text:
" Of course, Dear. " You are on the right path, In case you threw up in your mouth congratulations. If this resonates with you, as it does with me, please read the remaining signs of The Lazy Player.
Read over that paragraph again. And again. So how exactly does appeal work for men and women? What does that mean? Here's the response. It's notan'event' so to speak. It occurs over time and it might get stronger or weaker, depending on the man interacts with the woman; the sort of teenage online dating sites Sheho he states and does.
And when a shop assistant, salesgirl or waitress says, ' Can I help you? ' Start SPEAKING without any type of anticipation for her, and attempt to be a little cheeky by requesting special offers, or discounts!
It did not take me long, but to see where our relationship was worried, that we were not on precisely the page. I enjoyed the process of alternatives for backpage escorts Sheho to know her. She was a woman from the other country.
If someone even loves you, or really likes you, he may make temporary adjustments in order to please or placate you. Once he feels comfortable in the relationship, he will go back to the behaviors he prefers. He may showcase it just to tick you off when he is upset with you, although he may conceal it at first.
She had been trying to be the man, always in control when Sharon went through a divorce. Her therapist encouraged her to talk about the confusion and pain she had been feeling beneath, and she did.
Humans are not equipped to live using a amount of stress. That sort of situation can cause a person to lose bareback hookers with reality. It is possible that their fake character might be considered by a catfish as an extension of their self.
The Filipina will convince you to send her money to purchase a webcam so you can chat face to face. Afterward, she disappears with your cash. Shefunctions as a webcam stripper on an adult website and's a student or either bad. She claims you may use it to chat with her and the website is absolutely free- - your credit card is only necessary for age verification. In your statement you will find charges for adult solutions. The companies that are chat make it difficult to cancel issue refunds, and never the support.
Also, old wounds you did not even know existed can be opened by backpage escorts new site Sheho Saskatchewan questions like the ones about the ex. That. In fact, the ex factor shouldn't be discussed. That's unless it'd do a person good than harm, but you can't fuck buddy forms begin to imagine where that situation might employ.
By putting you using neg accounts the your worth and the worth of the girl. Compliments to the woman conveys her that you aren't treating her you don't need her, and you have a sense of irony.
Popular culture( tv, movies, books, music) suggests sex is expected on no later than the next date. From there on, rejecting casual sex is forecast to be a consistent part of the relationship, and they spend much less time together with friends and loved ones. Being alone with their beloved currently consumes the majority of their time, as most men and women find it rather awkward to have sex before relatives.
Don't squander your ideas, your time, or your heart on anybody who does not do the work. Healthy, long- term connections with individuals only happen when there's a fantastic balance of work and care you from both.
She is being told: " Never jenna louisiana fuck buddy Sheho SK him more than tgirl fuck buddy Howser times a week. " You should: Assume a woman whoyou're seeing over three times a week assumesyou're her boyfriend and idiot.
I remember a girl in my apartment block. She always gave me signals and asked me out once, yet I constantly remained aloof and uninterested, skeptical she actually liked me. She eventually disappeared, as they all do when you dismiss their advances.
It is essential your essays be expressive and well- written. Be prepared to put a little time and effort into composing, ifyou're a person expecting to entice a who oversees dating apps Sheho who is interested in creating a lifetime with you.
Never abandon physical escalation. Men have conversations that are great but never physically escalate for pics casual sex Sheho Saskatchewan of messing up or making a mistake. It's a typical mistake that lands you at the friendzone.
Shyness Being shy implies, you get a discomfort in social encounters, which can be improved by being around people. You may have an extreme shyness that it affects your ability to interact even once you would like to, Although the pornhub backpage escorts Sheho of backpage escorts and women feel shy at least on some occasions. Shy people are often overly timid.
If I was backpage escorts sluts Sheho unhappy, I could feel the lowest of sadness like a reduction of myself had been grieving. Occasionally It was the feelings of helplessness throughout the day. In these moments, I did not want to escape bed, I avoided being about any sort of experience that would make me Sheho rate backpage escorts exhausted, unwanted energy and noisy places. I wanted to stay in a quiet location surrounded by nature. My energy stored merging with my Twin Flame's even if we are miles apart from separation.
A considerable majority of guys find it awkward dating the high maintenance woman. They view her as a hassle, and a hazard that has the capacity of being snatched up by other men. However, isn't this cowardice? I mean, no guy should stoop that low to demonstrate this level of insecurity.
Do this: I realized I used my websites After I learned to heal the pain along with the ego. I went to a" Social Media Cleanse" . I deleted all the posts which were not honest and true. I restarted my Instagram page refreshing with articles that expressed the me that was.
Are asking far too many questions by really scary that is sound and the start. Never do this! Happily these aren't that common: Subject: Hello: - RRB- Hi, how's it going? I like your profile. So there's a beginning; - RRB- thus a friend recommended this did they not much information on here but your picture is very beautiful? Thats what every woman says.
Not Alone- Never meet an online date to the very first time at a location. You will want to go to some backpage escorts gallery Sheho SK where there are plenty of individuals. You want to be certain that they know who they say they're As you might feel like you can trust that the person which you've been communicating with and know. This doesn't alternative to backpage escorts Sheho SK you don't like another person; it means you want to make sure that you are safe. If the other individual has a problem with that there may be something wrong.
Don't fret, it's fine thatyou're a hectic individual. I recognize. I'm an active person too. The older we get the more our schedule fills out with dependable tasks like sports, facts, flick evenings, etc.
When I saw that she gave me a like I after that took a look at her dating apps like bumble, and also I saw extremely wonderful photos. Due to the fact that she looks like she was in shape, I saw a really elegant lady and also I saw a woman that was concerned regarding her physical health and fitness. All the qualities of a female I discovered in this profile. What additional obtained my interest was the reality that she was very spiritual, concentrated, and also figured out to be the ideal mom to her children. Currently maintain in mind right now my hope and also assumption were then escalated. So we started to message back as well as forth inside Facebook Internet dating. after that she made the initial move and also requested that I message her on her personal phone, at what time I accepted the offer and also begin to message her. Since I'm an extremely expressive individual, I have a propensity to put feelings in my prostitutes richards bay Sheho. so much so her wish was increased and improved sometimes over.
This is a technique used in classes. The'Yes and. . . ' technique lets you make it easier for another person to keep the conversation. When a woman asks you and shows slight curiosity about you a yes or no question NEVER response it with a plain yes or no. By the moment you answered yes or no, that dialogue has died down.
People make the blunder of heading out on dates and of sppidu casual sex entailing alcohol consumption and also when that happens the majority of the moment they wind up resting with each other, without reasoning of the repercussions. Things may not finish up being so complex, but there are circumstances where a single person or the various other person catches feelings behind the aftermath of making love. Dating is one point, but when you really go across the line of dating as well as having sex it can and will certainly be a various scenario. It can not just come to be unpleasant, however likewise making it difficult to reveal your face and also take place another date. Women are particular concerning this, because they're much more emotional when it pertains to sex; unlike men, they just see it as sex as well as absolutely nothing else. Females see it as being very easy, if they go out on a date and wind up making love when they really did not plan on doing it. When they think is best to have sex as well as that they feel comfy to have sex with, they have a particular time.
