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Article Archives
Volume 11 | Issue 11
JDD: Celebrating 10 Years of Publishing Excellence
Dr. Sherry Hsiung|No abstract details for the moment.
Melanoma-Detecting Technologiesand Standard of Care
Macrene R. Alexiades-Armenakas MD PhD|No abstract details for the moment.
No abstract details for the moment.
Original Articles
Fractional Laser Skin Resurfacing
Macrene R. Alexiades-Armenakas MD PhD,a,b Jeffrey S. Dover MD,a-c and Kenneth A. Arndt MDc-e|Laser skin resurfacing (LSR) has evolved over the past 2 decades from traditional ablative to fractional nonablative and fractional ablative resurfacing. Traditional ablative LSR was highly effective in reducing rhytides, photoaging, and acne scarring but was associated with significant side effects and complications. In contrast, nonablative LSR was very safe but failed to deliver consistent clinical improvement. Fractional LSR has achieved the middle ground; it combined the efficacy of traditional LSR with the safety of nonablative modalities. The first fractional laser was a nonablative erbium-doped yttrium aluminum garnet (Er:YAG) laser that produced microscopic columns of thermal injury in the epidermis and upper dermis. Heralding an entirely new concept of laser energy delivery, it delivered the laser beam in microarrays. It resulted in microscopic columns of treated tissue and intervening areas of untreated skin, which yielded rapid reepithelialization. Fractional delivery was quickly applied to ablative wavelengths such as carbon dioxide, Er:YAG, and yttrium scandium gallium garnet (2,790 nm), providing more significant clinical outcomes. Adjustable laser parameters, including power, pitch, dwell time, and spot density, allowed for precise determination of percent surface area, affected penetration depth, and clinical recovery time and efficacy. Fractional LSR has been a significant advance to the laser field, striking the balance between safety and efficacy.
J Drugs Dermatol. 2012;11(11):1274-1287.
Background:Over the past 10 years, radiofrequency (RF) technology has been utilized for nonablative treatments for the treatment of rhytides and skin laxity. This manuscript reviews the scientific background of collagen synthesis in vivo and in response to RF energy as well as a clinical study of 17 patients receiving a series of facial treatments with a 4-MHz monopolar RF (Pellevé,Ellman International, Inc, Oceanside, NY). Clinical methods, results, and a review of the literature for RF aesthetic treatments of the face are presented.
Methods:Seventeen patients were treated in one site with 6 total treatments scheduled as follows:1 session was performed every 15 days for 2 consecutive sessions, 1 session every month for 2 consecutive sessions, and 1 session every 2 months for 2 consecutive sessions. Both the treating physician and the patients via live viewing and comparison with baseline photographs performed assessment of results. Results are reported as averages across the 17 patients.
Results: Two weeks after the first treatment,patients noted an overall average of 25% to 30% improvement. Just before the last or sixth treatment, there was an average of 50% improvement noted by the physician, with patients ranking an average self-improvement of 48%. The treating physician rated average improvement of 46% compared with baseline,whereas the patients ranked average improvement of 30% compared with baseline at 1 year after treatment was initiated (6 months after the final treatment).Patients find this treatment to be very well tolerated, with minimal to no discomfort and no downtime or significant side effects.
Conclusions: The Pellevé 4-MHz monopolar RF device is effective, safe, and very well tolerated for treating laxity, texture, and wrinkles of the skin without complication or discomfort. Evidence in the literature supports the scientific mechanism of action of acute collagen modification and continued neocollagenesis observed with the system. In this cohort, patients maintain approximately 50% improvement on average at 6 months and a 30% to 50% improvement 1 year after beginning the treatments, 6 months after completion.
Quality-switched (QS) lasers and their applications have evolved greatly since the ruby laser's effect on tattoo ink was first reported in the 1960s. The 1983 description of selective photothermolysis explained the efficacy of QS lasers for the treatment of cutaneous pigmented lesions and tattoos and cemented their status as the gold standard for these targets. Within the past decade, the uses for QS lasers have expanded dramatically, including nonablative rejuvenation and the treatment of onychomycosis. Additional applications and refined techniques and technologies promise to maintain the stature of QS lasers as an integral part of the laser surgeon's arsenal.
J Drugs Dermatol. 2012;11(11):1296-1299.
Fractional, Nonablative Q-switched 1,064-nm Neodymium YAG Laser to Rejuvenate Photoaged Skin: A Pilot Case SeriesBackground: Scientific research in the field of energy-based and light-based procedures made it possible to develop a very new and innovative generation of lasers that combine the benefit of a nonablative and a fractional laser device, promising skin rejuvenation without harming the epidermis. With this pilot case series, we performed one of the first systematic reports evaluating efficacy and safety of the fractional, nonablative Q-switched 1,064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser device in the treatment of rhytides of the face, neck, and chest.
Methods: Seven healthy female subjects (mean ±standard deviation age, 53.8 ± 10.0 years) with visible signs of facial and neck skin aging were treated with fractional, nonablative Q-switched 1,064-nm Nd:YAG laser device (Pixel QS Nd:YAG; Alma Lasers Ltd, Caesarea, Israel). Treated areas were the face, including the periorbital and perioral regions (particularly the upper lip), neck, and chest. Treatments consisted of 3 sessions at 2- to 4-week intervals. Follow-up was performed monthly following the final treatment. The Alexiades-Armenakas Comprehensive Grading Scale of Skin Aging was employed to assess efficacy. Pain ratings were recorded by 10-point visual assessment scoring.
Results: Employing the validated, quantitative grading scale for rhytides of the face and neck, a 0.29 grade improvement, or 11.3% improvement, over baseline grade was observed in the 7-subject cohort that completed follow-up following a mean of approximately 2 treatments at approximately 1-month follow-up. No pain and rapidly resolving minimal erythema were noted in all subjects during treatment.
Conclusion: The results of this pilot case series suggest that the treatment with the fractional, nonablative Q-switched 1,064-nm Nd:YAG laser device significantly improves superficial rhytides. With its outstanding safety, it seems to be particularly suitable for the treatment of sensitive areas, such as the periorbital region, lips, neck, and chest. The Q-switched Nd:YAG laser is a facile, safe, and fast treatment for aesthetic skin rejuvenation.
J Drugs Dermatol. 2012;11(11):1300-1304.
Safety and Efficacy of a New Device Combining Radiofrequency and Low-Frequency Pulsed Electromagnetic Fields for the Treatment of Facial RhytidesBackground: A distinct trend in aesthetic medicine is the patient's demand for efficient, noninvasive treatments with no downtime. Ongoing with this, these so-called lunchtime procedures are expected to be as safe and painless as possible. A new technique based on a combination of radiofrequency (RF) and pulsed electromagnetic fields (PEMF) was recently introduced and is supposed to be effective in the treatment of facial wrinkles and virtually pain free. The objective of this study was to investigate the safety and efficacy of this technology for the treatment of facial rhytides.
Methods: Thirty-one subjects with facial wrinkles and rhytides were entered into this study. Every subject received 10 treatments of the face with a device that combines 1 MHz radiofrequency with PEMF with a flux of 15 gauss. Patients rated the pain level immediately after the treatment by using a visual analog scale (VAS) for pain. Side effects were recorded at every visit. The study's efficacy end point was evaluated by 2 blinded physicians who rated the standardized pictures from baseline and 3-month follow-up using the Fitzpatrick Wrinkle and Elastosis Scale (FWES).
Results: No unexpected adverse side effects were detected or reported for the duration of the study. Both raters recognized improvements of at least 1 grade on the FWES in 30 of 31 subjects (97%). The score decreased from 5.2 before the first treatment to 3.6 at 3 months after the last treatment. Furthermore, all patients rated the treatment to be free of pain on the VAS pain scale.
Conclusion: The results of this study show that the combination of multipolar RF with PEMF is a safe, effective, and painless approach to treat facial rhytides and is suitable to answer the demands of patients for safe treatments without pain or downtime.
J Drugs Dermatol. 2012;11(11):1306-1309.
Split-Face Comparison of Ultrapulse-Mode and Superpulse- Mode Fractionated Carbon Dioxide Lasers on Photoaged Skin
Background: Both ultrapulse-mode and superpulse-mode fractional CO2 lasers (UPCO2 and SPCO2) could be successfully used in treating photoaged skin.
Objective: This evidence-based study was intended to compare the therapeutic and adverse effects of UPCO2 and SPCO2 in treating photoaged skin in Chinese subjects.
Methods: Eighteen Chinese subjects with Fitzpatrick skin type IV were enrolled in a randomized, split-face trial. Subjects received SPCO2 on one half of the face and UPCO2 on the other half. Before and after photos, skin color, epidermal water content, sebum level, periorbital wrinkles, skin roughness, and self-esteem questionnaires were used.
Results: Global evaluation and subjects' self-esteem assessments showed a similar trend at 1-month and 3-month follow-up visits on both sides. The UPCO2 laser has a shorter downtime of 6.25±2.71 days compared with 6.41±2.67 days for SPCO2, but has a higher incidence of edema, spot bleeding, prolonged redness and postinflammatory hyperpigmentation. More subjects prefer SPCO2 treatment because of similar efficacy and fewer adverse effects.
