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The majority of schwannomas and neurofibromas are benign, slow-growing tumors with little or no capacity for infiltration of surrounding neural tissues. Therefore, the focus of initial management has traditionally been aggressive surgical resection (Jackler and Pitts 1990; Macfarlane and King 1995; Samii et al 1995; Seppala et al 1995a; 1995b; Strauss and Post 1995). This approach is appropriate for most intracranial, spinal, and peripheral nerve schwannomas and neurofibromas because complete surgical extirpation is often curative. However, in certain cases of vestibular schwannoma, it is not always clear whether to proceed directly with surgical intervention or to carefully observe the patient (Fucci et al 1999; Mirz et al 1999; Rosenberg 2000; Nutik and Babb 2001; Al Sanosi et al 2006). In the MRI era, many vestibular tumors are detected at an early stage as small, intracanalicular or cisternal lesions less than 2.0 cm in diameter. When treated conservatively, approximately 20% to 60% of these small tumors do not enlarge during the period of observation (Wazen et al 1985; Thomsen and Tos 1990; Bederson et al 1991; Nedzelski et al 1992; Macfarlane and King 1995; Fucci et al 1999; Mirz et al 1999; Rosenberg 2000; Flint et al 2005; Al Sanosi et al 2006; Ferri et al 2008; Martin et al 2008; Bakkouri et al 2009; Sughrue et al 2010). Of those tumors that do enlarge, 75% to 80% grow slowly, at a rate of 1 mm to 2 mm per year. The growth rate may be even slower in elderly patients. For example, in a series of 70 patients over 65 years of age followed by Rosenberg over a mean follow-up period of 4.8 years, only 4 patients (5.7%) required surgical intervention (Rosenberg 2000). The growth rate does not seem to correlate significantly with patient age, initial tumor size, or duration of symptoms (Bederson et al 1991; Nedzelski et al 1992; Fucci et al 1999; Mirz et al 1999; Bakkouri et al 2009). In more than 383 patients treated in an expectant, conservative manner, tumor behavior during the initial follow-up period of 12 to 58 months was predictive of further growth (Bederson et al 1991; Nedzelski et al 1992; Fucci et al 1999; Mirz et al 1999; Al Sanosi et al 2006; Ferri et al 2008). Tumors were likely to remain quiescent if they demonstrated little or no growth during the observation period. Conversely, tumors that subsequently required surgery grew steadily during the observation period, often with an accelerated growth rate (greater than 2 mm per year). These data have led many authors to adopt a conservative, observational approach for the following patients: any patient with generally poor health, elderly patients with tumors less than 10 mm in size, elderly patients reluctant to proceed with surgery, and any patient with significant hearing loss in the opposite ear (Jackler and Pitts 1990; Bederson et al 1991; Nedzelski et al 1992; Macfarlane and King 1995; Fucci et al 1999; Mirz et al 1999; Bakkouri et al 2009). Tumors with a growth rate equal to or greater than 2 mm per year should be considered for surgical removal. In general, the delay in surgical intervention does not appear to result in more morbidity for the patient (Flint et al 2005; Ferri et al 2008). In a recent comparison of conservative versus primary surgical management of acoustic schwannomas, Martin and colleagues noted that facial nerve preservation (p < 0.001) and hearing preservation (p < 0.000) were both superior in the conservatively treated cohort of patients (Martin et al 2008). Conservative approaches are unjustified in most young patients, whose tumors generally have accelerated growth rates, and in patients with tumors exceeding 2.5 cm in diameter. A recent meta-analysis of the conservative approach literature reviewed the data on 982 patients to assess hearing outcomes (Sughrue et al 2010). Patients with lower rates of tumor growth (≤ 2.5 mm/year) had significantly higher rates of hearing preservation in comparison to those with higher growth rates (75% vs. 32%, p < 0.0001). The authors concluded that a rapid growth rate (ie, > 2.5 mm/year) was a better predictor of hearing loss than the initial size of the tumor in patients with tumors less than 25 mm in diameter.
Surgical resection of vestibular schwannoma. Surgical resection is the treatment of choice for most patients with a vestibular schwannoma. Complete removal is usually attempted in all patients, except for selected cases (eg, elderly patients) wherein a shortened procedure may significantly reduce potential morbidity and mortality. Three surgical approaches are used for vestibular schwannoma removal: (1) suboccipital (retrosigmoid), (2) translabyrinthine (anterosigmoid), and (3) middle fossa (subtemporal) (King and Morrison 1980; Bentivoglio et al 1988; Jackler and Pitts 1990; Jackler and Pitts 1992; Macfarlane and King 1995). Each has specific advantages to offer, based on selection criteria that include tumor size, depth of internal auditory canal penetration by tumor, hearing status, exposure of the facial nerve, and patient age (Jackler and Pitts 1992). In general, the ability to perform a complete resection and preserve cranial nerve function correlates strongly with tumor size and is most favorable in tumors less than 1 cm in diameter.
The suboccipital or retrosigmoid approach uses a craniectomy just posterior to the sigmoid sinus; exposure of the tumor and cerebellopontine angle is excellent (Bentivoglio et al 1988; Jackler and Pitts 1990; 1992; Samii and Matthies 1997a; Ojemann 2001). The major advantages of this approach are the level of exposure and the possibility of preserving hearing. Disadvantages include the need for cerebellar retraction (with an associated increased incidence of postoperative dysmetria) and frequent postoperative headaches. Many surgeons use this approach for tumors less than 2 cm in patients with good hearing, and for large tumors that extend toward the jugular foramen (Jackler and Pitts 1990; 1992; Macfarlane and King 1995; Samii and Matthies 1997a; Ojemann 2001). A retrosigmoid transmeatal approach is particularly good for "extra-large" tumors (greater than 4 cm in diameter) that require extensive exposure for tumor resection and preservation of cranial nerve function (Jung et al 2000).
The translabyrinthine or retrosigmoid approach uses a craniotomy of the lateral portion of the temporal bone, including the mastoid air cells and semicircular canals, to gain exposure of the internal auditory canal and cerebellopontine angle (King and Morrison 1980; Jackler and Pitts 1992; Lanman et al 1999; Sluyter et al 2001). The advantages of this approach are that minimal cerebellar retraction is necessary, cerebellopontine angle exposure is good, all drilling of the temporal bone is completed before the dura is opened, the entire intratemporal course of the facial nerve is accessible, and the incidence of postoperative headache and cerebrospinal fluid leakage is reduced. The major disadvantages of the translabyrinthine approach are that hearing is irrevocably abolished and exposure may be limited inferiorly by the jugular foramen (Jackler and Pitts 1990; 1992; Macfarlane and King 1995). Most surgeons recommend this approach for all intracanalicular and medium-sized cisternal tumors associated with poor hearing, selected tumors with deep internal auditory canal penetration associated with good hearing, and most large cisternal tumors exceeding 3 cm (Jackler and Pitts 1992; Lanman et al 1999; Sluyter et al 2001).
The middle fossa, or subtemporal approach, uses a small temporal craniotomy anterosuperior to the external auditory canal. The facial nerve is usually draped over the top surface of the tumor with this exposure, and must be manipulated for tumor removal. The middle fossa approach is most often used for intracanalicular tumors or small cisternal tumors (less than 5 mm beyond the porus acusticus); exposure of the cerebellopontine angle is minimal. The advantages of this approach are the possibility of sparing hearing and the low incidence of postoperative headaches as much of the procedure is extradural (Jackler and Pitts 1990; 1992; Irving et al 1998; Brackman et al 2000; Gonzalez et al 2000). In a direct comparison of hearing preservation after use of the retrosigmoid or middle fossa approaches, the middle fossa method demonstrated significantly improved results (52% vs. 14% of patients with Class B or better hearing; p = 0.009) (Irving et al 1998). The middle fossa approach is more likely to achieve hearing preservation (1) when the patient has adequate preoperative hearing, (2) if the auditory evoked brainstem response shows shorter latency value, and (3) when the tumor arises from the superior vestibular branch of the nerve (Brackman et al 2000). Disadvantages of the middle fossa approach include restricted cerebellopontine angle exposure, increased potential for facial nerve trauma, and complications from retraction of the temporal lobe (ie, epilepsy, dysphasia, cerebral hematoma).
Reports by several authors document the potential benefits of using endoscopy during surgical resection of vestibular schwannomas (Goksu et al 1999; Wackym et al 1999). The major benefits are higher magnification (to better define neurovascular anatomy of the posterior fossa), improved visualization of the tumor (especially within the internal auditory canal), and a reduced risk of postoperative cerebrospinal fluid leakage.
Intraoperative cranial nerve monitoring has emerged as an excellent method for potentially reducing the morbidity of vestibular schwannoma resection (Jackler and Pitts 1990; Harper et al 1992; Yingling and Gardi 1992; Glasscock et al 1993; Macfarlane and King 1995). This technique assists in identifying cranial nerves in the operative field (using intracranial electrical stimulation), and facilitates their dissection from tumor while minimizing significant trauma. Commonly monitored motor nerves include the facial, trigeminal, and spinal accessory. Postoperative function of cranial nerves V, VII, and XI is significantly improved when monitoring is used for tumor resection (Wiet et al 1992; Yingling and Gardi 1992; Strauss 2002). This is especially important for large medially placed tumors; in 36% of patients in 1 series, the facial nerve was split in its passage through and around the mass (Strauss 2002). The auditory nerve is monitored using auditory evoked brainstem response only during hearing preservation operations (Ojemann et al 1984; Harper et al 1992; Glasscock et al 1993; Matthies and Samii 1997b). The benefits of operative monitoring of cranial nerve 8 are controversial, but procedural morbidity is probably reduced in some patients with tumors less than 2 cm (Jackler and Pitts 1990; Harper et al 1992; Yingling and Gardi 1992; Matthies and Samii 1997b). Furthermore, some authors contend that the quality of the preoperative auditory brainstem response positively correlates with postoperative cranial nerve VIII function and extent of hearing preservation (Matthies and Samii 1997c).
Overall, the mortality of vestibular schwannoma removal is 1% to 2% for an experienced surgeon. Most of the fatalities occur in elderly patients or patients with large tumors. Almost 50% of these deaths are caused by medical complications such as pulmonary embolism, myocardial infarction, and pneumonia. Potential complications are numerous and include vascular injury, hemorrhage (0.5% to 2%), cerebellar injury (1% to 2%), cranial nerve injury, headache (10% to 30% last 4 weeks or more), vertigo, pneumocephalus, meningitis (2% to 6%), aseptic meningitis (5% to 10%), cerebrospinal fluid leakage (10% to 30%), hydrocephalus, and various medical conditions (King and Morrison 1980; Bentivoglio et al 1988; Jackler and Pitts 1990; 1992; Wiet et al 1992; Macfarlane and King 1995; Samii and Matthies 1997a; 1997b; Pirouzmand et al 2001). There is no difference in the rate of postoperative cerebrospinal fluid leak between the rectosigmoid and translabyrinthine approaches (Brennan et al 2001). However, leaks from translabyrinthine approaches more often need surgical repair.
