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Conceived and designed the experiments: DM BJB MY MR YT RS AW SA. Performed the experiments: DM BJB TH YT EW. Analyzed the data: DM BJB MY MR HGY EW DL. Contributed reagents/materials/analysis tools: AW. Wrote the paper: DM SA.
African-American breast cancer patients experience higher mortality rates than European-American patients despite having a lower incidence of the disease. We tested the hypothesis that intrinsic differences in the tumor biology may contribute to this cancer health disparity.
Using laser capture microdissection, we examined genome-wide mRNA expression specific to tumor epithelium and tumor stroma in 18 African-American and 17 European-American patients. Numerous genes were differentially expressed between these two patient groups and a two-gene signature in the tumor epithelium distinguished between them. To identify the biological processes in tumors that are different by race/ethnicity, Gene Ontology and disease association analyses were performed. Several biological processes were identified which may contribute to enhanced disease aggressiveness in African-American patients, including angiogenesis and chemotaxis. African-American tumors also contained a prominent interferon signature. The role of angiogenesis in the tumor biology of African-Americans was further investigated by examining the extent of vascularization and macrophage infiltration in an expanded set of 248 breast tumors. Immunohistochemistry revealed that microvessel density and macrophage infiltration is higher in tumors of African-Americans than in tumors of European-Americans. Lastly, using an in silico approach, we explored the potential of tailored treatment options for African-American patients based on their gene expression profile. This exploratory approach generated lists of therapeutics that may have specific antagonistic activity against tumors of African-American patients, e.g., sirolimus, resveratrol, and chlorpromazine in estrogen receptor-negative tumors.
The gene expression profiles of breast tumors indicate that differences in tumor biology may exist between African-American and European-American patients beyond the knowledge of current markers. Notably, pathways related to tumor angiogenesis and chemotaxis could be functionally different in these two patient groups.
The age-adjusted breast cancer incidence and mortality rates vary substantially among race/ethnic groups [1]. Most notably, European-American women have the highest risk of developing the disease, while African-American women experience the highest mortality rates. This difference in survival between African-American and European-American breast cancer patients has been attributed to differences in socioeconomic factors and access to healthcare. However, after accounting for those differences, African-American women were still found to have lower breast cancer survival rates than European-American women [2]–[5]. The data suggest that having equal medical care may not eliminate the survival disparity between African-American and European-American breast cancer patients, and that other causes are involved in this problem.
It has been proposed that differences in tumor biology may contribute to the survival health disparity associated with breast cancer [6], [7]. Race/ethnic differences in the expression of cell cycle-regulatory proteins in breast tumors have been described [8]. African-American patients also have a greater prevalence of more aggressive, poorly differentiated, estrogen-receptor (ER)-negative tumors and a higher rate of lymph node involvement than European-Americans [4], [5], and they develop breast cancer at an age younger than 35 twice as frequently as European-American women [9]. Recently, a high prevalence of basal-like breast cancers was observed among pre-menopausal African-American breast cancer patients [10], [11]. Because the basal-like subtype is a poor prognosis marker, its increased frequency among African-American patients, when compared with non-African-American patients, could contribute to their disproportionately high breast cancer mortality. However, even after removal of all basal-like cases from the analysis, African-American breast cancer cases still had poorer outcomes than non-African-American cases [10].
We hypothesized that differences exist in the microenvironment of breast tumors comparing African-American with European-American patients. Our laboratory recently observed such differences in prostate cancer and also noted an increased expression of interferon-responsive genes in tumors of African-American men [12]. Analogous to the prostate study, we analyzed the gene expression profiles of breast tumors and used bioinformatics tools to identify differences in oncogenic pathways between the African-American and European-American patients. Guided by the gene expression profiling results, we examined microvessel density and macrophage infiltration in breast tumors by immunohistochemistry. The importance of both for breast cancer growth and spread has been demonstrated [13]–[15]. Using these approaches, we found differences in angiogenesis, chemotaxis, and immunobiology of breast tumors among the two patient groups. In addition, many interferon-regulated genes were found be up-regulated in tumors of African-American patients.
Total RNA was isolated from LCM-dissected tumor epithelia and tumor stroma of 35 breast tumors (18 African-American and 17 European-American breast cancer patients). For one African-American patient, LCM did not provide sufficient amounts of good quality RNA from the tumor stroma. Further analyses (e.g., qRT-PCR, Western blotting, and immunohistochemistry) were performed on an extended breast tumor set from 248 breast cancer patients that included 32 of the 35 tumors in the gene expression profiling study. The demographic and clinicopathological data of the 248 patients are shown in Table 1. Clinical characteristics of the LCM-dissected tumors are summarized in Table 2. Consistent with other studies, we observed that African-American women had a higher prevalence of ER-negative and high grade tumors than European-American women.
In an initial analysis, the gene expression profile of the tumor epithelium was compared between African-American and European-American patients. Numerous genes were found to be differentially expressed between them using a FDR-controlled P≤0.01 as the cutoff for inclusion into the gene list (Table S1). Consistent with the immunohistochemistry in other studies [8], several cell cycle regulators (e.g., CDKN2A (p16), CCNA2, CCNB1, CCNE2) were expressed at significantly higher levels in the tumor epithelium of African-Americans than European-Americans.
As the cumulative effect of multiple genes rather than a single gene effect determines cancer phenotypes, analyses were performed that were aimed to identify biological networks in the microdissected tumor epithelium and tumor stroma that may contribute to the survival health disparity in breast cancer. To find biological processes that differ by race/ethnicity, a cluster analysis was applied to display Gene Ontology biological processes with significant enrichment of those genes that are expressed differentially among the two patient groups (Figure 1). Processes related to cell cycle control and chemotaxis in the tumor epithelium and neovascularization in the tumor stroma were most significantly enriched for differently expressed genes comparing the African-American patients with the European-American patients. Further analysis indicated that the enrichment for differentially expressed genes in these processes was not the product of a confounding influence by other tumor markers. Lists of differentially expressed genes by those markers, e.g., comparing ER-negative with ER-positive tumors or p53 aberrant with p53 wild-type tumors or HER2-negative with HER2-positive tumors, did not yield the same significant enrichment in these processes. Instead, a distinct pattern was observed which denotes biological processes including endoplasmic reticulum-associated degradation and chemotaxis in the tumor epithelium and angiogenesis in the tumor stroma that could be functionally different in African-American and European-American breast tumors (Figure 2). We also assessed whether genes that are differentially expressed between breast tumors from African-American and European-American patients have a common association with other diseases or pathological reactions. We found that those associations exist, e.g., with immune-related reactions (skin-prick test, asthma) and inflammation (Figure S1).
Next, we examined the genes that were most significantly differentially expressed between the African-American and European-American patients independent of the tumors' ER-status (Table 3). Examples of those included PSPHL, TMPO, CRYBB2, and AMFR in the tumor epithelium and PSPHL, CXCL10 and CXCL11 in the tumor stroma. The function of PSPHL is unknown while CRYBB2 encodes a protein linked to congenital eye defects [16]. TMPO is thymopoietin and AMFR is the autocrine mobility factor receptor/gp78. CXCL10 and CXCL11 are ligands of the chemokine receptor CXCR3.
AMFR is a candidate oncogene that promotes metastasis [17] and a key gene in endoplasmic reticulum-associated degradation, which was identified as a race/ethnicity-related biological process in this study. To corroborate the AMFR microarray data, we followed up by Western blot analysis. AMFR protein expression was determined in tumor extracts from 6 African-American and 6 European-American patients that were randomly selected from available fresh-frozen tumor tissues. As shown in Figure 3, AMFR was significantly higher expressed in African-American tumors than in European-American tumors.
We previously had demonstrated that PSPHL and CRYBB2 could be used as a two gene classifier to differentiate between African-American and European-American prostate cancer patients [12]. To test if similar signatures exist in breast cancer, we applied the prediction analysis of microarray algorithm to interrogate our datasets for genes that can differentiate between African-American and European-American breast cancer patients. In accordance with the prostate study, the two gene signature consisting of probesets for PSPHL (205048_s_at) and CRYBB2 (206777_s_at) was identified as the top-ranked predictor that can distinguish between the breast tumor epithelia from African-Americans and European-Americans (Table 4). Ninety-four percent of the African-American patients and all European-American patients were correctly classified by the expression pattern of the two genes. This result was confirmed in 55 additional breast tumors (27 African-American and 28 European-American breast cancer patients) using qRT-PCR quantification of PSPHL and CRYBB2 expression. In this validation set, the two-gene signature correctly classified 93% of the African-American patients and 86% of the European-American patients.
For the tumor stroma, a five gene classifier consisting of probesets for PSPHL (205048_s_at), CXCL10 (204533_at), CXCL11 (211122_s_at), ISG20 (204698_at), and GMDS (204875_s_at) was identified. The expression pattern of these five stromal genes correctly classified 16 out of 17 African-Americans (94%) and 14 out of 17 European-Americans (82%). Notably, three genes in the classifier for the tumor stroma, CXCL10, CXCL11, and ISG20, are known interferon γ-regulated genes. An interferon gene signature was also present in the profiles derived from the tumor epithelium of the ER-positive tumors (e.g., STAT1, IFIT1, IFIH1, IFI27, ISG15, OAS1, OAS3, OASL; Table S2) and ER-negative tumors (e.g., HLA-DQA1 and HLA-DQB1; Table S3). The presence of this signature was further supported by a Gene Set Enrichment Analysis (GSEA) that revealed significant associations between the parenchymal signature in the ER-positive tumors and published signatures derived from interferon (α,β,γ)-treated cells (Table 5).
