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Hi Braeden,
I'd recommend taking a look at the Getting Started section of the OpenGL Wiki. There's a lot of good info and links to tutorials for both modern and fixed-function OpenGL programming.
Good luck!
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- Overcast, mist
- Temperature: 57 °F
Mon, 07/25/2016 - 09:53
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Mon, 07/25/2016 - 10:15
Crescent City
- Overcast
- Temperature: 59 °F
Mon, 07/25/2016 - 09:56
Crescent City
There was bad news and good news on Humboldt's jobless rate. It ticked up last month but we remain down a significant amount in comparison to last year. That's according to the County's Employment Development Department.
Humboldt County's preliminary October unemployment rate is 7.8 percent. That's up by just .1 percent from September's results. But Humboldt County remained down 1.6 percent for the month over last year at this same time. Humboldt moved up to 22nd among the 58 counties statewide. There was a job increase for industrial employment and for the entire year to date, Humboldt is currently up 600 jobs. Farm work, manufacturing, trade, information and government were the biggest gainers with 100 or more jobs create. The single exception was professional and business services, which cut 100 jobs.

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Cutaneous Squamous Cell Carcinoma
- Author: Talib Najjar, DMD, MDS, PhD; Chief Editor: Arlen D Meyers, MD, MBA more...
Practice Essentials
Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer, after basal cell carcinoma. Other significant skin lesions are actinic keratosis and melanoma. Actinic keratosis and basal cell carcinoma are easily excised and have a very good prognosis. However, SCC of the skin has a poor prognosis, especially if it invades vital structures or metastasizes to the lymph nodes. Actinic keratosis is the premalignant precursor for cSCC, and early treatment will save the patient morbidity. Extrinsic factors, such as ultraviolet light from sun exposure, are linked to cutaneous cell carcinoma, while intrinsic factors, such as the use of antioxidants, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs), are reported to reduce the risk of developing cSCC. The image below depicts a large, ulcerated, invasive SCC of the left lower eyelid.
Signs and symptoms
Clinically, cSCC presents as a shallow ulcer with elevated margins, often covered by a plaque and usually located in a sun-exposed area. Typical surface changes may include scaling, deep ulceration, crusting, and cutaneous horn.
A less common presentation of cSCC includes a pink cutaneous nodule without overlying surface changes. Regional metastasis of head and neck cSCC may result in enlarged and palpable submandibular or cervical lymph nodes.
If cSCC invades the adjacent peripheral nerve, it causes numbness, pain, and muscle weakness. These may be some of the clinical signs of invasion other than palpable lymph nodes.
Diagnostic workup of suspected cSCC will include computed tomography (CT) scanning to evaluate for soft tissue or bony invasion and lymph node metastasis. Magnetic resonance imaging (MRI) may be used to rule out invasion of neural or vital structures. Incisional or excisional biopsy are essential for definitive diagnosis. The choice of biopsy will depend on the size and location of the lesion.
Treatment options include the following:
Surgical excision with clear margins, as verified by frozen sections
Mohs micrographic surgery for invasive cSCC in the facial region
Radiation therapy as an adjuvant to surgery, to provide improved locoregional control, or as primary therapy in patients who are unable to undergo surgical excision
Chemotherapy, such as treatment with oral 5-fluorouracil (5-FU) and epidermal growth factor receptor (EGFR) inhibitors, as adjuvant therapy for select highest-risk cases
Systemic chemotherapy for metastatic cSCC
See Treatment and Medication for more detail.
Cutaneous squamous cell carcinoma (cSCC) is the second most common skin cancer and one of the most common cancers overall in the United States. An estimated 3.5 million cases of nonmelanoma skin cancers were diagnosed in the United States in 2006; of those, approximately 80% were basal cell carcinoma (BCC) and 20% were cSCC.
Despite increased knowledge and public education regarding the causes of skin cancer and modes of prevention, the incidence of cSCC continues to rise worldwide. This increasing incidence is likely multifactorial; the speculated causes for the rise include an aging population, improved detection, an increased use of tanning beds, and environmental factors, such as depletion of the ozone layer. (See the image below.)
Although cSCC is not often fatal, it can cause significant morbidity, especially when it involves the facial skin. Most cSCCs are located in the head-and-neck region, and extensive excision required in an advanced stage of the disease can cause disfigurement. Furthermore, the cost of treatment has been shown to pose a significant public health burden. In a study of the US Medicare population, the treatment of nonmelanoma skin cancers ranked fifth among the most expensive cancers to treat in the head-and-neck region.
Diagnosis of cSCC begins with a careful history and physical examination. A biopsy should be performed for any lesion suspected of being a cutaneous neoplasm to rule out basal cell carcinoma and other dermal lesions.
Given the central role that ultraviolet radiation (UVR) plays in the pathogenesis of cSCC, methods aimed at decreasing UVR exposure form the cornerstone of cSCC prevention. In addition, treatment of precancerous lesions and in situ SCC may prevent the future development of invasive lesions. (See the image below.)
Electrodessication and curettage is a simple technique that can be used to treat localized, superficial cSCC, while surgical excision and Mohs micrographic surgery are the two primary treatment options for invasive cSCC. Radiation therapy is typically used as an adjuvant to surgery, with primary radiation therapy typically reserved for patients who are unable to undergo surgical excision.
Chemotherapy may be considered as adjuvant therapy in select highest-risk cases of cSCC. In particular, emerging evidence suggests that epidermal growth factor receptor (EGFR) inhibitors may be useful adjuncts to surgical treatment. Systemic chemotherapy may be considered for metastatic cSCC.
By convention, the term head-and-neck SCC typically refers to SCC of the mucosal linings of the head and neck rather than to cSCC.
Although conjunctival SCC also involves mucosa rather than skin, it is briefly considered in the Clinical Presentation and Treatment sections.
Malignant transformation of normal epidermal keratinocytes is the hallmark of cSCC. One critical pathogenic event is the development of apoptotic resistance through functional loss of TP53, a well-studied tumor suppressor gene. TP53 mutations are seen in over 90% of skin cancers diagnosed in the United States, as well as in most precursor skin lesions, suggesting that loss of TP53 is an early event in the development of cSCC.[1]
UVR causes deoxyribonucleic acid (DNA) damage through the creation of pyrimidine dimers, a process known to result in the genetic mutation of TP53. Upon subsequent UVR exposure, keratinocytes undergo clonal expansion, acquiring further genetic defects, ultimately leading to invasive cSCC.
Many other genetic abnormalities are believed to contribute to the pathogenesis of cSCC, including mutations of BCL2 and RAS. Likewise, alterations in intracellular signal transduction pathways, including the epidermal growth factor receptor (EGFR) and cyclo-oxygenase (COX), have been shown to play a role in the development of cSCC.
Squamous cell carcinoma in situ (CIS), sometimes referred to as Bowen disease, is a precursor to invasive cSCC. Characteristics of this lesion include nuclear atypia, frequent mitoses, cellular pleomorphism, and dyskeratosis, parakeratosis, and hyperkeratosis.
CIS is differentiated from actinic keratosis, a similar precancerous skin lesion, by the full-thickness involvement of the epidermis in CIS. Invasive cSCC is differentiated from CIS and actinic keratosis by the invasion of the basement membrane by malignant-appearing cells. With invasive cSCC, nests of atypical cells are found within the dermis, surrounded by an inflammatory infiltrate.
Conventional cSCC can be divided into the following 3 histologic grades, based the degree of nuclear atypia and keratinization found (see the images below):
Well differentiated: Characterized by more normal-appearing nuclei with abundant cytoplasm and extracellular keratin pearls
Moderately differentiated: Exhibits features intermediate between well-differentiated and poorly differentiated lesions
Poorly differentiated: Shows a high degree of nuclear atypia with frequent mitoses, a greater nuclear-cytoplasmic ratio, and less keratinization; it may be difficult to distinguish from mesenchymal tumors, melanoma, or lymphomaProgressively severe atypia. The epithelium to the left is close to normal, but the epithelium to the right shows full-thickness atypia (ie, carcinoma in situ). This image illustrates carcinogenesis, the process whereby cells exposed to a carcinogen become cancerous over time.Squamous cell carcinoma. The lesion closely approximates the specimen in the previous image. Field cancerization is illustrated; that is, if >1 cell is exposed to a carcinogen, >1 cell becomes cancerous. Note the marked inflammatory-cell response. Should limited biopsy reveal only severe atypia with a severe inflammatory response, the lesion should be investigated further, because a cancer is likely nearby.