Conclusion: The effectiveness of the SPCO2 laser in treating photoaged skin is very similar to the UPCO2 laser, with less erythema, but more crusting and longer downtime.
J Drugs Dermatol. 2012;11(11):1310-1314
Melasma is a complex multifactorial disorder whose pathogenesis is not well understood. In addition to increased pigmentation, increased vascularity associated with pigmentation is present. A variety of topical treatments targeting pigmentation are available with temporary improvement of mainly the epidermal components of melasma. Intense pulsed light (IPL) is a broadband light source that can target a wide range of cutaneous structures, including deeper pigmentation and vasculature. We describe 5 cases of persistent facial melasma treated with the IPL and a hydroquinone-based skin care system (Obagi Nu-Derm; Obagi Medical Products, Long Beach, CA), showing improvement of facial melasma pigmentation and vascularity.
J Drugs Dermatol. 2012;11(11):1316-1230.
Treatment of Sebaceous Hyperplasia With a Novel 1,720-nm Laser
Douglas Winstanley DO, Travis Blalock MD, Nancy Houghton BS, and E. Victor Ross MD|Background: Sebaceous hyperplasia is a common benign proliferation of sebaceous glands. Multiple treatment methods have been applied in the past, including electrodessication, ablative and visible light lasers, applications of acids, and photodynamic therapy. Often, however, only the superficial component of the lesion is treated, leading to rapid recurrence. It has been shown that human fat has absorption peaks at 1,210 nm and 1,720 nm. We report the first use of a novel 1,720-nm laser in the treatment of sebaceous hyperplasia in human subjects.
Methods: Four patients with sebaceous hyperplasia underwent a test spot treatment followed by 2 full treatment sessions using the 1,720-nm laser. Photos were taken before treatment, at each treatment session, and 3 months following the last treatment. Pretreatment photographs and 3-month follow-up photographs were compared to assess efficacy.
Results: Four weeks after the final treatment, 3 dermatologists blinded to the date of the photographs and uninvolved with the study evaluated the photos and scored them based on a global assessment comprised of: 1) lesion diameter, 2) lesion height, and 3) lesion color. Many of the lesions resolved almost completely after a single treatment, and no additional treatment was required. Overall, there was a reduction in the color, diameter, and height of the lesions. Crusts were noted by all patients and resolved within 10 days.
Conclusion: The use of this novel device that exploits the intrinsic selectivity of 1,720 nm achieved nearly complete clearance of sebaceous hyperplasia lesions without depressions or scarring. Complete heating of the sebaceous gland and sparing of the surrounding skin offered by this device resulted in clinically apparent improvement with a minimum of adverse effects.
J Drugs Dermatol. 2012;11(11):1323-1326.
Background: To evaluate the efficacy of a novel long-pulse alexandrite laser with contact cooling in the treatment of benign pigmented lesions.
Methods: Five patients were enrolled in the study. All patients presented with epidermal pigmented lesions on the arms, hands, chest, or legs. Patients were all female with a mean age of 59 years. At the initial evaluation, baseline pigment readings were determined with a pigment meter. Test spots were performed with escalating doses of alexandrite laser (ClearScan ALX, Sciton, Palo Alto, CA) deployed by a 7-mm spot equipped with a 30 mm x 30 mm scanner and a 10-ms pulse duration. Contact cooling was used, and temperature was maintained at 18°C to 20°C. Patients returned 4 to 7 days after test spots for evaluation for the purpose of optimizing settings. The highest settings that allowed for epidermal preservation and crusting of the hyperpigmented lesions were applied for the remainder of the treatment zones. Determinations of improvement were made by evaluation of photographs with standard settings using polarized and nonpolarized images. At each appointment, baseline pigment measurements were made to ensure there were no significant changes between treatment sessions. Two treatment sessions were performed approximately 4 weeks apart, and the final evaluation was 3 months after the final treatment.
Results: Evaluation by a panel of blind observers determined a mean improvement of approximately 30%. Darker lesions responded better than lighter lesions. So-called low-contrast lesions performed the poorest. Pain was approximately 2/10 with the use of 5% lidocaine numbing cream applied approximately 45 minutes before each procedure. Pain was most severe where there was underlying hair.
Conclusion: A long-pulse alexandrite laser equipped with contact cooling can achieve significant pigmentation improvement.
J Drugs Dermatol. 2012;11(11):1327-1330.
Clinical Evaluation of the Safety and Efficacy of a Novel Superficial and Deep Carbon Dioxide Fractional System in the Treatment of Patients With Skin of ColorFractional carbon dioxide (CO2) laser treatments have become a standard for treating a myriad of skin concerns. One of the biggest challenges facing us in this regard is treating the vast number of patients with skin of color who we encounter regularly in our practices. A novel superficial and deep CO2 ablative fractional device with both components coming from a single handpiece has been developed and is now being evaluated for patients with skin of color. In the 5 patients studied, side effects were not apparent and no postinflammatory hyperpigmentation was identified. This initial report suggests further evaluation is important to enhance our ablative fractional therapies.
J Drugs Dermatol. 2012;11(11):1331-1335.
The Optimal Filler: Immediate and Long-Term Results With Emulsified Silicone(1,000 centistokes) With Cross-Linked Hyaluronic AcidBackground: Silicone is one of the oldest and longest lasting of the dermal fillers. Microdroplet silicone injections have proven to be safe and effective. This paper describes how to obtain microdroplet silicone (1,000 centistokes) in a consistent manner, including a discussion of its efficacy and safety.
Methods and Materials: A simple, permanent method of tissue augmentation is described. U.S. Food and Drug Administration- approved liquid silicone (Silikon®) is emulsified with cross-linked hyaluronic acid through a Luer-Lok to Luer-Lok connector between two 3-cc syringes. This stable emulsion is injected through a 27G needle or through a 25G or 27G microcannula into the middermis, subcutaneous tissue, or periosteum.
Results: The results of 95 cases are described. The emulsion is most beneficial for distensible acne valleys, nasolabial folds, glabellar frown lines, augmentation of the vermilion border of the lips, and projection of the nose, cheekbones, and chin. Exterior nasal deviations and soft tissue defects are also improved. Complications are minimal and include temporary bruising, erythema, and mild edema. Any temporary small nodules are easily leveled with massage. Occasionally, it takes a repeat session at 1 month to completely elevate depressions. The resulting elevations remain stable during the 2-year follow-up period. No silicone granulomas have developed.
Conclusions: This methodology has replaced many indications for temporary, semipermanent, or permanent fillers.
J Drugs Dermatol. 2012;11(11):1336-1341.
Oxidative damage by reactive oxygen species (ROS) plays a major role in aging and carcinogenesis. Little is known about either the effects of acute ROS in necrosis and inflammation of skin or the therapeutic agents for prevention and treatment. Previously, our laboratory identified caffeine as an inhibitor of hydrogen peroxide (H2O2)-generated lipid peroxidation products in human skin fibroblasts. Here, we study effects of caffeine on acute ROS-mediated necrosis. Human skin fibroblasts were incubated with caffeine, followed by H2O2 challenge. Flow cytometry was used to analyze cell morphology, counts, apoptosis and necrosis, and ROS. We found that caffeine protects from H2O2 cell damage at lower (0.01 mM) and intermediate (0.1 mM) doses. The beneficial effects of caffeine appear to be mediated by a mechanism other than antioxidant function.
J Drugs Dermatol. 2012;11(11):1342-1346.
Impact of Clobetasol Propionate 0.05% Spray on Health-Related Quality of Life in Patients With Plaque PsoriasisPsoriasis causes significant distress and impairment in health-related quality of life (QOL) in afflicted patients. For this reason, QOL is an essential and important measure of treatment outcome in patients with the disease. Clobetasol propionate is a super-highpotent class I topical corticosteroid. The spray formulation is approved for twice-daily use for up to 4 weeks by patients 18 years and older with moderate to severe plaque psoriasis. Data collected from 2,236 patients enrolled in 5 clinical trials demonstrate consistent improvement in QOL measures using multiple instruments. In a randomized, double-blind trial in patients with scalp psoriasis, treatment with clobetasol propionate 0.05% spray produced significantly greater improvement in QOL compared with vehicle, as measured by the Scalpdex QOL instrument. In another randomized trial in patients with moderate to severe plaque psoriasis, clobetasol propionate 0.05% spray produced significantly greater reductions in mean affected body surface area and significantly greater improvements in QOL, as measured by the Dermatology Life Quality Index (DLQI), compared with a 0.05% foam formulation. When compared with calcipotriene/betamethasone dipropionate ointment, clobetasol propionate 0.05% spray produced greater rates of lesion clearance and similar improvement in QOL scores after 2 or 4 weeks of treatment. When clobetasol propionate 0.05% spray was used as monotherapy or as an add-on therapy for 4 weeks in a large, observational trial, approximately 80% of patients experienced consistent and significant improvement in QOL on 2 separate, validated QOL instruments (DLQI and the Koo-Menter Psoriasis Index). In conclusion, clobetasol propionate 0.05% spray is an efficacious and safe treatment for plaque psoriasis and produces significant improvement in QOL for affected patients.
J Drugs Dermatol. 2012;11(11):1348-1354.