The most differently expressed genes in ER-negative tumors between African-American and European-American women were HLA-D family members, HLA-DQA1 and HLA-DQB1. The up-regulation of the MHC II antigen (HLA-D) in the ER-negative African-American breast cancer patients was corroborated by Western blot analysis (Figure 3). The microarray data did not show that HLA-DQ is significantly differentially expressed by race/ethnicity in the ER-positive tumors. We confirmed this finding by qRT-PCR analysis in a validation set consisting of 59 tumors (Figure 4).
Our previous analyses indicated that biological processes related to chemotaxis and tumor angiogenesis could be functionally different between breast tumors from African-American patients and European-American patients. Known inducers of angiogenesis, such as vascular endothelial growth factor and syndecan-1, were among the genes that were higher expressed in the tumor epithelium of African-American patients than European-American patients (Table S1). Thus, we examined microvessel density, a surrogate for angiogenesis, and the number of tumor-associated macrophages (TAM) and FoxP3-positive T-regulatory cells in breast tumors by immunohistochemistry and assessed their relation to the race/ethnic background of the patients. Both TAM and T-regulatory cells have previously been associated with increased angiogenesis in breast tumors [14], [18]. African-American patients (n=125) were significantly more likely than European-American patients (n=83) to have a high tumor vessel density (P=0.047; Fisher's exact test). This relationship was partly confounded by differences in age at diagnosis, tumor ER status, TNM stage, and grade of the tumors among the two patient groups, as indicated by a logistic regression analysis (Table 6). African-American patients (n=142) were also significantly more likely than European-American patients (n=105) to have a high TAM count (P=0.01; Fisher's exact test). This relationship was independent of the age at diagnosis, tumor ER status, and disease stage and grade (Table 6). A significant correlation between microvessel density and TAMs existed in tumors of African-American women (rho=0.45; P<0.0001; Spearman rank correlation) and tumors of European-American women (rho=0.22; P=0.04; Spearman rank correlation). After adjusting for age at diagnosis, tumor ER status, and disease stage and grade, the association remained significant only in African-American patients. No association was observed between the number of FoxP3-postive T-regulatory cells in breast tumors and race/ethnicity. However, our analysis revealed a significant association between an increased number of these cells and the basal-like breast cancer subtype (Figure 5).
We explored the potential to tailor treatment options for African-American patients based on their gene expression profiles. The Connectivity Map database is a collection of genome-wide transcriptional expression data from cell lines, including MCF-7 breast cancer cells, which were treated with a panel of bioactive small molecules [19]. Integrated pattern-matching algorithms enable the discovery of functional connections between these molecule-induced signatures and disease-induced signatures through the feature of common gene expression changes. A significant negative correlation between a molecule-induced signature and disease-induced signature indicates that this molecule could potentially reverse the disease signature. We used this database to identify small molecules that may reverse the gene expression signature in the tumor epithelium of breast tumors that differentiates African-American women from European-American women. By this mechanism, these compounds may also target the survival health disparity. The analysis revealed a significant negative correlation between gene signatures in MCF-7 cells induced by LY-294002 (Ppermutation=0.0002), a PI3-kinase inhibitor, and Y-27632 (Ppermutation=0.008), a Rho signaling inhibitor, and the genes that are differentially expressed between African-American and European-American women in ER-positive tumors. The analysis for ER-negative tumors revealed significant negative correlations between the signatures induced by sirolimus (rapamycin) (Ppermutation=0.006), an immunosuppressant drug, resveratrol (Ppermutation=0.046), an antibacterial and antifungal phytoalexin, and chlorpromazine (Ppermutation=0.025), a phenothiazine, and the genes that are differentially expressed between African-American and European-American women in these tumors (Figure 6). The results indicate that these compounds may potentially antagonize the gene expression profiles in ER-positive and ER-negative tumors that differentiate African-American breast cancer patients from European-American breast cancer patients. We did not apply this same analysis to the tumor stroma signature because the MCF7 therapy response could be very different from the therapy response of stromal cells.
We used gene expression profiling to identify biological differences in the microdissected tumor epithelium and tumor stroma that may exist between African-American and European-American breast cancer patients from the greater Baltimore area. African-Americans from this area, and for most of the U.S., have ancestral links to specific regions in West Africa and experience an increased frequency of aggressive breast cancer similar to West African women [20].
Our study focused on the discovery of differentially regulated biological processes comparing African-American and European-American breast cancer patients as opposed to the discovery of specific genes. This approach was used as it may reveal differences in oncogenic pathways and the tumor microenvironment, and therefore may provide insight into therapeutic opportunities [12], [21]. Using this design, we found that biological processes related to chemotaxis, angiogenesis, endoplasmic reticulum function, and cell cycle control were most significantly enriched for genes that are differentially expressed by race/ethnicity. Of those processes, only the cell cycle control association appeared to be significantly confounded by differences in other tumor markers such as the race/ethnic difference in the tumor ER status.
One of our most interesting observations was the presence of an interferon signature in tumors of the African-American patients. The rationale of examining our datasets for an interferon signature was based on our previous observation in prostate cancer showing that interferon γ-responsive genes are up-regulated in African-American tumors [12]. Interferons are commonly induced by pathogens and is a key pro-inflammatory cytokine in inflammation and autoimmune disease. In tumor biology, interferon γ is the master regulator of the Th1 response and enhances tumor immunogenicity and abrogated tumor development in mouse models [22]. However, an interferon γ signature can be merely an indicator of a chronic inflammation and has been observed as a component of breast cancer progression in HER2-transgenic mice [23]. Currently, we are uncertain why breast tumors from African-American patients have an interferon signature, or why interferon-regulated genes were more differentially expressed in the ER-positive than ER-negative tumors, although this may reflect estrogenic regulation of host immunity [24]. The signature in the tumor epithelium could partly be caused by infiltrating immune cells, which cannot be completely separated from the tumor epithelial cells by LCM. Several of the interferon-related genes in our tumor signature have previously been reported as key genes in the cellular defense against bacterial and viral pathogens [25]–[27] and in the promotion of all steps of breast tumorigenesis including tumor development, growth, survival, and metastasis [28]–[30]. We hypothesize that etiologic agents may induce the signature in breast and prostate tumors of African-Americans. Alternatively, chronic inflammation and/or specific genetic variations in immune-related genes could be more prevalent among these African-American cancer patients and cause the heightened interferon activity in their tumors.
There have been two recent reports that investigated gene expression variations between individuals with European ancestry and individuals with African ancestry (Nigeria) using lymphoblastoid cell lines [31], [32]. Analogous to the present study, the authors assessed the enrichment of biological processes and pathways by genes that are differentially expressed by race/ethnicity. Notably, processes related to antimicrobial humoral response, inflammation mediated by chemokines and cytokines, histamine H1 receptor-mediated signaling pathway, toll-receptor signaling pathway, and the VEGF signaling pathway were identified. The results from these two studies suggest that differences in the genetic background between healthy volunteers of European ancestry and those from Nigeria cause gene expression differences affecting host immune response, inflammation and chemotaxis, and angiogenesis. These findings are consistent with our findings in breast tumors, and while preliminary, raise the possibility that differences in common genetic variations among African-American and European-American breast cancer patients may lead to group-specific alterations in cancer-related pathways that control host response, inflammation, and tumor angiogenesis.
Few others have studied race/ethnic differences in the expression of tumor markers in breast cancer and observed that p16, p53, and cyclin E were more commonly expressed in tumors from African-American patients than European-American patients [8], [33]. p16 is encoded by CDKN2A. This gene was also up-regulated in the African-American tumors of this study, as indicated by the microarray data. Nuclear accumulation of p53 protein in tumor cells is a surrogate for a functional impairment of the p53 pathway while the overexpression of cyclin E is most frequently caused by a post-transcriptional mechanism that leads to the accumulation of hyperactive low molecular weight cyclin E isoforms [34], [35]. Consistent with the previous reports, p53 and cyclin E protein accumulation was also more common in African-American tumors than European-American tumors in the present study.
The gene expression profiles of breast tumors indicated that pathways related to tumor angiogenesis and chemotaxis could be functionally different between African-American and European-American patients. For further corroboration of these findings, we demonstrated higher levels of microvessel density and TAMs in African-American tumors than European-American tumors. Increased microvessel density and the infiltration of tumors by macrophages have been shown to be poor prognosis markers [13]–[15]. The two markers are interrelated as TAMs are a major source of chemokines and cytokines which induce tumor angiogenesis [14], [15]. From the present study, we do not know why TAM infiltration is increased in tumors from African-American women. Possibly, tumors from African-American patients release more chemotactic cytokines to attract the infiltration of TAM than those from European-American patients. Among the most important of the chemotactic signals that attract TAM are MCP-1, CSF-1, and VEGF [15]. Of those, VEGF was found to be higher expressed in the African-American tumors. We also assessed the infiltration of tumors by FoxP3-positive T-regulatory cells. The number of these cells in breast tumors has been associated with an increased risk of relapse in breast cancer [36]. Although the number of these immune suppressive cells was not significantly different between African-American and European-American breast tumors, elevated numbers of these cells were found in basal-like tumors. Future studies should investigate whether these T-regulatory cells are related to poor outcome among young African-American breast cancer patients who frequently present with the basal-like subtype [10], [11].
