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Nationwide - Oct 15th Show your doctor the scientific proof. Start now - gather the proof - Go to ***********ncbi.nlm.nih.gov/ search cannabinoids (your ailment) for example: cannabinoids arthritis cannabis arthritis endocannabinoid system arthritis Find the best studies relating to you or a loved one. Print those along with: ***********ncbi.nlm.nih.gov/pmc/articles/PMC2873996/?tool=pmcentrez ***********jaoa****/content/108/10/586.full ***********aerzteblatt.de/int/archive/article?id=127603 ***********fda.gov/ohrms/dockets/dailys/02/Aug02/082202/80022395.pdf ***********ncbi.nlm.nih.gov/pubmed/16596788 ***********ncbi.nlm.nih.gov/pubmed/19675519 ***********ncbi.nlm.nih.gov/pubmed/18404144 ***********ncbi.nlm.nih.gov/pubmed/20166925 Bring the printed studies to your doctor and ask that he read them. Tell them cannabis is medicine, you want it now and would they please get onboard with efforts for medicinal use in your state. If you are a
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$65.00Size Guide
We are moving to our new location SOON!
$65.00Size Guide
Itsy Bitsy's focus is to make everyone feel special when they walk in the door. We especially love when our Itsy Bitsy customers are here to where they can play with our toys on the floor or you might find Susan and her AMAZING TEAM holding babies while moms and grandmothers shop. Our boutique is an easy going and fun place to find something special or even easy soft play clothes you can't find just anywhere.
Steps how to decide what you want.
Allow an additional 5 business days for monogramming. And then we will ship your products per your shipping requirements when you bought your products.

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A light body lotion rejuvenates, moisturizes and calms the senses with a fresh lavender scent. A perfect product for everyday moisturizing.
Handmade by Los Poblanos Organic Farm in New Mexico.
Size: 8 oz
Daphnis and Chloe is a Greek culinary herb and spice company dedicated to chefs and home cooks who are looking for Mediterranean ingredients of the finest quality.
The municipality of Almopia in Northern Greece is one of the few producer areas of "Bukovo", a Mediterranean spice made by a local variety of red horn peppers and named after the Slavic word for "spicy". The remote Greek villages of Garefi and Ksifiani are praised producers of this Balcanic vegetable, used by the locals to make a smoked, sweet, and delicately spicy blend very popular in the surrounding cuisines but almost unknown elsewhere.
Our Daphnis and Chloe Chili Flakes come from an organic producer who smokes his peppers with birch wood, according to a traditional smoking process that lasts for weeks. For an unexplainable reason, our male customers are particularly fond of them.
Chili flakes can be used in the cooking or as a seasoning. Being only delicately spicy, they are great for giving a smoky effect to your favourite meals. Here at Daphnis and Chloe we love pairing them with thyme, oregano or fennel seeds.
Grown in Greece.
Size: 40gm.
Best before date: 10/2016.
This super cute hedgehog door stop, is made of natural materials. Being both functional and adorable, the hedgehog's spikes are made of bassine fibre, perfect for cleaning shoes.
Handmade in Germany by a family run company, Redecker.
Made of oiled beechwood an bassine fibre.
Measuring 265mm.
Care tip, hand wash.
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Lightweight and easy to handle. This brush is perfect for cleaning baby's bottles, decanters and containers with awkward shapes. Handmade in Germany by the hertiage family run company -Redecker.
Ideal baby shower gift.
Made from bristles twisted in wire
Measuring 45 mm (head) by 320 mm.
Care tip is to hand wash.


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If you are a self-hosted WordPress (.org) user, chances are that you've already taken the plunge into the world of plugins. If not, then perhaps this will be the straw that got the camel interested in developing their website or blog! For those who are familiar with WordPress plugins, we'd like to state for the record that this week's feature is one that will have you coming back for more…plugins!
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While it may seem like a luxury, you will soon find that having power reclining furniture and its customized position capability is a necessity for your home. Customized motion means that you can stop the recliner seat and back with simultaneous movement at whatever position best suits you, whether you need to soothe back pain or sit up and eat a snack while you watch TV. Gentle, power motion is suitable for all levels of mobility, and is as easy to use as a single touch.
We'll specially make a sofa or chair in the fabrics you want, and get it to you faster than those other suppliers. We're always working to reduce lead times and bring the product to to your home faster, usually in as few as 21 days. Check with the store to find a lead time adjusted for your location.
Use the built-in console to store remotes, chargers and other small items that could easily get lost in the depths of cushions. With this hidden storage you are able to keep your living room organized while always knowing where to find essential items.
Keep your drink within reach as you enjoy a movie, your favorite TV show or a sporting event. Having built in cup holders also helps eliminate spills and stains in your living room as you don't have to keep your beverage by your feet on the floor.
Unlike recliners that are built with a two or three-piece seat and leg rest cushion, this recliner has a single chaise cushion that extends from the seat to the feet. This style offers fuller comfort and support for your legs, and eliminates the open gap that toddlers can get fingers or toys stuck in.
This brand was tested to have a softer, plusher seat feel than even the big name brands. High density polyurethane foam is wrapped in high-loft polyester fiber, creating a soft but durable cushion. These cushions will provide you with years of that brand-new feel.
One recliner is nice, but why not share the love with a two-seat recliner? Stop future arguments for the best seat in the house with a power reclining loveseat and its two, blissful reclining seats with full, chaise-cushion support. Also boasts plush support for arms and back plus a center console with storage and two cupholders.
The Seger Casual Power Rocking Reclining Loveseat with Cupholder Console by Best Home Furnishings at AHFA in the area. Product availability may vary. Contact us for the most current availability on this product.
With a design based off our best-selling recliner, the relaxed and cozy feel of this collection is perfect for entertaining guests or just ordinary, everyday lounging. This collection is pillow-plush from top to toe with the sink-in seating we're famous for. The reclining sofa and loveseats all feature full-support chaise legrests and the option of power recline for the ultimate comfort treat.
The Seger collection is a great option if you are looking for Casual furniture in the area.
This item has been tagged as: Sectional with Recliner, Recliner Sectional, Reclining Sectional, Seating, Couches, Couch, Sofa, Reclining Home Theater Furniture, Living Room Furniture, Accent Furniture, Reclining Love Seat, Loveseat Recliner, Reclining Couch, Reclining Sofa, Couch with Recliner, Sofa with Recliner, Motion Furniture, Moving Furniture, Living Room Furniture, Family Room Furniture, Great Room Furniture, Den Furniture, Home Furnishing
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Nonparametric statistical methods
Wiley, 1973 - Mathematics - 503 pages
This Second Edition of Myles Hollander and Douglas A. Wolfe's successful Nonparametric Statistical Methods meets the needs of a new generation of users, with completely up-to-date coverage of this important statistical area. Like its predecessor, the revised edition, along with its companion ftp site, aims to equip readers with the conceptual and technical skills necessary to select and apply the appropriate procedures for a given situation. An extensive array of examples drawn from actual experiments illustrates clearly how to use nonparametric approaches to handle one- or two-sample location and dispersion problems, dichotomous data, and one-way and two-way layout problems. An ideal text for an upper-level undergraduate or first-year graduate course, Nonparametric Statistical Methods, Second Edition is also an invaluable source for professionals who want to keep abreast of the latest developments within this dynamic branch of modern statistics.
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The D1chotomous Data Problem
The OneSample Locat1on Problem
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Nonparametric Statistical Methods
Myles Hollander,Douglas A. Wolfe,Eric Chicken
Limited preview - 2013
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accept H0 applied asymptotic efficiency asymptotic relative efficiency asymptotically distribution-free test Bernoulli trials calculate Chapter chorioamnion compute confidence coefficient continuous population continuous random variable corresponding data of Table denote differences distribution function distribution-free confidence interval Doksum empirical distribution function equal equation equivalent terminology Example experimentwise error rate graphical procedure H0 is true Hodges and Lehmann integer jackknife joint ranking large sample approximation level of significance median multiple comparison procedure mutually independent null distribution null hypothesis observations obtained one-sample one-sided test ooooo ordered values percentile point point estimator PROBLEMS procedures based procedures of Sections Properties random member random variable reject H0 respect Shorack sign statistic sign test signed rank statistic signed rank test specified standard deviation subgroup symmetric test based test of H0 test procedures tied group tion two-sample two-sided type I error underlying population usage variance versus the alternative Wilcoxon
References to this book
An Introduction to Copulas
Roger B. Nelsen
Limited preview - 2006
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Regression Analysis by Example
Samprit Chatterjee,Ali S. Hadi
Limited preview - 2006


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September 6 - October 26, 2013
MINUS SPACE is delighted to present the survey exhibition Julian Pretto Gallery. Organized in collaboration with artist John Zinsser, this is the first exhibition to examine the history and legacy of gallerist Julian Pretto (1945-1995) and his fabled downtown New York galleries, active during the mid-1970s through the mid-1990s.
Julian Pretto Gallery
September 6 - October 26, 2013


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I always post my drawings at like midnight and no one sees them -.- but I'm impatient so here it is. It's Miranda Kerr. I guess she's a Victoria Secret model? Ref: [Link]
Java Draw Created Mar 02, 2013 460 x 640px Unless noted Copyright 2013 happiness_Z.
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Very pretty!!
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in order to thank everyone, characteristic, novel style, varieties, low price and good quality, and the low sale price. Thank everyone ==== ( http://www.fullmalls.com ) =====