Green Tea Catechins: Biologic Properties, Proposed Mechanisms of Action, and Clinical ImplicationsBotanical products, including and especially green tea leaves, have a wide range of both reputed and demonstrated health benefits and have been used medicinally for thousands of years. This paper focuses on green tea catechins, principally reviewing their known biologic properties and potential mechanisms of action (MOAs). The primary objective is to discuss the proposed antiviral, antiproliferative, and immunostimulatory activity of catechins based on strong evidence from in vitro and in vivo studies conducted to date, including two preclinical in vitro studies with sinecatechins, a proprietary mixture of catechins. This review also discusses the clinical implications of catechins for the treatment of external genital and perianal warts (EGWs) and other conditions caused by human papillomavirus (HPV). While the MOA of catechins in the treatment of EGWs and other HPV-related conditions may be related to or associated with postulated or proven antiviral and immunostimulatory activity, the precise clinical significance of the various in vitro findings remains largely unknown.
J Drugs Dermatol. 2012;11(11)e55-e60.
The Effect of Hand-Foot Skin Reaction Associated With the Multikinase Inhibitors Sorafenib and Sunitinib on Health-Related Quality of LifeIntroduction: The multikinase inhibitors sorafenib (SO) and sunitinib (SU) have shown benefit in a wide range of solid tumors. Although these agents are generally well tolerated, they may be associated with dermatologic adverse events, particularly hand-foot skin reaction (HFSR). The aim of this study is to evaluate the impact of HFSR associated with these multikinase inhibitors on patient health-related quality of life (HRQOL).
Methods: Twenty-three patients with HFSR related to SO or SU were graded using the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) Version 3.0 for clinical severity and for impact on HRQOL through completion of the patient self-administered Skindex-16 (SK-16). Clinical severity scores were compared to HRQOL assessments.
Results: Of the 23 patients with HFSR, clinical severity was grade 1 in 17.4%, grade 2 in 74%, and grade 3 in 8.6%. Median SK-16 scores were reported for symptoms (53.3), emotions (30.6), and functioning subscales (33.3). Median symptoms and emotions scores positively correlated with HFSR clinical severity grade.
Conclusions: These findings demonstrate that HFSR related to SO or SU negatively impacts HRQOL, with the symptoms domain being most significantly affected. In addition, CTCAE toxicity grading correlates with HRQOL.
J Drugs Dermatol. 2012;11(11)e61-e65.
Comparative Study of Topical 80% Trichloroacetic Acid With 35% TrichloroaceticAcid in the Treatment of the Common Wart
Fakhrozaman Pezeshkpoor MD,a Mahnaz Banihashemi MD,a Mohammad Javad Yazdanpanah MD,a Hadis Yousefzadeh,b Mohammad Sharghi MD,c Hossein Hoseinzadehd|Background: Common warts caused by the human papillomavirus (HPV) are considered to be the most common infectious skin disease. No individual treatment for common warts is effective as monotherapy in eradicating the lesions. The aim of this study is to evaluate the clinical efficacy of a 35% and an 80% trichloroacetic acid (TCA) solution in the treatment of the common wart.
Methods: In this single-blinded clinical trial, 62 eligible patients with common warts referred to the dermatology clinic of Ghaem Hospital in Mashhad, Iran. Patients were randomly divided into two groups, each treated with a TCA solution (group A, TCA 80%; group B, TCA 35%) once per week until complete clearance of the lesions or for a maximum duration of six weeks. Seven patients were excluded from the final analysis (one patient in group A and six patients in group B) for various reasons, including irregular follow-up, using physical tools such as razor blades to remove the lesion, and failure to complete treatment; and 55 patients were included in the final analysis.
Results: Improvement to treatment responses was classified as: no change (no changes in the number of warts), mild (clearing of less than 25% of warts), moderate (clearing of 25% to 75% of warts), and good (clearing of more than 75% of warts). At the end of follow-up, the clinical improvement of group A (n=30) was: 10 patients (33.3%) with a mild response, 6 patients (20%) with a moderate response, and 14 patients (46.7%) with a good response. In group B (n=25), 16 patients (64%) showed a mild response, 6 patients (24%) a moderate response, and 3 patients (12%) a good response. There was a statistically significant difference in improvement between the two treatment groups (P=.017). Improvement was greater with a higher concentration of TCA solution.
Conclusion: This study showed that a different concentration of TCA solution was an effective form of treatment for common warts. Trichloroacetic acid 80% is more effective, but this solution must be used only with careful consideration by a physician.
J Drugs Dermatol. 2012;11(11)e66-e69.
Isoconazole Nitrate vs Isoconazole Nitrate and Diflucortolone Valerate in the Treatment of Tinea Inguinalis: Results of a Multicenter Retrospective StudyBackground and Objective: Many tinea inguinalis infections are characterized by pronounced inflammatory lesions and pruritus. Therefore, a therapy with a topical corticosteroid in addition to a topical antimycotic agent might be beneficial. In this multicenter, retrospective study, we compared the mycological and clinical efficacy and tolerability of isoconazole nitrate alone vs isoconazole nitrate and diflucortolone valerate in 58 adult patients with tinea inguinalis.
Patients and Methods: Treatment duration was three weeks. The efficacy of the treatment was based on the assessment of several signs and symptoms, which were collected on a 4-point scale. All patients were examined clinically before the beginning of the treatment, one week later, two weeks later, and at the end of the treatment. Mycological examinations were performed before the beginning of the treatment and at the end of the study.
Results: Treatment results with the combination of isoconazole nitrate and diflucortolone valerate were superior regarding erythema and pruritus. Both erythema and pruritus resolved in a larger percentage of patients and more quickly. Both regimens were well tolerated. Mycological cure rates were similar in both groups of patients.
Conclusions: Combination therapy with isoconazole nitrate and diflucortolone valerate is an effective and well-tolerated regimen in adult patients with tinea inguinalis.
J Drugs Dermatol. 2012;11(11)e70-e73.
Case Reports
Urticaria After Methyl Aminolevulinate Photodynamic Therapy in a Patient With Nevoid Basal Cell Carcinoma SyndromeMethyl aminolevulinate photodynamic therapy (MAL-PDT) is utilized in several countries for the treatment of basal cell carcinoma, but allergic sensitization has been reported by the manufacturer. To the best of our knowledge, we report the first case of urticaria following MAL-PDT in a patient with nevoid basal cell carcinoma syndrome. Prophylactic use of antihistamines may allow continued use of MAL-PDT in this setting.
J Drugs Dermatol. 2012;11(11):1364-1365.
We herein report a case of psoriasis verrucosa that was successfully treated with adalimumab. A 55-year-old Japanese male had a five-year history of psoriasis vulgaris treated with topical agents. His past history included atypical psychosis treated with lithium carbonate and obesity. Despite treatment, verrucous scales developed on erythematous plaque. After treatment with adalimumab, these improved remarkably, and the patient's Psoriasis Area and Severity Index score decreased from 16.2 to 3.7.
J Drugs Dermatol. 2012;11(11)e74-e75.
Resident Rounds. Part I: Program Spotlight: Virginia Commonwealth University Health System Department of Dermatology
Resident Rounds is a section of the JDD dedicated to highlighting various dermatology departments with residency training programs. Resident Rounds includes three sections: (1) a program spotlight, highlighting pertinent information about the department and residency training program; (2) a section presenting study materials used by residents at the program; and (3) a section designed to highlight recent interesting cases seen at the institution. This issue of Resident Rounds features the Virginia Commonwealth University Health System Department of Dermatology. The editor of Resident Rounds is Omar A. Ibrahimi MD PhD. He is currently the Director of Cutaneous Laser and Cosmetic Surgery and a Mohs surgeon at the University of Connecticut. Dr. Ibrahimi is also a Visiting Scientist at the Wellman Center for Photomedicine at Massachusetts General Hospital/Harvard Medical School. If you are interested in highlighting your training program in a future issue, please contact Dr. Ibrahimi at firstname.lastname@example.com.
Early in the course of surgical education, dermatologic and plastic surgery trainees shift from theory to practice. This shift must be done cautiously so as not to cause unnecessary damage to the patient, especially when attempting to reconstruct soft tissue defects on the face. Helical rim defects present an excellent opportunity because the postauricular region provides a safe environment for novice surgeons to practice the theoretical and manual aspects of basic flap reconstruction. This paper explains key features on how to plan basic flaps based on postauricular tissues.
J Drugs Dermatol. 2012;11(11):1358-1360.
No abstract details for the moment.
No abstract details for the moment.
News, Views, & Reviews
The Role of RNA Interference in Dermatology: Current Perspectives and Future DirectionsNo abstract details for the moment.
Clinical Trial Review is a JDD department designed to provide physicians with information on drugs and devices undergoing clinical testing. It is our goal to inform the reader of the status of select drug and device studies relevant to the practice of dermatology before this information is available through standard channels. To participate in or learn more about these and additional trials, visit www.clinicaltrials.gov.
Pipeline Previews brings to you information on the newest drugs and medical products as they become available to the dermatologic community. This department may include additional information from the manufacturers, plus reports from physicians who wish to share their clinical experience with these new products. In addition, we will inform our readers about the latest drugs receiving Food and Drug Administration (FDA) approval.


