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The Palestinians do not recognize the Jews' right to a state, so Israel must take steps on its own to improve the atmosphere.2 comments
- Haaretz.com
- הארץ
- TheMarker
- עכבר העיר
- TheMarker Café
Malakhi Rosenfeld, 26, victim of Monday West Bank drive-by shooting, laid to rest (Haaretz)
Haifa to renew funding for Al-Midan theater this month (Haaretz)
UN declares highest-level humanitarian emergency in Yemen (AP)
European Council President Donald Tusk says can't help Greeks if they reject it (Reuters)
UN nuclear agency report says Iran largely meeting nuclear commitments (AP)
Houthi shells kill 18 in Yemen, dengue fever spreading rapidly (Reuters)
Sources: Egypt security forces kill nine 'armed men' in Cairo suburb (Reuters)
Two explosions heard in Egyptian town of Rafah, witnesses say (Reuters)
Spain seizes 3.5 tons of cocaine, 69 arrested across Europe (AP)
Shlomo Avineri
Ukraine has a long way to go to achieve democracy and stability, and its fate is far from being stable and assured - and not only because of Moscow's policy.1 comments
Netanyahu should take a lesson from Menachem Begin, whose insistence on passing the Basic Law on Jerusalem only harmed the very thing he sought to protect.27 comments
Reality is always complex, and we do need to teach it in Israel's schools — but not the unilateral Palestinian narrative that was adopted in the Haaretz editorial from April 29.50 comments
So far, the Palestinian negotiating tactic has been to get concessions, then cut off talks and 'start where we left off.'13 comments
- Four reasons why Israel must be recognized as a Jewish state
- John Kerry's Mideast peace deal is a disaster
- Abbas won't agree to a nominal state
- The Arafat precedent
- Abbas' aide: No framework deal unless it includes Palestinian, Arab positions
- NYT: Obama to pressure Netanyahu to accept framework deal
- Netanyahu is not convincing
- Waiting for the Palestinian Godot
- The Nakba according to Haaretz
We don't need the Palestinians to recognize Israel as a Jewish state, but we do need to hear them say - publicly - that they accept us.15 comments
- Netanyahu to Abbas: Accept Israel as Jewish state - it's a basic demand for peace
- Peres: Palestinian recognition of Jewish state 'unnecessary'
- Striving for an illusion-free Middle East peace
- Abbas proposes NATO mission in future Palestinian state
- Netanyahu: Abbas' refusal to recognize Israel as Jewish state is 'absurd'
- Jordanian FM: Palestinians don't need to recognize Jewish state
- When squeezed, both Netanyahu and Abbas will accept Kerry's plan
Former Israeli Prime Minister Ariel Sharon was able to do what the left wanted but never had the mandate for, but his final act remained a work in progress.4 comments
- My travels with Ariel Sharon
- Sharon's lasting legacy: Proving that rabbis and settlers can be defied
- INTERACTIVE: Key moments in the life of Ariel Sharon
- Ariel Sharon, former Israeli prime minister, dies at 85
- World leaders talk about Ariel Sharon
- Ariel Sharon: Champion of controversy
- Sharon realized the limits of military power
Mandela's knowledge of Zionism was filtered through the lens of the movement's harshest critics – Jewish communists.13 comments
By focusing on the extermination camps in Poland, a distortion has developed in the presentation and understanding of the Holocaust.8 comments
Obama has not proven any leadership, determination or skill in handling the most serious international crisis since he took office. Doubt is appropriate until proven otherwise.4 comments
The complications that accompany secular democracy in Middle East nations presents Western spectators with a difficult moral dilemma.2 comments
Boycotting Israel, while chiding Britain and the U.S. for 'war crimes' but not boycotting them, shows that the renowned scientist has dual standards.12 comments
Israel, a country that needs effective foreign relations as much as nearly any other, should not be without a foreign minister - especially now.6 comments
- Foreign ministers slated to meet with Netanyahu are getting Steinitz instead
- Lieberman pleads not guilty as trial gets underway; first hearings set for late April
- Israel's AG still avoiding taking stance on reserving Foreign Ministry for Lieberman
- Covert probe opened against Lieberman associates suspected of irregular trips abroad
- The Lieberman fear factor
- Israeli diplomats boycotting Steinitz's upcoming trip to U.S.
To be an effective opposition party, Labor must offer both criticism and detailed policy alternatives that champion its social-democratic values.1 comments
- Shelly Yacimovich's extreme political makeover
- David's Harp / Israel's poor, poor middle class
- A five-part economic primer for Israel's new MKs
- Lapid must cut the deficit to save Israel's economy
- Labor Party members vote in close primary race
- Labor voters in Israel's north complain of lack of polling stations
It's been 20 years since the failed Oslo Accords. Now is the time for a different, piecemeal approach to reducing the conflict between Israel and the Palestinians.13 comments
Even if Netanyahu assembles the next government, the relative strength of the center-left parties does matter and Labor is the only one with a true shot at making a difference.0 comments
The three leaders of Hatnuah left their parent parties due to their own failures - whether in the general elections or in primaries. They are not Churchill.2 comments
How Netanyahu might have responded to Abbas: 'You have already come a long way, Mr. President. In the name of the people of Israel, in all their diversity, I would like to congratulate you.'7 comments
It is a pity that after months of activity hidden from the public eye she did not manage to overcome her passions and admit her limitations and has decided, after all, to run in the election on an independent list.3 comments
There is no doubt that the ability of foreign nationals to contribute so substantially to primary campaigns undermines the right of Israeli citizens to choose their representatives to the Knesset.4 comments
Some opponents of an Israeli strike on Iran have been saying infuriating things that have no place in a democratic state, even if one can understand the agony and sincerity of opponents,0 comments
The civil war in Syria is not only a war against Assad's repressive regime. It has taken on religious and ethnic characteristics.0 comments
With Ankara's approach to Damascus, we should reexamine the attitude toward Turkey that prevails in Israel.3 comments
Labor can leverage its situation despite the coalition's solid parliamentary majority and the featherweight opposition in the current Knesset. The question is whether Labor's leadership is up to the task.0 comments
A proposed bill would give the vote only to Israelis who have been abroad less than four years, providing they declare their intent to return to Israel.13 comments
The prime minister's biggest current problem isn't an enlarged prostate or a razor-thin Knesset majority – his inability to work with others is finally catching up with him.20:33 01.07.15 | 0 comments
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Hey, readers! Looking for some good reading material this Sunday morning? I'll do the heavy lifting for you. Look below. Quite a Title The Truth About Happiness and Travel. Well, let's here it, Christine Garvin. Reality is what we see, think, and believe. Our thoughts are what bring us happiness, and the anticipation of something good […]
Tag Archives: Greenland
Consume & Update: Greenland, Snobs and Facebook
March 7, 2010 – 09:00
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Villa in north baliIndonesia, Bali, Buleleng
About This Listing
Space where guests can cook their own meals
In the building, free or for a fee
In the building, free or for a fee
Space where guests can cook their own meals
Towels, bed sheets, soap, and toilet paper
Central heating or a heater in the listing
In the building, free or for a fee
In the building, free or for a fee
Continuous access in the listing
Breakfast is provided.
The listing can accommodate a gathering of 25 or more attendees
Easy access to the building and listing for guests in wheelchairs
Private or Shared
Free, in the building or nearby
Posted emergency information and resources
The Space
Nice villa on the hills of lovina,close to popular divesites in north bali,internet and sattelite tv,three bedrooms and big living room,swimming pool,tropical garden and three bedrooms and fully equiped kitchen,carport and porch...
The tourism industry is primarily focused in the south, while significant in the other parts of the island as well. The main tourist locations are the town of Kuta (with its beach), and its outer suburbs of Legian and Seminyak (which were once independent townships), the east coast town of Sanur (once the only tourist hub), in the center of the island Ubud, to the south of the Ngurah Rai International Airport, Jimbaran, and the newer development of Nusa Dua and Pecatu.
A coastal road surrounds the island, and three major two-lane arteries cross the central mountains at passes reaching to 1,750m in height (at Penelokan). The Ngurah Rai Bypass is a four-lane expressway that partly encircles Denpasar and enables cars to travel quickly in the heavily populated south. Bali has no railway lines yet.
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About the Host, Geert
enthousastic , easygoing and life enjoying man
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Watch: Jack White and a hot cop don't stop in 'Freedom at 21' video
Leave it to director Hype Williams to suspend color along with reality and disbelief in an action-packed clip for Jack White. "Freedom at 21" is the celebration and dissent of women who do whatever the hell they please, and in this case, it's a hot cop who shirks her regular duties in order to turn. you. on.
White, as is his nature, is looking gaunt and borderline batsh*t in the video, the track culled from his eccentric solo debut "Blunderbuss." It's further evidence of the mystery that you never see the Third Man main man and Johnny Depp in the same room.
And, much like his "Sixteen Saltines" clip, this one leaves viewers on the edge of their seat, without resolve. White seemingly craves a violent death involving his car.


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- Michael Rothstein, ESPN Staff Writer
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ALLEN PARK, Mich. -- In their never-ending search for players, the Detroit Lions made a curious signing Thursday morning.
Carlin Isles, a member of the United States rugby sevens team, signed as a wide receiver on the Lions' practice squad after trying out with the team earlier this week.
Isles ran the 40-yard dash in 4.22 seconds during his workout with the team this week, according to the Detroit Free Press.
"You're looking for athletes," Lions coach Jim Schwartz said. "It hasn't been unusual to see basketball players transition to the NFL, and it's not just recently; that goes way back.
