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Intracranial extension of Schneiderian inverted papilloma: a case report and literature review
Intrakranielle Ausbreitung des invertierten Papilloms: Fallvorstellung und Literaturübersicht
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|11. Januar 2012
|18. Juni 2012
Inverted papilloma is an uncommon primary nasal tumor. Despite its benign nature, this tumor represents three typical characteristics: a high propensity of recurrence, local aggressiveness and association with malignancy. Inverted papilloma can reduce the patient's quality of life due to compromised nasal function, extension to the orbit and brain. The authors reported the unusual case of a 72-year-old male patient with inverted papilloma, which fatally extended to the intracranial temporal fossa after multiple recurrences. To the authors' knowledge, this is the twelfth case in the literature of inverted papilla extending into the temporal fossa. The current and pertinent literature in English, French and German was reviewed, and an algorithm for managing inverted papilloma was also proposed.
Innerhalb der Tumoren der Nasenhaupt- und Nasennebenhöhlen sind invertierte Papillome vergleichsweise seltene Neubildungen. Trotz ihrer benignen Natur weist diese Tumorentität drei wesentliche Besonderheiten auf: die ausgesprochene Rezidivfreudigkeit, das lokal aggressiv-infiltrative Wachstum und das beträchtliche Potential zur malignen Entartung. Invertierte Papillome können Symptome im Bereich der Nasen- und Nasennebenhöhlen verursachen, aber auch Orbita und Schädelbasis infiltrieren. Berichtet wird über den ungewöhnlichen Fall eines 72-jährigen männlichen Patienten mit invertiertem Papillom, bei welchem es nach multiplen Rezidiven durch Schädelbasisarrosion und -infiltration zu einem fatalen Ausgang kam. Nach Kenntnis der Autoren handelt es sich um den bisher zwölften publizierten Fall einer solchen Tumorausbreitung.
Neben einer aktuellen Literaturübersicht, die englisch-, französisch- und deutschsprachige Publikationen einschließt, wird außerdem ein Therapiealgorithmus vorgeschlagen.
The World Health Organization (WHO) defined Schneiderian papillomas as a benign epithelial neoplasia composed of well-differentiated columnar or ciliated respiratory epithelium with various degree of squamous differentiation [1], [2]. These tumors arise from the Schneiderian membrane that lines the nasal cavity and paranasal sinuses. This membrane is derived from ectoderm of the nasal placode and suffers from many structural changes, predisposing neoplastic differentiation. Schneiderian papillomas can be classified in descending order of frequency into 3 types: exophytic (everted or fungiform), inverted, and oncocytic (columnar or cylindrical) [1], [2], [3], [4], [5], [6], [7], [8], [9].
Inverted papilloma (IP) is an uncommon lesion that accounts for 0.5–4% of all primary nasal tumors. It affects all ages, most commonly white males in the fifth to the seventh decades of life (average age, 53 years). There is a strong male predominance of 3:1 to 5:1. The most frequent sites are the lateral nasal wall near the middle turbinate or ethmoid recesses and the maxillary sinuses. The nasal septum, frontal and sphenoid sinuses are rarely affected. The tumor may extend beyond the nasal fossa and paranasal sinuses into the nasopharynx, pterygoid fossa, nasolacrimal duct, retrobulbar region and brain in descending order of frequency. Despite being benign, 3 typical characteristics of this tumor include its relatively high recurrence rate, local aggressiveness and potential for malignant transformation: atypia, dysplasia, carcinoma in situ, and frank squamous cell carcinoma (SCC) [1], [2], [3], [4], [5], [7], [8], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28].
The aims of this article were (1) to report a case of IP with multiple recurrences and fatal extension into the intracranial temporal fossa; (2) to review the current and pertinent literature in English, French and German; and (3) to establish an algorithm for managing sinonasal IP lesions.
Case report
A 72-year-old German man was referred to our craniomaxillofacial plastic surgical department. He reported a few-month history of left-sided facial pain and pressure, retrobulbar headache, nasal fullness, purulent nasal discharge, posterior nasal drip, epiphora and proptosis. The patient was otherwise healthy, with the exception of senile dementia. He stayed in a nursing home for the elderly. His caregiver denied history of tobacco smoking, alcohol consumption and allergy of the patient. Over the past 12 years, the patient received 2 endonasal resections with radiotherapy and one tumor extirpation for nasal lesions at the same location at otolaryngology clinics elsewhere. Histopathological diagnosis of the first operation was unspecific inflammation of the nasal mucosa, while the pathological diagnosis of the other 2 surgeries was IP.
Clinical examination, anterior rhinoscopy and endoscopy revealed purulent secretions and a papilloma-like tumor occupying and obstructing the entire left nasal cavity, and proptosis of the left eye. There was no diplopia, cranial nerve palsy nor palpable cervical lymphadenopathy. Since recurrent IP was suspected, the patient was elected to computed tomogram (CT) of the head and neck area, which showed a heterogeneous opacification of an expansile mass in the left nose and the ethmoid sinus. The medial orbital wall, the anterior wall of the sphenoid sinus and the roof of the left ethmoid sinus were eroded with protrusion of the mass to the left orbit. Nasal septal perforation due to prior endonasal resections was also observed (Figure 1 [Fig. 1] and Figure 2 [Fig. 2]).
Under general anesthesia, the patient underwent an extensive resection with orbital preservation via a left lateral rhinotomy approach. There was no contamination of the cerebrospinal fluid (CSF) during the surgery. Histopathological examination of the resected specimens confirmed the diagnosis of IP without evidence of malignancy (Figure 3 [Fig. 3]).
Our patient was hospitalized for a week after the surgery and recovered well postoperatively. Two weeks later, he regained a well formed naso-orbital area with minor deformity. The patient remained disease-free after one year before loss to the follow up. Two years after the resection from our institution, the nursing home reported us about the patient's acute neurological deterioration and death of disease with no response to treatment at the nursing home. The autopsy result showed tumor extension to the intracranial temporal fossa without malignant changes of the tumor. There was no attempt to do postmortem imaging for scientific purposes.
The patient's family gave the written consent before our chart reviewing. The requirement for ethical approval was waived by the institutional research ethics committee.
Discussion and literature review
To date, the etiology of IP remains unknown. Many factors may cause IP, including allergy, chronic rhinosinusitis, proliferation of nasal polyps, human papilloma virus (HPV) 6/11 and 16/18, environmental agents, carcinogens, tobacco smoking, hepatocyte growth factor (HGF) and its receptor, c-Met, as well as several enzymes, such as metalloproteinase-9 (MMP-9) [2], [4], [5], [8], [9], [10], [11], [13], [15], [22], [23], [24], [29], [30], [31].
Based on the "hit-and-run" mechanism in the oncogenesis of Schneiderian papillomas by HPV, sinonasal HPV 6/11 infection occurs in an early event during the multistep tumorigenesis process. Types of the papillomas depend on locations of the infection: HPV infection of nasal septal mucosa in exophytic papilloma, and HPV infection of the lateral nasal wall and/or paranasal sinus mucosa in IP. For unknown reasons, IP epithelium tends to be nonkeratinized. Hence, viral replication and reinfection rarely or never occur. As the superficial epithelial cells are shed, HPV can be lost from the lesion. This partly explains why HPV 6/11 infection rate in IP is lower than in exophytic papilloma. The progression of IP to dysplasia and malignancy results from (1) secondary infection of HPV 16/18, (2) loss of tumor suppressor genes, (3) integration of HPV 6/11 and/or HPV 16/18, or (4) a combination of these 3 factors [31]. It is possible that the development of carcinomas in IP is heralded by a reduced cellular apoptosis, which is triggered by HPV infection [32]. In addition to HPV, studies have showed that p21 and p53, probably coupled with epidermal growth factor receptor (EGFR; ErbB-1), transforming growth factor alpha (TGF-α), desmoglein 3, and the muscle segment homeobox gene Msx2, are predictive of malignant transformation [1], [4], [5], [9], [11], [13], [20], [26], [31]. The role of HPV in the pathogenesis of IP was extensively reviewed by Lawson et al. [31].
