text:
|Reviews for Chicharong Flower: Translated
| Eru no Tsubasa chapter 9 . 7/12/2010
AWWW! Sweet and funny! XD
| Sandataba chapter 9 . 6/18/2010
I had to go out and buy chicharon after reading this. Oh, cholesterolific ecstacy. This should be rated 'M' for Masyadong nakakataba... ng puso. ;D
| anthropomorphychan chapter 9 . 6/14/2010
That was a total crack up! lol.
YOur explanations were extremely helpful ... (I've been out of the country for far too long! :D)
Nice job, the translation was done well! :D
| Valentine35 chapter 1 . 6/8/2010
awesome priest makes me laugh lol
| shoshoryuu07 chapter 9 . 6/5/2010
I LOVED THIS! : Thank you for updating, THIS IS SOOO FLUFFY! WE FILIPINOS ARE GOOD. ))) I love this! :
| shoshoryuu07 chapter 8 . 4/29/2010
Iba talaga ang mga Pinoy. DA BEST. :d
| Afictionado chapter 8 . 12/30/2009
I like the story. You are very inventive in terms of unexpected come backs from Tenten. He he! Hope you'll update soon.
| Kichapi chapter 1 . 9/23/2009
ahahahah! enjoy talaga tong basahin, ang cutee ng english version. Kahit ilang years na ang nakalipas nung ipublish yung orig Filipino ver. Kudos!
| au coeur brise chapter 8 . 8/28/2009
Update mo na ung chapter nine! ang ganda-ganda nang kwento! SOBRA! nakaka addict! Addict na kami ng best friend ko sa kwentong ito! Wala ba itong sequel?
| clack chapter 8 . 8/4/2009
finish soon :)
| minkik11 chapter 1 . 7/28/2009
woh...todo na to!grabeh!
| rayaikawa chapter 1 . 2/14/2009
haha...It's so funny. Kaya lng mas kakatawa pagtagalog :)
| Sovanthay chapter 8 . 12/1/2008
You should update this story :)
& Some of your other NejixTen stories as well.
If you're not busy anyways.
I really like em :)
Anyways, awesome story, hope it continues.
| Blood Stained Sorceress chapter 8 . 9/20/2008
This story was extremely intertaining! I havn't laughed that much in a long time!
| Elephantie chapter 8 . 2/13/2008
neji you dumbo!
ooh i loved every second of it! i love all your nejiten stories!
i hope you UPDATE very soon! XD


text:
The new Volkswagen Golf GTi | GTD has arrived at Lookers Volkswagen. We have a range of offers now available. Contact your local Lookers Volkswagen dealership for further information.
Volkswagen Golf GTI from £356 per month
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Thank you for visiting our Volkswagen Golf GTI finance section. It is here where you will find a selection of Golf GTI finance facilities for all of our latest offers which are funded via our Volkswagen Solutions product.
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Registered in England number 2835230.Text here ...

subset: commoncrawl


text:
A selection of illustrated maps created for the Sunday Times Travel magazine.
Food illustrations for a variety of clients including Jamie magazine.
Illustrations with a salty, whitewashed feel for Monty Halls book documenting the fisherman's fight for survival in a small Cornish fishing village.
Wyevale Garden Centres have teamed up with The Telegraph to create a series of gardens designed by television garden presenter Toby Buckland. Scott created these illustrations from sketches and plant lists provided by Toby.
Hand lettering for a variety of editorial and publishing clients including Waitrose Kitchen, Wanderlust, Quercus, Sunday Times and Olive magazine.
Monthly garden plans for Homes & Gardens magazine.
Working from plant ideas supplied by Joe Swift, Scott illustrated these planting plans for the Gardeners World magazine.
Modern jazz inspired monoprints.
Destination maps for the CSMA magazine.


text:
|Reviews for They Call it a Cliché
| Not a Guest chapter 34 . 3/3
Fictionpress won't let me log in
Aw :-( I'm sorry. I was just cruising along after finally making my own account on here and came across this. Even though it's literally been years, I still want to say that I'm sorry that you had to go through all of that. But I still want to read your stories, because I'm getting signals that they were pretty great :-) Wish you the best.
| hobovill99 chapter 34 . 6/20/2014
:( Damn. I got to this story too late to actually read it, but it seems like it was awesome. I'm really sorry to hear that you got plagiarized so many times. I admit that sometimes I see something so well written that I just wish it could be mine, but I find plagiarizing to be desperate and, and you said, unethical. I'm not a plagiarizer, but I'd like to know: Is there anywhere else I can read this story? Sorry if you mentioned it and I'm just a crappy skim-reader.
| AgentDolly chapter 34 . 4/21/2014
Wow, the story seemed good! I feel bad for you...all those idiots. :(
And by the same author, WTF!
| tash159hotmail.com chapter 1 . 3/10/2014
please post the story back
| pandalove11 chapter 1 . 12/11/2013
I'm so angry for you that this happened. You were one of my favorite authors and this was one of my favorite stories on fictionpress. I read this a few times, years back, when I was in middle school; now in freaking college, I wanted to come back and read it again. That's how much I love your stories. I'm a sap for your stories, they give me some time away from the world, and in college, I need that time away. You probably don't check fictionpress much anymore, and I know you don't like getting asked to send your stories out, but I'm like desperate to read your stories again (I know, sad), but please, if you can and are willing to, we can exchange info (email and whatnot) and I can read your stories over and over again. I'd be incredibly happy. Please consider. Thank you!
| OurHeartsBleeding chapter 34 . 10/21/2013
Good for you, for doing what's right. I've known of a couple authors who have gone about it in the right way and have actually copyrighted their work and are selling it on Amazon, which is possibly something that you can do.
Plagiarism is NOT okay, and it sucks that stories have to get taken down because people are too lazy to come up with their own work.
Bah! Now you got me all worked up. Lol.
| Evilsister95 chapter 5 . 6/2/2013
This was a really good story when I read in back in 08!
| Anonymouse chapter 34 . 5/18/2013
...I've just read this and...THIS IS HORRIBLE. Plagiarism is just about one of the stupidest things people do. I can't really do anything about it, but I hope it gets better.
| RuneSun9000 chapter 1 . 2/1/2013
i read your summary and i would love to read it further. (i hope so) :)
| desuetude chapter 1 . 1/2/2013
Damn you plagiarism!
| jazzrun10 chapter 1 . 11/24/2012
The darn plagiarism D:
| Amber Dawn12 chapter 34 . 11/15/2012
Could u please send me this story then? I hate plagiarises too and that is y I don't put my stories up on FP. Anyway, I really would like to read this story...so yeah
| Guest chapter 1 . 10/24/2012
Honestly. I can't even explain to you just HOW many times I've been getting into a story when all of a sudden everything is ripped away from me because of Plagiarism. It's happened so many times. And it's crazy. I respect your decision. But honestly, really pisses me off sometimes. Not every reader out there wants to plagiarise your work. Seriously. So the amount of waiting and everything that must be done to get into the place is horrid. I'm seriously hating it. But. Idk where i'm going with this. I'm just pissed that this is like the fifty billionth time ive gotten into a story and everything decides to be removed. Gosh. I understand that you're doing what you have to do. I just don't think its fair to those of us that prefer not to use their usernames for reviewing because .. . never mind. I think its sad ur giving up altogether. You had great potential. Sorry.
| KOREANGIRL1824 chapter 1 . 10/19/2012
I Lake the Summers of your Store and Would like to read them
| Derryn chapter 1 . 9/25/2012
this story sounds really good but the problem is ...i cant read it! urggghhh Down with the PLAGIARISERS