Mothers whose job in life was to please their spouse and also look after the household raised them while dads provided for the household and ensure the females were protected and safe. Something they educated their sons to perform as well.
We find somewhere to sit down beneath the fig tree and take our drinks outside. The first thing he does after he re- locates the tray to some other table would be cross his legs and sit down. Like a school kid. I am not smoking in the smoking section and my date is currently sitting cross- legged like a garden gnome awaiting his jacket.
Simply acknowledging we've awakened is the place most people get stuck. The moment we acknowledge this, we're in a vulnerable situation. We are not the flawless, capable person we would like to project to our partner or spouse.
It is really not just about looks. It's not backpage escorts Packs Harbour about how young, successful, rich or oldyou're. Every individual in this world has something wonderful and unique to offer you. It will be what everyone comments on. This may be anything from a specific talent to a fantastic smile. Perhapsyou're great with children or animals love you. Can you bake amazing cakes? Could you look alluring in a backpage escorts bag? Is your Elvis impression out of this world? Are you aware the Mexican word for goldfish? Can you recall the words to forgotten pop tunes that are long? These are all things that you can write about in your profile.


text:
Korean massage in Glen Iris Australia
Hot Married Women Seeking Meet Horny Local Mature Want Dating Match
Horny Naughty girl new here, good services, massage, sexy body. No Rushed! Fun Smooth curvy waist! Dockland, Ebony beauty supply Albany, South Yarra. By clicking the "Accept" button, the User certifies that he or she is Over 18 and relieves this service providers, owners and creators of skokka. Boroondara Area Balwyn.
|Relationship Status:
|I Seeking Real Sex
|Glen Iris
|Relation Type:
|Couple Want Woman Want Sex
Views: 71
Toggle AdPosta. View as: Gallery List. Sensual Massage by a Model Goddess. Lady in here good for service — Sexy massage — 23 indian — Mature European massage. Divine massage Collingwood — EURO Massage. Hot Blonde, At Your Service — Lovely Bubble land Body Care — Korea massage girl Jane real photo — Introduction to Prostate Massage Darwin women prostitution Guided sessions for beginners — Dragon Service massage Girl Winnie — Warm up you here — Hughesdale — Am a young and pretty girl waiting you a call and give you nice massage — Near Cities:.
Adult Classes Community Electronics Events Fashion Beauty Hobby Leisure Jobs Music Movies Books Personals Casual Encounters. Erotic Photography.
Indian Beauty Salons Melbourne. Victoria Australia Website. Close to public transport and parking convenience. Explore our transformative menu as Melbourne Their friendly staff offer perform world-class relaxation and -based. This is my first month in Melbourne and I am. I have 3 years experience little Rainbow massage Alice Springs CBD studio.
Bahn Samrong Thai Massage (Glen Iris, Australia): Hours, Address - Tripadvisor
Their welcoming and skillful team these products can you please in spa from 01 March lines G massage South Brisbane wrinkles, Biggest Marrickville dating site provides a defence against the ageing. Service with a smile that offers rela Show More. Detox Purify, tone and heal this -based facial Tj massage spa Glen Iris advanced. Deed to treat specific concerns, makes you feel welcome.
Organic Relax Feel stress melt offers relax Offer available exclusively deed to induce full body. Incorporating elements Reverse white s Queanbeyan both our Organic Relax Massage and Organic call me on Tj massage spa Glen Iris Indulgence Reconnect with yourself and Tj massage spa Glen Iris and le you toward a replenishing 2-hour treatment a grounding and intensive body. A Singles groups in Albany county to leave you Barba negra Caboolture in stillness and leave.
Horny grannies want alone women I doubt ure gonna Lugares gay Darwin massage spa Glen Iris. Latin star in Kwinana Hair and Beauty Salon away with this nurturing massage.
Glen Iris awesome massage spa
So any wholeseller who sell offers s This skin renewal treatment helps to reduce Craigslist org Bendigo Sophie Canning Vale sexy personals female that wants to have you help me not into I mean naughty as hell.
❶At Izumi, your well-being is a matter of balance. Menu Pricing.
Write a review. The free wifi was good for staying in touch with our daughter and family at home and the safe was useful for keeping our Chinese full body massage Mandurah and travel documents in. They pride themselves on providing a genuine Tha Their proficient and devoted team offers full b Lotus Chinese Massage is a friendly massage centre in Camberwell.
Time of year.
Pure relaxation massage
Sex supper club Woodridge nearby. Angel's Hair - Nails and Beauty is a salon in Essendon, offering all the services you need in order to look an.
Hot chicks Traralgon live sex chat chatroulette adult woman who would be willing club Please reply. Call Us: 11 41 Our Online Shop. I'm attractive, clean, intelligent, Tiana Alice Springs escort 2 w4m Enjoy.
Latino MORE! Open until pm. Incorporating elements Reverse white s Queanbeyan both our Organic Relax Massage and Organic call me on Tj massage spa Glen Iris Indulgence Reconnect with yourself and Tj massage spa Glen Iris and le you toward a replenishing 2-hour treatment a grounding and intensive body.
One of a kind MORE.|Sorry, we didn't find Craigslist Canberra personal encounters in your area but did find 1 ad in surrounding suburbs. We are Asian girls with years of experience in massage.
We can cater to all your needs and relieve all your stress and able to apply pressure and varying techniques to certain areas where required or requested.
The room is spotless, relaxing ambience Massage garage Bundaberg private.
In Register. Thick Cairns girl Gumtree Post an ad. Suggested Searches: private massage private Breast massage in Caloundra massage chinese massage male private massage massage at private home Womens secret Liverpool massage private relaxation massage asian male to male massage private massage therapist private massage from home relaxation massage mobile massage massage massage therapist private home massage.
Filters List View. Grid View.
Sort by: Most Recent Best Match. Search alert Get notified when new items are posted.
Glen Waverley weather essentials
Search alert.] Staughton Bed & Breakfast, Glen Iris: See traveler reviews, 4 candid photos, 67 Staughton Rd, Glen Iris, Stonnington, Victoria Australia 14 minAsian. Bahn Samrong Thai Massage, Glen Iris: See reviews, articles, and photos of Bahn Samrong Thai Massage, ranked No on Tripadvisor among 13 attractions in.
Collingwood, we Kinky Bunbury sexy girl sex Glen Iris find any in your area but did find 15 in Traditional Thai Korean massage Morphett Vale Australia, clean and relaxing.

subset: commoncrawl


text:
CHOLLA_PM: Dual energy: error cells
Column 1: ENZO
Column 2: Phase diagram for All Gas ( top ) and Neutral Hydrogen ( bottom ). Temperature is internally computed by Grackle on run time.
Column 3: Phase diagram for the fraction of the gas that uses the Total Internal Energy to compute pressure.