Differential diagnosis
While inflammatory nasal polyps are typically bilateral, most IP lesions are unilateral at diagnosis [7], [16], [33]. Small IP lesions are usually asymptomatic and detected incidentally on radiographic imaging performed for nonrhinologic purposes. When the tumor reaches a grotesque size, it can cause nasal congestion, posterior nasal drip, epistaxis, hyposmia or anosmia, frontal headaches, epiphora, proptosis, diplopia, facial numbness and swelling. Pain and epistaxis associated with IP are rare, but they may indicate secondary infection or malignant changes of the lesion [2], [3], [4], [5], [14], [15], [20], [21]. These symptoms overlap with a myriad of other conditions, such as allergy, chronic rhinosinusitis and migraine [14]. Under the endoscopic view, the tumor is often seen as one or more polypoid masses with multiple digitations and a papillary surface located laterally to the middle turbinate [5].
Differential diagnosis of IP includes antral choanal polyp, nasal cavity squamous polyp, allergic fungal sinusitis, fibrous dysplasia, giant cell granuloma, juvenile angiofibroma, nasal glioma, meningoencephalocele, mucocele, mucus retention cyst, Tornwaldt's cyst, grossly enlarged adenoids, SCC, lymphoma, adenocarcinoma and esthesioneuroblastoma [5], [8], [21], [34]. It is generally accepted that unilateral tumor localization involving the lateral nasal wall and the middle meatus is a diagnostic clue to IP. However, even experienced head and neck radiologists also have difficulty in diagnosing IP without a histopathological report because of the absence of pathognomonic radiographic appearance of this tumor [14], [16], [19], [20].
Radiological aspects
Radiographic features of IP depend on the extent of disease. Early lesions appear as soft-tissue density masses, which are heterogeneously enhanced with contrast on CT, within the nasal cavity and/or paranasal sinuses. With progression, the lesions increase opacification and thickening of one or more of the sinuses. Expansion and displacement of adjacent structures associated with the tumor may be observed. However, the nasal septum is usually preserved until late in the disease course. Although focal osteosclerosis is a common hyperplastic reaction to chronic rhinosinusitis, and bone erosion can be secondary to benign nasal polyposis, both focal bone sclerosis and erosion can be found in IP patients. There are 2 forms of focal hyperostosis of IP: (1) plaque-like bone thickening, often at the lateral nasal wall; and (2) cone-shaped bone thickening, commonly at the walls of paranasal sinuses or the nasal bony septum. IP and esthesioneuroblastomas are the 2 most common nasal tumors associated with intralesional calcification [2], [3], [4], [13], [14], [15], [16], [20], [26], [33].
CT of IP usually shows a mass extending from the middle meatus to the adjacent maxillary antrum, through an expanded maxillary ostium. Although CT is helpful in determining tumor location and extension, it cannot differentiate tumor from inflammatory changes or diseases within the sinus, such as retained secretion, entrapped debris and scar tissue. Hence, tumor size and extension are often overestimated, leading potentially to overtreatment and increased subsequent morbidity. Administration of corticosteroid and antibiotics prior to CT imaging can reduce the inflammatory polyps and thereby decreases overestimation of the lesion. Alternatively, this drawback can be resolved by using magnetic resonance imaging (MRI): either T2-weighted images or T1-weighted images with contrast or both [4], [5], [6], [7], [15], [16], [19], [21], [29], [33], [35].
IP is hypodense to isodense on T1-weighted images and isodense to hyperdense on T2-weighted images. T2-weighted MRI can distinguish IP (low to intermediate signal intensity with heterogeneous enhancement throughout the tumor post-gadolinium) from inflammatory tissue and inspissated mucus (bright signal intensity due to high water content). On MRI, IP lesions frequently present a convoluted cerebriform or columnar pattern or a septate-striated appearance. However, T2-weighted MRI cannot differentiate between postoperative scarring and a recurrent tumor. Moreover, destruction of sinus walls is more difficult to recognize by MRI, compared to CT. To date, there has been no adequate evidence to prove that MRI is better than CT in identifying IP preoperatively. A combination of CT and MRI is usually recommended before treatment, although its cost-effective analysis remains unclear [2], [5], [8], [14], [15], [19], [21], [26], [33].
Preoperatively, MRI is invaluable in assessing intracranial or orbital extension of the tumor, which will impact treatment decisions [2], [13]. When IP appears hypointense with/without bone erosion instead of a hyperintense, heterogeneous enhancement on MRI, it tends to have a malignant transformation [2], [33].
Pathological aspects
Classification or staging systems for IP remain unsettled [4], [5]. Recently, Cannady et al. [36] proposed the new prognostic staging system based on tumor locations/extension [36].
Microscopic findings of IP are distinctive. Literally, the name "inverted papilloma" describes an endophytic or inverted growth pattern of the epithelium into the underlying stroma rather than outward proliferation from the surface. The epithelial basement membrane is intact [9], [13], [17]. The tumor is composed mainly of hyperplastic basement membrane-enclosed epithelium into the underlying stroma. The epithelium is multilayer, up to 30 cells in thickness. The squamous or respiratory epithelium is usually mixed with mucocytes. Non-keratinizing squamous or transitional-type epithelium is the predominant cell type and frequently covered by a single layer of ciliated coloumnar epithelium. The stroma has a variable morphology, ranging from dense and fibrous to loose and myxoid with/without inflammatory infiltration. However, it lacks eosinophils, which is common in allergic polyps. Minimal nuclear atypia is frequently found together with basal and parabasal mitoses [3], [5], [9].
Only on rare occasions when IP exhibits focal surface changes similar to verruca vulgaris: focal papillary squamous epithelial hyperplasia with marked keratosis and/or parakeratosis with prominent granular cell layer and numerous koilocytes, WHO recommends that, the patient be diagnosed as 'IP with focal verrucous hyperplasia' and followed closely for possible development of verrucous carcinoma or SCC [3]. When an area of moderate to severe dysplasia or atypia and/or focal surface keratinization is found, microscopic evaluation of all specimen tissue is obligatory to avoid overlooking small foci of malignant transformation [3], [31], [33]. The most reliable criteria for carcinomatous changes include the loss of polarity, anaplasia of the cells and the lack of maturation. Squamous epithelium with marked atypia, an increased nuclear to cytoplasmic ratio, conspicuous nucleoli, atypical mitosis in the middle and upper layers, a loss of polarity, presence of dyskeratotic cells and the absence of eosinophils, is common in the malignant areas of IP [5], [9]. Conversely, benign behavior is linked to the presence of inflammatory polyp and the absence of hyper-keratosis [9]. Histopathological examination of all sinonasal polypoid specimens is mandatory since unexpected pathologies are common, especially in cases of unilateral polyps [5], [34].
There has been evidence that a combination of histopathological parameters including the presence of hyperkeratosis and squamous epithelial hyperplasia, a high mitotic index (>2 mitoses per high power field) and an absence of inflammatory polyps may be negative prognostic indicators [1], [2], [5]. However, recent studies showed no strong correlation between the degree of atypia/dysplasia or the mitotic index, and recurrence or transformation into carcinomas [11], [17], [33]. Therefore, some authors suggest treating IP with atypia or dysplasia in the same manner as in benign diseases [17].
Surgical aspects