Other histologic variants include acantholytic (adenoid) SCC, which is characterized by a pseudoglandular appearance, and spindle cell SCC, which has atypical, spindle-shaped cells. Both of these variants exhibit a more aggressive clinical course.
Exposure to cancer-promoting stressors and the response of the body to those exposures (host response) promote the development of cSCC. Well-known risk factors include the following:
UVR exposure
Exposure to ionizing radiation or chemical carcinogens
Human papillomavirus (HPV) infection
Chronic UVR exposure, such as through tanning beds, medical UV treatments, or cumulative lifetime sun exposure, is the most important risk factor for the development of cSCC. UVR is a known mutagen capable of inducing DNA damage that can lead to keratinocyte transformation. UVR has also been shown to alter the cutaneous immune response, leaving the skin susceptible to tumor formation.[2]
A number of surrogate indices of chronic UVR exposure from the sun are well known. Specifically, epidemiologic evidence suggests that geographic proximity to the equator, a history of precancerous lesions or prior skin cancers, older age, and male sex predispose an individual to the development of cSCC.
Immunosuppression is also increasingly recognized as a risk factor for the development of skin cancer; this is true of iatrogenic and noniatrogenic immunosuppression (eg, in organ transplant recipients and persons with the human immunodeficiency virus (HIV), respectively). Regardless of the reason for immunosuppression, cSCC that arises in the setting of immunosuppression exhibits a more aggressive course, with a higher rate of local recurrence, metastasis, and death.
Host responses that influence cSCC development include chronic inflammation, genetic predisposition to DNA damage, and, in particular, susceptibility to UVR damage. Well-known markers for UVR vulnerability include the following:
Fair skin (or a history of repeated sunburns)
Hazel or blue eyes
Blonde or red hair
The genetic influences that contribute to the development of cSCC from UVR are still poorly described. Only one such abnormality, a rare genetic defect that affects the repair mechanism for UVR-induced DNA damage, resulting in xeroderma pigmentosum, has been causally linked to UVR-induced cSCC. Xeroderma pigmentosum is characterized by severe sensitivity to UVR and premature development of cSCC.
A study by Schwaederle et al using next-generation sequencing indicated that seven genes (TP53, PIK3CA, CCND1, CDKN2A, SOX2, NOTCH 1, FBXW7) are altered more frequently in various types of SCC (including cSCC) than in non-SCC, while an eighth gene, KRAS, is altered less frequently in SCC.[3]
Infections that increase the risk for cSCC include the following:
Acne conglobate
Hidradenitis suppurativa
Dissecting cellulitis of the scalp
Lupus vulgaris
Chronic deep fungal infection
Dermatoses that influence cSCC development include the following:
Xeroderma pigmentosum
Dystrophic epidermolysis bullosa
Epidermodysplasia verruciformis
Dyskeratosis congenital
Porokeratosis (Mibelli type, disseminated superficial actinic type, linear type)
Nevus sebaceous
KID (keratitis, ichthyosis, deafness) syndrome
A cSCC may arise at a site of chronic inflammation, such as the following:
Marjolin ulcer
Burn scar or thermal injury
Venous ulcer
Discoid lupus erythematosus [4]
Erosive oral lichen planus
Lichen sclerosis et atrophicus
Mutilating keratoderma
Necrobiotic lipoidica
A study by Mohan et al indicated that treatment of basal cell carcinoma with the smoothened inhibitor vismodegib increases the risk for the subsequent development of cSCC. The study, which included 180 patients, found no significant rise in other cancers.[5]
Some of the above risk factors are discussed in more detail below. These etiologic agents, as determined on the basis of demographic and statistical data, are of limited predictive value in any given individual.
UVR exposure
In most cases, the primary risk factor for cSCC is cumulative lifetime sun exposure; that is, cSCC can develop even if the associated sun exposure occurred decades before.[6] The frequency of SCC is increased at lower latitudes, correlating with an increased intensity of ambient light.
The component of sunlight believed to be most important in cutaneous carcinogenesis is UVB (290-320 nm), which is an initiator and a promoter of carcinogenesis. In animal models, UV-induced photocarcinogenesis appears to involve the UVB and UVA-2 spectral ranges.[7]
UV-light treatments used for psoriasis (and other recalcitrant dermatoses) also predispose to the development of SCC. Psoralen and UVA (PUVA) therapy is particularly phototoxic, with mutations in both TP53 and the oncogene Ha -Ras being present in a large proportion of patients with PUVA-associated cSCC.[8] In addition to being mutagenic, UVA in conjunction with UVB is a potent suppressor of the cutaneous immune system, which likely contributes to its role in cutaneous carcinogenesis.
Fair complexion
Persons with a fair complexion; hazel, blue, or gray eyes; and light-colored hair (blond or red), as well as those who burn easily when exposed to the sun, are at higher risk for cSCC than are persons with other physical characteristics. Individuals with Fitzpatrick skin types I and II account for most of the patients who develop SCC.
Patients with oculocutaneous albinism are also at risk; SCCs account for the most common type of cutaneous malignancy in this group. Such individuals lack natural protection from UV-induced carcinogenesis, owing to reduced levels of the photoprotective pigment, melanin.[9]
DNA repair failure
Healthy human skin is constantly repairing UV-induced damage through DNA repair mechanisms. Patients with xeroderma pigmentosum have a deficiency in an enzyme essential for normal DNA repair and are thus prone to the development of innumerable SCCs and, less commonly, other cutaneous tumors.[10]
The specific mechanisms by which immunosuppression leads to SCC development are poorly understood, but diminished immunosurveillance is thought to be critical. CD8+ T cells specific for the tumor suppressor gene TP53 have been observed in patients with SCC, suggesting that a functional immune system may target keratinocytes expressing mutated TP53.[11] Suppression of the immune system would presumably abrogate this response, possibly facilitating the development of SCC.
Iatrogenic immunosuppression
For organ transplant recipients on long-term immunosuppressive treatment, skin cancers account for 90% of all diagnosed malignancies.[12] In this group of patients, cSCC is more common than other keratinocyte-derived neoplasms, including BCC.
The use of immunosuppressive medications to prevent rejection in organ transplant recipients is associated with a 65- to 250-fold increased risk of developing SCC compared with the general population.[13] Additionally, organ transplant recipients have a high risk of developing further SCCs, with 66% developing a second SCC within 5 years of their first SCC diagnosis.[14]
The degree of risk correlates with the intensity of immunosuppression (ie, number and/or dosage of medications) typically required to prevent rejection in this patient population. For example, heart transplant recipients have 3 times the risk of SCC compared with kidney transplant recipients.
However, while the proportion of recipients developing new tumors is greater with heart transplants than with kidney transplants, the mean number of tumors per patient is higher in kidney transplant recipients. This may be due to a longer duration of immunosuppression in kidney transplant patients, who tend to be younger than patients who undergo heart transplantation.[14]
The primary risk factor in organ transplant patients is cumulative lifetime UV exposure in combination with having Fitzpatrick skin type I or II. The risk of SCC also increases with the number of years post-transplantation, presumably because of the cumulative effects of prolonged immunosuppressive therapy.
Not only is SCC a more frequent occurrence in organ transplant recipients, the tumors can be very aggressive clinically. In a study of cardiothoracic transplant recipients (heart or heart-lung transplants), 4% of patients developed aggressive cSCC within 10 years of transplantation.[15] The majority (15 of 18) of the lesions were poorly differentiated, and two thirds of the patients with aggressive lesions had distant-organ metastases or died of their disease.
Pretransplantation end-organ disease may also impact the development of post-transplant SCC. For example, among renal transplant recipients, the highest prevalence of skin cancer was observed in patients with polycystic kidney disease, whereas the lowest incidence was seen in those with diabetic nephropathy. Similarly, cholestatic liver disease was associated with a greater post-transplantation risk of skin cancer compared with other causes of liver failure.
Noniatrogenic immunosuppression
Patients with HIV-associated immunosuppression have a more modestly elevated risk of developing a nonmelanoma skin cancer (3-5 times that of the general population). However, they do not have the altered SCC-to-BCC ratio typical of transplant recipients.[16]
Defects in cell-mediated immunity related to lymphoproliferative disorders (eg, chronic lymphocytic leukemia) predispose to the development of aggressive SCC.