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Mid-range cruising, shoal-draft & great performance
You'll be pleased to know it isn't all new. Some recent innovations on our other performance cruisers are changing the definition as to what "real" cruising design is all about. For example, the "single handing" cockpit and owner's forward double stateroom are proven winners from the top-of-the-line J/40 cruiser. The "UFO" (Underwater Flying Object) shoal draft keel and "hideaway" double entry head have been checked out with high scores on the J/37 cruiser. And, quality Tillotson-Pearson construction isn't new to sailing aficionados either. It's nice to know some things don't change.
So What's New?
Waterline Length
Shoal Draft UFO Keel
The UFO keel is part bulb and part wing in design, with more mass and strength than conventional fin or wing keels to minimize damage in groundings. It is shaped to prevent snaring pots or weeds, and provides exceptional upwind stability due to low center of gravity.
J/34c Brings Out Your Best
Single Handed Ease of Operation
Best Built
J/34c Cruising the Bahamas- great story about preparing for long-distance cruising offshore- by Glenn & Pam Cooper.
Introduced: 1987 Built to: Hull #36 Last Model Year: 1990


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- Introduction
- Grading and Types of Malignancies
- HPV and ASIL: Risk Factors
- LSIL to HSIL: Risk Factors
- HIV-HPV Interactions
- Symptoms of Disease
- Therapeutic Interventions
- The HAART Factor
- HPV Vaccines
- Screening Techniques
- Barriers to Screening
- Awaiting Standard of Care
- Selected Sources
- See Also:
It is generally known that men who have sex with men (MSM) are at increased risk for contracting hepatitis A virus (HAV) and hepatitis B virus (HBV), both of which can be prevented by vaccination. Less widely known is the fact that MSM have high rates of anal cancer, or carcinoma, compared with the general population, and that HIV positive MSM have a substantially greater risk for anal cancer than do HIV negative MSM. In fact, anal cancer in MSM regardless of HIV serostatus is currently more common than cervical (uterine) cancer is in HIV negative women. Recent studies also suggest that HIV positive women have nearly the same levels of anal human papillomavirus (HPV) infection, a major risk factor for anal carcinoma, as do HIV positive men. These statistics bear some attention since anal carcinoma, unlike non-Hodgkin's lymphoma (cancer of the lymphoid tissue) and other cancers affecting people with HIV, may be largely preventable.
In this article the term MSM refers to self-identified homosexual and bisexual men who engage in receptive anal intercourse as well as men who engage in receptive anal intercourse with other men but consider themselves heterosexual. Anal neoplasia prevalence in HIV positive women does not necessarily imply that this group engages in receptive anal intercourse at the same rates seen in MSM.
Anal intraepithelial neoplasia (AIN, or abnormal cell growth in anal tissue that may progress to cancer) has been historically overlooked by health-care providers. One reason may be that no firm guidelines have been established for carrying out routine screening of persons in high-risk groups or for prescribing treatment for various manifestations of anal neoplasia. This is due in part to a lack of large-scale prospective studies (which involve gathering data forward over time) showing whether screening is beneficial. Other factors may be that providers are unfamiliar or uncomfortable with this disease or are unwilling to acknowledge the threat it poses to certain populations.
Yet as many HIV positive persons continue to live longer with HIV due to highly active antiretroviral therapy (HAART) and antimicrobial treatment and prophylaxis (preventive agents) against opportunistic infections (OIs), incidence of anal neoplasia and cancer may increase. And as more HIV positive people, as well as HIV negative MSM in general, learn about the risks of anal cancer, they are more likely to request screening for the disease. Various techniques for screening and treating anal neoplasia and cancer have been identified and can be readily implemented. However, health-care providers will need specialized training, and prospective studies will need to be completed, before this potentially widening problem is contained.
Disease of the Anal and Cervical Regions
The term neoplasia (plural of neoplasm) refers to abnormal cell growth and tumor (abnormal tissue) formation in the body; neoplasia may be benign (noncancerous) or malignant (cancerous). The full spectrum of AIN (mild to severe) is also known as dysplasia, a condition that refers to abnormalities in the structure, size, and organization of cells. Severe dysplasia is essentially synonymous with carcinoma in situ (cancer confined to its site of origin); neither term should be confused with invasive cancer. In this article, anal cancer and anal carcinoma refer to invasive anal cancer.
Cervical intraepithelial neoplasia (CIN), a precursor to invasive cervical cancer in women, provides the most useful model for understanding AIN. Similar tissue structure and apparently similar natural history (normal progression) of disease states in the anal and cervical regions have led clinicians and researchers to develop a working analogy between the two zones. What little is known about anal neoplasia -- especially in persons with HIV infection -- has been largely based on studies done in the past ten years. In contrast, a substantial body of data has been collected over the past several decades relating to the etiology (cause) and pathogenesis (development) of cervical neoplasia. In the absence of large-scale natural history studies of AIN, experts have often deduced from what is known of CIN and applied cervical neoplasia data cautiously to the study and treatment of anal neoplasia.
AIN typically presents as lesions (localized tissue changes) in the transformation, or transition, zone of the anal canal, where the squamous epithelium of the anus meets the columnar epithelium of the rectum. These lesions are frequently referred to as anal squamous intraepithelial lesions, or ASIL. Similarly, most occurrences of CIN first appear in the transformation zone of the cervix, where the squamous epithelium of the exocervix (outer cervix) joins with the columnar epithelium of the endocervix (inner cervix). These cervical lesions are often referred to as cervical squamous intraepithelial lesions, or CSIL. (The epithelium is the thin layer of cells that covers internal and external body surfaces. Squamous cells are flat, scale-like cells such as those comprising the surface of the skin; columnar cells are prismatic [prism-shaped] in form and comprise the majority of cells in both large and small intestines.)
Both the anal and cervical regions are frequent sites of HPV infection. HPV is a blanket term for over 100 distinct papillomaviruses (a subset of neoplasm-inducing papovaviruses) that cause a variety of human warts, including common warts of the extremities, internal and external genital warts, and tissue changes associated with cancer of the anus and cervix. HPV infection of the anus or cervix may be latent, subclinical, or readily apparent. The latent, or clinically invisible, infection period can last from two weeks up to about eight months after the virus has been acquired via mucosal tissues (moist linings of body orifices, such as the anus); in some people, HPV infection may remain latent for years or decades. Subclinical, or not clinically obvious, manifestations of HPV infection can be detected only with a high-resolution anoscope or colposcope, small devices used for viewing the anal canal and cervix, respectively (see "Step II: Anoscopy"). Apparent HPV infection typically presents in the form of visible, usually benign genital warts known as condyloma acuminata, or as dysplasia.
Condylomas, or condylomata, and mild, low-grade dysplasia are frequently related to HPV types 6 and 11, two of the less-virulent viral types (i.e., types that are less likely to cause disease). In contrast, cancer of the anus and cervix have been linked particularly to HPV type 16, in addition to 18, 31, 33, 35, and other viral types that mainly present in subclinical forms. Some HPV types also appear to cause warts and cancer of the penis; cancer of the mouth (especially the tonsils), skin, and vulva; and recurrent respiratory papillomatosis (papillomas, or benign tumors, of the respiratory tract).
Persons with HIV and HPV tend to be infected simultaneously with several different HPV types. In a study done in the mid-1990s by Joel Palefsky, MD, and colleagues from the University of California, San Francisco (UCSF), 73% (196) of 269 HIV positive MSM with anal HPV infection were infected with multiple HPV types. (Type 16 was by far the most common viral type, occurring in 41% [109] of the 269 HPV positive subjects.) The appearance of a condition associated with a less-virulent HPV type, such as genital warts, therefore may not rule out the coexistence of an oncogenic, or cancer-causing, viral type. (See Anal Cancer and Colon Cancer: Two Unrelated Cancers for more information on genital warts.) Specific HPV types are detected by using polymerase chain reaction (PCR) assays, which amplify viral genetic material, or the Hybrid Capture test, which can distinguish between benign and oncogenic viral types.
HPV is commonly transmitted by anal and vaginal sexual intercourse; it may also be transmitted by finger-genital contact, according to a study published in the October 1999 issue of Sexually Transmitted Infections, and presumably by finger-anal contact. Although HPV is hardly a household term, it is widespread. By the beginning of 2000, according to the Centers for Disease Control and Prevention (CDC), genital HPV infection was the most common sexually transmitted disease (STD) in the U.S., affecting approximately 20 million people. Among MSM, HPV infection is almost universal in some areas of the country. In the study mentioned in the previous paragraph, Dr. Palefsky and colleagues found that 61% of 262 HIV negative MSM and 93% of 346 HIV positive MSM -- all of whom lived in San Francisco -- were infected in the anus with at least one HPV type. (Dr. Palefsky and colleagues have reported on this cohort in a number of different venues; unless otherwise indicated, this group of 346 HIV positive and 262 HIV negative MSM will subsequently be referred to as the San Francisco cohort.)
Grading and Types of Malignancies
HPV most readily infects and causes lesions in the transformation zones of the anal and cervical canals, which are thought to be susceptible due to the overlap and joining together of different tissue types. (For the purposes of this article, this section will focus on ASIL although similar pathological characteristics are seen with CSIL.) If HPV-infected cells in the anal transformation zone (or anywhere else in the anal or perianal region) start replicating abnormally, a spectrum of different neoplastic (abnormal tissue) irregularities may develop. Cellular changes are staged, or graded, according to the Bethesda System, which was developed by the National Cancer Institute (NCI) in 1988 for grading cell specimens from cervical/vaginal Papanicolaou ("Pap") smears. (A Pap smear is a microscopically analyzed slide of cells swabbed from mucosal tissue; see "Step I: Anal Cytology" for more information on this technique.) The grading stages below are from anal Pap smears.
AIN I, considered mild dysplasia, is also known as low-grade ASIL, or LSIL. Dysplastic cells have abnormal nuclei and abnormal ratios of nucleus to cytoplasm (the nucleus is the central part of a cell that contains its genetic material; the cytoplasm is the gel-like substance that composes cells and lies outside the cell nucleus). Visible anal warts, considered very mild to mild dysplasia, are also a form of LSIL.
AIN II, considered moderate dysplasia, and AIN III, severe dysplasia or anal carcinoma in situ, are also known as HSIL, or high-grade ASIL. HSIL is a progressive, potentially precancerous condition that requires attention whether the person is HIV positive or not; a small proportion of AIN III-type lesions that are not treated or removed may develop into invasive cancer, destroying adjacent tissues and/or organs and ultimately causing death. The prognosis (prediction of future disease course) with LSIL, a marker for HPV infection, is much less clearly defined at this time, but generally requires follow-up (future monitoring). As already mentioned, genital warts are usually harmless but may be accompanied by virulent (more aggressive, disease-causing) HPV types in persons with HIV. Other untreated low-grade lesions may spontaneously resolve (diminish or disappear). Conversely, LSIL may evolve into HSIL and thus act as a precursor to cancer. High-grade lesions in the anal canal resolve or regress in fewer than 25% of cases, even in persons taking HAART. As with high-grade CSIL and cervical cancer, HSIL may take several years to progress to anal cancer, indicating a potentially serious rise in new cases of anal carcinoma as HIV positive persons live longer. However, the natural history of anal neoplasia will be known only after large prospective studies are completed.
Different degrees of anal carcinoma may be staged according to the NCI's classification system based on tissue biopsy, or sampling. Stage 0 refers to early carcinoma in situ. Stage I cancer is localized, no larger than 2 cm in size, and not found on the external sphincter, the muscle that controls the opening of the anus. Stage II cancer is larger than 2 cm in size but does not affect adjacent organs or lymph nodes. If the cancer has spread either to organs located near the anal canal (e.g., the urethra [urinary canal], bladder, or vagina) or to nearby lymph nodes, it is classified as Stage IIIA. If it has spread to both adjacent lymph nodes and organs, it is classified as Stage IIIB. Cancer classified as Stage IV has spread to abdominal lymph nodes at some distance from the original carcinoma as well as to a part of the spine known as the sacrum and to other body organs. Recurrent cancer reappears after treatment, either to the site of the original lesion or to another area of the body.
HPV and ASIL: Risk Factors
While there is no single cause for ASIL, a number of different risk factors appear to make certain people more susceptible to anal lesions. Prior HPV infection is high on this list of facilitating factors. Not surprisingly, many of the risk factors that have been determined for HPV infection itself are the same as those for anal neoplasia (see next section). The higher the total number of one's sexual partners, the higher the relative risk of contracting HPV, even in heterosexual women without a history of anal intercourse. HIV negative persons with an STD, such as genital herpes, tend to have higher HPV infection rates compared with healthy persons, as do those who engage in receptive anal intercourse (whether MSM or women) and those who use recreational drugs rectally (e.g., methamphetamine ["speed"] or MDMA ["ecstasy"] injected with a syringe). The same is likely true for HIV positive MSM; a correlation between the degree of immunosuppression in the individual and the likelihood of HPV infection has been documented. Cigarette smoking is also a risk factor.
Risk Factors for HPV Infection of the Anus
Likewise, MSM with suppressed immune systems -- notably those with HIV infection and low CD4 cell counts (fewer than 200 cells/mm3) -- are particularly vulnerable to ASIL. Nevertheless, even HIV positive MSM with higher CD4 cell levels are twice as likely to experience anal lesions as are HIV negative MSM. The anal cancer rate among HIV negative MSM is greater than 35 cases per 100,000 people, while the rate among the population as a whole is only about 0.9 per 100,000 people, indicating that increased awareness about anal carcinoma is necessary for MSM generally and for HIV positive MSM in particular.
