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Early systemic sclerosis: short-term disease evolution and factors predicting the development of new manifestations of organ involvement
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We investigated early systemic sclerosis (SSc) (that is, Raynaud's phenomenon with SSc marker autoantibodies and/or typical capillaroscopic findings and no manifestations other than puffy fingers or arthritis) versus undifferentiated connective tissue disease (UCTD) to identify predictors of short-term disease evolution.
Thirty-nine early SSc and 37 UCTD patients were investigated. At baseline, all patients underwent clinical evaluation, B-mode echocardiography, lung function tests and esophageal manometry to detect preclinical alterations of internal organs, and were re-assessed every year. Twenty-one early SSc and 24 UCTD patients, and 25 controls were also investigated for serum endothelial, T-cell and fibroblast activation markers.
At baseline, 48.7% of early SSc and 37.8% of UCTD patients had at least one preclinical functional alteration (P > 0.05). Ninety-two percent of early SSc patients developed manifestations consistent with definite SSc (that is, skin sclerosis, digital ulcers/scars, two or more teleangectasias, clinically visible nailfold capillaries, cutaneous calcinosis, X-ray bibasilar lung fibrosis, X-ray esophageal dysmotility, ECG signs of myocardial fibrosis and laboratory signs of renal crisis) within five years versus 17.1% of UCTD patients (X2 = 12.26; P = 0.0005). Avascular areas (HR = 4.39 95% CI 1.18 to 16.3; P = 0.02), increased levels of soluble IL-2 receptor alpha (HR = 4.39; 95% CI 1.03 to 18.6; P = 0.03), and of procollagen III aminopropeptide predicted disease evolution (HR = 4.55; 95% CI 1.18 to 17; P = 0.04).
Most early SSc but only a few UCTD patients progress to definite SSc within a short-term follow-up. Measurement of circulating markers of T-cell and fibroblast activation might serve to identify early SSc patients who are more likely to develop features of definite SSc.
anticentromere antibodies
American College of Rheumatology
alanine aminotransferase
antinuclear antibodies
acetylsalicylic acid
aspartate aminotransferase
area under the observed receiver operating curve
blood urea nitrogen
calcium channel blockers
confidence interval
diffusing lung capacity for carbon monoxide
- E/A ratiearly/(A
= atrial) late ventricular filling velocity ratio
erythrosedimentaton rate
European Scleroderma Trials and Research
forced vital capacity
hazard ratio
carboxyterminal telopeptide of type I collagen
low esophageal sphincter
nailfold videocapillaroscopy
aminoterminal propeptide of type III collagen
receiver-operating characteristic
Raynaud's Phenomenon
standard deviation
- sE-selectin
soluble E-selectin
- sIL-2Ra
soluble IL-2 receptor alpha
- SSc
systemic sclerosis
undifferentiated connective tissue disease
very early diagnosis of systemic sclerosis.
Raynaud's phenomenon (RP), which occurs in more than 95% of patients affected by systemic sclerosis (SSc), is the most frequent onset manifestation of the disease [1]. The identification of patients with secondary RP, who experience it as the first symptom/sign of SSc or of any other autoimmune systemic rheumatic disease, has long been recognized as a challenge for both the prevention and early treatment of such disorders [2]. Various attempts have been made to address this issue. Fine et al. [3] designated "prescleroderma" any condition characterized by RP, digital ischemic changes and SSc marker autoantibodies and/or capillaroscopic findings typical of the scleroderma pattern. Subsequently, LeRoy and Medsger [4] proposed that a condition characterized by RP and either marker autoantibodies or typical capillaroscopic findings be designated "limited" SSc to foster the inclusion of patients not meeting the American College of Rheumatology (ACR) SSc criteria [5] in clinical studies. A few years ago, Koenig et al. [6] validated the criteria proposed by LeRoy and Medsger [4] in a large prospective study, and found that RP patients with SSc marker autoantibodies and/or typical SSc capillaroscopic findings and no manifestation other than puffy fingers and/or arthritis, who will be referred to as early SSc patients in the present paper, developed definite SSc in 47%, 69% and 79% of the cases within 5, 10 and 15 years, respectively, from the onset of RP. Here we describe the evolution of the disease in patients with early SSc during a short-term follow-up. Specifically, we looked for baseline factors predictive of the development of further SSc manifestations in early SSc patients. To our knowledge, this topic has not been explored previously.
Materials and methods
All patients admitted to the Rheumatology Unit of the Second University of Naples for a suspected secondary RP from 1 November 2000 to 31 October 2010 were considered eligible for the study if they fulfilled LeRoy and Medsger's criteria [7] for RP, that is, bilateral, episodic bi- or triphasic color changes of fingers (pallor followed by dusky blueness and/or redness) induced by a cold challenge. Patients who met the ACR criteria for the classification of SSc [4] or any other connective tissue disease were excluded from the study, as were patients displaying any feature consistent with definite SSc [6], that is, skin sclerosis, digital ulcers/scars, two or more teleangectasias, clinically visible nailfold capillaries, cutaneous calcinosis, X-ray bibasilar lung fibrosis, X-ray esophageal dysmotility, ECG signs of myocardial fibrosis (cardiac blocks, Q waves), blood tests (serum creatinine) indicative of previous scleroderma renal crisis.
After giving informed written consent, according to standard clinical practice and to ensure a correct classification, the selected RP patients underwent: a detailed history and physical examination, to identify any of the previously listed clinical signs that excluded enrolment in the study, puffy fingers, and present or previous arthritis; routine laboratory investigations, devoted to exclude comorbidities and not relevant to the definition of the disease subset (that is, early SSc, definite SSc, UCTD), including blood cell count, urinalysis, blood urea nitrogen (BUN), serum creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), erythrosedimentation rate (ESR), serum protein electrophoresis with the evaluation of gammaglobulin concentration, serum C3 and C4 concentration; nailfold videocapillaroscopy (NVC) using an optical probe videocapillaroscope equipped with a ×200 magnification contact lens and connected to image analysis software (Videocap, DS MediGroup, Milan, Italy). The nailfold of the second, third, fourth and fifth finger was examined bilaterally in each patient. Four consecutive fields extending over 1 mm in the middle of the nailfold were studied per finger. The procedure was carried out by a physician (MI) experienced in NVC [8, 9, 10]; an autoantibody screening and profiling of sera collected at the first visit, performed as previously described [11], including antinuclear antibodies (ANA), SSc and other connective tissue disease marker autoantibodies, namely anti-Scl-70, anticentromere (ACA), anti-RNA polymerase III, anti-fibrillarin, anti-PmScl, anti-Th/To, anti-SSA, anti-SSB, anti-Sm, anti-Jo1, anti-U1RNP and anti-dsDNA antibodies; chest X-ray, barium esophageal X-ray and ECG to identify patients not eligible for the study because of findings consistent with lung, esophageal or cardiac SSc involvement as assessed by routine examinations and current treatment. Thus, patients satisfying the Koenig et al. criteria for early SSc [6], that is, RP plus either SSc marker autoantibodies and/or megacapillaries or avascular areas and no manifestation other than puffy fingers and/or arthritis, were enrolled in the study. In addition, patients who met the criteria for undifferentiated connective tissue disease (UCTD) (ANA positivity, but no SSc marker or any other connective tissue disease autoantibody, no scleroderma videocapillaroscopic findings or any clinical manifestation pathognomonic of any other connective tissue disease) [12, 13], were also enrolled in the study.
At baseline, all patients underwent B-mode echocardiography, lung function tests, and esophageal manometry. The detection of diastolic abnormalities at B-mode echocardiography, indicated by an inverted ratio between early (E)/late (atrial = A) ventricular filling velocity (E/A ratio < 1), in the absence of arterial hypertension, coronary artery disease and other symptoms/signs of cardiac disease, was regarded as early scleroderma heart involvement [14]. The detection of a diffusing lung capacity for carbon monoxide (DLCO) or a forced vital capacity (FVC) <80% of the predicted values in the absence of a smoking habit and/or obstructive lung disease at lung function study was regarded as SSc lung involvement [15, 16]. The detection of a basal low esophageal sphincter (LES) pressure <15 mmHg, with or without impaired peristalsis, at esophageal manometry was regarded as early SSc esophageal involvement [8].
Lastly, 45 out of the enrolled 76 patients (21 early SSc and 24 UCTD patients) and 25 controls, matched for sex and age and affected with osteoarthritis or primary fibromyalgia syndrome, were investigated for serum endothelial, T-cell and fibroblast activation markers, namely soluble E-selectin (sE-selectin); soluble IL-2 receptor alpha (sIL-2Rα); carboxyterminal telopeptide of type I collagen (ICTP), and aminoterminal propeptide of type III collagen (PIIINP). SIL-2Rα and sE-selectin concentrations were measured by a multiplex suspension immunoassay. The assay was based on the use of polystyrene spectrally encoded beads of 5 to 6 μm diameter as the solid support. Each bead was coupled with a capture antibody specific to the analyte of interest. A first incubation step allowed the binding of the analyte from the test sample to the solid support, then the complex bead-capture antibody-analyte was challenged with a biotinylated detection antibody. Finally, a streptavidin-phycoerythrin conjugate, the reporter molecule, was added to the system to complete the reaction on the surface of each bead, thus labeling the analytes (either sIL-2Rα or sE-selectin). The assay was read with a double laser-based instrument (Luminex 200, Luminex Corporation, Austin, Texas, USA), which identifies each bead by a distinct spectral region and quantifies the concentration of the bound analyte (pg/ml) by analyzing the fluorescence intensity of the streptavidin-phycoerythrin conjugate. Capture and detection antibodies directed against sIL-2Rα and sE-selectin were both originated in mice. All reagents for this assay were provided by Merk Millipore, Billerica, MA, USA. ICTP and PIIINP concentrations were measured by a conventional competitive radio-immunoassay (RIA) and expressed as μg/l, using the UniQ kits by Orion Diagnostica, Espoo, Finland. Again, none of the investigated activation markers contributed to the definition of the disease subset (that is, early SSc, definite SSc, UCTD).
Each patient was re-evaluated every six months for symptoms/signs of SSc or any other connective tissue disease, and underwent yearly ECG, chest and esophageal X-ray, and lung function tests. The follow-up status was assessed in December 2011.
The study protocol was reviewed and approved by the local Ethics Committee.