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subset: commoncrawl


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Performance Transformations, Inc.
Founder of an international consulting practice specializing in transforming business performance in service industries. Practice includes consulting, keynote speaking, and publishing.
- Clients are Fortune 500 companies in the service sector, including American Express International Credit Card Division (Asia, Latin America and Europe), American Express US Centurion (Black Card) Travel, G.E. Credit Card Division, Prime Therapeutics, Fifth Third Bank, Time Warner, Daytimers.
- Recruited by CEOs and COOs to act as their trusted advisor for performance turnarounds, including the development of new operating models, performance metrics, acquisition and growth strategies, as well as customer experience, revenue, cost improvements and service enhancements.
- Developed performance metrics for the international division of American Express, aligning the focus of the line employees to SVPs and the mission of the company.
- Developed strategic operational roadmaps for American Express International, Prime Therapeutics (Blue Cross/Blue Shield) and Fifth Third Bank.
- Developed the operational strategy and executable tactics for American Express' Centurion Travel Division's new service delivery operating model.
- Author of Book:Driving Peak Sales Performance.Published by CC Press 2005


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After I saw you: What if every love story was meant to be? (video)
After I saw you is an animated film about relationships, love and meditation. On first glance, one would not notice that it's a documentary, because it's animated and rhyming. However, the film came from an autobiographical poem by Leah Pearlman, the founder of Dharma Comics.
It's amazing how this video can touch all of us, all of those who have fallen in love.
- 10 Heartwarming Sketches About Love and Romance by Zac Retz!
- Korean Artist Beautifully Captures What Real Love Truly Looks Like
- "Where there is love there is life!" -Mahatma Gandhi
- John Lennon's "Imagine", made into a beautiful comic.
- This Is Why A Good Man Will Never Cheat On You
- What Marriage Is Really Like
- Heartbreaking Facebook Post By A Man Who Has Just Found Out His Wife's Been Cheating For 10 Years
- A Man Who Just Got Divorced Wrote This Epic Marriage Advice
- My Dear Son, This is How to Treat a Woman
- 7 Basic Differences Between Loving And Being In Love With Somebody
- The Difference Between Needing, Wanting And Loving Somebody
- 10 Signs That Your Relationship Will Last
- 20 Signs That You Have Found The Love Of Your Life
- Research: Sex Could Improve Brain Function
- Sex and Aural Energy
- 16 Reasons To Have Daily Sex
- Dating Then And Now: 8 Basic Differences That Should Make You Reconsider The Way You Flirt
- What Happens When People Realize How Their Loved Ones Rate Them
- They Asked These 2 Strangers The Same Questions. You'll Be In Tears By The End
- She Sat With Many Strangers That Day, But When This Man Shows Up I Got Goosebumps
- Why Readers, Scientifically, Are The Best People To Fall In Love With
- 8 crazy symptoms of being in love
- 10 Signs Of True Love
- This Hilarious Short Animated Film Shows Exactly What Happens In Your Mind When You Meet Your Crush
- The Pain Of Being In Love With Someone You Can Never Be With
- As I Began To Love Myself – Charlie Chaplin – A Beautiful Self Love Poem
- "Where there is love there is life!" -Mahatma Gandhi
- What Albert Einstein Taught Us About Love
- Brain Scans Show The Real Impact Love Has On A Child's Brain
- What Self-Love Means: 20+ Ways to be Good to Yourself
- Research Mapping Human Emotions Shows Strong Mind Body Connection
- The Effect Of Positive Emotions On Our Health
- Social Science Says Lasting Relationships Come Down To 2 Basic Traits
- 18 Signs That You're In A Happy Relationship
- 20 Powerful Secrets to Meaningful Relationships
- Signs That Your Relationship Can Last
- 5 things you should do for yourself before getting into a relationship
- 5 Signs You're in a Toxic or Draining Relationship
- 9 Good Signs That You're In The Right Relationship
- When You're In A Good Relationship, You Learn These 10 Things
- 10 Toxic Relationships Mentally Strong People Avoid
- 10 Signs You Have Found Your Soulmate
- The Four Types Of Friends According To The Buddha
After I saw you: What if every love story was meant to be? (video) Reviewed by Unknown on 12:26 AM Rating:


