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Original Article
Parent proxy–reported health-related quality of life and fatigue in pediatric patients diagnosed with brain tumors and acute lymphoblastic leukemia
Version of Record online: 23 SEP 2004
DOI: 10.1002/cncr.20609
Copyright © 2004 American Cancer Society
Volume 101, Issue 9, pages 2116–2125, 1 November 2004
Additional Information
How to Cite
Meeske, K., Katz, E. R., Palmer, S. N., Burwinkle, T. and Varni, J. W. (2004), Parent proxy–reported health-related quality of life and fatigue in pediatric patients diagnosed with brain tumors and acute lymphoblastic leukemia. Cancer, 101: 2116–2125. doi: 10.1002/cncr.20609
Publication History
- Issue online: 18 OCT 2004
- Version of Record online: 23 SEP 2004
- Manuscript Accepted: 19 JUL 2004
- Manuscript Revised: 12 JUL 2004
- Manuscript Received: 31 MAY 2004
Funded by
- Kellerman Foundation
- Abstract
- Article
- References
- Cited By
- health-related quality of life;
- PedsQL™ fatigue;
- brain tumor;
- pediatrics;
- children;
- acute lymphoblastic leukemia
Pediatric patients with brain tumors (BT) are often excluded from health-related quality of life (HRQOL) studies even though they experience more severe disease and treatment-related sequelae than children with other types of cancer. Parent proxy assessments of HRQOL allow for greater inclusion of children who are developmentally immature, physically ill, or cognitively impaired.
Parents of children ages 2–18 years who were diagnosed at Childrens Hospital Los Angeles and Children's Hospital San Diego with BT (n = 86) or acute lymphoblastic leukemia (ALL; n = 170) evaluated their children's HRQOL over the previous week using the parent-proxy versions of the Pediatric Quality of Life Inventory (PedsQL™) 4.0 Generic Core scales, the PedsQL™ 3.0 Acute Cancer Module, and the PedsQL™ Multidimensional Fatigue scales. Multiple regression analyses were used to determine the independent effect of the child's diagnosis on HRQOL. Separate analyses were conducted for patients receiving treatment, patients who had not received treatment for < 12 months, and patients who had not received treatment for ≥ 12 months.
Patients with BT exhibited more problems than patients with ALL in the physical, social, psychosocial, school, cognitive, and fatigue domains of HRQOL. The Core Physical Health, Core Psychosocial Health, and Fatigue Total scores for patients with BT demonstrated peak improvements for children who had not received treatment for < 12 months and sharp declines for children who had not received treatment for ≥ 12 months. The Core Physical Health and Fatigue Total scores for patients with ALL were highest (better HRQOL) for those who had not received treatment for ≥ 12 months.
Pediatric patients and survivors of BT experienced more fatigue and HRQOL problems than patients with ALL, and HRQOL differed by treatment status. Cancer 2004. © 2004 American Cancer Society.
Approximately 12,400 children and adolescents under the age of 20 are diagnosed with cancer each year in the United States.1 Brain tumors (BT) and acute lymphoblastic leukemia (ALL) are the two most common forms of pediatric cancer.2 From 1990 to 1995, 2200 children were diagnosed with a BT and 2300 were diagnosed with ALL annually.3, 4 Five-year survival rates are now approaching 70% for patients with BT (with the proportion varying by tumor type) and are exceeding 80% for patients with ALL.3, 4 Studies demonstrate that children with a BT experience more severe disease and treatment sequelae than children with other types of cancer, including those diagnosed with ALL.5–7
The assessment of health-related quality of life (HRQOL) has emerged as a powerful method of monitoring medical populations, evaluating treatment outcomes, and identifying patients at risk for adjustment problems.8 Unfortunately, patients with BT are often excluded from quality of life (QOL) studies due to their acute morbidity and frequent presentation of cognitive impairments.9 As a result, there is limited information on the unique experiences of patients with BT and how their long-term sequelae affect HRQOL.9
The Pediatric Quality of Life Inventory (PedsQL™) is a multidimensional instrument designed to evaluate the HRQOL of children.10 The PedsQL™ 4.0 Generic Core scales measure the physical, emotional, social, and role-functioning dimensions of HRQOL, allowing for comparisons across healthy children and patient groups.10 Disease-specific modules enhance the measurement sensitivity of health domains germane to chronic health conditions.10 For example, the PedsQL™ 3.0 Acute Cancer Module focuses on dimensions of HRQOL pertinent to the lives of pediatric oncology patients, whereas the recently developed PedsQL™ Multidimensional Fatigue scales allow investigators to thoroughly evaluate fatigue symptoms.10 Because fatigue has been identified recently as a common problem for oncology patients, the development of the fatigue module is a major advance in the measurement of pediatric HRQOL.10–12
Although a patient's perception of QOL is an important element in the measurement of HRQOL, parent proxy-report is essential when a child cannot participate in the evaluation process, or when the validity of the child's responses is in question.13 Because many children with BT are diagnosed at an early age,3 and experience significant medical, neurologic, cognitive, and psychosocial impairments,5–7 it is often necessary to rely on parent proxy-report to evaluate HRQOL. In oncology populations, the PedsQL™ Measurement Model demonstrates medium to strong concordance between parent proxy-reports and child self-reports.10 These findings indicate that parent proxy-report is a valid method of estimating HRQOL when the child is unable to do so.
The current study compares HRQOL in patients diagnosed with BT with those diagnosed with ALL. We utilized the PedsQL™ parent proxy-report measures to capture HRQOL data from a diverse population that includes children too young or too impaired to provide self-report. Based on the literature, we hypothesized that children with BT would have significantly more impaired HRQOL than children with ALL in the following dimensions: physical health, cognitive functioning, social functioning, and school functioning.
Subjects and Settings
Eligible participants were English and Spanish-speaking parents of children ages 2–18 years with a diagnosis of BT or ALL. Families were recruited from Childrens Hospital Los Angeles (CHLA) and Children's Hospital and Health Center in San Diego (CHSD). Families whose children were recently diagnosed (< 6 weeks ago) and families in medical crisis were excluded. One parent per family participated in the study. When both parents were present at the interview, the child's primary caretaker completed the forms. Parents were given the option to complete forms in either English or Spanish.
Investigators used clinic rosters to identify eligible patients who visited either hospital between April 2000 and January 2001. Additional patients with BT were recruited at CHLA from August 2002 to February 2003. Informed consent was obtained from all participants. The institutional review boards at CHLA and CHSD approved all study procedures in accordance with requirements established by the U.S. Department of Health and Human Services.
We enrolled 256 families, 215 (84%) from CHLA and 41 from CHSD (16%). The nonparticipation rate at CHLA was 13%. Parents who chose not to participate reported that they did not have enough time or that they did not want to lengthen their clinic visit because their children were tired or not feeling well. The nonparticipation rate for CHSD is not available.
The PedsQL™ 4.0 Measurement Model
The PedsQL™ Measurement Model comprises a set of developmentally appropriate generic core scales and disease-specific modules that measure HRQOL for children and adolescents ages 2–18 years. Both self-report and parent proxy–report versions of the questionnaires are available.10 The parent proxy–report version of the PedsQL™ uses a 5-point Likert scale in which parents rate how much a problem each item has been for their children over the past 7 days (0 = never a problem; 1 = almost never a problem; 2 = sometimes a problem; 3 = often a problem; and 4 = almost always a problem).10 Responses are reverse scored and linearly transformed to a scale ranging from 0 to 100, with higher scores indicating better HRQOL.10
The PedsQL™ 4.0 Generic Core scales: parent proxy report.
The PedsQL™ 4.0 Generic Core scales (23 items) measure physical health (8 items), emotional functioning (5 items), social functioning (5 items), and school functioning (5 items).14 Three summary scores can be calculated: a Physical Health score (8 items), a Psychosocial Health score (15 items), and a Total Core score (23 items).14 Population norms for the PedsQL™ Acute Version of the 4.0 Generic Core scales have been established.10 PedsQL™ scores that are 1 standard deviation (SD) below the population mean indicate at-risk status for poor HRQOL.8
The PedsQL™ 3.0 Acute Cancer Module: parent proxy-report.
The PedsQL™ 3.0 Cancer Module (27 items) assesses 8 dimensions of HRQOL specific to cancer: pain and hurt (2 items), nausea (5 items), procedural anxiety (3 items), treatment anxiety (3 items), worry (3 items), cognitive problems (5 items), perceived physical appearance (3 items), and communication (3 items).10 Scores are calculated for each of the previously named subscales, and a total cancer score represents HRQOL as measured by the PedsQL™ Acute Cancer Module.10
The PedsQL™ Multidimensional Fatigue scales: parent proxy-report.
The PedsQL™ Multidimensional Fatigue scales (18 items) assess general fatigue (6 items), sleep/rest fatigue (6 items), and cognitive fatigue (6 items).10 Each of the three subscales yields a score, and a total fatigue score represents HRQOL as measured by the PedsQL™ Multidimensional Fatigue scales.10 Population norms for the PedsQL™ Multidimensional Fatigue scales have been reported by Varni et al.10
Validity and reliability of PedsQL™ measures
The PedsQL™ 4.0 Generic Core scales, the PedsQL™ 3.0 Acute Cancer Module, and the PedsQL™ Multidimensional Fatigue scales have been tested with pediatric oncology patients and have demonstrated strong internal consistency, reliability, and validity.10 In the current study, Cronbach alpha coefficients15 for the Core, Cancer, and Fatigue scales were > 0.70, which is recommended for group comparisons.16 Total scores on the PedsQL™ 3.0 Acute Cancer Module and the PedsQL™ Multidimensional Fatigue scale were moderately correlated with the PedsQL™ 4.0 Generic Core total score (r = 0.75–0.79), suggesting that the constructs of HRQOL and fatigue are unique but highly related.17
PedsQL™ Family Information Form.
