text:
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Pheochromocytomas and extra-adrenal paragangliomas are rare tumors arising from neural crest tissue that develops into sympathetic and parasympathetic paraganglia throughout the body. Sympathetic paraganglia include the following:
Parasympathetic paraganglia include the following:
The most recent World Health Organization classification utilizes the term pheochromocytoma exclusively for tumors arising from the adrenal medulla and the term extra-adrenal paraganglioma for similar tumors that arise from other locations.[1]
The incidence of pheochromocytoma is 2 to 8 per million persons per year.[2,3] Pheochromocytoma is present in 0.1% to 1% of patients with hypertension,[4,5,6] and it is present in approximately 5% of patients with incidentally discovered adrenal masses.[7] The peak incidence occurs in the third to fifth decades of life; the average age at diagnosis is 24.9 years in hereditary cases and 43.9 years in sporadic cases.[8] The incidence is equal between males and females,[9] and there are no known environmental, dietary, or lifestyle risk factors that have been linked to the development of pheochromocytoma.
Of all pheochromocytomas and extra-adrenal paragangliomas, 25% occur in the setting of an hereditary syndrome.[8,9,10] The following major genetic syndromes have been identified as carrying an increased risk of pheochromocytoma:
Pheochromocytomas and extra-adrenal paragangliomas can also occur in the following two other very rare syndromes:
More genetic causes of pheochromocytoma and paraganglioma are yet to be discovered. For example, truncating germline mutations in the transmembrane-encoding gene TMEM127 on chromosome 2q11 have been shown to be present in approximately 30% of affected patients with familial disease and in about 3% of patients with apparently sporadic pheochromocytomas without a known genetic cause.[18]TMEM127 is a negative regulator of mammalian target of rapamycin (mTOR) effector proteins.
Patients with pheochromocytomas and sympathetic extra-adrenal paragangliomas may present with symptoms of excess catecholamine production, including the following:
These symptoms are often paroxysmal, although sustained hypertension in between paroxysmal episodes occurs in 50% to 60% of patients with pheochromocytoma.[19] Symptoms of catecholamine excess can be spontaneous or induced by a variety of events, including the following:
Episodes of hypertension can be variable in frequency, severity, and duration and are often extremely difficult to manage medically. Hypertensive crisis can lead to cardiac arrhythmias, myocardial infarction, and even death.
Parasympathetic extra-adrenal paragangliomas do not secrete catecholamines and usually present as a neck mass with symptoms related to compression or are incidentally discovered on an imaging study performed for an unrelated reason. In addition, approximately half of patients with pheochromocytoma are asymptomatic because their neoplasms are discovered in the presymptomatic state by either abdominal imaging for other reasons (e.g., adrenal incidentalomas) or genetic testing in at-risk family members.[20,21,22,23]
The diagnosis of pheochromocytoma is established by biochemical testing to document excess catecholamine secretion. Controversy exists as to the optimal single test to make the diagnosis. Measurement of plasma-free fractionated metanephrines (e.g., metanephrine and normetanephrine) has a high sensitivity (97%–99%) but a relatively low specificity (85%).
A 24-hour urine collection for catecholamines (e.g., epinephrine, norepinephrine, and dopamine) and fractionated metanephrines (e.g., metanephrine and normetanephrine) has a relatively low sensitivity (77%–90%) but a high specificity (98%). Pretest probability is also important. The specificity of plasma-free fractionated metanephrines is 82% in patients tested for sporadic pheochromocytoma versus 96% in patients tested for hereditary pheochromocytoma.[24,25]
Measurement of plasma-free fractionated metanephrines appears to be an ideal case detection test for patients at higher baseline risk of pheochromocytoma. Examples of these patients might include the following:
The test is associated with a relatively high false-positive rate in patients with a lower baseline risk of pheochromocytoma.
In general, it is reasonable to use measurement of plasma-free fractionated metanephrines for initial case detection, which is followed by 24-hour measurement of urine-fractionated metanephrines and catecholamines for confirmation. Test results can be difficult to interpret because of the false-positive results. False-positive results can be caused by any of the following:[19,24]
A mildly elevated catecholamine or metanephrine level is usually the result of assay interference caused by drugs or other factors. Patients with symptomatic pheochromocytoma almost always have increases in catecholamines or metanephrines two to three times higher than the upper limits of reference ranges.[19] Provocative testing (e.g., using glucagon) can be dangerous, adds no value to other current testing methods, and is not recommended.[27]
Once the biochemical diagnosis of a catecholamine-secreting tumor is confirmed, localization studies should be performed.
Computed tomography (CT) imaging or magnetic resonance imaging (MRI) of the abdomen and pelvis (at least through the level of the aortic bifurcation) are the most commonly used methods for localization.[28] Both have similar sensitivities (90%–100%) and specificities (70%–80%).[28]
CT imaging provides excellent anatomic detail. MRI provides good anatomic detail.
Additional functional imaging may be necessary if CT imaging or MRI fails to localize the tumor. It might also be useful in patients who are at risk for multifocal, malignant, or recurrent disease. 123 I-metaiodobenzylguanidine (MIBG) scintigraphy coupled with CT imaging provides anatomic and functional information with good sensitivity (80%–90%) and specificity (95%–100%).[28]
131 I-MIBG can be used in the same way, but the image quality is not as high as with 123 I-MIBG.[29] Other functional imaging alternatives include 111 In-octreotide scintigraphy and 18 F-fluorodeoxyglucose positron emission tomography, both of which can be coupled with CT imaging for improved anatomic detail. It is rare for localization of a catecholamine-secreting tumor to be unsuccessful if currently available imaging methods are used.
It has been proposed that all patients diagnosed with a pheochromocytoma or paraganglioma should consider genetic testing because the incidence of a hereditary syndrome in apparently sporadic cases is as high as 25%.[8,9,30] Early identification of a hereditary syndrome allows for early screening for other associated tumors and identification of family members who are at risk. In addition, some patients with a hereditary syndrome are more likely to develop multifocal, malignant, or recurrent disease. Knowledge of the specific genetic mutation permits increased vigilance during preoperative localization or postoperative surveillance of such patients.
