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Expertise: Water-from-Air Systems, Atmospheric Water Generators, & Dehumidifiers
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Presented at CWWA Conference 2014! Another Water Resource for Caribbean Countries—Water-from-Air
Cite as: Wahlgren, R. V. (2014, October) Another Water Resource for Caribbean Countries: Water-from-Air. Paper presented at the Caribbean Water & Wastewater Association, Twenty-Third Annual Water & Wastewater Conference and Exhibition, October 6–11, 2014, Atlantis, Paradise Island, Bahamas. Retrieved from https://s3.amazonaws.com/eventmobi-assets/eventsbyids/6712/documents/seminar/424180/Wahlgren,_R_11_Paper-WaterFromAir.pdf
Now available!
Atlas of the Water-from-Air Resource for California
A fascinating month-by-month and site-by-site examination of an invisible water resource that has the potential for filling some of California's drinking-water supply needs.
The audience for this atlas is the water-from-air industry community, water resource administrators, elected officials, and the interested public. This atlas is also of interest to engineers and technicians in the heating, ventilation, and air-conditioning (HVAC) industry because the local water vapour density represents the latent portion of the cooling load attributable to outdoor air for HVAC equipment at the site.
* Dew-point Tables, Air-moisture Tables: Pin our tables on your wall next to your atmospheric water generator or your dehumidifier!
** Water-from-Air Resource Wall-charts: Our wall-charts look really cool pinned up next to your water-from-air equipment!
Water-from-air waterworks...


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- Age / Gender:
- n/a, Unspecified
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- Location not disclosed
- Joined:
- 4/17/13
- All Stats >
User Statshot
- Community Stats
Level 1 Blank Slate
Normal Whistle
Ranked as Civilian
Contact Info / Websites
Recent Game Medals
Aggressor II 50 Points Fire a weapon 100 times. Medal Stats.
Reloader I 10 Points Reload a weapon 5 times. Medal Stats.
Stealth 10 Points Fire a silenced weapon 25 times. Medal Stats.
Animator 25 Points Create a custom timeline sequence. Medal Stats.
Aggressor I 10 Points Fire a weapon 10 times. Medal Stats.
Fire a Bow 5 Points This is much cooler than using a sword! Medal Stats.
Use a Bed 5 Points Sleep is time travel! Medal Stats.
Tame a Dog 5 Points They'll be your best friends in the world! Medal Stats.
Kill a Cow 5 Points Leather can be made into the first tier of armor Medal Stats.
Kill a Sheep 5 Points Bahhh! They drop wool. Medal Stats.
Total Medals Earned: 99 (From 17 different games.)
Favorite Art
Favorite Games
Madness 6.5 Scene Creator Rated 4.3076 Stars Madness Combat 6.5 Scene Creator Gadgets - Dress Up Infiltrating the Airship Rated 4.5328 Stars Henry's skills are put to use on the Toppat Clan and their airship. Adventure - Point 'n Click Madness: Will It Slice? Rated 3.3549 Stars Will the new experimental weapon slice through the zombie outbreak? Action - Shooter - Run 'n Gun Ragdoll Laser Dodge 2 Rated 3.8609 Stars Fight to Survive in this Epic Battle of Ragdolls vs. Lasers!!! Skill - Avoid

subset: commoncrawl


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49, Marion, ARI'm right here - honest, strong, independent, successful, romantic, God fearing and appreciate a good joke / laugh. I enjoy spending time with family as well as hanging out wi...
50, West Memphis, ARCome from a small town in eastern Arkansas wherre I have lived and worked with family all my life. I am an eagle scout and 4th degree knights of Columbus I tend to be. Very pr...
Catholic Dating By Major City:
- Clarkedale,
- Edmondson,
- Earle,
- Marion,
- Proctor,
- West Memphis,
- Turrell,
- Heth,
- Parkin,
- Gilmore,
- Memphis,
- Tyronza,
- Hughes,
- Walls,
- Lake Cormorant


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Born in London, Georgia Hardinge's transient early life and international background gave her much opportunity to travel and develop her fascination with design. Training at Parsons School of Art and design in Paris, Georgia won acclaim by receiving the best designer award for her graduate collection. It was here that she first developed her sculptural aesthetic.
After gaining experience in the industry Georgia launched her label in 2010 and begun to build her identity as a sculptural designer. Her inspiration for design comes from a passion for architectural shapes and sculpture, which can be seen throughout her work. She works closely with a pleat specialist to develop pleating techniques from paper sculptures and new technological fabrics and textile treatments. The Georgia Hardinge brand incorporates a strong sculptural style but also has a unique quality through fabric manipulation and strong print design that is flattering and wearable.
Georgia's Autumn Winter 2011 'Merit Award' win granted her first stand-alone runway show at Fashion Scout, since then she has continued to shine with celebrated collaborations including bespoke outfits for the Victoria Secret fashion show with sponsorship from Swarovski and designing a limited edition Lancôme bottle, exclusively sold in Selfridges. The label has seen its second successful collaboration with the high street, Georgia Hardinge for River Island, a 14 piece collection that sold in 20 stores and online nationwide. Her film for River Island won best cinematography and Georgia was given the award for best fashion film at Berlin Fashion Film Festival. Sponsorship from the Center for Fashion Enterprise as a participant in their highly sought after Pioneer Program has been another great achievement for Hardinge. Most recently Georgia was awarded "BFC Contemporary" sponsorship by The British Fashion Council in collaboration with Ebay.
Receiving international press as Grazia and Elle's 'One to Watch', Instyle's 'Name to Know' and main fashion features in Sunday Time Style, ID, British Vogue, Stylist, Harper's Bazaar, L'officiel and Nylon to name a few publications. Celebrity fans include Florence and the Machine, Beyonce, Alicia Keys, Nelly Furtado, Lady Gaga, Erin O'Conner, Ellie Goulding and Iggy Azelia.
Georgia Hardinge continues to grow and increase its international stockists with each season, having been stocked in Harvey Nichols and Galleries La Fayette (Dubai pop up with AOD), Curve, The Swank and Alter Style.
Georgia lives and works in London…..


