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Posted by Seitan Narcis Albert at 5:09 AM |
Use of a proton-pump inhibitor (PPI) after Helicobacter pylori eradication more than doubles the risk for gastric cancer, according to a population-based study from Hong Kong.
The "clear dose-response and time-response" trend in PPI use and gastric cancer risk observed suggests the need for "caution when prescribing long-term PPIs to these patients even after successful eradication of H. pylori," write Wai Keung Leung, MBChB, MD, from Queen Mary Hospital, Hong Kong, and colleagues.
The study was published online October 31 in Gut.
The researchers point out, however, that this was an observational study, which can't prove cause and effect.
The new results also conflict with a recently published, US Food and Drug Administration–mandated follow-up study conducted with pantoprazole, said David A. Johnson, MD, chief of gastroenterology at Eastern Virginia Medical School in Norfolk (Aliment Pharmacol Ther. 2016;43:73-82).
"No increased risk [for gastric cancer] was observed with prolonged PPI exposure," he said.
Dr Johnson, who was asked for comment, also stated that the study has a "geographic bias" because it is from Hong Kong and "specific risks for gastric cancer are well recognized in Asian patients."
In the new study, Dr Leung and colleagues partly focused on H pylori infection and its relationship with gastric cancer.
H pylori eradication has been shown to reduce the risk for gastric cancer by 33% to 47%, but many patients develop gastric cancer even after eradication of H pylori. PPI therapy, "although generally considered safe," is associated with worsening gastric atrophy, particularly in H pylori–infected patients, the researchers point out. A recent meta-analysis found a 43% increased risk for gastric cancer among long-term PPI users, but it is was unable to adjust for H pylori, the major confounding factor.
Using a territory-wide health database in Hong Kong, Dr Leung and colleagues compared the risk for gastric cancer in PPI users and histamine-2 receptor antagonist (H2RA) users among 63,397 adults successfully treated with a 7-day course of triple therapy to eradicate H pylori between 2003 and 2012.
"PPIs are much more potent than H2RA in terms of gastric acid suppression, and previous studies did not reveal any association between gastric cancer development and H2RA. Hence, H2RA was selected as a negative control exposure in our study," the researchers explain.
During a median follow-up of 7.6 years, 153 (0.24%) people developed gastric cancer after H pylori eradication therapy, mostly in noncardia regions (62%). None of the patients with gastric cancer tested positive for H pylori at diagnosis, but all had long-standing gastritis. The median age at cancer diagnosis was 71.4 years, and the median time from H pylori eradication to gastric cancer was 4.9 years.
After propensity score adjustment, people taking PPIs at least weekly had a greater than twofold increased risk for gastric cancer development (hazard ratio [HR], 2.44; 95% confidence interval [CI], 1.42 - 4.20). The propensity score–adjusted absolute risk difference between PPI use and non-PPI use was 4.29 excess gastric cancer cases per 10,000 person-years.
H2RA users had no increased risk (HR, 0.72; 95% CI, 0.48 - 1.07), which "further supports the specific role of PPIs on gastric cancer development," the researchers say.
After stratification by tumor site, PPI use was only significantly associated with an increased risk for noncardia gastric cancer (HR, 2.59; 95% CI, 1.42 - 4.72) but not cardia cancer (HR, 1.97; 95% CI, 0.57 - 6.82); "although this result should be interpreted with caution as this subgroup analysis has a relatively small number of cardia cancers," the researchers say.
Gastric cancer risk increased with longer duration of PPI use. The HR was 5.04 (95% CI, 1.23 - 20.61) for 1 year of use or longer, 6.65 (95% CI, 1.62 - 27.26) for 2 years of use or longer, and 8.34 (95% CI, 2.02 - 34.41) for 3 years use or longer.
More frequent use was also associated with greater risk. When compared with the reference group (less than weekly use), gastric cancer risk progressively increased with more frequent PPI use. The HR was 2.43 (95% CI, 1.37 - 4.31) for weekly to less than daily use, increasing to 4.55 (95% CI, 1.12 - 18.52) for daily PPI use.
The results remained significant by various sensitivity analyses.
A strength of the study is its use of data from a large population-based database with complete information on subsequent diagnoses and drug prescriptions, which minimizes selection, information, and recall biases, the researchers say. Use of strict exclusion criteria as well as propensity score adjustment to control for potential confounders and restricting the sample to patients with successful H pylorieradication are other strengths.
In terms of study weaknesses, the researchers lacked information on some risk factors, such as diet, family history, and socioeconomic status. And despite the large sample of more than 63,000 H pylori–infected patients, the small number of gastric cancer cases did not allow for any "meaningful evaluation of the dosage effect and role of different PPIs," the researchers say.
The team also notes that PPIs users may have a higher chance of undergoing endoscopy than non-PPI users, leading to discovery of more gastric cancers due to surveillance bias.
Dr Johnson said there was another study weakness: "Important" demographic variables that are risk factors for gastric cancer — such as smoking, alcohol use, obesity, diet, and family history — are not accounted for.
He also made a general observation about PPI-related research: "Most studies showed that any potential effects of PPIs tend to disappear with time and that the most likely explanation for the effects is confounding by indication rather than causality."
Despite these limitations, Dr Leung and colleagues write that, to their knowledge, "this is the first study to demonstrate that long-term PPIs use, even after H. pylori eradication therapy, is still associated with an increased risk of gastric cancer. This is likely related to the profound acid suppression of PPIs that worsens atrophic gastritis, particularly in those patients with established gastric atrophy as a result of chronic H. pylori-induced inflammation."
EDITOR'S NOTE: The story has been updated to included comments from an expert not involved with the study.
The study had no specific funding. Dr Leung has received honorarium for attending advisory board meetings of Takeda and Abbott Laboratories. Dr Johnson has or has had financial ties to Pfizer Inc, which makes a PPI; Epigenomics; WebMD; CRH Medical; and Medtronic.
Sunday, November 12, 2017 14 comments
Posted by Seitan Narcis Albert at 5:07 AM |
Long-term statin use is associated with an increased risk of type 2 diabetes of approximately 30% in individuals at high risk of the disease, even after taking into account known risk factors and potential confounders, say US researchers.
They looked at the development of diabetes among statin users in the Diabetes Prevention Program (DPP), which included more than 3200 participants.
Over 10 years, statin use was linked to a 36% increased risk of being diagnosed with type 2 diabetes, falling to 27% after taking into account baseline risk factors and clinical criteria used to determine the need for statins.
The findings are consistent with previous studies suggesting that statin use substantially increases the risk of type 2 diabetes.
The new study was published online October 23 in BMJ Open Diabetes Research & Care by lead author Jill P Crandall, MD, department of medicine and diabetes research center, Albert Einstein College of Medicine, New York, New York, and colleagues.
As previously reported by Medscape Medical News, a study of more than 8700 Finnish men aged 45 to 73 years showed that over 6 years of statins therapy were linked to a 46% increased risk of type 2 diabetes — more than double prior estimates.
This was followed by recent data from the Australian Longitudinal Study on Women's Health, which indicated that, among almost 8400 women aged 76 to 82 years, the risk of new-onset diabetes ranged from 17% with the lowest statin doses to 51% with the highest doses.
Despite accumulating evidence, the current researchers still maintain that the overall healthcare advice remains unchanged — the benefits of statins outweigh the risks.
"For individual patients, a potential modest increase in diabetes risk clearly needs to be balanced against the consistent and highly significant reductions in myocardial infarction, stroke, and cardiovascular death associated with statin treatment," they state.
They add: "Nonetheless, glucose status should be monitored and healthy lifestyle behaviors reinforced in high-risk patients who are prescribed statins for cardiovascular disease prophylaxis."
First Look at Diabetes Risk From Statins in High-Risk Patients
The researchers point out that the diabetogenic effect of statins has previously been studied in individuals typically at relatively low risk of diabetes and that the incidence of disease was based on self-report, rather than being the primary outcome.
They therefore set out to examine the issue in DPP participants, which included 3234 US adults randomized to intensive lifestyle intervention, metformin, or placebo.
After a mean follow-up of 3.2 years, participants were invited to take part in the DPP outcomes study, which included quarterly lifestyle sessions alongside open-label metformin for those originally randomized to the drug and two additional lifestyle programs per year for those originally randomized to the lifestyle intervention.
Approximately 50% of DPP participants were from ethnic groups and 20% were aged ≥ 60 years. To be included, they had to be aged ≥ 25 years and have a body mass index ≥ 24 kg/m2. They also had to have a fasting plasma glucose (FPG) of 95–125 mg/dL and impaired glucose tolerance, placing them at high risk of type 2 diabetes.
The primary end point was diabetes diagnosis using an annual 75-g oral glucose tolerance test or semiannual FPG level with repeat confirmation testing. Lipids and blood pressure were assessed annually and statin use was based on self-report.
From a baseline of approximately 4%, statin use progressively increased at the 10-year follow-up to reach 35% in the placebo group, 37% in the metformin group, and 33% in the lifestyle intervention group (P = .36 between groups).
Simvastatin was the most commonly used statin, taken by 40% of participants, followed by atorvastatin by 37% and, much less frequently, lovastatin and pravastatin, by 9% and 8%, respectively.
Statins users were typically older and more likely to be men than nonusers but did not differ by ethnicity. Compared with nonusers, they also had modestly higher baseline FPG and HbA1c, higher baseline low-density lipoprotein (LDL) cholesterol and triglycerides, and were more likely to have a history of cardiovascular disease and hypertension.
Taking into account age, sex, and ethnicity, researchers found that statin use was associated with a significantly increased risk of developing diabetes, at a hazard ratio (HR) of 1.36 for all three groups combined.
Further adjustment for baseline diabetes risk factors, including family history of diabetes and FPG, reduced the HR to 1.35, and additional adjustment for statin treatment confounders, such as blood pressure, cholesterol levels, baseline cardiovascular risk factors, and socioeconomic status, lowered the HR to 1.27.
Diabetes risk did not differ depending on statin potency or magnitude of LDL-cholesterol reduction, although longer statin use was significantly associated with greater diabetes risk (HR per visit with statin use, 1.06; P=.007).
Mechanisms Underlying Effect "Poorly Understood"
Discussing the findings, the researchers say that "it has been suggested that statins may 'uncover' diabetes in individuals at high risk, which on a population basis, could result in modest increase in diabetes risk."
They point out, however, that "variation in baseline diabetes risk factors failed to explain the further risk associated with statin therapy in our cohort, and the HR estimate was greatest among our lifestyle participants, who experienced the largest study-related reductions in diabetes risk."
The mechanisms underlying any diabetogenic effect of statins are "poorly understood," they add.
Although several studies have looked at changes in insulin sensitivity during statin use, "we saw no evidence of an effect of statins to modify insulin resistance, assessed as fasting insulin concentrations," they write.
And although statins have been reported to reduce pancreatic beta-cell insulin secretion in vitro, "the relevance to insulin secretion in vivo is not known," they state.
Taken together, evidence from studies published so far points to "an acceleration of typical glycemic deterioration, rather than a unique or statin-specific mechanism," they conclude.
Posted by Seitan Narcis Albert at 5:04 AM |
The risk of breast cancer returning continues long after the initial treatment has been completed. A new analysis shows that in the 20 years after initial diagnosis, there is an ongoing, steady risk of the cancer recurring in the form of deadly metastatic disease.
The absolute, cumulative risk for metastatic or distant recurrence among women with estrogen receptor–positive (ER+) breast cancer ranged from 10% to 41% over that time span, depending on various disease characteristics.
The findings about women with ER+ disease, which is the most common form of breast cancer, were published online November 8 in the New England Journal of Medicine.
The data come from a meta-analysis that included 88 clinical trials involving 62,923 women who were disease free after 5 years of scheduled endocrine therapy with tamoxifen or aromatase inhibitors.
Thus, all of the recurrences happened after that initial 5 years.
