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Advanced-Stage Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancer Treatment
Treatment options for patients with all stages of ovarian epithelial, fallopian tube, and primary peritoneal cancer have consisted of surgery followed by platinum-based chemotherapy.
Primary surgical cytoreduction
Patients diagnosed with stage III and stage IV disease are treated with surgery and chemotherapy; however, the outcome is generally less favorable for patients with stage IV disease. The role of surgery for patients with stage IV disease is unclear, but in most instances, the bulk of the disease is intra-abdominal, and surgical procedures similar to those used in the management of patients with stage III disease are applied. The options for intraperitoneal (IP) regimens are also less likely to apply both practically (as far as inserting an IP catheter at the outset) and theoretically (aimed at destroying microscopic disease in the peritoneal cavity) in patients with stage IV disease.
Surgery has been used as a therapeutic modality and also to adequately stage the disease. Surgery should include total abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy and debulking of as much gross tumor as can safely be performed. While primary cytoreductive surgery may not correct for biologic characteristics of the tumor, considerable evidence indicates that the volume of disease left at the completion of the primary surgical procedure is related to patient survival.[1] A literature review showed that patients with optimal cytoreduction had a median survival of 39 months compared with survival of only 17 months in patients with suboptimal residual disease.[1][Level of evidence: 3iA]
Results of a retrospective analysis of 349 patients with postoperative residual masses no larger than 1 cm suggested that patients who present at the outset with large-volume disease and achieve small-volume disease by surgical debulking have poorer outcomes than similar patients who present with small-volume disease.[2] Gradual improvement in survival with decreasing residual tumor volume is likely. Although the association may not be causal, retrospective analyses, including a meta-analysis of patients receiving platinum-based chemotherapy, have found cytoreduction to be an independent prognostic variable for survival.[3,4]
For the past three decades, the GOG has conducted separate trials for women whose disease has been optimally cytoreduced (most recently defined as ≤1 cm residuum) and for those who had suboptimal cytoreductions (>1 cm residuum). The extent of residual disease following the initial surgery is a determinant of outcome in most series [1-4] and has been used in the design of clinical trials, particularly by the GOG.
On the basis of these findings, the standard treatment approaches are subdivided into the following:
- Treatment options for patients with optimally cytoreduced stage III disease.
- Treatment options for patients with suboptimally cytoreduced stage III and stage IV disease.
Neoadjuvant chemotherapy followed by surgery
A study led by the European Organization for the Research and Treatment of Cancer (EORTC) Gynecological Cancer Group (GCG), together with the National Cancer Institute of Canada (NCIC) Clinical Trials Group (EORTC-55971 [NCT00003636]), between 1998 and 2006 included 670 women with stage IIIC and IV ovarian, tubal, and primary peritoneal cancer.[5] The women were randomly assigned to primary debulking surgery followed by at least six courses of platinum-based chemotherapy or to three courses of neoadjuvant platinum-based chemotherapy followed by so-called interval debulking surgery, and at least three more courses of platinum-based chemotherapy. Methods included efforts to ensure accuracy of diagnosis (vis-à-vis peritoneal carcinomatosis of gastrointestinal origin) and stratification by largest preoperative tumor size (excluding ovaries) (<5 cm, >5 cm–10 cm, >10 cm–20 cm, or >20 cm). Other stratification factors were for institution, method of biopsy (i.e., image-guided, laparoscopy, laparotomy, or fine-needle aspiration), and tumor stage (i.e., stages IIIC or IV). The primary endpoint of the study was overall survival (OS), with primary debulking surgery considered the standard.
Median OS for the primary debulking surgery was 29 months, compared with 30 months for patients assigned to neoadjuvant chemotherapy. The hazard ratio (HR) for death in the group assigned to neoadjuvant chemotherapy followed by interval debulking, as compared with the group assigned to primary debulking surgery followed by chemotherapy, was 0.98 (90% confidence interval [CI], 0.84–1.13; P = .01 for noninferiority).[5][Level of evidence: 1iiA] Perioperative and postoperative morbidity and mortality were higher in the primary-surgery group (7.4% severe hemorrhage and 2.5% deaths, contrasting with 4.1% severe hemorrhage and 0.7% deaths in the neoadjuvant group). The strongest independent predictor of prolonged survival was the absence of residual tumor after surgery. The subset of patients achieving optimal cytoreduction (≤1 cm residuum), whether after primary debulking surgery or after neoadjuvant chemotherapy followed by interval debulking surgery, had the best median OS.
Surgery followed by IP chemotherapy
The pharmacologic basis for the delivery of anticancer drugs by the IP route was established in the late 1970s and early 1980s. When several drugs were studied, mostly in the setting of minimal residual disease at reassessment after patients had received their initial chemotherapy, cisplatin alone and in combination received the most attention. Favorable outcomes from IP cisplatin were most often seen when tumors had shown responsiveness to platinums and with small-volume tumors (usually defined as tumors <1 cm).[6] In the 1990s, randomized trials were conducted to evaluate whether the IP route would prove superior to the intravenous (IV) route. IP cisplatin was the common denominator of these randomized trials.
The use of IP cisplatin as part of the initial up-front approach in patients with stage III optimally debulked ovarian cancer is supported principally by the results of three randomized clinical trials (SWOG-8501, GOG-0114, and GOG-0172).[7-9] These studies tested the role of IP drugs (IP cisplatin in all three studies and IP paclitaxel in the last study) against the standard IV regimen. In the three studies, superior progression-free survival (PFS) and OS favoring the IP arm were documented. Specifically, the most recent study, GOG-0172, resulted in a median survival rate of 66 months for patients on the IP arm versus 50 months for patients who received IV administration of cisplatin and paclitaxel (P = .03).[9][Level of evidence:1iiA] Toxic effects were greater in the IP arm, contributed to in large part by the cisplatin dose per cycle (100 mg/m2) and by sensory neuropathy from the additional IP as well as from the IV administration of paclitaxel. The rate of completion of six cycles of treatment was also less frequent in the IP arm (42% vs. 83%) because of the toxic effects and catheter-related problems.[10]
Notwithstanding these problems, IP therapy for patients with optimally debulked ovarian cancer is receiving wider adoption, and efforts are under way by the GOG to examine some modifications of the IP regimen used in GOG-0172 to improve its tolerability (e.g., to reduce by ≥25% the total 3-hour amount of cisplatin given; a shift from the less practical 24-hour IV administration of paclitaxel to a 3-hour IV administration). A Cochrane-sponsored meta-analysis of all randomized IP versus IV trials shows an HR of 0.79 for disease-free survival and 0.79 for OS, favoring the IP arms.[11] In another meta-analysis of seven IP versus IV randomized trials that were conducted by Cancer Care of Ontario, the relative ratio (RR) of progression at 5 years based on the three trials that reported this endpoint was 0.91 (95% CI, 0.85–0.98), and the RR of death at 5 years based on six trials was 0.88 (95% CI, 0.81–0.95).[10]
Several ongoing trials include an intermittent dosing arm comparing both intraperitoneal chemotherapy and conventional-schedule IV treatment in patients after both optimal and suboptimal cytoreduction. When these results are available, it will be easier to identify the patient populations that are best suited for intermittent dosing.
Adjuvant Therapy
First-line treatment of ovarian cancer is cisplatin, given IV, or its second-generation analog, carboplatin, given either alone or in combination with other drugs. Clinical response rates from these drugs regularly exceed 60%, and median time-to-recurrence usually exceeds 1 year in this subset of suboptimally debulked women. Trials by various cooperative groups in the subsequent two decades addressed issues of optimal dose-intensity [12-14] for both cisplatin and carboplatin,[15] schedule,[16] and the equivalent results obtained with either of these platinum drugs, usually in combination with cyclophosphamide.[17] With the introduction of the taxane paclitaxel, two trials confirmed the superiority of cisplatin combined with paclitaxel to the previous standard of cisplatin plus cyclophosphamide; however, two trials that compared the agent with either cisplatin or carboplatin as a single agent failed to confirm such superiority in all outcome parameters (i.e., response, time-to-progression, and survival) (see Table 2).
Nevertheless, for patients with ovarian cancer, the combination of cisplatin or carboplatin and paclitaxel has been used as the initial treatment (defined as induction chemotherapy) for several reasons:
- GOG-132 was regarded by many as showing that sequential treatment with cisplatin and paclitaxel was equivalent to the combination because many patients crossed over before progression; moreover, the cisplatin-only arm was more toxic because it utilized a 100 mg/m2 dose.
- The Medical Research Council (MRC-ICON3) study, while having fewer early crossovers, could be interpreted similarly in regard to the impact on survival of sequential treatment.
- Data from MRC-ICON4 have shown a survival advantage for patients treated with the combination treatment regimen versus those treated with single-agent carboplatin upon recurrence (see Table 3).
- In past trials, single-agent platinums were not superior to platinum combined with an alkylating agent; therefore, the explanation of a detrimental effect of cyclophosphamide is unlikely.
Since the adoption of the platinum-plus-taxane combination as the standard nearly worldwide, clinical trials have demonstrated:
- Noninferiority for carboplatin plus paclitaxel versus cisplatin plus paclitaxel.[18-20]
- Noninferiority for carboplatin plus paclitaxel versus carboplatin plus docetaxel.[21]
- No advantage but increased toxic effects by adding epirubicin to the carboplatin plus paclitaxel doublet.[22]
- Noninferiority for carboplatin plus paclitaxel versus sequential carboplatin-containing doublets with either gemcitabine or topotecan; or, triplets with the addition of gemcitabine or pegylated liposomal doxorubicin to the reference doublet as shown below:[23,24]
- From February 2001 to September 2004, the Gynecologic Cancer InterGroup trial GOG-0182 randomly assigned 4,312 women with stage III or stage IV epithelial ovarian, fallopian tube, or primary peritoneal cancer to four different experimental arms and to a reference treatment consisting of carboplatin (area under the curve [AUC] 6) and paclitaxel (175 mg/m2) every 3 weeks for eight cycles.[23] Stratification factors were residual-disease status and the intention to perform interval debulking surgery. Lethal events attributable to treatment occurred in fewer than 1% of patients without clustering to any one regimen. None of the experimental regimens were inferior. With a median duration of follow-up of 3.7 years, the adjusted relative risk of death ranged from 0.952 to 1.114, with the control arm achieving a PFS of 16.0 months and a median OS of 44.1 months.
In this large study consisting of 84% to 87% of patients with Féderation Internationale de Gynécologie et d'Obstétrique stage III disease, as expected, the extent of cytoreduction was an important prognostic factor in OS. PFS in patients with residuum greater than 1 cm was 13 months, but OS was 33 months; with residuum less than or equal to 1 cm, PFS was 16 months, but OS was 40 months; and with microscopic residuum, PFS was 29 months, but OS was 68 months.[23]
- From February 2001 to September 2004, the Gynecologic Cancer InterGroup trial GOG-0182 randomly assigned 4,312 women with stage III or stage IV epithelial ovarian, fallopian tube, or primary peritoneal cancer to four different experimental arms and to a reference treatment consisting of carboplatin (area under the curve [AUC] 6) and paclitaxel (175 mg/m2) every 3 weeks for eight cycles.[23] Stratification factors were residual-disease status and the intention to perform interval debulking surgery. Lethal events attributable to treatment occurred in fewer than 1% of patients without clustering to any one regimen. None of the experimental regimens were inferior. With a median duration of follow-up of 3.7 years, the adjusted relative risk of death ranged from 0.952 to 1.114, with the control arm achieving a PFS of 16.0 months and a median OS of 44.1 months.
A trial of the Japanese Gynecologic Oncology Group (JGOG-3601 [NCT00226915]) circumvented this treatment trend and included patients with stage II through stage IV disease in addition to the patients undergoing neoadjuvant therapy. With results initially published in 2009 and long-term results updated in 2013, the JGOG-3601 has stimulated a number of other trials that address weekly dosing schedules versus the conventional every-3-weeks (intermittent) dosing in first-line epithelial ovarian cancer.[25-27] Conducted between 2003 and 2006, the Japanese trial accrued 637 patients and randomly assigned them to a range of six to nine cycles of the weekly (named "dose-dense") 80 mg/m2 of paclitaxel or to the usual intermittent schedule of paclitaxel at 180 mg/m2. Both regimens were given with carboplatin (AUC 6) in every-3-weeks cycles. With a primary endpoint of PFS, an increase from 16 to 21 months in the PFS of the weekly paclitaxel-based regimen was sought.
The PFS surpassed expectations at the 1.5-year follow-up after cessation of treatment. The weekly regimen had a median PFS of 28.0 months (95% CI, 22.3–35.4 months), and the intermittent median PFS was 17.2 months (15.7–21.1; HR, 0.71), favoring the weekly regimen (P = .0015). The 3-year OS also favored the weekly regimen (P = .03). The 2013 updated results revealed unexpected median survival results for the weekly regimen (median OS, 8.3 years vs. 5.1 years; P = .040); the intermittent regimen results are also noteworthy relative to other clinical trials of weekly dosing schedules.
