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Property Location With a stay at D1 Hotel Patong, you'll be centrally located in Patong, convenient to Jungceylon Shopping Center and Patong Beach. This guesthouse is within close proximity of Bangla Boxing Stadium and Banana Walk.Rooms Make yourself at home in one of the 16 air-conditioned rooms featuring refrigerators and LCD televisions. Rooms have private balconies. Complimentary wireless Internet access keeps you connected, and cable programming is available for your entertainment. Private bathrooms with showers feature complimentary toiletries and hair dryers.Amenities Make use of convenient amenities, which include complimentary wireless Internet access and concierge services.Dining Satisfy your appetite at a coffee shop/café serving guests of D1 Hotel Patong.Business, Other Amenities Featured amenities include express check-in, express check-out, and dry cleaning/laundry services. Free self parking is available onsite.
- Обслуживание гостей 24 часа
- Услуги консьержа
- Прачечная


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The Banzai Run is a scenic 32k that celebrates Vancouver's running splendour. Vancouver Ichiban, ya!!
Burn'aby Burn 2.0
Burn Baby Burn… Broadway's super hot Central Valley Greenway 29k route to Burnaby is back, baby!
Cambie Kumbaya 19k
Come on people now. Smile on your brother. Everybody get together and run the Kumbaya 19k right now. Oh, wait, I think that's the wrong song.
Dimitri's Tugboat 10k
Test your sea legs on Dimitri's Tugboat, a 10k loop in honour of Cambie's fastest ship designer, Dimitri Mylonas.
Sassy Sassy Sunday 23k
A sassy 23k jaunt from the Cambie Running Room to the trails of Pacific Spirit Park.
Prospect Point Figure-8 19k
Who doesn't love a stroll in the park and long walks on the beach?

subset: commoncrawl


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Hitched 2.0: We Already Got Fake Married
Andy's already seen me in a wedding dress. While he was in a tux. And we posed for happy-couple-getting-married pictures. Let me back up. I didn't want him to see me in a wedding dress—mine or otherwise—until that whole walking-down-the-aisle moment. When planning our venues and basic wedding day set-up, we went to great pains to try to figure out a timeline that would allow us to do pictures between the ceremony and reception, while not making our guests have to entertain themselves, all dressed up and in the summer heat, for three hours. It wasn't about superstition. I didn't think that Andy seeing me in my dress before the ceremony would result in bad luck or a terrible marriage. It was more about the "wow" factor. I want to preserve the gravity and the emotion of that ceremonial moment. I want his breath to be taken away by the sight of me in that white dress. I want him to cry, dammit. And in my mind, if he sees me for the first time during some contrived "first look," by the time we get to the vows, it'll be old news. He'll already be used to the sight; he'll already have had that "Oh my God, this is it; I get to marry this amazing-beautiful-smart girl today" (modesty) realization. No breath will be taken away. No tears will come.
But, alas, my dream moment just wasn't in the cards. As hard as we tried, we could not figure out a scenario that included a photo break between the ceremony and reception that wasn't a logistical nightmare for ourselves or our guests. So, we caved. We're doing our ceremony and reception in the same place, with no time in between, so we're doing our photos before the ceremony. I've had plenty of time to come to terms with this, and I really am fine with it. It'll be way more pleasant for our guests, we'll be able to attend the cocktail hour ourselves, and it allows us to follow Jewish tradition and sign our Ketubah before saying our vows. (I'm Jewish; he's not, but we're incorporating some religious elements, and that's one of them.)
But just as I was starting to not only become comfortable, but get genuinely excited about this plan, a new unexpected hitch (ha, ha) came up: Andy and I were asked to act as models for a styled wedding photo shoot by a local photographer and event designer. We said yes right away—I mean, come on, don't we all want to embrace our inner Cara Delevignes at some point? It wasn't until later on, as details started to filter in, that I realized, "Wait a minute: I'm going to be wearing a wedding dress for this. In front of Andy."
I'll be honest, I panicked a little bit. I was so excited to do the photo shoot, but legitimately nervous about having a wedding dress moment with my fiancé before our actual wedding. The paranoid thoughts flooded my mind. The same fear I had about taking photos before our real ceremony returned. And then there were new ones. "What if he likes the photo shoot dress better than my real dress?" "What if this takes away from his emotion not just during our ceremony, but during our first look, too?" "What if he has zero emotional reaction during the photo shoot? Do I want him to have one?" I expressed most of these fears to Andy, and he assured me I was being ridiculous and this experience would make our actual wedding no less special. I was appeased … kind of.
I went into the shoot with a mixed feelings and nerves. I was thrilled to participate, get out of my comfort zone, and work with some new people. And then I saw the dress I'd be wearing. It was gorgeous, and the fear that Andy would like it more than my own dress popped right back up. "Whatever," I told myself. "This isn't our actual wedding, it'll be fun, and I'm still obsessed with my own dress, so he will be too, by proxy." I slipped the dress on by myself, in the bathroom of the venue, and returned "on set" to little fanfare. Andy was being poked and prodded by the stylist when he saw me—in the same moment everyone else there saw me—and all we could do when we met eyes was laugh. There we were, all dressed up to get married, him seeing me in a big white dress, with a fake, half-ceremony-half-reception set up and a handful of other people buzzing about working on their tasks for the shoot.
We proceeded to pose for plenty of lovey-dovey, romantic, wedding-like photos, and the more shots that were taken, the more normal the whole thing became. There were a few moments when I thought I may have spotted a twinkle of emotion in Andy's eyes, but I can't be totally sure. And you know what? It doesn't matter. It may seem silly that I've been so concerned about keeping my "look" under wraps to build up to the biggest moment of our relationship; and to be so fixated on making sure that moment is romantic, emotional, and momentous. But that's what I want, and what I hope for. What I've realized through all of my fretting, though, is that no photo shoot, or dress, or styled moment will take away from that. It'll be an extraordinary moment because it is extraordinary. After five years together, we're saying vows in front of our friends and family and tying the damn knot. And that's what will cause the tears to come.
Plus, the hands-on photo practice can only help us look our best for the real deal. And the pictures did turn out pretty great. Maybe we'll sneak a few into our wedding album.
Photo by Jennifer Claire Photography
Hitched, our weekly column about getting married, is back! This time around, we'll be walking down the aisle (well, in spirit) with writer Emma Sarran, who will be sharing her thoughts on long engagements, the institution of matrimony and that godforsaken wedding industrial complex every Thursday. Follow her on Twitter!