Even though women are less likely to engage in receptive anal intercourse, especially when compared with MSM, recent data indicate that HIV positive women also have unusually high rates of anal HPV infection. In a report presented by Dr. Palefsky at the XIII International AIDS Conference held July 9-14, 2000, in Durban, South Africa, 76% (170) of subjects in a cohort of 223 HIV positive women showed evidence of anal HPV DNA (genetic material). Prevalence of HPV infection was inversely related to CD4 cell level (i.e., women with fewer CD4 cells/mm3 were more likely to have anal HPV). According to Ruth Greenblatt, MD, one of the study authors, anal neoplasia currently appears to be more common than cervical neoplasia in the HIV positive female population surveyed at the San Francisco site of WIHS, the Women's Interagency HIV Study. (For additional WIHS data on women with anal HPV infection, see "Lessons Learned from Natural History Studies in Women" in this issue of BETA.) Other researchers have reported a high risk for ASIL among HIV positive female and male adolescents aged 13-18 as well.
Risk Factors for ASIL
Keeping in mind the statistics mentioned above, it follows that men who engage in receptive anal intercourse, regardless of HIV status, are at increased risk for ASIL and anal cancer. Trauma to the anal region likely contributes to the elevated risk. Conversely, HIV positive women who may not participate in anal sex frequently or at all seem to have a predisposition to anal infection with HPV due to immune suppression or other risk factors. As Dr. Palefsky and colleagues reported in the February 1, 2001 issue of the Journal of Infectious Diseases, cervical HPV infection may act as a reservoir or source of anal HPV infection. Studies show that women who have high-grade lesions or cancer of the cervix or vulva are more likely to develop anal lesions, as are persons infected with HPV who have had genital warts. Other independent risk factors for ASIL include cigarette smoking and a history of injection drug use.
LSIL to HSIL: Risk Factors
HIV-related suppression of the immune system not only increases the likelihood of becoming infected with HPV and developing ASIL, but it also appears to increase the chances that existing low-grade lesions will evolve into HSIL and, presumably, anal cancer. Dr. Palefsky and colleagues from UCSF characterized the incidence and progression of LSIL and HSIL in the all-male San Francisco cohort over a two-year period. Participants were periodically evaluated using HPV tests, anal cytology (microscopic analysis of cells collected by treated swab), anoscopy (visual surveillance of the anal canal using an anoscope), and biopsies of visible lesions (i.e., removal of abnormal tissue for microscopic examination). Additional data were collected regarding HIV serostatus, CD4 cell count, lifestyle factors, sexual habits, and medical history.
Among 224 subjects whose anal tissues were normal at baseline, 20% (17 of 87) who were HIV positive and 8% (11 of 137) who were HIV negative developed HSIL within two years of follow-up. Among 69 subjects who had LSIL at baseline, 62% (34 of 55) who were HIV positive and 36% (5 of 14) who were HIV negative had lesions that progressed to HSIL within two years of follow-up. Men with HIV as a group fared worse than the HIV negative subjects in the study, and HIV positive men with fewer than 200 CD4 cells/mm3 displayed the greatest risk of developing anal disease. According to these researchers, the relative risk (RR) for progression of anal disease was 2.4 in HIV positive men generally; in those with weaker immune systems, the RR was 3.1. (Relative risk is a measure of comparative risk of developing a disease or condition. The measurement is calculated by dividing the proportion of people with the disease in question who are also exposed to the relevant risk factor by the proportion of people with the disease who have not been exposed to the risk factor.) Results from this study were published in the April 1, 1998 issue of the Journal of Acquired Immune Deficiency Syndromes.
Risk Factors for HSIL
Dr. Palefsky's team also identified persistent infection with multiple HPV types, including oncogenic types, as being yet another risk factor for ASIL disease progression. Again, the risk for HIV positive men was higher than for HIV negative men. Among HIV positive men, 62% (25 of 40) who were infected with a single HPV type and 77% (70 of 90) who were infected with multiple HPV types displayed ASIL progression. Among HIV negative men, anal lesions progressed in 42% (21 of 50) with a single HPV type and 57% (11 of 19) with multiple HPV types.
Although prospective research data are lacking, HIV positive women potentially have a similar risk of anal disease progression as their male counterparts. HIV-HPV coinfected women in the San Francisco WIHS cohort were more likely to have multiple HPV types than the HIV negative/HPV positive women surveyed. Furthermore, lower CD4 cell levels were associated with an increase in the mean (average) number of HPV types.
HIV-HPV Interactions
The higher risk for both anal HPV infection and ASIL seen in HIV positive persons is likely caused by several cofactors. In the laboratory, the expression of oncogenic HPV type 16 E6 and E7 proteins appears to be enhanced by the HIV-1 Tat protein. Cytokines (chemical messenger proteins) secreted by HIV-infected lymphocytes (a type of white blood cell) may contribute to the risk of neoplasia development. In addition, HIV-related immunosuppression may result in the loss of a cell-mediated immune response specifically against HPV. Other cofactors also may be involved.
Symptoms of Disease
Persons with anal dysplasia may not experience any overt symptoms or they may experience bleeding, irritation, pruritis (itching), or a burning sensation. Severe dysplasia is not believed to cause more symptoms than low-grade dysplasia. Persons with invasive cancer are likely to report anal abscesses, masses of tissue ("lumps"), ulcers, anal discharge, and tenesmus (a frequent urge to defecate accompanied by pain, cramping, and straining).
Therapeutic Interventions
Because no treatment guidelines have been approved thus far by the U.S. Public Health Service (USPHS), all forms of therapy for persons with ASIL are considered experimental. Furthermore, opinion remains divided within the medical community as to the relative effectiveness of various procedures. Currently, the most common treatment for invasive anal carcinoma consists of chemotherapy (anticancer drugs) combined with radiation therapy. The most common treatments for higher-grade lesions include surgery (cold-scalpel or electrofulguration), laser therapy, and the use of topical agents. Targeted treatment outcomes are the elimination of all neoplasms; the prevention of their recurrence, which is difficult to achieve; and increased survival and quality of life for people with the disease. Before the advent of chemotherapy/radiation treatment (see below), removal of the rectum and anus (a procedure known as abdominoperineal resection, or APR) used to be performed on those with more severe stages of anal carcinoma. However, this type of radical surgery should be considered only when the potential benefit clearly outweighs the potential risk, as when no other treatment option exists or if radiation treatment causes excessive pain or proctitis (inflammation of the rectum marked by soreness and bloody stools). Anyone considering treatment should consult with several health-care providers -- including at least one cancer specialist (oncologist) -- before undergoing any course of action.
In persons with low-grade lesions, regular monitoring done approximately every six months to detect any changes that may indicate a progression to HSIL should be sufficient (see "Screening Techniques" below). Low-grade lesions are often not treated directly unless the person with LSIL feels it is necessary, e.g., due to physical discomfort.
Chemotherapy/Radiation Combination Treatment
This combination treatment is currently considered standard therapy for invasive anal carcinoma. The chemotherapeutic (medicinal) component of this approach, given by IV (intravenously), is as follows:
- 1,000 mg/m2 of 5-fluorouracil per 24 hours for four days, given as a continuous 96-hour infusion on days 1-4 and repeated on days 29-32 plus
- 10 mg/m2 of mitomycin C or 75 mg/m2 of cisplatin on days 1 and 29.
Mild to life-threatening adverse effects are commonly reported in persons who use chemotherapeutic drugs. 5-fluorouracil may lower white blood cell counts, and both mitomycin C and cisplatin may cause bone marrow suppression, leading to low white blood cell and platelet counts. Suppression of the bone marrow and low blood cell levels are potentially life-threatening. Some adverse effects caused by chemotherapy may resolve on their own over time or persist; still others may not appear until months or years after the medication is used. Any noticeable side effects should be reported to a clinician.
Radiation therapy involves targeting the DNA, or genetic material, of malignant cells with high-energy rays or radioactive particles. This procedure, also known as radiotherapy, may shrink or eliminate tumors, destroy cancerous cells, or prevent malignant cells from growing and dividing. Radiation therapy is given daily (Monday through Friday) for approximately five weeks beginning on the same day that chemotherapy is started (day 1). The area treated includes the anus and the lymph node regions in the pelvis and groins (inguinal nodes). The dose of radiation therapy can vary from a low dose of 3,000 cGy (centigray) to a more commonly used dose of about 5,500 cGy, delivered in increments or fractions of approximately 200 cGy daily.
Radiation treatment may cause a host of side effects, most of which do not persist. However, a physician should be notified if symptoms such as nausea, vomiting, unexplained weight loss, pain, or bleeding should continue.
Surgical removal of diseased tissue, also known as cold-scalpel resection, is often done when lesions grow larger than 1 cm2. Neoplastic tumors may also be surgically destroyed using an electric current; this process is called electrofulguration. Both of these procedures are likely to cause considerable pain and discomfort to the individual for several weeks following surgery. They may also lead to complications such as the inability to control defecation ("bowel movements") or anal stenosis (constriction of the anal canal). Anal stenosis may be avoided by removing malignant lesions in stages, particularly those that form around the circumference of the anal canal. Another drawback to surgery is the possibility of incomplete removal of diseased tissue, which may lead to a recurrence of HSIL and malignant lesions.
Laser Therapy
Anal lesions may also be destroyed using intense heat delivered by powerful, controlled, and extremely narrow light beams. Laser therapy, also known as laser ablation, holds certain advantages over the surgical procedures mentioned above. For example, lasers reduce the likelihood of infection at the affected site and are more precise than traditional scalpels. However, very little data on the effectiveness of using lasers for anal carcinoma have been collected, and it is not known if this relatively new method of treating this disease will prevent the side effects and complications associated with more traditional surgical methods. In addition, the high cost of laser equipment and limited number of specialists who are trained to perform this procedure make widespread use of lasers unlikely in the near future.
Topical Agents
Applying medicine directly to high-grade anal lesions may seem like a less risky or at least less painful alternative to surgery and radiation/chemotherapy. However, topical agents may cause bleeding, local infection, ulcerations, and scarring; they may also make the treated area more painful. To date, no topical agents are proven to be effective in anal disease, although new therapies are being evaluated in ongoing studies. In general, small anal lesions (smaller than 1 cm2) are more likely to respond well to localized topical treatment. TCA is most often used, both internally and externally. Some clinicians use other agents, such as podophyllin, for internal lesions; however, the safety and effectiveness of such treatments remain questionable. (See "Genital Warts" sidebar for more information on TCA and other topical therapies specifically for condylomas).
The HAART Factor
Antiretroviral therapies used to treat HIV have shown secondary benefit in treating other diseases or disorders seen in people with HIV infection, such as Mycobacterium avium complex (MAC) and other OIs. This appears to be due chiefly as a result of improved immune function seen in people who use HAART. Antiretroviral medications have also decreased rates of Kaposi's sarcoma (KS) and primary brain lymphoma in people with HIV, but not other lymphomas or anal neoplasia. In a cohort of 800 MSM currently being followed by Dr. Palefsky and other UCSF researchers (i.e., the San Francisco cohort with additional subjects included), the natural history of anal carcinoma to date does not seem to be altered by treatment with HAART. Preliminary data do suggest, however, that people who begin taking HAART with higher CD4 cell counts on average show the slowest rates of disease progression. These unpublished data were reported during a plenary lecture given at the 4th International AIDS Malignancy Conference, held May 16-18, 2000, in Bethesda, MD.
Further studies may yet show that improved immune function gained by the use of HAART can lower the risk of anal cancer by controlling HPV infection and causing LSIL to stabilize or resolve rather than progress to HSIL. From what is known already, it seems more likely that as HIV positive people live longer while taking HAART, their chances of developing progressive diseases such as anal cancer will increase over time. Conversely, some evidence indicates that HAART may stabilize or reverse CSIL in women with HIV.
HPV Vaccines
An effective HPV vaccine would likely have a profound impact on the incidence not only of condylomas but on anal (and cervical) cancer as well. However, developing a prophylactic, or preventive, vaccine to inhibit HPV infection from taking place presents researchers with significant challenges, many of which are similar for other sexually transmitted viral infections. HPV is difficult to culture (grow) in the laboratory and is found only in humans, making animal studies difficult to perform. Potentially useful animal models include canine oral papillomavirus (COPV) in dogs and papillomavirus infections in rabbits. People are generally exposed to viral STDs on a chronic and repetitive basis (i.e., through sex); the level of immunity offered by any HPV vaccine candidate would have to account for this phenomenon. This is theoretically possible, as with the effective and widely available vaccine for HBV (there are far fewer HBV types than HPV types, however).
Persons with prior HPV infection would benefit from an effective therapeutic (treatment) vaccine, which hopefully would eradicate the virus altogether, or at least control the infection by preventing any abnormal effects such as warts and cellular changes. To date, no such vaccine has been developed.
Prevention and treatment of active HPV infection in people with HIV seems to have taken on a new urgency: a team of researchers recently reported that HPV infection may speed the progression of HIV disease, much as HIV infection appears to accelerate the progression of anal neoplasia. Otoniel Martinez-Maza, PhD, and other researchers from the University of California, Los Angeles (UCLA), discovered that growth factors and proteins produced by HPV-infected cells stimulated latent (inactive) HIV-infected cells and prompted them to generate new copies of HIV in vitro (in the test tube). Whether a similar phenomenon takes place in vivo (in the body) remains to be confirmed. This report appeared in the December 2000 issue of Obstetrics and Gynecology.
In addition, Deborah Greenspan, BDS, DSc, and colleagues from UCSF have reported dramatic increases in the prevalence of HPV-related oral warts in HIV positive persons taking HAART, particularly protease inhibitor (PI) drugs.
Screening Techniques