The women all had stage T1 (≤2 cm) or T2 (>2 cm to 5 cm) breast cancers (of varying grades) with fewer than 10 positive lymph nodes and no distant metastases. The patients were followed for up to 15 years after the 5-year treatment period, which generated 20-year data.
What is "surprising" about the findings is the "unrelenting risk over 20 years" and that metastases occur even among patients with the best prognoses, senior author Daniel Hayes, MD, of the University of Michigan Cancer Center in Ann Arbor, told Medscape Medical News.
The main aim of the study was to identify subgroups of patients for whom endocrine therapy could be stopped (thereby avoiding the side effects) after 5 years because their risk for long-term distant recurrence was "so small," say Dr Hayes and his international team of coauthors.
But they found that even among women with the least-threatening profile of small tumors (T1) who had no lymph node involvement (N0), there was a cumulative recurrence risk of 13% over a 20-year period. (The risk was 10% for the less aggressive, low-grade cancers; 13% for moderate-grade cancers; and 17% for high-grade.)
Notably, the annual rate of distant recurrence for these patients was about 1% for a period of 5 to 20 years (ie, after treatment ended), resulting in the 13% cumulative risk.
The new study "quantifies the 20-year risk more reliably than previous studies," owing to size, length of follow-up, and the quality of clinical trial-only evidence, say the authors.
The data "can help women and their health care professionals decide whether to extend therapy beyond 5 years and whether to persist if adverse events occur," they conclude.
An expert not involved with the study welcomed it but called attention to the concept of data reliability.
It is likely that the risk estimates presented in the paper do not completely apply to contemporary patients. Dr Lajos Pusztai
In short, some of the risks reported in the new study are probably higher than those seen currently, he suggested.
Nevertheless, Dr Pusztai agreed with the study authors that the major predictor of distant recurrence risk was status of the tumor stage and lymph node involvement at diagnosis.
Table 1. Distant Recurrence Risk to 20 Years
|Stage at Diagnosis
|Nodes Involved
|Cumulative Risk
|1 - 3
|4 - 9
|1 - 3
|4 - 9
The main massage for me is that clinical stage matters. Dr Lajos Pusztai
The study authors state, "The risk of distant recurrence was strongly correlated with the original TN status." They also report that tumor grade and Ki-67 status were of only moderate independent predictive value for recurrence and that HER2 status was not predictive (however, only 2% of the women received trastuzumab).
Talking With Patients
Dr Pusztai said that the new data raise "a pressing clinical question: who are the patients who really need 10 years of endocrine treatment and who are cured with 5 years?"
He explained that several randomized clinical trials have demonstrated that 10 years of adjuvant antiestrogen therapy is more efficacious than 5 years of therapy. However, "the improvement is small, with 2% to 3% fewer distant recurrences, and the costs and potential side effects of taking a pill for 10 years are not negligible," he observed.
Useful" molecular diagnostic tests, including the Breast Cancer Index and the Prosigna assay, can now help identify patients who are both at risk for recurrence and remain endocrine sensitive and therefore benefit from extended endocrine therapy, he added.
Another expert who was approached for comment, Virginia Kaklamani, MD, of the Unitersity of Texas Health Science Center, San Antonio, said the new study "changes the conversation with patients.
"Extended endocrine therapy becomes an important part of the discussion, given the fact that [distant] recurrence after 5 years is higher than recurrence during the first 5 years," she told Medscape Medical News.
Extended endocrine therapy becomes an important part of the discussion. Dr Virginia Kaklamani
This is a reference to the fact that the study analyzed recurrence and disease-specific mortality risks in 5-year increments. And for each subgroup analysis, the same pattern was seen: a steady increase of associated risk over time, up to 20 years.
Steven Vogl, MD, a private practitioner in New York City, said the study was "good to have" and that he would look at it "again and again" with patients.
"What's nice about this paper is that they give you what you need to know ― the risk of distant metastases and death from breast cancer," he told Medscape Medical News.
He explained that breast cancer is only deadly once it spreads to distant vital organs.
Overall, the risk for breast cancer mortality "looks identical to distant recurrence except with lower percentages at each time point," summarized Dr Hayes.
Table 2. Cancer Mortality Risk to 20 Years
|Stage at Diagnosis
|Nodes Involved
|Cumulative Risk
|1 - 3
|4 - 9
|1 - 3
|4 - 9
The new meta-analysis has several limitations, including that it involved women who were scheduled to receive 5 years of endocrine therapy ― not who completed it. In six of the trials that investigated only tamoxifen, a "substantial minority" (11% to 31%) of women did not complete treatment.
That fact may lead to higher rates of recurrence risk in the study, just as 100% completion would lead to lower risk.
However, the authors also suspect that the rate of distant recurrence would have been 5% to 10% higher had the data not been tamped down by unreported breast-cancer events.
The team also could not "reliably assess" the relevance of chemotherapy to prognosis after the treatment period ended at 20 years. They acknowledged that the risk for recurrence after 5 years may be lower for women who receive contemporary chemotherapy compared to the risk for women in the study, echoing Dr Pusztai's comments.
The study was funded by Cancer Research UK, the British Heart Foundation, and the Medical Research Council at the University of Oxford. Dr Pusztai has worked with Biotheranostic to assess use of their Breast Cancer Index. Dr Hayes, and Dr Kaklamani, and Dr Vogl have disclosed no relevant financial relationships.
Posted by Seitan Narcis Albert at 5:00 AM |
That is a question that a great many cancer patients would love to hear from their oncologists, but unfortunately, sexuality is not a topic that gets much attention.
A panel of experts here at the Palliative Care in Oncology Symposium (PCOS) 2017 tackled the subject of sex and the cancer patient and presented preliminary data demonstrating how "low-tech" interventions can make a dramatic difference for patients.
Sexuality is a somewhat taboo topic in oncology care, and perhaps even moreso in palliative care, explained panel member Anne Katz, PhD, RN, certified sexuality counselor at Cancer Care Manitoba, Canada. "But we know that this is important to patients and their partners across the cancer journey."
She cited a study (Psychooncology. 2011;21:594-601) that found that fewer than half (45%) of all cancer patients had a conversation with their healthcare provider about sex. By cancer type, 21% of lung cancer patients had such a conversation, as did 33% of breast cancer patients, 41% of colorectal cancer patients, and 80% of prostate cancer patients.
Men, it seems, get the "sex talk" a lot more frequently than women do.
According to Dr Katz, the "whole thing is skewed" by prostate cancer. More than twice as many men speak to their providers about sex as compared to women.
"If we didn't talk about nausea, if we didn't talk about constipation, we would be regarded as negligent, even indulging in malpractice," Dr Katz pointed out. "Yet we are leaving out conversations about this very important quality-of-life issue, which persists into end-of-life care.
"Sexuality is much more than just intercourse. It is about touch and intimacy and about much more than what we do in the bedroom," she said.
A recent study (J Cancer Surviv. 2017 Apr;11:175-188) again showed that a "preponderance" of men (60%) had a discussion about sex with their provider, whereas fewer than half as many women did (28%).
However, healthcare providers thought "they were doing a good job," with almost 90% reporting that they were. "So there is a very large gap as to who is saying what and who is hearing what," explained Dr Katz.
Another problem is that the cancer patient is much more likely to raise the topic with their provider, rather than the reverse. This is a problem, she pointed out, "because in every other area, we raise the topic with our patients, indicating that its important. By not opening the door, by not starting the conversation, we are saying to our patients that 'this is not important and I don't want to talk about it.' "
Panelist Sharon Bober, PhD, founder and director of the Sexual Health Program at the Dana-Farber Cancer Institute in Boston, Massachusetts, agreed with that summation. "We have to expand our perspective on what sexuality is, in the context of serious illness and palliative care. It's too easy to be reductionist and think about whether some can or cannot have sex - this isn't what it's about."
We have to expand our perspective on what sexuality is, in the context of serious illness and palliative care. Dr Sharon Bober
Sexuality, she noted, is a human experience across the lifespan. It's a multidimensional experience that involves physiology, behavior, emotion, cognition, and identity.
"What we can take from some of the qualitative and survey work that's been done to date is that expressions of sexuality can be a vital aspect of providing comfort and relieving suffering, maintaining connections in the face of life-limiting illness, and affirming a sense of self when other roles are lost," Dr Bober explained. "When sexually is not made part of care, there is an implicit message that is it no longer important and/or the challenges cannot be addressed."
Unfortunately, providers often took a medicalized approach, as was evidenced in one study (Contemp Nurse. 2007 Dec;27:49-60). Patient sexuality and intimacy were largely medicalized; the discussion remained at the level of patient fertility, contraception, and erectile or menopausal status, Dr Katz noted.
"There is a lot of active avoidance," she said. She pointed out that the "patient reports the topic and the oncologist takes three steps back and flies out the door."
The oncologist takes three steps back and flies out the door. Dr Anne Katz
Some of the reasons given for not discussing sexuality were reactions of colleagues, fear of litigation, and fear of misinterpretation.
The topic needs to be brought up in the context of quality of life, she emphasized, "but we need to open the door."
There is the fear of not knowing what to say, but there is "Dr Google, there are books, there are experts, and if you don't know, you will find the resources to refer patients to them," Dr Katz said. "We have a responsibility to discuss sexual side effects of cancer treatment."
Very Brief but Very Effective
Sexual function is profoundly disrupted by gynecologic cancer treatment, and 90% of patients with ovarian cancer report distressing changes in sexual function. "The good news is that ovarian cancer patients are living longer, and almost 50% of survivors will live many years post diagnosis," explained Dr Bober. "But they often have to endure multiple surgeries and multiple rounds of chemotherapy, and sexuality and distress are generally not addressed."
She pointed out that with ovarian cancer patients, "no one talks about this. The thought Is often that you have bigger fish to fry, you may not live anyway ― there are all kinds of reasons that this doesn't get addressed."
Dr Bober described an intervention that they devised at Dana Faber to address sexual dysfunction in ovarian cancer survivors. Not only was it brief, easily accessible, and "doable" by patients, but final results showed that it was quite effective.
The format was integrative. It was composed of a single half-day group intervention with a didactic teaching and experiential exercises, coupled with an individualized action plan. After the session was completed, the participants were asked to reflect on what was pertinent to them and what they were going to work on during the next 6 weeks.
The session was followed by a brief telephone call, in which the action plan was reviewed and additional support was offered if needed, to uncover additional challenges that needed to be addressed.
Because this was a pilot study, it did not include a control group per se, Dr Bober explained, but participants served as their own controls. This was accomplished by having a 2-month run-in period, during which women filled out surveys at baseline then waited for 2 months before completing the survey a second time before beginning the intervention. The purpose of the 2-month run-in period was to estimate changes in symptoms that could not be attributed to the intervention.
The design comprised three modules. Module 1 was targeted on sexual health education, which discussed vaginal health, enhancing arousal, and increasing low desire. Module 2 involved body awareness and relaxation training, in which participants learned pelvic floor education, progressive muscle relaxation, and body scan. Module 3 involved a mindfulness-based cognitive training, which sought to increase nonjudging awareness of automatic thoughts, with progression from avoidance/distraction to acceptance.
The cohort included 46 women with stage I-IV ovarian cancer who reported at least one distressing sexual symptom. The mean time since diagnosis was 6.3 years (range, 1 - 20 years). "Twenty years is a very long time to be dealing with distressing sexual problems," emphasized Dr Bober.
Within this group, 13% were currently receiving chemotherapy, and 44% were currently taking medication for anxiety, depression, or pain.
In evaluating the program, 97% of the women found the it helpful, 100% found it easy to understand, and 95% found the it enjoyable.