"Even track guys like Bob Hayes and Renaldo Nehemiah -- things like that. An athlete's an athlete, and there are skills you can develop, and if you see something that you like, then you can work with him."
Isles played football and ran track at Ashland University, a Division II school, before moving to rugby.
Dubbed by RugbyMag.com as "the fastest man in American rugby," Isles became a YouTube sensation playing rugby because of his speed.
The practice squad spot opened up when Detroit sent tight end Dorin Dickerson to injured reserve and promoted practice squad tight end Matt Veldman to the 53-man roster.
Dickerson hid a concussion from the Lions after being hit in the second half of Sunday's 23-20 overtime loss to the New York Giants. He was eventually diagnosed with a concussion in overtime.
Texans rookie Ivory arrested on burglary charge
11hTania Ganguli
Taking Sides: Russell Wilson contract negotiations
1dDoug Clawson, ESPN Stats & Information
Rugby star Carlin Isles joins Lions
12/26/2013 - NFL Dorin Dickerson Detroit Lions + more


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Hey everyone.
I was just looking for feed back from you about your babies and their breathing support requirements.
My little one is 36 days old now and on CPAP/biphasic. He was born at 28 +5 after almost 7 weeks of low AFI due to my pre term premature rupture of membranes.
When we was born he was on the vent for 1/2 a day, then biphasic fpr 2 and CPAP for 1. They then trialed him room air with no breathing support for 10 hours one day and 8 the next. He did way better then they expected. But then he began slidding backwards and the docs felt they had pushed him to hard.
Since then he has been back and forth on biphasic and CPAP. He was ventilated again for about 8 days due to requiring 3 surgeries. But extubated himself after the surgeries were complete. LOL.
One of these surgeries was to close his PDA in his heart as well.
So we are day 36 and on biphasic still requiring between 26 - 30% 02, and is on a rate of 10 breaths per minute with the biphasic portion. (he was put back on the biphasic rate about 5 days ago, as the respitory therapists thought it would help him bring his oxygen requirements down some)
Some days I just find myself getting frustrated with the breathing support. Wondering how long it will be till he can come off. OR mostly, how long till we can get the CPAP down to room air so we can actually start thinking of trialing with no breathing support or Cannula's.
I guess it has been such a long road for us already in the NICU (in the short 36 days that feels like 6 months). I just get this overwhelming feeling sometimes that he will never come off CPAP.
Everyone keeps telling me that he will turn a corner one day and the CPAP will be gone. BUt right now, it is hard to visualize.
Anyway, just wondering what your experiences have been, when your LO was born, how long on breathing support, etc.


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Our full-length Showcase Days have concluded for the 2014-15 academic year. Please look for new 2015-16 dates soon!
Want to Join Us For a Showcase Day?Showcase Days begin with check-in from 9:30 – 10:00. Your visit starts with an Admissions presentation about our campus, the application process, and financial aid. An interactive student panel allows you to learn about campus housing, student life, and insights into a spotlighted major from the perspective of the student. After a full campus and housing walking tour, you may select an academic session to see if a certain major is right for you or to learn more about our offerings in the area you plan to pursue. You will meet with staff from that discipline to learn about specific programs, career trajectories, research opportunities, internships, and noteworthy events and alumni from that area of study. The formal Showcase program ends at 2:00pm; however, we invite you to remain for a special First Friday interactive information session featuring one of our degree programs. These take place from 2:00pm to 3:00pm. We can't wait to see you here!
Optional Overnight Stay with your Showcase Day
An overnight experience at our River Crossing Campus Housing will be available on the Thursday night before the visit on two Showcase Days (new dates for 2015-16 coming soon). Overnight visitors will stay with an IU South Bend student, so you'll have a chance to hear about campus life from current students and ask all those questions that you don't think will be answered by your tour guide. Be sure to indicate your interest on the sign up form to reserve your space! Reservations for the overnight experience are limited and must be confirmed in order to participate. You will get an email to the address listed on the registration form that must be returned to us.
First Fridays Downtown
When visiting South Bend on a First Friday, be sure to leave time for a trip to our downtown area where you can enjoy the festivities that highlight shopping and dining, as well as arts and entertainment venues. Learn more at DTSB's First Friday Web site. The celebration begins each First Friday at 5:00pm.
Please contact the Office of Admissions (574) 520-4839 or
toll free 1-877-GO-2-IUSB if you have questions.


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Terrorist Watchlist:
Routinely Assessing Impacts of Agency Actions since the December 25, 2009, Attempted Attack Could Help Inform Future Efforts
GAO-12-476: Published: May 31, 2012. Publicly Released: May 31, 2012.
Additional Materials:
- Highlights Page:
- Full Report:
- Accessible Text:
(202) 512-6510
Office of Public Affairs
(202) 512-4800
What GAO Found
In July 2010, the federal government finalized guidance to address weaknesses in the watchlist nominations process that were exposed by the December 2009 attempted attack and to clarify how agencies are to nominate individuals to the watchlist. The nominating agencies GAO contacted expressed concerns about the increasing volumes of information and related challenges in processing this information. Nevertheless, nominating agencies are sending more information for inclusion in the terrorist watchlist after the attempted attack than before the attempted attack. Agencies are also pursuing staffing, technology, and other solutions to address challenges in processing the volumes of information. In 2011, an interagency policy committee began an initiative to assess the initial impacts the guidance has had on nominating agencies, but did not provide details on whether such assessments would be routinely conducted in the future. Routine assessments could help the government determine the extent to which impacts are acceptable and manageable from a policy perspective and inform future efforts to strengthen the nominations process.
After the attempted attack, federal agencies took steps to reassess the threat posed by certain individuals already identified in government databases and either add them to the watchlist or change their watchlist status, which included adding individuals to the watchlist's aviation-related subset lists. For example, the number of U.S. persons (U.S. citizens and lawful permanent residents) on the subset No Fly List the government uses to deny individuals the boarding of aircraft more than doubled after the attempted attack.
Screening agencies are addressing gaps in processes that were exposed by the attempted attack. For example, based on the growth of lists used to screen aviation passengers and continued implementation of Secure Flight—which enabled the Transportation Security Administration to assume direct responsibility for conducting watchlist screening from air carriers—more individuals have been denied boarding aircraft or subjected to additional physical screening before boarding. Secure Flight has also reduced the likelihood of passengers being misidentified as being on the watchlist and has allowed agencies to use a broader set of watchlist records during screening. U.S. Customs and Border Protection has built upon its practice of evaluating individuals before they board flights to the United States, resulting in hundreds more non-U.S. persons on the watchlist being kept off flights because the agency determined they would likely be deemed inadmissible upon arrival at a U.S. airport. The Department of State revoked hundreds of visas shortly after the attempted attack because it determined that the individuals could present an immediate threat to the United States. These actions are intended to enhance homeland security, but have also impacted agency resources and the traveling public. An interagency policy committee is also assessing the outcomes and impacts of these actions, but it did not provide details on this effort. Routine assessments could help decision makers and Congress determine if the watchlist is achieving its intended outcomes and help information future efforts.
Why GAO Did This Study
The December 25, 2009, attempted bombing of Northwest Flight 253 exposed weaknesses in how the federal government nominated individuals to the terrorist watchlist and gaps in how agencies used the list to screen individuals to determine if they posed a security threat. In response, the President tasked agencies to take corrective actions. GAO was asked to assess (1) government actions since the incident to strengthen the nominations process, (2) how the composition of the watchlist has changed based on these actions, and (3) how agencies are addressing gaps in screening processes. GAO analyzed government reports, the guidance used by agencies to nominate individuals to the watchlist, data on the volumes of nominations from January 2009 through May 2011, the composition of the list, and the outcomes of screening agency programs. GAO also interviewed officials from intelligence, law enforcement, and screening agencies to discuss changes to policies, guidance, and processes and related impacts on agency operations and the traveling public, among other things. This report is a public version of the classified report that GAO issued in December 2011 and omits certain information, such as details on the nominations guidance and the specific outcomes of screening processes.
What GAO Recommends
GAO recommends that the Assistant to the President for Homeland Security and Counterterrorism ensure that the outcomes and impacts of agencies' actions to strengthen nominations and screening processes are routinely assessed. Technical comments were provided and incorporated.
For more information, contact Eileen Larence at (202) 512-6510 or firstname.lastname@example.com.
Recommendations for Executive Action
Status: Open
Comments: When we confirm what actions the Executive Office of the President's Homeland Security Council has taken in response to this recommendation, we will provide updated information. Status last confirmed on 01/30/2014.
Recommendation: To help inform future efforts to strengthen watchlisting and screening processes, the Assistant to the President for Homeland Security and Counterterrorism should establish mechanisms or use existing interagency bodies to routinely assess whether use of the watchlist during agency screening processes is achieving intended results, including whether the overall outcomes and impacts of screening on agency resources and the traveling public are acceptable and manageable or if adjustments to agency programs or the watchlisting guidance are needed.
Agency Affected: Executive Office of the President: Homeland Security Council
Status: Open
Comments: When we confirm what actions the Executive Office of the President's Homeland Security Council has taken in response to this recommendation, we will provide updated information. Status last confirmed on 01/30/2014.
Recommendation: To help inform future efforts to strengthen watchlisting and screening processes, the Assistant to the President for Homeland Security and Counterterrorism should establish mechanisms or use existing interagency bodies to routinely assess how the watchlisting guidance has impacted the watchlisting community-including its capacity to submit and process nominations in accordance with provisions in the guidance-and whether any adjustments to agency programs or the guidance are needed.