If gene expression differences exist between African-American and European-American breast cancer patients, those differences could potentially be exploited for tailored therapy. In an exploratory approach, we used the Connectivity Map database to identify small molecules that may antagonize the gene expression signature in the tumor epithelium of breast tumors that differentiated African-American patients from European-American patients. An antagonist could potentially improve the therapeutic outcome of high risk breast cancer patients, e.g., African-American patients with ER-negative tumors. Significant negative connectivity scores, indicating an antagonistic effect of the small molecule drug on the query signature, were obtained for the PI3-kinase inhibitor, LY-294002, and Rho signaling inhibitor, Y-27632, in ER-positive breast tumors and for sirolimus, resveratrol, and chlorpromazine in ER-negative tumors. Although preliminary, these findings are novel and may have implications for cancer therapy. The toxicity profile of LY-294002 excludes it from clinical trials, but its antagonist effect suggests that ER-positive African-American and European-American breast cancer patients could respond differentially to therapeutic PI3-kinase inhibitors. Sirolimus is rapamycin, which is a mTOR inhibitor and an immunosuppressant. Sirolimus and other mTOR inhibitors are currently in clinical trials, and their anti-tumor efficacy in breast cancer in preclinical models has been demonstrated [37], [38]. Resveratrol is a chemopreventive agent that has a plethora of effects in breast cancer including anti-inflammatory activities, apoptosis induction, angiogenesis inhibition, and effects on PI3-kinase signaling, among others [39], [40]. Chlorpromazine is a psychotropic agent and not an anti-cancer drug. However, recent data have shown that chlorpromazine has anti-proliferative and pro-apoptotic effects in cancer cells [41], [42], and future studies should evaluate the activity of chlorpromazine in breast cancer.
Our study has strengths and limitations. We conducted a microarray analysis of microdissected tumor epithelium and tumor stroma, thus providing comprehensive databases of gene expression for these two cellular compartments in African-American and European-American breast tumors. The use of LCM also largely ruled out that varying amounts of tumor and stroma between African-American and European-American tumors is a confounder of the datasets. Despite the advantages of more rigorous histological sampling enabled by LCM, the approach has limitations. LCM is labor intensive and cannot be applied for the analyses of large sample sets, and further stratification of the breast tumors in the many subtypes (basal-like, ERBB+, normal-like, luminal A & B & C) was not possible in this sample set because of sample size limitations.
In conclusion, the gene expression profiles of breast tumors correspond to differences in tumor biology between African-American and European-American patients. Particularly, pathways related to chemotaxis, tumor angiogenesis, and immunobiology could be functionally different in the two patient groups. The therapeutic implications of those differences should be evaluated in future studies.
Fresh-frozen (n=35) and paraffin-embedded (n=248) tumor specimens were obtained from breast cancer patients that resided in the greater Baltimore area, as described previously [43], [44]. Patients were recruited at the University of Maryland Medical Center (UMD), the Baltimore Veterans Affairs Medical Center, Union Memorial Hospital, Mercy Medical Center, and the Sinai Hospital in Baltimore between 1993 and 2003. All patients were identified through surgery lists and enrolled into the study prior to surgery. They signed a consent form and completed an interviewer-administered questionnaire. These patients had pathologically confirmed breast cancer, were of African-American or European-American descent by self-report, were diagnosed with breast cancer within the last 6 months before recruitment, and had, by self-report, no previous history of the disease. Clinical and pathological information, including tumor ER status, was obtained from medical records and pathology reports. Disease staging was performed according to the tumor–node–metastasis (TNM) system of the American Joint Committee on Cancer/the Union Internationale Contre le Cancer (AJCC/UICC). The Nottingham system was used to determine the tumor grade. The collection of tumor specimens, survey data, and clinical and pathological information was reviewed and approved by the University of Maryland Institutional Review Board for the participating institutions (UMD protocol #0298229). IRB approval of this protocol was then obtained at all institutions (Veterans Affairs Medical Center, Union Memorial Hospital, Mercy Medical Center, and Sinai Hospital). The research was also reviewed and approved by the NIH Office of Human Subjects Research (OHSR #2248).
Enriched tumor epithelium and tumor stroma from 35 fresh-frozen surgical breast tumors was obtained by laser capture microdissection (LCM) as described [44]. In brief, frozen eight-micron serial sections from OCT-preserved frozen tissues were prepared and mounted on plain, uncharged microscope slides. One Hematoxylin/eosin-stained section of each specimen was reviewed by a pathologist before commencing dissection. The pathologist indicated which representative sections of the tumors should be microdissected. LCM was performed at the NIH Collaborative Research LCM Core Laboratory with the Pixcell II LCM system (Arcturus, Mountain View, CA). At least 3000 to 5000 cells were obtained per specimen. Total RNA was isolated using the PicoPure protocol (Arcturus, Mountain View, CA). The mRNA was amplified with two linear amplification steps by in vitro transcription using the MEGAscript T7 kit (Ambion, Austin, TX) followed by the labeling step using the BioArray HighYield RNA Transcript Labeling Kit T3 from Enzo Life Sciences (Farmingdale, NY). Labeled cRNA was hybridized onto Affymetrix HG-U133A GeneChips. Cel files with the normalized expression data, and additional tumor marker information, were deposited in the GEO repository (GSE5847). Table S4 lists the GEO accession number for the Cel files of each sample.
All chips were normalized with the robust multichip analysis procedure [45]. Gene lists comparing expression of tumor epithelium from African-Americans to tumor epithelium from European-Americans and tumor stroma from African-Americans to tumor stroma from European-Americans were generated using moderated t-scores to obtain P values that are false discovery rate (FDR)-controlled [44]. Prediction analysis for microarrays (PAM) was used to classify patients as either African-American or European-American [46]. Pathway and disease association analyses were performed with the in-house WPS software [47] and a P≤0.01 cutoff point for inclusion of differentially expressed genes. Biological processes were annotated according to Gene Ontology Biological Processes (GOBP) (Gene Ontology Consortium: http://www.geneontology.org). A one-sided Fisher's exact test was used to determine which biological processes had a statistically significant enrichment of differentially expressed genes. If the microarray analysis yielded several significantly differentially expressed transcripts that all encoded one gene, only one entry of this gene was used for significance testing. We then compiled the Fisher's exact test results for cluster analyses and displayed the results in color-coded heat maps to reveal the patterns of significantly altered biological processes and pathways. The color coding of our heatmaps is related to the enrichment of genes in a biological process/pathway (−Log(P value)-based) with red indicating a higher enrichment. A disease association analysis was conducted using both our WPS software and information provided by the genetic association database (http://geneticassociationdb.nih.gov). In this analysis, we assessed whether differentially expressed genes between breast tumors from African-American and European-American patients had previously been associated with other diseases, as indicated by the genetic association database, and whether these disease-associated genes, were significantly enriched in the breast tumor gene signature using the one-sided Fisher's exact test. The results were displayed in a heatmap. We also performed a Gene Set Enrichment Analysis [48] to find significant overlaps between race/ethnicity-related gene signatures in breast cancer and published signatures archived in the molecular signature database (http://www.broad.mit.edu/gsea/msigdb/).
Functional connections between gene signatures derived from the comparison between African-American and European-American breast patients and gene signatures induced by small molecules (164 molecules that target cancer and other diseases) were explored using the Connectivity Map database at http://www.broad.mit.edu/cmap. The database is a collection of genome-wide transcriptional expression data from cultured cells treated with bioactive small molecules at different concentrations and pattern-matching algorithms that enable the discovery of functional connections between drugs, genes and diseases [19]. The significance of a negative or positive correlation (permutated P value) between a query signature, e.g., a list of differentially expressed genes (P≤0.01) from the comparison between African-American and European-American breast cancer patients, and the expression data from a cell line treated with a small molecule is calculated based on the likelihood that the correlation between these two lists is a product of chance as described in the manual of cmap.
Total RNA was extracted from 59 fresh-frozen breast tumors (bulk tissue) using the Trizol method and subjected to reverse transcription for quantitative PCR (qRT-PCR). Twenty-eight of the tumors were from African-American patients and 31 were from European-American patients. None of those tumors was used in the gene expression profiling study. qRT-PCR was subsequently performed in duplicate using the TaqMan PSPHL, CRYBB2, and HLA-DQ expression assays (Applied Biosystems, Foster City, CA), which include pre-optimized probes and primer sets for these genes. The CRYBB2 assay was designed to specifically target the Affymetrix microarray probeset for this gene. Data were collected using the ABI PRISM® 7500 Sequence Detection System. The 18 s RNA was used as the internal standard reference. Normalized expression was calculated using the comparative Ct method and fold changes were derived from the values for each gene. A power analysis was performed with the publicly available PS software [49], [50] to assess that the chosen sample size was sufficient to detect a 1.5-fold difference or greater in expression between the two patient groups with an assumed standard deviation of 0.6 and α<0.05 in a two-sided t-test. With these assumptions, we had a power >90% to detect a statistically significant difference between 28 African-American tumors and 31 European-American tumors.
Fresh-frozen tumor samples were crushed into small pieces in liquid nitrogen and homogenized in 2 ml of M-PER lysis buffer containing protease inhibitors and iodoacetamide (all Pierce Biotechnology, Rockford, IL). Protein concentrations were determined with the Bio-Rad Protein Assay (Bio-Rad Laboratories, Hercules, CA). Western blot analysis was performed according to standard procedures and 50 µg of total protein were loaded per lane. The following antibodies were used to visualize the membrane-bound proteins: 1100 diluted mouse monoclonal antibody for HLA-D (MHC class II antigen) (Abcam, Cambridge, MA); 1 µg/ml rabbit polyclonal antibody (Ab2) for autocrine mobility factor receptor (gp78) [17].