With regard to helping sexual functioning, "There were no changes during the run-in period, for the most part, demonstrating that time alone did not change the situation," said Dr Bober. "But at month 2 after the interactions, there was significant improvement over multiple domains of sexual function. And for the most part it held over to 6 months."
Although the pilot study was not focused on mental health per se, there was significantly less psychological distress observed in the participants, especially regarding symptoms of depression and distress.
It was a small pilot study, she emphasized, but the implications are that brief sexual health rehabilitation in the context of serious illness is effective. "There was meaningful improvement in sexual function and emotional distress, and improvements at 6 months."
Dr Bober emphasized that there is an enormous need for evidence-based intervention research, with interventions conducted outside of an academic center in order to reach more people. "There is a need for identify optimal methods for delivery," she said. "In some of the palliative care literature, patients talk about struggling with this issue within 2 to 3 months before they die, so this is not something that is relevant only if you're well."
Pilot Study in Transplant Patients
Similar to other oncology settings, sexual dysfunction is a common long-term complication for survivors of allogeneic hematopoietic stem cell transplant (HCT), but it is rarely discussed, and interventions to enhance sexual function in this population are lacking.
The preliminary efficacy of a multimodal intervention designed to improve sexual function in allogeneic HCT survivors was very encouraging, reported Areej El-Jawahri, MD, instructor of medicine at Harvard Medical School and director of the Bone Marrow Transplant Survivorship Program at the Massachusetts General Hospital, Boston.
Dr El-Jawahri and her colleagues conducted a pilot study to assess the feasibility and preliminary efficacy of the intervention in a cohort of 50 patients. The participants were at least 3 months' post transplant and had screened positive for distress caused by sexual dysfunction.
"There was a very wide age range, from 24 years to 75 years," she said. "The median time from HCT at enrollment was 29 months, but there was also a wide range between 3 and 173 months."
The primary endpoint of the study was feasibility: 75% of patients who screened positive would agree to participate and attend the first visit, and at least 80% would attend at least two intervention visits.
The majority of patients had acute leukemia (55%), and nearly 64% had chronic graft vs host disease (GVHD).
The format consisted of monthly intervention visits with trained study clinicians. The visits focused on assessing sexual dysfunction, educating and empowering patients to address this topic, and implementing therapeutic interventions that targeted their specific needs.
The PROMIS Sexual Function and Satisfaction Measure, Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT), and Hospital Anxiety and Depression Scale (HADS) were used to assess sexual function, quality of life (QOL), and mood at baseline and 6 months post intervention.
The study met its primary endpoint of feasibility; 94% (47/50) agreed to participate, and 100% of this group attended at least two interventions. The median number of visits were two (range, two to five). The median duration of the first visit was 50 min; for the second visit, it was 30 min. In addition, 28% (13/47) had a partner attend an intervention visit.
Results were encouraging, Dr El-Jawahri pointed out. "Sexual activity in the group increased."
Before the intervention, 32.6% of patients reported not engaging in any sexual activity; that number declined to 6.5% after the intervention.
In men, the following therapies were implemented: phosphodiesterase inhibitors (PDI) on demand (57%), psychoeducation (52%), penile constriction rings (48%), referral to a sexual health clinic (9%), daily PDI treatment (4%), topical GVHD treatment (4%), and hormone replacement therapy (4%).
For women, therapies included vaginal estrogen (67%), dilator (63%), lubricant (58%), psychoeducation (42%), topical GVHD treatment (42%), topical lidocaine (8%), and referral to a sexual health clinic (4%).
"All outcomes were clinically and statistically significant," said Dr El-Jawahri.
|Preintervention (%)
|Postintervention (%)
|P Value
|Global satisfaction with sex
|Interest in sex
|Vaginal discomfort
|Vaginal lubrication
|Erectile functioning
The program was efficacious in improving QOL and mood.
"This has very promising efficacy, but we need to conduct a randomized clinical trial, and there is a need to asses longer-term outcomes," Dr El-Jawahri concluded. "It also has potential for adaptation to other types of cancer survivors as clinicians to deliver this kind of intervention and allow for dissemination."
Dr El-Jawahri's study was funded by the National Comprehensive Cancer Network and the Patty Brisben Foundation. Dr Bober has a relationship with Apexo Neuro; Dr Katz and Dr El-Jawahri have disclosed no relevant financial relationships.
Palliative Care in Oncology Symposium (PCOS) 2017. Panel and abstract 191 (Dr El-Jawahri), presented October 28, 2017.
Posted by Seitan Narcis Albert at 4:57 AM |
Results of a 70-gene signature assay (70-GS) can influence recommendations about adjuvant treatment for patients with early breast cancer classified as intermediate risk by a 21-gene assay (21-GA), researchers say.
"The use of genomic assays in early stage ER-positive, HER2-negative breast cancer has become a standard practice for determining who should get adjuvant chemotherapy," Dr. Hatem Soliman of Moffitt Cancer Center in Tampa, Florida, told Reuters Health.
"There are still some situations where the initial genomic test doesn't provide a clear answer. In these cases, the provider and patient may require additional information - almost like a second opinion - to guide them," he said by email.
"However," he added, "this is costly and should be done only in cases where the clinicopathologic information and initial genomic test are equivocal."
To investigate, Dr. Soliman and colleagues enrolled 840 patients (mean age, 59; 87% white) with early-stage breast cancer and a 21-gene assay recurrence score of 18 to 30 (intermediate risk). All patients also were classified with the 70-GS, and results were given to physicians before adjuvant treatment was started.
As reported in JAMA Oncology, online October 26, on the basis of 21-GA result (before 70-GS assessment), 382 patients (45.5%) were recommended to receive adjuvant chemotherapy and 458 (54.5%) were recommended not to receive it.
The 70-GS reclassified the intermediate-risk patients as low-risk in 374 cases (44.5%) and high-risk in 466 cases (55.5%).
Receiving the 70-GS classifications significantly influenced adjuvant treatment assessment. Among the low-risk patients, 108 (28.9%) had chemotherapy removed from their treatment recommendation, whereas 171 (36.7%) high-risk patients had chemotherapy added.
The 70-GS results were significantly associated with the physician's adjuvant treatment recommendation: 88% of high-risk patients were recommended to receive adjuvant chemotherapy, and 91% of low-risk patients were recommended not to receive it.
After receiving the 70-GS results, physicians reported having greater confidence in their treatment recommendation in 79% of cases.
Dr. Soliman said, "The information provided by the 70-GS assay had a significant clinical impact on adjuvant therapy recommendations. So in cases where there is initial uncertainty regarding the use of adjuvant chemotherapy, the 70-GS assay can aid in identifying patients with an excellent prognosis using endocrine therapy alone."
Experts in cancer genetics weighed in on the findings in emails to Reuters Health.
Dr. Sofia Merajver, Scientific Director of the Breast Cancer Program and Director of the Breast and Ovarian Cancer Risk Evaluation Program at the UM Comprehensive Cancer Center in Ann Arbor said, "It is unknown whether survival would be improved by the change in therapy for those patients, and that is the gold standard."
"Plus, the total expression of proteins is not sufficient to define the signaling processes inside cells, nor is a single static measure robust enough to predict long-term survival or time to recurrence, the outcome variables patients are truly interested in," she observed.
"In essence, this paper just proves what doctors and patients are willing to do. The hope is that the value of adjusting the therapy was not overstated during this research, since so much (outcomes) data still needs to be collected."
Dr. Dana Zakalik, Director of the Beaumont Cancer Genetics Program at Beaumont Hospital in Royal Oak, Michigan, commented, "The 70-gene assay seems to 'simplify' the genomic risk score into two categories (high vs. low) and addresses the uncertainty of the 'intermediate' risk score of the 21-gene assay, for which we still await data."
"We need more data and validation to answer whether this is a better assay or whether it merely simplified it by just having a high versus a low group," he added.
"There has not been a head-to-head comparison between the different assays, so we need more research and longer follow-up. Hopefully," he said, "we will soon have data on the 'intermediate' group of the 21-gene assay, and perhaps that will resolve some questions."
Dr. Glenn Gerhard, Chair of the Department of Medical Genetics and Molecular Biochemistry at Temple University in Philadelphia said, "Risk stratification for breast cancer for the significant number of patients classified as intermediate risk by the 21-GA assay is problematic; thus, other approaches are needed."
"More comprehensive genomic testing using the 70-GS assay provides important additional information in a setting in which physicians use limited clinical data and other more traditional information to guide decision making," he added.
Like Dr. Merajver, Dr. Gerhard noted that "recurrence and survival data were not collected as part of the study; thus, whether the changes in treatment decisions altered outcomes has not yet been determined."
"The results were also restricted to patients with ER-positive, HER2-negative cancers, to those with a designated range of 21-GA results, and to a largely white population," noted. "Thus, the extent of generalizability is not known."
The study was sponsored by Agendia, a molecular diagnostics company that employs four of the authors.
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Today's Featured Artist: Michael Godard
Transform your photos into one-of-a-kind, hand painted masterpieces!
Cloud Mountain by John Vandebrooke - 10.000" x 6.875"
Wood Print
Hanging Wire
Assembly Charge
Wood Print
Cloud Mountain wood print by John Vandebrooke. Bring your artwork to life with the texture and added depth of a wood print. Your image gets printed directly onto a sheet of 3/4" thick maple wood. There are D-clips on the back of the print for mounting it to your wall using mounting hooks and nails (included).
Ships Within
2 - 3 business days
There are no comments for Cloud Mountain. Click here to post the first comment.
Front View
Back View
Bring your artwork to life with the texture and depth of a wood print. Your image gets printed directly onto a sheet of 3/4" thick maple wood.
All wood prints ship within 3 - 4 business days and arrive "ready to hang" with mounting hooks and nails.
Wood prints are extremely durable and add a rustic feel to any image.
For additional product photos and information, visit our wood prints product page.
Average Rating (4.86 Stars):
Lisa Barca-Hall
October 14th, 2018
This particular scene is from a place very near my father's house and the memorial bench for his late wife. He himself has taken many similar photographs of this beautiful spot. I love this piece. Having it printed on the wood gave this piece depth and character, like a painting. A little clarity was obscured by the wood grain but it's beautiful.
Judy Sadoyama
October 13th, 2018
I have always loved mermaids and artist Skoosh's friendship series was one I immediately fell in love with. Treated myself to one on wood and I absolutely love it. The wood is substantial and works wonderfully with the colors on the print. Eventually it will go up on the wall of my craft room/office but for now it's right next to my laptop where i can see it as I get through my day. Can't wait for the rest of the series to be available.
Nina Evans
October 10th, 2018
Mostly done with a hot iron. Hot stylus pen point for trees.
Art was a distraction from business for some 40 years and then upon retirement I discovered wax and my world turned upside down. I did a 180 degree turn and art became my focus, thus the name of my studio 180. I started in a co op gallery in Edmonds, WA called Gallery North. Soon was asked to teach wax painting and also to give talks and demos at art groups and civic groups. Since my wife and I like to escape the rain in the winter we headed south to Calif , AZ , TX and NM and I found venues along the way to teach on the road. This has been our winter paid vacations for several years. I took my lead from Michael Bossoms of Wales. He had developed a style I call the European Style of Encaustic using just hot tools. The look is vibrant and...
Our return policy is very simple:
If you're not happy with a purchase that you made on Pixels.com, for any reason, you can return it to us within 30 days of the order date. As soon as it arrives, we'll issue a full refund for the entire purchase price. Please note - Pixels does not reimburse the outgoing or return shipping charges unless the return is due to a defect in quality.
Pixels sells thousands of pieces of artwork each month - all with a 100% money-back guarantee. We take great pride in the fact that hundreds of thousands of artists have chosen Pixels to fulfill their orders, and we look forward to helping you select your next piece!
Customer Service: 877-807-5901
(Call Any Time - 24 Hours Per Day)
All wood prints ship from our production facility within 2 - 3 business days of your order.