Certain subgroups of patients are at very low risk of having an inherited syndrome (e.g., <2% in patients diagnosed with apparently sporadic pheochromocytoma after age 50 years).[8] Therefore, genetic testing for all patients diagnosed with a pheochromocytoma or paraganglioma may not be practical or cost effective from a population standpoint. It is currently recommended that every patient diagnosed with a pheochromocytoma or extra-adrenal paraganglioma should first undergo risk evaluation for a hereditary syndrome by a certified genetic counselor.
Genetic testing is recommended in the following situations:
In patients with a unilateral pheochromocytoma and no personal or family history suggestive of hereditary disease, genetic testing can be considered if patients are between the ages of 40 years and 50 years, but genetic testing is not recommended if patients are older than 50 years. If a mutation is identified, predictive genetic testing should be offered to asymptomatic at-risk family members.
Definitive treatment for localized and regional pheochromocytoma, including localized disease recurrence, consists of alpha- and beta-adrenergic blockade followed by surgery. For patients with unresectable or metastatic disease, treatment may include a combination of the following:
Refer to the Regional Pheochromocytoma section, the Metastatic Pheochromocytoma section, and the Recurrent Pheochromocytoma section of this summary for more information on treatment.
|DeLellis R, Lloyd R, Heitz P, eds.: Pathology and Genetics: Tumours of Endocrine Organs (IARC WHO Classification of Tumours). Lyon, France: IARC Press, 2004.
|Beard CM, Sheps SG, Kurland LT, et al.: Occurrence of pheochromocytoma in Rochester, Minnesota, 1950 through 1979. Mayo Clin Proc 58 (12): 802-4, 1983.
|Stenström G, Svärdsudd K: Pheochromocytoma in Sweden 1958-1981. An analysis of the National Cancer Registry Data. Acta Med Scand 220 (3): 225-32, 1986.
|Sinclair AM, Isles CG, Brown I, et al.: Secondary hypertension in a blood pressure clinic. Arch Intern Med 147 (7): 1289-93, 1987.
|Anderson GH Jr, Blakeman N, Streeten DH: The effect of age on prevalence of secondary forms of hypertension in 4429 consecutively referred patients. J Hypertens 12 (5): 609-15, 1994.
|Omura M, Saito J, Yamaguchi K, et al.: Prospective study on the prevalence of secondary hypertension among hypertensive patients visiting a general outpatient clinic in Japan. Hypertens Res 27 (3): 193-202, 2004.
|Young WF Jr: Management approaches to adrenal incidentalomas. A view from Rochester, Minnesota. Endocrinol Metab Clin North Am 29 (1): 159-85, x, 2000.
|Neumann HP, Bausch B, McWhinney SR, et al.: Germ-line mutations in nonsyndromic pheochromocytoma. N Engl J Med 346 (19): 1459-66, 2002.
|Amar L, Bertherat J, Baudin E, et al.: Genetic testing in pheochromocytoma or functional paraganglioma. J Clin Oncol 23 (34): 8812-8, 2005.
|Jiménez C, Cote G, Arnold A, et al.: Review: Should patients with apparently sporadic pheochromocytomas or paragangliomas be screened for hereditary syndromes? J Clin Endocrinol Metab 91 (8): 2851-8, 2006.
|Baysal BE, Ferrell RE, Willett-Brozick JE, et al.: Mutations in SDHD, a mitochondrial complex II gene, in hereditary paraganglioma. Science 287 (5454): 848-51, 2000.
|Hao HX, Khalimonchuk O, Schraders M, et al.: SDH5, a gene required for flavination of succinate dehydrogenase, is mutated in paraganglioma. Science 325 (5944): 1139-42, 2009.
|Niemann S, Müller U: Mutations in SDHC cause autosomal dominant paraganglioma, type 3. Nat Genet 26 (3): 268-70, 2000.
|Astuti D, Latif F, Dallol A, et al.: Gene mutations in the succinate dehydrogenase subunit SDHB cause susceptibility to familial pheochromocytoma and to familial paraganglioma. Am J Hum Genet 69 (1): 49-54, 2001.
|Burnichon N, Brière JJ, Libé R, et al.: SDHA is a tumor suppressor gene causing paraganglioma. Hum Mol Genet 19 (15): 3011-20, 2010.
|Carney JA: Gastric stromal sarcoma, pulmonary chondroma, and extra-adrenal paraganglioma (Carney Triad): natural history, adrenocortical component, and possible familial occurrence. Mayo Clin Proc 74 (6): 543-52, 1999.
|Carney JA, Stratakis CA: Familial paraganglioma and gastric stromal sarcoma: a new syndrome distinct from the Carney triad. Am J Med Genet 108 (2): 132-9, 2002.
|Qin Y, Yao L, King EE, et al.: Germline mutations in TMEM127 confer susceptibility to pheochromocytoma. Nat Genet 42 (3): 229-33, 2010.
|Lenders JW, Eisenhofer G, Mannelli M, et al.: Phaeochromocytoma. Lancet 366 (9486): 665-75, 2005 Aug 20-26.
|Klein R, Lloyd R, Young W: Hereditary Paraganglioma-Pheochromocytoma Syndromes. In: Pagon R, Bird T, Dolan C, et al., eds.: GeneReviews. Seattle, WA: University of Washington, 2009, pp. Available on line. Last accessed October 19, 2010.
|Kopetschke R, Slisko M, Kilisli A, et al.: Frequent incidental discovery of phaeochromocytoma: data from a German cohort of 201 phaeochromocytoma. Eur J Endocrinol 161 (2): 355-61, 2009.
|Motta-Ramirez GA, Remer EM, Herts BR, et al.: Comparison of CT findings in symptomatic and incidentally discovered pheochromocytomas. AJR Am J Roentgenol 185 (3): 684-8, 2005.
|Young WF Jr: Clinical practice. The incidentally discovered adrenal mass. N Engl J Med 356 (6): 601-10, 2007.
|Lenders JW, Pacak K, Walther MM, et al.: Biochemical diagnosis of pheochromocytoma: which test is best? JAMA 287 (11): 1427-34, 2002.