text:
ATTN: Shadow And Act HAS MOVED To The indieWIRE Network! Change Your FEED Links! Details Here!
And we're live!!! Yay! We made it folks, I'm happy to say.
Shadow And Act has now officially joined the indieWIRE Network. Click the image above to our new home @ http://blogs.indiewire.com/shadowandact, where you will find us from now on.
Also, be sure to please change your bookmark links, your RSS feeds (HERE), etc.
Our Twitter and Facebook accounts remains the same, so if you're already a fan on Facebook, or a follower on Twitter, there's nothing more you have to do.
This current site will remain up for some time so you'll still be able to revisit old posts. Just don't hang around here for too long!
Without further ado, head on over to our new address.
Thank you all and cheers!
Here's to what's next!
Comments are closed.
Copyright © 2015 ATTN: Shadow And Act HAS MOVED —> - All Rights Reserved
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6pm is happy to offer free standard ground shipping all orders, regardless of size or value.
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Shipments can be sent to both PO Boxes and Military APO/FPO addresses. Please allow additional time for orders shipped to these addresses.* Expedited shipping is not available to these address types. *Please Note: At this time we cannot ship items considered a hazardous material by the Department of Transportation due to the alcohol content (fragrances, nail polish, etc.) to Alaska, Hawaii, PO Boxes, military addresses (APO, FPO), or US territories (i.e. Guam, Puerto Rico).
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text:
Apple shaken by iPhone baby game
Controversial Baby Shaker application withdrawn after groups write to Steve Jobs and other executives in outrage
Deepest budget cuts since 70s to fill '£45bn hole'
Alistair Darling accused of 'tax bombshell' as thinktank warns of massive cash gap
Front page
Former winners at Cannes Film Festival hoping for a sequel
Quentin Tarantino, Jane Campion, Lars von Trier and Ken Loach all return to Cannes this year
Top stories p3
Labour warned budget spending cuts will wipe out decade of growth
Labour MPs and trade unions vow to fight Alistair Darling's 'catastrophic' public spending cuts announced in budget
Budget 2009: Cameron and Osborne's savings plan
Michael White: Torys believe the 50p tax rate is a trap and that Brownites hope they will pledge to repeal
Which government departments will suffer from the budget cuts?
Guardian specialists assess some of the candidates for the chop if public spending squeeze goes ahead
Rise of the state under New Labour is over. Prepare for the fall, and it will be dramatic
Tom Clark: If this happens again by 2017/18 public spending could be at less than it was John Major's last year
Top stories p12
Britain's credit rating continues to suffer as quantitative easing gets more difficult
UK debt against default is now more expensive than Spain's - traditionally a country with far worse finances
Budget 2009: 50p income tax rate could cost government money, warns IFS
Institute for Fiscal Studies says tax avoidance and wealthy reining in spending could undermine Treasury plan
Top stories p14
Switzerland life tempts high-end taxpayers after Darling's budget
Swiss thinktank predicts that 25,000 will leave Britain because of the 50% income tax rate


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text:
Boyfriend Of Park Min Young
Park Shin Hye shares plans with her future boyfriend
Actress Park Min Young Reveals Her Weight Loss Secrets for "Healer"
During a recent interview, the star of "Healer," actress Park Min Young has revealed her weight loss secret!
On the February 7th broadcast of KBS' "Entertainment Weekly," Park Min Young took part in a brief interview with the entertainment news program and talked about dieting hard for her role in KBS' "Healer," as an entertainment journalist.. ... Read more
Ji Chang Wook Reveals Story Behind His Intimate Scenes With Park Min Young in "Healer"
Actor Ji Chang Wook has shared his concerns about filming the many intimate and affectionate scenes in "Healer."
In a recent interview with news outlet OSEN, Ji Chang Wook talks about the many romantic scenes he filmed for "Healer," which called for lots of skinship and kisses. He makes the interviewer laugh by saying, "When I looked at the scripts and saw that a kiss was written in, I would sigh and think 'Again?'". ... Read more
'Healer' Ji Chang Wook Knows How Park Min Young Feels About Him
In "Healer" Ji Chang Wook and Park Min Young saw that the other person had feelings for them.
On the KBS 2TV Monday/Tuesday drama "Healer" broadcast on January 26th, Suh Jung Hoo (played by Ji Chang Wook) was visited by Chae Young Shin (played by Park Min Young) who confessed her feelings for him. . ... Read more
Park Min Young reveals Ji Chang Wook to be a "Jinergizer" and more
Park Min Young met up with KBS 2TV"s "Entertainment Relay" in the midst of her busy filming and photoshoot schedule!
The reporter commented, "I heard that you keep pulling all-nighters [to film your drama]," to which Park Min Young revealed, "I think I slept for around 20 minutes today. I thought I wouldn"t wake up, but I woke up well. I still have that young stamina." . ... Read more
[Healer] Behind Ji Chang Wook & Park Min Young's Emotional Tearful Kiss
The production crew of KBS2TV's drama "Healer" reveals images behind the tearful kiss scenes of adorable couple Ji Chang Wook and Park Min Young!. ... Read more
"Healer" Reveals More Stunning Cuts Of Ji Chang Wook and Park Min Young
To further amp up excitement for the highly anticipated KBS drama, 'Healer,' some still cuts taken from the set were reveals on January 26th, showing the sweet romance of Ji Chang Wook and Park Min Young!. ... Read more
Wooyoung and Park Se Young implemented their last responsibility in "We Got Married"
On the recent episode of "We Got Married" airing on September 13, Wooyoung (member of 2PM) and Park Se Young implemented their last responsibility informing everyone that their virtual marriage is now coming to an end.. ... Read more
Moon Geun Young And Park Seo Joon Opt Out Of 'Chaebol's Daughter' While Park Hyung Sik Signs On
Moon Geun Young and Park Seo Joon have both declined roles in the upcoming drama "Chaebol"s Daughter." But Park Hyung Sik"s agency Star Empire Entertainment has announced that he will play a chaebol in the drama. . ... Read more


text: An Awesome Pep Talk From a Kid President [VIDEO] By Tom Morgan January 29, 2013 9:59 AM Share on Facebook Share on Twitter Feeling down today? Need a little bit of 'hope'? Leave it to the 'kid president' for encouragement…. Well said Mr. President, and I love Space Jam too. Filed Under: Amazing | Heartwarming | humor | Kid President Category: SoJO Morning Show | Videos Share on Facebook Share on Twitter More Leave a comment Send to a friend! Print this page Pin it! Reddit This! Share on Tumblr! Best of SoJo 104.9 Recommended For You Best of the Web


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Fri., September 25, 2009 6:33am
VP Joe Biden Visits Flood Victims; 14 Counties Now Eligible for Federal Aid
Catoosa, DeKalb, Fulton, Gwinnett, Newton, Walker and Rockdale counties add
Full Story
Mon., September 21, 2009 1:58pm
Overtopped Levees Force Hundreds From Their Homes
About 300 residents in Chattooga County had to flee their homes because le
Mon., September 21, 2009 3:37am
North Georgia Flooding Kills Eight, Brings Evacuations, Snarls Traffic
Water has crested over a levee in Trion. And Atlanta rush hour is moving sl
Fri., August 21, 2009 11:16am
Massive Animal Rescue Effort Swings Into Georgia
A coalition of animal rescue groups wants to bring awareness to Georgia's o
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More information
For more on cancer and cell phones, visit the U.S. National Cancer Institute.
SOURCES: Nora D. Volkow, M.D., director, National Institute on Drug Abuse, U.S. National Institutes of Health; Giuseppe Esposito, M.D., chief, nuclear medicine, Georgetown University Hospital, and associate professor, radiology, Georgetown University Medical Center, Washington, D.C.; John Walls, vice president, public affairs, CTIA-The Wireless Association; Feb. 23, 2011, Journal of the American Medical Association
|Copyright©2010 ScoutNews,LLC.
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About Vaseline
Vaseline is manufactured by Unilever (NYSE: UL, UN), one of the world's largest consumer products companies. With a 135-year heritage as America's most trusted healthy skin expert and more than 30 years as a leading hand and body lotion, Vaseline delivers products that meet the specific needs of consumers, no matter their lifestage or lifestyle. In addition to the Vaseline Lotions, the Vaseline family of products also features a complete line of Vaseline Petroleum Jelly, bath products and lip therapy products. All Vaseline products can be purchased at supermarkets, drugstores, mass merchandisers and club retailers nationwide. For more information visit http://www.vaseline.com.
About Unilever
Unilever (NYSE: UL, UN), one of the world's largest consumer products companies, aims to add vitality to life by meeting everyday needs for nutrition, hygiene and personal care. Each day, around the world, consumers make 150 million decisions to purchase Unilever products. The company has a portfolio of brands that make people feel good, look good and get more out of life.
In the United States these brands include recognized names such as:
Axe, "all," Ben & Jerry's, Bertolli, Breyers, Caress, Country Crock,
Degree, Dove personal care products, Hellmann's, Knorr, Lipton, Popsicle,
Promise, Q-Tips, Skippy, Slim-Fast, Snuggle, Suave, Sunsilk and Vaseline.
All of
|SOURCE Unilever
Copyright©2008 PR Newswire.
All rights reserved


