text:
|Nobody invades my city— —and absolutely NOBODY HURTS MY DOG!![1]
|Lord Hinjo
|Biographical information
Year 1155
|First Comic
|Last Comic
|Physical description
|Hair color
|Chronological and political information
Azure Refugees
|Known masters
Lord Shojo (former)
|Known relatives
Shojo† (uncle)
|D&D Stats
Paladin class abilities, Summon Conscience, paladin mount: dire wolf "Argent".
Lord Hinjo is a Paladin of Azure City's Sapphire Guard[3] and the nephew and heir of Lord Shojo.[4][5][6] After Shojo's untimely death, Hinjo succeeded him as ruler of the Azurites and commander of the Sapphire Guard, becoming known as Lord Hinjo.[7][8] Lord Hinjo has continued to lead the Azurites in exile in their efforts to establish a new colony on an island near the Western Continent.
Biography Edit
How the Paladin Got His ScarEdit
As a young man, Hinjo was working for the Diplomatic Corps of the city, where he learned rumors of the Sapphire Guard. Seeking information he infiltrated O-Chul's mission to discover who had provoked the Hobgoblins of the Southern Mountains under the assumed name Hin Jozuki. He was unsuccessful at diplomacy, but when he was uncovered by O-Chul, he was able to shed some light on the secretive organization of paladins and his cousin Miko Miyazaki.
No Cure for the Paladin BluesEdit
Hinjo first appeared when the Order of the Stick arrived at Azure City, helping Miko escort them to their trial. He is much more easy going than fellow paladin Miko Miyazaki, telling the Order jokes and generally getting on well with them. Miko's disapproval of this caused him to mock her to the Order, observing that her attitude was the reason she was generally sent on the long missions.[3] During the trial, it was revealed that Hinjo is the nephew of Lord Shojo and heir to the throne.
War and XPsEdit
A few days after the Order returned from Cliffport, Hinjo and Miko were outside the throne room and overheard Roy and Shojo discussing their plan to investigate the other Gates, something forbidden to the Sapphire Guard. Hinjo initially sided with Miko in condemning his uncle, but failed to protect him when she decided to take his life.
With the death of Shojo and the fall of Miko, Hinjo became both the new lord of Azure City as well as the commander of the Sapphire Guard. He immediately set out to defend the city from the impending invasion of Xykon's army, the news of which had been brought by Miko.
Hinjo's rule was opposed by Azure City's noble class, most notably Daimyo Kubota, which tried several times to assassinate him in his short time on the throne.[9][10][1].
When Xykon arrived with his horde of hobgoblins, Lord Hinjo led the Azurite forces in the Battle of Azure City. Due to his duties to the city, he was not present in the throne room when Xykon faced the other members of the Sapphire Guard, and because of this he was among the four known paladins of the Guard to survive that day.
With the battle lost, Hinjo fled the city with Durkon, Vaarsuvius, and Elan aboard his royal junk.
Don't Split the PartyEdit
Hinjo continued to lead the Azurites in exile, taking the fleet to visit several former allies seeking help in retaking the city or a place to start over. None of the former allies helped, due to their fear of Xykon.
For their actions during the battle, Hinjo elevated Kazumi Kato and Daigo Da- to noble status, creating House Kato.
Hinjo sent Elan on a diplomatic mission to Orc Island, which resulted in the capture of Lien, but ultimately led to good relations with the orcs who provided supplies to the fleet.
Diamyo Kubota made another attempt to take the throne (in exile) while the fleet was resting off what later be known as Therkla's Island. After Elan thwarted his initial attempts to have Hinjo assassinated by his ninja Therkla, Kubota attempted to lure Elan off to have her assassinate him instead. However, Therkla had fallen in love with Elan, and refused to kill him. At her planned tryst, Hinjo lead a group of Azurites along with Vaarsuvius and Durkon, hiding under an illusion until Therkla and the imp Qarr revealed their plans. Then they attempted to take the pair.
In an unlikely turn of events, Qarr was able to summon a gargantuan Pit Fiend, which did battle with Hinjo and his allies. Hinjo and Argent were able to do some damage to the devil, but ultimately it was Vaarsuvius and Durkon who dispatched the fiend, turning it to stone.
During the battle, Kubota also attempted to kill House Kato in order to solidify himself among the nobles. Therkla was killed in the struggle, and Vaarsuvius returned from the battle to dispatch Kubota, leaving Hinjo much more secure in his throne.
After Vaarsuvius returned from the Soul Splice and fight with Xykon, Hinjo was reunited with O-Chul the last of the four surviving paladins of the Sapphire Guard. Hinjo and the Azurites in exile were epic teleported to an island near the coast of the Western Continent, where an abandoned elven fort provided the ideal location for the Azurites to reestablish themselves.
Hinjo sent O-Chul and Lien to the North Pole to scout out Kraagor's Gate while the Order went to the Western Continent to prevent Xykon from reaching Girard's Gate. He himself stayed with his people to lead their settlement.
Blood Runs in the FamilyEdit
Hinjo and the Order of the Stick went their separate ways, but still remained in touch by way of Sending spells.[11][12][13]
When last seen, Hinjo had just learned of the fall of Azure City's resistance movement, the death of Ho Thanh, leaving only three paladins in the Sapphire Guard, and Xykon's leaving the city, which apparently gave him the motivation to stop his XP-earning activities and intervene in some way.[14][15]
Current ActivitiesEdit
Hinjo's current location and activities are unknown. He is aware of the status of the Order and his paladins at Kraagor's Gate.
Personality and Traits Edit
Hinjo is a considerably more positive portrayal of a paladin than Miko Miyazaki, lacking her holier-than-thou attitude. As a paladin, however, like her, he does take his honor extremely seriously, refusing to break the oath he made, even if it might be a better long-term move. Knowing the tenuous nature of his position as ruler,[16] he is also very politically savvy, and is careful to always have on the right air and manner when others are watching him. Nevertheless he also attempts to project a firm stance against the nobles, and refuses to budge to their demands.[9] Also, Hinjo has shown a very Lawful preference that people follow the orders given, conceding that the ship captain who disobeyed orders and sailed away too early may have indeed saved his life, and that of everyone aboard, but still taking the moment to reinforce that he expects people to obey orders.[17]
As heir and subsequently leader of the Sapphire Guard, he has considerable knowledge of their lore; he knows about the Snarl and had foreknowledge of the Guard's ability to rise as ghosts when slain by Xykon in the throne room.[18]
Hinjo is particularly loyal and protective of his dire wolf mount, Argent.
Powers and Abilities Edit
Hinjo is a highly competent fighter, fighting with a single silver katana (he also possesses a cold iron katana)[19][20] shows great skill fighting from his dire wolf mount. His mount shows himself to be able to harm devils with its bite due to having silver teeth fillings from a trip to the dentist after Shojo once fed it 20 pounds of strawberry cake frosting.[19] Miko describes him as the "second most powerful paladin" in the Sapphire Guard, with her as the most powerful.[20] While her own arrogance almost certainly factors into this declaration, she is able to back it up. When they eventually fight he is beaten even though Miko had lost her Paladin powers, suggesting that she is a number of levels above him, although his initial reluctance to kill her may have given her something of an edge.[20] He is perhaps not quite up to the level of the Order of the Stick and was nearly killed by a single disintegrate spell from Redcloak.[21]
- Sapphire Guard Paladin: Hinjo has all the paladin abilities of his level, though he has not demonstrated some of them.
- Aura of Good
- Detect Evil
- Smite Evil: Hinjo smote both the Huecuva[1] and the Pit Fiend.[19]
- Divine Grace: Hinjo notes in the Huecuva fight that he "can make any saving throw you can dish out".[1]
- Lay on Hands: Hinjo lays hands on O-Chul to heal him after he escaped from Xykon[22]
- Aura of Courage: Hinjo presumably used this to counteract the fear aura of the Pit Fiend they fought on Therkla's Island. None of his soldiers fled in that battle.
- Divine Health
- Turn Undead
- Paladin Mount: Hinjo calls his Dire Wolf mount Argent by throwing a pokeball and saying "Argent, I choose you!".
- Summon Conscience: a fictional game feature, Hinjo calls this a "key class ability".[16]
Weapons and Equipment Edit
- Cold-iron Katana: Hinjo mentions that he has this for fighting devils, it may be the one that he used in his fight against Miko in #409.
- Silvered Katana: Hinjo uses this katana in the fight against the Pit Fiend at Therkla's Island.
- Magic Boots: Hinjo possesses a pair of magic boots of unknown enchantment.
- Cloak and Armor: As a paladin of the Sapphire Guard, Hinjo is always wearing his sapphire blue cloak and plate armor.
Trivia Edit
- Hinjo is the most frequently appearing good-aligned character outside of the Order of the Stick in the comics.
- Hinjo is red-green colorblind.[23]
Gallery Edit
- ↑ 1.0 1.1 1.2 1.3 Comic 453, "Heck of a Fight"
- ↑ How the Paladin Got His Scar, p. 57
- ↑ 3.0 3.1 Comic #265, "A Tale of Two Paladins"
- ↑ Comic #277, "The Crayons of Time: Breaking Up is Hard to Do"
- ↑ Comic #287, "Paladins Make Good Tour Guides"
- ↑ Comic #302, "New Beginnings"
- ↑ Comic #412, "Catching Up"
- ↑ Comic #503, "Surreptitious Admirer"
- ↑ 9.0 9.1 Comic #414, "Noble is Goodble"
- ↑ Comic #435, "Amoral Dilemma"
- ↑ Comic #747, "Make It Three, Just to Be Safe"
- ↑ Comic #893,"Closing In"
- ↑ Comic #895,"Plain Sight"
- ↑ Comic #827, "Crushed"
- ↑ Comic #865, "Getting Defensive"
- ↑ 16.0 16.1 Comic #410, "The New Lord in Town"
- ↑ Comic #482, "Leaving Azure City"
- ↑ Comic #449, "Land of the Rising..."
- ↑ 19.0 19.1 19.2 Comic #588, "His Name Probably Helps, Too"
- ↑ 20.0 20.1 20.2 Comic #409, "Intercession"
- ↑ Comic #480, "Change of Address Needed"
- ↑ Comic #663, "Or Mention That He's Getting Too Old for This"
- ↑ Re: OOTS #959 - The Discussion Thread - The Giant
|Sapphire Guard
|Soon Kim • Lord Shojo • Hinjo • Miko Miyazaki • O-Chul • Lien • Ho Thanh • Ronjo • Jiaya • Yunji • Argent • Windstriker • Razor
|265, 266, 267, 268, 284, 287, 298, 302, 307, 403, 405, 406, 407, 408, 409, 410, 411, 412, 413, 414, 415, 418, 420, 421, 422, 424, 425, 426, 428, 429, 432, 433, 435, 438, 445, 449, 453, 454, 455, 461, 463, 467, 468, 471, 473, 478, 479, 480, 481, 482, 484, 501, 502, 503, 506, 507, 508, 562, 563, 581, 582, 583, 584, 585, 586, 588, 591, 598, 599, 628, 663, 670, 671, 672, 747, 865, 887, 998