IP is a slow-growing, locally invasive tumor that runs a benign course in most cases. However, if neglected, the persistent and infiltrative tumor can cause gross morbidity or even kill the patient by progressive spread to involve vital structures such as orbits (1–8%) or brain (0.34%) [3], [10]. Intracranial extension in the absence of malignancy is usually seen in recurrent cases especially when the lesion involves the cribriform plate, frontal sinus, fovea ethmoidalis and orbits [23], [37]. It may be due to the technical difficulties of undertaking complete resection in these anatomical areas [2], [33].
Anterior cranial fossa invasion occurs after destruction of the posterior table of the frontal sinus or the roof of the nasal cavity. Moreover, iatrogenic tumor seeding due to prior extracranial surgery can lead to intracranial and dural involvement [10]. As previously mentioned, HPV is frequently found in IP and can result in recurrence [31], [33], [37], any perioperative contamination of the CSF can spread the virus and/or tumor to the subdural space. Some authors suggest that the periorbita and dura be preserved; the tumor instead be treated with bipolar electrocautery. It is believed that preservation of the dura and orbital septum provides an effective barrier to tumor spread [2], [13].
When the dura is opened for en bloc resection or partially resected during the operation, care must be taken not to contaminate the CSF because this endangers the patient with possible diffuse tumor seeding [37]. It is therefore no surprise that once the disease transgresses the dura, the patient will have a poor prognosis [23], [37]. In the study by Vural et al. [37], 3 (25%) of 12 IP patients with intracranial invasion died with disease after an average follow-up of 9 months (range, 2–17); all of them had dural involvement. Therefore, IP approaching the anterior skull base should be aggressively treated to reduce the risk of local recurrence and intracranial invasion [37].
Until now, only 12 IP cases with extension to intracranial temporal fossa, including our patient, have been reported in the literature. It has been hypothesized that temporal bone or fossa involvement results from (1) direct extension from the sinonasal cavity via the Eustachian tube or directly through the skull base, (2) a primary middle ear involvement secondary to metaplastic changes of the middle ear mucosa, or (3) tumor seeding in extranasal regions due to surgical manipulation during sinonasal tumor removal [22], [29]. Bui et al. [11] reported a patient with IP of the nasal fossa who developed multiple recurrences in the middle ear before intracranial extension of the auricular lesion. In our case, local invasion of the lesion may cause bony destruction and give access for intracranial spread.
The treatment of choice for IP is wide excision using either an open or endoscopic approach. Rhinologic/head and neck surgeons today typically tailor their approaches, based on the extent and location of the tumor as determined preoperatively and intraoperatively, the skill and expertise of the surgeon and the available technology [2], [3], [4], [5], [6], [13], [19]. Surgical approaches used for IP resection can be categorized as followed: (1) nonendoscopic endonasal approach; (2) limited external nasal approach (e.g. Caldwell-Luc); (3) radical external nasal approach (e.g. medial maxillectomy via a lateral rhinotomy or midfacial degloving approach); (4) endonasal endoscopic approach; and (5) a combination of these approaches [2], [12].
External approaches provide good exposure and a favorable tumor control rate, but they are associated with significant morbidity and a prolonged recovery period [12], [26]. In contrast, endoscopic tools enhance illumination, magnification and angled visualization of the operative field and allow the use of powered instrumentation. This technique can be used in selected cases with a limited disease encroaching on the ethmoid sinuses, the lateral nasal wall, and the medial maxillary wall, including difficult-access locations such as the anterior or lateral wall of the maxillary sinus and the alveolar recess. Other pertinent benefits are decreased resection of healthy tissues and postoperative morbidity, such as bleeding/epistaxis, crusting, facial swelling, facial pain/neuralgia, epiphora, dacryocystitis, blepharitis, diplopia, mucocele, Eustachian tube dysfunction, CSF leak and external scarring. Moreover, endoscopic resection can be performed in an ambulatory setting and offers advantages in terms of patient comfort and health care cost [3], [4], [5], [12], [14], [15], [18], [25], [37], [38], [39], [40].
An adjunct to endoscopic resection may be considered if the extranasal component of the tumor cannot be adequately visualized endoscopically, for example, a Caldwell-Luc approach when the lateral, inferior or anterior walls of the maxillary sinus are involved; the osteoplastic frontal flap or Draf II- or III-type approaches (median drainage procedure) for the frontal sinus and/or supraorbital involvement. Temporary septotomy may be used when the tumor confines to the posterior nasal cavity and/or sphenoid sinus [6], [13], [26], [33], [37], [40]. Hence, the patient should be advised that adding or conversion to an open technique may be necessary if the endoscopic approach proves unsatisfactory during the procedure, such as limited access to the entire tumor [33], [39]. Contraindications to endoscopic excision include massive skull base erosion, dural or extensive frontal or infratemporal involvement, intraorbital extension (as seen in our patient), abundant scar tissue from previous surgery and presence of malignancy [2], [4], [15], [39].
Extensive tumors usually require a lateral rhinotomy and medial maxillectomy, which comprise the following 5 steps: (1) uncinectomy, (2) mega-antrostomy, (3) inferior turbinectomy, (4) debridement of mucosa overlying the medial maxillary wall, and (5) drilling the bony wall with a cutting or diamond burr, or osteotomizing with a chisel. This radical procedure allows en bloc resection of the lateral nasal wall, ethmoid labyrinth, and medial portion of the maxilla, which are the common tumor locations. The stalk or attachment of the tumor should be identified and completely removed along with the surrounding mucosa to reduce the risk of further recurrence [4], [5], [13], [25], [40]. It has been our experience that the Le Fort I approach to the tumor at the lateral nasal wall should be avoided because the osteotomy line may cut through the tumor or its stalk or site of attachment directly, increasing the risks of tumor spread and recurrences. Using the Caldwell-Luc approach alone provides limited surgical access and hence contributes to high recurrence rates. To avoid external scarring and morbidity, Rouge-Denker's rhinotomy, septal translocation or a midfacial degloving or sublabial vestibular approach can be used [2], [5], [10], [15]. IP affecting the anterior skull base, an aggressive form, may require a craniofacial resection [10], [37]. However, the frontal sinus should not be obliterated after removing the tumor in order to be able to assess the sinus postoperatively by endoscopy or radiography [13], [14].
Although some authors advocated the benefit of postoperative radiation for preventing tumor progression or recurrence in aggressive IP, side effects of radiotherapy should not be underestimated. The patients may suffer from radiation retinopathy, glaucoma, radiation-induced cataract or central retinal artery obstruction [41]. Radiation to the anterior cranial fossa can cause radiation-induced encephalomalacia and frontal lobe dysfunction [10]. Adjuvant radiotherapy with or without chemotherapy, therefore, reserves only for patients with multiple recurrences, unoperatable or incompletely resectable tumors or those associated with malignancy [2], [4], [8], [9], [11], [17], [22], [23], [33]. Radiation techniques and dose fractionation schedules for patients with IP-associated malignancy follow those for carcinomas of the nasal cavity and paranasal sinuses [4]. As with other cancer patients, the treatment plan should be decided by the interdisciplinary tumor board/committee together with the patient [7], [33].