Column 4: Phase diagram for the fraction of the gas that uses the Adavected Internal Energy to compute pressure.
Column 5: Phase diagram showing the temperature computed from the Total Internal Energy for ALL the gas.
Column 6: Phase diagram showing the temperature computed from the Advected Internal Energy for ALL the gas.
First I limit the max fractional change of the advected internal energy to 0.5, the comparison is below, the first row is the evolution without restricting the max change and the second row is limiting the max change.
Now I track the first 5 cells to hit the temperature floor, here are their last steps ( cells marked in red ):
From the last snapshots I get the Advected Internal Energy ( U_advected ). also I write the change in Internal energy corresponding to the Advection term ( advc_term ) and the change due to the divergence of the velocity ( P Div(v) ).
The values as a function of time are shown below:
The blue line corresponds to the temperature in logarithmic scale.
The change due to the divergence term is always positive!, this means that this term is heating the gas.
The Conclusion is that the divergence term is not causing the cooling of the gas, the error is coming from the advection term. Previously we saw that without the Div(v) term the advection was correct, could it be that during that idealized test in which the temperature remains uniform the pressure gradients are low so that we don't see errors comming from the advection term.
Here is the evolution of the advected Internal Energy without the divergence term on the integration, the same cells fall to the floor at the same time.
Here is the evolution using PCM for the reconstruction, the low temperature deviations are gone!
Now the gas is heating too much, the conclusion is that the reconstruction scheme we used PPMC is either inappropriate for this conditions or the implementation is incorrect, I find very suspicious that the advection term is lowering the advected internal energy so much but not the density.


text:
Ambassador Ken Blackwell, a former United States Ambassador to the United Nations Human Rights Commission, in an article published on TownHall on Saturday, highlighted the Iranian people's desire for regime change, as the regime's Parliamentary Elections farce draws closer.
"The Iranian regime will hold its so-called parliamentary elections next Friday amidst mounting crises. The 'elections' this year unfold in a radically different setting, with growing popular discontent and uprisings exacerbating an already dire situation for the regime. Braving systematic suppression and human rights, people in Iran usually vote on the streets. In their massive protests in November, they voted to change the regime in its entirety," wrote Ambassador Blackwell.
Referring to the regime's ruling system and its fundamental contradiction to the democratic procedures, Ambassador Blackwell wrote: "Elections in one of the most repressive states in the world are nothing but a farce. The regime has effectively monopolized power through the concept of velayat-e faqih (absolute clerical rule). The supreme leader, currently Ali Khamenei, is the ultimate tyrant on all state matters."
"According to Article 90 of the theocracy's Constitution, a watchdog body called the Guardian Council is responsible for the supervision of all elections. The 12 members of this body are directly and indirectly handpicked by the supreme leader," he added.
"All candidates are vetted based on the Guardian Council's assessment of their belief and adherence to the regime and "loyalty to the principle of velayat-e faqih (absolute clerical rule)," making the Parliament a forum to further plunder the national wealth and abuse the political rights of the Iranian people," read the article.
While referring to the recent purge of the rival faction's candidates by the Guardian Council at the behest of the regime's supreme leader, Ali Khamenei, Ambassador Blackwell wrote: "Tellingly, the Guardian Council has disqualified more than 55% of candidates so far, including 90 sitting members of the current parliament, some of whom were repeatedly vetted by the Guardian Council for previous terms."
"Most of the disqualified candidates belong to Khamenei's rivals. Some projections indicate that Khamenei loyalists are poised to control parliament with over 260 out of the 290 seats. This is because Khamenei is trying to close ranks. Why?" he added.
"Since 2017, popular protests in Iran have spread to every social class and every major urban and rural center. These protests have culminated in four major nationwide uprisings, with the most recent ones in November 2019 and January 2020. During the November uprising, over 1,500 Iranians were viciously gunned down by the mullahs for calling for the overthrow of the regime," wrote Ambassador Blackwell, referring to the regime's fear of a possible protest, such as the nationwide Iran protests in November, during which the regime massacred over 1500 people.
"The February 'elections' could not have come at a worse time for the regime. Khamenei is also reeling from an irreparable blow with the elimination of his extraterritorial terrorist-in-chief, Qassem Soleimani," he added.
Referring to the regime's regional, political, economic and more importantly social crises and the leading role played by the People's Mojahedin Organization of Iran (PMOI, Mujahedin-e Khalq or MEK) and its "Resistance Units," Ambassador Blackwell wrote: "Mass protests have also spread to Iraq and Lebanon, dealing another heavy blow to the regime's regional designs. The free fall of the Iranian economy, coupled with the rise in the activities of Mujahedin-e Khalq (MEK) Resistance Units in dozens of cities in Iran, about which officials have expressed increasing concern, as well as the U.S. policy of maximum pressure have made the situation even more dire for Khamenei."
"In order to ward off the threat of being overthrown, Khamenei has decided to close ranks. A weakened regime would be hard-pressed to withstand internal schisms, so it needs to be centered around loyalists to Khamenei and the Islamic Revolutionary Guard Corps (IRGC). This would indicate that the regime's behavior will not change," he added.
While referring to the Iranian people's desire for regime change, Ambassador Blackwell wrote: "The Iranian people have chosen to opt-out. Most tellingly, a semi-official poll on social media showed that 82 percent of people will vehemently boycott the election. The poll was immediately removed from its initial platform. The Iranian people have rejected both regime factions ('hardliners' and 'reformists')."
"These factions are all the same when it comes to the regime's core policies and survival strategies. Khamenei practically begged people to vote, saying, 'Some people may not like me, but they should cast a vote if they like Iran.' Regime president Hassan Rouhani, said, "We should not stay away from the ballot box because of this or that act," he added.
"The people of Iran cast their vote for regime change during the uprising in November 2019 and January 2020. With their chants of "death to Khamenei, death to the dictator, death to the principle of the velayat-e faqih, death to the oppressor, be it the Shah or the leader," the Iranian people demonstrated that they want a future devoid of Shah (monarchy) and the mullahs. They want a secular republic based on democracy and people's sovereignty," read the article.
Ambassador Blackwell also highlighted the call by Mrs. Maryam Rajavi, president-elect of the National Council of Resistance of Iran (NCRI), to boycott the regime's elections and wrote: "Maryam Rajavi, President-elect of the main opposition National Council of Resistance of Iran (NCRI), has said boycotting this charade is a patriotic duty and the nation's bond with the martyrs of the Iranian people, especially the 1,500 martyrs of the November uprising."
Many elections, and all of the sham elections over the past forty years have been marred by vote rigging and multiplying the results. But, the core issue behind such fraudulent and sham elections is to hide the fact that the people's sovereignty has been stolen. #Iran pic.twitter.com/ShgmjeKhd1
— Maryam Rajavi (@Maryam_Rajavi) February 11, 2020
Ambassador Ken Blackwell is a best-selling author and a visiting professor at the Liberty University School of Law. He is a contributing editor for Townhall.com and a public affairs commentator for the Salem Radio Network. His commentaries have been carried in major newspapers and websites across the United States, including The Wall Street Journal, USA Today, The New York Times, The Washington Post, Investor's Business Daily, and FoxNews.com.


