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Traumatic optic neuropathy (TON) refers to any insult to the optic nerve secondary to trauma. It can be classified depending on the site of injury (optic nerve head, intraorbital, intracanalicular or intracranial) or according to the mode of injury (direct or indirect). Direct TON results from anatomical disruption of the optic nerve, for example, a projectile penetrating the orbit of the eye and impinging on the optic nerve. Indirect TON is caused by the transmission of forces to the optic nerve from a distant site without disruption of normal tissue structures. The deformative stress transmitted to the skull from blunt trauma is concentrated in the region of the optic canal. Since the optic nerve's dural sheath is tightly adherent to the periosteum, the intracanalicular segment is particularly susceptible to injury (Anderson 1982; Gross 1981). The intracranial portion of the optic nerve in close proximity to the falciform dural fold is the next most common site of injury (Crompton 1970). In one report using computed tomography (CT) scans about half of all TON cases were found to have an associated sphenoidal bone fracture, an indirect measure of the significant compressive forces involved (Seiff 1990). However, both direct and indirect mechanisms can contribute to optic nerve damage and a clear distinction is not always possible.
Traumatic optic neuropathy is an uncommon cause of visual loss following blunt or penetrating head trauma with a reported incidence of 0.7% to 2.5% in published case series (al-Qurainy 1991; Edmund 1963; Nau 1987). A recent national epidemiological survey of TON in the UK found a minimum prevalence in the general population of 1 in 1,000,000 (Lee 2010). The vast majority of affected patients are young males (79% to 85%) in their early thirties (Lee 2010; Levin 1999). The most common causes of TON in adults are motor vehicle and bicycle accidents (49%), falls (27%) and assaults (13%) (Steinsapir 1998). In a paediatric case series, TON was the result of a fall in 50% and a road traffic accident in 40% of cases (Mahapatra 1993).
Clinical features
Traumatic optic neuropathy is a clinical diagnosis supported by a history of direct or indirect trauma to the head or face. The injury can sometimes be trivial and a careful history must be elicited from the patient. Although usually straightforward, the assessment of TON can sometimes prove difficult in the setting of severe trauma when the patient's level of consciousness is impaired. It is also important to exclude possible reversible causes of visual loss that require immediate attention, for example, a retrobulbar haemorrhage.
The features of TON are:
1. unilateral or bilateral ocular involvement;
2. relative afferent papillary defect except in cases of symmetric, bilateral TON;
3. variable loss of visual acuity ranging from normal to no light perception. Studies have shown that 40% to 60% of patients present with severe visual loss of light perception or worse (Lee 2010; Lessell 1989; Mauriello 1992; Spoor 1990). Direct TON causes severe and immediate visual loss with little likelihood for recovery. The prognosis is better for indirect TON but a high degree of clinical vigilance must be maintained since it can be associated with delayed visual loss secondary to the development of an optic nerve sheath haematoma;
4. impairment of colour vision;
5. variable visual field defects;
6. an optic disc appearance that will depend on the anatomical site of injury. With injuries to the optic nerve anterior to the entry point of the central retinal vessels there is optic disc swelling with associated retinal haemorrhages. With more posterior injuries, which are more common, the fundus looks normal;
7. development of optic atrophy which usually becomes evident about six weeks following the injury.
Computerised tomography (CT) is the best imaging modality for delineating optic canal fractures but the use of neuroimaging in TON varies widely. Some clinicians request CT or magnetic resonance imaging (MRI) or both for all cases, whereas others limit them to those patients with progressive visual deterioration or when therapeutic interventions are being considered (Raji 1982; Seiff 1984; Takehara 1994). The clinical usefulness of neuroimaging in TON remains debatable since there is no consistent correlation between the finding of an optic canal fracture, severity of visual loss and prognosis for visual recovery (Ishikawa 1996; Levin 1994; Mine 1999).
Prognostic factors
Most studies in TON show a significant association between initial and final visual acuities, patients with no light perception at presentation invariably having limited or no visual improvement. Other poor prognostic factors include loss of consciousness, lack of visual recovery after 48 hours and absence of visual evoked responses. The presence of an optic canal fracture was found to predict a poor outcome in some case series but not by others (Carta 2003; Chou 1996; Rajiniganth 2003; Tandon 1994; Yang 2004; Wang 2001). Direct TON is a distinct category that results in severe, irreversible visual loss and no intervention is of proven benefit.
The pathophysiology of indirect TON is likely to be multifactorial and the concept of primary and secondary injury has been proposed (Osborne 2004; Steinsapir 2005). Retinal ganglion cells (RGCs) are specialised cells within the optic nerve and form part of an intricate chain responsible for transmitting information from the eye to the vision centres within the brain. Following trauma there is an immediate shearing of a proportion of RGC axons, an irreversible process with subsequent RGC degeneration. It is postulated that there is then optic nerve swelling within the limited confines of the optic canal secondary to direct mechanical trauma or vascular ischaemia. This further impairs the already compromised blood supply to surviving RGCs setting up a downward spiral towards cell death. This model forms the rationale for optic nerve decompression, whether by medical or surgical means, in order to break this vicious cycle and preserve RGCs that survived the initial insult.
Treatment options
The main treatment options in current use for TON are:
1. systemic steroids of varying dose, duration and mode of administration;
2. surgical decompression of the optic canal;
3. a combination of steroids and surgery;
4. observation alone i.e. conservative management.
Steroids in TON
Steroids have been used in TON since the early 1980s and the pharmacological rationale first arose from their perceived benefits when applied to various animal models of central nervous system injuries (Anderson 1982; Braughler 1987; Hall 1984). Steroids were thought to exert a neuroprotective effect following trauma, the postulated mechanism being their antioxidant properties and the inhibition of free radical-induced lipid peroxidation (Hall 1992). This hypothesis was further reinforced following its clinical application to traumatic spinal cord injuries. The second National Acute Spinal Cord Injury Study (NASCIS-II) was a multicentre, randomised, double-blind, placebo-controlled trial set up to assess the benefits of megadose steroids in patients with acute spinal cord injury. The treatment regime consisted of an initial bolus dose of 30 mg/kg, followed by an infusion at 5.4 mg/kg/hr for a total duration of 23 hours. Patients who received steroids within eight hours of their injury had significantly better improvement in neurological functions compared to those in the placebo group or those who were treated after eight hours (Bracken 1990). In the third National Acute Spinal Cord Injury Study (NASCIS-III), patients who received steroids three to eight hours after their injury experienced greater motor and functional recovery when this regime was maintained for 48 hours instead of 24 hours. For those patients who were treated within three hours of injury, the neurological outcomes in the 24-hour and 48-hour arms of the trial were similar (Bracken 1997). Unsurprisingly, the findings of the NASCIS trials have heavily influenced clinical practice, leading to the increased use of steroids in TON since the mid 1990s.
Steroid regimes
For the purpose of this review, we have used the following classification for the various steroid regimes used in the literature: low dose (< 100 mg), moderate dose (100 to 499 mg), high dose (500 to 1999 mg), very high dose (2000 to 5399 mg) and megadose (> 5400 mg), based upon the initial daily dose of methylprednisolone used (Levin 1999; Steinsapir 2005). The equivalent dose for other steroid agents such as dexamethasone can be calculated based upon their relative potencies compared to methylprednisolone.
Rationale for a systematic review
Traumatic optic neuropathy is an important cause of severe visual loss among young adults but clinicians remain divided over the best management strategy in this condition. The role of steroids in TON remains unclear and a systematic review of the literature on this particular issue is needed to make recommendations for best practice. Surgical decompression of the optic nerve in TON has been the subject of another Cochrane review by the same authors (Yu-Wai-Man 2005).
The aim of this review was to examine the effects and safety of steroids in the management of TON.
Criteria for considering studies for this review
Types of studies
This review included only randomised controlled trials (RCTs).
Types of participants
We included trials in which participants were people diagnosed clinically as having either direct or indirect TON. Bilateral cases were excluded.
Types of interventions
We only included RCTs of TON with the following comparisons:
1. any steroid regimen versus no treatment;
2. any steroid regimen versus any form of surgical optic nerve decompression;
3. any steroid regimen versus a combination of steroids and surgery.
Types of outcome measures
Primary outcomes
The primary outcome measures were the number of Snellen lines of visual acuity gained or lost, at three and six months follow up.
Secondary outcomes
We considered the following secondary outcomes:
1. any other validated measures of visual function, for example, contrast sensitivity and visual fields;
2. any adverse outcomes reported in the trials;
3. any validated quality of life measures assessing participants' views of their treatment and visual disability resulting from TON.
Follow up
We included trials in which participants were followed for at least one month.
Search methods for identification of studies
Electronic searches
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2013, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com (accessed 21 May 2013), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to May 2013), EMBASE (January 1980 to May 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to May 2013), Web of Science Conference Proceedings Citation Index- Science (CPCI-S) (January 1990 to May 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (http://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 21 May 2013.
See: Appendices for details of search strategies for CENTRAL (Appendix 1), MEDLINE (Appendix 2), EMBASE (Appendix 3), LILACS (Appendix 4), CPCI-S (Appendix 5), mRCT (Appendix 6), ClinicalTrials.gov (Appendix 7) and the ICTRP (Appendix 8).
Searching other resources
We searched the reference lists of included studies, other reviews and book chapters on TON to find references to additional trials. We did not manually search any journals or conference proceedings. We contacted trial investigators and experts in the field to identify additional published and unpublished studies.
Data collection and analysis
Selection of studies
Two review authors independently assessed the titles and abstracts resulting from the electronic searches. We obtained full copies of studies that appeared to meet our inclusion criteria. Both authors then assessed the reports to ensure that they met the inclusion criteria detailed above. Any disagreement was discussed and a consensus opinion reached. We excluded reports that did not completely fulfil our inclusion criteria.
Data extraction and management
This was done independently by two review authors and the following information was included.
- study design: method of randomisation, exclusion after randomisation, masking (blinding) of outcome measures, loss to follow up;
- participants: setting; numbers enrolled, numbers randomised, demographics, inclusion and exclusion criteria;
- interventions: timing, duration, dose and mode of administration of steroids; details of surgical interventions; information on operating surgeons if available, for example, level of expertise;
- outcomes: primary and secondary outcomes as detailed above;
- other: additional details thought relevant, for example funding sources.