Multiple factors influence recurrence rates of IP, including tumor location, extent, histology, multicentricity, method of removal, primary versus secondary resection, follow up and biological variability of the tumor [17]. Recently, smoking and tumor with extranasal/sinus extension have been found to be associated with the recurrence of IP after surgical resection [33], [42]. However, most recurrences are related to incomplete tumor removal rather than to metachronous disease [5], [11], [15], [17], [26], [33], [37]. Conservative surgery (polypectomy, Caldwell-Luc or simple excision) yields 67–78% recurrences, while recurrence rates are 0–14% after a lateral rhinotomy and medial maxillectomy or midfacial degloving [5]. Hence, there is general consensus that IP is best managed and controlled by radical resection. Intraoperative frozen section should be performed when feasible, to ensure adequate tumor resection with tumor-free margins [25]. Parallel with this, the risk of malignant transformation in metachronous lesions can be reduced when complete excision is accomplished [1].
Although many initial IP lesions are unifocal, inadequate tumor removal promotes multifocality [18]. A unilateral mass with a lobulated pattern is a common radiographic feature of tumor recurrence [19]. Recurrence occurring despite radical resection may result from the multicentric nature of the papilloma [17]. Most recurrences occur at the margins of previous surgical resections within the first few years of therapy, but 17% of the patients have late recurrences after 5 years [1], [3], [8], [9], [10], [17], [23], [37]. Hence, the patients should be followed up for at least 6 years [8], [35]. Careful endoscopic follow-up examination, including nasal endoscopy and biopsy of suspected areas, and serial CT scans/MRI postoperatively would help detect early recurrence and allow timely intervention [10], [15], [23]. Many authors recommend MRI as the best follow-up imaging because it is more sensitive and specific in differentiating soft tissue mass from underlying inflammation and other postoperative changes such as scar tissue, and because of no radiation risk [29], [33].
Based on the current literature and our experience, we established an algorithm for managing sinonasal IP (Figure 4 [Fig. 4]).
This case report presents an IP case with fatal extension to the temporal fossa. This is a typical case of intracranial spread of IP after multiple recurrences. Although IP is benign, it reduces the patient's quality of life due to compromised nasal function, extension to the orbit and brain [6]. Three typical characteristics of IP include a high propensity of recurrence, local aggressiveness and association with malignancy. Hence, this benign tumor requires radical surgery. Strict attention must be paid to identifying the site of tumor attachment and aggressive resection of a margin of mucosa and bone at this location [13]. Any tumor attached to periorbita or dura should be dealt with by bipolar electrocautery rather than by excision of the dura or periorbita because they provide an effective barrier to tumor spread [2], [13]. Long-term follow up of the patients is also mandatory, as disease can be quite extensive before it becomes symptomatic [17].
Competing interests
The authors declare that they have no competing interests.
The authors thank Dr. Popchai Ngamskulrungroj MD, PhD, for his help with the literature search.
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- Salima K, Anissa S, Samah T, Ines C, Najeh B, Samia S, Ghazi B. Le papillome inversé dégénéré des fosses nasales [Malignant degeneration of an inverted papilloma of the nasal cavity]. Tunis Med. 2010 May;88(5):369-70.
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- Bathma S, Harvinder S, Philip R, Rosalind S, Gurdeep S. Endoscopic management of sinonasal inverted papilloma. Med J Malaysia. 2011;66(1):15-8.
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- Carta F, Verillaud B, Herman P. Role of endoscopic approach in the management of inverted papilloma. Curr Opin Otolaryngol Head Neck Surg. 2011 Feb;19(1):21-4. DOI: 10.1097/MOO.0b013e3283425213
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- Kim K, Kim D, Koo Y, Kim CH, Choi EC, Lee JG, Yoon JH. Sinonasal carcinoma associated with inverted papilloma: a report of 16 cases. J Craniomaxillofac Surg. 2012 Jun;40(4):e125-9. DOI: 10.1016/j.jcms.2011.07.007
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- Dominas N, Sandalcioglu E, Lang S, Mattheis S. Invertiertes Papillom der Nasennebenhöhlen mit intrakranieller Beteiligung [Inverted papilloma of the paranasal sinuses with intracranial extension]. Laryngorhinootologie. 2011 Jun;90(6):371-2. DOI: 10.1055/s-0031-1275306
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- Shen J, Baik F, Mafee MF, Peterson M, Nguyen QT. Inverting papilloma of the temporal bone: case report and meta-analysis of risk factors. Otol Neurotol. 2011 Sep;32(7):1124-33. DOI: 10.1097/MAO.0b013e31822a2b16
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- Poomsawat S, Punyasingh J, Vejchapipat P, Larbcharoensub N. Co-expression of hepatocyte growth factor and c-met in epithelial odontogenic tumors. Acta Histochem. 2012 Jul;114(4):400-5. DOI: 10.1016/j.acthis.2011.07.010
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- Lawson W, Schlecht NF, Brandwein-Gensler M. The role of the human papillomavirus in the pathogenesis of Schneiderian inverted papillomas: an analytic overview of the evidence. Head Neck Pathol. 2008 Jun;2(2):49-59. DOI: 10.1007/s12105-008-0048-3
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- Tanvetyanon T, Qin D, Padhya T, Kapoor R, McCaffrey J, Trotti A. Survival outcomes of squamous cell carcinoma arising from sinonasal inverted papilloma: report of 6 cases with systematic review and pooled analysis. Am J Otolaryngol. 2009 Jan-Feb;30(1):38-43. DOI: 10.1016/j.amjoto.2008.02.005
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- Jankowski R, Coste A, Verdalle P. Papillome inversé rhinosinusien [Inverted nasosinusal papilloma]. Ann Otolaryngol Chir Cervicofac. 2008 Sep;125(4):224-33. DOI: 10.1016/j.aorl.2008.07.004
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- Yaman H, Alkan N, Yilmaz S, Koc S, Belada A. Is routine histopathological analysis of nasal polyposis specimens necessary? Eur Arch Otorhinolaryngol. 2011 Jul;268(7):1013-5. DOI: 10.1007/s00405-011-1534-x
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- Delank KW. Die endonasale Resektion inverser Papillome der Nasen- und Nasennebenhöhlen: "faux-pas" oder "dernier crie"? [Endonasal Resection of Sinunasal Inverted Papilloma: "faux-pas" or "dernier crie"]. Laryngorhinootologie. 2006 Sep;85(9):633-4. DOI: 10.1055/s-2006-944518
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- Cannady SB, Batra PS, Sautter NB, Roh HJ, Citardi MJ. New staging system for sinonasal inverted papilloma in the endoscopic era. Laryngoscope. 2007 Jul;117(7):1283-7. DOI: 10.1097/MLG.0b013e31803330f1
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- Vural E, Suen JY, Hanna E. Intracranial extension of inverted papilloma: An unusual and potentially fatal complication. Head Neck. 1999 Dec;21(8):703-6. DOI: 10.1002/(SICI)1097-0347(199912)21:8<703::AID-HED4>3.0.CO;2-H
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- Ridder GJ, Behringer S, Kayser G, Pfeiffer J. Malignome auf dem Boden invertierter Papillome der Nase und Nasennebenhöhlen [Malignancies arising in sinonasal inverted papillomas]. Laryngorhinootologie. 2008 Nov;87(11):783-90. DOI: 10.1055/s-2008-1077292
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- Facon F, Dessi P. Chirurgie endonasale micro-invasive: apport de l'endoscopie en chirurgie maxillo-faciale [Microinvasive endonasal surgery: contribution of endoscopy to maxillofacial surgery]. Rev Stomatol Chir Maxillofac. 2005 Sep;106(4):230-42. DOI: 10.1016/S0035-1768(05)85852-8
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- Minovi A, Kollert M, Draf W, Bockmühl U. Endonasale mikro-endoskopische Resektion invertierter Papillome der Nase und ihrer Nebenhöhlen [Endonasal micro-endoscopic resection of sinonasal inverted papilloma]. Laryngorhinootologie. 2006 Jun;85(6):421-5. DOI: 10.1055/s-2006-925059
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- Sauter A. Focal malignancy in sinonasal inverted papilloma – is postoperative radiotherapy recommendable? Oral Oncol. 2011 Sep;47(9):779.
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- Moon IJ, Lee DY, Suh MW, Han DH, Kim ST, Min YG, Lee CH, Rhee CS. Cigarette smoking increases risk of recurrence for sinonasal inverted papilloma. Am J Rhinol Allergy. 2010 Sep-Oct;24(5):325-9. DOI: 10.2500/ajra.2010.24.3510


