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Ovarian cancer
An in-depth report on the causes, diagnosis, treatment, and prevention of ovarian cancer.
Ovarian Cancer
Ovarian cancer is the ninth most common cancer in women, and the fifth leading cause of female cancer death. Detection of ovarian cancer while it is in its early stages significantly improves prognosis. Unfortunately, most cases of ovarian cancer are discovered when the cancer is already advanced.
Unlike Pap tests for cervical cancer, there is currently no effective screening method for ovarian cancer. Imaging tests such as transvaginal ultrasound and blood tests such as CA-125 have not proven to be useful screening tools. Studies indicate that screening with these tests does not reduce ovarian cancer death and may cause women to undergo unnecessary medical treatment due to their high rate of "false positives."
The United States Preventive Services Task Force and other medical associations do not recommend routine screening for ovarian cancer for most women. However, these tests can help doctors track the results of treatments for ovarian cancer.
Ovarian cancer grows quickly and can progress from early to advanced stages within a year. Paying attention to symptoms can help improve a woman's chances of being diagnosed and treated promptly. If you have the following symptoms on a daily basis for more than a few weeks, you should see your doctor (preferably a gynecologist):
- Bloating
- Pelvic or abdominal pain
- Difficulty eating or feeling full quickly
Risk Factors
The main risk factors of ovarian cancer are:
- Older age
- Family history of ovarian, breast, or hereditary colorectal cancer
- BRCA1 or BRCA2 genetic mutations
- Obesity
- Hormone replacement therapy use for 5 or more years
- Not having had children
Protective Factors
Factors that may help reduce the risk of ovarian cancer include:
- Birth control pills
- Childbirth and breastfeeding
- Tubal ligation (tying fallopian tubes) or hysterectomy (removal of uterus) after childbearing
- Bilateral salpingo-oophorectomy surgery (removal of both ovaries and fallopian tubes) may be recommended for women at high risk for ovarian cancer, particularly those who have BRCA1 and BRCA2 genetic mutations
Ovarian cancer is usually treated by surgery followed by chemotherapy. Surgery involves removal of the ovaries, fallopian tubes, uterus, and the omentum (a layer of fatty tissue in the abdomen).
Patients with ovarian cancer should seek care from a qualified gynecologic oncologist (a surgical specialist in female reproductive cancers) and a qualified medical oncologist with special expertise in the chemotherapy of gynecologic cancer.
According to a 2013 study , only about a third of American women receive the proper care for ovarian cancer as outlined in guidelines by the National Comprehensive Cancer Network (NCC). Women whose care adhered to the NCCN guidelines had a much better chance for survival. The best outcomes were seen with hospitals and doctors that treated a large number of ovarian cancer patients.
The ovaries are two small, almond-shaped organs located on either side of the uterus. They are key components of a woman's reproductive system:
- Ovaries store 200,000 - 400,000 follicles, tiny sacs that are present from birth that nurture immature eggs (ova).
- During each normal (usually monthly) reproductive cycle, a follicle in one ovary bursts and releases a mature or "ripened" egg. The egg travels down the fallopian tube into the uterus, where it either is fertilized by a man's sperm or, if unfertilized, breaks down and is shed with menstrual bleeding.
- Ovaries produce the important reproductive hormones estrogen and progesterone.
Ovarian Cancers
Ovarian cancers are potentially life-threatening malignancies that develop in one or both ovaries. Malignant ovarian tumors generally fall into three primary classes:
- Epithelial tumors
- Germ cell tumors
- Stromal tumors
Epithelial Tumors. Epithelial tumors account for up to 90% of all ovarian cancers and are the primary focus of this report. These cancers develop in a layer of cube-shaped cells known as the germinal epithelium, which surrounds the outside of the ovaries.
Germ Cell Tumors. Germ cell tumors, which account for about 3% of all ovarian cancers, are found in the egg-maturation cells of the ovary. They occur most often in teenagers and young women. Although they progress rapidly, they are very responsive to treatments. About 90% of patients with germ cell malignancies can be cured, often preserving fertility.
Stromal Tumors. Stromal tumors, which account for about 6% of all ovarian cancers, develop from connective tissue cells that hold the ovary together and that produce the female hormones, estrogen and progesterone. Stromal tumors do not usually spread, in which case the prognosis is good. If they spread, however, they can be more difficult to treat than the other types of ovarian tumors.
Ovarian Cancer Progression
Ovarian cancer progresses almost silently, usually with vague symptoms. By the time serious symptoms do appear, the ovarian tumor may have grown large enough to shed cancer cells throughout the abdomen. At such an advanced stage, the cancer is more difficult to cure.
Ovarian cancer cells that have spread outside the ovaries are referred to as metastatic ovarian cancers. Ovarian tumors tend to spread to the following locations:
- Diaphragm
- Intestine
- Omentum (a layer of fatty tissue in the abdomen)
Cancer cells can also spread to other organs through lymph channels and the bloodstream.
Other Ovarian Growths
Not all ovarian growths are malignant. Benign ovarian cysts are common and are entirely different from ovarian cancer.
Ovarian cysts typically develop in one of two ways:
- Follicular Cysts. During normal ovulation, follicles (the little sacs in the ovary) expel eggs. If the egg is not expelled, fluids and other substances can build up inside the follicle, forming a follicular cyst.
- Corpus Luteum Cysts. Benign cysts may form when an egg has been released, but the emptied follicle (now called the corpus luteum) does not break down normally, instead filling with blood from nearby blood vessels.
Both follicular cysts and corpus luteum cysts are normal parts of the menstrual cycle and nearly always resolve within one or two cycles without treatment.
Risk Factors and Prevention
Ovarian cancer is the ninth most common cancer in women, and the fifth leading cause of female cancer death. Each year in the United States, about 22,000 women are diagnosed with ovarian cancer. About 14,000 American women die each year from the disease.
Certain factors increase the risk for ovarian cancer, while other factors reduce risk. Many of the preventive factors are related to the number of times a woman ovulates during her lifetime, which is indicated by the number of menstrual periods she has. Fewer menstrual periods and ovulations appear to be associated with reduced risk for ovarian cancer.
Factors That Increase the Risk for Ovarian Cancer
The main risk factors for ovarian cancer are:
- Age
- Family history of ovarian, breast, or colorectal cancer
- BRCA1, BRCA2 genetic mutations
- Obesity
- Hormone replacement therapy use
- Menstrual and reproductive history
Age. Ovarian cancer risk increases with age. About two-thirds of women are diagnosed with ovarian cancer at age 55 or older. The average age for the onset of ovarian cancer is about age 63, although ovarian cancer can develop in women of all ages.
Family History. A family history of breast or ovarian cancer is one of the strongest risk factors for ovarian cancer. Women are also at high risk for ovarian cancer if they have a family history of a hereditary form of colorectal cancer.
In general, women are considered at high risk for ovarian cancer if they have:
- A first-degree relative (mother, sister, or daughter) with ovarian cancer at any age. The risk increases with the number of affected first-degree relatives.
- A first-degree relative (or two second-degree relatives on the same side) with early onset breast cancer (occurring before age 50)
- A family member with both breast and ovarian cancer
- A family history of male breast cancer
- A family history of hereditary nonpolyposis colorectal cancer
- Ashkenazi (Eastern European) Jewish ancestry
When a woman describes her family history to her doctor, she should include the history of cancer in women on both the mother's and the father's side. Both are significant.
Genetic Mutations. The main genetic mutations associated with increased ovarian cancer risk are:
- BRCA1 and BRCA2 genes. Inherited mutations in the genes called BRCA1 and BRCA2 increase the risk for ovarian and breast cancers. While these mutations are more common among women of Ashkenazi Jewish ancestry, they are not restricted to this population and can occur in women of any ethnicity, including women of Asian and African descent. Women with a BRCA1 mutation have about a 40 - 60% lifetime risk for ovarian cancer. Women with a BRCA2 mutation have about a 10 - 30% lifetime risk for ovarian cancer. (By contrast, the lifetime ovarian cancer risk for women in the general public is about 1.5%.)
- HNPCC. Women who have genetic mutations associated with hereditary nonpolyposis colorectal cancer (HNPCC) have about a 10% lifetime risk of developing ovarian cancer
Obesity. Many studies have found an association between obesity and increased risk for ovarian cancer.
Hormone Replacement Therapy (HRT). Long-term use (more than 5 years) of hormone replacement therapy (HRT) may increase the risk of developing and dying from ovarian cancer. The risk seems to be particularly significant for women who take estrogen-only HRT. The risk is less clear for combination estrogen-progestin HRT. For women who take HRT, those who have a uterus (have not had a hysterectomy) are given combination HRT because progestin helps protect against the development of uterine cancer.
Menstrual and Reproductive History. Women are at increased risk for ovarian cancer if they began menstruating at an early age (before age 12), have not had any children, had their first child after age 30, or experienced early menopause (before age 50).
Endometriosis. Endometriosis may increase the risk for certain types of ovarian cancer. However, most women with endometriosis do not develop ovarian cancer. Endometriosis is a condition in which the cells that line the uterus grow in other areas of the body, such as the ovaries.
Risk Factors with Less Conclusive Evidence. Dietary fats have been studied as a possible risk factor for ovarian cancer. While some research reports an association between a high intake in animal fats and a greater risk, other studies have not found that dietary fat intake increases the risk for ovarian cancer.
Some older studies indicated that use of the fertility drug clomiphene (Clomid) could increase the risk for ovarian cancer. However, infertility itself is a risk factor for ovarian cancer, so it is not certain whether fertility drugs play an additional role in affecting risk. More recent studies suggest that fertility drugs do not increase ovarian cancer risk.
There is inconclusive evidence as to whether environmental factors increase the risk for ovarian cancer. Possible carcinogens studied include radiation exposure, talcum powder, and asbestos.