|Sawka AM, Jaeschke R, Singh RJ, et al.: A comparison of biochemical tests for pheochromocytoma: measurement of fractionated plasma metanephrines compared with the combination of 24-hour urinary metanephrines and catecholamines. J Clin Endocrinol Metab 88 (2): 553-8, 2003.
|Perry CG, Sawka AM, Singh R, et al.: The diagnostic efficacy of urinary fractionated metanephrines measured by tandem mass spectrometry in detection of pheochromocytoma. Clin Endocrinol (Oxf) 66 (5): 703-8, 2007.
|Young WF Jr: Phaeochromocytoma: how to catch a moonbeam in your hand. Eur J Endocrinol 136 (1): 28-9, 1997.
|Ilias I, Pacak K: Current approaches and recommended algorithm for the diagnostic localization of pheochromocytoma. J Clin Endocrinol Metab 89 (2): 479-91, 2004.
|Furuta N, Kiyota H, Yoshigoe F, et al.: Diagnosis of pheochromocytoma using [123I]-compared with [131I]-metaiodobenzylguanidine scintigraphy. Int J Urol 6 (3): 119-24, 1999.
|Neumann HP, Pawlu C, Peczkowska M, et al.: Distinct clinical features of paraganglioma syndromes associated with SDHB and SDHD gene mutations. JAMA 292 (8): 943-51, 2004.
Pathologic Classification
Pheochromocytoma and paraganglioma characteristically form small nests of uniform polygonal chromaffin cells ("zellballen"). A diagnosis of malignancy can only be made by identifying tumor deposits in tissues that do not normally contain chromaffin cells (e.g., lymph nodes, liver, bone, lung, and other distant metastatic sites).
Regional or distant metastatic disease is documented on initial pathology in only 3% to 8% of patients; thus, an attempt has been made to identify tumor characteristics associated with future malignant behavior. Pathologic features associated with malignancy include the following:
In the absence of clearly documented malignancy, no combination of clinical, histopathologic, or biochemical features has been shown to reliably predict the biologic behavior of pheochromocytoma. If no definite malignancy is identified, pathology generally provides insufficient prognostic information regarding the likelihood of recurrence or metastasis. These tumors cannot be considered benign by default; patients require continued lifelong surveillance.[1,2,3,4,5,6,7]
|Plouin PF, Chatellier G, Fofol I, et al.: Tumor recurrence and hypertension persistence after successful pheochromocytoma operation. Hypertension 29 (5): 1133-9, 1997.
|Thompson LD: Pheochromocytoma of the Adrenal gland Scaled Score (PASS) to separate benign from malignant neoplasms: a clinicopathologic and immunophenotypic study of 100 cases. Am J Surg Pathol 26 (5): 551-66, 2002.
|Nativ O, Grant CS, Sheps SG, et al.: The clinical significance of nuclear DNA ploidy pattern in 184 patients with pheochromocytoma. Cancer 69 (11): 2683-7, 1992.
|Wu D, Tischler AS, Lloyd RV, et al.: Observer variation in the application of the Pheochromocytoma of the Adrenal Gland Scaled Score. Am J Surg Pathol 33 (4): 599-608, 2009.
|Kimura N, Watanabe T, Noshiro T, et al.: Histological grading of adrenal and extra-adrenal pheochromocytomas and relationship to prognosis: a clinicopathological analysis of 116 adrenal pheochromocytomas and 30 extra-adrenal sympathetic paragangliomas including 38 malignant tumors. Endocr Pathol 16 (1): 23-32, 2005.
|Linnoila RI, Keiser HR, Steinberg SM, et al.: Histopathology of benign versus malignant sympathoadrenal paragangliomas: clinicopathologic study of 120 cases including unusual histologic features. Hum Pathol 21 (11): 1168-80, 1990.
|Tischler AS: Pheochromocytoma and extra-adrenal paraganglioma: updates. Arch Pathol Lab Med 132 (8): 1272-84, 2008.
There is no standard staging system for pheochromocytoma and paraganglioma. Patients have traditionally been divided into categories based on the presence of localized (apparently benign), regional, and metastatic disease.
There are no clear data regarding the survival of patients with localized (apparently benign) disease or regional disease. Although patients with localized (apparently benign) disease should experience an overall survival approaching that of age-matched disease-free individuals, 6.5% to 16.5% of these patients will develop a recurrence, usually 5 to 15 years after initial surgery.[1,2,3]
Approximately 50% of patients with recurrent disease experience distant metastasis.[3] The 5-year survival in the setting of metastatic disease (whether identified at the time of initial diagnosis or identified postoperatively as recurrent disease) is 40% to 45%.[4]
|Plouin PF, Chatellier G, Fofol I, et al.: Tumor recurrence and hypertension persistence after successful pheochromocytoma operation. Hypertension 29 (5): 1133-9, 1997.
|van Heerden JA, Roland CF, Carney JA, et al.: Long-term evaluation following resection of apparently benign pheochromocytoma(s)/paraganglioma(s). World J Surg 14 (3): 325-9, 1990 May-Jun.
|Amar L, Servais A, Gimenez-Roqueplo AP, et al.: Year of diagnosis, features at presentation, and risk of recurrence in patients with pheochromocytoma or secreting paraganglioma. J Clin Endocrinol Metab 90 (4): 2110-6, 2005.
|Averbuch SD, Steakley CS, Young RC, et al.: Malignant pheochromocytoma: effective treatment with a combination of cyclophosphamide, vincristine, and dacarbazine. Ann Intern Med 109 (4): 267-73, 1988.
Only limited data are available from phase II or phase III clinical trials to guide the management of patients diagnosed with pheochromocytoma or paraganglioma.