GraphPad Prism 5.0 (GraphPad Software Inc., San Diego, California, U.S.A.) and MedCalc 11.3 (MedCalc Software bvba, Mariakerke, Belgium) for Windows software were used for statistical analyses. Continuous data were expressed as mean ± SD and median with range, and were compared by Student's t-test or Mann-Whitney U test as appropriate. Categorical data were analysed by Fisher's exact test. Kaplan-Meier curves were used to describe the cumulative rates of SSc manifestations over time in the subgroups of patients, and the log-rank test was applied to analyse differences. Risk prediction was assessed by univariate and multivariate logistic regression analysis. Receiver-operating characteristic (ROC) curve analysis was performed to identify the cut-off values of both activation markers predicting the evolution of early SSc to definite SSc and their respective sensitivity and specificity. Statistical significance was expressed by a P-value < 0.05.
From 1 November 2000 to 31 October 2010, 76 patients with RP who fulfilled the entry criteria were admitted to the outpatient clinic. The cohort consisted of 74 women and 2 men, aged from 17 to 73 years (median 41 years), with a disease duration from RP onset ranging from 0.5 to 30 years, (median 3.5 years). Thirty-nine (51.3%) of them fulfilled the criteria for early SSc and 37 (48.7%) for UCTD.
Epidemiologic, clinical, laboratory and capillaroscopic features at presentation of early SSc and UCTD patients
Early SSc
(n= 39)
(n= 37)
Sex: F/M
Age; years (median; range)
41 (17 to 73)
38 (18 to 71)
RP duration; years (median; range)
3 (0.5 to 24)
4 (0.5 to 30)
Puffy fingers
ESR >20 mm/h
Gammaglobulins >1.5 g/dl
C3 <80 mg/dl or C4 <15 mg/dl
38 (97.4)
37 (100)
ANA titre (median, range)
SSc-marker antibodies +
(1:80 to 1:5,120)
(1:80 to 1:5,120)
< 0.0001
36 (92.3)
< 0.0001
Anti-Scl-70 +
26 (66.7)
8 (20.5)
1 (2.6)
1 (2.6)
NVC SSc pattern
23 (59)
< 0.0001
Megacapillaries + avascular areas
19 (48.7)
< 0.0001
Avascular areas or megacapillaries
4 (10.2)
Smoking habit
17 (43.5)
13 (35.1)
Preclinical alterations of heart, lung and esophageal function in early SSc and UCTD patients
Early SSc
(n= 39)
(n= 37)
E/A ratio <1*
2/31 (6.5)
1/26 (3.8)
11/39 (28.2)
10/37 (27)
1/39 (2.6)
1/37 (2.7)
Basal LES pressure <15 mmHg
11/36 (30.6)
4/27 (14.8)
One or more functional alteration
19/39 (48.7)
14/37 (37.8)
Endothelial, T-cell and fibroblast activation markers in early SSc, UCTD patients and controls
Early SSc
(n= 21)
(n= 24)
(n= 25)
sE-selectin (pg/ml)
median (range)
0.732 (0.35 to 1.2)
0.87 (0.32 to 1.99) #
0.806 (0.4 to 1.76)
sIL-2Rα (pg/ml)
median (range)
239 (66.7 to 1,002)
346 (14.3 to 931)
301 (17.9 to 807)
ICTP (μg/l)
median (range)
3.998 (1.88 to 10.5)*; °
2.86 (1.17 to 4.25)
3.21 (1.39 to 5.27)
PIIINP (μg/l)
median (range)
1.491 (0.002 to 5.43)
1.66 (0.01 to 2.98)
1.65 (0.35 to 7.49)
Early SSc patients were monitored for between 1 and 8 years (17 patient-year; median 3 years); UCTD patients were also monitored for between 1 and 8 years (14 patient-year; median 2 years). Fifteen out of 39 (38.5%) early SSc and 20 out of 37 (54.1%) UCTD patients were followed for at least five years. At December 2011, one patient with early SSc had died from pulmonary thromboembolism secondary to deep vein thrombosis; and another early SSc patient was lost to follow-up.
After enrolment, all patients were treated with 100 mg/day acetylsalicylic acid (ASA) and calcium channel blockers (CCB - either nifedipine 20 to 60 mg/day or amlodipine 5 to 10 mg/day) for RP. The four UCTD patients presenting with arthritis were also treated with hydroxychloroquine (HCQ) 6.5 mg/kg/day.
Manifestations of definite SSc at routine examinations in early SSc and UCTD patients at follow-up
Early SSc
(n= 39)
(n= 37)
1° y
2° y
3° y
4° y
5° y
1° y
2° y*
Digital ulcers/scars
5 (12.8)
1 (2.7)
Teleangeactasias (≥2)
14 (35.9)
Skin sclerosis
4 (10.2)
mRSS (median, range)
(2 to 8)
(2 to 8)
Chest X-ray bibasilar lung fibrosis
2 (5.1)
1 (2.7)
Esophageal dysmotility at barium X-ray
3 (7.7)
3 (8.1)
Cardiac blocks and/or Q waves
2 (5.1)
30 (76.9)
5 (13.5)
< 0.0001
Finally, we evaluated whether the serologic, capillaroscopic, clinical and functional parameters were predictive of the development of additional clinical and/or functional alterations in patients with early SSc. The HR was significant for PIIINP (HR = 4.55; 95% CI 1.18 to 17; P = 0.04), sIL-2Rα (HR = 4.39; 95% CI 1.03 to 18.6; P = 0.03), and avascular areas (HR = 4.39; 95% CI 1.18 to 16.3; P = 0.02). No factor was associated with the development of additional manifestations in patients with UCTD.
In order to evaluate the cut-off value with higher sensitivity and specificity of each activation marker potentially useful in predicting the development of further SSc manifestations in the short term, we performed a ROC analysis for each marker, but we found inconsistent results for both sIL-2Rα (area under the observed receiver operating curve (AUC) 0.6250) and PIIINP (AUC 0.5515), possibly because of the low number of patients investigated for each marker who did not develop any manifestation during follow-up (4/21 of those evaluated).
The aim of this study was to investigate the disease course in patients with strictly defined early SSc compared to patients with UCTD during the five years after presentation, and to look for baseline features predictive of further organ involvement. The results reported herein confirm, in a larger population, our previous data on the prevalence of preclinical organ involvement in early SSc [11] and demonstrate that preclinical, scleroderma-type, functional heart or lung or esophageal abnormalities are common both in patients with early SSc and in patients with UCTD. Impaired left ventricular filling, as the earliest finding of SSc myocardial disease [17], and/or a reduced DLCO, as the earliest finding of SSc pulmonary involvement [16], and/or a reduced basal LES pressure, as the earliest detectable SSc esophageal abnormality [18], were detected in 19/39 (48.7%) early SSc and in 14/37 (37.8%) UCTD patients (P > 0.05). Therefore, both patients with early SSc, who have recently been shown to be at very high risk for developing definite SSc during a long-term observation, that is, 10 and 15 years [6], and patients with UCTD, who have a much lower risk of developing definite SSc, may already have a preclinical scleroderma-like internal organ involvement at presentation. Our results indicate that, at presentation, patients with early SSc do not differ in any aspect from patients with UCTD. Of note, however, a reduced basal LES pressure at enrolment was approximately two-fold more frequently observed in early SSc than in UCTD patients (11/36 - 30.6% versus 4/27 - 14.8%; P = 0.23). This suggests that a subclinical scleroderma-like esophageal involvement in early SSc, as compared to UCTD patients, could be statistically significant in a larger cohort study.
The above findings were not entirely unexpected. In various studies of patients with RP, lung function alterations were more prevalent in, but not exclusive to, patients with typical capillaroscopic abnormalities and/or marker autoantibodies [19, 20, 21, 22, 23, 24, 25, 26].
We also found that circulating markers of endothelial, and B-cell (gammaglobulins) and T-cell (sIL-2Rα) responses are altered in some patients with early SSc or UCTD, whereas abnormalities in circulating markers of fibroblast activation, namely ICTP ± PIIINP, appear to be restricted to early SSc. However, these findings must be interpreted with caution, due to the small number of our test sera.
We found that patients with early SSc developed manifestations consistent with definite SSc in a significantly higher percentage than patients with UCTD (92% vs 17.1% at five years). Therefore, even preclinical internal organ involvement does not seem to differ in patients with early SSc with respect to those with UCTD, the disease course is quite different. It is noteworthy that the drugs prescribed at admission in patients from both groups (calcium channel blockers, ASA) are not known to influence the disease course.
We also investigated the predictive role of any parameter evaluated at presentation for the development of further scleroderma-like manifestations. We did not find any parameter predictive of further disease manifestations in patients with UCTD. Instead, the presence of avascular areas at nailfold capillaroscopy and of increased serum levels of PIINP and sIL-2Rα was significantly associated with an increased risk of developing definite SSc in patients with early SSc. These results suggest that patients with early SSc should undergo evaluation of fibroblast and T-cell activation markers. Further studies on larger cohorts are required to define the role of these and other potential activation markers, not assessed in our study, in the identification of patients at risk for developing definite SSc.
We detected a higher incidence of definite SSc with respect to Koenig et al. [6]. In fact, 47% of their patients with early SSc and 4% of their patients with UCTD had developed definite SSc at five years. This discrepancy probably depends on two factors: first, 93.45% of the patients studied by Koenig and colleagues had been referred by primary care physicians, whereas our Unit is a tertiary referral center; second, the prevalence of anti-Scl-70 positivity has long been known to be much higher in Italian (25%) [27] than in French Canadian (9.7%) patients [10].
Taken together, our results indicate that patients with early SSc or UCTD in whom a scleroderma-like functional internal organ involvement has been detected should be regarded as being affected by SSc and, therefore, challenge the time-honoured practice of calculating the duration of SSc starting from the first non-RP symptom. In addition, from a clinical point of view, our data suggest that internal organ involvement should be assessed by sensitive and specific functional studies in patients presenting with early SSc or UCTD in order to identify any early alteration. Recently, researchers from the European Scleroderma Trials and Research (EUSTAR) group proposed criteria for the very early diagnosis of SSc (VEDOSS) [28], namely RP, puffy fingers, marker autoantibodies and typical capillaroscopic alterations. In this context, based on our findings, we would label "very early SSc" the 20 SSc patients with early SSc who did not display any functional alteration and "early SSc" the 19 patients with RP and any associated functional alteration despite the absence of any sign/symptom. We failed to identify parameters associated with preclinical internal involvement in patients with early SSc or UCTD. Hopefully, the VEDOSS study, which includes a much larger number of patients, will succeed in this task.
In conclusion, the results of our study should prompt the clinician to investigate early SSc patients for preclinical, functional internal organ involvement and to put them under strict surveillance.
This study was supported by the Italian Foundation for Arthritis Research (FIRA).
Supplementary material
Copyright information
This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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Unearthen Mini Spectra Ring with Smokey Quartz
Unearthen Mini Spectra Ring with Smokey Quartz
Mini Spectra ring from Unearthen set with a Smokey Quartz in a Sterling Silver band. Each piece is unique and handmade in Los Angeles. The Smokey Quartz is known as a stone that penetrates, dissolves, and transforms negative emotions and emotional blockages.
Saint Cloud
Talk about heaven sent. Houston's Saint Cloud boutique is full of lust-worthy jewelry, accessories and home goods. Creative Director Cecilia Marquez and her partner, Jessica Rodriguez, artfully curate the gorgeous shop to offer small luxuries produced with thought and care from all over the world.
Do you have questions about this product? We're here to help!