Agency Affected: Executive Office of the President: Homeland Security Council
Explore the full database of GAO's Open Recommendations »
Jun 10, 2015
Screening Partnership Program:TSA's Cost and Performance Independent StudyGAO-15-612R: Published: Jun 10, 2015. Publicly Released: Jun 10, 2015.
Jun 2, 2015
Border Security:Progress and Challenges in DHS's Efforts to Address High-Risk Travelers and Maritime CargoGAO-15-668T: Published: Jun 2, 2015. Publicly Released: Jun 2, 2015.
State Department:Preliminary Observations on the Bureau of Counterterrorism's Resources, Performance, and CoordinationGAO-15-655T: Published: Jun 2, 2015. Publicly Released: Jun 2, 2015.
May 13, 2015
Aviation Security:TSA Has Taken Steps to Improve Oversight of Key Programs, but Additional Actions Are NeededGAO-15-559T: Published: May 13, 2015. Publicly Released: May 13, 2015.
Border Security:Progress and Challenges in DHS's Efforts to Implement and Assess Infrastructure and TechnologyGAO-15-595T: Published: May 13, 2015. Publicly Released: May 13, 2015.
Apr 30, 2015
Southwest Border:Issues Related to Private Property DamageGAO-15-399: Published: Apr 30, 2015. Publicly Released: Apr 30, 2015.
Homeland Security:Actions Needed to Better Manage Security Screening at Federal Buildings and CourthousesGAO-15-445: Published: Mar 31, 2015. Publicly Released: Apr 30, 2015.
Apr 22, 2015
Homeland Security Acquisitions:Addressing Gaps in Oversight and Information is Key to Improving Program OutcomesGAO-15-541T: Published: Apr 22, 2015. Publicly Released: Apr 22, 2015.
Homeland Security Acquisitions:Major Program Assessments Reveal Actions Needed to Improve AccountabilityGAO-15-171SP: Published: Apr 22, 2015. Publicly Released: Apr 22, 2015.
Apr 6, 2015
Coast Guard:Timely Actions Needed to Address Risks in Using Rotational CrewsGAO-15-195: Published: Mar 6, 2015. Publicly Released: Apr 6, 2015.
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Deviant Art
Black Butler Quiz 1: Which Butler Suits YouWhich Butler suits you bestBlack Butler Quiz 1: Which Butler Suits You3 years ago in Comedy More Like This
1. Morning! Your butler has come to wake you, but you're still sleepy. Reaction?
a) Roll over and stick my head under my pillow. It's too early for sunlight! (3)
b) I don't want to wake up, but the day must go on... something warm to drink would help keep me awake though. (5)
c) Send the butler away and grab a few more hours of beauty sleep! (7)
2. Now you've finally made your way downstairs and your butler is serving you breakfast. Which would be your first preference?
a) A nice, soft scone. (5)
b) something fried, like pancakes or doughnuts perhaps. (5)
c) I don't usually eat breakfast, but if I had to I'd pick something fruity. (8)
3. Time for a dancing lesson! You do know the waltz, don't you?
a) Of course! It's my favorite dance! (6)
b) Yeah, but dancing is stupid. I'd rather go outside or read a good book than spend my morning stepping about in circles. (3)
c) Er... (4)
4. It's almost time for lunch, but a matter has come up amongst the servants. Your
|Sta.sh Submit


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VIEWS: 2 PAGES: 11 POSTED ON: 5/19/2012 Public Domain
CARE OF PATIENTS WITH CANCER dear firstname.lastname@example.com KOMUNITAS BLOGGER UNIVERSITAS SRIWIJAYA CARE OF PATIENTS WITH CANCER Characteristics of Normal Cells The Biology of Normal Cells 1) Have limited cell division 2) Undergo Apoptosis 3) Show specific morphology 4) Perform specific differentiated functions 5) Adhere tightly together 6) Non migratory 7) Grow in orderly and well regulated manner 8) Are euploid * Normal cell growth (cell cycle) consists of 5 intervals or phases * Differentiation – refers to the process whereby cells develop specific structures and functions in order to specialize in certain tasks * Cellular adaptation a. Hypertrophy – refers to an increase in size of normal cells b. Atrophy – refers to the shrinkage of cell size c. Hyperplasia – refers to an increase in the number of normal cells d. Metaplasia – refers to a conversion from the normal patters of differentiation of one type of cell into another type of cell not normal for that tissue e. Dysplasia – refers to an alteration in the shape, size, appearance and distribution of cells f. Anaplasia – refers to disorganized, irregular cells that have nor structure and have loss of differentiation; the result is always malignant Evolution of Cancer Cells Cancer – refers to a disease whereby cells mutate into abnormal cells that proliferate abnormally Neoplasia – refers to an abnormal cell growth or tumor - a mass of new tissue functioning independently and serving no useful purpose Invasion – occurs when cancer cells infiltrate adjacent tissues surrounding the neoplasm Metastasis – occurs when malignant cells travel through the blood or lymph system and invade other tissues and organs to form a secondary tumor C. Characteristics of malignant cells 1. Rapid cell division and growth: regulation of the rate of mitosis is lost 2. No contact inhibition: cells do not respect boundaries of other cells and invade their tissue areas 3. Loss of differentiation: cells lose specialized characteristics of function for that cell type and revert back to an earlier, more primitive cell type 4. Ability to migrate (metastasize): cells move to distant areas of the body and establish new site malignant lesions (tumors) 5. Alteration in cell structure: differences are evident between normal and malignant cells with respect to cell membrane, cytoplasm and overall cell shape 6. Self-survival a. may develop ectopic sites to produce hormones needed for own growth b. can develop a connective tissue stroma to support growth c. May develop own blood supply by secreting angiotensin growth factor to stimulate local blood vessels to grow into tumor D. Epidemiology of Cancer 1. Incidence of cancer a. Cancer affects every age group though most cancer and cancer deaths occur in people older than 65 years of age b. Cancer ranks 3rd as the cause of morbidity in the Philippines c. Highest incidence of all cancer is prostate cancer d. Highest cancer incidence in males in order of frequency: prostate cancer, lung cancer and colorectal cancer e. Highest cancer incidence in females in order of frequency: breast cancer, lung cancer and colorectal cancer 2. Common sites of cancer and their sites of metastasis Cancer Type Sites of Metastasis 1. Brain Cancer Central Nervous System 2. Breast cancer Brain Liver Regional lymph nodes Vertebrae 3. Colon cancer Brain Liver Lung Lymph nodes Ovaries 4. Lung cancer Bone Brain Liver Lymph nodes Pancreas Spinal cord 5. Prostate cancer Bladder Bone Liver External factors causing CANCER 1. Chemical Carcinogens- over 1,000 chemicals are known to be carcinogenic • Alcoholic beverages (Liver, esophagus, mouth, breast colon) -- serves as a promoter in cancers of the liver and esophagus - when combined with tobacco, the risks for other cancers are even higher • Anabolic Steroid (Liver) • Arsenic (Lung; Skin) • Asbestos (Lung; peritoneum) • Benzene (Leukemia · Diesel exhaust (Lung) · Hair dyes (bladder) · Pesticides (Lungs) · Sunlight (Skin; eyes) · Tobacco (Lungs; esophagus; mouth; pharynx; larynx n smokeless tobacco (snuff and chewing tobacco) increases the risk of oral and esophageal cancers * long-term exposure to secondhand smoke increases the risk for lung and bladder cancers 2. Physical Carcinogens – Radiation – Chronic Irritation- GERD 3. Viral Carcinogens - some viral infections tend to increase risk of cancer Ex: Epstein Barr Genital herpes Papillomavirus Hepatitis B Human cytomegalovirus 4. Dietary Factors - diets in high fat, low in fiber and those containing nitrosamines found in preserved meats and pickled foods promote certain cancers such as colon, breast, esophageal and gastric Personal factors causing CANCER 1. Immune Functions 2. Age a. Increased risk for people over age of 65 b. Factors attributed to cancer in elderly include hormonal changes, altered immune responses and the accumulation of free radicals c. Age has been identified as the single most important factor related to the development of cancer 3. Gender a. certain cancers are more commonly seen in specific genders ex: breast cancer –more common in female colon cancer – more common in males 4. Genetic Risk - 15% of cancers may be attributed to a hereditary component Ex: Breast, colon, lung, ovarian and prostate cancers 5. Race – can affect any population - African-Americans experience a higher rate of cancer than any other racial or ethnic group CARCINOGENESIS: Transformation of Normal Cells into Cancer Cells 1. Initiation – occurs when carcinogen damages DNA - carcinogenesis cause changes in the structure and function of the cell at the genetic or molecular level. This damage may be reversible or may lead to genetic mutations if not repaired; however the mutations may not lead immediately to cancer 2. Promotion – occurs with additional assaults to the cell, resulting in further genetic damage 3. These genetic events result in a malignant conversion 4. Progression – the cells are increasingly malignant in appearance and behaviour and develop into an invasive cancer with metastases to distant body parts Comparison of the Characteristics of Normal and Cancer Cells Characteristic Normal Cells Cancer Cells Mitotic cell division Mitotic division lead to 2 daughter cells Mitosis leads to multiple daughter cells that may or may not resemble the parent. Multiple mitotic spindles Appearance 1. Cells of same type homogeneous in size, shape, and growth 2. Cells cohesive, form regular pattern of expansion 3. Uniform size to nucleus 4. Have characteristic pattern of organization 5. Mixture of stem cells (precursors) and well-differentiated cells 1. cells larger and grow more rapidly than normal; pleomorphic 2. Cells not as cohesive; irregular patterns of expansion 3. Larger, more prominent nucleus 4. Lack characteristic pattern of organization of host cell 5. Anaplastic, lack of differentiated cell characteristics, specific functions Growth pattern 1. do not invade adjacent tissue 2. Proliferate in response to specific stimuli 3. Grow in ideal conditions (ex: nutrients, oxygen, space, correct biochemical environment) 