After resection of a vestibular schwannoma, follow-up imaging with MRI is recommended. A recent study suggests that for uncomplicated cases with a complete resection, initial follow-up imaging should be at 1 year (Bennett et al 2008). Patients with residual enhancement and/or subtotal resections, or underlying NF2, should undergo follow-up MRI on a more frequent and consistent basis.
Surgical resection of other cranial nerve, spinal, and peripheral nerve schwannomas. The basic principles of surgery for schwannomas from other sites are similar to those for vestibular tumors. In most cases, a complete resection is curative; subtotal removal often results in eventual recurrence of tumor. The most common operation for resection of a trigeminal schwannoma uses a subtemporal-intradural approach (McCormick et al 1988; Miller 1988; Pollack et al 1989; Samii et al 1995; Strauss and Post 1995; Sarma et al 2002; Moffat et al 2006; Zhang et al 2009). This technique is best for tumors in the middle fossa, Meckel cave region. Tumors that have significant extension toward the cavernous sinus and superior orbital fissure may require a frontotemporal-transsylvian approach. Tumors confined mainly to the posterior fossa are resected using a suboccipital approach in most cases, although some authors prefer the orbitozygomatic extradural or the subtemporal-infratemporal approaches instead, depending on the branch of the nerve involved (Krishnamurthy et al 1998). A combined approach is necessary for dumbbell-shaped tumors; for instance, the extradural zygomatic middle fossa approach. With this technique, Al-Mefty and coworkers were able to perform gross total resections with excellent preservation of cranial nerve function (Al-Mefty et al 2002). Intraoperative monitoring may be helpful in some cases (Strauss and Post 1995). Using conventional techniques, the mortality rate is 2% to 3%, with total or near-total removal of tumor in 70% to 75% of cases (Samii et al 1995; Strauss and Post 1995; Zhang et al 2009). However, the recurrence rate approaches 50% in many series. Some authors recommend more extensive skull base approaches for resection, claiming that improved tumor exposure and ease of dissection allow for more frequent complete and improved clinical outcome (Taha et al 1995; Yoshida and Kawase 1999; Moffat et al 2006; Fukaya et al 2010). For example, Fukaya and colleagues recently reported the surgical results of a series of 57 trigeminal schwannomas, most of which underwent resection using a skull base approach (Fukaya et al 2010). Complete resection was accomplished in 42 of 45 patients (90%), with no surgery-related mortalities. The most common surgical complications of skull base surgery are cranial nerve injury, cerebrospinal fluid leak, meningitis, and hydrocephalus. Facial nerve schwannomas are resected using an approach based on the extent and location of the tumor: middle fossa, suboccipital, or translabyrinthine (Rocchi et al 1991; Strauss and Post 1995; Sarma et al 2002; Kim et al 2003). If hearing is poor, the translabyrinthine approach is recommended. If a hearing preservation operation is attempted, the preferred approach is either suboccipital or middle fossa. Complications are similar to those of trigeminal tumors. Schwannomas of the jugular complex (IX, X, XI) are resected most often using a suboccipital approach, occasionally in combination with a mastoidectomy (Sweasey et al 1991; Strauss and Post 1995; Rapana et al 1997; Wilson et al 2005; Bulsara et al 2008). Schwannomas of the ocular motor cranial nerves (III, IV, VI) are generally resected using frontotemporal or subtemporal approaches (Miller 1988; Mehta et al 1990; Tung et al 1991; Jackowski et al 1994; Strauss and Post 1995; Mariniello et al 1999; Sarma et al 2002). Tumors located mainly within the posterior fossa can be removed with a suboccipital technique. The complete resection rate for ocular motor nerve schwannomas is approximately 50% (Strauss and Post 1995). In selected cases, preservation of oculomotor nerve function can be attempted by sural nerve grafting (Mariniello et al 1999). Hypoglossal schwannomas are most often resected using a lateral suboccipital approach (Miller 1988; Strauss and Post 1995; Tucker et al 2007). The operative mortality in these patients is relatively high (6% to 7%), usually because of respiratory complications such as aspiration and pneumonia. Surgical resection of intrasellar schwannomas can be accomplished using a trans-sphenoidal approach (Honegger et al 2005). A gross total resection is often possible.
Surgical treatment of spinal schwannomas and neurofibromas is similar to that for tumors of the cranial nerves; complete resection is curative in most cases. The operative approach is usually a midline partial or total laminectomy (Seppala et al 1995a; 1995b; Conti et al 2004). The tumors are always attached to at least 1 nerve root. Schwannomas can be completely resected in 85% to 90% of cases without sacrifice of the parent nerve root (Seppala et al 1995b; Conti et al 2004; Safavi-Abbasi et al 2008). Radical resection is also possible for large, invasive tumors that extend into surrounding bones and soft tissues (Sridhar et al 2001). For tumors of the thoracic spine, some authors recommend resection via thoracoscopy (Dickman and Apfelbaum 1998). This technique is an excellent alternative to thoracotomy because of the smaller incision used, better cosmetic results, reduced postoperative pain, and earlier return to activity. Neurofibromas can be completely resected in 90% of cases (Seppala et al 1995a). However, in 80% to 90% of these patients the parent nerve root must be sacrificed during tumor removal. Complications most often consist of hemorrhage, wound infection, deep venous thrombosis, wound dehiscence, and pulmonary compromise (eg, embolism, pneumonia).
Schwannomas and neurofibromas of the peripheral nerves are usually solitary lesions in patients without neurofibromatosis. Surgical resection of schwannomas, when they develop from distal nerve branches, consists of simple dissection of the parent nerve from the tumor capsule and en bloc removal of the mass (Ariel 1988). Neurofibromas are often more difficult to dissect away from the parent nerve, as it may become encased within the mass. Schwannomas of the large nerve trunks (ie, brachial or lumbosacral plexus) can also be completely resected in most cases with careful microdissection of the parent nerve away from the tumor capsule (Lusk et al 1987). In contrast, complete resection of neurofibromas often requires sacrifice of fascicles of the parent nerve and nearby nerves that have become encased within the mass. Adherent tumor must often be dissected from remaining nerve fascicles. Some authors recommend an interfascicular approach in combination with nerve conduction testing to maximize the chance for complete resection (Kim et al 2005). With the recent improvements in microneurosurgical techniques, some authors are recommending a "nerve sparing" approach to surgical resection of benign peripheral nerve schwannomas and neurofibromas (Russell 2007). Localized surgical approaches are not adequate for treatment of malignant schwannomas or neurofibromas (Sordillo et al 1981; Ariel 1988; Baehring et al 2003; Carli et al 2005; Gupta and Maniker 2007; Widemann 2009). These tumors generally require either radical local excision or amputation. Radical local excision involves en bloc removal of the tumor and any attached nerve, bone, muscle, and blood vessels. Normal tissue planes must be attained on all surfaces, or amputation is necessary.
Radiation therapy of vestibular schwannomas. For a small subgroup of patients with vestibular schwannomas, conventional external beam radiation therapy or stereotactic radiosurgery may be adjunctive or alternative forms of therapy (Noren et al 1983; Wallner et al 1987; Hirsch and Noren 1988; Pollack et al 1989; Linskey et al 1990; 1992; Flickinger et al 1991; Lunsford and Linskey 1992; Macfarlane and King 1995; Murphy and Suh 2011). Conventional radiation therapy is not indicated for patients after a complete or near-total resection. It should be considered in patients with substantial residual tumor after surgery, for recurrent tumors in advanced stages of disease, and for those patients with large tumors who are poor surgical candidates. In a review of 124 patients with vestibular tumors that received radiation therapy after subtotal tumor removal, Wallner and colleagues concluded that irradiation significantly reduced the possibility of tumor progression (Wallner et al 1987). Irradiation with doses of 5000 to 5500 cGy, administered in 180 cGy fractions, decreased the recurrence rate from 46% to 6% (p = 0.01). Preoperative irradiation can also be used to reduce the risk of hemorrhage during resection for patients with highly vascular schwannomas (Wallner et al 1987; Ikeda et al 1988). Doses of approximately 3000 cGy can reduce vascularity after a period of 6 to 8 weeks.