Chronic inflammation or irritation
The Marjolin ulcer variant of SCC may develop in patients with a chronic scarring condition such as dystrophic epidermolysis bullosa. In fact, the leading cause of death in patients with dystrophic epidermolysis bullosa is metastatic cSCC,[17] with an 80% mortality rate within 5 years of diagnosis of the carcinoma[18] and with two thirds of patients dying from metastatic disease.[19]
Although the term Marjolin ulcer most frequently refers to an SCC that arises from chronically scarred or inflamed skin, malignant transformation to a BCC, melanoma, or sarcoma may also occur.[20]
In recent years, evidence suggests that patients with junctional epidermolysis bullosa may also be at increased risk for developing SCC.[21] The underlying pathogenesis of such lesions is not understood, but mutations in the TP53 and P16 tumor suppressor genes have been described in dystrophic epidermolysis bullosa–associated SCC.[22]
Skin cancers are the most frequently diagnosed cancers in the United States. Determining the number of cSCCs is difficult, however, because reporting of these cases to cancer registries is not required. One report estimated that in 2006, 3.5 million cases of nonmelanoma skin cancers (ie, BCCs and SCCs) were diagnosed. In comparison, the American Cancer Society estimated that almost 1.7 million cases of most other cancers would be diagnosed in 2013.[23]
Of nonmelanoma skin cancers, approximately 80% are basal cell carcinoma (BCC) and 20% are squamous cell carcinoma (SCC). Thus, cSCC is the second most common skin cancer and one of the most common cancers overall in the United States. Eyelid SCC, while not nearly as common as BCC of the eyelids, is the second or third most common eyelid malignancy, accounting for approximately 5% of all eyelid neoplasms.[24]
Rising incidence
Despite increased knowledge and public education regarding the causes of skin cancer and modes of prevention, the incidence of cSCC continues to rise worldwide. In Rochester, Minnesota, the annual age-adjusted incidence rates for SCC per 100,000 women rose from 47 cases from 1984-1986 to 100 cases from 1990-1992; the corresponding rates for men increased from 126 cases to 191 cases per 100,000 population.[25]
This increasing incidence is likely multifactorial; speculated causes include an aging population, improved detection, increased use of tanning beds, and environmental factors, such as depletion of the ozone layer.
Additionally, the number of patients on immunosuppressive therapy, used in solid organ transplantation and various rheumatologic and dermatologic conditions, is increasing. As noted previously, solid organ transplant recipients have a markedly elevated risk of SCC formation. Metastasis may also be more common in this group.[26]
Geography-related demographics
The incidence of cSCC varies geographically, from 0.03-3.5 cases per 100,000 people per year. Patients who live close to the equator tend to present at a younger age than do patients who live more distant from it.
The highest incidence of cSCC occurs in Australia, where nonmelanoma skin cancer incidences as high as 1.17 per 100, a rate 5 times greater than all other cancers combined, have been reported.[27] The high incidence is likely due to the large numbers of light-skinned people in this region who have had extensive sun exposure.[28]
Race-related demographics
SCC is the second leading cause of skin cancer in white individuals. Persons of Irish or Scottish ancestry have the highest prevalence in the United States. SCC is relatively rare in people of African or Asian descent, although it is the most common form of skin cancer in these groups. SCC in black persons carries a higher mortality rate, perhaps due to delayed diagnosis, because tumors are more likely to occur in sun-protected areas, including the scalp and sites of previous injury and scarring.[29]
Sex- and age-related demographics
SCC occurs in men 2-3 times more frequently than it does in women, most likely as a result of higher cumulative lifetime UV exposure in men. This increased exposure may be due to greater participation by men in occupations that entail more significant exposure to sunlight or to other occupational hazards, such as soot, oils, or tars.
The typical age at presentation for SCC is approximately 70 years. This varies widely, however, and in certain high-risk groups (eg, organ transplant recipients, patients with epidermolysis bullosa), SCC often manifests at a much younger age. In addition, a population-based study from Olmsted County, Minnesota of patients younger than 40 years with nonmelanoma skin cancer diagnosed between 1976 and 2003 demonstrated a significant increase in the incidence of SCC over the study period.[30]
Although cSCC is not often fatal, it can cause significant morbidity. Most cSCCs are located in the head and neck region, where surgery for advanced-stage disease can be disfiguring.
Furthermore, the cost of treatment has been shown to pose a significant public health burden. In a study of the Medicare population, the treatment of nonmelanoma skin cancers ranked fifth among the most expensive cancers to treat.[31]
Like many cancers, cSCC is classified according to the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) "tumor, node, metastasis" (TNM) staging system.[32] This anatomy-based staging system is designed to stratify patients into general prognostic cohorts based on the size and extent of disease (see Workup).
Although TNM staging is useful for estimating the outcome for a group of patients with cSCC who have similar tumor characteristics, it cannot estimate the risk for an individual patient. Current methods for estimating the outcome of a patient with cSCC depend heavily on the experience of the treating physician and can vary significantly between surgeons.
Despite the inherent limitations of TNM staging, the outcomes of patients with cSCC follow a predictable pattern. Most patients present with early stage tumors, and most of these patients fare well (overall 5-yr survival rate >90%) when the tumors are adequately treated. Various mortality rates have been reported, with some rates as high as 4-8%. By adhering to a policy of complete excision of all lesions, the recurrence rate should be 10% or less.
The outcome of patients with advanced-stage cSCC is considerably worse. For patients with lymph node metastases, the 5-year survival is even lower, estimated at 25-45%. Most large series in the literature have reported the risk of nodal or distant metastasis for primary tumors to be 2-6%.
High-risk SCC
A subset of SCCs carries an elevated risk of local recurrence, nodal or distant metastasis (usually to the lungs), and death. Tumors in this subset are termed high-risk SCCs. However, prognostic models do not exist for high-risk SCC. Because many of the risk factors discussed below occur concurrently in single tumors (intrinsic risk factors) and patients (extrinsic risk factors), determining which risk factors have the greatest prognostic significance is difficult.
In the absence of prognostic models that take the presence of multiple risk factors into account, estimating risk for individual patients is based on very limited data and gestalt. Due to the lack of data, evidence-based decision making is often not possible. Consequently, current management of high-risk SCC varies widely.[33]
In one case series, the 3-year disease-specific survival rate for SCC was estimated to be 85%. Survival rates approached 100% for lesions with no high-risk factors, but the disease-specific death rate was 30% for patients with at least 1 risk factor.[34] These estimates may not be reflective of the risk for SCC cases in general, possibly overestimating it, but the data highlight that a subset of SCC patients do poorly.
When SCC does metastasize, metastasis usually occurs within 5 years after the time of diagnosis and involves the primary (ie, first-echelon) draining lymph nodes. Once nodal metastasis of cSCC has occurred, the overall 5-year survival rate is low.
Patients with a compromised immune system, those with metastasis to multiple lymph nodes, and those with cervical lymph nodes larger than 3 cm in diameter have an extremely poor prognosis. Nevertheless, data from one study showed that the combined use of surgery and adjuvant radiotherapy for patients with nodal metastasis increased the 5-year disease-specific survival rate to 73%.[35]
Metastasis to distant organs (eg, lung metastasis) remains incurable. Thus, close surveillance and early detection of nodal metastasis can be life-saving and is of paramount importance.
SCC can be characterized as high-risk by virtue of tumor-related factors (intrinsic factors), patient-related factors (extrinsic factors), or a combination of both.
Intrinsic factors in high-risk SCC
Tumor-related factors in aggressive SCC include the following[36, 34] :
Tumor location (ie, lips, ears, anogenital region, within a scar or chronic wound)
Tumor size greater than 2 cm (or 1.5 cm on ear or lip)
Invasion to subcutaneous fat (or deeper)
Poorly differentiated tumor cells
Recurrent tumor
Perineural involvement (except, perhaps, for tumors with small-caliber nerve invasion and no other risk factors [37] )
Detailed information on tumor-related factors such as location, diameter, depth, cellular differentiation, recurrence, and perineural invasion are reviewed below.
Foremost among the factors influencing metastatic risk are the size and location of the tumor and, to a lesser extent, the growth rate. Rapidly growing lesions on the eyelid or ear metastasize in up to one third of cases. Unlike BCC of the eyelid, SCC of the eyelid can be an aggressive tumor that has potential to invade the orbit, metastasize to lymph nodes and distant sites, and cause death.[38, 39, 40, 41, 42]
Thick cSCCs (>4-5 mm) located near a parotid gland pose a high risk.[43] Rates of metastasis are particularly high for the ear (11%) and lip (13.7%), and the 5-year survival rate after metastasis from these primary sites ranges from 25% to 40% (see the image below).[36] Other cutaneous sites, as follow, are also associated with a higher risk of metastasis:
Hands (dorsal surface)
In one series, primary SCCs on the trunk and limbs were associated with a metastatic rate of 4.9%, but the study may have been biased toward larger lesions.