The PedsQL™ Family Information Form surveys demographic information, including parents' education, marital status, and occupation. These variables were used to calculate the Hollingshead socioeconomic status (SES) index.18
Medical chart data.
Research assistants extracted the following information from each child's medical record: diagnosis, location of BT, date of diagnosis, treatment status, and date of last treatment.
Statistical Analyses
Because adequate response equivalence has been demonstrated for the PedsQL™ Generic Core scales in English and Spanish,10, 14 and identical rigorous PedsQL™ translation standards were used in the development of Spanish language forms for the Core, Cancer, and Fatigue scales,10 responses were pooled across languages for each instrument. HRQOL scores did not differ significantly by either study location, allowing us to combine the data from the two sites.
Descriptive statistics (means, SD, and frequencies) were calculated for all variables. Standard procedures were used to compute PedsQL™ total, summary, and subscale scores. Families were categorized into three SES groups using the Hollingshead SES index.18 We used the patient's date of last treatment to categorize their treatment status as receiving treatment, having not received treatment for < 12 months, or having not received treatment for ≥ 12 months. Chi-square analyses were used to test for group differences between patients with BT and patients with ALL for demographic characteristics and medical/treatment factors.
Analyses of variance were performed to identify demographic and medical/treatment factors related to PedsQL™ scores across both diagnoses. Regression analyses were conducted to determine the independent effect of a child's cancer diagnosis on PedsQL™ total and subscale scores.19 Regression models included child's age at interview, gender, age at diagnosis, and treatment status as covariates. Patients with BT and patients with ALL were stratified by treatment group status (receiving treatment, having not received treatment for < 12 months, or having not received treatment for ≥ 12 months). Tests for linear and quadratic trends were calculated across ordinal categories. t tests were used to determine group differences in HRQOL scores. Pearson correlations were used to estimate the association between PedsQL™ scale scores. All statistical testing used an alpha value of 0.05 (two-tailed). All data analyses were conducted using SAS (Version 9.0; SAS, Cary, NC).
Two hundred fifty-six parents participated, including 86 (34%) with a child diagnosed with BT and 170 (66%) with a child diagnosed with ALL (Table 1). Patients ranged in age from 2 to 18 years and were more often male than female (males, n =149 [58%]; females, n = 107 [42%]). Most patients were diagnosed before age 5 years (n = 122 [48%]) and were receiving active treatment at the time of their assessment (n = 153 [60%]). More than one-half of the participants identified themselves as Latino (n = 141 [55%]). Eighty-eight percent of the parent proxy-reports were completed by female caregivers. Among patients with BT, tumor location was identified as infratentorial (n = 41), supratentorial (n = 20), and midline (n = 21). Information about tumor location was missing for four patients.
|No. of patients (%)
|Chi-square P value
|170 (100)
|86 (100)
|Child's age at evaluation (yrs)
|Mean (SD)
|7.8 (4.1)
|9.7 (4.4)
|42 (25)
|11 (13)
|51 (30)
|21 (24)
|51 (30)
|32 (37)
|26 (15)
|22 (26)
|Family's race/ethnicity
|91 (54)
|50 (58)
|47 (28)
|27 (31)
|32 (19)
|9 (10)
|Child's gender
|101 (59)
|48 (55)
|69 (41)
|38 (44)
|Family's socioeconomic statusab
|Mean (SD)
|34.5 (16.8)
|36.2 (17.5)
|Low (≤ 24)
|67 (40)
|30 (35)
|Moderate (25–44)
|53 (32)
|22 (26)
|High (≥ 45)
|47 (28)
|33 (38)
|Child's age at diagnosis (yrs)
|Mean (SD)
|7.1 (4.3)
|5 (3.7)
|< 5
|94 (55)
|28 (33)
|35 (21)
|22 (26)
|27 (16)
|25 (29)
|14 (8)
|11 (12)
|Child's treatment status
|Receiving treatment
|117 (69)
|36 (42)
|No treatment for < 12 mos
|26 (15)
|26 (30)
|No treatment for ≥ 12 mos
|27 (16)
|24 (28)
|Mother/stepmother, grandmother
|151 (89)
|75 (87)
|19 (11)
|11 (13)
|Mother's educationc
|< High school graduate
|65 (38)
|31 (36)
|High school graduate
|24 (14)
|15 (18)
|Some college
|44 (26)
|18 (21)
|≥ College graduate
|35 (21)
|21 (25)
|Father's educationd
|< High school graduate
|58 (37)
|31 (36)
|High school graduate
|21 (14)
|12 (14)
|Some college
|36 (23)
|18 (21)
|≥ College graduate
|40 (26)
|25 (29)
Patients with BT were older at the time of their evaluation (P = 0.03), older at diagnosis (P = 0.005), and more likely not to be receiving treatment (P = 0.001) compared with patients who had ALL. Among patients who had not received treatment for ≥ 12 months, the average time without treatment was 6.5 years for patients with ALL (range, 1–13 years) and 5.6 years for patients with BT (range, 1–12 years; t test P = 0.30). Patients with BT and ALL did not differ significantly as to gender, SES, ethnicity, or parents' educational status. Fathers' participation rates were similar for the two groups.
Association between health-related quality of life and demographic characteristics and disease treatment factors
Univariate results for demographic characteristics and disease/treatment factors are presented in Table 2. Patient's age at interview was inversely related to the Generic Core total score (trend P = 0.05), Core Physical subscale score (trend P = 0.04), and Multidimensional Fatigue total score (trend P = 0.0008). Gender was significantly related to the Core Physical subscale (P = 0.0003) and to the Core total score (P = 0.02), with lower parent proxy–reported scores for female patients. Child's age at diagnosis was inversely related to the Multidimensional Fatigue total score (trend P = 0.003). There was a positive relationship between treatment status and the Acute Cancer total score (trend P = 0.03). Ethnicity, SES, and parents' levels of education were unrelated to PedsQL™ Generic Core, Acute Cancer, or Multidimensional Fatigue scores (data not shown). Among patients with BT, PedsQL™ scores did not differ significantly by tumor location.
|Mean (SD)
|PedsQL™ Core Psychosocial Health score
|PedsQL™ Core Physical Health score
|PedsQL™ Core Total score
|PedsQL™ Acute Cancer Total score
|PedsQL™ Multidimentional Fatigue Total score
|Child's age at interview
|73.5 (17.5)
|74.5 (20.5)
|73.8 (18.1)
|77.9 (13.7)
|80.0 (14.5)
|71.8 (16.5)
|69.0 (24.2)
|70.7 (17.5)
|75.6 (17.3)
|77.5 (16.6)
|67.4 (16.6)
|62.5 (24.4)
|65.5 (16.9)
|73.3 (16.3)
|71.1 (19.6)
|67.4 (21.8)
|66.7 (26.3)
|67.2 (21.7)
|71.5 (20.6)
|66.5 (24.2)
|Trend P valuea
|Child's gender
|70.8 (19.0)
|72.2 (22.1)
|71.3 (18.5)
|76.3 (16.3)
|75.3 (19.5)
|68.7 (16.3)
|61.3 (25.6)
|65.9 (18.1)
|72.2 (17.8)
|72.0 (19.1)
|P valuea
|Child's age at diagnos is (yrs)
|< 5
|71.5 (17.7)
|71.7 (23.4)
|71.6 (18.5)
|76.4 (16.0)
|77.8 (17.2)
|69.0 (17.1)
|65.5 (22.6)
|67.6 (16.6)
|73.9 (17.5)
|74.0 (18.9)
|68.5 (18.5)
|63.2 (26.0)
|66.4 (19.1)
|73.4 (18.0)
|68.3 (22.3)
|66.9 (19.6)
|61.5 (25.7)
|64.9 (20.4)
|68.8 (18.5)
|65.7 (19.0)
|Trend P valuea
|Child's treatment status
|Receiving treatment
|69.1 (18.6)
|66.1 (25.3)
|67.8 (19.3)
|72.3 (18.1)
|72.4 (20.3)
|No treatment for < 12 mos
|74.2 (15.3)
|69.4 (20.9)
|72.5 (15.9)
|79.0 (13.6)
|77.9 (14.5)
|No treatment for ≥ 12 mos
|68.1 (17.7)
|70.3 (24.0)
|68.9 (18.4)
|77.0 (15.8)
|74.4 (20.6)
|Trend P valuea
Health-related quality of life for patients with brain tumors versus acute lymphoblastic leukemia
Results of the multiple regression models that compare HRQOL in patients with BT with patients with ALL are presented in Table 3. Significant group differences are present for the Core Physical Health summary subscale (P = 0.0004; mean difference, −10.7), Core Psychosocial Health summary subscale (P = 0.04; mean difference, −4.2), Core Social Functioning subscale (P = 0.05; mean difference, −5.3), Core School Functioning subscale (P = 0.02; mean difference, −8.2), Core total (P = 0.002; mean difference, −6.8), Cancer Worry subscale (P = 0.05; mean difference, 5.5), Cancer Cognitive subscale (P = 0.005; mean difference, −9.8), Multidimensional Fatigue General Fatigue subscale (P = 0.006; mean difference, −7.2), Multidimensional Fatigue Cognitive Fatigue subscale (P = 0.0003; mean difference, −11.6), and Multidimensional Fatigue total score (P = 0.02; mean difference, −6.0). With the exception of the Acute Cancer worry subscale, parent proxy–reported scores for patients with BT were significantly lower (i.e., indicative of more problems and poorer HRQOL) than parent proxy–reported scores for patients with ALL. No significant group differences were found for the Core Emotional Functioning subscale, the Fatigue Sleep/Rest subscale, or any of the following Acute Cancer Module subscales: Pain, Nausea, Procedural Anxiety, Treatment Anxiety, Perceived Physical Appearance, Communication, and Total.