Assessment of risk of bias in included studies
Two review authors independently appraised studies that met the inclusion criteria for methodological quality. We were not masked to publication details or trial results during this process. The following parameters were used as detailed in Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011):
1. method used for generating the randomisation sequence;
2. allocation concealment;
3. masking (blinding) of clinicians assessing outcome measures;
4. extent of follow up in the various intervention groups.
Each parameter was assessed and subsequently graded as: Yes (low risk of bias); No (high risk of bias) or Unclear. If any parameter was graded Unclear we attempted to contact the study authors for further details before reclassifying to either Yes or No. If clarification was not available, or if any disagreement arose between the two review authors, a consensus decision was reached.
Trials with inadequate methods for generating the randomisation sequence and allocation concealment were excluded. Trials assessed as No for extent of follow up in the various treatment groups was included and subjected to sensitivity analyses (see 'Sensitivity analysis').
In future, if more trials are included, we will follow the methodology below.
Data synthesis
For the primary outcome measures, we will collect the data as LogMAR visual acuity gained or lost at three and six months follow-up. If BCVA was measured using the Snellen chart, for the purpose of statistical analysis, Snellen ratios will be converted to LogMAR decimal values. A LogMAR value of 0 is equivalent to 6/6 Snellen vision and a value of 1.0 is equivalent to 6/60 Snellen vision, the largest optotype on standard Snellen charts. Patients with visual acuities reduced to counting fingers (CF) will be assigned a LogMAR value of 2.0, and those with only hand movement (HM) perception will be given a LogMAR value of 2.3 (Lange 2009; Schulze-Bonsel 2006).
Our goal will be to extract similar outcome data from each study to achieve consistency of results. If data are missing or difficult to interpret from a paper we will contact the authors for more information.
Before carrying out a meta-analysis we will assess heterogeneity by examining the characteristics of the study, the forest plot of results in the studies, and the results of the Chi
One review author (PYWM) will enter the data into RevMan 5 (RevMan 2012) and a second author (PGG) will check the data once it has been entered for errors and inconsistencies.
Sensitivity analysis
We will perform sensitivity analyses to assess how robust the results are to changes in the methods for the review, such as:
1. changing inclusion criteria, for example, timing, duration, dose and mode of administration of steroids;
2. excluding studies graded as No (high risk of bias) for methodological quality;
3. excluding unpublished studies.
Description of studies
Results of the search
The original electronic searches identified 247 reports of studies. These references were checked for potential inclusion in the review, in addition a further 296 references identified from the electronic search for a Cochrane review on surgery for TON (Yu-Wai-Man 2005) were also checked to ensure that no potentially relevant references were missed. It was clear from the abstracts that none were RCTs of steroids in TON. The following experts were contacted and no relevant trials were identified: Professors Roy W Beck, Andrew G Lee, Leonard A Levin, Alfredo A Sadun, Stuart R Seiff and Kenneth D Steinsapir.
Updated searches
An update search was done in November 2010. After deduplication the search identified a total of 501 references. The Trials Search Co-ordinator (TSC) scanned the search results and removed references which were not relevant to the scope of the review. We assessed 10 reports of studies for potential inclusion in the review. Nine reports were excluded after reading the abstract. We obtained a full-text copy of one report (Entezari 2007) which was identified as being eligible for inclusion in the review.
The update search in May 2013 identified a further 378 references. The TSC removed 34 duplicates, scanned 344 references and removed 331 records which were not relevant to the scope of the review. We screened the remaining 13 references and identified one ongoing study; the Traumatic Optic Neuropathy Treatment Trial (TONTT) (NCT01783847). This study will be eligible for inclusion in the review and we will assess this study when data becomes available.
Included studies
We included one study (Entezari 2007) as it met our inclusion criteria. See the 'Characteristics of included studies' table for further details. The Traumatic Optic Neuropathy Treatment Trial (TONTT) will be added to the included studies section when the trial has been completed and data is available for analysis.
Risk of bias in included studies
We graded the included study (Entezari 2007) as having a low risk of bias based on the various assessed parameters of methodological quality.
Eligible participants were randomly assigned to the placebo and treatment arms of the trial.
Both participants and the investigators performing the eye examinations were masked (blinded) to treatment assignment.
Incomplete outcome data
Three months follow-up data were available for all 31 participants successfully randomised into the study.
Selective reporting
The published report included all the expected primary and secondary outcome measures for a trial of this nature.
Other potential sources of bias
Effects of interventions
Mean final BCVA was 1.78±1.23 LogMAR in the placebo group, and 1.11±1.14 LogMAR in the steroid group. The mean difference in BCVA between the placebo and steroid groups was 0.67 LogMAR (95% confidence interval -1.54 to 0.20), and this difference was not statistically significant (P = 0.13). Three months after the initial insult, an improvement in BCVA of 0.40 LogMAR occurred in eight eyes (8/15, 53.3%) in the placebo group, and in 11 eyes (11/16, 68.8%) in the treatment group. This difference was not statistically significant (P = 0.38).
There are several published case series in the literature looking at the role of steroids in traumatic optic neuropathy (TON) and these are discussed below (Chou 1996; Cook 1996; Joseph 1990; Lee 2010; Levin 1999; Steinsapir 2005). We identified only one double-masked, RCT comparing high dose intravenous steroids to placebo in patients with indirect TON diagnosed within seven days of the initial injury. Overall, we found no convincing evidence that steroids provide any additional visual benefit in TON.
Methodological flaws
All the published case series in TON suffer from several methodological flaws that render interpretation difficult. The majority are small, retrospective studies that lack the sample size for rigorous statistical analysis and the absence of adequate randomisation introduces the possibility of selection bias. An example would be patients who failed to improve with observation alone and then get reassigned to receive steroids a few days later. Because these patients probably represent a subgroup with poor potential for visual recovery, introducing these non-responders will have the effect of biasing the results against the steroid group.
Another criticism of some of these case series is the failure to properly document the time interval between the onset of injury and recruitment. This information is important as vision can improve spontaneously in TON (see below). If cases of recent onset are preferentially recruited into a treatment study, the results are more likely to demonstrate a better visual outcome compared to case series where early TON cases are not actively sought by the investigators. Furthermore, the assessment and definition of visual improvement were frequently not clearly stated. In the acute setting, the baseline visual status was often assessed at the bedside but the final outcome was always based upon subsequent clinic reviews. Presumably, most of these patients will then have had a formal refraction to determine best-corrected visual acuity, which might account for part or all of the observed improvement especially if the actual difference was small. These inherent biases in case selection and methods of outcome assessment cast doubt over the benefit reported by positive studies recommending steroids over observation in TON.
Comparing studies
It is very difficult to compare different studies, even qualitatively, because of the wide range of steroid regimes used in terms of dose, duration and mode of administration. Steroids have been used both on its own and in combination with surgical optic nerve decompression either pre-, intra- or postoperatively. The most commonly used agent in TON is intravenous methylprednisolone in the very high dose to megadose range. Unfortunately, case series lack an appropriate control group, which is essential if one is to establish whether the outcome of a particular intervention is better than the natural history of the disease. The differential follow-up times in the treatment groups also prevents any valid comparison.
International Optic Nerve Trauma Study (IONTS)
The International Optic Nerve Trauma Study (IONTS) is the largest, prospective, multi-centre study of TON published to date (Levin 1999). It was intended to be an RCT but it had to be converted to an observational study after two years due to recruitment failure. The study analysed a total of 133 people with indirect TON treated within seven days of injury and categorised into three groups: untreated (n = 9), steroids (n = 85), or optic canal decompression surgery (n = 33). The majority of the steroid group had either a megadose (40%) or very high dose regime (18%) and all the participants in the surgical group, except for one, also received steroids. Follow-up data was available for 104 cases at one month and for 40 cases at six months. After adjustment for baseline visual acuity, there were no significant differences between the three treatment groups; visual acuity increased by three lines or more in 57% of the untreated group, 52% of the steroid group and 32% of the surgery group, (P = 0.22). There was no indication that either the dose or timing of steroid treatment was associated with an increased probability of visual recovery. Although some case series report higher improvement rates with steroids, most figures are in the 44% to 62% range and therefore comparable to IONTS (Chou 1996; Cook 1996; Joseph 1990; Seiff 1990; Steinsapir 2005). It must be stressed also that in none of these TON studies is there any evidence of any additional functional visual benefit with steroids.
National Acute Spinal Cord Injury Study (NASCIS) controversy
The application of steroids to TON relies heavily on extrapolation made from the NASCIS trials and therefore a critical appraisal of their results is appropriate. There is ongoing debate in the literature regarding the significance of the neurological benefit reported by NASCIS among patients treated within the eight-hour window of sustaining a spinal cord injury (see comments in Geisler 2002; Hurlbert 2006; Spencer 2003; Steinsapir 2005). The mean difference (MD) between the steroid group versus placebo indicated a significant benefit for motor scores (MD 5.20, 95% confidence interval (CI) 0.53 to 9.87) but not sensory scores (MD 2.41, 95% CI -1.72 to 6.54) at one-year of follow up. Critics of NASCIS argue that the finding of a beneficial effect for the early treatment group was based on a post-hoc analysis of a small subgroup of the trial, 129 out of the 487 participants, and therefore might represent a statistical artefact. Concerns have also been raised on possible randomisation imbalance between the treatment arms, which might have biased the results in favour of the steroid group. For clinicians, perhaps the most compelling argument is that although statistically significant, the relatively small change in motor scores might not translate into any functional benefit. A Cochrane review on steroids for acute spinal cord injury has not resolved the controversy surrounding the NASCIS trials (Bracken 2012). Its conclusions support the notion that steroids enhance neurological recovery when administered within eight hours of spinal cord injury but the impartiality of this review has been questioned on the basis that the author was one of the principal investigators of the NASCIS trials.
Irrespective of the arguments surrounding the NASCIS results, the unanswered question remains whether extrapolating data from the spinal cord to TON is biologically plausible. The optic nerve is a predominantly "white matter" tract and differs histologically from the spinal cord in both its cellular environment and organisation. Furthermore, there is no comparative data on the actual concentration of active metabolites achieved locally within the optic nerve and the spinal cord following intravenous steroid injections. Unfortunately, these issues add further to the uncertainties of using steroids in TON.