In the absence of an effective HPV vaccine, and because not every case of anal carcinoma is accompanied by HPV infection, preventing anal cancer from developing in high-risk groups may be accomplished by educating such populations about the disease and about practicing safer sex (e.g., using condoms). Disease prevention may also be achieved through the screening process. (Although HPV infection is a high-risk factor for anal neoplasia, testing for it is primarily used for research. Nevertheless, HPV infection should be considered a marker for high-risk groups, such as HIV positive MSM or women, who should be screened on a regular basis.)
Screening for anal cancer is a three-step process.
Step I: Anal Cytology
The first step involves anal cytology, or the examination of anal cells for structural abnormalities. This screening process, which can be easily performed during a routine visit to the doctor, is similar to cervical/vaginal Pap smears done in women. The procedure is simple, inexpensive, and causes mild discomfort at most. Dacron swabs are inserted into the anal opening and swirled along the tissues lining the anal canal, including the transformation zone and the lower rectum. The cell-coated swabs are rubbed or smeared onto a glass slide, sprayed with a fixative, and later microscopically examined at a laboratory. (Dacron swabs, available from Baxter Healthcare Corporation, are recommended over plain cotton swabs, as anal cells tend to cling to cotton.) A more accurate and uniform interpretation of cytology may be achieved with the Cytyc ThinPrep system, approved by the Food and Drug Administration (FDA), in which cell samples are transferred to a preservative solution instead being smeared onto a slide. At the laboratory, a processor separates and filters debris and other noncellular material (e.g., blood and mucus) from the solution; the "rinsed" anal cells are then fixed onto slides of potentially greater clarity than those created using the traditional Pap smear procedure.
Step II: Anoscopy
A visual examination of the anal tissues will likely be warranted if abnormal anal cytology is discovered during the initial screening process. Abnormal cytology includes evidence of ASIL and some cases of atypical squamous cells of undetermined significance (ASCUS). Visual diagnostic evaluation cannot be done with the naked eye, even with an intense light source; it must be performed with a high-resolution anoscope. This small instrument, equipped with a light and magnifying lens, is inserted shallowly into the anal canal and allows the physician to examine any lesions that may exist, particularly in the transformation zone. So-called microinvasive cancers that often develop at the base of benign warts also may be detected during anoscopy. A solution of 3% acetic acid, swabbed directly onto anal tissues before examination with the anoscope, causes lesions and areas of abnormal cell cytology to appear white. The acid application is an essential component of this procedure. For instance, flat condylomas, which may signal infection with an oncogenic HPV type, are often invisible without the aid of acetic acid.
Step III: Anal Biopsy
Biopsy refers to the surgical removal of a small amount of tissue that is then analyzed by microscope to establish a diagnosis (a determination as to the existence of a disease or condition). This procedure can also be done during a regular out-patient visit to the doctor. A biopsy of lesions and abnormal tissues discovered during an anoscopic examination allows the physician to grade any neoplastic tissue and propose a course of treatment, neither of which should be done on the basis of cytology alone.
The Cervical Cancer Model
The screening protocol, or formula, for the anal canal outlined above is not officially sanctioned by any medical or government body. Rather, it is based on the screening method used for women at high risk for developing cervical cancer. The similarities seen between anal and cervical lesions and carcinoma, including etiology strongly related to certain HPV types, appear to warrant employing a similar method of detection.
Cervical cytology, i.e., the introduction of the Pap smear, has been credited for much of the decline seen in cases of cervical cancer over the past few decades in developed countries. The incidence of cervical carcinoma was approximately 35 cases per 100,000 persons in the U.S. before the use of Pap smears -- statistically equal to the current incidence of anal carcinoma in HIV negative MSM. The cervical cancer rate has dropped to about 8 cases per 100,000 since cervical cytology became widespread. It is hoped that anal screening will lead to a similar decline in anal cancer rates among MSM. Anal Pap smears -- especially ThinPrep slides -- appear to be as sensitive as cervical smears (an approximate sensitivity rate of 73%). And the high-grade lesions detected by anoscopy correspond in significant ways to similar high-grade lesions detected in cervical colposcopy (a colposcope is much like an anoscope, and is used to visually examine the cervix and vagina. For more information on CIN and cervical cancer, see "Cervical Intraepithelial Neoplasia" in the June 1996 issue of BETA.)
Barriers to Screening
One might suppose that the diagnostic usefulness of anal screening, and its apparent necessity in a time of potential increases in an already high rate of incidence among specific populations, would lead to widespread use of this tool. Nonetheless, anal screening is currently being done by only a very small number of clinicians, and mostly in a research setting. Aside from the lack of officially recognized diagnostic and therapeutic strategies, other factors contribute to the general indifference toward anal neoplasia. Some physicians, especially those who do not have many patients among high-risk groups, may not feel that special vigilance or training are essential for this relatively uncommon condition. Likewise, many people -- even among those who are most prone to developing the disease -- may not know that they are at risk for anal cancer.
Another barrier has traditionally been the lack of a cost/benefit analysis that compares the costs of anal screening, treatment, and follow-up with those of a similar disease, such as cervical cancer. Two such analyses have recently been conducted, however, and the results suggest that a benefit would be achieved with periodic screening of both HIV positive and HIV negative MSM.
Cost/Benefit Analysis for HIV Positive MSM
In a report that appeared in the May 19, 1999 issue of the Journal of the American Medical Association, Sue J. Goldie, MD, MPH, of the Harvard School of Public Health and colleagues estimated the cost-effectiveness of anal cytology screening in a hypothetical cohort of HIV positive MSM. By calculating the effect of different screening strategies (including no screening) on lifetime costs, life expectancy, and quality-adjusted life expectancy for this population, Dr. Goldie's team arrived at an encouraging result: screening for ASIL raised quality-adjusted life expectancy regardless of HIV disease stage.
Specifically, these researchers found that screening done every two years, beginning during acute (early) HIV infection, led to a quantified benefit (a 2.7-month gain in quality-adjusted life expectancy) at an incremental cost of $13,000 per QALY saved, compared with no screening. (QALY, or quality-adjusted life year, refers to a year of life graded between 0.0 and 1.0 according to the type of ill health experienced during the year.) Annual screening augmented this benefit at an incremental cost of $16,600 per QALY saved; screening done every six months provided no significant added benefit. For those undergoing screening during later HIV disease (i.e., with lower CD4 cell levels), a projected cost-effectiveness ratio of less than $25,000 per QALY saved could be gained with annual screening. As the researchers pointed out, these results compare favorably with other preventive measures in HIV disease, such as the use of TMP-SMX (Bactrim, Septra) for Pneumocystis carinii pneumonia (PCP) prophylaxis ($13,000 per year of life saved). In addition, anal screening in this population appears to be much less expensive than cervical cancer screening done every three years in HIV negative women ($180,000 per year of life saved).
Cost/Benefit Analysis for HIV Negative MSM
Dr. Goldie and colleagues then applied a similar mathematical model in a cost/benefit analysis of anal cytology screening for HIV negative MSM. Annual screening provided less than 0.5 quality-adjusted months of additional life expectancy at an incremental cost of $34,800 per QALY gained. Screening every two years cost $15,100 per QALY gained compared with screening every three years, which was associated with a 1.8-month increase in the quality-adjusted life expectancy at a cost of $7,000 per QALY gained. In this case, the figures for screenings done every two or three years compare well with other, standard preventive health interventions. The results of this second analysis were published in the June 1, 2000 issue of the American Journal of Medicine.
Real-World Implications
The data derived from these two studies indicate that annual screening of HIV positive MSM and biennial or triennial screening of HIV negative MSM may confer an appreciable life-saving benefit at a reasonable cost. Additional analyses are needed to determine the cost-effectiveness of screening in HIV positive women and adolescents; similar screening intervals for these groups may also prove beneficial and economically sound.
Awaiting Standard of Care
There is clearly a need to define a standard of care for anal neoplasia. Current treatments, which are still evolving and problematic, have shown some success in eliminating premalignant and malignant lesions, or at least preventing them from spreading to other parts of the body. More importantly, anal screening appears to be a successful, cost-effective method for detecting anal cancer and its precursor conditions and thereby extending the lives of individuals at high risk.
From the data currently available, it seems prudent to screen all persons who are prone to anal cancer. If the majority of women in developed nations are able to receive regular cervical screenings, there is no medical reason why HIV negative MSM as well as HIV positive MSM, women, and adolescents should not expect a similar anal examination. With evidence that anal cancer may already be preventable, clinicians should make an effort to learn more about the disease. This is especially true for clinicians with patients in high-risk groups.
Some proposals and guidelines regarding genital HPV infection are already beginning to appear on a national scale. The CDC has drawn up an outline of recommendations aimed at setting basic, preliminary standards for preventing and evaluating genital HPV infection. These proposals were based on a meeting of experts convened by the CDC on April 13-14, 1999, in Atlanta, and include language specifically addressing anal cancer. The document is available at www.cdc.gov/nchstp/dstd/Reports_Publications/HPVSupplement%20.pdf. In December 2000, Congress approved an HPV education and prevention program, drafted by Rep. Tom Coburn (R-OK), as a provision to the FY (fiscal year) 2001 Health and Human Services (HHS) bill. Though the provision focuses on HPV education for health-care professionals and the public in the context of cervical cancer, it may open the way for continued discussions of and recommendations regarding HPV and genital neoplasia as part of the national health-care agenda.
It is incumbent upon persons in high-risk groups to strongly request that they be evaluated and to encourage their health-care providers to attend training sessions to become proficient in screening and treatment modalities. (For information about training programs in San Francisco, interested clinicians should contact Dr. Joel Palefsky by e-mail at firstname.lastname@example.com.) When there is sufficient demand, a medical procedure like anal screening can become more commonplace. Those people most at risk for anal cancer must ensure that it becomes routine. Until then, safer sexual practices will help to prevent HPV transmission and the transmission of additional oncogenic viral types to those already infected.
Special thanks to Dr. Joel Palefsky for his assistance in preparing this article.
Nicholas Cheonis is Associate Editor of BETA_._
Selected Sources
Butsashvili, M. and others. Human papillomavirus infection in HIV positive men. XIII International AIDS Conference. Durban, South Africa. July 9-14, 2000. Abstract WePeA4037.
Butsashvili, M. and others. Human papillomavirus infection in HIV positive men. XIII International AIDS Conference. Durban, South Africa. July 9-14, 2000. Abstract WePeA4037.
Centers for Disease Control and Prevention. Prevention of genital HPV infection and sequelae: report of an external consultants' meeting (www.cdc.gov/nchstp/dstd/Reports_Publications/99HPVReport.htm). December 1999.
De Ruiter, A. and others. A comparison between cytology and histology to detect anal intraepithelial neoplasia. Genitourinary Medicine 70: 22-25. 1994.
Goldie, S.J. and others. Cost-effectiveness of screening for anal squamous intraepithelial lesions and anal cancer in human immunodeficiency virus-negative homosexual and bisexual men. American Journal of Medicine 108(8): 634-641. June 1, 2000.
Goldie, S.J. and others. The clinical effectiveness and cost-effectiveness of screening for anal squamous intraepithelial lesions in homosexual and bisexual HIV-positive men. Journal of the American Medical Association 281(19): 1822-1829. May 19, 1999.
Greenblatt, R. Personal communication. January 8, 2001.
Greenspan, D. and others. Emergence of oral warts in the HAART era. 6th Conference on Retroviruses and Opportunistic Infections. Chicago. January 31-February 4, 1999. Abstract 704.
Hanna, L. Human papillomavirus infection and anal neoplasia. Bulletin of Experimental Treatments for AIDS 34: 18-22. September 1997.
Höcht, S. and others. Low acute toxicity of radiotherapy and radiochemotherapy in patients with cancer of the anal canal and HIV-infection. _Acta Oncologic_a 36(8): 799-802. December 9, 1997.
Moscicki, A.-B. and others. Adolescent males and females with HIV at high risk for anal squamous intra-epithelial lesions. XIII International AIDS Conference. Abstract TuOrB305.
Orlando, G. and others. Diagnosis and management of genital warts in HIV disease. The AIDS Reader 10(1): 36-41. 2000.
Palefsky, J.M. Anal human papillomavirus infection and anal cancer in HIV-positive individuals: an emerging problem. AIDS 8(3): 283-295. March 1994.
Palefsky, J.M. and others. Anal human papillomavirus infection in HIV+ and high-risk HIV- women. XIII International AIDS Conference. Abstract TuPeB3161.
Palefsky, J.M. Personal communication. January 18, 2001.
Palefsky, J.M. and others. Prevalence and risk factors for anal human papillomavirus infection in human immunodeficiency virus (HIV)-positive and high-risk HIV-negative women. Journal of Infectious Diseases 183(3): 383-391. February 1, 2001.
Palefsky, J.M. and others. Prevalence and risk factors for human papillomavirus infection of the anal canal in human immunodeficiency virus (HIV)-positive and HIV-negative homosexual men. Journal of Infectious Diseases 177: 361-367. February 1998.
Palefsky, J.M. and others. Virologic, immunologic, and clinical parameters in the incidence and progression of anal squamous intraepithelial lesions in HIV positive and HIV negative homosexual men. Journal of Acquired Immune Deficiency Syndromes 17(4): 314-319. April 1, 1998.
Roehr, B. Malignancy mirages. Journal of the International Association of Physicians in AIDS Care (www.iapac.org/conferences/malig008m.html). August 2000.
Sherman, M.E. and others. Cytologic diagnosis of anal intraepithelial neoplasia using smears and cytyc thin-preps. Modern Pathology 8(3): 270-274. April 1995.
Sonnex, C. and others. Detection of human papillomavirus DNA on the fingers of patients with genital warts. Sexually Transmitted Infections 75(5): 317-319. October 1999.
Tyring, S.K. Prophylactic and therapeutic antiviral vaccines. 58th Annual Meeting of the American Academy of Dermatology. San Francisco. March 10-15, 2000. Symposium 313.
Back to the SFAF BETA Winter 2001 contents page.