SCCs that arise in injured or chronically diseased skin are associated with a risk of metastasis that approaches 40%. Numerous studies have demonstrated that the Marjolin ulcer subtype of SCC behaves aggressively, with metastasis rates of up to 35%[44] ; older studies found a mortality rate of 33%.[45] Marjolin ulcer most frequently refers to an SCC that arises from chronically scarred or inflamed skin; however, malignant transformation to a BCC, melanoma, or sarcoma may also occur.[20] The poor prognosis is likely related to delayed diagnosis.
Diameter and thickness
Lesions of invasive SCC measuring smaller than 2 cm in diameter have been associated with a 9.1% rate of metastasis, whereas those larger than 2 cm in diameter have a metastatic rate of up to 30.3%. A prospective study reported a 3-year, disease-specific survival rate of 67% for lesions larger than 4 cm, compared with 93% for tumors smaller than 4 cm.[34]
A 2008 prospective cohort study found a rate of metastasis of 4% for tumors with a thickness of 2-6 mm.[46] For tumors thicker than 6 mm, the risk increased to 16%.
With increasing depth of invasion of the primary SCC tumor, the risk of local recurrence and nodal metastasis increases and the rate of survival decreases. Lesions with a depth of less than 2 mm rarely metastasize; those with a depth of invasion of 2-4 mm have a historical recurrence rate of 5.3% and a metastasis rate of 6.7%. The association of tumor depth with survival rate has been reported as follows:
Less than 2 mm: 95% survival rate
From 2-9 mm: 80% survival rate
Larger than 9 mm: 65% survival rate
Cellular differentiation
More poorly differentiated tumors have a worse prognosis in SCC, with reported recurrence rates of 33-54%.[36] The actual value of histologic grading alone, however, is less clear, because poorly differentiated tumors that metastasize or recur usually have additional primary risk factors (eg, large diameter, deep invasion). Nonetheless, poorly differentiated lesions are generally considered to behave more aggressively.
Tumor recurrence
Recurrence risk is increased with high-risk tumors; lesions larger than 2 cm recur at a rate of 15.7% after excision. Poorly differentiated lesions recur at a rate of 25% after excision, as opposed to well-differentiated lesions, which recur at a rate of 11.8%.
Local recurrence rates following extirpation of a recurrent SCC range from 10% to 23%. Reported rates of metastasis are as high as 25-45%, but these figures may overestimate the risk in recurrences that are caught early.
Perineural invasion
Perineural invasion has been estimated to occur in up to 7% of persons with cutaneous SCC. The prognosis in such cases is worse, with historical rates of metastasis reported to be as high as 47%. Much lower rates of metastasis (8%) have been reported using Mohs micrographic surgery.[36] The degree of nerve involvement likely has a large impact on prognosis.
Involvement of major (ie, named) nerve branches carries a very high risk of recurrence, metastasis, and death. The risks are substantially decreased when tumor-free margins are painstakingly obtained by removal of the involved nerve. However, the prognosis is still guarded.
One study showed the diameter of involved nerves to significantly impact outcomes in cSCC. No disease-specific deaths occurred in patients with involvement of nerves that were less than 0.1 mm in diameter, compared with 32% of patients dying from cSCC when nerves of 0.1 mm or larger were involved.[47]
Extrinsic factors in high-risk SCC
General patient-related factors are as follows (see Etiology):
Organ transplantation
Hematologic malignancy (eg, chronic lymphocytic leukemia)
Long-term immunosuppressive therapy
HIV infection or acquired immunodeficiency syndrome (AIDS)
A study by Manyam et al that included 38 immunocompetent individuals with cSCC and 21 immunosuppressed patients with the disease found immunosuppression to be more frequently associated with poorly differentiated tumors, lymphovascular invasion, and extracapsular extension.[48]
SCC arising in patients with chronic lymphocytic leukemia or small lymphocytic lymphoma also carries a worse prognosis. For example, one study found that in patients with chronic lymphocytic leukemia, the SCC recurrence rate in those treated with Mohs micrographic surgery was 7-fold higher at 5 years than it was in patients without the leukemia.[49]
Another study found that in patients with chronic lymphocytic leukemia or small lymphocytic lymphoma, SCCs are often multiple (67%) and high grade (56%) and have a high risk of recurrence and metastasis (25%), as well as death from disease (41%).[50]
The risk of aggressive SCC in patients with bullous disease is markedly elevated. The risk of death is particularly high in those with epidermolysis bullosa, with an 80% mortality rate 5 years after diagnosis of the first primary SCC.
Arsenic exposure[51] and PUVA light exposure are additional risk factors associated with aggressive disease.
Patient Education
Patients should be counseled to avoid excessive UV radiation by limiting outdoor activity to early morning and late afternoon, using protective clothing, and wearing a broad-brimmed hat to shade the head and neck. Daily application of a broad-spectrum sunscreen with a sun protection factor (SPF) of at least 15 should also be encouraged. The use of artificial tanning devices should be strongly discouraged, because this has been associated with a 2.5-fold increase in the risk of developing SCC.
Lesions can recur even years after excision, so patients should have routine examinations. In addition, patients should be counseled regarding treatment of areas of chronic skin inflammation or trauma to prevent the future development of SCC at those sites.
Educating people who live in tropical areas and in regions with a high degree of solar exposure is particularly important.
These measures are also critically important for patients who are immunosuppressed, and they should be an integral part of the educational program for patients who have recently undergone organ transplantation.
For patient education information, see the Cancer Center, as well as Skin Cancer and Skin Biopsy.
For information on cancer risk, prevention, and screening in organ transplant patients, see the AT-RISC Alliance and the International Transplant Skin Cancer Collaborative. For more information about Mohs micrographic surgery, see the American College of Mohs Surgery.
Brash DE. Roles of the transcription factor p53 in keratinocyte carcinomas. Br J Dermatol. 2006 May. 154 Suppl 1:8-10. [Medline].
Hanneman KK, Cooper KD, Baron ED. Ultraviolet immunosuppression: mechanisms and consequences. Dermatol Clin. 2006 Jan. 24(1):19-25. [Medline].
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|Primary Tumor
|Regional Lymph Nodes
|Distant Metastasis
|Stage 0
|Stage I
|Stage II
|Stage III
|Stage IV
|Any T
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text:
You can't say they didn't try, but the news is sad nonetheless. ESA announced the mission for the Philae lander – the first spacecraft to ever land on a comet — is officially over. The system that enables communications between the Rosetta spacecraft and Philae – which sitting in a shaded region on Comet 67P/Churyumov-Gerasimenko […]
Astronomers have theorized there could be an intermediate stage between neutron stars and black holes called quark stars. Are they out there?
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UV-curable optically clear hard coatings are engineered for superior scratch, abrasion, and chemical resistance providing increased protection that results in extended film life. These coatings offer excellent transparency and low haze characteristics, maintaining optical clarity over time for better performance and aesthetics. Dymax optically clear coatings are used in applications requiring thin protective coatings on various film substrates such as TAC, PET, PC, and PMMA. These optical coatings are formulated to cure with Dymax's broad-spectrum UV light curing equipment.
Optically clear hard coatings for plastics are typically used in the manufacture of electronic touch-panels, polarized sunglasses, safety glasses and goggles, and LCD polarized displays.
|Optically Clear Hard Coatings Selector Guide
Benefits of using UV-curable optically clear hard coatings include:
- Superior scratch, abrasion, and chemical resistance. These coatings have an enhanced ability to withstand damage from sharp objects and the ability to withstand wear from the rubbing of an object.
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©2002 Gary L. Thomas; (P)2009 Zondervan
"A nuanced approach to worship"
Gary Thomas gained some acclaim with his biblically solid exploration of marriage in Sacred Marriage. Our church recommended that book, so when I heard about Sacred Pathways from another respected source, I decided to give it a "read." His thesis is that, while scripture study and prayer should be a daily part of our lives, we all have our own innate needs and inclinations when it comes to worshipping God that may be satisfied in a variety of ways. Some of us have our hearts lifted to Him by being in nature, for instance, while others feel most connected to him via ritual or the senses. In all, he lists 9 pathways: the naturalist, sensate, traditionalist, ascetic, activist, caregiver, enthusiast, contemplative and intellectual. I immediately recognized my own primary path, but he encourages you to read the other chapters to identify secondary pathways. Thomas also identifies risk areas for each pathway. For instance, the naturalist may be at risk for worshipping the creation rather than the Creator.