Formalin-fixed and paraffin-embedded 5 µm slides were deparaffinized and placed into citrate buffer for antigen retrieval. To detect FoxP3, slides were pre-treated with trypsin for 10 min at 37°C prior to antigen retrieval. Slides were microwaved and rinsed in 1× phosphate-buffered saline (PBS) buffer. Endogenous peroxidase was blocked using the DakoCytomation Envision System-HRP blocking buffer according to the manufacturer's protocol (DakoCytomation, Carpinteria, CA). After an overnight incubation with the primary antibody at 4°C, slides were washed in PBS and incubated with a corresponding HRP-labeled secondary antibody using the DakoCytomation Envision System reagents. Slides were washed after 30 min incubation at room temperature, were stained with DAB, and counterstained with Methyl Green. Marker expression was evaluated using the following primary antibodies: 1100 diluted monoclonal DO-7 antibody (DakoCytomation) for p53; 1100 diluted rabbit polyclonal antibody (DakoCytomation) for c-erbB-2 (HER2); ready-to-use monoclonal Ab-2 (Clone HE12, cross-reacts with the C-terminus) antibody (Lab Vision Corp., Fremont, CA) for cyclin E; ready-to-use mouse monoclonal Ab-1 (Clone JC/70A) antibody for CD31 (Lab Vision Corp., Fremont, CA); ready-to-use mouse monoclonal Ab-3 antibody for CD68 (Lab Vision Corp.); ready-to-use mouse monoclonal antibody for CD138/syndecan-1 (Lab Vision Corp.); 11500 diluted rabbit polyclonal antibody for FoxP3 (Abcam); 1250 diluted mouse monoclonal antibody for cytokeratin 5 (Lab Vision Corp.); and ready-to-use mouse monoclonal antibody for EGFR (HER1) (Lab Vision Corp.). Nuclear p53 expression was scored positive if more than 10% of the tumor cells expressed nuclear p53, as described [44], [51]. To score the immunohistochemistry of cyclin E (nuclear), cytokeratin-5 (cytosolic), EGFR (membrane-bound), and HER2 (membrane-bound), a combined score of intensity and distribution was used to categorize the immunohistochemical staining for protein expression according to a standard protocol [52], [53]. Intensity received a score of 0 to 3 if the staining was negative, weak, moderate, or strong. The distribution received a score of 0 to 4 if the staining distribution was <10% positive cells, 10%–30%, >30%–50%, >50%–80%, and >80%. A sum score was then divided into four groups as follows: (1) negative=0–1, (2) weak=2–3, (3) moderate=4–5, and (4) strong=6–7. Negative to weak staining was scored as being negative. Moderate to strong nuclear staining was scored as being positive.
In accordance with the literature [10], basal-like breast tumors were defined as being ER-negative and HER2-negative, cytokeratin 5-positive and/or HER1-positive. The ER status was obtained from medical records. Basal-like breast cancers, as defined by these criteria, were significantly associated with an aberrant tumor p53 status and accumulation of nuclear cyclin E expression (each P<0.001). Both have previously been described as markers of basal-like breast cancers [54], [55].
The quantification of the tumor microvessel density was performed on CD31-positive microvessels according to the method of Weidner et al. [13]. If the available tumor section did not contain representative fields for the count, the tumor was not scored. The number of macrophages and T regulatory cells in the tumor specimens was determined by counting the number of CD68-positive macrophages and FoxP3-positive T-regulatory cells per 250× field in 3 representative fields. If the available tumor section did not contain 3 representative fields for the count, the tumor was not scored.
Stata 7.0 (Stata Corp, College Station, TX) statistical software was used for data analysis. Statistical tests were two-sided and an association was considered statistically significant with P<0.05. The t-test and the Wilcoxon rank sum test were applied to analyze the relationship between race/ethnicity and continuous data. The Spearman correlation coefficient was calculated for correlation analyses of continuous and categorical data. The P for trend was determined by Spearman rank correlation. The χ2 and Fisher's exact tests were used to analyze dichotomized data and multivariate logistic regression was used to calculate odds ratios. To generate dichotomized data for immunohistochemistry, scores were divided into moderate to strong versus negative to weak, or into strong versus negative-moderate. Continuous data, such as CD31 and CD68 counts, were dichotomized into low and high using the median value as the cutoff.
Disease association analysis. Shown is a heat map. The list of differentially expressed genes (P≤0.01) comparing tumor epithelium from African-American breast cancer patients (AA) with tumor epithelium from European-American patients (EA) was analyzed for their relationship with other diseases using the genetic association database. The red color indicates common associations between differentially expressed genes in a gene list, e.g., AA versus EA (all tumors), and other diseases. The disease association analysis was performed for four gene lists: AA (n=18) versus EA (n=17) for all tumors combined; AA (n=13) versus EA (n=5) for ER-negative tumors, AA (n=5) versus EA (n=11) for ER-positive tumors and ER-positive (n=16) versus ER-negative tumors (n=18). Red color intensity is a surrogate for the strength of the association.
We would like to thank Raymond Jones, Audrey Salabes, John Cottrell, Leoni Leondaridis, Glennwood Trivers, Elise Bowman, and personnel at the University of Maryland and the Baltimore Veterans Administration, and the Surgery and Pathology Departments at the University of Maryland Medical Center, Baltimore Veterans Affairs Medical Center, Union Memorial Hospital, Mercy Medical Center, and Sinai Hospital for their contributions in the collection of tissue specimens and the clinical data. We also would like to thank Theresa Whiteside for providing the FoxP3 immunohistochemistry protocol.
Competing Interests: The authors have declared that no competing interests exist.
Funding: This research was supported by the Intramural Research Program of the NIH, National Cancer Institute, Center for Cancer Research. Damali N. Martin is supported by the Cancer Prevention Fellowship Program, Office for Preventive Oncology, National Cancer Institute. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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text:
Short breaks for children and young people with a disability
Review of short breaks
Our approach to short breaks is currently being reviewed and if you would like to contribute to the process please contact 020 8489 3205.
What are short breaks?
Haringey offers short breaks (previously known as respite care) to children and young people who have a disability and their families. This is to enable parents to sometimes have a break from the responsibility of the day-to-day care, and also to enable children and young people to have the opportunity to enjoy activities with their peers.
The short breaks available at the moment take different forms:
- children and young people may attend day activities or after school clubs
- children may go out during the day with a carer or a befriender
- children may stay overnight in a carers home
- children may stay overnight in a residential setting
- help may be provided in the family home to help with some of the household tasks such as getting the children ready for school or bed
- nursing care may be provided in the child's home if appropriate
Money may also be provided in the form of Direct Payments so that families can arrange and pay for their own short breaks.
In Haringey short breaks are agreed at the Integrated Additional Services panel (IASP) The Panel is made up of people representing the health; social care; education; and housing services.
Find out more
Short breaks are offered at:
- The Haslemere Centre
Haringey's Haslemere Centre offers support and short breaks for disabled children and young people. It provides a weekend residential short break service and one mid-week overnight provision. The service provides residential care for up to six children and young people, in addition to day services during the week and in school holidays
- Family Link Service
Family Link is a day fostering service for children and young people with special educational needs and disabilities. Our Family Link Carers are specially trained foster carers who provide day respite and some overnight care for children who would not otherwise be able to spend time away from their parents. The family Link carers may care for the child in their own home, or take them out on trips and activities
For more information about short breaks please contact the team administrator in the Disabled Children's Team:
Disabled Children's Team
40 Cumberland Road
Wood Green
Tel: 020 8489 3947
- If the person you care for is an adult visit our Respite Breaks page.
Attached files
|access to short breaks.pdf
|Short Breaks services statement
|information on how decisions are made.pdf
Page Last Updated:
How can we improve this page?
Use this form to let us know what you think of this page. All comments are reviewed by us once every week.
This form is not for service issues or requests - all such comments should go to Customer Services.


text:
Amerisave Mortgage
Consumer Reviews and Complaints
What do I like about your service? 4 words: HOLLY **... CHRIS **!!! This lady and gentleman are AWESOME! Their responsiveness, clarity in explaining the process, pleasant & professional demeanor, and just overall exemplary service excellence has been phenomenal. They set the bar high and deliver at every turn in every single one of these areas daily. There hasn't been one moment where I was unclear on what's been required of me or what the next steps are in the process. Thank you for a pleasant experience. (I will be a returning customer in the future.)
We appreciate your repeat business!
Original review: Jan. 5, 2017
This is my 5th loan from Amerisave. Obviously I am a happy Amerisave customer here. In the beginning, I tried 2 to 3 lenders to compare & then chose Amerisave based on great rates & ease of use. I did that once more for my second loan. After that I stopped doing further research and now I just trust Amerisave to that degree. What I like most is: Great rates & low cost, Ease of use, everything online & paperless, And the IMPORTANT one: No hidden costs, no surprises, no gimmicks. What I see is what I get. Not many businesses in America in this category anymore.
Kellie, we're thrilled to hear that we exceeded your expectations. We'll be sure to let Frank, Josh and Fellon know what a great team effort they displayed.
Original review: Jan. 3, 2017
I was extremely apprehensive when I initially applied for my loan because the process was so easy. I kept waiting for a bump in the road but my entire loan process was seamless from start to finish. Frank helped with me the initial application and then Josh was there to also assist--they were both fantastic and available to answer any question. Fellon was my loan processor and was simply magnificent! She, too, answered all of my questions in an extremely speedy fashion and believe me, I had a ton of questions! Fellon really took the time to explain everything and put my mind at ease! Fellon made the process so much easier and I will forever be grateful to her, Frank and Josh.