|Mean (SD)
|P valuea
|ALL (n = 170)
|BT (n = 86)
|PedsQL™ Generic Core scales
|71.3 (18.1)
|64.5 (18.5)
|Physical Health
|71.2 (22.5)
|60.5 (25.8)
|Psychosocial Health
|71.3 (17.9)
|67.1 (17.7)
|Emotional Functioning
|67.6 (20.0)
|67.2 (20.0)
|Social Functioning
|77.0 (20.4)
|71.7 (20.2)
|School Functioning
|68.0 (22.5)
|59.8 (24.7)
|PedsQL™ Acute Cancer Module
|75.1 (16.3)
|73.4 (18.5)
|75.4 (25.4)
|76.7 (26.6)
|79.0 (21.5)
|81.7 (21.7)
|Procedural Anxiety
|58.8 (32.3)
|65.7 (32.7)
|Treatment Anxiety
|72.5 (29.5)
|74.3 (28.9)
|77.7 (29.1)
|83.2 (21.6)
|74.5 (21.8)
|64.7 (24.8)
|Perceived Physical Appearance
|79.8 (23.0)
|79.3 (24.0)
|76.2 (25.0)
|70.8 (33.8)
|PedsQL™ Multidimensional Fatigue scales
|75.9 (17.8)
|69.9 (21.6)
|General Fatigue
|73.8 (20.3)
|66.6 (25.4)
|Sleep/rest Fatigue
|74.4 (21.4)
|75.9 (21.8)
|Cognitive Fatigue
|79.4 (21.5)
|67.8 (28.4)
Health-related quality of life by treatment group status
To further explore the differences between patients with BT and ALL, we examined the two PedsQL™ Generic Core summary scales, (i.e., Physical Health and Psychosocial Health), PedsQL™ Acute Cancer Module total scores, and PedsQL™ Multidimensional Fatigue scale total scores for patients who were receiving treatment and patients who had not received treatment for < 12 and ≥ 12 months, respectively (Table 4).
|Mean (SD)
|Linear trend P value
|Quadratic trend P value
|Receiving treatment
|No treatment for < 12 mos
|No treatment for ≥ 12 mos
|PedsQL™ Generic Core scales
|Physical Health
|50.3 (26.0)
|73.5 (18.8)
|61.7 (26.4)
|71.0 (23.1)
|65.4 (22.4)
|77.9 (19.1)
|Psychosocial Health
|64.8 (18.1)
|73.9 (16.2)
|63.2 (17.3)
|70.4 (18.7)
|74.5 (14.8)
|72.4 (17.3)
|PedsQL™ Acute Cancer Module
|Total score
|68.5 (20.4)
|78.5 (16.1)
|75.2 (16.8)
|73.4 (17.3)
|79.5 (11.0)
|78.5 (16.1)
|PedsQL™ Multidimensional Fatigue scales
|Total score
|64.9 (22.9)
|79.0 (14.6)
|67.7 (23.6)
|74.6 (18.9)
|76.8 (14.6)
|80.2 (15.5)
Physical health for patients with brain tumors and acute lymphoblastic leukemia.
We found a reverse pattern with respect to physical functioning when BT group and ALL group scores were plotted for patients receiving treatment and for patients who had not received treatment for < 12 months and ≥ 12 months, respectively (Fig. 1). For patients with ALL, there was a slight reduction in physical functioning for patients who had not received treatment for < 12 months compared with patients receiving treatment (P = 0.26; mean difference, −5.6) followed by a significant increase in scores (indicative of better physical functioning) when patients with ALL who had not received treatment for ≥ 12 months were compared with their counterparts who had not received treatment for < 12 months (P = 0.02; mean difference, 12.5). With physical functioning, there was a significant linear trend for patients with ALL across the treatment groups (linear trend P = 0.03). For patients with BT, we found a quadratic trend, not a linear trend, across the treatment groups (Physical Health: quadratic trend P = 0.01). Physical Health scores peaked (better physical functioning) among patients with BT who had not received treatment for < 12 months. There was a marked decrease in Physical Health scores for patients with BT who had not received treatment for ≥ 12 months compared with patients who had not received treatment for < 12 months (Physical Health: P = 0.07; mean difference, 11.8).
Psychosocial health for patients with brain tumors and acute lymphoblastic leukemia.
Although patients with BT and ALL demonstrated similar patterns in terms of psychosocial functioning across the three treatment groups, the pattern was more pronounced for the patients with BT (Fig. 2). For patients with BT, we again found a significant quadratic trend across the treatment groups (quadratic trend P = 0.04). Psychosocial functioning scores were highest for patients with BT who had not received treatment for < 12 months and lowest (poorer psychosocial functioning) for patients who had not received treatment for ≥ 12 months. In contrast, we found that psychosocial functioning in patients with ALL remained rather flat across the three treatment groups.
Acute Cancer Module total scores for patients with brain tumors and acute lymphoblastic leukemia.
With the Acute Cancer total score, we found a linear pattern for patients with BT and ALL across the treatment groups (ALL: linear trend P = 0.009; BT: linear trend P = 0.07). Patients with BT and ALL who were receiving treament experienced more cancer-specific problems than patients who were not receiving treatment.
Multidimensional Fatigue total scores for patients with brain tumors and acute lymphoblastic leukemia.
The fatigue patterns across treatment groups also varied for patients with BT and ALL (Fig. 3). For patients with ALL, there was a gradual decrease in fatigue symptoms (higher fatigue scores) across the treatment groups (linear trend P = 0.008). In contrast, patients with BT demonstrated the familiar quadratic pattern with fatigue scores being highest (less fatigue) in patients who had not received treatment for < 12 months compared with patients who were receiving treatment and patients who had not received treatment for ≥ 12 months (quadratic trend P = 0.06). Patients with BT who had not received treatment for ≥ 12 months demonstrated a trend toward more fatigue (lower scores) when compared with patients who had not received treatment for < 12 months (P = 0.07; mean difference, 11.3).
Health-related quality of life in patients with brain tumors and acute lymphoblastic leukemia compared with healthy children
To further understand HRQOL in patients with BT and ALL, we compared data from patients who had not received treatment for ≥ 12 months (i.e., long-term cancer survivors) with normative data collected from parents of healthy children.10, 14 On the PedsQL™ Generic Core scale, we found that 63% of the patients with BT and 37% of the patients with ALL had a total score > 1 SD below the normative value (n = 157; mean, mean parent proxy-report total Core score for healthy children, 84.5; SD, 15.7). On the PedsQL™ Multidimensional Fatigue scales, the mean fatigue total score for patients with ALL fell within the normal range, whereas the mean total Fatigue score for patients with BT was nearly 2 SD below the norm (N = 102; mean parent proxy–reported total Fatigue score for healthy children, 89.6; SD, 11.4).10 Patients with BT were significantly more fatigued than their peers (P = 0.0001).
In the current study, parent proxy-reports were used to assess HRQOL in children diagnosed with a BT and ALL. Specific dimensions of HRQOL, including physical health, psychosocial health, and fatigue, were charted for patients who were receiving treatment and also for patients who had not received treatment for < 12 months and ≥ 12 months, respectively. The use of parent-proxy assessments of HRQOL allowed for greater inclusion of children who were developmentally immature, physically ill, or cognitively impaired. For example, 95 (35%) of the 256 parents who participated reported that their children could not provide self-report. This methodology, which results in a more representative sample, is important because children who cannot provide self-report often have the greatest need for clinical services.
Analysis of parent proxy-reports found that overall, children with a BT experienced more HRQOL problems than children with ALL. According to parents, patients with BT had significantly poorer HRQOL than patients with ALL in the dimensions of physical and psychosocial health, and cognitive, social, and school functioning. These findings are consistent with literature indicating that patients with BT often experience problems with physical, intellectual, and psychosocial functioning that fail to resolve over time.7, 20–24
Based on our findings, patients with ALL appear to worry significantly more than patients with BT. The PedsQL™ Acute Cancer worry subscale items evaluate the parent's perception of their child's worry about 1) the side effects of treatment, 2) the efficacy of medical treatments, and 3) disease recurrence. Although the cognitive impairments of patients with BT may limit their insight and worry, it is also possible that the clinic experience itself may induce more worry for patients with ALL compared with patients with BT. For example, patients with ALL undergo disease evaluations and medical procedures with each clinic visit, including blood counts and/or lumbar punctures and bone marrow aspirations. Disease evaluations for patients with BT are less frequent, and tend to be less invasive (e.g., imaging studies). The frequent medical procedures experienced by ALL patients have the potential to affect HRQOL ratings when assessments are obtained in the clinical setting. It is also noteworthy that the standard treatment for patients with ALL occurs over a longer period of time than many treatments for patients with BT. Therefore, it is plausible that the length of time of active treatment is positively correlated with feelings of uncertainty and worry.