subset: commoncrawl


text: I'll be buying a PowerBook in a few months and am wondering what your thoughts are on the 12" vs. the 15": - Obviously, the 15" has to be updated with Airport X, aluminum, etc in the relatively near future, right? When do you think this will happen? - Do you think we'll ever see DVI in the 12"? If so, when? It seems to me that Apple might be holding off on releasing new 15" PB until it can milk all the sales it can out of the 12" and 17" models, which both have their limitations (namely, lack of compatibility with Apple displays and prohibitive cose, respectively). How long can they play this game?


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"The decline of free checking is the first of many middle-class perks likely to vanish in the rush to regulate."
That was the conlcusion of John Berlau, director of the Center for Investors and Entrepreneurs at the Competitive Enterprise Institute. Berlau's recent oped in the Wall Street Journal lamented the loss of certain conveniences that banks have sacrificed to comply with new financial legislation and regulations.
Over the past few months, the middle class has seen a beneficial feature of modern banking—free checking—begin to vanish due to these "reforms" and the substantial loss of bank revenues that they've caused.
There are two main culprits in free checking's demise: the Federal Reserve's new rules, in effect since July, that restrict banks from charging overdraft fees when customers overdraw their checking accounts; and the amendment from Sen. Dick Durbin (D., Ill.) in Dodd-Frank that puts price controls on the interchange fees that merchants pay to banks and credit unions to process debit cards.


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Enchanting Roses (NEW)
This fabric is covered in light flowery roses, it's very textured and has a light pink tone to it. Paired with our GOLD triangle jewels on the side make this a gorgeous suit.
You may also turn this Triangle-String top into a Built-in Cup Triangle. Please choose from the drop down menu.
Bottom comes in regular coverage, unless you choose a different option. See last photo for coverage chart.
Contact with any questions.


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Kayla is the new girl on campus. She meets Niall, but...
Give me luv<3 ~Harry fan-fic~
- by One_Direction27
- Rating:
- Published: 26 Jan 2013
- Updated: 31 Jul 2013
- Status: In Progress
Juliet Dawn and her sister Violet Dawn, are both into Ed Sheeran.They would kill for him.One day their mom got the tickets to see Ed Sheeran.When they got to backstage, they met one of Ed's BFF's, Harry Styles.What should Violet do after he falls for her.
Join MovellasFind out what all the buzz is about. Join now to start sharing your creativity and passion
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Tell me about new product features as they come out
Thanks for your request!
Automate your workflow – let Upsource analyze your code and track progress, while you focus on improvements.
Participate in discussions and manage your reviews without leaving the comfort of your IDE.
Explore new changes in the browser with IDE-like navigation, reply by email, and never miss an important change.
Spot parts of your project in need of developers' attention, such as hotspots and abandoned files.
Spread responsibilities and make sure no part of code is "owned" by a sole developer.
New team members can quickly learn how the project evolved and discover responsibility scopes of other team members.
Discuss changes, @mention others, react to comments, and unlock achievements as you discover new features and help your teammates!
Make Upsource part of your process easily: integrate it with issue trackers, CI servers, and sync with GitHub.
Don't worry about outgrowing Upsource! No matter how large your team becomes and how many projects you have, Upsource can handle it.
With Upsource 2018.1 you gain even more control over your code reviews: set priorities and categorize them using labels, mark files as unread to remind yourself to go back to them later, clarify the expectations by adding docs and specs as attachments, and finally give a *thumbs up* straight from your IDE.
Make sure your Upsource instance is GDPR compliant. Collect and track individual acceptance of an information notice/user agreement as outlined in the General Data Protection Regulation (GDPR) requirements for businesses that operate in EU member states.
This Upsource release incorporates brand new versions of IntelliJ IDEA engine, Hub, and Cassandra, supports Android 3.0 projects, comes with built-in TLS support, adds multiple user interface enhancements, and shows generally improved performance.
Teams all over the world use Upsource to build better software and stronger teams


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State Rep. Tom Armstrong, D-Plantation, chastised the state Department of Transportation Thursday for its plans to block one of two entrances into the Pine Island Ridge community when Interstate 595 is built.
``It`s an attempt to disenfranchise 6,000 residents from legitimate access to their property,`` said Armstrong, whose District 96 includes Pine Island Ridge. ``The DOT has become a callous giant that feels it doesn`t have to pay attention to people.``
Armstrong said he has asked the chairman of the House Transportation Committee to convene a public hearing in his district to discuss the problem.
Pine Island Ridge is an unincorporated community of about 6,000 residents just south of State Road 84, between Pine Island and Nob Hill roads. Motorists heading west from Fort Lauderdale on State Road 84 currently can make a left turn directly into the community on Pine Ridge Drive.
But the $1.2 billion I-595 project, which will be paved between the existing eastbound and westbound lanes of State Road 84, would block that westbound entrance.
The only westbound access to Pine Island Ridge and the two shopping plazas straddling Pine Ridge Drive would be from Pine Island Road.
``That entire strip center could literally go down the tubes and become a skeleton,`` Armstrong said. ``This is probably one of the worst planning attempts I`ve seen -- it`s crazy.``
Area residents and merchants have asked that an underpass be built to retain westbound access from State Road 84, but DOT engineers say it would be too costly.