text:
It's no secret that reefs worldwide are under pressure from threats like climate change, ocean acidification, sedimentation, overfishing, and pollution from industrial and agricultural activities.
But did you know that one of the growing threats to our reefs lives in your beach bag?
Sunscreen, or more specifically the chemicals found in many sunscreens, are contributing to coral bleaching and the subsequent death of our coral reefs.
In a 2008 survey, researchers at Italy's University of Marche estimated that 4,000 to 6,000 metric tons of sunscreen wash off swimmers annually in oceans worldwide, and that up to 10 percent of coral reefs are threatened by sunscreen-induced bleaching (source).
How Does Sunscreen Damage the Reef?
Four ingredients commonly found in sunscreen: paraben, cinnamate, benzophenone, and a camphor derivative, can awaken dormant viruses in the symbiotic algae zooxanthellae than live inside reef-building coral species.
These chemicals cause the viruses to replicate until their algae hosts explode, spreading the viruses into the surrounding seawater where it can infect adjourning coral communities.
Zooxanthellae provide coral with food energy through photosynthesis and contribute to the organisms' vibrant colour. Without the algae, the coral bleaches, turns white and dies.
According to the study, the effect is not dose dependent. This means that the exposure of coral to a very small dose of sunscreen is enough to produce a cascading effect.
What Can You Do?
One of the simplest ways you can continue to enjoy the ocean without frying to a crisp is to choose a reef-safe sunscreen.
These sunscreens use physical filters like zinc oxide or titanium dioxide, which reflect rather than absorb ultraviolet radiation. The bonus is that reef-safe sunscreens are generally also natural and eco-friendly sunscreens.
At Sustainahome we use, and recommend, Eco Logical Sunscreen.
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subset: commoncrawl


text:
Alex Tekip
Telephone: 517-355-3844
ANR Communications & Marketing
Communications ManagerCook-Seevers Hall
458 W. Circle Drive, Room 5
East Lansing, MI 48824
Alex develops, facilitates and executes communications and marketing tasks for the Food@MSU initiative, including projects, programs, and social and digital media. She offers ideas, insight, direction and creative solutions with the ultimate goal of expanding the campaign's influence and impact. She drafts press releases, articles and other related items, assists with outreach within and outside of the MSU community, and helps plan Our Table events.
Additionally, Alex helps support communication efforts in the:
- Department of Food Science and Human Nutrition
- Department of Agricultural, Food and Resource Economics
Tags: food@msu communications


text:
It's not long now until the hotly anticipated, deluxe Berlin Burlesque Academy opens it's doors to aspiring performers and undiscovered talent.
The celebrated and renowned Marlene von Steenvag, owner and director of the new school, has dedicated much of her life to the art of burlesque and strip tease. Known to the world as the Queen of German Burlesque, you'll truly be placing yourself in the best of hands if you want to learn about the glamorous and seductive performance art.
Glamorous and seductive
If you're looking to explore the world of burlesque, engage in new levels of fitness on an enjoyable level or simply discover something new about yourself, this is the academy for you. The school is also equipped with a full dance studio, so you'll feel like a real professional no matter what your experience level.
BBA is opening on the 1st August at Greifenhagener Str. 64, 10437, with a fantastic workshops and classes scheduled for the next coming months:
August offers classes such as Step Into The Spotlight
August offers classes such as Step Into The Spotlight, an introductory class for those wishing to enter the world of burlesque. The Secrets of Burlesque shall explore the hidden magic behind some of the greatest performances and acts in the biz and of course, the highly anticipated Show Perfection class which climaxes with a live performance to an audience, if you're brave enough to bare all of course.
Learn to pose and strut like the goddess you are
September has something different too. You'll be able to learn chair routines in the chair dance workshop or if dancing is not your thing, try the catwalk class where you can learn to pose and strut like the goddess you are. I, personally, cannot wait to attend some of the classes and see the shows of the new burlesque performers that will surely be graduating under the watchful eye of Marlene. So grab your sequins and your feathers and get ready to learn something out of the world.
We have a fantastic pair of tickets up for grabs!
To find out more about the classes head to marlene-von-steenvag.de/en/#burlesqueacademy and just for all of our lovely readers we have a fantastic pair of tickets up for grabs for the Show Perfection workshop on August 12th, so you and a friend can enjoy the class together. To be in with a chance of winning these tickets simply send your details to win (at) All Tomorrows Parties.de.


text:
A harmonious fusion of old and new, traditional and contemporary, nature's wonder and man's artistry.
Samuel Behnam is an award winning New York based jewelry designer and founder of the Samuel B. Collection. Inspired by the immeasurable beauty of nature and the ancient traditions of Balinese and Thai jewelry craftsmanship, Samuel has made designing stunning jewelry his life's work.