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Possible Duplicate:
How do I install Ubuntu?
I have an older HP laptop that came with Vista. Instead of installing Win8, I installed Ubuntu as an application where it prompts for Windows or Ubuntu during the boot process.
Well, Windows has not been booting for a year... I think it was crushed by a virus. I'm happily using Ubuntu but I'm wondering if there's a way to do a fresh install of just Ubuntu and wipe the hard drive completely with this unique setup where Ubuntu is attached to Windows but I can't get into Windows?

subset: commoncrawl


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Title V
- Allocations to Local Educational Agencies - Maintains, for funding up to the FY 2002 level, requirement that States allocate at least 85 percent of their funds to LEAs based on relative enrollments in public and private schools. In addition, however, 100 percent of the funds that a State receives beyond what it received in fiscal year 2002 must be distributed to LEAs. For small States, at least 50 percent of those funds must be distributed to LEAs.
Administration - Modifies antecedent law so that States may use their entire 15 percent set-aside for administration.
School Renovation, IDEA, and technology - Adds a provision that allows SEAs to use program funds for certain activities authorized in the Department's fiscal year 2001 Appropriations Act, including urgent school renovation, activities authorized under part B of the Individuals with Disabilities Education Act (IDEA), and technology activities related to school renovation.
Other new allowable uses - Including the support of charter schools; statewide education reform, school improvement programs and technical assistance and direct grants to LEAs; yearly student assessments; implementation of State and local achievement standards; and independent analyses to measure and report on student achievement; and certain school safety programs.
Local Uses of Funds - New allowable activities include, among other things: professional development and class-size reduction activities; charter schools; community service programs; consumer, economic, and personal finance education; public school choice; programs to hire and support school nurses; school-based mental health services; alternative education programs; prekindergarten programs; academic intervention programs; programs for CPR training in schools; smaller learning communities programs; activities to advance student achievement; programs and activities that use best practice models; same-gender schools and classrooms; service-learning activities; school safety programs; programs that use research-based cognitive and perceptual development approaches and rely on a "diagnostic-prescriptive model" to improve students' learning; Title I supplemental educational services; magnet schools; dropout prevention; gifted and talented education; and parental and community involvement.
Adds new requirements that, within 120 days of enactment, the Secretary issue specific award criteria and other guidelines for LEAs planning to use program funds to provide same gender schools and classrooms.
Eliminates the FY 1998 evaluation requirement in the State application section of current law. Replaces the current-law requirement on the biennial submission of data on the use of funds, types of services provided, and students served with a requirement for an annual statewide summary of how the program is improving student achievement or improving the quality of education for students.
Adds a requirement that local applications include assurances that programs, services, and activities will be evaluated annually.
Federal to State - Funds are allocated by formula based on States' relative share of the school-age population, with each State receiving a minimum of ½ of 1 percent.
State to Local - States must allocate at least 85 percent of their funds to LEAs based on the relative enrollments in public and private schools. This formula must be adjusted, upon approval of the Secretary, to provide higher per-pupil allocations to LEAs that have the greatest numbers or percentages of children whose education imposes a higher than average cost per child, such as: 1) children living in areas with high concentrations of low-income families, 2) children from low-income families, and 3) children living in sparsely populated areas.
100 percent of the funds that a State receives beyond what it received in FY 2002 must be distributed to LEAs. For small States, at least 50 percent of those funds must be distributed to LEAs.
Federal - Up to 1 percent for the outlying areas.
State - Up to 15 percent for State administration.
Per-Pupil Facilities Aid Grants - Authorizes a new program of competitive 5-year grants to States with already established per-pupil aid programs to assist charter schools with their school facility costs. These State programs must be specified in State law and provide annual funding on a per-pupil basis for charter school facilities; the financing must include, or be dedicated solely for, the funding of facilities. Federal funds may be used to match funds for State per-pupil facility aid programs. The Federal share of funds decreases each year (from 90 percent in the first year to 20 percent in year 5) and phases out entirely after 5 years.
LEA Costs - Prohibits local educational agencies from reserving administrative fees or expenses from subgrant awards unless agreed to by the LEA and subgrantee.
Notification - Requires that applicants for the Charter Schools Grants program provide copies of applications to the State public chartering authority, if it exists.
State - Requires the authorized State public chartering agency to review and evaluate charter schools supported by the program at least once every 5 years to determine whether schools are meeting the terms of their charters and meeting or exceeding State or charter school goals for student academic achievement.
Per-Pupil Facilities Aid Programs - Requires grantees to submit an annual report on their operations and activities to the Secretary.
Authorization of Appropriations - Authorizes the first $200 million for the regular Charter School Grant program and the next $100 million for the Per-Pupil Facilities grants. At appropriations levels above $300 million, funds are evenly divided between the two programs.
Charter Schools Program - Competitive grants to SEAs that have the authority, under the law, to approve charter schools. SEAs, in turn, make competitive grants to charter schools. If an SEA chooses not to compete, charter schools in the State may apply directly to the Secretary.
Per-Pupil Facilities Aid Program - Competitive awards to SEAs that, in turn, make formula grants to charter schools on a per-pupil basis.
Federal - 5 percent of the Charter School Grants funds or $5 million, whichever is greater (but not more than $8 million), for national activities including evaluations and technical assistance.
Charter School Grants - Up to 5 percent of the funds may be used for administrative expenses; up to 10 percent for a revolving loan fund; and up to 10 percent for dissemination activities.
Per-Pupil Facilities Aid Programs - Up to 5 percent of the funds may be used for evaluations, technical assistance, and dissemination activities.
- One minor change to last year's language is a deletion of a requirement for "one-time" grants.
Eligible Entities - private, non-profit, organizations; governmental entities; and consortia of these two types of entities.
Use of Funds - Allows grantees to reserve one-quarter of one percent of the grant for administrative costs. The remainder of the funds must be deposited in a reserve account and be used for one or more of the following purposes:
Guaranteeing, insuring, and reinsuring bonds, notes, and other debt used to finance charter school facilities.
Guaranteeing and insuring leases of personal and real property.
Facilitating charter schools' facilities financing by identifying potential lending sources, encouraging private lending, and other similar activities.
Facilitating the issuance of bonds by charter schools, or by other public entities for the benefit of charter schools, by providing technical, administrative, and other appropriate assistance (including the recruitment of bond counsel, underwriters, and potential investors and the consolidation of multiple charter school projects within a single bond issue).
Federal - Requires the Department to submit annual reports to Congress on activities conducted under this program.
Grant recipients - Requires grantees to submit annual financial and progress reports to the Department. Permits the Department to revoke funds in the event of inadequate progress.
Federal - Awarded competitively to eligible entities. Requires the Department to award at least three grants (unless Funding is insufficient), with at least one grant each to the three types of eligible entities as long as the Department receives applications of sufficient quality from each type of entity.
Grant recipients - Grant recipients identify charter schools to benefit from leveraged grant funds.
Eligible Entities - SEAs, LEAs, or partnerships that include at least one SEA or LEA working in cooperation with public, for-profit, or non-profit entities.
Use of Funds - Authorizes grantees to use program funds to: (1) plan the public school choice program; (2) make tuition transfer payments to the schools that students choose to attend; (3) increase the capacity of high-demand schools to serve greater numbers of students (except that program funds cannot be used for school construction); (4) carry out public information campaigns to inform parents and students about public school choice opportunities; and (5) pay other costs reasonably necessary to implement a public school choice program.
Transportation - Requires grantees to provide participating students with transportation, or pay transportation costs, to their school of choice.
Participation and Selection of Students - Stipulates that student participation in each program must be voluntary. Also requires that, when more students apply to participate in the program than can be accommodated, grantees must select students to participate on the basis of a lottery.
Applications - Requires that applications for program funds include descriptions of: (1) the public school choice program; (2) how and when parents will be given notice of the existence of the program; (3) how students will be selected for the program; and (4) how the program will be coordinated with other Federal and non-Federal projects.
Priorities - Requires that the Secretary give priority to projects that would: (1) provide the widest variety of choices to all students in the schools participating in the program; (2) have the greatest impact in allowing students in low-performing schools to attend higher-performing schools; and (3) implement an interdistrict public school choice program.
Federal - Requires the Secretary to evaluate: (1) the extent to which the programs funded promote educational equity and excellence; (2) the characteristics of participating students; and (3) the effect of the program on the academic achievement of students participating in the program, particularly students who move from low- to higher-performing schools, and on the overall quality of participating schools and districts.
Grantee - No specific accountability provisions.
- Federal - Competitive awards to eligible entities.
Federal - Up to 5 percent for evaluation, information dissemination, and technical assistance.
Grantee - Up to 5 percent for administrative expenses.
Innovative programs - Deletes the Magnet Schools "Innovative Programs" authority, which authorized up to 5 percent of funds for grants that involve desegregation activities in schools other than magnet schools, such as neighborhood or community schools.
Use of Funds - New allowable uses of funds include activities to: promote sustainability of the local program, such as professional development; enable schools to serve students attending a school but not enrolled in the magnet program; and design magnet schools for students in all grades. Also, increases the cap on the amount of funds that may be used for planning, from 10 percent to 15 percent in a project's third-year. (First- and second-year limits are unchanged.)
National Activities - Expands national activities to include, besides evaluation, technical assistance and dissemination activities. Requires the Secretary to collect and disseminate information on successful magnet school programs.
- Federal - Authorizes evaluations that address the extent to which magnet school programs; lead to educational quality and improvement; enhance student access to quality education; eliminate, reduce, or prevent minority group isolation; and differ from other programs in terms of the organizational characteristics and resource allocations.
- Federal to Local - Competitive grants to LEAs or consortia of LEAs with court-ordered or federally approved voluntary desegregation plans.
- Federal - Up to 2 percent for evaluation, technical assistance, and dissemination.
Innovative Programs
(Title V, Part A)
Retains, with a few changes, the previous Title VI Innovative Education State Grants program that provides flexible funds to States and LEAs for innovative educational programs.
Major Changes from Current Law
State Uses of Funds
Accountability (new requirements)
Charter Schools
(Title V, Part B, Subpart 1)
Retains, with a few changes, the Charter Schools grants program that awards grants to State educational agencies (SEAs) and charter schools to support the planning, design, and initial implementation of charter schools. The reauthorization makes only minor changes to the current program, except for adding a new authority for Per-Pupil Facilities Aid Grants.
Changes from Current Law
Allocation of Funds
Set- Asides
Credit Enhancement Initiatives to Assist Charter School Facility Acquisition, Construction, and Renovation
(Title V, Part B, Subpart 2)
Authorizes grants for innovative credit enhancement initiatives to help charter schools with the cost of acquiring, constructing, and renovating facilities. The language is almost identical to the Charter Schools Facilities Financing Demonstration program authorized in the 2001 appropriations act.
Changes from Current Law
Program Description
Voluntary Public School Choice
(Title V, Part B, Subpart 3)
Authorizes competitive awards of up to 5 years to establish or expand programs that provide students and parents with greater public school choice. Grantees may use up to one year for planning or program design.
Program Description
Magnet Schools Assistance
(Title V, Part C)
Retains the current Magnet Schools Assistance program, which provides grants to establish and operate magnet schools in local educational agencies that are under a court ordered or federally-approved voluntary desegregation plan to eliminate, reduce, or prevent minority group isolation in elementary and secondary schools. The reauthorization makes only minor changes to the current statue, except that it deletes the authority for grants for Innovative Programs.
Changes from Current Law
Allocation of Funds


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Training & Advocacy
Women on Waves provides training to organizations around the world. The aim of the training is to disseminate information about misoprostol for the use of safe abortion and safe birth as widely as possible. Misoprostol is an essential medicine that should be affordable and accessible to all women.
Training medical abortion and PAC care in DRC, South Kivu
Beginning of February 2018, in south Kivu DRC, in a region with a high number of STI and HIV infections, Women on Waves gave a five-day training in cooperation with GFV-VIH, a local organization. The training included all kinds of SRHR topics such as: medical abortion, post-abortion care Read more »
Training General Physicians in the Netherlands
Medabon the combination package mifepristone and misoprostol became available in the Netherlands in May 2015. Contrary to the other mifepristone products it was registered for distribution by regular pharmacies. This means that finally general physicians can prescribe it for the overtime treatment. Read more »
Outreach to Syrian refugee community and women in Turkey
Between 22-29 April 2015 a small delegation of Women On Waves/ Web has visited several cities in Turkey to investigate the status of Syrian women and women living in Turkey and to support them in reproductive health issues as well as to reach out to the Syrian community in Turkey to discuss matters… Read more »
Advocacy in Surinam
WoW travelled to Surinam, to give a training on the use of misoprostol for safe abortion and to discuss the possibility of a harm reduction model to provide information about misoprostol for safe abortion. Read more »
Community Training in Bangladesh
In February, August and September 2011, Marlies from Women on Waves, traveled to Rajbari in Bangladesh to give a safe abortion training to medical doctors in Rajbari, as well as healthcare providers who have no real medical training, midwives, and Traditional Birth Attendances (TBA). Read more »
Misoprostol training Tanzania 2008