4. Exhibit contact inhibition 5. Cell birth equals or is less than cell death 6. Stable cell membrane 7. Constant or predictable growth rate 8. Cannot grow outside specific environment (ex: breast cells grow only in breast) 1. invade adjacent tissues 2. Proliferation in response to abnormal stimuli 3. Grow in adverse conditions such as a lack of nutrients 4. Do not exhibit contact inhibition 5. Cell birth exceeds cell death 6. Loss of cell control a result of cell membrane changes 7. Growth rate erratic 8. Able to break off cells that migrate through bloodstream or lymphatics or seed to distant sites and grow in other sites Function 1. have specific, designated purpose 2. Contribute to the overall well-being of the host 3. Function in specific, predetermined manners (ex: cells in the thyroid secrete thyroid hormone) 1. serve no useful purpose 2. do not contribute to the well-being of the host; parasitic, actually feed off host without contributing anything 3. If cells function at all, they do not function normally or they may actually cause damage (ex: lung cancer cells secrete ACTH and cause excessive stimulation of adrenal cortex) Other 1. develop specific antigens, characteristic of the particular cell formed 2. Chromosomes remain constant throughout cell division 3. Complex metabolic and enzyme pattern 4. Cannot invade, erode, or spread 5. cannot grow in present of necrosis or inflammation 1. develop antigens completely different from a normal cell 2. chromosomal aberrations 3. have more primitive and simplified metabolic and enzyme pattern 4. invade, erode and spread 5. grow in presence of necrosis and inflammatory cells such as lymphocytes and macrophages 6. exhibit periods of latency that vary from tumor to tumor 7. have own blood supply and supporting stroma Metastasis - ability of cancer cells to spread from the original site of the tumor to distant organs Stages: 1. Detachment * tumor cell loses cohesiveness and it has increasing motility * tumor cell detaches from the primary tumor and create defects in the basemement membranes with resulting stromal invasion and spread into the circulation 2. Migration * Cancer cells migrate via the lymph or blood circulation or by direct extension * the lymphatic system provides the most common pathway for the initial spread of malignant cancer cells * The blood vessels carry cancer cells from the primary tumor to the capillary beds of the lungs, liver and bones * Direct tumor extension of tumors to adjacent tissues also occurs 3. Dissemination * Cancer cells are established at the secondary site which may result from entrapment due to the size of the tumor clump, adherence to cells at the new site through specific interactions, or by binding to exposed basement membrane 4. Angiogenesis * Vascularization of the tumor The Immune System and Cancer Two critical components of the immune response 1. the ability to recognize a pathogen as foreign 2. the ability to mount a response to eliminate the pathogen * T-cell lymphocyte, macrophages, and antigens recognize cancers cells as non-self and destroy them · Immune Surveillance Theory – proposes that immune responses, particularly cell-mediated responses, provide a defense against cancer cells by recognizing the antigens on the surface of some neoplastic cells as foreign - they are killed by cytotoxic T cells that have receptors for specific tumor antigens and by interferon-activated natural killer (NK) lymphocytes and macrophages - macrophages phagocytize the pathogen and present it as antigen to T and B lymphocytes · Failure of Immune Defenses - the immune system may be unable to recognize cancer cells as foreign or to mount an immune response due to the following: a. it's immature, old or weak b. malnutrition or chronic ailment c. cancer cells escape detection because they resemble normal cells. Others produce substances that shield them from recognition or they may be coated with fibrin d. use of immunosuppressive drugs which can suppress immune system Classification of Neoplasms 1. Benign – from latin word "benigunus"- kind 2. Malignant Comparision of the characteristics of Benign and Malignant neoplasm Characteristic Benign Neoplasm Malignant Neoplasm Speed Growth Grows slowly Usually continues to grow throughout life unless surgically removed May have periods of remission Usually grows rapidly Tends to grow relentlessly throughout life Rarely, neoplasm may regress spontaneously Mode of Growth Grows by enlarging and expanding Always remains localized; never infiltrates surrounding tissues Grows by infiltrating surrounding tissues May remain localized (in situ) but usually infiltrates other tissues Capsule Almost always contained within a fibrous capsule Capsule does not prevent expansion of neoplasm but does prevent growth by nfiltrations Capsule advantageous because encapsulated tumor can be removed surgically Never contained within a capsule Absence of capsule allows neoplastic cells to invade surrounding tissues Surgical removal of tumor difficult Cell characteristics Usually well differentiated Mitotic figures absent or scanty Anaplastic cells absent Cells function poorly in comparison with normal cells from which they arise If neoplasm arises in glandular tissue, cells may secrete hormones Usually poorly differentiated Large numbers of normal and abnormal mitotic figures present Cells tend to be anaplastic Cells too abnormal to perform any physiologic functions Occasionally a malignant tumor arising in glandular tissue secretes hormnes Recurrence Unusual when surgically removed Common following surgery because tumor cells spread into surrounding tissues Metastasis Never occur Very common Effect of Neoplasm Not harmful to host unless located in area where it compresses tissue or obstructs vital organs Does not produce cachexia (weight loss, debilitation, anemia, weakness, wasting) Always harmful to host Causes death unless removed surgically or destroyed by radiation or chemotherapy Causes disfigurement, disrupted organ function, nutritional imbalances May result in ulcerations, sepsis, perforations, hemorrhage, tissue slough Almost always produces cachexia, which leaves person prone to pneumonia, anemia, and other conditions Prognosis Very good Tumor generally removed surgically Depends on cell type and speed of diagnosis Poor prognosis if cells are poorly differentiated and evidence of metastatic spread exists Good prognosis indicated if cells still resemble normal cells and there is no evidence of metastasis Classification of cancer according to tissue of origin 1. Carcinoma - refers to a tumor that arises from epithelial tissue; the name of the cancer identifies the location example: basal cell carcinoma 2. Sarcoma - refers to a tumor arising from supportive tissues; the name of the cancer identifies the specific tissue affected example: osteosarcoma Tissue of Origin Benign Neoplasms Malignant Neoplasms Connective Tissue Bone Fibrous tissue Adipose tissue Osteoma Fibroma Lipoma Osteosarcoma Fibrosarcoma Liposarcoma Epithelial Tissue Glandular Surface Adenoma Papilloma Adenocarcinoma Squamous cell carcinoma Hematopoietic Erythrocytes Granulocytes Lymphatic tissue Erythroleukemia Leukemia Hodgkin's disease, malignant lymphoma Lymphocytes Plasma cells Lymphocytic leukaemia Multiple myeloma Cancer Prevention and Control 1. Prevention – involves measures to avoid or reduce exposure to carcinogens - activities are aimed at interventions before pathologic change has begun 2. Screening – helps to identify high-risk populations and individuals 3. Early Detection – involves finding a precancerous lesion or a cancer at its earliest, most treatable stage - also called secondary prevention - methods a. inspection b. palpation c. use of tests or procedures Approaches to Cancer prevention 1. Education 2. regulation – prohibit the sale of tobacco and alcohol to minors, limiting smoking in public places, imposing excise taxes, regulating the use of manufactured carcinogens such as asbestos, and prohibiting carcinogens in foods 3. host modification - aims to alter the body's internal environment to decrease the risk of or to reverse a carcinogenic process Cancer Prevention 1. Skin: Avoid exposure to sunlight 2. Oral: Annual oral examination 3. Breast: Monthly BSE from age 20 4. Lungs: Avoid cigarette smoking; annual chest x-ray 5. Colon: DRE for person over age 40. Rectal biopsy, proctosigmoidoscopic examination, Guiac stool examination for persons age 50 and above 6. Uterus: annual Pap's smear from age 40 7. Basic: annual physical examination and blood examination Dietary Recommendations against cancer 1. Avoid obesity 2. Cut down on total fat intake 3. Eat more high fiber foods – raw fruits and vegetables, whole grain cereal 4. Include food rich in vitamin A and C in daily diet 5. Include cruciferous vegetables in the diet-brocolli, cabbage, cauliflower, brussel sprouts 6. Be moderate in the consumption of alcoholic beverages 7. Be moderate in the consumption of salt-cured, smoked-cured and nitrate-cured foods Recommendations of the American Cancer Society for Early Cancer Detection 1. For detection of breast cancer a. Beginning at age 20, routinely perform monthly breast self-examination b. Women ages 20-39 should have breast examination by a healthcare provider every 3 years c. Women age 40 and older should have a yearly mammogram and breast self- examination by a healthcare provider 2. For detection of colon and rectal cancer a. all persons age 50 and older should have a yearly fecal occult blood test b. digital rectal examination and flexible sigmoidoscopy should be done every 5 years c. Colonoscopy with barium enema should be done every 10 years 3. For detection of uterine cancer a. yearly papanicolao (Pap) smear for sexually active females and any female over age 18 b. At menopause, high-risk women should have an endometrial tissue sample 4. For detection of prostate cancer a. beginning at age 50, have a yearly digital rectal examination b. beginning at age 50, have a yearly prostate-specific antigen (PSA) test American Cancer Society's seven warning signs of cancer (uses acronym CAUTION): 1. Change in bowel or bladder habits 2. A sore that does not heal 3. Unusual bleeding or discharge 