All in all, a thought-provoking and interesting read. Having read it, I have a better understanding of why the question of church worship style can be so intractable. I gave it only 4 stars because Thomas reads the book himself, and while his voice is pleasant, I suspect a professional reader might have been better.
A brand new wife, two kitten children, and a whole lot of thoughts.
Gary Thomas is a very enthusiastic author and reader. He's very easy to listen to.
The book itself was so helpful. Not only did it help me identify my own "spiritual temperaments", but it also encouraged me to pursue other ways of connecting with God. This book was great for someone seeking to deepen their relationship with God.
I think one could mistakenly interpret this book as attempting to limit experience with God to one or two ways, but the author encourages readers to relate with Him in ways that might be foreign. He explains that Jesus had ALL of the spiritual temperaments - to really be like Christ, we should challenge ourselves to relate with God in new ways.
"Spiritual "pathway" test"
Great book that encourages Christians to relate to God according to how and who they are as individuals.
Each chapter has a "test" to help you discover which of the 9 spiritual pathways are strong and which are weak.
Kind of like those "Spiritual Gifts" Assessments.
Nice that the author read it.
I think this book will be around for decades.
"Extraordinarily Helpful, unhindered by tangents"
Gary Thomas' profound insight into differing "spiritual temperaments" can give very clear, systematic direction to anyone's pursuit of God. Sacred Pathways is presented in a structured format, making it helpful for future reference (as one will always have their favorite chapters). This book is not to be taken as law, but when one sees the heart in it, the profundity becomes clear.
cons: Thomas, the author/narrator, is a preacher. And, as a preacher, he tends to go on tangents. Some are necessary. Some are helpful. Luckily, they do not subtract from the greater work as a whole.
"Eye-opening book about spiritual formation"
This is a wonderful book with a very unique take about how different Christians are nurtured /draw close to God. I found it highly interesting and well done (both the book and the audio). I highly recommend it!
Simple approach with excellent descriptions of each pathway.
Yes. Sacred Marriage is another of his works that is excellent. I highly recommend it as well. Both are stellar works.
"Good read"
This was helpful to read and see how people connect with God differently. The best pet to me is that this book continually points out that we cannot live apart from scripture or being apart of a local church.
"Great Book. I think every Christian should read it"
Great Book. I think every Christian should read this. it will help every believer understand others and help them understand why they may not be understood.
"Comprehensive temperaments of relating to God"
I could relate to many of the temperaments that he was referring to. I really enjoyed how this highlights the diversity that is in people. Rather than man everyone into a carbon copy of me, I would nurture them to follow the pathway which helps them relate to Father God in their unique way.
I liked how he gave some of the pitfalls of each temperament. I could identify with these and see how they may negatively affected many of the people I have known over the years.
I love Gary's books. In this one, I just enjoyed the depth of research and how he did not demean any one way of relating to God. Rather, he provided such an in depth representation of the goodness of each temperament.
I had more of an aha! feeling. I am not messed up after all. You know how you can be different from those around and assume you are over doing things a little.
Good Book
"A Great Spiritual Growth Book for Christians"
I enjoyed listening to this book. It helped me understand myself better through the questions asked at the end of the chapters.
"What a delight!"
What a breath of fresh air this book is to me! It opened my eyes and gave me insight into my soul's design and the divine designs of my loved ones' souls. We are free to be who we are. We are designed specifically to love God in our own way. I have been inspired by the suggestions in this book to follow many of the authors that are my same spiritual temperament and have thoroughly enjoyed finding other writers who speak my soul's language! This is one of my very favorite books!
"Very helpful book"
A great overview of different ways of experiencing God. We used this book as a theme for a very popular sermon series at Church. Recommend.
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Recently added to fr.urbandictionary.com
jan. 11
Bringing personal work to the office: paying bills, playing games and reading online newspapers on company time (OCT).
de C.J.Matrix 9 septembre 2003
jan. 10
When it's time to go,you yell "Church on the move"-- everyone you're with knows to leave the location.
Snoop Dogg-- when you're at the club and its time to bounce you yell "Church on the move" and everyone knows its time to get up outta there!
de sarah Mc 16 décembre 2007
jan. 9
To turn off any device that people can reach you with (cell phone, two-way, computer, home phone, morse code, etc.) in order to avoid someone.
Megan is blacking out Brent because he was acting like a dick. She don't play that!
de Magno Jimenez 17 décembre 2007
jan. 8
An abbreviation for "seriously".
Dinosaurs are srsly scene.
You should srsly get your act together.
You should srsly get your act together.
de Dick_Cheney 6 octobre 2006
jan. 7
Nekkid is not simply being without clothing--It means you are gettin' nekkid for mischevious purposes. Naked is natural; nekkid is naughty.
"Come over quick, Shirley! I'm getting nekkid!"
de JamiSpoon 24 mai 2003
jan. 6
"Can't Remember Shit". Popularized by the movie Glory Daze.
I look back just a month ago and CRS.
de Bungalow Bill 1 décembre 2001
jan. 5
In Scotland, pregnant. See also up the duff.
She's up the spout again.
de Keith the Incredible Sockpuppet 18 novembre 2004


text:
Nobu's Vegetarian Cookbook
Nobu's Vegetarian Cookbook
PIE Books, Hardcover, 9784894449053, 176pp.
Publication Date: February 7, 2012
Throughout the book, the emphasis is on fine and healthy Japanese dining. Nobu uses a wide range of cooking techniques from marinating and pickling to steaming, roasting, boiling, frying, grating, etc. to bring out the full flavors and textures of the vegetables. He also introduces tofu and yuba, both traditional Japanese ingredients made from soybeans, and offers ten recipes for vegetable sweets and fifteen for cocktails.
Nobu Matsuhisa, born in Japan, was classically trained in a sushi restaurant in Tokyo before he headed to Peru. He then went on to successive ventures in Argentina, Alaska, and L.A., where he opened Matsuhisa in 1987. Seven years later, Robert De Niro persuaded him to open Nobu New York City. Since then, he has opened 25 more restaurants around the world. In recognition of his influence on cooking worldwide, Time magazine chose him as one of Asia's Heroes in 2005. He has appeared as a guest on numerous television shows ,including "The Martha Stewart Show," "The Tonight Show with Jay Leno," "The Today Show," and others. Masashi Kuma is a James Beard Award–nominated photographer.


text:
Table of Contents
- Abdominal pain facts
- What is abdominal pain?
- What causes abdominal pain?
- When should I call my doctor about abdominal pain?
- How is the cause of abdominal pain diagnosed?
- Signs and symptoms associated with abdominal pain
- Signs and symptoms associated with abdominal pain (Part 2)
- Signs and symptoms associated with abdominal pain (Part 3)
- Physical examination to diagnose abdominal pain
- Exams and tests to diagnose abdominal pain
- Exams and tests to diagnose abdominal pain (Part 2)
- Exams and tests to diagnose abdominal pain (Part 3)
- IBS (irritable bowel syndrome) and diagnosing abdominal pain
- Why can diagnosis of the cause of abdominal pain be difficult?
- What are home remedies for certain causes of abdominal pain?
- What medications can be used to treat certain causes of abdominal pain?
- What lifestyle choices can I make to prevent abdominal pain?
Quick GuideWhat's Causing Your Abdominal Pain?
Signs and symptoms associated with abdominal pain (Part 2)
- The pattern of the pain.
- Obstruction of the intestine initially causes waves of crampy abdominal pain due to contractions of the intestinal muscles and distention of the intestine.
- True cramp-like pain suggests vigorous contractions of the intestines.
- Obstruction of the bile ducts by gallstones typically causes steady (constant) upper abdominal pain that lasts between 30 minutes and several hours.
- Acute pancreatitis typically causes severe, unrelenting, steady pain in the upper abdomen and upper back.
- The pain of acute appendicitis initially may start near the umbilicus, but as the inflammation progresses, the pain moves to the right lower abdomen.
- The character of pain may change over time. For example, obstruction of the bile ducts sometimes progresses to inflammation of the gallbladder with or without infection (acute cholecystitis). When this happens, the characteristics of the pain change to those of inflammatory pain. (See below.)
- The duration of the pain.