Other than ethnicity, this trial population differed from other studies in the following ways:
- A lower median age (57 years).
- 20% stage II.
- 11% treated in the neoadjuvant setting.
- 33% with histologies other than high-grade serous or endometrioid.
- 33% without high-grade histologies.
Treatment Options for Patients With Suboptimally Cytoreduced Stage III and Stage IV Disease
Cytoreductive surgery
The value of interval cytoreductive surgery has been the subject of two large phase III trials. In the first study, performed by the EORTC, patients subjected to debulking after four cycles of cyclophosphamide and cisplatin (with additional cycles given later) had an improved survival rate compared with patients who completed six cycles of this chemotherapy without surgery.[28][Level of evidence: 1iiB] The GOG-0162 trial was designed to answer a very similar question but used the then-standard paclitaxel-plus-cisplatin regimen as the chemotherapy.[29] This trial did not demonstrate any advantage from the use of interval cytoreductive surgery. The divergence of results may be caused by the efficacy of the chemotherapy obscuring any effects of interval cytoreduction, the wider use of maximal surgical effort at the time of diagnosis by U.S. gynecologic oncologists, or unknown factors. Although many patients with stage IV disease also undergo cytoreductive surgery at diagnosis, whether this improves survival has not been established.
Systemic chemotherapy
Trial | Treatment Regimens | No. of Patients | % Early Crossover | Progression-free Survival (mo) | Overall Survival (mo) |
AUC = area under the curve; EORTC = European Organization for Research and Treatment of Cancer; GOG = Gynecologic Oncology Group; MRC = Medical Research Council. | |||||
aStatistically inferior result (P < .001–< .05). | |||||
GOG-132 | Paclitaxel (135 mg/m2, 24 h) and cisplatin (75 mg/m2) | 201 | 22% | 14.2 | 26.6 |
Cisplatin (100 mg/m2) | 200 | 40% | 16.4 | 30.2 | |
Paclitaxel (200 mg/m2, 24 h) | 213 | 23% | 11.2a | 26 | |
MRC-ICON3[30] | Paclitaxel (175 mg/m2, 3 h) and carboplatin AUC 6 | 478 | 23% | 17.3 | 36.1 |
Carboplatin AUC 6 | 943 | 25% | 16.1 | 35.4 | |
Paclitaxel (175 mg/m2, 3 h) and carboplatin AUC 6 | 232 | 23% | 17 | 40 | |
Cyclophosphamide (500 mg/m2) and doxorubicin (50 mg/m2) and cisplatin (50 mg/m2) | 421 | 20% | 17 | 40 | |
GOG-111[18] | Paclitaxel (135 mg/m2, 24 h) and cisplatin (75 mg/m2) | 184 | None | 18 | 38 |
Cyclophosphamide (750 mg/m2) and cisplatin (75 mg/m2) | 202 | None | 13a | 24a | |
EORTC-55931[19] | Paclitaxel (175 mg/m2, 3 h) and cisplatin (75 mg/m2) | 162 | None | 15.5 | 35.6 |
Cyclophosphamide (750 mg/m2) and cisplatin (75 mg/m2) | 161 | 4% | 11.5a | 25.8a |
Consolidation and/or maintenance therapy
Trials of consolidation and/or maintenance therapy have been carried out with drugs that contribute to the treatment of recurrent ovarian cancer. Presently, none of the treatments given after the initial platinum/paclitaxel induction has been shown to improve survival; these treatments include the following:
- IP cisplatin (four cycles).[31]
- Yttrium-labeled radioimmunoconjugate plus IP chemotherapy.[32]
- IV topotecan (four cycles).[33]
- Oregovomab vaccination (randomized trial vs. placebo).[34]
- High-dose chemotherapy with hematopoietic support.[35]
- Monthly paclitaxel (12 cycles).[36,37]
- Olaparib, an oral poly (adenosine diphosphate [ADP]-ribose) polymerase (PARP) inhibitor (phase II trial).[38]
A GOG-178 study of 277 patients compared 3 doses versus 12 doses of monthly paclitaxel given every 4 weeks following a clinically defined complete response at the time of completion of platinum/paclitaxel induction. However, the study was stopped early because of a very significant difference in PFS (28 months vs. 21 months).[36][Level of evidence: 1iiDiii] Subsequent updates of these data have raised the possibility that a subset of patients with low CA-125 levels might show a survival benefit.[39] A trial to confirm the value of maintenance with taxanes versus observation is being conducted by the GOG.
A smaller Italian study entered 200 patients over 7 years who were randomly assigned to either 12 similar courses of monthly paclitaxel or observation; patients were in clinical complete response (n = 95) or pathologic complete response (n = 105) after induction therapy at the time of their random assignment.[37] Sensory neuropathy was the most prominent toxicity and was grade 2 in 21.3% of the patients and grade 3 in 6.7% of the patients. The median PFS for the maintenance paclitaxel arm was 34 months (95% CI, 20–43 months) and 30 months (95% CI, 17–53 months) for the observation arm. Neither PFS nor OS differences were significant.[37]
An accompanying editorial points out the weaknesses of both studies in order to draw conclusions (both stopped early and were noninformative for survival endpoint).[40] Also, although both studies addressed the issue of maintenance paclitaxel administered monthly, the patient populations differed. This was reflected by the considerably better outcome in both arms of the Italian study. Taken together, paclitaxel maintenance is of unproven value and requires validation by the ongoing and larger GOG-178 study cited above.
Two phase III trials (GOG-0218 [NCT00262847] and ICON 7 [NCT00483782]) have evaluated the role of bevacizumab in first-line therapy for ovarian, fallopian tube, and primary peritoneal cancer following surgical cytoreduction.[41,42] Both trials showed a modest improvement in PFS when bevacizumab was added to initial chemotherapy and continued every 3 weeks for 16 and 12 additional cycles, as a maintenance phase.
GOG-0218 was a double-blinded, randomized controlled trial that included 1,873 women with stage III or IV disease, all of whom received chemotherapy—carboplatin (AUC 6) and paclitaxel (175 mg/m2 for 6 cycles).[41] Participants were randomly assigned to receive:
- Chemotherapy plus placebo (cycles 2 through 22) (i.e., control).
- Chemotherapy plus bevacizumab (15 mg/kg cycles 2 through 6), followed by placebo (cycles 7 through 22) (i.e., bevacizumab initiation).
- Chemotherapy plus bevacizumab (15 mg/kg cycles 2 through 22) (i.e., bevacizumab throughout).
The women were enrolled with a primary endpoint of PFS; 40% of the patients had suboptimally resected stage III disease, and 26% had stage IV disease. There was no difference in PFS between the control group and the bevacizumab-initiation group. There was a statistically significant increase in PFS in the bevacizumab-throughout group when compared with the control group (14.1 vs. 10.3 months), with an HR of progression or death of 0.717 in the bevacizumab-throughout group (95% CI, 0.625–0.824; P < .001). Median OS was 39.3 months for the control group, 38.7 months for the bevacizumab-initiation group, and 39.7 months for the bevacizumab-throughout group. Quality of life was not different between the three groups. Hypertension grade 2 or higher was more common with bevacizumab than with the placebo. There were more treatment-related deaths in the bevacizumab-throughout arm (10 of 607, 2.3%) than in the control arm (6 of 601, 1.0%).[41][Level of evidence: 1iDiii]
ICON 7 randomly assigned 1,528 women after initial surgery to chemotherapy—carboplatin (AUC 5 or 6) plus paclitaxel (175 mg/m2 for six cycles)—or to chemotherapy plus bevacizumab (7.5 mg/kg for six cycles), followed by bevacizumab alone for an additional 12 cycles. The women were randomly assigned, and PFS was the main outcome measure; 9% of patients had early-stage, high-grade tumors, and 70% had stage IIIC or IV disease. Twenty-six percent had more than 1 cm of residual tumor prior to initiating chemotherapy. Median PFS was 17.3 months in the control group and 19 months in the bevacizumab group. HR for progression or death in the bevacizumab group was 0.81 (95% CI, 0.70–0.94; P = .004). Bevacizumab was associated with an increase in bleeding, hypertension (grade 2 or higher), thromboembolic events (grade 3 or higher), and gastrointestinal perforations. Grade 3 or higher adverse events were more common in the bevacizumab group. Quality of life was not different between the two groups.[42][Level of evidence: 1iiDiii]
A third trial, OCEANS (Ovarian Cancer Study Comparing Efficacy and Safety of Chemotherapy and Anti-Angiogenic Therapy in Platinum-Sensitive Recurrent Diseases [NCT00434642]), assessed the role of bevacizumab in the treatment of platinum-sensitive recurrences (see Table 3 for other trials in this setting). In this double-blind, placebo-controlled, phase III trial of chemotherapy (gemcitabine + carboplatin) with or without bevacizumab for recurrent epithelial ovarian, primary peritoneal, or fallopian tube cancer, 242 patients were randomly assigned per arm.[43] Median PFS for patients receiving bevacizumab was 12.4 months versus 8.4 months for those receiving a placebo. The effect of bevacizumab on HR to progression in patients assigned to the bevacizumab arm compared with placebo was 0.484 (95% CI, 0.388–0.605; P <.0001). Objective responses to chemotherapy were increased when combined with bevacizumab (78.5% vs. 57.4%; P < .0001).
In contrast to the first-line studies, treatment was allowed to continue beyond six cycles to ten cycles in responding patients, but there was no maintenance. A subsequent analysis will appear when additional survival data become mature; however, at the time of publication, differences in median survival were not apparent, and crossover from a placebo to bevacizumab had occurred in 31% of the patients. Bevacizumab-associated toxicities such as hypertension and proteinuria were more prominent than in the first-line trials, but feared safety issues, such as gastrointestinal perforations, did not occur during the study. Discontinuing treatment because of adverse events was more common with bevacizumab (n = 55 vs. n = 12 for placebo), but fewer patients discontinued treatment because of disease progression (n = 104 vs. n = 160 for placebo).[43][Level of evidence: 1iiDiii]
These three studies confirm the effect of improving PFS when bevacizumab is added to chemotherapy for ovarian cancer. In the OCEANS trial, the HR for progression was even more prominent than in the first-line trials, and a significant effect was seen when the bevacizumab and chemotherapy combination was extended beyond six cycles until progression. Without additional data, a statement about how bevacizumab should be used in ovarian cancer treatment is not possible because of the uncertain impact on OS, lack of clear delineation of who derives the greatest benefit, and prominent, associated toxicities.[44]
At this time, the evidence does not support the use of bevacizumab as front-line therapy, because the gain in PFS comes with increased toxicity without improvement in OS or quality of life.
Treatment Options Under Clinical Evaluation
- Additional IP radioimmunoconjugates, vaccines, and targeted drugs are under clinical evaluation, primarily as consolidation therapy.
Information about ongoing clinical trials is available from the NCI Web site.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage II ovarian epithelial cancer, stage III ovarian epithelial cancer, stage IV ovarian epithelial cancer, fallopian tube cancer and primary peritoneal cavity cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
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- Piccart MJ, Bertelsen K, James K, et al.: Randomized intergroup trial of cisplatin-paclitaxel versus cisplatin-cyclophosphamide in women with advanced epithelial ovarian cancer: three-year results. J Natl Cancer Inst 92 (9): 699-708, 2000. [PUBMED Abstract]
- Verheijen RH, Massuger LF, Benigno BB, et al.: Phase III trial of intraperitoneal therapy with yttrium-90-labeled HMFG1 murine monoclonal antibody in patients with epithelial ovarian cancer after a surgically defined complete remission. J Clin Oncol 24 (4): 571-8, 2006. [PUBMED Abstract]
- Pfisterer J, Weber B, Reuss A, et al.: Randomized phase III trial of topotecan following carboplatin and paclitaxel in first-line treatment of advanced ovarian cancer: a gynecologic cancer intergroup trial of the AGO-OVAR and GINECO. J Natl Cancer Inst 98 (15): 1036-45, 2006. [PUBMED Abstract]
- Berek JS, Taylor PT, Gordon A, et al.: Randomized, placebo-controlled study of oregovomab for consolidation of clinical remission in patients with advanced ovarian cancer. J Clin Oncol 22 (17): 3507-16, 2004. [PUBMED Abstract]
- Stadtmauer EA, O'Neill A, Goldstein LJ, et al.: Phase III randomized trial of high-dose chemotherapy (HDC) and stem cell support (SCT) shows no difference in overall survival or severe toxicity compared to maintenance chemotherapy with cyclophosphamide, methotrexate and 5-fluorourcil (CMF) for women with metastatic breast cancer who are responding to conventional induction chemotherapy: the 'Philadelphia' Intergroup study (PBT-1). [Abstract] Proceedings of the American Society of Clinical Oncology 18: A1, 1a, 1999.
- Markman M, Liu PY, Wilczynski S, et al.: Phase III randomized trial of 12 versus 3 months of maintenance paclitaxel in patients with advanced ovarian cancer after complete response to platinum and paclitaxel-based chemotherapy: a Southwest Oncology Group and Gynecologic Oncology Group trial. J Clin Oncol 21 (13): 2460-5, 2003. [PUBMED Abstract]
- Pecorelli S, Favalli G, Gadducci A, et al.: Phase III trial of observation versus six courses of paclitaxel in patients with advanced epithelial ovarian cancer in complete response after six courses of paclitaxel/platinum-based chemotherapy: final results of the After-6 protocol 1. J Clin Oncol 27 (28): 4642-8, 2009. [PUBMED Abstract]
- Ledermann J, Harter P, Gourley C, et al.: Olaparib maintenance therapy in platinum-sensitive relapsed ovarian cancer. N Engl J Med 366 (15): 1382-92, 2012. [PUBMED Abstract]
- Liu PY, Alberts DS, Monk BJ, et al.: An early signal of CA-125 progression for ovarian cancer patients receiving maintenance treatment after complete clinical response to primary therapy. J Clin Oncol 25 (24): 3615-20, 2007. [PUBMED Abstract]
- McGuire WP: Maintenance therapy for ovarian cancer: of Helsinki and Hippocrates. J Clin Oncol 27 (28): 4633-4, 2009. [PUBMED Abstract]
- Burger RA, Brady MF, Bookman MA, et al.: Incorporation of bevacizumab in the primary treatment of ovarian cancer. N Engl J Med 365 (26): 2473-83, 2011. [PUBMED Abstract]
- Perren TJ, Swart AM, Pfisterer J, et al.: A phase 3 trial of bevacizumab in ovarian cancer. N Engl J Med 365 (26): 2484-96, 2011. [PUBMED Abstract]
- Aghajanian C, Blank SV, Goff BA, et al.: OCEANS: a randomized, double-blind, placebo-controlled phase III trial of chemotherapy with or without bevacizumab in patients with platinum-sensitive recurrent epithelial ovarian, primary peritoneal, or fallopian tube cancer. J Clin Oncol 30 (17): 2039-45, 2012. [PUBMED Abstract]
- Muggia F: Bevacizumab in ovarian cancer: unanswered questions. Drugs 72 (7): 931-6, 2012. [PUBMED Abstract]