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Available at:
But when his hometown falls on hard times and needs his help, Grif reluctantly agrees to commute between coasts. He never expects the lush scenery, in the form of pretty tomboy Carlie Beth Parrish, to be such a temptation.
After an impetuous one-night stand with Grif Steele fifteen years ago, hardworking blacksmith Carlie Beth has tried to make a living and raise her daughter in the hometown she loves. Then, too-sexy-for-his-Rolex Grif blows back into town like the perfect storm, making Carlie feel less like a thirty-something mom and more like an infatuated teenager.
When a stalker targets his hometown and Grif suspects Carlie Beth might be the next victim, he can't help but step in to protect her. But once he discovers the fourteen-year-old secret she's been keeping from him, will he embrace the truth or will he turn his back on Steele Ridge and Carlie Beth forever?


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We're looking for dynamic People with international vocations, who speak several languages and have what it takes to quickly succeed in becoming strong, reliable team players.
Our goal is finding people with the right skills to understand and support the Group's values and energetically champion them into the future. A sharing, team-based approach and cutting-edge innovation guarantee high performance and motivation in a context in which commitment to internal and external customers is key and is coupled with strong ambition to develop "exceptional" new products and services.
Our Company Culture is based on Performance and we strongly value meritocracy and diversity. People Development is promoted through career opportunities, job rotation, international experience, Masters Degrees and Executive programs.
"We don't manage professionals we create the conditions in which they can "soar"- and maximise their contribution to our Organisation."
We are looking for graduates in the following fields:
Mechanical, Electronic and Electrical Engineering - Management-Economics, Statistics-Politics, Science-Communication, Science-Industrial Design-Languages.
International experience such as studying or working abroad is a great advantage to your profile during our assessment process.
The recruitment process is managed by our Assessment Centre and Candidate Job interviews are conducted by our HR Department and by the Line Manager.
Please send us a copy of your CV (in .doc, .rtf, or .pdf format).
Just click on your field of interest below and email the Manfrotto Human Resources Department:
- Research, Design & Development
- Sales & Marketing
- Operations & Manufacturing
- Procurement & Logistics
- Quality, H&S, Environment
- Facilities
- Top Management
- HR & Organization
Your privacy is important to us. Our full privacy statement can be read here.


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What is it/what does it do?You don't even need to click through to the product's website, I have summarised all they have to say about themselves here:
A completely new way of learning a musical instrument
- Helping boost your team skills and sharpen your concentration
- Helping foster your self-expression and relieves stress
- Helping boost your listening and communication skills
- Helping increase the capacity of your memory
- Helping enhance your coordination
Is anyone actually buying it?Let's look at some hard facts now. We can turn to statistics provided by the payment processor. They have something called the product's "Gravity". It's an indication of a product's sales rank. I've taken this amount and produced a rating out of 100. Products with a high rating are popular. The Music Coach scores 70.60/100 which is about standard.
Your buying optionsHopefully by now you've read through the résumé of what the product does (or claims to do…). You've examined in detail the user reviews and testimonials. Maybe you've decided you'd like to buy the product. So what now?
Option 1: Buy DirectYou click on the following link to http://www.yourmusiccoach.com/, and find their link to buy the product. You'll be taken to the payment processor page and you can pay with a credit/debit card or PayPal. As of the time of writing this review the standard price for the product was USD19.
Option 2: Buy Through MeIf you click this link: yourmusiccoach.com you'll also be taken through to yourmusiccoach.com, where you can buy the product in the same way as the first option. This time though, because you were sent to the site via a special link, I get the credit for sending over a potential buyer. If you do end up buying, I will receive a commission. The cost to you is the same regardless of which method you choose You might want to go for this option if:
- You feel this site has helped you and you'd like to say thanks.
- You'd like to receive a purchase bonus (see below)


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"Grassham" Surname
Frequency of "Grassham" Surname in the US
2000 US Census
The surname "Grassham" is not included in the US Census Bureau's ranking of surnames with 100 or more people. Since fewer than 100 people with this surname were included in the 2000 Census, it is relatively uncommon.
Source: "Frequently Occurring Surnames from the Census 2000", US Census Bureau.
1990 US Census
Accoring to the US Census Bureau, "Grassham" ranked #63,694 in frequency out of 88,799 surnames for which statistics were released from the 1990 Census.
Source: "Frequently Occurring Surnames from the 1990 Census", US Census Bureau.
"Grassham" Graves on Histopolis
Histopolis currently has 2 grave(s) with the surname "Grassham".
Search the Histopols Grave Index for the surname "Grassham".
Resource Links for "Grassham"
Do you know of a web page containing information about this surname that would be useful to genealogy or history researchers? Please add it now! (Free registration required)
Surnames that Sound Like "Grassham"
The surname "Grassham" has a Soundex code of G625. The following 389 surname(s) may sound similar to "Grassham" since they share the same Soundex code.


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Tillman J. Breckenridge
Adjunct Professor of Law & Managing Attorney, William & Mary's Appellate and Supreme Court Clinic
Degrees: J.D., University of Virginia; B.A., University of Virginia
Email: [[w|tjbreckenridge,Tillman J. Breckenridge]]
Tillman Breckenridge is a partner at Bailey Glasser LLP. His practice includes a diverse array of appellate litigation matters at all levels. He has represented companies, organizations, individuals, and foreign, state and local governments before the United States Supreme Court and the U.S. Courts of Appeals for the Second, Third, Fourth, Fifth, Sixth, Seventh, Eighth, Ninth, Eleventh, District of Columbia, and Federal Circuits as well as the Supreme Court of Virginia, the California Courts of Appeal and the Illinois Courts of Appeal. Additionally, Tillman has been a lecturer at DePaul University on the subjects of Constitutional Civil Liberties and First Amendment law.


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CORAL GABLES — The University of Miami just keeps finding production from different players.
Left fielder Dave DiNatale, who hit ninth, had a career-high four hits and five RBI to lead the Hurricanes to a 16-7 victory against Florida Atlantic on Tuesday at Mark Light Field.
UM, which is ranked No. 3, improved to 22-2. The Hurricanes have won nine consecutive since losing to North Carolina State on March 16.
But they needed to overcome a slow start to defeat the Owls, who fell to 16-7. The 'Canes found themselves trailing early in the first meeting between the schools in three years.
Three of FAU's first four batters reached base in the first inning. Then with the bases loaded, designated hitter Tom Hatcher hit a grand slam off John Housey.
The Hurricanes quickly recovered in their first at-bat, scoring three runs. Yonder Alonso, Dennis Raben and Ryan Jackson each had an RBI. Housey settled to pitch four scoreless innings. He allowed six hits and three earned runs in five innings.
UM took the lead for good in the fourth when DiNatale hit a two-run homer. He finished 4 for 5 and scored two runs. Jemile Weeks added a sacrifice fly in the inning to make it 6-4. The Hurricanes put things away in the sixth when they scored six runs.
The inning, in which UM batted around, began with Blake Tekotte hitting a solo home run. Jason Haggerty and Jackson had RBI, and DiNatale plated two with a double, putting the Hurricanes up 12-4.


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This page lists the song chart entries of Sammy Kaye. The songs are listed with the most widely successful first.
A popular band leader of the 1940s. Like all big bands of the era there is a certain level of confusion about which songs are credited to him and which are credited to his singers.


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Viettel, the military-owned mobile services provider, will invest in a telecommunications project in Belarus.
The move was revealed during the two-day official visit by Party General Secretary Nguyen Phu Trong to Belarus last week. Belarusian President Alexander Lukashenko confirmed that the country would provide the conditions necessary for Viettel's investment.
Belarus recorded GDP growth of 2.1 per cent in 2013, to $150 billion, and GDP per capita of $16,000. Compared to other countries where Viettel has invested, Belarus has a relatively low population, of about 9.6 million people.
Viettel has expanded its presence in seven countries and picked up 68 million customers, in Cambodia, Laos and Timor Leste, as well as Haiti, Mozambique, Peru and Cameroon. The group's vision is consolidate its operations in the East African region as it has already been granted a license in Tanzania, East Africa's second-largest telecommunications market after Kenya. It has withdrawn, however, from a planned stake purchase in Telkom Kenya, which is 30 per cent owned by the Kenyan Government.
Total revenues from Viettel's overseas businesses in 2013 reached nearly $8 billion. For the first nine months of this year Viettel Global, the international investment branch of Viettel, made net profits of VND1.47 trillion ($68.7 million), an increase of 37 per cent compared to the same period last year.