Stereotactic radiosurgery is a method of delivering focused irradiation within the boundaries of a tumor in a single fraction, using great precision (Loeffler and Alexander 1990; Battista 2009). The treatment is most often administered using a gamma knife; however, linear accelerator and proton beam units are also used and demonstrate comparable local control and complication rates (Mendenhall et al 1996; Suh et al 2000; Spiegelmann et al 2001; Friedman et al 2006). Similar to conventional external beam irradiation, radiosurgery is considered an alternative or adjunctive therapy in carefully selected patients with vestibular schwannomas (Linskey et al 1990; 1992; Flickinger et al 1991; Lunsford and Linskey 1992; Shetter 1997; Kondziolka et al 1998; Pollock et al 1998b; Prasad et al 2000; Suh et al 2000; Lunsford et al 2005; Likhterov et al 2007; Battista 2009; Murphy and Suh 2011). Patients most appropriate for radiosurgical therapy include those who are medically unstable, are elderly (greater than 65 years old), are contralaterally deaf, have failed an initial surgical resection, or refuse surgical intervention (Linskey et al 1992; Lunsford and Linskey 1992). Lesions less than 3 cm in diameter are most suitable for radiosurgery. The most common treatment plan involves a margin dose of 16 to 18 Gy (in a single fraction) at or above the 50% isodose line, depending on the estimated tumor volume (Flickinger et al 1991; Linskey et al 1992; Lunsford and Linskey 1992; Kondziolka et al 1998). Depending on the configuration of the tumor, 1 or more isocenters are used to cover the treatment volume (average 2.5 isocenters). Clinical response as measured by CT or MRI demonstrates tumor shrinkage in 20% to 30%, stable tumor in 60% to 75%, and tumor progression in 3% to 5% (Flickinger et al 1991; Linskey et al 1992; Lunsford and Linskey 1992; Shetter 1997). More recent papers with long term follow-up after radiosurgery have noted reduction in tumor size ranging from 62% to 81% (Kondziolka et al 1998; Prasad et al 2000; Lunsford et al 2005; Battista 2009). The estimated overall local control rate for radiosurgery is approximately 92% to 98% (Lunsford and Linskey 1992; Mendenhall et al 1996; Shetter 1997; Kondziolka et al 1998; Pollock et al 1998a; 1998b; Lunsford et al 2005; Friedman et al 2006; Likhterov et al 2007). A recent review of 208 consecutive patients, with median follow-up time of 56 months, noted growth of tumors 30 patients (14%) (Pollock 2006). Of this cohort, only 6 had progressive tumor enlargement that required further treatment with surgical resection or radiosurgery. The conclusion of the author was that initial enlargement after radiosurgery did not necessarily denote failure of the procedure. This has been corroborated in a recent study by Nagano and colleagues in which a 25% to 47% increase in tumor size was noted in over half their cohort of 100 consecutive vestibular schwannoma patients treated with radiosurgery. Peak tumor expansion was usually noted by 6 months after treatment and normalized within 12 months. High-dose treatment (ie, 3.5 Gy/min) was marginally correlated with the likelihood of tumor expansion (Nagano et al 2008). In a review of schwannomas that recurred after 1 or more attempts at surgical resection, radiosurgery was able to achieve growth control in 73 of 78 tumors (94%) (Pollock et al 1998a). The median interval from time of treatment to objective tumor shrinkage is approximately 12 months. Loss of central tumor enhancement is observed in 75% to 80% of cases after a median interval of 6 months. This is postulated to occur by radiation-induced vascular injury, thrombosis, and occlusion. The rate of useful preservation of hearing is 50% at 6 months and 38% at 1 year (Linskey et al 1992; Lunsford and Linskey 1992; Shetter 1997). Hearing begins to decline at a median of 6 months and is not correlated with loss of tumor contrast enhancement, tumor margin dose, or tumor margin isodose. Several recent reviews of hearing preservation after radiosurgery for vestibular schwannoma suggest an overall rate of preservation of approximately 51% at 3 to 4 years after treatment, with doses of less than 13 Gy being more likely to maintain hearing (Kano et al 2009a; Timmer et al 2009; Yang et al 2010). The degree of hearing preservation appears to be correlated to the maximal radiation dose at the cochlea, emphasizing the need for meticulous radiation planning. Some authors have also used gamma knife radiosurgery in patients with vestibular schwannomas that have failed initial radiosurgery with a different platform (ie, LINAC) (Dewan and Noren 2008). In 8 of the tumors, shrinkage was noted on follow-up MRI. Acute complications include nausea or vomiting (21%) and headaches (10% to 12%). Although rare, hearing loss and facial weakness within 24 to 48 hours of radiosurgical treatment have also been reported (Chang et al 1998; Tago et al 2000). Delayed facial neuropathy occurs in 34% of patients with normal preoperative function and 27% of patients with abnormal preoperative function. The facial weakness improves or recovers by 6 months in most patients. Radiosurgical doses of greater than or equal to 18 Gy appear to cause permanent facial neuropathy (Miller et al 1999). Patients receiving doses of less than or equal to 16 Gy were significantly less likely to develop facial neuropathy. Longer follow-up is required before conclusions can be drawn regarding efficacy of local growth control using the reduced dose protocol. Delayed trigeminal neuropathy occurs in 32% of patients with normal preoperative function and 46% of patients with abnormal preoperative function. Trigeminal dysfunction improves, but does not resolve within 6 months in most patients. The mechanism of cranial nerve injury remains unclear, but is probably a combination of direct radiation injury, localized edema, demyelination, and vascular compromise. Although data by Linskey and colleagues suggest that the length of cranial nerve irradiated correlates with the risk of delayed injury, additional studies indicate that the dose to the brainstem may be a more important predictor of post-treatment cranial neuropathy (Linskey et al 1993; Foote et al 2001). In a review of complication rates in a cohort of 190 patients treated with a median of 13 Gy, Flickinger and colleagues noted similar local control rates to other studies using higher doses; however, there were lower rates of hearing loss, facial numbness, and facial weakness (Flickinger et al 2001). Other potential complications include worsened balance (31%), vertigo (4%), and hydrocephalus. Another radiosurgical approach is to use protons, which confer a radiobiological advantage for beam accuracy. Weber and colleagues have used proton beam radiosurgery in a series of 88 patients, with 93.6%, 5-year tumor control rates and comparatively low rates of facial and trigeminal neuropathy (Weber et al 2003).
Some authors feel fractionated radiosurgery may be superior to standard radiosurgery, due to the radiobiological advantages inherent to fractionation, such as reduced risk of cranial nerve injury (Szumacher et al 2002; Sawamura et al 2003; Combs et al 2005; Likhterov et al 2007). In a series of 39 patients with vestibular schwannomas, Szumacher and colleagues noted local tumor control in 95% of the cohort at 21.8 months median follow-up (Szumacher et al 2002). At 22 months median follow-up, no new cases of cranial nerve dysfunction were noted. After fractionated radiosurgery, of those patients with functional hearing before treatment, 68% were able to maintain a similar level of function. Similar results have been reported by several groups in large cohorts of more than 100 patients (Sawamura et al 2003; Combs et al 2005). In contrast, other authors report that single-fraction linear accelerator-based radiosurgery may be as effective as fractionated methods in terms of tumor control rates (Meijer et al 2003). The Stanford group recently reported their experience using the Cyberknife, with minimal fractionation over 3 days (Sakamoto et al 2009). A total of 61 patients with vestibular schwannomas were treated, with a mean maximal tumor dimension of 18.5 mm. The local control rate was 98%; tumor shrinkage was noted in 29 tumors. None of the patients developed new facial weakness or trigeminal deficits. Some authors have also suggested that hypofractionated stereotactic radiotherapy can be effective (Sakanaka et al 2011). In a series of 27 patients with vestibular schwannoma, linear accelerator radiosurgery was administered to a total dose of either 30 to 39 Gy over 10 to 13 fractions, or 20 to 24 Gy over 5 to 6 fractions. Local control rates were 100% and 92% for the high- and low-dose cohorts, respectively. In addition, with this approach, minimal facial and trigeminal nerve morbidity was noted.
Currently, 20% to 25% of vestibular schwannomas are treated with radiosurgery either as initial therapy or at recurrence (Pollock et al 1998b). Pollock and colleagues predict that over the next 10 years to 20 years, radiosurgery will replace surgical resection as the initial treatment of choice for these tumors (Pollock et al 1998b). Nonrandomized comparisons between series of patients treated operatively and by gamma knife suggest similar tumor growth control and a reduced risk of hearing loss, facial palsy, facial hypesthesia, and feeding problems in the radiosurgical cohort (Regis et al 2002; Karpinos et al 2003; Pollock et al 2006). In a recent prospective, nonrandomized comparison of stereotactic radiosurgery (N = 46) and surgical resection (N = 36), Pollock and colleagues concluded that radiosurgery was more effective in terms of facial function and hearing preservation (p < 0.001), as well as on several subscales of the Health Status Questionnaire (eg, physical functioning, energy/fatigue) (Pollock et al 2006). The improved results of radiosurgery were only noted for patients with small and medium sized tumors. A similar study was recently published out of Norway by Myrseth and colleagues in which a cohort of 91 prospective patients with small- to medium-sized vestibular schwannomas were treated with gamma knife radiosurgery (N = 63) or open microsurgery (N = 28) (Myrseth et al 2009). The results were again in favor of the radiosurgery cohort, with better preserved facial nerve function and hearing (P < 0.001) than the surgical group. In addition, quality of life measures were significantly better in the radiosurgery cohort.
Radiation therapy of nonvestibular schwannomas. Several authors have used radiosurgical approaches to treat nonvestibular schwannomas with excellent results, similar to the data for vestibular tumors. Pollock and colleagues treated 23 patients with tumors of the trochlear, trigeminal, jugular, and hypoglossal nerves (Pollock et al 2002). Local control rates were 96%, with a 17% rate of cranial nerve morbidity. Similar results are reported by Zhang and colleagues in a series of patients with jugular foramen schwannomas (Zhang et al 2002). Gamma knife radiosurgery has been applied to a series of 21 patients with trigeminal schwannomas (Phi et al 2007). Tumor growth control was achieved in 95% of cases. In 6 patients (27%), new or worsening cranial neuropathies were noted after treatment. In a more recent series of 33 patients with trigeminal schwannomas, progression-free survival rates at 5 and 10 years were both 82.0% after gamma knife radiosurgery (Kano et al 2009b). In a similar study of jugular foramen schwannomas, stereotactic radiosurgery was applied to 35 tumors (Martin et al 2007). Tumors regressed in 17 patients and remained stable in 16 patients. The 5- and 10-year actuarial control rates were 97% and 94%, respectively. Preexisting cranial neuropathies improved in 20% of cases and remained stable in 77%. Recent data from several groups suggest that gamma knife radiosurgery can also be of benefit for patients with facial nerve schwannomas (Litre et al 2008; Madhok et al 2009). In a series of 11 patients, 10 remained stable or regressed after treatment, with satisfactory preservation of facial nerve function (Litre et al 2008). Similar results were noted from Madhok and colleagues in a series of 6 patients (Madhok et al 2009). A small series of 8 patients with schwannomas of cranial nerves III, IV, and VI have been reported by Kim and colleagues (Kim et al 2008). All of the tumors had shrinkage on follow-up MRI, and several patients had improvement in diplopia.
Some authors have applied fractionated radiosurgical techniques to nonvestibular schwannomas. Zabel and coworkers used a median dose of 57.6 Gy with 1.8 Gy fractions on 13 patients (Zabel et al 2001). Local control rates were 100%, with 4 tumors decreasing in size. No new cranial nerve or brainstem deficits were noted. After maximal surgical resection, external beam radiotherapy should also be considered in selected patients with malignant peripheral nerve sheath tumors, especially those with gross residual disease (Baehring et al 2003; Carli et al 2005; Gupta and Maniker 2007; Widemann 2009).