Although the current study is not longitudinal, the cross-sectional view of HRQOL scores among patients receiving treatment, patients who had not received treatment for < 12 months, and patients who had not received treatment for ≥ 12 months suggests that patients with BT and ALL may follow different trajectories once they complete their therapies. Psychosocial Health scores for patients with ALL remained relatively consistent across the three treatment groups. However, with respect to Physical Health, patients with ALL who had not received treatment for ≥ 12 months had significantly higher scores than did those who had not received treatment for < 12 months, suggesting an improvement over time. In contrast, the Physical Health and Psychosocial Health scores of patients with BT demonstrated an inverted U (quadratic) pattern, with peak improvements for children who had not received treatment for < 12 months and sharp declines for children who had not received treatment for ≥ 12 months.
Patients who have not received treatment for < 12 months are in a period of transition, and it appears that patients with BT and patients with ALL experience this transition phase, or early phase of survivorship, differently. BT and ALL treatment regimens may help to explain these differences. For instance, patients with BT often receive intensive treatments throughout their entire course of therapy. Only when treatment ends do these patients have the opportunity to fully recover from the acute toxic effects of surgery, radiotherapy, and chemotherapy. Thus, HRQOL scores for patients with BT are apt to improve dramatically once treatment has been discontinued. In contrast, the final phase of treatment for patients with ALL (i.e., maintenance therapy) lasts for a long period of time, and is rather mild with minimal side effects. Patients with ALL make gradual progress toward recovery long before the end of treatment. Thus, HRQOL changes are apt to be minimal for patients with ALL who are receiving treatment compared with those who have not received treatment for < 12 months. Monitoring patients as they proceed through the various phases of treatment and survivorship should help to identify factors that facilitate or impede transitions to maximum health.
Comparisons between parent proxy–reported total Core scale scores for healthy children and for patients who had not received treatment for ≥ 12 months revealed that approximately two-thirds of the patients with BT and one-third of the patients with ALL were > 1 SD below the healthy norms.14 This finding is consistent with extant literature indicating that survivors of a BT are at high risk of developing significant physical, cognitive, and social problems,7, 20–24 whereas most survivors of ALL return to normal levels of functioning.25, 26 In the current study, HRQOL findings among long-term survivors illustrate the higher prevalence of problems among patients with BT, but also demonstrate the need for ongoing support and clinical services for both populations. Longitudinal HRQOL studies are needed for the early identification of patients at greatest risk for adjustment difficulties to maximize coping skills and minimize HRQOL problems.
Although adult patients identify fatigue as the most common and distressing cancer-related symptom,27 little is known about fatigue in pediatric patients with cancer. Only recently have valid, developmentally sensitive, multidimensional measures been available to assess fatigue in children with cancer.10
As one of the first studies to evaluate fatigue in pediatric patients with BT, our data suggest that the pattern of fatigue over the course of treatment differs for patients with BT and ALL. For patients with ALL, fatigue symptoms decrease as time without treatment increases, and comparisons with healthy norms indicate that long-term survivors of ALL experience no more fatigue than their healthy peers. These findings are consistent with another recent study that has examined fatigue in long-term survivors of ALL.25 Among patients with BT, fatigue follows the familiar quadratic pattern, with patients receiving treatment and patients who have not received treatment for ≥ 12 months experiencing similar levels of fatigue. In contrast to survivors of ALL, long-term survivors of BT were significantly more fatigued than their healthy peers.
In our study, fatigue was inversely related to the child's overall HRQOL (PedsQL™ Generic Core total score) (P = 0.0001), a finding that has been reported frequently among adult patients with cancer.28, 29 Fatigue appears to be a significant issue for patients with BT, including those who have not received treatment for years. Additional research is needed to determine if factors such as tumor location, treatment modalities, physical disabilities, endocrine abnormalities, and/or neurocognitive impairments play a role in the development of fatigue. Now that pediatric assessment measures such as the PedsQL™ Multidimensional Fatigue Module are available, investigators are in a position to better define fatigue and its impact on HRQOL.
Several factors must be considered when interpreting our results. The current study utilized a convenience sampling methodology, with no information available on nonparticipating patients. The wide variability in HRQOL scores for patients with BT and ALL suggests that a broad range of subjects were recruited from both patient populations, and the subjects included are representative of the population from which they were drawn. However, when data are gathered in a clinic setting, the sickest children (who may be hospitalized or in hospice care) and healthy survivors (who are not experiencing problems) are both less likely to visit the clinic, and may not be included in the study. Selection bias, if present, is most likely nondifferential in nature because recruitment procedures were identical for patients with BT and ALL.
Although parent proxy–reported HRQOL assessments provide important clinical information about a child's adjustment to illness, parent reports may be subject to inflation due to parental stress. A study by Johnston et al.30 suggests that parents of patients with cancer and healthy children tend to rate their children's HRQOL poorer than children report for themselves. It is noteworthy that although parents may overreport HRQOL problems, a recent study by Carpentieri et al.13 suggests that the self-reports of patients with BT may underestimate HRQOL problems because of "psychologically-based or neurologically-based denial, defensiveness, or lack of insight" (p. 284).13 Given that both types of reports have strengths and weaknesses, parent proxy-reports and self-reports presumably provide unique and complementary information concerning the child's HRQOL, and both can be useful in clinical decision-making.10
To summarize, parent perceptions of child HRQOL are important because they often drive pediatric health care decisions and program development.31 Parent proxy-reports also allow investigators to assess HRQOL for young children and extremely ill or cognitively delayed children who are unable to complete self-report forms. The findings indicate that patients with BT are at higher risk for HRQOL problems than patients with ALL, and that patients with BT and ALL experience stages of treatment differently. In the current study, the majority of survivors of BT have significant physical, psychosocial, and fatigue problems. Although most long-term survivors of ALL appear to return to normal functioning, a subset of the ALL population continues to struggle with psychosocial problems. A principal clinical implication of our research is that psychosocial support interventions for patients with BT and ALL need to be appropriately timed in relation to the stage of the patient's treatment and recovery. A clear understanding of the types of problems experienced during distinct phases of treatment can be useful in the development of HRQOL screening programs, psychosocial interventions for patients with BT and ALL, and long-term follow-up care programs. Longitudinal studies using both self-reporting and parent proxy-report are needed to identify factors that facilitate or impede transitions to maximum health, and to determine whether child-reported patterns of HRQOL are similar to the patterns reported by parents.
- 1Introduction. In: RiesLA, SmithMA, GurneyJG, et al., editors. Cancer incidence and survival among children and adolescents: United States SEER program 1975–1995 [monograph online]. Bethesda: National Cancer Institute, 1999: 1–17. Available from URL: http://seer.cancer.gov/publications/childhood [accessed April 5, 2004]., , .
- 2RiesLA, EisnerMP, KosaryCL, et al., editors. SEER cancer statistics review, 1975–2000. Bethesda: National Cancer Institute, 2003. Available from URL: http://seer.cancer.gov/csr/1975_2000 [accessed April 5, 2004].
- 3CNS and miscellaneous intracranial neoplasms. In: RiesLA, SmithMA, GurneyJG, et al., editors. Cancer incidence and survival among children and adolescents: United States SEER program 1975–1995. Bethesda: National Cancer Institute, 1999: 51–64. Available from URL: http://seer.cancer.gov/publications/childhood [accessed March 17, 2004]., , .
- 4Leukemia. In: RiesLA, SmithMA, GurneyJG, et al., editors. Cancer incidence and survival among children and adolescents: United States SEER program 1975–1995. Bethesda: National Cancer Institute, 1999: 17–34. Available from URL: http://seer.cancer.gov/publications/childhood [accessed March 17, 2004]., , , .
- 5Medical and neurocognitive late effects among survivors of childhood central nervous system tumors. Cancer. 2001; 92: 2709–2719., , , et al.
- 6Brain tumors in children. In: HollandJF, editor. Cancer medicine. Baltimore: Williams and Wilkins, 1997: 2975–2989., , .
- 7A controlled study of peer relationships of children surviving brain tumors: teacher, peer and self-ratings. J Pediatr Psychol. 1998; 23: 279–287., , , .
- 8The PedsQL 4.0 as a pediatric population health measure: feasibility, reliability, and validity. Ambul Pediatr. 2003; 3: 329–341., , , .
- 9Psychological outcomes in long-term survivors of childhood brain cancer: a report from the Childhood Cancer Survivor Study. J Clin Oncol. 2004; 22: 999–1006., , , et al.
- 10The PedsQL in pediatric cancer: reliability and validity of the Pediatric Quality of Life Inventory Generic Core Scales, Multidimensional Fatigue Scale, and Cancer Module. Cancer. 2002; 94: 2090–2106., , , , .
- 11The Functional Assessment of Cancer Therapy—Anemia (FACT-An) Scale: a new tool for the assessment of outcomes in cancer anemia and fatigue. Semin Hematol. 1997; 34: 13–19..
- 12Measurement of fatigue in cancer patients: development and validation of the Fatigue Symptom Inventory. Qual Life Res. 1998; 7: 301–310., , , et al.
- 13Psychosocial and behavioral functioning among pediatric brain tumor survivors. J Neurooncol. 2003; 63: 279–287., , , et al.
- 14The PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory Version 4.0 Generic Core scales in healthy patient populations. Med Care. 2001; 39: 800–812., , .
- 15Coefficient alpha and the internal structure of tests. Psychometrika. 1951; 16: 297–334..
