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Health Information
August 2012
Handout on Health: Scleroderma
This booklet is for people who have scleroderma, as well as for their family members, friends, and others who want to find out more about the disease. This booklet describes the different forms of scleroderma and provides information on their symptoms, diagnosis, and treatment, including what patients can do to help manage their disease and the problems associated with it. This booklet also highlights research efforts into the understanding and treatment of scleroderma, many of which are supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and other components of the U.S. Department of Health and Human Services' National Institutes of Health (NIH). If you have further questions after reading this booklet, you may wish to discuss them with your doctor.
What Is Scleroderma?
Derived from the Greek words "sklerosis," meaning hardness, and "derma," meaning skin, scleroderma literally means "hard skin." Although it is often referred to as if it were a single disease, scleroderma is really a symptom of a group of diseases that involve the abnormal growth of connective tissue, which supports the skin and internal organs. It is sometimes used, therefore, as an umbrella term for these disorders. In some forms of scleroderma, hard, tight skin is the extent of this abnormal process. In other forms, however, the problem goes much deeper, affecting blood vessels and internal organs, such as the heart, lungs, and kidneys.
Scleroderma is called both a rheumatic (roo-MA-tik) disease and a connective tissue disease. The term rheumatic disease refers to a group of conditions characterized by inflammation or pain in the muscles, joints, or fibrous tissue. A connective tissue disease is one that affects tissues such as skin, tendons, and cartilage.
In this booklet we'll discuss the forms of scleroderma and the problems associated with each of them, as well as diagnosis and disease management. We'll also take a look at what research is telling us about their possible causes and most effective treatments. And we will describe ways for people with scleroderma to live longer, healthier, and more productive lives.
- What Are the Different Types of Scleroderma?
- What Causes Scleroderma?
- Who Gets Scleroderma?
- How Is Scleroderma Diagnosed?
- What Other Conditions Can Look Like Scleroderma?
- How Is Scleroderma Treated?
- How Can Scleroderma Affect My Life?
- How Can I Play a Role in My Health Care?
- Is Research Close to Finding a Cure?
- More Questions? Count on More Answers
- For More Information
What Are the Different Types of Scleroderma?
The group of diseases we call scleroderma falls into two main classes: localized scleroderma and systemic sclerosis. (Localized diseases affect only certain parts of the body; systemic diseases can affect the whole body.) Both groups include subgroups (see chart). Although there are different ways these groups and subgroups may be broken down or referred to (and your doctor may use different terms from what you see here), the following is a common way of classifying these diseases:
Types of Scleroderma
Localized Scleroderma
Localized types of scleroderma are those limited to the skin and related tissues and, in some cases, the muscle below. Internal organs are not affected by localized scleroderma, and localized scleroderma can never progress to the systemic form of the disease. Often, localized conditions improve or go away on their own over time, but the skin changes and damage that occur when the disease is active can be permanent. For some people, localized scleroderma is serious and disabling.
There are two generally recognized types of localized scleroderma:
Morphea: Morphea (mor-FEE-ah) comes from a Greek word that means "form" or "structure." The word refers to local patches of scleroderma. The first signs of the disease are reddish patches of skin that thicken into firm, oval-shaped areas. The center of each patch becomes ivory colored with violet borders. These patches sweat very little and have little hair growth. Patches appear most often on the chest, stomach, and back. Sometimes they appear on the face, arms, and legs.
Morphea can be either localized or generalized. Localized morphea limits itself to one or several patches, ranging in size from a half-inch to 12 inches in diameter. The condition sometimes appears on areas treated by radiation therapy. Some people have both morphea and linear scleroderma (described below). The disease is referred to as generalized morphea when the skin patches become very hard and dark and spread over larger areas of the body. Regardless of the type, morphea generally fades out in 3 to 5 years; however, people are often left with darkened skin patches and, in rare cases, muscle weakness.
Linear scleroderma: As suggested by its name, the disease is characterized by a single line or band of thickened or abnormally colored skin. Usually, the line runs down an arm or leg, but in some people it runs down the forehead. People sometimes use the French term en coup de sabre, or "sword stroke," to describe this highly visible line.
Systemic Scleroderma (also known as Systemic Sclerosis)
This is the term for the form of the disease that not only includes the skin, but also involves the tissues beneath, the blood vessels, and the major organs. Systemic sclerosis is typically broken down into limited cutaneous scleroderma and diffuse cutaneous scleroderma. Some doctors break systemic sclerosis down into a third subset called systemic sclerosis sine (SEEN-ay, Latin for "without") scleroderma. This means that patients have other manifestations of scleroderma but they do not have any overt skin thickening.
Limited cutaneous scleroderma: Limited cutaneous scleroderma typically comes on gradually and affects the skin only in certain areas: the fingers, hands, face, lower arms, and legs. Most people with limited disease have Raynaud's phenomenon for years before skin thickening starts. Telangiectasia and calcinosis often follow (see definitions below). Gastrointestinal involvement occurs commonly, and some patients have severe lung problems, even though the skin thickening remains limited. People with limited disease often have all or some of the symptoms that some doctors call CREST, which stands for the following:
- Calcinosis (KAL-sin-OH-sis): The formation of calcium deposits in the connective tissues, which can be detected by x ray. These deposits are typically found on the fingers, hands, face, and trunk and on the skin above elbows and knees. When the deposits break through the skin, painful ulcers can result.
- Raynaud's (ray-NOHZ) phenomenon: A condition in which the small blood vessels of the hands or feet contract in response to cold or anxiety. As the vessels contract, the hands or feet turn white and cold, then blue. As blood flow returns, they become red. Fingertip tissues may suffer damage, leading to ulcers, scars, or gangrene.
- Esophageal (eh-SOFF-uh-GEE-ul) dysfunction: Impaired function of the esophagus (the tube connecting the throat and the stomach) that occurs when smooth muscles in the esophagus lose normal movement. In the upper and lower esophagus, the result can be swallowing difficulties. In the lower esophagus, the result can be chronic heartburn or inflammation.
- Sclerodactyly (SKLER-oh-DAK-till-ee): Thick and tight skin on the fingers, resulting from deposits of excess collagen within skin layers. The condition makes it harder to bend or straighten the fingers. The skin may also appear shiny and darkened, with hair loss.
- Telangiectasia (tel-AN-jee-ek-TAY-zee-uh): A condition caused by the swelling of tiny blood vessels, in which small red spots appear on the hands and face. Although not painful, these red spots can create cosmetic problems.
Diffuse cutaneous scleroderma: This condition typically comes on suddenly. Skin thickening begins in the hands and spreads quickly and over much of the body, affecting the hands, face, upper arms, upper legs, chest, and stomach in a symmetrical fashion (for example, if one arm or one side of the trunk is affected, the other is also affected). Some people may have more area of their skin affected than others. Internally, this condition can damage key organs such as the intestines, lungs, heart, and kidneys.
People with diffuse disease often are tired, lose appetite and weight, and have joint swelling or pain. Skin changes can cause the skin to swell, appear shiny, and feel tight and itchy.
The damage of diffuse scleroderma typically occurs over a few years. After the first 3 to 5 years, people with diffuse disease often enter a stable phase lasting for varying lengths of time. During this phase, symptoms subside: joint pain eases, fatigue lessens, and appetite returns. Progressive skin thickening and organ damage decrease.
Gradually, however, the skin may begin to soften, which tends to occur in reverse order of the thickening process: the last areas thickened are the first to begin softening. Some patients' skin returns to a somewhat normal state, while other patients are left with thin, fragile skin without hair or sweat glands. Serious new damage to the heart, lungs, or kidneys is unlikely to occur, although patients are left with whatever damage they have in specific organs.
People with diffuse scleroderma face the most serious long-term outlook if they develop severe kidney, lung, digestive, or heart problems. Fortunately, less than one-third of patients with diffuse disease develop these severe problems. Early diagnosis and continual and careful monitoring are important.
What Causes Scleroderma?
Although scientists don't know exactly what causes scleroderma, they are certain that people cannot catch it from or transmit it to others. Studies of twins suggest it is also not inherited. Scientists suspect that scleroderma comes from several factors that may include:
Abnormal immune or inflammatory activity: Like many other rheumatic disorders, scleroderma is believed to be an autoimmune disease. An autoimmune disease is one in which the immune system, for unknown reasons, turns against one's own body.
In scleroderma, the immune system is thought to stimulate cells called fibroblasts so they produce too much collagen. The collagen forms thick connective tissue that builds up within the skin and internal organs and can interfere with their functioning. Blood vessels and joints can also be affected.
Genetic makeup: Although genes seem to put certain people at risk for scleroderma and play a role in its course, the disease is not passed from parent to child like some genetic diseases.
Environmental triggers: Research suggests that exposure to some environmental factors may trigger scleroderma-like disease (which is not actually scleroderma) in people who are genetically predisposed to it. Suspected triggers include viral infections, certain adhesive and coating materials, and organic solvents such as vinyl chloride or trichloroethylene. But no environmental agent has been shown to cause scleroderma. In the past, some people believed that silicone breast implants might have been a factor in developing connective tissue diseases such as scleroderma. But several studies have not shown evidence of a connection.
Hormones: Women develop scleroderma more often than men. Scientists suspect that hormonal differences between women and men play a part in the disease. However, the role of estrogen or other female hormones has not been proven.
Who Gets Scleroderma?
Although scleroderma is more common in women, the disease also occurs in men and children. It affects people of all races and ethnic groups. However, there are some patterns by disease type. For example:
- Localized forms of scleroderma are more common in people of European descent than in African Americans. Morphea usually appears between the ages of 20 and 40, and linear scleroderma usually occurs in children or teenagers.
- Systemic scleroderma, whether limited or diffuse, typically occurs in people from 30 to 50 years old. It affects more women of African American than European descent.
Because scleroderma can be hard to diagnose and it overlaps with or resembles other diseases, scientists can only estimate how many cases there actually are. It is estimated that 49,000 adults in the United States have systemic sclerosis.1
1Helmick CG, Felson DT, Lawrence RC, Gabriel S, Hirsch R, Kwoh CK, Liang MH, Kremers M, Mayes MD, Merkel PA, Pillemer SR, Reveille JD, Stone JH; National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I. Arthritis Rheum. 2008 Jan;58(1):15-25.
For some people, scleroderma (particularly the localized forms) is fairly mild and resolves with time. But for others, living with the disease and its effects day to day has a significant impact on their quality of life.
How Is Scleroderma Diagnosed?
Depending on your particular symptoms, a diagnosis of scleroderma may be made by:
- A general internist.
- A dermatologist (a doctor who specializes in treating diseases of the skin, hair, and nails).
- An orthopaedist (a doctor who treats bone and joint disorders).
- A pulmonologist (a lung specialist).
- A rheumatologist (a doctor specializing in treatment of musculoskeletal disorders and rheumatic diseases).
A diagnosis of scleroderma is based largely on the medical history and findings from the physical exam. To make a diagnosis, your doctor will ask you a lot of questions about what has happened to you over time and about any symptoms you may be experiencing. Are you having a problem with heartburn or swallowing? Are you often tired or achy? Do your hands turn white in response to anxiety or cold temperatures?
Once your doctor has taken a thorough medical history, he or she will perform a physical exam. Finding one or more of the following factors can help the doctor diagnose a certain form of scleroderma:
- changed skin appearance and texture, including swollen fingers and hands and tight skin around the hands, face, mouth, or elsewhere
- calcium deposits developing under the skin
- changes in the tiny blood vessels (capillaries) at the base of the fingernails
- thickened skin patches.
Finally, your doctor may order lab tests to help confirm a suspected diagnosis. At least two proteins, called antibodies, are commonly found in the blood of people with scleroderma:
- Antitopoisomerase-1 or Anti-Scl-70 antibodies appear in the blood of up to 30 percent of people with diffuse systemic sclerosis.
- Anticentromere antibodies are found in the blood of many people with limited systemic sclerosis.
A number of other scleroderma-specific antibodies can occur in people with scleroderma, although less frequently. When present, however, they are helpful in clinical diagnosis and may give additional information as to the risks for specific organ problems.
Because not all people with scleroderma have these antibodies and because not all people with the antibodies have scleroderma, lab test results alone cannot confirm the diagnosis.
In some cases, your doctor may order a skin biopsy (the surgical removal of a small sample of skin for microscopic examination) to aid in or help confirm a diagnosis. However, skin biopsies also have their limitations: biopsy results cannot distinguish between localized and systemic disease, for example.
Diagnosing scleroderma is easiest when a person has typical symptoms and rapid skin thickening. In other cases, a diagnosis may take months, or even years, as the disease unfolds and reveals itself and as the doctor is able to rule out some other potential causes of the symptoms. In some cases, a diagnosis is never made, because the symptoms that prompted the visit to the doctor go away on their own.
Some patients have some symptoms related to scleroderma and may fit into one of the following groups:
- Undifferentiated connective tissue disease (UCTD): This is a term for patients who have some signs and symptoms of various related diseases, but not enough symptoms of any one disease to make a definitive diagnosis. In other words, their condition hasn't "differentiated" into a particular connective tissue disease. In time, UCTD can go in one of three directions: it can change into a systemic disease such as systemic sclerosis, systemic lupus erythematosus, or rheumatoid arthritis; it can remain undifferentiated; or it can improve spontaneously.
- Overlap syndromes: This is a disease combination in which patients have symptoms and lab findings characteristic of two or more conditions.
What Other Conditions Can Look Like Scleroderma?
A number of other diseases have symptoms similar to those seen in scleroderma. Here are some of the most common scleroderma "look-alikes."
Eosinophilic fasciitis (EF) (EE-oh-SIN-oh-FIL-ik fa-shi-EYE-tis): This disease involves the fascia (FA-shuh), the thin connective tissue around the muscles, particularly those of the forearms, arms, legs, and trunk. EF causes the muscles to become encased in collagen, the fibrous protein that makes up tissue such as the skin and tendons. Permanent shortening of the muscles and tendons, called contractures, may develop, sometimes causing disfigurement and problems with joint motion and function. EF may begin after hard physical exertion. The disease usually fades away after several years, but people sometimes have relapses. Although the upper layers of the skin are not thickened in EF, the thickened fascia may cause the skin to look somewhat like the tight, hard skin of scleroderma. A skin biopsy easily distinguishes between the two diseases.