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The IEU represents Directors of Studies, teachers and support staff in the English Language Intensive Courses for Overseas Students industry.
In 1989 the IEU established the first award in Australia for the ELICOS industry and has achieved regular wage increases ever since.
The Union is constantly involved in negotiations to improve wages and conditions for teachers at the state level and for teachers and support staff at individual colleges.
Officers from the Union are available to advise you on your entitlements and working conditions either over the phone or by visiting your workplace.
In addition, every issue of Newsmonth contains an editorial by ELICOS Organiser Kendall Warren.
Do you have something to say about an issue impacting on your industry or do you want to know your rights? Email ELICOS Organiser Kendall Warren at email@example.com.
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Action in Catholic systemic schools
Support staff and teachers are voting for action to support their Union in negotiations with the Catholic employers.19 Jul 2017
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Learn how to make sustainability a success in your school or centre – participate in a range of stimulating workshops.12 Jul 2017
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This year's IEU Early Childhood Conference is all about challenging the things we know are wrong.12 Jul 2017


text:
Mother's heartbreak as A-level student dies two weeks after taking abortion drugs
The boyfriend: Naeem Muzaffar spent days in hospital with his girlfriend Manon Jones
A 'bubbly' A-level student died when an abortion went tragically wrong.
Manon Jones, 18, was given two powerful drugs to terminate the six-week pregnancy.
After her condition deteriorated she went to hospital, but doctors were distracted by another emergency and delayed giving her a life-saving blood transfusion for more than four hours.
Her mother told an inquest of the 'worst hours of my life' before medical staff turned off her life-support.
Llywela Jones said the family and her daughter's boyfriend spent days with her in intensive care. 'I gradually realised that Manon had already left us and was not likely to recover,' she said.
'We washed her beautiful dark hair and dressed her in a party dress and gave her a little makeup and jewellery and perfume so that she left the ward looking her best, as she would have wanted.
'To have such a beautiful and precious daughter end her life in such a way, it seemed such an unnecessary tragedy, a mother's worst fears come true.'
In Britain, around one-third of the 131,000 terminations carried out before ten weeks use medical rather than surgical methods, and the figure is rising.
The Government has given the go-ahead for more early abortions using pills at family planning centres, cottage hospitals and even large GP surgeries.
The inquest heard that Miss Jones was a Christian and a keen member of the local church youth club who sang with her family at their chapel in north Wales.
She met Naeem Muzaffar at City of Bristol College where she went to study for three A-levels, and became 'besotted' with him. Her mother said that her daughter opted for an abortion to avoid conflict with her Muslim boyfriend's family.
Mrs Jones told the hearing at Flax Bourton, near Bath: 'Manon found it very hard to make a decision to terminate the pregnancy, she wanted to keep the child but there were difficult circumstances which she had to consider with her boyfriend's family and their Muslim religion.'
Student Manon Jones died at Bristol's Southmead Hospital
The teenager took the first dose of medication to terminate the pregnancy on June 10, 2005, and the second two days later.
Her mother said: 'She was scared and I tried to reassure her. It was a very emotional experience for us both.'
After the termination Miss Jones complained of light-headednessand heavy bleeding. On June 15 her boyfriend took her back to Southmead Hospital, Bristol, for a scan, which she was told was 'normal.'
Four days later she left for a holiday abroad with friends but cut it short because she felt so unwell, and on June 23 she returned to Bristol, where she admitted herself to Southmead Hospital.
When Mrs Jones arrived her daughter was already in intensive care, following seizures and cardiac arrest.
Doctors took the decision to turn off Miss Jones' life support on June 27, 2005.
Scroll down for more
Dr Hugh White told the inquest a post-mortem examination revealed the student died of hypovolemia, an abnormal decrease in blood volume, and shock caused by 'retained productsof conception' - the embryo.
Dr Lucy Jackson, in obstetrics and gynaecology, treated Miss Jones when she returned to hospital and said she was talking coherently and bleeding was minimal.
She said an initial blood test did not immediately lead her to consider hypovolemia. 'It did not fit the clinical picture,' she said. 'I was surprised by the results of the test.'
Following a second blood test, Dr Jackson decided a blood transfusion was immediately required but that Miss Jones was stable enough to 'wait for the blood to arrive'.
But another emergency case during an 'extremely busy' night took the doctor away and the teenager's care was compromised.
Fighting back tears, Dr Jackson said: 'If we hadn't been so busy, particularly with the other emergency, we would have had more time and things could have been different.'
Giving an expert opinion on the case, Dr Richard Porter, an obstetrician at the Royal United Hospital in Bath, criticised staff at the Bristol hospital.
He said it was 'wholly inadequate' to leave Miss Jones waiting more than four hours for a transfusion.'
But, the doctor added, it was 'hard not to conclude' that Miss Jones would have survived had she not gone on holiday and attended hospital earlier.
Avon deputy coroner Brian Whitehouse, recording a narrative verdict, described Miss Jones's death as 'the saddest case I have had to deal with in 40 years'.
He said he had 'concerns' about the medical evidence and said junior doctors who treated Miss Jones when she admitted herself to hospital should have sought 'more experienced' staff for assistance.
But he said: 'In spite of these concerns, I find in these particular circumstances there was no failure on the part of the NHS to provide basic medical care.'
Miss Jones's mother and father Dewi Jones, who are divorced, declined to comment as they left the inquest.
A statement from North Bristol NHS Trust said it accepted the coroner's findings and offered 'sincere condolences' to Miss Jones' family.
It said: 'This was a unique case and since it happened, we have introduced further measures to ensure that seriously deteriorating patients are identified early and prompt action is taken.'
Last night the family of Miss Jones' boyfriend appeared to know little of the couple's relationship.
Naeem Muzaffar, 20, refused to comment, but at the family home in Bristol his older brother Taz said: 'This is the first I have heard about it.
'He is a good kid and everything seemed to be fine. He made a mistake.'
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January 13th, 2016
Episode 1452 of 5181 episodes
Christmas is a time for love and affection, and what better way to to show it than with a hug? That is why NIVEA and Leo Burnett Madrid carried out an experiment which, thanks to technology, will allow families who spend those days apart to hug each other as if they were together. VIEW OUTDOOR
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text: Lawyer: "Cut Noise In Workplace To Avoid Deafness" Law Firm Irwin Mitchell Supporting HSE 'Buy Quiet' Campaign 01.06.2010 An industrial illness specialist from law firm Irwin Mitchell in Sheffield is supporting a campaign encouraging manufacturers and businesses to adopt quieter workplaces to reduce the number of people suffering from industrial deafness. The Health and Safety Executive (HSE) has recently launched its 'Buy Quiet' initiative, to show companies how they can protect their employees from noise related illnesses. 170,000 people in the UK suffer deafness, tinnitus or other ear conditions as a result of exposure to excessive noise at work. Mark Allen, Industrial Illness specialist at Irwin Mitchell in Sheffield, said: "We welcome this initiative and hope it will raise awareness of the dangers of working in loud environments. Manufacturing companies are naturally the most common to suffer from problems due to loud machinery but other businesses are affected too. "We deal with people everyday whose lives have been massively affected by illnesses such as industrial deafness and tinnitus, and have handled hundreds of cases where simple, cheap measures could have reduced noise to a safe level. "Reducing noise at the source is one of the best ways to reduce the noise exposure of employees. It also helps make the workplace a less stressful environment and can eliminate the need for protective clothing such as ear muffs and plugs. "Noise-induced deafness can take a number of years to develop, and employers must understand that they have a responsibility to reduce noise in the workplace. Simple things such as buying quieter machinery and equipment can have a huge impact later in life." If you or a loved one has suffered from hearing damage such as acoustic shock, tinnitus, and noise-induced hearing loss caused by conditions at work our solicitors could help you claim compensation. See our Industrial Disease Claims page for more information. Related articles 17.08.2017Settlement For Family Of Elderly Man Who Died After Being Hit By Car As He Crossed The Road 16.08.2017Irwin Mitchell Private Wealth Reacts To Retired Senior Judge's Comments On Powers Of Attorney 16.08.2017Family Of Cancer Victim 'Hit By Treatment Delays' To Receive Settlement Following Legal Action 16.08.2017NHS Figures Show Rise In Number Of Birth Injury Cases 14.08.2017Metal On Metal Hip Replacement Patients "Slipping Through The Net When It Comes To Aftercare," Experts Warn