Reviewed on 5/1/2015ReferencesMedically reviewed by Avrom Simon, MD; Board Certified Preventative Medicine with Subspecialty in Occupational Medicine
- The pain of IBS typically waxes and wanes over months or years and may last for years or decades.
- Biliary colic lasts no more than several hours.
- The pain of pancreatitis lasts one or more days.
- The pain of acid-related diseases - gastroesophageal reflux disease (GERD) or duodenal ulcers - typically show periodicity, that is, a period of weeks or months during which the pain is worse followed by periods of weeks or months during which the pain is better.
- Functional pain may show this same pattern of periodicity.
Fauci, Anthony S. et al. Harrison's Principles of Internal Medicine. 17th ed. United States: McGraw-Hill Professional, 2008.
Time.com. Why Belly Pain Is Such a Headache for ER Doctors.
UpToDate.com. Differential diagnosis of abdominal pain in adults.
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James Tozzi
|This article is a stub. You can help by expanding it.
This article is part of the Tobacco portal on Sourcewatch funded from 2006 - 2009 by the American Legacy Foundation.
Jim Tozzi and his partner, and ex Republican politician/bureaucrat, Thorne G Auchter ran one of the more successful lobbying operations in Washington. They functioned behind a pair of companies, known as Federal Focus and Multinational Business Services, together with two so-called think-tanks, the Institute for Regulatory Policy and the Center for Regulatory Effectiveness. The main client of these partners was the tobacco industry, in particular Philip Morris.
One of the more successful of their ploys, was to use the non-profit Federal Focus as a service company to support other lobbyists and public relations operations in exchange for access to their favourite politicians. If the lobbyist was mounting a major social function with inviting Congressmen, Senators, or political party leaders or influence peddlers, Federal Focus would provide free entertainment (inevitably a trad. jazz band). Federal Focus made a tax-loss, while the quid pro quo was that Tozzi and Auchter were able to use these function to lobby on behalf of their own clients.
James J. Tozzi was born in ±1938 and earned a PhD in Economics and Business Administration from the University of Florida. After spending some time in New Orleans he realized he would never make his fortune playing jazz (trumpet) and moved to Washington DC. In 1964 he joined the Office of the Secretary of the Army, Department of Defense, working on budget and strategic response issues.
In 1972 he transfered to the Office of Management and Budget (OMB), and quickly he rose to the position of Deputy Administrator during the administration of President Ronald Reagan. After restructuring or the OMB, Tozzi came to direct the OMB's Office of Information and Regulatory Affairs where he became the gatekeeper for virtually all proposed regulations dealing with public health and safety. He was still Deputy Administrator of OMB when he resigned in 1983 at age 45 to begin working as a lobbyist.
According to the Washington Post, Tozzi was effectively in charge of OMB in the 1980s when evidence emerged that giving aspirin to children with flu symptoms increased the risk of Reye's syndrome, a potentially fatal complication. A federal health agency recommended legislation to enforce warnings on aspirin containers, but Tozzi took the position that the evidence was not adequate. Almost 200 children died of Reye's disease in the following years before activists could persuade Congress to enforce labelling. {Note: the syndrome is now extremely rare.] [1](See Tozzi response below)
In these early years of the 1980s (1981-85), his future partner, Thorne G Auchter, was the Assistant Secretary for Labor at the Occupational Safety & Health Administration. The OSHA also regulated smoking in workplaces, along with threats arising from other workplace pollutants. After leaving the OSHA he and Auchter established Federal Focus, which received funding from Philip Morris.[1]
In 1986 Thorne Auchter and Tozzi founded Federal Focus, as a 501(c)(3)}non-profit organization. At the end of 1991 Thorne Auchter founded the Institute for Regulatory Policy (IRP) as a subsidiary of Federal Focus, and James Tozzi changed his own focus to Multinational Business Services (MBS) which they founded around 1992. [2] The "EPA Watch" of May 15, 1992 mentioned Jim Tozzi as the "director of the Washington-based Multinational Business Services Inc. (MBS)". [3] By then, Tozzi and Auchter were fully involved in tobacco-support activities for Philip Morris.
Where are they now
1992 Tozzi has been a member of the Environmental Financial Advisory Board (EFAB) since 1992 and currently serves as chairman of the International/Energy Workgroup. The EFAB provides advice to the Administrator and Program Offices of the Environmental Protection Agency (EPA) on "how to pay" questions for environmental protection.
1996 In 1996 Jim Tozzi, James MacRea and possibly also Thorne Auchter founded the Center for Regulatory Effectiveness (CRE) [4] [5] of which Tozzi and MacRea are still a "Member of the Advisory Board". [6]
2001 Tozzi was a major behind-the-scenes architect of the Data Quality Act (DQA) which he helped to become law in 2001.
2002 Thw 990 tax form this year for the non-profit Federal Focus (the last available on GuideStar) has four people listed as managers: Jim J. Tozzi (director), Barbara Tozzi (treasurer), William Kelly (secretary), and James Tang (vice president). [7] Federal Focus still uses the same address in Washington that was also used for MBS.[8] Tozzi, who played the cornet since age 7, still seems to use the Federal Focus Jazz Band as the distinguishing feature of his lobby operations. He plays for disadvantage children.
Tozzi Responds to Reye charge
Tozzi disputes the Post Article on Reye's Syndrome (Source pgs. 305 & 309, Courting Change, a book published by the Public Citizen Litigation Group) He maintains:
The Reyes Syndrome Rule (on labelling) was withdrawn from the OMB's review by the Secretary of Health and Human Services (HHS), so the assertion that Jim Tozzi rejected the proposed Reyes Syndrome labeling is completely inaccurate. The facts are, as demonstrated in the record, as follows:
- Sept 20 1982 The Secretary of HHS sent a proposed labeling regulation to OMB.
- Nov 8 1982 The American Academy of Pediatrics announces "Labeling aspirin-containing preparations as contraindicted in the treatment of influenza or chicken pox should be delayed until more conclusive evidence of the association of aspirin administration and Reye's Syndrome is shown by further investigation."
- Nov 18 1982 The Secretary of HHS withdrew the rule from OMB review.
The record clearly demonstrates that Tozzi did not delay the implementation of the review for years.
Related SourceWatch Resources
Related Links
- Stewart Fist, "The Sound Science Coalition", 2000?
- "How Big Tobacco Defines Wireless and EMF Health Debates", Microwave News, November 2001
- "Environmental Financial Advisory Board Newsletter: March 2002", Environmental Protection Agency,
- "Jim Tozzi, Center for Regulatory Effectiveness", FederalTimes.com, November 11, 2002
- "Jim Tozzi: On Jazz And OMB", The Federal Paper, November 18, 2002
- "Steven J. Milloy: The "Junkman" Exposed", Americans for Nonsmokers' Rights, December 2003
- Chris Mooney , "Paralysis by Analysis, Jim Tozzi's regulation to end all regulation", Washington Monthly, May 2004
- Rick Weiss, "'Data Quality' Law Is Nemesis Of Regulation," Washington Post, August 16, 2004.
- Eric Bailey, "Activist Enlists Unlikely Ally in Bid to Legalize Pot," Los Angeles Times, July 18, 2005.
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Highland Tap has occupied its cozy subterranean space at the corner of North Highland and Virginia avenues for longer than most locals can remember. The scene hasn't changed much over the years. Most of the action is at the smoky bar, which still packs in prowling twentysomethings elbow-to-elbow on Friday and Saturday nights. The dining room -- with its spacious booths, dim lighting and stone walls -- has always had the feel, to me, of a stately old English pub. Though after all these years, the decor is starting to feel a bit worn-out.
As for the menu, beef takes center stage. Would you expect otherwise from a place that bills itself as a "steak cellar"? An old-fashioned French dip sandwich hit all the right notes, with its crispy baguette and shaved prime rib. If the meat was just a little on the dry side, a quick dunk in the au jus set things right. A giant stack of crunchy, cornmeal-battered onion rings were as good as I remembered from my boozy, post-college bar-hopping days.
French onion soup, on the other hand, needed help. Vidalia onions and a thick blanket of melted mozzarella made for a too-sweet concoction that cried out for something sharp like Gruyere or Emmenthal. A side dish of au gratin potatoes in an asiago cheese sauce were decadently creamy, though I wished the flavor of dried thyme wasn't so overpowering. Certain items on the menu, pork tenderloin and salmon filet in particular, seemed pricey at close to $20 apiece. But steaks did their steep price tags justice. Generous cuts were nicely seasoned and grilled to order.