4. Thickening or lump in breast or elsewhere 5. Indigestions or difficulty in swallowing 6. Obvious change in wart or mole 7. Nagging cough or hoarseness Diagnostic tests of Cancer 1. Biopsy/cytology a. Histologic and cytologic examination of specimens are performed by the pathologist on tissues collected by needle aspiration of solid tumors, exfoliation from epithelial surface, and aspiration of fluid from blood or body cavities b. Tissues may be obtained by excisional biopsy, incisional biopsy, and needle biopsy c. By examination of these tissues, the name, grade, and stage of the tumor can be identified 2. Papanicolao Test (Pap Smear) Class I: Normal Class II: Inflammation Class III: Mild to moderate dysplasia Class IV: Probably malignant Class V: Malignant 3. Ultrasound 4. MRI 5. X-rays 6. CT scan 7. Radiographic techniques 8. Antigen Skin test 9. Laboratory tests a. Alpha-feto- protein b. HCG c. Prostatic Acid Phosphatase (PSA) d. Carcinoembroyenic antigens (CEA) 10. Endoscopic examination 11. Monoclonal antibodies C. Tumor markers 1. Tumor markers are protein substances found in the blood or blody fluids 2. Are released either by the tumor itself, or by the body as a defense in response to the tumor (called host response) 3. Tumor markers are derived from the tumor itself. And include the ff: a. Oncofetal antigens, present normally in fetal tissue, may indicate an anaplastic process in tumor cells; carcinoembyonic antigen (CEA) and alpha-fetoprotein (AFP) are examples of oncofetal antigens. b. Hormones are present in large quantities in the human body; however, high levels of hormones may indicate a hormone-secreting malignancy; hormones that may be utilized as tumor markers include the antidiuretic hormone (ADH), calcitonin, catecholamines, human chorionic gonadotropin (HCG), and parathyroid hormone (PTH) c. Isoenzymes that are normally present in a particular tissue may be released into bloodstream if the tissue is experiencing rapid, excessive growth as the result of tumor; are examples include neuron-specific enolase (NSE) and prostatic acid phosphatase (PAP) d. Tissue-specific proteins identify the type of tissue affected by malignancy; an example of a tissue-specific protein is the protastic- specific antigen (PSA) utilized to identify prostate cancer 4.Host-response tumor makers include the following: a. C-reactive protein b. Interleukin-2 c. Lactic dehydrogenase d. Serum Ferritin e. Tumor necrosis factor Staging 1. The TNM tumor system is utilized for classifying tumors a. T indicates the tumor size 1) T0 indicates no evidence of tumor 2) Tis indicates tumor in situ 3) T1,T2,T3,T4 indicate progressive degrees of tumor size and involvement b. N indicates lymph node involvement 1) N0 indicates no abnormal lymph nodes detected 2) N1a, N2a indicate regional nodes involved with increasing degree from N1a to N2a, no metastases detected 3) N1b, N2b, N3b indicate regional lymph nodes involvement with increasing Degree from N1b to N3b, metastasis suspected 4) Nx indicates inability to assess regional nodes c. M indicates distant metastases 1) M0 indicates no evidence of distant metastasis 2) M1, M2,M3 indicate ascending degrees of distant metastasis and includes distant lymph nodes Different Modalities for Cancer 1. Surgical interventions 2. Chemotherapy 3. Radiation therapy 4. Immunotherapy 6. Bone Marrow transplantation Surgical Intervention 1. Preventive surgery- removal of precancerous lesions or benign tumors 2. Diagnostic surgery- biopsy 3. Curative surgery- removal of an entire tumor 4. Reconstructive surgery – improvement of structures and function of an organ 5. Palliative surgery – relief of distressin signs and symptoms; retardations of metastasis Common Nursing Techniques and Procedures A. Radiation therapy 1. Is used to kill a tumor, reduce the tumor size, relieve obstruction, or decrease pain 2. Causes lethal injury to DNA, so it can destroy rapidly multiplying cancer cells, as well as normal cells 3. Can be classified as internal radiation therapy (bachytherapy) or external radiation therapy (teletherapy) B. The client undergoing brachytheraphy ( internal radiation) 1. Sources of internal radiation a. Implanted into affected tissue or body cavity b. Ingested as a solution c. Injected as a solution into the bloodstream or body cavity d. Introduced through a catheter into the tumor 2. Side effects of internal radiation a. Fatigue b. Anorexia c. Immunosuppression d. Other side effects similar to external radiation 3. Priority nursing diagnoses: Impaired tissue integrity; fatigue; anxiety; risk for infection; Social isolation; Imbalanced nutrition: less than body requirements 4. Client education a. Avoid close contact with others until treatment is completed b. Maintain daily activities unless contraindicated, allowing for extra rest periods as needed c. Maintain balanced diet; may tolerate food better if consumes small, frequent meals d. Maintain fluid intake ensure adequate hydration (2-3 liters/day) e. If implant is temporary, maintain bedrest to avoid dislodging the implant. f. Excreted body fluids may be radioactive; double-flush toilets after use g. Radiation therapy may lead to bone marrow suppression 5. Nursing management of client receiving internal radiation a. Exposure to small amounts of radiation is possible during close contact with persons receiving internal radiation: understand the principles of protection from exposure to radiation: time, distance, and shielding 1) Time: minimize time spent in close proximity to the radiation source; a common standard is to limit contact time to 30 minutes total per 8-hour shift; minimum distance of 6 feet used when possible 2) Distance: maintain the maximum distance possible from the radiation source 3) Shielding: use lead shields and other precautions to reduce exposure to radiation b. Place client in private room c. Instruct visitors to maintain at least a distance of 6 feet from the client and limit visitors to 10-30 minutes d. Ensure proper handling and disposal of body fluids, assuring the containers are marked appropriately e. Ensure proper handling of bed linens and clothing f. In the event of a dislodged implant, use long-handled forceps and place the implant into a lead container; never directly touch the implant g. Do not allow pregnant woman to come into any contact with radiation sources; screen visitors and staff for pregnancy h. If working routinely near radiation sources, wear a monitoring device to measure exposure i. Educate client in all safety measures 6. Evaluation: client demonstrates measures to protect others from exposure to radiation, identifies interventions to reduce risk of infection, remains free from infection, achieves adequate fluid and nutritional intake, and participates in activities of daily living (ADLs) at level of ability C. The client undergoing external radiation therapy (teletheraphy) 1. The radiation oncologist marks specific locations for radiation treatment using a semipermanent type of ink a. Treatment is usually given 15-30 minutes per day, 5 day per week, for 2-7 weeks b. The client does not pose a risk for radiation exposure to other people 2. side effects of external radiation therapy a. Tissue damage to target area (erythema, sloughing, hemorrhage) b. Ulcerations of oral mucous membranes c. Gastrointestinal effects such as nausea, vomiting, and diarrhea d. Radiation pneumonia e. Fatigue f. Alopecia g. Immunosuppression 3.Priority nursing diagnoses: risk for infection; impaired skin integrity; social isolation; disturbed body image; anxiety; fatigue 4. Client education exam for external radiation a. Wash the marked area of the skin with plain water only and pat skin dry; do not use soaps, deodorants, lotions, perfumes, powders or medications on the site during the duration of the treatment; do not wash off the treatment site marks b. Avoid rubbing, scratching, or scrubbing the treatment site; do not apply extreme temperatures (Heat or Cold) to the treatment site ; if shaving, use only an electric razor c. Wear soft, loose-fitting over the treatment area d. Protect skin from sun exposure during the treatment and for at least 1 year after the treatment is completed; when going outdoors, use sun- blocking agents with sun protector factor (SPF) of at least 15 e. Maintain proper rest, diet, and fluid intake as essential to promoting health and repair of normal tissues f. Hair loss may occur; choose a wig, hat, or scarf to cover and protect head (refer to care of client with alopecia later in chapter) 5. Nursing management of the client receiving external radiation a. Monitor for adverse side effects of radiation b. Monitor for significant decreases in white blood cell counts and platelet counts c. Client teaching (refer to later sections for management of immunosuppression, thrombocytopenia 6. Evaluation; client identifies interventions to reduce risk of infection, remains free from infection, achieves adequate fluid and nutritional intake, participates in activities of daily living (ADLs) at level of ability, and maintains intact skin. The Client Undergoing a Bone Marrow Transplant (BMT) 1. BMT – used in the treatment of leukemias, usually in conjunction with radiation or chemotherapy a. Autologous BMT – the client is infused with own bone marrow harvested during remission of disease b. Allogenic BMT – the client is infused with donor bone marrow harvested from a healthy individual 2. The bone marrow is usually harvested from the iliac crest, then frozen and stored until transfusion 3. Before receiving the BMT, the client must first undergo a phase of immunosuppressive therapy to destroy the immune system, infection, bleeding, and death are major complications that can occur during this conditioning phase 4. After immunosuppression, the bone marrow is transfused intravenously through a central line 5. Side of BMT a. malnutrition b. infection related to immunosuppression c. bleeding related to thrombocytopenia 6. Priority Nursing Diagnoses a. Risk for infection b. Risk for hemorrhage c. Risk for imbalanced nutrition d. Social isolation e. Anxiety 7. Nursing Management of client undergoing a bone marrow transplant a. Monitor for graft-versus-host disease b. Provide