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Holiday events, from light shows to menorahs
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A vote of the members of Rolling Green Country Club on Rand Road and Euclid Avenue in Arlington Hts. on whether to sell the 100-year-old famed golf course and its various facilities will be taken on Saturday, Dec. 20.
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text: Contents[show] Henry Hugglemonster as Sportacus Summer Hugglemonster as Stephanie Randall (from Monsters, Inc) as Robbie Rotten Mike Wazowski (from Monsters, Inc) as Ziggy Denzell Dugglemonster as Stingy Gertie as Trixie Cobby Hugglemonster as Pixel Daddo Hugglemonster as Mayor Millford Meanswell Momma Hugglemonster as Bessie Buzybody Retrieved from "http://scratchpad.wikia.com/wiki/Henry_Hugglemonster/LazyTown?oldid=2149759" Ad blocker interference detected! Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers Wikia is not accessible if you've made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected. Categories: Henry Hugglemonster LazyTown Henry Hugglemonster parodies LazyTown parodies


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Freestyle Skateboarding Tricks: Flat Ground, Rails and Transitions. Sean D'Arcy and Phillip Marshall
by Sean D'Arcy
it was amazing · Rating details · 1 Rating · 0 Reviews
Skateboarding is incredibly popular, and the streets are filled with children and teenagers trying to impress their friends with their skateboarding skills. 'Freestyle Skateboarding Tricks' is illustrated with hundreds of colour photos of skateboarders demonstrating their amazing moves.
Paperback, 120 pages
Published October 1st 2010 by A&C Black
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Artist's description:
This is a stag who has been through a few seasons. He's earnt his place in the herd and is ready to defend it.
Painted in waterercolour and ink on heavyweight watercolour paper, this painting was a lot of fun to paint and draw.
It will come in a mount and will be ready to drop into a 50x50cm frame, or I can supply it framed in an oak or white frame. Just email me to discuss options.
Materials used:
Ink and artist quality pigments on Bockingford paper
Old Salty
Watercolour by Liz Chaderton
$257.49 Sold
- Watercolour on Paper
- One of a kind artwork
- Size: 15.75 x 15.75 in (unframed) / 13.78 x 13.78 in (actual image size)
- This artwork is sold unframed
- Signed on the front
- Style: Expressive and gestural
- Subject: Animals and birds
More by Liz Chaderton View all
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Fishers heron
Mixed Media paintingby Liz Chaderton
Tiny tawny
Mixed Media paintingby Liz Chaderton
On the track of a hare
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Westie pup
Watercolourby Liz Chaderton


text:
American Horror Story is such a disappointment. I had to force my eyes open to watch the entire first season. Only the last two episodes where any fun with the big reveal. Gross (bowl of brains scene), but hardly frightening. I just don't get why schlocky, but entertaining Harper's Island got panned and this was so rated (possibly because of better marketing, I'm guessing, I mean look at the poster!) About as pants-wetting as a spilled cup of tepid tea. As usual good acting, let down by crap everything else. Award: two out of five chainsaws, because of the acting and the last two episodes. Why can't they make something really horrible that will plague us with nightmares? Blame insomnia for this cranky review.
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"There's Ed, Op Ed, Op, and then there's this blog."—The Captain!
"Well done son, keep it up!"—The Captain's Mum
"People will think you're a nerd."—The Captain's Dad
"I hate this!"—vox populi
"I don't care."—The Captain!
"Who the Hell is the Captain anyway?"—Roy Mathur
"The Captain is not an adventurer, rock star and supervillain with a penchant for G&Ts, C7H10N4O2 and insanely loud music. His exploits do not usually involve arriving just in time to save the multiverse (or thoroughly bugger it up) in a Vimana shaped like a wardrobe. And, contrary to the wanted posters, he is certainly not a multi-tentacled cyborg from the 27th dimension."—Anonymous
"Finally an honest review…great!"—Shayne T. Wright
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Commercial/Industrial/Business - Clay City, KY
JUST REDUCED ! ! Turn-key pottery business includes store, converted barn that houses work areas, kiln and various equipment associated with making pottery, and over 10,000 molds. This deal also includes a 4 bay garage and a bonus 2-story building that has endless potential as additional business space. Owner also wishes to offer a 3 bedroom, 1 bath home located at 1738 Black Creek as part of this deal. Check MLS 1709282 for details on the house. HOUSE is priced separately and HAS ALSO BEEN REDUCED ! ! ! You do not have to buy the house to buy the business, but the house will not be sold until the business is sold.
Would you like more information regarding this property?
Please call (859) 744-3637.
Data Provided by:
Lexington Bluegrass Association of Realtors


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Two swallows stand on a wire in front of my house.
Uploaded: Aug 20, 2015
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Tags: bird, swallow, on a wire, in front of, stand on a wire, two swallows
All the way up
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Bird sitting on a log in front of the forest
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In front of window with this girl
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Trees in line, 90 degree photo, nice in front of sun!
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Bird house on the tree in front of my house
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the pier in Binz, on the island of Rügen...... (Germany)
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Cut it out!
The Full House home is available for rent on Craigslist — and what could be better than potentially living in the iconic sitcom's house 21 years after the show went off the air?
The Full House home on the show. (Photo Credit: R/R)
Although TheOpenHouse.com says the house was sold for $4 million earlier this year, it's now available to rent for $13,950 a month.
MORE: Lori Loughlin Reveals Which Full House Costars She's Closest With Today — Find Out Who She Chose!
The exterior of the San Francisco house represented the Tanner home on the hit show from 1987 until 1995. Too bad renting the property today sadly won't include former TV residents John Stamos, Dave Coulier, Candace Cameron Bure and the rest of the crew!
Click through the gallery below to see the cast of Full House then and now!
John has appeared in numerous television series including ER and Necessary Roughness. He also starred in the FOX sitcom Grandfathered with Josh Peck.
Getty Images


text: Amazing Kerala Tour Packages At Joy Travels - Other Classified Ads in New Delhi Find best Kerala vacation trip package at the best prices with amazing deals offers by Joy Travels. You can book online Kerala vacation packages from website joy-travels.com & joytravels.co.in. Last Updated June 22, 2017 Category Other Location 8, Regal Building, Parliament Street, Connaught Place New Delhi, Delhi 110001, New Delhi, India Show Map Website www.joy-travels.com/indian-holidays/kerala/ More Info Find Other in New Delhi 07 Send Message Share This Classified With Your Social Networks Subscribe to this RSS Feed Keywords Location: Category: Report Ad Member Spotlight Benny Tao Micargi Bicycles Micargi Bicycles View Profile | Browse Other Members Business Spotlight OffSureIT - Software Solutions Http://www.offsureit.com/ View Profile | Browse Other Businesses