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Real Estate
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Clinic: Jackson has bipolar disorder
August 14, 2012
By Sophia Tareen, Associated Press
CHICAGO - U.S. Rep. Jesse Jackson Jr., a Chicago Democrat who took a hushed medical leave two months ago, is being treated for bipolar disorder, the Mayo Clinic announced Monday. The Rochester, Minn., clinic specified his condition as Bipolar II, which is defined as periodic episodes of depression and hypomania, a less serious form of mania. "Congressman Jackson is responding well to the treatment and regaining his strength," the clinic said in a statement. Bipolar II is a treatable condition that affects parts of the brain controlling emotion, thought, and drive and is likely caused "by a complex set of genetic and environmental factors," the clinic said.
Check Up: Study suggests link between migraines, bipolar disorder
May 11, 2014
By Stacey Burling, Inquirer Staff Writer
Doctors who work with patients with bipolar disorder should keep in mind that those people are also at high risk for migraine headaches, a Pennsylvania State University researcher says. A new study led by Erika Saunders, executive vice-chair of psychiatry at the Penn State Milton S. Hershey Medical Center, found that people with bipolar disorder were far likelier than the general population to get migraines and that those who got the awful headaches were at risk for worse psychosocial functioning, more severe depression, and earlier onset of bipolar symptoms.
Alleged child-killer says he has bipolar disorder
August 28, 2003
By Jacqueline Soteropoulos INQUIRER STAFF WRITER
Jerry Chambers, charged with murder in the beating, suffocation and starvation of 3-year-old Porchia Bennett, said in court yesterday that he suffers from bipolar disorder, a mental illness his attorney could later use as part of the defense. "Obviously, that will have some impact on which way we're going to go," defense lawyer Charles P. Mirarchi 3d told reporters. "He maintains his innocence at this point. " At yesterday's brief scheduling hearing, Assistant District Attorney Richard Sax told the judge he needed two days in which to present evidence at a preliminary hearing for Chambers and his girlfriend, Candice Geiger, who is Porchia's aunt and took care of the child and her three older sisters for nearly a year.
Computer collages as art therapy Carolyn Lee Vehslage's quilts, which reflect her bipolar disorder, help her and others to cope.
November 26, 2006
By Rusty Pray INQUIRER STAFF WRITER
When fabric artist Carolyn Lee Vehslage began creating computer collages, she intended them to represent her frustrations with computers and as a study of technology's impact on all of us. But the more she worked on them, the more the former computer network engineer began to understand that they represented "more than a discussion of technology and how it complicates our lives. " "I finally realized they resonated so much with me because they reflected my bipolar disorder, which I've had all my life.
In the mood
January 2, 2013
By Tirdad Derakhshani, Inquirer Staff Writer
Manic depression is touching my soul. - Jimi Hendrix It is a peculiarity of the modern American temperament that spiritual and mental health, no less than shoe styles or skirt lengths, are subject to fashions and fads. So it seems with bipolar mood disorder, which lately appears to pervade popular culture. Catherine Zeta-Jones, Demi Lovato, and Russell Brand have spoken out about their struggle with the illness. Michael Angelakos, lead singer of indie rockers Passion Pit, stunned the music press last summer when he came out as bipolar, while Sinead O'Connor canceled her tour last spring, citing the illness.
Woman Must Repay Stolen School Money She Must Spend Five Weekends In Jail For The Radnor Embezzlement. Her Lawyer Cited ``bipolar Disorder.''
February 28, 1997
By Douglas Herbert, INQUIRER CORRESPONDENT
A 33-year-old woman who pleaded guilty to stealing $54,733 while serving as treasurer of a Radnor elementary school's parent-teacher organization has been sentenced in Delaware County Court to five consecutive weekends in prison and ordered to pay full restitution. Judge Frank T. Hazel's sentencing of Elaine D. Sauerteig of Malvern came more than six months after her arrest Aug. 2 on charges of pilfering money from Ithan Elementary School's events fund from August 1995 to June 1996.
Bipolar illness not just for adults As diagnosis for children grows, study looks at how to help.
June 1, 2005
By Stacey Burling INQUIRER STAFF WRITER
Before his fifth birthday, Jeri Turrin's happy, playful son turned frustrated, disruptive - full of mad energy. He'd race from one end of the house to the other, jumping off the banister because he thought he could fly. His mother feared his horrible rages. "He would punch me so hard I would throw up," the Columbus, N.J., woman said. A doctor thought that Bradley had attention deficit hyperactivity disorder, but the Ritalin he prescribed made the boy hallucinate. At 6, Bradley drew his own gravestone and wrote, "I want to die. " Jeri Turrin learned that her son had a mental illness doctors once thought kids couldn't have: bipolar disorder.
Lansdale Police: disabled vet missing
December 12, 2012
Lansdale Police are looking for a disabled military veteran who has been missing since Nov. 30. Family members say Timothy Baker, 52, of West Main Street in Lansdale, suffers from depression and bipolar disorder. He is on medication, but it was found at his home. Baker is about 5-feet-11 inches and weighs 275 pounds. He is an African American with brown hair and eyes, and a scar on the back of his neck. He drives a black Chrysler 300 with the Pennsylvania license plate of HZL-1175, police said.
He'll Satisfy The Need To Give Love And Care
September 5, 1997
By Paddy Noyes, FOR THE INQUIRER
"Everybody deserves a place of his own, where he's wanted. And that sure includes Michael," his foster mother says. "Some of his problems are different," she continues, "but the satisfaction of knowing he's being cared for and loved makes it worth the extra effort. " Michael, 13, was a premature baby and weighed only 3 pounds at birth. His social worker says neglect and abuse in his background could be a factor in his disabilities. He is not verbal, and has cerebral palsy, a nonprogressive muscle condition.
Mezvinsky plan for trial is criticized Prosecutors want to bar testimony supporting the ex-representative's mental-health defense.
October 11, 2001
By Ralph Vigoda INQUIRER STAFF WRITER
The mental-health defense planned by former U.S. Rep. Edward Mezvinsky to explain why he defrauded friends, family and institutions of more than $10 million is not supported by evidence and should not be heard at his trial next year, the U.S. Attorney's Office said yesterday. In a 59-page motion filed yesterday, prosecutors asked U.S. District Judge Stewart Dalzell to bar the testimony of four experts who concluded that Mezvinsky's physical and mental health likely suffered because of his use of the anti-malaria drug Lariam.
Next »
Latest treatment for mental illness: Better sleep
June 1, 2015
By Stacey Burling, Inquirer Staff Writer
Philip Gehrman is a psychologist at the University of Pennsylvania who studies the intersection of sleep and mental illness, a hot topic in treating everything from depression to bipolar disorder to PTSD. "Yeah, I'm depressed," patients will often tell him. "If I could just sleep better, my mood would be fine. " He thinks some of them may be right. Experts say doctors have long recognized that insomnia or changes in sleep "architecture" - the length and quality of different stages of sleep - are symptoms of virtually all mental illnesses.
Missing and endangered
January 29, 2015
By Ronnie Polaneczky, Daily News Columnist
BY EARLY YESTERDAY, Snow- meh -geddon 2015 had coughed out its last harmless flakes. So I turned off the windshield wipers, the better to look out for Ashjakia "Kia" Washington as I crawled through West Philly. I hadn't much hope of finding her. But for once, I wanted to do something tangible in response to yet another notice from the Philadelphia Police Department that an "endangered" person had gone missing. The department issues a lot of these alerts, because endangered people are the people we worry about the most: the mentally or medically compromised, the intellectually or physically disabled, the elderly, the underage.
Teacher's body recovered in Schuylkill
January 27, 2015
BY WILLIAM BENDER, Daily News Staff Writer email@example.com, 215-854-5255
FOR A FEW brief hours yesterday afternoon, there was still hope. Police reported that the Greater Philadelphia Search and Rescue - a group formed in 1979 to help locate lost and missing people - had found a body at 1:18 p.m., caught in the tree line along the Schuylkill near the Falls Bridge. Despite immediate speculation that it could be the body of missing Bucks County teacher Christopher Tully, police would only identify the man as "John Doe. " But as the sun was setting, Tully's brother, Eddie, broke the news to thousands of supporters that #findtully was over.
Corvette-in-river guy 'didn't realize I was doing anything wrong'
November 13, 2014
BY DANA DiFILIPPO, Daily News Staff Writer firstname.lastname@example.com, 215-854-5934
UPDATE: John Kramer was arraigned early Thursday and his bail was set at $15,000 on two counts of reckless endangerment and one count each of harassment and violating a court order, according to court records. He has not yet posted the 10 percent – or $1,500 – he needs to be released. Kramer's next court date is set for Dec. 18. JOHN KRAMER wants you to know he's not a bad person. Two days after he sent his speeding red Corvette plunging into the Delaware River in a spat with his estranged wife, Kramer turned himself in to police yesterday to face charges that he'd violated a restraining order, harassed his estranged wife and endangered the police divers who had to fish the car out of the river.
Professor urges treatment for pedophilia
October 8, 2014
BY JASON NARK, Daily News Staff Writer firstname.lastname@example.com, 215-854-5916
IT'S NOT A CRIME to be a pedophile. Swallow that sentence and let it mingle with the stomach acid before you grab the pitchforks and head down to the comment section, because an assistant professor at Rutgers School of Law in Camden says that it's true and that pedophilia needs to be treated as the mental disorder it is. It's important to know what Margo Kaplan wasn't saying, however, in her Sunday New York Times op-ed "Pedophilia: A...
Check Up: Study suggests link between migraines, bipolar disorder
May 11, 2014
By Stacey Burling, Inquirer Staff Writer
Doctors who work with patients with bipolar disorder should keep in mind that those people are also at high risk for migraine headaches, a Pennsylvania State University researcher says. A new study led by Erika Saunders, executive vice-chair of psychiatry at the Penn State Milton S. Hershey Medical Center, found that people with bipolar disorder were far likelier than the general population to get migraines and that those who got the awful headaches were at risk for worse psychosocial functioning, more severe depression, and earlier onset of bipolar symptoms.
Chesco woman gets house arrest for Medicaid fraud
April 17, 2014
By Michaelle Bond, Inquirer Staff Writer
WEST CHESTER A West Chester woman convicted of Medicaid fraud and stealing money meant for her 22-year-old autistic daughter was sentenced to 12 years on probation Tuesday and must pay back about $180,000. Michelle Cohen, 52, will have to pay more than $160,000 to the state Department of Public Welfare and $19,400 to the West Chester Area School District, as well as more than $20,000 to the state for the cost of prosecuting her, Judge Jacqueline C. Cody said. Cohen will serve the first six months of her sentence under house arrest and do 250 hours of community service after that.
Dad: Son who fought with SEPTA cop should have been committed
March 21, 2014
BY DAVID GAMBACORTA, Daily News Staff Writer firstname.lastname@example.com, 215-854-5994
PERCY PRIDE'S phone started ringing when the surveillance video hit the TV news Monday night, a video of a big guy brawling with a SEPTA cop on a crowded subway platform. People thought it was his son, Steve Mason. Nah, Pride thought, it couldn't be. He looked closer. It was his son, all right - but that didn't seem possible. Pride said he'd spoken to his son earlier in the day, when Mason, 40, had called from the Warren E. Smith Health Center in North Philly. Mason needed help.
Workshops will help families cope with mental illness
March 10, 2014
By Stacey Burling, Inquirer Staff Writer
It's hard enough to get along with people with "normal" emotions, let alone those with mental illnesses that make feelings intense, unpredictable, and volatile. Having a family member with bipolar disorder, borderline personality disorder, or major depression can feel like being trapped on an emotional roller coaster, said Edie Mannion, director and cofounder of the Mental Health Association of Southeastern Pennsylvania's Training and Education Center. She helped develop a class for family members who want to get off the carnival ride.
Bucks psychiatrist charged with inappropriate conduct
January 25, 2014
By Chris Palmer, Inquirer Staff Writer
A pediatric psychiatrist in Doylestown was arrested Thursday and charged with inappropriately touching three female patients during treatments, according to the Bucks County District Attorney's Office. Basem Shlewiet, 42, who has a private practice on North Franklin Street, allegedly fondled the breasts of two patients - ages 22 and 14 - while purporting to use a stethoscope, according to a criminal complaint. He touched a 17-year-old around the groin, the complaint said. All three incidents occurred in 2013, according to the complaint.
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The Beauty Lessons We've Learned From Kate Moss
The phrase "style icon" gets thrown around way too much. But in Kate Moss's case? It's totally accurate. And although she's the ultimate chameleon on the job, when she's on her own, there are some beauty looks she practically owns. Here's what we've learned from the world's coolest supermodel.
- Kendall Jenner's Simple Hack For Perfectly Textured Hair
- How to Turn Second-Day Hair Into an Amazing Updo
- The Exact Facial Cleanser Kylie Jenner and Khloé Kardashian Use Every Night
- Selena Gomez Has a Genius Trick to Make Your Eyes Look Brighter
- Kylie Jenner Just Revealed Her Daily Makeup Routine and All the Products She Uses
- 10 Times The Fashion World Was Obsessed With Star Wars
- 12 Amazing Korean Beauty Products That Glow Recipe's Founders Swear By
- The Winter Skin-Care Swaps Allure Editors Always Make
- 13 Inspirational Celebrity Quotes About Aging You Have to Read
- The Best Multitasking Beauty Products for Holiday Party Season