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Wedding weekend was GREAT!
Just a quicky before I'm hitting the hay…the wedding weekend was GREAT! Axel and Beike both said 'YES' and are married, an amazing group of people attended a superb weekend. I'm running out of words, it was so darn special having the *honor* to be commissar of the weekend (is that the same as 'master of ceremony'??). Even was able to REALLY enjoy everything…mission accomplished!! 🙂


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Ok, after reading chapter 2 of this book, I've come to the conclusion that you and I, Twin brother, on completely different pages when it comes to this book. (Both literally, I am guessing I am still lagging a bit behind you on page count, and metaphorically.)
It seems that what I love about the book, you hate. What I find hilarious, you find frustrating. You are the Felix to my Oscar, the Lucy to your Ethel in the reading of this book. You a buttoned-up prudish frump of a reader who wants narrative sense and factual footnotes, me a zany slobbish, carefree reader who is taking the book for what it is.
Case in point: The Footnotes.
You wrote quite a stirring love poem to the art of the footnote in your previous post, and while I usually find footnotes annoying and disruptive to narrative flow I come across footnotes such as this gem on the scientific basis of nighttime:
It is not clear whether de Selby had heard this but he suggests (Garcia p. 12) that night, far from being caused by the commonly accepted theory of planetary movements, was due to accumulations of 'black air' produced by certain volcanic activities of which he does not treat in detail.
How, how I say, can you hate a footnote like that. That, my friend, is what is commonly referred to as a "hoot."
You and I tend to see eye to eye on these sorts of things (and when not eye to eye at least eye to forehead.) When last were our views last so diametrically opposed? Was it our differing levels of excitement about the cinematic potential Eat, Pray, Love. No, that doesn't quite cut it, and then it dawned on me:
Whereas, I love this fungal delicacy on everything from omelets. Alone or in a casserole. I love them. You on the other hand have had, shall I say, irrational dislike of this food since we were wee.
In this book, as with mushrooms, I am right and you are wrong.
Both are a delight.
Have I mentioned that I love that the narrator has named his soul Joe.
See? A hoot.


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MoDocs elects James F. Conant, M.D. as Chairman of the Board
Saint Joseph, MO – May 1, 2017. James F. Conant, M.D. has been elected Chairman of the Board of Directors of MoDocs, a leading medical malpractice insurance company with offices in Saint Joseph and Chesterfield. MoDocs is doctor owned and serves over 600 physicians statewide.
During the Annual Meeting of its members, Dr. Conant was re-elected to his board position. Subsequently, during the Board Meeting, Dr. Conant was elected to serve as the Chairman of the Board of Directors.
Dr. Conant's distinguished career spans over three decades of service, including many leadership roles in local and state medical organizations and hospitals. Dr. Conant is a Fellow of the AAFP. Currently he is a member of the MSMA, the AAFP and is a delegate from the State of Missouri to the AMA. He was the President and Chief of Staff of Jefferson Memorial Hospital in 1982-1983. He formerly served as the MSMA Hospital/Medical Staff Section Representative from Heartland Health. He also served as the Vice-Councilor of Organized Medical Staff Section for the MSMA from 2001-2010. Dr. Conant served as President of Health Choice of Northwest Missouri. As a supporter of continuing medical education, he has served as Associate Councilor from Missouri to the SMA for many years and as Councilor for Missouri from 2011-2015. He served as President of the Buchanan County Medical Society in 1995 and served on the Physicians' Advisory Committee for the Missouri Department of Social Services Division of Aging. He also served in the US Army in Korea.
Dr. Conant received a Bachelor's degree in Natural Science with an emphasis in Biology from Missouri Western State University in 1971. His Doctor of Medicine was conferred in 1975 at the University of Missouri – Columbia and his internship at St. John's Mercy Medical Center in St. Louis was completed in 1976. Dr. Conant was honored as a Distinguished Alumnus from Missouri Western State University. He has been the recipient of numerous educational and professional awards and honors.
Dr. Conant and his wife Marsha are natives of St. Joseph, Missouri where they currently reside. Mrs. Conant was recently inducted as President of the MSMA Alliance. They are the parents of 4 adult children: James II, Elizabeth, Marjorie and Eleanore. They also have 2 new grandchildren. Dr. and Mrs. Conant are actively involved in the local community and participate in numerous charitable endeavors.


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An equitable system for maintaining and upgrading client work after launch.
What Are 'Maintenance Blocks'? It's an idea I developed which is meant to provide a fair system for undertaking bug fixes or upgrades on client work. In simple terms; they are pre-paid units of maintenance.
It never felt quite right to round-up 15 minutes of work to one hour (for the purpose of creating an invoice). However, I wasn't happy about doing work for free for a client just because it was a small task (e.g. creating a new email account, adding Google Analytics to a website, etc).
One of the major advantages of maintenance blocks for clients is that a lower rate is locked-in for future work. There is also a degree of convenience since invoices aren't being sent out for small pieces of work. In addition, maintenance blocks are very flexible since they can be used for either bug fixes or upgrades to a client's existing project.
Maintenance blocks are also about mutual obligation. Having a client pre-pay for maintenance work ahead of time is a sign of good faith. In return, I give a guarantee on turn-around time (generally 48 hours from the time the request is acknowledged). If I don't respond within the agreed amount of time, the client gets their work done for free.
I designed maintenance blocks to be purchased in 'packs', generally eight or sixteen blocks, with each block being equivalent to 15 minutes of work. Depending on the complexity of the task (be it an upgrade or bug fix), varying amounts of blocks are consumed. Generally speaking, a minor change would use 1 block, an intermediate change would consume 2-3 blocks, and a major change will use 4 or more blocks (nb. minor or intermediate changes are most common).
I generally have it so blocks do expire, but the amount of time they stay valid is quite long (e.g. 6 months for eight blocks).
The way a client uses maintenance blocks is quite simple. They would email a request for change via email, I then let the client know how many blocks need to be used for the change and how many maintenance blocks they will have left after the change (e.g. "you have 3 maintenance blocks remaining, the change you are requesting will use 2 of those blocks - leaving you with 1 block"). The client then confirms their agreement or raises any questions they may have.
The system is squarely aimed at small bug fixes or changes. For example; "the positioning of the logo on my website looks funny in Google's new browser, can you fix it?" or "please add a new menu item and page to my website called 'Customer Feedback'." The system is not meant to cover major changes (e.g. adding online shopping facilities, re-vamping the layout of a website, etc). Generally, if a change is more then 16 blocks in size (i.e. more then 4 hours), I consider it to be beyond the scope of the maintenance blocks system, and therefore would require a separate contract to be negotiated.
Why do maintenance blocks get used for bug fixes you may ask? When a project is still under 'software warranty' (typically, for a period of 6 months after completion), blocks don't get consumed for bug fixes. But after the warranty period has expired, I do charge clients for fixes on their projects even if they are my fault. With the work I do, most bugs are found during the QA cycle, with few emerging past the 6 month point (but it still can happen).
Lastly, I don't 'force' clients to use the maintenance block system if they don't want to. The alternative is to negotiate a charge-out-rate and turn-around time whenever work needs to be done. At it's core, the system was created to make everyones' life easier. Costs are settled before-hand, thus allowing us to get on with what's important; the work.