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Acle Medical CentreTel: 01493 717796
Reedham SurgeryTel: 01493 717796
When you first register with the practice you will be asked to complete a registration form and a questionnaire if appropriate. You will be able to see any doctor you wish. If you move away from the area you will need to register with another practice within the locality.
Students should register with their college or university doctor, if they need medical attention during their holiday they will need to register as a temporary resident, please see below.
Medical treatment is available from the date of registration. Please contact reception for further information.
The Royal College of General Practitioners has produced a useful guide for patients about the services on offer at GP Surgeries and how to access them. You can download the guide below.
A Patient Guide to GP Services
If you wish to pre-register click on the link below to open the form. When you have completed all of the details, click on the "Send" button to mail your form to us. When you visit the surgery for the first time you will be asked to sign the form to confirm that the details are correct.
Pre-registration Form
When you register you will also be asked to fill out a medical questionnaire. This is because it can take a considerable time for us to receive your medical records. There is an online version of this file too, which you may fill out and send to us. When you come to the surgery you will be asked to sign this form to confirm that the details are correct.
Online Medical Questionnaire For New Patients
Note that by sending the form you will be transmitting information about your self across the Internet and although every effort is made to keep this information secure, no guarantee can be offered in this respect.
Alternatively you may print off a registration form, fill it out and bring it in with you on your first visit to the practice.
Registration Form
If you are ill while away from home or if you are not registered with a doctor but need to see one you can receive emergency treatment from the local GP practice .
You can be registered as a temporary patient for up to three months. This will allow you to be on the local practice and still remain a patient of your permanent GP. After three months you will have to permanently register with the practice.
To register as a temporary patient simply contact the local practice you wish to use. Practices do not have to accept you as a temporary patient although they do have an obligation to offer emergency treatment. You cannot register as a temporary patient at a practice in the town or area where you are already registered.
Download the Temporary Resident Registration Form
These fact sheets have been written to explain the role of UK health services, the National Health Service (NHS), to newly-arrived individuals seeking asylum. They cover issues such as the role of GPs, their function as gatekeepers to the health services, how to register and how to access emergency services.
Special care has been taken to ensure that information is given in clear language, and the content and style has been tested with user groups.
Open the leaflets in one of the following languages
Accessible Information Standard
The Accessible Information Standard is a new 'information standard' for implementation by all organisations that provide NHS or adult social care. The Standard aims to ensure that people who have a disability or sensory loss receive information that they can access and understand, for example in large print, braille or via email, and professional communication support if they need it, for example from a British Sign Language interpreter. The Standard requires organisations that provide NHS or adult social care to:
Although not exhaustive, the standard is likely to apply to people who are blind and/or deaf, those who have some hearing or visual loss, and people with learning disabilities.
Full compliance with the Standard is a legal duty and required by 31 July 2016.
Successful implementation of the Standard aims to lead to improved outcomes and experiences, and the provision of safer and more personalised care and services to those individuals who come within the Standard's scope.
At practice level we will be making sure that we amend our commonly used forms to ask patients if they have any special communication needs. We will then record any on the patient's medical record so that anyone seeing the patient is aware that the patient may need assistance with communication. We will make sure that all our forms are available in larger print for patients.
Copyright 2006 - 2018 My Surgery Website | Privacy & Usage | Edit | Staff Home | Site Map | Accessibility | Site T&C's | Service T&C's


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Google has confirmed that it will hide content removed using the "right to be forgotten" ruling from more versions of its search engine, thus removing challenged content in more countries.
The current ruling only applies to versions of Google used within the EU, whose citizens can submit requests for information about them to be removed from search results. However, other users could still use an international version of Google and see the full list of unedited results.
Now, all successfully challenged results that have been removed will not appear on any version of the search engine, including Google.com, when they are being viewed from countries where the removal was approved. The change is set to be rolled out in the near future, although Google has not yet officially confirmed a date.
The new approach will be applied when a European IP address is detected, regardless of the version of Google they are using. Since the initial "right to be forgotten" ruling was made in 2014, Google has received more than 380,000 removal requests, with around 42 per cent of those requests being accepted.
The company has been under pressure from the French data protection authority to remove data from sites globally, threatening to fine the firm if it failed to comply.
Renate Samson, chief executive of privacy campaign group Big Brother Watch, welcomed the change.
"The move by Google to ensure 'right to be forgotten' across European versions of Google offers reassurance to the thousands of regular, ordinary citizens who have sought the right for inaccurate or out-of-date content about them to be blocked from Google's searches," she said.
"Whilst right to be forgotten remains a controversial issue, it is a key part of the new European General Data Protection Regulations set to be in place within the next couple of years. Google's move therefore is a necessary step in the direction of improved data protection."
Internet privacy is currently high on the agenda in the UK, with the government's so-called Snooper's Charter coming under fire from technology firms and individual rights advocates alike.
Now, a powerful committee of lawmakers examining the Draft Investigatory Powers Bill have said while they broadly support its aims in principle, significant changes must be made to the planned surveillance law which would - if left unchecked - hand UK authorities some of the most extensive monitoring capabilities in the Western world. The committee has made 86 recommendations for change.
"We think part of it is flawed and part of it needs to be looked at in greater detail," Paul Murphy, the committee chairman, told reporters.
This latest criticism of the bill follows similar comments earlier this week by a parliamentary committee, overseeing intelligence and security, which called for more work on the bill, saying it did not not sufficiently safeguard privacy and gave spies more powers than they need.
When the surveillance plan was first unveiled, in November 2015, it detailed sweeping new powers which would force technology firms to store details of every website people visited for a year, as well as spelling out the facility for UK spies to collect bulk data and hack into individuals' computers and smartphones.
The committee made special note of the requirement for internet service providers to store all "internet connection records" (ICRs) for a year, allowing the authorities to find out which websites people have visited, questioning the practicality, cost and security of storing all this data.
Global technology firms such as Google, Apple and Facebook have already expressed serious reservations about this aspect and also the bill's implications for encrypted services, penning a joint open letter to the UK government.
Ministers and intelligence chiefs say current surveillance laws are outdated, leaving the police and spies unable to keep up with technology used by terrorists and serious criminals.
The government and spy chiefs say there should be no dark spaces on the internet beyond their reach, but companies say forcing them to provide "backdoors" or to break their encryption services would weaken their own security measures.
A previous British bill, dubbed the "snoopers' charter", was ditched in 2014 amid widespread public opposition. The resurrection of a blanket surveillance bill has obliged campaigners to renew their challenge.
"Everyone in the UK - in fact, everyone around the world, given the global extent of many of the powers the UK government would have under the bill - needs to be worried about this legislation," said Sarah St.Vincent from the Center for Democracy & Technology, a Washington-based group advocating internet freedom.


text: I have a pretty new MacBook Pro (non-retina). All was working well, but after updating to 10.8.4, I seem to have a WiFI issue. All other devices in the house work fine with WiFi. When I can get Speedtest.net page to load, the results are good, about 30mbps down and 5mbps up and 11ms ping. However, webpages load ******, anytime I make a 2nd tab in safari, the new page is slow to load if it does at all. Some Messages accounts won't connect (gmail and AIM), other apps that require the Internet are just slow. Has anybody else experienced this and/or have a fix before I bother calling Apple and all that?


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Rilakkuma Weekend Party: Saturday, August 14, 2010
Rilakkuma Weekend Pop-Up Shop & Events: August 14-15, 2010
Rilakkuma Weekend x Umami Burger Two-Week Promotion: August 7-22, 2010
This August, Los Angeles will experience a taste of Japan. Highly-popular San-X characters Rilakkuma and Mamegoma will be presenting Rilakkuma Weekend, an amazing weekend of food, fun and shopping, in association with Umami Burger. For the occasion, Jamie Rivadeneira of JapanLA will curate a custom San-X pop-up shop filled with San-X characters and rare merchandise from Japan. The weekend will also include a party and Japanese-inspired events produced by Bubble Punch.
Rilakkuma is one of the most popular characters in Japan and is produced by San-X. The name Rilakkuma is a unique combination of the Japanese pronunciation of relax and the Japanese word for bear. True to its name, Rilakkuma enjoys relaxing, and its favorite activities include eating, sleeping, and listening to music. Accompanying Rilakkuma will be San-X pal Mamegoma, an adorable seal character.
To celebrate Rilakkuma and Mamegoma's U.S. arrival, Umami Burger will present a special two-week promotion at all four Los Angeles locations: Los Feliz, La Brea, Space 15 Twenty and Santa Monica. Limited-edition collectible merchandise and serveware will be featured at Umami Burger during the week leading up to and following Rilakkuma Weekend. Come join the fun and experience the fifth taste of LA with Rilakkuma and Mamegoma!
Rilakkuma Weekend Schedule & Locations:
Rilakkuma Weekend Pop-Up Party
Saturday, August 14, 2010
7326 Melrose Avenue
Los Angeles, CA 90046
Shopping & Special Events
Rilakkuma Weekend Pop-Up Shop
August 14-15, 2010
Saturday: 11am-11pm, Sunday: 11am-7pm
7326 Melrose Avenue
Los Angeles, CA 90046
Rilakkuma Weekend x Umami Burger Promotion
Two-Weeks: August 7 to August 22, 2010
All four Umami Burger Locations:
850 South La Brea Avenue, Los Angeles, CA (323) 931-3000
4655 Hollywood Boulevard, Los Angeles, CA (323) 669-3922
1520 North Cahuenga Boulevard, Los Angeles, CA (323) 469-3100
500 Broadway Santa Monica, CA (310) 451-1300
All events will be open to the public and free of charge, and please visit www.japanla.com for complete event information.
SAN-X Co., Ltd. is based in Tokyo, Japan and creates unique and fun characters that are embraced by fans around the world. Founded in 1932, San-X has produced approximately over one thousand characters, including Rilakkuma, Monokuro Boo, Mamegoma, Tsuginohikerori, Kutsushitanyanko, Kamonohashikamo, Kireizukinseikatsu, Tarepanda, and Afro Ken. San-X characters are licensed worldwide in China, Taiwan, Hong Kong, Korea, Thailand, Indonesia, Malaysia, Italy, Brazil, Philippines, Singapore and the USA, and they have partnered with globally recognized brands such as Kit Kat, Toyota, Tower Records, Fuji-TV and Sega Toys to produce unique tie-ins and collaborations. For more information, please visit www.san-x.jp.
Launched in 2009, Umami Burger is a growing burger concept dedicated to the "fifth taste" by Los Angeles-based entrepreneur and restaurant creator Adam Fleischman. In his newest venture, Fleischman has created a fleet of exotic and tasty burgers made with traditional as well as unexpected ingredients (house-processed cheeses, house-made condiments, and house-ground beef). The restaurant's namesake burger combines more than six umami-rich ingredients, including a Parmesan cheese crisp and oven-dried tomatoes. Umami Burger has four locations: 850 S. La Brea Avenue in Los Angeles, 4655 Hollywood Blvd in Los Feliz, Space 1520 at 1520 Cahuenga in Hollywood, and 500 S Broadway in Santa Monica, and for more information, please visit www.umamiburger.com.
Inspired by Japanese and American Pop Culture, JapanLA is a unique retail destination that caters to adults who love "kawaii" or "cute" toys, apparel, and gifts. Owner Jamie Rivadeneira curates a highly-edited selection of rare and limited-edition items imported from Japan's most popular character brands. They also carry items inspired by Japanese pop culture, including handpicked items made by local and international independent artists. Also a lifestyle brand, JapanLA plans creative theme parties and organizes its highly-anticipated annual "JapanLA Super Mega Fun Tokyo Tour," where customers and friends travel to Japanese destinations such as Harajuku, Shibuya, and Akihabara. JapanLA makes it fun for people of all ages to share their love for "cute" in their life. JapanLA is located in the Melrose Shopping Area, at 648 N. Fuller Ave., Los Angeles, CA 90036. Please visit the website at www.japanla.com <http://www.japanla.com/> or call (323) 934-5201 for more information.
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- LA 3.19.11 #PRAYFORJAPAN +++ Art Fundraiser Exhibition, Sweet Streets & JapanLA
- NY 3/3: Every Wednesday After Work Party at POP BURGER LOUNGE
- LA 9/18: Space15Twenty Yard Sale