text:
As wretched as the Iraq War was, the absence of any meaningful accountability for the U.S. policymakers and pundits who made the catastrophe happen is nearly as stomach-turning. Every day the same faces show up on the TV talk shows and Op-Ed pages spouting more of their "wisdom," as Adil E. Shamoo notes.
Lost History
WPost Pushes for Syrian War
The neoconservative Washington Post wants people to forget about how it and other Iraq War boosters got pretty much everything wrong about that disaster. Amnesia is especially important now as the Post and the neocons begin a new push for U.S. military intervention in Syria, notes ex-CIA analyst Paul R. Pillar.
America's Matrix
From the Archive: A decade ago, as U.S. troops gained control of Iraq, there were many false alarms about finding WMD, leading to President Bush declaring the discovery of mobile biological weapons labs. Robert Parry led the way in challenging that bogus claim in this analysis of America's false reality.
Crazy Gun-Toting Insurrectionists
Exclusive: Just a few months after 20 first-graders were mowed down by a deranged killer wielding an assault rifle, the prospects of restraining this gun madness are fading. A major factor is the Right's success in promulgating a bogus history of what the Framers were doing with the Second Amendment, writes Robert Parry.
DiEugenio on Parry's New Book
Exclusive: America's political dysfunction stems, in large part, from the Right's success in distorting U.S. history and the mainstream news media's failure to counter those false narratives. That has left the nation adrift in a faux reality, a crisis described by Robert Parry's new book and analyzed by Jim DiEugenio.
Watergate's Washed-Away Lessons
The Republican Party that emerged from Vietnam and Watergate was determined to obliterate the lessons learned, and the Democrats veered between timidity and complicity as those lessons were unlearned. Now, the key lessons are more reminiscence than real, as Michael Winship laments.
The Two Views of Jesus's Murder
Christianity has two conflicting views of Jesus's Crucifixion, that God sacrificed his Son to atone for mankind's sins, or that Jesus demanded economic and political justice for the poor and was killed by Jerusalem's power structure. The two interpretations lead in very different directions, as Rev. Howard Bess explains.
George W. Bush's Lie-bury
As minor African despots are dragged before the International Criminal Court, ex-President George W. Bush remains free, despite having committed major war crimes like torture and aggressive war. With the blood of hundreds of thousands on his hands, he will now celebrate his presidential library, Coleen Rowley notes.
Reaping the Seeds of Nuke Tests
The warnings about fallout from nuclear tests six decades ago often noted that cancers from the radiation would probably not begin appearing in large numbers for many years. But that time is now – and medical experts are wondering whether the surge in some cancers is a result, writes John LaForge.
Obama's Nuke Double Standards
President Obama warns that "all options are on the table" regarding a possible attack against Iran, though there's no credible evidence that it's building a nuclear bomb. By contrast, Israel maintains an undeclared nuclear arsenal and the U.S. has thousands of nukes with no specific plans to get rid of them, Nat Parry notes.


text:
B. Ryders
7701 White Lane Bakersfield
Bakersfield, CA
United States
Indianapolis Motor Speedway, Indianapolis, Ind.
Joey Foley / JoeyFoley.com
July 4, 2015 |
Nikon At Jones Beach Theater, Wantagh, N.Y.
Greg Allen / Invision / AP
August 13, 2015 |
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text:
Badgers look to bounce back against top-ranked Buckeyes
Originally Published: October 31, 2007By Bruce Hooley | Special to ESPN.com
Shane Carter isn't afraid to admit it. There's an Ohio State receiver he doubts he can cover.
That seems an alarming bit of honesty, since Carter is Wisconsin's free safety and the Badgers (7-2, 3-2) play Saturday at No. 1 Ohio State (9-0, 5-0). Carter, though, can't bring himself to offer any bravado he's pretty sure he can't back up.
"I'd like to say I could cover him, but, really, I doubt it," Carter said. "After all, no one in the NFL could."
Turns ...
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March Headshot Party with Sofia Negron Photography and SB Beauty
Hi All! Our monthly headshot party is scheduled for Tuesday March 3, 2015 from 9:30AM-5:00PM. Schedule your appointmentRead more and see photos »
Follow Blog
Follow my blog with BloglovinRead more and see photos »
New York wedding photographer at Grounds for Sculpture
Everyone loved the photo of the bride laughing hysterically in the church after her veil got stepped on and pulled rightRead more and see photos »
Wedding snafu causes laughs all around
What would you do if someone stepped on your veil at the altar and pulled it right off your head? This bride laughedRead more and see photos »
Chic fall wedding in Philadelphia
Happy Anniversary Elizabeth and Derek. They had a gorgeous fall wedding and who says you can't get great photosRead more and see photos »
Stylish wedding reception at New York's New Museum
Here are some moments captured from Ashley and David's stylish New York cocktail reception at the New Museum. ItRead more and see photos »
Stylish New York wedding at the New Museum
As the wedding season winds down, I am finally finding the time to share these gorgeous couples and fabulous weddings IRead more and see photos »
Wedding moment with love notes
Kristin and Sean are the sweetest and cutest couple ever. As they say, "It's Mad Love!" This weddingRead more and see photos »
New York wedding moment at Cabana in the Maritime Hotel
This fun filled New York wedding moment comes from Clare and Andy's wedding. Two Brits who fell in love, moved toRead more and see photos »
Rioult Dance Company's New York City Joyce Theater Season
I loved photographing another dance season for Rioult. For Rioult's 20th anniversary, the company integratedRead more and see photos »