- 16Psychometric theory. 3rd ed. New York: McGraw-Hill, 1994., .
- 17Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum and Associates, 1998..
- 18Four factor index of social status. New Haven: Department of Sociology, Yale University, 1975..
- 19Statistical methods in cancer research. I. The analysis of case-control studies. Lyon: International Agency for Research on Cancer, 1980., .
- 20Memory deficits among children with craniopharyngiomas. Neurosurgery. 2001; 49: 1053–1057., , , et al.
- 21Neurocognitive deficits in medulloblastoma survivors and white matter loss. Ann Neurol. 1999; 46: 834–841., , , et al.
- 22The neurodevelopmental price of survival in children with malignant brain tumors. Childs Nerv Syst. 2000; 16: 751–754., .
- 23Long-term neurobehavioral outcome in pediatric brain tumor patients: review and methodological critique. J Clin Exp Neuropsychol. 1994; 16: 21–42., .
- 24The value of the PedsQL in assessing quality of life in survivors of childhood cancer. Child Care Health Dev. 2003; 29: 95–102., , , , .
- 25Comparison of psychologic outcome in adult survivors of childhood acute lymphoblastic leukemia versus sibling controls: a cooperative Children's Cancer Group and National Institutes of Health study. J Clin Oncol. 1997; 15: 547–556., , , et al.
- 26Health status in adults treated for childhood cancer: a report from the Childhood Cancer Survivor Study. JAMA. 2003; 290: 1583–1592., , , et al.
- 27Cancer-related fatigue: inevitable, unimportant and untreatable? Results of a multi-centre patient survey. Ann Oncol. 2000; 11: 971–975., , , , , .
- 28Fatigue in breast cancer survivors: occurrence, correlates and impact on quality of life. J Clin Oncol. 2000; 18: 743–753., , , et al.
- 29Characteristics and correlates of fatigue after adjuvant chemotherapy for breast cancer. J Clin Oncol. 1998; 16: 1689–1696., , , et al.
- 30Parent and child reporting of negative life events: discrepancy and agreement across pediatric samples. J Pediatr Psychol. 2001; 42: 661–667., , , .
- 31Screening for behavioral and emotional problems in children and adolescents with congenital or acquired limb deficiencies. Am J Dis Child. 1992; 146: 103–107., .


text:
Release Date:
June 5, 2012
Date Published:
June 5, 2012
Harry Bosch has been given three years before he must retire from the LAPD, and he wants cases more fiercely than ever. In one morning, he gets two.
DNA from a 1989 rape and murder matches a 29-year-old convicted rapist. Was he an eight-year-old killer or has something gone terribly wrong in the new Regional Crime Lab? The latter possibility could compromise all of the lab's DNA cases currently in court.
Then Bosch and his partner are called to a death scene fraught with internal politics. Councilman Irvin Irving's son jumped or was pushed from a window at the Chateau Marmont. Irving, Bosch's longtime nemesis, has demanded that Harry handle the investigation.
Relentlessly pursuing both cases, Bosch makes two chilling discoveries: a killer operating unknown in the city for as many as three decades, and a political conspiracy that goes back into the dark history of the police department.
- Genre: Mystery + Crime
- Publisher: Little, Brown & Company
- Pages: 527
- Release Date: June 5, 2012
other Info.
- Online Item #: 14072382
- Store Item Number (DPCI): 059-04-2472
- Made in the USA and Imported

subset: commoncrawl


text: Trained by coach extraordinaire Rodrigo Cavaca, Renato Cardoso made a big name for himself in late 2012 being revered by jiu jitsu's media as the new "crown jewel" of the Checkmat Team. This status came after a series of magnificent performances in his first couple of months as a black belt, when Renato Cardoso conquered the medium heavyweight world jiu jitsu title (CBJJE) as well as the Sao Paulo International Open (IBJJF), only a few weeks later in both his weight class and the absolute, this time submitting every one of his 9 opponents. In mid 2014 Cardoso switched training camps and moved to the Alliance academy in Sao Paulo. Renato Cardoso Jiu Jitsu Full Name: Renato Guimarães Cardoso Nickname(s): Renato has a few nicknames, such as "Paraíba" (the name of a state, but also the equivalent to Red Neck) or "Pernambuco" both names attributed to him due to the region where Renato grew up, and also Côco (Coconut in Portuguese) due to the shape of his head. Lineage: Mitsuyo Maeda > Carlos Gracie > Carlson Gracie > Élcio Figueiredo > Rodrigo Cavaca > Renato Cardoso Main Achievements: South American Champion (2014 weight & absolute) Sao Paulo Open (2012 weight & absolute) World Champion – CBJJE (2012) Pan American Champion – IBJJF (2012 brown belt) Brazilian National Champion (2012 brown, 2009 purple absolute) Sao Paulo State Champion (2015 black, 2011 weight & absolute brown) XII Copa Internacional Champion (2011 brown) OSASCO Cup Champion (2011 brown) Brazilian National Championship 2nd Place (2015 absolute) World Championship 3rd Place – IBJJF (2015) Pan American Championship 3rd Place – IBJJF (2016) Favourite Position/Technique: 50/50 guard, Triangle Choke and "Botinha" Footlock Weight Division: Peso Médio/Peso Meio-Pesado Team/Association: Alliance academy Renato Cardoso Biography Renato Cardoso was born on the 13th of April, 1988 in São Paulo, Brazil, though he moved to Pernambuco when he was 6 years old. Renato started training martial arts through judo, when he was 13 years old and competed in the sport, winning a Pernambuco State championship when he was a blue belt. His interest for jiu jitsu came through a few of his friends and neighbours who practiced BJJ, they took Renato to his first class when he was in his late 15's, and he immediately fell in love with jiu jitsu and started training consistently. His first academy was at the garage of a weight lifting gym, which had a very small matted area of 2×2 meters. The coaches were Adriano Stanislau and Denis "Deninho" Mitchael, both were very big influences in Renato Cardoso's jiu jitsu career, and Cardoso defended the colours of "Boca-De La Riva" during the guidance of the Stanislau/Mitchael duo; these two coaches graduated Renato with his blue and purple belts. The "Boca-De La Riva" team split with Denis Mitchael's move to Florida, US, and Renato Cardoso found a new team to train with, Nova União, training under Vitor Hugo and Bruno Novaes, who later awarded Cardoso his brown belt. Renato Cardoso's friendship with Rodrigo Cavaca dates from 2009, they met at the Brazilian National Championships, a tournament Renato won in the absolute division winning against none other then future team mates Antonio Junior "Cara de Sapato" (in the semi final) and Marcus Almeida "Buchecha" in the final. Renato met Checkmat's coach, Cavaca at this competition, and the two became friends. In 2010, Cavaca and Cardoso met again at the same tournament, after failing to medal that year Renato complained to Cavaca that there was not enough sparring partners and hard training at his town for him to push for the top spots at the major tournaments, and that though he wanted to make a living of BJJ, it just wasn't happening for him given the state of jiu jitsu where he lived. Rodrigo Cavaca offered him a spot at his academy in Santos, Sao Paulo, and proposed him to teach at one of his affiliated academies as a way to earn a living, Rodrigo Cardoso immediately accepted and joined the Cavaca training centre, sharing the mats with BJJ phenomenon's like Marcus "Buchecha", Michelle Nicolini, "Cara de Sapato", Bernardo Tavolaro, Nivaldo Oliveira and many others. With high level training partners, Renato's jiu jitsu level sky rocketed, and he started making an impression once again, his hard work earned him his black belt from Cavaca on the 15th of June, 2012. A month later after receiving his black belt, Renato Cardoso made his debut at the World Championships of CBJJE, he passed the test with flying