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"Gloriously scattershot punk & clever songwriting, served with a sneer" CMJ Music Marathon 2009
"Finally someone worthy of a Buzzcocks comparison, really good songs" — Steve Diggle (The Buzzcocks)
"Lyrical Genius" Roman Jugg (the damned)
Andy J. Gallagher first hit London's intimate music venues with punky avant-Britpop band The Shopkeeper Appeared. Fame beckoned with airtime plays on BBC Radio One and gigs with global superstars Radiohead, but Gallagher, ever-hungry for new creative experiences, headed off to explore the world's music scenes collaborating with a host of characters, including Sparks' guitarist Adrian Fisher.
This global odyssey triggered a torrent of creativity and Gallagher's most inspired writing to date. When Roman Jugg, ex-member of seminal punk band The Damned, heard Gallagher's new demos, he declared Gallagher a "lyrical genius" and insisted on producing his debut album, "Helicopter Dolphin Submarine." Charged with raw, living vigour, an exuberance of personality and peopled by real world characters, Andy J. Gallagher's debut LP has perfectly pinned down the zeitgeist of modern urbanites living in a wayward generation.
Wearing his influences from David Bowie to The Velvet Underground, Elvis Presley, The Kinks and The Ramones to name but a few, firmly on his sleeve, Gallagher's dazzling lyrics and sparkling songs have been showered in praise by the media and legendary musicians alike.
More quality from @andrearadri https://t.co/00npYC3ReT
Now that is a statement. #lufc https://t.co/WpzPD7CCcU
RT @nightanddaycafe: > @MAH_Gigs present @StellaProduct @andyjgallagher #Tuareg // Thu 28 Sept // tix @WeGotTickets // https://t.co/OnpqlbLrfF
RT @brushfest: weather for sunday 27th, warm 21 degrees,sunny and dry all day and evening! perfect.
RT @brushfest: Next week Brushfest will be in full swing! Don't miss out on savings by buying your tickets @ https://t.co/LQpeVdQMrx in advance. W
RT @Indie365Radio: #NP Andy J Gallagher @andyjgallagher @plugginbaby @emma_scott - Because We Are on @Indie365Radio
RT @BBCMOTD: Trevor Sinclair is disappointed in the tweet Chris Wood has sent today #LUFC https://t.co/YxYG6Tgp8G
RT @brushfest: Did you see footage of @DepecheModeBand at Brushfest last year? https://t.co/MqrN0QmQI6
Billy Ocean - Red Light Spells Danger (Audio) https://t.co/QB2ZgXvRfm


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Kate Spade announced it's exploring "strategic alternatives" in its earnings report today. The statement confirms industry chatter which has speculated the firm is looking for a buyer—possibly from competitors like Michael Kors or Coach.
Shares at the company were up by 6.8% in premarket trading on the news.
Takeover talk began in November when Caerus Investors, an investor in the firm, issued a letter to the board, asking it to consider selling the company.
The company said it's working with Perella Weinberg Partners as its financial advisor and Paul, Weiss, Rifkind, Wharton & Garrison to assess alternatives, though no further details were or will be provided as possible deals are in the works.
"Our solid fourth quarter and fiscal year performance demonstrate the strength of our differentiated business model, as we continued to gain market share and deliver strong growth despite a challenging retail environment. In 2016, we further strengthened our handbag portfolio, introduced new categories to our casual ready-to-wear classifications, and thoughtfully expanded our global store base, opening 52 net new owned and partner-operated stores," said Craig A. Leavitt, chief executive officer of Kate Spade & Company. "At the same time, we remain committed to maximizing value and are exploring strategic alternatives that are in the best interests of our company and shareholders."
Kate Spade reported a net sales increase of 9.8% to $471 million for the fourth quarter, ended Dec. 31, 2016. Comp stores sales, including e-commerce, increased by 9.3%.
The company's North American net sales were up 9.5% to $407 million compared to the same period in 2015, and international business reached $59 million, an increase of 12.4%.
Year-on-year net sales increased by 11.2% to $1.38 billion.
Net income for the quarter reached $86 million and $154 million for the year.
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Under Armour's CEO is leaving Trump's manufacturing council, plus Twisted X launched footwear made from recycled plastic bottles.Read more
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President Trump has taken a first step toward calling out China for alleged intellectual property rights violations—which could also end up being the first shot in an all out trade war.Read more
Financial Roundup: Foot Traffic Drives TJX While Conversions Fuel Coach
TJX continues to defy the retail apocalypse, luring shoppers and boosting sales with its treasure hunt format, while Coach, Inc., is reinvigorating its consumer base by controlling its distribution and developing product that speaks to them.Read more
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text: I found myself there today after lunch when I was craving something sweet and needed it quickly. I guess I should be careful what I wish for. The frosted fudge bar I just bit into is tooth-achingly sweet, no hint of anything else but sweetness to cut the sweet. Blah. Is there anything there worth eating?


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Saturday morning, time for breakfast at the Monument Cafe with my father, our friend Marilyn, my son John Paul and my brother Ed.
The food is good (I get eggs, ham, hash browns and bread), and the coffee (from Cianfrani's Coffee Shop) is excellent. But mostly it's the company I enjoy the most.
I'll get to see Jack Starky, a retired pharmacist. He always seems to be genuinely happy to see me, and I know I really enjoy seeing him and catching up on his doings for the past week. And on rare occasions Cindy and her son, Chapman, will come in for breakfast. I get a kick out of seeing those 2. Cindy tells me that Chapman (he's 4 now) gets so excited about coming and getting his pancakes and seeing Mr. Starky and Mr. Paul. In the almost 3 years that I've seen them come in I've only heard Chapman speak one time. And I think that's because he didn't know I was listening.
Breakfast was alright, but they forgot our toast and the waitress was scarce. For the most part this doesn't happen but occasionally it does.
Got brother Ed to the airport, he will be on his way to Ossinning via Houston and Newark. It was good to see him. Now it's my turn to go to NY and visit him.
Saturday night, and it's time for the biergarten at the Walburg restaurant (walburgrestaurant.com). It's time to leave so I'll have to post about it later.
Have a good and safe Saturday everyone.
a wider berth... - Only took an hour this morning to chop my road wide enough to get past the bad spot. Tune in tomorrow night for the video. Another big storm came throug...
18 hours ago