Chemotherapy. In general, chemotherapy has not been applied to patients with sporadic schwannomas or neurofibromas. A small phase I trial of thalidomide, an angiogenesis inhibitor, has been completed in patients with neurofibromatosis type 1 and plexiform neurofibromas (Gupta et al 2003). The drug was well tolerated up to doses of 200 mg/day. Several patients were noted to have minor responses (less than 25% reduction in size) and stabilized disease. Plotkin and colleagues recently tested a series of 43 patients with unresectable neurofibromatosis type 2-related and sporadic vestibular schwannomas for expression of vascular endothelial growth factor (VEGF) and VEGF receptors and attempted treatment with bevacizumab, a humanized monoclonal antibody against VEGF (Plotkin et al 2009). VEGF was expressed in 100% of the tumors, with expression of VEGFR-2 noted in 32% of all tumor vessels. Ten patients were treated with bevacizumab (5 mg/kg intravenously every 2 weeks). Tumor shrinkage was noted in 9 patients on follow-up MRI, with a median best response to treatment volume reduction of 26%. Several patients had durable responses that were maintained over 11 to 14 months. In addition, 4 of 7 evaluable patients had some improvement in hearing. These results are consistent with subsequent case reports of patients treated with bevacizumab. Mautner and colleagues reported 2 patients with NF2-related vestibular schwannomas treated with bevacizumab, both of which had tumor regression of 40% or more (Mautner et al 2010). One of the patients was treated for 6 months and also had improved hearing. Other authors have evaluated anti-VEGF therapy in an animal model (Wong et al 2010). They treated rats implanted with HE1193 or murine NF2-/- tumors with either bevacizumab (10 mg/kg/week) or vandetanib (50 mg/kg/day). There were improvements in tumor vessel diameter, length/surface area density, and permeability in both types of tumors, with both drugs. An increase in necrosis was noted in HE1193 tumors, whereas the NF2-/- tumors were noted to have increased apoptosis. In addition, the tumor growth rate was decreased by 50%, and the survival time was increased by 50% in both drug groups. Although chemotherapy is not generally considered to be of benefit for patients with malignant peripheral nerve sheath tumors, some authors have noted modest benefit in pediatric patients using ifosfamide-based regimens (Carli et al 2005; Gupta and Maniker 2007).
In vitro and animal model experiments with molecular chemotherapy drugs are now underway. Using an in vitro model system of schwannoma, Ammoun and colleagues have shown that sorafenib (BAY 43-9006), an inhibitor of PDGFR and c-Raf, can inhibit PDGFR-beta-mediated ERK1/2 and Akt activity and can reduce cell proliferation in schwannoma cells (Ammoun et al 2008). Another study investigated the activity of AZD6244, an inhibitor of MEK1/2 that is involved in the activation of the extracellular signal-regulated kinase pathways and cell proliferation in schwannoma cells (Ammoun et al 2010b). At low concentrations, AZD6244 was able to abolish platelet-derived growth factor-mediated activation and cell proliferation in schwannoma cell lines. Another follow-up study by Ammoun and colleagues used receptor tyrosine kinase arrays to screen tumor samples from NF2-related and sporadic vestibular schwannomas (Ammoun et al 2010a). Eleven patient samples and 2 control samples were analyzed; all of the tumors were positive for activated epidermal growth factor receptor, and more than half were also positive for activated ErbB2 and ErbB3. Activated ERK1/2 was also noted in all of the tumor samples. Based on these results, the small molecule EGFR/ErbB2 inhibitor, lapatinib, was used to treat in vitro human schwannoma cells. Lapatinib was able to inhibit ErbB2 phosphorylation and survivin upregulation, as well as downstream ERK1/2 and Akt activation. Proliferation of schwannoma cells was inhibited. OSU-0312, a newly developed drug that selectively targets the Akt pathway via inhibition of PDK1, has been shown to suppress schwannoma cell proliferation and decrease phospho-Akt in culture systems (Jacob et al 2008). Recent follow-up studies from the same authors have noted that OSU-03012 has activity against typical and malignant schwannoma cells (Lee et al 2009). The drug was able to inhibit cell proliferation in culture, with an IC50 of 2.6 to 3.1 μM. OSU-03012 was able to induce apoptosis in regular and malignant cell lines while markedly reducing Akt phosphorylation. In xenograft models with the malignant cell line, OSU-03012 was able to inhibit growth by 55% after 9 weeks of oral treatment. Using a mouse schwannoma xenograft model, Clark and colleagues treated animals with trastuzumab, erlotinib, or saline. Both trastuzumab and erlotinib significantly reduced the growth of schwannoma xenografts in comparison with controls (p < 0.05). Erlotinib, but not trastuzumab, was noted to induce a significantly higher rate of apoptosis in schwannoma cells (p < 0.01) (Clark et al 2008). Erlotinib (150 mg/day) was recently tested in a series of 11 patients with NF2 who had progressive vestibular schwannomas (Plotkin et al 2010). There were no patients with objective MRI responses, although minimal shrinkage was noted in a few. Several patients had stabilization of disease, with a median time to progression of 9.2 months. Hearing responses were not significantly improved in any of the cohort.
Mukherjee and colleagues evaluated sporadic and neurofibromatosis type 2 (NF2)-related schwannomas for the presence of platelet-derived growth factor receptor (PDGFR) and c-kit receptors to assess potential sensitivity to imatinib mesylate, a tyrosine kinase inhibitor of PDGFR and c-kit (Mukherjee et al 2009). Increased expression and activation of PDGFR-alpha, PDGFR-beta, and c-kit receptors was noted. Imatinib mesylate was able to inhibit proliferation and anchorage-dependent growth of NF2-null HEI-193 schwannoma cells. In addition, imatinib was able to induce apoptosis in a dose-dependent manner. Similar work by Altuna and colleagues noted expression of PDGFR in 67.5% of vestibular schwannoma samples (Altuna et al 2011). After treatment with imatinib (5 or 10 μM), there was downregulation of phospho-PDGFR. In addition, the use of imatinib induced a dose-dependent increase in G1 percentage (61.6% to 70.7% and 74%; at 5 or 10 μM, respectively), during cell cycle analysis. Imatinib was also able to induce a dose-dependent growth inhibition in colony formation assays using cell lines and cultures derived from fresh tumor tissue.


text:
There is no minimum age to begin learning a language. According to scientific evidence, the sooner a child is exposed to a new language, the better.
Exposure to a foreign language in infancy will help the child learn to speak a second language, and with a more natural accent.Not only will it be easier for the child to speak this language, but the child will also maintain better concentration.
Studies have revealed that bilingual children have better concentration, and that bilingualism can even delay the onset of Alzheimer's.
Dr. José Antonio Portellano, a neuropsychologist at the Universidad Complutense de Madrid, affirms the importance of early foreign language exposure through his metaphor of a blank diary. If we wait to write the pages of bilingualism, the diary fills up and we are left to scribble in the margins.
Bilingual immersion can never come too early. Bilingual education needs to include multiple elements of support and reinforcement; watching cartoons in English isn't enough. What is most important is that a child's exposure to a new language integrates with the child's natural behavior.
By introducing English through songs, stories, and games to children in the home as the Lingokids method does, the language does not become attached to a "foreign" concept, rather a natural part of life.

subset: commoncrawl


text:
Sept. 30, 2014
COACH KELLY: I think we all know a lot about Stanford and Coach Shaw and the consistency that they have played at the national level. We have a great deal of respect for their football team, their program, their coaching staff, their players. It's a veteran football team.
Statistically I think we all know, best defense right now in the country. Offensively a physical brand ever football. Kevin Hogan is an experienced quarterback led by Ty Montgomery, one of the best skill players and special teams player in the country.
Defensively, you know, just a veteran group, Tarpley inside, Anderson off the edge, Richards, I mean, Lyons I could go on and on. I could probably list ten or 15 guys on their roster. Just a deep and talented veteran team and we're just going to have to play really, really good football on Saturday. So with that, I'll open up to questions.
|Notre Dame
Stanford, Calif.
No. 25 Irish Fall at No. 8 Stanford, 27-20
Notre Dame rallies to within one score before committing turnovers on final two drives.
Q. A lot of personnel turnover on defense and new defensive coordinator, what has allowed them to kind of just?
COACH KELLY: Well, they have great continuity. Hired within the staff, same philosophy. David Shaw obviously has maintained that kind of continuity in terms of scheme. They are playing with veteran players that know how to win. It's a winning program.
So a great deal of continuity within their program, even though there's new people at the top of the leadership.
Q. Talk about Joe Schmidt. Your success with walk ons is no secret but going back three or four years, could you have imagined he would turn into the kind of defensive leader and starting middle linebacker that he has?
COACH KELLY: Yeah, I mean, you always hope for great stories and I think the one thing that I've always felt is core to successful coaching is developing your players. Now, you want that to equal wins because if you do that, you get to keep your job. But the core of what we do as coaches and teachers is to develop your players.
So we felt like with player development, that Joe had a chance to be successful here at Notre Dame, or we would not have invited him into the program as a walk on, and a lot of that has to do with Joe, as well. You know, he's put in his time. He's developed physically and mentally and we've done a really good job of bringing him along, so I think both parties working together have gotten him to this point.
Q. Are you surprised a guy like that didn't have bigger offers?
COACH KELLY: Yeah, you know, I think there's a handful of those guys every year. You know, when I recruited J.J. Watt at Central Michigan, you know, why didn't he have more offers. You know, so everywhere that I've been, I've recruited somebody along the way that has turned out to be a great player and he didn't have a lot of offers.
So I think he's another case where there's always going to be a couple of those guys every year.
Q. Will you do anything different this week in terms of reinforcing the importance of protecting the football?
COACH KELLY: Well, I think there's some things specifically. One of the fumbles that we had on the the fire was out at direct snap. We'll spend a little bit more time out at direct snap, because as you know, we are a shotgun base team.
So I think we can spend a little bit more time taking direct snap. Although we do in pre practice take direct snaps; every day, we'll take some more. I think we can work after practice a little bit more on ball security with our quarterbacks and trying to rip the ball loose.
So I think there's some tangible things that we can do to make sure that those errors are eradicated and I think there's some things that Everett is going to need to do relative to progressions and discipline within his progressions.
So I think on both ends, some coaching things and some player discipline can eradicate all of those errors.
Q. Your receiver group is fairly young, can you assess the way they have played?
COACH KELLY: I think it's a group that is gaining confidence along the way. They are making some plays, and I think as you make plays, I've always felt that that's how you gain confidence. I think Chris Brown made some plays and you could see he gained some confidence curing the game.
Certainly Will Fuller is gaining confidence each and every week. You know, so I just think it's a matter of those guys continuing to make plays. I thought that they blocked well opponent the perimeter, which is another important part of the development of our wide receiving core.
So we are four games into it. You know, a third of the way, and I think that they have made pretty good progress. There's a ways to go but pretty good progress in the first third.
Q. The last time Stanford came here, iconic and exciting game. Curious if you can give your recollections of that game and in particular how it ended, and in perspective, what that win might have meant?
COACH KELLY: What I remember about it is playing two quarterbacks. Everett was hurt in the game and we had to go to Tommy. Tommy made a couple big plays. I remember a great defensive goal line stand. I remember as we were trying to go in to score, the rains came and I figured that that meant we were going to win.