Surgery is the mainstay of treatment for most patients; however, preoperative medical preparation is critical. Alpha-adrenergic blockade should be initiated at the time of diagnosis and maximized preoperatively to prevent potentially life-threatening cardiovascular complications, which can occur as a result of excess catecholamine secretion during surgery. Complications may include the following:
Phenoxybenzamine (a nonselective alpha-antagonist) is the usual drug of choice; prazosin, terazosin, and doxazosin (selective alpha-1-antagonists) are alternative choices.[1,2] Prazosin, terazosin, and doxazosin are shorter acting than phenoxybenzamine, and therefore, the duration of postoperative hypotension is theoretically less than with phenoxybenzamine; however, there is less overall experience with selective alpha-1-antagonists than with phenoxybenzamine.
A preoperative treatment period of 1 to 3 weeks is usually sufficient; resolution of spells and a target low normal blood pressure for age indicate that alpha-adrenergic blockade is adequate. During alpha-adrenergic blockade, liberal salt and fluid intake should be encouraged because volume loading reduces excessive orthostatic hypotension both preoperatively and postoperatively. If tachycardia develops or if blood pressure control is not optimal with alpha-adrenergic blockade, a beta-adrenergic blocker (e.g., metoprolol or propranolol) can be added but only after alpha-blockade. Beta-adrenergic blockade must never be initiated before alpha-adrenergic blockade; doing so blocks beta-adrenergic receptor-mediated vasodilation and results in unopposed alpha-adrenergic receptor-mediated vasoconstriction, which can lead to a life-threatening crisis.
|Cubeddu LX, Zarate NA, Rosales CB, et al.: Prazosin and propranolol in preoperative management of pheochromocytoma. Clin Pharmacol Ther 32 (2): 156-60, 1982.
|Prys-Roberts C, Farndon JR: Efficacy and safety of doxazosin for perioperative management of patients with pheochromocytoma. World J Surg 26 (8): 1037-42, 2002.
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
Treatment Options
Surgical resection, i.e., adrenalectomy, is the definitive treatment for patients with localized pheochromocytoma. If preoperative imaging reveals an adrenal pheochromocytoma that is approximately 6 cm or smaller in diameter, without radiographic evidence of invasion into adjacent structures or evidence of regional or metastatic disease (i.e., presumably a benign tumor), and there is a normal contralateral adrenal gland, a minimally invasive adrenalectomy is the generally preferred approach. Both anterior transabdominal laparoscopic adrenalectomy as well as posterior retroperitoneoscopic adrenalectomy have been demonstrated to be safe for the majority of patients with a modestly sized, radiographically benign pheochromocytoma.[1,2] If preoperative imaging suggests malignancy, or if the patient has an extra-adrenal paraganglioma or multifocal disease, an open approach is generally preferred.
Intraoperative hypertension can be controlled with intravenous infusion of phentolamine, sodium nitroprusside, or a short-acting calcium-channel blocker (e.g., nicardipine). Tumor removal may be followed by a sudden drop in blood pressure that may require rapid volume replacement and intravenous vasoconstrictors (e.g., norepinephrine or phenylephrine). Postoperatively, patients should remain in a monitored environment for 24 hours. Postoperative hypotension is managed primarily by volume expansion, and postoperative hypertension usually responds to diuretics.
Inherited Pheochromocytoma
Treatment Options
The surgical management of pheochromocytoma in patients with the hereditary syndromes multiple endocrine neoplasia type 2 (MEN2) and von Hippel-Lindau (VHL) disease has been controversial. In both of these syndromes, pheochromocytoma is bilateral in at least 50% of patients; however, malignancy is very uncommon. Bilateral total adrenalectomy commits all patients to lifelong steroid dependence, and up to 25% of patients will experience Addisonian crisis (acute adrenal insufficiency).[3,4]
Current recommendations generally favor preservation of adrenal cortical tissue in patients with MEN2 and VHL syndromes when possible. Patients who initially present with unilateral pheochromocytoma should undergo unilateral adrenalectomy, and patients who present with bilateral pheochromocytomas or who develop pheochromocytoma in their remaining adrenal gland should undergo cortical-sparing adrenalectomy, when technically feasible.[3]
In a single-institution study involving 56 patients with pheochromocytoma, 57% of patients (i.e., 17 of 30 patients) who underwent one or more cortical-sparing adrenalectomies avoided the need for routine steroid replacement; the clinical recurrence rate was low (i.e., 3 of 30 patients) and none of the patients developed metastatic disease.[5][Level of evidence: 3iiDii] A similar approach may be reasonable in other hereditary pheochromocytoma-paraganglioma syndromes that are characterized by benign disease, but there are currently insufficient data upon which to base unequivocal recommendations.
Follow-Up Evaluation
Long-term follow-up is essential for all patients with pheochromocytoma or extra-adrenal paraganglioma, even if initial pathology demonstrates no findings that are concerning for malignancy. After resection of a solitary sporadic pheochromocytoma, patients should undergo baseline postoperative biochemical testing followed by annual lifelong biochemical testing. Patients who have undergone resection of a non-catecholamine-producing tumor should initially undergo annual imaging with computed tomography imaging or magnetic resonance imaging and periodic imaging with radiolabeled metaiodobenzylguanidine to monitor for recurrence or metastasis. Patients who have undergone resection of a pheochromocytoma or paraganglioma in the setting of a hereditary syndrome require lifelong annual biochemical screening in addition to routine screening for other component tumors of their specific syndrome.[6]
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with localized benign pheochromocytoma and paraganglioma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
|Walz MK, Alesina PF, Wenger FA, et al.: Posterior retroperitoneoscopic adrenalectomy--results of 560 procedures in 520 patients. Surgery 140 (6): 943-8; discussion 948-50, 2006.
|Gagner M, Breton G, Pharand D, et al.: Is laparoscopic adrenalectomy indicated for pheochromocytomas? Surgery 120 (6): 1076-9; discussion 1079-80, 1996.
|Lee JE, Curley SA, Gagel RF, et al.: Cortical-sparing adrenalectomy for patients with bilateral pheochromocytoma. Surgery 120 (6): 1064-70; discussion 1070-1, 1996.
|de Graaf JS, Dullaart RP, Zwierstra RP: Complications after bilateral adrenalectomy for phaeochromocytoma in multiple endocrine neoplasia type 2--a plea to conserve adrenal function. Eur J Surg 165 (9): 843-6, 1999.
|Yip L, Lee JE, Shapiro SE, et al.: Surgical management of hereditary pheochromocytoma. J Am Coll Surg 198 (4): 525-34; discussion 534-5, 2004.
|GeneTests: Medical Genetics Information Resource [Database]. Seattle, WA: University of Washington, 2010. Available online. Last accessed Aug 24, 2010.