text:
This trial aims to evaluate the effectiveness of a group cognitive behavioural intervention to alleviate menopausal symptoms (hot flushes and night sweats) in women who have had breast cancer treatment. Hot flushes and night sweats are highly prevalent but challenging to treat in this population. Cognitive behaviour therapy has been found to reduce these symptoms in well women and results of an exploratory trial suggest that it might be effective for breast cancer patients. Two hypotheses are tested:
Compared to usual care, group cognitive behavioural therapy will:
1. Significantly reduce the problem rating and frequency of hot flushes and nights sweats after six weeks of treatment and at six months post-randomisation.
2. Improve mood and quality of life after six weeks of treatment and at six months post-randomisation.
Ninety-six women who have completed their main treatment for breast cancer and who have been experiencing problematic hot flushes and night sweats for over two months are recruited into the trial from oncology and breast clinics in South East London. They are randomised to either six weekly group cognitive behavioural therapy (Group CBT) sessions or to usual care. Group CBT includes information and discussion about hot flushes and night sweats in the context of breast cancer, monitoring and modifying precipitants, relaxation and paced respiration, stress management, cognitive therapy for unhelpful thoughts and beliefs, managing sleep and night sweats and maintaining changes.
Prior to randomisation women attend a clinical interview, undergo 24-hour sternal skin conductance monitoring, and complete questionnaire measures of hot flushes and night sweats, mood, quality of life, hot flush beliefs and behaviours, optimism and somatic amplification. Post-treatment measures (sternal skin conductance and questionnaires) are collected six to eight weeks later and follow-up measures (questionnaires and a use of medical services measure) at six months post-randomisation.
MENOS 1 is the first randomised controlled trial of cognitive behavioural therapy for hot flushes and night sweats that measures both self-reported and physiologically indexed symptoms. The results will inform future clinical practice by developing an evidence-based, non-medical treatment, which can be delivered by trained health professionals.
Trial Registration
Current Controlled Trials ISRCTN13771934
Hot flushes and night sweats (HF/NS) affect 65-85% of breast cancer survivors, with 60% rating them as severe [1]. They are associated with sleep problems, reduced health-related quality of life [2-4] and are more chronic in this population [5]. Chemotherapy and endocrine treatments such as tamoxifen can induce or exacerbate menopausal symptoms and those taking hormone therapy (HT) are generally advised to stop treatment. HT is an effective treatment, but there is uncertainty associated with its safety. Results of prospective trials [6,7] highlight the association between HT and breast cancer and cardiovascular risks. Therefore a clear need exists for safe and effective non-hormonal targeted therapies that are well tolerated [8].
The exact aetiology of HF/NS is unknown, but they appear to be associated with the rate of change of plasma oestrogen, which influences the thermoregulatory system via the hypothalamus [9]. Alterations in oestrogen levels and neurotransmitters (norepinephrine and serotonin) have been implicated in the pathogenesis of HF/NS [5]. Freedman [10] proposed that there is a narrowed thermoneutral zone (temperature range in which thermoregulation is not triggered) in women who have HF/NS resulting in flushes being triggered by small elevations in core body temperature, caused by changes in ambient temperature or triggers, such as anxiety or stimulants. There is some evidence that the thermoneutral zone is narrowed by elevated brain norepinephrine [10,11], and that stressors increase incidence of hot flushes [12]. Anxiety [13] and cognitions (negative thoughts associated with embarrassment, social anxiety, feeling out of control and unable to cope) are associated with reports of more frequent and problematic HF/NS [14,15], and lifestyle, mood and cognitive and behavioural reactions are likely to influence perception of symptoms [16]. Although the aetiology of hot flushes and night sweats is likely to be the same, their impacts on women are very different. Hot flushes during the day tend to be associated with problems of social anxiety, discomfort and managing day to day activities, whereas night sweats occurring during the night tend to be associated with sleep disruption and associated problems.
Evaluating treatment efficacy depends on valid and reliable measures of HF/NS. The most commonly used measures of HF/NS are women's own self-reports. These include diaries, in which women note the time when a hot flush occurs and usually a severity rating (e.g. mild, moderate or severe). Electronic event markers can also provide a convenient method of registering a perceived hot flush. Sternal skin conductance (SSC) is considered to be the most valid physiological index of HF/NS [17]. A hot flush is marked by a sudden increase in skin conductivity, due to a sweat response, which tails off as sweating decreases (a 'swishy tail'). This pattern is in contrast with a 'saw-tooth' fluctuation in sweating which occurs in typical thermoregulatory control. SSC does not, however, correlate well with subjective measures of severity or problem ratings, and hot flushes defined by SSC and self-reported hot flushes are not always concordant [18]. Reasons for discordance are not well understood, but use of both measures can increase understanding of the impacts of interventions [16]. For example, self-report but not physiological measures (SSC) have shown placebo effects [19], but physiological measures are less predictive of problem ratings and help seeking than self-reports. For these reasons SSC should be used together with self-report measures (frequency and the extent to which they are problematic) [20]. SSC has not yet been used to evaluate treatments in the UK. 24 hour SSC monitoring has been piloted and has been acceptable to women [21,22].
Non-hormonal treatments for menopausal symptoms in breast cancer patients
Non-hormonal treatments for HF/NS tend to be preferred but the efficacy and acceptability of treatments limit their use. Following a systematic review of non-hormonal medicines for HF/NS, Nelson, Vesco, Haney and others [23] concluded that SSRIs or SNRIs, clonidine and gabapentin trials provide evidence for efficacy but that adverse effects might restrict use for some women. Carpenter, Storniolo, Johns et al [19] reported modest reductions (22%) in HF/NS with Venlafaxine (37.5 mgs) but most patients discontinued treatment at 12 months follow up. These conclusions support those of a position statement by the North American Menopause Society [24]. Furthermore, possible negative interactions between some SSRIs and the effects of tamoxifen may limit prescribing options for women who have had breast cancer [25].
Non-medical treatments are popular, including acupuncture, yoga, exercise, and cognitive behavioural therapy. Studies of acupuncture often report significant reductions in HF/NS following treatment, although few studies report between group effects when compared to sham, superficial or placebo acupuncture [26]. A recent meta-analysis [27] of 4 RCTs of acupuncture for HF/NS in women who have had breast cancer found one RCT that reported significantly fewer HF/NS following acupuncture compared to sham acupuncture [28]. In well women one study out of six reviewed [29] reported a reduction in severity following acupuncture compared to placebo [30]. Both studies involved a comparatively large number of acupuncture sessions, suggesting that it may be effective over and above placebo effects if delivered intensively. Furthermore it would also be worth investigating the reasons for these consistent placebo improvements, and whether they are enduring.
Regular exercise has been associated with fewer HF/NS in cross-sectional studies, but interventions to reduce symptoms using exercise have been less successful [31]. In a systematic review of seven studies, about half reported significant within-group improvements following exercise, but only two reported improvements in HF/NS compared to a no treatment control (one was not powered to find a significant difference [32]). Although there were no studies focusing on breast cancer patients, an RCT of exercise for breast cancer patients with treatment induced HF/NS is due to publish findings in 2011 [33]. Theoretically, yoga may be more effective than exercise; as well as being low intensity exercise, yoga is used as a relaxation technique, which may also reduce HF/NS [34]. A systematic review revealed a reduction in reported HF/NS in 4 out of 7 studies [35], however most RCTs did not find an effect. The exception was an RCT of an intensive yoga programme (60 minutes a day, 5 days a week for 8 weeks) [36]. The only study to measure frequency of physiological HF/NS as well as self-reported HF/NS found no reduction in sternal skin conductance or diary reported hot flushes and night sweats following yoga [37]. There is growing evidence that relaxation therapy and paced respiration can alleviate HF/NS in well women [38-41]. In two preliminary studies with breast cancer patients relaxation significantly reduced HF/NS after 12 sessions [42] but not after one session [43]. A treatment package including behavioural (relaxation and counselling) and pharmacological interventions for breast cancer patients has been evaluated in the US with positive results [44].
A CBT intervention for HF/NS, which includes relaxation and paced respiration, has been developed in the UK by Hunter and colleagues [45-47]. This four-session CBT intervention was shown to be effective in an exploratory patient preference trial of well women (around 40% reduction of HF frequency and problem rating) [45]; a finding replicated by Keefer and Blanchard [48] using 8 sessions of CBT. Women who have had breast cancer tend to experience more frequent and problematic menopausal symptoms than well women going through the natural menopause [3]. In a study of 113 women, who had completed active treatment for breast cancer within the past 5 years, 80% reported HF and 72% NS, a significantly higher prevalence than found in well postmenopausal women [49]. Treatment preferences were explored and preferences were expressed for CBT (63%), complementary therapies (46%), antidepressant treatment (25%) and HT (26%). 53% expressed interest in group and/or individual CBT sessions [3].
Based on earlier work, an exploratory trial of a six-session Group CBT intervention was evaluated in a pre-post study of 24 breast cancer patients [47]. The weekly problem rating reduced on average from 5.9 (SD = 2.1) to 3.4 (SD = 1.8) at post-treatment and 2.8 (SD = 1.8) at follow-up (10 point scale); frequency of HF/NS per week reduced from 68.2 (SD = 28.7) to 46.7 (SD = 30.2) at post-treatment and to 36.9 (SD = 32.5) at 3 months follow up; a significant reduction in HF problem rating and frequency. Feedback from the women, elicited during and at the end of the groups, was very positive [47]. Relaxation/breathing and cognitive strategies used at the onset of HF/NS, as well as group support to make behavioural changes, were seen as most useful. The majority (88%) completed the 3 month follow-up assessment, suggesting good adherence to the study. These results suggest that CBT may be effective in reducing HF/NS and their impacts in breast cancer patients. However, a randomised controlled trial is needed. Furthermore, most studies of the efficacy of CBT used self-reported improvements in HF/NS, thus investigation into the impacts on physiological symptoms is warranted.
Current study
This present study aims to evaluate the effectiveness of Group CBT to alleviate HF/NS in women who have had treatment for breast cancer, comparing Group CBT and usual care in a randomised controlled trial, with both physiological and self-reported measures of HF/NS and a 6-month post-randomisation follow-up. We hypothesize that Group CBT will be more effective than usual care in reducing HF/NS problem rating and frequency. Secondary analyses will examine the effects of Group CBT on hypothesised mediating variables, including mood, quality of life, beliefs and behaviours, optimism and somatisation. If effective, the treatment can be promoted by publication of the treatment manual and by training and supervising health professionals in the application of the treatment.
The trial tests four main hypotheses:
1. There will be a significant reduction in problem rating of HF/NS following Group CBT compared to usual care.
2. There will be a significant reduction in frequency of self-reported and SSC-defined HF/NS following Group CBT compared to usual care.
3. Changes in problem rating and frequency of HF/NS following Group CBT will be maintained at six months post-randomisation.
4. There will be significant improvements in mood, beliefs and behaviours about HF/NS and quality of life following Group CBT compared to usual care.