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Why is the US so violent?
In the discussions about gun control following last week's massacre at Sandy Hook School, I find myself strangely resistant to the "let's just go ban the darned things" approach. Let me say that I'm all for rethinking how access to guns is regulated and such, particularly in terms of having arms available via collectivities such as militias, rather than an individual right of citizens. But I instinctively feel that that the just-ban-them response is the kind of simple-sounding public policies that may well intentioned but ultimately have far-reaching unintended consequences.
Barry Ritholtz's website has an interesting chart that showing the relationship of gun ownership rates in industrialized countries to the firearm homicide rate. I don't have the raw data to reproduce the chart here, but I do include a link:
A larger version of the graphic can be found here: http://www.ritholtz.com/blog/wp-content/uploads/2012/12/guns.jpg
The surrounding text is here: http://www.ritholtz.com/blog/2012/12/10-tuesday-am-reads-48/
The chart illustrates how higher gun ownership rates go hand in hand with higher firearm-related homicides. But there are two issues with this chart that are worth thinking about.
The first is a technical issue: the axes should be flipped. If we want to show that increased firearm possession leads to increased gun-homicide, gun possession should be on the horizontal axis, not the vertical (by convention). The way this reads, it looks like the chart is arguing that high homicide rates lead people to want to own more guns. This is actually a plausible interpretation of this data, as well, but probably not the way the author intended.
More importantly, the US is an outlier here, both in terms of gun deaths and in terms of gun ownership. The US's presence in the chart actually skews the regression line in a noticeable way.
If we were to remove the US from the sample and re-run the regression, the line would be much steeper and probably explain more variance (i.e. a higher R^2). It would also suggest that gun ownership has a much smaller effect – though still a real one – on gun homicides than the chart currently suggests.
I don't have access to the raw data, so I can't run the regression myself, but I have tried to hand-draw the regression line to illustrate. This is imperfect, but good enough to make the point.
This chart estimates the regression line excluding the United States. Although I may have made small errors due to the fact that I am eyeballing the line rather than computing it from the raw data, the line is much steeper.
But assuming that high gun ownership causes high gun-homicide rates, what does this line predict about the United States? It suggests that the United States is substantially more violent than what would be predicted by its gun ownership rate. By my eyeball estimate, about three times more violent. Although guns are part of the story, they are not the whole story, and – in fact – they may not even be the most important part of the story.
Yes, let's think about how to regulate guns. But the larger question is really "Why are we so violent?" I don't know the full answer: common culprits are cinema, video games, media glorification, the drive of excessive competitiveness, etc..
Yes, let's have a real discussion about sensible regulation, and I don't see any reason why assault weapons need to be available to individuals for the asking, but I think a key underlying issue is also to figure out why we are so violent in the first place.