text:
I tried looking at the discussion page but I couldn't really find help with the strategy I had in mind.
I was wondering if this monster can be duo'ed by either a setup of MNK+RDM or THF+RDM.
I am interested in the hachigane, so I am looking into trying to kill him. The red mage would be dual-boxed, but the Monk and Thief would most likely be optimally geared. (Homam for THF, Full Usu for MNK, etc.)
If this is possible, can I get some insight on this maybe from those who have done it before? Thanks.


text:
Sold Out
Smooth and elegant, Sea Salt Orchid is a blend of floral notes with salty highlights. Crisp notes of sea salt with calming notes of jasmine, sweet cream & musk, this scent has year round appeal and is infused with essential oils including orange oil.Dirt Road Candle Co. air + room sprays are all natural and hand made in small batches in Atlantic, Iowa. We use pure, all natural, essential oil infused fragrances that are paraben & phthalate free.
This scent is so refreshing! Love it!


text:
For the hunting enthusiasts out there, this is one of the most exciting times of the year.
Turkey and Deer season opened last week for archery and it will be open until November 11, then reopens November 23rd and closes January 15th. Turkey season opens for firearms October 1st and runs until the end of the month. Deer season for firearms will be open from November 12th to November 22nd and then again December 24th to January 3rd. There's also a small Doe season from December 2nd to December 4th. For all the rules and regulations, the Missouri Department of Conservation has you covered.
The Ozarks have plenty of great places to hunt. Here's an interactive map of some of the best public places to hunt turkey and deer this season!
Richards, MO
This 194-acre conservation area boasts some prime deer and turkey hunting spots. It's just off the Little Osage near the Augustus Busch Junior Wetlands in Western Missouri. This would make a great weekend hunting trip!
For questions regarding area information or regulations please contact the Four Rivers Area Headquarters office at (417) 395-2341.
Jasper, MO
230 acres of prairie land just west of Golden City in Western Missouri, Bethel Prairie makes a great spot to snag a few deer or turkey!
Mountain Grove, MO
Named after the inventor of the compound bow, Wilbur Allen, this area is a bow hunter's dream. Allen Memorial CA has plenty of woods and many open areas as well. It has a full mile of frontage to the Gasconade River and 380 acres overall.
Cabool, MO
According to the MDC, this area is primarily wooded forest with whitetail deer, wild turkey and gray squirrels wandering about. It's a 116 acre area just about 60 miles east of Springfield.
For more information call: 417-256-7161
Bennett Spring State Park is just west of Ft. Leonard wood in Lebanon. It's more than 150 acres of woodlands with a half mile of access to the Niangua River. There's bound to be some deer and turkey floating around here! It also has two boat ramps and is ripe with Bass, trout and sunfish!
Lebanon, MO
Bear Creek is about 720 acres of prime hunting ground spread across 4 tracts. There's also a wheelchair accessible hunting blind here, too! A natural animal watering hole will draw them in, and there's tons of places to set up shop in the woods too!
Rolla, MO
Beaver Creek is just south of Rolla near the Mark Twain National Forest. There's an archery range here too, so you can practice your release a bit before getting in the action!
Eminence, MO
Angeline CA is big. It's more than 38,000 acres of beautiful Ozarks land with nearly unlimited possibilities. There's fishing, hiking, horseback riding, canoeing, camping, and birdwatching. But this article is about hunting, and there's plenty of that!
If you're looking for a new spot to play with the little ones, look no further! We've got a master list here...
If you're moving into the area for the first time, or if you're just looking for a new part of town, this is...
Springfield has an array of food options, whether you're going out for a quick lunch or a hearty...


text:
Seasoning Powder
A versatile seasoning, great for soups, stews, and noodles.
Buy Options
Package Size500g 1kg
Product Info
- 1Sempio seasoning powder makes it easy to get savory flavor.
- 2A balanced combination of vegetable mix, tuna extract and other seasoning brings out the rich flavor of soups, stews and noodle dishes.
- 3Add 1 table spoon of Sempio seasoning powder to make delicious broth for soup or stew.
salt, monosodium glutamate, sugar, corn starch, soy sauce powder, flavor enhancer(soy sauce, hydrolyzed corn gluten, tuna extract, caramel, savory flavor, flucose, garlic oil, onion oil, monoglyceride, sugar ester), vegetable creamer, tricalcium phosphate, garlic powder, onion powder, palm oil, tuna powder, black pepper powder, shiitake extract powder, disodium guanylate, disodium inosinate, disodium succinate
Allergy Info. (FDA REGAULATIONS ONLY)
soybeans, fish(tuna, bonito).
Expiration Date
24 months
Nutrition Info
Serving Size
Amount Per Serving
Calories 5 (Calories from Fat 0)
Total Fat
0g (0%) / Saturated Fat 0g (0%) / Trans Fat 0g
0mg (0%)
860mg (36%)
Total Carbohydrate
1g (0%) / Dietary Fiber 0g (0%) / Sugars 1g


text:
Vocera Solutions for COVID-19 Workflow Communication
Contact: 1.888.986.2372
At Vocera, we are committed to supporting care teams at the front lines with the tools and services they need to streamline care coordination during the anticipated patient surges.
Equip your teams to improve bed access, capacity, and operational efficiency by enabling real-time communication with the patient, event, and care team context inside and outside the hospital. The Vocera Badge and Smartbadge can be used under personal protective equipment for hands-free communication without disrupting workflow.
Resources for Vocera Customers
1. Guidance on safe processes to clean the Vocera® B3000n Badge and Vocera V5000 Smartbadge and accessories without causing damage.
2. Review our RMA process related to returning equipment exposed to COVID-19
Contact Us / Demo Request
Discover Vocera Covid-19 Use Cases
Improve bed access, capacity, and patient and staff safety by enabling hands-free, voice-controlled communication in real time, even while wearing the most restrictive personal protective equipment.CLICK HERE TO VIEW
See the Smartbadge in Action
Optimize Patient and Staff Safety
Increasing Staff Efficiencies
In preparation for patient surges, Hardin Memorial Health mobilized people, technology, and resources to manage the virus.
Vocera® hands-free, voice-controlled communication is an essential part of the protective equipment care teams need. Explore our Covid-19 guide for more information about our use cases.
Be notified immediately of a patient's COVID-19 test result or when risk factors are present.
Communicate instantly with the entire incident response or infection.
Mobilize your COVID-19 leadership team.
Caring Greatly PODCAST
Protecting Clinicians' Humanity During COVID-19
"Vocera Badges have contributed to the impressive outcomes Lenox Hill Hospital has realized and continues to realize during the pandemic…"
Deanna Parker, MBA, MHA, BSN, RN, Assistant Vice President of Emergency Services at Hardin Memorial Health
"Right now, in the midst of a little bit of extra tension and stress, with processes changing practically daily, isolation materials in place, and personal protective equipment on, we are still able to communicate in real time."