Treatment Options
Surgical resection is the definitive treatment for pheochromocytoma or extra-adrenal paraganglioma that is regionally advanced (e.g., from direct tumor extension into adjacent organs or because of regional lymph node involvement). Data to guide management are limited because regional disease is diagnosed in very few patients who present with pheochromocytoma.[1] However, aggressive surgical resection to remove all existing disease can render patients symptom free.[2] Surgical management of these patients may require en bloc resection of all or part of adjacent organs (e.g., kidney, liver, inferior vena cava) along with extended lymph node dissection. Patients who have undergone complete resection of regional pheochromocytoma require lifelong monitoring for disease recurrence.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with regional pheochromocytoma and paraganglioma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
|Amar L, Servais A, Gimenez-Roqueplo AP, et al.: Year of diagnosis, features at presentation, and risk of recurrence in patients with pheochromocytoma or secreting paraganglioma. J Clin Endocrinol Metab 90 (4): 2110-6, 2005.
|Zarnegar R, Kebebew E, Duh QY, et al.: Malignant pheochromocytoma. Surg Oncol Clin N Am 15 (3): 555-71, 2006.
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
Treatment Options
The most common sites of metastasis for pheochromocytoma or extra-adrenal paraganglioma are lymph nodes, bones, lungs, and liver. Patients with known or suspected malignancy should undergo staging with computed tomography or magnetic resonance imaging as well as functional imaging (e.g., with 123 I-metaiodobenzylguanidine [MIBG]) to determine the extent and location of disease. Patients are often very symptomatic from excess catecholamine secretion. Phenoxybenzamine is effective, and metyrosine, which is a drug that blocks catecholamine synthesis, can be added if needed.
If all identifiable disease is resectable, including a limited number of distant metastases, surgery can provide durable palliation of symptoms and occasional long-term remission. If disease is unresectable, surgical debulking will not improve survival; however, it is occasionally indicated for symptom palliation.
Chemotherapy has not been shown to improve survival in patients with metastatic pheochromocytoma; however, chemotherapy can be attempted for the palliation of symptoms. The best-established chemotherapy regimen is a combination of cyclophosphamide, vincristine, and dacarbazine (the Averbuch protocol).[1] Results of this regimen in 18 patients after 22 years of follow-up demonstrated a complete response rate of 11%, a partial response rate of 44%, a biochemical response rate of 72%, and a median survival of 3.3 years.[2][Level of evidence: 3iiiDiv] Several other chemotherapy regimens have been used in small numbers of patients, but the overall results were disappointing.[3,4]
Novel targeted therapies are emerging as potential treatment strategies for metastatic pheochromocytoma. Disappointing initial results were reported with the mammalian target of rapamycin (mTOR) inhibitor everolimus,[5] but results from a very small number of patients treated with the tyrosine kinase inhibitor sunitinib have been more promising.[6,7]
131 I-MIBG radiation therapy has been used for the treatment of MIBG-avid metastases.[8,9] In a phase II study of high-dose 131 I-MIBG radiation therapy involving 49 patients, 8% had a complete response, 14% had a partial response, and the estimated 5-year survival was 64%.[10][Level of evidence: 3iiiDiv] Approximately 60% of metastatic pheochromocytoma or paraganglioma sites are MIBG-avid;[10] protocol-based treatment with other experimental radiolabeled agents, such as radiolabeled somatostatin, can be considered for metastases that do not take up MIBG.
Other palliative treatment modalities include external-beam radiation therapy (e.g., for palliation of bone metastases) and embolization, radiofrequency ablation, or cryoablation (e.g., for palliation of bulky hepatic metastases or isolated bony metastases).
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with metastatic pheochromocytoma and paraganglioma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
|Averbuch SD, Steakley CS, Young RC, et al.: Malignant pheochromocytoma: effective treatment with a combination of cyclophosphamide, vincristine, and dacarbazine. Ann Intern Med 109 (4): 267-73, 1988.
|Huang H, Abraham J, Hung E, et al.: Treatment of malignant pheochromocytoma/paraganglioma with cyclophosphamide, vincristine, and dacarbazine: recommendation from a 22-year follow-up of 18 patients. Cancer 113 (8): 2020-8, 2008.
|Nakane M, Takahashi S, Sekine I, et al.: Successful treatment of malignant pheochromocytoma with combination chemotherapy containing anthracycline. Ann Oncol 14 (9): 1449-51, 2003.
|Kulke MH, Stuart K, Enzinger PC, et al.: Phase II study of temozolomide and thalidomide in patients with metastatic neuroendocrine tumors. J Clin Oncol 24 (3): 401-6, 2006.
|Druce MR, Kaltsas GA, Fraenkel M, et al.: Novel and evolving therapies in the treatment of malignant phaeochromocytoma: experience with the mTOR inhibitor everolimus (RAD001). Horm Metab Res 41 (9): 697-702, 2009.
|Jimenez C, Cabanillas ME, Santarpia L, et al.: Use of the tyrosine kinase inhibitor sunitinib in a patient with von Hippel-Lindau disease: targeting angiogenic factors in pheochromocytoma and other von Hippel-Lindau disease-related tumors. J Clin Endocrinol Metab 94 (2): 386-91, 2009.
|Joshua AM, Ezzat S, Asa SL, et al.: Rationale and evidence for sunitinib in the treatment of malignant paraganglioma/pheochromocytoma. J Clin Endocrinol Metab 94 (1): 5-9, 2009.
|Buscombe JR, Cwikla JB, Caplin ME, et al.: Long-term efficacy of low activity meta-[131I]iodobenzylguanidine therapy in patients with disseminated neuroendocrine tumours depends on initial response. Nucl Med Commun 26 (11): 969-76, 2005.
|Scholz T, Eisenhofer G, Pacak K, et al.: Clinical review: Current treatment of malignant pheochromocytoma. J Clin Endocrinol Metab 92 (4): 1217-25, 2007.
|Gonias S, Goldsby R, Matthay KK, et al.: Phase II study of high-dose [131I]metaiodobenzylguanidine therapy for patients with metastatic pheochromocytoma and paraganglioma. J Clin Oncol 27 (25): 4162-8, 2009.