Practical issues
There are practical limitations to applying the NASCIS findings given the narrow window of opportunity available for initiating treatment. There are often unavoidable delays in diagnosing TON when patients have life threatening injuries and these have to take precedence before an ophthalmological opinion is sought. If the patient is unconscious for a prolonged period of time, visual loss is likely to be reported late and even if a clinical diagnosis is made within eight hours, there are ethical considerations to starting controversial treatment without proper informed consent.
Spontaneous visual recovery
A visual recovery rate of 40% to 60% has been reported for indirect TON cases managed conservatively, with baseline visual acuity being the most important predictor of final outcome (Chou 1996; Cook 1996; Levin 1999; Seiff 1990; Steinsapir 2005). These figures are very much comparable with those achieved in patients treated with steroids, surgery or a combination of both. Consistent with these earlier case series, the RCT included in this review (Entezari 2007) provides additional convincing evidence that high dose intravenous steroids does not improve visual outcome when administered in the acute stage, i.e. within seven days of onset of TON.
Adverse effects
If the benefits of a therapeutic intervention are unclear or likely to be small, it becomes even more important to consider the possible adverse effects. The more important studies in the literature regarding the safety profile of different steroid regimes are summarised below.
a. High dose steroids
The Optic Neuritis Treatment Trial (ONTT) used a high dose steroid regime: 250 mg of intravenous methylprednisolone every six hours for three days, followed by 1 mg/kg/day of oral prednisolone for 11 days. Only two participants (1.3%) in the intravenous methylprednisolone group had serious side effects, one case of acute psychosis and one case of acute pancreatitis, both resolving without sequelae (Beck 1992).
b. Very high dose steroids
A meta-analysis has been published of about 2000 patients from 51 studies receiving very high dose intravenous methylprednisolone prior to elective and trauma surgery, not requiring intensive care. Pooled data failed to show any significant increase in complication rates although more cases of gastrointestinal bleeding and wound complications were observed in the steroid group (Sauerland 2000).
c. Megadose steroids
Although not statistically significant, gastrointestinal bleeding (RR 2.11, 95% CI 0.81 to 5.49) and wound infections (RR 1.48, 95% CI 0.48 to 4.56) were observed more frequently in NASCIS-II patients treated with steroids for 24 hours (Bracken 1990). In NASCIS-III, there was a trend towards more cases of severe sepsis (RR 4.00, 95% CI 0.45 to 35.38) and severe pneumonia (RR 2.25, 95% CI 0.71 to 7.15) in those on the extended steroid regime of 48 hours instead of just 24 hours (Bracken 1997).
Overall, these studies indicate that steroids are relatively safe but serious complications can occur and these need to be considered, especially if pre-existing susceptibility factors are present.
d. Corticosteroid Randomisation After Significant Head Injury (CRASH) study
The CRASH study was recently published and its findings are relevant to the present discussion on the role of steroids in TON (Edwards 2005). It was a large RCT investigating the effectiveness and safety of steroids in patients with acute traumatic brain injury. Patients presenting within eight hours of head trauma were allocated to either placebo or megadose intravenous methylprednisolone (2 g over one hour followed by 0.4 g/h for 48 hours). The initial protocol was to recruit 20,000 participants but the trial was terminated prematurely after 10,008 people had been enrolled. This decision was reached by the data monitoring and ethics committee after interim statistical analysis of the results showed that steroids were having a detrimental effect. At six months follow up, the risk of death was higher in the steroid group than in the placebo group (25.7% versus 22.3%; RR 1.15, 95% CI 1.07 to 1.24; P = 0.0001), as was the risk of death or severe disability (38.1% versus 36.3%; RR 1.05, 95% CI 0.99 to 1.10; P = 0.079). There was no evidence that the effect of steroids differed by timing of injury or severity. This landmark trial and a recent Cochrane review on corticosteroids for acute traumatic brain injury (Alderson 2005) both conclude that steroids should no longer be routinely used in patients with traumatic brain injury. The findings of the CRASH study must therefore be seriously considered in the subgroup of TON patients who have co-existing head injuries. The underlying mechanism for the increased mortality in the group treated with steroids remains to be elucidated.
e. Animal studies
Experimental models of TON have been developed and the most widely used one involves a direct, mechanical crush injury to the rat's optic nerve (Levkovitch-Verbin). Although one should be cautious when extrapolating evidence from animal studies, these have provided important insights into the pathophysiology of optic nerve injury and the effects of steroids. In two studies, rats treated with various regimes of methylprednisolone were compared with sham controls following an optic nerve crush injury. One study failed to show any difference on retinal ganglion cells survival and axonal regeneration between the two groups (Ohlsson 2004). However, the other study found that steroids exacerbated axonal loss and there was a significant, dose-dependent decline in axon counts with increasing doses of steroids (Steinsapir 2000). These conclusions are thought provoking and some investigators now believe that steroids can exert a negative effect on neuronal survival by suppressing key events in an endogenous neuroprotective pathway (Diem 2003). For this reason, a maximum daily dose of 1g methylprednisolone, or equivalent, has been advocated in TON to minimise the risk of neurotoxicity (Steinsapir 2005).
Authors' conclusions
Implications for practice
There is a relatively high rate of spontaneous visual recovery in traumatic optic neuropathy (TON) and there is no convincing evidence that steroids provide any additional benefit over conservative management. Each case needs to be assessed on an individual basis and the patient needs to be made fully aware of both the theoretical risks suggested by recent studies, and the real risks, although rare, of a serious adverse reaction to steroids.
Implications for research
The logistics required for an adequately powered randomised controlled trial (RCT) in TON are daunting, and it is unclear whether additional RCTs looking at a very high dose or megadose steroids would be ethical given the current evidence. Areas of prevention should be explored further to determine whether public health strategies are effective in reducing the incidence of TON in high-risk groups. Recent animal studies and the CRASH trial have also highlighted significant gaps in our understanding of central nervous system injuries and there is an urgent need for further research into the role of steroids in modulating neuronal recovery.
We gratefully acknowledge the active support of Anupa Shah and the Cochrane Eyes and Vision Group (CEVG) editorial team. We thank Catey Bunce, James Acheson, Stephen Gichuhi and Tianjing Li for their comments on this review and/or the protocol.
Richard Wormald (Co-ordinating Editor for CEVG) acknowledges financial support for his CEVG research sessions from the Department of Health through the award made by the National Institute for Health Research to Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology for a Specialist Biomedical Research Centre for Ophthalmology.
The views expressed in this publication are those of the authors and not necessarily those of the NIHR, NHS or the Department of Health.
Data and analyses
This review has no analyses.
Appendix 1. CENTRAL search strategy
#1 MeSH descriptor Optic Nerve
#2 MeSH descriptor Optic Nerve Diseases
#3 MeSH descriptor Optic Nerve Injuries
#4 optic near nerve*
#5 optic near neuropath*
#6 optic near injur*
#7 optic near trauma*
#8 optic near contusion*
#9 optic near compress*
#10 optic near avulsion*
#11 optic near transection*
#12 optic near damage*
#14 MeSH descriptor Steroids
#15 steroid*
#16 MeSH descriptor Prednisolone
#17 prednisolone
#18 MeSH descriptor Prednisone
#19 prednisone
#20 MeSH descriptor Methylprednisolone
Appendix 2. MEDLINE (OvidSP) search strategy
1 randomized controlled trial.pt.
2 (randomized or randomised).ab,ti.
3 placebo.ab,ti.
4 dt.fs.
5 randomly.ab,ti.
6 trial.ab,ti.
7 groups.ab,ti.
8 or/1-7
9 exp animals/
10 exp humans/
11 9 not (9 and 10)
12 8 not 11
13 exp optic nerve/
14 exp optic nerve disease/
15 exp optic nerve injuries/
16 (optic adj2 nerve$).tw.
17 (optic adj2 neuropath$).tw.
18 (optic adj3 injur$).tw.
19 (optic adj3 trauma$).tw.
20 (optic adj3 contusion$).tw.
21 (optic adj3 compress$).tw.
22 (optic adj3 avulsion$).tw.
23 (optic adj3 transection$).tw.
24 (optic adj3 damage$).tw.
25 or/13-24
26 exp steroids/
27 steroid$.tw.
28 exp prednisolone/
29 prednisolone.tw.
30 exp prednisone/
31 prednisone.tw.
32 exp methylprednisolone/
33 or/26-32
34 25 and 33
35 12 and 34
The search filter for trials at the beginning of the MEDLINE strategy is from the published paper by Glanville et al (Glanville 2006).
Appendix 3. EMBASE (OvidSP) search strategy
1 exp randomized controlled trial/
2 exp randomization/
3 exp double blind procedure/
4 exp single blind procedure/
5 random$.tw.
6 or/1-5
7 (animal or animal experiment).sh.
8 human.sh.
9 7 and 8
10 7 not 9
11 6 not 10
12 exp clinical trial/
13 (clin$ adj3 trial$).tw.
14 ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$)).tw.
15 exp placebo/
16 placebo$.tw.
17 random$.tw.
18 exp experimental design/
19 exp crossover procedure/
20 exp control group/
21 exp latin square design/
22 or/12-21
23 22 not 10
24 23 not 11
25 exp comparative study/
26 exp evaluation/
27 exp prospective study/
28 (control$ or prospectiv$ or volunteer$).tw.
29 or/25-28
30 29 not 10
31 30 not (11 or 23)
32 11 or 24 or 31
33 exp optic nerve/
34 exp optic nerve disease/
35 exp optic nerve injury/
36 (optic adj2 nerve$).tw.
37 (optic adj2 neuropath$).tw.
38 (optic adj3 injur$).tw.
39 (optic adj3 trauma$).tw.
40 (optic adj3 contusion$).tw.
41 (optic adj3 compress$).tw.
42 (optic adj3 avulsion$).tw.
43 (optic adj3 transection$).tw.
44 (optic adj3 damage$).tw.
45 or/33-44
46 exp steroid/
47 steroid$.tw.
48 exp prednisolone/
49 prednisolone.tw.
50 exp prednisone/
51 prednisone.tw.
52 exp methylprednisolone/
53 or/46-52
54 45 and 53
55 32 and 54
Appendix 4. LILACS search terms
optic and nerve$ and steroid$
Appendix 5. Web of Science CPCI-S search strategy
#8 TS=prednisone
#7 TS=prednisolone
#6 TS=steroid
#4 TS=optic trauma
#3 TS=optic injury
#2 TS=optic nerve
#1 TS=optic neuropathy
Appendix 6. metaRegister of Controlled Trials search strategy
optic AND nerve AND steroid
Appendix 7. ClinicalTrials. gov search strategy
optic AND nerve AND steroid
Appendix 8. ICTRP search strategy
optic nerve AND steroid
What's new
Last assessed as up-to-date: 21 May 2013.
Protocol first published: Issue 2, 2006
Review first published: Issue 4, 2007
Contributions of authors
Conceiving the review: PYWM
Designing the review: PYWM
Coordinating the review: PYWM
Data collection for the review
- Designing search strategies: Cochrane Eyes and Vision Group editorial base
- Undertaking searches: Cochrane Eyes and Vision Group editorial base
- Screening search results: PYWM, PGG
- Organising retrieval of papers: PYWM
- Screening retrieved papers against inclusion criteria: PYWM, PGG
- Appraising quality of papers: PYWM, PGG
- Extracting data from papers: PYWM, PGG
- Writing to authors of papers for additional information: PYWM, PGG
- Providing additional data about papers: PYWM, PGG
- Obtaining and screening data on unpublished studies: PYWM, PGG
Data management for the review
- Entering data into RevMan: PYWM
- Checking data entered into RevMan: PGG
- Analysis of data: PYWM, PGG
Interpretation of data
- Providing a clinical perspective: PYWM, PGG
- Writing the review: PYWM
Declarations of interest
None known.
Sources of support
Internal sources
- Department of Ophthalmology, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK.
External sources
- No sources of support supplied
Index terms
Medical Subject Headings (MeSH)
Injections, Intravenous; Methylprednisolone [administration & dosage]; Optic Nerve Injuries [*drug therapy]; Randomized Controlled Trials as Topic; Steroids [administration & dosage; *therapeutic use]; Visual Acuity [physiology]
MeSH check words