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Investigators claim to have enough evidence to prove Serebrennikov guilty of fraudRussian Politics & Diplomacy August 22, 21:35
Washington tries to use events in Khan Shaykhun to justify its strike on Syria — MoscowRussian Politics & Diplomacy August 22, 21:31
Egypt to receive 15 Russian 'Alligator' helicopters in 2017Military & Defense August 22, 19:57
Christophe de Margerie LNG tanker covers Northern Sea Route in record 6.5 daysBusiness & Economy August 22, 19:32
Kirill Serebrennikov dismisses fraud accusations as absurdSociety & Culture August 22, 19:18
From climate to transport: Arctic projects of Russian and Japanese scientistsBusiness & Economy August 22, 19:10
Trump's Afghan strategy implies attempts to address issues by military means — analystWorld August 22, 19:00
Russian defense chief tests new neural network-based combat moduleMilitary & Defense August 22, 18:41
Poroshenko seeks to discuss alleged nuclear missile supplies to North Korea in UNWorld August 22, 18:31
{{element.title}}{{element.heading}} {{element.date}}
KIEV, May 12. /TASS/. Ukrainian authorities instead of having effective economic and social reforms are begging for help from the International Monetary Fund (IMF), the Opposition Bloc faction in the country's Verkhovna Rada (parliament) said in a statement presented on Tuesday.
"The authorities excuse their inability for reforms by the war, which now has become clear even to the international counterparts and Ukraine's creditors as they say they are not happy with the speed of reforms in the country."
The government, which is "sick with begging for loans and borrowings, is humiliating all hard-working Ukrainians, who are happy to work for their country."
The opposition says the authorities should do everything to stop the hostilities in Ukraine's south-east, to begin realistic reforms, to cancel raised tariffs and to offer social protection for the retirees and poor.
A mission of IMF commenced work in Ukraine on Tuesday, a representative of Ukraine's Finance Ministry told TASS.
"The mission's planned work started today in Ukraine. It will last for around 2-3 weeks, if needed the mission's work period may be extended," the representative said.
In March this year, Ukraine received the first IMF tranche worth $5 bln within the framework of the 4-year financial aid plan worth a total of $17.5 bln.
The new IMF program is the main component part of the international anti-crisis aid package provided to Ukraine, estimated at around $40 bln in the next 4 years. Within the package, remission of around $15 bln worth of Ukraine's debts is also stipulated.


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Baltimore, Maryland
Don't bother to ask, dear reader. And don't bother to inquire about the cost either. The Bank of Japan is using the QE trick, buying $75 billion worth of bonds each month. At this rate, the central bank will have a balance sheet three times larger than the Fed (as a proportion of the economy) by March of next year.
The authorities are also directly intervening to buy stocks. Why depend on bankers and speculators to juice up your stock market? Do it yourself! According to the report in the Telegraph, the Bank of Japan buys about $200 million worth of exchange traded funds whenever it sees the stock market index stumbling.
In Japan, as in the US, bond buying pushes down interest rates. Low interest rates encourage borrowing...and bubbles...while simultaneously trimming real investment and real output. Result: consumer prices rise.
Getting the real interest rate below zero, in a deflationary economy, is an achievement of its own. No matter how close to zero you go, you still have the price level below you. But give the bonsai prime minister credit. When we last looked the real interest rate was about MINUS 0.8% on the 10-year government bond.
The fiscal arrow too has come to be a pain in the side of the economy. For a quarter of a century, Japan's strategy has been to replace the credit going to households and businesses with credit going to the government. In America, people spent money they didn't have on things they didn't need. In Japan, the government did it.
And now it is doing more of it. This is great news for the cronies and zombies. The Japanese feds borrow the savings of the people and give it to the insiders. The country gets more over-priced infrastructure (vandalism in concrete). The insiders get more money. And the old folks' savings disappear.
The third arrow was the last to be sent off. Where it was going no one quite knew. But it pierced the flesh of Japan's women.
"Since I hoisted the banter of 'womenonomics," in Japan, 530,000 women have entered the labor market."
Is that something to be proud of? Or ashamed of? Women who had been happily tending their families and their homes are now bussing and toting so that "economic growth can be sustained in Japan with its aging population and its falling birthrate."
Putting women in the workaday world may actually depress the birthrate further. We don't know. That's why we're so impressed by dynamic leaders like Mr. Abe. He seems to know everything. He'll help these working women by getting jobs by allowing them to hire foreign housekeepers.
"Diversity" is the key word in the labor market, he says. This is news. We thought 'jobs' or 'wages' were pretty important. But no. Abe says "inflexible labor systems will be reviewed to enable all people, including women, youths, older workers, and people with special talents, to fully display their capabilities."
Way to go, Abe! Take their savings. Then, put them to work!
Bill Bonner is the President & Founder of Agora Inc, an international publisher of financial and special interest books and newsletters.
Equitymaster requests your view! Post a comment on "What's happening in Japan?". Click here!
Equitymaster requests your view! Post a comment on "What's happening in Japan?". Click here!