My loan "team" was amazing--totally surprised me because I wasn't expecting a good experience based on previous experiences with other lenders. My family and I thank you for all of your efforts--they do not go unnoticed! Fellon, Frank and Josh really took the time to walk us through everything without a hitch. Our entire loan process was just at 30 days--quite impressive! I cannot thank my team enough for everything!
I was very hesitant to refinance my mortgage, and especially concerned about doing it online, but using Amerisave has been an incredibly problem-free experience when I consider how complicated I thought a mortgage refinance was going to be. Because I was such a cautious customer, early on, I wrote to Aaron **, my Amerisave representative, asking him if he thought I was being too difficult, but he assured me that I was in the right place. Today, my wife and I received the notice that the old mortgage has been paid off, and we are into the new mortgage. We are saving over $300.00 per month. We are very happy with our experience at Amerisave, and we would gladly use them again. A big thank you to Aaron **, Amanda **, and Rebecca ** for their customer service and patience.
Maryellen ** is an extraordinary loan processor. She picked up a fumbled ball and turned it into a touchdown with her intelligence, hard work and dedication. She overcame several obstacles to get the job done. We felt she was genuinely concerned about getting our mortgage loan refinanced. It was a pleasure working with her. I will tell family, friends and acquaintances about her and that the entire process at Amerisave from the loan origination with Eric **, to the lady in underwriting, Maryellen's supervisor who waived a fee for us and Maryellen processing and closing was amazing. And that Amerisave lived up to their promise of great rates and low fees. My wife and I sincerely thank you all for doing such a great job.
Great customer service is important to us Scott. Thanks for the review!
Original review: Jan. 31, 2017
The loan originator and the loan processor were both very helpful in getting the loan approved quickly. The entire process went smoothly. It took us less than three weeks from the time we inquired about the loan to when we were scheduled to close on our loan.
We are very happy with the service, Kristen **, and Kristina **. Very friendly, fast and professional. In 3 weeks all was done. Would recommend the company. They told you all the options and they worked for you.
We really do care Rossie! Thanks for the review!
Original review: Jan. 30, 2017
They are willing to go the extra mile to assist you. They not only care about your business they care about you. They work to meet your needs. They truly want to assist you in making your life better by being successful in the outcome of your refinancing.
Jeff and Ian in particular have been very efficient--Jeff in particular. Jeff is excellent upper management material but you will lose a very efficient, personal sales person, if he becomes upper management. One of the most knowledgeable people in the business and I am not easy to please.
We're happy to hear that Liz! We appreciate your business and your recommendations!
Original review: Jan. 30, 2017
When we began this process, we were apprehensive as we had a couple of bad experiences with a couple of other lenders. Jessica ** and the team at Amerisave were able to lay to rest all of our apprehensions. The professionalism, the promptness, the knowledge, the speed at which things get done, all were simply incredible and impressive. Every single person we have interacted with has made this refinance a most pleasant experience. I will be recommending this team to everyone I know.
How do I know I can trust these reviews about AmeriSave Mortgage Corporation?
- 743,097 reviews on ConsumerAffairs are verified.
- We require contact information to ensure our reviewers are real.
- We use intelligent software that helps us maintain the integrity of reviews.
- Our moderators read all reviews to verify quality and helpfulness.
For more information about reviews on ConsumerAffairs.com please visit our FAQ.
Way to go Geneva! Thanks for the feedback, David!
Original review: Jan. 30, 2017
Friendly and helpful service with positive attitude to continue checking rules. The primary mortgage contact was professional and responsive of my questions and needs while I provided documentation. She made a difficult task easier and smooth for us. Geneva is a outstanding employee.
We believe great customer service is key, Kay! Thanks for the review!
Original review: Jan. 30, 2017
I received excellent customer service from Amerisave. Andrew and Daphne, our customer service representatives were very helpful. They were very informative and always kept the lines of communication open during our loan application and processing. I would recommend Amerisave for your loan or refinancing needs.
The individuals who handled my refinance were excellent. Richard ** was very helpful in the initial stages and Stacey ** was GREAT in seeing the process through. Finally, I love your website as it is easily the most informative website that I came across when I was deciding which company to take my business to.
Glad you found our services easy to use Rick! Thanks for the feedback.
Original review: Jan. 30, 2017
The service was very easy. Did application and sent in most items needed the first day. Process was easy, just scanned the paperwork and uploaded it. My file was assigned to Irene ** who was very easy to work with. She always kept in contact via email or phone to let me know what she needed or how the process was going. Thanks Irene. You were great!
Thanks for all of the feedback Ryan! We're happy you found our services useful!
Original review: Jan. 28, 2017
Highest recommendation to refinance with Amerisave. My experience consisted of open communication, constant unsolicited but properly timed updates, easy accessibility to representatives, my questions were always answered timely, the friendliness of the staff, ease of use of the website and its status update board, electronic documentation/upload was very convenient as well. We were very satisfied with Todd ** and Erin **: both are extremely professional, friendly, easy to talk to, always answered our questions and made sure we understood, and were both helpful in assisting us with our first refinance...Couldn't have done it without you and your team. Thank you both!
Thanks for the review, Michele!
Original review: Jan. 27, 2017
All staff were positive and supportive. I will use as well as recommend Amerisave again. I appreciated their patience and helpfulness. I do not enjoy the process of finding documentation but your staff made it painless and not pressured. Thank you very much for all that you did.
Customer service is important to us, Ricardo! thanks for your positive feedback!
Original review: Jan. 27, 2017
I had started the refinance process before with a couple of other lenders, only to be hung up for 2 months and no loan. I decided to try AmeriSave. First call with my Loan Originator and the next day he had me turning in the Docs they needed. Being able to use AmeriSave's Portal and checklist to receive the approvals was fast and easy. I usually had an answer by the next day. My loan was completed on my home computer from the comfort of my home. At closing, my Title Company made the comment, "Wow, that was fast!" Thanks to my Loan Originator, Robert ** and my Loan Processor, James ** for their expediency and great customer service.
Thanks for the review, Pamlea! We appreciate your business!
Original review: Jan. 27, 2017
Everyone who helped me through this process was extremely patient and helpful. The mortgage process can be a painful one but the team at Amerisave did their best to get me through in as fast and painless a way as possible. Tim, my loan originator, said he'd help me get the loan I needed and was as good as his word. Chris **, my processor was very patient and understanding even when it took me a while to get everything submitted. He was always available to answer my questions and stayed in touch so if I got confused about anything he could help me out. The closing was set up at the time and place convenient for me and went off without a hitch. I don't think you could go wrong working with Amerisave for your financing needs. Thank you for everything. All the help is truly appreciated.
I am very content with Amerisave and all the staff that helped me along way including Mr. Andrew **, Mrs. Kristen **, and Mrs. Irene **. The document portal's ease of use made a positive difference. I would gladly recommend to friends and family!
Thanks for the positive feedback, Clare! We're glad your experience was easy and enjoyable!
Original review: Jan. 26, 2017
Hands down, this was the best and easiest refi experience! Jessica, Shawanda, Ben, and the entire AmeriSave team were extremely professional, responsive, and efficient. Each Amerisave representative demonstrated exceptional knowledge of VA loans and related issues. I would definitely recommend Amerisave to anyone considering a refi.
I had a great experience with Amerisave Mortgage, it was the smoothest financial transaction I have ever had. Robert ** and Robert ** most helpful. They kept me informed and also kept the process moving. Every timeline they gave me was met.
Very professional, very friendly. Quick moving and the client portal is very smooth and easy to navigate. Amanda is the best!! Very professional and friendly! I would work with her again and again! Keep it up Amerisave!! Couldn't ask for a better experience!!
Great communication from everyone at AmeriSave. The AmeriSave crew is on top of everything! The electronic communication keeps the applicant up to date throughout the process. This is the most efficient application and approval process for a mortgage that I have experienced.
I was very impressed with the professionalism. All my questions were answered quickly and I was encouraged to call anytime. They kept me updated daily. Daniel and Jeremy were very kind. Several times I had to call back needing clarification and they always assured me they were more than happy to answer all questions any time.
Thanks for the feedback, Linda! We appreciate your business and look forward to your future business!
Original review: Jan. 25, 2017
Very pleased with our overall experience with Amerisave. Would recommend them to anyone. The team that worked with us was great especially James **. He was kind, patience, professional and very knowledgeable a real asset to Amerisave Mortgage. Thanks James. Other members on the team was also helpful. I had heard some negative things about Amerisave but I must say my dealings with them was all positive. In the future if I need a mortgage company I would most definitely use them.
Everything with my refinance has been handled promptly and efficiently. All the members of the Amerisave team have been knowledgeable and helpful during the application and documentation process. We look forward to a similarly efficient closing process with this loan.
Johan ** is so professional and courteous. He is very knowledgeable about the whole lending process and explains things in a manner in which it is easy to understand. I would recommend him to anyone that I know who is considering purchasing a home.
So far, the process is going great. Thanks to Trevor **. He follows through on everything and answer every question that I have concern with. The portal is very informative and is transparent with the process. I am looking forward in giving my final review after the final process.
Fast. I've waited up to 2 weeks for an approval that Justin ** gave me in less than a day. I was referred to Amerisave by a coworker that was extremely happy with their service as well and will always recommend this company from here on.