Skin thickening on the fingers and hands: This also appears with diabetes, mycosis fungoides, amyloidosis, and adult celiac disease. It can also result from hand trauma.
Generalized scleroderma-like skin thickening: This may occur with scleromyxedema, graft-versus-host disease, porphyria cutanea tarda, and human adjuvant disease.
Internal organ damage: Similar to that seen in systemic sclerosis, this may instead be related to primary pulmonary hypertension, idiopathic pulmonary fibrosis, or collagenous colitis.
Raynaud's phenomenon: This condition also appears with atherosclerosis or systemic lupus erythematosus or in the absence of underlying disease.
An explanation of most of these other diseases is beyond the scope of this booklet. What's important to understand, however, is that diagnosing scleroderma isn't always easy, and it may take time for you and your doctor to do this. Although having a definite diagnosis may be helpful, you do not need to know the precise form of your disease to receive proper treatment.
How Is Scleroderma Treated?
Because scleroderma can affect many different organs and organ systems, you may have several different doctors involved in your care. Typically, care will be managed by a rheumatologist (a doctor specializing in treatment of musculoskeletal disorders and rheumatic diseases). Your rheumatologist may refer you to other specialists, depending on the specific problems you are having. For example, you may see a dermatologist for the treatment of skin symptoms, a nephrologist for kidney complications, a cardiologist for heart complications, a gastroenterologist for problems of the digestive tract, and a pulmonary specialist for lung involvement.
In addition to doctors, professionals such as nurse practitioners, physician assistants, physical or occupational therapists, psychologists, and social workers may play a role in your care. Dentists, orthodontists, and even speech therapists can treat oral complications that arise from thickening of tissues in and around the mouth and on the face.
Currently, there is no treatment that controls or stops the underlying problem—the overproduction of collagen—in all forms of scleroderma. Thus, treatment and management focus on relieving symptoms and limiting damage. Your treatment will depend on the particular problems you are having. Some treatments will be prescribed or given by your doctor. Others are things you can do on your own.
Here is a listing of the potential problems that can occur in systemic scleroderma and the medical and nonmedical treatments for them. These problems do not occur as a result or complication of localized scleroderma. This listing is not complete because different people experience different problems with scleroderma and not all treatments work equally well for all people. Work with your doctor to find the best treatment for your specific symptoms.
Raynaud's phenomenon: Most people with scleroderma have this condition, in which the fingers and sometimes other extremities change color in response to cold temperature or anxiety. For many, Raynaud's phenomenon precedes other manifestations of the disease. In other people, however, Raynaud's phenomenon is unrelated to scleroderma, but may signal damage to the blood vessels supplying the hands arising from occupational injuries (from using jackhammers, for example), trauma, excessive smoking, circulatory problems, drug use, or exposure to toxic substances. For some people, cold fingers and toes are the extent of the problem and are little more than a nuisance. For others, the condition can worsen and lead to puffy fingers, finger ulcers, and other complications that require aggressive treatment.
If you have Raynaud's phenomenon, the following measures may make you more comfortable and help prevent problems:
- Don't smoke! Smoking narrows the blood vessels even more and makes Raynaud's phenomenon worse.
- Dress warmly, with special attention to hands and feet. Dress in layers and try to stay indoors during cold weather.
- Use biofeedback, which governs various body processes that are not normally thought of as being under conscious control, and relaxation exercises.
- For severe cases, speak to your doctor about prescribing drugs called calcium channel blockers, which can open up small blood vessels and improve circulation. Other drugs are in development and may become available.
- If Raynaud's phenomenon leads to skin sores or ulcers, increasing your dose of calcium channel blockers (ONLY under the direction of your doctor) may help. You can also protect skin ulcers from further injury or infection by applying nitroglycerine paste or antibiotic cream. Severe ulcerations on the fingertips can be treated with bioengineered skin.
Stiff, painful joints: In diffuse systemic sclerosis, hand joints can stiffen because of hardened skin around the joints or inflammation within them. Other joints can also become stiff and swollen.
- Stretching exercises under the direction of a physical or occupational therapist are extremely important to prevent loss of joint motion. These should be started as soon as scleroderma is diagnosed.
- Exercise regularly. Ask your doctor or physical therapist about an exercise plan that will help you increase and maintain range of motion in affected joints. Swimming can help maintain muscle strength, flexibility, and joint mobility.
- Use acetaminophen or an over-the-counter or prescription nonsteroidal anti-inflammatory drug, as recommended by your doctor, to help relieve joint or muscle pain. If pain is severe, speak to a rheumatologist about the possibility of prescription-strength drugs to ease pain and inflammation.
- Learn to do things in a new way. A physical or occupational therapist can help you learn to perform daily tasks, such as lifting and carrying objects or opening doors, in ways that will put less stress on tender joints.
Skin problems: When too much collagen builds up in the skin, it crowds out sweat and oil glands, causing the skin to become dry and stiff. If your skin is affected, try the following:
- Apply oil-based creams and lotions frequently, and always right after bathing.
- Apply sunscreen before you venture outdoors to protect against further damage from the sun's rays.
- Use humidifiers to moisten the air in your home in colder winter climates. Clean humidifiers often to stop bacteria from growing in the water.
- Avoid very hot baths and showers, as hot water dries the skin.
- Avoid harsh soaps, household cleaners, and caustic chemicals, if at all possible. Otherwise, be sure to wear rubber gloves when you use such products.
- Exercise regularly. Exercise, especially swimming, stimulates blood circulation to affected areas.
Dry mouth and dental problems: Dental problems are common in people with scleroderma for a number of reasons:
- Tightening facial skin can make the mouth opening smaller and narrower, which makes it hard to care for teeth.
- Dry mouth caused by salivary gland damage speeds up tooth decay.
- Damage to connective tissues in the mouth can lead to loose teeth.
You can avoid tooth and gum problems in several ways:
- Brush and floss your teeth regularly. If hand pain and stiffness make this difficult, consult your doctor or an occupational therapist about specially made toothbrush handles and devices to make flossing easier.
- Have regular dental checkups. Contact your dentist immediately if you experience mouth sores, mouth pain, or loose teeth.
- If decay is a problem, ask your dentist about fluoride rinses or prescription toothpastes that remineralize and harden tooth enamel.
- Consult a physical therapist about facial exercises to help keep your mouth and face more flexible.
- Keep your mouth moist by drinking plenty of water, sucking ice chips, using sugarless gum and hard candy, and avoiding mouthwashes with alcohol. If dry mouth still bothers you, ask your doctor about a saliva substitute—or prescription medications such as pilocarpine hydrochloride or cevimeline hydrochloride—that can stimulate the flow of saliva.
Gastrointestinal (GI) problems: Systemic sclerosis can affect any part of the digestive system. As a result, you may experience problems such as heartburn, difficulty swallowing, early satiety (the feeling of being full after you've barely started eating), or intestinal complaints such as diarrhea, constipation, and gas. In cases where the intestines are damaged, your body may have difficulty absorbing nutrients from food. Although GI problems are diverse, here are some things that might help at least some of the problems you have:
- Eat small, frequent meals.
- To keep stomach contents from backing up into the esophagus, stand or sit for at least an hour (preferably 2 or 3 hours) after eating. When it is time to sleep, keep the head of your bed raised using blocks.
- Avoid late-night meals, spicy or fatty foods, alcohol, and caffeine, which can aggravate GI distress.
- Eat moist, soft foods, and chew them well. If you have difficulty swallowing or if your body doesn't absorb nutrients properly, your doctor may prescribe a special diet.
- Ask your doctor about prescription medications for problems such as diarrhea, constipation, and heartburn. Some drugs called proton pump inhibitors are highly effective against heartburn. Oral antibiotics may stop bacterial overgrowth in the bowel, which can be a cause of diarrhea in some people with systemic sclerosis.
Lung damage: Virtually all people with systemic sclerosis have some loss of lung function. Some develop severe lung disease, which comes in two forms: pulmonary fibrosis (hardening or scarring of lung tissue because of excess collagen) and pulmonary hypertension (high blood pressure in the artery that carries blood from the heart to the lungs). Treatment for the two conditions is different:
- Pulmonary fibrosis may be treated with drugs that suppress the immune system, along with low doses of corticosteroids.
- Pulmonary hypertension may be treated with drugs that dilate the blood vessels, such as prostacyclin, or with newer medications that are prescribed specifically for treating pulmonary hypertension.
Regardless of your particular lung problem or its medical treatment, your role in the treatment process is essentially the same. To minimize lung complications, work closely with your medical team. Do the following:
- Watch for signs of lung disease, including fatigue, shortness of breath or difficulty breathing, and swollen feet. Report these symptoms to your doctor.
- Have your lungs closely checked, using standard lung-function tests, during the early stages of skin thickening. These tests, which can find problems at the earliest and most treatable stages, are needed because lung damage can occur even before you notice any symptoms.
- Get regular flu and pneumonia vaccines as recommended by your doctor. Contracting either illness could be dangerous for a person with lung disease.
Heart problems: Common among people with scleroderma, heart problems include scarring and weakening of the heart (cardiomyopathy), inflamed heart muscle (myocarditis), and abnormal heartbeat (arrhythmia). All of these problems can be treated. Treatment ranges from drugs to surgery and varies depending on the nature of the condition.
Kidney problems: Renal crisis is an uncommon but serious complication in patients with systemic sclerosis. Renal crisis results in severe uncontrolled high blood pressure, which can quickly lead to kidney failure. It's very important that you take measures to identify and treat the hypertension as soon as it occurs. These are things you can do:
- Check your blood pressure regularly. You should also check it if you have any new or different symptoms such as a headache or shortness of breath. If your blood pressure is higher than usual, call your doctor right away.
- If you have kidney problems, take your prescribed medications faithfully. In the past two decades, drugs known as ACE (angiotensin-converting enzyme) inhibitors, have made scleroderma-related kidney failure a less threatening problem than it used to be. But for these drugs to work, you must take them as soon as the hypertension is present.
Cosmetic problems: Even if scleroderma doesn't cause any lasting physical disability, its effects on the skin's appearance—particularly on the face—can take their toll on your self-esteem. Fortunately, there are procedures to correct some of the cosmetic problems scleroderma causes:
- The appearance of telangiectasias—small red spots on the hands and face caused by swelling of tiny blood vessels beneath the skin—may be reduced or even eliminated with the use of guided lasers.
- Facial changes of localized scleroderma—such as the en coup de sabre that may run down the forehead in people with linear scleroderma—may be corrected through cosmetic surgery. (However, such surgery is not appropriate for areas of the skin where the disease is active.)
How Can Scleroderma Affect My Life?
Having a chronic disease can affect almost every aspect of your life, from family relationships to holding a job. For people with scleroderma, there may be other concerns about appearance or even the ability to dress, bathe, or handle the most basic daily tasks. Here are some areas in which scleroderma could intrude.
Appearance and self-esteem: Aside from the initial concerns about health and longevity, people with scleroderma quickly become concerned with how the disease will affect their appearance. Thick, hardened skin can be difficult to accept, particularly on the face. Systemic scleroderma may result in facial changes that eventually cause the opening to the mouth to become smaller and the upper lip to virtually disappear. Linear scleroderma may leave its mark on the forehead. Although these problems can't always be prevented, their effects may be minimized with proper treatment. Also, special cosmetics—and in some cases plastic surgery—can help conceal scleroderma's damage.
Caring for yourself: Tight, hard connective tissue in the hands can make it difficult to do what were once simple tasks, such as brushing your teeth and hair, pouring a cup of coffee, using a knife and fork, unlocking a door, or buttoning a jacket. If you have trouble using your hands, consult an occupational therapist, who can recommend new ways of doing things or devices to make tasks easier. Devices as simple as Velcro fasteners and built-up brush handles can help you be more independent.
Family relationships: Spouses, children, parents, and siblings may have trouble understanding why you don't have the energy to keep house, drive to soccer practice, prepare meals, or hold a job the way you used to. If your condition isn't that visible, they may even suggest you are just being lazy. On the other hand, they may be overly concerned and eager to help you, not allowing you to do the things you are able to do or giving up their own interests and activities to be with you. It's important to learn as much about your form of the disease as you can and to share any information you have with your family. Involving them in counseling or a support group may also help them better understand the disease and how they can help you.
Sexual relations: Sexual relationships can be affected when systemic scleroderma enters the picture. For men, the disease's effects on the blood vessels can lead to problems achieving an erection. For women, damage to the moisture-producing glands can cause vaginal dryness that makes intercourse painful. People of either sex may find they have difficulty moving the way they once did. They may be self-conscious about their appearance or afraid that their sexual partner will no longer find them attractive. With communication between partners, good medical care, and perhaps counseling, many of these changes can be overcome or at least worked around.
How Can I Play a Role in My Health Care?
Although your doctors direct your treatment, you are the one who must take your medicine regularly, follow your doctor's advice, and report any problems promptly. In other words, the relationship between you and your doctors is a partnership, and you are the most important partner. Here's what you can do to make the most of this important role.
- Get educated: Knowledge is your best defense against this disease. Learn as much as you can about scleroderma, both for your own benefit and to educate the people in your support network.
- Seek support: Recruit family members, friends, and coworkers to build a support network. This network will help you get through difficult times: when you are in pain; when you feel angry, sad, or afraid; or when you're depressed. Also, look for a scleroderma support group in your community by calling a national scleroderma organization. (See "For More Information.") If you can't find a support group, you might want to consider organizing one.