text:
How to remind participants to sign documents within KeepSolid Sign app on macOS device
Working with documents in KeepSolid electronic signature software, an author can remind participants that they have documents waiting for their signatures. This can be done through the Reminder option just in 2 clicks:
1. On the Document Info tab, click the Reminder button next to the appropriate signer.
Note: This button is active only for the participant who is to sign at the moment.
2. Click Notify in the request window.
The participant will get a push notification and an email containing a link to sign the document in the web application.
The number of possible reminders is unlimited. So, if your colleague does not revert with a signed document, just repeat the steps and send another reminder.


text:
Big Time Rush/JE, Big Time Luck
Title: Big Time Luck [James/Hashimoto]
Rating/Warnings: PG-13 for MS backstage action
Summary: The kid is cute enough that James is willing to forgive the purple, shiny suit.
AN: cierra_james wanted BTR's James meets Hasshi.
Big Time Luck
"What's lucky about it, though?" the Japanese kid wanted to know.
"Everything," James answered, after Logan had translated and then he ran the comb through his hair one more time, because it could only be the worst kind of luck to be aired on Japanese national television for the first time with a crooked part.
The Japanese kid went on rambling at him, a total chatterbox, and it didn't seem to bother him that James went right on examining his reflection. The kid was cute enough, James guessed, not as cute or as tall as him but then again who was? Also his suit was a sort of unfortunate shiny purple, but James had seen enough other artists on Logan's laptop to conclude that Japanese boybands were just plain weird about that sort of thing.
The Music Station staff member leaned in to tell them politely that call would be in a few minutes and they should please hurry. Then she caught sight of the kid, still blathering happily away, and said a few things in stern, rapid Japanese that brought the kid over to her at a trot, waving goodbye to James as he left.
Cute kid, James supposed, and then he forgot all about it when Kendall distracted them with silly questions about where his pants had got to.
After the filming, heart still racing from their live performance during the show, James nearly jumped out of his skin when on the way back to their dressing room, strong hands grabbed his wrists and then his back was thumped solidly against the wall.
He found himself blinking at the cute(ish) kid from before, the kid's cheeks flushed and eyes bright from his own group's performance (which had struck James as being surprisingly bendy more than anything).
"Yo," the kid said, voice lower than from before, and then he said some other stuff.
"Logan?" James asked.
"Um," Logan cleared his throat, "I think he likes that you're tall. Like, really likes it."
"Tall," the kid echoed, looking satisfied. "James?" he said like a question, and James nodded, even if the kid's pronunciation was a little odd. "Hasshi."
"You're Hasshi?" James asked. He flexed his wrists a little and they barely moved; this kid was even stronger than Carlos, and then the kid leaned in a little closer and suddenly James understood what was going on.
"I'm gonna go," said Logan, who also apparently understood. "NOW, Kendall!"
"So," James cleared his throat as the sounds of his bandmates scurrying off faded away. "Hi?"
"Hi," Hasshi said, grinning still and pressing even closer, and then his mouth was on James's and James thought that Tokyo was definitely someplace worth visiting even despite their shiny purple pants.
But there was no way this kid was getting anywhere near his lucky comb.
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Home » Delph Miniatures » Shop by Room » Doctor's, Medical and Hospital » DM-M133 - 1:12 Scale Medical Examination Couch
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text:
Hello everyone, Godfrey here with a look at what is happening to the scale of 40k. While normally, my talk of scale is based around the point level at which we play this game, today I'm going to take a look at the scale of the miniatures being pumped out by Games Workshop. It's hard not to have seen some of these new models as they tend to take up quite a large amount of space on the table... at least in terms of vertical scale.
The first of these new scale of models, what I am calling the harbinger of Colossus class units was the Tyranid Trygon/Mawlock kit. This model occupied a huge space at the time, and where the Carnifex was already considered pretty large, this new beast stands at average about 2.5 fexes tall.
Next in line, we see the Dreadknight. This monster was considered ridiculous as it brought a 2+ save and the ability to be classified as a "jump" unit. While the scale in terms of proportion wasn't greater than its predecessor, the rules were leaps and bounds ahead of the curve.
The first few armies we saw come about from 6th edition were not especially different in terms of the models they introduced. Admittedly, Chaos has had a fairly bulky model in both of its CSM and Daemon books in the form of the Defiler and it's close cousin, the Soul Grinder. While these models are indeed very hefty in scale, their limited abilities on the tabletop kept them from seeing play too frequently. While the Defiler and Soul Grinder defiantly being worth their points with the coming of 6th, more so to the latter as it gained some much needed utility with Skyfire, they have never really seen the table on a large scale. Because of this, their existence has been relatively ineffectual on the game itself.
Fast forward a few months, and we saw the coming of the new Tau codex and therefore the Riptide. Admittedly it isn't as big as the Defiler in terms of space it actually takes up on the 6x4 space, however it dwarfed almost every other model with some ease. Because of the "True Line of Sight" rule, this vertical scale allows the model to get around a fairly sizable amount of balance factors we have had established for a while.
Now, moving even closer to the present, we see the largest model we have seen GW release to date. The Wraithknight. This behemoth stands at an unprecedented 8.5" tall. This increases to over 10" if you count the weapon if modeled vertically. This is interesting as a Warhound Titan stands a mere 3" taller at this point, meaning we are very much blurring the area where 40k stops, and Apocalypse begins. And with the new rules for Apocalypse on the Horizon, I have to wonder of much of this "Bigger is clearly better" mentality will make it's way into the new units coming from GW for that.
While the units are impressive to look at, I'm a little nervous about what it means for the game. We've seen another similar game attempt something very similar to this in the past when Warmachine added the colossal units to it's game. These units are still being banned at many tournament level events because of their sheer power and because of this, we have units that people may purchase and then are unable to use, and with prices continuing to increase further and further... I can only see these units as being investments made by the company to develop, only to see players realize they are too damn good to allow on mass scale.
|Scale photo of some of these new models compared to Apoc. units.
So what does this mean for the game? How will these new Colossi effect the game, and the other, less huge units we are used to? Are the missions we have now balanced when we start seeing these monsters fielded more prevalently? All in all, with flyers, and huge creatures walking about... I can imagine Apocalypse is going to be made huge in the wake of these new changes.


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Customer Account Specialist
Job Description
About Us
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Job Profile
The Customer Account Specialist is responsible for the daily, weekly, and monthly processing of client premium payments, review and reconciliation of client invoices as needed, track all remittances for clients per account per month, interact with vendors via phone, email to verify receipt of payments and proper payment posting, monitor accounts to make sure payments are received within designated due dates, and provide account details as requested interdepartmentally. This position will have experience with handling accounts that are tiered in out-of-pocket for members, deductible, co-insurance, and lifetime max as applicable. This position will have fundamental accounting principles to include accounts receivable, accounts payable, cash handling, general ledger credits and debits and will remain abreast of subsidy levels and accounts applicable for accurate processing.
Benefits and EEOC
Community employees' benefits are provided by Harris Health. These benefits are designed to provide you with flexibility and choices in meeting your specific needs.
Community is an Equal Opportunity Employer.
Job Category
CHC Call Center Operations
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: 3/17/2020
Job Status: Full Time
Job Reference #: 150281


text: Derek Parfit famously defends a number of surprising views about "fission." One is that, in such a scenario, it is indeterminate whether I have survived or not. Another is that the fission case shows that it does not matter, in itself, whether I survive or not. Most critics of the first view contend that fission makes me cease to exist. Most opponents of the second view contend that fission does not preserve everything that matters in ordinary survival. In this paper I shall provide a critique that does not rely on either of these contentions. There are other, interrelated reasons to reject Parfit's defense of the two theses. In particular, the availability of the following view creates trouble for Parfit: I determinately survive fission, but it is indeterminate which fission product I am.


