All three girls had watched.
I took some weight on my elbows, feeling like I weighed a thousand pounds. Lizzy took a deep breath. I rolled off of her to let her get a real lungful of air. No way he can do me now. The second time was much better. For both of us. This is not to say either of us ever regretted that first crazy, wild animal coupling. In later years, she would put on those socks, and when she did, I knew she wanted it rough.
The second time, though, she was coached by her friends. First, they coached her through sucking me back to rigidity. They were still naked, so I really didn't have any trouble getting rigid. Lizzy was reluctant to take the mess that was my penis into her mouth at first. Then Sam said "It will taste like you on my lips, with him there too, but you'll probably taste yourself more than him.
She sucked on it, moving her tongue all around my still soft member and pulled off with a squelching sound and swallowed. She licked her lips and looked at Sam. The next thing the girls taught her to do was ride it, so that she had the control, instead of me, which meant she could make me last longer. I began to wonder just how experienced these girls were, which only heightened the excitement.
What can I say? Personally, I cannot keep up with my partners sex drive and I am happy he watches pornography to masturbate. It takes the pressure off me and I feel relief knowing that he understands my body is not able to have sex as often as his body would like to. In the animal kingdom, males are generally more aggressive when it comes to the mating ritual, often taking charge.
I suppose you could call it dominating behaviour. This is natural in animals and humans. The idea that the mere existence of porn is degrading to women both as individuals and as a class is a red herring. Using this word exposes the person using it more than it reveals any truth about porn. Any feelings, thoughts or fantasies, of which women and men are capable, are appropriate subjects for art.
Pornography, by its very definition, deals directly and unapologetically with the sexual realm in all its complexity and contradiction. This value-laden assertion is most often made regarding materials taken out of context, often by those who deliberately manipulate the content in the service of an existing prejudice.
They have claimed:. It is not fantasy. These are purely shock tactics. I expect pornography to be mimicked in the real world: Not all porn is hardcore. Finding the right porn for you is much the same as ordering a pizza. You can view pornography without the dirty talk. Not all porn is the same, there are different categories, which is why the Internet is so vast of different types.
Pornography continues to be a contentious matter with those on one side arguing it detrimental to society while others argue it is pleasurable to many and a feature of freedom. However, no matter what, there will always be pornography. There will never be a worldwide ban on producing or viewing pornography. But getting paid to do something degrading does not justify it.
How many dollars would you want to be paid to for each of these acts: These acts are all in certain pornos, and not totally uncommon. Even if you can put a price on these acts, do you think a porn actress is really getting paid that much? Just like any other movie made in Hollywood, porn also uses special effects.
A woman may appear to be flogged and whipped in an adult film, it may leave red marks and her face may seem distraught. A female adult performer is called a performer for a reason- she performs, she is an actress. At the end of the day I reiterate:. They choose what they are happy and not happy to do. This is a mouthful of stereotypes- where do I even start!
Bad parenting also does not make one want to perform in adult movies. It makes no sense. Drug habits and STDs go hand in hand. If someone has a drug problem they are likely to share needles, contract a STD, have sex and pass it on to others. Porn performers are not hired if they are suspected of having a drug problem. There is also a strict no drugs or alcohol policy on set.
Performers are tested as regularly as every 14 days by a certified clinic. These results are uploaded onto an intranet system by the certified clinic so they can no longer be faked or altered. Being tested every days decreases risk and maintains the adult movie industry to be a safe place of work.
Personally I believe adult performers are safer and more aware of their sexual health than the average person. How long have you been having unprotected sex for? When were you last tested? Uneducated is my favourite ignorant statement. Many performers hold high levels of education, degrees and masters degrees. Many performers are using the money they make from adult films to pay for their college tuition, their mortgages, putting it into a savings account or planning to invest it into their future.
And finally, yes, it is an easy way to make money. It takes self-esteem, confidence, thick skin and a sense of humour to go into adult movies head on with criticism from people who are frightened of things they do not understand. Today there are laws and unions to stop exploitation and to make it a safe environment for everyone involved.
The pornography industry employs a vast range of people, not just the performers. Instead, use the videos to explore what turns you on and to allow yourself to have fantasies, Mihalko suggests. Or how you may become curious to try new positions, role-play, or bring a vibrator or handcuffs into the bedroom.
My boyfriend and I had a great discussion about this thesis. He stated: I replied back with: If I watched Dancing with the Stars and wanted to go to ballroom dancing lessons, and pressured you into coming to them with me, would you the resent Dancing with the Stars for giving me the idea? To me, sex and ballroom dancing are an activity. I want you to come ballroom dancing with me because it would mean a lot due to the fact that you are my partner, as you would ask me to have anal sex with you because you want to share me in an experience with you.