subset: commoncrawl


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Costume Information
Description | |
EDIT: This is version 1 of the costume, and I will remake parts of it so that its more accurate. I only had a short time to complete this in, and literally only 5 mins to cut the wig, so this is the best that I could muster in the time. If I was going to do any crossplay, it would have to be Chie, because she's bad ass, and recognises steak as our one true food god. |


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Hi! We are looking for a new intern to work with us in our San Francisco shop in the Mission District. Below are things we look for.
At LPP, we are a family and community with both the artists/designers we work with along with our community who supports us. We are looking for someone who wants to be part of this family. We seek out of the box kind of thinkers, someone who has ideas and wants to help make them become a reality. We value and encourage your ideas. We are a super small company and we all do a little bit of everything, but we have big ideas for growth and hope you will be the perfect fit to be a part of it!
What we are looking for in an intern:
- Must be able to work at the SF shop Tuesday mornings for 4-5 hours
- Who can fullfill and pack orders
- Own a laptop and able to bring it on Tuesdays
- Must have a knowledge about contemporary art
- A plus: knowledge about contemporary design/ fashion
- Must be internet savvy. You are the kind of person who is online often, follows a variety of art/ design/ lifestyle/ culture blogs. You are always discovering new artists, designers, the latest trends, shops, etc. You have a Facebook, Twitter and blog that you regularly update.
- Must have some knowlodge of Photoshop and Illustrator.
- We would love someone outgoing and excited to meet new people. Someone who wants to create various collaborations with Little Paper Planes outside of the internet realm.
- Excellent communication is key and able to take direction easily
- Good writing skills
- Sense of humor. We all like to laugh a lot, so that is important.
To be considered for an internship please email the following:
Please write a cover letter telling us why you would like to work with us at Little Paper Planes. Tell us what your interests in as a general. We want to know who you are and what you like. What would you like to get out of an internship? Are you interested in design? Laying out books? Discovering new artists and doing studio visits? Coming up with new content for the blog?
Please list 10 artists you are currently coveting along with favorite blogs, websites, and everything in between to give us an idea of your aesthetics and if you would be a right fit for us.
Send the above information and resume to firstname.lastname@example.com
Make sure the subject line is: INTERNSHIP
All internships are unpaid but school credit can be given.


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Welcome Guest, click here to register
These bowls look great filled with pastries, flowers, or fruit for a gorgeous centerpiece. These footed bowls inspired by Victorian compotes make versatile statement pieces whether used separately or stacked to form an elegant tower.
La Patisserie Large Footed Bowl
11.5"d x 7.5" h,


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Irrespective of the season, there's always something going on in Cornwall.
The winds of late October have encouraged the autumn leaves that were still clinging to branches to finally fall to rest. November is such a lovely month for woodland walks and as the month draws to an end, the County starts to gear itself up for Christmas. It's an ideal time to visit Cornwall and pick up a quirky Christmas gift from one of many independent retailers and at the host of Christmas Craft Fairs. There's also the City of Lights Parade which is a must see event for first time visitors to Truro.
Here are a selection of things to do around and about The Roseland Peninsula in November.
There's also a very useful publication called Inside Cornwall that provides much more information and can be purchased in almost all newsagents in the County. Two other good sources of information are King Harry's Cornwall and the Visit Cornwall websites.
1 - 26 Nov - Farwell to sails. An exhibition commemorating the 60th anniversary of the last voyage around Cape Horn by commercial square-rigged sailing ships. National Maritime Museum, Discovery Quay, Falmouth.
6 Nov - Eden Arts Cafe. Live music with resident band Jelly Jazz. Eden Project, Bodelva from 7.30pm.
13 - 15 Nov - Cornwall Film Festival. The annual celebration of Cornish and international film-making at various venues across Falmouth and Penryn.
17 - 21 Nov. Grapes of Wrath. Fantastic book brought to life on the stage with Christopher Timothy and Sorcha Cusack. Hall for Cornwall, Back Quay, Truro form 7.30pm.
18 Nov - Truro City of Lights. The City of Lights Festival and parade returns to Truro again this year in time for the Christmas lights switch on. This year's theme is Truro's social and maritime history. Lemon Quay from 7pm.
20 - 22 Nov - Music at Tresanton. A weekend of world-class chamber music performance from the Waldstein Ensemble and Friends. Tresanton Hotel, St Mawes.
25 - 28 Nov - Made in Cornwall Fair. A selection of Cornish products, including food, drink, pottery, jewellery, paintings, glass and pottery for sale. Lemon Quay, Truro from 9:00am daily.
28 - 29 Nov - Natural Christmas. Pick up tips on how to use natural items, such as dried leaves, lichen and seed-heads in your Christmas decorations. Trelissick Gardens, Feock from 12:00pm.
28 Nov - String Serenade. The Roseland Music Society brings a group of talented Russian musicians (The Dominant String Quartet) to Portscatho for a wonderful evening playing pieces by Haydn, Beethoven, Shostakovich and Borodin. Gerrans Parish Memorial Hall, Portscatho from 7.30pm