colours, submitting all of his opponents on the way to the final of the medium heavyweight division, which he won, and the absolute division, falling short at the final of the open weight against heavy favourite Claudio Calasans, losing by 1 advantage (2×2 points on scoreboard and 2×3 advantages). He would fight again in August at the Sao Paulo International Open, submitting all of his opponents in both his weight and the absolute division. On the second semester of 2014, Renato Cardoso decided to cut his ties with the Checkmat team, moving to the Alliance academy. Renato Cardoso Grappling Record 84 WINS BY POINTS 25 (30%) BY ADVANTAGES 5 (6%) BY SUBMISSION 51 (61%) BY DECISION 3 (4%) BY PENALTIES 0 (0%) BY DQ 0 (0%) 51 SUBMISSIONS WINS #214eb8 Botinha 47 24 #86e620 Triangle 14 7 #5AD3D1 Kneebar 14 7 #d1212a Wristlock 8 4 #fad11b Armbar 6 3 #f58822 Triangle armbar 4 2 #224aba Estima lock 2 1 #ff9124 Injury 2 1 #bf1f6c Footlock 2 1 #22c9a5 Choke from back 2 1 51 (100%) SUBMISSIONS 33 LOSSES BY POINTS 15 (45%) BY ADVANTAGES 10 (30%) BY SUBMISSION 5 (15%) BY DECISION 2 (6%) BY PENALTIES 1 (3%) BY DQ 0 (0%) 5 SUBMISSIONS LOSSES #214eb8 Choke from back 40 2 #86e620 Omoplata 20 1 #5AD3D1 Bow and arrow 20 1 #d1212a Toe hold 20 1 5 (100%) SUBMISSIONS Renato Cardoso Fight History ID Opponent W/L Method Competition Weight Stage Year 3327Claudio CalasansClaudio CalasansLPts: 0x0, AdvMundial CBJJEABSF20124171Leandro LoLeandro LoLPts: 15x4Pan Am. CBJJEABSNA20134215Bernardo FariaBernardo FariaLOmoplataEuropean OpenABS1/4F20134374Andre GalvaoAndre GalvaoLChoke from backPan American88KGR220134450Manny DiazLPts: 2x0Copa Podio88KGGP20134454Jaime CanutoJaime CanutoLPts: 0x0, AdvCopa Podio88KGGP20134456Paulo MiyaoPaulo MiyaoLChoke from backCopa Podio88KGGP20134497Abraham MarteAbraham MarteLBow and arrowWorld Champ.ABSRDS20134645Murilo SantanaMurilo SantanaLPts: 8x0Mundial CBJJE88KGF20134948Diogo SampaioDiogo SampaioLPts: 4x0World Pro Trial88KGF20144952Murilo SantanaMurilo SantanaLReferee DecisionWorld Pro TrialABSF20145085Gustavo CamposGustavo CamposLPts: 8x8, AdvPan American88KGSF20145217Alexandre RibeiroAlexandre RibeiroLPts: 2x0BrasileiroABSSF20145232Felipe PenaFelipe PenaLAdvBrasileiro88KGF20145334Andre GalvaoAndre GalvaoLPts: 0x0, AdvWorld Pro.88KGSF20145494Gustavo CamposGustavo CamposLPts: 11x2World Champ.88KG1/4F20145982Claudio CalasansClaudio CalasansLPts: 0x0, AdvBrazil Nat. Pro85KG1/4F20156043Tarcisio JardimTarcisio JardimLPts: 0x0, AdvEuropeanABS1/4F20156140Andre GalvaoAndre GalvaoLPts: 4x0European88KGF20156385Keenan CorneliusKeenan CorneliusLPts: 5x2Pan American88KG1/4F20156626Claudio CalasansClaudio CalasansLPts: 0x0, AdvWorld Pro85KGR220156756Erberth SantosErberth SantosLPts: 0x0, PenBrasileiroABSF20156966Leandro LoLeandro LoLPts: 15x2World Champ.88KGSF20157509Igor SchneiderIgor SchneiderLPts: 5x2Brazil Nat. ProO77KGSF20157768Erberth SantosErberth SantosLAdvSP National Pro94KGF20157777Leandro PedrosaLPts: 4x2SP National ProO77KG1/4F20157962Erberth SantosErberth SantosLPts: 4x2South AmericanABSSF20157980Patrick GaudioPatrick GaudioLPts: 2x2, AdvSouth American88KGF20158599Leandro LoLeandro LoLToe holdPan American88KGSF20168760Lucio LagartoLReferee DecisionWorld ProABSR120168880Leandro LoLeandro LoLPts: 2x0World Pro85KGSF20169069Erberth SantosErberth SantosLPointsBrasileiroABSSF20169255Keenan CorneliusKeenan CorneliusLPts: 5x2World Champ.88KG1/4F20163322Jaroslaw GajekWTriangleMundial CBJJE88KG1/4F20123323Anderson CyborgWBotinhaMundial CBJJE88KGSF20123324Vitor ToledoVitor ToledoWPts: 0x0, AdvMundial CBJJE88KGF20123325Mario HenriqueWTriangleMundial CBJJEABS1/4F20123326Leandro BrassotoWBotinhaMundial CBJJEABSSF20124178UnknownWBotinhaManaus Pro Trials85KGR120134179UnknownWBotinhaManaus Pro Trials85KG1/4F20134180Felipe PreguiçaWKneebarManaus Pro Trials85KGSF20134213Nic RubenWPts: 0x0, AdvEuropean OpenABSR120134214Jose JuniorJose JuniorWBotinhaEuropean OpenABSR220134373Felipe PenaFelipe PenaWPointsPan American88KGR120134442Travis StevensWTriangle armbarCopa Podio88KGGP20134481Nilson BragaWPointsWorld Champ.ABSRDS20134642Jurandir VieiraWBotinhaMundial CBJJE88KG1/4F20134644Anderson CyborgWBotinhaMundial CBJJE88KGSF20134945Sergio MoraesSergio MoraesWKneebarWorld Pro Trial88KG1/4F20144946Pedro MelloWTriangleWorld Pro Trial88KGSF20144967M. WisniewskiWN/AEuropean88KGSF20145079William ZumbroWPointsPan American88KGR120145082Vitor ToledoVitor ToledoWPointsPan American88KG1/4F20145213Cassio FrancisCassio FrancisWPointsBrasileiroABSR120145331Max CarvalhoWPts: 0x0, AdvWorld Pro.88KG1/4F20145336Marcus ViniciusWPointsWorld Pro.88KG3PLC20145636UnknownWTriangleCamp. InternacionalABSSF20145637Paulo MiyaoPaulo MiyaoWPts: 3x0Camp. InternacionalABSF20145760Stefano GoiaWWristlockBJJ StarsABSSPF20145865Andre G.WKneebarSouth AmericanABS1/4F20145869Vinicius MarinhoVinicius MarinhoWBotinhaSouth AmericanABSSF20145871Tony FerrazWPts: 20x0South American88KG1/4F20145872Stefano CorreaWBotinhaSouth American88KGSF20145873Victor BomfimWKneebarSouth American88KGF20146022Jose JuniorJose JuniorWBotinhaEuropeanABSR220156036C. NegromonteWPts: 2x0EuropeanABSR320156130Julien CazierWBotinhaEuropean88KGR220156136Thiago BragaWPts: 4x2European88KG1/4F20156139Max CarvalhoWPts: 7x0European88KGSF20156183Anderson WesileyWBotinhaWorld Pro Trials88KGF20156184Raphael NicolasWAdvWorld Pro TrialsABSF20156381Steven PetersonWPts: 0x0, AdvPan American88KGR220156616Darren O'ConnalWWristlockWorld Pro85KGR120156678Fabio PulitaWPointsWorld ProABSR120156735Adriano MelettoWChoke from backBrasileiro88KG1/4F20156736William LimaWReferee DecisionBrasileiro88KGSF20156737Pedro PimentaWArmbarBrasileiro88KGF20156745Stefano CorreaWEstima lockBrasileiroABSR120156748Ricardo RochaWBotinhaBrasileiroABSR220156751Felipe CesarFelipe CesarWTriangleBrasileiroABS1/4F20156755Pedro MouraWArmbarBrasileiroABSSF20156956Pedro MelloWBotinhaWorld Champ.88KG1/8F20156962Thiago SaThiago SaWTriangleWorld Champ.88KG1/4F20157188Gabriel VieiraWPts: 2x0Mundial CBJJEABS1/4F20157189Rodrigo RibeiroWReferee DecisionMundial CBJJEABSSF20157190Otavio NataliWReferee DecisionMundial CBJJEABSF20157289F. ToshioWPts: 10x0SP Open88KG1/4F20157290Marcos PauloWKneebarSP Open88KGSF20157291Stefano CorreaWBotinhaSP Open88KGF20157299UnknownWBotinhaSP OpenABS1/4F20157300Rodrigo RibeiroWPts: 14x2SP OpenABSSF20157301Caio AlmeidaWPts: 6x0SP OpenABSF20157497Gilberto MedeirosWPts: 4x0Brazil Nat. Pro85KG1/4F20157498Igor MarquesWBotinhaBrazil Nat. Pro85KGF20157508UnknownWBotinhaBrazil Nat. ProO77KGR120157637UnknownWBotinhaFloripa OpenABSR120157641Otavio NataliWPts: 3x0Floripa OpenABSF20157764UnknownWBotinhaSP National Pro94KG1/4F20157766UnknownWBotinhaSP National Pro94KGSF20157772UnknownWInjurySP National ProO77KGR120157945Thiago SouzaWWristlockSouth AmericanABSR120157955UnknownWBotinhaSouth AmericanABS1/8F20157959Patrick GaudioPatrick GaudioWFootlockSouth AmericanABS1/4F20157977Marcus OliveiraWPts: 12x0South American88KG1/4F20157978Pedro HenriqueWKneebarSouth American88KGSF20158591Inacio NetoWPts: 9x2Pan American88KG1/8F20168597Rodrigo FrajardoWPts: 16x0Pan American88KG1/4F20168870Charles NegromonteWPts: 2x0World Pro85KG1/8F20168877Rodrigo ReisWBotinhaWorld Pro85KG1/4F20169011Wesley ArcheteWKneebarBrasileiro88KG1/8F20169015Pedro DiasWTriangleBrasileiro88KG1/4F20169019William MartinsWPts: 2x0Brasileiro88KGSF20169020Patrick GaudioPatrick GaudioWPointsBrasileiro88KGF20169057Matheus CostaWArmbarBrasileiroABSRD20169064Fernando GomesWBotinhaBrasileiroABS1/8F20169068Diego RamalhoWWristlockBrasileiroABS1/4F20169250Giacomo ZaniniWTriangle armbarWorld Champ.88KG1/8F2016 Cover picture by Gracie Mag Renato Cardoso vs Mario Henrique Renato Cardoso vs Leandro Brassoloto Renato Cardoso vs Jaroslaw Gajek Renato Cardoso vs Anderson Cyborg


text:
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Weird Al Yankovic will be kicking off his 2016 tour on June 3rd in Saint Petersburg, FL at the Mahaffey Theatre.