Treatment Options
After resection of a localized pheochromocytoma presumed to represent a benign tumor and documented normal postoperative biochemical testing, disease recurrence occurs in 6.5% to 16.5% of patients, and 50% of patients with disease recurrence develop metastatic disease.[1,2,3] Insufficient data exist to determine recurrence rates after complete surgical resection of regional or metastatic disease.
Treatment for recurrent disease involves appropriate medical management (i.e., alpha-adrenergic blockade) followed by complete surgical resection, when possible. Palliation of symptoms, including those related to catecholamine excess and local mass effect, is the primary focus of treatment for disease that is not resectable. Chemotherapy, targeted therapies, high-dose 131 I-metaiodobenzylguanidine radiation therapy, ablation therapies, and radiation therapy are options for patients with local-regional or metastatic disease who are not considered candidates for surgical resection. (Refer to the Metastatic Pheochromocytoma section of this summary for more information.)
Patients with inherited pheochromocytoma or paraganglioma are at risk for the development of recurrent disease in the form of additional primary tumors. Follow-up evaluation and management of additional primary tumors in such patients is essential. (Refer to the Localized Pheochromocytoma section of this summary for more information.)
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent pheochromocytoma and paraganglioma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
|Plouin PF, Chatellier G, Fofol I, et al.: Tumor recurrence and hypertension persistence after successful pheochromocytoma operation. Hypertension 29 (5): 1133-9, 1997.
|van Heerden JA, Roland CF, Carney JA, et al.: Long-term evaluation following resection of apparently benign pheochromocytoma(s)/paraganglioma(s). World J Surg 14 (3): 325-9, 1990 May-Jun.
|Amar L, Servais A, Gimenez-Roqueplo AP, et al.: Year of diagnosis, features at presentation, and risk of recurrence in patients with pheochromocytoma or secreting paraganglioma. J Clin Endocrinol Metab 90 (4): 2110-6, 2005.
Pheochromocytoma diagnosed during pregnancy is extremely rare (0.007% of all pregnancies).[1,2] However, this situation deserves mention because women with hereditary conditions that increase the risk of developing pheochromocytoma are often also of child-bearing age, and the outcome of undiagnosed pheochromocytoma during pregnancy can be catastrophic.
Prenatal diagnosis clearly results in decreased mortality for both mother and neonate.[3] Prior to 1970, a prenatal diagnosis of pheochromocytoma was made in only approximately 25% of cases, and the mortality rate for both mother and neonate was around 50%.[4,5] The prenatal diagnosis rate rose to greater than 80% through the 1980s and 1990s, and decreased maternal and neonatal mortality rates were 6% and 15%, respectively.[4,6]
The diagnosis of pheochromocytoma should be suspected in any pregnant woman who develops hypertension in the first trimester, paroxysmal hypertension, or hypertension that is unusually difficult to treat.[2,7] Normal pregnancy does not affect catecholamine levels.[8] Thus, the usual biochemical tests are valid. Magnetic resonance imaging is the localization method of choice because it does not expose the fetus to ionizing radiation.
Phenoxybenzamine use is safe in pregnancy, but beta-adrenergic blockers should be initiated only if needed because their use has been associated with intrauterine growth retardation.[9,10] Resection of the tumor can often be performed safely during the second trimester, or tumor resection can be combined with cesarean section when the fetus is ready to be delivered. Case reports have documented successful outcomes in the rare circumstance when surgical resection was delayed until a short time after vaginal delivery.[11] The successful management of pheochromocytoma in pregnancy depends on careful monitoring and the availability of an experienced team of specialists.
|Harrington JL, Farley DR, van Heerden JA, et al.: Adrenal tumors and pregnancy. World J Surg 23 (2): 182-6, 1999.
|Sarathi V, Lila AR, Bandgar TR, et al.: Pheochromocytoma and pregnancy: a rare but dangerous combination. Endocr Pract 16 (2): 300-9, 2010 Mar-Apr.
|Freier DT, Thompson NW: Pheochromocytoma and pregnancy: the epitome of high risk. Surgery 114 (6): 1148-52, 1993.
|Mannelli M, Bemporad D: Diagnosis and management of pheochromocytoma during pregnancy. J Endocrinol Invest 25 (6): 567-71, 2002.
|Schenker JG, Granat M: Phaeochromocytoma and pregnancy--an updated appraisal. Aust N Z J Obstet Gynaecol 22 (1): 1-10, 1982.
|Ahlawat SK, Jain S, Kumari S, et al.: Pheochromocytoma associated with pregnancy: case report and review of the literature. Obstet Gynecol Surv 54 (11): 728-37, 1999.
|Keely E: Endocrine causes of hypertension in pregnancy--when to start looking for zebras. Semin Perinatol 22 (6): 471-84, 1998.
|Jaffe RB, Harrison TS, Cerny JC: Localization of metastatic pheochromocytoma in pregnancy by caval catheterization. Including urinary catecholamine values in uncomplicated pregnancies. Am J Obstet Gynecol 104 (7): 939-44, 1969.
|Butters L, Kennedy S, Rubin PC: Atenolol in essential hypertension during pregnancy. BMJ 301 (6752): 587-9, 1990.
|Montan S, Ingemarsson I, Marsál K, et al.: Randomised controlled trial of atenolol and pindolol in human pregnancy: effects on fetal haemodynamics. BMJ 304 (6832): 946-9, 1992.
|Junglee N, Harries SE, Davies N, et al.: Pheochromocytoma in Pregnancy: When is Operative Intervention Indicated? J Womens Health (Larchmt) 16 (9): 1362-5, 2007.