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awesome feeling to this shot, nice!
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Biotivia PteroMax Resveratrol, Capsule
Size/Count 30.0 ea
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Dietary Supplement
Unique high potency Stilbene and Polyphenol Complex
A concentrated complex of the polyphenols and stilbenes contained in red wine grapes and the polygonum cuspidatum plant augmented by additional amounts of key polyphenols.
Formulated to provide a scientifically balanced high potency complex of the critical stilbenes Pterostilbene, Trans-resveratrol, and Polydatin which have shown extraordinary health effects in multiple scientific studies and trials. Ptero Max is augmented with substantial amounts of the full spectrum of polyphenols and stilibenes contained in both the red wine grape and the polygonum-cuspidatum plant, also known as Japanese Giant Knotweed.
Questions? 1-888-245-5893
*These statements and/or claims have not been evaluated by the US FDA. This product is not intended to prevent, diagnose, cure, or treat any disease or medical condition.
Take one capsule at least 45 minutes prior to having breakfast upon waking each morning.
Keep in cool dark place or refrigerate. Replace cap tightly after use.
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This new lineup of selected investigative tools and resources (many of them completely FREE), how-to reports and great online FREE lifetime live support brings an exciting new opportunity to satisfy your needs to learn confidential things about people or businesses. Can't be matched by any other previously devised traditional resource or directory for amateur and professional private investigators alike
CLICK HERE for more info
Cemeteries of Clark County, Kentucky - Cemetery Records - GenealogyCemetery records of Clark County, Kentucky.. RSS FEEDS. New Cemeteries - a newsfeed of all new cemetery transcriptions published on Interment (daily).
Winchester Cemetery - Clark County, KentuckyCemetery records of Winchester Cemetery, in Clark County, Kentucky.. New Cemeteries - a newsfeed of all new cemetery transcriptions published on.


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Oxford Castle encourages children's fancy dress at Comic Relief event
Kids in Oxford are likely to be going through their box of children's fancy dress to get ready for a special event to raise money for Comic Relief this year.
There are bound to be a number of different fun fancy dress events going on around the country on Red Nose Day (March 18th 2011) but one has really got the attention of residents is one being held at Oxford Castle.
Kids who get creative with their fancy dress outfits or wear a red nose will be able to get free admission to the attraction
- TAGS Children's, historic
- CATEGORIES Children's Fancy Dress


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Florida, United States of America (USA).
LV. Pan, Father Christmas hanging from kite and wearing water skis. CU. Girl looks up in the air and says 'Look there's Santa'. LV. Santa coming down onto water in Cypress Gardens. LV. He skis on water and onto shore where he hands out presents to six bathing beauties. SCU. Girls kiss Santa. TS. Girls water skiing, they raise left ski and line reads 'Merry Xmas And Happy New Year to Y'All'.


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"I love these potatoes! In a pinch, I turn up the oven to 400 degrees and also have substituted ramono cheese when I ran out of parmesan and olive oil when I didn't have butter. Yummy with or without modifications. Thank you for sharing this lovely recipe!"
"I have made this recipe so many times (usually double it) and love it! I reduce the sugar to 1/2 cup and use 1/4 cup lemon juice as I rarely have whole lemons on hand. Thank you for this tasty way to use rhubarb. :)"
"Very good tasting salsa and easy to make. 1/4 tsp salt worked well for me and a double recipe fit nicely into my food processor. Yay!"


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Book your room at O Hotel
Deluxe Room, 1 Queen Bed, No View
Max Occupancy: 2 guests (up to 1 child, 1 infant)3.5-star Los Angeles hotel in Downtown Los Angeles, walk to Nokia Theater
Located in Downtown Los Angeles, this hotel is within a 15-minute walk of Macy's Plaza, Nokia Theater, and Staples Center. Los Angeles Convention Center and Walt Disney Concert Hall are also within 1 mi (2 km).
Hotel Features
This smoke-free hotel features a restaurant, a fitness center, and a bar/lounge. Additionally, WiFi in public areas, conference rooms, and concierge services are onsite.
Room Amenities
All 67 rooms provide conveniences like refrigerators and coffee makers, plus pillowtop beds and flat-screen TVs with cable channels. IPod docks, room service, and free local calls are among the other amenities available to guests.
Information missing or incorrect? Tell us!


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Loan Applications and Financial Aid Forms
Welcome to the Forms and Application Center. Here you will find the most common forms you will need in relations to Federal Financial Aid. We also can provide you with application forms for various loans.
Loan Application and Request Forms
- Apply for Stafford Loans
- Request Application Information for Parent Plus Loans
- Find a Lender and Apply for Private Student Loans
If you have a loan through the Federal Family Education Loan Program (FFELP), please contact your lender for their specific version of your necessary form. To discover who holds your federal loans, perform a "financial aid review" at the National Student Loan Data System.
Financial Aid Help Forms
- Financial Aid Shopping Sheet - The federal shopping sheet is a financial aid award letter, designed to better allow students to compare college costs and financial aid across schools. This sample letter provides a good breakdown of financial aid types for parents and students looking to compare college costs.
- Financial Aid Checklist Worksheet - A helpful, printable form to keep track of what you need to do for Federal Financial Aid for the 2010-11 school year.
- Application Form Tracking Worksheet - Keep track of everything with this easy to use form.
- Cost of Attendance Worksheet - The cost of attendance is unique for each student. Use this sheet for personal calculations.
- Award Package Comparison Sheet - School offering varying awards and differing packages. Use this comparison sheet to weigh your options!
- Sample Scholarship Inquiry Letter
Federal Direct Loan Program (FDLP) Deferment Forms
Deferment forms are used to temporarily suspend all principal and interest payments due to one of the circumstances below.
Economic Hardship Deferment Form
This form is used when you receive federal or state public assistance or earn less than a federal minimum wage or exceed a federally defined debt-to-income ratio. Generally speaking, if you are employed and your federal loan payments amount to more than 20% of your adjusted gross income (AGI), you use this form.
Education Related Deferment Form
This form is used if you are participating in a Graduate Fellowship program, internship and/or residency program, in a full-time rehabilitation training program or teaching in a federally designated teacher shortage area.
In School Deferment Form
If you are currently in school half-time or more at a Title IV, accredited college, you may be eligible to use this form to defer payments until 6 months after your graduation or 2 months after dropping out of your course of study.
This form can also be used for parents or legal guardians that borrowed a Federal Parent PLUS loan for their child.
Parental Leave / Working Mother Deferment Form
To quality for this loan, you must be pregnant or caring for a newborn or newly adopted child; must not be working full-time or attending school; must have been enrolled in school at least half-time during the six months preceding the requested deferment period; and must meet other conditions, or,
You must be the mother of a preschool age child, be working full-time but earning not more than $1 above minimum wage, and meet other conditions.
Public Service Deferment Form
Are you an active member of the U.S. Armed Forces, Peace Corps, a Public Health Worker, a worker at a tax-exempt organization or on duty for the National Oceanic & Atmospheric Administration (NOAA)? If so, this deferment may allow you to temporarily suspend your federal loan payments.
Temporary Total Disability Deferment Form
To qualify for this deferment, you must be unable to work and earn money or go to school for at least 60 days in order to recover from an illness or injury or care for a spouse or dependent with an illness or injury. The condition cannot have existed before you applied for the loan(s).
Unemployment Deferment Form
You must be seeking but unable to find full-time employment (more than 30 hours per week) that is expected to last at least 3 months.
Federal Direct Loan Program (FDLP) Forbearance Forms
Forbearance forms can be used to temporarily suspend or reduce your monthly student loan payments due to one of the circumstances below.
Americorps (CNCS) Forbearance Form
This forbearance allows you to stop payments temporarily if you are serving in an approved national service position. The forbearance form must be certified by the Corporation for National Community Service (CNCS).
General Forbearance Form
This forbearance allows you to postpone or reduce the amount of your monthly payment for a limited and specific period of time.
Internship / Residency Forbearance Form
This forbearance allows you to postpone or reduce the amount of your monthly payment for a limited and specific period of time if you have been accepted into an Internship/Residency Program.
Loan Debt Burden Forbearance Form
This forbearance allows you to postpone or reduce the amount of your monthly payment for a limited and specific period of time if you provide acceptable documentation showing that your monthly payments for eligible education loan(s) exceed 20% of your total monthly gross income.
Teacher Loan Forgiveness Forbearance Form
This forbearance allows you to postpone your monthly payment for a limited and specific period of time while you are performing qualifying teaching service as a teacher in an eligible elementary or secondary school or educational service agency.
Loan Forms
- Loan Forgiveness Form (Childcare)
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Financial Aid Professionals
All the above forms are in PDF format. You will need Adobe Reader to properly view and print them - download here.


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A simple yet beautiful ornament made from an old book!
Old sweatshirt, new cut out.
a inverted cross double ring covered in blue glitter :)
Remaking t-shirts never gets old!
Just a new baubble for my neck ;)
catch all your sweet dreams :)
tights designed to look like skeleton legs :)
Nice earrings in style of Luna :)
Dig out one of your thimbles and make a cute necklace!
For every wizard.
go crayola go!
Lace and fabric markers come together make this unique top.