The study design is shown in Figure 1. It is a randomised controlled trial of Group CBT for HF/NS in women who have completed treatment for breast cancer. Participants are block-randomised to receive either usual care (access to clinic support) or to usual care plus six weekly sessions of Group CBT (herein referred to as Group CBT). The Group CBT was developed from previous work and an exploratory trial [45,50] and is specified in a treatment manual. Group CBT is delivered by a clinical psychologist in this trial, but the treatment is designed to be facilitated by appropriately trained and supervised health professionals. Post-treatment assessment is conducted 7-9 weeks post-randomisation (0-2 weeks after 6 weeks of treatment or usual care). Follow up assessment is conducted 6 months post-randomisation. The primary outcome is problem rating of HF/NS at post-treatment assessment. The trial is conducted in compliance with the Helsinki Declaration [51] and is badged with the National Cancer Research Network (UKCRN; Study ID: 4975). NHS REC approval has been granted (South East London 2 REC, ref: 08/H0802/106) and local ethics and R&D approval has been obtained for recruitment of breast cancer patients from all hospitals in the South East London Cancer Research Network (SELCRN). The trial is registered with Current Controlled Trials (ISRCTN13771934). A trial steering committee (TSC) has agreed the research protocol and monitors implementation. Data and participant welfare are monitored by a data management committee (DMC).
Figure 1. Description of overall trial design.
Study sample and recruitment
Participants are recruited from six hospital sites in South East London over an 18 month period from March 2009 to September 2010. Breast cancer patients who report HF/NS at clinic appointments are being recruited into the study by referrals from oncologists, surgeons, radiographers, breast care nurses and SELCRN research nurses working in clinics. Participants are also able to opt in to the study by responding to posters, leaflets and websites. Inclusion criteria
1. English speaking patients, aged 18 plus, who have had breast cancer or ducal carcinoma in situ.
2. No evidence of distant metastatic disease.
3. Have had problematic HF/NS for at least 2 months.
4. Have completed active treatment (surgery, radiotherapy and/or chemotherapy) and being in remission, but may be on endocrine treatment such as tamoxifen.
5. Prior medical treatment for HF/NS is recorded. If women have derived partial benefit and are stable on a treatment, they can be included if they have been on this treatment for 2 months or longer.
Women are excluded if depression or general cancer concerns are the main problem that they are seeking help for, not HF/NS, or if they are unable to commit time to attend the sessions.
Women referred from the clinics are contacted by telephone for a screening interview. A researcher conducts an eligibility check using the above criteria and explains what happens in the two arms of the trial and the randomisation process. Those eligible and interested in participating are sent a participant information sheet, a socio-demographic questionnaire and a two-week HF/NS diary to complete, and an appointment for the baseline assessment is arranged. The consent process is completed whereby the researcher summarises the information in the participant information sheet and responds to questions about the study. Participants then provide written consent. Diaries and demographic questions are not collected from those who do not consent or who withdraw consent during baseline assessment. The researcher then conducts a clinical interview covering breast cancer treatment history, medical history including mental health issues, menopause symptoms and treatments used, concomitant medication and therapy use, and current life concerns. Participants are given a questionnaire to complete, assessing HF/NS frequency and problem rating, beliefs about HF/NS, health related quality of life, stress, dispositional optimism and somatisation. After checking that the participant has no allergy to adhesive dressings (e.g. plasters) and does not wear a pacemaker, the SSC hot flush monitor is fitted. Participants are given a magnet event marker, worn on a bracelet, and a 24-hour hot flush diary. They mark the experience of a HF/NS by passing the magnet over the monitor and noting the time and severity of the HF/NS in the diary. Participants wear the monitor for 24 hours, carrying out their usual daily activities and removing the monitor only to shower or bathe.
Women are randomised in blocks of 12-20, when sufficient participants have been assessed at baseline. Participant IDs are sent for randomisation by an independent statistician at the Mental Health and Neurology Clinical Trials Unit at King's College London. Women are stratified by age (<50, > = 50) and individually randomised to the two treatment arms in the ratio 1:1, using an internet-based system. Group allocation is sent to the clinical psychologist who delivers the treatment (and therefore cannot be blind to condition). The trial coordinator and trial statistician are not informed of group allocation.
Within four weeks after randomisation, women in the group treatment arm attend six 1 1/2 hour sessions of group CBT, once a week for six weeks. Women from both arms attend post-treatment assessments in the two weeks following the treatment phase (see Figure 1). Post-treatment assessments are conducted by the trial coordinator, who is blind to group allocation. Participants are interviewed about their use of health services and treatments, as well as any changes to lifestyle and health during the treatment phase. They complete post-treatment questionnaires measuring HF/NS frequency and severity, HF/NS beliefs, health related quality of life, stress and somatisation, and repeat the 24-hour SSC hot flush monitoring. Six months after randomisation, participants complete a follow-up questionnaire identical to the post-treatment questionnaire, including use of health services and treatments, and changes in lifestyle and health over the previous four months since post-treatment assessment.
Group CBT Intervention
Group CBT comprises 6 weekly sessions of 1.5 hours each. The approach is interactive and psycho-educational, with a focus on helping participants to develop individual treatment strategies through active cognitive and behavioural change. Each session is run according to protocol set out in a treatment manual, including presentation slides and handouts. A clinical psychologist has been trained to deliver the treatment and assistants also are trained to assist in the groups. Sessions are taped and 2 independent psychologists, experienced in cognitive behavioural therapy, rate 10% of the sessions for adherence to protocol using a coding sheet created for the purpose. The components of each session are listed in Table 1. The change techniques used in each component are categorised using a 40-item revised version of Abraham and Michie's 26-item taxonomy of behaviour change techniques [52,53]. At each session participants create an action plan of homework to carry out between sessions. At the start of each session participants feed back their experiences of implementing changes during the previous week. Where difficulties are encountered, the group is encouraged to provide support and help the participant in problem-solving. Positive effects of changes are highlighted and discussed. Participants continue to practice, monitor and implement changes from previous weeks in addition to the new action plan each week. Paced breathing and relaxation are practiced within each session and as homework using a CD (developed for the treatment).
Table 1. Intervention techniques used in the Group CBT treatment
Session 1 aims to engage participants by introducing them to the CBT model of HF/NS [16,46]. Participants discuss their experiences of menopause and personal goals for the treatment. They are informed about, and discuss, physiological, cognitive, behavioural, and emotional components of HF/NS. This is embedded within an overall CBT model of menopausal symptoms that acknowledges the effect of stress upon the hot flush threshold. Common triggers are discussed and for homework participants monitor HF/NS for triggers and experiment by modifying them. Full body relaxation is introduced in the first session without paced breathing, and participants practice relaxation for homework.
Session 2 reviews homework and introduces a cognitive behavioural model of stress and stress management using a series of interactive exercises and discussion. Cognitive therapy is used to increase awareness of the role of unhelpful and overly negative thoughts and to facilitate calm responses. Behavioural strategies are encouraged to promote well-being and to reduce stress. Participants are asked to identify a stress reducing goal and implement it as homework. Paced breathing (slow, deep and even breathing with attentional focus on the breathing) is introduced to the relaxation session and participants are prompted to continue practice of paced breathing and relaxation as homework.
Session 3 focuses on cognitive and behavioural aspects of hot flushes. Participants revisit the CBT model introduced in session 1 and information about psychological processes contributing to distress during a hot flush are introduced. Cognitive behavioural strategies for managing hot flushes during social situations, and in relation to a perceived loss of control are discussed. Participants create an action plan to implement a cognitive behavioural strategy as homework. The role of paced breathing in reducing the impact of a hot flush is introduced and participants are asked to practice paced breathing at the onset of a flush for homework. This is suggested within an approach of accepting the flush (not fighting it), and letting the flush flow over them as they breathe; in doing so the focus of attention is on the body and breathing rather than thoughts. They then redirect attention to their activities.
Session 4 is the first of two sleep sessions, and lays the foundations for managing night sweats by improving general sleep quality. Participants are taught the mechanisms of sleep and cognitive processes that influence subjective judgements of sleep to address anxieties about sleep. Behavioural strategies (adapted from Harvey [54]) are introduced and participants are asked to create a sleep goal (action plan) and implement it as homework.
Session 5 builds on behavioural sleep strategies by adding in the cognitive component. Participants discuss cognitive strategies to address sleep-related and general anxieties leading to wakefulness. Calm management of night sweats is encouraged that incorporates paced breathing. Strategies to deal with overly anxious thinking are discussed. Participants are asked to identify and implement a relevant sleep goal as homework.
Session 6 reviews the overall model and goals of the previous five weeks. Participants write and share individual maintenance plans by considering cognitive and behavioural changes made through psycho-education and homework tasks. They make action plans to maintain changes and identify potential barriers or setbacks and ways of overcoming them. This session also schedules some time for discussion of menopause-related topics not covered in previous sessions, chosen by the participants, which may include weight gain, memory, adjusting to life after breast cancer, and sexuality.
Usual care
The control arm receives standard care, that is, they have access to their oncologist and clinical nurse specialist, as well as cancer information and support services. Treatments and services accessed during the treatment phase are logged at post-treatment assessment. The usual care group are offered a form of CBT off-trial at the end of the trial.
The measures taken at each stage of the trial are summarised in table 2.
Table 2. Study measures
Socio-demographic variables include date of birth, height, weight, ethnicity, number of children, education, marital status, employment status, smoking, drinking and exercise. Breast cancer treatment, use of treatments for menopause and concomitant medications and therapies are also recorded.
Primary Outcome: Hot flush problem rating
Hot flush problem rating is a subscale of the Hot Flush Rating Scale [55], calculated as the mean of three items each measured on a 10 point scale (low to high), e.g. "To what extent do you regard your flushes/sweats as a problem?" (1 = not at all a problem, 10 = very much a problem).
Secondary Outcomes
Hot flush frequency and severity are assessed using the following measures:
Hot Flush Rating Scale [55]: Frequency subscale
The frequency subscale of the HFRS is a retrospective estimation of the number of HF/NS experienced in the previous week, e.g. "How often have you had hot flushes in the past week?" Average severity of HF/NS over the previous week is estimated for hot flushes and for night sweats separately (1 = mild, 2 = moderate and 3 = severe).
24-hour hot flush diary
Women monitor their HF/NS prospectively for 24 hours. When they experience a hot flush or night sweat they note down the severity (1 = mild, 2 = moderate and 3 = severe) and the time at which it occurred.
24-hour ambulatory sternal skin conductance and event marker
During the 24-hour diary monitoring period women wear an ambulatory SSC monitor [56]. The monitor is approximately 6 × 6 cm, with two 8 cm electrodes attached to an adhesive electrode patch by press studs. The adhesive electrode patch is attached to the sternum, two inches below the sternal notch, which holds the monitor close to the body. Skin conductance is measured by passing a pulse through the electrodes every 5 seconds, indicated by a green flash of an LED on the monitor. A hot flush is defined by an increase in conductance of 2 mmhos or more in 30 seconds, occurring no less than 15 minutes since the last SSC-defined HF/NS (i.e. 15 minute lock out period [57]). For each SSC-defined hot flush or night sweat, SSC level and the time at which it occurred are extracted for analysis. Women can indicate that they are experiencing a HF/NS by passing a magnet near to the monitor. The magnet is worn on a bracelet. The times at which the magnetic event marker is registered are summed to produce a 24 hour HF/NS frequency.