Call 1-800-4-CANCER
For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time. A trained Cancer Information Specialist is available to answer your questions.
Chat online
The NCI's LiveHelp® online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 8:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.
Write to us
For more information from the NCI, please write to this address:
|NCI Public Inquiries Office
|Suite 3036A
|6116 Executive Boulevard, MSC8322
|Bethesda, MD 20892-8322
Search the NCI Web site
The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use the search box in the upper right corner of each Web page. The results for a wide range of search terms will include a list of "Best Bets," editorially chosen Web pages that are most closely related to the search term entered.
There are also many other places to get materials and information about cancer treatment and services. Hospitals in your area may have information about local and regional agencies that have information on finances, getting to and from treatment, receiving care at home, and dealing with problems related to cancer treatment.
Find Publications
The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
This summary was renamed from Pheochromocytoma Treatment and was extensively revised.
About PDQ
|Full description of the NCI PDQ database.
Additional PDQ Summaries
|Treatment options for adult cancers.
|Treatment options for childhood cancers.
|Side effects of cancer treatment, management of cancer-related complications and pain, and psychosocial concerns.
|Tests or procedures that detect specific types of cancer.
|Risk factors and methods to increase chances of preventing specific types of cancer.
|Genetics of specific cancers and inherited cancer syndromes, and ethical, legal, and social concerns.
|Information about complementary and alternative forms of treatment for patients with cancer.
This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of pheochromocytoma and paraganglioma. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board. Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
Permission to Use This Summary
PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."
The preferred citation for this PDQ summary is:
National Cancer Institute: PDQ® Pheochromocytoma and Paraganglioma Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/treatment/pheochromocytoma/HealthProfessional. Accessed <MM/DD/YYYY>.
Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.
Based on the strength of the available evidence, treatment options may be described as either "standard" or "under clinical evaluation." These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Coping with Cancer: Financial, Insurance, and Legal Information page.
Contact Us
More information about contacting us or receiving help with the Cancer.gov Web site can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the Web site's Contact Form.
Last Revised: 2010-10-27
This information does not replace the advice of a doctor. Healthwise, Incorporated disclaims any warranty or liability for your use of this information.


text:
By Sandra HolzOn Jan 12, 2018 Resume Examples
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subset: commoncrawl


text:
Level 3 Communications (NYSE: LVLT) is a provider of a range of integrated communications services including network and Internet services, colocation service, media services and voice services. Its operations are divided into communications and coal mining.[1] Its largest segment, communications, consists of Core Network Services, Wholesale Voice Services, and Other Communications Services.[2] Its operations are primarily located in North America and Europe. As the demand for online video, gaming, and the streaming of movies and live events continues to rise, providers of these services are striking long-term contracts to IP Upstream carriers. Reaching deals with streaming companies has been critical to Level 3's revenue growth. [3]
Level 3 reported a loss of $622 on $3.65 billion in 2010 revenues, compared to a loss of $618 million on $3.76 billion in revenues in 2009.[4] The declines in profitability and revenues can be partially attributed to a decline sales from large companies. In addition, expenses have risen as a result of high interest costs associated with the company's debt load. However, contracts with companies providing streaming services has the potential of providing new sources of revenue growth.[5]
Increases in consumer demand for online video, online gaming, streaming full-length movies and lives events has the potential of providing significant growth opportunities for communication services providers. In 2010, Americans spent as much time online as they did watching TV, and Level 3 expects that the amount of time spent streaming online to increase.[6] Level 3's broadcast services network and Vyvx capabilities delivered approximately 15,000 video feeds month as well as major live events like the Super Bowl, which the network has delivered for the past 22 years. In 2010, Level 3 Communications' IP Upstream service was selected to be a primary content delivery network (CDN) for Netflix's fast-growing streaming service.[7] However, this rapid growth is not without its costs. Level 3 says it will double its storage capacity to help accommodate the new contract. Expanding its services has the potential of forcing the company to increases its debt load, which would lead to significantly higher costs.[8]
In an effort to control or reduce costs, many of Level 3's customers have deferred or foregone purchases of services.[9] In addition, customers have also had trouble making periodic payments. As a result, there has been a decline in demand for communication services, which has resulted in lower revenues for Level 3. Meanwhile, utility costs have remained relatively stable for communication companies, leading to tighter margins.[10] However, as the result of a gradual pick up in economic activity, Level 3's profit margins on the Core Network Services have improved.[11] Increased economic activity has the potential of leading to increased revenues and profits on Level 3's core operations.[12]
While rising demand for IP Upstream services provides a new growth opportunity, a slow economic recovery has led to decline in demand for many other services provided by diversified communication companies. In addition, competition for fewer contacts for many networking services has led to depressed margins.
LVLT's top three competitors in telecommunications are:[13]


text:
The Aladdin Factor
Berkley Books, 1995 - Self-Help - 277 pages
Anything is possible...if you dare to ask!
Personal happiness. Creative fulfillment. Professional success. Freedom from fear- -and a new promise of joy that's yours for the asking.
We have the ability at our fingertips to achieve these things. It's the Aladdin Factor: the magical wellspring of confidence, desire--and the willingness to ask--that allows us to make wishes come true. Now bestselling motivational authors Jack Canfield and Mark Victor Hansen introduce us to the Aladdin Factor--and help us put it into effect in our own lives.
The Aladdin Factor helps us by pinpointing the major stumbling blocks to asking--and teaching simple techniques to overcome them. With inspirational stories about people who have succeeded by asking for what they want, this book shows us how to turn our lives around--no matter what kind of obstacles we face. And with this knowledge, we can reap the riches of a truly well-lived life--a treasure that comes not from an enchanted lamp, but from the heart.
From inside the book
11 pages matching Mark Victor Hansen in this book
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LibraryThing ReviewUser Review - Diwanna - LibraryThing
I hated the format of this book. It was like Canfield would make a single small statement like "Be Bold" and then would add some strange quotes and anecdotes from other people all in different fonts ... Read full review
User Review - Flag as inappropriate
Must read.oNE OF THE BEST i EVER READ IN MY LIFE. Helped me in doing which I thot was imposssible. Just by implementing A Factor (Ask Factor) in life i have achieved a lot. I keep reading it when I am confused about any decsions in my corporate or personal life....it works even in todays life.....