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Occupation: Business Owner Education: Bachelor's degree in Business Administration, Baylor University Legislative Experience: House Member, 2006 - 2012; Senate Member, 2013 - present Hometown: North Richland Hills Party: Republican
First elected to the Texas Senate in 2012, Kelly Hancock represents Senate District 9, which includes portions of Tarrant and Dallas Counties. He served three terms in the Texas House of Representatives where he advocated for core conservative values of limited government, lower taxes and strong family values.
Throughout his legislative career, Kelly has worked to pass voter identification legislation, pro-life legislation, eminent domain legislation, immigration reform legislation and state sovereignty legislation.
Numerous organizations such as the Texas Conservative Coalition, the National Coalition for Capital and the Texas Conservative Roundtable have acknowledged Senator Hancock for his efforts in promoting fiscal responsibility and conservative values. He's been recognized as a "Courageous Conservative," a "Champion of Small Business" and a "Lone Star Conservative Leader."
A graduate of Baylor University with a degree in Business, Senator Hancock possesses an extensive business background through his work at Advanced Chemical Logistics, his family-founded company. His commitment to public service began shortly after the birth of his first child, Chloe, and spent the next 13 years serving on the Birdville ISD School Board.
Kelly and his wife, Robin, have been married 26 years and have three children: Chloe, Skylar and Harrison.
January 14, 2015Hancock Takes Oath of Office as 84th Legislature Convenes
December 5, 2013Senator Kelly Hancock Tours Aviall Services, Inc. Headquarters
October 7, 2013Senator Hancock announces mobile election ID stations coming to Senate District 9
September 30, 2013Texas Receives Top Credit Rating from S&P
September 19, 2013Senator Hancock Appointed to Senate Select Committee on Transportation Funding
September 30, 2013Senator Hancock's Capitol Report 2013


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Updated: 02/18/2014 11:47 PM
Created: 02/18/2014 11:04 PM WHEC.com
By: Lynette Adams
It's more than likely you or someone you know has been directly affected by Alzheimer's disease.
One of the toughest symptoms family members of an Alzheimer's patient are forced to watch is seeing their loved ones become more short-tempered, or even verbally or physically abusive.
But a new study led by a University of Rochester doctor is giving patients and their caregivers hope.
Researchers found 40-percent of patients who took the drug commonly known as Celexa or Cipramil felt considerable relief from their symptoms, compared with 26-percent in a group who took a placebo.
Doctors say the patients weren't the only ones who felt better.
"The difference was actually enough that the caregivers of the patients that got the medication had reduced distress," said Dr. Anton Porsteinsson, UR Medicine.
On Tuesday News10NBC spoke with a local woman about who knows all too well what these findings could mean for thousands of people in our area.
This is huge for caregivers. Tuesday night News10NBC learned it's often a rollercoaster ride for them. The person with the disease can be cooperative one day, refuse to cooperate the next and the third day say they wish they could die. So the medication could help improve the quality of life for both of them.
"It was hard, sometimes I would just go in my bedroom and cry," said Toni Lomax.
Lomax is talking about the two years she was her mother's sole caregiver.
Lomax works full-time. Caring for her mother with Alzheimer's became too much, so two years ago she placed her in a nursing care facility.
When News10NBC shared the results of the study, Lomax said the medication could have made a difference for her mom.
"If she wasn't so agitated and things didn't make her so upset, maybe she could have continued going to her program on a daily basis, because that's what we started out doing. She would go to a program, then I would go to work. But then she stopped going. She didn't want to go. She'd go one day and I was like, I can't do this," said Lomax.
Mollie Richards and her husband Ralph founded the Mt. Olivet Alzheimer's Ministry at Mt. Olivet Baptist Church in Rochester. They were our 2012 Jefferson Award Winners for a decade of work.
"I'm very excited to hear the news, because we work directly with caregivers," said Richards.
Richards, whose father and mother-in-law had Alzheimer's, says this shows researchers are concerned not only for the person with Alzheimer's, but also for their caregiver.
"A caregiver's burden is very high. I don't know if you've heard. We used to hear it all the time that often the caregiver dies before the person with Alzheimer's because of the stress of caring for someone that is agitated, that you have difficulty communicating with. So this would be very, very beneficial," said Richards.
There are other anti-psychotic drugs that are prescribed for people with Alzheimer's, but they can significantly increase a person's risk of stroke, heart attack, or death.
Researchers found a moderate dose of Celexa may not carry these risks or side effects, but this study is far from over.
News10NBC/WHEC-TV welcomes your opinion and interaction on our website, but please remember to keep it clean. If you're advertising for another business, being profane, vulgar or slanderous your post will be deleted. By commenting on this website, you agree that anything you post may be used, along with your name and profile picture, in accordance with our Privacy Policy and the license you have granted pursuant to our Terms of Use. Comments are not pre-screened before they posted.


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The World's Most Incredible Underwater Hotel Rooms
If you're looking for an unusual tropical vacation this time around, check out the world's most incredible underwater hotel rooms.
Best Sand Sculpting Contest Returns To Treasure Island With Music, Fireworks
Sanding Ovations Sand Sculpting and Music Festival is a free event held on the weekend before Thanksgiving in Sand Sculpture Capital of Florida, Treasure Island.
The Jamaica Destination Guide
Jamaica is a quintessential Caribbean travel destination. Here's a guide to both the basics and the intoxicatingly refreshing things to do.
The Bahamas Destination Guide
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The rise and fall of class popularity
Having played a Druid since the beginning of Burning Crusade and observed it going from the second least-played class at 60 to the third or fourth most-played class at 80, I have my own theories about what's influenced Druid population numbers particularly, but I need to do a little more digging before I can be sure. However, I don't know whether any of it really applies to other classes, and the meteoric rise of the Death Knight is a thought-provoking (and somewhat troubling) trend.
Filed under: Analysis / Opinion, Classes, Wrath of the Lich King


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Wireless charging soon available for small devices
In future, small devices can be placed on a laptop PC that operates as a NFC-compatible charging plate
Wireless charging will soon be available for devices smaller than mobile phones.
VTT Technical Research Centre of Finland is working with the industry's leading technological companies and standardisation bodies to expand the scope of application of wireless charging technology to other, smaller portable devices, such as mobile phone accessories, wrist devices, wireless mice and sensors.
This can be done by combining wireless power transmission with NFC connectivity technology, which enables cost-effective and compact design.
Consumers' need to recharge the batteries of various kinds of portable devices, whenever and wherever they are, continues to grow, and over the next five years, wireless charging will be available for more and more mobile devices. The first mobile phones with wireless charging capability are already on the market.
Examples include recent smartphone releases by leading mobile phone manufacturers, many of which have wireless charging either built in or available through a special cover accessory charging case.
The increase of features in mobile devices has caused cost pressures, increased power consumption, and created new challenges for keeping devices sufficiently compact.
Combining wireless charging with NFC (Near-Field Communication) technology makes it possible to design increasingly compact and cost-effective wireless charging circuits, which is essential especially for small devices.
In the near future, NFC devices will be able to receive electrical power wirelessly, as well as acting as charging platforms capable of transmitting wireless electrical power.
The challenges include, among others, current NFC antenna circuits, which have not been optimised for efficient, wireless energy transfer.
In addition to technological development, introducing NFC-based charging to commercial products requires amendments to the NFC standards so that they also support the design of open interfaces, both in the device to be charged and the wireless charger devices.
This work is under way at the NFC Forum.
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| Email | Full Article (TrendHunter.com/id/47156) |
Body paint is at once beautiful, titillating and extraordinary. Body painting turns human skin into a canvas, 'clothing' and moving art.
These body paint features showcase body painting at its best. From sensual body paint bikinis to extreme body painting competitions and canvases for activism, you're sure to find a collection of body paint photos that suits your fancy.