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Hoghenhine o'Mine
hoghenhine, n. — a person who has stayed in a household for three nights, and so becomes the legal responsibility of the host; a member of a household; a dependant
Rosie will always be a member of the Smith family, could never be any the less so. But now she's a welcome member of our household.
Gabby finds times and things to jealously guard as hers, but mostly applauds the addition. The two run races through the house and tag along behind SuziQ together and take long walks around the neighborhood hunting squirrels side by side.
The cats are learning to tolerate the new little ball of white lightning.


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Snack Review
Taste test: These pork rinds had a light beige/orange color, as there was a thin orange seasoning on the surfaces of the irregularly shaped pieces.
We crunched in to find a very light and airy feel, nicely crisp but not dense at all, with mostly just an intense pork rinds flavor at first. The expected heat arrived in the aftertaste, but not in a majorly intense way. There were enough spices to mix nicely with the pork rinds for a nice mildly spicy taste, but not enough to real bring on much burn. Very tasty!
Shop: Buy Pork Rinds on Amazon #ad
Smell test: Strong pork rinds smell. Couldn't really smell the hot peppers.
From the package: "0g total carbs per serving" ... "One intense snack experience."
Online store: Buy Pork Rinds on Amazon #ad
Company: Snyder's-Lance
Categories for this snack:
This snack was discovered by PJ in Raleigh, NC. Review published .
Most popular in previous months
Still hungry? Check out the 100 latest reviews


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The Most Romantic Things to Do in Los Angeles
by Ariane Resnick, CNC
Rekindling Romance in The City of Angels
No city is more equipped to help you relight the fire in your love life like Los Angeles, known for its perfectly serene weather and gorgeous views. From picturesque beaches to private sunset tours and dining at a small version of Paris, LA has date activities for every type of couple. Read on for recommendations that will accommodate you no matter your mood or budget.
When You Want to Keep It Casual
You may want to up your romance quotient without taking out your ponytail or getting out of your leggings. If so, try these casual yet romantic date ideas:
- Take in a movie at a drive-in. Los Angeles has a host of drive-in movie theaters, where you can enjoy the art our city is known for without ever having to get out of your car.
- Hit the beach. Every coastal town has one or more, and the sunsets over them make for some of the most romantic views in Los Angeles. Branch out from the usual Santa Monica Pier and hit up a secluded spot in Malibu or Redondo beach.
- Your pants may get a little water splashed on them when you pedal a boat in Echo Park Lake. Swan boats rent hourly from 9 am to sunset.
When You Both Love Food
If you think nothing says "love" like a decadent meal, these spots make for a great romantic LA date:
- The outdoor seating at Cliff's Edge is some of the prettiest in the city, and you aren't limited to dinner; this romantic LA restaurant offers brunch as well.
- Cozy and dimly lit, Elf Cafe is a vegetarian restaurant with a menu rich enough to satiate any carnivore. Their menu is Moroccan inspired and their wine program features natural and biodynamic wines.
- Can't get to Paris? Enjoy the next best thing in Los Angeles at Le Petit Paris. The 300-seat space in Downtown LA's El Dorado building is lovely inside and out.
When Money Is No Object
When a paycheck is burning a hole in your pocket, the list of romantic things to do in LA knows no bounds. Here are a few high-priced adventures:
- Two and a half hours and nine courses are on the menu at Maude, Curtis Stone's Beverly Hills restaurant with a prix fixe seasonal menu. No children under age 10 are allowed—ensuring a romantic atmosphere—and the restaurant has received numerous awards.
- Want to see that gorgeous LA sunset up close? Book a private helicopter sunset ride with a service such as Orbic Air, which gives you the option of recording your romantic tour on video.
- Pamper one another—or have strangers do the dirty work—at a fancy spa like the Ritz-Carlton. In typical Cali spirit, they even have a selection of CBD-enhanced treatments.
When You Need Something New
If you and your partner are more the silly sorts, these Los Angeles date ideas might work best for you:
- Escape rooms are popular throughout LA, but Escape Room LA is a top choice with its five different game rooms.
- Laugh off your troubles at a comedy club. Many famous actors and comedians got their starts at local LA haunts such as The Comedy Store and The Laugh Factory.
- For those who enjoy booze and learning new things, many Los Angeles distilleries offer What's better to rekindle your romance than sips of freshly made spirits?
Ariane Resnick is a special diet chef, certified nutritionist, and bestselling author. She has been featured in media such as Forbes, CBS's "The Doctors," and Huffington Post, and her private clientele includes celebrities such as P!nk.
- https://www.laparks.org/aquatic/echo-pedal-boats-concession
- http://www.cliffsedgecafe.com/
- http://elfcafe.com/
- http://lepetitparisla.com/
- http://www.mauderestaurant.com/
- https://orbicair.com/i-9050417-private-romantic-sunset-helicopter-tour.html
- http://www.ritzcarlton.com/en/hotels/california/los-angeles/spa?scid=bb1a189a-fec3-4d19-a255-54ba596febe2
- https://www.escaperoomla.com/
- https://www.discoverlosangeles.com/blog/take-spirited-tour-los-angeles-distilleries


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'12 Years A Slave' Star Lupita Nyong'o Covers W Magazine's February 2014 'Movie Issue'
One role into her silver screen career and Lupita Nyong'o has already become 2014's Hollywood and fashion industry darling.
The Mexico-born Kenyan actress made our souls weep in Steve McQueen's 12 Years A Slave and she makes fashionistas swoon on every red carpet she hits.
Joined by fellow Oscar contenders Oprah, Jennifer Lawrence, Cate Blachett, Amy Adams, and Matthew McConaughey, Lupita covers W Magazine's February 2014 'Movie Issue' photographed by Juergen Teller and styled by Edward Enninful.
Lupita's next Hollywood feature is the Jaume Collet-Serra-directed thriller Non-Stop, starring Liam Neeson and Julianne Moore, which will hit theaters February 21, 2014.