subset: commoncrawl


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An Online Learning Community and Course (October 2016 – February 2017)
Program Overview
The Integrative Medicine Scholars Program is an online series of interactive lectures and activities that will widen scholars' understanding of Complementary and Alternative Medicine (CAM). The goal of the program is not only to introduce the scholar to various methods of treatment, but also to encourage and facilitate use of self-care techniques. Webinar sessions will enlighten students about various CAM techniques and Integrative Medicine topics, each presented by expert physicians, scientists, and practitioners. Additionally, each scholar will be highly encouraged to experience a new Integrative Medicine modality of their choice (e.g., yoga, tai chi, acupuncture). Our perspective is that Integrative Medicine is the future. It is our responsibility as future physicians to adopt a commitment to self-care and a mind-body-spirit approach to patient care. We hope you will join us on this exciting journey, and be open to new experiences, connections, and ideas about health and healing.
What should I expect?
The program will consist of one or two 2-hour online webinar meetings per month. The webinars will be held on Wednesdays from 8-10 pm EDT/EST from October 2016 through February 2017. Webinar sessions will be led by a guest physician, scientist, or expert on the given topic. Prior to the meeting, scholars will be expected to review material (articles, videos, discussion forums, etc.) assigned by the speaker. Preparation for each webinar should take an hour of your time or less. During the presentation, scholars are given the opportunity to share experiences, to ask questions, and to reflect. Group sessions may be small (8-10 participants) or large (all participants). Additionally, scholars are expected to watch a documentary (typically two hours long) chosen by the course directors. Participants are expected to use the knowledge acquired during the program to create the final project (Project-in-a-Box) which can be presented to other students and/or at AMSA National Convention in February 2017. Depending on the participant's idea, the project can take a few hours or a few weeks to create.
Why will I LOVE this Scholars Program?
By the end of the program, students should be able to:
- Develop a broader knowledge and deeper understanding of Integrative Medicine.
- Introduce others to alternative medicine modalities with confidence and insight.
- Understand the strengths and limitations of applying evidence-based medicine principles to the circumstances of an individual patient.
- Develop a respect for the potential of different healing modalities for patients.
- Become leaders in Integrative and Mind-Body-Spirit patient care.
For More Information, Download the Program Syllabus
|Program Registration
|AMSA Student Member
* Non-member fee includes AMSA membership, if applicable


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This comfortable city hotel is the perfect place to take a rest in after work or sightseeing around Krakow. The air-conditioned hotel was built in 2012 and comprises a total of 48 rooms. Guests are welcomed in the lobby, which offers a 24-hour reception and a hotel safe as well as a cloakroom and lift access to upper floors. It offers a restaurant, a pub and café with breathtaking views of the city's panorama. Among its facilities, guests can enjoy its terrace and a well-equipped conference hall perfectly suited for conferences, trainings, banquets and other business and social events. Airport shuttle and city tours can be organised at the front desk. Wireless Internet access is also available.
As the name suggests, the hotel is located at the foot of Wawel Hill. It occupies a location 700 m from the beach on the Vistula river bank and is a 10-minute slow walk from the Market Square. It is moreover situated 400 m from the platform of the panoramic balloon, 80 m from Vistula river bank, 400 m from Krakow's Planty's and 10 km from the Wieliczka Salt Mine. For public transportation, guests will find the water tram stop 70 m away, while the underground station and guarded parking is 50 m away. Balice Airport is 15 km from the hotel.
The hotel offers accommodation in single, double and twin rooms. All rooms are well equipped so that guests have the best conditions both for relaxation and work. Each room, regardless of the type, comes en suite with a shower and a hairdryer and is equipped with individually controlled air conditioning and heating, satellite TV, a radio, Internet access as well as tea and coffee making facilities.
Guests can relax in the sauna.
The hotel serves a breakfast buffet, while the lunchtime and evening meals can be enjoyed á la carte.
In the hotel payment can be made by Polish z?oty. The hotel accepts American Express, Diners Club, JCB, MasterCard and VISA for credit card payments.
From Krakow airport: Head east towards the A4 motorway - Rzeszow direction. After 4.5 km take a slight right turn towards Mirowska - Krakow centrum direction. After 400 metres turn left and head towards Mirowska. Continue straight onto Mirowska for 1.9 km. Turn right onto Ksiecia Jozefa and continue for 1.4 km. Continue onto Route 780 for 3.3 km. When guests see the Wawel Hill go straight through the junction to the old town. Turn right onto Straszewskiego and after 400 m turn right again. Turn right again after 150 m. The hotel will be on the right.
Check-in starts at 2 pm and check-out is until 12 pm. Hotel staff can help with organising trips around Krakow and neighbourhoods such as Wieliczka and Oswiecim. Above all, there is the possibility of ordering transport from/to Balice Airport or the railway station.
Room Facilities:
Satellite cable TV
Internet access
Tea Coffee
Central airconditioned
Individual airconditioned
Disabled bathroom


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WATERBURY, Conn. – Lilly Mae Louise Caruso-Ciminera passed away peacefully Jan. 18, 2013, in Prospect, Conn., with her son, Pasquel, by her side. Lilly was born April 28, 1924, in Bangor, to Lilly and Pasquel Caruso.
She leaves two sons, Anthony and Pasquel who reside in Connecticut. Surviving, in addition to her sons, are sisters, Jeannette Perry of Florida, Marlene Sonderman of Prospect, Conn., and Theresa Griebler of Minnesota; one brother, John Caruso of Brewer; two grandchildren, three great-grandchildren, many nieces and nephews.