Weird Al Yankovic will be setting out on his "Mandatory Word Tour". Here all his hits like "Another One Rides The Dust," "My Bologna," "Eat It" and "Smells Like Nirvana".
Yankovic will be out in support of his latest album, 2014's Mandatory Fun.
2016 Weird Al Yankovic Tour Dates
June 3 – Saint Petersburg, Fla., The Mahaffey Theater
June 4 – West Palm Beach, Fla., Kravis Center
June 5 – Fort Myers, Fla., Barbara B. Mann Perf. Arts Hall
June 7 – Mobile, Ala., Saenger Theatre
June 9 – Lakeland, Fla., Youkey Theatre
June 10 – Miami, Fla., The Adrienne Arsht Center For The Performing Arts Of Miami-Dade County
June 11 – Saint Augustine, Fla., St. Augustine Amphitheatre
June 12 – Birmingham, Ala., Concert Hall At The BJCC
June 15 – Louisville, Ky., Iroquois Amphitheater
June 16 – Nashville, Tenn., Grand Ole Opry House
June 17 – Huntsville, Ala., Mark C. Smith Concert Hall
June 18 – Greensboro, N.C., White Oak Amphitheatre At Greensboro Coliseum Complex
June 19 – Atlanta, Ga., Fox Theatre
June 21 – Portsmouth, Va., Portsmouth Pavilion
June 22 – Baltimore, Md., Hippodrome Theatre / France-Merrick Perf. Arts Ctr.
June 24 – Akron, Ohio, Akron Civic Theatre
June 25 – Bay City, Mich., Veterans Memorial Park
June 26 – Fort Wayne, Ind., Foellinger Theatre
June 28 – Evansville, Ind., Victory Theatre
July 1 – Toledo, Ohio, Toledo Zoo Amphitheatre
July 2 – Aurora, Ill., RiverEdge Park
July 3 – Merrillville, Ind., Star Plaza Theatre
July 6 – Columbus, Ohio, Palace Theatre
July 7 – Indianapolis, Ind., Farm Bureau Insurance Lawn At White River State Park
July 8 – Cincinnati, Ohio, PNC Pavilion At Riverbend
July 9 – Chattanooga, Tenn., Tivoli Theatre
July 10 – Southaven, Miss., BankPlus Amphitheater At Snowden Grove
July 12 – Austin, Texas, Bass Concert Hall
July 14 – Houston, Texas, Alice & George Brown Theater
July 15 – Biloxi, Miss., Hard Rock Live
July 16 – Dallas, Texas, Margot & Bill Winspear Opera House
July 17 – Enid, Okla., Enid Event Center
July 19 – El Paso, Texas, The Plaza Theatre
July 21 – San Diego, Calif., Cal Coast Credit Union Open Air Theatre
July 22 – Los Angeles, Calif., Hollywood Bowl
July 23 – Los Angeles, Calif., Hollywood Bowl
July 24 – San Jose, Calif., City National Civic
July 26 – Seattle, Wash., Woodland Park Zoo
July 27 – Seattle, Wash., Woodland Park Zoo
July 28 – Troutdale, Ore., McMenamins Edgefield Amphitheater
July 29 – Eugene, Ore., Cuthbert Amphitheater
July 30 – Rohnert Park, Calif., Green Music Center
Aug. 2 – Santa Barbara, Calif., Arlington Theatre
Aug. 3 – Phoenix, Ariz., Comerica Theatre
Aug. 5 – Salt Lake City, Utah, Red Butte Garden
Aug. 7 – Kansas City, Mo., Starlight Theatre
Aug. 9 – Cedar Rapids, Iowa, McGrath Amphitheatre
Aug. 10 – Lincoln, Neb., Pinewood Bowl Theater
Aug. 13 – Sturgis, S.D., Sturgis Buffalo Chip (Sturgis Rally)
Aug. 14 – Regina, Saskatchewan, Conexus Arts Centre
Aug. 15 – Winnipeg, Manitoba, Burton Cummings Theatre
Aug. 18 – Thunder Bay, Ontario, Thunder Bay Community Auditorium
Aug. 19 – Minneapolis, Minn., State Theatre
Aug. 20 – Appleton, Wis., Fox Cities Performing Arts Center
Aug. 21 – Madison, Wis., Overture Center For The Arts
Aug. 23 – Rockford, Ill., Coronado Performing Arts Center
Aug. 24 – Paducah, Ky., The Carson Center
Aug. 26 – Grand Rapids, Mich., DeVos Performance Hall
Aug. 27 – Sterling Heights, Mich., Freedom Hill Amphitheatre
Aug. 28 – Huber Heights, Ohio, Rose Music Center At The Heights
Aug. 30 – Wilmington, Del., Playhouse Theatre
Sept. 1 – Lowell, Mass., Boarding House Park
Sept. 2 – Gilford, N.H., Bank Of NH Pavilion
Sept. 3 – Canandaigua, N.Y., Constellation Brands – Marvin Sands PAC (CMAC)
Sept. 4 – Big Flats, N.Y., The Summer Stage At Tag's
Sept. 7 – Columbia, S.C., Koger Center For The Arts
Sept. 8 – Wilmington, N.C., Cape Fear Community College
Sept. 9 – Durham, N.C., Durham Performing Arts Center
Sept. 10 – Asheville, N.C., Thomas Wolfe Auditorium
Sept. 11 – Vienna, Va., Filene Center At Wolf Trap
Sept. 13 – Hershey, Pa., Hershey Theatre
Sept. 14 – Providence, R.I., Providence Perf. Arts Ctr.
Sept. 16 – Pittsburgh, Pa., Benedum Center
Sept. 17 – Schenectady, N.Y., The Main Stage At Proctors
Sept. 18 – Waterbury, Conn., Palace Theater
Sept. 22 – Charleston, W. Va., Clay Center For The Arts & Sciences
Sept. 23 – Atlantic City, N.J., Caesars Circus Maximus Theater
Sept. 24 – New York, N.Y., Radio City Music Hall
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text: Unicyclist combines riding with geocaching, trail maintenance This topic contains 0 replies, has 1 voice, and was last updated by RustyRed 3 yrs. Viewing 1 post (of 1 total) ← Forums Home Author Posts Author Posts RustyRed Private Message Jul 19 2013 at 1:06pm # W00t! Let's hear it for positive cycling news! And geocaching too! (I'm one of those trail-riding geocachers too!) http://www.post-gazette.com/stories/local/neighborhoods-north/a-newsmaker-you-should-know-unicyclist-combines-riding-with-geocaching-trail-maintenance-695862/ Viewing 1 post (of 1 total) ← Forums Home You must be logged in to reply to this topic.


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To the Editor:
I came across a pro-Trump message that a supporter had fingered in the wet cement at the Princeton Shopping Center. Being an avowed Democrat and a Trump critic, my first inclination was to walk over to Ace Hardware, purchase some paint and a brush and add a preceding epithet to the Trump logo. I refrained knowing that I'd sully my brand or the brand of the candidate I support by doing so.
And ironically, letting the name stand or rather sit in the cement actually speaks more to why voters should not vote for Trump than anything I could add to his name. Whoever chose to finger his name in the cement was hewing to the Trump mindset of contempt and disdain for legal and social norms. Norms that are already perilously weakened as showcased daily in the media — social and otherwise.
All mock seriousness and snark aside, I'm really frightened by the current political state of affairs in our country as well as globally. I hope that the inherent sanity and goodness I believe exists in most people in America will prevail in November.
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> Browse by Title
> Loans to Foreign Governments
Loans to Foreign Governments
: Resume of the Laws Under Which Loans Were Made to Foreign Governments During and Since the War and the Main Features of the Loans as Disclosed By Correspondence Between the President, the State Department, the Treasury Department, and Foreign Governments Submitted to the Committee on the Judiciary
December 6, 1921
Download (PDF)
Presented by Mr. Reed.
Running title: Foreign loans and authority for making same.
Metadata (XML)
Metadata (JSON)
Loans to Foreign Governments, December 6, 1921.
accessed on July 24, 2016.


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Kids travel world without leaving Houma
Published: Sunday, March 18, 2007 at 6:01 a.m.
Last Modified: Saturday, March 17, 2007 at 10:17 p.m.
HOUMA -- Children and parents took virtual tours of dozens of countries Saturday, learning about different cultures and customs while never leaving downtown Houma.
The globe-trotting experience was part of the third-annual CASA for Kidz Spring Fest: A World of Fun.
The all-day event, in the Courthouse Square, drew about 2,000 people and raised $15,000 for the nonprofit Court Appointed Special Advocates of Terrebonne, or CASA. Every dollar raised for the event is put back into the local group, organizers said.
CASA uses volunteers to give abused, neglected or abandoned children a voice in the court system.
The volunteers also keep track of the children outside the court, said Courtney Arceneaux, CASA executive director. For instance, if a child is interested in music, the nonprofit will try to find him or her an instrument. The 50 local volunteers tend to each childs medical, clothing and school needs. In 2006, volunteers worked with 120 local kids.
Saturdays festival included booths representing different countries, where kids could participate in activities designed to make learning fun.
Eddie Olivier said his Ireland booth, sponsored by Aflac insurance company, had given out 800 shamrock refrigerator magnets and necklaces. It was a lucky coincidence the company got to be Ireland on St. Patricks Day, Olivier said.
"This is a great idea," he said. "You get caught up in work and all the stress. And to spend time with children is a good relaxer, and its for a good cause."
Each booth is sponsored with $250 from either the volunteers running it or a sponsor.