Health related quality of life
General physical and mental health are indexed using the General Health Survey Short Form 36 (SF-36) [58], a widely used 36 item health survey. Two physical and mental health summary scales are constructed, with a possible range from 0 to 100, where higher scores indicate better health [59]. Perceptions of physical and emotional symptoms are measured using the Women's Health Questionnaire (WHQ) [49] which is standardised on samples of mid-aged women. The WHQ contains 36 items, for example, "I feel more tired than usual", which are scored on 4-point scales. Nine subscales are formed by counting the number of items scoring 2 or 3 and dividing by the number of items for each scale, resulting in scales from 0 to 1. The WHQ has been widely used to evaluate interventions for menopausal symptoms [60].
Process measures
Beliefs about hot flushes and night sweats
HF/NS beliefs are measured using the Hot Flush Beliefs Scale [15], a 27-item scale comprising three subscales including social context, coping with hot flushes, and coping with night sweats. An additional scale is included which measures behavioural reactions to HF/NS, the Hot Flush Behaviour Scale (HFBehS).
Perceived stress
The Perceived Stress Scale [61] measures 10 items, for example "How often have you been upset because of something that happened unexpectedly?", on a scale from 0 (never) to 4 (very often). Items are summed to form a 0-40 scale, where 0 is low stress and 40 is high stress.
Somatic amplification
Barsky, Grace and Klerman's [62] Somatic Amplification Scale is a 10 item scale measuring a general tendency toward body focus, including items such as "When someone else coughs, it makes me cough too" (1 = not like me to 5 = very much like me). The mean of the 10 items is calculated resulting in a 5-point scale where 5 is high somatic amplification.
Dispositional optimism
The Revised Life Orientation Test (LOT R [63]) measures dispositional optimism on a 8-item scale including "In uncertain times, I usually expect the best" (0 = strongly disagree to 4 = strongly agree). A mean of all items is calculated, resulting in a 5-point scale where high scores indicate higher dispositional optimism.
Treatment evaluation
Participants randomised to the group CBT arm are asked to rate the usefulness of the sessions overall and of specific elements of the intervention; use of the relaxation CD, attendance and completion of homework are also being measured.
Adverse events
An adverse events protocol has been agreed by the DMC and TSC, adapted for a non-medical trial using the Medical Research Council/Department for Health Joint Project Guideline notes on Pharmocovigilance [64]. This excludes study outcomes, such as increases in frequency or severity of HF/NS that occur as part of normal fluctuations in menopause symptoms. Adverse events are logged in the trial master file and reported to the principle investigator and trial coordinator. In accordance with the National Patient Safety Agency's requirements for reporting of serious adverse events (SAE), any adverse event deemed to be a related or unexpected SAE will be reported to the principle investigator, the sponsor and the DMC within 48 hours, and reported to the Hospital Research Ethics Committee in accordance with their procedures. Reoccurrence of breast cancer or secondary cancer does not need to be reported in this way, as it is an expected unrelated serious adverse event (see appendix 3 of the Joint Guidelines [64]). An adverse events report of these occurrences will be included in the report to the DMC in accordance with the DMC charter.
Power calculation
The sample size is calculated on the HFRS problem rating subscale [55], estimating a mean of 5 (SD = 2.4) and a clinically relevant difference of 2 points [45] at two weeks post-treatment. A total sample size of 76, 38 in each group, will have 90% power to detect a difference in mean HF/NS Problem Rating of 2, controlling for baseline value, assuming a common standard deviation of 2.4, a correlation between baseline and end of treatment values of 0.4 (giving a correction factor of 0.84 [65]) and a 5% two-sided significance level. Due to clustering of outcomes within therapy groups, the sample size has been adjusted by assuming an intra-class correlation of 0.07 [66] and 8 participants per group giving a variance inflation factor of 1.49. Ninety six women will be recruited in to the trial to allow for a 20% attrition rate.
An analysis plan has been agreed (i.e. prior to completion of data collection). A trial statistician, employed by the Mental Health and Neurology Clinical Trials Unit at King's College London, carries out primary and secondary data analysis, and is blind to group allocation. Unless indicated, scales are calculated according to published scoring algorithms. All statistical tests are two sided (level of significance = 0.05). The analyses are preformed using the statistical software Stata version 11.0. An intention to treat analysis of the primary outcome is performed. Difference in problem rating between the two intervention groups is tested using a linear mixed model, utilising fixed and random effects. The regression model compares the problem rating subscale of HFRS between intervention groups, after allowing for the baseline measurements to control for pre-treatment differences, stratification factors (age: 50 years or older versus younger than 50 years), and clinically relevant covariates. Greater precision of estimates is expected within therapy groups. Therefore models are adjusted for the therapy group; this variable is able to randomly vary around the intercept (random effects). Secondary outcomes at post-treatment are analysed similarly. Follow-up data at 6 months is also explored through linear mixed models utilising repeated measures analyses, allowing simultaneous modelling of the two outcome time points. Mediation of treatment effects by hot flush beliefs and behaviours, mood, stress, quality of life and frequency of HF/NS defined by skin conductance rises will be explored using a two stage least squared method in Stata [67]. Moderation by optimism and somatisation is also tested using multiple-group modelling [68].
This study is a randomised controlled trial of cognitive behavioural therapy to treat hot flushes and/or night sweats experienced by women who have completed treatment for breast cancer. This non-medical treatment aims to alleviate HF/NS symptoms in women who have limited medical treatment options due to contraindications. It is a robustly designed trial, comparing six sessions of Group CBT to usual care using both self-reported and physiological outcome measures. The primary outcome is change in HF/NS problem rating at post-treatment: an average reduction in problem rating of 2 points on the HFRS problem rating subscale is needed for treatment efficacy to be considered clinically significant. The study also tests the hypotheses that Group CBT will reduce frequency of HF/NS, improve mood, sleep, general wellbeing, and beliefs about HF/NS. It is further hypothesised that these improvements will be maintained at six months post-randomisation. If this non-medical treatment is found to be successful it could be delivered in primary or secondary care settings by appropriately trained and supervised health professionals.
Methodological considerations
The design has several strengths. The treatment has been extensively developed and piloted for feasibility, acceptability and preliminary outcomes. Preliminary results found an average 2.5 point reduction in problem rating (49% reduction) as well as a significant reduction in self-reported frequency, and significant improvements in sleep quality and quality of life were also reported [47]. A treatment manual specifies the detail for each session so that it is replicable, and checks are in place to ensure adherence to protocol. Measures of treatment efficacy are robust: as well as questionnaire-based estimations of recent symptoms, the trial includes prospective monitoring of symptoms using self-report and physiological measures. Very few trials of treatments for HF/NS include both types of prospective monitoring, and no trials of CBT for HF/NS have done so. The study sample is drawn from a socially and culturally diverse area of the UK; the uptake and adherence to the treatment by women from different backgrounds will be reported.
There are some limitations that should be considered. Recruitment procedures are designed to reach all of the symptomatic breast cancer patients who attend clinics in the South East London Network (SELCRN) hospitals. Clinic and research staff approach patients directly and posters and leaflets are placed in waiting rooms so that patients can opt in themselves. Nonetheless, the sample might not be representative of symptomatic breast cancer patients in general and we cannot know how many people were made aware of the trial through these recruitment procedures.
The treatment is compared to a usual care group to see whether it improves on current practice, but usual care control groups have some drawbacks. Usual care may vary between centres, although typically treatment is minimal. Those receiving usual care may be more likely to seek complimentary therapies if they are having no other treatment. Complementary therapy use and clinic treatments are monitored in the trial and may have to be controlled for in analysis. If usual care is minimal then it will be similar to a no-treatment control group, and treatment effects might be due to the extra attention rather than the treatment per se (i.e. any intervention is better than nothing). Transitory changes and biased reporting should be apparent by comparing self-reported HF/NS with physiological measures and post-treatment with follow up data. Early in the treatment development phase it makes sense to compare with current practice, especially as some improvement in usual care would be predicted if only because symptoms do get better in time. Should treatment effects be robust, further research into the active treatment components can be tested using attention control groups.
Breast cancer survivors who are experiencing problematic HF/NS have few treatment options. Cognitive behavioural therapy has resulted in some promising reductions in HF/NS problem rating and frequency in these women. This study is a randomised controlled trial of Group CBT for HF/NS which also includes physiological outcome measures. The trial tests for treatment effects on HF/NS, sleep, mood, beliefs about HF/NS and general wellbeing. This study represents an important step in the development of a cost-effective non-medical treatment for HF/NS designed to be implemented on a wider scale by trained and supervised health professions.
CBT: Cognitive behavioural therapy; HF/NS: hot flushes and/or night sweats; HFRS: Hot flush rating scale; HFBS: Hot flush beliefs scale; SF-36: General Health Survey Short form 36; WHQ: Women's Health Questionnaire; LOT R: Revised Life Orientation Test; TSC: Trial Steering Committee; DMC: Data Management Committee; NHS: National Health Service; UKCRN: United Kingdom Cancer Research Network; SELCRN: South East London Cancer Research Network; RCT: Randomised controlled trial; SSC: Sternal skin conductance; HT: Hormone therapy (previously termed hormone replacement therapy or HRT).
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
EM is the trial coordinator on the study and generated the first draft of this manuscript based on the study protocol; MS contributed to the intervention manual and carried out the Group CBT intervention; JH is the statistician to the study; MSH is the principal investigator of this study and wrote the original protocol and supervised the intervention. All authors approved the final version of the manuscript.
Beth Grunfeld, Trudie Chalder, Sharon Lowe-Lauri, Hisham Hamed, Mark Harries, Jo Marsden, Ruth Pickering, Alex Gentry-Maharaj, Michael Craig, and Caroline Burgess contributed to development of the study, and participated in trial steering and data management committees. We would like to thank the team at the South East London Cancer Research Network, Gian Gargaro at the Guy's Cancer Support Service, and the clinical staff at Guy's Hospital, University Hospital Lewisham, King's College Hospital, Princess Royal University Hospital at Bromley, Queen Mary's Sidcup and Queen Elizabeth Woolwich, for their help with participant recruitment. Myra Hunter is supported by the NIHR Biomedical Research Centre for Mental Health, South London & Maudsley NHS Foundation Trust and Institute of Psychiatry, King's College London.
This study is supported by a grant from Cancer Research UK (grant ref: C8303/A6130).
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text:
El Indio
Mario Morejon -EL INDIO- born in Cuba, began to play the trumpet with eight years, classically trained at the Habana´s NationalSchool of Arts (1990-1994). With 14 years old was playing with Bobby Carcases and Afro Jazz Band and with eighteen years old with Chucho Valdez and Irakere Band, after that with Habana Ensemble and anothers proyect´s with many diferent musicians like, Paquito de Rivera, Giovani Hidalgo, Eddy Palmieri, Tata Guines, Changuito, Miguel Anga, Ivan Lins, Wynton Marsalis, Roy Hagrove, and other´s.
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Tocar Tu Piel