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News Archive
July 30th development release: ActionScript 3
July 30th, 2006
Got another development release for you. The big change in this one is the ActionScript parser has been upgraded to support version 3. It has support for regular expressions, XML literals, constants, and other goodies as described on the development page. It even supports .mxml files in addition to .as files, so you can use Natural Docs in <mx:Script> blocks or even in plain XML comments.
The other features are pretty minor. There's an -oft (--only-file-titles) command line option that lets you force the source file name to always be the page and menu title. The search results will try to dynamically update rather than reloading the page every time. The search box was tested and tweaked for IE 6 and 7, Firefox 1.5, Opera 9, 8.5, and 8, and Konqueror 3.5. You can now use braces and parenthesis in your file names without killing the menu.
- Greg
|Copyright © 2003-2011 Greg Valure


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Skip navigation.
Enrollment numbers for the 2015 spring semester at Northwestern Oklahoma State University are similar to a year ago.
In a preliminary enrollment report to the Oklahoma State Regents for Higher Education, Northwestern reported 1,964 students enrolled in spring semester classes, compared with 1,993 a year ago.
A vibrant regional economy continues to attract some potential college-bound students into the workforce.
"It's a very competitive environment for students," Dr. Janet Cunningham, university president, said. "However, we are seeing some positive signs that indicate interest among current high school seniors is high, and that students who previously entered the workforce are looking to return."
Enrollment by campus shows 1,260 students in Alva, 259 enrolled at Enid and 215 attending classes in Woodward.
Two bright spots in enrollment included enrollment at outreach sites and in concurrent classes.
Enrollment at Northwestern's outreach sites, including the University Center of Ponca City, rose more than 9 percent to 177 students. The number of high school students enrolled in concurrent classes increased nearly 18 percent to 86 students.
MISSION STATEMENT: Northwestern Oklahoma State University provides quality educational and cultural opportunities to learners with diverse needs by cultivating ethical leadership and service, critical thinking and fiscal responsibility.


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- For the Skip Sandwich DX's less powerful version, see Skip Sandwich.
|Skip Sandwich DX
|Appears in
|HP recovery
|Sells for
|Best Condiments
|Jar of Delisauce
Tin of Cocoa
|Dropped from
|Ego Orb (8/128 chance)
High-class UFO (4/128 chance)
|Gives you a spring in your step for about 20 seconds. It also helps you recover your power a bit.
The Skip Sandwich DX (also referred to as the Skip Sandwich Deluxe) (Japanese: ダブルスキップサンド) is an HP recovery item in EarthBound. When a character eats it, they recover 6 HP. If this is used in the overworld, it has the additional effect of making the entire party increase their moving speed to a run for twenty seconds. There is also an item called the Skip Sandwich that restores an equal amount of HP, but only lets the party run in the overworld for ten seconds.
Skip Sandwich DXs can be obtained in many places: they are sold in Winters, Fourside, and Summers for $98, they can be dropped by defeated Ego Orbs and High-class UFOs with a 8/128 and 4/128 chance respectively, and they can be found in a Gift box in the Dusty Dunes Desert and in a coffin in the passage between Threed and Grapefruit Falls.
- Main article: Skip sandwich
Skip sandwiches can be used to perform a glitch to slip through cliffs to reach inaccessible areas.


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JAY Z: Five Percenter Drama
JAY Z: Five Percenter Drama
Jay Z has been spitting lyrics about the Gods and Earths for years, but the New York Post apparently didn't realize the rapper had ties to the Five Percent Nation until now.
Alarmed by the sight of Jay wearing a Five Percenter medallion at a recent Brooklyn Nets game, the Post published an article this weekend investigating Jay's ties with to a group. The paper writes that the group's core belief is that "black people are the fathers and mothers of civilization, white men are the devil, the Christian god is nothing more than a ghost and only a small percentage of people understand the world."
After exploring the group's Harlem roots and relationship to the Nation of Islam, and emphasizing its anti-white views, the paper says that Jay replied "a little bit" when asked if the medallion had any significance to him.
The Post also contacted Saladin Allah, a spokesperson for the Five Percent's upstate branch. He says, "Jay Z is not an active member — no one has vouched for him. It was always understood that you don't wear the regalia if you don't totally subscribe to the life."
TeeRoy's 2 Cents:
- Jay Z is has rocked that chain before. Guess no one in the mainstream press realized what it means before.
- The Post is just trolling on this one.
- People have talked about Jay's link to the Five Percenters for years.
- This must be why he recorded and toured with Justin Timberlake.


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13-Day Mexico Adventure: Puebla - San Cristobal - Oaxaca - Merida
Mexico City
Summary of The Day: There are no scheduled activities on the first day of the tour. On arrival please ask reception when the pre-departure meeting will be held.
Mexico City is the world's most populated city with over 20 million people. Founded by Spanish conquerors in 1521, Mexico's capital sits at 7,575 feet above sea level and was built on the site of the ancient Aztec capital of Tenochtitlan. The extensive metro system and trolley buses make getting around easy and fun.
A good starting point is the main plaza - the enormous Zocalo - where you will find the impressive Metropolitan Cathedral sporting a magnificent Latin-Baroque style facade. Remember to look through the glass flooring outside of the church to see the ancient Aztec city beneath. Just behind the cathedral are the Aztec ruins of ancient Teocali, discovered in 1978. Other points of interest include the world-famous Anthropology Museum and the National Palace, where you can see murals depicting the history of Mexico by one of the country's most famous artists, Diego Rivera. A museum dedicated to his equally famous wife, Frida Kahlo, is located in Coyoacan, her childhood home. In the evening you can enjoy a spicy Mexican dinner and maybe a few tequilas in Zona Rosa.
- Tips:
- Meeting point: Hotel El Salvador, Republica del Salvador 16, Centro Historico de Mexico, C.P 06080, Mexico City. Please double-check your voucher for necessary details regarding accommodations of the days following. All hotels provided are of a 3 star standard.
- Hotel:
- Hotel El Salvador or similar
Visiting Attractions
Mexico City - Puebla
Summary of The Day: En route to Puebla we'll stop to tour the ancient site of Teotihuacan, an abandoned city built around 300 BC by a civilization now lost in the mists of time. The complex is a fascinating combination of ceremonial pyramids connected by the Street of the Dead, palaces, old temples and the Plaza of the Sun. The buildings are decorated with friezes and other ornate artworks.
We'll continue on to one of Mexico's oldest towns: Puebla, set in a valley with dramatic volcanoes and snow-topped peaks as the backdrop. The historic city center has been listed as a UNESCO World Heritage site thanks to its immaculately-preserved Spanish colonial architecture. Puebla is the best place to try mole poblano, a rich, spicy sauce containing chocolate, cinnamon and nuts, as well as different types of hot peppers, often served over chicken.
Visiting Attractions
Summary of The Day: Next up is Oaxaca, a beautiful city bordered by mountains and thick forests. The pleasant Plaza de la Constitucion offers the best in food and drink while you watch the world go by. Our program includes a guided excursion of Monte Alban, the holy city of the ancient Zapotecs. There are many structures to explore around the Grand Plaza including tombs, ceremonial altars, tunnels, pyramids and palaces, many decorated by glyphs, paintings and intricate carvings.
Visiting Attractions
Night Bus to San Cristobal
Summary of The Day: After enjoying our time here we take a night bus bound for San Cristobal de Las Casas.
San Cristobal
Summary of The Day: Ascending into the mountainous Chiapas region we arrive at the fascinating colonial city of San Cristobal de las Casas. Situated in the middle of the highlands, surrounded by 21 indigenous villages with distinct languages, dress and customs, here you will find some of Mexico's richest examples of indigenous culture. Red-tiled houses painted in brilliant colors dominate the city, maintaining a delightful provincial charm.
There is also an option to cruise along the stunning Sumidero Canyon on speedboat along an 18-mile section of the Grijalva river to the hydro-electric dam, with plenty of opportunities to photograph local wildlife such as birds, crocodiles and iguanas.
San Cristobal
Summary of The Day: Today's program includes a tour of the nearby villages, where you can buy beautifully-made local handicrafts and get a true feel for how modern descendents of the ancient Maya people live today.
San Cristobal
Summary of The Day: Our exploration of San Cristobal continues.
Summary of The Day: Next we'll visit the town and ruins of Palenque, famous for the tombs found filled with the treasures honoring the renowned Lord Pakal and the Red Queen. This archaeological site houses more than 200 structures including a series of hilltop temples, towers, tombs and pyramids. Decorated with elaborate friezes, sculptures and inscriptions, Palenque is unquestionably one of the most important Mayan archaeological sites. Paths cutting through the jungle lead to various temples and gorgeous waterfalls, where over time, strange figures have taken shape in the rocks.
Other attractions near Palenque include the fantastic Agua Azul Nature Reserve with more than 200 small waterfalls, and the incredible Misol-Ha waterfall with a nearly 100-foot drop (optional half day tour includes both these falls).
Visiting Attractions
Summary of The Day: Our exploration of Palenque continues.
Visiting Attractions
Palenque - Merida
Summary of The Day: Capital of the Yucatan province, Merida is a pleasant mixture of colonial buildings, churches and plazas. The markets simply overflow with beautiful weavings, hammocks and batiks, making this a great place to buy handmade crafts and souvenirs. At night the city comes alive with live theater and concerts. There are many excursions on offer here, from a comprehensive hop-on, hop-off tour of the city to a relaxing horse-drawn carriage tour around the cobbled streets of El Centro and Pasaje Montejo Boulevard. If you want to explore the region near Merida you could visit the small fishing town of Celestun with its large flamingo population. Alternatively, you may opt to take a dip in the local cenotes, or freshwater swimming holes connected by spectacular limestone caverns and deep underwater rivers once sacred to the ancient Maya, covering the entire Yucatan peninsula.
Visiting Attractions
Summary of The Day: Our exploration of Merida continues.
Visiting Attractions
Merida - Cancun
Summary of The Day: Up until 1970, Isla Cancun was home to the caretakers of the coconut plantation with only 117 people living in nearby Puerto Juarez, a fishing village and military base.
Today over two million visitors a year come to Cancun to relax on one of several beautiful beaches and swim in the turquoise waters. If Cancun becomes too much for you, you can always take a ferry out to the more relaxed Isla Mujeres or arrange a snorkeling or diving excursion.
We'll travel first to Chichen Itza, an impressive Maya-Toltec site recently voted one of the New Seven Wonders of the World. Constructed between the 7th and 10th century AD, Chichen Itza was a center of pilgrimage for the Maya for over one thousand years. Among the sights your local guide will point out during the tour of the site are the ball court where the captain of the winning team was beheaded and the sacred cenote where treasures and the remains of human sacrifices have been discovered. The most famous attraction is the great Pyramid of Kukulcan, dedicated to the feathered serpent god Kukulcan and built with such precision that a shadow serpent descends down the steps during the equinox.
Visiting Attractions
Summary of The Day: Your adventure of a lifetime comes to an end today. If you have a late flight or have lengthened your stay by adding post-tour accommodations, you will have more time to explore the sights.
Visiting Attractions
Standard Price/Person By Occupancy
Pre-/Post- Accommodation
* You must be at least 18 years old to join the tour.
* Single Occupancy price applies when one people stays in one standard hotel room.
* Double Occupancy price applies when two people stay in one standard hotel room.
- Guided tour of Teotihuacan ruins
- Guided tour of Monte Alban ruins
- San Cristobal village tour
- Guided tour of Palenque ruins
- Guided tour of Chichen Itza
- 11-night accommodations (hotels, hostels, guesthouses
- One night on an overnight bus
- 9 breakfasts
- Travel by public bus, taxi
- English-speaking local guide(s) on included excursions
- Airfare and the cost of other transportation between your home and departure city
- Tips
- Visa fees
- Travel insurance
- Airport transfers and pre and post-tour accommodations
- Personal expenses
- Optional excursions (prices and availability subject to change): - Na Bolom Museum: USD 5.00/person
- Canyon Sumidero: USD 22.00/person
- Agua Azul and Misol Ha waterfalls: USD 15.00/person
- Anthropological Museum: USD 3.00/person
- Uxmal ruins: USD 45.00/person
- Cenotes: USD 50.00/person
- Merida hop-on hop-off: USD 10.00/person
- Isla Mujeres: USD 7.00/person ferry
- Xelha Theme Park: USD 75.00/person
- Xcaret Theme Park: USD 75.00/person
- Swimming with whale sharks (May - Sep): USD 150.00/person
- Cancellation Policy:
- 27 Days Prior to Departure Date - 100% of Reservation Cost
- 28-59 Days Prior to Departure Date - 50% of Reservation Cost
- 60 or More Days Prior to Departure Date - 10% of Reservation Cost
- This is an adventure tour. We see a destination from the locals' perspective using a variety of transport, staying in small, locally-owned guesthouses.
- Maximum group size is 16 people.
- Travel insurance is a compulsory requirement for all bookings.
- You are required to purchase comprehensive travel insurance before travelling with us and provide details of your insurance to your tour leader at the beginning of your tour.
- Please make sure you know exactly what you are covered for, remembering there are many adventure activities available during the tour which may not be covered by basic insurance. Make sure that your travel insurance covers general medical expenses, hospitalizations and medical evacuations. Also ensure that you are covered for travel at high altitudes if necessary for your tour.
- A suitable insurance policy should provide adequate cover for medical expenses arising through illness or accident prior to or during the holiday and loss of holiday monies through cancellation or curtailment of the holiday for insurable reasons. You must be in possession of a travel insurance policy that includes a minimum of £100,000 (or equivalent currency) in cover for any medical expenses that you might incur when travelling, and for repatriation to your home country in the event of a medical emergency.
- Detailed itineraries are provided in good faith and it is our intention to adhere to the published route. Changes may be made before or during your tour for operational or safety reasons. Impromptu changes may also occur whilst you are travelling as a result of one-off circumstances such as an excursion being closed on a particular day, weather conditions or transport. Delays are rare but occur occasionally and for this reason and the reasons above this itinerary should be considered as a guide only. Published transport times are approximate and may vary depending on local conditions.
- We recommend that you obtain some Mexican pesos as soon as you arrive at Mexico City International Airport. There are numerous international ATMs inside the airport, as well as exchange booths offering a good rate.
- If you have booked an airport arrival transfer, please look out for someone with a sign which has your name, local operator name, or both after exiting the customs hall. If you are likely to be delayed by more than two hours, please contact the emergency number at least six hours before arrival. If we are advised in time, we will make every effort to reschedule your transfer and your driver will be asked to wait for two hours after your new expected arrival time. However, if we are not made aware of any change, the driver will only wait for two hours after the original scheduled arrival time and after this point it will be up to you to arrange transport to your hotel at your own expense.
- To protect your personal property, please carry all valuable items on your person at all times. Do not leave any valuable items on the bus or at the hotel, attraction or restaurant. Tours4Fun, local operators, drivers and tour guides are not responsible for any loss or theft at any location.
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There are many important dates and deadlines to keep track of as a parent and student. This page contains our 2016-2017 school calendar from the start of school, grading periods, test dates, federal/state holidays, and other events that is happening at BASIS Oro Valley. Click on the link below to view the 2016-2017 school calendar. We have posted our proposed 2017-2018 school calendar. Click on the link below to view the 2017-2018 calendar.
BASIS Oro Valley & Oro Valley Primary 2016-2017 School Calendar
BASIS Oro Valley 2017-2018 Proposed School Calendar
BASIS Oro Valley Primary 2017-2018 Proposed School Calendar