- Assemble a health care team: You and your doctors will lead the team. Other members may include physical and occupational therapists, a psychologist or social worker, a dentist, and a pharmacist.
- Be patient: Understand that a final diagnosis can be difficult and may take a long time. Find a doctor with experience treating people with systemic and localized scleroderma. Then, even if you don't yet have a specific diagnosis, you will get understanding and the right treatment for your symptoms.
- Speak up: When you have problems or notice changes in your condition, don't feel too self-conscious to speak up during your appointment or even call your doctor or another member of your health care team. No problem is too small to ask about, and early treatment for any problem can make the disease more manageable.
- Don't accept depression: Although it's understandable that a person with a chronic illness such as scleroderma would become depressed, don't accept depression as a normal consequence of your condition. If depression makes it hard for you to function well, don't hesitate to ask your health care team for help. You may benefit from speaking with a psychologist or social worker or from using one of the effective medications on the market.
- Learn coping skills: Meditation, calming exercises, and relaxation techniques may help you cope with emotional difficulties and relieve pain and fatigue. Ask a member of your health care team to teach you these skills or to refer you to someone who can.
- Ask the experts: If you have problems doing daily activities, from brushing your hair and teeth to driving your car, consult an occupational or physical therapist. They have more helpful hints and devices than you can probably imagine. Social workers can often help resolve financial and insurance matters.
Is Research Close to Finding a Cure?
No one can say for sure when—or if—a cure will be found. But research is providing the next best thing: better ways to treat symptoms, prevent organ damage, and improve the quality of life for people with scleroderma. In the past two decades, multidisciplinary research has also provided new clues for understanding the disease, which is an important step toward prevention and cure.
Studies of the immune system, genetics, cell biology, and molecular biology have helped reveal the causes of scleroderma, improve existing treatment, and create entirely new treatment approaches.
Some advances in the understanding or treatment of scleroderma include the following:
- Building on research that identified a gene associated with scleroderma in Oklahoma Choctaw Native Americans, scientists are using new technology to look for other genes associated with the disease's development and severity.
- The drug cyclophosphamide has been found effective in treating lung fibrosis. One study suggested that treating lung problems early with this immunosuppressive drug may help prevent further damage and increase chances of survival. In further research assessing the impact of cyclophosphamide on quality of life in people with lung involvement, 47 percent of people on the drug reported their health was somewhat or much better after 1 year, compared with 18 percent in the placebo group.
- ACE inhibitors are used increasingly for scleroderma-related kidney problems. ACE inhibitors have greatly reduced the risk of kidney failure in people with scleroderma. Now there is evidence that use of ACE inhibitors can actually heal the kidneys of people on dialysis for scleroderma-related kidney failure. As many as half the people who continue ACE inhibitors while on dialysis may be able to go off dialysis in 12 to 18 months.
- Several drugs are now available to treat pulmonary hypertension. Previously, pulmonary hypertension was associated with a poor outcome, but medications such as prostacyclins, endothelin-receptor antagonists, and phosphodiesterase inhibitors have increased the quality of life and life expectancy for people with this dangerous form of lung damage.
Other studies are examining the following:
- The immune system: Researchers are looking at the complex immune system trying to determine why the body creates antibodies against its own tissues. Identifying where and when the antibodies are created could lead researchers to find targets for new therapies. Researchers are already trying new therapies, including those that suppress specific parts of the immune system.
- Genes: Studies continue to find the genes that predispose a person to getting scleroderma. Those genes may be targets for future therapies. Researchers are also trying to find genes that indicate who will develop what type of scleroderma; this could someday help doctors intervene early in patients whose prognosis might indicate, for example, pulmonary hypertension.
- Drug therapies: A drug that has been used to treat some cancers has been found to be effective in preventing the development of fibrosis in animal models, and investigators are trying to find out why. Other researchers are testing a drug and comparing it to existing therapies to see if it results in sustained improvement with less toxicity.
- Animal models: Experiments using mice have proved valuable in past research on scleroderma. Further research using existing strains of mice continues. Researchers are also trying to develop new strains that can help in their study of this disease.
- The fibrosis process: Researchers are looking into the many factors that lead to fibrosis. Some are pursuing the genetics of fibrosis. One study is looking at a small molecule, halofuginone, which seems to protect against fibrosis; other small molecules may similarly protect the tissues. Another study looks at a small molecule that apparently contributes to fibrosis. Such discoveries could be future targets for therapies. Another study is pursuing an idea that the cells that overproduce the collagen, fibrocytes, in lung tissue, actually originate in the blood and then move into the damaged lungs; this is contrary to previous assumptions suggesting that the cells that overproduce collagen originate in the lung.
- The identification of several early immune system targets in scleroderma: Building on this research, scientists are continuing to look for ways to treat scleroderma earlier, before it has a chance to cause irreparable damage.
- Cytokines: Studies have shown that certain chemicals called cytokines, made from cells in the body, enhance the development of increased collagen. New agents that counteract these cytokines may be helpful in preventing collagen build up.
Scleroderma research continues to advance as scientists and doctors learn more about how the disease develops and its underlying mechanisms. NIAMS funds a research center specializing in scleroderma at the University of Texas Health Science Center at Houston. Scientists there are conducting laboratory and clinical research on the disease with the goal of translating basic science findings quickly into improved treatment and patient care.
- NIH Clinical Research Trials and You helps people learn more about clinical trials, why they matter, and how to participate. Visitors to the website will find information about the basics of participating in a clinical trial, first-hand stories from actual clinical trial volunteers, explanations from researchers, and links to how to search for a trial or enroll in a research-matching program.
- ClinicalTrials.gov offers up-to-date information for locating federally and privately supported clinical trials for a wide range of diseases and conditions.
- NIH RePORTER is an electronic tool that allows users to search a repository of both intramural and extramural NIH-funded research projects from the past 25 years and access publications (since 1985) and patents resulting from NIH funding.
- PubMed is a free service of the U.S. National Library of Medicine that lets you search millions of journal citations and abstracts in the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and preclinical sciences.
More Questions? Count on More Answers
Scleroderma poses a series of challenges for both patients and their health care teams. The good news is that scientists, doctors, and other health care professionals continue to find new ways to make earlier diagnoses and manage disease better. In addition, active patient support groups share with, care for, and educate each other. The impact of all of this activity is that people with scleroderma do much better and remain active far longer than they did 20 or 30 years ago. As for tomorrow, patients and the medical community will continue to push for longer, healthier, and more active lives for people with the diseases collectively known as scleroderma.
For More Information
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Information Clearinghouse
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484
Toll Free: 877-22-NIAMS (877-226-4267)
Fax: 301-718-6366
Email: firstname.lastname@example.com
Website: http://www.niams.nih.gov
Other Resources
American Academy of Dermatology (AAD)
Website: http://www.aad.org
American College of Rheumatology
Website: http://www.rheumatology.org
Scleroderma Foundation
Website: http://www.scleroderma.org
Scleroderma Research Foundation
Website: http://www.srfcure.org
Arthritis Foundation
Website: http://www.arthritis.org
For additional contact information, visit the NIAMS website or call the NIAMS Information Clearinghouse.
Key Words
Antibodies. Special proteins produced by the body's immune system. They recognize and help fight infectious agents, such as bacteria and other foreign substances that invade the body. The presence of certain antibodies in the blood can help to diagnose some diseases, including some forms of scleroderma.
Atherosclerosis. Aabnormal fatty deposits in the inner layers of large or medium-sized arteries, which can lead to hardening and narrowing of the arteries and blockages of the blood supply, especially to the heart.
Autoimmune disease. A disease in which the body's immune system turns against and damages its own tissues.
Calcinosis. The formation of calcium deposits in the connective tissues, which can be detected by x ray. These deposits are typically found on the fingers, hands, face, and trunk and on the skin above elbows and knees. When the deposits break through the skin, painful ulcers can result.
Calcium channel blockers. Medicines that lower blood pressure, relieve chest pain, and stabilize normal heart rhythms by inhibiting calcium movement into the heart muscles and smooth muscle cells. They are used to treat a variety of conditions and to prevent circulatory and kidney problems in scleroderma.
Collagen. A fabric-like material of fibrous threads that is a key component of the body's connective tissues. In scleroderma, either too much collagen is produced or it is produced in the wrong places, causing stiff and inflamed skin, blood vessels, and internal organs.
Connective tissue. Tissues such as skin, tendons, and cartilage that support and hold body parts together. The chief component of connective tissue is collagen.
CREST syndrome. An acronym for a collection of symptoms that occur to some degree in all people with systemic sclerosis. The symptoms are calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia. Because of the predominance of CREST symptoms in people with limited systemic sclerosis, some people use the term CREST syndrome when referring to that form of the disease.
Eosinophilic fasciitis. A scleroderma-like disorder (often considered to be a localized form of scleroderma) featuring inflammation of the fascia (the thin, sheet-like connective tissues surrounding the muscles and other body structures) and an abnormally high number of a specific kind of white blood cells (eosinophils). The result of the inflammation may be fibrous buildup in the skin of arms and legs, contractures, and carpal tunnel syndrome.
Esophageal dysfunction. Impaired function of the esophagus (the tube connecting the throat and the stomach) that occurs when smooth muscles in the esophagus lose normal movement. In the upper and lower esophagus, the result can be swallowing difficulties. In the lower esophagus, the result can be chronic heartburn or inflammation.
Fibroblast. A type of cell in connective tissue that secretes proteins, including collagen.
Fibrosis. A condition marked by increased fibrous tissue that develops between the cells of various organs or tissues. It is a common feature of scleroderma and some other diseases. Fibrosis causes hardening or stiffening of tissues in the skin, joints, and internal organs.
Graft-versus-host disease. A major complication of bone marrow transplantations and sometimes blood transfusions in which white blood cells called lymphocytes, which are found in the marrow or blood, attack tissues in the body into which they were transplanted.
Pulmonary fibrosis. Hardening or scarring of lung tissue because of excess collagen. Pulmonary fibrosis occurs in a small percentage of people with systemic sclerosis.
Pulmonary hypertension. Abnormally high blood pressure in the arteries supplying the lungs that may be caused by a number of factors, including damage from fibrosis.
Raynaud's phenomenon. A condition in which the small blood vessels of the hands or feet contract in response to cold or anxiety. As the vessels contract, the hands or feet turn white and cold, then blue. As blood flow returns, they become red. Fingertip tissues may suffer damage, leading to ulcers, scars, or gangrene.
Rheumatic. An adjective used to describe a group of conditions characterized by inflammation or pain in the muscles, joints, and fibrous tissue. Rheumatic diseases or disorders can be related to autoimmunity or other causes.
Sclerodactyly. Thick and tight skin on the fingers, resulting from deposits of excess collagen within skin layers. The condition makes it harder to bend or straighten the fingers. The skin may also appear shiny and darkened, with hair loss.
Systemic condition. A condition involving the body as a whole, as opposed to limited conditions that affect particular parts of the body.
Systemic lupus erythematosus. A systemic rheumatic disease that occurs predominantly in women and is characterized by autoimmune activity, a facial rash across the bridge of the nose and cheeks, Raynaud's phenomenon, joint pain and swelling, fever, chest pain, hair loss, and other symptoms. Many of its symptoms overlap with those of scleroderma.
Telangiectasia. A condition caused by the swelling of tiny blood vessels, in which small red spots appear on the hands and face. Although not painful, these red spots can create cosmetic problems.
The NIAMS gratefully acknowledges the assistance of the following individuals in the preparation and review of previous versions of this booklet: Reva Lawrence, M.P.H., Barbara Mittleman, M.D., Alan Moshell, M.D., and Susana Serrate-Sztein, M.D., NIAMS/NIH; Stanley Pillemer, M.D., National Institute of Dental and Craniofacial Research, NIH; Philip Clements, M.D., University of California at Los Angeles, CA; Vincent Falanga, M.D., Boston University, Boston, MA; E. Carwile LeRoy, M.D., Medical University of South Carolina, Charleston, SC; Morris Reichlin, M.D., Oklahoma Medical Research Foundation, Oklahoma City, OK; Larry Solomon, M.D., Lutheran General Children's Hospital, Park Ridge, IL; Virginia Steen, M.D., Georgetown University Medical Center, Washington, DC; Barbara White, M.D., University of Maryland at Baltimore, Catonsville, MD; and the Scleroderma Foundation, Danvers, MA. Special thanks also go to the patients who reviewed this publication and provided valuable assistance.
The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the U.S. Department of Health and Human Services' National Institutes of Health (NIH), is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. The NIAMS Information Clearinghouse is a public service sponsored by the Institute that provides health information and information sources. Additional information can be found on the NIAMS website at www.niams.nih.gov.
For Your Information
This publication contains information about medications used to treat the health condition discussed here. When this publication was developed, we included the most up-to-date (accurate) information available. Occasionally, new information on medication is released.
For updates and for any questions about any medications you are taking, please contact
U.S. Food and Drug Administration
Toll Free: 888–INFO–FDA (888–463–6332)
Website: http://www.fda.gov
For updates and questions about statistics, please contact
Centers for Disease Control and Prevention's National Center for Health Statistics
Website: http://www.cdc.gov/nchs
This publication is not copyrighted. Readers are encouraged to duplicate and distribute as many copies as needed.
Additional copies of this publication are available from:
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Information Clearinghouse
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484
Toll Free: 877-22-NIAMS (877-226-4267)
Fax: 301-718-6366
Email: email@example.com
Website: http://www.niams.nih.gov
NIH Publication No. 12–4271