There's no question that the food takes a backseat to the cocktails at Highland Tap. That's just the curse of being first and foremost a bar. But if one too many martinis have made the staircase that leads back up to street level look intimidating, it's good to know you can fortify yourself with a respectable meal before returning to the cold, cruel world.
Extra Helpings
TEMPT ME WITH TAKEOUT -- If you haven't been by Alon's Bakery on North Highland lately, drop everything and go immediately. They have just reopened a new, larger space with expanded offerings. Now, besides delectable pastries, cookies and artisan breads, Alon's is also carrying artisan cheeses and a whole case of prepared foods. On a recent visit, the fingerling potato salad and chickpea salad with feta were delicious. Alon's also offers an eclectic assortment of wines and high-quality chocolate. Though the selection is smaller, Alon's gives Whole Foods a run for its money in terms of quality and price. Also very cool is that you can place orders on the website. 1394 N. Highland Ave. 404-872-6000. www.alons.com.
TRADE-WORTHY TREATS -- The pedestrian brown-bag lunch gets a makeover Sat., Sept. 4, at Whole Foods on Ponce de Leon. To celebrate the start of a new school year, chef Sheri Davis of Dish restaurant will be doing in-store demonstrations of healthy, delicious recipes that kids will actually eat. Demos are free to the public, and will take place from noon-2 p.m. 650 Ponce de Leon Ave. 404-853-1681. www.wholefoods.com.
START YOUR WEEK OFF RIGHT -- Don't let Mondays drag you down. Stop in at Pura Vida
and play some dominoes, drink $6 mojitos and $5 Bacardi-tinis, and chill out the Latin American way. 656 N. Highland Ave. 404-870-9797. www.puravidatapas.com.
SOUTHERN COMFORT -- Wisteria celebrates its third anniversary Mon., Sept. 6, with a Southern-style barbecue prepared by chef/owner Jason Hill. Dinner will be served buffet-style and will be paired with microbrewed beers. The dinner runs from 6-10 p.m. and reservations are recommended. The cost is $33.33 per person, plus tax and gratuity. 471 N. Highland Ave. 404-525-3363.
IT'S GREEK TO ME -- In celebration of the Greek harvest, Kyma will host a wine tasting Wed., Sept. 8, from 6-7:30 p.m. Sofia Perpera from All About Greek Wine will share her knowledge of Greek wines and select some of her favorite vintages to sample. The cost of $30 per person includes wine tasting and paired appetizers. 3085 Piedmont Road. 404-262-0702. www.buckheadrestaurants.com.
WINE WEDNESDAYS -- Head over to the Food Studio on Wed., Sept. 8, for the restaurant's monthly wine tasting. The theme is "Cabernets and Merlots: Washington vs. California." The tasting runs from 5:30-7 p.m. and costs $20 per person (hors d'oeuvres included). Come as you are -- no reservations necessary. Through November, Fifth Group Restaurants (Food Studio, South City Kitchen, La Tavola and Sala) is hosting an ongoing wine series. A Fifth Group Wine Wednesday Passport, which guests receive at the first tasting they attend, will be stamped at each event. Nine stamps earn a complimentary 10th tasting. 887 W. Marietta St., Studio K-102. 404-815-6677. www.fifthgroup.com.
Omg, glad to find this thread. I was a waiter for 12 years and have…
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Holiday Cottages In Gorteen
Please find below a selection of self catering holiday cottages to rent in Gorteen, County Sligo.
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Please find below a selection of self catering holiday cottages to rent in Gorteen, County Sligo.
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Cosy end-terrace cottage in the heart of Gorteen with woodburner. Superb traditional music heritage. Close to Knock Airport. Shop and pub 5 mins walk. (Ref. 918746)
7 nights from £223Book Now
A great country cottage located in the County Sligo countryside just outside the village of Monasteraden. Oil stove. Sligo 27 miles. Carrick on Shannon 19 miles. (Ref. 934168)
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Wonderful, semi-detached cottage situated next to the owners' home in the heart of Monasteraden, on the shores of Lough Gara. En-suite facilities. WiFi. Wii with games. Air-hockey and fussball. Garden with furniture. Ballaghaderreen 5 miles. (Ref. 913340)
7 nights from £495Book Now
Renovated farmhouse in Keash near Ballymote. Stylish and contemporary with a woodburning stove. Stunning views of Caves of Keash. Excellent touring base. Ballymote 4 miles. (Ref. 30562)
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A superb detached cottage located in tranquil surroundings in beautiful County Sligo. Three sitting rooms. Large garden. Ideal touring location. Boyle 5 miles. (Ref. 26160)
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Semi-detached cottage in Ballaghaderreen. Homely and traditional with enclosed garden. Pet-friendly. Excellent touring base for North West Ireland. Knock Airport 15 mins drive. Ballaghaderreen 10 mins walk. (Ref. 930080)
7 nights from £202Book Now
Cosy detached cottage near Ballaghadereen. Ideal for couples. Open fire. Close to Knock Airport. Excellent touring base for Roscommon, Mayo and Sligo. Ballaghaderreen 1 mile. (Ref. 921487)
7 nights from £204Book Now
Delightful 200-year old detached cottage near Charlestown, County Mayo. Traditional furnishings complemented by modern conveniences. Large garden. Peaceful. Ideal touring location. Charlestown 5 miles. (Ref. 26099)
7 nights from £215Book Now
Spacious, detached contemporary holiday home near Castlebaldwin. Ground floor en-suite bedrooms. Pellet stove. Garden with views of Lough Arrow. Castlebaldwin 1.9 miles. (Ref. 9986)
7 nights from £315Book Now
A superb first floor apartment in Boyle, County Roscommon. Open plan living space. Balcony with beautiful abbey and river views. Off road parking. Carrick-on-Shannon 9.5 miles. (Ref. 922827)
7 nights from £290Book Now


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Please don't spam this forum with your new surf camp / charter / villa / surf school. Go to SurferDream.com and list your business there for free.
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Rigley field maintenance dude looking east
Posted inFiji
RE: how good do you have to be to surf in fiji?« on: November 19 2006 12:11:00 »
Um!!!!!!!!!! You didn't really anwer the dudes question though. He asked , How good do you have to be to surf thw surf there. Okay Einstien !!!! Da!!!!!


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Jon Dwane Arnett (Jaguar Jon)
Position: HB-E
5-11, 197lb (180cm, 89kg)
Born: April 20, 1935 in Los Angeles, CA
College: USC (College Stats)
Weighted Career AV (100-95-...): 31 (3206th overall since 1960)
High School: Manual Arts (CA)
Draft: Los Angeles Rams in the 1st round (2nd overall) of the 1957 NFL Draft.
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Famous Birthdays
Country singer who had five straight #1 hit singles in the 1980s, including "Don't Close Your Eyes" and "It Aint Nothin'." He released nineteen hit singles over the course of his life.
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Second time will likely be a charm for Lowe'sCos. in its attempt to acquire Quebec's Rona Inc.
The fact both boards agreed to the C$3.2 billion ($2.3 billion) offer, along with Lowe's commitment to preserve head-office jobs and maintain supply agreements, will likely seal the deal. Political conditions in Canada's second-most populous province also favor the acquisition after helping to scupper a hostile offer in 2012.
A BCom student case competition team won the Montreal PRMIA Risk Management challenge for the second consecutive year. The roster of the McGill-Desautels team includes Simon Altman, Evan Coulter, Liam Maclure, and Valentyn Litvin. They are coached by Professor Sebastien Betermier.
The team will compete in Chicago for the International Championship early March, against 7 other finalist teams. PRMIA is the Professional Risk Managers' International Association.
Authors: Lee, M. D., Zikic, J., Noh, S.-C., Sargent, L.
Publication: Human Resource Management
Authors: Hewlin, P.F., Kim, S.S., Song, Y.H.
Publication: Journal of Occupational and Organizational Psychology
Authors: Skarlicki, D.P., van Jaarsveld, D.D., Shao, R., Song, Y.H., Wang, M.
Publication: Journal of Applied Psychology
Some of the most recognized national and international companies are opening their doors to give third and fourth year university students a first-hand glimpse of what it takes to be a leading Canadian CEO. Championed by global executive search firm, Odgers Berndtson, the CEO x 1 Day program has selected 18 students from across the country for the unique chance to shadow some of the country's most highly accomplished industry leaders for one day.
Authors: Betermier, S., Calvet, L. E. and Sodini, P.