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Venice Property Management
Why are we consistently named the leading property management company in and around Venice? Because we know property management is more than placing tenants and collecting rent.
We're committed to full-service property management and an outstanding customer experience for owners and tenants.
We've built a reputation for reliable, professional service that helps you earn more and worry less as a real estate investor.
What will a Property Manager Do For My Plantation Property?
Dynamic Property Marketing
We have a "19 Days on Market" benchmark which provides you with a lower vacancy rate and better advertising. We'll find you a high quality tenant in 19 days or less.
Read More »
We specialize in strategic marketing that starts with online advertising. By advertising on popular rental sites like HotPads and Trulia, we reach a large tenant pool. We also use the MLS, and more than 70 different advertising channels to ensure we get your property in front of as many tenants as possible.
Our owners also benefit from our name recognition. Gulf Coast Property Management is well-known throughout Venice, and good tenants looking for homes tend to turn to us.
Three full time leasing agents on our team are 100 percent responsible for filling vacancies. They don't have to worry about property management duties, so they're available to answer questions, show properties, and talk to prospective tenants. They work seven days a week, and they'll show homes to interested tenants in the evenings and whenever it's convenient.
Careful Tenant Screening
Our rental criteria is strict because we know the damage a bad tenant can do. We have a rigorous and consistent screening process that results in placing the best possible tenant.
Read More »
We'll conditionally approve tenants who meet our criteria as soon as they submit an application, which is evaluated by our internal team. Then, we verify everything on there, including income, employment, rental history, and credit. All supporting documentation is collected and compared to the application.
We want to fill vacancies as soon as we can, but we're committed to a rigorous screening process. It may seem like we're being over cautious when we ask for pay stubs or bank statements. But, we won't compromise. Protecting your asset is our highest priority.
Tenant Move-in Process
Once we have approved a prospect, we collect advance rent and a security deposit and move forward with the lease. Our leases are prepared by an attorney and protect the landlord to the fullest extent of Florida Law.
Read More »
The Florida Landlord Tenant Act is always changing, and we make sure the lease you and your tenant sign reflect all the necessary terms, conditions, addenda, and disclosures. All of our leases are prepared and reviewed by an attorney who understands property management law in Florida.
Inspecting the property before your tenant moves in is critical, and we document the condition of your home in great detail using 3D virtual tour technology to show exactly how your property looks. This attention to detail saves us from disagreements with tenants when it's time to return security deposits.
Thorough Property Inspections
Regular rental property inspections are part of how we manage homes at Gulf Coast.
Read More »
It starts with a thorough move-in inspection so we can document the condition of your property before the tenant moves in. Then, we inspect 90 days after the move-in date. This lets us know your tenant is following the terms of the lease and taking good care of your home. If we need to revisit some expectations and reinforce some responsibilities, we do it.
We also conduct a renewal inspection when your tenants decide to stay another year. We'll inspect the property, check-in with the tenant, and get the new lease signed. If our inspection reveals any reason that the tenancy should not be extended, we'll hold off on signing the new lease until we can determine whether we want to keep the tenant in place.
When tenants know that we care about the condition of the home and invest in its upkeep, they'll be sure to maintain it to our high standards.
For your convenience, all inspection reports, including photos and comments are stored in your Owner Portal. You have access to this information 24/7, 365 days a year.
Comprehensive Property Maintenance
There's no way to escape maintenance and repairs when you own a rental property.
Read More »
At Gulf Coast Property Management, we have a skilled and affordable in-house maintenance team that provides outstanding work with your budget in mind. We're also mindful of damages that may be due to tenant neglect or abuse. If we find that tenants are responsible for a repair, we'll charge the tenant and save you money. We're proud that our maintenance personnel are licensed, insured, and certified by the EPA. If you have your own preferred vendors or warranties in place, we'll work with those preferences.
Rent Collection & Accounting
Our rent collection policies are fair and consistent, and we offer tenants a number of convenient and secure ways to pay their rent on time.
Read More »
With our online tenant portal, most tenants pay rent electronically.
Our management of your money goes well beyond rent collection. At Gulf Coast Property Management, our accounting work is full-service.
With innovative property management software, we're able to provide detailed and transparent statements and reports. Check your balances, review your invoices, and look for rent payments with your online Owner's Portal.
Tenants are incentivized to pay rent on time because we partner with Experian and Rent Bureau to share all of the on-time rental payments made by your tenants. This helps us attract great tenants and prevents the placement of tenants who aren't serious about paying rent on time.
Evictions & Legal Help
We're proud of our eviction rate, which is below .01%. Great tenant screening and respectful tenant relationships contribute to this success.
Read More »
We keep up with all state, local, and federal rental laws and requirements, keeping you and your asset protected from claims, lawsuits, and liability.
Trust Gulf Coast as your rental management partner and you will benefit from property management expertise and years of industry experience.
Areas We Serve
Property Management Testimonials:
"Gulf Coast Property Management manages three of my rental properties and they make being a Landlord easy. When a repair issue comes up, they are on the ball and the items are addressed in a timely manner. They secure the best rate and repairman available. I am grateful for the peace of mind that Gulf Coast Property Management provides."
"I recently purchased an investment property in the Bradenton area. As an out of town investor, I wanted to partner with a reputable and strong property management company who could ensure my property runs smoothly without a lot of my own time. Gulf Coast Property Management fit this description perfectly. If you are looking to hire a property management company that allows you be be hands-off look no further. Their response time and direct deposit into my bank account makes my life easy."
"I am an out-of-state investor and recently purchased an investment property in the Sarasota area about a year ago. I was looking for a trusted company who I could rely on, given that I am located in California. I performed several interviews with rental management companies. My search ended with Gulf Coast. I found the staff to be friendly, patient and knowledgeable as they addressed all of my questions and concerns. I have been impressed with Gulf Coast's ability to handle maintenance concerns, collect rent, and deposit funds into my bank in a timely manner. I highly recommend Gulf Coast to anyone looking for a great property management team."
"Owning multiple investment properties can be stressful at times. I am happy that I have found Gulf Coast to manage my rental properties and ease the pressure. They are have come up with several solutions to maximize the returns on my investments. I am confident in looking to Gulf Coast for advice with all investment and rental-related guidance."
Get a Free Rental Analysis for Your Property in Pelican Pointe, Florida
Talk to us about how much you can charge in rent for your Venice investment property. We're often asked about the local market and what it means for their rent potential. When we're estimating your rent, we consider property size, location, and condition.
What's the Highest Rent I Should Charge For My Investment Property?
Talk to us about whether it's a good idea to price your property at the top of the normal range. Remember that vacancies are often more expensive than collecting a little less rent every month.
How Much Does Venice Golf & Country Club Property Management Cost?
We're completely upfront and transparent when we're talking about property management fees. Here's what you'll pay at Gulf Coast:
Owning multiple investment properties can be stressful at times. I am happy that I have found Gulf Coast to manage my rental properties and ease the pressure. They are have come up with several solutions to maximize the returns on my investments. I am confident in looking to Gulf Coast for advice with all investment and rental-related guidance.
Are you a Sarasota National investor with multiple properties?
We have management packages that fit your needs, wherever your properties happen to be. Click this button to learn more.
Discover Why Gulf Coast Is Your Best Choice For Managing Your Venice, Florida, Property:
Located in southwest Florida, on the sunny Gulf of Mexico coast, Venice is a city known for its sunsets and shark teeth. It has been ranked by Coastal Living as one of the happiest seaside towns in the country, and for good reason. Who wouldn't be happy living in a place that has abundant sunshine, gorgeous beaches, and enough recreation to appease even the greatest of adrenaline seekers? Like its namesake in Italy, Venice is surrounded by water. The Intracoastal Waterway separates it from Florida's mainland.
The Venice Pier is a popular place for fishing, enjoying a drink or a meal, and listening to live music. It also features breathtaking sunsets nearly every night. The Pier in its current form was built in 2004. In 1981, the original pier was swept to sea during a storm. In 1984, the city rebuilt it using swamp timber, but the modern pier is made from sturdy wood composite. It's the perfect place to fish for dinner or enjoy a romantic stroll.
The beaches are covered with fine white sand, and both visitors and residents can often be found digging shells and shark teeth out of the surf. The city is about more than just beach fun. The Venice Museum and Archives (known locally as VMA) hosts exhibits and permanent collections that may rival larger and more cosmopolitan cities. If you visit the Venice Centre Mall, pay attention to the tributes to its history. It was once a school for the Kentucky military, and then the building was used as a hotel. The area is close to a lot of nature and hiking opportunities, with Myakka River State Park and its plethora of wildlife less than half an hour away.
The Venice economy is strong and growing, making it an ideal market for investors who want to rely on a steady tenant pool. The median household income is higher than the national average, and rental prices have risen steadily over the last five years. Whether you're looking to purchase your first investment home or you're hoping to add another home to your growing portfolio, you can count on a number of excellent opportunities in the Venice housing market.
It's also a great place to pick out a retirement home. You can buy something that you may live in at some point in the future, and rent it out until then. If you decide to do this, count on your team at Gulf Coast Property Management to take care of the property until you're ready to take possession.
We serve all of Venice, including zip codes 34285, 34292, 34275, 34284, 34293 and nearby.
Gulf Coast Property Management | Venice, Florida
Venice Office
Email: firstname.lastname@example.com
Mon-Fri: 9:00am – 5:30pm
Sat: 9:00am – 5:00pm
Expand business hours »
What People Are Saying About Us
This experience has been a pleasure from day 1. All of our concerns have always been dealt with in a very timely and efficient manner. We are being kept updated on everything happening at our property without feeling like we're being spammed.
Chelsea is amazing to deal with, she replies to and acts on emails faster than I've ever experienced with anyone else on the property market. Even a Friday evening 6pm has not held her back from communicating information between our tenants and us.
Jay Carter
I had the pleasure of working with Laurie to find our new home and have Kelly as my property manager. Everything has gone better than I could have hoped or imagined. We began very stressed trying to find a home and when we came across the house we chose, Laurie was so kind during the showing and made everything so easy after that point. Kelly has been wonderful since we started living here and been super helpful with any questions we have. We are so happy this was our first experience moving into a home!
Stephanie Romanello
Scott has proved to be a personal, professional and people oriented person to work with. He spent time to look over things preparing for rental and I felt included through his listening and feedback. He responds promptly and courteously to handle questions in email. In fact I feel like he takes care of everything that I would do and more. I am in process of moving and he reduced my stress level by clarifying tasks that Gulf Coast could complete. He also thinks of things to do I didn't think of and seeks my approval before acting on tasks. He is a class act. My only complaint is that he showed up extra early for initial appt. but that is better than not at all or late! Overall I highly rate him as a welcome presence on Gulf Coast staff. I already feel part of their team with dignity and respect.
Keith Gerber
I've been very happy with the service from Gulf Coast Management! Very prompt if I need something fixed in my unit. Kelly Crawford always answers my emails and has been easy to work with! Excellent service!
Julia Payton
As a long-term Plantation rental guests, my husband and I want to thank Elaine Dexter at making our visits a fantastic experience. Everything runs smoothly when she is in charge. She goes out of her way to handle any problem or concern (be it large or small) with a sense of urgency & commitment. You can tell that she truly cares! Looking forward to seeing Elaine in November, because I know that our visit will be a memorable one. We know we will be in good hands with no worries at all.
Lynn Anderson
Want to Learn More?
If you'd like to learn more about our properties and what it's like to work with Gulf Coast Property Management, get in touch. We'd be happy to talk more about our rental properties, our application requirements, and our leasing process.
Areas We Serve
Bradenton | Ellenton | Lakewood Ranch | Parrish | Sarasota | Venice | Palm Island |
Englewood | North Port | Port Charlotte | Punta Gorda | Barrier Islands