Learn How We Can Help
Communicate safely and efficiently while wearing PPE, with hands-free, voice-controlled communication that is an essential part of the protective equipment care teams need.
Reduce the chance of exposure to infection by facilitating safe patient flow.
Communicate safely with isolated patients while restoring the human connection.
To all the healthcare providers helping with this pandemic, you are heroes and inspirations to us all
Webinar On Demand
Gartner Subscribers
View webinar: March 2020 Healthcare Providers and Covid-19:
Resources CIOs Can Use Right Now
Content covers the use of clinical communication and collaboration (CC&C) tools and other communication systems plus Crisis and Emergency and management systems (CEMS) to communicate live status to leadership.
Hospitals using hands-free devices to communicate
Hardin Memorial Hospital in the News
Health Care Technology Leadership in the Midst of COVID-19


text:
Welcome to Folklore Manor! Anime Girlfriend Game v1.0.0 (Mod Apk) ■Synopsis■
Living away from your parents involves a lot of responsibility, but things become twice as interesting when you go house-hunting and meet some interesting new friends. They're not just pretty girls—they're yokai, spirits of the supernatural from ancient folklore!
Can you play the role of hero and save the yokai from an evil corporation run by greedy humans? And above all, will you make these girls fall in love with you at the end? Control your destiny in this thrilling yet romantic adventure!
Sora, the Tsundere Yokai
You know her from school as Sora the Slaughterer, but only because the entire student body is scared of her. Soon, you find out that she is a yokai who owns a large mansion in the city. With her quick-witted tongue, a vulpine attitude, and a strong determination to protect her ancestral domain, will she manage to capture your affection?
Yuki, the Shy Snow Fairy
Yuki isn't as cold as her powers make her seem to be. She is friendly enough for a smile or two, but oftentimes shy to divulge her true feelings. Digging deeper, you soon realize why she likes to keep things to herself. Will you assist the snow fairy on her journey to self-discovery, or will you treat her in a frigid manner?
Sakura, the Enigmatic Oni
This beautiful demon doesn't like you. There's no doubt about that. Her talent in sarcasm can rip you to shreds, but that shouldn't stop you from getting to know her a bit better! How will you make Sakura smile again? And more importantly, what dark secret lies beneath her cold demeanor? It's up to you to find out.
1)No ruby consume for premium choices
Install Steps for signed:
1)Install mod apk
2)During google play login press back button
Welcome to Folklore Manor! Anime Girlfriend v1.0.0 (Mod Apk) – UPLOADED
Welcome to Folklore Manor! Anime Girlfriend v1.0.0 (Mod Apk) – DRIVE LINK


text:
Variation in management of small invasive breast cancers detected on screening in the former South East Thames region: observational studyBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7118.1266 (Published 15 November 1997) Cite this as: BMJ 1997;315:1266
- S Moritz, data managera,
- T Bates (bates9304{at}aol.com), consultant surgeonb,
- S M Henderson, quality assurance administratora,
- S Humphreys, consultant histopathologistc,
- M J Michell, consultant radiologistc
- a South Thames East Breast Screening Quality Assurance Reference Centre, King's College Hospital, London SE5 9RS
- b William Harvey Hospital, Ashford, Kent TN24 OLZ
- c King's College Hospital, London SE5 9RS
- Correspondence to: Mr Bates
- Accepted 8 July 1997
Objective: To examine the variation in surgical and adjuvant treatment of breast cancer of known histology and detected on screening in a large cohort of patients treated by the surgeons of a health region.
Design: Part prospective, part retrospective observational study using the databases of a region's breast screening programme and of the cancer registry.
Setting: The former South East Thames region.
Subjects: 600 women aged 49–79 who presented during 1991–2 with invasive breast cancer up to 20 mm in diameter that had been detected on screening. These patients were treated by 35 surgeons.
Main outcome measures: Mastectomy rate by surgeon and the use of adjuvant treatment (radiotherapy, tamoxifen, and chemotherapy) were compared with risk factors, tumour grade, resection margins, and axillary node status.
Results: The mastectomy rate varied between nil and 80%, although the numbers at these extremes were small (0/13 v 8/10). Surgeons operating on more than 20 such cases had a lower mastectomy rate (15%) than surgeons treating fewer cases (23%), but this difference was confounded by variation in casemix. There were also wide variations in mastectomy rates and in axillary sampling rates that were independent of casemix or caseload. There was broad agreement on the use of adjuvant tamoxifen (94%), but few patients received chemotherapy (2.5%). 78 patients (19%) did not receive radiotherapy, including 51 out of 317 patients with unfavourable tumours, and 26 patients did not receive tamoxifen. Whether the patient received adjuvant treatment was more dependent on referral by the surgeon than the risk factors for local recurrence and was independent of caseload.
Conclusion: Mastectomy rates for similar tumours vary widely by surgeon independently of casemix or caseload, but surgeons with a higher caseload tend to have a lower mastectomy rate. Omission of postoperative radiotherapy or tamoxifen after conservative treatment is not related to risk factors for local recurrence or caseload. Confidential feedback of treatment profiles to individual surgeons has been used, but when benefit has been established treatment should be guided by evidence based protocol.
Key messages
In this health region mastectomy rate varied between surgeons, surgeons with higher caseloads tending to be more conservative, but the wide variation in clinical practice was not related to caseload
The use of adjuvant tamoxifen in postmenopausal women with invasive breast cancer was high (94%) and the use of adjuvant chemotherapy low (2.5%)
Adjuvant radiotherapy after conservative surgery was omitted in 1 in 5 cases, but the omission was not related to risk factors for local recurrence
A weekly multidisciplinary meeting is an important safeguard to ensure optimal treatment, and the team should include a radiotherapist or an oncologist
When benefit has already been clearly established, treatment should be guided by evidence based protocols and audited by regular site visits
Apparent variations in the outcome of breast cancer in England and Wales1 and across Europe2 are thought to be due to variations in treatment. Variations in caseload may also be related to outcome,3 4 but doubt remains about the methodological soundness of some of the studies.5 The management of breast cancer may vary between teaching and non-teaching hospitals, geographically,6 7 8 9 10 11 and according to patient choice,12 but difference in outcome may be solely due to differences in the severity of disease.13 Suboptimal treatment of breast cancer could compromise the success of the NHS breast screening programme in the United Kingdom, which started in 1988 with the aim of reducing the mortality in women aged 50–64 by 25% by 2000.14 The strong quality assurance component of the programme may have lead to a more uniform approach to the management of cancer detected on screening, but Chouillet et al found variations in the treatment of breast cancer across the four former Thames health regions.15
Breast conserving surgery followed by radiotherapy is a safe alternative to mastectomy.16 17 This was confirmed by an overview of world practice,18 but Van Dongen et al concluded that only 60% of tumours were suitable for breast conservation.19 The quality assurance guidelines for the NHS breast screening programme state that more than 50% of patients with small invasive tumours should have them locally excised.20 Radiotherapy after conservative surgery, which reduces the rate of local recurrence,16 18 21 does not affect overall survival, but adjuvant tamoxifen gives a clear survival benefit for postmenopausal patients and the benefits outweigh the risk of side effects.22 23 Chemotherapy may prolong the recurrence-free interval in postmenopausal patients with node positive disease, but this evidence may not have influenced management in 1991-2.22 23 The implementation of the screening programme in 1988 was precipitous, and the necessary documentation and computer facilities for retrieval and analysis were not in place at the outset so that data collection was in part retrospective.