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King James Version (KJV) | New International Version (NIV) |
1 And Abram went up out of Egypt, he, and his wife, and all that he had, and Lot with him, into the south. | 1 So Abram went up from Egypt to the Negev, with his wife and everything he had, and Lot went with him. |
2 And Abram was very rich in cattle, in silver, and in gold. | 2 Abram had become very wealthy in livestock and in silver and gold. |
3 And he went on his journeys from the south even to Bethel, unto the place where his tent had been at the beginning, between Bethel and Hai; | 3 From the Negev he went from place to place until he came to Bethel, to the place between Bethel and Ai where his tent had been earlier |
4 Unto the place of the altar, which he had made there at the first: and there Abram called on the name of the LORD. | 4 and where he had first built an altar. There Abram called on the name of the LORD. |
5 And Lot also, which went with Abram, had flocks, and herds, and tents. | 5 Now Lot, who was moving about with Abram, also had flocks and herds and tents. |
6 And the land was not able to bear them, that they might dwell together: for their substance was great, so that they could not dwell together. | 6 But the land could not support them while they stayed together, for their possessions were so great that they were not able to stay together. |
7 And there was a strife between the herdmen of Abram's cattle and the herdmen of Lot's cattle: and the Canaanite and the Perizzite dwelled then in the land. | 7 And quarreling arose between Abram's herdsmen and the herdsmen of Lot. The Canaanites and Perizzites were also living in the land at that time. |
8 And Abram said unto Lot, Let there be no strife, I pray thee, between me and thee, and between my herdmen and thy herdmen ; for we be brethren. | 8 So Abram said to Lot, "Let's not have any quarreling between you and me, or between your herdsmen and mine, for we are brothers. |
9 Is not the whole land before thee? separate thyself , I pray thee, from me: if thou wilt take the left hand, then I will go to the right ; or if thou depart to the right hand, then I will go to the left . | 9 Is not the whole land before you? Let's part company. If you go to the left, I'll go to the right; if you go to the right, I'll go to the left." |
10 And Lot lifted up his eyes, and beheld all the plain of Jordan, that it was well watered every where, before the LORD destroyed Sodom and Gomorrah, even as the garden of the LORD, like the land of Egypt, as thou comest unto Zoar. | 10 Lot looked up and saw that the whole plain of the Jordan was well watered, like the garden of the LORD, like the land of Egypt, toward Zoar. (This was before the LORD destroyed Sodom and Gomorrah.) |
11 Then Lot chose him all the plain of Jordan; and Lot journeyed east: and they separated themselves the one from the other. | 11 So Lot chose for himself the whole plain of the Jordan and set out toward the east. The two men parted company: |
12 Abram dwelled in the land of Canaan, and Lot dwelled in the cities of the plain, and pitched his tent toward Sodom. | 12 Abram lived in the land of Canaan, while Lot lived among the cities of the plain and pitched his tents near Sodom. |
13 But the men of Sodom were wicked and sinners before the LORD exceedingly. | 13 Now the men of Sodom were wicked and were sinning greatly against the LORD. |
14 And the LORD said unto Abram, after that Lot was separated from him, Lift up now thine eyes, and look from the place where thou art northward, and southward, and eastward, and westward: | 14 The LORD said to Abram after Lot had parted from him, "Lift up your eyes from where you are and look north and south, east and west. |
15 For all the land which thou seest , to thee will I give it , and to thy seed for ever. | 15 All the land that you see I will give to you and your offspring forever. |
16 And I will make thy seed as the dust of the earth: so that if a man can number the dust of the earth, then shall thy seed also be numbered . | 16 I will make your offspring like the dust of the earth, so that if anyone could count the dust, then your offspring could be counted. |
17 Arise , walk through the land in the length of it and in the breadth of it; for I will give it unto thee. | 17 Go, walk through the length and breadth of the land, for I am giving it to you." |
18 Then Abram removed his tent , and came and dwelt in the plain of Mamre, which is in Hebron, and built there an altar unto the LORD. | 18 So Abram moved his tents and went to live near the great trees of Mamre at Hebron, where he built an altar to the LORD. |
The King James Version is in the public domain. (The King James Bible Version Online) | Scripture quoted by permission. Quotations designated (NIV) are from THE HOLY BIBLE: NEW INTERNATIONAL VERSION®. NIV®. Copyright © 1973, 1978, 1984 by Biblica. All rights reserved worldwide. (New International Version Bible Online) |


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Tomato growing season again :) Last year we took a trip into Saskatoon so I just had to stop at Lee Valley. I looked at the trelises and the spirals that were discussed in a thread last year. I purchased the trelises, as I had visions of being impaled by the spirals if we had to ever use our brakes. As Weeper said, the trelises were very sturdy and held up the tomatoes perfectly, even in our strong winds. Veseys sells something similar called stackable tomato ladders. Has anyone seen those or used them? I know people use the tomato cages and also twine or rope, but as I get older I want something that is tidy with no fuss or muss. I'm just wondering about getting more trelises or trying the stackables??? |
Follow-Up Postings:
Those ladders look intriguing. I use velcro to keep the plant attached to whatever support mechanism. It's cheap, easy and very effective. |
I saw some amazing tomato cages in a video yesterday I have not seen them in person but they fold flat for storage and are 6 ft tall - Texas Tomato Cages. |
Here is a link that might be useful: space saving tomato cages
- Posted by SouthCountryGuy SE BC 4b-5a (My Page) on Tue, Apr 9, 13 at 21:27
Okay you made me do it...i bought 10 different kinds of tomato seeds for one upside down planter... you folks bring the worst out in me....!!!! |
I prefer a 7' bamboo stake. Keep the plant to ONE stem and tie it to the stake as it grows. By the time the plant gets to the top of the stake, it's time to top it anyway. |
Here is a link that might be useful: Tomatoes
I presently own round stacking ones but love the idea of folding them flat. |
- Posted by runswithscissors MT 4/5 (My Page) on Fri, Apr 12, 13 at 22:14
Yes Nuts, I have used them for years. They are super heavy duty. They don't stay red for more than a season tho, as the sun turns them a blah-pink...that okay. Here's a few lessons I've learned with them: To use this type of support, you MUST apply some sort of pruning method, so that the main stem leans against the spine of the ladder. Also, keep this lean thing in mind to help you decide which direction to use it. The wind will blow it down if you have it sidways to the predominate direction of wind. So the spine needs to hold the wind back or hold the tomatoe against the wind. I found that for me the ladder was strongest by leaning the tomatoe towards the wind direction, instead of against. Another lesson I learned: use the ladders only for the variety of tomato that tends to grow tall, rather than waste them on bushier plants. Simple cages will work better for those. For my super-strong tomatoes I combine the two. Brandy Boy, for example grows HUGE! in all directions and definately requires team effort. So do my Sweet 100's. This year I'm going with all heirlooms. (Dester, Black Icicle, Paul Robeson, Cuor Di bue, Sub-Arctic, Constoluto, white queen, Emerald Apple.) Hope this helps. |
- Posted by nutsaboutflowers 2b/3a (My Page) on Sat, Apr 13, 13 at 14:02
It most certainly does. Thanks :) |
I use the Florida Weave method with 10' lengths of rebar and twine. No pruning needed but I like to prune off most of the non-producing foliage. |
- Posted by nutsaboutflowers 2b/3a (My Page) on Sun, Apr 14, 13 at 11:48
Hey Pudge :) I've used Florida weave with twine but the rain made it stretch too much. The rebar would do the trick though. We really need a new Bubble. I still have over 3 feet of snow. Two years ago I wrote that my bulbs were coming up on april 16th :( |
Hey NAF :) I use that plastic type of baler twine - doesn't stretch although I do need to anchor the end lengths of rebar or else they start to lean toward the middle. Some tent pegs and more twine is my fix for that. We are also still covered in snow - no patches of grass or anything showing yet, heck there's still a bunch of snow on the rooftops that hasn't yet melted. Sick of winter doesn't even begin to describe it. But I am starting some tomato seeds today. I have hope. |
I have tried a lot of different support methods over the years but always go back to 7' stakes. It just seems easier and have been so busy in the spring in the past. I prune the plants back to 1-2 stems and top off at 7' also. I have not grown tomatoes in this climate yet. I am sticking to short season and cherry types this year. My seedlings are all about 2" tall now on the windowsill. |
I have a couple of tomato questions. I have one of those big trellises from Lee Valley that I mentioned to Lynn awhile ago. The rest of my trellises are shorter, but heavy duty steel cages, probably at least 20-22 inches across. The varieties I'm planting this year are: Celebrity, Sungold cherry, Roma, and Sweet Million cherry. Are any of these particularly large(plant size)? Do I need to plant only one tomato per cage, or can 2 plants share a cage if I plant them on opposite sides? Do any of these varieties not require staking? I know sometimes the seed company will say "doesn't require staking" but in our windy prairie gardens, that often isn't true! This is my first year with vegetables, so I have a million questions! |
Definitely need staking, Katie. In fact, Sungold and Sweet Million, both of which I also plant every year, get very tall and vine like. I use 7 foot wrought iron trellises against the fence, deck or a south facing wall and tie them up as they grow. And, even though Celebrity and Roma are both determinate (or semi) it is probably a good idea, IMO, to only plant one tomato per cage. They can probably share a common side of the cage, however, since they are not so big. You have more room to tend them and ripen on the vine if they are not too crowded. :) I have even used an exercise pen for the dogs that folds out like an accordion with a plant on both sides. :) Welcome to the world of homegrown tomatoes! They are the subjects of my dreams all winter! :) Ginny |
My favourite support is a plain old wooden stake. I've found that the tomatoes ripen faster when I tie everything up to a single stake than when I cage them. Wood is less slippery to tie to than any metal stakes I've tried. That said, I have to admit reality. Summer is busy and I rarely keep up with tying branches and when they get to be a certain size they're terribly hard to tie back to the stake without breaking the branch or pinching a cluster. That, and I never seem to be able to sink them far enough into our clay subsoil that they don't tilt to the side at least a bit at best or fall over at worst. I've got 21 of the Lee Valley spirals and instead of using them as stakes this year, I'm going to try them in 7 tripods. I'll still be able to wind the main branches into the spiral and have more options for tying the others. We'll see how it goes. Nice that they have those little holes at the top to tie them together. Peavey Mart sells a really heavy-duty, round, stackable tomato cage (I think they call it a peony cage, but there are more rings, like a tomato cage). We have 4 already and they last forever, unlike the easily-kinked, common tomato cages made with higher-gauge wire. I'm going to get more of those for the determinates this year and be done with it. There's only so much time in a day. Rona had some nifty cages in stock when I was in Saskatoon on the weekend. They were round and stackable, but the base was wider than the top. Smart. Especially when you're rural and dealing with high winds. Unfortunately, I couldn't fit a stack of 10 in our car unless I left hubby and one of the kids behind in order to fold down a couple of seats. Drat. |
- Posted by nutsaboutflowers 2b/3a (My Page) on Tue, May 14, 13 at 18:21
Katie, the Lee Valley ones don't need to be used all four parts together in a cage shape. You've probably realized that already. Your first vegetable garden. How exciting.! |
Macky, you must have an amazing garden...and so much work to do! It sounds like it is positively enormous! I think hubby should have realized that his staying behind was a necessary and unavoidable sacrifice. ;) Lynn, yeah, I was thinking of breaking the cages into 2 and just using the "V" shape for each plant, but I wasn't sure how steady it would be. Maybe I'll try that this year and see how it goes. My garden is in the most windy part of our yard, unfortunately, the highest point in the yard and the old elms got torn out the year we moved in, so it is unprotected on the north side. I do have a shelterbelt planted, but the evergreens won't be blocking any wind for quite a few years, and the maples will be awhile too. |
That's what I thought, but... *shrug* My sketched plan for this year plants 3,150 square feet. Some years we keep up. Many years we don't. It still produces enough to make a dent in the groceries either way. :) I've given up an 11 by 11' spot of prime dirt for the kids; that's space I usually use for tomatoes, so I'm down to only 22 toms this year. The break in our treeline leaves us unprotected from southwest winds. This year I'm planting the corn along the west side of the garden to create a wall. I'll hill them to give them better grip. If something has to be sacrificed to wind, I'd rather it be the corn than anything else. I had the broccoli along that bed last year and lost nearly half of them, snapped right off by the high winds. :( |
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First of all - did this trade make sense? By all accounts the answer is a resounding yes, for a franchise that has the money to spend without sending its salary cap all out of whack. The Wilf regime qualifies in the latter regard and is apparently willing to invest money today to make money, or advance an agenda, down the long road. The agenda, of course, would be the new stadium. Zygi Wilf will not be quite mistaken for Santa Claus, given that obvious agenda, but how refreshing, after the threats, bullying, and whining of Red McCombs, all the while beggaring the franchise, to be sweetly wooed. It is the difference between perfume and a bouquet of flowers, or a screech of brakes accompanied by the imperative, "put out or get out!"
In any case, the Vikes used up two number threes and a first round pick to get an immediate answer to their pass rush problems, which was not available at slot #17, nor probably at all this year. I count that the cost of the later third round choice, very cheap indeed, (although the expense in compensation for Allen was not.) The Vikes could not have traded up for either DE Gholston or Long for the same value, and Allen is a proven commodity.
But now, a look at the draft day additions. Safety Tyrell Johnson out of Arkansas State is a pick that can't be appreciated if you are consulting old information, which listed him in Lindy's Draft Guide, for instance, as a projected seventh rounder, at 6' 198 lbs., running a 4.53 forty, ranked 24th out of 29 listed safeties. Phew! However, as of draft day he was certified 6', 207 lbs. and running a 4.44 forty, fast, even for a wideout. And he has a vertical leap of 39" (that's really good). Better yet, many of the draft day gurus rated him the best safety taken this year, better than first rounder Kenny Phillips out of Miami.
Now we jump down to the fifth round, where John David Booty, QB out of USC, was snatched at the last instant. He would have been worth a third round pick based solely on a name which will always give pleasure no matter what the man does. He was ranked a consistent 6th among QBs this year, a probable second round pick. He is deemed a possible franchise QB, especially in the west coast offense, and that after breaking a finger on his passing hand midseason his senior year.
Next comes Letroy Guidon a defensive tackle from Florida State, implicated in an academic cheating scandal, who declared that he came out after his junior year because "I've really got family issues." He has solid measurables but is a little shaky on the character side. Hopefully, his Florida pedigree of milk-fed family values will help him tiptoe through the fleshpots and temptations of Mankato and Lake Minnetonka, and that no one will open a joint along the Minnesota River called, "Piggy's."
John Sullivan of Notre Dame is a highly regarded three-year starter at center whose downside is that he is merely intelligent and productive, but not a fabulous athlete - sounds like another Matt Birk to me. And then comes Jaymar Johnson, a wideout not listed in most draft guides who is very fast, tall, but skinny. A typical flyer out of the last round rounds. Another Florida guy.
But wait. There is one more package, lost among the trash and leftovers, one Erin Henderson, brother to our own E.J., who was a projected second rounder, but never got picked at all through some inexplicable oddity of the draft. He signed a free agent contract with the Vikes, and has been described as a "more athletic version of his brother," "likely to contribute immediately." That was as good as an upgrade on one of the third round picks dealt to the Chiefs.
It could be our year. Then again, our year has been fairly predictable these past many.