text: VISITVisitor InformationDirectionsThronson CaféMuseum StorePublic ToursGroup ToursSchool VisitsNearby AttractionsEXHIBITIONSCurrent ExhibitionsUpcoming ExhibitionsPast ExhibitionsOutlooks Exhibition SeriesArt Is EverywhereCOLLECTIONSBritish Pre-RaphaelitesHoward PyleAmerican IllustrationJohn SloanAmerican Art, 19th Century – PresentCopeland Sculpture GardenThe Helen Farr Sloan Library and ArchivesNew AcquisitionsCurator CornerSearch The CollectionPROGRAMS & EVENTSCalendarAdult ProgramsTalks & ToursFamily and YouthArt CampConcerts on KentmereCalls for ArtisansConnected SeriesHoliday House TourEDUCATIONStudio Art ClassesSchool & Teacher ProgramsOutreach: Art ExcursionsHomeschool ProgramsDocentsKids' CornerRed Apple FundMEMBERSHIPWhy Membership MattersMembership LevelsDirectors CircleRossetti CircleArt Is CardReciprocal MuseumsSUPPORTAnnual GivingLegacy Giving1912 Loyalty SocietyDonor PortraitsCorporate SupportFinancial Documents2014 Annual ReportABOUTCentennial HistoryBuilding DesignGoing GreenDelArt BlogE-NewsMuseum RentalPress RoomOpportunitiesVolunteerContact UsStaff ListBoard Of TrusteesMuseum CouncilFirstPrevious1234..6667NextLastBerenice AbbottDate: American photographer, 1898–1991Biography: American photographer Berenice Abbott is best known for her documentary photographs of New York City's streets and buildings. She was born in Springfield, Ohio, and attended Ohio State University. In 1918, she moved with friends to Greenwich Village in New York. She shared an apartment with the writer Djuna Barnes, philosopher Kenneth Burke, and literary critic Malcolm Cowley. She joined the artistic and literary scene in the Village, befriending the anarchist Hippolyte Havel, playwright Eugene O'Neill, and artist Man Ray. She went to Europe in 1921, studying sculpture in Paris and Berlin and publishing an experimental literary journal. She began to photograph after working as a darkroom assistant for Man Ray. Her early photographs were portraits of individuals in the artistic and literary worlds, and she had her first solo exhibition in 1926. In 1925 Man Ray introduced her to the work of Eugene Atget and she purchased many of his prints and negatives in 1928. She produced a book of his work and persuaded the Museum of Modern Art to purchase her archive of his work in 1968. Abbott chronicled the buildings and inhabitants of New York in her series Changing New York, produced in the 1930s, and published as a book in 1939.Related worksMurray Hill Hotel: SpiralsBrowse All