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The Epistle To The Romans Chapter 15:23-33 (24 of 25) by Harley Howard
This content is part of a series.The Epistle To The Romans Chapter 15:23-33 (24 of 25)
Harley Howard
23 But now having no more place in these parts, and
having a great desire these many years to come unto
24 Whensoever I take my journey into Spain, I will
come to you: for I trust to see you in my journey, and
to be brought on my way thitherward by you, if first I
be somewhat filled with your company.
25 But now I go unto Jerusalem to minister unto the
Paul's desire was to visit the Roman believers.
Paul's habit did not change. His habit was always to
visit the saints when he finished missionary works.
There was not much down time for Paul. The Bible
reveals that Paul was a great worker for the Lord and
to the people of God and even to sinners. But before
he could visit them he had to go and minister to the
Jerusalem saints. This means that Paul brought the
collection that he collected from the other churches
to help the poor saints in Jerusalem.
26 For it hath pleased them of Macedonia and Achaia to
make a certain contribution for the poor saints which
are at Jerusalem.
This collection from these Macedonian churches we have
seen in 2nd Corinthians. Achaia is in a region in Rome
and the reference may have been to the Corinthian
27 It hath pleased them verily; and their debtors they
are. For if the Gentiles have been made partakers of
their spiritual things, their duty is also to minister
unto them in carnal things.
This is a very interesting statement for a number of
reasons. The Gentile churches owed a debt to the
Jewish believers because the gospel came to them
through the Jews. We saw this in Romans 11. We can
also see that spiritual matters are of far greater
importance than material matters. We also can see
that the saints owe a debt to those who serve in
spiritual matters. The Gentiles owed the Jews in
Jerusalem whatever support that was needed because
they were the cont ...
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Featured Worship Backgrounds


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Ma'am it looks like you dropped your pocket. Ohh, I'm just kidding, I wanted to see you bend over. I'm kind of a perv like that. It's just that I don't see many women come through here dressed like you.
This is in Germany.Can you see the store in the background?The second letter is a ä and only in Germany we have these words (äöü) is called umlauts.This is another proof that Americans are prim!!!
^^You must be friends with the two faggots in this photoshopped picture.
This is America, we dont give a shit what Germans think
So many manpurses! She doesn't even have to worry about anyone staring at that point
I'll have what she's having!
that chic can kick any one of those fags' asses
rape is not a fucking crime...
i got something better than that whistle for her to suck on !
^^ agreed, 2inda. Rape is every man's God-given right! It's a part of what defines us as the superior sex.
@strangler Were you by any chance raped by your mother?
if you look reeeallly close you can see a crowd people in this photo.
she's the best dressed person there, but she could use a shave
Fap ya fap ya
she has an amazing body , really sexy looking lady !!!!!!!!!!!!
she's definitely not getting raped by anyone in this crowd.
this bitch is ok.
We kicked Germany's ass in the first two world wars. Want to try for a perfect score, cockbreath?
she's surounded by fags. she has no worrys.
she needs a shave
The rod Stewart wanna be, is checking out the penis she has poking out the back
Excuse me Miss, Would you mind sucking my dick.,.,.,.,.
cs staff photoshop her dick off?
Linsey Lohan off of house arrest.
Well, at least we know she can suck something. Now to replace what the fuckever that is with my dick.