Publication: Journal of Finance
From baseball to banking, the ability to mine data on performance, customer preferences and other trends is the new must-have for the corporate bottom line.
But still too rare, say employers, is the analyst who combines technical expertise to delve into "big data" and communication skills to explain the findings in everyday language to colleagues and senior managers.
Mr. Michael G. Klein, a doctoral student at McGill University in the Operations Management area will be presenting his research proposal:
Analytical Models for Specialist Care in Rural Areas
Michael G. Klein
Mr. Amir Akbari, a doctoral student at McGill University in the Finance area will be presenting his research proposal:
Three Essays on Empirical Asset Pricing
Amir Akbari


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Super hyped to have those guys showing up at Troll for that week. For sure those were the best days ever! Enjoy some first time ever at Troll, Yawgoon's moves by Marcus Rand and SoCal hammers from the Big Bear guys. Supper thankful for the hospitality to Austin Young, Jeffy Gabrick and everyone at Troll!
Thanks: Marcus Rand, Jake Schaible, Jared Macdaniel, Walker Murphy, Mike Gray, Hunter Murphy, Robert Toste, Melissa Evans, Jeffy Gabrick, and Austin Young.
Film/Еdit: Dimo Petkov
Super 8: Hristo Petkov
On a side note, the Stinky crew rolled through with Jeffy for a tour of The House, it'll be good to have them back, and we're beyond stoked to see the Stinky Socks X Trollhaugen collaboration.
Transworld Snowboarding keeps running with their Sunday in the Park weekly park edits out of Bear Mountain. With fresh tread moving faster than ever Adam Ruzzamenti put together a handful of racers sprinting for their best. Stay tuned for more.
Featuring: Ian Sams, Todd Kirby, Gared Schneider, Micah Hoogeveen, Brett Spurr, Mike Gray, Kyle Schafer, Johnny Miller, & Dylan Alito
Edit by: Adam Ruzzamenti "bEEF"
Filmed by: Adam Ruzzamenti "bEEF",Lee Stockwell, & Mark Thalman
When the Strange Brew van rolls through, people stop to watch; be it out of fear, wonder, or fascination. Billowing out the doors like a cloud of smoke is a winged murder who swoops through every spot. This spot is Hyland and the crew murdered it.
Boarders: Brady Lem, Jordan Daniels, Andy P., Sam Bakken, Cody Beiersdorf, Craig Cameron, Danny Kern, Tommy Gesme, Keenan Cawley, & Hunter Murphy
Edit: Brett Wulc
Film: Brett Wulc / Danny Kern
[vimeo 121438362 w=730]
The season is winding down here in Minnesota which can only mean one thing, spring boarding. Bring on the slush and BBQs. This monday minute is from a day at Trollhaugen with our Euro homies from Different Vision Productions and a couple clips from lapping Hyland. Enjoy!
Riders: Benny Milam, Justin Fronius, Jesse Augustinus, Austin Young, Oivind Fykse, Cody Beiersdorf, Drew Poganski, Zac Marben, Jake Devries, & Kyle Kennedy
Film/ Edit: Riley Erickson
Additional filming: Jake Durham
Check out this two-time X Games gold medalist Sebastien Toutant's entry for the 2015 Real Snow all-video snowboard contest. Seb Toots is an unreal slopestyle jump jock, but that doesn't stop him from throwing down in the streets. Just recently being dropped by Ride Snowboards Seb shows taht he's working harder than ever to bring the cheddar home.
Discover 60,000 ways to explore the Land of 10,000 Lakes. Whether you play in it, explore in it or relax in it, we always have the best gear on-hand and in-season.
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CINCINNATI — As much as they wanted to avoid it, the New York Giants are starting to look like the team that won the Super Bowl last season.
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Southern Style
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Fundraisers, Holidays & Special Events!
Take a Break & I'll Bake is a family owned southern style bakery. We provide quality baked goods for fundraisers, special events and restaurants.
Our goal is to create delectable, delicious fresh baked goods to meet your organization's needs. We pride ourselves on bringing a southern style taste you'll never forget.


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[twow Spoilers] Arianne II, Part 2
malek replied to Angalin's topic in The Winds of WinterFirst of all - what a gorgeous chapter. 2'nd Who is a tall, dark, handsom guy that Arianne will fall for, bringing ruin to her father's plans ?! :cool4:
[TWOW Spoilers] Miscon reading : two Winds of Winter chapters
malek replied to Hmadkour's topic in The Winds of WinterDamn ! All I really heard from that chapter was - Ser Hyle Hunt is dead :bang:
Ever since series were first anounced I hoped they will put in just that one little exchange between Tyrion and Bronn that I find best in the series. And was soooo glad when I've seen it in this episode, though Flynn could have delivered it bit better (at least while rubbing his fingers together). I've read some posts from those that haven't read the books about how Bronn is a golden hearted sellsword, and there is some on Ned Stark in him ?! Hope that this exchange oppened eyes of these.
Can't really remember ot from the books, but it seems awfully out of character for Stannis to cheat on his wife. Hmmm... One more thing. Ever since series got green light I hoped for just one thing, that little exchange between Tyrion and Bronn. In my opinion these are the best lines in series, and I'm so happy I've heard them on TV. Though Flynn could have delivered it better, certainly with a fingers rubbing gesture.
READ FIRST: Rules
malek replied to Ran's topic in A Dance with DragonsSorry, I tried to start a thread without reading this :bang: Wont happen again.
[Book Spoilers] EP108 Discussion Part 2
malek replied to Xray the Enforcer's topic in E08: The Pointy EndLoved this episode :thumbsup: Some well known lines from the book were used, and it is certainly a huge plus for it. But looking back now: Bronn commenting how he could get the Vale if he had dozen good man to command and some climbing spikes, and Tyrion promising mountain clans The Vale of Arryn. Considering they kept it in the series, perhaps Bronn wont stop at Stockworth...
The Game of Thrones TV Adaptation FAQ
malek replied to Werthead's topic in Open Discussion (SPOILERS)Eeeeeeeeer NO Bronn ?! :tantrum: :thumbsdown:
[Pre-ADwD Spoilers] "New" POV 1 - Spoilers for ADwD
malek replied to Ran's topic in Pre-ADwD ArchiveCould it be that Ramsey is taking Theon with him, because he came to some sort of an understanding with Asha ?! About him helping her take over Iron Islands, and her helping him dispose of his father, supporting each other afterwards ? . . . Me neither... :leaving:
When we are talking about betrayals, it was never said that She will be betrayed three times, but that She will know three betrayals. I'am sure that first one must be Miir Maz Dur. She betrayed Dany for blood, becoese dothraki killed her people, but Dany betrayed her too becouse of blood. She burned Her becouse She was responsible for deaths of those that She loved (Drogo, and her unborn). I dont belive for moment that Jorah was one ment to betray her for gold. It must be Ilyrio, if not him, then Dariio, but that is less probable. Last betrayal, one becouse of love might even save her. I'am quite sure that Jorah earned his royal pardon, and it is most definite that He will face Dany again. This time they will be on oposite sides, and He will save Her (probably sacrifising his life in proces) becouse He loves her. This is My little pet theory


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Star Tracks
The actress keeps a growing profile in West Hollywood. Plus: Sheryl Crow, Mischa Barton and more
Credit: Randy Snyder / Herald Dispatch
Published: Friday Apr 07, 2006 | 11:15 AM EDT
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Politics is a delicate business, and rarely more so than when trying to satisfy both movement conservatives and the moderates who determine general elections
A new ruling has given the greenlight to federal parties who want to provide a platform for swag producers to show off their wares at political conventions
Given recent shifts in NDP support to the Liberals, the Conservatives will have to find two million more votes if they are going to come close to winning
Immigration officials also told a Commons committee that Yazidis were never highlighted specifically by the Conservatives as a group to prioritize for resettlement
Instead of the expected big names — backbenchers, defeated MPs and other relatively unknown candidates are joining the race or considering doing so
MacKay said in May that he was gauging support for a potential leadership campaign, but also trying to determine if he still had the political fire
Peter MacKay, Kevin O'Leary, and Lisa Raitt are among the politicians who haven't yet announced whether they intend to run for leadership of the party
If Canada has a conservative Disneyland, it's Calgary Heritage Park Historical Village
Clement, whose portfolios have included Treasury Board president, has long been considered a possible candidate to replace former prime minister Stephen Harper
Perhaps Alberta looks like the surer thing to Kenney. It may indeed be the best option for him. But I'm not so certain it's best for the country