subset: commoncrawl


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I am currently creating a project (in C#) in which you will be able to create any board game and play online. There are not much kind of programs like this, though I believe there is at least already one out there.
It will provide the basic functionalities that are common for all games. The basic program will provide pawns, cards, dices and in general all the basic stuff. The idea is you could play any game as long as you provide the images for the cards, pawns etc. The players will be responsible to play with the rules and place pawns correctly, as you would do in real life.
Also, using this code you could make a games with rules that will check how valid each move is and provide advanced functionality depending on the game. You will just have to provie the extra code.
It is rather a small project and an easy one, but for many board game lovers I believe it will be useful. I am creating the game board logic and I would like somebody to create the connection logic. Someone will be the server and players will connect to him/her. Each player will be able to issue a command which can be a string for now. Like "Move this piece there". The command will be issued to everybody so everyone's board will be updated.
1) So looking for someoneone to create the connection part
2) Ideas about the project? Useful? Sounds good?


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Indian River
Mackinac City
Home>Your Interests>Blueways>Straits Area Blueway
Route: MDOT ROADSIDE PARK (RICHARD KUZMA) TO MACKINAW CITY
Distance: 8 Miles
Access Sites: 02-11 & 02-13
Shoreline Land Use: Waterfront residential. No public lands except for Mill Creek rest stop
Points of Interest: Views of freighters, Mackinac Bridge, Bois Blanc Island and Mackinac Island
Rest Stops: rest stop at mill creek park, undeveloped, no signs, no parking
Hazards & Cautions: Recreational boat traffic and large ferry boats near Mackinaw City can make paddling difficult and cause safety issues.
Route: MACKINAW CITY WATERFRONT
Distance: 1.5 Miles
Access Sites: 02-13 & 02-21
Shoreline Land Use: Commercial, residential, hotels and numerous city parks.
Points of Interest: Numerous city parks. Views of freighters, passenger ferries, Mackinac Bridge, Bois Blanc Island and Mackinac Island
Rest Stops: Numerous city parks
Hazards & Cautions: Recreational boat and ferry boat traffic is heavy during summer months, particularly during holidays and weekends. Should be careful when paddling along waterfront. Paddling in the Straits is difficult with currents and wind.
Route: MACKINAC BRIDGE TO WAWATAM TOWNSHIP PARK
Distance: 6 Miles
Access Sites: 02-21 & 01-04
Shoreline Land Use: Residential near Mackinaw City, the rest is undeveloped.
Points of Interest: McGulpin Point Lighthouse, Headlands County Park, Mackinac Bridge.
Rest Stops: 01-07, 01-06, 01-05
Hazards & Cautions: Paddling in the Straits is difficult with currents and wind.
Route: WAWATAM TOWNSHIP PARK TO WILDERNESS STATE PARK
Distance: 6 Miles
Access Sites: 01-04 & 01-01
Shoreline Land Use: Mix of residential and public undeveloped.
Points of Interest: Cecil Bay Park and mouth of Carp River
Rest Stops: Cecil Bay Park
Hazards & Cautions: Shallow bays, waves in high winds
Comments: There is a store near the Cecil Bay Park. Camping is available further west in the Wilderness State Park
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text: It looks like we are finally going to see the Bermuda High kick into place Friday and Saturday. This is going to setup some E/SE fetch towards the southern half of the east coast Sunday and Monday. Small to fun sized medium period swells. Of course OBX will get the best of it, as they always do. At times, the Bermuda high can stay in places for long periods of time, and that is when we get those small, but consistent stretches of summer time surf. I certainly wouldn't mind if that would happen.