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|1,000 sq. ft.
|Property type
|Minimum Stay
|3 - 5 nights
The Tahoe Cedarwood is THE vacation location if you are single, married, a family, honeymooning, or planning one. Along with Satellite TV, the home has a full sized washer and dryer, and private driveway. Just 4 blocks from the beach on Lake Tahoe's beautiful North Shore, this lovely home is within 30 minutes drive to over 10 winter ski resorts and over 12 summer golf courses. Ice skating is as close as Northstar at Tahoe 5 miles away or at Squaw Valley just over 15 miles. Horseback riding or mountain biking (from easy to extreme) are available. Carefree hiking, biking, picnicking, and fishing abounds, with rental services within 5 blocks in case you forgot your toys. There's a boat launch, winter snowmobiling/tours, snowshoeing and cross-country skiing nearby. Historic Virginia City, with its gold and silver mines, is just 1 hour's drive
Home includes: free wireless internet, satellite television with pay-per-view movies, full size washing machine, dryer, and a complete kitchen with microwave, stove and oven, pots and pans, toaster, dishwasher, and coffeemaker.
I have lived on the north shore of Lake Tahoe for over 30 years, and love it here. I also love to share the opportunities to enjoy the beauty and grandeur, with opportunities for summer and winter recreation that is truly enjoyable.
Lisa purchased this house in 2005
My daughter, granddaughter (age 5), and I booked a last minute vacation and were fortunate enough to discover this charming Tahoe cabin. We stayed four nights and things couldn't have been more perfect! First of all, both owners were a delight to work with - very responsive, helpful, and gracious. Lovely people! The cabin was cozy and immaculate and the kitchen had everything we needed. The beach is very close by - just a short walk - and even though the home is in a regular neighborhood we felt tucked away in the woods. We loved our stay here and hope to return again next year. Thank you Lisa and John for making our visit to beautiful Lake Tahoe such a wonderful experience.
The male owner was very friendly and helpful and I did not feel rushed on the phone at all. He explained routes and gave so many helpful hints. They sent us a map in the mail and made us feel very welcome.
The place is really close to the beach and the surrounding forest area made it a very cool place to get your morning workout in.
The place is cleaner then I expected and the kitchen is very nice and well stocked.
They have beach towels and some toys! and pretty much thought of everything you might use including organic olive oil!!!
The female (Lisa) owner was sort of vindictive and arrogant when I spoke to her. She was just dumbfounded when I told her that I would bring most of my own groceries for the most part and asked me "why would you do that? I did not like speaking to her on the phone at all, she sounded like a very arrogant woman.
The place had no AC and got to be over 80 degrees inside at night which was very uncomfortable, especially when you are from the hot western states. If you are used to AC do not rent this you will hate it, it was so hot inside that I could not sleep.
The front yard is not maintained and very ugly. I know that they tried to pull off the "you are in nature" yard but all I saw was a yard with potential that my children could not use because it was 3 feet tall with weeds.
***Three weeks have gone by and I have still not received a receipt in the mail or my deposit refund on my credit card which was promised to me 1 week after my departure. I have texted Lisa but I still have no response! This is just sloppy work on their part. Im sure that I will get it back but why is it taking this long!
2 stars here from me since I did not have a terrible experience. I had a personality conflict with Lisa (which can be overlooked). However I felt like I was burning up at night and could not sleep because of the heat inside. Otherwise it was an OK first time Tahoe place to stay but with so many options at the Lake you can do a lot better even in this very affordable price category.
We stayed at this awesome cabin for 5 nights during my daughters softball tournament in Incline village. 2 blocks from Kings Beach this cabin has everything you need for a quiet and fun stay. This cabin is very clean and feels like home. This getaway is close to everything. Thanks for the memorable stay!
We thoroughly enjoyed our stay at Cedarwood . . . it was everything that was promised. The owners were helpful and accessible. The short walk to the main core of town and the beach was perfectly easy! The beach towels were especially handy, since we had forgotten ours! I'd recommend this cabin any time! We were summer renters, and as such, didn't need the heater or the fireplace . . . we'll have to come back in the winter to try that out. We really felt that we were in a mountain cabin, the decor was just perfect.
We recently stayed at the Cedarwood Tahoe. Ours stay was exactly as promised. The kitchen is well equipped, the house is cozy and only a few minutes walk to the beach. We will consider renting again, the landlords were easy to reach and very attentive.
This was such a wonderful cabin! My husband and I stayed for nearly a week and never ran out of things to do. The location was great... so close to the beach. We loved walking to restaurants and the beach but also driving short distances to various nearby towns and ski resorts. The owners were terrific and offered very helpful insiders' advice. I would definitely recommend renting this place! I also definetly recommend renting activity gear from Don at Tahoe Bike & Ski- very reasonably priced and friendly!
Other Activities: summer concerts, kayaking, parasailing, night clubs, dancing, casinos
Golf: We are two blocks from the Old Brockway Golf Course, rated by Golf Today magazine as one of the top ten golf courses in Northern California. With fairways along towering Jeffery Pines and views of Lake Tahoe and majestic mountains throughout the course, this course was the home of the very first Bing Crosby tournament in 1934. The course remains a family owned course committed to organic management practices.
Ski: This home is centrally located, providing excellent access to several of the great ski area resorts in Lake Tahoe. There are ski and snowboard rental shops down the road (avoid the rental shop lines) and some of the local casinos also sell lift tickets the night before (avoid lift ticket lines). Northstar, Diamond Peak, and Squaw Valley shuttle buses stop at the nearby Safeway (avoid parking hassles).
15 minutes from Northstar Ski Resort
15 minutes from Diamond Peak Ski Area
15 minutes from Lakeview Cross Country Ski Area
30 minutes from Squaw Valley Ski Resort (home of the 1960 Olympic Games)
30 minutes from Homewood Ski Area
30 minutes from Alpine Meadows Ski Area
50 minutes from Heavenly Valley Ski Area
|Rate Period
|Weekend Night
Summer Season
Jul 10 2017 - Sep 5 2017
4 night minimum stay
Christmas & New Years
Dec 19 - Dec 31
5 night minimum stay
Peak Ski Month
Feb 1 - Feb 28
3 night minimum stay
My Standard Rate
3 night minimum stay
|Refundable damage deposit
|Tax Rate
Stay six nights and the sixth night is free.
For Christmas and New Year's holiday, and any stay longer than 14 days including ski leases, rent and tax is due 30 days before arrival, and is not refundable after that point.
Ski lease rate is $94 per night, $2,800 per month. Minimum Ski Lease is 45 days.
Dates of Ski Lease are flexible. Ski lease available starting January 1st.
Damage deposit is due upon confirmation of reservation, and refunded after your stay after any damage repair expenses or rental of pay-per-view programming. Cancelling your reservation within 30 days of planned arrival results in forfeiting of the deposit.
Rent and tax is due upon arrival, except for Christmas and New Years holidays, and any stay longer than 14 days, including Ski Leases.


text:
Discussion in 'Fan Zone' started by DanManJ, Aug 21, 2013.
What would have been the down side to signing Sean at the end of the season vs. now?
The increased cost...
Why would the cost increase that much over 18 weeks (i.e. before the end of the season / FA..)?
Because you run the chance that he has a monster year, and then the price certainly goes up.
Dallas also gets to account for 20% of his 10m signing bonus this year. That leaves only 8m in dead money and allows for easier restructures down the road when they need some space. Putting a player at ease mentally cannot be overlooked as well. Lee has achieved financial security and can focus on football only and won't have to deal with questions about his contract.


text:
Application Instructions
Please Note:
- Deadline: The application deadline is NOVEMBER 15th, 2016. Be proactive in your application process and be sure to give your advisors, rector, and academic references plenty of time to submit their information.
- All students applying to Study Abroad programs must use myNDabroad, the online application system.
- When logged into the system, please save your work frequently and bookmark the URL.
- You may apply to a maximum of three programs.
Information Needed for Application:
- Semester of choice: Be sure to select your first-choice term for the program to which you are applying. If you are able to attend during an alternate term, please indicate that in the application questionnaire.
- Names of the DUS for your major(s) and the advising assistant dean from your college
- Names of one or two academic references (as required): Please contact your professors to ask permission before listing them as an academic reference. Once you submit your approval/recommendation request, the requested faculty member will receive a notification email. You may list a non-Notre Dame faculty member by providing his/her name and e-mail address.
- Name of rector: Once you submit your rector recommendation request, your rector will receive a notification email.
- Statement of Goals (maximum 300 words): This is the most important element of the application. Why have you chosen a specific location and what do you hope to achieve during your study abroad? You can visit the Writing Center for writing consultation.
Additional Information:
DUS Approvals: Applicants other than freshmen must schedule separate meetings with the DUS of their major(s) AND an associate/assistant dean. Be prepared to articulate your proposed plans to study abroad in terms of your academic goals. During or after the meetings, your DUS and dean will complete the online academic approval form. Please be aware that most schools and colleges set deadlines for granting approvals.
Applying to Multiple Programs: Students are encouraged to apply to multiple programs. Those who do will be asked to rank them AFTER the application deadline.
After Submitting: Please check your application page frequently to make sure all references and academic approvals have been received. We are unable to evaluate your application file until all materials have been received. Our office will send decision letters to applicants in due course.