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Bluegrass Tunes from Mollybloom
OPB | Aug. 21, 2008 8 p.m.
When you first see Mollybloom, you might think they're really a stand-up comedy troupe disguised as a bluegrass band. But this dynamic quintet has plenty of catchy songs and musical chops to rival their sense of humor.
First Broadcast: 2006
Producer: Jessica Martin


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Friday, March 22, 2013 10:21 AM
On March 16th, 2013 at 12:30 PM, Third District Patrol Deputy Officers were dispatched to Tulane University Hospital In New Orleans in reference to the possible child abuse of a two-year-old black female, identified as, Darionne Taylor, B/F, of Marrero. Darionne Taylor was suffering from head injuries, severe swelling to the forehead and a large bite mark to her back. She was determined to be in critical condition, on a ventilator, and unresponsive at that time.
Patrol officers learned the victim had been transported from 1540 Wakefield Drive in Marrero by West Jefferson EMS the night before, on March 15th. An individual identified as Cyril Jones, B/M, 23, of that same address told our officers he was babysitting Darionne Taylor and three other children, when Darionne began jumping on the bed and fell from it, causing her to hit her head on the floor.
Personal Violence Detectives responded to the hospital an began conducting follow-up interviews with Cyril Jones in an effort to determine what led to the injuries Darionne Taylor. Attending Physicians told our investigators Ms. Taylor's injuries, although severe, were not consistent with a fall, as reported by Jones.
Cyril Jones, along with the victim's mother, Devone Taylor were transported to our Criminal Investigations Bureau for questioning. Devone Taylor told detectives she left her daughter, along with several nieces and nephews in the custody of her boyfriend, Cyril Jones at the 1540 Wakefield Drive address. While at work, she was told that Darionne had fallen from the bed, was not breathing, and was taken to the hospital.
As investigators continued interviewing Jones, who repeatedly described to them the victim sustained her injuries after falling from a bed. Ultimately, Cyril Jones admitted the bite on Divonne's back was the result, in his words, "I just clicked out", lost his temper with Darionne because she was not listening. Jones admitted he grabbed Darionne and bit her on her back. Jones went on to state that on the night of March 15, 2013, Darionne was running around the house and not listening. Jones stated so he grabbed Darionne and threw her to the floor in the bedroom, causing her to strike her head. Jones told the child to go to sleep. Jones stated a short time later, Taylor was jumping on the bed a second time subsequently falling from it onto the floor below. Jones stated he picked Darionne up and began shaking her violently, telling her not to jump on the bed. He claimed he carried the child to the kitchen where she began to go unconscious. Jones stated he put water on the child's face at which time she began convulsing. It was then, Jones called 911.
Based on his confession, an arrest warrant for Cyril Jones charging him with two counts Second Degree Cruelty of a Juvenile was issued by Detective Sergeant KevinDecker. Jones was booked into the JPCC that same day. ?
Darionne Taylor remained in critical condition at Tulane Hospital until March 21st, 2013 at 7:14 PM when she was pronounced dead after succumbing to the injuries she sustained in the March 15th. incident. Sergeant Kevin Decker prepared an arrest warrant for Cyril Jones charging him with Second Degree Murder. Jones was rebooked at the JPCC last night with that charge.
Colonel John N. Fortunato
Public Information Office
Jefferson Parish Sheriff's Office
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The Salvation Army: Roots of the Angel Tree and More
Every year you see the Salvation Army on every corner, ringing bells and collecting change. But their Red Kettle program is only one of many that are offered not only around the holidays, but year round. Col. Charles White and Amy Sky from the Salvation Army's Nashville Area Command talk about the organization's recent emphasis on disaster relief, their transitional housing and adult education programs to provide shelter to Nashville's homeless and set them on the right track with GED programs and job placement. You'll also hear about the birth of the popular Angel Tree program, and find out how the items you drop off for the Army's thrift stores are helping to fight addiction and feed recovery for those in adult rehabilitation. To learn more, visit online at SalArmy-Nashville.org, or to volunteer, call 615-242-0411.