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In company filings this week, social networking giant Facebook provided a customary laundry list of risk factors that could impact the company's business going forward. A few of those risks have raised eyebrows in the technology, advertising, and investment communities, particularly Facebook's own assessment that some 8.7 percent of profiles on the service are "fake."
For years, Facebook has hammered home the message that it only wants profiles from real people and businesses on the service. Folks found to be maintaining a Facebook profile under a pseudonym, handle, or a name other than the one that appears on their birth certificate have often their profiles summarily deleted from the platform.
Is the fact that nearly one in ten profiles on Facebook are "fake" a tribute to Facebook's efforts to keep it real and only permit profiles reflecting real-life people and businesses? Or does it represent a significant failure to keep scammers, ne'er-do-wells, and "fake people" off the service?
Who's fake?
Facebook breaks down its estimate of "fake" users into a few categories. By far the largest is people who maintain two or more Facebook accounts, in spite of Facebook's efforts to enforce its terms of service and limit individuals to a single profile. The company estimates that about 4.8 percent of its 955 million active accounts — or about 45.8 million users — represent such duplicate accounts.
Many of those users aren't fake at all: They're real people who are really using Facebook. However, those duplicate accounts are a violation of Facebook's terms of service. If Facebook believes (or just suspects) someone is operating more than one profile, they'll often encourage users to narrow themselves down to just one profile, or sometimes require users verify the identity of a questionable profile by attaching a mobile number or submitting a drivers' license photo. Sometimes Facebook just outright suspends or deletes the profiles it believes violate its terms of use.
More recently, the company has rolled out an automated profiling system that issues warnings to users the company believes might be operating multiple accounts. That system appears to be generating many false positives, particularly in cases where multiple people use the same computer.
The Good…
Many folks who use multiple accounts do so for entirely innocuous reasons. They may have a personal account for themselves, but also operate a separate account for a business as part of their job or profession. Some people use multiple accounts as a way to separate professional and personal uses of Facebook. A so-called social media consultant might maintain a sizable network of connections on their personal profile, but have a second (quieter) profile where they engage with family and maybe a few guilty pleasures like Farmville and Words with Friends that they don't want diluting the "branding" of their "real" personal page. Others might set up secondary profiles for more pressing privacy reasons: for instance, to avoid the scrutiny of bullies or an abusive former spouse.
Many of these uses of multiple accounts are essentially challenges to Facebook's "real names" policy, and Facebook's stock response is that users must stick to a single account and avail themselves of the services' expanded (and famously fiddly) privacy controls to regulate what information is available to different sets of Facebook users. That's a tricky line to walk, since Facebook is notorious for opting its users into sharing information by default, meaning the best way to try to keep something private on Facebook is probably not to do it via an account everybody knows about.
Facebook would probably argue other common-but-understandable uses for multiple profiles are simply misunderstandings of the platform. That social media consultant ought to set up a business account, rather than relying on a personal account. For some folks — retailers would be a good example — Facebook's business accounts are a good option, but for professionals whose business is social media, they fall flat. Business accounts don't show up in search, can't send or receive friend requests, or make apps. So, many people who are very serious about social media undoubtedly operate multiple Facebook profiles.
Of course, an unknown (and essentially unknowable) number of secondary profiles are set up for less innocent purposes, such as harassing other Facebook users, or setting up an army of fake accounts in an effort to game services offered via Facebook, or generate fake "likes" and visits to bolster visibility and advertising revenue — a variant on "click fraud" schemes that still beleaguer the online advertising industry.
The confused…
Facebook further estimates that about 2.4 percent (about 23 million) personal accounts are "misclassified" — users who have set up a personal profile for a business, video game avatar, or something like a family pet. Facebook permits "entities" like these to exist on the service, but only as Pages associated with a personal profile. In other words, there's no official way for someone's World of Warcraft character to have a Facebook page that's independent of the player's "real" Facebook profile. (Mark Zuckerberg's dog, Beast, is an example of a Page associated with a personal account.)
…and the ugly
Facebook estimates another 1.5 percent (about 14 million accounts) are operated by bad actors: "undesirables" who have set up accounts for purposes like "like" fraud and spamming. Facebook primarily identifies these accounts by analyzing their accounts activity. The behaviors of an account created purely to generate spam via comments, wall posts, and similar actions are usually quite a bit different from a "real" new user, who often upload contact lists, search for friends, surf around a bunch of pages, fiddle with preferences, and (yup) play games.
Why "fake" matters to Facebook's bottom line
Now that Facebook is a public company, it is required to disclose more details of its business operations and status to investors. Although Facebook's most recent 10-Q filing contains an enormous lists of potential risks to the company, that's utterly normal for this type of disclosure. If one were to evaluate companies solely by the risks disclosed in SEC filings, one would think the climate for all U.S. businesses is unequivocal sky-is-falling doom-and-gloom. The bulk of listed risks are (pardon our French) CYA tactics: Sometimes it's a wonder companies don't note a zombie apocalypse as a major future threat. In the event something goes horribly wrong and Facebook tanks, the company will be able to point back to these filings and tell investors they had fair warning.
Nonetheless, the bulk of Facebook's revenues derive from selling advertising; so far in 2012, advertising sales account for 83 percent of the company's revenue. The value of that advertising is tightly linked to the company's ability to collate and analyze user information, then put those ads in front of the users who are most likely to respond. Facebook might be based on a culture of "real names," but the financial reason it doesn't want people running multiple accounts is that it interferes with the company's ability to comprehensively profile a user. A user might be on Facebook eight hours a day, but if she uses eight different profiles, Facebook isn't collating information about that user anywhere near as efficiently as it would like.
By disclosing that nearly nine percent of its accounts worldwide are, in its own eyes, "fake," Facebook effectively diminishes the value of its advertising platform. Is it nine percent less effective? Probably not, particularly since a lot of those so-called "fake" profiles aren't going to generate much useful information that would influence Facebook's targeted advertising. But advertisers are going to read the disclosure as "Facebook says 83 million accounts are useless to us." That may mean they're going to bid less money — or less frequently — to put advertisements or sponsored stories on Facebook — and that can directly impact Facebook's bottom line.
But do these "fake" accounts have an effect on diluting Facebook's advertising reach? Perhaps. The BBC's Rory Cellan-Jones recently tested Facebook's advertising platform by setting up a page for a fake business, VirtualBagel Ltd., then buying advertising intended to get users to "like" the page. VirtualBagels offered no products, no coupons, no special offers, and had no significant content. What happened? Within 24 hours VirtualBagels had 1,600 "likes." Moreover, a significant portion of those likes came from Facebook users purported located in Egypt, Indonesia, and the Philippines…and almost none came from the United States or the United Kingdom. Facebook told the BBC that there was "no significant issue" with fake profiles or their advertising platform, and that Cellan-Jones' test was worthless.
But here's a line from Facebook's 10-Q filing that's not a CYA statement: "The loss of advertisers, or reduction in spending by advertisers with Facebook, could seriously harm our business."
Editors' Recommendations
- The best dating apps for 2020
- The secret way most apps spy on you even when you think they aren't
- Online platforms like Facebook are losing yet another 'infodemic' war
- How to use Skype
- How to run a free background check


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Archive for May 7, 2014
Water Conservation at Smithsonian Gardens
Join us this Saturday, May 9th, from 10 a.m. to 3 p.m for a celebration of "Water, Water, Everywhere" at Garden Fest in the Enid A. Haupt Garden. In this blog entry Sarah Tietbohl writes about just one of the many ways we try to conserve water at Smithsonian Gardens.
When I first started at Smithsonian Gardens in 2010 I was assigned the job of cleaning the Moongate fountain in the Enid A. Haupt Garden. I was excited about this task as I would have an opportunity to learn to use a new piece of equipment and keep cool during the hot summer months. I estimated that the fountain would need to be cleaned maybe once a month. With the pond open between April and October, that would total seven times a year. That spring, the cleaning schedule started out at once a month. As the season went on and the temperatures climbed into the 90s, I noticed that the fountain was growing algae at a rapid pace. It turned the water a sickly slimy-green color. That once-a-month cleaning turned into scouring once or twice a week! That season, I ended up cleaning the fountain well over twenty times. The next year it was the same story.
After the summer of 2011, I really started to think about all of the water, energy, and time it takes to clean the Moongate fountain. I started to gauge the amount of water that was being used in one year to clean and fill the fountain. I calculated that it takes 2,300 gallons of water just to fill the fountain each time it is cleaned, plus 200 gallons or so to clean it. I decided to research environmentally-friendly products that would reduce the amount of algal growth, thereby cutting down on the amount of water needed to re-fill the fountain after each cleaning. Fewer cleaning sessions would also result in less emissions (and noise) generated from the power washer that runs every time the fountain is cleaned. I started experimenting with a non-toxic black pond dye. Adding black dye to the fountain reduced the amount of sunlight that was able to penetrate the water, which in turn reduced the algal growth. I found the dye to be very effective and talked my colleagues into using it in the fountains in the Ripley and Folger Gardens as well. Thanks to the black dye solution, Smithsonian Gardens has reduced fountain water use from 60,000 gallons a year to slightly less than 22,000 gallons- a terrific way for Smithsonian Gardens to employ a sustainable alternative in its operations.
-Sarah Tietbohl, Smithsonian Gardens