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Grinnell guard scores 89 points - NCAA.com
That's insane. Guy took 88 shots though...
He was 27-55 and made 20 free throws.
It just made Sportscenter.
Impressive as hell. It's funny how games like that make you learn history that you didn't know like this guy Bevo Francis in the 50s. Ridiculous:
Bevo Francis - Wikipedia, the free encyclopedia
Just wow.
I realize Grinnell's style of play may increase the possibility of something like that, but ...
It's 89 points!
He scored 36 in their first game (an exhibition) too. He's a junior too..impressive, even for D3. If he keeps this up, he could be the next Devean George :D
Originally Posted by kas4cy
That's insane. Guy took 88 shots though...
No, he took 55 shots. 3 pointers are included when you look at a FG stat.
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Police beat for July 1, 2008
Published: Tuesday, July 1, 2008 at 6:30 a.m.
Last Modified: Tuesday, July 1, 2008 at 5:27 a.m.
Authorities identify man in motorcycle fatality
The Florida Highway Patrol has identified the motorcyclist killed Sunday on County Road 484.
Jeffery David Waldron, 43, of Jacksonville, died at the scene in the accident at 5:10 two miles east of State Road 200. His passenger, Vicki Renae Hitzing, 44, of Jacksonville, was critically injured and was airlifted to Shands at the University of Florida.
According to the FHP report, the motorcycle was traveling west on CR 484 when it left the paved portion of the road and went onto the grassy northbound shoulder. The bike overturned several times.
Deputies chase ATV driver in neighborhood
An Ocala man allegedly raced his four-wheeler through neighborhood streets in northwest Ocala with hopes of getting away from Marion County Sheriff's Office deputies Sunday afternoon.
Deputies say they chased Armando Gonzalez, 24, and his Yamaha ATV from Northwest 57th Lane to the woods off Northwest 52nd Avenue. According to the Sheriff's Office report, Gonzalez sped by an ice cream truck on 52nd Avenue where a few children had gathered.
Deputies set up a perimeter and found Gonzalez near 44th Avenue in the Ashley Farm subdivision at about 4 p.m. The report states that Gonzalez told deputies that he ran away because he did not want to go to jail.
Gonzalez was taken to the Marion County Jail and charged with felony fleeing and reckless driving.
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Sean Thackrey Pleiades XXIII Red Blend
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Item #60621
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- Size: 750ml
- Type: Red Wine
- Country: United States
- Region: California
"Powerful and intense with rugged tannins using methods from ancient texts. Named for the Pleiades star cluster, this wine is a blend of syrah, sangiovese, mourvedre, barbera, carignane, petite sirah and viognier, among others. Thackrey blends by taste and doesn't keep track of the fruit that ends up in each blend, so it's different from year to year. Juicy fruit, earth and Thackrey's signature eucalyptus note." Reviewed by: Producer
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Long Island Events
11th Annual Building Business in Brookhaven Expo
Don't miss out on this networking and business trade show! Enjoy complimentary food from Brookhaven Town businesses! Vendor exhibit tables available for $125 for table or food exhibition ...MORE
2nd Annual Pink Pumpkin Patch
Join us at 3 PM on the lawn of the County Executive Office at 1550 Franklin Ave. in Mineola as we help raise money for the Breast Cancer Research ...MORE
Columbus Day Comedy Show
Four Headline Stand-Up Comics: Featuring: Kevin Meaney Steve Marshall JJ Ramirez John JosephMORE
Salamander Log Rolling: Family Nature Walk
On this walk with Andy, aka "Mr. Salamander," you'll discover some unusual creatures that live in the leaf litter under the rotting logs on the forest floor. In ...MORE
Babylon Fall Festival
Festival will feature hay rides, a pumpkin patch, petting zoo, face painting, live musical entertainment and food!MORE
Run/Walk to End Domestic Violence
Run for the cause and win amazing prizes: 5K RUN: 1st PLACE - 2 TICKETS to METS PLAYOFF GAME 3 2nd PLACE - $ 200 GIFT CERTIFICATE ...MORE
15th Annual Long Island Pancreatic Cancer Research Walk
On Sunday, October 11, thousands will gather at Jones Beach State Park with their friends and families for the 15th annual Lustgarten Foundation Pancreatic Cancer Research Walk. Last ...MORE
The Long Island Serenity and Wellness Expo
The Serenity and Wellness Center presents: The Long Island Serenity and Wellness Expo on Oct 11th, 2015 at the Upsky Hotel, 110 Motor Parkway, Hauppauge, NY 11788. This ...MORE
Community Day Celebration
Come on down and join Sid Jacobson JCC as we celebrate our brand new Kroll Family Aquatics Center with a day filled with fun and excitment for all ...MORE
Wild Witches & Playful Pumpkins
What is your favorite Halloween character? Wild witches, playful pumpkins, ghosts, superheroes, and more! Create your own giant sized Halloween character using three-dimensional paper folding techniques and paper ...MORE
The Great Big Long Island Challah Bake
#KneadingItTogether for Jewish women, daughters, friends, neighbors! Challah Bake Long Island is partnering with the international Shabbat Project. It is taught that when a woman bakes challah and ...MORE
Strides for Stripes Zebra Walk. Wipe out NET Cancer
NCAN's 7th Annual 'Strides for Stripes' Walk! Your participation makes life better for thousands of people who suffer from this disease. The Walk at Eisenhower Park- This is ...MORE
Events and things to do on Long Island, New York - No matter what excites you, there's plenty of fun things to do and events to go to right here on Long Island. Whether you're passionate about music and the arts, love planning a day of Family Fun, or you're searching for the best happenings this weekend, our Events Calendar has all of the best local events for Long Islanders to enjoy all week long!
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2nd Annual Pink Pumpkin Patch
at County Executive Office Mineola
Time : 03:00 PM
Join us at 3 PM on the lawn of the County Executive Office at 1550 Franklin Ave. in Mineola as we help raise money for the Breast Cancer Research Foundation. First Company Pink is...
11th Annual Building Business in Brookhaven Expo
at Brookhaven Town Hall Brookhaven
Time : 05:30 PM - 08:00 PM
Don't miss out on this networking and business trade show! Enjoy complimentary food from Brookhaven Town businesses! Vendor exhibit tables available for $125 for table or food exhibition...
James Rosenquist: Tripartite Prints
at Heckscher Museum of Art Huntington
In the 1970s, Pop Art pioneer James Rosenquist created a series of large lithographs that are characterized by their horizontal, tripartite compositions. Constructed of fragmented and juxtaposed...
Light Over Water
at Oyster Bay Historical Society Oyster Bay
The Oyster Bay Historical Society's fall exhibition features Kirk Larsen's paintings, watercolors, and drawings of the boats, baymen, and yachts of Oyster Bay Harbor. The exhibition opens...
Mindful Yoga Therapy (Mental Health Awareness Week)
at Downtown Sayville Yoga Sayville
A short lecture describing yoga and how the practice of yoga is energy medicine for the mind, body, and spirit. This discussion will be followed by a practical demonstration of some yoga poses,...
Recovering Together: Supporting A Loved One With Mental Illness
at Patchogue-Medford Library Patchogue
Matt Costanzo, a mental health survivor, musician, public speaker and mental health professional, will discuss the challenges of fostering nurturing relationships and explore how to...
Haunted Tunnel
at Woodside Nursery Patchogue
We offer a wide variety of Family Fun things to do! Children will enjoy entering our "Octobercation" outdoor exibit. Here they will see and learn tips about Trick or Treat Saftey, see...
Perfect Little Pumpkins
at Long Island Children's Museum Garden City
It's pumpkin picking season! Create a cute pumpkin mask to wear home to your patch! All ages welcome!
Melanie Moczarski: Lingua Franca
at Tripoli Gallery East Hampton
Tripoli Gallery is pleased to present Melanie J. Moczarski: Lingua Franca. Marking her first solo show at Tripoli Gallery, the exhibition of new works will be on view at Tripoli Gallery East...
Traveling Exhibit-Once Upon A Time... Exploring the World of Fairy Tales
at Long Island Children's Museum Garden City
From an African jungle to a giant's castle, visitors will step into larger-than-life pages of seven favorite fairy tales. Enter the exhibit via a magical portal into a fabulous storybook...
This is Climate Change - An Education Project
at Any Street with Storm-produced hazards East Northport
In an effort to help the public see that climate change is REAL and happening RIGHT NOW in your own neighborhood, we are creating simple signs that say "THIS WAS CAUSED BY...
Lichtenstein Sale
at Guild Hall East Hampton
WOW! The Shop at Guild Hall is reducing the price of Roy Lichtenstein themed stock over Columbus Day weekend. All Lichtenstein merchandise will be 15% off (25% off for GH members). In addition to...
Senior Health Expo (Mental Health Awareness Week)
at St. Paul's School - Field House Garden City
Time : 09:00 AM
Showcasing services by the Mental Health Association of Nassau County. This free event also features flu vaccinations, pneumonia shots, screenings for blood pressure as well as many...
Emerging Professional Networking Event (Mental Health Awareness Week)
at Mental Health Association of Nassau County Hempstead
Time : 09:00 AM
Mental Health Association of Nassau County 16 Main Street Hempstead, NY For information: (516) 489-2322 x1251
Family and Work: Recovery In Action
at Pilgrim State Psychiatric Center West Brentwood
Time : 08:30 AM
Family and Work: Recovery in Action - All Day Conference For agenda, registration, and directions, click here Speakers include: Lisa Dixon, MD, MPH, Professo...