text:
No refunds are permitted on HOT DEALS. Where a
booking is Cancelled or Amended the full quoted amount of the reservation will
be charged. Payment will be taken at time of reservation.
Stay in one of our Gardenview Rooms with 2 Queens beds,
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Join Distinction Te Anau Hotel & Villas & Trips and Tramps for:
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Upgrade this package to a family of 2 adults and 2 children for $610.00 (using existing bedding).
2 x nights accommodation for 2 people at Distinction Te Anau Hotel & Villas
+ Complimentary upgrade to a Lakeview Room
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+ Full daily breakfasts for 2 people
+ On your first night, enjoy a 2 course dinner prepared from fresh in season produce at the hotel's on-site restaurant, overlooking picturesque Lake Te Anau.
+ 2 tickets to Ata Whenua Cinema - Relax in the most comfortable cinema in the South Island while watching the awe inspiring scenery unfold.
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subset: commoncrawl


text:
A Book "Records of Old Mobile Cathedral of Immaclate Conception Mobile, Alabama" Index 1 Transulated and Indexad by Brother Jerome Lepre, S.C Jan 1992 you can contact The Jackson Count Genealogical Society P.O. Box 984 Pascagoula, Mississippi 39567. I also remember recieving a notice a few years back of the church publishing another book but of course I couldn't find it amung all my papers. Hope it Helps.
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Wiki Headlines
18th Nov: We've switched servers and will be updating the old code over the next couple months, meaning that several things might break. Please report issues here.
main index
This is a summary of the Heroine archetypes from The Complete Writer's Guide to Heroes & Heroines: Sixteen Master Archetypes (see the footnote on the index page, Heroes And Heroines). You can also find the Hero archetypes on Romance Genre Heroes. Most of the Heroines are female versions of the Heroes.Also listed are the villainous versions of the Hero archetypes; these come from the website of one of the authors (again, see the footnote on the index page).
Quick OverviewThe eight Heroine archetypes presented are as follows:
Character Examples
Comparing the Gender RolesLet's consider the Hero/Heroine pairs. These subdivide as follows:
Greater Detail