So again, I just don't know there's anything really we can take from that game other than it was another step for us during a long season of close victories. I don't know what the significance was in the program other than, you know, we beat a good Stanford team. But we beat a good Oklahoma team that year, too. So again, I think it was just a good, solid football game, and I think we continue to work on getting better and both teams have obviously shown that they are pretty good teams.
Q. Curious what Everett's practices, what his reactions have been like in the couple days since that game now?
COACH KELLY: Well, we'll practice today. But we had meetings yesterday, and one of the things we do is we announced special teams Player of the Week and we have our own, you know, awards that we give out, and one of them is we announce whether there are any national awards and Everett was I think the FBS offensive Player of the Week.
I announce them just because those are things that those kids should hear, and he wasn't too fired up about that.
So I think he feels like from his perspective that maybe he didn't deserve it, I don't know. I don't want to put words in his mouth, but you could tell, if he sits right there in front of me, his body language would suggest that that award should have went to somebody else.
So my guess is, and we'll go to practice today, so I can probably answer your question a little bit better. Body language, film study, all suggested that he's eager to go out and improve as a quarterback.
Q. Ben Councell is a guy we've been talking to you about for a while, and you seemed to suggest that maybe this was the kind of game that would fit; is that in alignment with what you said earlier, and is he healthy and unrusty and ready to go?
COACH KELLY: Yeah, I think he's definitely somebody that we count on and Coach VanGorder is clearly going to employ some different defensive schemes this week.
You know, Ben will be part of the rotation there. We'll see how it plays out. But Ben's healthy and again I think he only got one rep on Saturday, but he's somebody that is definitely in the rotation for us.
Q. Amir, Collinsworth and Jarrett Grace, what are their statuses?
COACH KELLY: Amir will practice today. Collinsworth, Austin, is so much further along. I would expect that he would help us this weekend. And Jarrett Grace, it's a day to day situation for him. And I don't think there's really I don't think our trainers could tell you when that day is that he breaks through, but he's made progress every day.
Q. With the offensive line, you talked a little bit Sunday about, you know, kind of investing in this new alignment and so forth. It's a group that comes early, stays late and you've got talent and you've got depth there and you microwave the chemistry a little bit, or does that come into play in games and experience in those situations?
COACH KELLY: Yeah, it's just simply going to be you know, in this past game, communication was probably the one thing that we'll have to do a better job of communicating with each other and just being comfortable with some new roles.
So I thought there were some good things that occurred out there. You know, we saw look, we're not going to establish, you know, after one game, hey, we've got a left side. That's going to take time.
It's really a work in progress, but there were signs there that we saw that we really liked. I mean, given the defense that we saw on Saturday, there was a lot going on. We sorted out a lot of things. That was not the kind of first game you'd want for five guys coming together for the first time. They sorted a lot of things out and did some pretty good things.
Q. You moved into this week where we're finally going to have hearings for players is your understanding that all the hearings will take place and then you'll find out what's happened?
Will it be piecemeal to find each one out as they happen?
COACH KELLY: Somebody who asked me, I think my wife asked me she did. I really don't know. I have no idea what the process is, other than what a couple of the players have informed me of relative to the hearings taking place this week. But I have no knowledge of when a decision will be levied, how that will take place, whether the players are informed through an e mail or a letter. I just don't have any of that information.
Q. The team has done a very good job of not being distracted by this this announcement could kind of stir that all up again.
COACH KELLY: I mean, they have been pretty resilient up to this point. I think that their focus is they are all pretty excited about playing Stanford, and they know that they are going to have to be at their very, very best to beat Stanford, and any distraction at all will take away from playing a very good football team.
So my sense is that I've got a pretty good feel for this group, and they are really excited about the game. And I'm not saying that they don't care about what happens to their teammates. That's not what I'm saying at all. But they know that they have to be looked in on this game.
Q. Defensively, Stanford has been known as a strong run defense for the past few years and now they are the No. 1 pass defense. What the have you seen from them that's allowed them to be so successful?
COACH KELLY: Well, they have two outstanding corners. It starts at the cornerback position, and I only have three so play a lot of man coverage. You know, do a very good job mixing things up with their scheme, play some zone, play some man. You know, good pass rush obviously helps when you're talking about limiting your opponent in the passing game.
So fairly comprehensive in that I think you start on the perimeter with the cornerback play. Their nickel can match up. I think we have all learned that, as well, that you get really good nickel play, as well. That's going to enhance your coverage ability.
So just a really good defense across the board, and I think it starts with the corners.
Q. They seem to be up front a little small ir, more athletic and more aggressive. Is that more of a scheme change or adjustment to the personnel that happens to be there at this time?
COACH KELLY: Well, Anderson is 287 Murphy (ph) is 284
Q. Compared to what they were last year
COACH KELLY: Well, I think Murphy was a high draft pick. Maybe they lost an NFL player or two, but these are still really fine college football players, and so I haven't seen much of a different size.
You know, 34 is probably one of the more athletic players that we have seen, and I say 34 because I can't pronounce Peter's last name very well. I keep butchering it in the staff meeting, so I'll stay away from it. We recruited him along with he's good friends with Doug Randolph. But he's really athletic and causes some problems in pass rush. He's a little bit different from the prototypical, big, physical Stanford rush player. But he causes all kinds of problems. Other than that, they look the part. They look like a Stanford defense.
Q. And on the other side, they seem to be kind of going through what you guys have been going through, trying to establish their running game, not quite what it's been from a statistical standpoint, talented players. Do you see them going through the same thing you guys have so far, trying to get those guys on the same page?
COACH KELLY: Yeah, you know, I think both of us are trying to find that consistency on both sides of the ball. They have had some turnovers. We have been pretty good in the red zone. They haven't probably felt like they have been as effective in the red zone as they would like, and I know David feels like they are ready to play that kind of offense.
But they are very similar to what they have done. They are in profile from what they have shown in the past. You know, Owusu is a great size kid and Montgomery is a dynamic player. Veach (ph) at the offensive line is one of the best one in the country. They have got the physical offensive line and an experienced quarterback. They have got a match up problem guy with Devon and then great skill with Ty.
So they have got all the pieces there. You know, it's just a matter of time. We just hope it's not this Saturday.
Q. You talked about the team being young and inexperienced, and some people are questioning whether Notre Dame is a Top 10 team. Do you feel a third of the way through the season that you have a Top 10 team?
COACH KELLY: I really don't know. I mean, I don't spend much time, quite honestly, thinking about those things. And I mean, I have to rank us based upon preseason rankings and then if we win, I keep us ranked.
But I don't really think about, hey, have we got a Top 10 team. I really think more about developing our football team, our entire team. And that's really what takes up my time. I'd like to give you a better answer, but I just don't spend much time thinking about it in those terms.
Q. The teams you've played have not been as strong as expected. Stanford is probably the best test you've seen so far. Will you have a better idea after this game, do you think, where exactly your team is?
COACH KELLY: Yeah, you know, I think every week we're presented with that and we go in there with a great amount of respect for Stanford.
But, you know, maybe in three weeks we'll find out that, you know, Stanford wasn't the kind of team, or, you know, Notre Dame wasn't.
Again, we just don't spend much time thinking in those terms. I get where you're coming from from your perspective, but we really focus on what we need to do to get better. We turned the ball over; we gave up some big plays on the perimeter. We focus a lot more on that stuff than the bigger picture issues that I know you have to focus on.
So I think for us, we are so single minded in our focus about developing our players because of what you said originally. We are not an experienced group and if we sway too far from working on getting out of our break, and taking a direct snap because we fumble, you know what I mean, we're going to be in trouble. And so that's where I really have to stay as a task master when it comes to those details.
Q. One of the question marks was the defensive line. How do you think it's performed so far and do I feel how do you think Sheldon Day has done?
COACH KELLY: Sheldon Day has been outstanding. There's probably one part in the game where you can really point to where you separates himself from everybody and that's late in the game, you can arguably say the game is probably over, and he is I mean, he is the pass rusher. I mean, he is by himself, getting after the quarterback. So I thought that singularly was a moment where he separated himself from everybody in terms of his effort, intensity, late in the fourth quarter, we are up a couple of scores and he's out there just playing at 110 percent. That's the mark of a potentially great player.
Q. You saw that Brady Hoke (ph) came under scrutiny leaving the quarterback in after he got hit. Do you have somebody, maybe you don't feel like that inaudible. How do you try to safeguard against something like that happening?
COACH KELLY: Yeah, we have a protocol within our athletic training program that oversees all the players on the field. We have a spotter within our athletic training program. Rob Hunt has spotters that are watching the players on the field. So there's somebody that's responsible for spotting any injuries that are on the field. That's their job. Then there is protocol for how those injuries are assessed. And of course, we have a protocol for, you know, whether there's head injuries or, you know, any other kind of injuries and then they have to go through a battery of test.
So feel very comfortable with our procedures. I'm sure we'll like everybody else in the country, review ours again. But I feel very comfortable that there's really good communication and that we're clearly looking out for all of our student athletes in this game.
Q. With so many moving parts, I'm sure you have a hard time keeping track of who is where during the game. If somebody has a concussion, how do you safeguard that person going in without your knowledge or you're not sure what their condition is?
COACH KELLY: Yeah, our trainers and our doctors control who goes back in the game. So it's out of the hands of assistant coaches and the head coach as to who goes back in the game.
So if somebody is out of the game, Rob Hunt will communicate that with me. He'll say, so and so is out. We're working to see if we can get him back in, or he's out for the game. And we've had that here and that communication since he's from here and it's been very good communication as far as I'm concerned.
Q. Do you think the helmets there could be confusion, does anybody make sure that somebody who is out can't slip on the field?
COACH KELLY: Yeah, I think within his group, and again, we're talking about doctors and trainers, there's a very cohesive group there. They know what their marching orders are. This isn't one where a kid is going to suffer some form of an injury to their head and kind of slide back out on the field.
I haven't even seen an indication that that could possibly occur. If I thought there was a way that it could occur, we probably would have had that conversation already. I feel very comfortable that our training staff and Rob Hunt and our team doctors handle that matter.
Sometimes I even get frustrated. I want to get the guys in if they are capable but they have a protocol they have to go through and sometimes that requires them to leave the field, and they have to take them into the locker room, because they have to be in a place where there's not so much stimulus. That just takes a while. That's just the way it is. We understand that.
Q. I think Stanford has only given up four plays of 20 yards or more, and I don't think any 30 yards or more but they have not played a dynamic offense like yours. You've said in the past about the importance of big chunk plays. Is this one of those games, or is that just not realistic?