Factors That Appear to Reduce the Risk for Ovarian Cancer
In general, factors or behaviors that limit stimulation of the ovaries or inhibit ovulation seem protective. These preventive factors include:
- Oral contraceptive use
- Pregnancy and childbirth
- Tubal ligation and hysterectomy
Oral Contraceptives. Birth control pills definitely reduce the risk of ovarian cancer. Studies suggest that routine use of birth control pills reduces a woman's risk of ovarian cancer by about 50% when compared to women who have never taken oral contraceptives. The longer a woman takes oral contraceptives the greater the protection and the longer protection lasts after stopping oral contraceptives. However, birth control pills are not safe or appropriate for all women.
Pregnancy and Childbirth. The more times a woman gives birth, the less likely she is to develop ovarian cancer. Breast-feeding for a year or more after giving birth may also decrease ovarian cancer risk.
Tubal Ligation and Hysterectomy. Tubal ligation, a method of sterilization that ties off the fallopian tubes, has been associated with a decreased risk for ovarian cancer when it is performed after a woman has completed childbearing. Similarly, hysterectomy, the surgical removal of the uterus, is also associated with decreased risk. However, these procedures should not be performed solely for ovarian cancer risk reduction.
Preventive Factors with Less Conclusive Evidence. Some studies, but not all, have suggested that tea consumption is associated with reduced risk of ovarian cancer.
Preventive Strategies for High-Risk Women
Women with a strong family history of ovarian cancer may wish to discuss these preventive strategies with their doctors.
Genetic Counseling and Screening for BRCA Genes. The latest guidelines from the U.S. Preventive Services Task Force (USPSTF) recommend BRCA testing for women at high risk for ovarian cancer. The USPSTF does not recommend routine genetic counseling or testing for BRCA genes in low-risk women (no family history of BRCA1 or BRCA2 genetic mutations).
Screening with Ultrasound or Blood Tests. Screening high risk women is not recommended:
- Transvaginal ultrasound is not helpful for identifying early-stage ovarian cancer in high-risk women. In addition, ultrasound does not provide enough specific information to reliably determine which abnormal masses are cancerous or noncancerous.
- The CA-125 blood test is not approved for screening in the general population.
Evidence indicates that these screening tests do not help prevent ovarian cancer death. In addition, these tests produce a high level of "false positives," meaning that women may be incorrectly subjected to unnecessary invasive tests for ovarian cancer.
Removal of Ovaries (Oophorectomy). Surgical removal of the ovaries, called oophorectomy, significantly reduces the risk for ovarian cancer. When it is used to specifically prevent ovarian cancer in high-risk women, the procedure is called a prophylactic oophorectomy. Prophylactic oophorectomy is approximately 95% protective against ovarian cancer and is recommended for women at high risk for ovarian cancer. These women generally have the BRCA1 or BRCA2 genetic mutation, or have two or more first-degree relatives who have had ovarian cancer.
Bilateral oophorectomy is the removal of both ovaries. Bilateral salpingo-oophorectomy is the removal of both fallopian tubes plus both ovaries. Several recent studies indicate that salpingo-oophorectomy is very effective in reducing risk for ovarian cancer in women who carry the BRCA1 or BRCA2 mutation.
Even after oophorectomy, women in high-risk groups for ovarian cancer still have a risk for the development of cancer in the peritoneum (the thin membrane that lines the inside of the abdomen).
Premenopausal women should be aware that oophorectomy causes immediate menopause, which poses a risk for several health problems, including osteoporosis and heart disease. Estrogen replacement, given for a period of time, can help offset these problems but may cause problems of its own. Women who have a bilateral oophorectomy and do not receive hormone replacement therapy may experience more severe hot flashes than women who naturally enter menopause.
Ovarian cancer used to be considered a "silent killer." Symptoms were thought to appear only when the cancer was in an advanced stage. Now, doctors believe that even early-stage ovarian cancer can produce symptoms.
See your doctor if you have the following symptoms on a daily basis for more than a few weeks:
- Bloating
- Pelvic or abdominal pain
- Difficulty eating or feeling full quickly
Ovarian cancer grows quickly and can progress from early to advanced stages within a year. Paying attention to symptoms can help improve a woman's chances of being diagnosed and treated promptly. Detecting cancer while it is still in its earliest stages may help improve prognosis.
Be aware that these symptoms are very common in women who do not have cancer and are not specific for ovarian cancer. While prompt follow-up with your doctor is important when one or more of these are present, there are many other explanations for these symptoms besides ovarian cancer.
Other symptoms are also sometimes associated with ovarian cancer. These symptoms include fatigue, indigestion, back pain, pain during intercourse, constipation, and menstrual irregularities.
Based on the symptoms and physical examination, the doctor may order pelvic imaging tests or blood tests. If these tests reveal possible signs of cancer, patients should be referred to a gynecologic oncologist who specializes in female reproductive system cancers.
Up to 95% of women diagnosed with ovarian cancer will survive longer than 5 years if the cancer is treated before it has spread beyond the ovaries. Although doctors are working hard to develop ways to diagnose early ovarian cancer, there are currently no effective screening tests for early detection. Therefore, only about 25% of ovarian cancer cases are diagnosed at such early stages. It is possible to perform genetic screeningto detecthigh-risk women, but this raises some complex issues.
Annual Gynecologic Checkup
Every woman should have a regular annual examination with her doctor that includes a pelvic exam.
A pelvic exam is performed in two ways. The doctor inserts two fingers into the vagina while feeling the abdomen with the other hand. The doctor also performs a bimanual rectovaginal exam, which involves the insertion of one finger into the vagina and another into the rectum.
Both exams enable the doctor to evaluate the size and shape of the ovaries. Enlarged ovaries and abdominal swelling can be signs of ovarian cancer. A mass felt during a pelvic exam often requires further evaluation by ultrasound and sometimes requires surgery to make a definitive diagnosis.
Ruling out Benign Conditions
Many women are treated each year in the United States because of ovarian growths or lesions. Many more women find out about some ovarian abnormality during their annual gynecological exam. The vast majority of conditions are noncancerous. They include:
- Benign functional ovarian cysts
- Abscesses and infection
- Uterine fibroids
- Endometriosis
- Polycystic ovaries
- Ectopic pregnancies
- Meig syndrome (a benign ovarian growth associated with fluid buildup in the abdomen and around the lungs)
- Ovarian hyperstimulation syndrome following fertility treatments.
Once a growth is detected, the additional tests described below may help the doctor evaluate the risk for it being cancerous. If ovarian cancer has been diagnosed, these tests are also used to monitor how the cancer is progressing.
Transvaginal Ultrasound and Other Imaging Tests
Ultrasound. Ultrasound is a noninvasive diagnostic tool that can evaluate tumors and masses discovered during the rectovaginal exam:
- Typically, a probe that emits sound waves (ultrasound) is placed in the vagina. The sound waves bounce off tissues, organs, and masses in the pelvic cavity. These echoes are collected and converted into a picture of the area called a sonogram. Healthy tissue, fluid-filled cysts, and solid tumors produce different sound waves.
- The ultrasound probe may also be placed on abdominal walls above the ovaries (transabdominal ultrasound), but it does not provide as clear a picture of the ovaries. This technique may be needed to evaluate larger masses or cancer that has spread into the abdomen.
Other Imaging Techniques. Other imaging techniques are less common for the diagnosis or evaluation of suspected ovarian cancer but may help determine if cancer has spread to other parts of the body:
- Computed tomography (CT). Computed tomography records x-ray absorption rates of tissue and bone. These data are converted into clear images on a screen. CT scans help determine if cancer has spread to the lymph nodes, abdominal organs, abdominal fluid, and the liver.
- Magnetic resonance imaging (MRI). MRI creates multiple cross-sectional images of the pelvis and abdominal organs, which are assembled into three-dimensional images. An MRI is not usually used to diagnose ovarian cancer, but may help determine if cancer has spread to the brain or spinal cord.
- Chest x-rays. Find cancer that has spread to the lungs.
CA-125 and Other Blood Tests
CA-125 Blood Test. CA-125 is a protein that is secreted by ovarian cancer cells and is elevated in over 80% of patients with ovarian cancer. Oncologists will usually only obtain a blood test for this protein if ovarian cancer is strongly suspected or has been diagnosed. In general, a CA-125 level is considered to be normal if it is less than 35 U/mL (microns per milliliter). The test may also be useful for evaluating tumor growth and predicting survival in patients with recurrent cancer who have been treated with topotecan or paclitaxel-carboplatin chemotherapy regimens.
The test is not useful for diagnosis or early screening, however. In about half of women with very early ovarian cancer, CA-125 levels are not elevated above the normal standard. Furthermore, an elevated level can be caused by a number of other conditions including:
- Endometriosis
- Uterine fibroids
- Noncancerous ovarian cysts
- Pregnancy
- Pelvic inflammatory disease
- Liver diseases
- Heart failure
- Other tumors, such as breast, colon, lung, and pancreatic cancers
- Age and menstrual status can also affect the levels of CA-125
OVA1 Blood Test. The OVA1 blood test helpspredict whether ovarian cancer is more likely to be present in a pelvic mass. The test measures the level of CA-125 and four other proteins. The test can help doctors decide what type of surgery should be performed. The OVA1 test is used in addition to, not in place of, other diagnostic and clinical procedures. It is not used to screen for or provide a definite diagnosis of ovarian cancer, but can help doctors to determine that a malignancy is more likely to be present.
Exploratory Surgery
An exploratory surgical procedure is required to confirm a diagnosis of ovarian cancer. It is also necessary to properly stage a patient, since the imaging tests may miss small implants of ovarian tumor within the pelvis and the abdominal cavity. Surgery may be laparotomy or a less-invasive laparoscopy. A gynecologic oncologist usually performs these procedures.