Sexual pleasure is one of the ways to keep mentally healthy. For those that have no other outlet, being able to watch pornography or read erotica fulfils that need. There are some people who have a specific personal need that is a fetish and this is the only way they can find personal pleasure, others can only find satisfaction through exhibitionism.
While this may be hard to fathom for those without fetishes, it is clear that pornography is a healthy way for them to be sexual fulfilled. Personally how I masturbate and how I have sex are 2 completely different experiences. I like to be dominating and I love dirty talk. I view myself as the male and love to take control. This is so very different to how I actually like to have sex.
When I have sex with my partner I like to be submissive and manhandled. Pornography does not degrade society, as it is an absolute choice to view or read it. With pornography, there is always consent and no one is unwilling to be partaking in it. Likewise, there is no force to view or read pornography and those who disapprove have the power to choose not to seek it out. Pornography is not to be confused with rape.
Pornography does not encourage rape. An interesting study was conducted in with female university students regarding childhood exposure to pornography, current sexual fantasies, and endorsement of rape-supportive attitudes. Although many studies have been conducted over time, no study has been supported to link pornography and rape.
Population size, the proportion of young adults, the percentage divorced, and population change were all significant predictors of rape. Data collected on incidence of rape in 4 societies Denmark, Sweden, Germany and the USA where pornography is widely available, revealed rape and other violent offences in these 4 countries does not seem to have any detrimental effects in the form of increased sexual violence.
Theory and Practice? Well I guess I should explain a bit about myself. Why does my opinion matter? What would I know? I love my job. Why did I choose porn as my career? To be honest I thought my chances of getting into porn would be as likely as me being a rock star. Which translates to nil. I was a nurse working part-time and as an extra income I did some bikini waitressing on the weekends.
This soon eventuated into topless waitressing, then nude waitressing. Eventually I became a striptease performer for bucks parties and parties alike. I chose this because I wanted to. No one forced me or coerced me.
Sorry to disappoint but I was sick of people reporting me. Do the papas and the cardinal pick sweet or salty popcorn. Brunette gf gets big pov facial and laughs. As an artist with a blog, I mostly upload comics I draw expressing my life.
- I heard him chuckle and I looked up.
- Since political, religious and local community leaders are most often men, men and boys have great influence over any effort to improve girls' lives and achieve gender equality.
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Latina beauty sucks and fuck his meaty fat cock Recent novels with an adult audience have included reflections on girlhood experiences. Blowjob cum on her tits 9:


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Hardwood is a highly durable flooring solution that combines functionality with a natural rustic aesthetic appeal. However, its one main weakness is prolonged water exposure, which can cause all sorts of staining, warping, and damage to your floors. In the event of a leak or flood in your home, your hardwood flooring could be left damaged and marred. Thankfully, there are a couple of things that you can do to help restore the appearance of your hardwood flooring.
Drying and Cleaning
The first thing that you should do if your hardwood floors experience any sort of water damage is to make sure that the entire area is dry. While you can fix puddles and leaks on the actual hardwood by drying them up with a mop or rags, in order to cut down on the amount of moisture in the air in the room, you may want to also install a number of fans and portable dehumidifiers, available at most hardware stores, to increase ventilation and ensure that your flooring (as well as the rest of the room) is completely dry.
Removing Water Stains
Water damage can leave unsightly, chalky white stains on your hardwood flooring that can be hard to remove. These stains can be fairly easily cleaned if you use a rag soaked in mineral oil, scrubbing liberally over the stained area. You may have to reapply mineral oil several times in order to completely eliminate the stain.
If a black stain has taken hold on your hardwood floor, you'll have to use rough sandpaper to sand away the surface of the flooring itself. Then, take oxalic acid (available at most hardware stores) mixed into water and scrub it into the stained area. Let it sit, and reapply as needed until your hardwood has been restored to its natural color. Then, you may want to reapply a stain or finish to the sanded hardwood to match that section to the rest of your floor.
Reversing Warping
If certain boards in your hardwood floor have become slightly warped due to water exposure, you can attempt to bend them back into place by placing a heavy object on top of the warped section. Leave it there for a couple of days to allow the board to bend back into shape. However, severely warped boards that refuse to bend back into place, or that have actually ripped their nails out of the underfloor will need to be completely replaced with new floorboards.