text:
Synopsis: Police officer Rick Grimes leads a group of survivors in a world overrun by zombies.READ MORE ABOUT The Walking Dead
This week had everything you look for from "The Walking Dead" – gross zombie death, intense suspense and obvious metaphors.Read More »
You see a murderous horde, Fred sees a "zombie flash mob."Read More »
Carol and Daryl search for Beth in a quiet episode.Read More »
The Walking Dead isn't just getting better. It's starting over.Read More »
Plus: the Disney Vault needs to be opened, and whether music critics are an endangered species.Read More »


text:
Hello Everyone.
Well I am finally researching this side of my family. I'm a direct descendent of Casper Bunner and Christina Brown and am hoping to get some/any information regarding Casper's parents and or children. Here is my line:
Casper Bunner - Christina Brown
John Bunner - Martha ???? Not sure of last name
James S. Ferrell - Rebecca Bunner
James Ferrell - Catherine Summers
Ferrell line continues.
Any help would be greatly appreciated regarding the Bunner side.
Take care
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The failure of Indian recurve archers Deepika Kumari, Tarundeep Roy and Rahul Banerjee etc to make a mark in Incheon Asian Games or in London... ...http://www.dnaindia.com/sport/report-indian-archers-to-get-mental-trainers-for-international-events-2033643
Rio De Janeiro, Nov 1 Olympic medal prospect Marcus D' Almeida hopes this week's Brazilian Archery Championships can kickstart his quest for gold... ...http://www.prokerala.com/news/articles/a501686.html
2014 was a vital year for the archers. The much-awaited World Cup archery tournament was held in four preliminary phases, starting from 22nd April... ...https://in.news.yahoo.com/important-milestones-events-matches-world-052209281.html
Deepika Kumari was visibly pensive as she wrapped up practice at JRD Tata Sports Complex, Jamshedpur, earlier this week. Her erstwhile exuberance... ...http://www.telegraphindia.com/1141020/jsp/jharkhand/story_18944264.jsp
Michael Phelps of the United States. Photograph: Sean Kilpatrick / AP Photo / The Canadian Press/File photo American swimmer Michael Phelps, the... ...http://www.rediff.com/sports/report/sports-shorts-olympic-champ-phelps-suspended-for-six-months-australian-open-prize-money-increased-keane-ferguson-pirlo/20141007.htm


text:
"We are not going in circles, we are going upwards. The path is a spiral; we have already climbed many steps." ― Hermann Hesse, Siddhartha
When I was like 14, I read The Hot Zone, and became immutably terrified forever of filoviruses like ebola that cause hemorrhagic fever. I, and basically every woman I know who is now in her 30s, became convinced that it was only a matter of time before some avian swine monkey sheep flu got on a plane in the rainforest and came to wipe us all out. Not just killing you quickly and mercifully, but making your organs liquify and blood shoot out of every orifice and pore. I was afraid of pandemics. I was afraid of AIDS. I was afraid of global warming and nuclear war and a meteor hitting the earth and killing everyone on it, because dinosaurs used to walk where I stand. DINOSAURS. There used to be giant monster lizards roaming all over this shit and they're gasoline now. I mean, it doesn't look good, you know? So this summer, I watched in horror, paralyzed, as more and more people in West Africa became sick with ebola. Yep, this is it, I thought. This is what it's going to be. Zombies are real. We are all going to fucking die.
But actually, I just wasn't that scared really. Like, I thought I should be scared, because some really scary shit went down this summer. But I wasn't. Not really. Not even when people in Dallas started to get ebola. I mean, I know the science behind contagions like this, and I think in the back of my mind, I believed the CDC could keep it under control, in spite of the massive failures of the healthcare system.
But...Did I really believe that?
Or am I just too numb to actually feel anything?
I cried at a Ryan Adams concert a couple weeks ago. My amazing, lovely friend who works at KLRU took me to his ACL taping, and a few songs in, I cried. Like real tears. I don't even like Ryan Adams. At all. Not really. I mean, there are worse things to listen to, but he's really not my jam at all. But I felt something. I was present. Because it was the first show I had been to in so long where no one, not a single person, was on their phone. There were no screens or Instagrams or Tweets or Facebooking. It was just a guy and a guitar and a roomful of quiet, attentive people. It FELT like one of the most amazing shows ever. I know that's not actually true, but it felt real, Like it used to. It made me remember that I used to like bands.
I feel like I've awoken and found myself having retreated into a world of distraction, of endless clicks and likes and texts and messages and fewer and fewer real experiences with people. I don't write anymore because I have nothing to say. I am not here. And I am desperate for personal, meaningful, visceral human contact. I am quietly yearning to be ravaged by emotion and physical affection and just... anything. Everything. I used to feel special, like I knew myself, like I had everything planned out forever. But now I just feel like life is blowing by me at a pace I can't fathom and I am too busy clicking on another story to notice.
Fuck Facebook. Seriously. Fuck it so hard. Stop fucking making us into idiot drones who watch two minute viral videos and click through 40 page slideshows of dumb gifs of cats and read celebrity gossip that tears people down and invades their privacy and rants on politics and on feminism which always turn into really being about racism and think that's what being alive is. Fuck politics and sports and pundits and Jezebel and basic bitches and award shows and stupid bullshit pop culture. I'm so tired of feeling like I live in Idiocracy.
And yet... there's always that hopeless, reckless optimism inside me that just won't die no matter how hard I try to kill it. I'm trying to find my way out. I am back at the beginning, trying to get back on track with fitness and self care to maybe, somehow, pull myself out of the hole of apathy I fell into. When the path is a spiral, eventually you're going back up again. I want to be present with people in my life. I want to put down the phone and the laptop and be there. I want to create and grow and laugh and love. I want to go and do. I want to move and breathe and feel all the feelings there are. I want sunrises and fireworks and magic. I can still love. I know it. We are still so young. There is so much left to look forward to.
This world, our now, is terrifying. It's dark and violent and dangerous and chaotic. Everything falls apart, and sometimes it comes back together, and then it falls apart again. All we have is each other. All we have is today. We have to go outside and listen and look at each other and hug and laugh and kiss and fuck and sweat and cry and scream and dance and run and play and do it now. This computer is not life. It's not.
This is all over the goddamn place, but it's something. Who knows, maybe I'll write something else in a few days. Rinse. Repeat.


text:
Select () or exclude () categories to narrow your recipe search.
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Find exactly what you're looking for with the web's most powerful recipe filtering tool.
1/3 Photos of Chinese Chicken Noodle Salad
Prep Time:
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If you love pasta salads that contain crisp veggies you'll love this. The dressing is really delicious. The flavors get better after 2 or 3 days in the fridge. I got this great recipe from a friend.
Units: US | Metric
Serving Size: 1 (132 g)
Servings Per Recipe: 12
Every recipe, menu, tip and how-to is right here, at your service.