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Peer-Reviewed Publications
Found 8 results[ Title]
Filters: Author is Maltese, Matthew R [Clear All Filters]
Validation of a helmet-based system to measure head impact biomechanics in ice hockey." Med Sci Sports Exerc. 2014;46(1):115-23."
Kinematic Comparison of the Hybrid III and Q-Series Pediatric ATDs to Pediatric Volunteers in Low-Speed Frontal Crashes." Ann Adv Automot Med. 2012;56:285-98."
Evaluation of the hybrid III and Q-series pediatric ATD upper neck loads as compared to pediatric volunteers in low-speed frontal crashes." Ann Biomed Eng. 2013;41(11):2381-90."
Evaluation of pediatric ATD biofidelity as compared to child volunteers in low-speed far-side oblique and lateral impacts." Traffic Inj Prev. 2014;15 Suppl 1:S206-14."
Electromyography responses of pediatric and young adult volunteers in low-speed frontal impacts." J Electromyogr Kinesiol. 2013;23(5):1206-14."
The effect of pretensioning and age on torso rollout in restrained human volunteers in far-side lateral and oblique loading." Stapp Car Crash J. 2012;56:443-67."
Comparison of kinematic responses of the head and spine for children and adults in low-speed frontal sled tests." Stapp Car Crash J. 2009;53:329-72."


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Terms and Conditions
The following are the general terms and conditions (the "Terms and Conditions") which govern the use of the content and the services provided to you via this internet site and constitute an agreement between you and Technoline Limited.
Technoline Limited (hereinafter referred to as "Technoline") is the owner and operator of the internet website available at http://www.technoline-mt.com (hereinafter referred to as the "Website"). Technoline is a limited liability company registered and validly existing under the law of Malta with its registered address at 51, Edgar Bernard Street, Gzira, Malta.
The use by you of this Website including the viewing, caching, storing or any other form of utilisation of the services or information available through the Website shall be deemed to signify your agreement to these Terms and Conditions. If you are not in agreement with the terms contained in these Terms and Conditions you are kindly solicited not to use this Website. Your use of the Website further signifies that you have the legal capacity to enter and be bound with these Terms and Conditions.
This Website offers general information about the products and services offered by Technoline. This Website also offers you the possibility of purchasing our products directly online.
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All online purchases will only be accepted against credit/debit card payment or payment by Paypal. All credit/debit card payments shall be processed by our Payment Gateway Provider. Consequently no credit/debit card information (apart from your name, surname) will be stored on our systems.
Delivery of the Goods
Whilst delivery costs of the products to Malta are included in the price, deliveries to Gozo might be subject to further delivery charges. Any applicable delivery costs will be clearly visible during checkout and you will have the right to cancel your order prior to confirmation. Any delivery costs applicable shall be due at the time of purchase of the products. Products purchased shall be delivered to the address you indicate to Technoline. Risk in the products shall pass to you upon delivery of the products. Property in the products shall pass to you only after full payment is made and there is no other sum due by you to Technoline.
Technoline will aim to deliver all products within five (5) days from payment unless you require a specific day for delivery. Once the appointment is agreed upon with you, failing to accept the goods at the predetermined time will excuse Technoline from any delivery obligations, and the products must be then collected from the Technoline showroom.
Technoline delivers products only to Malta and Gozo. No Delivery of products is made outside of Malta and Gozo.
Cancellation and Returns
Technoline will require immediate notification of any loss or damage to the products. Ensure that you thoroughly inspect the products upon receipt and notify to Technoline any loss or damage. In case that the products received are damaged or defective, Technoline shall, at its own option, replace or repair any damaged or defective products or refund you the amount you paid provided that you notify Technoline in writing of the issue encountered within 10 days from the delivery of the products. Nothing in this clause will affect your statutory rights.
You have the right to cancel your agreement of purchase at any time before the expiry of 15 days from when the goods are delivered in which case you must return the products to the Technoline showroom in good order, undamaged and in their original packaging. Returns will only be accepted during working times that is between 08:00 – 17:00 Mon to Fri (Excluding Public holidays or company shut down dates)
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The information and content provided in this Website is provided on an 'As Is' basis and Technoline makes no representation or warranty of any kind or nature, whether express or implied, in relation to the information or content contained herein including the products listed on this Website and provides no warranty regarding the merchantability or fitness for a particular purpose of the products listed beyond those specified by the manufacturer of the product. Technoline does not accept any liability for any loss, whether direct or indirect, loss of income, profit or future earnings, loss or damage to property and loss from claims by third parties arising out of the use of this Website or products purchased through this Website. Technoline provides no further warranties other than those specifically listed in these Terms and Conditions and all express, implied and statutory warranties on part of Technoline are expressly disclaimed to the fullest extent permitted by law. Nothing in this clause will affect your statutory rights.
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Technoline shall collect and process any personal data relating to you in accordance with the Data Protection Act (Chapter 440 of the Laws of Malta). The only data processed by Technoline about its customers are the details submitted by the customers namely: Name, Surname, address, email address, telephone number and details about the products purchased.
These Terms and Conditions as well as your contract of purchase for the products shall be governed by the laws of Malta and all disputes arising therefrom shall be of the exclusive jurisdiction of the courts of Malta. The invalidity or unenforceability of any part of these Terms and Conditions shall not affect the validity or enforceability of the remainder of these Terms and Conditions. No waiver by Technoline of any breach of these Terms and Conditions shall be construed as a waiver for any subsequent breach of the same or any other provision contained in these Terms and Conditions. Technoline reserves all rights, title and interest in any Intellectual Property rights contained in this Website and owned by Technoline.
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Colouring in is a great activity for kids and Kidspot has hundreds of free printables that you can print out at home and give to your child to colour in with crayons, markers and pencils. There are all kinds of themes and patterns, simply click the image to print and enjoy.
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Title Insurance on Refinance
Q. I just received my closing statements from my refinance and it looks like I had to purchase another title insurance policy. I'm pretty sure I bought one when I purchased the property, why do I have to buy another? Michael L.; Arlington, Texas
A. Title insurance protects you, the buyer, for issues that could affect the title; that occurred before you purchased the property. These could be items like liens, ownership disputes and unpaid taxes. When you acquired the property, a policy was purchased protecting you. Many times the seller pays for this policy but it's negotiable; and you bought a policy for the lender.
Yes, it seems foolish to purchase two policies covering the same thing, but you have no choice because your bank demands its own policy protection. Also, the policy you purchase for the bank is generally only for the mortgage amount, whereas the policy from the seller at closing is generally for the entire purchase price.
Now that you are refinancing, you get to buy a new policy for a new lender. Even if it is the same lender, you still get to buy a new policy. This new policy covers the period before you purchased the property, plus the time you've owned the property up until the date of refinancing, and any increased loan amount.
It used to be common – and may still be in some areas – that if you used the same title company there would be a discounted price on the policy. I haven't found these recently, but definitely call up your original title company and see if they have a reduced price for a "bring down" policy that simply updates the original one.
Lead-Based Paint
Q. I'm ready to purchase a property and I've received a disclosure that there may be lead-based paint at the property. The seller says they don't know, they're just required to alert me that there may be lead-based paint. Is this a health issue? Martha C., Brooklyn, N.Y.
A. OK, first I'm not a doctor, so as to whether it is a health issue, you'd have to do your own research and speak to a medical professional and form your own opinion on this issue. I can give you the basics on the matter and hopefully that will assist.
Many studies show that heavy metals like lead may be hazardous to one's health, particularly for infants whose brains are developing and who ingest it. Lead was a component in paint up until 1978. Before the 1960s some paint had much higher concentrations of lead. Federal law requires landlords and property sellers to disclose that lead may be present in the paint from homes built in 1978 or before.
It's estimated that about 40 percent of homes in the United States were built before 1978 and have some lead-based paint. The most common issue seems to be found in older homes that have chipped paint because the property has not been maintained and infants eat the paint. Another potential issue is when homes are renovated and walls are demolished and release dust that contains lead-based paint and isn't cleaned up before an infant inhabits the house. But in general, for the average house, the lead paint is probably sealed behind many layers of new paint during the past 35 years and probably poses little danger.
However, talk to your home inspector, do some research, consult a doctor or expert, or have the house tested for lead levels. Then you'll know the facts so you can make the appropriate decision for your family.