Laparotomy is an open-surgery procedure that requires general anesthesia. The surgeon makes an incision from the pubic bone to the navel to explore the abdominal cavity. Laparoscopy does not require general anesthesia and the oncologist uses only small incisions to insert a lighted instrument to examine the organs and evaluate the spread of the tumor. With both procedures, tissue samples (biopsies) can be removed for further testing.
About 75% of women survive ovarian cancer at least 1 year after diagnosis. Nearly half are alive 5 years after diagnosis. This is called the 5-year survival rate.
Survival rates vary depending on different factors, including age and the stage at which it is detected. In general, women younger than age 65 have better survival rates than older women.
Unfortunately, most patients with ovarian cancer are not diagnosed until the disease is advanced. This usually means the cancer has spread to the upper abdomen. In order to establish a prognosis and determine treatment, the doctor needs to know the cell type, stage, and grade of the disease.
Prognosis by Cell Type
When examined under the microscope, there are a number of different cell types of ovarian cancer. Mucinous and clear cell tumors tend to be more difficult to treat.
Prognosis by Stage
Cancers are staged (I through IV) according to whether they are still localized (remaining in the ovary) or have spread beyond the original site.
The survival rate varies according to the cancer stage:
- Five-year survival rates are over 90% if the cancer is still confined to the ovary at diagnosis. However, only 19% of ovarian cancers are found at this stage.
- If the cancer has spread to nearby regions in the pelvis, the 5-year survival rate is about 70%.
- If the cancer has spread to sites outside the pelvis, the 5-year survival rate is about 30%.
Prognosis by Grade
Tumors are graded according to how well or poorly organized they are (their differentiation). Ovarian tumors are graded on a scale of 1, 2, or 3. Grade 1 tends to closely resemble normal tissue and has a better prognosis than grade 3, which indicates very abnormal, poorly defined tissue.
In general, the course of treatment is determined by the stage of the cancer. Stages range from I to IV based on the cancer's specific characteristics,including whether it has spread beyond the ovaries. Surgery is the main treatment for ovarian cancer. Following surgery, women with higher-stage tumors may receive chemotherapy. Women can also consider enrolling in clinical trials that are investigating new types of treatments.
About 10 - 15% of epithelial ovarian tumors are referred to as "borderline" because their appearance and behavior under the microscope is between benign and malignant. These tumors are also called "carcinomas of low malignant potential" because they rarely metastasize or cause death. Borderline ovarian tumors are most often seen in younger women with epithelial ovarian cancer. Surgery is usually recommended to remove these tumors. Chemotherapy may also be used to treat borderline tumors that appear to have more aggressive features (such as recurring after surgery).
Stage I. In stage I, the cancer has not spread. It is confined to one ovary (stage IA) or both ovaries (stage IB). In stages IA and IB, the ovarian capsules are intact, and there are no tumors on the surface. Stage IC can affect one or both ovaries, but the tumors are on the surface, or the capsule (outer covering of the ovary) has burst, or there is evidence of tumor cells in abdominal fluid (ascites). The overall 5-year survival rate for stage IA or IB can be as high as 90%, depending on the type of tumors and whether cells are well or poorly differentiated. Stage IC has a poorer outlook than the earlier stages. It is very important that women receive an accurate staging assessment, including a pathologic review conducted by a gynecologic pathologist.
Stage II. In stage II, the cancer is in one or both ovaries and has spread to other areas in the pelvis. It may have advanced to the uterus or fallopian tubes (stage IIA), or other areas within the pelvis such as the bladder, colon or rectum (stage IIB), but is still limited to the pelvic area. Stage IIC includes the pelvic involvement described in stages IIA and IIB and also includes cancer cells found in the abdominal fluid.
Stage III. In stage III, one or both of the following are present: (1) The cancer has spread beyond the pelvis to the omentum (a layer of fatty tissue in the abdomen) and other areas within the abdomen, such as the surface of the liver or intestine. (2) The cancer has spread to the lymph nodes.
Stage IV. Stage IV is the most advanced cancer stage. The cancer may have spread to the inside of the liver or spleen. There may be distant spreading of the cancer, such as ovarian cancer cells in the fluid around the lungs.
Treatment Options for Stage I and Stage II Ovarian Cancer
Treatment options for stage I and stage II ovarian epithelial cancer may include:
- Surgery: Removal of the uterus (total hysterectomy), removal of both ovaries and fallopian tubes (bilateral salpingo-oophorectomy); partial removal of the omentum (omentectomy); and surgical staging of the lymph nodes and other tissues in the pelvis and abdomen. (Carefully selected premenopausal women in Stage I with the lowest-grade tumors in one ovary may sometimes be treated only with the removal of the diseased ovary and tube in order to preserve fertility.)
- Chemotherapy: Patients with stage IA or B disease, grade 1 (or sometimes grade 2), usually do not need further therapy after surgery. However, higher risk patients (stage IC, stage I/grade 3) are usually treated with platinum-based chemotherapy to reduce their risk of subsequent relapse.
- Clinical trials with radiation therapy, chemotherapy, or new treatments
Treatment Options for Stage III and Stage IV Ovarian Cancer
Treatment options for stage III and stage IV ovarian epithelial cancer may include:
- Surgery: Removal of the tumor (debulking), total abdominal hysterectomy, bilateral salpingo-oopherectomy, and omentectomy
- Chemotherapy: Combination chemotherapy with a platinum-based drug and a taxane drug delivered intraperitoneally (through the abdominal cavity)
- Clinical trials of biologic drugs (targeted therapy) following combination chemotherapy
Treatment Options for Recurrent Ovarian Cancer
If ovarian cancer returns or persists after treatment, chemotherapy is the mainstay treatment, although it is not generally curative in the setting of relapsed disease. Clinical trial options include additional surgical debulking, targeted therapy with a biologic drug combined with chemotherapy, or hormone therapy.
Surgery for ovarian cancer uses laparotomy, a major abdominal operation. It is the primary diagnostic tool for ovarian cancer and also plays a role in treatment. Complete surgical intervention includes the following:
- Surgical staging (examining all tissues and organs in the pelvic cavity for accurate assessment of the disease stage).
- Debulking (removal of as much of the cancerous tissue as possible). This is a critically important component of ovarian cancer management and should be performed by a surgeon trained in cancer surgery techniques. The more of the tumor that is successfully removed, the better the chances for survival.
It is extremely important that patients with ovarian cancer seek care from a qualified gynecologic oncologist (a surgical specialist in female reproductive cancers) and a qualified medical oncologist with special expertise in the chemotherapeutic management of gynecologic cancer. Studies indicate that it is best for patients, especially those with advanced-stage ovarian cancer, to receive care at medical centers that specialize in cancer treatment and surgery.
Women of child-bearing age should discuss with their doctors any concerns and questions they may have about how various cancer treatments could affect their fertility. They may also wish to have a consultation with a fertility specialist. Assisted reproductive technology such as embryo or oocyte (egg) cryopreservation ("freezing") may offer some women an option to later have children. It is very important that you have these discussions with your health care team prior to starting cancer treatment.
Surgical Staging
Surgical staging includes biopsies of the following:
- The undersurface of the diaphragm
- The omentum (a layer of fatty tissue in the abdomen)
- Sometimes lymph nodes along the abdominal aorta
An abdominal wash is performed by injecting a salt solution into the abdominal cavity to facilitate microscopic detection of cancerous cells not visible to the naked eye. The surgeon then evaluates the pelvis and abdomen and removes suspected cancer tissue. The entire affected ovary is usually removed (oophorectomy) during surgical staging if the surgeon believes it might be cancerous. The tissue is sent to a laboratory for an immediate evaluation called a frozen section diagnosis. The doctor will also examine the bowel and bladder for cancer invasion.
Debulking, also called surgical cytoreduction, involves removing as much of the tumor as possible. The goal is to leave behind no tumor larger than 1 centimeter. Debulking is usually followed by chemotherapy. Reducing the size of the tumor helps the chemotherapy act more effectively.
The surgery itself is typically performed as follows:
- In premenopausal women in a very early stage of ovarian cancer who want to retain the ability to have children, the surgeon may be able to remove only the affected ovary and its accompanying fallopian tube. Studies indicate that in carefully selected young patients, many can expect normal fertility afterward. However, most women with ovarian cancer are not candidates for this procedure.
- In premenopausal women in later stages of ovarian cancer, and in all postmenopausal women, the surgeon usually removes the uterus (a hysterectomy) and both ovaries and fallopian tubes (a bilateral salpingo-oophorectomy). In addition, the surgeon usually removes the omentum (omentectomy), and pelvic lymph nodes (lymphadenectomy).
- If the tumor has spread beyond the reproductive organs, the surgeon may need to remove parts of the diaphragm, bowel, spleen, or liver. For recurrent ovarian cancer, a second debulking surgery may be helpful.
Hysterectomy and Premature Menopause
Hysterectomy results in infertility. A woman will no longer have menstrual periods and she can no longer become pregnant. Surgical removal of the ovaries (oophorectomy) causes immediate menopause. Symptoms such as hot flashes come on abruptly and may be more intense than those of natural menopause. Other menopausal symptoms include vaginal dryness, sleep problems, and weight gain. .
The most important complications that occur in women who have had their ovaries removed are due to estrogen loss, which places women at risk for osteoporosis (loss of bone density) and a possible increase in risks for heart disease. Hormone replacement therapy after a hysterectomy is given as estrogen-only therapy (ET). It does have risks, including increasing the chances for breast cancer and stroke.It does not appear to increasethe risk for ovarian cancer recurrence.