text:
Today's Devotional
Streams of MercyWhat steps can you take to adopt God's perspective on mercy?
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Developing a model of recovery in mental health
The recovery process is characterized by the interaction of a set of individual, environmental and organizational conditions common to different people suffering with a mental health problem. The fact that most of the studies have been working with schizophrenic patients we cannot extend what has been learned about the process of recovery to other types of mental problem. In the meantime, the prevalence of anxiety, affective and borderline personality disorders continues to increase, imposing a significant socioeconomic burden on the Canadian healthcare system and on the patients, their family and significant other
Method and design
To operationalize the study, a qualitative, inductive design was chosen. Qualitative research open the way to learning – the inside – about different perspectives and issues people face in their process of recovery. The study proposal is involving a multisite study that will be conducted in three different cities of the Province of Québec in Canada: Montréal, Québec and Trois-Rivières. The plan is to select 108 participants, divided into four comparison groups representing four types of mental health problem. Each comparison group (n = 27) will be made up of 9 units. Each unit will comprise one person with a mental health problem (schizophrenia, affective anxiety, and borderline personality disorders. Data will be collected through semi-structured open-ended interview. The in-depth qualitative analysis inspired from the grounded theory approach will permit the illustration of the recovery process.
The transformation of our Health Care System and the importance being put on the people well-being and autonomy development of the person who are suffering with mental problem This study protocol follows-up on earlier theory-building process that begun with the work of Noiseux
The aim of this research project is to continue the work of theory-building begun in the study by Noiseux
Statement of the problem and relevance of the study
In Canada, recovery has become the guiding principle of the mental health system, resulting in advocacy for care and services that would facilitate the process
Over the past twenty years, many research studies have described the nature of recovery and some of the internal and external conditions associated with it and have thus contributed to the development of new knowledge about the process. The literature indicates that recovery is not a cure, but a profoundly personal path that individuals may follow; it entails work, particularly work on themselves, their feelings, desires, competencies, roles, and plans for the future
Although these studies have helped identify conditions associated with recovery, they have not provided an explanation of how they influence each other or of how the mechanisms by which they operate might help us understand the process through which people manage to recover. It is thus important to recognize that because of the limitations of all the studies up to now, it has not been possible to posit a theoretical model of recovery. These limitations stem mainly from the research methods adopted and from the use of limited samples drawn from a single data source (e.g., people with mental health problems). The studies have primarily used exploratory and descriptive study designs and were conducted with people who had been diagnosed with schizophrenia. They were not extended to include a variety of data sources that would have enabled the investigators to take into account the perceptions of other actors, such as family members and care providers, who are directly concerned with the recovery process
Furthermore, developing a theoretical model of recovery involves a new paradigm, whose scope cannot be considered unless a wide range of perspectives from different data sources are taken into account
In general, the studies have significant limitations that imposing consequences for the interpretation of the recovery process and the implementation of mental health services and care. In the absence of a sound theoretical model, a linear vision of recovery currently guides mental health programs and services; they advocate that the individual follow a series of predetermined steps based on notions of normalization to attain structured objectives
Purpose and objectives of the study
The purpose of this study is to continue the theory building begun by Noiseux
Review of the relevant literature
Prevalence and impacts of mental health problems
In 2001, the World Health Organization (WHO) reported an increase in mental health problems around the world, while observing a decline in the prevalence and incidence of physical health problems
Rediscovery of the phenomenon of recovery
The review of the literature reveals four main types of studies that have contributed to the emergence of a new perspective on recovery in mental health. The research may be grouped into (a) longitudinal studies, (b) autobiographical and anecdotal accounts, (c) qualitative studies, and (d) studies of models of recovery-oriented services. Longitudinal studies conducted since the 1980s have been chiefly behind the emergence of the hypothesis of possible recovery for people with a mental disorder, associating the phenomenon with functional improvement in health status
As the autobiographical accounts of people with a mental health problem
Qualitative studies have helped shore up and better document the concepts of process and subjective experience
The evolution of knowledge about the conditions of recovery has resulted in proposals of a variety of models, whose main emphasis is on services that focus on recovery Anthony
Jacobson and Greenley
Limitations of the studies
It should perhaps be noted that the body of knowledge on recovery is under construction, given the limitations that can be observed in the numerous studies reviewed
Theoretical framework
Development of a theoretical model of recovery
The aim of the study by Noiseux
Thus, because of the recurrence and persistence of the schizophrenic symptoms that overcome them, people see their life turned upside down and may come to experience a real descent into hell. When they hit bottom, and the suffering has become unbearable, they feel a spark that leads them to engage in a process of introspection. If such incidents or events occur to people who have a fighting spirit, they represent conditions that the participants themselves connect with recovery or that analysis of the data allows one to associate with conditions that affect recovery. These conditions lead, in particular, to the discovery of keys to well-being that enable individuals to manage the internal and external forces and to at last see light at the end of the tunnel.
These indicators describe not only the complex, painful subjective reality of living with schizophrenia, but also the daily efforts and great perseverance that enable people to play an active role –or role of "actor"–in their recovery. They thus call into question the traditional, paternalistic practices, which assign the individual a more passive role. The role of family members and care providers then becomes that of a "director" who underscores the individuals' efforts and victories, even the smallest ones; who supports them when they suffer relapse or failure; and who encourages them and helps them find their footing again despite the internal fragility that is under constant threat from internal and external reality.
The participants in the study by Noiseux
Methods and design
Research Design
A qualitative, inductive design was selected to develop our understanding of the process of recovery in mental health. By giving prominence to the perspectives of different groups of actors, qualitative research opens the way to learning–from the inside–about the dilemmas and issues people face in their recovery. Given our current state of knowledge and the research questions posed in this study, the methodology chosen was the grounded theory approach. This approach seems most suitable for developing a theoretical model to explain a complex, little-known, ever-evolving process
Selection of settings and participants
This multisite study will be conducted in four regions in Quebec: (a) Montreal, (b) Quebec City, (c) Trois-Rivières. We will thus be able to recruit participants from different rural and urban social environments that provide different levels of mental health services. In the four sites, three types of settings will be selected in order to involve a variety of actors or data sources: (a) structured treatment programs administered by a hospital or specialized department of psychiatry (e.g., Louis-H. Lafontaine Hospital, the Pavillon Albert-Prévost at the Sacré-Cœur de Montréal Hospital, the Robert-Giffard Hospital, (b) self-help groups (e.g., Schizophrenia Society of Canada, Depression and Maniaco-Depression Association) and (c) community organizations (e.g., APUR).
The participants selected for this study are people with a mental health problem, a member of their family and one of their care providers. The plan is to select a total of 108 participants, divided into four comparison groups representing respectively the four types of mental health problem under investigation (schizophrenic disorders, affective disorders, anxiety disorders, and borderline personality disorders). Each comparison group (n = 27) will be made up of 12 units. Each unit will comprise one person with a mental health problem, one member of his or her family and one of his or her care providers. This theoretical sample of 108 participants will be divided among the four sites in accordance with population density (see Table
Table 1
Formation of the theoretical sample
Types of mental health problems
Borderline personnality
3 u
3 u
3 u
3 u
12 u
Quebec City
3 u
3 u
3 u
3 u
12 u
3 u
3 u
3 u
3 u
12 u
9 u
9 u
9 u
9 u
36 u
n = 27
n = 27
n = 27
n = 27
n = 108
1 u = 1 unit = 1 person with a mental health problem, 1 family member and 1 care provider
Participants will be selected in accordance with the following inclusion and exclusion criteria: To be included in the study, people with a mental health problem must: (a) have a diagnosis of schizophrenic disorder, affective disorder, anxiety disorder, or borderline personality disorder based on a psychiatric evaluation; (b) be able to identify a significant family member and a care provider likely to take part in the study; (c) live in the community; (d) be in a stable condition (able to manage symptoms) and (e) know how to speak, read and write French. To be included, family members must: (a) have a significant bond with the person with the mental health problem who has agreed to take part in the study (e.g., parent, spouse, brother, sister, friend) and (b) know how to speak, read and write French. To be included, care providers must: (a) have followed a person with a mental health problem who has agreed to take part in the study for at least the past year (nurse, psychiatrist, social worker, psychologist, etc.) and (b) know how to speak, read and write French.
People with a mental health problem and their family members are excluded if they: (a) go through an acute crisis episode and are hospitalized; (b) have a major physical health problem; or (c) are diagnosed as intellectually deficient.
Recruitment of participants: Different strategies will be used to select the participants in the settings and sites mentioned earlier. In the hospitals, the research project will be presented to the respective psychiatric departments. Eligible individuals will be identified with the assistance of the heads of client programs (for schizophrenic, affective, anxiety, and borderline personality disorders) in order to enlist their cooperation in recruiting participants who meet the inclusion criteria. The client-program heads will contact the people with a mental health problem who have been identified as eligible to pave the way for a preliminary contact with the investigator to explain the purpose of the study. After the preliminary contact, the individuals will be asked to get in touch with the investigator to say whether or not they are interested in taking part and to confirm the participation of a family member and a care provider, who will also be contacted so that they can be given information on the research project and give their consent to take part.
In the self-help and community groups, the investigator will get in touch with the people in charge to present the research project and prepare a document to publicize the study and ask individuals who might be interested to take part. These individuals will have to contact the investigator or the research assistant directly to obtain information, decide whether they are willing to participate and, if they are, to set a time and place for the interview. Those wishing to take part will also have to identify a family member and a care provider from their network, depending on each case. Every participant will be met for a single interview lasting some 60 to 90 minutes. The interview will be recorded on digital audiotape. The interviewer will have to have professional clinical experience in the mental-health field and will be trained to conduct this type of interview, which necessarily entails creating a climate of trust. The individuals with a mental health problem and their family member will receive monetary compensation for travel and for taking part in the study.
Conduct of the study
Data collection