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Cancer-related fatigue (CRF) is a symptom frequently experienced by survivors regardless of tumor type or its treatment.1 This report is focused on CRF among the increasing number of breast cancer survivors, which currently number >2.5 M in the United States. CRF is described as a clinical entity characterized by tiredness to exhaustion not precipitated by activity or, if after activity, out of proportion to the level of exertion. It is not relieved by rest and may be worsened with rest. CRF may result from the tumor itself, antedating its treatment. Experts in the field2, 3 have outlined the benefits of using a case-definition approach to CRF. This approach suggests 4 criteria to establish the diagnosis, including: 1) a period of 2 weeks or longer within the preceding month during which significant CRF or diminished energy was experienced each day or almost every day along with additional CRF-related symptoms; 2) the experience of CRF results in significant distress or impairment of function; 3) the presence of clinical evidence suggesting that CRF is a consequence of cancer or cancer therapy; and 4) CRF is not primarily a consequence of a concurrent psychiatric condition, such as major depression.3 Thought leaders recently have suggested that clinicians agree on the definition adopted by the National Comprehensive Cancer Network (NCCN)4 and use the above criteria for assessing clinically significant CRF.5 There is value in using a consistent definition and methods to determine cases of moderate-to-severe CRF and its responsiveness to treatment.
CRF has been documented as the most distressing symptom reported by cancer patients and is more disruptive than pain to normal routines and quality of life (QOL).6 de Jong et al7 reported that 58% to 94% of patients with breast cancer experience CRF during treatment, and between 56% and 95% have CRF after they receive adjuvant chemotherapy. Its overall prevalence is 48%, although it is higher in certain tumors (eg, pancreatic, breast, lymphoma) and during treatment. This is true whether the treatment consists of single or combined regimens, including surgery, chemotherapy, radiation, and/or biologic agents. Symptom onset may be contemporaneous or remote from treatment. CRF is frequently persistent and does not resolve with tumor control or treatment cessation. Cancer survivors, defined here as anyone who has been diagnosed with cancer from the time of diagnosis until death,8, 9 frequently report that they never return to their prediagnosis energy level, and this diminishes their QOL.10
Contributing Factors to Cancer-Related Fatigue
Effective treatment begins by identifying the factors that contribute to this debilitating symptom. Research supports CRF as a multifactorial construct influenced by numerous biopsychosocial factors. Possible causal factors include physical conditions, affective and cognitive states, and distress or spiritual suffering.11 The work of several investigators7, 11 points to the affective dimension as a major contributor; however, affective state does not account for most of the variance among those who report higher CRF.
Investigators have established an important role for proinflammatory cytokines as potential contributors to CRF. Elevated cytokines are among several important findings in fatigue-promoting medical conditions.12, 13 Interleukin-1 receptor antagonists, soluble tumor necrosis factor receptor type II, and neopterin levels were significantly higher in a cohort of fatigued breast cancer survivors compared with the levels in nonfatigued survivors 5 years after diagnosis.14, 15 One hypothesis is that CRF may be the final common pathway of several contributing systems, including the central nervous system, immunoregulatory pathways, and the neuromusculoskeletal and cardiopulmonary systems. Current thinking suggests that both the physiological and immunologic systems, which control inflammatory pathways, and the affective components, which implicate 5-OH tryptamine and catecholamines and regulate the central nervous system, are involved in CRF.16
Other contributors to CRF are metabolic in nature. Data suggest that CRF may result from abnormalities of energy production and use that favor tumor growth.17 CRF, thus, may reflect disordered mitochondrial biogenesis, which upsets the balance between aerobic and anaerobic metabolism. Muscle tissue prefers oxidative phosphorylation as an energy source. However, researchers have observed that tumor cells seem to have an advantage when there is a high rate of conversion of glucose to lactate, favoring the glycolytic pathway.18, 19 This theory would predict the same inadequate production of adenosine triphosphate from oxidative phosphorylation that has been associated with a favorable environment for malignancy and may simultaneously deprive the body of the energy production needed to maintain muscular and neurocognitive function.20 Mitochondria are critical for energy production, which is essential for protein synthesis. Abnormalities in energy generation are associated with diminution of muscle biosynthesis, such as in aging muscle (sarcopenia).21 Muscle is a rich source of mitochondria, and abnormalities have an impact on cardiac performance. Deficits, which may or may not respond to training, are sensitive to neuromuscular measures of skeletal muscle strength and endurance.22
This theory is supported by observations that either resistance training or aerobic exercise stimulates mitochondrial biogenesis.23-26 Aerobic exercise is an effective strategy for treating CRF and may act through several pathways, including decrease in serum proinflammatory cytokines,27 mobilization of visceral fat, and/or increased insulin sensitivity and glucose uptake.28 Exercise is of specific benefit to women with breast cancer because of the adverse associations between obesity and breast cancer29, 30 and the recurrence and mortality from breast cancer associated with obesity.29, 31 Physical activity reportedly helps regulate sleep, mood,32 and diurnal variation of cortisol.33
Another important contributor to bioenergetics pertains to insulin sensitivity. CRF may be associated with abnormalities of glucose uptake by muscle essential for normal, efficient function. Those with relative insulin resistance have abnormalities of glucose uptake by muscle and increased body fat.34 These abnormalities may be associated with CRF and possibly may be treated with hypoglycemics or agents to increase insulin sensitivity.
On a functional level, CRF has been associated with sleep disturbances.35, 36 Other characteristics of the clinically fatigued breast cancer survivor include: younger age, a body mass index >25 kg/m2, a higher number of positive lymph nodes, an increase in limb volume, an increased in the white blood cell count over baseline, and a low level of physical activity and physical function.37 Some of these factors are remediable. Early intervention for lymphedema may prevent CRF. Increased levels of moderate and strenuous activity may mitigate fatigue through various critical metabolic and inflammatory pathways, including proinflammatory cytokines,27 mobilization of visceral fat, and increased insulin sensitivity and glucose uptake.28
Common problems
Many problems are commonly experienced by breast cancer survivors and may be associated with CRF.38 The number, type, and incidence of problems may vary by stage of disease, time since diagnosis, treatment, and age. Problems associated with fatigue may be the result of the cancer itself, its treatments, and/or other comorbid conditions.39, 40 Problems, depending on the number and severity, may influence the CRF experience and overall QOL41 (see the articles by Demark-Wahnefried et al, Hayes et al, McNeely et al, Schmitz et al, Schmitz, Speck et al, Stubblefield et al, and Winters-Stone et al in this supplement42-48).
Two large samples of women with early stage breast cancer within 6 months of diagnosis (n = 1219)49 or approximately 7 months after undergoing primary surgery (n = 1372) were surveyed for symptoms and QOL.40 Both samples reported experiencing multiple symptoms, and many women reported that ≥3 symptoms had a negative impact on QOL. Over half the women in the first study reported the following 6 symptoms: systemic treatment side effects (87.7%), fatigue (81.7%), breast symptoms (72.1%), sleep disturbance (57.1%), arm symptoms (55.6%), and pain (50%). Findings were similar in the second sample; almost half of women reported that symptoms interfered with daily functioning or mood and at least 1 of the following symptoms: difficulty sleeping (61.2%), hot flashes (43%), nausea/vomiting (27.4%), vaginal dryness (25.7%), or arm problems (23.9%); fatigue was not included in that study.
Treatment side effects
Cancer treatments are associated with a variety of side effects. Surgery may contribute to pain, lymphedema, and altered upper quadrant function; radiation therapy may contribute to skin changes, pain, and lymphedema; chemotherapy may contribute to peripheral neuropathy and cognitive impairment; and hormone therapy may contribute to arthralgia and hot flashes. Depending on menopausal status and treatment, the most common symptoms from hormone therapy include hot flashes, vaginal dryness, and dyspareunia.50 Hot flashes have been associated with sleep disturbances and CRF and are commonly reported by women who are receiving aromatase inhibitors.51 Women who received both radiation and chemotherapy, compared with those who received radiation alone, were more likely to be fatigued up to 10 years after treatment.52 Later treatment side effects may include osteoporosis and cardiovascular disease. Medications used to manage many of the side effects also contribute to the fatigue experience.