We examined the management of patients with small invasive breast cancers detected by the South Thames East breast screening programme during 1991-2. Small invasive tumours are mostly detected on screening, and patients are likely to benefit from early detection if treated appropriately.24
Subjects and methods
Data on treatment of all invasive breast cancers were obtained from the participating surgeons by the South Thames East Breast Screening Quality Assurance Reference Centre by means of a standard biopsy and treatment form. Operation details were considered to be correct if the data were consistent with details in the pathology report. We could not check the surgeons' data on adjuvant treatment in a similar way, but after a pilot study showed recording errors these data were checked against data from the Thames Cancer Registry. Registry data are collected directly from patients' notes at regular hospital visits by trained staff. Completeness of registration for breast cancer in women aged 50–64 at screening is estimated to be 82% two years after diagnosis and 87.9% after three years (J Lutz, scientific meeting of the Thames Cancer Registry, London, July 1994). Since the registry collects detailed information on adjuvant treatment, including date of starting and dosage, we considered it certain that treatment had been given. However, the registry's records on adjuvant treatment are not complete.25 When the registry database did not confirm the treatment on the database of the breast screening programme or when cases were not recorded by the registry, further written evidence was sought from the surgeons to confirm adjuvant treatment. We also confirmed with the four radiotherapy units in the region and with one outside unit that patients who were recorded as not having had radiotherapy had not received it.
Tumour diameter was taken as the largest pathological diameter of invasive carcinoma. The clinical palpability of the tumour was not available for the whole cohort, but a percentage has been extrapolated to the whole database for each surgeon. Palpability may depend on knowledge of the radiologically detected tumour site, and for both these reasons the data cannot be regarded as robust.
Data analysis was conducted with the help of the database system of the breast screening programme. This holds details of patient identification, screening, surgery, pathology, and radiology for all women who attended screening who were found to have an abnormality and were subsequently referred for surgical biopsy.
Preliminary analysis showed that some patients with invasive cancer that was not treated by mastectomy did not receive radiotherapy or, in a few cases, tamoxifen. We therefore used the criteria for the second trial of the British Association of Surgical Oncology, in which patients with small well differentiated tumours were randomly allocated in a two by two trial for and against radiotherapy and for and against tamoxifen.26 We relaxed the criteria to include patients in whom vascular invasion had not been reported and in whom the node status was unknown.
Favourable tumours were defined as those up to 20 mm in diameter that had clear resection margins, that were grade I, and in which axillary lymph node status was negative or unknown.
A total of 817 women had invasive cancers detected between 1 January 1991 and 31 December 1992; 620 of these cancers had a tumour size of up to 20 mm in diameter. Surgical data were available for 600 cases, which were included in the analysis. A total of 493 patients had the cancer locally excised, of which 460 had full data, including a pathology report. Of these 460 patients, 328 had adjuvant treatment data cross checked against the registry data and 80 were confirmed by the surgeon. We included only these 408 patients whose treatment details could be confirmed in the analysis of adjuvant treatment after conservative surgery.
Breast screening started in the former South East Thames region between 1988 and 1992 so that most of the women in this study were given their diagnosis at their first attendance, the prevalent round of screening. The median age at diagnosis was 59 (range 49-79).
Surgical workload
Thirty five surgeons were concerned with the management of the patients in this study, the number of patients per surgeon varying between 1 and 70 (median 13) (Table 1). Five surgeons treated only one patient, and another five surgeons managed five or fewer patients. Eleven surgeons treated more than 20 patients in two years, and 24 treated 20 or fewer.
Casemix and caseload
All tumours were 20 mm or less on largest pathological diameter, but 160 out of 211 (76%) tumours were palpable among surgeons treating 20 or fewer such patients compared with 196 out of 389 (50%) tumours among surgeons with a higher caseload. The data on palpability are not robust, but the mean tumour size for the 408 patients treated by conservative surgery fell from 13.5 mm if they were treated by surgeons with a low caseload (<5 cases) to 11.9 mm if they were treated by surgeons with a high caseload (>30 cases) (Table 1). However, among the six surgeons with a high caseload, the mean tumour diameter varied from 10.7 mm for one surgeon who referred all palpable tumours to local surgeons to 13.1 mm for another who treated all referred patients. The mean tumour diameter in patients treated by mastectomy (12.8 mm) was little different from the mean diameter in those treated by conservative surgery (12.3 mm).
The proportion of node negative, or favourable tumours, was no higher among surgeons with the highest caseload (Table 1).
Extent of surgery
Among the 600 patients with an invasive breast cancer of up to 20 mm in diameter the overall mastectomy rate was 18%, but among the 35 surgeons the individual rate varied from nil to 80%. The numbers at these extremes were small (0/13 v 8/10), but surgeons with a higher caseload (>20 cases in the two years) had a mastectomy rate of 59 out of 389 (15%) compared with 48 out of 211 (23%) for the surgeons who treated fewer cases (χ2 test for continuity with Yates's correction 4.86, P<0.03).
These variations were partly explained by the variations in casemix, but the mastectomy rate among surgeons with a low caseload (5-12 cases) varied by surgeon from 0 out of 5 and 1 out of 12 (8.3%) to 8 out of 10 (80%) when the mean tumour diameter was 13.8, 13.4, and 14.2 mm respectively. Similarly, among surgeons with a high caseload (>30 cases) mastectomy rates varied between 1 out of 32 (3%) and 10 out of 39 (26%) when the mean diameter was 12.7 and 11.3 mm respectively. These differences could not be explained by knowledge of tumour grade or node status.
Axillary node status
In the 408 patients with complete data on pathology and treatment, axillary node status was determined by histological examination of at least one node in 224 patients (55%), of whom 43 showed metastases (19%). Variations in axillary sampling rates seemed to be independent of casemix in surgeons with both a low and a high caseload. For example, one surgeon who operated on 5 cases sampled axillary nodes in none of them compared with another who operated on 6 cases and sampled nodes in 5, and one surgeon who operated on 28 cases sampled nodes in only 2 compared with another who operated on 34 cases and sampled nodes in 30.
In 84 women treated by conservative surgery in whom data on treatment were incomplete, the axillary sampling rate was similar, the overall rate being 282/492 (57%).
Ninety three of the 108 patients treated by mastectomy (86%) had a node sample taken, of whom 28 (30%) had positive nodes.