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The Legend of Zelda: Ocarina of Time - Bottles Locations
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CELTA and DELTA are different qualifications. If they're asking for a Bachelor degree, then the CELTA is not equivalent. Many MA programs give credits for the DELTA, but they don't recognise it as equivalent, though some scales put it on the same level. If they're looking for a degree, then it is likely that neither will do, especially in a buyer's market where there are many graduates after jobs.
English Teacher


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The humble exhaust fan doesn't usually get the attention it deserves. Exhaust fans can make the rooms they're installed in a lot more pleasant, comfortable, and healthy. The fans provide necessary ventilation to areas of the home that have none, or where additional spot ventilation is needed.
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Proper venting is important to a home's indoor air quality and to protect it against mold and mildew.
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Proper exhaust fan installation is crucial for safety reasons. Electrical wiring and correct venting require the skills of a professional electrician. Did you know that exhaust fans must be vented to the outdoors to work properly? Unfortunately, many fans are incorrectly vented to the attic or a nearby crawl space.
If your fans aren't clearing out moisture and odors like they're supposed to, improper installation may be the problem. When not vented to the outdoors, exhaust fans send the excess airborne moisture and fumes to another area of the home, which causes mold growth and lowers air quality. And failing to seal the vent pipe correctly can lead to water damage to your roof or wall. Or you may need a larger or more powerful exhaust fan replacement. A licensed electrician from Mr. Electric can guide you to the right product for your needs and do the job right, the first time.
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If you're lacking exhaust fans or yours are in disrepair, contact Mr. Electric. We're right in your neighborhood and provide a free home electrical inspection with your appointment. Call today at (844) 866-1367 or schedule an appointment online.


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Some Dude Smashed A $1 Million Bus During The San Francisco Giants Riots
And now the Internet is working to unmask him.
This photo was taken during the riots after the San Francisco Giants won the World Series.
That's a $1 million San Francisco Municipal bus that this guy is taking a fence to. He's not the only one who did some serious damage after the Giants' win, but now SFPD is trying to track him down through the Internet.


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On Friday, 27 August 2004, UNESCO Director-General Koïchiro Matsuura and Nippon Hoso Kyokai (NHK) President Katsuji Ebisawa held a public signing ceremony at NHK Headquarters in Tokyo, Japan to seal their new partnership agreement.
Through the Heritage Images Archives Initiative, NHK is offering to contribute to the documenting and safeguarding of tangible and intangible cultural heritage, and of natural heritage, in order to ensure transmission of knowledge between generations and promote cultural diversity.
In the first joint project under the partnership, NHK will produce digital, high definition short TV documentaries on heritage. In the long term, these documentaries are expected to cover all World Heritage sites, as well as all cultural expressions and spaces protected by the International Convention for the Safeguarding of the Intangible Cultural Heritage.


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VICTORIA -- Premier Christy Clark has a monumental rebuilding job ahead of her as four key members of her government have announced they won't be running in the May 2013 British Columbia election.
Critics, even supporters, agree the pending departures of the four members, including two former Liberal leadership candidates, represent serious blows to Clark's already battered Liberal government, but they are not knock-out punches.
It's now up to Clark, who has promised to shuffle her cabinet within days and bring fresh eyes to her Liberal election team, to use her highly regarded and feared political skills to bring her government back from the brink, said outgoing Liberal veteran George Abbott.
"She's a remarkable campaigner and a remarkable communicator," said Abbott, a four-term Liberal who announced he won't be running next May. "She can turn this around."
Abbott was one of the three high-profile members of the B.C. Liberal government who announced Thursday they will not be seeking re-election.
Also announcing their departures were Children's Minister Mary McNeil and three-term veteran John Les, Clark's parliamentary secretary and a former solicitor general.
The announcements come one day after Kevin Falcon announced he would not seek re-election and resigned his cabinet post as finance minister.
Clark has been battered by pundits' suggestions that her team is bailing in anticipation of a rout in next May's election, but she has instead said the departures are a normal part of politics, especially with MLAs who have spent more than a decade in the legislature.
Clark said she's taking the resignations as an opportunity for party renewal.
Chuck Strahl, former B.C. federal Conservative MP and a one-time Clark-government advisor, said the losses of Falcon, Abbott and Les are huge drains on the Liberal government's experience pool, but their losses also represent opportunities for others to surface.
"It's hard to replace that many years of experience," said the former federal aboriginal affairs minister. "But there's another dynamic that's created with a new crop of people."
Strahl said there are always turnovers in governments, especially in long-running governments like the B.C. Liberals who are seeking their fourth consecutive mandate.
"Are you really surprised John Les said that he's had enough -- he's been in public life for 30 years?" said Strahl. "The timing of it is never great because it will always be read into it that there's some nefarious thing going about."
Clark has pointed out the B.C. Liberals have endured huge bench strength losses in the past, only to find new blood and win again at the polls.
She cited the 2005 election where former finance minister Gary Collins, attorney general Geoff Plant and Clark herself, who was then children's minister, all decided to leave politics. The Liberals still won the election.
She said the Liberals also won the 2009 vote even though star cabinet minister Carole Taylor decided not to seek re-election.
So far, joining Abbott, Falcon, Les and McNeil on the Clark Liberal resignation bandwagon are Kevin Krueger, Dave Hayer, Harry Bloy, Bill Barisoff, Kash Heed and Murray Coell. Coell is the only cabinet minister among them and Barisoff is Speaker.
Former Liberal John van Dongen bolted to sit as a B.C. Conservative.
Former Liberal cabinet ministers Barry Penner and Iain Black left Clark's government earlier, and their seats were won by Opposition New Democrats in byelections last spring.
Paul Ramsey, a former NDP cabinet minister during the 1990s and a party election strategist, said the departures of Falcon and Abbott and the others would normally be viewed as normal turnovers, but since the Liberals are low in the polls and apparently losing strength, the departures are troubling.
"If the Liberals were at 40 per cent in the polls rather than 23 per cent, this would not be a big deal," he said. "Context is everything and what I see is weakness on the front bench. Inevitably the public sees it as weakness."
Opposition New Democrat Leader Adrian Dix said individuals come and go in politics, but what he's seeing is a government that is losing its way under Clark's leadership.
"Their problem is not individuals," Dix said. "The problem is the government has very little direction."
Abbott, who described himself as a political warhorse after 33 years in public life, said even though the Liberals are currently down in the public opinion polls, public opinion can change almost overnight, especially during campaigns.
"One's political fortunes can turn around very quickly; sometimes a day is a lifetime in politics," he said. "What we will see are likely younger, different MLA's having an opportunity to show what they can do."
Retired University of Victoria political scientist Norman Ruff described the recent resignation announcements by Falcon and Abbott "as a house of cards."
He said it appears that the veteran ministers did not do Clark any favours by announcing their resignations before she shuffled her cabinet.
Ruff said Clark would have shown more control over her own government if she had unveiled a new cabinet without Falcon, Abbott and McNeil prior to their announcements.
Abbott has represented the Shuswap riding since 1996, while Falcon was elected in 2001.
At his news conference Thursday, Abbott displayed the kind of dry wit and good humour he has become known for, even as he steered the province through a divisive, year-long job action by teachers.
Abbott said Thursday the legislature had become "my personal Hotel California."
He noted the 1970s-era song also includes the lines "You can check out any time you like, but you can never leave," and "I was thinking to myself this could be heaven or this could be hell."
Abbott, who had served as minister in the delicate portfolios of health and aboriginal relations, ran an uncharacteristically bitter leadership campaign which he lost to Clark last year and placed behind Falcon. Prior to politics, he was a political science instructor, berry farmer and minor hockey coach.
McNeil, who represents Vancouver-False-Creek, was first elected in 2009, but said she now wants to spend more time with her family.
"My decision comes after much discussion with my family over this summer," McNeil said in a statement.
"It was not an easy one to make as I have very much enjoyed my time in public office. The most important (factor) for me was my family, especially my thirteen wonderful grandchildren, who I know have lost out on quality time with their grandmother these past four years."
Les was elected in 2001 in Chilliwack after 16 years in municipal politics. Provincially, he served as solicitor general and small business minister under former premier Gordon Campbell. He did not sit on the front benches of Clark's cabinet.
Clark issued a statement Thursday thanking all three for their service


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This site is the archived OWASP Foundation Wiki and is no longer accepting Account Requests.
To view the new OWASP Foundation website, please visit https://owasp.org
Inner classes
From OWASP
OWASP Code Review Guide Table of Contents
Inner classes have been called "dangerous" by several Java security guidelines. However, there is no additional danger inherent in the use of inner classes that is not inherent in the use of other types of polymorphism. In general, use as little polymorphism as possible since it, by definition, it exposes data.
Java Security Researcher Tom Hawtin sums up the "danger" of inner classes in his blog at http://jroller.com/page/tackline