Arm/upper quadrant symptoms
After undergoing breast cancer surgery, women may experience problems associated with CRF, including pain, range-of-motion limitations, lymphedema, and functional disability.53, 54 Women are at greater risk for these problems if they undergo axillary lymph node dissection, if they receive radiation to the axilla, if they have a higher body mass index, if they experience a postoperative infection, or if they develop a local recurrence. Upper-quadrant morbidity negatively impacts daytime functioning, activities, and QOL.55-60 Lymphedema in survivors has been linked to worse emotional well being and QOL.61
Sleep disturbances
Sleep problems affect most patients during chemotherapy.62, 63 Many breast cancer survivors experience disturbed sleep, and a subset meets the criteria for insomnia.64, 65 The problem may be pre-existing or may result from the cancer and its treatment. Hot flashes and pain affect sleep efficiency and quality and contribute to CRF and daytime dysfunction.66, 67 Sleep problems have been associated with CRF, depression, and poorer overall QOL.68, 69 Some of the effect of pain on CRF reportedly was mediated by sleep disturbance, but pain also had a direct effect on CRF.70
Psychological distress
Mood disturbances and fatigue frequently co-occur, and mood disturbance may amplify the perception of fatigue. Some breast cancer survivors have pre-existing fatigue that may accompany depression or anxiety, whereas others develop these mood disturbances after diagnosis. Among patients with newly diagnosed breast cancer (n = 236), 27% reported a previous depression, 11% currently met criteria for major depression, and 10% met criteria for post-traumatic stress syndrome.71 These diagnoses were associated with marked functional impairment compared with women who did not have a diagnosis of depression or post-traumatic stress disorder (PTSD). Most of the women with PTSD reported that their symptoms were from a combination of the breast cancer and a previous event. It is noteworthy that 56% of the women with major depression who were on antidepressants still met criteria for major depression.
Among another sample of 1083 women with breast cancer, 38% reported moderate-to-high anxiety, 22% had moderate-to-high depression, and 12% had PTSD not associated with time since diagnosis.72 Greater than 40% of these women had 1 psychological diagnosis, and 7.8% met criteria for all 3 diagnoses. A review of studies examining the prevalence of depression in breast cancer survivors indicated that >60% experienced mood disorders, and 13.5% met criteria for major depression. Fatigue almost universally accompanies these conditions.73
Comorbid conditions
Cancer does not occur in a vacuum. Chronic comorbid conditions, such as hypothyroidism, and related treatments may contribute to fatigue, especially in an aging population. One study that included >1500 patients reported that >66% of patients with cancer had at least 1 comorbid condition, and approximately 33% had ≥2 comorbid conditions.74 The most common comorbid conditions included hypertension, cardiovascular diseases, respiratory diseases, diabetes, cerebral-vascular diseases, and arthritis. The most frequent pattern of comorbidities in women, with incidence increasing with age, included hypertension with diabetes, other cardiovascular disease, and arthritis. Hypothyroidism is a frequent comorbidity in postmenopausal women.
Among 1800 postmenopausal breast cancer survivors, 93% had 1 or more comorbid conditions, and 43% had ≥4 comorbid conditions.75 Hypertension was the most common condition followed by arthritis, and aging was associated with a higher number of conditions. A history of 1 or more previous cancers was reported in 15% of these women. During the 30-month postdiagnosis period, 14.6% of patients died (51.3% of breast cancer, 17.1% of heart disease, and 8.4% of another cancer). Hypertension, heart disease, and diabetes were identified as the 3 most common comorbid conditions in 799 women when diagnosed with breast cancer.76 Hypertension predicted long-term fatigue in women with breast cancer up to 10 years after diagnosis.52
It is difficult to isolate the multiple contributors to fatigue in breast cancer survivors with comorbid conditions. It is important to obtain a thorough history of the diagnosis and treatment of comorbid conditions preoperatively and to review their management regularly, especially in older women. This population benefits from coordinated care between the oncology team and the primary care provider, and referrals to rehabilitation specialists should be made as needed.77-79
Describing important characteristics of CRF has posed significant practical and methodologic problems. First, the primary source of information comes from patients' self-reports, and what they mean by "fatigue" varies. Self-report is the cornerstone of assessing CRF but may represent only 1 approach to measuring the consequences and corollaries of this symptom. Self-reports of CRF, biologic measures, and physical and cognitive performance do not correlate well, perhaps because each measure is capturing different aspects of the phenomena of fatigue.80
Second, universal agreement is lacking about a conceptual framework for CRF, and this hinders progress in defining and measuring the phenomenon. One approach has been to postulate that there are 2 types of CRF: central and peripheral. Central fatigue is the failure to initiate and/or sustain attentional tasks and activities requiring self-motivation. Peripheral fatigue is a decline in physical performance resulting from inadequate cardiorespiratory, muscle-metabolic, and physiologic function. The value of these distinctions is that they potentially can be differentiated using a combination of patient-reported and clinician-reported measures. It has been demonstrated that central fatigue and peripheral fatigue are distinct and definable in objective terms.81 Each is associated with different biologic correlates and physical performance indicators and is described using different adjectives (eg, "I am exhausted all the time" vs "I get tired running"). Care in selecting fatigue measures will assist in providing a comprehensive evaluation. Good reviews of this literature are available.82-84
Health care providers do not routinely assess patients to determine causes of fatigue or prescribe effective treatments for it.85 Establishing a standard, reliable, and clinically feasible instrument to measure CRF will increase the likelihood that health care providers will use it. Collecting data in a systematic way is likely to assist in identifying correlates of, and possibly contributors to, CRF and may lead to the selection of effective interventions.
The NCCN guidelines for CRF recommend screening all patients at regular intervals.4 All patients/families need to receive education, counseling, and general strategies for managing CRF. When patients report moderate or severe CRF, a focused history and assessment need to be performed of treatable, contributing factors (medications/side effects, pain, emotional distress, anemia, sleep disturbance, nutritional deficit/imbalance, decreased functional status, comorbidities). Evidence-based interventions to reduce CRF should be selected based on individual needs and desires.
A range of nonpharmacologic and pharmacologic interventions has been tested to reduce CRF. The widely disseminated NCCN Cancer-Related Fatigue Guidelines in Oncology4 and Oncology Nursing Society (ONS) Putting Evidence into Practice (PEP) fatigue guidelines86 reflect evidence of the efficacy of interventions to modify CRF. The NCCN CRF guidelines are written for all diagnosed cancer patients according to their phase on the cancer trajectory: on active treatment, post-treatment, or at the end of life. Most nonpharmacologic interventions for reducing CRF have been tested in patients with local/regional disease, whereas pharmacologic treatments have been tested in patients with advanced/metastatic disease. In the paragraphs below, we summarize current knowledge regarding interventions to treat CRF in mixed types of cancers, with a focus on breast cancer patients.
Nonpharmacologic interventions to decrease cancer-related fatigue
No gold standard exists for the nonpharmacologic treatment of CRF in patients with breast cancer. Several nonpharmacologic interventions have been tested and have demonstrated positive effects in treating CRF. Numerous recent systematic reviews and meta-analyses have evaluated the efficacy of interventions to reduce CRF in adults with mixed types of cancer.86-100 Breast cancer patients have participated in most studies. These interventions have been categorized in 2 major, clinically applicable domains: physical activity enhancement and psychosocial therapies.
Physical activity enhancement involves the use of some form of exercise. Interventions include various modes, intensity, and timing of exercise activities, such as walking, cardiovascular and/or flexibility training, and resistance training. Exercise interventions have included both supervised and home-based programs.89
Two recent meta-analytic reviews concluded that exercise interventions had a near moderate effect size (ES) in reducing CRF compared with the control condition, usually "standard care."89, 92 Kangas and colleagues reported ES in 16 randomized controlled trials (RCTs) (N = 1001) with a weighted, pooled mean ES of −0.42 (z = −4.41; P < .001). A Cochrane meta-analysis of 28 RCTs89 reported a smaller overall ES with a standard mean difference of −0.23 (95% confidence interval [CI], −0.33 to −0.13). Benefits favored programs with multiple exercise components, at least partially home-based, individualized, and >8 weeks long.89, 92