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Unfortunately, due to low ticket sales we have taken the decision to postpone Glasgow Anime & Gaming Con (May 6-7th) until 2018.
We apologise for this, but the numbers of attendance would not have been good to put on an event of the quality that we want and that you deserve. If you have made payment for tickets (including Supporting Membership and T-Shirts), you will be refunded in full without any admin fee within the next five working days - please let us know if you do not receive it.
If you have signed up to help us flyer, we will still honour this and send you a T-Shirt. Please email firstname.lastname@example.com with your address and size, and we'll post it out to you.
Regarding our other events - we'd like to reassure you that all our other events are 100% going ahead and are doing well in terms of sales. Some of our events such as Manchester and London are at record levels of sales, while others such as Bristol are set to sell out and every other event including Alcon is doing perfectly fine. Unfortunately, Glasgow is a brand-new event in a region that we're unfamiliar with and has proven too difficult a step at this stage for us, which is why we have taken the decision to postpone and build this area up first.
Again, we apologise for any inconvenience. We hope that this does not put you off from attending future events and indeed Glasgow Anime & Gaming Con when it does go ahead later than planned in 2018. You can view a full calendar of all our other 2017 events here - http://www.animeleague.net/forum/content.php?836
If you have any questions or concerns then please don't hesitate to email email@example.com
Many Thanks
Animeleague Staff
Originally Posted by ImmortalJed
I'm ill enough as it is, don't need you bunch of braindead fools nomming on me and making it worse
I considered a road trip to Glasgow to check it out. Good thing I didn't.
At least you guys can now focus on your other thriving cons.
We can still have a roadtrip to Edinburgh/Glasgow.
RedWarriors Beautiful CreaturesPharaohAtemButaFaithyIvoryWickedNekoIzzylolinUsagiAryaMakiChanTeenyIf you want to be on this list then just ask. Just Do It.
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Florida gets final chunk of money for high speed rail | Transportation
Tampa, Florida -- Governor-elect Rick Scott could still say no to the high speed rail line linking Tampa and Orlando, but the latest announcement from Washington would make that a politically tougher move.
That's because the $2.6 billion bullet train line is now entirely funded.
Calling it an "early Christmas present," U.S. Senator Bill Nelson (D-Fla.) said Thursday that Florida will receive some $342 million in federal money to help build the high-speed rail system.
What's the saying? One state's trash -- is another state's treasure? The new governors of Ohio and Wisconsin made the promise to turn away high speed rail money in their states.
So Thursday, the U.S. Department of Transportation took away their $1.2 billion in bullet train bucks and divvied the cash up between other states.
Florida got $342 million. That's the amount that was still missing from the $2.6 billion cost to build the Tampa-Orlando line.
About 90 percent of that total $2.6 billion cost will come from the federal government.
The rest, $280 million, will be either state money that's already been set aside for the project, or could come from the private company that will eventually be chosen to run the high speed rail line.
More Florida High speed rail coverage:
11/10/10 - High-speed rail stops in Lakeland under scrutiny
11/9/10 - Nelson, Iorio plead with Rick Scott to support high-speed rail
10/8/10 - Election Day could derail high-speed trains
8/7/10 - High-speed rail workshop for local businesses
7/19/10 - Work on high-speed rail lines begin along I-4
State Senator Paula Dockery (R-Lakeland), a member of Scott's transition team, is preparing to brief the Gov.-elect on rail issues and doesn't anticipate him pulling the plug on the high-speed electric train.
"There seems to be some misconception out there that this is going to be a drain on the taxpayers of Florida," said Dockery. "Nothing could be further from the truth. And that's what Rick Scott wants to see."
Dockery says a private-public partnership with the companies bidding for the project could net hundreds of millions for the state -- possibly more than the $280 million the state has pledged for the project.
"I don't anticipate the state needing to put any money in toward the construction of the Tampa-to-Orlando leg," said Dockery.
Scott has not taken a firm position on whether he will green light the project to go forward.
During his campaign for governor, Scott said he would only support high speed rail in Florida if it wouldn't be a burden on Florida taxpayers and looked like it would show a good return on any state money invested in it.
After the election, the New York Times reported Scott was willing to take another look at the numbers to see if the project was viable, in his view.
Sen. Nelson, who announced the extra money for Florida, said he also thinks Scott will get on board with the bullet train project.
"I think, for the governor-elect to reject it at this point... it's almost beyond the point of no return because of the value to Florida and the number of jobs in the middle of a recession," Nelson said.
Building the rail line is expected to employ close to 10,000 people by 2012.
The first stage of Florida's high speed rail line will have five stops, connecting Tampa, Polk County, Walt Disney World, the Orange County Convention Center, and Orlando International Airport.
That line is scheduled to be up and running by 2015.


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DandeLight necesitaba un nuevo diseño de logotipo y lanzó un concurso de diseño en 99designs.
Un ganador ha sido elegido entre 100 diseños de 24 diseñadores freelance.
Celebrating 20 Years
Specialised Lighting Solutions (SLS) are a total lighting solutions provider to the commercial and industrial sectors.
SLS take a floor plan and make recommendations according to the layout and lighting needs as well as providing quality products and ongoing service, all whilst focusing on energy efficiency. SLS also have the advantage of being able to offer custom made products where needed...
Commercial applications, retail, property management, industrial sectors.
This is not a new SLS logo, it is a separate logo from the brand which will be added to marketing material to represent our 20 year milestone...
It is all about innovation. The logo needs to help with the perception that we are moving forward and have grown from 20 years ago.
You may use the Style Guide as refernce to assist (Eg: Font), however it not essential. We'd like you to think 'outside' the square. Our preference is no light globes as we are more than just light globes, we are a TOTAL SOLUTIONS PROVIDER. Globe logos will still be considered if they are appealing.
You may use the blue and orange featured in the Style Guide or choose another colour you think may suit.
Descubre cómo funciona un concurso de diseño u obtén más información sobre nuestros servicios de diseño de logo.


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Neo-Nazis scoop YouTube ad revenue from UK telcos
Blood and dishonour
Neo-Nazis operating in the UK have reportedly used YouTube's advertising revenue-sharing system to gobble up payments from companies that include BT, O2 and Virgin Media.
None of the telcos were aware that the right-wing extremists who had posted the videos on Google's website were exploiting the search giant's Adsense network, which allows YouTube members who upload non-copyrighted vids onto the service to slurp up a portion of the advertising bucks.
The payments have apparently helped neo-Nazi groups to generate funding after they posted videos on the site that are often marked by YouTube as "potentially offensive or inappropriate" material.
The Sydney Morning Herald reported that Google had since taken down the videos after been alerted to the fact that the extremists were benefiting from the ads displayed on the content.
WARNING: This video is full of crap
It's unlikely, however, that Google will be able to effectively police such videos, and anyway, the extremists aren't breaking any of the company's Ts&Cs; the company allows any YouTube member to benefit from its revenue-sharing service as long as the material is original and not violating someone else's copyright.
Google does state on its community guidelines:
We encourage free speech and defend everyone's right to express unpopular points of view. But we don't permit hate speech (speech which attacks or demeans a group based on race or ethnic origin, religion, disability, gender, age, veteran status, and sexual orientation/gender identity).
But such "offensive" material can only be removed on a case-by-case basis if complaints are sent to Mountain View. In the meantime, the YouTube members who wise up to joining AdSense can benefit, temporarily at least, from ads running on their videos, no matter how nasty the vids themselves might be.
A YouTube exec once told your correspondent that members of the YouTube community needed to act a bit like online curtain-twitchers to report such vulgar videos to Google.
Virgin Media, as one of the companies whose adverts were displayed on the neo-Nazi vids on YouTube, told the Herald:
"Virgin Media has a strict policy on its ad placement, so we are concerned about ads appearing against unrelated and unsuitable content on YouTube. We are currently engaged with our advertising partners and Google to understand what measures can be put into place to prevent these occurrences going forward." ®
Sponsored: Practical tips for Office 365 tenant-to-tenant migration


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Looking at language
The study of the neural basis of language has largely focused on regions in the cortex - the outer brain layers thought by many researchers to have expanded during human evolution. Research at Brown University's Department of Cognitive and Linguistic Sciences, reported in the September Issue of Cortex, published by Elsevier, adds to evidence that deeper, subcortical regions are also critical by pinpointing when Parkinson's disease patients have difficulty while processing grammatically complex sentences. In Parkinson's disease, degeneration of subcortical dopamine-secreting neurons leads not only to motor symptoms but often also to cognitive deficits.
Jesse Hochstadt recorded eye movements of Parkinson's patients as they listened to sentences containing restrictive relative clauses ("The queen who was kicking the cook was fat") and tried to choose matching pictures. Patients who made more errors were slower to stop looking at pictures ruled out by the relative clause (a cook kicking a queen) when they had heard only as far as that clause's verb ("The queen who was kicking"). But at the ends of sentences, they were not slower to rule out pictures (such as a thin queen kicking a fat cook) that disagreed with the main clause ("The queen … was fat"), despite the memory demands imposed by the intervening relative clause. These patients again showed poor relative-clause and good main-clause processing when relative clauses were at the ends of sentences ("The queen was kicking the cook who was thin").
Patients with such syntax processing difficulty also had difficulty switching between making choices based on size or shape in a non-linguistic task. This association, Hochstadt proposes, may indicate that processing relative clauses requires structural "switching away" from main clauses; alternatively, because restrictive relative clauses generally refer to facts already mentioned, processing them may involve shifting attention to this "background" information from main-clause "foreground" information.
These joint effects of subcortical neurodegeneration on syntax and "set-switching" are consistent with widely publicized research indicating that mutations in the human FOXP2 gene cause deficits in language and cognition by affecting development of subcortical structures, and that evolution of modern Homo sapiens involved modification of this gene.
More information: The article is "Set-shifting and the on-line processing of relative clauses in Parkinson's Disease: Results from a novel eye-tracking method" by Jesse Hochstadt and appears in Cortex, Volume 45, Issue 8 (September 2009), published by Elsevier. http://www.elsevier.com/locate/cortex
Source: Elsevier
Explore further