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FRANKFORT, Ky. – Retailer Urban Outfitters Inc. has responded to a multi-state campaign and stopped selling flasks, shot glasses and pint glasses that look like prescription pill bottles, political leaders in drug-plagued Kentucky said Wednesday.
The state's top leaders, including Gov. Steve Beshear and Republican U.S. Rep. Hal Rogers, chairman of the powerful House Appropriations Committee, had joined in a push to get the retailer to pull the items, saying they trivialized the pain and suffering of people struggling with addiction.
"I wrote a letter to the Urban Outfitters CEO shortly after learning about this abominable product line, and I'm very pleased that the store has changed course," Beshear said in a statement Wednesday. "There's nothing fashionable about prescription drug abuse, and selling teen-targeted items that glamorize prescription drugs is repulsive."
The company, which caters to teens and young adults, sent a statement to the Courier-Journal of Louisville saying it had stopped selling the items, the newspaper reported Wednesday. The company did not respond to telephone calls and emails from The Associated Press on Wednesday.
The anti-drug group The Partnership at Drugfree.org initiated the push to get the shops to stop selling the items. Political leaders and Kentucky Attorney General Jack Conway signed on last month in Kentucky, where more people now die from drug overdoses than car crashes.
Conway joined 23 of his colleagues from across the country in calling on Urban Outfitters to pull the items, which he said "make light of an epidemic that kills more than 1,000 Kentuckians each year and is responsible for more deaths than heroin and cocaine combined."
Conway said prescription drugs are now the leading cause of accidental death in the United States, and he said too many teens are experimenting with them, believing that they're safer than street drugs.
"Urban Outfitters is doing the right thing by removing these tasteless products that make light of an epidemic that kills thousands of people each month in the United States," said Conway, co-chairman of the Substance Abuse Committee of the National Association of Attorneys General.


text: THE ISSUE: Superstorm Sandy is another affirmation of what scientists have been warning of. THE STAKES: Regardless of where the storm lands, we're all in ultimately in its path. It would be nice to think that once you have a 100-year storm, it'll be another 100 years before the next one comes. Or, if you have two, why then, you're off the hook for a couple of centuries. And three — that's got to be good through 2312. Right? Consider the absurdity — and ignorance — of such wishful thinking the next time someone declares that there's no reason to be fussing about climate change, or doing anything about its effects and our contribution to it. Consider, too, that storms like Hurricane Irene, Tropical Storm Lee, and Superstorm Sandy, and the havoc they've brought, one year after another, are very much in keeping with what scientists have been warning of for years — rare events becoming more and more common. Last February researchers at MIT and Princeton released findings that climate change likely means that what we now dub 100-year storms could more likely come every three to 20 years. Even more devastating 500-year storms could be expected to show up from 25 to 240 years apart. Maybe now some slow-to-the-game politicians are getting it, as Superstorm Sandy's last winds and rains fade and its toll comes more into focus. Seventy-two people dead in the United States alone. More than 8 million homes without power at one point. Homes, parks and beaches washed away in two states. Air traffic halted. New York City's subway system stopped. Two Manhattan hospitals evacuated because emergency backup systems failed. People in high rises without elevator service. The New York Stock Exchange down for two straight days, the first time since 1888. The cost? Some early estimates put the damage at $20 billion. Lost business could mean another $10 billion to $30 billion more. It's against that cost, and the likelihood that we'll be paying such multi-billion dollar tabs with increasing frequency in coming years, that we need to weigh the undoubtedly lower but still steep price tag for protecting lives and property against future storms. What more needs to be done to ensure that hospitals have their disaster readiness plans and equipment in place? Should New York City put floodgates on its sewers and subways, or build a seawall to withstand the surge from storms like Sandy? Should vulnerable upstate communities do more to prepare against the kind of rising streams that all but wiped out some of them in 2011? How quickly should such large public projects be done? How would we pay for them? And how, for that matter, do you plan for changes scientists are still coming to understand? It's encouraging that Gov. Andrew Cuomo acknowledges that, for all practical purposes, "there's no such thing as a 100-year flood" anymore, and that there's a "longer conversation" about this overdue. We need, first, for government and citizens alike on the same page that science and nature already are. And that goes double for a Congress whose ranks include committed deniers of science. Armed with plenty of money from the oil and coal industries, and with rhetorical support from virtually every leading candidate for the 2012 Republican presidential nomination, they're determined to block any effort to reduce what nearly all scientists agree is human beings' contribution to global warming. Maybe a brisk October flood with a price tag in the tens of billions will be the splash of cold water they need to come to their senses. Next, then, would come a discussion about what's necessary to protect the lives and property that would otherwise be lost, whether or not they're willing to open their eyes to it. More Information To comment: firstname.lastname@example.com or at http://blogs.timesunion.com/opinion See MoreCollapse


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Now let's build the Setsugen 2 on the HD6870. The installation is quite straight forward but fiddly especially when fixing the screws. You can't see the holes where the screws must go in because the scews are going through the back of the card. This is the only problem mounting the Setsugen 2. As usual make sure all chips are clean before strapping the heatsinks with adhesive pads - press them properly and give it an hour before installing the cooler. When you are done, the card should look like this:
For our first tests we used the fan that came in the package. The new fan-mounting clips are much easier to use compared to the previous Setsugen. Any 12mm fan will fit. If you decide to use a standard 25mm fan, you need to use cable straps and the card will exceed the two-slot design.
On the backside you see the screws which gave us some headaches. The mouting plate is coated with a thin plastic cover to prevent potential short-circuiting.
Even as two slot design, the card now weights a ton less, because only the GPU plate and the heatpipes are made of cooper, while the rest is made from aluminum. The cooler weights only 435g and even with the heatsinks you should not exceed half a kilogram.
The cooler is about 5cm taller than pretty much any graphics card, so make sure your case can fit the cooler.


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Posts Tagged 'Alexis Walkenstein'
Happy Birthday Fulton J. Sheen
He was the first "Tele-Evangelist", a master of catechesis and the new evangelization, had an intense love for the Our Lady and is on his way to sainthood,. AND … he also happens to be my Holy Crush. Enter the Venerable Fulton J. Sheen. While I'd love to claim to be his biggest fan, I'd…Read More


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In response to criticism, the U.S. has drastically reduced the number of drone strikes in Pakistan and is limiting them to "high-value targets." The Associated Press reports:
The CIA has been instructed to be more cautious with its attacks, limiting them to high-value targets and dropping the practice of so-called "signature strikes" - hitting larger groups of suspected militants based purely on their behavior, such as being armed and meeting with known militants, said a current U.S. intelligence official and a former intelligence official briefed on the drone program. …
Two other senior American officials said the U.S. scaled back the number of attacks and tightened up its targeting criteria as a concession to the Pakistani army, considered the most powerful institution in the country and the final arbiter on the future of the drone program.
Read more here.
Got something to say about what you're reading? We value your feedback!


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Horse found wandering in Granby part of statewide animal abandonment investigation
GRANBY >> The horse found on Meadowbrook Road Jan. 23 is now part of an investigation, Granby Animal Control Officer Jennifer Abalan said Feb. 21.
Abalan said the circumstances of why the horse is part of an investigation are not being made public at this time, but said the horse is being well-cared for at a farm she said is in the area.
She is confident that the horse will have a happy future, no matter how the case turns out.
"We have not located the owner of the horse as of yet," said Abalan. "There is still an ongoing investigation in this matter, and we are hoping to have it resolved as soon as possible."
Abalan said once the investigation is completed, if an owner is not identified, the town will be moving forward with the process of allowing the horse to be adopted, something she believes could be a very positive thing for the horse.
"We have gotten a lot of calls and a lot of people who are interested in adopting it," said Abalan. "I am hopeful that this will have a happy ending."
Abalan said she has received more than 45 inquiries from local horse owners interested in taking the horse.
"We have a lot of farms in the community," said Abalan. "A lot of horse owners usually are open to adding another one to their barn."
The adoption process has yet to be determined, as well as a date when the horse may become available, but Abalan said a veterinarian has been checking on the horse and has determined the horse is in good health.
"Whoever did have this horse previously did make sure that she was maintained," said Abalan. "Her teeth are in good shape and she appears to be disease-free."
The horse is approximately 10 years old, Abalan said. The horse, a mare, was found Wednesday, Jan. 23 at about 3:55 p.m. on Meadowbrook Road.
After the horse was corralled by Abalan and a Granby police officer, she was put up for one evening by a farmer in the nearby vicinity. The horse was wearing a purple blanket, which had no identifying markings showing where she came from.
The horse has no microchips or other identifying marks, Abalan said. She is described as having has no other distinct markings and is 15 hands tall.
During the initial investigation, postings on Facebook and flyers have been used to find her owner. The police department has also conferred with surrounding communities that are rich in horse farms, including Southwick, Massachusetts, and Suffield.
Abalan said anyone with new information about the horse that was found should immediately call the Granby Police Department.


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Here at last! A link to the episode of BBC TV's Story of Ireland which deals with the Rebellion of 1798 and the United Irishmen.
Earlier this year, this four-part series presented by Fergal Keane took us at some speed through the history of the island of Ireland.
I posted my thoughts at the time it was transmitted (May 30th, 2011) but I'd love to know what you think.