private room for the hospitalized client; client will be hospitalized for 6-8 weeks c. Encourage contact with significant others by using telephone, computer, and other means of communication to reduce feelings of isolation d. Refer to management for imbalanced nutrition, immunosuppression and thrombocytopenia 8. Evaluation: client evaluates understanding of risks and participates in activities that reduce risk of infection, hemorrhage, and malnutrition; client demonstrates effective coping mechanisms The Client Undergoing other therapeutic interventions 1. Immunotherapy/biologic response modifiers (BMR) a. Enhances the person's own immune responses in order to modify the biologic processes resulting in malignant cells b. Currently considered experimental in use c. Monoclonal antibodies: antibodies are recovered from an inoculated animal with a specific tumor antigen, then given to the person with that particular cancer type; the goal is: destruction of the tumor d. Cytokines: normal growth-regulating molecules possessing antitumor abilities 1) Interleukin-2(IL-2) increases immune response effective and destroys abnormal cells 2) Interferons are substances produced by cells to protect them from viral infection and replication; interferon-alpha 2b is most commonly used 3) Hematopoietic growth factors such as granulocyte colony- stimulating factor (G-CSF) and erythropoietin, balance the suppression of granulocytes and erythrocytes resulting from chemotherapy e. natural killer cells (NK cells) : exert a spontaneous cytotoxic effect on specific cancer cells; they also secrete cytokines and provide a resistance to metastasis 2. Gene therapy a. Current use in investigational b. Increases susceptibility of cancer cells to the destruction by other treatments; insertion of specific genes enhances ability of client's own immune system to recognize and destroy cancer cells 3. Photodynamic theory a. Used to treat specific superficial tumors such as those of the surface of bladder, bronchus, chest wall, head, neck and peritoneal cavity b. Photofirin, a photosensitizing compound, is administered intravenously where it is retained by malignant tissue c. Three days after injection, the drug is activated by a laser treatment which continues for 3 more days d. The drug produces a cytotoxic oxygen molecule (singlet oxygen) e. During intravenous administration, monitor for chills, nausea, rash, local skin reactions, and temporary photosensitivity f. Drug remains in tissues 4-6 weeks after injection; direct or indirect exposure to sun activates drug, resulting in chemical sunburn; educate client to protect skin from exposure to sun Oncologic Emergencies: Diagnosis and Management 1. Spinal Cord Compression a. Occurs secondary to pressure from expanding tumors b. Early symptoms include back and leg pain, coldness, numbness, tingling, paresthesias, progression leads to bowel and bladder dysfunction, weakness, and paralysis c. Early detection is essential: investigate all complaints of back pain or neurological changes d. Treatment is aimed at reducing tumor size by radiation and/or surgery to relieve compression and prevent irreversible paraplegia; may receive corticosteroids to reduce cord edema e. Nursing interventions include early recognition of symptoms, neurological checks and medication administration 2. Superior vena cava syndrome a. Compression or obstruction of the superior vena cava (SVC) b. Usually associated with cancer of the lungs and lymphomas c. signs and symptoms are the result of blockage of venous circulations of head, neck, and upper trunk d. Early signs and symptoms are periorbital edema and facial edema e. Symptoms progress to edema of neck, arms, and hands, difficulty swallowing, shortness of breath f. Late signs and symptoms are cyanosis, altered mental status, headache, and hypotension g. Death may occur if compression is not relieved h. Treatment included high-dose radiation to shrink tumor and relieve symptoms i.Nursing interventions include: a. Monitoring vital signs b. providing oxygen support c. preparing tracheostomy if necessary d. initiating seizure precautions e. administering corticosteroids to reduce edema 3. Disseminated intravascular coagulopathy (DIC) a. Severe disorder of coagulation, often triggered by sepsis, whereby abnormal clot formation occurs in the microvasculature; this process depletes the clotting factors and platelets, allowing extensive bleeding to occur tissue hypoxia occurs as a result of the blockage of blood vessels from the clots b. Signs and symptoms are related to decreased blood flow to major organs (tachycardia, oliguria, dyspnea) and depleted clotting factors (abnormal bleeding and hemorrhage) c. Treatment includes anticoagulants to decrease stimulations of coagulation and transfusion of one or more of the following: 1) fresh frozen plasma (FFP) 2) cryoprecipitate 3) platelets 4) packed RBC d. Nursing interventions include assessing client, monitoring for bleeding, applying pressure dressings to venipuncture sites, and preventing risk of sepsis e. Mortality for clients experiencing DIC is greater than 70% despite aggressive treatment 4. Cardiac tamponade a. Pericardial effusion secondary to metastases or esophageal cancer can lead to compression of heart, restricting heart movement and resulting in cardiac tamponade b. Signs and symptoms are related to cardiogenic shock or circulatory collapse: anxiety, cyanosis, dyspnea,hypotension, tachycardia,tachypnea,impaired levels of consciousness, and increased central venous pressure c. Pericardiocentesis is performed to remove fluid from pericardial sac d. Nursing interventions 1) administering oxygen 2) maintaining intravenous line 3) Monitoring vital signs 4) hemodynamic monitoring 5) administration of vasopressor agents COMMON CANCER DISORDERS I. BREAST CANCER - unregulated growth of abnormal cells in breast tissue Etiology and pathophysiology A. cause is unknown but many risk factors influence development 1. Female gender and white Caucasian race 2. family history of mother or sister with breast cancer 3. medical history of cancer of other breast, endometrial cancer or atypical Hyperplasia 4. Menarche before age 12 (early) or menopause after age 50(Late) 5. First birth after 30 years of age, oral contraceptive use (early or prolonged), prolonged use of estrogen replacement therapy 6. Lifestyle factors: high-fat diet, obesity, high socioeconomic status, breast trauma, smoking, ingesting more than 2 alcoholic drinks daily 7. Exposure to radiation through chest x-ray, fluoroscopy B. Begins as a single transformed cells and is hormones-dependent; does not develop in women without functioning ovaries who never received hormones replacement therapy C. Most often occurs in ductal areas of breast D. Noninvasive: does not penetrate surrounding tissues; may be ductal or lobular; usually diagnosed through mammogram or nipple discharge E. Invasive: penetration of tumor into surrounding tissue Manifestations 1. Lump in upper outer quadrant of breast, usually nontender but may be tender 2. dimpling of breast tissue surrounding nipple, or bleeding from the nipple 3. Asymmetry with affected breast being higher 4. Regional lymph nodes swollen and tender Management 1. Radiation therapy 2. Mastectomy a) Segmental mastectomy – or lumpectomy; removes the tumor and margin of breast tissue surrounding the tumor b) simple mastectomy – removal of the complete breast but no other structures c) Modified radical mastectomy – removal of the breast and axillary lymph nodes but chest wall muscles are not resected d) Radical mastectomy – removal of the breast, axillary lymph nodes and underlying chest wall muscles e) Breast reconstruction – may be performed at the time of mastectomy or may be done at a later time; can be accomplished through submuscular breast implant, placing an implant after using a tissue expander, using muscles with intact blood supply from the back or abdomen, or creating a free muscle flap with the gluteus maximus muscle 3. Medication therapy a. Tamoxifen (Novadex) interferes with estrogen activity for treating advanced breast cancer b. Chemotherapy – when axillary nodes are involved Care of patient undergoing mastectomy 1. Maintain usual postoperative assessment 2. Begin emotional support before surgery and continue in postoperative period 3. Turn, cough and deep breathe to prevent respiratory complications; restrictive surgical dressing may decrease chest expansion 4. Position client on back or unaffected side 5. Jackson-Pratt drain or Hemovac may be in place to drain fluids that accumulate when lymph nodes are removed 6. Note signs of bleeding on dressing and reinforce pressure dressing as needed 7. Encourage early range of motion exercise to prevent contractures are lymphedema 8. Use unaffected arm only to provide IV fluids and take blood pressure 9. Discharge instructions a) Use caution when lifting heavy objects with arms on affected side b) Avoid injury and infection on affected side; wear rubber gloves when washing dishes and garden gloves when working outside c) Don't allow procedures, such as blood pressure or venipunctures on the affected side d) Refer client to support group for psychosocial support B. PROSTATE CANCER - unregulated growth of abnormal cells in the prostate gland Etiology/pathophysiology 1. Adenocarcinoma is most common type; high levels of testosterone may play a Role 2. Usually begins in peripheral tissue on back and sides of the gland 3. Metastasis via lymph and venous changes is common; bony tissue is major site of distant metastasis- especially pelvic bones and spine 4. Is seen predominantly over 40 years of age Clinical Manifestations 1. Clients in early stages often show no symptoms; tumor may be found during digital prostate exam 2. Genitourinary: dysuria, frequency, reduced force of stream, hematuria, nocturia,abnormal prostate found on DRE 3. Musculoskeletal: back pain, migratory bone pain, bone or joint pain 4. Neurologic: nerve pain, muscle spasms, bowel or bladder dysfunction, bilateral weakness of lower extremities 5. Systemic: fatique and weight loss Diagnostic and Laboratory tests 1. Prostate-specific antigen (PSA) levels 2. Transurectal ultrasound (obtained