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After near record setting heat to start the week our first storm system arrive right on cue Friday. It brought in quite the extreme shift in weather conditions.
Now the focus goes to a second storm headed our way for your weekend. The second system will be stronger and colder and windier.
SATURDAY: Expect some lingering rain for the morning hours, with a few breaks of sunshine by the afternoon hours. An intense line of storms is expected to move through by the evening hours into late Saturday night. This line of storms could produce upwards of 1" in some locations with the potential for some small hail and damaging winds. Daytime highs will be chilly today. Inland highs will top out in the lower 60s, Bayside & at the Coast near 60 with a few upper 50s. Winds could gust up to 40 mph, especially at the Coast & hills.
SUNDAY: A few morning showers will still be pushing through the area, before we see some afternoon sun. A few isolated storms are possible, but they will be few and far in between. Daytime highs will remain cool with Inland locations near 60, Bayside and at the Coast upper 50s. Winds will gust today up to 40 mph.
HOLIDAY WEEK AHEAD: A few dry days are ahead for Monday and Tuesday with seasonal highs: 60 - 65. By Wednesday, a few spotty showers are possible, most likely in the North Bay. This will keep the onshore flow in place for Thanksgiving, so a few areas of drizzle or fog is likely by Thursday morning. At this point no major storm system looks to impact the Bay Area for Turkey Day!