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A Little Thing Called 'Love'....❤
You and Princeton were going out for your 6 month anniversary. You loved each other very much, although when it came to dates Prince seemed to go a little over board. You are an easy simple girl, that doesn't care where you go as long as you're together.
You're almost ready and you get a knock on your door. You go to answer, with your hair half done.
Prince- Hey baby. He says as he leans in for a kiss, you pull away and playfully hit him, then lead him in to sit down until you were fully ready.
You- Come on Princey i'm ready. You said as you opened the door.
Prince- okay uh the car is open i'll meet you in there, i gotta pee.
You- ok, hurry!
Prince gets in the car and you make your way to the surprise he has for you.
Prince- y/n/n close your eyes
You- Okay
He pulls up at the place and guides you out the car and leads you to where you are spending your anniversary
Prince- bit to the left a bit... watch these steps, we're here babe
You- okay can i open my eyes?
Prince- Yeah, look
You open your eyes to see a beautiful roof top view of the city, you looked to your left and saw a dinner table
You- so Prince what are we gonna do here
Prince- we're gonna eat, talk and i have something planned after!
You- sounds perfect, just like you. I love you princeypoo
Prince- I love you too y/n/n
*you kiss*
He sits you down and claps his hands signalling the waiter.
Prince- Hey, can we get 2 waters and the specials on the list please?
Waiter- sure coming up
You- So, where do you see yourself in 5 years time?
Prince- wait so on OUR anniversary you wanna talk about MY future? i was hoping to talk about our future
You- Yeah i was gonna get to that! answer the question
Prince- Well i see myself with a fiancée maybe a kid, that i'd spoil very much! and being in my dream job
You- Well that girl and that kid will be very lucky to have a guy like you, shame it isn't me
Prince- come on babe you know who i'm talking about when i say that!
You- yeah i know- me but i just wanted a reaction outta you!
Prince- in fact i meant rihanna... but you're a close second!
You- *sarcastically* HA-HA-HA
Prince- You know i'm just playin' i plan to be with you, forever.
You- aww so sweet
You ate and talked more then finished up. You then made your way to the other surprise Prince planned
He pulled up and you opened your eyes.
You- The beach?! aw so romantic! there aren't many people here
Prince- yeah lets get sat down!
He pulled out a blanket and a basket, and you had a little picnic
He then pulled out of the basket chocolate covered strawberries- your favourite
He fed them to you, you did the same. overall a really romantic evening
You got home and Prince came in. You ran upstairs to change your clothes, but what you didnt know was, Prince followed you.
*you getting changed*
Prince- Hey boo
*Jumps and screams*
You- aahhh Prince not cool
He comes up behind you and grabs your waist, you try pulling away but he starts kissing your neck, causing you to moan, you then turn round to kiss him, which leads to a make out session. you then jump up, your legs are now around his waist, you being closest to the bed, you flop onto the bed (him being on top), he takes off his shirt while you take off your shorts, he then full takes off your top that you hadn't finished putting on.
Prince- Hey um you wanna do this angrily?
You- oh yes, angry sex is the best sex. so we gotta swear anything said is just for pleasure non of it is meant?
Prince- yep
Prince gets straight to it, he reveals Mr Fernando and goes right into you, slowly to start you off.
You- There were guys staring at me when we were on the beach. Winking and everything, one even came up to me and flirted, it was hot.
That made him angry but not enough to pound the shit outta you- just yet
You- You know your friend Roc? I liked him before i liked you, i still think he's hot
He got really angry and went faster and harder
Prince- uurrrggghhh say my name
You- No.
Prince- say it
You- you know what i like? strong boys with muscles that can protect m-(gco)
He went proper hard almost ripping you.
You- PRINCETOOONNNNNN!!!!!!!!!!!
He slowed it down then kissed down you your area and started eating you out like a beast. you let out a loud moan
It was your turn, you decided to go for head, you know how he likes it and what gets him going.
You bent down and just straight away stuck it in your mouth. You tickled it with your tongue, he started to giggle then you nibbled on it.
Prince- Girls always be flritin' i kinda like the attention
You started to do it the way he liked but harder
Prince- i saw a girl today she was gorgeous, her ass was on point, i gotta tap that
You made him scream so loud the neighbours may have heard.
You kissed and kissed until you got tired and fell asleep together.
This one wasn't great but i'm thinking and trying!
Next one coming soon- very soon


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New Bafana coach to miss announcementComment on this story
Johannesburg – The new Bafana Bafana coach will not be in attendance when the SA Football Association makes the announcement on Saturday, Safa president Danny Jordaan said on Wednesday.
"No, he won't be there on Saturday," Jordaan said.
"He will be unveiled at a later stage, Saturday will only be the announcement of the new coach."
Last weekend, Jordaan said he hoped to bring the new boss of the national soccer team to Johannesburg for the announcement, but said on Wednesday this would not be the case.
Saturday's highly-anticipated announcement is expected to take place at Safa headquarters, at the Soccer City complex, which is home to the FNB Stadium.
Also on Saturday, Orlando Pirates and Kaizer Chiefs kick off the fourth edition of the Carling Black Label Cup at 3pm at the iconic FNB Stadium.
Jordaan said he was unable to guarantee he would make it in time for the pre-season spectacle due to a national executive committee meeting.
The meeting would conclude with the announcement of the new coach. – Sapa
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Stock Market & Financial Investment News
News Breaks
March 27, 2014
Ally Financial to offer 95M shares in an IPO, Treasury to sell shares
Ally Financial announced that it has launched an initial public offering of shares of its common stock. The shares will be offered by the U.S. Department of the Treasury as part of its planned exit of its investment in Ally. Treasury is offering 95M shares of Ally common stock at a price per share ranging between $25 and $28. Citigroup, Goldman, Sachs & Co., Morgan Stanley and Barclays are acting as joint global coordinators on the offering.
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Hillary Rodham Clinton's campaign stop was interrupted Monday when two men stood in the crowd and began screaming, "Iron my shirt!" during one of her final appearances before the New Hampshire primary.
Clinton, a former first lady running to become the nation's first female president, laughed at the seemingly sexist protest that suggested a woman's place is doing the laundry and not running the country.
"Ah, the remnants of sexism _ alive and well," Clinton said to applause in a school auditorium.
Read more here.
Watch the video below:


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Sat, 28 Nov, 2015, 4:36 AM EST - Canadian Markets closed
Canada Business Magazine has released their list of the … More » Canadian Business Magazine ranks the country's top 25 brands
It's finally here: that time to trade in your suit and tie for a comfy golf polo and pitching … More » The most expensive places in the world to retire
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Heading towards its 50th anniversary in 2017, McDonald's Canada unveiled the next chapter of its … More » The McDonald's of the future
We're fortunate in Canada, in that most people have 24/7 access to clean, cool, unlimited fresh … More » Five weird and pricey bottles of water
On Tuesday, a Delaware court More » Company founders who fell from grace
SHANGHAI (Reuters) - Companies from China and South Africa have signed 23 deals worth … More » China, South Africa firms sign $930 million in deals ahead of Xi trip: Xinhua
The Toronto Zoo's twin giant panda cubs have been moved to a larger incubator and … More » Canada panda cubs doing well, moved to larger incubator: zoo
Less than a week after Facebook Chief Executive Mark Zuckerberg said he would take … More » Facebook makes paid time off for baby leave a global benefit
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This weekend brings us the latest adaptation of Mary Shelley's incredible Gothic … More » 10 Best On-Screen Versions of Frankenstein
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The young and exciting smartwatch field may finally have its breakthrough device.
Apple Tuesday introduced us to the Apple Watch, an iPhone-connected, … More » The Apple Watch: Time to buy one?
Although the retail brands are many, there are only a handful of conglomerates behind the world's top cosmetics and personal care products. Here we count … More » World's biggest health and beauty brands
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Consumer Reports' Get It or Forget It series continues with a visit to the Home Depot. More » Home Depot: What you should (and should never) buy
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Minnesota, known for its extreme cold, is now also sizzzling hot, following a surge in popularity for … More » The hot new fashion hub? Minnesota
Everything old is new again. Guess which oversized (if beloved) rodent made $5 million last year? More » YouTube's highest paid channel
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From key performance indicators to school redistricting to stop-arm violation tracking, there are many ways to benefit from the information in a computerized routing program.
Suppliers of light-emitting diode (LED) systems say they provide greater longevity, visibility and efficiency. Here, we provide details on some of the latest LED units for school buses.
Any drivers who are worried about being photographed and fined, whether at a traffic light or next to a school bus, should shift their focus to following the laws.
The association discusses steps that it has taken and continues to take to reduce the incidence of bullying on board school buses. These efforts include partnering with the U.S. Dept. of Education's Office of Safe and Drug Free Schools to make available free professional training for the school bus industry to encourage positive interventions.
Pupil transporters discuss practices they have established toward this effort, such as assigned seating. They also address the importance of creating policies on eating and drinking and transporting backpacks and instruments, as well as ways to reduce noise inside the bus.
As evidenced by the infamous Fox River Grove crash, documenting school bus route hazards is critical. Detailed, accurate route descriptions are essential, and drivers must be involved in the documenting process.
School buses in the U.S. safely shuttle some 24 million kids to and from school each day, but are the big, yellow vessels contributing to the education process in other ways?
Get breaking news, industry updates, product announcements and more.
Shop at School Bus Store


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1. Re: Webgateway vs. siteadvisorfschulte Feb 4, 2013 6:50 AM (in response to Brian Pedersen)
Hi Brian!
Can you give an example URL and the results you see using Web Gateway and Site Advisor?
In general, you should see the same results Though, the configuration of Web Gateway (e.g. if local database and/or cloud is used; usage of DNS in cases that the URL is uncategorized) or some delay when the database is updated could sometimes lead to slightly different results.
2. Re: Webgateway vs. siteadvisorBrian Pedersen Feb 4, 2013 7:42 AM (in response to fschulte)
Hi Felix
Thanks for fast reply!
We have just added this sites and have some which siteadvisoer havent' tested yet:
3. Re: Webgateway vs. siteadvisorfschulte Feb 5, 2013 3:16 AM (in response to Brian Pedersen)
Hi Brian!
I just checked both URLs and both show up as Green/Minimal Risk but have no categories assigned.
In this case MWG applies a heuristic (enabled by default) which will do a DNS lookup and will categorize the returned IP address. If the site is hosted on a suspicious web server (because other suspicious sites are also hosted on that server) the final reputation result will also be suspicious/medium risk/yellow. This is what happens in your case.
E.g. Resolving frismus.nu I get 126.96.36.199. Categorizing then this IP through Site Advisor or trustedsource.org I get a yellow result.
If this heuristic shows to many false positives you can disable it: Go to Policy -> Settings -> URL Filter and disable the checkbox (called something like) "Do forward DNS lookup".
4. Re: Webgateway vs. siteadvisorBrian Pedersen Feb 5, 2013 7:35 AM (in response to fschulte)
Hi fschulte
Thank you for your answer this was a nice and easy solution.
5. Re: Webgateway vs. siteadvisorRegis Feb 11, 2013 9:21 AM (in response to Brian Pedersen)
This is a timely thread as I'd encountered several of these head scratchers myself of late.
As Felix said, if the URL is uncategorized, the reputation of the IP is used for categorization it seems. In my case, I was seeing things getting categorized as Malicious Sites in my log files, but checking at https://www.trustedsource.org/en/feedback/url it showed the URL in my logs as uncategorized. Sure enough that same URL entered as its corresponding IP address, however, showed the same categorization I saw in my logs.


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All I can say, you made a good choice with Unreal 3 engine.
WarCraft III: World of WarCraft (Wc3:WoW) is the most accurate WoW replica mod for WarCraft III: The Frozen Throne, featuring many elements as WoW does. It is a Single Player Campaign and the WarCraft III engine does not allow Campaigns to be played online or even on LAN. Wc3:WoW is currently being developed by a group of developers who hope to become pro some day called Condemned Entertainment. Previously, the team was given the simple 'Wc3:WoW Team' title, but after realizing it wasn't a professional team title to stick with, the team name was changed. Right now, the leader of Wc3:WoW is Craka_J, who had led the project through tedious development for over 4 years.
Well, you'll never hear about us being short on music or sound effects thanks to good ol' BETA Tester Doron. We've also got some news about the interface and terrain!
Posted by Craka_J on Apr 17th, 2010
A lot of people are still asking me if Wc3:WoW will feature music and sound effects from World of Warcraft, and to answer that question briefly, the answer is yes! All the music in World of Warcraft will be in Wc3:WoW, as well as sound effects. Some sound effects in WarCraft III are used in World of Warcraft though, so we're already at a head-start on that. But thanks to Doron, we officially have every WoW song and sound. No need to worry about hearing WarCraft III music in Wc3:WoW!
On top of that, Doron has also found all the icons and interface images in the World of Warcraft MPQ which are conveniently already .blp format, the same format WarCraft III uses for icons and images! I find this to be a huge plus for us because it will require pretty much no more screenshots of the interface and makes the life of Yixx and our artists much easier. I'm excited to get some of this in very soon.
This weekend I am being forced to work on Wc3:WoW pretty much because my internet speed is terrible in online games due to this never ending rain... but that's a good thing! I'm working on Durotar and Mulgore still. Might even start work on Arathi Basin or Warsong Gulch since every time I listen to the PVP music I want to make it. I know I still haven't uploaded any eye-candy, and I'm sorry, but think of it this way... at least you know I'm working hard on something so that can happen. The weekend isn't over yet, so who knows. Maybe you'll see something tomorrow if I get enough done!
I've been working on Warsong Gulch a lot this evening. So far the scale is perfect for Warcraft III. The only issue as far as terrain goes is the tunnels that lead to the flagroom, but I have an idea of how to counter it. I just hope it works. Will need to discuss the issue with Yixx and see if we can get around the problem without having to port your character straight to the top of the base or in a different area of the map.
I know this may be uninteresting, but I am currently searching for people who are good programmers/scripters for Unreal 3 Engine. I am currently leading a team of developers on an indie multiplayer game project that uses the Unreal 3 Engine / Unreal Development Kit and need more scripters, texture artists, sound effects artists, and maybe an animator. The team currently has 4 artists, 2 designers, 1 programmer, and 1 musician. Message me for more details if you can help!
All I can say, you made a good choice with Unreal 3 engine.
Don't worry, we're not recreating World of Warcraft or anything related to a Blizzard Entertainment game. It's a totally new IP.
Nice work man, I can see its going forward! :D


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- 170Promote
Framed Art Print
waiverby Heather Goodwind
Choose from a variety of frame styles, colors and sizes to compliment your favorite Society6 gallery, or fine art print - made ready to hang. Fine-crafted from solid woods, premium shatterproof acrylic protects the face of the art print, while an acid free dust cover on the back provides a custom finish. All framed art prints include wall hanging hardware.
I love it. Great work Heather.
Oh Yeah! ✯ ✯ ✯ ✯ ✯ 👍
cool and very interesting
like a seed, maybe a cell, a ovule,... a mother-earth feeling, but 'waiver' makes me think about of other possibilities. The waiver of the tree? the waiver of the mother-earth? the waiver of the woman?
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Emerging Trends in Computational Biology, Bioinformatics, and Systems Biology discusses the latest developments in all aspects of computational biology, bioinformatics, and systems biology and the application of data-analytics and algorithms, mathematical modeling, and simu- lation techniques. ? Discusses the development and application of data-analytical... more...
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Applied Computing in Medicine and Health is a comprehensive presentation of on-going investigations into current applied computing challenges and advances, with a focus on a particular class of applications, primarily artificial intelligence methods and techniques in medicine and health. Applied computing is the use of practical computer science... more...
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text: Angelina - Unregistered January 17, 2012 9:32 PM All those with karting exp, there is a diff. betn kartingn F1. In karting u don't have to develop the car unlike F1. That's the reason Ferrari chooses experienced drivers n kicked off Raikkonen with poor feedback. Only in Macca, engineers call the shots. In redbull its not Newey its Vettel who suggests Newey what he wants to b developed. Not sure if Seb would have been so good if redbull had releasd him to Macca in 2008. 0 agree 0 disagree