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Zana Hoxha Krasniqi
Founder and Artistic Director, FEMART Festival
If we don't claim our space as women and as artists, our voices will be lost.
About Zana
Zana Hoxha Krasniqi is a feminist artist from Gjakova and the founder and director of Artpolis and FEMART Festival, an NGO that combines art and activism to encourage dialogue. Through Artpolis, Hoxha, whose background is in theater direction, has directed and supported a number of regional plays that call attention to social injustices.


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Tag Archives: DIET
Cholesterol is a major component of plaque in arteries. Lowering cholesterol decreases its accumulation in arteries and will decrease the amount of plaque and frequency of heart attacks. Most plaques are asymptomatic before a heart attack – even when the vessel … Continue reading
Posted in Patient Education Guide Tagged Adverse Effects, CHOLESTEROL, DIET, exercise, hyperlipidemia Comments Off on Hyperlipidemia
Diet – Sacred Heart
Sacred Heart Memorial Hospital Diet Basic Fat Burning Soup Recipe 6 Large Green Onions 2 Green Peppers 1 or 2 Large Cans of Tomatoes 1 Bunch of Celery 1 Large Head of Cabbage 1 Pkg. Lipton … Continue reading
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Nutritional Counseling
At Whole Health Center Houston, we recognize the importance of food and exercise on overall health. Therefore, diet and lifestyle changes are essential to many of our treatment protocols. We do not use a standard dietary recommendation or protocol for … Continue reading
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Diet – The Hallelujah Diet
by Rev. George H. Malkmus People often ask me, "What do you eat?" Here is my answer: Breakfast One tablespoon of BARLEYGREEN* powder either dry and let it dissolve in my mouth or in a couple ounces of distilled water … Continue reading
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Insomnia: Causes and Correction
Today the inability to sleep plagues millions of Americans. Sleeping pills, including tranquilizers, represent the most prescribed group of medications in America. Rather than simply treating the symptom, nutritional research reveals that biochemical causes of insomnia can be addressed by … Continue reading
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How to Destroy Your Health
Get emotional and excited over every trifling occurrence, especially if it is no concern of yours. Eat and drink indiscriminately. Cut down your sleep. This is an excellent way to undermine the nervous system. Never relax. Relaxation gives the body a … Continue reading
Posted in Patient Education Guide Tagged DIET, exercise, health, sleep Comments Off on How to Destroy Your Health
Drinking a healthy smoothie a day will be a tremendous boost to most peoples' well being. In order for the smoothie program to be successful it must meet at least the following criteria: It must be easy. It must be … Continue reading


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Sunday, July 05, 2009
Market on the 4th
It was July 4th at Mount Joy Farmers Market. Flags lined the streets of our small town, and at Market, one of our vendors set up a little vignette to celebrate!
There were even red, white and blue potato varieties. Supposedly they hold their color and it was very tempting to try making potato salad with them, but knowing our family we stuck to the tried and true!
I walked around market part of the way through the day and when I got home and downloaded the pictures I took, I was thrilled and amazed by the beauty that surrounds us every week.
You can tell the pride that goes into growing or producing the products by the way they are displayed.
CORN - Seems a little early for local, but....
Wonderfully displayed root veggies
And more
Tomatoes - again, very early this year. All the rain really slowed the crop.
More and more variety every week.
Not local, but... yum! Melons
And some of the delicious baked goods offerred.
Some of the herb and flower plants you can find every week!
And, of course, a sunflower to finish off the day!
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When it comes to devout NYC designers, Wendy Mullin of Built by Wendy ranks high on our list. And while her approach to young, cool timeless basics rarely strays too far from home, we can always expect a few inspired twists with every new collection. Such is the case with her upcoming fall/winter collection, which, wouldn't you know it, we snagged a peek of right here! Called "Building of the Future," the collection reveals war-time inspirations, ranging from Bauhaus stoicism to the Eastern European youth-in-revolt photography of Josef Koudelka. The grainy photos and odd-ball poses totally channel '80s Vogue, but the clothing is most definitely of-the-moment. The muted palette—grays, warm, earthy browns, and grassy greens—are punctuated by flashes of primary shades and killer prints. We're majorly obsessed with the bomber jackets, plaid voile blouses, and flannel jumpers that will keep us cozy during the winter chill. And that's one war worth fighting for...
Built by Wendy is giving NY newsletter readers some love with 20% off any one single spring 2010 collection item for today only in either of her stores (NYC or Williamsburg). Sign up for the email here to get some amazing deals.
7 Centre Market Place, (between Broome and Grand streets); 212-925-6538