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Eric Blair
January 22, 2012
Okay. It's time somebody says it. Something seems very strange about the GOP primary pre-polling and vote thus far.
As a Ron Paul fan, I didn't want to seem like a sore loser after the odd Iowa result where the failed no-name Senator, Rick Santorum, was catapulted to victory with very little tangible support.
But now, how on earth could Newt Gingrich win the South Carolina primary when the day before the vote he had to cancel a major campaign stop because of lack of attendance?
The Associated Press reported:
Newt Gingrich has cancelled a campaign appearance in South Carolina because of poor attendance.
The Republican presidential candidate was scheduled to speak to the Southern Republican Leadership on Friday. But a campaign spokesman told reporters that he would no longer be appearing due to poor attendance.
There were just a few dozen people in the audience at the College of Charleston's arena, where the event was taking place.
Meanwhile, on the same day Ron Paul boasted over 1000 attendees at his campaign event in Charleston:
2012 Republican Presidential candidate Ron Paul attracted more than 1,000 supporters in Charleston today, demonstrating his strong support among younger voters and his overall popularity.
The crowd gathered expressly for the 12-term Congressman from Texas as he participated in "The Bully Pulpit Series" at 11:00 a.m. EST at the College of Charleston, located at 7 College Way, Charleston. The candidate had been in Washington the day prior for a key House vote against President Obama raising the debt ceiling, but upon his return there was apparently no loss of enthusiasm.
Ron Paul speaking to enthusiastic crowd in Charleston, S.C.
Primary elections are traditionally driven by enthusiasm. In other words, the average voter does not turn out for primaries unless they are motivated by a certain candidate. So, could someone please explain to me how Newt Gingrich, who has virtually no ground game, no money, and no fervent supporters, just won the South Carolina primary?
Could the conspiracy to keep Ron Paul out of the Oval Office be this coordinated, this pervasive?
This post first appeared on the Activist Post website.
Paul Joseph Watson
Prison Planet.com
February 16, 2011
In a shocking act of mass public deception, Fox News attempted to skew Ron Paul's 2011 CPAC straw poll win by representing it with footage from the previous year's CPAC event, at which Mitt Romney supporters had loudly booed the result, another example of the continuing dirty tricks campaign being waged against Paul by the establishment media.
Congressman Paul replicated his 2010 victory over Mitt Romney by defeating the former Governor of Massachusetts for a second consecutive year at the annual CPAC conference.
However, before anchor Bill Hemmer introduced a segment concerning the story, Fox News played a clip of the 2010 announcement of the poll results, during which Mitt Romney supporters had loudly booed Ron Paul's victory, passing off last year's footage as representative of this year's event.
Hemmer then proceeded to state, "In the end he was the winner, probably not the reaction he was hoping for," describing the reaction as "mixed applause and boos," before directly asking Ron Paul if he knew who was booing him.
"Who was in the audience booing you, did you get a name, did you get an ID on those people?" asked Hemmer.
In reality, there were hardly any boos after Ron Paul was announced as the 2011 CPAC winner, the result was met with a massively positive reaction, only Fox News deemed it necessary to hide that fact from their viewers. The video clip above shows the real footage from the 2011 event, proving that Fox News had attempted to deceive Americans into thinking that Paul's victory was unpopular, by deliberately using the wrong footage.
A separate We Are Change Oklahoma clip of the 2011 straw poll victory confirms that Paul's win was met overwhelmingly by a loud chorus of cheers and applause.
This is the second time in the space of a week that Fox News has deliberately used dirty tricks to try and ostracize Ron Paul by discrediting the legitimacy of his potential candidacy for president.
A Fox News poll released earlier this week which asked who would make the best president included many of the potential candidates that Ron Paul trounced in the CPAC straw poll, yet the Congressman's name was not even included in the survey.
Exemplifying again how the establishment consistently tries to derail Paul's momentum by ignoring his very existence, obscure names like John Thune and Jon Huntsman were included in the Fox poll and yet Paul was omitted entirely.
While Fox News continues to act as an accommodating platform for the pied pipers of the hijacked tea party movement, people like Tea Party Caucus leader Michele Bachmann and Sarah Palin, real conservatives like Ron Paul and his son Senator Rand Paul are subject to dirty tricks and underhanded ploys.
Given the energetic power of his grass roots base, the establishment is scared to death of Ron Paul building any kind of momentum as the 2012 campaign race nears, which is why they have to resort to pulling stunts like this to hoax the American people into thinking that the message of liberty and freedom is unpopular, when in reality it is spreading like wildfire and would completely overrun the status quo if Ron Paul was allowed to communicate on a level playing field.
Paul Joseph Watson is the editor and writer for Prison Planet.com. He is the author of Order Out Of Chaos. Watson is also a fill-in host for The Alex Jones Show. Watson has been interviewed by many publications and radio shows, including Vanity Fair and Coast to Coast AM, America's most listened to late night talk show.


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Manager's Report - December 2016
Butler Electric Gives YOU a Holiday Refund!
I hope you and your family had a great Thanksgiving and are looking forward to the Christmas season. I hope you get to spend quality time with friends and family during this magical time of the year.
We have some great news for Butler Electric members! As a cooperative, our objective is to run as efficiently as possible. I am happy to announce that you will see a holiday refund on your December bill. The Board of Trustees is excited that the cooperative can continue giving back to our members during the holiday season.
Several factors made this refund possible. First, 25 percent of our membership conserved power use between the hours of 3 and 6 p.m. peak times, which lowers the cooperative's power cost and provides members with immediate bill reductions. In addition, we installed a half megawatt generator to assist with peak shaving efforts.
In December 2015, our Board of Trustees approved revenue neutral rates changes that adjust annually. On your January bill, you may notice a small increase in the customer charge, but you will see a decrease in the kWh charge. By doing this, we are able to track costs more accurately, as well as protect our members from extremely hot summers and cold winters.
The co-op sta and Board of Trustees are in the process of preparing our 2017 budget and work plans. A lot of discussion has involved renewable generation options and continued right-of-way tree maintenance to reduce blinking and increase reliability. Work plans are developed and focused around our number one priority—you!
In closing, from all of us at Butler Electric have a safe and happy holiday season and a wonderful new year.


text: Up for sales is a single (1) Factory OEM 18" 2006-2009 Ford Mustang GT Wheel Rim Black - 3648. Wheel is 18" diameter and is 8.5" wide. The wheel has a Machined and Black finish and is made from Aluminum. The hollander interchange number is 3648. The wheel is Refurbished. Wheels are guaranteed to be straight and true and free of any scratches, dents, and blemishes or your money back! Backed by a 12 month limited warranty.


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About Orthodontics
What is orthodontics?
Orthodontics (also referred to as dentofacial orthopedics) is a specialized form of dentistry focusing on the diagnosis, prevention, and treatment of dental and facial abnormalities.
Who is an orthodontist?
An orthodontist is a dental specialist who has received two to three years of additional training and experience. Your orthodontist is able to straighten teeth, correct misaligned jaw structure, and improve the function of your smile.
How Orthodontic Treatment Works
Orthodontic appliances can be made of metal, ceramic, or plastic. They may be removable or they may be brackets bonded to the teeth. By placing a constant, gentle force in a carefully controlled direction, braces slowly move teeth to a corrected position. This is a great time to wear braces! Gone are the days when a metal band with a bracket was placed around each tooth. You can often choose brackets that are clear or metallic, and sometimes you can choose the color of the ties that hold the wire in brackets. Wires are also less noticeable than they used to be, and the latest materials move teeth faster with less discomfort to patients.