COACH KELLY: Oh, no, we won't win if we don't get big chunk plays. But we are not going to go five, seven, ten yards and score enough points to win. No, we'll have to find our chances. We'll have to create opportunities and we'll have to make some plays down the field, there's no question.
So creating those opportunities during the game, is part of what we have to prep during the week.
Q. With regard to the attempted spike of the football, what do you teach the players in terms of when they hear a whistle?
Imagine you'd like them to keep playing, but it may be their instinct to stop. Last year there was an incident in Pittsburgh where Joe Schmidt didn't chase a fumble. What do you see in regard to that?
COACH KELLY: I think in that instance right there, particularly, the Joe Schmidt situation is a little bit different. We've already talked about that to our team.
With Everett's situation, he heard the Whittle and he just backed off and we talked about it. We felt like he did what he should have done in that particular instance. We want him to make sure that he doesn't leave it up to the officials to decide that play again.
But I think with that whistle situation, I think he handled it the right way. It's something that is not scripted. I don't think he didn't do the right thing. If he doesn't hear the whistle, he's got to go get the ball. So what we talked about, you don't hear a whistle, you've got to get on that football. He hears a whistle and he backs off.
Q. This isn't a compare and contrast question, but wondering what Mike Denbrock as your coordinator this year, how you two have worked together and what has he allowed you to do now back in the role of play calling?
COACH KELLY: He does a legally good job of pulling out of the library. We really took a great amount of time of really setting the things in motion that I wanted to achieve offensively. And if you walked into our offensive staff room, you would see volumes of information on the walls, and most of that is philosophy in terms of, here are the things we want to do.
Mike is really good about, you know, pulling the things that he knows that I like to accomplish, you know, in our offensive game plan.
So I think that's what we've accomplished, where he can start to pull things off that wall and I don't have to be in that room and then he can start presenting, hey, what do you think about this, and by and large, we're on the same page as it comes to putting together the game plan.
Q. Was there a moment during the game with Everett making some of the mistakes that he did that you gave consideration to putting Malik Zaire in?
COACH KELLY: No.
Q. And lastly from me, at home, you've won the last six is it the ability to practice in your stadium to what do you attribute the 15 1 mark in the last 16 games?
COACH KELLY: Probably a little bit of all of those things. I think part of it is probably me, too, and getting comfortable with all that goes on during the week. At Notre Dame, there's a lot that goes on and probably just setting what I feel like is a really good schedule for our guys that doesn't overload them and then really, getting them to feel comfortable and relaxed at home. I felt like early in my time here, we were a little uptight and maybe trying to do too much. I think we have relaxed and played a lot more comfortable and really look at it as a home field advantage.
Q. Inaudible has that number improved to where you're a little more comfortable with it?
COACH KELLY: We've been within a few percentage points. We haven't seen a huge drop. And we've seen that our technique is getting better. Our assignments are still in a position that needs to continue to get better. Technique is better. That has moved up. We've got to continue to get better in the assignment area.
Q. In terms of Max, how much does that fall on his plate?
COACH KELLY: Well, Max had a pretty good game relative to assignment. There were some other players that dipped a little bit there. Max is learning the game more so than a particular scheme. And so every game for him out there, as you know, he didn't play the second half of the Purdue game.
So every game out there, he's getting more comfortable and seeing things. It's not that he blows an assignment because he doesn't follow it. It's because the game, he's still learning the game and he's getting better at it every single day.
Q. Is it an issue like having a bad plan is better than having no plan at all?
COACH KELLY: No, no. Again, I want to let's be clear about Max Redfield. Max Redfield is an outstanding athlete, and he knows everything in our playbook.
But when the game starts and your vision requires you to vision something the game is fast right now in some instances and when the game slows down a little bit for him, he is a really smart kid. He understands hour defensive systems. He understands the calls. He is the young and inexperienced that I'm talking about, but there's nobody that's working as hard as him. I mean, he's in here every day learning it. It's just going to take a little time for him. And we're fine, because he's working hard at it.
Q. Going back to the game two years ago, I know you mentioned there are not a ton of takeaways you can take into this year, but in terms of winning those close games and just having that mentality to be able to pull through the a three point win, a seven point win, how important was that development to the point where you could go to Oklahoma and have a tide game in the fourth quarter and then win?
COACH KELLY: Yeah, is that was clearly part of that team, you know, in 2012, they felt like they could win any game they played. You know, Pittsburgh in overtime, that was that group. Each year is a different group.
So we have not been in that situation yet here. So it's hard to tell. This is a different group. And not saying that they couldn't be that same group. They just haven't been challenged in that respect.
But you knew in 2012, that was the leadership in that group that they refused to believe that they could lose a game.
Q. Like your team, Stanford has three guys that are carrying the ball for them offensively. My first question is: Are they different styles of runners?
And my second question is: Their leading rusher in a couple categories, what are you seeing from Wright?
COACH KELLY: Well, Wright is an outstanding back, first of all. But they have some similar traits. They are all about 5 9, 5 10, 190 pounds, physical kids. They are hard runners.
I mean, you know, all of them have a similar pedigree. They are looking for a similar back. You have a catcher coming out of the backfield and they are very much involved in their protections. These are complete backs. They do all phases of the run they are not specialists, if you will.
So good inside, outside runners. That's why they are playing three of them because all three of them have very similar skill sets.
Q. Is his skill set hard to come by where he can do both, he doesn't have one strength one direction or a weakness; he can do both reasonably well?
COACH KELLY: Yeah, he's kind of an interesting player in that, you know, you would say that he's when you look at him, you say, wow, that looks like a prototypical safety, right, and he started his career there, or maybe even a running back. But he has a really interesting skill set in that he's got a burst, he can catch the football, and he's a really good blocker on the perimeter, which they are hard to find. And, willing; you know, he's willing to do some of the dirty work at that position.
So you're always looking for that kind of player that is willing to get in there and do some of the tough work that he's able to do and you're not afraid to throw him the football because he can make those plays.
Now, he's still got a ways to go in route running. He's got a ways to go in tracking the deep ball. But those are the things that he's got to improve on. But the short, intermediate throws, the blocking, he's really been able to help our football team in that respect.
Q. With Amir, how much do you expect him to play on Saturday?
COACH KELLY: I think we are all very surprised where he is today. I thought that, you know, we would probably get him back to running and maybe doing a little bit of individual, but he's cleared for everything today. I'm going to put him in everything but one on one today, just so I don't get him tangled up with somebody.
But I'm going to put him in team. I'm going to put him in seven on seven and I'll probably give him 50 percent of the reps that I would normally give him and then I'll have a good sense after today where we are with him.
Q. Do you feel like they are ready for this kind of
COACH KELLY: Oh, I think so. Yeah, look, our quarterback is capable of being a game changer. I think that we have backs that can impact the game. I think we have wide receivers. I think we have an extremely capable tight end in our offensive line is emerging.
In my opinion, there's no reason why we can't go into this game feeling like yeah, we have to play well. We can't turn the football over five times, but there is no reason why this offense can't win against the No. 1 defense in the country and feel like it can put points on the board.
Now, I don't think anybody is going in there thinking we are going to short circuit the scoreboard. But we're going to play pretty good defense, too. So I think it's a confidence but they know clearly that mistakes will not be I mean, there's no way you can overcome the mistakes that we've made.
Q. On Saturday the personal foul against Romeo, I think you just answered my question (Laughter). I guess what do you do after that when you see something on tape, where it's like, I disagree with this call; how do you register the complaint after the fact?
COACH KELLY: If you knew Romeo, Romeo didn't know what he did. I mean, there's no malice or intend with Romeo.
We have to sometimes hit him with a wet towel once in awhile to get him fired up. It's just one of those things where I think they are trying to protect the quarterback and I think he thought he was trying to drive him into the ground, and we said that that would be the first time that Romeo had driven anybody into the ground. So he didn't see it that way.
Q. As part of the hearing process, players are allowed to bring in members has anyone asked you to appear on their behalf?
COACH KELLY: I'd rather not get into the specifics. I think that's between me and the players.
Q. Given how much time has passed
COACH KELLY: No, I would still stand with that. How much they could play would be clearly based upon when there is a finality to it, right. If it's Friday night, that certainly is going to make it very difficult. If it's tonight, certainly that would increase the odds. But I think I would still stand behind that comment provided that there is at least some time to learn the game plan.
I think today would be about learning the game plan more than anything else. I believe all the guys have tried to stay in a sense a physical conditioning level. Certainly they would not be able to play 40, 50 plays, but I think it would be more about picking up the game plan now.
Q. Given Notre Dame's commitment going forward with the ACC, has there been any discussion about the future of the Stanford series?
COACH KELLY: Yeah, it's one that we will try to protect at all costs. And I know my athletic director, Jack Swarbrick, has communicated to me that he has worked closely with the Pac 12 to make sure that through scheduling that we can keep this series alive.


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From Network World: Cisco Intersight brings cloud management to compute
I don't think anyone would argue with the premise that data centers have increased significantly over the past decade. Data centers used to be orderly, as each application had its own dedicated hardware and software. This was highly inefficient, but most data centers could be managed with a handful of people.Â
Then something changed. Businesses were driven to improve the utilization of infrastructure and increase the level of agility, and along came a number of technologies such as virtualization, containers and the cloud. Also, organizations started to embrace the concept of DevOps, which necessitates a level of dynamism and speed never seen before in data centers.Â
To read this article in full or to leave a comment, please click here


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Pocket app for Android Wear lets you save article, leave phone in your jeans
Google's Android Wear smartwatches are being designed to alert wearers of short notifications and messages, but one company intends to expand its use for longer-form content.
A new Pocket app is being demoed as a way to bookmarking pages on the wrist-worn wearable, which makes it easier to read later on with a bigger screen.
The startup company illustrates that receiving an Android Wear notification from a friend who is recommends an interesting article can be put aside for reading in-depth later on.
The prototype version of Pocket for the smartwatch only requires a swipe to the left and a single tap to save to the deferred reading app.
Why this works
Pocket would make it easier to read the article at a more convenient time, like during a commute.
At the same time, Android Wear would make it easier to save without take out your phone that seems to be getting a bigger and bigger display every two years.
The combination is still in its infancy, according to Max Weiner, Pocket's Android Development lead.
That's not surprising since the Android War SDK just came out and the circular-shaped Moto 360 and still-veiled-in-darkness LG G Watch are the only two Google watches announced.
- Read: Moto 360's beautiful face might feature an OLED sapphire glass screen


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An occasional listing covering bits and bobs about my various trips, climbing or otherwise, plus anything else that pops up. Feel free to add a comment or ask a question.