if PSA results are abnormal) 3. tissue biopsy 4. bone scan 5. MRI 6. CT scans to detect metastasis Therapeutic Management 1. Hormone therapy 2. Radiation therapy 3. Brachy therapy (Radioactive seeds implanted in the prostate) 4. Prostatic cryosurgery 5. Surgery a) Orchiectomy – decreases androgen production b) Radical procedures include removal of gland, capsule,ampulla,vas deferens,seminal vesicles, adjacent lymph nodes, and cuff of bladder neck c) Suprapubic prostatectomy – abdominal and bladder incisions to remove prostate tissue d) Retropubic prostatectomy – low abdominal incision without opening bladder e) Perineal prostatectomy – incision between scrotum and anus (perineal area) f) Homium laser – laser treatment; less bleeding, fewer complications and shorted hospital day 6. Medication therapy a. estrogen therapy of luteinizing hormone antagonist (Lupron) given to slow rate of growth and extension of tumor Nursing Management of Patient Undergoing Prostate Surgery 1. Maintain usual postoperative assessment 2. If dressings are present, monitor for drainage and change as needed 3. Monitor vital signs closely for 24 hours, observing for signs of hemorrhage (frank blood in urine, large blood clots, decreased haemoglobin and hematocrit, tachycardia, and hypotension) 4. IN clients who have a urinary catheter following surgery, traction may be applied against the prostatic fossa to prevent bleeding; the balloon at the tip of the catheter exerts pressure to prevent hemorrhage; the surgeon positions the external end of the catheter by anchoring it tightly to the client's inner thigh to maintain traction; the catheter should not be repositioned 5. A client who has a large indwelling catheter may feel the urge to void, which results from stimulation of the micturition center, explain to the client that this is a normal sensations; efforts by the client to void or strain will increase the risk of bleeding and aggravate pain 6. Continuous bladder irrigation (CBI) may be ordered on a client postoperatively a. The purpose of the CBI is to prevent the formation of blood clots b. If blood clots do form, the urinary catheter will become plugged and prevent outflow of urine; the obstruction will also cause bladder spasms and pain c. A key nursing intervention for the client in CBI is to keep the outflow from the catheter light pink or clear; the rate of administration of the irrigating solution is therefore titrated to keep the color of the outflow this color and prevent blood clots from forming; it is essential to calculate intake and output to determine true urine output d. Indications that the rate of the irrigations is inadequate include: decreased outflow from the catheter; bladder spasms; and dark-colored or frankly bloody drainage 7. Monitor client for signs of hemorrhage;bladder spasms and frank bloody output may indicate bleeding 8. The irrigating solution used during and after surgery may be absorbed causing fluid shifts and dilutional hyponatremia, referred to as TURP syndrome; monitor the client for signs of hyponatremia and bradycardia, nausea and vomiting, monitor serum sodium levels and haemoglobin and hematocrit; in addition, other signs of volume excess will also be evident, including hypertension and confusion 9. If manual irrigations are ordered, maintain sterile technique 10. Medicate as needed for pain DOWNLOAD
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AMERICA -- WHO REALLY PAYS THE TAXES? by Donald L. Barlett and James B. Steele, is an involving, well-researched, and very well-written book. Read morePublished on September 30, 2010 by Patricia
This would be an interesting read if there were any truth to it. It took me about 15 minutes to disprove the theories presented herein. Read morePublished on July 14, 2008 by S. Scott


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Originally written on Fox Sports Southwest | Last updated 11/4/12
ATLANTA (AP) -- Michael Turner finally found some room to run in the second half. It was just in time for the NFL's last unbeaten team. Turner had a tiebreaking 3-yard touchdown run in the fourth quarter, Matt Bryant kicked four field goals and the Atlanta Falcons beat the Dallas Cowboys 19-13 on Sunday night to protect their perfect record. Turner had 20 carries for 102 yards and Matt Ryan had a season-high 342 yards passing for the Falcons (8-0), who took their first lead with 14:16 left in the game. Tony Romo completed 6 of 6 passes for 78 yards, including a 21-yard scoring pass to Kevin Ogletree, on the Cowboys' touchdown drive later in the fourth. The Falcons then worked the clock, holding the ball for 5 minutes, 4 seconds, leaving only 17 seconds after Bryant's 32-yard field goal. The Cowboys burned all their timeouts as Ryan kept the Falcons' offense on the field in the crucial time-consuming drive. Ryan passed to Jacquizz Rodgers for 31 yards and 11 yards on third-down ...
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Prysmian Lands EUR 230 Mln 50Hertz Cable Deal
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#300 of 382
Northridge, CA
Comment, Like, Favorite
Expert Printing and Assembly
Shipping Within 2 - 3 Business Days
Millions of Satisfied Customers
Mandala Armenian Cross
Bedros Awak
Digital Art - Digital Art
Mandala of an ancient Armenian cross, surrounded by Armenian heritage designs that are as ancient as thousand years, with grape vines scrolling from corner symbolizes the life, and a prayer verse is circulating in middle of the mandala.
July 31st, 2012
Viewed 1,859 Times - Last Visitor from New York, NY on 07/04/2015 at 4:21 PM
Sales Sheet
More from Bedros Awak
Binghamton, NY - United States
Wonderful work, congratulations on your sale!!!
Thank you Christina.
Medell�n & Cartagena - Colombia
Superb! Congrats on your sale!
Thank you David.
La Plata, Bu - Argentina
Congrats Bedros!
Thank you Lazaro.
Fort Worth, TX - United States
congrats on your beautiful sale! v
Nuremberg, Ba - Germany
Wonderful work Bedros. I like it. :) Congratulations on your $ale!
Thank you Sven.
Holbrook, MA - United States
Congratulations on your sale - voted
Thank you Alexandra.
Christchurch, E9 - New Zealand
Bedros,Congrats on your sale!!!
Thank you Joyce.
Sunshine Coast, Qu - Australia
Such beautiful detail in this lovely work of art....congratulations on your sale Bedros!
Thank you Linde.
Philadelphia, PA - United States
Congrats on your sale!!!!
Thank you Bill.
Pelham, NH - United States
I am always drawn to our Armenian Cross! Magnificent Piece of work!
Thank you Helena for supporting my art.
Columbus, OH - United States
Love the warm colors of this one...it has a more traditional feel? seems like it could be an ancient piece...like it really pays homage to the heritage of the Mandala. fav/v89
Thank you Karen so much for supporting my art.
Banjarbaru, Ka - Indonesia
Such a marvelous image... Love all your digital artworks...you are a very talented artist ..Keep on work!!
Thank you Jason so much for your encouraging words about my mandala designs.
Aberdeen - United Kingdom
Stunning image! v/f
Thank you Liz.
Largo, FL - United States
This is just beautiful Bedros
Thank you Arlen.
Hamilton, ON - Canada
Congratulations on your sale Bedros of this beautiful mandala! v/f/g+
Thanks Barbara for your comment.
Voorhees, NJ - United States
Magnificent-congrats on your sale, Bedros :)!! v/f -Kim
Thank you Kim for always supporting my art.
Richland, WA - United States
So happy for your sale, Bedros!
Thank you Ann, wish you good luck for sale.
Largo, FL - United States
Beutiful print of the Armenian Cross Bedros
Thank you Arien.
Rochester, NY - United States
Good job Bedros, congrats on the sale.
Thank you Mark .
Silver City, NM - United States
Congratulations on your sale!
Thanks Vicki.
Hamilton, On - Canada
very nice Bedros vF and Merry belated Otrthodox Christmas to you!
Thanks Danielle for your support.
Rochester, Ne - United States
This is Beautiful, Congratulations on your sale!!!
Thank you Aimee.
Budapest, H - Hungary
Congratulations on your sale........Odon
Thanks Odon.
Henderson, NV - United States
Congrats on your sale, Bedros...
Thanks Alan & Marcia.
Northridge, CA - United States
Thanks Paula for purchasing this artwork, I really put my time and soul to create something related with Armenian heritage and religion meanwhile maintaining it's contemporary display in modern life.
Bedros, I just ordered this print framed. I can't wait until it arrives. I am Armenian so this holds a lot of meaning for me. It is incredibly beautiful work and it will be the perfect focal point in my house. Thank you! Paula Arzoian
Depoe Bay, OR - United States
Bedros, I really love this mandala. Your use of rich coppery colours and fine detailing is exquisite! F/V/G+
Thanks Glenna for your compliments.
Jacksonville, fl - United States
revisiting/ R2 G+ promo ( voted prev etc...tally's are v74/G+38/ vw 493)
Thanks Sherry for promoting my art.
Ossineke, MI - United States
I love the intricate detail. v/f/g+
Thanks Rhonda.
Palmetto, FL - United States
REally nice...v/f/g+1
Thanks Skip for your support.
Fort Worth, TX - United States
My G+ seems to have been disabled for spamming, but I can at least vote and LIKE for now. so sorry!
Sorry to hear that Joan, I read the post in Google+ promoting section, and understand what went wrong.
Michalovce - Slovak Republic
nice digital work...V/G+
Thank you Martin.
Fort Worth, TX - United States
Grand Forks, BC - Canada
Beautiful Armenian Cross Mandala, this cross is very special to me and I love the way you honoured it in this beautiful piece!! F/V
Thanks so much for being supportive to me.
New Orleans, La - United States
Very nice, the words surrounding the cross adds an extra element. voted tweet faceboook
Thanks Marian for your great support.
Los Angeles, CA - United States
Such an amazing artwork with it's design and colors so beautiful, v,f,fb.
Thanks Ara for your support.
Maui, Ha - United States
. . . . ╰⊰✿ . �.�☆ ☆�.� Featured: :: Square Format :: �.�☆ ☆�.� . ✿⊱╮ . . . . . http://fineartamerica.com/groups/dimensions.html http://fineartamerica.com/groups/square-format.html http://fineartamerica.com/groups/greeting-cards.html
Thank you Sharon so much, for featuring my mandala in your group home page.