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Lane AM, Kim IK, Gragoudas ES. Long-term Risk of Melanoma-Related Mortality for Patients With Uveal Melanoma Treated With Proton Beam Therapy. JAMA Ophthalmol. 2015;133(7):792–796. doi:10.1001/jamaophthalmol.2015.0887
© 2020
Little is known about the long-term risk of dying of uveal melanoma after treatment with radiotherapy.
To determine the long-term risk of dying of this disease, we evaluated melanoma-related mortality rates up to 25 years after proton beam therapy in a large series of patients with uveal melanoma.
Design, Setting, and Participants
In this analysis, we included 3088 patients with uveal melanoma, identified from a hospital-based cohort and treated with proton irradiation between January 1975 and December 2005. Vital status and cause of death were ascertained through active follow-up and searches of government databases (the Social Security Death Index and the National Death Index) through December 31, 2008. Cumulative rates of melanoma-related mortality were calculated using the Kaplan-Meier method. Patient and tumor characteristics of known prognostic significance for melanoma-associated death were evaluated, including patient age and tumor dimensions.
Main Outcomes and Measures
The primary outcome measure was cumulative rates of melanoma-specific mortality, and secondary measures included annual melanoma-specific mortality hazard rates and cumulative all-cause mortality rates.
Of 1490 deceased patients, 620 (41.6%) died of ocular melanoma. In addition, 19 patients were alive, but their melanoma metastasized, by the end of the observation period (mean follow-up after diagnosis of metastasis, 5.3 years). All-cause mortality rates in this cohort were 49.0% (95% CI, 47.0-51.1) at 15 years, 58.6% (95% CI, 56.4%-60.8%) at 20 years, and 66.8% (95% CI, 64.2%-69.4%) at 25 years. Melanoma-related mortality rates were 24.6% (95% CI, 22.8-26.4) at 15 years after treatment, 25.8% (95% CI, 24.0-27.8) at 20 years after treatment, and 26.4% (95% CI, 24.5-28.5) at 25 years after treatment. The 20-year mortality rate was 8.6% (95% CI, 6.2-11.9) for younger patients (≤60 years) with small tumors (≤11 mm) and 40.1% (95% CI, 36.1-44.3) for older patients (>60 years) with large tumors (>11 mm).
Conclusions and Relevance
In this large series of patients with ocular melanoma treated conservatively with proton beam irradiation, the cumulative melanoma-related mortality rates continued to increase up to 23 years after treatment. Annual rates decreased considerably (to <1%) 14 years after treatment. Information regarding the long-term risk of dying of uveal melanoma may be useful to clinicians when counseling patients.
Published data1,2 on survival after enucleation indicate that the long-term risk of dying of uveal melanoma continues many years after diagnosis and treatment. In one study,1 metastasis was detected 23 years after diagnosis, and in another study,2 34 years after diagnosis. In both studies,1,2 the 25-year mortality rate for patients with uveal melanoma was 50% or more.
It has now been more than 30 years since radiotherapy was established as a standard of care for uveal melanoma,3-5 yet little is known about the long-term risk of melanoma-related death for patients treated with proton beam irradiation of their tumors. Twelve-year melanoma-related mortality rates have been presented from the Collaborative Ocular Melanoma Study,6 with similar rates observed between patients who were randomly assigned to receive plaque radiotherapy with iodine 125 and those who were randomly assigned to receive enucleation. Gragoudas et al7 calculated rates of several patient outcomes after proton beam irradiation using risk scores based on Cox regression models; 15 years after treatment, melanoma-related mortality rates of more than 50% were only observed among patients with the highest-risk scores.
In 1975, the first patient was treated with proton beam radiotherapy for uveal melanoma at the Massachusetts Eye and Ear Infirmary (MEEI) in Boston, and since then, more than 4000 patients have been treated. The majority of these patients are monitored throughout their lives as part of a Uveal Melanoma Registry established at the MEEI in the 1980s. As a result, mature data are now available from the registry allowing for evaluation of mortality rates up to 25 years after treatment in a large series of patients to determine whether rates are similar to those observed after enucleation or whether late-occurring differences emerge. We also evaluated known prognostic factors for melanoma-related deaths to explore whether the magnitude of effect for these factors varies over time.
• We evaluated the long-term risk of dying of uveal melanoma after treatment with proton irradiation in a large hospital-based cohort.
• Although risk is low, patients continue to die of melanoma more than 20 years after treatment.
• Less frequent monitoring of patients surviving 10 or more years after treatment may be appropriate; monitoring for life may be prudent.
• Data from this study regarding long-term risk of dying of uveal melanoma may be useful to clinicians when counseling patients.
Patients (N = 3088) with choroidal and ciliary body tumors who were subsequently treated with proton beam therapy between January 1975 and December 2005, and followed through December 31, 2008, were included in our analysis (see Table for baseline demographics and tumor characteristics). Patients who were not residents of the United States were excluded from analyses. The median follow-up time was 12.3 years (mean follow-up time, 13.4 years; shortest follow-up time, 1.0 year; longest follow-up time, 33.5 years).
Screening for metastasis, performed at the baseline evaluation, includes a physical examination, radiography, and liver function tests. If abnormalities are found, imaging studies (computed tomography, magnetic resonance imaging, or ultrasonography) are completed to further evaluate the patient's condition. A liver biopsy may be performed if the results of the imaging studies are abnormal. Liver function tests are performed every 6 months for 5 years and annually thereafter. If abnormal results are found, imaging studies and biopsy are performed as indicated.
Vital status was ascertained using several methods, including active surveillance at the MEEI and/or use of online resources (namely, the Social Security Death Index, which is a free online service that uses data provided by the Social Security Administration). Data on cause of death were also obtained through active surveillance at the MEEI and by use of the National Death Index, a federal repository that receives data from death certificates provided by state bureaus. Approximately 6% (n = 180) of patients were lost to follow-up (date of last contact prior to censor date or unable to determine cause of death).
The Kaplan-Meier method was used to calculate cumulative rates of melanoma-related mortality, and annual rates were estimated using actuarial methods. Cox regression analysis was completed to assess prognostic factors for melanoma-related metastasis to determine if influence on risk changes over time.
The MEEI intitutional review board reviewed and approved this minimal risk study, and a waiver of informed consent and Health Insurance Portability and Accountability Act authorization was granted.
Overall, 1490 of 3088 patients (48.3%) died by the end of the observation period. Fifteen years after diagnosis and treatment, the cumulative all-cause mortality rate had reached 49.0% (95% CI, 47.0-51.1). Rates continued to increase by approximately 10%, with each 5-year interval: the 20-year rate was 58.6% (95% CI, 56.4%-60.8%) and 25-year rate was 66.8% (95% CI, 64.2%-69.4%).
Of the 1490 deceased patients, 620 (41.6%) died of melanoma-related metastasis. In addition, 19 patients were alive, but their melanoma had metastasized by the end of the observation period (the mean follow-up from diagnosis of metastasis to the end of observation was 5.3 years among these patients).
Unadjusted cumulative rates of melanoma-related mortality increased very little between 15 and 25 years after proton beam irradiation, from 24.6% (95% CI, 22.8-26.4) to 26.4% (95% CI, 24.5-28.5) (Figure 1). Differences in 20-year melanoma-related mortality rates, adjusted for categories of prognostic factors that were previously evaluated by the Collaborative Ocular Melanoma Study investigators,6 were striking (Figure 2): 8.6% (95% CI, 6.2-11.9) of younger patients (≤60 years) with small tumors (≤11 mm) had died of uveal melanoma, whereas 40.1% (95% CI, 36.1-44.3) of older patients (>60 years) with large tumors (>11 mm) had died of uveal melanoma.
The highest annual rates of death from melanoma (approximately 3%-4%) were observed 3 to 6 years after proton beam irradiation. The peak rate was identified 3 years after diagnosis and treatment (3.9% [95% CI, 3.2-4.7]) and varied little through 6 years of follow-up (2.8% [95% CI, 2.2-3.6]). These rates decreased over time but did not drop below 1% until 14 years after treatment. Annual rates of melanoma-related mortality for patients with small tumors remained relatively stable at approximately 1% from 3 to 7 years after diagnosis and treatment (0.87% at 3 years to 0.93% at 7 years), and only the 5-year rate exceeded 1% (1.4% [95% CI, 0.8-2.3]). In contrast, patients with larger tumors experienced greater decreases over time; the 3-year annual rate was 5.9%, whereas the 6- and 10-year annual rates were 4.2% and 2.2%, respectively, suggesting that risk decreases over time (Figure 3). The median time from tumor diagnosis to death from metastasis was 4.8 years for patients 60 years of age or younger and 3.6 years for older patients (P < .001).
Multivariate Cox regression analysis, which included significant prognostic factors based on our previous analyses7 of outcomes after proton beam irradiation (including age at treatment, tumor pigmentation, symptoms at diagnosis, ciliary body involvement, extrascleral extension, and iris color) confirmed that the largest tumor diameter is the most important clinical predictor of melanoma-related mortality, with a 19% increase in risk associated with each 1-mm increase in size (relative risk [RR], 1.19 [95% CI, 1.16-1.23]; P < .001). The addition of tumor height to this model was not informative; height was not found to be a significant predictor of mortality in this cohort (RR, 0.99 [95% CI, 0.97-1.02]; P = .71).