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Carol A. Goad
- Christian Speaker in Joplin, MO
- Travels up to 150 miles
- $300-$1500 Please contact me with your situation
- Free Quote
Why book Carol A. Goad?
She is has been through cancer, the loss of a child, the rigors of raising teenagers, and the ups and downs of what those things can do to a marriage.
God has called her to speak to women in particular in her own humorous slightly sarcastic way about how to look at these trials like small slightly annoying speed bumps in life, and how the true hero is our Faith, our ability to Love and God, our night in shining armor.
What an inspiring speaker!
Carol spoke at our Thursday morning ladies church group meeting. When I first contacted her, I didn't expect her to accept my invitation unless she was already in the area. Her home is nearly 3 hours away. But she graciously accepted, and we are so fortunate that she did. Our ladies loved her talk. Her talk was moving, humble, funny, and most of all inspirational. I am still getting positive feedback from members, and thanks to Carol, I know I can find a silver lining in every situation!
|Priced Fairly
|Lisa K.
|WINGS - Women in God's Spirit, St. Margaret of Scotland Catholic Church
|Other in Lees Summit, MO
|Event Date:
|Oct 11, 2012
|Hired As:
|Christian Speaker, Christian Speaker, Motivational Speaker
Response from Carol A. Goad:
Your group made me feel extremely welcome. I am humbled that you asked me to come! Thank You for having me!
Laugh out loud funny.
If you haven't laughed so hard you are crying, Well you are about too. I can't wait to see what she does next!
|Deana F.
|Other in Joplin, MO
|Event Date:
|Oct 15, 2011
Carol's faith through adversity shines through.
I had the opportunity to hear Carol at her first speech. Although she was very nervous, she did very well in conveying her message to us all. I would definitely go to another event that she is the speaker. She has a true spirit of God's amazing love. Carol has the ability to touch lives through her humor and experiences of life.
|Debbie C.
|Fundraiser in Joplin, MO
|Event Date:
|Oct 7, 2011
Carol Goad is an amazing speaker! Her story will make you laugh, cry, and really think!! You won't be sorry for having her as a guest speaker.
|Jamie H.
|Fundraiser in Joplin, MO
|Event Date:
|Oct 7, 2011
Amazing Speaker
Carol Goad is a phenomenal speaker with an amazing talent to entertain the audience with her humorous spirit and warm personality. Her message is truly inspiring and heart-felt.
|Amanda B.
|Fundraiser in Joplin, MO
|Event Date:
|Oct 7, 2011
Blessed beyond measure...
Mrs. Goad has a love for God that shines on her face from the very first words that come out of her mouth through her laughter and tears about how our Heavenly Father has blessed her through her cancer treatment, the lose of her daughter and the trials of raising 5 children whom she loves very much. If you have darkness in your life and in need of someone to shine some light on you, Carol Goad is the speaker to listen to. Expect your heart to sing with hope and sides to ache from laughter. I am forever changed eternally blessed.
|Fundraiser in Joplin, MO
|Event Date:
|Oct 7, 2011
Booking Info
- Typical Gig: 30 - 90 minutes
- Fee: $300-$1500 Please contact me with your situation
- Languages: English
Some of the comments from my last performance
"Totally Awesome, Loved it!"
"Love God, Love you!"
A personal favorite.... "You brought joy and praise to something that is so hard to get through! You made me laugh, and cry. Loved It!"
Additional Booking Notes
Just a P/A... annndd a bowl full of the Green and Yellow (only)peanut M&M's!
Carol resides in SW Missouri and can do 30 to 60 minutes of speaking.
Her topics are,
Breast Cancer,
Dealing with loss of children
Her goal is to be a light for God and show others who he is.
Saints not allowed!
Influences & Inspiration
Obviously God is my major influence. My family's strength through all of lifes curve balls, and their ability to continue to worship our savior when many would have blamed God and given up.
Outside influences,
Mark Lowery
Chondra Pierce
Anita Renfro
Lisa Bevere
Setup Requirements
You might also like:
Motivational Speaker
Nixa, MO
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Springfield, MO
We are a comedy improv troupe from NW Arkansas who specializes in short form gigs…
Comedy Improv Show
Rogers, AR
WT Ministries is a multi-faceted, multi-generational, and multi-denominational ministry…
Christian Speaker
Nixa, MO


text:
|Is the zona pellucida thickness of human embryos influenced by women's age and hormonal levels?
MedLine Citation:
|PMID: 22608315 Owner: NLM Status: Publisher
|OBJECTIVE: To evaluate whether zona pellucida thickness (ZPT) of human embryos is correlated with maternal age, patient's hormonal status, embryo quality, and IVF outcomes. DESIGN: Prospective study. SETTING: University-affiliated IVF clinic. PATIENT(S): Couples undergoing IVF-ET cycles. INTERVENTION(S): Zona measurements, clinical data collection. MAIN OUTCOME MEASURE(S): Correlation between the ZPT and maternal age, basal FSH and E(2) levels, stimulation protocols, cause of infertility, embryo quality, and implantation/pregnancy rates. RESULT(S): The measurements of ZPT were collected from 5,184 day 3 human embryos originated from 744 IVF patients. The overall mean ZPT was 16.18 ± 2.00 μm. No significant correlation was observed between the ZPT and the patient's age, E(2) values on the day of hCG administration, basal concentration of serum FSH, stimulation protocol, infertility diagnosis, and implantation/pregnancy rates. The ZPT was strongly influenced only by the embryo quality: Embryos with good morphology exhibited considerably thinner ZP compared with those of less favorable morphology (mean 15.87 ± 2.48 μm vs. 16.36 ± 2.57 μm, respectively). The ZPT had no significant impact on the implantation and pregnancy rates. CONCLUSION(S): The thickness of the human ZP of day 3 embryos is not influenced by women's age and hormonal levels. The strong correlation between ZPT and embryo quality suggests that thickness of ZP depends on inherent embryo properties. The overall ZPT is not a good predictive indicator for IVF clinical outcomes.
|Hanna Balakier; Agata Sojecki; Gelareh Motamedi; Siamak Bashar; Rodica Mandel; Clifford Librach
Related Documents :
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Publication Detail:
|Type: JOURNAL ARTICLE Date: 2012-5-17
Journal Detail:
|Title: Fertility and sterility Volume: - ISSN: 1556-5653 ISO Abbreviation: - Publication Date: 2012 May
Date Detail:
|Created Date: 2012-5-21 Completed Date: - Revised Date: -
Medline Journal Info:
|Nlm Unique ID: 0372772 Medline TA: Fertil Steril Country: -
Other Details:
|Languages: ENG Pagination: - Citation Subset: -
Copyright Information:
|Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.
|Create Fertility Centre, Toronto, Ontario, Canada.
Export Citation:
|APA/MLA Format Download EndNote Download BibTex
|MeSH Terms
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
Previous Document: Spermatogonial stem cell preservation in boys with Klinefelter syndrome: to bank or not to bank, tha...
Next Document: Oocyte vitrification does not increase the risk of embryonic aneuploidy or diminish the implantation...


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- esterbl What is it* sorry☺
- iheartmynails @esterbl It's called a "caviar manicure" and those are microbeads. =)
- esterbl Thanks😃They are so cute👍
- iheartmynails @esterbl You're welcome! I'm glad you like them. :)
- iheartmynails @sofia_neckopulos Thank you!! =)
- nicaasoanes I have some of those ..expensive @iheartmynails
- iheartmynails @nicaa_98 Yeah, they kinda were. :\/
- nicaasoanes @iheartmynails it looks good though x


text:
West End shows its best for inaugural Westival
Posted: May 05, 2014|
A festival filled with music, market stalls and merriment drew hundreds of people to Leicester's West End.
Braunstone Gate was filled with friends and families yesterday sampling the first Westival.
The road was closed to traffic as stalls selling clothes, food and jewellery were set up. Bars spilled out into the street and a variety of acts performed throughout the day.
Dave McGuckin, 26, of Hinckley Road, took a stroll through the festival before performing a comedy set at Mobius in the evening.
He said: "It seems lovely and there are a lot of people here. I'm glad it popular. I got involved through a friend who knew the organisers, so I'm going to be up later doing a set.
"It would be great to make this an annual thing.
"I would definitely get involved. It wouldd be hard not to – I only live down the road."
The event was organised by businesses.
Vinny Singla, 29, who owns SPA Investments, in Braunstone Gate, said: "It's about bringing people down here and making them aware of what we have got.
"It's not just about encouraging people down here at night for a beer."