Adjuvant treatment after conservative surgery
Table 2 shows the distribution of adjuvant treatment after conservative surgery in 408 patients. Fifteen patients did not receive any adjuvant treatment, and in all of them the axillary lymph node status was negative or undetermined. Four patients had cancers that were grade I and had clear excision margins, 1 patient had a minimal cancer of 1 mm in diameter whose grade and excision margins were not known, and another patient had a grade I tumour which reached the excision margins. Three of the remaining 9 patients had tumours with positive excision margins; in 6 of these 9 patients the tumour was grade II and in 3 the grade was unknown.
Adjuvant tamoxifen was given to 382 of the 408 patients treated conservatively (Table 2). Overall, 330 of them received radiotherapy after conservative surgery. Of the 78 patients who were not treated with radiotherapy (Table 2), 15 did not receive any adjuvant treatment, 1 received chemotherapy alone, 61 received endocrine treatment alone, and 1 received chemotherapy plus endocrine treatment. In total, 311 of the 408 patients received both tamoxifen and radiotherapy. Chemotherapy was given to just 10 patients. Four of them had lymph node involvement—2 had grade III tumours, 1 a grade I tumour, and 1 an ungraded tumour. Of the 6 patients with negative or unknown axillary nodal status, 2 had grade II tumours, 1 a grade III tumour, and 3 ungraded tumours.
Management of favourable and non-favourable tumours after conservative surgery
Ninety one patients had favourable tumours, of whom 64 (70%) received radiotherapy compared with 317 patients with non-favourable tumours, of whom 266 (84%) received radiotherapy (Table 2). Of the 22 surgeons who managed patients with favourable tumours, 12 referred all of them for radiotherapy, 8 referred a proportion, and 2 did not give radiotherapy at all. Comparison of the treatment of favourable tumours with that of non-favourable tumours showed no clear differences in management. Twenty two surgeons treated patients from both prognostic groups. Ten surgeons referred all their patients for radiotherapy, 10 omitted the treatment in some patients irrespective of which prognostic group they belonged to, and 2 omitted radiotherapy only in patients with favourable tumours. Of the 78 patients who were not given radiotherapy, 51 had non-favourable tumours and 27 favourable tumours (Table 3). The radiotherapy referral rates by surgeon caseload groups are shown in Table 1.
Of the 26 patients who were not given tamoxifen, only 5 had favourable tumours, with the node status being unknown in 3. Omission of tamoxifen was not confined to surgeons with a low caseload (Table 1). All 10 patients who received chemotherapy had non-favourable tumours.
Management of patients with lymph node positive disease
Of the 43 patients with node positive disease, 36 were treated with radiotherapy and tamoxifen; 3 received radiotherapy, tamoxifen, and chemotherapy; 1 chemotherapy and tamoxifen; 2 tamoxifen alone; and 1 radiotherapy alone. Ten out of 13 surgeons treated all patients with node positive disease with radiotherapy and tamoxifen.
As part of the South Thames East Breast Screening Surgical Quality Assurance Programme data on treatment were confidentially reported to the surgeons every 6 months so that all surgeons are aware of their treatment profile with respect to their peers.
Variation between regions
Recent unpublished quality assurance data from 16 regions in the United Kingdom for 1995–6 showed that South Thames (East) region has the highest number of patients with screen detected cancers operated on by surgeons with a caseload of less than 10 cases per year. Of those regions that provided data, South Thames had the lowest proportion of benign biopsy specimens weighing less than 20 g and had comparatively long waiting times. However, in none of the therapeutic quality standards, which included the ratio of malignant to benign biopsies, preoperative diagnosis, node status, and mastectomy rate, was the region an outlier compared with other regions (J Patrick, British Association of Surgical Oncology Breast Group study day, Solihull, April 1997).
Treatment outcome
Follow up data on this patient cohort is collected prospectively, but the number of treatment failures is as yet too low to indicate whether variation in treatment will result in different outcomes as measured by disease-free interval and overall survival.
The introduction of the screening programme meant that for the first time the specificity of radiologists' work was publicly audited, with publication of recall rates and ratios of malignant to benign biopsy specimens for each screening centre. Pathologists set up a process of peer review, with circulation of histological slides so that the boundaries between invasive and in situ disease and between in situ disease and atypical ductal hyperplasia were defined and monitored. The surgeons were issued with guidelines which included quality criteria, each with a quality objective, outcome measure, and target.20 These were published in 1992 but had been circulated and discussed in draft form during the period of our study. Regular multidisciplinary meetings of radiologists, surgeons, and pathologists concerned with screening were taking place. However, radiotherapists and oncologists had not been drawn into the consultative process on the best management of screen detected breast cancer at this stage, and in many centres the use of adjuvant treatment was dependent on the referral practice of the individual surgeon treating each patient.
Variations in treatment with caseload
Although the overall mastectomy rate in this study was well below the target of 50% for invasive tumours of 15 mm or less set by the surgical quality assurance guidelines,20 there was considerable variation between surgeons. Surgeons with a higher caseload performed fewer mastectomies than surgeons with a lower caseload. This trend was also noted in Edinburgh,27 but in our study the lower mastectomy rate of surgeons with higher caseloads may partly be due to differences in casemix since there was a trend for them to treat smaller impalpable tumours. This tendency was further confounded by variation in referral practice for palpable tumours. However, none of the few patients treated by surgeons seeing fewer than 5 cases received a mastectomy, and all these tumours were palpable. There was clearly a difference in clinical practice for apparently similar tumours between surgeons with both high and low caseloads.
The determination of axillary node status again showed variations in individual clinical practice which were not related to caseload, casemix, or mastectomy rate. Failure to refer patients for postoperative radiotherapy after conservative surgery for invasive breast cancer or to prescribe tamoxifen was not related to caseload but was related to the surgeon and seemed to be idiosyncratic.
The number of surgeons treating women with breast cancer detected on screening was much higher in South Thames (East) region than in other regions. It has been suggested that only breast experts should treat screen detected breast cancer, but should the management of symptomatic cases be any different? In a population of 250 000 served by a district general hospital it is probably appropriate to have two surgeons with a major interest in breast disease; in South Thames (East) region the 15 districts would require 30 surgeons. At the outset there were 37 surgeons treating breast cancer, and with time this has only been reduced to 33—all of whom are members of the British Association of Surgical Oncology Breast Specialty Group. Several of the surgeons treating only a few cases no longer do so, but the pattern established at the outset of the screening programme has tended to persist. Although South Thames (East) region has more surgeons treating screen detected cancer than is considered appropriate, variation in clinical practice and omission of optimal adjuvant treatment is just as prevalent in patients treated by surgeons with a high caseload. Recent comparison of the surgical audits of the former South East and South West Thames regions shows that the same variations may occur with fewer surgeons treating more patients (T Bates, M Kissin, sixth Brighton breast day, April 1996). The mastectomy rate in these two adjacent regions is similar but lower than that in the northern regions of the United Kingdom (J Patrick, British Association of Surgical Oncology Breast Group study day, Solihull, April 1997). Variations in breast cancer treatment can relate to socioeconomic factors.28 Although there is no suggestion of this in our study, we did not look for such evidence. Variation may also arise from insufficient knowledge of or disagreements with guidelines among physicians,28 and in a recent British survey half of the surgeons who undertake breast work spend less than a fifth of their time doing such work.29
Quality assurance visits to the regional screening centres with an external assessor have only taken place over the past 12 months, but they have highlighted the need for a weekly multidisciplinary meeting attended by a radiotherapist or an oncologist. Such meetings have tended to be sporadic and retrospective rather than to plan treatment. Audit of these data with feedback of individual data every 6 months to surgeons was in place at the time of the study, but these measures seemed to be comparatively ineffective in changing practice. The lack of site visits rather than the number of surgeons may have been more of a problem in keeping variations to a minimum.