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Gurnee Medication Nurse FT 2nd Shift (37523)
Job Description
SUMMARY: Provides skilled nursing care for assigned residents according to established standards and practices relating to basic nursing, restorative, and personal care services; where quality assurance, resident safety, and infection control are inherent responsibilities of the position.
- Communicates resident health problems, situations, changes and incidents to nursing leadership and the residents' responsible party as directed.
- Ensures that staff observes residents for significant changes, adverse reactions, emesis, drainage, bleeding and any post operative changes and communicable diseases.
- Ensures that resident's needs are met or fulfilled.
- Prepares, administers and charts the administration of prescribed medications; documents effectiveness and adverse reactions.
- Processes daily physician orders.
- Reviews all MARs on a daily basis.
- Ensures residents medication supply is maintained on a daily basis, i.e. re-ordering refills and/or new orders.
- Ensures and performs personal comfort activities such as giving bed bath or shower or assisting with bath or shower. Observes skin and pressure areas; assists with personal hygiene services such as oral hygiene, hair care, nail care, shaving, dentures, eye wear and makeup, etc.
- Prepares for and participates in care conferences.
- Prepares and monitors residents for meals, and between-meal nourishments; assists in positioning; sets up table; personally feeds residents if necessary.
- Responds to nurse call and paging systems; monitors residents to ensure the resident remains clean, dry and comfortable by changing clothes, gowns, linens, dressing as necessary; provides clean water and refreshments, assists in keeping the room clean and neat by straightening and replenishing person supplies.
- Ensures that bedfast residents are repositioned at predetermined intervals; assists with skin care and treatments as assigned; assists and positions residents into and out wheelchair, bed, stretcher, and stationary chair using proper body mechanics and staff assistance according to written procedures and ambulates residents.
- Monitors resident safety on a continuing basis, seeks assistance in emergencies, assists family members in times of stress or crisis, perform established notification procedures during emergency situation.
- Takes and records at predetermined intervals vital signs such as temperature, pulse, respiration weight and blood pressure, measures intake. Collects sputum, urine, and stool, discharge drainage and other specimens as ordered.
- Performs periodic cleaning duties, maintains orderliness of the nurse's station; collects and disposes of contents in trash containers.
- Works cooperatively with members of the care team, maintains effective interdepartmental and interpersonal relations residents, staff and visitors, avoid unnecessary noise.
- Completes incident reports report before the end of the shift and takes appropriate action.
- Performs other administrative duties such as answering phones and other related duties.
- Participates in all new resident admissions.
- Sets priorities in implementing resident care.
- Assists nursing leadership to ensure shift runs well in supervisor's absence.
- Performs other duties as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
- Completion of a Professional Nursing Program, approved by the state of which you are employed, and licensed to practice as a licensed or registered nurse.
- Experience in Memory Care preferred.
- Must have a valid driver's license
- Ability to work evenings, weekends and flexible hours when necessary to meet the needs of our residents.
- Ability to read and interpret documents such as safety rules, operating procedures, policies and employee manuals. Ability to write reports and correspondence. Ability to speak effectively before groups.
- Ability to solve practical problems and deal with a variety of variables in situations.
- High level of interpersonal skills to handle sensitive and confidential situations and documentation, and interaction with residents' families and families experiencing loss.
- Attention to detail to ensure accuracy.
- Must be able to speak, read, write and understand English.
- This position requires local travel and occasional out of town travel.
- Teamwork - Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit.
- Business Acumen - Understands business and implications of decisions on the business.
- Ethics - Follows through on commitments; Inspires the trust of others; Works with integrity and ethically; Upholds organizational values.
- Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions.
- Dependability - Follows instructions, responds to management direction; results oriented and committed to achieving objectives and tasks as required.
PHYSICAL DEMANDS: The physical demands are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Required to stand and walk regularly, occasionally sit, and lift and/or move up to 100 pounds.
- The noise level in the work environment is usually moderate.
Application Instructions
Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!Apply Online
Posted: 11/27/2019
Job Status: Full Time