text:
- Home
- Jpop
- Ogata Megumi
- Sunrise, Sunset
National Anison Translation Month Visit our forum for help on making wallpapers!
Sunrise, Sunset
Album / Collection: "Rain"
Track # 11
Description: -
lyrics and performance by em-ou (Ogata Megumi)
music & arrangement by Ookuma Kenichi
View Kanji
New Feature! In kanji view, mouseover a kanji character for lookup information!
Contributed by Risu-chan <[email protected]>
Animelyrics.com now has an OpenSearch plugin that you can install into your browser (FireFox and IE 7 supported)
My Little Pony Ties
Lyrics copyright to their respective owners or translators. No copyright infringment is intended or implied.
Layout and other content copyright Anime Lyrics dot Com / Anime Globe Productions
This is some text here


text:
Here is a link to a one minute clip of Ben Harper's new song 'Don't Give Up On Me Now' (you have to scroll down a little to get to the player):
It looks like this song has been released in France as the first single from Give Till It's Gone. I found several French sites with short clips of the new song, but I couldn't find the full version. I will keep looking and post it here if I find it. It sounds great! I can't wait to hear the entire song!
London, Shepherd's Bush 2013
Hi there, I dont know if I am writing in a proper board but I have got a problem with activation, link i receive in email is not working... http://www.benharper.com/?648c5f658c6a033015c572799d0 or http://www.benharper.com/?648c5f658c6a033015c572799d0,


text:
December 1, 2015
NASHVILLE, Tenn. (AP) -- A proposal to increase the fine for not wearing a seat belt has failed this session.
Members of the House Transportation Committee voted 11-2 on Tuesday to defeat the measure. Earlier in the day, the companion bill passed the Senate Finance Committee 6-4.
Currently the penalty for not wearing a seat belt is $10. The legislation would have bumped the fine to $50.
Sponsors say the measure is simply to encourage people to buckle up.
But critics say individuals shouldn't be penalized for choosing not to wear a seat belt.
Click Here to access the online Public Inspection File
Viewers with disabilities can get assistance accessing this station's FCC Public Inspection File by contacting the station with the information listed below. Questions or concerns relating to the accessibility of the FCC's online public file system should be directed to the FCC at 888-225-5322, 888-835-5322 (TTY), or firstname.lastname@example.com.


text:
Bourahama Sidibe converted a stoppage-time penalty to give Djoliba of Mali a 2-1 home victory over Wydad Casablanca from Morocco today in the CAF Confederation Cup.
In a tale of two penalties on Matchday 3, Mohammed Berrabeh missed one in the first half for Wydad before the visitors went ahead on 38 minutes when Younes Houassi scored his third goal of the campaign.
A dreadful defensive blunder by Youssef Rabeh gifted Alou Bagayoko a 73rd-minute equaliser before Sidibe rubbed salt into Moroccan wounds with his last-gasp winner.
Stade Malien had to settle for a 1-1 draw with Congo Brazzaville visitors AC Leopards in another Group B match in the Malian this weekend with Ousmane Cisse putting the local club ahead and Treston Lakolo levelling before half-time.
Djoliba have seven points, Leopards three and Wydad and Stade two each halfway through the six-round group phase with each club chasing a top-two finish and a place in the semi-finals of the second-tier competition.


text:
Okay, look, we like the Pre. We like it a lot, actually -- but failing our ability to get hold of one of those any time soon, we'll gladly take a boatload of screenshots in its place. These shots, taken from a late-2008 copy of the Mojo SDK, show some core goodies like messaging and Synergy contact management -- there's still a lot of stuff missing, yes, but this version has been floating around for a few months now, so the build demonstrated on Pres at CES was likely a good deal fresher. Click on for the full gallery!
Big thanks to Boy Genius for hooking us up with shots from his tipster!
Get it for FREE
- Key specs
- Prices
- Discussions
- Type Mobile / embedded OS
- Source model Closed, w/ open source
- Released 2011-07-01