The decision to use estrogen therapy (ET) depends in part on a woman's age as well as other medical factors. For younger women (in their 20s, 30s, or 40s), the benefits of ET for bone and heart health may outweigh the risks. For women closer to the age of menopause, risks may outweigh benefits. Discuss with your doctor whether hormone replacement therapy is a safe or appropriate option for you.
Surgery for Bowel Obstruction
Bowel obstruction is common in ovarian cancer. Certain patients may need a surgical procedure called a colostomy when part of the colon is removed.
Following surgery, patients (other than those with early-stage, low-grade disease) usually have chemotherapy. Unlike surgery and radiation, which treat the cancerous tumor and the area surrounding it, drug therapy destroys rapidly dividing cells throughout the body, so it is a systemic therapy.
Ovarian cancers are very sensitive to chemotherapy and often respond well initially. Unfortunately, in most cases, ovarian cancer recurs. With treatment advances, however, more than half of women now survive 5 years or longer. Doctors are now approaching this disease as a chronic and potentially long-term illness that requires the following:
- Identifying the disease recurrence as soon as possible
- Administering treatments that are as effective as possible without causing suffering
- Partnering with the patient in determining her own best course
Drugs Used in Chemotherapy
Standard Chemotherapy. The standard initial chemotherapy uses a combination of:
- A platinum-based drug such as carboplatin (Paraplatin, generic) or cisplatin (Platinol, generic). Carboplatin is preferred over cisplatin in the combination. Carboplatin works as well as cisplatin but is less toxic and can be administered in a more convenient, outpatient regimen.
- A taxane such as paclitaxel (Taxol, generic) or docetaxel (Taxotere, generic). Currently, paclitaxel is the drug most often used as initial therapy in combination with a platinum drug.
Chemotherapy for Relapsed or Refractory Cancer. Unfortunately, even in patients who respond, the disease eventually becomes resistant to the first-line drugs, and the cancer returns. Some ovarian tumors are resistant to platinum drugs.
Once cancer recurs or continues to progress, the patient may be treated with more cycles of carboplatin and a taxane drug, or a different type of chemotherapy drug may be used in combination treatment.
Recurrent ovarian cancer may be treated with gemcitabine (Gemzar, generic), a drug used in combination with carboplatin for women with advanced ovarian cancer that has relapsed at least 6 months after initial therapy. Other drugs used for recurrent ovarian cancer include doxorubicin (Adriamycin, Doxil, generic), etoposide (Vepesid, generic), and vinorelbine (Navelbine, generic).
Hormonal therapy is also an option for patients who cannot tolerate or who have not been helped by chemotherapy. Hormonal therapy drugs include tamoxifen (Nolvadex, generic), and aromatase inhibitors such as letrozole (Femara, generic), anastrozole (Arimidex, generic), and exemestane (Aromasin, generic).
Administration of Chemotherapy
In general, the typical initial chemotherapy regimen is:
- Paclitaxel and carboplatin are administered in an outpatient clinic within several weeks of the surgery.
- Each treatment takes about 4 - 5 hours to complete.
- It is repeated every 3 weeks for a total of six times. (Each 3-week interval is known as a cycle of chemotherapy.)
Chemotherapy is either administered intravenously (by vein) or intraperitoneally (through the abdominal cavity). Recent research has indicated that patients with stage III ovarian cancer who receive intraperitoneal chemotherapy have a significant survival advantage compared with patients who receive standard intravenous chemotherapy. However, intraperitoneal chemotherapy can cause more severe side effects, including abdominal pain and bowel damage. Some patients cannot tolerate intraperitoneal chemotherapy. Intraperitoneal chemotherapy requires careful catheter insertion and maintenance, and doctors need to be well trained to perform this procedure.
Side Effects of Chemotherapy
Side effects occur with all chemotherapy drugs. They are more severe with higher doses and increase over the course of treatment. Some may be long-lasting.
Common side effects may include:
- Nausea and vomiting. Drugs known as serotonin antagonists, especially ondansetron (Zofran, generic), can relieve these side effects in nearly all patients given moderate drugs and most patients who take more powerful drugs.
- Diarrhea
- Temporary hair loss
- Weight loss
- Fatigue
- Depression
Serious short- and long-term complications can also occur and may vary depending on the specific drugs used. These complications may include:
- Anemia (low red blood cell count)
- Increased chance for infection from severe reduction in white blood cells (neutropenia)
- Abnormal bleeding (thrombocytopenia)
- Problems with concentration, motor function, and memory
Follow-Up Recommendations
After surgery and chemotherapy, patients should have:
- A physical exam (including pelvic exam) every 2 - 4 months for the first 2 years, followed by every 3 - 6 months for 3 years, and then annually.
- A CA-125 blood test at each office visit if the level was initially elevated. Falling CA-125 levels indicate effective treatment while persistently elevated levels indicate resistance to the chemotherapy.
- Your doctor may also order a computed tomography (CT), MRI, or PETscan of your chest, abdominal, and pelvic areas and a chest x-ray.
- If your family history suggests a genetic component, genetic counseling may be recommended.
Investigational Drugs
Any patient with ovarian cancer is a candidate for clinical trials. In addition to testing high-dose or combinations of chemotherapy, biologic drugs that target specific proteins are being investigated. These drugs are primarily being studied for treatment of advanced or recurrent ovarian cancer, in combination with standard chemotherapy drugs. The biologic drug bevacizumab (Avastin) has been the main targeted therapy studied for ovarian cancer.
Radiation Therapy
Radiation therapy is not typically used in ovarian cancer. This is because radiation would need to be given to the entire abdomen and pelvis, increasing its toxicity. Radiation is sometimes useful to treat isolated areas of tumor that are causing pain and are no longer responsive to chemotherapy, and to kill cancer cells that still remain after other treatments.
- www.cancer.gov -- National Cancer Institute
- www.cancer.org -- American Cancer Society
- www.cancer.net -- Cancer.Net
- www.nccn.org -- National Comprehensive Cancer Network
- www.ovarian.org -- National Ovarian Cancer Coalition
- www.ovariancancer.org -- Ovarian Cancer National Alliance
- www.sgo.org -- Society of Gynecologic Oncologists
- www.foundationforwomenscancer.org -- Foundation for Women's Cancer
- www.ovariancancer.com -- The Gilda Radner Familial Ovarian Cancer Registry
- www.cancer.gov/clinicaltrials -- Find clinical trials
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Management of adnexal masses. Obstet Gynecol. 2007; 110(1): 201-14.
American College of Obstetricians and Gynecologists Committee on GynecologicPractice. Committee Opinion No. 477: the role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer. Obstet Gynecol. 2011 Mar;117(3):742-6.
Berek JS, Chalas E, Edelson M, Moore DH, Burke WM, Cliby WA, et al. Prophylactic and risk-reducing bilateral salpingo-oophorectomy: recommendations based on risk of ovarian cancer. Obstet Gynecol. 2010 Sep;116(3):733-43.
Bristow RE, Chang J, Ziogas A, Anton-Culver H. Adherence to treatment guidelines for ovarian cancer as a measure of quality care. Obstet Gynecol. 2013 Jun;121(6):1226-34.
Burger RA, Brady MF, Bookman MA, Fleming GF, Monk BJ, Huang H, et al. Incorporation of bevacizumab in the primary treatment of ovarian cancer. N Engl J Med. 2011 Dec 29;365(26):2473-83.
Buys SS, Partridge E, Black A, Johnson CC, Lamerato L, Isaacs C, et al. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA. 2011 Jun 8;305(22):2295-303..
Chan JK, Tian C, Monk BJ, Herzog T, Kapp DS, Bell J, et al. Prognostic factors for high-risk early-stage epithelial ovarian cancer: a Gynecologic Oncology Group study. Cancer. 2008; 112(10): 2202-10.
Daly MB, Axilbund JE, Buys S, Crawford B, Farrell CD, Friedman S, et al. Genetic/familial high-risk assessment: breast and ovarian. J Natl Compr Canc Netw. 2010 May;8(5):562-94.
Domchek SM, Friebel TM, Singer CF, Evans DG, Lynch HT, Isaacs C, et al. Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality. JAMA. 2010 Sep 1;304(9):967-75..
Elit L, Oliver TK, Covens A, Kwon J, Fung MF, Hirte HW, et al. Intraperitoneal chemotherapy in the first-line treatment of women with stage III epithelial ovarian cancer: a systematic review with metaanalyses. Cancer. 2007; 109(4): 692-702.
Goff BA, Mandel LS, Drescher CW, Urban N, Gough S, Schurman KM, et al. Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer. 2007 Jan 15;109(2):221-7.
Goff BA, Matthews BJ, Larson EH, Andrilla CH, Wynn M, Lishner DM, et al. Predictors of comprehensive surgical treatment in patients with ovarian cancer. Cancer. 2007 May 15;109(10):2031-42.
Havrilesky LJ, Moorman PG, Lowery WJ, Gierisch JM, Coeytaux RR, Urrutia RP, et al. Oral contraceptive pills as primary prevention for ovarian cancer: a systematic review and meta-analysis. Obstet Gynecol. 2013 Jul;122(1):139-47.
Jensen A, Sharif H, Frederiksen K, Kjaer SK. Use of fertility drugs and risk of ovarian cancer: Danish Population Based Cohort Study. BMJ. 2009 Feb 5;338:b249.
Loren AW, Mangu PB, Beck LN, Brennan L, Magdalinski AJ, Partridge AH, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013 Jul 1;31(19):2500-10. Epub 2013 May 28.
Mavaddat N, Peock S, Frost D, Ellis S, Platte R, Fineberg E, et al. Cancer risks for BRCA1 and BRCA2 mutation carriers: results from prospective analysis of EMBRACE. J Natl Cancer Inst. 2013 Jun 5;105(11):812-22. Epub 2013 Apr 29.
Morch LS, Lokkegaard E, Andreasen AH, Kruger-Kjaer, Lidegaard O. Hormone therapy and ovarian cancer. JAMA. 2009 Jul 15;302(3):298-305.
Moyer VA; U.S. Preventive Services Task Force. Screening for ovarian cancer: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2012 Dec 18;157(12):900-4.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Ovarian cancer: including fallopian tube cancer and primary peritoneal cancer. Version 2.2013.
Pearce CL, Templeman C, Rossing MA, Lee A, Near AM, Webb PM, et al. Association between endometriosis and risk of histological subtypes of ovarian cancer: a pooled analysis of case-control studies. Lancet Oncol. 2012 Apr;13(4):385-94. Epub 2012 Feb 22.
Prentice RL, Thomson CA, Caan B, Hubbell FA, Anderson GL, Beresford SA, et al. Low-fat dietary pattern and cancer incidence in the Women's Health Initiative Dietary Modification Randomized Controlled Trial. J Natl Cancer Inst. 2007; 99(20): 1534-43.
U.S. Preventive Services Task Force. Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement. Ann Intern Med. 2005 Sep 6;143(5):355-61.
Advanced Studyec
Review Date: 12/17/2013�
Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.