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I finally posted a new version of the real analysis book with the new metric space chapter, it weighs in at 192 pages now (with 12pt font though). It also fixes a now record number of errata; though my standard for what is an erratum rather than just a simple obvious typo has dropped slightly. One thing that makes me feel better about errata is that it seems Rudin's 3rd edition of principles still has some errata that is essentially the same as what I did (independently, not that I really worry about taking credit for errata:).
The differential equations book nowadays seems to be hitting fewer and fewer problems: 6 errata in the past year, 2 of which have been in new stuff added before the summer. This is despite several people using the books and one ongoing partial translation. So I guess they are rather "correct" by now.
My goal right now is to get them to be correct rather than perfect. So I haven't really been reordering things or rewriting things that could be improved. I've been at most doing small improvements in exposition. The main thing is that I want to spend time doing other things too of course:)


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Every may, hundreds of students don caps and gowns, march into the Swails Center, and prepare to graduate. As they walk across the stage, they not only recieve their diploma, an outward sign of the education they've just obtained. They also take a huge step in their callings of becoming Christ-like disciples who integrate faith, learning, and living.
This year at our commencement ceremony, we will be honored to have Mrs. Linda Thomas stand before our graduating seniors and encourage them as they make this leap. In March, Mrs. Thomas was re-elected to serve a second term as Chairperson of the Board of Trustees at Emmanuel. She joined the Board in 2001 and became the first woman to serve as chair when she was elected to her first four-term in 2008. "Linda Thomas has led our Board through a time of great change and growth. Her commitment to excellence and her professionalism has allowed the Board to come together in great unity and purpose," says Dr. Michael Stewart, President of Emmanuel. "I look forward to our partnership in the years to come."
Mrs. Thomas is an active member of Holly Hill Pentecostal Holiness Church in Vanceboro, N.C., and has faithfully served in the International Pentecostal Holiness Church Women's Ministries on the local, conference, and general levels. Most recently, she was Assistant Director of the General Women's Ministries (2001-09). Other IPHC assignments include her service in the Polity Committee for the 2009 General Convention and the By-Laws Committee for the upcoming 2013 General Convention.
Mrs. Thomas and her husband, former State Senator Joseph Eugene Thomas, own and operate Thomas Development, Inc., in Vanceboro. They have four grown children and seven grandchildren.


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Grains closed mixed today with July corn down ½ cent at $5.67 ½, July soybeans up 9 ½ cents at $13.49 ½, and July wheat down 14 ½ cents at $6.13 ¼.
Today was another low volume trading session but it was not without large swings especially in the spreads. The July – December corn spread closed 15 ½ cents higher on the day at +59 ¾. This same spread had a larger trading range than July corn had all alone! July corn held support for most of the day despite the selloff in wheat and the new crop corn contracts. CIF basis for corn and soybeans was up sharply at midday for the June/July timeframe and this was likely providing additional support to these markets.
So why did December corn have such a large selloff to close back down near the year's low? It could be that the market was looking for a reduction to the crop rating which never came on yesterday afternoon's report. The Reuters poll shows that they were expecting at least a 1% drop in the good-excellent corn ratings and instead the ratings remained unchanged except for a 2% swap from good to the excellent category. Soybeans on the other hand received a less favorable rating than expected at 65% good-excellent and in turn held strong support all day.
The main driving force for grains is still the weather. Changes to the morning and midday models will continue to have large impacts on the prices. We also have Fed Chairman Ben Bernanke speaking to Congress on Thursday and many are projecting another round of quantitative easing coming up soon. If this is announced, or even just the fear of this being announced, we could see another drop in the dollar and a financial push back into "hard assets" like gold or other commodities. If you need to catch up on sales having scale up orders in is not a bad way to get positioned in case we see a rally. We have found heavy resistance in December corn at the 50 and 100 day moving averages over the past 6-8 months. Currently the 50 day moving average is at $5.31 and the 100 day is up at $5.48. These may be good target levels to have orders placed.
If you would like a free trial of the EHedger research please click on the link below. To discuss opening a futures/options account please contact EHedger at 866-433-4371. Thanks and have a great week!
Chart: December corn (red – 50day, blue – 100day)
Chart: Nov. soybeans w/ Fibonacci retracement levels (next major target at $12.23 ¼)
Best Regards,
Trading commodity futures and options involves substantial risk of loss and may not be suitable for all investors. You should carefully consider whether trading is suitable for you in light of your circumstances, knowledge and financial resources. The market information contained in this message has been obtained from sources believed to be reliable, but is not guaranteed as to its accuracy or completeness. Market information may not be consistent with current or future market positions of EHedger LLC, its affiliates, officers, directors, employees or agents.


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Our Career Video Library includes 100's of videos. Feel free to Browse the videos that interest you.
|A Day in the Life of a Pilot
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|Helicopter Pilot - A Day in the Life
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|Pros & Cons of becoming a Co-Pilot


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Data Collection
Duration: 1 day
Audience: Administrators and Implementers
Prerequisites: Data model and Output reporting
Objectives: This training course covers the basics of the application process setup and all the main features for collecting data.
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If you are interested in arranging a customized training program, would like to discuss organizing an in-house training session or if you have any other CCH Tagetik education-related questions, please call us at our offices or send a request using the form below.
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Please fill-out the following form for more information about this live training:


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Life in the United Kingdom: A Guide for New Residents
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Fortune names Whirlpool most admired company
Fortune Magazine has recognized Whirlpool Corp. as the World's Most Admired Company in the home equipment and furniture industry sector. It's the third consecutive year the Benton Harbor-based manufacturer has finished first in the category.
"As the largest and most innovative company in the world with over 102 years of history, it is an honor to once again be named one of Fortune Magazine's most admired companies," said Jeff M. Fettig, Whirlpool chairman and CEO, in a statement.
"We are particularly proud of our scores in the management and global competitiveness categories and believe that we are poised for continued success in 2013 — benefitting our consumers, suppliers, employees, shareholders and communities, especially those in which we operate," added Fettig.
Whirlpool reportedly received its highest scores in people management, quality of management and global competitiveness.
Other companies that also ranked first in their respective industry sectors were Boeing, Nike, Apple, American Express, GE, IBM and Google.
Whirlpool had annual sales of approximately $18 billion in 2012. The company employs 68,000 and has 65 manufacturing and technology centers around the world. Whirlpool manufactures and markets home appliances and offers such brand names as Whirlpool, Maytag, KitchenAid, Jenn-Air, Amana and others. Whirlpool shares are traded on the New York Stock Exchange under the symbol WHR.


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Amarin Announces Notification of Patent Allowance for U.S. Application 13/623,450 Related to Vascepa(R) and FDA Approved MARINE Indication
Strengthens Positioning of Vascepa for Exclusivity Into 2030
BEDMINSTER, N.J., and DUBLIN, Ireland, Dec. 13, 2012 (GLOBE NEWSWIRE)
-- Amarin Corporation plc (Nasdaq:AMRN), a biopharmaceutical company focused on the commercialization and development of therapeutics to improve cardiovascular health, announced today that the United States Patent and Trademark Office (USPTO) has published notification of Notice of Allowance for U.S. Patent Application Serial Number
13/623,450. This application includes claims intended to protect the Vascepa(R) (icosapent ethyl) indication approved by the U.S. Food and Drug Administration (FDA) based on Amarin's MARINE clinical trial results. A Notice of Allowance is issued after the USPTO makes a determination that a patent can be granted from an application. The issued patent
would have a term that expires no earlier than in 2030. After issuance, Amarin plans to list this patent in the FDA's Approved Drug Products with Therapeutic Equivalence Evaluations, or Orange Book.
The claims in this allowed application cover a method of use relating to Vascepa's MARINE indication. Specifically, the allowed independent claim covers use of highly pure icosapent ethyl, or EPA, including Vascepa, in lowering triglycerides regardless of the drug's effect on LDL-C levels.
"This allowance is significant in that it would broaden our currently issued MARINE method of use claims to cover the use of Vascepa (and other highly pure EPA formulations) without regard to LDL-C levels," stated Joseph Zakrzewski, Chairman and CEO of Amarin. "The issuance of this Notice of Allowance represents yet another significant step toward Amarin's goal of protecting the commercial potential of Vascepa to beyond 2030 through patent protection, regulatory exclusivity and trade secrets and by taking advantage of manufacturing barriers to entry."
This application is part of an expanding patent portfolio for Amarin with 11 patent applications now either issued or allowed with the USPTO and over 30 additional applications pending in the United States. Amarin is also pursuing patent applications related to Vascepa in multiple jurisdictions outside the United States, including the application for Amarin's MARINE method of use patent in Europe for which Amarin has announced receipt of an Intention to Grant letter.
The 13/623,450 Notice of Allowance has not yet been posted on the USPTO public PAIR website. Amarin has posted this Notice of Allowance and related claims in the Press Release section of its corporate website.
About Amarin
Amarin Corporation plc is a biopharmaceutical company focused on the commercialization and development of therapeutics to improve cardiovascular health. Amarin's product development program leverages its extensive experience in lipid science and the potential therapeutic benefits of polyunsaturated fatty acids. Vascepa(R) (icosapent ethyl), Amarin's first FDA approved product, is a patented, ultra pure omega-3 fatty acid product comprising not less than 96% EPA. For more information about Vascepa visit www.vascepa.com. For more information about Amarin visit www.amarincorp.com.
The Amarin Corporation plc logo is available at http://www.globenewswire.com/newsroom/prs/?pkgid=13817
Forward-looking statements
This press release contains forward-looking statements, including
statements about whether the subject patent would be issued and
adequately protect Vascepa against competition, the expiration date of
the pending patent, Amarin's plan to list the patent, when issued, in
FDA's Orange Book, Amarin's plan to protect the commercial potential of
Vascepa, and the future status of pending patent applications. These
forward-looking statements are not promises or guarantees and involve
substantial risks and uncertainties. Among the factors that could cause
actual results to differ materially from those described or projected
herein include the following: events that could interfere with the
issuance of a patent, or once issued, the continued validity or
enforceability of a patent; Amarin's ability generally to maintain
adequate patent protection and successfully enforce patent claims
against third parties; commercializing Vascepa without violating the
intellectual property rights of others; and uncertainties associated
generally with research and development, clinical trials and related
regulatory approvals. A further list and description of these risks,
uncertainties and other risks associated with an investment in Amarin
can be found in Amarin's filings with the U.S. Securities and Exchange
Commission, including its most recent Quarterly Report on Form 10-Q.
Existing and prospective investors are cautioned not to place undue
reliance on these forward-looking statements, which speak only as of
the date hereof. Amarin undertakes no obligation to update or revise
the information contained in this press release, whether as a result of
new information, future events or circumstances or otherwise.
CONTACT: Stephen D. Schultz
Investor Relations and Corporate Communications
Amarin Corporation
In U.S.: +1 (908) 719-1315
[email protected]