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Saturday, February 25, 2012
Butterfly Flake
This is easy and fast to work up. I hope you enjoy it. I used # 30 DMC cebelia, and a size 11 steel hook. It was a nice break from the # 100 I have been working with.
Round 1). 18 sc in a magic ring. Join with sl st in first sc and draw ring closed.
Round 2). Ch 1, sc in same sc as join. Ch 3, Sk 2 sc, sc in next sc, around for a total of six ch 3. Join with sc in 1st sc.
Round 3). * Sl st in ch 3 space, Ch 3, tr, 4 dtr, tr, ch 3, sl st all in same ch 3 space. Sc in next sc.* Repeat * to * around, except join with sl st in 1st sc.
Round 4). *Ch 24, sc in 2nd and 3rd ch from hook. Ch 9, dc in 16th ch of ch 24. Ch 13, sc in 2d and 3rd ch from hook. Ch 7 tr in top of dc. Ch 8, 2 sc in 2nd ch from hook, ch 1, sk next ch, sl st in next 5 ch. Ch 8, 2 sc in 2nd ch from hook, sk next ch, sl st in next 5 ch, sl st in top of tr. Ch 10, sc in 2nd and 3rd ch from hook. Ch 10, sl st in bottom of tr and sl st in top of dc. Ch 12, sc in 2nd and 3rd ch from hook. Ch 5, sl st in bottom of dc. Sl st in each remaining st of ch 24. Sl st in top of sc. Ch 14, sc in 2nd ch from hook. Ch 12, sk stitches on petal and sl st in next sc.* Repeat * to * around. End off, weave in ends.
Pin to a cardboard box or dense cork covered in tinfoil (plastic wrap if using glue). I prefer liquid starch, because it does the least amount of damage to fine stitches and thread luster, but you may wish to use glue with this flake, so the spokes won't be limp.
I will return soon with the finishing touches of my paper heart doily. I haven't forgotten, in case your worried about seein it finished...Until next time.
I retain all rights to my patterns and photos, but you may do what ever you wish your finished piece.
9 comments:
I love your creations.ReplyDelete
Thank you for sharing this lovely snowflake! i was just thinking 'wonder how i could put butterflies in a snowflake'...amazing! going to work one in purple in honor of my purple crocus which started to bloom today!ReplyDelete
Wow that is just beautiful!ReplyDelete
Beautiful and unique! I'd been thinking about trying a butterfly flake, and you beat me to the punch!ReplyDeleteReplies
I would soooo love to see what you would work up!Delete
OMGoodness, all you creative minds!!! How wonderful!! And you're sharing with all of us that don't have that gift, but can work with our hands!!! LOL Thank you so much!!! Just gorgeous!!! :)ReplyDelete
what is a magic circle?ReplyDelete
This is gorgeous as is all of your work. I'm so happy I found your siteReplyDelete
Typo discovered: on step 4 it should read ch 15 and not ch 5. It is a beautiful snowflake.ReplyDelete


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Blue Cross of Georgia health insurance rates. Affordable health insurance plans, low rates for all in Atlanta and around Georgia. Instant insurance quotes, compare plans & apply direct.
You can purchase Blue Cross of Georgia health insurance with or without dental coverage. Their dental plan is mid-priced offering routine cleanings and exams twice yearly at a nominal charge. Other basic services are covered after satisfying a $50 annual deductible. The Blue Cross dental network is statewide and includes many dentists.
BCBSGA HSA (Health Savings Account)
Blue Cross of Georgia health insurance includes several copay plans and two
HSA qualified plans. The copay plans include an emergency room copay. All plans (including the HSA) cover annual exams for a nominal copay. Major medical deductibles range from $750 to $20,000. Rx deductibles apply before you can access the Rx copay. The HSA plans are issued on a single or family basis. They offer plans that cover expenses at 80% after the deductible as well as 100%. Some plans from Blue Cross do not cover brand name prescription drugs or outpatient benefits.
BCBSGA offers maternity coverage, but only if you purchase a maternity rider at time of application. Like all health insurance companies in Georgia, complications associated with pregnancy are covered as any illness. Maternity benefits covered by the rider are available after the policy has been in effect for 12 months.
As of 10/1/2010 Blue Cross is not offering maternity coverage.
Georgia health insurance shop offers many options and some of the most competitive plans can be found through BCBSGA. With dozens of plans to pick from we can help you find one to meet your needs and budget.
HSA (Health Savings Account) is a popular choice for Georgia health insurance. The BCBSGA plans include annual wellness exams with no waiting period.
BCBSGA Blue Choice 100% (HSA compatible) – No wait annual exam, deductible waived. Exam covered at 100%. Annual out of pocket per person or family is equal to the deductible.
BCBSGA SmartSense POS – A new plan introduced in November, 2009. (SmartSense PPO available in select zip codes). Yearly exam covered with no deductible, insured responsible for 30% of the fee. Office visit copays are $30, copay for ER is $500. Choice of deductibles from $750 to $20,000. Annual out of pocket is the deductible plus $3,000. Maternity is not an option with the SmartSense plans. Optional Enhanced Rx benefit, dental and life available.
BCBSGA Premier PPO – Premier offers unlimited doctor visits with a $35 office copay. Yearly exam covered with no deductible, insured is responsible for 20% of the fee. Choice of deductibles from $750 to $20,000. Annual out of pocket is the deductible plus $2,500 (except on deductibles of $10,000 or $20,000 where your out of pocket is limited to the deductible). Optional maternity benefit. Optional Enhanced Rx benefit, dental and life available. UNDERWRITING Underwriting can be brutal and often requires a lot of patience. We pre-screen every application before sending it on to Blue Cross for review. Blue Cross does not issue riders for pre-existing conditions. Instead, they surcharge the standard premium rates to account for the risk.
You can view
Blue Cross health insurance plans and rates at their site or
compare to other health insurance companies in Atlanta Georgia
using our quote engine.


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The name (Holy Fire) comes from the church of Aghia Foteini next to the beach. An illustration of Francesco Basilicata (1618) is titled Spiaggia di Santa Lucia (the same, in Italian) and you can indeed make out this very same beach.
It is quiet and sheltered, with high cliffs, small pebbles and sand, as well as crystal-clear waters that drop away suddenly. Around it are many tall pines, tamarisks and olive trees.
The beach is reasonably well organized: apart from the sunbeds, umbrellas and showers, you will come across some tavernas and rent-rooms to make your stay comfortable – and a beach bar. On the beach are volley-ball courts: every July since 2000 a tournament is arranged. The bottom of the sea-bed is perfect for underwater exploration.
If when here you walk along to the east end, you will come across a spring of fresh water by a rock on the beach.
If you are on the lookout for a little peace and quiet, the well-named small bay of Galini (Serenity) is the very next one you meet, a mere stroll away from Aghia Fotia.
- Tips, Suggestions, Iseful info
- History, Culture
- What to do (Activities)
- What to see (Culture, Nature)
Additional Info
- location Agia Fotia, Ierapetra, Lasithi
- free camping Yes
- nudism No
- beach type Thin Pebble
- accommodation Yes - some choices
- dinning Yes - enough choices
- other facilities
There are umbrellas, sun beds and showers. There is also a tennis beach volley.
Access Info
relevant routes & paths:
Distance: 48 km from the town of Agios Nikolaos, 13 km from Ierapetra.
By car/motorcycle: From Ierapetra follow the road to the east. After 13 kilometers you are at the beach. Likewise, you can start from Sitia and follow the main road leading to Ierapetra, passing through Makrigialos and Agia Fotia.
By bus: Services run to Agia Fotia from Ierapetra and Sitia.