The evidence suggests that physical activity enhancement, and specifically exercise, has benefit in managing CRF both during and after cancer treatment. Current evidence does not clarify which elements of exercise are most effective, including type (aerobic and/or resistance), mode, and dose,(frequency, intensity, length of sessions). Physical activity interventions need to be individualized based on the level of physical capacity and pre-existing conditions and should begin at low intensity levels with gradual progression. Most studies prescribed less than moderate intensity aerobic activity, as recommended for healthy adults, probably because participants were advised to start at a lower level and to progress according to their physical capacity. Few adverse events from exercise, including back, wrist, lower-leg, and rotator cuff injury, were reported.25 The NCCN CRF guidelines4 call attention to specific indications for referral to physical therapy and instances in which exercise may be contraindicated or used cautiously. There is insufficient evidence to evaluate the efficacy of physical activity as a supportive care intervention for patients with cancer who are receiving palliative care.101
Recent systematic reviews and meta-analyses have focused specifically on exercise in patients with breast cancer.25, 100, 102, 103 Duijts and colleagues observed statistically significant results with physical exercise interventions for CRF in patients with breast cancer (ES, −0.315; 95% CI, −0.532 to 0.098; P = .004). Those findings were consistent with results from other studies in breast cancer.24, 25, 100, 103, 104 In addition to effectively reducing CRF, most studies report that exercise is feasible for women with stage I through IIIA breast cancer during and after cancer-directed treatment.
Psychosocial therapies comprise a diverse set of educational, supportive, and behavioral approaches grouped for clinical application in the NCCN CRF guidelines. Kangas and colleagues92 conducted a systematic review of 113 studies that included a CRF outcome. The studies included RCTs and non-RCTs. That meta-analysis included findings from 41 RCTs that tested the efficacy of psychosocial interventions administered during and after treatment in adults with mixed cancer diagnoses. The effect of psychosocial interventions was in the small-to-moderate range and was clinically meaningful. The individual ES for the 41 psychosocial RCTs (N = 3620) had a significant, weighted, pooled mean ES of −0.31 (z = −9.62; P < .001).
Interventions were grouped in categories of cognitive behavioral therapy (CBT), supportive-expressive therapy, education/counseling, behavioral/relaxation therapy, massage, and mental restorative treatments. Psychosocial interventions that exhibited the most benefit across several RCTs included CBT, education/counseling, and supportive/expressive therapy. Behavioral interventions, such as relaxation and imagery and general fatigue education, produced smaller and sometimes nonsignificant effects.92 Massage and therapies for mental rest and restoration also demonstrated benefit. Effective psychosocial interventions for reducing CRF in adults during cancer treatment contained certain specific elements, namely, tailored education about CRF, self-care and coping techniques, activity management, and energy-conservation activities.90
A meta-analysis focused on the effectiveness of behavioral techniques on CRF in breast cancer102 included 14 studies and concluded that behavioral techniques had a positive effect (ES, −0.158; 95% CI, −.233 to −0.082; P < .001). The majority of interventions were delivered during active treatment. The format for delivery varied from 2 to 12 sessions and included individual, group, and combined intervention approaches.
Less evidence is available to support other types of interventions for reducing CRF. CBT for insomnia was rated as "likely to be effective" by ONS-PEP86 and was included in the 2011 NCCN guidelines, but more evidence is needed.105 Patients with breast cancer comprise most or all of the patients who experience reduced fatigue after a CBT intervention for insomnia.106-109
Since the most recent meta-analysis, several feasibility and RCT studies have been published that tested types of physical activity/exercise, physically based therapies, CBT, and psychosocial interventions to lower CRF in patients with cancer. Most findings were consistent with prior studies, and the results did not alter the evidence-based guidelines for CRF. It is noteworthy that 2 of those studies tested single versus combined physical activity and/or psychosocial interventions to reduce fatigue in cancer patients with mixed diagnoses. During curative cancer treatment, reduced fatigue occurred after CBT without a lasting increase in physical activity.110 Approximately 1 year after completing treatment, survivors reported significantly reduced fatigue from both physical training (PT) alone and PT + CBT compared with a wait-list control group, but CBT did not add to the benefits from PT.
Pharmacologic interventions
Appropriate CRF management requires optimal cancer treatment and reduction of potentially reversible contributors, such as mood disorders, hypothyroidism, anemia, infection, and comorbid diseases.87 The effects on CRF from a wide variety of pharmacologic agents have been examined in single-arm studies and, to a lesser extent, in RCTs, but no consensus has been reached regarding which agents are efficacious4 The NCCN guidelines recommend treatment for pain, emotional distress, and anemia as well as optimizing treatment for sleep dysfunction, nutritional deficits/imbalance, and comorbidities.
A meta-analysis of 2 studies in which CRF was treated indicated that methylphenidate was superior to placebo (standardized mean difference in change in CRF score, −0.30; 95% CI, −0.54 to −0.05; P = .02); however, progestational steroids (medroxyprogesterone acetate or megestrol acetate) and paroxetine were no better than placebo.82 A meta-analysis of psychostimulant trials (only 1 included exclusively breast cancer patients) lead to similar findings (standardized mean difference in change in fatigue score, −0.28; 95% CI, −0.48 to −0.09; P = .005) but also reported that several trials did not demonstrate a benefit over placebo. Two Cochrane reviews111, 112 concluded that methylphenidate produced a small but significant improvement in CRF over placebo in patients with mixed tumors who had advanced disease, but those results need to be confirmed in a single, large RCT.
Future interventions
Future interventions need to focus on patients who have moderate-to-severe CRF that has an impact on physical and mood status. Consensus on the definition for the symptom/syndrome of CRF is recommended. Theoretical models to determine contributors that initiate and sustain CRF or that influence the efficacy of interventions for CRF require testing. Contributing factors and symptoms that cluster with CRF need to be included when designing studies. Metrics for both subjective and objective measures, including inflammatory and genetic markers, and longitudinal designs are recommended. Advanced statistical procedures, such as structural equation modeling and growth curve modeling, are recommended when appropriate.
We need to learn when to offer single or combined pharmacologic and nonpharmacologic treatments. Placebo and nocebo effects have been observed in double-blind RCTs that tested agents for CRF in advanced cancer patients and warrant further exploration.113 We need to determine the most appropriate recommendations for exercise based on CRF level. In addition, we must develop and test interventions to increase physical activity in survivors who have clinically significant CRF. Further studies are indicated to determine the effectiveness of evidenced-based interventions in community settings: What works in the short and long term, for whom, and in which settings?
Assessment and management of CRF are essential components of a surveillance model of physical rehabilitation for women with breast cancer (see Stout et al114 in this supplement). During the preoperative evaluation, identification and management of baseline CRF and co-occurring symptoms, such as pain from a biopsy, and an assessment of activity limitations are essential. The preoperative CRF level may reflect the presence and impact on function of premorbid conditions and may serve as a prognostic indicator of subsequent risk for impairment. In the first few months of the postoperative rehabilitation period, reassessment of CRF, with particular attention to its correlation with pain and function, can assist in identifying women who are and are not performing exercise and other health promoting behaviors at the recommended levels and can help in selecting an intervention.
Ongoing surveillance provides an opportunity to identify long-term or persistent, moderate-to-severe CRF. A moderate-to-severe CRF level (≥4 on a scale from 0 to 10), particularly in survivors with lower premorbid physical function, indicates the need for a comprehensive primary fatigue evaluation4 and prompt referral to an appropriate rehabilitation program. When CRF is detected, pain, other co-occurring symptoms, and function need to be assessed and managed. Every ongoing surveillance encounter provides an opportunity to promptly initiate a referral for rehabilitation to an appropriate symptom-management expert. Every encounter also provides time to discuss health-promoting skills and behaviors, including exercise, which lead to better QOL and may help reduce the risk of breast cancer reoccurrence.