To assess whether the magnitude of effect of risk factors changes over time, we developed 2 regression models defining our end point based on time of occurrence after tumor diagnosis. These analyses revealed that age at diagnosis/treatment is a strong predictor of melanoma-related mortality occurring within 3 years of diagnosis of choroidal melanoma (RR, 1.03 [95% CI, 1.02-1.04]; P < .001), but its association with deaths from melanoma that occur after 3 years is weaker (RR, 1.01 [95% CI, 1.002-1.02]; P = .01). The association between largest tumor diameter and melanoma-related mortality remains significant for both early- and late-occurring deaths: for melanoma-related deaths occurring within 3 years of primary diagnosis, the RR is 1.21 (95% CI, 1.15-1.27) (P < .001), and for melanoma-related deaths occurring after 3 years of the primary diagnosis, the RR is 1.21 (95% CI, 1.17-1.25) (P < .001).
The cumulative melanoma-related mortality rate is approaching 27% at 25 years after proton beam therapy and 50% at 25 years after enucleation.1 It is difficult to explain this strikingly large difference in very long-term mortality when reported rates at 5 or 10 years after enucleation or radiation are quite similar.8-12 One possible explanation is that more patients with certain characteristics that increase risk (eg, larger tumors) may have been treated with enucleation than with radiotherapy but the data are not available to evaluate this. A similar rate in the high-risk score group at MEEI supports this explanation, but it is unclear why these differences in mortality associated with uveal melanoma are not observed throughout the entire follow-up period. The 12-year rate of melanoma-related mortality among older patients (≥60 years) with large tumors (largest basal diameter ≥11 mm) treated by plaque radiotherapy in the Collaborative Ocular Melanoma Study6 was approximately 30%, consistent with our findings.
Both published studies1,2 of very long-term follow-up after enucleation included only patients with 20 years2 or 25 years1 of follow-up. In contrast, our analyses included all patients treated during a 30-year period. Although the mean follow-up was 12.3 years (interquartile range, 6.6-19.8 years) among living patients, including patients who were treated as recently as 3 years before the end of follow-up (censor date) may have skewed our results toward the observed lower rates of mortality from uveal melanoma. We therefore completed a subgroup analysis of our cohort, including only those individuals who could have had 20 years of follow-up (ie, the 1107 patients treated through December 1988). The 25-year melanoma-related mortality rate was 30.4% (95% CI, 27.6-33.5), somewhat higher than that of our larger cohort but lower than the rates reported after enucleation. Prognostic factors relating to tumor size in our subgroup analysis were similar to those reported by Kujala et al.2 Largest tumor diameter was significantly associated with melanoma-related mortality in all models, whereas tumor height was not significantly associated with risk in multivariate analysis.
There were several factors that we did not evaluate in our study. Specifically, radiation dose, tumor recurrence, and treatment for metastasis were not evaluated. Tumor recurrence is a well-established risk factor portending poor prognosis. Our study was not designed to assess recurrences, so the effect that recurrences may have on the long-term mortality findings described here are unknown. However, tumor recurrences after proton beam therapy are quite low,7,13 and late-occurring recurrences are rare,13,14 suggesting that the effect of this outcome on long-term melanoma-related mortality is minimal.
Likewise, we feel it is unlikely that radiation dose effects melanoma-related mortality. Previous findings of a randomized clinical trial of standard dose (70 Gy) vs lower dose (50 Gy) proton irradiation did not reveal differences in metastasis or tumor regrowth between the 2 dose groups.15 In addition, the vast majority of patients in this cohort (86.9%) received the standard radiation dose.
Although we did not assess the effects of treatment for metastatic disease, the results of an earlier study16 by our group did not provide evidence that treatment for metastasis reduces melanoma-related mortality. There was no advantage to early treatment (ie, treatment that was initiated for patients who received a diagnosis before symptoms had developed [presumably "early" treatment] compared with patients who received a diagnosis and were treated after developing symptoms ["late" treatment]).16
Underascertainment of patients who were alive with metastasis at the end of our study period is possible. However, we do not feel that the potential of underreporting this group has meaningful implications for the primary goal of our study, which was to determine the long-term risk of dying of uveal melanoma. Given the short survival time between metastasis diagnosis and death, it is likely that any cases of undetected incident metastasis were captured during the observation period as deaths from melanoma metastasis.
Of greater concern is underascertainment of the primary end point (ie, the incidence of melanoma-related mortality in our cohort). We prospectively followed up with patients after their entry into the Melanoma Registry for a number of outcomes that were captured at regular follow-up visits to monitor the tumor. When these active surveillance efforts were unsuccessful, we used a 2-step process to determine deaths and cause of death. The Social Security Death Index was used to determine deaths, matching the records in the Index by personal identifiers such as social security number, name, date of birth, and residence, or a combination of these. A list of the deceased patients identified in this way were then submitted to the National Death Index to determine cause of death. Although complete ascertainment using these indexes cannot be guaranteed, high rates of identification of decedents have been demonstrated,17-19 and comparisons of causes of death between the National Death Index and other sources reveal high rates of agreement.19
Patients continue to be at risk of death from melanoma more than 20 years after treatment, with the last observed death in this series occurring over 22 years after irradiation. Annual rates of death from melanoma decrease after 6 years but remain 1% or greater until 14 years after irradiation. A total of 216 patients (7.0%) in our cohort died of uveal melanoma between 6 and 14 years after initial diagnosis and treatment, with an additional 18 deaths occurring after 14 years. Given this low risk of death, less frequent monitoring of patients 10 to 15 years after treatment may be appropriate. Patients are at greater risk of dying of nonmelanoma causes if they survive 10 years or more after the diagnosis and treatment of the tumor, with all-cause mortality increasing almost 10% during each 5-year interval. In contrast, melanoma-related rates increase approximately 1% during the same time periods. Nevertheless, it seems prudent to monitor patients for life because new treatments for metastatic melanoma continue to emerge and to be evaluated in clinical trials.
Submitted for Publication: October 8, 2014; final revision received February 21, 2015; accepted March 1, 2015.
Corresponding Author: Evangelos S. Gragoudas, MD, Retina Service, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114 (email@example.com).
Published Online: April 23, 2015. doi:10.1001/jamaophthalmol.2015.0887.
Author Contributions: Ms Lane had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Lane, Gragoudas.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Lane, Gragoudas.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Lane.
Obtained funding: Gragoudas.
Administrative, technical, or material support: Gragoudas.
Study supervision: Gragoudas.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and Dr Gragoudas reports having been an advisor to Aura Biosciences and MPM Capital; having received royalties from QLT Phototherapeutics Inc; and having been a consultant for Ocata Therapeutics (formerly known as Advanced Cell Technology Inc). All of these financial activities were outside the submitted work. No other disclosures were reported.
Funding/Support: The MEEI Melanoma Research Fund provided financial support only.
Role of the Funder/Sponsor: The MEEI Melanoma Research Fund had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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Elisabeth Higgins Null
The Fight for Equality in Mississippi's Delta Schools Continues
For many of today's young people, the civil rights movement has been relegated to America's mythic past. Though they celebrate the toppling of segregation's...
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Rebuilt as a cyborg powered by baby food and justice, RoboCop brutally steamrolls his way through the criminal underworld while all manner of stomach-roiling gore explodes around him. A rapist gets shot in the penis, a man gets mulched into wet, quivering pieces by the artillery cannons of an evil walking tank, and Miguel Ferrer snorts lines of cocaine off of two sets of prostitute breasts before getting his kneecaps blasted apart and then blown up with a grenade.
In short, it is one of the finest motion pictures ever made.
The Kid-Friendly Adaptation:
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MGM Animation
With a green scarf, obviously, to keep his snow warm.
And here he is going undercover in a Carmen Sandiego hat, disappearing so completely into his disguise that we almost didn't recognize him.
MGM Animation
"You're not a cop, right? Because if you're a cop, you gotta say you're a cop."