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Pattaya's luxurious resort and spa is surrounded by the perfect spot
of vacations with 60-room boutique-style masterpiece, elegant and comfort
settings of own tropical Bali garden, complemented by 27 oversized
stand-alone private pool villas suite and garden suite with Jacuzzi.
Pattaya's newest resort also has a collection of the finest ultra-luxury
relaxations and experiences with various unique features of
Garden Villas, Deluxe Pavilion, Garden Suite with Jacuzzi and Pool Villa Suite.
Sea Sand Sun Resort and Villas transcends the ordinary and delivers a private
stunning-beachfront resort experiences with the natural beauty.
Recharging your senses with less tensions and worries retreated by professional spa treatments. Sea Sand Sun Resort and Villas has a comprehensive menu of services and intimate-warm dinning in the comfortable setting on luxurious relaxation by "Horizon Sea View Restaurant". Our customers can also get pleasure from romantic sunset, cocktails, conversation, and all luxuries of the resort life overlooking facing the Gulf of Siam from the land of quite moments and privacy. Importantly don't forget to keep body fit and mind at the ease with exercise facilities and outdoor activities.
Sea Sand Sun Resort and Villas is located at Chonburi Province, approximately 15 kilometers south of Pattaya and 163 kilometers from Bangkok. Traveling time by car services from Bangkok or Suvarnabhumi International Airport is only 1:30 minutes.
|The 60 luxurious guest rooms are stylish, elegant surroundings with Thai modern decor make an inspiring experience in a tropical Bali garden setting, complemented by 25 oversized stand-alone private pool villas Suite and Garden Suite with Jacuzzi. The resort is located on the beachfront looking towards the Gulf of Siam. All rooms including Garden Boutique, Garden Villas and Deluxe Pavilion and have either comfortable king size bed or twin beds with cozy duvets, most with an open-style bathroom and all with private balconies. A unique feature of the Garden Suite with Jacuzzi and Pool Villas Suite are the first of their kind in Pattaya, Na Jomtien area. Each villa is secluded by a wall of lush vegetation to assure privacy atmosphere and has its own executive private plunge pool, plus a bathtub in a rustic garden setting surrounded by tropical Bali garden style Bedroom, Living room, Bathroom, Facilities, Gallery, and Virtual tour.
Garden Boutique(55 sq.m | 6 rooms, with 4 rooms interconnecting together)
The beautiful outdoor garden and its architecture are inviting. Have a meaningful stay in this wonderful resort.
Garden Villa(55 sq.m | 6 rooms)
This uniquely designed villa is suitable for couples who want to spend a fantabulous moment and experience romance with nature.
Deluxe Pavilion(120 sq.m | 4 Luxurious clusters with 16 Deluxe Pavilion rooms)
Its perfect location and its design with private terrace and balcony will let you experience to mingle with nature.
Overlooking the majestic landscape of the resort. The room is simply luxury at its best.
Garden Suite with Jacuzzi(200 sq.m | 6 Luxurious rooms)
One of the guest's favorite rooms in this resort; where you can experience privacy at its best. A stand-alone villa with private Jacuzzi.
This Villa is very spacious and good for travellers who are looking for luxury and comfort.
Surrounded with beautiful greeneries and towering trees. The whole setting and architecture will truly fascinate you.
Pool Villas Suite(200 sq.m | 15 Luxurious rooms)
One of the signature villas this resort can offer. Another stand-alone villa with a private pool.
Spoil yourself with the luxury this resort can offer. The best of its own.
Our seaside restaurant "Horizon
Sea View Restaurant" serves a most comprehensive range
of Thai and International cuisine. You may enjoy Daily American Breakfast,
Lunch or Dinner in are freshing atmosphere with first-class service.
Our resident chef adds brilliance to individual recipes and personally supervises the selection of the freshest and lively seafood, meats and vegetables to assure you of the most delicious flavor. We also specialize in sensational BBQ dinners. Seaside Bar gathering after dinner to chat over a pleasant drink and enjoy the cool sea breezes. We offer a wide drink menu, imported and local wine and beers, plus a selection of soft drinks and fruit juices.
Sea Sand Sun Spa
Indulge yourself in an invigorating treatment based on your highest relaxation is serene sanctuary. Experience the rhythms of touch and spoil yourself with and ideal massage for a truly relax and refreshing with Sea Sand Sun special blended aroma oils to encourage and balance the flow of energy and promote well-being. Our signature treatment that helps fight excess fat under skin and smoothen your skin while performing the cellulite fighting. Sea Sand Sun Spa is concentrating on a perfect pathway to bring back timeless peaceful and uplifting spirit. After a long sunny day - Facial De La Mer (Facial for Sensitive Skin) By our own recipes, Sea Sand Sun Spa recommended sensitive facial scrub will stimulate circulation. This massage induces a state of deep relaxation. Homemade sensitive facial mask will restore the balance of your skin in order to leave your skin clean and fresh.
Reveal your inner beauty through a healthy from within with Sea Sand Sun Spa the oasis by the shore.
Sea Sand Sun Resort and Villas Meetings and Events venue, a magnificent setting offers 3 versatile function rooms and 3
outdoor venues with diverse layouts to fit your vision ideal for small to medium scale meetings and conferences, exclusive,
top-level meeting, social occasion, fabulous themed parties or dreamy beach weddings.
Our meeting and event planning staff offers the dedication and professionalism you
require to ensure that your event will exceed your expectations
|Swimming Pool
|Swimming Pool
|Swimming Pool
|Sun Bed
|Wedding Ceremony
|Wedding Ceremony
By Car: Chon
Buri is one-hour drive from Bangkok along Highway No. 34 (Bang Na-Trat).
Alternatively, a faster trip can be made by taking Motor Way (new Bangkok-Chon
Buri Route).
By Bus : The two-hours journey from Bangkok can be made on regular buses originating from the Eastern Bus Terminal (Ekkamai). Air-conditioned buses leave Ekkamai every 40 minutes from 5.30 a.m.-9 p.m. Non air-conditioned buses leave Ekkamai every 30 minutes from 5 a.m.-9 p.m. There are also air-conditioned buses leaving the Mo Chit 2 Bus Terminal on Kamphaeng Phet 2 Road from 6.30 a.m.-6.30 p.m. Si Racha Tour Tel: 0 2936 4029 also operates air-conditioned bus services to Chon Buri and Bang Saen.


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About PAG
Policies and Resolutions
The nine-member Regional Council is the governing body of Pima Association of Governments and meets monthly, typically at noon on the fourth Thursday of each month. The Regional Council takes action on policies, plans or reports that pertain to cross-jurisdictional issues on transportation, air quality, water quality, land use or human services.
PAG is the federally designated metropolitan planning organization, the designated lead agency for the U.S. Environmental Protection Agency for air quality and water quality, and the lead agency for regional solid waste planning.
PAG also is the fiscal manager of the Regional Transportation Authority.
2020 Members
Pima Association of Governments is a member of the Joint Planning Advisory Council, a planning partnership for the Arizona Sun Corridor. Other members include Maricopa Association of Governments, Central Arizona Governments and the Sun Corridor Metropolitan Planning Organization. Partnering agencies include the Yuma Metropolitan Planning Organization, Arizona-Mexico Commission, CANAMEX Corridor Coalition, Arizona Department of Transportation, AECOM, Arizona State Land Department, Morrison Institute for Public Policy and Arizona State University's North American Center for Transborder Studies.
For more information on JPAC, please click here.
©Pima Association of Governments | 1 E Broadway Blvd, Suite 401, Tucson, AZ 85701 | Telephone (520) 792-1093, FAX (520) 620-6981


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25th Anniversary Edition.
7" Silver Splendor Body Massager
Cybersex Probe: Cyberskin Pleasure Sleeve designed to fit 7" Body Massager.
Cybersex Penis Pleasure Sleeve: Designed to fit 7" Body Massager.
Cyber Body Tickler: Hi-Power Mini Massager
Ships Everywhere.
I am completely thrilled with my order. Thank you.Anonymous - August 20 2015


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Dragons Hoard Issue 5
Dragon's Hoard Volume 5
This fifth installment of Dragon's Hoard, Dragon's Hoard Volume 5 brings another full color issue to our dedicated and new fans alike. This issue is proud to feature more artists and is chock full of the feral dragon erotica our fans love!
Table of Contents:
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please email or call (702) 291-8286 or fax (702) 537-2001.
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text: Just wondering if any of the members who were here before 2009 are still around. Sold my truck then and haven't been around. Always wanted to get another truck but not looking like that will ever happen. Just wanted to say HI again to you old guys!! Thought about selling my collection, anyone interested.


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Was Bremadent Dental Laboratory really featured on the BBC? .... Who is new at the Lab? What is with the ticks on dockets? Click below to find out
Leave a Reply.
Private Dental Laboratory in London
About the author:
Kash Qureshi is a Clinical Dental Technician (Denturist) in the U.K who oversees and quality controls over 3000+ fixed and removable prosthesis including implant cases from a clinical and technical aspect monthly at Bremadent Dental Laboratory & Swissedent Denture Clinic in London.
www.swissedent.co.uk www.bremadent.co.uk firstname.lastname@example.com
April 2020
© 2018 Bremadent Dental Laboratory is a trading style of Bremadent Premier (Bristol) LTD whose Registered Trading Address is at: 25a James Street, Walthamstow, London E17 7PJ, whose Registered Office Address is at: Leytonstone House, 3 Hanbury Drive, Leytonstone, London, E11 1GA whose Registered in England No: 06377738.