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Fisher-Price Rumbling Gold Mine Run
Fisher-Price Rumbling Gold Mine Run brings Thomas on a real adventure. Kids can push Thomas through the adventure ramp and then press the Water Tower to move Thomas up the ramp and through the tunnel. Conveyer belt sounds play as Thomas rolls up the ramp. Full of movements through the mine, caves and tunnels, the game even has an explosion at the mine door. At the loading area by the mountain, children can load up for delivery mining supplies or gold ore.
Why You'll Love It: Kids will get a chance to venture into gold mines and experience the thrill of caves and tunnels with Thomas.
Age: 3 years and up
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text:
Marshall for Senate
Updated: 01/07/2008 - Delegate Bob Marshall, one of the state legislature's most persistent abortion opponents, will announce his Republican candidacy for the U.S. Senate.
Updated: 01/07/2008 - Delegate Bob Marshall, one of the state legislature's most persistent abortion opponents, will announce his Republican candidacy for the U.S. Senate.
Posted: 01/07/2008 - The deadline is approaching for voter registration for the Presidential primaries.
Posted: 01/07/2008 - The Presidential Debate over the weekend attracted a young crowd, in spite of NFL Wildcard games because of Facebook.
Posted: 01/07/2008 - As the race begins to take shape, Virginia could play a bigger role later this year.
Updated: 01/04/2008 - Thursday marks a complex and odd part of the political process that will play a large role in deciding who becomes the next U.S. President: the Iowa Caucus.
Posted: 01/02/2008 - With the races too close to call, candidates spent their last full campaign day before the Iowa caucuses urging voters for their support.
Updated: 01/02/2008 - Candidates are using the first day of 2008 to make last-minute appeals to the undecided voters of Iowa.
Posted: 12/24/2007 - Call it the anti-endorsement.
Posted: 12/21/2007 - A dozen presidential candidates, six Democrats and six Republicans, met the state's deadline for submitting petitions to qualify for Virginia's February 12 primaries.
Posted: 12/21/2007 - Governor Tim Kaine will be on the campaign trail in South Carolina and Iowa this weekend for Democratic presidential candidate Barack Obama.
Updated: 12/14/2007 - With the election two years away, State Senator Creigh Deeds of Bath County announced Thursday he's running for governor.
Posted: 12/10/2007 - He is the third Democrat to visit the city in the past three months.
Posted: 12/10/2007 - According to newly filed campaign finance reports, candidates in last month's Virginia legislative elections raised a record of slightly more than $67.2 million.
Posted: 12/07/2007 - Republican presidential candidate Mike Huckabee has unveiled a tough immigration proposal.
Posted: 12/06/2007 - Republican presidential candidate Mitt Romney is confronting skepticism about his Mormon faith.
Posted: 12/01/2007 - Negative TV ads hit the airwaves in Iowa and New Hampshire this weekend, marking the start of mudslinging in the 2008 presidential campaign.
Updated: 11/29/2007 - Democratic presidential candidate Dennis Kucinich plans to attend a Charlottesville fundraising event.
Updated: 11/29/2007 - Barack Obama became the first presidential candidate to submit petitions qualifying him for a spot on Virginia's primary ballot in February.
Updated: 11/07/2007 - Candidates for the 24th District State Senate seat worked through the night and into the morning to secure extra votes on Monday and Tuesday.
Updated: 04/19/2010 - With the rock star quality that he's known for, Presidential candidate Barrack Obama took to the stage in Charlottesville Monday night.
Posted: 10/16/2007 - Hillary Clinton has eclipsed all other presidential candidates among West Virginia political contributors.
Posted: 10/10/2007 - Republican Sam Brownback says he will end his presidential bid if he finishes lower than fourth place in the Iowa caucuses.


text:
Aegean's Beirut flights will run Tuesdays, Thursdays and Saturdays. (AP Photo/Thanassis Stavrakis, File)
BEIRUT: Greece's Aegean Airlines has launched its first direct route to Lebanon this month with round-trip tickets starting at $351.
Agenor Aviation Services, a division of Johnny R. Saadé Holdings, signed an agreement with Aegean Airlines earlier this month to be its exclusive representative in Lebanon.
Fares for one-way flights are approximately $117 and round-trip flights start at $351.
Flights are scheduled to operate on Tuesdays, Thursdays and Saturdays with three trips per week. The duration of the Beirut-Athens flight is roughly two hours.
The first flight between the two destinations debuted on June 6.
Flight chaos as ultra-Orthodox Jews refuse to sit near women
Fire grounds flights in Chicago, snarls air traffic
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Flight chaos as ultra-Orthodox Jews refuse to sit near women
Fire grounds flights in Chicago, snarls air traffic
Greece's Aegean Airlines has launched its first direct route to Lebanon this month with round-trip tickets starting at...
With the seemingly endless options of luxury apartments popping up all over the city, buyers, particularly a younger,...
Lebanese ministers Saturday sought to mitigate the repercussions of the recent food safety scandal on the economy...
In war-torn Syria, where Mikhail Zuhir comes from, a nighttime knock on the door can mean death, but when he rings the...
The mood in Lebanon may be gloomy on Independence Day after celebrations were canceled over the presidential vacuum,...
Cyprus has intensified screening at its ports, airports and checkpoints that dot the island's dividing line to prevent...


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Sponsored Deals
They're like ads, but good.
OK, yes, companies pay a little something to be Sponsored Deals. But we don't allow just any old crap in this section. Sponsored Deals are proposed to us by other retailers, manufacturers, and even other daily deal sites. If we find the deal compelling enough that our members will appreciate us bringing it to their attention, we'll feature it here. Believe it or not, we have a reputation to uphold. If your store would like to be considered for this space, please contact us for details. But if your deal is lame, or sketchy, no amount of money will let you buy your way in.
Community Deals
It's whatever you want it to be.
Pretty much, anyway. This is where you find the deals that wooters like you have ferreted out and brought to light. We're thinking it'll turn into a massive database of discounted products from around the Web, constantly expanding to absorb the newest deals from the very moment their prices are slashed, with each deal immediately rated by hordes of savvy voters to spotlight the very greatest deals in the world today. Hey, we can dream, right?
We use a fancy algorithm to determine which deals are catching the most buzz – they're under the Popular tab, which is the default view of this section. You can look for the most popular deals today, this week, or this month. The Fresh tab features the most recently submitted deals, so that's where to look for deals that everybody else doesn't know about yet. And the Search bar does what a Search bar does, only, uh, much wootier! Yeah! Right on!
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Organic bullets? Vegetarian haggis? Cheap tickets to Antarctica? The best high-performance sweatsocks for under $100? If you're looking for a deal that doesn't appear to show up in our Community Deals section, throw the question to your fellow cheapskates. Or answer a question for one of your fellow cheapskates. Or vote for your favorite questions, or your favorite answers, or… maybe we should call this section "Ask, Answer, Comment On, And Vote In The Community", but that won't fit on the page.


text:
Edgartown House Rental Photos and Description
5 Bedrooms, 2.5 Bathrooms, Basement, sleeps 14.
This large, 5 bedroom home is a few blocks from downtown Edgartown (restaurants, shops, historical sites, and marina). The bottom floor has a large L-shaped living/dining area with fully-equipped kitchen and breakfast bar. Also, on the first floor is a queen size bed with pillow top mattress, cable TV, half bath, and cable TV throughout the entire house. On the second floor is the master bedroom with king size bed with pillow top mattress, private bath, and private balcony outside of master bedroom. Also, on this floor is a ''kids bunk room'' with 2 bunk beds (full bottom bed, top is twin) which sleeps six. Second floor also includes full bath and laundry room. The third floor has 2 extra large bedrooms, both with king size beds, and lounge area. Other amenities include 4 cable outlets, big-screen TV, surround sound, high speed internet and air conditioning. Large side deck with jacuzzi, grill and outdoor dining. Large backyard.
Mahogany front porch, fully furnished.
Completely finished basement with ping pong and pool table, cable TV, and workout room. Full size futon included in basement.
- Suitability:
- non smoking only
- pets not allowed


text:
Representatives must horde power and leverage
to get re-elected.
There is (thusly) something wrong (very wrong) with people "electing" representatives.
If there were 435 RP's in office there'd be no point of Gov't -- because each one of them would never propose any form of spending, no one from their district would have benefited from spending millions to get them elected (so they wouldn't) and people would be "electing" them because they wanted to be left alone to "lord" over corporations via the market (consumer-sovereignty).
People (in reality) elect to have representatives reverse or circumvent consumer-will toward their groups benefit.
- Login to post comments


text:
November 28, 2014
UPDATED Wednesday, August 5, 2009 --- 10:00 a.m.
SHAWANO, Wis. (AP) -- Two people who died in a collision between their car and a semitrailer truck have been identified Wednesday as an elderly Shiocton couple.
Seventy-nine-year-old John Carpenter and his 78-year-old wife, Betty Carpenter, died at the scene of the crash Tuesday afternoon on Highway 29 west of Shawano.
Witnesses told Shawano County sheriff's investigators the car failed to stop for traffic when crossing the highway at an intersection.
The 72-year-old Rice Lake man driving the semi wasn't hurt.
Copyright 2009 by The Associated Press. All Rights Reserved.
Posted Wednesday, August 5, 2009 --- 7:40 a.m.
SHAWANO, Wis. (AP) -- Two people are dead after a car collided with a semi-truck on Wisconsin Highway 29 west of Shawano.
The victims are a man and a woman. Their names were not immediately released.
Emergency crews were called to the crash about 4 p.m. Tuesday.
The crash happened in the eastbound lanes of the highway. It remains under investigation.
Copyright 2009 by The Associated Press. All Rights Reserved.
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livejournal. a sarcastic take on 'lj' (el-jay)
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Back to game info
Dying Light Screenshots for PS4On: PS4, Xbox One, Xbox 360, PS3, PC
Survival horror game set in an open world with a a day-night cycle.
Latest Articles for Dying Light
Dying Light Steam bundle offers 4 copies for the price of 3
New promotion reduces cost of individual copies to £30 each.
Dying Light offers '50+ hours of gameplay', online invasion pre-order bonus revealed
Be The Zombie with pre-order game mode.