Amerisave has been a great lender refinancing our home so far. All the people I've dealt with along the way have been very nice and communication has been great. They respond very quickly and are on top of getting this loan taken care of. Also their rates are great that nobody can touch.
Professional and efficient. Everyone from the loan officer to his staff and the follow-up group did their jobs well. Those who did not directly work in the office, the ones they suggested, such as the appraisal personnel were also professional and efficient.
The person I was working with was everything I could ask for while doing his job. Extremely helpful, knowledgeable, and even funny when needed to lessen the stress of the process. The professionalism was apparent all the while, and rapid response to questions was appreciated.
This is the second refinance we have done with Amerisave and both times we worked with Dan ** and Ben **. This time was a bit more complicated because it was a VA loan but both of them persevered to make the process easier. We appreciate their efforts and almost feel like they are friends. We would certainly, and have, recommended Amerisave to others. Thank you!
Amerisave staff are very nice (Rick, Jessisa, and Brittany), wish everyone was like that. They worked very hard to get me a loan. I do not know if I got it yet, but they made it easy to apply. Thanks.
Everyone has taken all the time needed to answer all my questions. Even if it was the same question I had asked 5 minutes ago. I feel secure in this confusing process. Not having done this for quite some time, and never just online, is an experience.
Amerisave Mortgage Company Profile


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About us
The Heinrich Böll Foundation is a catalyst for green visions and projects, a think tank for policy reform, and an international network. The primary objectives guiding our work are establishing democracy and human rights, fighting against environmental degradation, safeguarding everyone's rights of social participation, supporting non-violent conflict resolution and defending the rights of individuals. We work with over 100 project partners in over 60 countries and currently maintain offices in 31 countries.
Craig Morris
Born in the United States, Craig has been living in Germany since 1992 and working in the renewables sector since 2001. In 2002, he founded Petite Planète, a translation and documentation agency focusing on renewables. He is the author of two books in German and English, has served as editor of several energy magazines, and is contributing editor at Renewables International. In 2013 and 2014, he served as technical editor of IRENA's REmap 2030, and in 2014, he won the IAEE's award for journalism in energy economics. He is co-author of the book "Energy Democracy."
Martin Pehnt
A trained physicist, Martin is scientific and managing director of the Institute for Energy and Environmental Research, where he also heads the Energy Department. He previously worked at the National Renewable Energy Laboratory (USA) and the German Aerospace Center (DLR). He now serves as an advisor for many national and international organizations, including German federal ministries, the Environmental Protection Agency, environmental NGOs, utilities, the World Bank, IRENA and the GIZ. Pehnt teaches at various universities.
Rebecca Bertram
leads the European Energy Transition work at the Heinrich Böll Foundation's Headquarters in Berlin. Her work focuses on integrating the various European energy discussions into the German energy decision-making process. Before returning to Berlin, Rebecca was the Program Director of the Energy and Environment Program at the Foundation's Washington office. She holds a Master's degree in International Affairs and Economics from the Johns Hopkins University's School of Advanced International Studies (SAIS).
Kathrin Glastra
is the Director of the European Energy Transition Programme at the Heinrich Böll Foundation's EU office in Brussels. She is responsible for the European perspectives on www.energytransition.org and coordinates the Foundation's network EnergyTransition@EU, a joint project between the offices in Berlin, Brussels, Paris, Prague, Thessaloniki and Warsaw. This network aims at discussing challenges and opportunities of energy transitions in Europe; strengthening a mutual, solution-oriented dialogue among the EU Member States and promoting visions for a European Energy Transition. Prior to joining the foundation, Kathrin worked in an EU consultancy. She studied Political Science, Law and Spanish in Münster and Aix-en-Provence and holds also an MA in Advanced European Studies from the College of Europe (Bruges).
Silvia Weko
is the project assistant for the German Energy Transition project at the headquarters of the Heinrich Böll Foundation. She is currently pursuing an MA in European History at the Humboldt University in Berlin.
Media Development
Lucid. Berlin
As a media solutions laboratory Lucid develops tools and designs which enable foundations, NGOs and institutions to inform, foster dialog and involve people. www.energytransition.org is the second international web project after discover boell that lucid has designed and produced for the Heinrich Böll Foundation.
About the project
Germany has drawn a lot of international attention for its aim to switch to a renewable energy economy and leave nuclear and fossil energy behind. A lot of the international reporting about the German Energy Transition, or Energiewende, has, however, been misleading - for instance, when it comes to the role of coal power, energy price trends, competitiveness and carbon emissions.
This website aims to explain what the Energiewende is, how it works, and what challenges lay ahead. It is intended to provide facts and explain the politics and policies to an international audience. The website highlights the effects of the Energiewende on the German economy, environment and society and addresses the most important related questions. We also aim to highlight that energy transitions can be structured very differently around the world depending on the energy mix and policy priorities of individual countries.
On our Energiewende Blog, a team of international energy experts write on how the German energy transition continues and how it relates to other countries.
All the texts and graphs except for blog posts are under Creative Commons License (CC BY SA) with the aim to make this information available to the public. We encourage you to use the materials in your work. In return, we would appreciate it if you would let us know what you have used. Blog posts can be reposted in exceptional cases. Please contact us if you wish to use this material.
We welcome your feedback and encourage you to comment and discuss the German Energiewende with us. However, keep in mind our comment policy.
If you would like to submit an article for publication, please contact Silvia Weko.


text: Support TCHS Dancing with the Rebel Stars 2017 Capital Campaign - "Always A Rebel Campaign" Rebel Open Golf Tournament Development Annual Report Annual Appeal Campaign Annual Appeal Campaign For the past decade, the Appeal for Enhancement of Technology has enabled Teurlings Catholic to excel in the global community by providing our students with state-of-the-art vehicles of communication. Our goal is to receive 100% participation from TCH parents, grandparents, pastors, volunteer boards, advisory council, faculty, and staff. When we all share in the commitment to improving our school, we all enjoy the benefits and successes of our children! Technology Enhancements made possible through generous donations to the TCH Annual Appeal: Classroom set of 31 English laptops Classroom set of 31 Microsoft Surface RT tablets 10 PCs for teachers and printers 2 HP 360 ProLiant Gen8 Servers Fiber replacement around campus along with wireless access points Promethean boards, ActivSlates, set of ActivExpressions, in addition to training Computer Lab set of 31 touch screen desktops and software 90 HP 11" Chromebooks 3 Spectrum Chromebook Carts 40 Aruba IAP205 Access Poinyd A gift of any size serves as a symbol of your commitment and support. Suggested levels include: $1,000 and above $500 to $999 $250 to $499 $100 to $249 $50 to $99 $25 to $49 $10 to $24 Spiritual Gift - Cannot contribute monetarily at this time but want to help TCH reach 100% participation by saying a prayer each morning for the success of the appeal. Click here for the 2016 Annual Appeal for the Enhancement of Technology brochure Questions? Comments? Concerns? Email us at firstname.lastname@example.com.


text:
- Archdiocese of Louisville
- Becoming a Member
- Bulletin
- Homilies
- Calendar
- Committees
- Financial Reports
- Forms
- ERE Registration
- Letter from the Pastor
- Lifelong Education
- Map to St. Martha
- Parish Council
- Sacramental Life
- St. Martha Boosters
- St. Martha School
- Staff Contacts
- Stewardship
- Volunteer Requirements
- Worship
- Youth Ministry
Welcome to St. Martha Church!
Young Adults- College age and beyond… Come as you are and who you are! Now is your chance to ask Questions and explore together all things Catholic and talk about how your generation can practice your faith in the world today.
Start-up Nights- Thursdays, March 9th and March 23rd - 7:00 PM in the basement of the Parish Office.
Facilitator: Jim Clark- Contact for more information. (502) 541-5091
Father Hamilton gave a special lecture on Monday, September 19th on the way Catholics read and interpret the Sacred Scriptures. Please click here to listen!
We, the church family of St. Martha, are a community of approximately 1,200 families that has been growing and forming since 1961.
Father Hamilton speaks on Stewardship
Server Schedule
Mass Schedule


text:
An LLM or Master of Laws degree is an academic degree, often sought by students with undergraduate law degrees who are looking to educate themselves more thoroughly in one specific area of law study. LLM programs are research-oriented and typically last for one year.
A Master of Laws, or LLM in business law is a high level degree that involves delving deeper into the intricacies of the legal system. While there are other specializations as well, this particular degree places focus on commerce and business.
Education in the United States is mainly provided by the public sector, with control and funding coming from three levels: state, local, and federal, in that order. The common requirements to study at a higher education level in United States will include your admissions essay (also known as the statement of purpose or personal statement), transcript of records, recommendation/reference letters, language tests
The City of Lansing is commonly referred to as "the heart of Michigan" and serves as the capital city of the large state. Listed as the fifth most populous in the state, the city has a solid system of education consisting of two law schools, two nursing schools, and two medical institutions. This is beside a host of other institutes found within.
Request Information Law Degrees in LLM Business Law in Lansing in USA 2017
or search for similar programs here


text:
|Procter, Thomas.
|A vvorthy vvorke profitable to this whole kingdome. Concerning the mending of all high-waies, as also for waters and iron workes. By Tho: Procter Esquire.
|Publication info:
|Ann Arbor, Michigan: University of Michigan, Digital Library Production Service
2011 December (TCP phase 2)
This keyboarded and encoded edition of the work described above is co-owned by the institutions providing financial support to the Early English Books Online Text Creation Partnership. Searching, reading, printing, or downloading EEBO-TCP texts is reserved for the authorized users of these project partner institutions. Permission must be granted for subsequent distribution, in print or electronically, of this text, in whole or in part. Please contact project staff at firstname.lastname@example.com for further information or permissions.
|Print source:
A vvorthy vvorke profitable to this whole kingdome. Concerning the mending of all high-waies, as also for waters and iron workes. By Tho: Procter Esquire.