Chatsworth, CA - United States
excellent design color & concept...voted
Thanks Sevan for supporting my art.
New Orleans, La - United States
beautiful great colors voted CFC#15
Thanks Marian for your comment.
Chatsworth, CA - United States
Dear Bedo, this is a true fine art. It is an amazing combination of colors and passion. It looks like it is talking to you. Keep up the good work, wishing you all the best.
Thanks Setrak for your great support and comment on my Mandala aftwork.
Chatsworth, CA - United States
Excellent work as usual, Bedros.
Thanks Aram for your support I really appreciate it.
Jacksonville, fl - United States
Revisiting Bedros..Tweet/G+ promotions.........Great work..as always. ....JV
I C, thanks.
Jacksonville, fl - United States
returned visit to add FB/Tweet/G+..your work is excellent!
Thanks Sherry.!
Northridge, CA - United States
Thanks you Florin for the comment.
M�nchen, Ba - Germany
An interesting mandala Bedros, especially creates an artefact effect!
San Miguel, CA - United States
And I return! This is such a beautiful mandala. I love the description, the colors, the exquisite design, the beautiful background. Thank you for your fine art! Already voted. Promoted on Facebook.
Thanks Susan for re-commenting on this work.
Suffolk, VA - United States
Beautiful. Great details and design. v
Thanks Jennifer for promoting my art.
Northridge, CA - United States
Thanks Matt, the color really matters when comes compelling with a design.
Bury, Ma - United Kingdom
Wow Bedros! Such fantastic detail. Such a beautiful design. The colors work so well together. V&F.
Rochester, NY - United States
Another great graphic.
Thanks Mark for your comment.
Please Wait...
Beverly Hills, CA (United States)
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Learn about Windows PowerShell
Summary: Use Windows PowerShell to display Windows Defender update status.
How can I use Windows PowerShell to check the update status of Windows Defender on my computer running Windows 8.1?
Use the Get-MPComputerStatus cmdlet and select properties that contain the word Updated:
Get-MpComputerStatus | select *updated
Hey Scripting guy. I was getting the following error "The extrinsic method could not be executed" I'm on 8.1 and ran it as administrator in PS. Didn't find a lot on the error in google. Thoughts?
found it. Defender had been disabled. Thanks!


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Ardie Savea is bracketed as both Hurricanes and Highlanders name unchanged teams for the Super Rugby final on Saturday.
Aviva Premiership champions Saracens will open the defence of their title at home to the Sale Sharks on October 17.
Ireland is one of four nations to formally express an interest in hosting the 2023 Rugby World Cup.
Former New Zealand All Blacks star Mils Muliaina has been charged by British police with sexual assault.
Winger Kristian Phillips has signed a one-year deal to return to the Ospreys after spending the last three seasons at Scarlets.
Overseas stars Matt Giteau and Drew Mitchell are part of Australia's training squad ahead of the Rugby Championship.
Former Leicester coach Phil Blake will not face any action from European rugby authorities for breaching betting rules.
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Graham Simmons gives a behind-the-scenes reflection on a weekend away in Paris for the Top 14 final.
Former All Black Jerry Collins and his partner have died in a tragic car crash in France.
Graham Simmons catches up with Ryan Lamb to talk about the kick that took Worcester into the promised land.
With confirmation that he has been axed from England's World Cup squad, we look at Dylan Hartley's disciplinary record.
Sky Sports columnist Jonathan Davies gives us the lowdown on his recovery so far following knee surgery.
Dewi Morris is predicting a Stade Francais win in this weekend's Top 14 final against Clermont.
Jonathan Davies writes about his new-found life of leisure in this week's column and Clermont's Top 14 semi-final.
Will Greenwood says it's too early to judge Danny Cipriani, but admits it is surprising he is on the front pages again.
We're well into the business-end of the football season - see all the action without a contract.
Graham Simmons catches up with Gloucester flanker Matt Kvesic.
Andy Goode tells Rugby Club there are weaknesses in Toulon's game that Leinster can exploit.
The Rugby Club panel were split on whether England should call up Steffon Armitage for the World Cup this autumn.


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Did I see discounted Beer and WINE in the VIP tent? Is it true?? Did they add the wine this year or was it there last year? I think I would have noticed that....
Started by Ketel1 , Mar 20 2014 07:03 PM
2 replies to this topic
Posted 20 March 2014 - 07:03 PM
Posted 22 March 2014 - 06:27 PM
i think we've had wine for at least a couple of years...
Posted 25 March 2014 - 07:40 PM
ha, guess I've been missing it...lol. wonder why?
Thanks tho!


text:
I saw what you tried to do there Mr Joe B. Carvalho, for we all loved and laughed at the Naked Gun series and Top Secret! all those years ago but no. just no. your movie is not that.
What it is is Skinny Soha in a movie with a skinnier plot and a Arshad Warsi who lost all goodwill he had created for himself after last year's Jolly LLB. A bumbling detective, a Dabbang cop, a lovelorn crimelord and our losing patience with producers who think they can make the next Jaane Bhi Do Yaaro!
Mr Joe B Carvalho could be recommended if your cable operator was playing it some afternoon and you had one large pizza with everything on it too many, it does have the potential to become part of some drinking game; but I will not recommend anyone buying the movie ticket, or the DVD.
And Mr. Javed Jaffery? Why? Why?view less


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What is this a bait question? backup your carbon and try it yourself - it's solid and runs very well. What a silly thing to ask in this thread - everyone would have varying opinions but bottom line is you have a choice. LOL You're a funny guy...
I scratched the display, is about 1 inch, not very visible and only when the phone is off. Is there a solution to remove the small scratch ? Could i, maybe, in the future, to replace the screen display ? Thank you
no man,the JBSourcery is 4.2.2 rom and there will not be a 4.3 version... you need to flash other custom ROM in order to get 4.3 version of android or to go to stock 4.3... That sounds much better :good: Thanks


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A vibrant, sunny striped design makes this rug a cheerful addition to a room. The handwoven flat-weave is constructed of wool made with a plush pile that ensures durability for years of quality wear. A rug pad is recommended to keep this foundation securely in place.


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Luis Aliva Melendez shot, killed in Columbia Heights
Police say 27-year-old Luis Aliva Melendez of Washington was shot early Saturday morning, several blocks away from the bustling Adams Morgan nightlife district. About an hour later and one mile away, three men and one woman were shot.
Alexandria police narrow focus to Severance in triple-homicide investigation
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Homeless man killed in D.C., sister speaks out
Thirty-three-year-old Rashard Raigns played defensive end for Colgate University, and studied in China for a short time – he even spoke fluent Mandarin.
Homicides in D.C. have reached 'historic low,' according to the Metropolitan Police Department
Homicides in D.C. have reached historically low levels despite being on an upswing, according to figures from the Metropolitan Police Department.
Marco Corletto charged in slaying of girlfriend in Leesburg
A man has been charged in a warrant with murder in the fatal stabbing of his girlfriend at her Leesburg condominium. Leesburg police say Marco Corletto critically wounded himself by stabbing his own arms after he fatally stabbed Roxana Rico on Friday afternoon.
Police: Thomas Everett Holland of Hyattsville killed 3-year-old Jayson Maurice with lethal drug cocktail
Deadly levels of cocaine, acetaminophen and codeine were found in the boy's system when he was brought to a local hospital.
Aaron Hernandez, former New England Patriot, indicted on murder charges
Police said there is 'probable cause' to believe he was involved in a 2012 double slaying in Boston.
South Korean ferry captain, some crew members indicted on homicide charges
Charges allege they were negligent and failed to protect more than 300 passengers who are dead or still missing.
Christie Lynn Pelland found dead inside Glen Burnie medical center
The victim has been identified by Anne Arundel County Police as 43-year-old Christie Lynn Pelland of Pasadena, Maryland, who worked as a cleaner for the building.
Mary Houston homicide investigation follows discovery of body in Northeast D.C.
Metropolitan police said Friday that they are investigating the death of a 75-year-old woman as a homicide.
D.C. police rule fire that killed Lucille Proctor a homicide
Washington police say the death of an 80-year-old woman in a house fire has been ruled a homicide.
Police respond to accident in Southeast, find man fatally stabbed
The victim was found around 10:38 p.m. Thursday.
Police unsure if D.C. gunshot death Wednesday is suicide or homicide
The man was discovered in a home in Northeast Wednesday afternoon. He later died of his gunshot wounds.
Fort Washington murder-suicide: Two dead
The suspect is identified as 32-year-old Lester Lee Fletcher, Jr., of the 8300 block of Founders Woods Way in Fort Washington. The victim is identified as 32-year-old Michelle Miranda-Fletcher, of the 7200 block of Jaywick Avenue.
One dead following shooting in Northeast D.C.
The shooting occurred just before 10 p.m. Monday in Northeast.
Man fatally shot in Southeast D.C. Friday night
Police are offering a reward for information leading to the shooter or shooters that killed a 35-year-old D.C. man late Friday night.
Update: Victim identified in Southeast D.C. murder, suspects sought
D.C. metropolitan police are searching for four suspects after a man was fatally shot early Friday morning in Southeast. A reward is offered for any information.
911 caller alerts PGPD to triple homicide in Capitol Heights
Responding to a 911 call Saturday, Prince George's County Police discovered three bodies in an apartment in the 5200 block of Marlboro Pike in Capitol Heights.
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