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Bookmark this site
SOFIA, Bulgaria -- The latest vending marketing stunt making headlines is a machine that rewarded people in Bulgaria with a free beer for doing nothing.
The "Amstel Pause" machine encouraged thirsty passersby to stand still in front of the machine and push a button to start a timer. The machine dispensed a free beer if they held their pose for three minutes.
The vending machine was placed in a busy location in Sofia, the capital of Bulgaria, for 16 days, during which it dispensed 1,344 free beers.
Watch the free beer vending machine in action here.

subset: commoncrawl


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11th Floor by Edouard Lock
Choreographer Edouard Lock has created an exclusive and elegant passion drama, inspired by jazz and film noir of the 1950's.
Press cuttings
"Luminous, consummate Cullberg"
"Compressed and suggestive"
"...a complete experience"
"...brilliant mastery of technique and expression"
"Smart, restrained, expressive - black is the new black. For Cullberg Ballet, almost anything is possible"
"extremely refined"
"A narrative in constant motion, a story that continuously surprises and challenges"
Västerbottens Folkblad
3 x BirgitRead more about show
40 M UNDER (dance film)
The dance film 40 M UNDER is Alexander Ekman's first lengthy film project. The film, which was recorded in the summer of 2009 in the former reactor hall at the Royal Institute of Technology in Stockholm, focuses on a few people who carry out a type of installation underground.
Against the Current, GlowRead more about show
Cullberg Out in context - PlaybackRead more about show
Cullberg to come: Word of MouthRead more about show
Cullbergbaletten celebrates 50 years!Read more about show
Ekman's Triptych - A Study of Entertainment
A full evening work in three parts by Alexander Ekman.
Choreographer Alexander Ekman is conquering the international dance scene. Four years ago he was said to be "a rising young choreographer to keep an eye on". August 2010 he created his first full length evening: Ekman's Triptych - A Study of Entertainment. Three separate works weave through a multitude of expressions, where dance meets dialogue, wit becomes wistful and the meaningful cohorts with the meaningless. What is entertainment?
Figure a Sea - choreography by Deborah Hay, music and sound score by Laurie AndersonRead more about show
High heels too
Canadian choreographer Benoît Lachambre creates a new piece for six of the Cullberg Ballet dancers, with world première in Stockholm in March 2013. The idea for the new work came when Lachambre took part in a contemporary dance project at one of Montréal's burlesque clubs, and created a solo on high heels for a dancer. In the new piece for Cullberg Ballet; High heels too, Lachambre collaborates with costume designer Alexandra Bertaut, visual artist Laurent Goldring, both based in Paris, and the New York-based composer Hahn Rowe.
Choreography: Margret Sara Guðjónsdóttir
Sound design: Margret Sara Guðjónsdóttir in collaboration with David Kiers
Lighting design: Martin Beeretz
Dancers: Adam Schütt, Anand Bolder, Eleanor Campbell, Vincent Van der Plas
Rehearsal director: Jane Hopper
Costume assistant: Tuva Danhard
Costume trainee: Cecilia Karlsson
Premiere: 8 February 2017 at Inkonst, Malmö
Duration: 40 minutes
Inhouse at Cullberg Ballet 27, 28 February, 1 March
The dancers present their own works on our home turf at Riksteatern in Hallunda, south of Stockholm. Join us for dancers in motorcycle helmets, video art installations, visual art, and a new version of Hamlet!
The Icelandic choreographer Margrét Sara Gudjónsdóttirs international audience success Soft target will be presented in a new try out version: Targeted, created with three of the company's dancers. Former Cullberg Ballet dancer, Canadian Hanako Hoshimi-Caines returns to Sweden with a new creation I read fiction to keep it real.
Free buses for the audience depart from Stockholm city center, Cityterminalen Thursday and Friday at 17:45 and returns from Hallunda at 21.00. Book the bus ticket and ticket to performance at email@example.com. Free admission! Limited number of seats!
Plateau Effect by Jefta van Dinther
Press cuttings Plateau Effect
Dagens Nyheter:
"Brutal, brilliant and thrilling by Cullberg Ballet."
"...a puzzling and intelligent ballet with a brilliant final."
"The long beginning is purely fabulous. Vertiginous, mysteriously beautiful, providing examples of Jefta van Dinther's choreographic trademark: the ability to, from a nearly simple concreteness, create an as intelligent as sensual associatively flow of movement."
Choreographer Jefta van Dinther is back with a new big stage production for 14 dancers in Cullbergbaletten. Elias, last year's major breakthrough artist in Swedish music, whose debut single 'Revolution' was a big hit last spring, provides recorded singing and voice-over, accompanied by sound design and music from David Kiers, set design by artist duo SIMKA and lighting design by Minna Tiikkainen. The new production, entitled 'Protagonist', will have its world premiere at Julidans in Amsterdam 7 July, and be performed for the first time in Sweden at Dansens Hus in Stockholm in November.
SamlingenRead more about show
The Mental States of Sweden in DanceRead more about show
The Return of The Modern DanceRead more about show
The Strindberg Project
New works by Tilman O'Donnell and Melanie Mederlind
Press cuttings
"It is humorous and effective and gradually builds to culminate in a moving whole." Aftonbladet
"Lyrical atmosphere." Svenska Dagbladet
"Playfulness and humour." Svenska Dagbladet
"Striking beautiful and thoughtful meditation..." Dagens Nyheter
"...subtle humour..." Dagens Nyheter
Opinions on August Strindberg are many and divided. In spring 2012 Cullberg Ballet will be inviting dancer and choreographer Tilman O'Donnell and director Melanie Mederlind to be inspired by, comment on or oppose this Swedish icon. They will each create dance works for an evening's performance to be premiered on the Dansens Hus main stage in Stockholm on 15 March 2012. Cullberg Ballet will encounter Strindberg in a new form. Exclusive, unexpected and up close.
True Stories of Castaways and Other Survivors
Norwegian choreographer Ina Christel Johannessen created a new piece for Cullberg Ballet in spring 2011; True Stories of Castaways and Other Survivors. Eight of Cullberg Ballet's dancers perform in this illustrative piece.


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From HaskellWiki
Added the quote by Graham Klyne.
Over the years I've received numerous complaints about the quicksort example. But none of the complainers sent me anything better so it's still here. Anyone want to come up with a better example?
--John Peterson 00:39, 26 January 2006 (UTC)
- Perhaps an in-place quicksort? —Ashley Y 04:24, 26 January 2006 (UTC)
- If you want to offer "proof" that functional programming is a good idea, starting out with an invalid example pretty much wipes out your credibility. Taking the quicksort example offered, you are saying that if memory and CPU use do not matter ... but they very often do (certainly for large sort operations). Reading up on Haskell looks too much like a waste of time. Why the equivalent quicksort code in Haskell is larger than the C code requires an explanation as to why this is a good idea - and is not suitable material for the introduction. --PrestonBannister 01:51, 12 August 2008 (UTC)
- Change the C to mergesort? Because that really is what the Haskell code does. (Okay, sure, it's a funny 3-way, bottom-up, lazy mergesort. Still.) -- AaronDenney 19:55, 10 July 2007 (UTC)
- Eh? The defining property of quicksort is that the diving phase is elaborate (filter < and >) but that the conquer phase is simple (list concatenation). For mergesort, it's the other way round. apfeλmus 10:51, 11 December 2007 (UTC)
What is this about Haskell being in 2nd place behind C (gcc) in the computer language shootout, the link provided shows it to be 13th (and 12th on the previous benchmark, even though it does proportionally worst). You're right about functional languages doing well though: Clean, OCaml and MLton indeed occupy positions 6,9,11. --Noegenesis 12:01, 28 August 2007 (UTC)
- It was in 2nd place when the article was written, since then benchmarks and programs have changed. dons 00:17, 12 December 2007 (UTC)
Most functional languages, and Haskell in particular, are strongly typed, eliminating a huge class of easy-to-make errors at compile time. This sentence confuses strong and static typing. MichalPalka 00:11, 2 December 2007 (UTC)


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I am having the same issues, your better of asking for help on other forums as these are no help at all.
Hello Every one ,
I have a probleme with my Graphic Card .. backtrack 5 r3 can't detect the graphic card and I can't get the 1600x900 resolution, so how to fixe this probleme? and this is My PC Version :http://www.mytek.tn/816-hp-pavilion-dv7-6c90sf.html
and its graphic card is :Graphique AMD Radeon HD 7690MXT (2Go dediée jusqu'à 5.22Go)
(I saw the tutorial that say how to fixe Open.. and ATI graphic cards , and I did all steps but nothing is done )
thank you any way
Last edited by sohaieb; 09-30-2012 at 06:45 AM.
I am having the same issues, your better of asking for help on other forums as these are no help at all.
No reponse??? (((((((((((((
I did that , and I'm waiting for all reponses , and always nothing else
even i am facing the same issue with my HPDv6 6516tx.after installing the drivers and reboot is performed , i could see black screen , i have tried all possible ways mentioned in the forum.but no luck, can someone Please Help me
@hitman123: I have your same problem , and I put this topic in all linux Forums , and no reponse until this time
Guys I have an acer with this card, for some reason it will boot fine if I have it "Wired" to the internet. I have no idea what the problem is!