If you are uncomfortable tending to your damaged floors, you can also contact a professional water mitigation service.Share
26 July 2017
When you first move into a home, it can be easy to be overwhelmed with projects. Although everything might seem perfect before you put in that offer, things can change drastically after you finally move in. You might notice problems with tile that you never detected, or you might wonder about that dip in the floor. Fortunately, if you find devastating issues, such as heavy termite damage or altered structure, you might be able to seek refuge from damage contractors. In addition to diagnosing and resolving issues, damage contractors might be able to help you to see what your house can become after things are repaired.


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A rare and magnificent original Art Deco pendant locket, crafted in platinum, diamonds and black onyx, circa 1920s. The sparkling and dramatic 'target' motif is consummately composed of high-quality European-cut diamonds and meticulously fitted curved black onyx sections. The back of the locket is composed of solid black onyx. A matching diamond set bail completes this sublime Art Deco masterwork measuring 1 1/4 inch in diameter. The pendant comes with an 18 inch platinum cable chain.
by Mary Borchert | Aug 7, 2017


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Giving My Boy A Barbie
June 2, 2018
We need to have a chat!
I need to talk about gender stereotypes!
Giving girls a barbie and boys a truck...
Invasive advertising, segregating girls and boys into pink or blue boxes...
Using phrases like "throws like a girl"...
Why can't we just let TOYS BE TOYS and once in a while have a girl who is the villain in the story and a girl being the one to rescue the guy from a burning building?
When I was younger it's fair to say I had a few barbies! I loved dressing them up, brushing their hair (cutting their hair! awks), acting out fashion shows etc. etc. etc. etc. etc... My barbie also came with a Ken and I reflect on this with a smile on my face because Ken was a bit of a drip for my barbies and as soon as my brother was out of sight, she dumped him for an action man, haha! If I had known what I know now when I was 6 she would have dumped them both, got an education and bought herself her own jeep and a pair of louboutins!
I am a feminist...
I am not a bra burning lesbian who doesn't shave her legs (aaaaaand, there's another stereotype!), apart from I don't shave my legs lol! Instead I am a woman who supports the rights and equality for BOTH men and women.
I often wonder why men are still being paid more than women and believe we still adhere to an oppressive system that is unjust!
Teddy is almost 8 months old and the expectation is that he will play football like his dad, watch football, wear football, talk football, sleep football blah blah blah! But what would happen if he wanted to dance around in a pink tutu? What if he grew up in a world where boys weren't expected to play with trucks and be "strong" or dress in a certain way? What if he grew up in a world where his interests where just that... HIS interests. What if he had the space to explore anything that makes his imagination go wild. What if he grew up in a world where men and women were equal?
While having a debate on this subject a few weeks ago I was asked "but would you buy a girl a truck!?" My reply was OF COURSE I WOULD BUY A GIRL A TRUCK! I would also give my boy a barbie if he wanted one! I hope that I will be able to bring him up to respect everyone no matter what their gender. To not feel limited by his gender because boys can't be ballet dancers and girls can't work in construction! To be caring, to show his emotions, to express love, compassion and fight for what he believes in.
We are all equally capable, equally valuable, equally brilliant and fascinating. Gender shouldn't create limitations and I feel responsible as a mother and as a woman to raise my child to change the world for the better!
Peace and love,
Laura x
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The transcripts of the trial of Charles Taylor, former President of Liberia.
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Hello and welcome! I am an Assistant Professor in the Department of Political Science at Rhodes College.
I study American political institutions, judicial politics, and research methodology. Broadly, my research centers on law and the impact of political institutions. I also study how political elites shape public perceptions of electorally insulated institutions, such as the U.S. Supreme Court, the Federal Bureau of Investigation, and the Department of Justice. My methodological interests center on measurement theory, improving statistical inference, and experimental analysis.
I received a B.B.A. in Economics from the University of Georgia and a M.A. and Ph.D. in Political Science from the University of South Carolina. My research is supported by the National Science Foundation and has been published or is forthcoming at American Politics Research, the Journal of Law and Courts, Political Research Quarterly, and Social Science Quarterly.


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Talent Zoo Posts
Interested in seeing what I'm blogging about for other sites. Check out my TalentZoo author page which contains all the articles I've contributed so far.