Procter, Thomas.
London: Printed by E. Allde & are to be sold at his house on Lambard-hill, neere Olde-fish-streete, 1607.
|Alternate titles:
|Worthy worke profitable to this whole kingdome Worthy worke profitable to this whole kingdome. Description of mending highwaies.
Running title reads: A description of mending highwaies.
Signatures: A-D4.
Reproduction of the original in the Henry E. Huntington Library.
|Subject terms:
Roads -- Design and construction -- Early works to 1800.
Roads -- Maintenance and repair -- Early works to 1800.
title page
To his moste excellent Maiestie con∣cerning these proiects of the Author.
A Description of the manner how to mend high-waies.
The benefits and profits that shall or may arise vnto his Maiestie and subiects, here by art and action doing, if set on worke accordingly.
Also for waters, Riuers and their benefits.
These hereunder doth declare & make known the bene∣fits & profits that shal or may arise vpon the making of yron, if the same shal be made with & after the direction of the said Author in act & action, with true performance accordingly.
To his Maiestie for Farme or Rent.


text:
Metals and mining, Shipbuilding
First icebreaker of "Gazpromneft" to escort tankers from the Novoportovsk field is launched.Edited by Rhod Mackenzie / 2016-11-25 10:06:35
The ceremony of launching the icebreaking ship "Aleksandr Sannikov" was held at Vyborg Shipyard Head icebreaker Arc130A project built by order of "Gazpromneft".
Russian Ministry of Economic Development to support building of icebreakers for Arctic oil terminalEdited by Rhod Mackenzie / 2015-08-19 12:12:38
Interdepartmental Commission under the Russian Ministry of Economic Development will support the investment project for the construction of icebreakers for Yamal. It chose 4 projects for their inclusion in the program of support, based on project financing.
Russia continues developing design of new nuclear icebreaker "Leader" despite sanctionsEdited by Rhod Mackenzie / 2015-02-27 01:43:25
This was reported by the deputy general director of Atomflot S. Golovin during the 2rd Arctic Investment Summit.
The 2nd International Investment Arctic Summit of Development "Nanotechnology, the military-industrial complex, investment and the Arctic, as a national idea" took place in Moscow on February 24 2015.
Nuclear icebreaker "Leader" of LC-110YA series will surpass even icebreakers LK-60 of the latest generation, intended for Yamal fields.
Power of leader is 110 MW, and it will be able to overcome ice with thickness of 4.5 meters, which will make the navigation on the Northern Sea Route year-round.
Hull beam of the icebreaker will be about 50 meters, which will enable to use it for convoying large tankers.
For comparison, nuclear icebreaker "Arktika" of the LK-60 series, which is now being built, will have capacity of 60 MW and will be able to overcome the solid ice with thickness of 3 meters.
"Rosneft" asks 400 billion roubles for the reconstruction of the "Zvezda" shipyard.Edited by Rhod Mackenzie / 2014-12-15 09:46:54
"Rosneft" had asked the government 400 billion roubles from the National Welfare Fund for the reconstruction of the Far Eastern shipyard "Zvezda", the source in the United Shipbuilding Company told RBC. This information was confirmed by a source in "Rosneft", stating that the amount of "similar to the truth".
In August 2013 Igor Sechin offered the oil company to pass the protracted project of "Zvezda" modernization. Vladimir Putin supported this idea, but stated that USC should have remained in the draft as a junior partner. At a meeting with President Vladimir Putin, which took place on November 13 in Vladivostok, it was decided that "Rosneft" is engaged in a project on its own, including the search for sources of financing, the official of the RF Ministry of Industry and Trade states.
Igor Sechin to take United Shipbuilding Corporation in tow – the Corporation calculates on Rosneft more and moreEdited by Rhod Mackenzie / 2013-04-25 02:00:39
The Rosneft's Head Igor Sechin has actively got into gear of the United Shipbuilding Corporation (OSK). The current criticism of OSK has started from him – against the background of this, the discussion of the change of the corporation's Head became more active. Now OSK calculates on large-scale orders from Rosneft too, connecting resumption of its largest projects (construction of new shipyard in Kotlin and Zvezda in the Far East) with them. Igor Sechin has already raised a question about the situation in OSK at the level of Vladimir Putin; the meeting will take place in his office on May, 6. Some sources of the Kommersant expect to get an announcement of personnel replacements that time.
The General Director of the Baltic shipbuilding plant (a part of OSK) Alexander Voznesensky stated that the project to construct New Admiralty shipyard on the island of Kotlin in Kronstadt, "might be revived".
South Koreans to build a coal terminal in PrimoryeEdited by Rhod Mackenzie / 2013-02-26 03:15:27
The South Korean energy company, Korea Western Power announced the project of the building of a coal terminal with the capacity of reaching 10 million tons in the south of Primorye. The company is also going to assist the development of the coal-mining enterprises in the Far East. The negotiations were conducted in Seoul by the RF Presidential Envoy in the Far Eastern Federal District, Viktor Ishayev and the CEO of Korea Western Power, Kim Mung Doc. Read more »
Severstal increases supplies of special steel to shipbuilding industry 2 timesEdited by Rhod Mackenzie / 2012-11-14 01:59:04
For the first 10 months of 2012, the Cherepovets metallurgic plant (CherMK), one of the largest integrated steel plants in the world (a part of the division Severstal Russian Steel) supplied special steel to enterprises of the shipbuilding industry by 2 times more than in the same period of 2011.
Special ship steel (cold-resistant steel grades AK and AB) is used, mainly, for defense orders, particularly for the construction of submarines and supermarine war ships. Read more »
Ruspolymet to launch a forging unit costing 1.5 billion roubles in Q4Edited by Rhod Mackenzie / 2011-04-26 03:11:38
OAO "Ruspolymet" will put a forging unit of Italian "Danieli" into production in quarter 4, 2011, they stated in the company to PRIME-TASS.
The project's cost is assessed at 1.5 billion roubles. The open forging press of 1600 tons breaking strain, a rail-riding manipulator of 5 tons carrying capacity and a mobile manipulator of 12 tons lifting capacity form part of the unit. It will also comprise furnaces of "Bosio" manufacturer (Slovenia), such as box-type heating gas furnace and bogie-type thermal gas furnace. Read more »
CherMK "Severstal" increased special ship-building steel shipment in 2010Edited by Rhod Mackenzie / 2011-03-11 02:04:53
The Cherepovetsk metallurgical combine, the main steel asset of the division "Severstal Rossiyskaya Stal" increased the shipment of special ship-building steel by twice, up to 5.4 thousand tons in 2010 against 2009, D.Goroshkov, sales manager of CherMK "Severstal" said.
CherMK "Severstal" is an exclusive supplier of special high-resistance steel to the two largest enterprises of the military sector of Russia, OAO "Production Association "Sevmash" and OAO "Admiralteiskoe verfi". The combine increased special steel supplies to these enterprises by 22% in 2009 against 2008. Read more »


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|Reviews for What Began as a Southern Belle
| FeliciaFelicis chapter 7 . 3/1/2015
It's been a while since you've updated, but I'd very much appreciate if you would do so once again. This is a great story and I would like to read more.
| Guest01 chapter 2 . 5/30/2014
This story is really really good! Can't wait to read more! :)
| Fire and Ash chapter 7 . 2/18/2014
Good story so far! I hope you update soon CX
| kurounue13 chapter 7 . 6/15/2011
i love it please update soon! yay for Chavez love!
| LauRa-ReaDinG-XoX chapter 7 . 3/20/2011
I love this story, i think its one of the best. I would love it if you updated faster :D
| converse-junkie chapter 6 . 12/12/2010
| ObsidianNight chapter 6 . 9/22/2010
A plesant read, well written with a nice flow to the story. I'm hoping there will be more chapters posted soon.
| SunlitMercy chapter 6 . 9/18/2010
| Remus san chapter 3 . 8/15/2010
Next chapter?Soon?Please?
| CarvedKid chapter 3 . 6/21/2010
Chavez is so charming to Grace. I love it, and I love how you write! You write and portray the characters perfectly and I really like Grace. Please update soon! :)
| secondchance123 chapter 3 . 6/8/2010
that was cool :D I like your story. I hope you update soon :)
| FireGoddess528 chapter 3 . 6/6/2010
D'awww Chavez is such a sweetie pie. Honestly, I'm very surprised your fic does not have a lot of reviews. It's very well written, and your character isn't one of the typical girl dresses like a boy and is just as rough and tough as the guys. While those stories can be entertaining, your OC is more like how a real woman would have been back in the time of Billy the Kid. I can't wait to read more, (hopefully there will be more Grace/Chavez cuteness) so please update soon.
| IluthraDanar chapter 2 . 5/19/2010
I love Young Guns!I like how you incorporate the film with a new character. I hope you continue. So many people start and then never finish.
| cheshirekadi chapter 2 . 5/11/2010
i love your i was wondering is there gonna be romance like out of curiosity cuz even w/o romance it would be cool but if there is with who or would it be a surprise?


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Decorating the Farm for the holidays fills me with joy and gratitude. Our property is blessed with holly bursting with red berries, hundreds of boxwood bushes and tall pine trees. I use them all to 'deck' both the inside and outside of our house. There's nothing prettier than fresh greens – and for us, it's wonderfully economical to cut our own.