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or just click on the e-mail link below.
If you would like to advertise on our
service, send your inquiry to email@example.com, or click
on the advertise link below.
In either case, thanks for visiting
our site!
E-mail us your Questions/Comments
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Leviton Compact Fluorescent Lamp Holder. Bidirectional lamp holder provided by the fixed end of the casing, pumping core lamp holder, casing cover, the protective net, a reflection plate, glass, etc., characterized in that the two fixed ends of the housing through the protective net is connected into a unitary, is installed on the fixed end housing threading tube and reflector plate, the left end of the flexible plug, core pulling the socket body and rubber seals, rubber seals installed on the right end of the socket body and tube positioning ring, core pulling. High mechanical strength, illumination and reliable anti-minutes can save time, quickly and easily replace the fluorescent tube and Leviton Compact Fluorescent Lamp Holder.
Leviton Compact Fluorescent Lamp Holder manufacturing process of the lamp positioning means of the housing, which comprises the working of the table, under the pressure of components, the controller and the drive, the lower press assembly is provided with the compression structure, the cylinder, the piston, the rack, positioning axis;the lower end of the bench provided fixture; match of said cylinder and piston, the piston with the rack is fixed, said shaft with the rack vertical positioning, positioning axis fixed gear engaging said gear rack, said positioning shaftfixed positioning of head, the positioning head has a two and the cap through hole of the housing end portion matches the positioning pin, said positioning pin with respect to the positioning head can be elastically stretchable; said controller, respectively, with a drive, the compressionThe structure, the cylinder is electrically connected; said drive table drive connection. The utility model using linear cylinder instead of the rotating cylinder, to reduce the the Leviton Compact Fluorescent Lamp Holder manufacturing cost of equipment and manufacturing technology requirements.
All fluorescent light fixtures consist of at least lamp(s), Leviton Compact Fluorescent Lamp Holder, fluorescent ballast and internal wiring. Some older types have "starters", too. The ballast is used to create the voltage and current necessary to start and illuminate the fluorescent lamp. In time, the ballast may need to be replaced. Read on to learn how to swap out the old with an approved replacement ballast of the same technology. Please read the entire article and warnings before attempting.
The Leviton Compact Fluorescent Lamp Holder continues to grow with the newly introduced T8 series featuring rotary lamp-lock technology and bottom push-in wiring. Our linear fluorescent brochure details the many different mounting, wire insertion and lamp insertion configurations available.
Leviton Compact Fluorescent Lamp Holder, med bi-pin, turn type, dedicated T8, snap-in mounting, 660w-600v. UL and CSA. With internal shunt.
Waterproof moistureproof T8 fluorescent lamp holder, suitable for moisture condensation or shallow water environment. Good insulation properties of rubber or resilient plastics material made ??its one end about 1/2 part of a hollow tubular, the pipe inner diameter is slightly smaller than the corresponding fluorescent tube outside diameter, the length can be formed with the glass portions of the fluorescent tubes partially overlap , inside the other end has a pin jack and pin connectors reed wire. Since the lamp holders sealed elastic material, when the fluorescent tube is inserted into one end of its tubular, i.e. closed state, the other end of the wire leads is also sealed to the elastomeric material wrapped in a sealed state.
More relative productss: Lamp Base Adapter , MR16 lamp holder base


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The Indian Ocean islands are quite famous as tourist destinations. Since they are in the Indian Ocean, they already have the advantage of boasting incredible weather. Consequently, the islands in the Indian Ocean indeed classify as tropical islands. Moreover, these are known for having stunning beaches, which is why they all rely a lot on their tourism industry. Most people know mainly about the Seychelles and maybe Mauritius because the latter is actually more developed, but there are several islands that are worth visiting in the Indian Ocean.
Mauritius is an island in the south west of the Indian Ocean and is the second most popular African island. One thing many people forget is that Mauritius is actually part of the Mascareigne Islands along with Reunion and Rodrigues, which is in fact a district of Mauritius. Mauritius has the distinct average of being more developed than the other Indian Ocean islands. As such, there are tons of things for tourists to do, and it boasts some extremely developed and vibrant towns. The Mauritius hotel numbers are also very large with a variety of accommodation for tourists.
The island of Reunion is located quite close to Mauritius and is mostly known for having an active volcano. Although Reunion is almost as beautiful as most other Indian Ocean islands, its tourism industry is not quite as developed, most likely because it is in fact part of France. Reunion island is also known for its mountains and forests, and it is probably the most mountainous island in the Indian Ocean. However, the cost of life is more expensive there and its tourist accommodations are not as diverse and as excellent as in other islands.
Seychelles is the most popular island of the Indian Ocean for very good reasons. This beautiful island is renowned for its magnificent beaches and its raw beauty. Seychelles is in fact an archipelago of 110 islands and relies almost exclusively on its tourism industry. This works out fine as Seychelles ranks among the top three destinations in the world and is widely regarded as the best location for honeymoons and wedding vacations. It also has the best climate out of all the Indian Ocean islands and is indeed a brilliant place for relaxing thanks to its laid-back lifestyle and the quality of the hotels Seychelles.
The Maldives, which is the smallest Asian country, is also quite popular with tourists and is famous for its unique geography and its uniqueness as an island. Indeed, Maldives is in fact an archipelago of no less than 1,900 incredibly small islands, some of which can be covered within minutes even on foot. Out of those 1,900 islands, only 185 are actually inhabited. However, the Maldives islands are extremely beautiful and are known for their blue lagoons and superb beaches.
Madagascar is the closest island to the African continent and is also the largest single one in the Indian Ocean. It is ultimately known for having an exclusive flora and fauna, which has made it very popular with experts in those fields. However, due to many civil issues and an unstable economic climate, Madagascar is not an ideal tourist destination. It is in fact often completely ignored and is not a common tourist destination.


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L.A.-based web series news and reviews site Tubefilter has acquired the N.Y. based web series news and reviews site Tilzy.tv. Both companies are private and terms of the deal were not disclosed.
Tubefilter is also giving its crew grown-up titles: co-founder Brady Brim-DeForest is now CEO, co-founder Drew Baldwin is senior vice president, product, and co-founder Marc Hustvedt is senior vice president and editor-in-chief. Tilzy.tv co-founders Jamison Tilsner and Joshua Cohen will work out of Tubefilter's New York office and become Tubefilter's COO and CIO, respectively.
The coupling of these two sites isn't too surprising. Tubefilter and Tilzy worked together to create the International Academy of Web Television and put on the first annual Streamy Awards this year. Plus, with both covering basically the same beat, it makes sense to consolidate instead of fighting over the same audience.
Now they can just fight with us.
We kid! We kid!
We've worked a bunch with both teams and they're all great guys. Congrats!


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The Knotty Pine String Band (left) from Omagh, Co. Tyrone, Northern Ireland, originally formed when the Appalachian & Bluegrass Music Festivals began to be held at the Ulster American Folk Park at Omagh. In 1998 they were one of the bands that took part in the first EWOB Festival at Lichtenvoorde in the Netherlands.
Since then, they have brought out several CDs and have toured widely, including the USA. They are planning another US tour for 2011, and would be glad to hear from anyone with contacts to venues on the West Coast. Please contact their fiddler, Declan O'Kane, by e-mail. To keep up with the band, visit their Facebook page.
2019 Bluegrass Conference
23 hours ago