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Results 1 to 2 of 2
13th July 2013 06:15 PM #1
- Join Date
- Jul 2013
- Posts
- 4
Is it alright to punish my kids when they commit mistakes?
My kids do not eat much. Every morning, I am having trouble talking to them only to finish their breakfast. Sometimes, I do not give them allowances and at times, I tend to let them finish their food even if they say they're already full. How will I tell them how important it is to eat more?
14th July 2013 02:08 AM #2
I think what is important here is to not create an emotional association with food. Emotional associations with food (e.g. feeling negative or guilty when you eat certain foods or if you eat too much/too little food) have been found to be connected with eating disorders in later life.
It is far better to empower your children to make good, healthy choices about food. Of course, this is easier said than done - especially where young children are concerned!
Bear in mind that it is normal for children (particularly toddlers) to go through a fussy/ faddy eating phase. This is a sign of their growing independence as well as their taste buds changing. I feel that the best way to deal with these phases is just to carry on as normal - offer well-balanced healthy meals and snacks throughout the day (with plenty of variety) and don't punish your children for not eating as much or only choosing to eat certain foods.
How old are your children?
For younger, active children who are going through a fussy phase a 'grazing plate' is an excellent way to get them to eat more on their terms. You leave a large plate on a low down table (i.e. a table that they can come and go to without help from you) full of a variety of interesting snack food which ideally releases energy slowly. For example, it could contain dried fruit, malt loaf, peanut butter on wholemeal bread, steamed chicken, avocado chunks etc. The idea is that a busy child will then come to the plate over a space of several hours (they have too much to do to sit still for long!) and eat a good variety of food.
Smoothies are another healthy way for your children to get lots of nutrients. There are so many different flavour combinations to try - there's bound to be one they enjoy!
Another way to get your children to enjoy meal-times more is to involve them in planning and preparing the meal - so that they take ownership of the meal and find it more interesting. You can create fun meals together like making pizza faces out of pizzas topped with roast vegetables.
Make meal-times a family time; a time when you share what is going on in each others' day; a time when you can joke and laugh together; a time to make memories.
I think you are right to want your children to eat healthily (especially at breakfast time - the most important meal of the day) but it is best to instill this through positive, gentle parenting.
Does anyone else have any ideas to help char_june with this?
Best wishes,


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Map My Tracks is your all-in-one fitness & GPS activity tracker that motivates you to stay fit, stay active and achieve your goals.
Map My Tracks is available on your favourite mobile device. Supports iOS8 Health, Pebble Watch and Wahoo Fitness.
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Hart comments after Round 2 of Constellation SENIOR PLAYERS
Following his second-round 65 at the 2013 Constellation SENIOR PLAYERS Championship, Jeff Hart talks about the state of his game.
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text:
1976 BMW 530i -- Where do I begin?
Thanks for dropping in. I recently purchased a running '76 530i. At some time in the past she had been covered with a tarp and parked for a bit before I got her.
There are a series of issues that will require addressing. Sooner than later hopefully. I'm not sure where to start and could use the input of my peers.
Cosmetically, she ain't nothing to look at right now. She needs a new paint job (the previous owner did a spray paint two tone thing), and basically a completely new interior. I just pulled the carpet kit the other day because the sunroof flooded the interior during a bad rain storm. Leather seats are all cracked and ruined, gear shift knob slides off, missing a part of the dash column, heat/cooling controls are either missing or disconnected, ceiling headliner needs a replacing also.
But let's not focus on the aesthetics.
Under the hood she's pulling down just shy of 190,000k miles. The EGR Service light is intermittently on, but remains off as long as I'm running the high-octane from Chevron. The radiator fan looks like it wobbles a little and has done some damage to the radiator. It also appears that the previous owner didn't like the way the vacuum lines were set up and he cut/plugged/removed several of them. It also appears the part of the fuel system which utilizes the charcoal filter has been bypassed. I still haven't figured that out yet... It would seem there is a likely issue with the timing as she's running rich right now although I keep getting conflicting advice regarding advancing the timing or retarding it, over 1700rpm. Second gear straight up grinds the first time I try to shift into it. I've tried double-clutching but with no luck. I can shift freely when the car is at a stop, so I think it's bad synchro's. After a good grind, and basically slamming it into 2nd when the RPM's are dialed, seems to fix the problem for the day allowing me to up shift or downshift into 2nd without any complaint. Finally, when I am sitting idling, as I have to do commonly when driving through San Jose, the temperature soars. When driving this car generally runs VERY cool, hardly above the blue line and before the first marker. As soon as I stop moving though the temp increases. The radiator overflow container has a leak and isn't holding pressure, which could be contributing, but so far the car has not overheated. Seems like once it hits the second marker the temperature gain stops... but I cannot be sure.
Then there's all the other stuff. The wheels are somewhat ground up, and the right rear tire is bald on the inside. There's some body damage to the rear of the car (looks like it was in a very minor fender bender) and the left brake light cover is busted up a little and needs a replacing. The right brake cover is in good shape but it looks like the guy applies some caulking around the housing to keep it from leaking. The sunroof, as I mentioned, needs the felt seal replaced. The power windows only work when I open the driver side door, and the motors don't have a lot of gusto. The windows are also off their track and require adjusting as I roll them up. The previous owner did a number on the exhaust as well, perhaps to affix a CAT on it at some time in the past. The Cat is gone, and the original exhaust pipe is back, but the pipe had been cut out before and obviously doesn't seal properly. I have patches at the point just after the manifold connection and just prior to the muffler.
Fortunately I have a very close friend who manages an auto shop that specializes in older model BMW, Volvo, and Audi. So despite my inadequate knowledge regarding the details of the car I do have someone local that I can trust to HELP me do some of the work myself. I know she's a beater... But she was only $1400, and despite all this crap I absolutely LOVE the car, the way it handles and drives should only get better as I put more into her.
Draining and replacing the fluids, from brakes to radiator, is the first goal for this weekend. I also want to start the process of replacing all the hoses and belts I can. If the AC is still good I might even get that recharged.
Then I'd probably move on to overhauling the entire exhaust system, clean it all out, replace seals where it's needed, and maybe even drop some new parts if I can get them.
Then I think I should work on the fuel delivery system, replace the filters and injectors (maybe upgrade) and spark plugs and wires. I'll probably work on the timing and might have to do a little cleaning of the air intake system.
After that I should probably replace the fan clutch and fan blade.
After this I'll need to take a look at the transmission, clutch, and distro. Rebuilding this stuff isn't beyond me but this is probably the part I'll outsource to my homie because he really knows what he's doing and shifting gears is kinda important.
Electrically the car isn't in bad shape. It has a newer ECU and fuses. There's also a new alternator, distributor, and battery. Still, I'd like the dash lights to come on and for the ability to roll the windows up and down while driving. So electrical would be next on the list.
Finally I can hit the interior. I'll pull off all the door panels, fix the windows and maybe replace the electrical motors in the front. Then I'll get the dash worked out, get all the lights working, get a stereo installed, and get all my air controls working again. Might as well drop in the carpet kit and headliner while I'm at it. I dig the springy seats so I'll probably have them all reupholstered.
Finally... I'm going to give her a good ol' fashioned $100 Rustoleum paint job myself. My brother's Father-in-law painted cars for years and he has his own equipment and garage so I might just sack it up and spray on a real top coat. With the Rustoleum I've done my homework and I know it's more about time-in and expectations-out.
Thanks for hanging with my lengthy post. I could really use some input. Anything helps.
I'll have some pictures tonight or tomorrow once I get home and I can take them.
Really.... this sounds like a parts car.. and, not a really good one, at that...
1976 530i
Hello, I also have a '76 530i that I have been driving for the past 26 years. These are basically trouble-free cars once you address all the weak points. The cooling system is one of those. You can take the radiator to a shop and they can remove one of the side tanks and rod it out. Once you do that, your temperature will be a lot cooler. Thermal reactors were another problem; they got so hot that they cracked the cylinder head. Best solution is to take them out and install a set of regular exhaust manifolds.
I did a 5 speed conversion on my car, so I still have a good 4 speed gearbox and driveshaft in my garage. I also have the factory manual, so if you need any one section in particular, I can send you a copy. Good luck with your project and post some pictures when you can. Carlos Rubio
Gotta admire a bloke who loves a chalange.................
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The Civil Clinic offers law students the opportunity to represent low-income persons in a variety of cases and disputes. Students handle a mixed caseload of family law, public benefits and general civil cases.
Student comments:
"This was my last in court experience for the Clinic. It was a great way to end the excellent experience I have had in the clinic over the past year! I learned a lot since I began in the clinic last year. I feel much more comfortable in the courtroom than I did when I started. I learned many valuable lessons about the practice of law that will be beneficial when I start to practice on my own. I appreciate all of the hard work everyone involved with the clinic does. It has been such a great learning experience to be able to actually handle a case from start to finish and have our supervisor's direction through the process. I cannot imagine a better experience to prepare us for the real world than participating in the clinic. I have truly enjoyed every aspect of the experience!"
"I cannot even put into words how glad I am that I took the civil clinic coursework this semester. I have quite a few friends in professional school like medical school and dental school. I have always been envious of the practical experience those programs offer to their students and have said more than once that I would be willing (if you can believe it) to stay in school for one more year if it meant I could gain some sort of practical experience. Thankfully, I was able to gain that experience without the extra year because of the OU Legal Clinic. I have learned so much in the clinic, not specifically about the theory of law, but about procedure, deadlines and, most importantly, what it takes to work with people. My experience in the Clinic has been so unbelievably refreshing after being in the classroom for 2-and-a-half years. It has solidified in my mind that I want to be a lawyer. It has made me believe not only that I have the ability to practice law but also that I will be able to succeed."
"Working at the clinic this semester has provided me with great fulfillment and has reminded me of my purpose. Helping others is the real reason why we should embrace the law or whatever profession we embrace. It's not about money or material things we can gain; it's about people."
Client comments:
"You all have the best program and the best interns I have ever seen, and I could not have ever gotten an attorney anywhere else that could have done a better job. Thanks for everything you all have done for me."