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Downtown DC Lunch - Best Desserts?
- f
- FoodieGrrl Nov 1, 2006 07:13 PM
Hello all!
Some friends are going out to celebrate a birthday over lunch next week. A nice lunch is key, but the birthday girl absolutely loves dessert and will never pass it up. Where are your favorite desserts. (The birthday club has been to DC Coast and Rosa Mexicano most recently, to give you an idea.)
re: EricDC
Was it chocolate at least? Just asking, because the birthday girl is 7 months pregnant too, and standing in the way of her and chocolate is a dangerous proposition!
One of my favorite desserts in DC is the cheesecake-brownie parfait thing at the Red Sage Grill (the upper level). I have a picture of it I took on my camera phone--it's that gorgeous! It's way too much dessert for one person, so I split it w/one or two other people. And for $5 or $6 bucks, that's a bargain.
I really like Corduroy's desserts. Pistachio bread pudding w/ ice cream and the chocolate tart w/ carmelized banana are two of my favorites.
Ceiba has great desserts: the thick hot Mexican chocolate with authentic churros for dipping, and a Bittersweet Chocolate Mousse (described as: Chocolate Cake, Spicy Mango, Toasted Coconut Tapioca). I haven't had that second one
Zaytinya has some delicious desserts too including rich ones with chocolate.
And yes on Corduroy as well.


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The tradition continues
Flakesgiving Meals
We're gonna feed thousands of families this weekend. To make sure everyone gets a meal, Mark and Paul have one new rule.
We're gonna feed thousands of families this weekend. To make sure everyone gets a meal, Mark and Paul have one new rule.
Justin is coming to Billings Saturday night and the promoter just opened up a section of $10 seats
Blake Shelton and Luke Bryant are featured in People Magazine's Sexiest Men Alive issue
Garth Brooks' comeback album "Man Against Machine" debuts on top of the Billboard country charts
The tradition continues
Sign up for your chance to win $10K from the...
Clint Black at Headwaters Country Jam
Football fans pick the winners
Linda Ronstadt has rarely talked about her life since revealing her Parkinson's diagnosis in August of 2013. In a new interview, the music legend says it's getting more difficult for her to perform routine tasks.
Today, we received an e-mail from Ryan & Alycia Fleury, who own and operate Fleury Concrete in Billings. They put it better than we ever could.
"We are friends, neighbors, and former employer of Colter Endy, who was a Billings Bulls player. He was seriously injured in a car accident on
Watch Shaq try to eat a cookie resting on his forehead. Fun!
Did you know the pilgrims and Indians shared pickles and salami?
The third cut on Trisha Yearwood's 'PrizeFighter: Hit After Hit' album is called 'I Remember You,' and the singer can't bring herself to listen to it. The lyrics recall memories of her mother, father and so many others she was close to. Then, her husband did something to make it even more personal.
What should've been a magical day turned into a nightmare for one new mother.
Some animals in need are going to have a Merry Christmas and a Happy New Year, thanks to Miranda Lambert and Ram Trucks.
Thanksgiving is less than a week away and now you can celebrate the special relationships for which you're the most thankful with a cool new video feature from Facebook.
Derek Carr threw a 9-yard touchdown pass to James Jones with 1:42 to play, and the Raiders shocked the Kansas City Chiefs, 24-20, in Oakland on Thursday night.


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Key Stage 4 Skills resources
'Skills'. What does that cover I hear you ask? To name just a few; essay writing, revision, speaking and listening, writing to analyse, writing to argue and writing to inform! There are others of course – take a look for yourselves.
Take Five
Brush up your teaching skills with our Take Five resource pack. Bursting with tips, tricks and activity ideas for everything from active approaches to Shakespeare to differentiation, make it your secret (teaching) weapon!
Creative writing - mystery, murder and suspense (1)
Grammar - sentence construction (12)
Oliver Twist by Charles Dickens (1)
Revision skills & exam preparation (11)
Speaking and listening tasks (40)
Thinking and discussion skills (7)
Topical and seasonal one-offs (9)
Writing for audience and purpose (4)
Writing to analyse, review, comment (3)
Writing to argue, persuade, advise (34)


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Shooting Events
The National Shooting Complex is one of the world's premier venues for competitive shooting tournaments, hosting such elite events as the Skeet World Championships, National Sporting Clays Championship, World English Sporting Clays Championship, Pan American Sporting Championship, the ACUI Intercollegiate Clay Target Championships, and many more. With its ample, versatile, and spacious facilities, the National Shooting Complex can host virtually any shooting event.
But you don't have to face national or international competition to shoot at the NSC — we're also the home club to many shooters in the San Antonio area, the destination of travelers on a shooting holiday, the site of charity fund-raiser shoots, and host to a variety of corporate events. There's always something going on at the National Shooting Complex!
Below are some of the public shooting events being hosted at the National Shooting Complex. Click the shoot name for links to more information and registration. See Open Public Shooting for other shooting opportunities.
See Events Calendar for all public events at the National Shooting Complex
Check back often – more events, info, and registration links are added as available
Upcoming Public Tournaments
|November 8, 2014
|Youth Target Foundation
|November 15, 2014
|Sky High for St. Jude Sporting Clays
|December 6, 2014
|Shoot for the Cure
|January 24, 2015
|Schreiner Shootout
|February 18-21, 2015
|SALE Junior Shoot-out


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Welcome to Peace Corps - Malawi
Nineteen Education 2014 PCVs pose for a photo after a colourful swearing-in Ceremony in Kasungu District.
Latest News
Cook with less fuel, produce less smoke, and save the forest!
Community members are increasing their income while helping to reduce deforestation rates along the Kuti Reserve. Adoption of energy efficient stoves is growing Read More »


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The latest addition to our Reviews Section is by Hannah Vose on A True Novel by Minae Mizumura, from Other Press.
To go against the grain of prologues and intros (more on that from This Hannah in a bit), here's the beginning of her review:
If you're one of those people who habitually skim the prologue to a book, Minae Mizumura's _A True Novel_—her third novel and the winner of the Yomiuri Literature Prize in Japan in 2002—might not appear to be for you. That is to say, the prologue takes up at least a third of the first volume of the book, and it's pretty important for understanding the circumstances in which the story that makes up this "true novel" takes place, in addition to sorting out what, exactly, a "true novel" is. Luckily for you, O prologue skippers of the world, there is nothing dry or uninteresting about the first 165 pages of this book, which introduces the protagonist, Taro Azuma, as Mizumura knew him when she lived in America during her teens. In fact, if you were somehow unaware of the name of the author when you came into the reading the book, you might not realize that the entire thing wasn't a fictional account from an outsider to establish what happened during the gaps in the main story. I actually forgot a couple of times that I was reading a prologue at all.
The main function of the prologue here is to both set up the circumstances which led to this novel being written, and to sort out for the reader what exactly a "true novel" is. On the outside, it seems like it might be an oxymoron: because a novel is fictional, it surely can't be "true," right? Or maybe the title refers more to the fact that the novel is an example of the "true" form that a novel should take. It turns out that in this case, "true" is a combination of the story's basis in reality and its following in the pattern of Western classics: authentic, "true" novels. Mizumura takes a few pages to explain the history of the "true" and "I-novels" and it makes no sense fragmented, so all I'm going to say is read the damn prologue, or else flounder in confusion. Your choice.
Like that little prologue? For the rest of the review, go here
Antoine Volodine's vast project (40 plus novels) of what he calls the post-exotic remains mostly untranslated, so for many of us, understanding it remains touched with mystery, whispers from those "who know," and guesswork. That's not to say that, were. . .
It hasn't quite neared the pitch of the waiting-in-line-at-midnight Harry Potter days, but in small bookstores and reading circles of New York City, an aura has attended the novelist Elena Ferrante and her works. One part curiosity (Who is she?),. . .
From the late 1940s to the early 1950s, Egypt was going through a period of transition. The country's people were growing unhappy with the corruption of power in the government, which had been under British rule for decades. The Egyptians'. . .
Miruna is a novella written in the voice of an adult who remembers the summer he (then, seven) and his sister, Miruna (then, six) spent in the Evil Vale with their grandfather (sometimes referred to as "Grandfather," other times as. . .
Kamal Jann by the Lebanese born author Dominique Eddé is a tale of familial and political intrigue, a murky stew of byzantine alliances, betrayals, and hostilities. It is a well-told story of revenge and, what's more, a serious novel that. . .
While looking back at an episode in his life, twenty-year-old Taguchi Hiro remembers what his friend Kumamoto Akira said about poetry.
Its perfection arises precisely from its imperfection . . . . I have an image in my head. I see. . .
The central concern of Sorj Chalandon's novel Return to Killybegs appears to be explaining how a person of staunch political activism can be lead to betray his cause, his country, his people. Truth be told, the real theme of the. . .
Spoiler alert: acclaimed writer Stefan Zweig and his wife Lotte kill themselves at the end of Lauren Seksik's 2010 novel, The Last Days.
It's hard to avoid spoiling this mystery. Zweig's suicide actually happened, in Brazil in 1942, and since then. . .
To call Kjell Askildsen's style sparse or terse would be to understate just how far he pushes his prose. Almost nothing is explained, elaborated on. In simple sentences, events occur, words are exchanged, narrators have brief thoughts. As often as. . .
After a mysterious woman confesses to an author simply known as "R" that she has loved him since she was a teenager, she offers the following explanation: "There is nothing on earth like the love of a child that passes. . .