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Check Availability
Contact Us
Relax in the grandeur of historic downtown Saint Joseph, Michigan. The Duncan House is an easy 5 minute walk to shopping, dining, wine tasting , art galleries, and world class beaches. Gourmet breakfasts and homemade snacks await you.
Rooms & Rates
The Michigan Room
The Beach Escape Room
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The michigan Room
Inspired by the rich history of Michigan and Saint Joseph, this room features a private bath with a jetted tub and a stunning four post canopy bed help you return to a quieter, slower paced time.
$215-$310 per night.
The Beach Escape Suite
You will feel like you are living at the beach in this room, complete with your own private sitting/breakfast room and a 1920's inspired bath with a large walk in shower. Please note that this is a second floor room.
$245 -$350 per night.
Deposits: To guarantee your reservation, a credit card deposit is required at the time your reservation is booked. A deposit of one night's room rate including tax is required for two nights or less. A deposit of 50% of the total room rate is required for three nights or more. All balances are due in full at check-in.
Rates: Rates and policies are subject to change. Posted rates do not include 6% Michigan use tax and $1/night Lake to Lake Michigan Association Fee. Rates include daily housekeeping, a gourmet breakfast and concierge service.
Payment Options: We gladly accept Visa, MasterCard, American Express and Discover. Cash may be used for payment balances upon arrival however, we do not accept Personal Checks or Money Orders.
Cancellation Policy: Please be sure of your plans before booking! As a small inn dealing almost exclusively with advance reservations, date changes and cancellations affect us significantly. Consequently, reservations cancelled more than 14 days prior to arrival will be refunded in full, less a $50 service charge. Reservations cancelled within 14 days of arrival will forfeit their deposit. We do allow guests to transfer a reservation to a future stay within one year of the original booking date. This is a one-time courtesy and the rescheduled date is non-refundable. No-shows and shortened stays will be charged the full amount of the reservation with no refunds or further date changes allowed. We recommend Trip Cancellation Insurance for our guests in the event you need to cancel a reservation on short notice.
Visitors and Children: Due to the size of our inn, we have limited ability to host additional guests. Please check with the innkeeper before inviting visitors. All rooms are single or double occupancy and children must be over 13 years of age to stay in a room unaccompanied by an adult. Children under 10 would likely be happier in a facility designed with children in mind.
Check-in and Check-out: Check-in time is 4-6pm Eastern Time. If you will need a later check-in, please contact the innkeeper 844-930-9698 so we can arrange to be there for your arrival. Check-out time is 12 noon Eastern Time. We regret we generally cannot accommodate late check-outs or early check-ins.
Smoking/Candles: Per Michigan state law and our insurance restrictions, there is no smoking allowed anywhere on the property of The Duncan House. We also do not allow any open-flame candles or incense. A $250 cleaning fee will be assessed for violations of this policy.
Pets: While we have two friendly golden retrievers that live on property, we unfortunately cannot accommodate our guestÕs pets at our inn. Our pets are confined to our personal living quarters and a secure fenced outdoor area of the property. Please contact us for recommendations on pet boarding in the area if you will be traveling with your pets.


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Tuesday, September 14, 2010
Spring Sketch
I will not get to final for a long while until I get some pretty big stuff off my plate. It is a companion piece to winter. I had hoped to do all four seasons for my Christmas card, but that looks pretty unlikely now.
Maybe for 2011...
2 comments:
Very nice. I like the draftsmanship here. ow did you piece this together?ReplyDelete
It looks like you are refining the composition a bit in Photoshop. I do this as a general rule. I noticed recently that Peter de Seve is doing it as well. He has a nice posting on his blog right now that shows a lot of digital sketching.ReplyDelete
Do you have the entire series sketched now? I think the wire-frame skirt was a great idea for winter.
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Leak Detection
At Plan B Plumbing Solutions there's not yet been a water leak haven't found.
With our state of the art water leak detection equipment we have everything required to locate even the smallest of water leaks.
Using state-of-the-art, non-invasive sound and thermal water leak detection technologies, we can locate and repair the problem quickly.
We like to think of ourselves as the best Water Leak Detection Plumbers that Oakleigh has to offer, in fact the best Water Leak Detection Plumbers that Melbourne has to offer !!!.
Drain Camera Inspection
We offer full colour drain camera "CCTV" inspections on storm water drains and sewer drains.
Using state of the art CCTV push camera system technology we can locate blockages or structural defects within your storm water and sewer drains.
The drain camera allows for accurate diagnosis of your storm water and sewer drains, locating cracks, breaks, tree root entry and other potential problems that can cost you significant money if left unattended.
It's also a cost effective way to avoid expensive excavations.
Drone Roof Inspections
Inspections with the use of drone technology makes Roof Inspections for properties above three stories easier, safer, faster and less costly.
The drone can access almost any part of the building, and collect more useful information using high-quality image and video.
The drone transmits the data to the inspection team on the ground or through the Cloud - allowing us to analyze the data and generate reports faster without putting anyone at risk.
Click HERE to watch the Drone in action.
Polycarbonate Roof Repairs
Our skilled team specializes in Polycarbonate roof repairs and restorations of Polycarbonate structures including pergolas, verandahs, skylights and canopies.
With the use of our highflying drones our team can easily access, asses and diagnose your roofing problems safely and effectively.
We service all repairs from small inconsistencies to large full sheet replacements.
Gas Fitting
Our expert plumbers are fully qualified and licensed to install, service and replace any gas or LPG systems in your home or business.
Plumbing Repairs
Plan B Plumbing Solutions offer a wide range of general and emergency plumbing services, gasfittings & hot water services.
Hot Water Heater Replacements
Servicing & repairs for all types of Hot Water Heaters including Gas Hot Water Heaters, Electric Hot Water Heaters, Solar Hot Water Heaters & Heat Pumps
Burst Pipe Repairs
Storm Water & Sewer Drain Camera Inspection
Tapware & Bathroom
Repair Leaking Taps
Toilet & Cistern Repairs & Replacements
Gas Installations
Gas Appliance Servicing
Dishwasher Installations
No matter what your plumbing issue, from small to large, if you need a plumber to repair it, we can do it.
Talk to us today about how we can help you with your plumbing repair needs.
Drainage Repairs
We specialise in Sewer & Storm Water Drainage renewal.
All defects located within your plumbing drainage systems can be repaired by our team of Licensed Plumbers.
Click here to view our most recent Storm Water Drainage Repair.
We used a Rigid Sea Snake CCTV Camera to locate the defective pipe. We then excavated and repaired the plumbing issue.
No matter how big or small the issue may be, we can provide you with a cost effective repair strategy to solve the problem.
Emergency Plumbing Repairs
When disaster strikes in the form of storm damage, water leak, burst pipe, overflowing sink, bath or sewerage you need to act quickly in order to prevent further damage from occurring.
At Plan B Plumbing Solutions we provide the convenience and reliability of Emergency Make Safe service to our clients.
This service is carried out as a temporary emergency repair to a home in order to prevent any further damage from occurring.
We have extensive experience with emergency Make Safes and understand the importance of clear communication and timely repairs.
Services Offered -
Tarpaulin - Roofs / Skylights
Sewage & Stormwater Repairs & Replacement
Roof Repairs & Replacement
Gutter/Spouting Repairs & Replacement
Downpipe Repairs and Replacement
Water Pipe Repairs
Don't wait for the problem to get worse. Contact us today 1300 075 262.


text:
The University of the Virgin Islands President serves as the Principal Investigator on the UVI Title III and SAFRA grant programs. Before the commencement of each five-year cycle, the President establishes a programmatic theme, based on the University's Strategic Plan. Faculty and staff are invited to submit project pre-proposals consistent with the theme and the overall objectives of the program. The Request for Proposals describes the program theme and the deadline by which pre-proposals must be submitted to the Office of the President.
Members of faculty and staff are required to conform to the internal review requirements of their respective colleges/schools. Proposals submitted to the President will not be considered if they have not been approved by the Dean, Division Chair or Unit Head, Vice Provost for Research and Public Service (if applicable), the Provost, and the Office of Sponsored Programs and Title III.
The UVI President determines which projects will be incorporated into the institution's application to the U.S. Department of Education, based on the consistency of the submittals with the selected theme. The Title III office will notify the project directors for each of the selected projects, invite them to prepare full proposals for consideration by the U.S. Department of Education, and provide them with instructions and technical assistance for doing so. Project proposals are not accepted for consideration if received by the Title III office after the established deadline.
Model proposals, depicting the proposal format(s) that should be utilized, and all necessary forms are available from the Title III Coordinator at the Office of Sponsored Programs. The project proposals must contain the following:
Draft proposals may be submitted to the Office of Sponsored Programs, not later than ten (10) working days prior to the federal deadline to allow ample time for review, revision, and preparation of the full UVI proposal.


text:
Die cut leaves from the vinyl sheet using the die cutting machine.
Arrange and adhere the leaves onto the jars.
Paint each jar using a sponge dauber. Let dry. Sponge on another coat of paint and let dry. Carefully peel off the vinyl leaves and discard.
Place gems into the jards then place a candle inside.
Wrap the jute around the rim of the jars and add a wooden tag.