Wednesday, 11 July 2007
Pokketz Rockets Rocks!
A quick mid-week visit to Birchen was in order - Mr Gregory was desperate for a day out and his car was playing up - so I took along a copy of the brand new Pokketz guidebook to give it a quick test-drive (test-climb?).
The volume performed as expected, locating the routes was easy AND it fitted snugly in my trouser pocket. We did a dozen routes and at the end of the session the guide had performed admirably, which is more can be said for the climbers - they were a little worse for wear (combined age of 128 probably had something to do with that!). We showed the book to a few other climbers and the response was favorable - and although there may be no need to carry the book up a 10m gritstone climb there is obviously potential on mountain crags and sea cliffs - anyone for a Gogarth Pokketz?
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September Snows
View-point at 10,945' We left the UK towards the end of August and the first 10 days were as expected, with everywhere being hot an...
Lofoten Climbs Edition II Cover - photo Andrew Burrr We have been in the Ariège for about 10 weeks now, and it is six months since we le...
We have been on Kalymnos for almost four weeks now and as ever the spring conditions have been superb; warm and sunny, without the oppressiv...
Orpierre, even the out of the way cliffs were busy From Orgon we moved on a couple of hours northwards and had a week in Orpierre. The f...


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Looking for a weekend activity that takes you outdoors and socialising with community members?
Look no further that the St Francis in the Wood Morning Market.
The morning market, which takes place on the first Saturday of every month, gives community members the opportunity to purchase homemade treats and items.
Coffee, cake and a variety of second hand items are also available at the market.
"Community support is vital to the market and to the church," said Father Whitehead.
Father Whitehead said the market is organised and run by a group of committed people from the church.
"We are fortunate to have these people," said Father Whitehead.
For more information on the St Francis in the Wood market, contact Ms Eileen Powell on 078 360 6743.


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Red Hat Bugzilla – Bug 430265
Review Request: hgsvn - A set of scripts to work locally on subversion checkouts using mercurial
Last modified: 2008-02-01 02:48:31 EST
Spec URL: http://terjeros.fedorapeople.org/hgsvn/hgsvn.spec
SRPM URL: http://terjeros.fedorapeople.org/hgsvn/hgsvn-0.1.5-1.fc8.src.rpm
This set of scripts allows to work locally on subversion managed
projects using the mercurial distributed version control system.
Why use mercurial? You can do local (disconnected) work, pull the
latest changes from the subversion server, manage private branches, submit
patches to project maintainers, etc. And of course you have fast local
operations like hg log, hg annotate...
The author sure didn't make it very easy to find the license version. I found
it properly specified only at the end of the __init__.py file.
Shouldn't this require mercurial and subversion in some fashion? It doesn't
really do much without them.
There's a test suite which can easily be run. Add build dependencies on
mercurial, subversion and python-nose and add a %check section containing:
%{__python} setup.py test
* source files match upstream:
* package meets naming and versioning guidelines.
* specfile is properly named, is cleanly written and uses macros consistently.
* summary is OK.
* description is OK (the mercurial advertisement is a bit annoying, but meh.)
* dist tag is present.
* build root is OK.
* license field matches the actual license.
* license is open source-compatible.
* license text included in package.
* latest version is being packaged.
* BuildRequires are proper.
* %clean is present.
* package builds in mock (rawhide, x86_64).
* package installs properly
* rpmlint is silent.
? final provides and requires, missing hg and svn?
hgsvn = 0.1.5-1.fc9
python(abi) = 2.5
X %check is not present, but it should be.
* owns the directories it creates.
* doesn't own any directories it shouldn't.
* no duplicates in %files.
* file permissions are appropriate.
* no scriptlets present.
* code, not content.
* documentation is small, so no -doc subpackage is necessary.
* %docs are not necessary for the proper functioning of the package.
> Shouldn't this require mercurial and subversion in some fashion?
Yes, added.
> There's a test suite which can easily be run. Add build dependencies on
> mercurial, subversion and python-nose and add a %check section containing:
> %{__python} setup.py test
You are correct, implemented.
Thanks for nice improvements!
Updated package:
spec: http://terjeros.fedorapeople.org/hgsvn/hgsvn.spec
srpm: http://terjeros.fedorapeople.org/hgsvn/hgsvn-0.1.5-2.fc8.src.rpm
Cool, dependencies look good:
python(abi) = 2.5
and the test suite is called and passes:
Ran 15 tests in 0.223s
New Package CVS Request
Package Name: hgsvn
Short Description: A set of scripts to work locally on subversion checkouts
using mercurial
Owners: terjeros
Branches: F-7 F-8
Cvsextras Commits: yes
CVS Done
available in rawhide, pushed to testing i f-7 and f-8.


text:
Relax setting and good people
not professional, constant time changes to schedule. Only work if you are desperate
Helpful (2)
I worked at Bio-Reference Labs full-time (More than a year)
Freedom to run territory as your own business.
Lots of pressure to maintain accounts while constantly prospecting for new accounts. Crappy pay. Little resources and support.
Advice to Management
Pay your people more - you get what you pay for.
Helpful (1)
I worked at Bio-Reference Labs full-time (More than a year)
the location was convenient to home
Management expects you to do the work of three people and pay you minimum. Too many meetings and nothing gets accomplished
Advice to Management
Get in the trenches and see what really goes on in your patient service centers. All you ever see is the dollar sign


text:
- Telephone:
- 07836 678089 | 01932 706908
Key factsPrint summary
1 PREVIOUS OWNER WITH FULL SERVICE HISTORY,REAR PARKING SENSORS,ALLOY WHEELS,AIR CONDITIONING,REMOTE CENTRAL LOCKING,ELECTRIC WINDOWS & MIRRORS Black Cloth interior, Metallic Black, IMMACULATE CONDITION THOUGHOUT., £6,675
This car comes with
Metallic Paint, BMW Professional Radio, Stop/start, Park Distance Control (PDC), Rear, Air Conditioning, Automatic with Two - Zone Control, 17in Light Alloy V - Spoke Style 141 Wheels with Run - Flat Tyres, Electronic Windows - Front, BMW Business Radio with Single CD Player (with MP3 Playback Capability), Tyre Puncture Warning System (TPWS), Alarm System (Thatcham 1), On - Board Computer (OBC), Remote central locking, Multi - Function Steering Wheel, Folding rear seats, Air conditioning, Cruise control, Dynamic Traction Control (DTC), ABS, AUX Input, Alloy wheels, Rear parking sensors, 6 Speed gearbox, Body Colour Bumpers, Child locks & Isofix system, Front Passenger Airbag with Deactivation, Drivers Airbag, Anti - Lock Braking System (ABS)
- 201704054113075
- 2010
- 10
- £6,675
- 668
- 70,000
- Cars
- 2Nagbt3KvFo=
Vehicle summary
|Body style
|Engine size
|1995 cc
|Fuel type
|Number of doors
|Number of seats
|Gearbox type
|CO2 emissions
|119 g/km
|Insurance group
|Standard manufacturer's warranty (miles)
|No details available
|Standard manufacturer's warranty (years)
|3 years
|Standard paintwork guarantee
|3 years
Performance & economy
|Fuel consumption (urban)
|52.3 mpg
|Fuel consumption (extra urban)
|70.6 mpg
|Fuel consumption (combined)
|62.8 mpg
|0 - 60 mph
|9.0 seconds
|Top speed
|130 mph
|Engine power
|143 bhp
|Engine torque
|221.28 lbs/ft
|1423 mm
|Height inclusive of roof rails
|No details available
|4360 mm
|2660 mm
|1748 mm
|Width including mirrors
|No details available
|Fuel tank capacity
|51 litres
|Minimum kerb weight
|No details available
|Interior features
|Exterior features
|Interior Trim, Satin Silver
|Exterior Mirrors, Electric Adjustment, Heated
|Power Socket in Rear of Centre Console - 12V
|17in Light Alloy V - Spoke Style 141 Wheels with Run - Flat Tyres
|Outside Temperature Display
|Windscreen Washer Jets, Heated
|Automatic Dimming Rear View
|Body Colour Bumpers
|On - Board Computer (OBC)
|Armrest - Front, Centre
|60:40 Split Folding Rear Seat
|Smokers Package
|Floor Mats, Velour
|Seat Height Adjustment - Front, Manual
|Upholstery - Electra Cloth
|Multi - Function Steering Wheel
|Centre Console
|Air Conditioning, Automatic with Two - Zone Control
|Sports Steering Wheel
|Electronic Windows - Front
|BMW Business Radio with Single CD Player (with MP3 Playback Capability)
|Three - Spoke Leather Steering Wheel
|Steering Column with Manual Reach and Rake Adjustment
|Drivers Airbag
|Alarm System (Thatcham 1)
|Dynamic Traction Control (DTC)
|Dynamic Stability Control (DSC)
|Front Passenger Airbag with Deactivation
|High Level Third Brake Light
|Child Seat ISOFIX Attachment, Front and Rear
|Airbags, Front Sides and ITS Head Airbags - Driver, Front Passenger and Rear
|Park Distance Control (PDC), Rear
|Tyre Puncture Warning System (TPWS)
|Mobility Tyre Sealing System
|Anti - Lock Braking System (ABS)
|Central Door Locking - Remote Control
|Front and Rear Head Restraints - Rear, Foldable and Removable
|Electronic Power Steering
|Electronic Brake - Force Distribution (EBD)
|Engine Immobiliser
|Foglights, Front
Please note
This includes MPG figures which are calculated under European Standards, in test conditions, and will vary under normal driving conditions. The information displayed above describes the typical specification of the most recent model of this vehicle. It is not the exact specification for the actual vehicle being offered for sale which may vary. Specifications for older models may also vary. Please contact us prior to purchase to confirm the exact specification of this vehicle.
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text:
Knocked Over By Love (KIngsley/Harry)Oct. 20th, 2014 12:06 am
Rating: PG-13
Word Count: 1,554
Summary: Harry periodically stops by the Minister of Magic's office.
Kingsley looked up from the report, which depicted various ways to safeguard the Wizarding world from the Muggles, at the sound of a prompt knock. "Yes?"
His secretary, Michelle, stuck her head in and said, "Mr. Harry Potter is here to see you."
"Let him in," Kingsley ordered.
A few moments later, Harry strolled in, a grin plastered on his face. "Hello, Mr. Minister of Magic."
Kingsley returned the grin and continued the old joke. "Hello, Mr. Savior of the Wizarding world. What can I do for you today?"