Valentines Marketing
First some History:(According to Wikipedia.org) Valentines Day was first associated with romantic love in the circle of Geoffrey Chaucer in the High Middle Ages, when the tradition of courtly love flourished. In 18th-century England, it evolved into an occasion in which lovers expressed their love for each other…
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Linea Resourcing
21. Linea Resourcing
Technical recruitment agency | Established in 2002
Linea is a specialist recruitment consultancy identifying leading management, technology and manufacturing talent. Its customers range from high profile PLCs to high tech start ups. It operates across a variety of technical sectors including automotive, medical devices, telecoms, defence, electronics, food manufacture, energy, mass transportation and aerospace. Linea prides itself on being experts at identifying rare, hard to find high demand skills. The organisation places candidates into permanent, contract and interim roles across the UK matching workers to demanding client job briefs. Its skill-based divisions play a pivotal role introducing its clients to leading talent from not only their own sector but complementary sectors. The synergy other sectors and industries can provide a business is being embraced by forward thinking organisations as they seek the talent they need to drive, shape and deliver business results. Linea regularly undertakes market intelligence work for clients to monitor industry developments, advising on employment trends, salary levels and skills availability. Candidates benefit from expert advice on career planning, CV appraisal, salary comparison and a 'genuine desire' from Linea to make a difference.
95.3% growth between 2008 and 2010
The main motivation for the founder, Mike Gorshkov, was a challenge to himself that he could build a successful business. As time has passed that motivation still runs deep and every time he achieves a goal, he focuses on the next challenge. The main start up issues during the first three years of business were staffing, work-life balance and business growth. Developing, attracting and retaining the best talent in the industry is top of its agenda. Linea has a reputation for being one of the best recruiter businesses in Wales and finding the right people to live up to that reputation, enhance it and develop it further is a continuing challenge. According to Mike, running a business becomes all-consuming and need to know when to switch off, particularly if you have a family. Someone once told him 'no one will work harder than you in your business'. Finding the right balance is difficult particularly in a fast moving competitive industry. Most people who launch a business are probably experts in the process of making their product, selling their service or managing a team. Founders need to be able to wear many hats – marketing manager, accounts manager, HR manager, sales manager and business owner. Nothing prepares people for this. However the biggest challenge in growing a business and adding value to the enterprise is the skill of growing a business. It is a skill in its own right and requires a lot of thought, clarity of direction, leadership and commitment to succeed.
Success Factor
A key factor in its success is the strong team at Linea and their dedication, passion and creativity that they bring to the business. The company works closely with its clients to meet their recruitment requirements and exceed expectations, whilst always following ethical and efficient recruitment processes. It remains focussed on a blend of niche, high demand/high value markets to drive the business forward.
The Future
Linea has several key objectives for growth. The company's focus is on strengthening its position in core and target markets and developing its brand as the technical recruiter of choice. It has plans to expand beyond Wales and open at least two offices in other regional UK markets. The company aims to grow the Cardiff office to a team of 30 fee earners and achieve turnover in excess of £20 million over the next five years.
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CFEL, (Centre for Exclence in Law) Law Education wing of Ehsaas International organises workshop on sexual harassment.
To enlighten girl students with self_defensive techniques conducive to minimization of sexual harassment and abuses, a dynamic counselling session on "women empowerment" was held today at Divine institute in Mir behri, Dal by CFEL , the team of law experts and student.
The programme, oriented to female students making them aware of the importance of schooling (education) as an instrument for change, is a legal academic assignment in order to empower and equip these girls for education in addition with modern defensive paraphernalia.
A free and Frank interactive session proceed for around two hours which was joined by a good number of students. The legal experts (guests also) who had organised this overly entailed programme, included Mr Wajid Rizvi, Mrs Aliya Akbar, Mrs Tasidia , Mrs Razia, Mrs Maroofa, Mr Majid.
On the occasion , Mr Wajid Rizvi provided a brief introduction about the women empowerment programme. The session was presided over by Mrs Aliya Akbar , incharge of the program, made the female students aware of the obstacles they face in defence from any kind of physical harrasment and abuses they have to face. She extensively apprised the students about the defensive skills by means of which they could protect and shield themselves. likewise the students were educated about the basic self- protective services , practically shown how to do self defense in case of any sensual harassment. Students also shared their incidents they had to face , and a case of a female student was so fruitfully resolved.
Besides the cfel team come up with a counselling session for 3rd 4th, 5th ,6th grade students , made them feel of basic need of education and has inspired them to take law as your career option.
Meanwhile the overall counselling session was energetic and mesmerised. The students from both the session expressed much satisfaction over the programme and expressed their willingness and interest to become part of such programmed in future.