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'Miller made several quality saves during three short-handed situations, including a 5-on-3, during the second. He also had a point-blank stop on Steven Stamkos in the third.'
Archives for February 2013
Myers scores go-ahead goal for Sabres
Buffalo 2, Tampa Bay 1
'Rolston, who replaced long-time Buffalo bench boss Lindy Ruff, had led the Sabres to back-to-back losses, but got 30 saves from Ryan Miller on Tuesday, as Buffalo snapped a four-game skid.'
Sabres Edge Lightning 2-1
'After skating to a scoreless 2nd period, Tyler Myers put Buffalo ahead very early in the final frame, ripping a shot into the Tampa Bay net 52 seconds in. Just moments after nearly tapping in a goal of his own, Thomas Vanek gained possession behind the Lightning net and fed Myers near the top of the faceoff circle. The Buffalo defenseman, after taking two penalties in the 2nd period, gave his team the lead for the first time.'
Sabres played looking for pace
'The Sabres kept skating until the Stamkos line put on a lot of pressure with about five minutes left. When Buffalo did get it out Hodgson went in alone only to be stopped by Garon.'
Rolston gets first win as Sabres edge Lightning
'Tyler Myers put broke a 1-1 tie and put Buffalo in the lead for good on the first shot for the Sabres in the final period, just 52 seconds after the faceoff. Myers took a pass from behind the Lightning net and one-timed it behind Mathieu Garon from the right faceoff circle.'
Rolston's first win snaps skid
'Tampa Bay came into the game with a league-high 69 goals scored, with their 33 third-period goals also tops in the NHL. Not only did the Sabres limit them to just one goal on the night, they held the Lightning off the scoresheet in the third after Tyler Myers scored what would end up being the game winner just 52 seconds into the final stanza.'
Wednesday's Rochester Coverage
Losing skid continues for Rochester Amerks (Rochester Democrat and Chronicle)
Palat is great as Syracuse Crunch streak reaches eight with 4-1 win at Rochester (Syracuse Post Standard)
Amerks fall to Syracuse, 4-1 (Amerks.com)
Ondrej Palat's hat trick lifts Crunch over Rochester (SyracuseCrunch.com)
Sunshine State could save season for Sabres
'"You need to have belief," winger Drew Stafford said Monday. "As bad as it gets, obviously we're not going to give up. We have the right guys in here that we can turn it around. We've done it before. … We've got roughly 30 games or so left and it's one of those things where it has to start tomorrow."'
Pardy's back to reinforce defense
'"It was frustrating," admitted Pardy, who was paired Monday with Mike Weber. "It's always frustrating when you get sent down. It's never easy to take but you have to use the time there to move forward and help yourself get better."'
Sabres' Rolston: 'It's going to be a process' improving
'"I know patience isn't big with anybody," interim coach Ron Rolston said Monday inside the First Niagara Center after the Sabres prepared for tonight's tilt in Tampa Bay against the Lightning. "It's not big with me. It's not big with fans. It's not big with media. But right now, it's going to be a process."'
Sabres summon Pardy from Rochester with Sulzer sidelined
'"You're always expecting injuries," said Pardy, who played his 184th NHL game on Feb. 5 before returning to the AHL. "It's going to happen at some point. You got to be ready for it either way. You don't know when it's going to come. You never want to see what's going on right now here with this start. It's tough for everybody. There's an opportunity for me here to come in and try to help out where I can."'
Tuesday's Tampa Bay Coverage
Preview: Lightning vs. Sabres (Tampa Bay Times)
Sabres-Lightning Preview (AP)
Buffalo Sabres (6-12-1) at Tampa Bay Lightning (9-8-1) (The Sports Network)
Sabres hope to right ship against Lightning (NHL.com)
Bolts vs. Sabres Preview (TampaBayLightning.com)
Sabres Vanek thinks it'll take .724 hockey to get into the playoffs
'"We don't have to kid ourselves, we have what, 29 games left? We probably need to win 21 of them to even have a chance. It's a big task, but I think this is a group that can put a streak together, but it starts with one. Not just to win, but it starts with having a good win, playing a good 60 minutes. A lot of our mistakes come from us turning it over and not getting out of the zone, but I don't think we're that far off. I know we've said that for week now and we keep losing, but as long as you believe, and I think the guys do then there's a chance."'
Sabres Vanek gets second day off in a row
'ek was given another day off after the team had Sunday off. When I asked him if he was hurting he said, "Yes, that's basically what it is, I'm trying to get better and ready for tomorrow." Ron Rolston said, "He's fine, just kind of a rest day, basically maintenance day for him."'
Sabres recall defenseman Adam Pardy
'Pardy (3/29/84, 6'4″, 226 lbs.) will join the Sabres for the second time this season after tallying an assist in his Sabres debut on Feb. 5 at Ottawa. Pardy has five points (1+4) and a plus-1 rating in 11 AHL games with the Americans.'


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Montecito 80" Rectangular Dining Set (Set of Table 2 Armchairs and 4 Side Chairs)
- No Longer Available -
Recalling the glamour of 1950s Hollywood, this iconic table features an angular solid brass frame for a tailored mid-century look.
Show Details +
- Table: 80"L x 44"W x 28"H
- Armchair: seat, 18"H; arm, 25"H; 24"W x 28"D x 31"H overall
- Side Chair: seat, 18"H; 20"W x 27"D x 31"H overall
Product Not Available
We're sorry. This product is no longer available
Please continue browsing.


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Yahoo! Go Version 2.0 : Coming this Friday
Rather than make a small device present Internet information like a larger screen PC, it puts all the important information and makes the most of small screen real estate. The use of specially-made widgets means getting to the web, emails, photos and news faster.
I'll wait for Friday before giving it my thumbs up.
In the mean time check Yahoo Go out for yourself.
Labels: mobile phone internet, surf internet, yahoo go


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Unique quilted heart makes a lovely cake, dusted with powdered sugar or decorated with frosting. The Quilted Heart pan is made of durable cast aluminum and has a premium nonstick interior, ensuring even baking results and easy release and cleanup every time you bake. 8 cup capacity. 11" x 10.875" x 2.25". Dishwasher safe. Made in the U.S.A.
- Item #: 7-NW-57848


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Details :
Title : Nuvve Nuvvu
Writer Name : Ch Karuna Sagar
Category : Poetry
Details :
Title : Nuvve Nuvvu
Writer Name : Ch Karuna Sagar
Category : Poetry
"kolpovadam ante oopiri povadame".... nice sagar garu
" nee mounam naa matanu mingesindi.., kolpovadam ante upiri povadame" very nice .. baga rasaru sagar
okko paragraph lo okko bhavanni imadchi rasaru sagar bagundi
Chala Bagundi
enti sagar garu manchi emotional ga rasaru enti katha :P..just kidding dont mind,its very nice
- Padmasri
This is a toy. It has more than 2 lobes consisting of bearings. They are available in various prices, shapes, weights, colours etc.
What is the use of this toy? As per my opinion this toy is a very famous time eating toy. There is a reason why I am saying this. First I say about som…
- B. Akhil Kumar
Education is the only way for the bright future. We know very well the importance of education in one's life. People and students might think that if you have strong desire for studying, you can gain knowledge and will be top student among all students even your studying center i…
- Padmasri
To have whatever we need, we do shopping. From grocery to everything we buy at stores and shops. If we have patience we go to ten shops until we get what we like. We will also be ready to spend huge money to buy the item if it deserves it.
When people do shopping they have to be awa…
- Padmasri
As per my opinion, everybody should have minimum knowledge of what are surrounding us. Today I wrote some things of spider. You know very well that spiders make house dirty. Yes they do. But, I am not talking about this thing.
The top 10 things of spider that we should know