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5 posters
3 groups
Sometimes in order to move forward, you have to go back. And in this raunchy comedy, Jim Owens does just that when he heads home for his high school reunion. In an attempt to relive the glory days with his boys and explore an old romance, he nearly destroys his hometown and friendships.
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de Cabanyes Candela, Sara MD*; Detterbeck, Frank C. MD†‡
*Hospital Clínico Universitario de Valladolid, Valladolid, Spain; †Yale Cancer Center Thoracic Oncology Program; and ‡Smilow Cancer Hospital at Yale-New Haven Hospital, New Haven, CT.
Disclosure: The authors have no conflicts of interest to report.
Address for correspondence: Frank C. Detterbeck, MD, Section of Thoracic Surgery, Yale University School of Medicine, 330 Cedar St., BB 205, New Haven, CT 06520-8062. E-mail: email@example.com
Background: Many clinicians use restaging after induction therapy as a way to select patients for surgery.
Methods: A systematic review was conducted to define the reliability of restaging tests after induction therapy for stage III(N2) lung cancer, when compared with pathologic findings at surgery.
Results: A complete response at all sites carries a false-negative (FN) rate of 50% for computed tomography and 30% for positron emission tomography. Mediastinal node involvement has FN and false-positive rates of 33% and 33% by computed tomography, and 25% and 33% by positron emission tomography. The FN rate of invasive restaging is 22% by repeat mediastinoscopy, 14% by esophageal ultrasound and needle aspiration in expert hands (reliable results are not yet available for endobronchial ultrasound), and 9% by primary mediastinoscopy done with optimal thoroughness. These results are not significantly affected by the type of induction therapy or the timing of restaging.
Conclusion: The ability to identify patients who have achieved mediastinal downstaging other than by a careful primary mediastinoscopy is poor.
Stage IIIa non-small cell lung cancer (NSCLC) accounts for approximately one third of patients presenting with this disease, and most of this stage group consists of patients with malignant involvement of the mediastinal lymph nodes (N2,3).1 Although the optimal management of these patients is unclear, a common practice has become to consider preoperative ("induction") therapy (chemotherapy ± radiotherapy [RT]) and possible surgery. Which patients are most appropriate to select for this approach is also unclear,2 but it is clear that a major prognostic factor is whether induction therapy achieves clearance of N2,3 node involvement (downstaging).3–5 This observation is based on the stage as determined after resection and raises the question of how well preoperative restaging tests can predict the pathologic stage and thus serve to select patients for resection.
Many physicians have, in fact, adopted the management strategy for stage IIIa(N2) NSCLC of induction treatment, followed by resection of patients believed to have been downstaged. This approach is taken despite the fact that most of the questions remain unanswered. Whether surgical resection adds further benefit over chemoradiotherapy is controversial.2,3,6 Should patients with a good response to chemoradiotherapy undergo surgery because of a good response or not undergo surgery because of a good response (or should resection be avoided in those with a poor response or actually be pursued provided there is no disease progression)2? Finally, whether restaging tests accurately predict the final pathologic stage and which restaging test is best are unclear. This article seeks to shed light on this last question.
We have conducted a systematic review of literature on methods of restaging after induction therapy for patients with stage IIIa(N2) NSCLC. The specific question addressed is how reliably each method of restaging predicts the actual pathologic stage. Methods of restaging include imaging (i.e., computed tomography [CT] or positron emission tomography [PET]), needle-based biopsy techniques (e.g., esophageal ultrasound or endobronchial ultrasound and needle aspiration [EUS/EBUS-NA]), or surgical techniques (e.g.,1st time mediastinoscopy or repeat mediastinoscopy). The primary question is how well restaging tests predict persistence or clearance of tumor from mediastinal nodes, because this is often cited as a criterion for selection of patients for resection. A secondary question is how well restaging tests can predict complete clearance of tumor from all sites (a pathologic complete response [pCR]), potentially making surgery unnecessary.
The postinduction therapy pathologic stage is, in reality, merely a surrogate end point for the real outcome measure of interest: long-term survival without recurrence. One can also pose the question of how well restaging tests predict survival and use the answers to select patients for a particular treatment approach. These issues are not addressed in this article but are the subject of another investigation. This review only addresses the end point of the correlation between restaging tests and actual pathologic stage, because many physicians already use restaging to select patients for surgery, without really knowing how well the restaging techniques actually perform.
A systematic review was conducted of data defining parameters of reliability (sensitivity, specificity, false-negative [FN], and false-positive [FP] rates) of methods of restaging of the mediastinum or the primary tumor after induction therapy for NSCLC. The study question in this review was to what extent the restaging test correlates with actual pathologic findings. Studies reporting on restaging with an end point of survival rather than a microscopic assessment of nodal involvement were excluded; such studies were saved separately and comprise the subject of a separate review.
The point of the study question is to assess the ability to select individual patients for a particular treatment approach. For example, if the absence of viable tumor at all sites could be reliably predicted, such patients could avoid surgery. On the other hand, if persistent N2 involvement is used to preclude surgery (or clearance of the mediastinum is used to select for surgery), then the FP rate (or the FN rate) in the mediastinum is the key measure of a restaging test's value. These parameters allow assessment of a negative or positive restaging test result in an individual patient. In contrast, sensitivity and specificity are less clinically relevant because they assess the test performance in a population of patients in whom the true final result (presence or absence of cancer) is already known. It must be emphasized that sensitivity and specificity cannot be used to estimate the FN or FP rate because they are calculated by entirely different formulas (the only exception is perfect sensitivity or specificity [100%] which does predict a FN or FP rate of 0, respectively, in most cases). The parameter accuracy is avoided. Although this term satisfies a desire for simplicity, condensing to a single measure omits so much information that the number is not useful to interpret test results either for an individual patient or in comparison with other tests, and it varies with prevalence of disease. Furthermore, it is misleading because it implies accuracy of a test result for a patient, which it does not.
Restaging tests that were considered are CT, PET, any method of needle aspiration (i.e., EBUS, EUS, and transbronchial needle aspiration [TBNA]) or mediastinoscopy. The gold standard against which a restaging test was compared was microscopic assessment of mediastinal nodes or of the primary tumor. A positive microscopic result was considered acceptable, regardless of the technique used (e.g., mediastinoscopy, EUS/EBUS-NA, or thoracotomy), but a negative result was not counted unless based on surgical exploration. The thoroughness of intraoperative surgical evaluation may vary,7 and unfortunately few studies defined this. The intent appears to have been a lymphadenectomy in most studies, but details of what was actually done were generally not provided.
A Medline search was conducted using the search terms: lung cancer, non-small cell lung cancer, induction, neoadjuvant, mediastinal staging, restaging, CT, computed tomography, PET, PET-CT, positron emission tomography, endobronchial ultrasound, esophageal ultrasound, needle aspiration, mediastinoscopy, and remediastinoscopy. The search was limited to English language peer-reviewed articles published between 1980 and 2009. In addition, the reference lists of retrieved articles and reviews and guidelines addressing induction therapy and restaging were reviewed. The programs of major lung cancer meetings from 2000 to 2009 were scanned, and authors of pertinent unpublished studies were contacted. Articles were selected that involved either prospective or retrospective clinical studies reporting on restaging (before resection) after induction treatment (chemotherapy, RT, or a combination) if data on at least 20 patients was reported. Because of the paucity of articles on needle aspiration methods of restaging, this was expanded to articles reporting on these techniques in at least 10 patients. We intended to limit the review to patients with biopsy-proven stage III (N2,3) NSCLC, but many studies did not adhere to this strictly. Therefore, we accepted all studies involving induction therapy and restaging for NSCLC. However, we excluded articles that focused primarily on Pancoast tumors. Furthermore, we excluded articles that did not allow calculation of test parameters.
The search strategy yielded a list of 170 articles. These titles were scanned, and the abstracts of relevant article were reviewed. Articles potentially meeting the inclusion criteria were selected for full review. Together with the manual search this produced a total of 129 articles that were reviewed in full. In the case of duplicate articles, only one was chosen that contained the most information. Articles were excluded if a later, updated publication contained data on the same patients. However, if overlapping series contained some unique patients, both were included. This process resulted in the selection of 32 articles, which met the study criteria, and provided data addressing the study questions. Data extracted included the number of patients, the method of restaging, type of induction therapy, interval between completion of induction therapy and restaging, and the feasibility of performing the restaging test (i.e., how often where adequate results obtained when the technique was attempted).
Test parameters are defined in the usual manner: sensitivity = true positive/(true positive + FN); specificity = true negative/(true negative + FP); FN rate = FN/(true negative + FN); FP rate = FP/(true positive + FP).8,9 We prefer the more straightforward terms FN rate and FP rate rather than negative predictive value (= 1 − FN rate) or positive predictive value (= 1 − FP rate). Because the FN and FP rates are markedly affected if the prevalence is very low or very high,8,9 we excluded these values from calculation of averages if the prevalence was <10% or >90%., respectively. The specificity and FP rate of restaging was often not evaluable because further confirmatory testing was not generally done if microscopic evidence of N2,3 involvement was found. In contrast, the requirement of confirmation by thoracotomy of a negative restaging result allowed accurate assessment of the FN rate and sensitivity. All results are consistently reported relative to detecting the presence of cancer; this involved recalculation of parameters from some studies that reported results relative to the presence of a response (i.e., the lack of cancer). Test parameters are calculated based only on patients in whom the test was feasible, so that test results can be interpreted. (However, in comparing sensitivity, the reader must also take into account the feasibility.)
Summary results involved simple averages without weighting according to the study size. A formal meta-analysis was not done because of the limited number of patients and articles, the variety of induction treatments, and the variety of subjective or objective criteria used to classify restaging test results. Instead, details of these characteristics are included in the tables and footnotes, so that the consistency and heterogeneity of the studies can be qualitatively assessed by the reader. The quality of the articles was not rated, but use of an appropriate confirmatory standard (as defined above) was strictly required of included studies. However, the thoroughness of the restaging procedures was rated according to a proposed classification.7 An analysis of publication bias was not done. The entire project including the search, data analysis, and writing was conducted independently by the authors.
If complete clearance of tumor at all sites could be reliably predicted, then these patients could be spared surgical resection. Studies of induction therapy have indeed shown that a pCR is achieved in some patients, although the proportion is low (<20%).3,10–15 Studies that have evaluated imaging tests for a pCR are summarized in Tables 1 and 2. The prevalence of persistent disease is high in these studies, consistent with the low pCR rates achieved after induction therapy. Most importantly, though, the FN rate of a complete response by imaging is high (approximately 50% by CT and 30% by PET).
The rate of pCR can also be related to the degree of radiographic response. In studies of >20 patients who have reported such data, a pCR was noted in approximately 57% of patients (range, 0–100%) who had a radiographic CR,13,15–20 in 16% of patients (range, 0–35%) with a radiographic PR,13,15–21 and in 0 to 10% of patients with radiographic stable disease.13,15–18,20,21
The studies involving CT have shown a great deal of variability (range of FN rate 0–100%). It is not clear why this is the case; details of the CT imaging were often not provided. Nevertheless, this variability does not inspire confidence in the use of CT to predict a pCR. The FN rate for CT appears particularly high after chemoradiotherapy, which is disappointing, because there is little confidence that chemotherapy alone can curelung cancer.