I spent the weekend filling window boxes and hanging wreaths.
And today – now that my tree is finally trimmed, and garlands are sufficiently swirled….
I thought I'd share a few of my upcoming holiday plans with you…
Next week, I've invited neighbors, family and friends to my annual Caroling Party.
It's always a sweet party
Monsieur Caspari plays carols on the piano – we sip champagne and nibble on homemade cookies — singing from songbooks long ago created by my grandmother for her own parties. My favorite song? 'The Holly and The Ivy'.
As our guests float out the door – humming their favorite tunes , I'll hand out Christmas crackers for them to enjoy in their own homes this season. I can't seem to collect enough of them at Caspari. Our children — no matter how old they get – love wearing the little paper hats and sharing the enclosed jokes and toys – all found inside each cracker.
Here are a just a few more of the many darling Caspari crackers available this season.
On to Christmas Eve – our family night.
The Christmas Eve table Caspari created for their Charlottesville Shop was a show stopper.
The china and serving dishes, flown in from Au Bain Marie Paris —-featuring pheasants, stag's heads, ducks and acorns—are so festive. So of course, I had to have them — and will cart them up to our ski house in Wintergreen to enjoy after Christmas.
Can you see how the Caspari ladies used rolls of wrapping paper to line their table? Brilliant! What a perfect way to add a pop of holiday pattern without investing in costly linens.
I already know how I'll set the Christmas Day Brunch table. With 'Farm to Stable', of course!
Did you spy the wrapping paper 'table runner' again?
And I think the Vista Alegre lettuce plates really add the perfect touch to this cozy table – so I bought a few of them too — my early Christmas gift to our kitchen!!!
With a bit more shopping, and lot more cooking, I think I'm holiday ready. Hope you are, too!
A very Merry Christmas to you from our Farm!!!xx, Coco


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Data on the Consumer Price Index ex Food and Energy for December is due at 3:30 pm (GMT+2) in the US. On a year-to-year basis, the index is expected to grow from 2.0% to 2.1%, and remain unchanged at 0.2% on a month-over-month basis. The index is considered a more precise measure of inflation and represents a price change for the fixed basket of goods and services that excludes food and energy. A growth in the index can support the Dollar.
The material published on this page is produced by LiteForex and should not be considered as the provision of investment advice for the purposes of Directive 2004/39/EC; furthermore it has not been prepared in accordance with legal requirements designed to promote the independence of investment research and is not subject to any prohibition on dealing ahead of the dissemination of investment research.


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Recent Articles on Beyond OCD
Being Proactive in Help your Child
If ever there were a time to be proactive, it's when your child exhibits behavior that may be symptomatic of OCD. If you think your child may have OCD – or you're not sure if the behavior is OCD, some other mental disorder or "normal" (but frustrating) developmental behavior – don't wait. Here are some steps you can take to get started and, if your child or teen is diagnosed with OCD, how you can make the most of treatment: Talk with your child's doctor. read more »
OCD At School - Helping a Child
OCD At School Teachers and other school personnel may be powerful allies in identifying, assessing and treating OCD. Because they interact with students for extended periods of time during the school year, they are uniquely positioned to observe behavior that deviates from the norm. School personnel, therefore, may play a critical role in helping identify behavior that is symptomatic of OCD. read more »
Symptoms in Teens - What Other Symptoms Might Be OCD?
OCD symptoms can be as varied as the people who have them. But there are some "warning signs" that can indicate OCD or another disorder. Remember, OCD and other disorders ARE treatable. Noticing what's wrong is a step in the right direction toward getting better. Could any of these situations describe your situation? read more »
What the Heck is OCD?
What the Heck is OCD? With OCD, "communication errors" occur when information is transmitted between different parts of the brain. Certain chemicals that help transmit messages in the brain aren't working like they're supposed to. This causes unwanted, disturbing thoughts, fears or worries, including thoughts that can be the opposite of what you really believe about things like religion, violence or sex. read more »
Beyond OCD : Just For Teens Section
Just For Teens To the Point: You Have OCD. Now What? Having Obsessive Compulsive Disorder isn't the end of the world. Obviously, you'd rather not have it. But just like other medical conditions such as diabetes and asthma, there is a treatment for OCD. You will be able to live with OCD and manage its symptoms. read more »
What Doesn't Cause OCD in Children
Children who have OCD didn't do something to cause it. And it's important to know that parents don't cause a child's OCD, either. It isn't caused by the way parents talk with their children or don't talk with them. It's not caused by how children are disciplined or not disciplined or how they were toilet-trained. read more »
Causes Of OCD In Children
Causes Of OCD In Children Parents don't cause OCD in their children by some flaw in their parenting abilities. OCD isn't caused by how you talk with your kids or don't talk with them, or how you discipline them. And it doesn't matter whether or not both parents work, there is a stay-at-home Mom or Dad, the parents are divorced or a parent remarries after divorce. read more »
When Someone You Love Has OCD
When Someone You Love Has OCD Obsessive Compulsive Disorder (OCD) affects millions of people in the U.S. If one of those people is someone you love, you know that the impact of OCD reaches far beyond the person who has been diagnosed with this disorder. Much has been written about OCD and its treatment. Much less has been written about the spouses, families and friends who must watch a loved one suffer, and who must also live with the effects of the disorder every day. read more »
Managing Emotions & Attitudes
It's important to realize that when a family member has OCD, everyone in the family experiences emotional ups and downs. One day, you may feel as if your loved one is making great strides in the fight against OCD; the next day, it may seem that he or she isn't even trying. If your loved one is taking medication, he or she may also experience some unpleasant side effects initially. read more »
OCD Information for Individuals
OCD Information for Individuals If you're looking for information about OCD, you've come to the right place. Learning about OCD is the first step in overcoming this potentially heartbreaking disorder. If you or someone you love suffers from OCD, you're not alone. Millions of people have it. OCD doesn't discriminate. read more »
Medications Approved for Treatment of OCD
Medications known as serotonin reuptake inhibitors (SRIs) have been used for many years to treat OCD. An SRI known as Anafranil has been available the longest and is the best-studied medicine for OCD. . Anafranil has been approved by the FDA to treat OCD in adults and children 10 years of age and above. Although it has been shown to be very effective, it has been associated with some potentially harmful side effects. read more »
What OCD Isn't - Beyond OCD Resources
Obsessive Compulsive Personality Disorder (OCPD) Obsessive Compulsive Personality Disorder is sometimes mistaken for OCD. While the names are confusingly similar, the disorders are quite different. OCPD is a personality disorder, wheras OCD is not. Usually identified in early adulthood, OCPD involves a preoccupation with orderliness, perfectionism and control in virtually every part of an individual's life. read more »
When Money Is a Problem - Options for Getting Better
When money is an issue, it can present challenges to getting OCD treatment. But don't give up. Here are some ideas for how to pay for treatment or stretch limited dollars to get help. Some colleges and universities offer Cognitive Behavior Therapy (CBT) without cost to registered students. Check the requirements to determine if you must be considered a full-time student to take advantage of the school's health services. read more »
Why Doing Your Compulsions Won't Make Your OCD Better
Why Doing Your Compulsions Won't Make Your OCD Better Research shows that performing compulsions actually makes obsessions come back stronger. The compulsions may give you temporary relief, but in the long run, they actually reinforce the obsessive thoughts. Here's an example: Sarah worries obsessively that her father will be killed in an accident unless she avoids using the number four – that's the obsession. read more »
Why OCD Occurs More In College Students
Why OCD Occurs More In College Students Medical problems can happen any time – that's why most colleges and universities have a health center on campus. Some disorders, including OCD, tend to surface for the first time at an age when many young people are in college. Other people have their first significant symptoms while they're away at school. read more »
Medication Can Help Treat OCD - But Don't Go It Alone.
Medication Can Help Treat OCD—But Don't Go It Alone. Many experts believe that Cognitive Behavior Therapy (CBT) tends to be a faster-acting and more cost-effective treatment for OCD over time than medication, and it doesn't involve the risk of side effects. In addition, studies have indicated that as many as 85% of people who complete CBT experience a significant reduction in symptoms; the success rate for medication is substantially lower. read more »
Telling Others About Your OCD
In a world of social networking sites such as Facebook, Twitter, LinkedIn and Pinterest, blogs on every topic imaginable, forwarded emails, "googling" for information about people, and personal YouTube videos just a click away, it sometimes seems that everyone's life is exposed for all to see. But many people prefer to be more private when it comes to OCD. read more »
About Disability Accommodations for OCD
About Disability Accommodations Most colleges and universities are required to offer accommodations to students with a disability (a physical or mental health problem that limits your major life activities) under Title II of the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973 These laws, which protect students from discrimination on the basis of disability, require schools to provide accommodations to help "level the playing field" for students with disabilities. read more »
About Medical Leaves of Absence for OCD Treatment
About Medical Leaves of Absence If your coursework is suffering because of OCD, and you're concerned about your grades, you may be thinking of taking a medical leave of absence from college so you can concentrate on treatment for OCD. Many cognitive behavior therapists who treat college students with OCD encourage students to stay in school during treatment. read more »
If Your College Limits the Number of CBT Therapy Sessions
If Your College Limits the Number of CBT Therapy Sessions If your college or university offers Cognitive Behavior Therapy through the student health center or counseling service, that's a plus. But if they limit the number of visits you can have, that can pose a challenge. The usual treatment time for CBT is approximately 12 to 16 weekly sessions. read more »


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