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text: Firstlady Bridal House opened in September 1996 by Mary Rowley and her partner Ray Kavanagh. In that time they have had the pleasure of helping thousands of brides choose their dream dress. Our bridal consultants have a wealth of experience to help guide our brides in beautiful surroundings which are quite unique. We moved premises in 2013 to a fabulous Edwardian building with several showrooms and two specially designed reception/changing rooms. Our brides love their own room for their private consultation along with comfortable seating for their guests.


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What to drive lust after when you discover cars in jr. high. Seems like an odd choice, right? Well, part of me wanted a Porsche 930 with its 4.9 second 0-60 time.
The practical eco-hippy in me wanted this car: the 1977 Honda Civic.
Well, not this EXACT car, because of the overindulgent, questionably conceived blackout treatment an stripes. It's not standard. It's either an owner add, a repaint, or – god help us, because Honda was supposed to be above this – a hastily conceived "Sport" package. We know dealers did this. Look at the rear valence[? – the panel under the hatch.] Some sort of badge resided there at some point.
Anyway, I wanted this car, because its MPG numbers were 54/41. This was under a different EPA regime, but still, impressive. The CVCC allowed it t run on regular gas. I didn't understand lead toxicity at the time, but I did understand the comparative rarity of platinum. Plus, in the cents and cents world of $2.47/hr BK Lounge wages, it was much less completely unaffordable than the Porsche.


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Friend's Email:
Subject: I have found a CD that I think you would enjoy
|Lock Up
Something Bitchin This Way Comes
Genres: Pop, Rock, Metal
Larger Image
CD Details
Similar CDs
Similarly Requested CDs
CD Reviews
Bradley D. Hall | Huntsville, AL USA | 02/18/2005
(4 out of 5 stars)
"If you like(d)the Minutemen and/or the first two Van Halen records, buy this. If you didn't (or don't) like the Minutemen and the first two Van Halen records, forget what I said and buy it anyway."
Good Stuff
M. Hanson | Omaha | 02/07/2006
(3 out of 5 stars)
"Bought this one on a whim after reading some of the other reviews. Very pleased with it, although it's a little too funky at times for an old rocker like me. Definately would recommend it though."


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Tag Archives: animation
There's Something In The Water
There's Something In The Water is a blog, and part of a clever campaign to promote V Water, an English flavoured water with vitamins. The themes keep calm and don't stress are emphasize in the cheerful animated film created for … Continue reading
Pirates! at Internet Archive
The Internet Archive's blog made a special post to celebrate the International Talk Like a Pirate Day: Pirates!. The post points to films, animations, audio archives and books with pirates on Archive's collection. Nice suggestions, specially the animations: Felix the … Continue reading
Talk Like a Pirate Day 2007
Once more it's time to celebrate the International Talk Like a Pirate Day. And I will do it on my way, sharing links, since I don't have any pirate costume. Catster and Dogster users are also participating of this special … Continue reading
Posted in animation, books, cinema, culture, events, fun, photography, pin-ups, video Tagged animation, books, bunnies, cinema, culture, events, funny, generator, illustration, photography, pictures, pin-ups, pirates, Talk Like A Pirate Day, video 3 Comments
Musicotherapie is a funny schizophrenic French animation presenting the director of a mental institute neurotic with all kind of noises. To make it worse, the insane patients start to compose a music with noises and fuss in the kitchen. This … Continue reading
Do you love animations? Visit Videos with Bibi
If you love animations, you should be a reader of Videos with Bibi. I have been posting there since February and the video blog (vlog) contains, until now, hundreds of videos. There is a bit of everything: documentaries, silent melodramas, … Continue reading
Antoine Antin
The animator Antoine Antin studied in the renamed French Gobelins school of image and have been working with animation since 2002. His portfolio includes many drawings, some videos and films. In the last years he has been working at BiboFilms, … Continue reading
Monster Party
The 2007 Fantasy Filmfest, a German festival of science fiction, horror and thriller films, has a delightful trailer: Monster Party. I'm a huge fan of the monsters of horror films, even the bad films, and this excellent stop-motion animation has … Continue reading
Posted in animation, video Tagged animation, horror, sci-fi, stop-motion, video 2 Comments
Hans Fischerkoesen
While most of directors who stayed in Germany in the 1930's and 1940's were working with the Nazi State and doing propaganda films, like Triumph of the Will, there are also few examples of those that were subverting those rules … Continue reading
AnimaBoom Winners
The winners of AniBOOM Awards 2006 were announced weeks ago. Among the 1,700 entries from 70 countries submitted to the contest there are many so-so works and there are also some little pearls that worth the visit. A good way … Continue reading
SpiderBuns (Spiderman) 1 and 2
The Angry Alien bunnies attacked again. This time the "victim" was the last two Spider-Man films with Tobey Maguire as the main character. Maguire is good, but not so good as the bunnies that had only 30 seconds to re-enact … Continue reading


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Free Range Worms
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- (08) 8255 ####
25 Gores RdMap
Davoren Park SA 5113Click to view map
About Us
Bulk, dolomite or fertilizer suppliers and similar products or services are available from Free Range Worms during normal business hours. For a fuller description of a more complete range of Fertilizers & Chemicals products or services please call us on (08) 8255 #### or email.
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Cumberland Produce
"i stopped off at this business and found the service excellent , the staff were very knowledgable and friendly plus they carried the goods to my car , am now a regular customer please try it out you wont be disappointed ."
sarah toale on 6th Dec 2011


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Build a Bouquet Happy Birthday by Fran Seiford
INSTRUCTIONSPrint Project
- Create a card base from a 4-1/4" X 11" panel of medium pink cardstock. Set aside.
- On a 4" X 10-3/4" panel of patterned pink cardstock, gently find the center by pinching at the sides.
- Align Pop-Up Cutting die with center markings and run through die cutting machine to create pop up stages and hang tabs.
- Emboss doily on inner card panel near fold with VersaMark ink and white embossing powder. OR Create a white cardstock doily using edge dies and cutting with pop-up die to fit around pop-up stage. See video for guidance.
- Gently train the folds on die cut panel so pop-up stage and hang tabs hang properly.
- Stamp Bouquet Bowl and Flowers and Leaves in black ink on Mixed Media White Paper
- Color as desired with colored pencils going outside the lines.
- Die cut flowers, leaves and vase by lining up inside edge of cutting die perfectly with cutting line of images.
- Cut with die cutting machine using magnetic platform or taping dies in place.
- Glue vase to pop-up stage being careful to get glue only on pop-up stage.
- Glue flowers to each other and hang tabs to hang over the vase.
- Stamp greeting in black ink on white cardstock and die cut with layered ovals in Pop-Up Die Set. Layer on colored oval for contrast. Glue on top hang tab.
- Glue inner panel to cardstock base by carefully applying glue around openings. Glue bottom half to inside of card first, fold shut, and apply glue to top half, close card to ensure card will close properly. Test card, then allow glue to dry.
- Perfectly Clear Acrylic Stamp Handle Multiple Styles & Colors
- Memento™ Tuxedo Black Ink Pad by Tsukineko® - MEM01 6.99
- Mixed Media White Paper 7.99
- Cling Build A Bouquet Set 11.99
- Build A Bouquet Die Set 19.99
- Build A Pop Up Die Set 19.99
Also uses these supplies:
Cardstock by Bazzill Basics®
Patterned Cardstock
Colored Pencils
Big Shot Die Cutting Machine by Sizzix
Magnetic Platform for Big Shot
Zip Dry™ Paper Glue by Beacon Adhesives
Related Projects
If you've use this product in a project of yours, we'd love to see it! You can submit your step-by-step instructions and supplies used by clicking below.Submit A Project


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Check out our specials and save on your next project.
Schedule your free in home estimate, by filling out our easy form.
Call now or come on down and visit our showroom today.
View our slab gallery
Has your kitchen, office, or bathroom become a bit drab and run-of-the-mill?
Are you looking for a reliable and trustworthy remodeling company that
can help you make these rooms more beautiful than ever? Look no further
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Contact us at 425-462-0375 for more information!


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Heres what I'm thinkin
An event for a tank engine Idle is playing. I want this tank to reduce the volume of EVERYTHING else in the world ONLY when the tank is within 5 meters of the listener (me). Essentially a 'ducking' system that is MANUAL, not AUTOMATIC. So, what if I could add a volume envelope to this tank event which would control the volume of another category? For example, I add a volume envelope to the tank event that controls my "ambience" category. I draw this volume curve to make it 0db from the distance of 0-5meters and then it ramps up to full level after that. Essentially it would look like a horizontally flipped volume curve of the tank's own attenuation curve but instead of controlling the tanks volume it controls something else.
This way, when I am near something loud such as a tank I don't have to hear everything else in the world that isn't important. essentially giving games unlimited headroom and compressing a huge dynamic range virtually.
- JamieMB asked 11 years ago
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Leche Flan is great for dessert and some take this for snacks. Just a caution for diabetics, this recipe is high in sugar.
- 2 cups thick coconut milk
- 6 egg yolks
- 4 egg whites
- 1 cup sugar, refined
- 1 cup brown sugar
- Dissolve brown sugar in 1/4 cup water and cook over moderate heat until the sugar browns, or caramelizes.
- Line a suitable mold with 3/4 of the caramelized syrup evenly, and set aside.
- Stir the milk into the remaining 1/4 of caramelized syrup.
- Place over low heat and stir continuously until all caramel is dissolved.
- Mix egg yolks and slightly beaten whites and beat lightly to mix thouroughly.
- Add sugar and lemon rind.
- Then add coconut milk with caramelized syrup and mix well.
- Strain through a cheese cloth and pour into the mold previously lined with caramel.
- Cook slowly in a pan with hot water without allowing water to boil.
- After about 1 and 1/2 hours cooking, place a piece of plain metal sheet above the mold and over it, place a few piece of live charcoal to brown top of custard.
- Or slip under broiler in oven just long enough to brown.
- Cool and unmold before serving.