The reliability of PET to detect residual tumor is more consistent but still carries an unacceptably high FN rate (∼30%). Most of the PET studies addressed only detection of residual cancer at the primary site. Subgroup analysis does not identify a group in which a negative PET is reliable (Table 2). The FP rate appears to be quite low in studies involving induction chemotherapy without radiation and in studies involving quantitative PET assessment (by the standardized uptake value or SUV). Cerfolio et al.,22 using a quantitative change from pre to postinduction PET, found better prediction of pCR after chemotherapy than chemoradiotherapy and after lower than higher doses of RT. Review of the results in Table 2 suggests this may be driven by differences in the FP rather than the FN rate. It should be noted that despite its name, SUV is not standardized, and there is significant variation between scanners and scans due to multiple factors.23,24
One study has analyzed in detail both CT and PET to define quantitatively what degree of change after induction treatment best predicts a pCR.22 CT did not perform well, even with a >90% decrease in the size of the primary cancer (FN rate 60%, FP rate 31%).22 The optimal change in SUV in the primary lesion by PET was found to be a >80% reduction (FN rate 0%, FP rate 5%). Whether this can be duplicated in a validation dataset from another institution remains to be seen. In summary, CT imaging is unable to reliably predict complete eradication of all viable tumor, and PET is generally also not sufficiently reliable, although a quantitative change of >80% holds promise.
The major focus of reassessment after induction therapy is whether there is malignant involvement of the mediastinal lymph nodes. Studies addressing this issue using imaging techniques are summarized in Table 3. Surprisingly, few studies have formally evaluated the reliability of restaging by CT (six studies involving 190 patients). The results support the general belief that CT is a poor restaging test (FN and FP rates of approximately 40%). Even if one focuses only on the patients without a radiographic response to induction therapy (stable disease), a substantial portion (9–36%) have, in fact, been downstaged to ypN0,1.16,25–27 Therefore, neither a complete response nor a complete lack of response in the mediastinum by CT is reliable in identifying those who have or have not been downstaged.
Ten studies involving 398 patients have evaluated the ability of PET to determine downstaging from N2,3 to ypN0,1 (Table 3). PET restaging is associated with a high FN (25%) and FP rate (33%). Subset analyses do not reveal a group in which PET performed sufficiently well to serve as a restaging test (Figure 1). The results for PET imaging are quite consistent among studies, with the exception of a low FP rate in one study28 and a low specificity in another.29 An explanation for these outliers is not readily apparent.
In a retrospective analysis, Cerfolio et al. found that approximately 1 month was the optimal timing of a restaging PET/CT after chemoradiotherapy. The end point in the analysis was both the overall stage and the mediastinal node status as suggested by restaging PET/CT versus the result of biopsy or resection. Subset analysis of all studies did not show a difference between PET restaging in less than or greater than 4 weeks. However, this included both studies involving chemoradiotherapy and chemotherapy alone. It is possible that this may make a difference in the optimal timing of PET. Others have suggested that an early PET response (after one dose of chemotherapy) is highly predictive of outcomes (but have not reported results of early PET with respect to mediastinal downstaging).30 We were not able to analyze an interaction between early versus late PET imaging and induction chemotherapy versus chemoradiotherapy further from the data reported.
Five studies involving 515 patients (Table 4) report results of repeat mediastinoscopy for restaging of stage III NSCLC (as well as other studies involving smaller overlapping cohorts of patients). All patients had undergone previous mediastinoscopy (not EBUS), which involved biopsy of stations 2R, 2L, 4R, 4L, and 7. All groups used a similar technique consisting of opening the previous scar and entering the mediastinum through the left paratracheal space, followed by extension of the dissection to the right paratracheal space. All authors used a traditional mediastinoscope except De Leyn et al., who used a videomediastinoscope. The thoroughness of the mediastinal evaluation in these studies is high.
Remediastinoscopy has been found to be safe, although one death has been reported.31 The feasibility of remediastinoscopy was 87%. Remediastinoscopy was considered valid when all previously positive stations were biopsied, but two studies defined biopsy of any tissue as sufficient.32,33 There is no apparent difference in the feasibility whether RT was given or whether the procedure was performed earlier or later. It has been suggested that the low feasibility reported by De Leyn et al.28 was due to the use of the larger videomediastinoscope, although in general videomediastinoscopy performs better than traditional mediastinoscopy.34
Remediastinoscopy quite consistently carries a high FN rate (22%). This is not worse if induction therapy included RT; in fact, the FN rate is lower after induction chemoradiotherapy versus chemotherapy alone (15% versus 33%). Further subgroup analyses were not able to be performed from the data reported.
A prospective multicenter study has evaluated thoracoscopic restaging after previous mediastinoscopy and induction therapy in 70 patients,35 but only preliminary data are available. The feasibility of thoracoscopic restaging was 74%, although complete ipsilateral restaging was possible in only 57%. The reported test parameters are sensitivity 75%, specificity 100%, FN rate 24%, and FP rate 0%. However, it is not clear whether these values included all patients, all feasible procedures, or only procedures involving complete restaging.
Several authors have reported results of mediastinal restaging techniques that are based on needle aspiration, involving 191 patients (Table 4). This involves several smaller studies of EUS, a larger multiinstitutional study of EBUS and one study of TBNA without node visualization. The level of thoroughness of mediastinal staging in these studies is much more limited than for remediastinoscopy (average number of node stations sampled per patient of 1.2,36 1.4,37 and 1.638). The feasibility of performing an "adequate" EBUS/EUS evaluation of the mediastinum is high (97%).
The average FN rate of needle-based techniques of mediastinal restaging is surprisingly good (14%). This is surprising, because in general, needle-based mediastinal staging has been associated with a FN rate of approximately 20 to 25%,34,39 making it hard to believe it is better in the setting of restaging. The FN rate of 0 in the study of TBNA (without visualization) is particularly surprising and can perhaps be explained by the small study size and patient selection. Exclusion of this study results in a FN rate of 18%. Similarly, the study by Annema et al37 included selected patients with nodes in stations 7 or 4L that were easily accessible by EUS-NA. The study by Herth et al38 was prospective and very carefully done, but the unusually high prevalence of persistent mediastinal disease renders the FN rate unstable. However, this is the only study that allows assessment of the FP rate, because resection was carried out in all patients, regardless of the EBUS results. Although needle-based techniques have occasionally produced FP results,40–42 none were found.38 The limited number of studies did not allow subset analyses to be performed.
Two studies addressed the performance of first-time mediastinoscopy for restaging in a total of 85 patients.43,44 All these patients originally had mediastinal node involvement documented by a needle technique. These studies used either video-assisted mediastinoscopy or transcervical extended mediastinal lymphadenectomy and a very thorough mediastinal evaluation. Neither of the studies reported the interval between the conclusion of induction treatment and restaging, and most of patients underwent induction chemotherapy alone. Results of these studies are shown in Table 4.
Many physicians have adopted the treatment strategy of induction therapy followed by resection of those patients thought to be downstaged. However, many aspects of this are unclear, including whether the strategy itself is beneficial, what induction treatment should be given, or how patients should be selected for this approach. Perhaps most surprising is how convinced many are that the criteria for selection of patients for subsequent resection are well established. It is often forgotten that downstaged patients have been identified after resection. Use of downstaging to select patients for surgery requires a reliable method of identifying them before resection.
The most widely used method of selecting patients for surgery is the radiographic response by CT to induction therapy. This occurs despite the fact that virtually every study that has analyzed this has found little, if any, correlation between the response by CT and pathologic findings after resection. This review also confirms that a normal-appearing mediastinum after induction therapy carries a 30% FN rate and an abnormal mediastinum a 30% FP rate. Therefore, use of CT alone to either select patients for or exclude them from surgery is not justified, at least not if the goal is to only resect those patients who are downstaged. Furthermore, a complete response by CT cannot be used to justify avoidance of resection because of a 50% FN rate. Although a radiographic response makes the patient and the physician feel good, it provides little information about the presence of absence of viable tumor.
PET imaging is also commonly used to predict downstaging, although it is well recognized that RT can cause fluorodeoxyglucose uptake due to inflammation. Although PET performs somewhat better than CT, approximately one fourth of patients with a negative ("cleared") mediastinum by PET still have pN2 involvement and approximately one third of those with persistent PET uptake in the mediastinum do not. Surprisingly, whether RT was given has no impact on these results. Indeed, no patient subsets could be identified in whom restaging PET is reliable. Finally, a complete response by PET in all sites cannot justify omitting resection: one third of such patients still have viable tumor. Perhaps more sophisticated assessments such as the percent change in PET activity can be used. However, it must be emphasized that such assessments require great attention to detail to ensure consistency in the measurements (i.e., the scanner, the region of interest, and the amount and timing of fluorodeoxyglucose).
Remediastinoscopy has been shown to be feasible and safe in experienced hands, but few institutions are comfortable with this technique. Because the results are disappointing (FN rate 25%), it is unlikely this will change. EBUS or EUS and needle aspiration are gradually becoming more widely available. The results seem to be slightly better than for remediastinoscopy (FN rate 15%), but the number of studies is limited, and it remains to be seen whether these will hold up as the procedure is practiced more widely (outside of the pioneering centers and in less well-selected patients). Primary mediastinoscopy performs fairly well, consistent with the performance of primary mediastinoscopy in general (especially the more thorough variations such as video-assisted mediastinal lymphadenectomy and transcervical extended mediastinal lymphadenectomy).39 However, this requires avoidance of mediastinoscopy in the initial staging. Often little thought is given to the eventual treatment strategy at the time that patients are first evaluated and staged.
A summary of the sensitivity and FN rates of various methods of restaging of the mediastinum is shown in Figures 2A, B. These results suggest that restaging to select only the patients who have been downstaged in the mediastinum for resection leaves much to be desired. Certainly, restaging by imaging alone is highly unreliable (both FN and FP rates are high). Furthermore, for those patients who have not been downstaged (by invasive restaging), it is unclear whether their survival is better with surgical resection or an alternative therapy (provided no distant metastases have appeared).2 It should be remembered that the majority of studies of induction therapy and resection took the approach of resection of all patients regardless of restaging (unless distant metastases had appeared). Restaging by EBUS/EUS is possibly acceptable if expertise is available or 1st time mediastinoscopy if thoughtful planning at presentation provided microscopic confirmation of N2,3 involvement without mediastinoscopy.
This review has only addressed the ability of restaging tests to reliably predict mediastinal downstaging (ypN0,1) and complete eradication of all tumor (pCR). This represents a surrogate end point that has been correlated with the ultimate goal of long-term cure. Studies linking characteristics of patients after induction therapy directly to long-term survival are beyond the scope of this review.
In summary, we have carried out a systematic review of studies addressing methods of restaging after induction therapy for stage III NSCLC, when compared with actual pathologic findings in the mediastinal nodes or primary site. Although these methods of restaging are commonly used to select or exclude patients from surgery, the data show them to be quite unreliable. In particular, mediastinal downstaging by CT, PET, or remediastinoscopy carry a FN rate of 20 to 30%. EUS and EBUS may perform slightly better, but data are limited. Primary mediastinoscopy seems to be the most reliable method of assessment. Ideally, initial invasive staging of the mediastinum should be done by a needle-based technique, so that primary mediastinoscopy can be used for restaging. Treatment approaches involving induction therapy and resection of downstaged patients should not be based on the assumption that imaging tests can predict the status of the mediastinal nodes.
This article has been cited 5 time(s).
Lung cancer; Restaging; Pathologic; Induction; Therapy
© 2010International Association for the Study of Lung Cancer
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