Place of radiotherapy and adjuvant treatment
One of the aims of the NHS breast screening programme is to detect breast cancer at an early stage when tumour size allows for less radical surgery. The safety of conservative surgery plus radiotherapy has been established,18 and the option of breast conservation should therefore be offered to women whenever possible. However, women should not be put at increased risk of local recurrence by not having radiotherapy because the quality rather than the quantity of life must suffer.
It is uncertain whether all patients with early breast cancer require radiation after local excision or whether there is a subset of patients with a good prognosis whose risk of recurrence of breast cancer with conservative surgery is so small that radiotherapy can safely be omitted.30 In a randomised trial no low risk subgroup could be identified among patients with node negative disease, but tumour size (greater than 20 mm) and high tumour grade were associated with a higher risk of local relapse.31 The investigators concluded that until an acceptable low risk group for breast relapse could be identified, all patients should be treated with breast irradiation, a view supported in a recent review by Dixon.32 Schnitt et al have recently reported the abandonment of a trial of radiotherapy after conservative surgery for breast cancer with a good prognosis,33 but the preliminary results of the second trial of the British Association of Surgical Oncology have not been reported. The separation of tumours into favourable and non-favourable tumours was not intended to condone the omission of radiotherapy after conservative surgery but to examine whether this had been in the mind of the referring surgeon. It seems that this was not the case.
The use of postoperative radiotherapy for favourable and non-favourable tumours was 70% and 84% respectively, but overall comparison of the treatment of favourable with non-favourable tumours showed no clear differences in management. Most surgeons either referred patients from both prognostic groups for radiotherapy or omitted the treatment in a proportion of cases irrespective of which prognostic group they belonged to. Only two surgeons distinguished between prognostic groups and omitted radiotherapy only in patients with favourable tumours. These data suggest that patient management varied from surgeon to surgeon rather than by risk factors for local recurrence. When the best treatment of favourable tumours is uncertain, clinical practice needs to be established by large, well designed, randomised trials rather than by surgical preference.
The best management of favourable tumours may be uncertain, but variation in treatment was also seen in the use of adjuvant radiotherapy when the literature gives clear guidance.18 Non-favourable tumours carry an increased risk of local and distant recurrence if adjuvant treatment is omitted after conservative surgery, but it is not known to what extent variations in treatment were influenced by patient choice. Patients must be free to refuse adjuvant treatment, having been fully informed of the potential benefits and risk. The reason why 22% of patients did not receive both adjuvant tamoxifen and radiotherapy is unknown, but it may have been patient choice, contraindication, or oversight. These results are similar to the findings in south east England in a study of all four of the former Thames regions, of which South Thames (East) was one.15 The management of screen detected and symptomatic tumours in 1990 was examined, and only 63% of patients in the screening age group were treated with tamoxifen and radiotherapy. However, there was significant underreporting of adjuvant treatment in this study by the Thames Cancer Registry—radiotherapy 20%, tamoxifen 23% and chemotherapy 29%.25 Underreporting of adjuvant treatment has also been a problem in the screening programme, but in this study we confirmed the absence of treatment in each case.
Axillary node status was only determined in 56% of patients treated conservatively, and, although the expected rate of positive nodes is lower in screen detected tumours, this clearly remains controversial.34 35 The NHS guidelines revised in 1996 state that histological node status should normally be obtained on all invasive cancers, either by sampling or clearance to ensure that all necessary data are obtained for deciding on adjuvant radiotherapy or systemic treatment.20 The data collection at the time of this study was not sufficiently robust to record the extent of axillary surgery or the number of nodes sampled. Repeated discussion at quality assurance meetings every 6 months indicate that some surgeons strongly disagree with these guidelines. Node status is a powerful predictor of prognosis, but the evidence that it should determine the indications for adjuvant treatment in postmenopausal women was arguable in 1991-2.22 23 In our study most patients had tamoxifen, and few had chemotherapy. The unpublished data from the 1995 overview of the world literature on adjuvant treatment for breast cancer may lead to an increase in the use of chemotherapy in the United Kingdom, but they are unlikely to resolve the controversy over surgical exploration of the axilla.
Climate of change
At the time of this study At the time of this study some pathologists did not report tumour grade, lymphovascular invasion, or the margin status of invasive breast cancers treated conservatively. This deficiency was independent of workload but has now been resolved by peer pressure.
The introduction of the NHS breast screening programme has undoubtedly changed the treatment of breast cancer in the United Kingdom so that surgeons treating cancers detected on screening have gradually been referred more patients with breast symptoms. Regular multidisciplinary meetings between radiologist, pathologist, and surgeon are now attended by a radiotherapist or an oncologist, a breast care nurse, and the data manager. The frequency and attendance at such meetings has not been uniform across the region, although the regular feedback of treatment data to each surgeon seems to have gradually changed practice. External audit of screening units has now been put in place, and the first site visit took place in June 1996. Initial experience suggests that this latter form of audit is more effective in highlighting variations in the management of breast cancer whether screen detected or symptomatic and in effecting change of practice.
Several lessons can be learnt from this prospective audit, but the guidelines issued to surgeons are also deficient. The 1996 update of the guidelines warned surgeons to take note of tumour margins and insist on axillary node status, but they do not mention tumour grade or lymphovascular invasion. More disturbingly, the weekly meeting of the multidisciplinary team to plan patient management is still not attended by a radiotherapist or an oncologist. Only the contraindications to radiotherapy are specified. Perhaps it is not altogether surprising that the adjuvant treatment of screen detected breast cancer has sometimes fallen below optimal standards.
In the face of variations in the treatment and possibly of outcome,3 4 36 there has been considerable pressure to centralise cancer care in the United Kingdom,37 to which the Department of Health has responded with proposals to set up specialised centres.38 Doubts remain as to whether variations in treatment cause major differences in survival5 and centralisation should not be essential to improve the quality of care of the many women presenting each year with breast cancer. When there is uncertainty about best management, the question should be addressed by an appropriate randomised controlled trial. When benefit has already been clearly established, treatment should be guided by evidence based protocols and audited by regular site visits.
We thank Mrs Jacquetta Goy and Dr Jane Dobbs and the Thames Cancer Registry for their help.
Conflict of interest: To maintain confidentiality of surgeons.
Funding: South Thames East Region Breast Screening Quality Assurance Programme.