Last year, CASA raised $8,500 during the festival and raised $20,000 to $25,000 altogether. The total profit was $17,500, Arceneaux said.
At the Brazil booth, local bikers, dressed in Carnival masks, talked with kids and pressed temporary tattoos on the little hands.
"Peoples reaction when they see bikers is ëWhat are they doing here? " said "Bird Man," a charter member of BACA, or Bikers Against Child Abuse. The nonprofit groups anonymous members take abused children under their wings, offering any support them can.
"Bikers are people, too," said "Banana," the local BACA chapters events coordinator. "We all have 9-to-5 jobs. This is what we do in our spare time."
Reader comments posted to this article may be published in our print edition. All rights reserved. This copyrighted material may not be re-published without permission. Links are encouraged.
Comments are currently unavailable on this article


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I have a VBA script that imports a layout into an exsting drawing, its a paperspace layout and contains one acadPViewport to view the model with.
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When I run exactly the same code inside my main code it has no effect.
Any ideas appreciated.


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The Cursed Crusade probably isn't on very many "Highly-Anticipated Games" lists, but that shouldn't discourage anyone from giving it a chance. In a rather smart move, Atlus has decided to release a pre-launch demo of Kylotonn Games' upcoming supernatural action RPG.
The publisher hasn't specified an exact date for the demo, but it will come prior to the game's release on October 25 and cover the "Assault on Castle Biron" mission. Templar Denz de Bayle and his comrade Esteban Noviembre must break down a castle's defenses to confront Martin d'Algais, a former friend of the de Bayle family.
A new trailer was also released today, delving into a different aspect of the game's story. So we know Denz (and possibly Esteban) is cursed with some kind of demonic power -- which makes him look pretty damn cool, actually -- but the video also addresses the moral ambiguity of the Holy Crusades. Denz had sought to join the Crusades thinking they were something else entirely, only to realize the truth much later. All the while, he seeks to rid himself of a curse that plagues him, though fortunately for players, this curse adds a bit of spice to the gameplay.
As always, Cursed Crusade will be available at launch at a discounted price of $40. In the mean time, keep an eye out on Xbox LIVE, PSN, and Steam for the demo.


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Hello everyone! I'm here to share my story. 3 years ago I weighed in at 308 lbs. I was obese, depressed, and hating life. So I decided to change my habits / lifestyle. Within a year I had lost 100lbs! My life has changed for the better. Today (7/22/15) I weigh 190lbs. I maintain a clean/ strict... READ MORE
43 Yr Old - Gastric Sleever - 100 Lb. Weight Loss - Seeking Full Body Lift / Contour! Dominican Republic, DO
Day 1 -- Finally making the decision to do the damn thang and get this body what it deserves! I am researching full body lift / contour to include TT, w/ Breast Implants, All Lipo available to me, BBL, Arm Lift, and Thigh Lift! In Columbia they offer a team of doctors so all procedures can be... READ MORE
53 Yr Old, Post Weight Loss of over 100 Pounds, Body Lift in 2 Stages, Dr. Turkle Transformed Me! Carmel, IN
I'm 53, a wife, and mother of 4 great kids! Over the past few years I have gone through a major transformation! After losing 120 pounds, I've had a BA, Arm Lift, TT, Lipo and just recently, a Posterior lift which turned my TT into a Body lift. A difficult childhood caused me to start down an ... READ MORE
26 Years Old, Massive Weight Loss, Upper and Lower Body Lift, Arms - Monterrey, MX
So let me start by saying I am soooooo impressed with my results! I have lived with huge amounts of back skin all my life and since losing 175lbs it has only gotten progressively worse. I first emailed dr. Munro-wilson after he was reccomended to me through an online support group. I called... READ MORE
23 No Kids Seeking the Brazilian Butt Lift W/ Dr. Omulepu! - Miami, FL
I've been reviewing some of Doctor Osakatukei Omulepu work, and Felled in love! I placed a down payment for my Brazilian butt lift procedure with Dr. Omulepu. Last month on the 17th. However, I didn't get to meet him. Due to the fact that I was originally scheduled with Spectrum, but the... READ MORE
Lower Body Lift, San Antonio, TX
I am married and have three children ages: 13, 10, and 6. I have fought my weight for my entire life. I got up to 297 pounds and refused to cross that 300 mark so I had weight loss surgery. I am down to 190 pounds and have been for about a year. I would like to get lower, but seem to have... READ MORE
54 Year Old Woman for a Body Lift After 150 Pound Massive Weight Loss - Vineland, NJ
I was so excited to lose 150 pounds after my gastric sleeve procedure, but I couldn't believe how much extra skin I had after my procedure. Dr. Bidic gave a talk to my massive weight loss group and he talked about all of the procedures that could improve the shape of someone who lost a lot of... READ MORE
40 Yrs Old Body Lift and Breast Lift with Implants - Toowoomba, AU
Day after surgery, feeling very sore and sorry for myself. Everything is swollen. Got up twice already.the lipo hurts the most. Was really emotional this morning and thought I was crazy getting it done. But feel better tonight. Will post after photos when able too. After the operation you feel... READ MORE
Finally my Turn. Akron, OH
Wow, where to start. Its been a long journey to my present and upcoming procedure. It started in 2005 with the gastric-by-pass and weighing in at 330 pounds. So over the next nine years I maintained my weight for the most part at 200 pounds, fluctuating once when I went back to college back to... READ MORE
Circumferential Body Lift -Dr. Manish Champaneria
I'm a busy wife and mamma to 5 kiddos and over 8 years have lost well over 100lbs, leaving me with unsightly loose skin. Over the Fall I was able to take off the last 20lbs, and my husband and I made the decision to begin the plastic surgery process to finish my journey. I had several consults... READ MORE
9 Years a Waiting - Grand Rapids, MI
I had RNY 4/26/06. Best decision ever! Lost 165 lbs and have maintained that since. The way my shape was I had 2 "Rolls" divided by my belly button. I really wanted my belly button to "see the light". It's been living in darkness between the rolls. Decided on the Lower Body Lift. My insurance... READ MORE
Lower body lift, butt and breast augmentation - Mayfield Heights, OH
After being morbid obese for years, I finallly lost the weight and got fit with a body fat percentage of 15. As a double board certified nurse practitioner who worked at one of the country's top 3 hosiptals, I took the task of finding the right ps. I had seen 2 other plastic surgeons and had one... READ MORE
34 Years Old. Lost 100 Pounds. One Child. LBL - Tijuana, MX
I decided on Dr. Cardinals because she sounds very credible and had many great reviews. So far everyone has been very nice. I scheduled my surgery for June 11th so I could lose 40 more pounds and get my BMI to 30. I'm 5'7 and weigh 226. I have 26 more pounds to go. It'll also give me more time... READ MORE
Dr Gustavo Almanzar - Dominican Republic
Hey everyone just sent a deposit for my wife and I to get our plastic surgery with Dr Gustavo almazar. He has been great so far always responds quickly. I'm having a chest lift and tummy tuck my wife is having a chest lift implants and tummy tuck. Going to log the whole experience anyone else... READ MORE
28yr Old Mother of 2 After Losing 188lbs. Texas, TX
I'm scheduled to travel out of state to have my belt lipectomy. Can't wait to not be uncomfortable and get rid of the old me. I had the VSG in 2013 and lost 188lbs. Any suggestions of things I should expect after surgery AND items I should bring to make my life easier post op (since I will be... READ MORE
Loving my Body by Dr. Peter Fisher! - San Antonio, TX
I estimate that I was at 400 pounds at my highest weight. I had multiple health conditions. I tried multiple options for weight loss, but when my health became critical, I had the VSG surgery in February 2014. I always had a flat butt, but after the VSG my breasts deflated. I weighed 271 at the... READ MORE
27 Year Old Mom of 1 Fixing Her Body - Corpus Christi, TX
I have always been skinny, I was really skinny before I got pregnant. Then when I was pregnant I ballooned up to 220 lbs & at 5'2" I was over weight. I wasn't happy with being that big so after I got the ok from my OBGYN to start working out, I did. But now I have a lot of loose skin. I hope I... READ MORE
Body Lift 2015, 45 Year Old Male - Saint Petersburg, FL
I recently just passed my six week mark post op from a lower body lift, and chest lipo. This was a big step for me, first time for any surgery! Just a little history, I had lost over 110 pounds, from weighing 305 lbs to 195 lbs on the day of surgery. I had been exercising, running, eating... READ MORE
Lower Body Lift with Spiral Thigh Lift Following 95# Weight Loss After Gastric Sleeve. - San Antonio, TX
I have been overweight my entire adult life. In 2013 I had the gastric sleeve and lost 95# within 6 months. I was thrilled with my weight loss, but not thrilled with the extra skin that was left hanging on my body. Six months ago I met Dr. Peter Fisher and without hesitation had a breast lift... READ MORE


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A Good Day to Die Hard is a 2013 American action film and the fifth installment in the Die Hard film series. The film was directed by John Moore and written by Skip Woods, and starring Bruce Willis as John McClane. The main plot finds McClane travelling to Russia to get his estranged son, Jack, out of prison, but is soon caught in the crossfire of a terrorist plot. Talks of a fifth Die Hard film began before the release of Live Free or Die Hard, with Willis affirming that the latter would not be the last in the series, but pre-production did not start until September 2011, when John Moore was officially announced as the director. Filming began in April 2012, primarily in Budapest, Hungary. Wikipedia
Jack McClane: Hang on, John!
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