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Eight beautiful videos by Conservation International. Each video is about 2 minutes long; videos are also in Spanish.
Julia Roberts is Mother Nature
Julia Roberts es Madre Naturaleza – subtitled SpanishHarrison Ford is The Ocean
Harrison Ford is El Océan – Subtitled SpanishKevin Spacey is The Rainforest
Kevin Spacey is El Bosque Tropical – subtitled SpanishPenélope Cruz is Water
Penélope Cruz es El Água – SpanishRobert Redford is The Redwood
Robert Redford is El Árbol - subtitled SpanishIan Somerhalder is Coral Reef
Ian Somerhalder es El Arrecife de Coral – subtitled SpanishLupita Nyong'o is Flower
Lupita Nyong'o is La Flor – subtitled SpanishEdward Norton is The Soil
Edward Norton es El Suelo - subtitled Spanish


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The General Services Administration is taking a first step in solving a financial and management problem that many large municipal governments already have in hand: the use of car-sharing services to cut down on the out-of-control costs of operating the government's huge fleet of cars and trucks.
In a request for information, GSA said it wanted to explore the use of commercial car-sharing ventures to help manage the 200,000 vehicles it maintains. At the same time, the agency announced it would launch pilot programs in Washington, D.C., New York City, Boston and Chicago to see how car-sharing might work across "multi-federal agencies in large metropolitan cities."
"GSA manages one of the largest federal fleets in the U.S. government," said Tom Sharpe of GSA's Federal Acquisition Services in an announcement. Under the "common sense" approach, GSA "will be able to test whether it is more cost-effective and beneficial to use a car-sharing service in lieu of taxi cabs, renting, leasing and/or purchasing a vehicle."
The solution could help the federal government get a handle on managing its astronomical fleet. According to the 2012 "Federal Fleet Report," the costs of the government fleet was $4.3 billion in 2012. Total mileage: 2.5 billion miles.
Major metropolitan city governments are already well out ahead of federal agencies in using car-sharing services and technology. New York City recently announced a fleet consolidation it expects will help it save $415 million by 2016. The Big Apple will also take advantage of the commercial Zipcar service to help reduce the size of its 25,000 vehicle fleet.
"Not only are we using Zipcars, which reduce the number of cars we have to have, we are going to use their technology to manage the cars we do have," said New York City Mayor Michael Bloomberg.
The plan calls for vehicles in the city fleet to be equipped with Zipcar's "Fast Fleet" services, which links a vehicle to a car-sharing network that is accessible on the Web.
"So you, as a city employee, normally entitled to a car aren't going to get a car anymore," Bloomberg said. "You go on a computer, they tell you where to pick it up and you'll have your key and it will only work for you at that point in time. That saves a tremendous amount of money."
The Cook County, Ill., government also is forming an alliance with Zipcar under which existing county cars and trucks would be managed using the company's car-sharing network. County employees would get a discount when using Zipcars in the Chicago area.
Meanwhile, the city of Houston is tapping a partnership with Zipcar to operate a shared motor pool. City cars would also be outfitted with Zipcar's FleetShare vehicle management network and Web services.
About the Author
Paul McCloskey is senior editor of GCN. A former editor-in-chief of both GCN and FCW, McCloskey was part of Federal Computer Week's founding editorial staff.
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Video Gallery
About Your Thyroid:
The thyroid gland is a small, butterfly-shaped gland located in the base of the neck just below the Adam's apple. Although relatively small, the thyroid gland plays a huge role in our body, influencing the function of many of the body's most important organs, including the heart, brain, liver, kidneys and skin. Ensuring that the thyroid gland is healthy and functioning properly is vitally important to the body's overall well-being.
How Your Thyroid WorksLEARN MORE
Ten Questions to Ask About Your Thyroid Health
Here we offer 10 questions to ask your doctor and pharmacist to arm you with the information you need to become your own thyroid health advocate.
How To Handle Hypothyroidism: Suspect, Detect, Defeat.
We've all experienced changes in our bodies from time to time that seem more of a nuisance than a medical issue...
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More valuable thyroid care information from the endocrinologists of AACE


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COOKEVILLE, Tenn. – The Tennessee Tech women's basketball team took over first place in the Ohio Valley Conference East Division and remained one of only two unbeaten teams in the league in conference play by outlasting a challenge from Belmont Saturday in Eblen Center and claiming a tough, 58-52 victory.
The Golden Eagles (8-7/2-0 OVC) withstood a late rally by the Bruins (7-8/2-1 OVC), who came into the fray with an unblemished league mark.
Diamond Henderson led all scorers with 17 points for the Golden Eagles. T'Keyah Williams (below) added 13 points, six rebounds and three steals while Jala Harris (above) contributed 12 points, five rebounds and five assists. Molly Heady also had a solid effort with eight points and seven rebounds.
Molly Ernst and ordyn Luffman topped Belmont with 10 points each, while Katie Brooks added eight points and four assists. Brooks scored six of her eight points in spearheading Belmont's rally in the final three minutes. Torie Vaught added nine points and Jordan Coleman led the Bruins on the boards with six rebounds.
Tech owned a lead the entire second half, and was up by six, 51-45, with 3:39 to play after Williams drove to the hoop and hit a layup.
Brooks dropped in back-to-back jumpers from the free throw line in the next minute to pull the Bruins within a basket, 51-49, and the senior guard knocked down two free throws with 1:51 remaining to tie the game at 51-51.
Williams lifted Tech on top , 52-51, with a free throw with 1:24 left and added two more free throws with 51 seconds to play, nudging Tech's lead to three points, 54-51.
Adrienne Tarrence hit one free throw with 34 seconds left to make it a two-point game, but Lashay Davis was perfect at the line in her two chances with 19.7 seconds to regain Tech's four-point edge, 56-52. Harris added the final two free throws with six seconds for the final margin.
The Golden Eagles limited Belmont to 15 points for the first
18:58 of the opening half, allowing just one offensive rebound and
28 percent shooting. Three Bruin free throws in the final
minute made it an eight-point Golden Eagle lead at the
intermission, 26-18.
Tech's offense, meanwhile, fared a little better while forging a double-figure lead in the first half with balanced scoring and a solid rebounding edge.
After Belmont had claimed an 8-7 lead seven minutes into the contest, Tech responded with a 10-0 run to claim a 17-8 lead. The run started with a layup by Williams and lasted through a 3-pointer by Harris.
With Harris and Williams each scoring six, and Tech going
8-for-10 at the free throw line, the Golden Eagles were up 26-15
with 1:18 to play. Tech owned a 25-15 rebound advantage in
the opening 20 minutes, overcoming 34.8 percent shooting and nine
Tech shot 42.1 percent in the second half and 38.1 percent for the game (16-for-42). The Golden Eagles were 23-for-29 (79.3 percent) at the foul line. Belmont improved dramatically in the second half to shoot 54.5 percent, finishing the game with a 37.3 percent mark. The Bruins were 10-for-16 at the line.
Tech owned a final 38-27 advantage in rebounds.
The Golden Eagles have one more home contest remaining in the early part of January, hosting Tennessee State Monday at 7 p.m.


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Healthy Schools Program Forum: Honors from the 2009 Awards Program.
Publication Date: August 2009
Publisher(s): Alliance for a Healthier Generation; Robert Wood Johnson Foundation
Author(s): Alliance for a Healthier Generation
Topic: Health (Health promotion)
Each of the schools listed here, as recipients of the Healthy Schools Program National Recognition Award, have reached an important benchmark in improving the learning and working environments of students and staff. By making significant changes in the areas of healthy eating, physical activity and staff wellness, these schools have joined a growing movement of committed individuals and organizations that are working to combat childhood obesity and foster healthier communities.
Each of the individual school representatives listed here are being honored with the Healthy Schools Program Champion Award for their successes in engaging, motivating and leading others to take steps toward implementing sustainable healthy programs and policies.
The Alliance Healthy Schools Program is proud to recognize these individual and collective accomplishments that positively impact healthy eating and physical activity behaviors in school.


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Vasa Murrhina is the name of a glassware made by the Vasa Murrhina Art Glass Company of Sandwich, Massachusetts, about 1884. The glassware was transparent and was embedded with small pieces of colored glass and metallic flakes. The mica flakes were coated with silver, gold, copper, or nickel. Some of the pieces were cased. The same type of glass was made in England. Collectors often confuse Vasa Murrhina glass with aventurine, spatter, or spangle glass. There is uncertainty about what actually was made by the Vasa Murrhina factory. Vasa Murrhina means "vessel of gems." Related pieces may be listed under Spangle Glass.
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