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Fox Attempts To Reinvigorate Its Campaign Against Susan Rice
Fox News baselessly accused former U.N. Ambassador and potential National Security Adviser Susan Rice of willfully lying about the Benghazi attacks during her September 2012 Sunday news show appearances, despite it being widely reported that Rice used talking points approved by the intelligence community.
In fall 2012, Fox News claimed that Rice lied in her appearances on Sunday news shows because she asserted that the September attack on U.S. facilities in Benghazi, Libya was related to an anti-Islam video released days before the attacks. Her assertion was based on talking points [1] prepared after the attack by the intelligence community [2], who at the time believed the Benghazi attacks were inspired by protests [3] at the U.S. Embassy in Cairo which were linked to the video. Fox News ignored that evidence to smear Rice and claim that her Sunday show appearances disqualified [4] her from being Obama's Secretary of State nominee -- a nomination that Obama had reportedly considered [5] prior to now-Secretary of State John Kerry's nomination and successful confirmation.
Fox News has revived these attacks following a May 15 Foreign Policy The Cable blog post that reported [6] Susan Rice "has become heir apparent to National Security Advisor Tom Donilon":
"It's definitely happening," a source who recently spoke with Rice told The Cable. "She is sure she is coming and so too her husband and closest friends."
"Susan is a very likely candidate to replace him whenever he would choose to leave," agreed Dennis Ross, a former special assistant to President Obama and counselor at the Washington Institute. "She is close to the president, has the credentials, and has a breadth of experience."
On the May 20 edition of Fox & Friends, co-host Brian Kilmeade once again [4] attacked Rice over her Sunday show appearances. Kilmeade claimed that none of the recently released emails [7] that document the creation of Rice's Sunday show talking points mentioned that an anti-Islam video may have catalyzed the attack, and that therefore Rice made purposefully misleading claims. He also suggested that then-CIA Director Gen. David Petraeus questioned the veracity of the talking points based on changes made following "the State Department's urgings":
KILMEADE: Yeah the CIA signed off on them, Mike Morell, but you know what? The CIA's director at the time, David Petraeus, essentially said this after he got these back and seen how they changed with the State Department's urgings and possibly the White House's input. He said, why even bother? Should we even bother releasing this? That's how different they were from the facts as they knew them.
An on-screen graphic also claimed that Rice used "false talking points":
In fact, every version of the CIA talking points, including the version ultimately used by Rice, stated that the attacks [8] were "spontaneously inspired by the protests at the U.S. Embassy in Cairo," which had been triggered by the video. Indeed, the email [9] that Kilmeade referenced reveals Petraeus had reservations about the talking points because he thought they didn't do enough [10] to connect the Benghazi attacks to the demonstrations in Cairo and the anti-Islam video. Petraeus ultimately testified [11] before Congress in November 2012 that the intelligence community signed off on the final draft of the talking points.
- Posted In
- Cabinet & Agencies [12], National Security & Foreign Policy [13]
- Network/Outlet
- Fox News Channel [14]
- Person
- Brian Kilmeade [15]
- Show/Publication
- FOX & Friends [16]
- Stories/Interests
- Benghazi [17]


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Take your Binoculars: It's Prime Time for Birds at Smith and Bybee Lakes
Apr 9, 2013 at 5:43 PM 2 Comments
Did you know the largest urban wetland in the US is in Portland?
Located in North Portland's Rivergate area adjacent to the Columbia Slough, the nearly 2,000 acre Smith and Bybee Wetlands Natural Area is designated a state "Important Bird Area" by the National Audubon Society (see more info below). Troy Clark, president of the Friends of Smith and Bybee Lakes organization is a passionate advocate for the wetland and has a bird list that is a record of nearly weekly visits dating back 20 years. During a recent morning visit he identified 53 species while walking and paddling the wetlands!
Find opportunities to get involved with the Friends group and other partners on Metro's Green Scene calendar or go to http://calendar.oregonmetro.gov/events. This Saturday, April 13, two events are happening:
- Morning: Wetlands bird walk with Metro
- Afternoon: Painted turtle walk with Metro
And on Saturday, May 11 there's a wetlands wildlife exploration kayak tour (you don't even need a kayak!)
An Important Bird Area (IBA) is a site that has been selected for its outstanding habitat value and the critical role it plays in hosting birds during breeding, migrating, or over-wintering. Collectively the IBAs form a global network of critical habitat. The Important Bird Area designation is recognized internationally, and thousands of IBAs have been designated across Europe, Asia and North America. Today, there are more than 2,500 state-level IBAs in the U.S.and nearly 450 globally-significant IBAs in the U.S. The Audubon Society of Portland oversees the 97 IBAs that have been identified in Oregon.
Find out more:
Map and site descriptions for Oregon IBAs | Portland-area IBA map
Environmental Services and partners work to protect and enhance significant natural resources in the city, like Smith and Bybee Wetlands, which are part of the city's green infrastructure. Wetlands help filter water to protect water quality, public health and the environment--at the same time, they provide green space for people, birds and wildlife to enjoy.
Photo: Streaked horned lark, a candidate for Endangered Species Act listing that is found in the Columbia Slough Watershed.
2 Comments
Betty Eich
Terrific events planned! I wish we lived closer!
Penny Beckwith
Great post! Troy is also leading a Bring Your Own Boat Paddle for the Columbia Slough Watershed Council on April 24th 5:30-7:30. Bring your boat and come paddle with us on Smith Bybee! Here's the info: http://www.columbiaslough.org/calendardetail.aspx?calendarid=201
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Laguna Beach Police Officer Killed
LAGUNA BEACH (CNS) - A 41-year-old Laguna Beach police officer on his motorcycle was killed when his cycle crashed into a pickup truck, a police captain said today.
Officer Jon Coutchie ``was just traveling through town. His shift was going to end at midnight," said Laguna Beach police Capt. Jason Kravetz.
Officers arriving at the crash on South Coast Highway ran into a nearby supermarket to buy an American flag to drape over Coutchie's body, in honor of his service as an Army Ranger and as a Laguna Beach police officer for four years, Kravetz said.
The crash was on Laguna Beach's main street at the Cleo Street intersection at 11:34 p.m. Saturday, according to the Coroner's Office. The police officer died at the scene.
Coutchie had been going north on Coast Highway in an attempt to locate a vehicle which had eluded another officer, Kravetz said. While looking for the speeding vehicle, he crashed with a Chevrolet pickup truck at the intersection of Cleo Street
One witness told a television reporter that the pickup truck had been going south, and its driver was attempting to turn left when the crash occurred. The investigation was handled by the California Highway Patrol.
Coutchie was born on Oct. 2, 1971 in Tucson, Ariz., and was raised in Orange County. He graduated from Laguna Hills High School in 1989.
After the Sept. 11, 2001 terrorist attacks, he enlisted and became an Army Ranger, serving from 2003-2007. He completed tours of duty in Iraq and Afghanistan, the police captain said.
After being honorably discharged from the Army, he became a part-time jailer at the Laguna Beach Police Department. The department sponsored him through the Goldenwest Police Academy in 2008. He completed his training in March 2009 and was selected as a motor officer in March 2013, he said.
``We will forever miss and love Jon here at the police department and will grieve along with the citizens of this community," Kravetz said.
Posted by KFI NEWS Editor Sean B. Frank


text: The Week's Best Stories From NPR Books Ramona Quimby: The Mischievous Girl Next Door July 23, 2010 Ramona has been making trouble ever since the 1950s, when she first appeared in print. Now she's the focus of a new movie, Ramona and Beezus. In a revival of NPR's 'In Character' series, Elizabeth Blair takes a look at Beverly Cleary's most beloved creation. Ramona Quimby: The Mischievous Girl Next Door Listen · 4:25 4:25 Toggle more options Download Embed Embed <iframe src="https://www.npr.org/player/embed/128689937/128712817" width="100%" height="290" frameborder="0" scrolling="no" title="NPR embedded audio player"> Transcript


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So skipfish contains a file called http_client.c which makes a call to idna.h and idna.h can't be found. There are a few things you should check.
1) What do you get when you do a "echo $LD_LIBRARY_PATH" at a command prompt?
2) You should search (via find or locate for idna.h and see if it actually is on your system somewhere).
Also did you read the docs before playing with it?
How to run the scanner?
To compile it, simply unpack the archive and try make. Chances are, you will need to install libidn first.
Next, you need to copy the desired dictionary file from dictionaries/ to skipfish.wl. Please read dictionaries/README-FIRST carefully to make the right choice. This step has a profound impact on the quality of scan results later on.


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The term chemotherapy is used to describe cancer-killing drugs. Chemotherapy may be used to:
Depending on the type of cancer and where it is found, chemotherapy may be given in a number of different ways, including:
When chemotherapy is given over a longer period of time, a thin catheter can be placed into a large vein near the heart. This is called a central line. The catheter is placed during a minor surgery.
There are many types of catheters, including:
Different chemotherapy drugs may be given at the same time or after each other. Patients may receive radiation therapy before, after, or while they are getting chemotherapy.
Chemotherapy is most often given in cycles. These cycles may last one day, several days, or a few weeks or more. There will usually be a rest period when no chemotherapy is given between each cycle. A rest period may last for days, weeks, or months. This allows the body and blood counts to recover before the next dose.
Often, the chemotherapy is given at a special clinic or at the hospital. Some people are able to receive chemotherapy in their home. If home chemotherapy is given, home health nurses will help with the medicines and IVs. Patients and their family members will receive special training.
Because these medicines travel through the blood to the entire body, chemotherapy is described as a body-wide (systemic) treatment.
As a result, chemotherapy may damage or kill some normal cells, such as those found in the bone marrow, hair, and the lining of the digestive tract.
When this damage occurs, there can be side effects. Some people who receive chemotherapy:
Side effects of chemotherapy depend on many things, including the type of cancer, and which drugs are being used. Each patient reacts differently to these drugs. Some newer chemotherapy drugs that better target cancer cells may cause fewer side effects.
Your doctor and nurse will explain what you can do at home to prevent or treat side effects, such as:
You will need to have follow-up visits with your doctor and nurse during and after chemotherapy. Blood tests and imaging tests, such as x-rays, MRI, CT, or PET scans will be done to:
Perry MC. Approach to the patient with cancer. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier;2011:chap 182.
1000 Johnson Ferry Road NE
Atlanta, GA 30342
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