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Opportunities at Crosscut Public Media
About Crosscut
Crosscut is a seven-year-old digital news service, which covers the Seattle Metro Area and Greater Northwest. We are also a nonprofit, which means we are a news organization with a mission. That mission is to help make our region a model for sane, sustainable 21st Century living. We use the word "sustainable" in its broadest possible sense. Not just cleaning up Puget Sound or moving more people onto public transit, though both would be nice. We're talking about how do we lure affluent kids back to public schools; infuse our civic life with the kind of smart, innovative technology and design we see happening all around us in Puget Sound; bring grace and gravity back to our civic discourse; embrace the region's growing diversity; support the arts; end homelessness; reinvent journalism.The kind of grand transformation we imagine demands originality and chutzpah from bold leaders. Crosscut spotlights the people, policies, initiatives and ideas that are moving us towards that sane, sustainable ideal. We are neither partisan nor patient. We don't presume to have the answers. We don't care where transformative ideas come from. We just want to put the very best ones in play. We are the go-to place for news, ideas and thoughtful analysis – and a very restless agent of change. .
We are a start-up non-profit with a great team, flexible workplace, and significant contacts in the community. We'd like to add some interns to contribute to Crosscut's growing success.Student Voice Internship
The Student Voice Intern will work directly with the Development Director to coordinate and market the Crosscut Student Voice, an op ed section of Crosscut.com dedicated to student opinions. This role scans Crosscut articles and upcoming topics to provide students with a relevant, timely question of the week. Responses are polled and top entries are publised on the site.
Applicants should have an interest in development and outreach of nonprofits, as well as gaining experience in a newsroom and fine-tuning editing skills.
During the duration of this internship, projects may include collaboration on:
- Coordinating Student Voice questions of the week, including email marketing of question and tracking of submissions
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This internship will be structured to challenge and grow the skills needed to provide a foundation for your professional goals in non-profit news or leadership. Through mentorship, coaching, and hands on partnership in the above areas, you'll gain substantial experience in editing, marketing, and development, as well as exposure to non-profit culture and newsmakers/reporters across the Northwest.
Please send a cover letter and resume to firstname.lastname@example.com Internship
Crosscut seeks an intern for 6-12 months with college degree and a passion for journalism and good writing. Lots of opportunity to keep the site updated, build offerings, work with experienced editors and writers, and to develop a nonprofit, independent, community-driven source of news in Seattle and the Northwest. Applicants should have wide range of interests, broad curiosity, excellent writing and editing skills, and some journalism experience. Ambitious self-starters are particularly welcome. Position is unpaid and part-time, but you will be encouraged to write as part of regular duties and as a paid freelancer. Successful interns can advance to staff positions. Please send resume and some writing samples to email@example.com


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|Industry Recognition
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I endorse this lawyer's work. I have known Robert since the mid 80's. He has developed a reputation as a hard working zealous advocate for his... more
I endorse this lawyer's work. This man can take a dead bang loser to a jury and pull out an acquittal. He has the spirit and values of a true defense... more


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Unrelated lineages of electric fish all use the same small set of genes to create their voltage, a genetic search shows. Maybe the same genes could one day power pacemakers, bioengineers suggest.
Business leaders and policymakers gathered at the White House to discuss how working families can get ahead. One participant explains how he feels companies can stay competitive and help families.
U.S. Sen. Tim Scott has become a leading conservative voice focused on building wealth among people of color. Scott tells host Michel Martin about his ideas for growing the economy.
Several primary elections wrapped up this week. Host Michel Martin speaks with two seasoned political analysts to learn more about the primary results and the races to watch later this year.
Tourism is an essential part of Cuba's economy. But as the industry grows, some worry it will create a gap between the haves and have-nots in a throwback to pre-revolution days.
Iowa, Minnesota and other parts of the Midwest have been hit with record levels of rainfall recently. As water floods homes and businesses and threatens crops, local officials scramble to help.
Focusing on Iraq's fight may be missing the point. Under the surface is a more fundamental war between al-Qaida leader Ayman al-Zawahri and Abu Bakr al-Baghdadi of the Islamic State of Iraq and Syria.
The Immigrant and Zinda Bhaag are idea-driven films that delve into the global arc of migration from different corners of the world.
Minority Sunnis are helping the militants sweeping Iraq's north and west. The support of ordinary Sunnis shows how difficult it will be to reverse the sectarian partition that's already happening.
Spanish Princess Infanta Cristina has been charged with money laundering. She faces 11 years behind bars for allegedly embezzling public money through fake charities.


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ATP Studenta Croatia Open Umag
Croatia Open semis postponed because of rain
UMAG, Croatia (AP) Heavy rain washed out the Croatia Open semifinals on Saturday. Organizers of the ATP clay-court event said the matches will be held on Sunday morning, and the finals
Croatia Open : Qualifier Cuevas upsets 6-seed Seppi in 2nd round
UMAG, Croatia -- Uruguay qualifier Pablo Cuevas upset sixth-seeded Andreas Seppi 6-3, 6-1 to make the Croatia Open quarterfinals on Thursday. Cuevas, held serve, played patiently from the baseline, and pushed Seppi into unforced errors
Rosol, Berlocq advance at Croatia Open
needed a late rally to beat 100th-ranked Diego Sebastian Schwartzman 6-3, 3-6, 7-6 (2) in the first round of the Croatia Open on Tuesday. Schwartzman was serving at 4-3 in the third set and the Argentine even had game point to increase his lead
Robredo, Cuevas reaches final of Croatia Open
UMAG, Croatia (AP) Defending champion Tommy Robredo reached the final of the Croatia Open , defeating third-seeded Marin Cilic of Croatia 7-6 (10), 6-3 on Sunday. The second-seeded Spaniard will face Uruguayan
Live: Brazil-Croatia open World Cup festivities in Sao Paulo
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Uruguayan Cuevas wins Croatia Open final
Uruguayan qualifier Pablo Cuevas beat defending champion Tommy Robredo of Spain 6-3, 6-4 on Sunday to win the Croatia Open final. The second-seeded Robredo had two break points at 1-1 in the first set, but it was Cuevas who first broke
Lukas Rosol, Carlos Berlocq escape first round at Croatia Open
needed a late rally to beat 100th-ranked Diego Sebastian Schwartzman 6-3, 3-6, 7-6 (2) in the first round of the Croatia Open on Tuesday. Schwartzman was serving at 4-3 in the third set and the Argentine even had game point to increase his lead
Your Top Plays for Today
MARIN CILIC REACH QUARTERFINALS OF CROATIA OPEN Defending champion Tommy Robredo ..... reach the quarterfinals of the Croatia Open . http://hosted.ap.org/dynamic/stories/T/TEN- CROATIA - OPEN ?SITE=AP&SECTION=HOME
Friday Sports In Brief
Top-seeded Fabio Fognini rallied to defeat Borna Coric of Croatia 5-7, 7-6 (4), 6-3 in the quarterfinals of the Croatia Open on Friday. Defending champion Tommy Robredo also advanced to the last four after beating fellow Spaniard Pablo Carreno Busta
Cilic, Rosol in Umag quarterfinals
seeded Marin Cilic of Croatia beat Dutchman Igor Sijsling 7-5, 6-3 on Wednesday to reach the quarterfinals of the Croatia Open . It was Cilic's fourth victory over Sijsling in as many encounters and the Croatian was dominant from the start. Playing