text:
All Android applications categories
All Android games categories
by: gnugu | 26
- Hello honey, can you stop at the grocery store and buy milk and bread?
- Sure honey, please email me the shopping list.
The ONLY app that allows you to receive email with multiple categorized shopping lists from anywhere.
Requires Gmail. **WARNING: Latest update of Gmail (2.3.5) breaks all third party applications including this one. Please do not upgrade your Gmail if you want to use this app.***
See Help for details.
Tags: got an a in shopping , shoppingpictures , youve got shopping
from 26 reviews


text:
APC Concept (Trojan x2) Vehicle
This particular vehicle was designed to accommodate x10 personnel for boarder control type assignments. Built by Stoof International from the chassis up with ballistic steel on a Toyota Land Cruiser 200 series model.
Stoof International's Peter Mead's Interview
Stoof International's Peter Mead is interviewed at INDESEC 2009.video posted by Stoof International Germany
B6 Armoured Vehicle Ballistic Testing
Stoof International's armoured Toyota Land Cruiser 200 Trojan und...video posted by Stoof International Germany
Stoof International Armoured Vehicles
Stoof has a vast experience in providing high quality armoured off roa...video posted by Stoof International Germany


text:
Welcome to
Spanish & Portuguese Studies
The Department of Spanish & Portuguese Studies is committed to the production and transmission of knowledge of the Spanish and Portuguese languages and the literatures and cultures of Spain, Portugal, Latin America, and U.S. Latinos.
Mission Statement »
FACULTY SPOTLIGHT | MARÍA GILLMAN By Irene Panke Hopkins Thanks to María Gillman, Principal Lecturer, Third-Year Language Coordinator and Department Director of Service Learning, SPS boasts... Read more
Study Abroad | Exploration Seminars in Mexico and Spain By Irene Panke Hopkins In her work with Heritage Learners, Professor Maria Gillman observed a startling phenomenon. "When they visited... Read more
Student Spotlight | Cameron Brandy By Irene Panke Hopkins When Cameron Brandy transferred to UW from Bellevue College in 2013, "he hit the ground running," said Senior Academic Counselor,... Read more
FACULTY RAVE | INMA RANEDA-CUARTERO By Irene Panke Hopkins Congratulations to Inma Raneda-Cuartero on her nomination for a Distinguished Teaching Award through UW's... Read more
ALUMNI SPOTLIGHT | David William Foster By Irene Panke Hopkins Distinguished Alumnus, David William Foster, is the 2014 recipient of the Victoria Urbano Academic Achievement Award.... Read more
Letter From the Chair: Ana M. Gómez-Bravo As I step in as new chair, I would like to first thank Professor Tony Geist for leaving such a cordial and vibrant department in my hands. When I arrived at... Read more
Study Abroad
For students who will have completed SPAN 102, 110, or 122, or students who have placed into SPAN 103
Contact Us
University of Washington
C-104 Padelford Hall
Box 354360
Seattle, WA 98195-4360
Phone: (206) 543-2020
Fax: (206) 685-7054
Email: email@example.com
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With 1.7 million freelancers, we'll match you with the perfect talent.
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estimator for structural steel fabricator. Able to take off quantities of structural steel, steel stairs and steel railings, steel bar joists and roof decking. Also able to estimate the time it takes to fabricate structural steel, steel stairs and railings; also able to estimate the time to erect all of the above items. Contact Bob Wolff, Sachs Steel,
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YURIA (ゆりあ), born on March 3rd, is a female singer from Osaka, Japan. She has been releasing many songs of TV animation programs, and been active in widespread fields, working as a radio personality, columnist, voice artist, musician, song writer, and a live music performer. Currently, in addition to her solo project, she takes part in bands such as; * Honey Bee * 道頓堀ダイバーズ (Doutonbori Divers) * すいーつたんけんたい (Sweets Tankentai) * Y-p-H * re-in.Carnation∞YURIA * PINKY DOODLE POODLE
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