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DVP September Board Meeting
- Article Information
- Wednesday, 21 August 2019 09:02
- Corinne Walton
This is a gentle reminder that the next meeting of the Derwent Valley Partnership Board will be taking place on Wednesday 25th September 2019 from 6pm-8pm in Consett Salvation Army Hall, Sherburn Terrace, Consett, DH8 6ND.
At this meeting you will be able to find out which local projects are currently being considered for financial support by the Partnership linked to our three priorities of environment, health and wellbeing and employment, enterprise and training. A brief update will also be provided in relation to Shotley Bridge Community Hospital (SBCH).
We would very much welcome your attendance at the meeting, however, we politely request that if you do wish to attend, you book a seat in advance as this helps us with the provision of paperwork and refreshments. All of our Board meetings are open to members of the public to attend and everyone is welcome. Refreshments are provided and there are parking facilities adjacent to the main hall.


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The lateral seepage from a river bank into a river produced by unconfined flow from a porous aquifer with a well-defined water table is portrayed in Fig. 15.6. The aquifer is assumed to be isotropic and homogeneous, and it is underlain by an impermeable stratum. The flow pattern in the combined unsaturated and saturated layers of such an aquifer is not so easily identified as in a completely saturated confined aquifer. The free surface of the water table has an increasingly downward slope to meet the river bank at point A, the top of a seepage surface. The water-table slope reflects a hydraulic gradient and the line of the water table describes a stream line if no recharge occurs from the ground surface. In effect, the water table is the upper boundary of a flow net in the saturated part of the aquifer. The river bed/bank interface is an equipotential line and hence all streamlines meeting it must turn to meet BC at right angles. The seepage surface AB is not an equipotential and the water table flowline is tangential to the river bank at A (Cedergren, 1997).
To be able to calculate the flow to the river, several approximations are generally made. These approximations, developed by Dupuit and Forchheimer, make the major assumptions:
(a) the hydraulic gradient dh/dx is equal to the slope of the water table;
(b) the related specific discharge is constant throughout the depth of flow; and
(c) the line ED may be taken to act as a constant head boundary with water table height hD.
Thus, the streamlines are taken to be horizontal and the equipotential lines vertical.
Making these assumptions for steady-flow conditions, the discharge per unit width (Q) over the depth of saturation (h), with hydraulic conductivity (K), is given at all sections by:
The integral of hydraulic conductivity over the depth of saturation (here Kh) is also known as the transmissivity, T, of the aquifer. In a real aquifer, there would be nonhorizontal flow components near the water table and near ABC. However, making the Dupuit-Forchheimer assumption of a horizontal flow pattern, satisfactory results are obtained for the discharge when the water table slope is small and the variation in the unconfined aquifer depth relative to that depth is small.
An extension of the seepage flow in an unconfined aquifer can include recharge from water percolating downwards through the unsaturated zone. This is a problem encountered by drainage engineers designing channels for leading off surplus water. In Fig. 15.7, drainage from the surface is assumed to give a uniform recharge rate R at the ground surface of an isotropic, homogeneous aquifer of hydraulic conductivity K. It is often required to know the depth of the water table relative to the water level in the river or channel. With steady-state conditions and adopting the Dupuit-Forchheimer assumptions, the Darcian velocity or specific discharge q at distance x, from Darcy's law, is q = -Kdh/dx. Then the flow Q at x per unit width for the aquifer depth h is Q = -Khdh/dx. However, from mass balance at steady state, the total recharge at any point is also given by Q = Rx. If all the flow in the aquifer is assumed to come from the recharge and none across the boundary ED at x = 0, then:
dx dx
Uniform rainfall rate
Water table
Ground si
Uniform rainfall rate
Water table
Ground si
a h2> RIVER
a h2> RIVER
Fig. 15.7 Recharging unconfined flow contributing lateral inflow to a river.
Integrating between h and h2 with x going from 0 to a (see Fig. 15.7) then:
Thus, h1, the water table depth at distance a from the river can be found, knowing the water level in the channel, the infiltration rate and K (ignoring the seepage surface). Under the steady recharge assumption, baseflow to the river per unit length of channel, Q, can be expressed in terms of recharge as:
Example: Calculation of water table heights in an unconfined aquifer
In Fig. 15.7, it is required to know the height of the water table at 150 m from the river when irrigation water is applied at a constant rate of 0.8 mm day-1 assuming a steady state is attained with the uniform irrigation rate, K = 4.3 m day-1 and a drain level at 12 m above the impermeable stratum. Substituting into (15.16):
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Someones Junk Is Someone Elses Treasure. Attending A Swap Meet, Garage Sales or Setting Up A Booth At A Flea Market Can Be Fun Exciting!