The grin vanished. "I made the Auror corps."
Kingsley furrowed his brow. "Isn't that a good thing? Didn't you want to become an Auror?"
"Yes, but I felt as if I got through the elimination process too easily. I don't want to be given the job simply because of my reputation or because we're friends. I need to know I got the job because I deserved it. Otherwise, I can't accept it."
Kingsley stood up and walked around his desk. "Do you really think so little of me that you think I fixed it so you got the job no matter what? I'm doing everything in my power to make sure there's no corruption within the Ministry. I definitely won't add to it, especially when I need my Aurors in top shape. You got the job because you're good at catching dark wizards."
Harry looked contrite and Kingsley knew apologies were about to be spewed. "I knew I should have known better. Most of me did know better, but there was a tiny nagging doubt, and I just had to be sure. I'm so used to people fawning over me and giving me anything they think I want, even if I don't deserve it. I just needed to make sure I deserved the job, especially if I want to get any respect from my peers."
Kingsley's eyes softened. He didn't truly blame Harry for his suspicions. "It's okay. You defeated Voldemort; I think it's time you trust your own skills. You belong with the Aurors."
Harry blushed. "Thanks, Kingsley. I'll leave you to get back to work." And Harry was gone as if he was never there.
But he had been there, and Kingsley was left thinking about how his heart fluttered when Harry blushed.
Kingsley was ready when his door opened. His current work was put away and his lunch was on his desk.
Harry popped his head into the office. "You ready for lunch?"
Kingsley gestured with his hand. "Come on in, Harry."
Harry smiled and opened the door wider. Once he was in the room, he softly closed the door, despite the fact there were already rumors circulating the office about Harry and the Minister. He sat his lunch on the desk and plopped down on the plush seat. "So, how have you been the last couple of weeks?"
Kingsley chewed and swallowed his bite before answering. "I've been fine." There was silence as Kingsley tried to think of a way to phrase his next question so he wouldn't hurt Harry's feelings. He decided to just be blunt. "Not like I don't enjoy your company, but why did you want to have lunch with me? I thought there was something you wanted to speak with me about." Kingsley took a bite.
Harry looked at his sandwich. "Am I bothering you?"
"Of course not," Kingsley said. "I'm just curious."
Harry nodded. "Despite being on the same level as the other Aurors, they treat me like a superior. They're constantly gawking at me. A couple of them have even asked me to push my bangs away so they could see my scar. I wanted to get away from them, even if it's only for an hour lunch period. At the same time, I didn't want to eat alone, and you were the first person that came to mind. I just wanted to be around a familiar person who treats me normally."
Kingsley reached across the desk and took Harry's hand. "You're always welcome here for lunch. Just owl or Floo me to make sure I don't have a meeting during the time. If I'm free, my time is yours."
Harry smiled. "Thanks, Kingsley. That means a lot to me."
The rest of the lunch continued in silence, but it wasn't oppressive. In fact, Kingsley thought he could eat in silence with Harry every day, if Harry wanted it of course.
Harry shook his head as Kingsley ate. "I don't know what to do," he bemoaned.
Kingsley stayed silent, knowing that Harry would explain in his own time. Nothing Kingsley said would force him to talk if he didn't want to.
"I don't want Ginny, but everyone seems to expect us to get together.
Kingsley paused in his eating and wiped his mouth with his napkin. "What do you want?"
Harry frowned. "I don't know, but I know it's not Ginny."
Kingsley narrowed his own eyes as Harry avoided all eye contact, looking everywhere in the office but at Kingsley. "You know something. You only avoid eye contact when you're trying to keep something secret."
Harry sighed. "Okay, the thing is..." Harry trailed off, seeming very unsure.
Kingsley patiently waited.
"This doesn't leave the office, but I kind of think Ginny might have the wrong parts, if you know what I mean."
Kingsley's heart skipped a beat. He definitely knew what Harry meant, but he knew he shouldn't get his hopes up, especially when that didn't mean he would be interested in Kingsley. "You need to tell Ginny that. I'm sure she'll accept it when she finds out it's because you're into blokes and not because you simply aren't interested in her. In fact, it might be easier for her to accept you're gay than you simply not being interested."
Harry wrinkled his nose. "I don't get girls."
Kingsley returned the look. "I don't either. It's why I decided to like blokes a long time ago."
There! Now at least Harry knew Kingsley liked the same parts. Now, if only...
"You like guys?" Harry asked.
Kingsley nodded. "Very much so."
Harry's eyes seemed to suddenly focus on him with a startling intensity. "Interesting."
Kingsley stayed late at his office. He didn't want to go home to an empty loft. It was just so lonely. He'd rather work late than go home and sleep.
There was a knock on the door and Harry came in without waiting for a noise of acceptance. After all, by then, Harry knew he was always welcomed.
"It's Friday night, Kingsley. Shouldn't you be out, painting the town red?"
Kingsley looked up at Harry, confusion in his eyes. "Is that a Muggle saying? I'm not sure I understand the meaning."
Harry chuckled. "It simply means shouldn't you be out having fun?"
"Oh. Well, I don't really anyone to have fun with, and it's no fun to be out alone." Kingsley's initial happy expression upon seeing Harry turned morose.
Harry bit his bottom lip. "Well, maybe you can come out with me."
Kingsley stared at Harry, unable to find words as his throat suddenly seemed to close, making it hard to breathe.
Harry blushed. "I mean, like a date because I, erm, kind of fancy you."
Kingsley said the only thing that came to his mind. "I'm so much older than you."
Harry's eyes met Kingsley's, and they implored him to understand. "I need someone older, someone mature, someone who went through the war like me. You are one of the only people who truly understand me. You see my flaws and accept them. You don't put me on some sort of pedestal. You let me be just Harry. You're intelligent and handsome, and when I see you, butterflies swarm in my stomach. You're all I can think about. If I even consider the idea of dating someone else, I feel as if I'm betraying you. I know what I want and it's you."
Kingsley stood up and moved around his desk. He went to Harry and pulled him into his arms. "You're one of the most amazing men I know. You're beautiful, and brave, and foolhardy. You desire justice more than anything, and you do everything you can to make sure it happens. I can't imagine a better person than you or someone else that I'd rather be with. I might be wrong, and I know I'll probably get loads of howlers about it, but I want you. And if you'll have me, I'll take you."
"Kiss me," Harry ordered.
Kingsley bent his head and allowed his lips to gently claim Harry's. He wanted their first kiss to be soft and probing. There would be time later on for passionate and rough.
Kingsley's tongue gently swiped against Harry's bottom lip, and Harry opened his mouth. His tongue explored and playfully battled against Harry's tongue and easily came out of it as the winner.
Hands bunched Kingsley's robes as hands gripped Harry's waist, and they continued to kiss.
When air became necessary, the broke the kiss, but they stayed close enough so their breath mingled.
"You never actually answered my question," Harry reminded him. "So, will you go out with me?"
Kingsley smirked and pulled Harry flush against his body so he could fell Kingsley's prominent interest. "It would be my pleasure."


text:
Business as Unusual
The painter, illustrator and conceptual artist Jim Avignon is one of the most unconventional characters in the current German art world. Vibrant colours and unpretentious materials, a good dose of wit and an enormous output are his trademarks. For the first time an opulent monograph allows a comprehensive insight into the complex oeuvre of the artist, who has always sought confrontation with the establishment and who could never decide whether he wanted to be pop-art, street-art, Picasso on acid or whether he was simply the fastest painter in the world.
Avignon's narrative about "things not going as planned" is full of concise quips and not without a certain delight. He expounds his peculiar relationship with the art market and describes the exhibitions that finally put him on the map as an exceptional artist. We get to read about odd detours into the world of commerce, a stolen bear, paintings that need ironing, call-for-help socks and how a mural almost landed him in jail. Avignon spills the beans about the high and lows of one of the strangest careers the art world has seen in the last 25 years—expect a lot of detail, an ironic undertone and an abundance of images.
Accompanying texts written by ATAK, Sandra Prill, and Lars Willumeit.
Upcoming exhibitions of Jim Avignon:
17/6–30/7 Die Kunstagentin, Cologne
30/6–23/7 Berlin Urban Spree, Berlin
9/7–17/9 Städtische Galerie Böblingen
7/10–28/10 Feinkunst Krüger, Hamburg


text:
Sioux Falls Jazz & Blues presents Erin Bode as part of their 2017-2018 Concert Series on Saturday, October 14 at 8 pm.
Single tickets are $37-$45. Series subscriber tickets are $34-$42. Tickets are available through SFJB online or by phone at 605-367-6000.
Doors : 7:30 pm
Show : 8 pm
The Erin Bode Groupe creates music forged from the Americana of its members' midwestern roots, infused with jazz grooves and made magic by Bode's bell-like voice. Sophisticated arrangements and attention to phrasing, both vocal and instrumental, further distinguish the band's fresh sound. Erin Bode's performance will sooth your soul and feed your heart. She's that good!


text:
Kettering University dietetic technician
Think about what career is best suited for you, and where you want to study. Request more information now.
Think about what career is best suited for you, and where you want to study. Request more information now.
Think about what career is best suited for you, and where you want to study. Request more information now.
Find info concerning Kettering University dietetic technician, registering for elective courses, and taking free tests online. Seek out nationally-accredited nursing programs for the best training. Given a brief hospital internship or prior work experience, you can expect a great return on your education. If you study nutrition, for example, there are a variety of concentrations that may appeal to you such as dietetic technician jobs, clinical internships, or vocational rehabilitation. Check with the nutrition department for an updated schedule of classes, registration deadlines, and a list of dietetic technician program requirements. Due to advances in health care, there is a growing skill-shortage of dietetic technicians, and of qualified medical personnel in general. Please use the form above to request admissions info for Kettering University.
Your weight loss program will succeed or fail based largely on your food environment. Start the day with breakfast, and serve yourself smaller portions. Restaurant and packaged foods generally contain a lot more sodium, fat, and calories than home-cooked meals. Create a shopping list and stick to it, and be especially careful to avoid foods at the ends of the supermarket aisles and along the checkout stands, where grocers tend to sell high-calorie, convenience foods.
In addition to your food and eating-related choices, a dietetic technician can improve your weight loss program by suggesting healthy lifestyle choices. Get plenty of sleep, as a lack of sleep has been shown to have a direct link to hunger, overeating, and subsequent weight gain. Exercise is a dieter's best friend. It not only burns calories, but can actually improve your resting metabolism. Finally, drink more water. You can easily reduce your daily calorie intake by replacing soda, alcohol, or coffee with water.
Per Diem Home Health Licensed Practical Nurse
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