Semi-structured interviews are a powerful tool and are considered to be indispensable to an in-depth exploration of the participants' perspectives on the recovery process
Throughout the study, the interviewers will make field notes to record their observations chronologically. These notes will be used to describe the environment surrounding the interviews, factual events, individuals' reactions, and personal impressions and reflections. The contents of the notes will be shared with the research-team investigators and collaborators in order to discuss possible biases or information that may be relevant to the data-analysis process
Data analysis and data collection will be carried out concurrently, in accordance with the grounded theory approach
A) Open coding
The significant events, facts or incidents will be underlined in the transcripts, and themes or keywords corresponding to each of the facts raised by the participants will be noted in the margins. Examples of such themes are relapse, strategy, fight, motivation, and marker. This first step may be described as a systematic exploration of the data on the lookout for "chance" discoveries. Once identified, as suggested by Huberman & Miles
B) Axial coding
That operation involves refining the open-coding grid in order to delimit the theoretical model. The categories delimiting the phenomenon under investigation are related to each other in terms of different levels of "conditions": causal conditions, interactional and structural contexts, action strategies, and consequences. The identification of these conditions serves as a point of departure for attaining a better understanding of and delineating the interplay of the individual, environmental and organizational conditions that influence recovery.
C) Selective coding
The purpose of the third step in analyzing the data is to integrate and refine the theoretical model. Three stages are involved. The first entails a process of integration for each comparison group through the statement of a core category: that is, a few words, a sentence or a conceptual idea that goes to the heart of the phenomenon. In other words, a category is a core category insofar as the other categories can be grafted on to it and variations between them are justified by reference to it
Criteria of scientific rigour in qualitative research
Like other qualitative research methods, grounded theory meets the criteria of scientific rigour: credibility, transferability, internal consistency, and reliability.
Credibility: This criterion entails data authenticity and that conclusion or propositions respect the data that has been collected
The following is the timetable planned for the project: September to December 2006: Development of research tools: guides for the analysis of relevant documents; interview guides; presentation of the project at the four selected sites to the participating groups and organizations. January to March 2007: Conduct of pre-tests with 12 people and adjustments to the interview guides. April 2007 to April 2008: Beginning of recruitment in the four sites, data collection (interviews) and data analysis, carried out concurrently. A 12-month recruitment period seems appropriate to us, given the specific inclusion criteria requiring a relationship between participants (individual-family member-care provider) to make up a unit. May to December 2008: Continuation of data analysis; holding two focus groups to validate the theoretical model of recovery. January to November 2009: Finalization of the analysis and the research report; dissemination and circulation of the findings.
Originality and benefits of the study
The unique and innovative nature of this research project derives from four distinctive features: (a) the background of the research team providing for a "triangulation" of perspectives; (b) the variety of groups, organizations and regions, making it possible to examine the issue in a variety of contexts; (c) the formation of units comprising three data sources; and (d) the continuation of a theory-building process, broadening the explanation of recovery to include four types of mental health problem. In addition, the study will generate an exceptional quantity and quality of qualitative data, from which empirical indicators of the recovery process will be derived. The ultimate goal is to construct a strong knowledge base so that we can clearly define a theoretical model with generalizable parameters that nonetheless takes into account the particular traits of individuals and their health condition. This study has undoubted potential to advance knowledge in the field of mental health. By emphasizing individuals' potential and resources rather than the deficits associated with their disease, the study will probably call some traditional theoretical positions into question. Finally, the heuristic value of a substantive theoretical model should influence policy orientations and the organization of mental health services that really focus on the recovery process.
Knowledge transfer and strategies for the dissemination of findings
For this study, knowledge transfer is of major importance because the raison d'être of a substantive theoretical model of recovery is to buttress and renew practices for the care of clients living with a mental health problem. To disseminate our findings and promote their incorporation into practice, our knowledge transfer activities should involve more than simple one-way distribution. They should also be based on reciprocal interaction between the investigators and partners from different groups and organizations. Moreover, we plan to bring out a plain-language version of the findings for care providers and self-help associations. Scientific articles reporting the findings will be submitted to various national and international periodicals.
Ethical considerations
The proposed research project will have to be approved by the scientific and Ethics Committees for Research of the CHUM (SL 06.055), HSCM (C.E. 2006-12-78), CHRTR (CÉR-2006-139-01) and CTR de Nemours (Quebec) that provide services to the community. Potential participants will be given clear explanations of the objective of the research and of the way the interviews are to be conducted. They will then be in a position to give their free and informed consent both to taking part in the study and to having the interviews digitally recorded. All recordings will be kept under lock and key in a secure location at the research centre involved throughout the course of data collection and analysis. Because of the need to disseminate the findings, the recordings will be destroyed seven years after completion of the study. The participants will also be assured of the confidentiality of any identifiable personal information through the use of pseudonyms to prevent recognition. If they suffer discomfort during the interview, participants will be told where they can find help. All participants will be informed of their right to withdraw from the study should they wish to do so.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
The authors approved the manuscript and are taking responsibilities for appropriate portions of the content. SN has made substantial contributions to conception and design, acquisition of data, analysis and interpretation of data and general supervision of the research group. DSCT has made important contribution to revising it critically for important intellectual content, analysis and interpretation of data. CL has been involved in the proposed research project will have to be approved by the scientific and Ethic Committee for CHRTR and his analysis data. NR has made a contribution to conception and design in this study protocol. RM has made important contribution to revising it critically for important intellectual and clinical content. EC has been a major contribution in analysis and interpretation of data. Finally, RL has been involved in the analysis and interpretation of data. What is more, the very fact these authors are being brought together from different sites and settings will facilitate participant recruitment. All authors read and approved the final manuscript.
The present study is being supported by the Canadian Institutes for Health Research (CIHR: 157898). The authors would also like to thank Mr Luc Vigneault and Mrs Francine Gagnier for there experience, comments and supports to realize this study. The authors would also to thank two Research Centers « Centre de recherche Fernand-Seguin » and « Centre de recherche du Centre Hospitalier de l'Université de Montréal (CR-CHUM) for technical support and our installations to realize this study.
Élaboration d'une théorie du rétablissement de personnes vivant avec la schizophrénie
What is recovery? A conceptual model and explication
Recovery as perceived by people with schizophrenia, family members and health professionals: A grounded theory
A recovery-oriented service system: Setting some system level standards
The process of recovery form schizophrenia
Experiencing recovery: A dimensional analysis of recovery narratives
Sense of self in recovery from severe mental illness
Illness as evolution: The search for identity and meaning in the recovery process
Recovery as policy in mental health services: Strategies emerging from the states
Recovery in Schizophrenia: Reality or Mere Slogan
The process of recovery form schizophrenia
Pour un système de santé axé sur le rétablissement. Douze points de repère pour l'organisation d'ensemble des services
Restoring psychiatric disability: Learning from first person recovery narratives
Exploring recovery from the perspective of people with psychiatric disabilities
Recovery from mental illness: The guiding vision of the mental health service system in the 1990s
Therapeutic agents of assertive community treatment
Recovery as a self-directed process of healing and transformation
Se rétablir après une crise psychotique: ouvrir une voie? Retrouver sa voix?
Le rétablissement de personnes vivant avec la schizophrénie
Research on evidence-based practices: Future direction in an era of recovery
L'entretien de type qualitative: considérations épistémologiques, théoriques et méthodologiques
Grounded theory methodology: An overview
Catamnestic long-term study on the course of life and aging of Schizophrenia
The natural history of schizophrenia in the long-Term
The varied outcomes of schizophrenia
The Maine and Vermont three-decade studies of serious mental illness: I. Matched comparison of cross-sectional outcome
The Maine and Vermont three-decade studies of serious mental illness: II. Longitudinal course
The Long-term Course of Childhood-onset Schizophrenia: A 42-year Followup
Chronicity in schizophrenia: revisited
European versus U.S. data on the course of schizophrenia
A selective review of recent North American long-term follow-up studies of schizophrenia
A biologist's view of pain, suffering and marginal life
Psychiatric hospitalization of adolescents for conduct disorder
Relearning after damage in connectionist networks: Toward a theory of rehabilitation
Spirituality and connectedness
I'm just an ordinary person
Recovery: The lived experience of rehabilitation
The independant living movement and people with disabilities: Taking back control over own lives
A new vision of healing as constructed by people with psychiatric disabilities working as mental health providers
How I perceive and manage my illness
Researching the unresearchable
Discovering recovery
De la réappropriation au pouvoir d'agir: la dimension discrète d'une réelle réadaptation
What recovery means to us: Consumer's perspectives
L'expérience du rétablissement: perspectives théoriques
In the eye of the beholder
Recovery and empowerment for people with psychiatric disabilities
Patients with schizophrenia valued self empowerment, understanding how self related to illness, and coping with relapse
Recovery from a severe psychiatric disability: Findings of a qualitative study
How do they see themselves? Self-perception and functioning for people with schizophrenia
Schizophrenic clients' experiences of power: Using hermeneutic analysis
The life world of the chronic mentally ill: Analysis of 40 written personal accounts
Being mentally ill: A phenomenological inquiry
Recovery from schizophrenia: A challenge for he 21st century
Patients' internal world experience of interacting with psychiatric nurses
Contexts of social relationship development among assertive community treatment clients
Introduction to a special series on recovery
Implementing Evidence-based Practices in Routine Mental Health Service Settings
Addictions services: Predictors of retention in dual-focus self-help groups
The road to recovery: where are we going and how do we get there? Empirically driven Conclusions and Future Directions for Service Development and Research
What does recovery mean to you? Lessons from the recovery experience for research and practice
Illness management and recovery: A review of the research
Recovering from illness or recovering your life? Implications of clinical versus social models of recovery from mental Health problems for employment support services
Recovery: Expanding the Vision of Evidence-Based Practice
Un système à rétablir
Modeling processes in recovery from mental illness: Relationships between symptoms, life satisfactions and self-concept
L'analyse par théorisation ancrée
Grounded theory and nursing knowledge
Using grounded theory method in nursing research
Interviewing: The art of science
Validity in Qualitative Research
Pre-publication history
The pre-publication history for this paper can be accessed here:


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