Must read.oNE OF THE BEST i EVER READ IN MY LIFE. Helped me in doing which I thot was imposssible. Just by implementing A Factor (Ask Factor) in life i have achieved a lot. I keep reading it when I am confused about any decsions in my corporate or personal life....it works even in todays life.....
Hyderabad, India
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Common terms and phrases
afraid Aladdin answer Arie Selinger Barbara De Angelis began believe Best of Bits better called child Clement Stone coach Craig create decided dollars dream eyes father fear feel Gate genie getting give goal happen heart hundred interview Jack Canfield Jim Rohn John Assaraf Johnny Hart kids knew KVIL lamp listen lives loan look Marcia Martin Mark Victor Mark Victor Hansen mind mother Myelin Project Napoleon Hill never Okay parents partner Patty Hansen person questions realized received rejection relationship remember request Self-Esteem seminar someone specific started stop story success talk teacher tell Thanks Thea Alexander there's thing thought tickets tion told Tommy wait walk week What's wife wish woman write York


text:
The Ocala Power Plant, a business incubator funded in part by the Ocala and Marion County governments, opened its doors 10 months ago with big plans to help bring jobs and draw new businesses to the area.
The Ocala Power Plant, a business incubator funded in part by the Ocala and Marion County governments, opened its doors 10 months ago with big plans to help bring jobs and draw new businesses to the area.
So far, the operation seems to be hitting the mark.
More than 100 potential tenants applied for inclusion in the incubator. Fourteen were accepted and occupy the 5,000 square feet of office space available in the Power Plant's building at 405 SE Osceola Ave. Their waiting list for space is long.
The companies have created 64 full-time jobs, including the jobs of a few company founders, who were working other jobs before joining the incubator, said Kevin Reed, Power Plant director.
One of the bigger successes is DS MediaLabs, a company that develops mobile phone applications.
Founded in 2007 in West Palm Beach, the company contracted in 2010 to develop software for another company exclusively. When that contract expired, DS MediaLabs came to the Power Plant and eventually relocated to Ocala.
"When we started here 10 months ago, we were in one of their smallest offices," said Shane Wooten, DS MediaLabs CFO and senior vice president of business development.
The company now employs eight additional full-time employees and10 interns, and it plans to keep growing.
It is one of two companies in the incubator that registered more than $1 million in revenue this year.
There are hundreds of incubators nationwide. Traditionally, they serve more like support groups than anything else, offering a place where budding businesses can congregate and collaborate in a secure and less stressful setting.
They bring in investors and try to match them with the incubated businesses. They also offer access to other business professionals in the community.
Some incubators target specific industries. The Power Plant does not have a single industry focus, but does lean toward technology startups.
To get in the Power Plant, a company needs to have a well-defined business plan and must have the potential to grow quickly. The business must also have an undercurrent of innovation.
Prospective companies with a customer base outside of the immediate area are preferred.
"We're looking for companies based in Ocala, but whose clients are based in California and Texas. We want to be in the export business," Reed said.
The company must then present its plans, with stated and measurable goals, to an acceptance committee who then votes on whether they get in or not.
Nothing for free
What the Power Plant doesn't do is provide direct financial support.
Everyone pays rent, which runs about $12 per square foot per year. The price is comparable to other Ocala commercial office space. The rent includes electric and high-speed Internet access.
Ocala does not charge the Power Plant for electric service and pays for the Internet access. The city also provided the building.
"Besides the electric and high-speed Internet being included in the cost, cleaning service and paper products are also included. All the little things that most startup companies don't think about. It's very turn key in that sense," Wooten said.
Growing is also easier. Unlike commercial office space, there are no contracts at the Power Plant.
"You have the flexibility. You can't always get out of the contract in other situations. Here, when we needed more space, we went to Kevin and it was no problem," Wooten said.
The flexibility of not having a contact can also work against the tenants as they can be replaced by another at anytime.
"We're kind of like a boarding school. You either graduate or you get expelled," Reed said.
Companies are reviewed by a committee every quarter and can be told to leave either because they have become successful enough or are not advancing.
"In both cases we can't really help them anymore. They either have enough to make it on their own or they are not making progress," Reed said.
But it can be even more cutthroat than that.
"We have 14 good companies in here. But, if a great company shows up at the door tomorrow, someone's going to get booted. It's not nice, but it's in the best interest of our community. Where we are held accountable to the community is job growth," Reed said.
What you get
The Power Plant's main goal is to make the building a hub of ideas. The goal is to have a building full of innovators bouncing ideas around and coming up with new and sometime collaborative efforts.
"The biggest benefit they get is to be around other entrepreneurs. You can't overstate how important that is," Reed said.
Elgin Carelock, CEO of Re-view Business Strategies, can attest. He is currently in negotiations with another Power Plant company.
"Me and another CEO were sitting up in the conference room having one of those meetings where we all sit around and brainstorm and he was talking about a particular project and I said, 'That is something we do.' We are weeks away from signing a formalized agreement to work on that project together. There were no other circumstances, that I could think of, where he and I would be sitting in the same room together except for us both being at the incubator," Carelock said.
Re-view, which develops detailed planning and business strategies for existing companies, was founded in March.
"If we get this project going, we'll add three jobs by the end of February," he said.
Another benefit to the tenants comes from the Power Plant's goodwill in the community. The plant has built relationships with schools, colleges and other businesses in the county.
"If you start a company at the kitchen table, it's really hard to convince someone to come to work for you at the kitchen table. Once you are in here, you legitimize the business by being in a place like this," Reed said.
Some companies have found that cache helpful.
"It's a good conversation starter. It helped us attract local talent. We were taken more seriously as one of the new technology startups at the Power Plant," Wooten said.
Carelock also found that to be true.
"Everyone knows that there's a lot of innovation going on in that place. To be part of it means you're an up-and-coming company. When some asked me and I tell them I'm at the Power Plant, they say they heard a lot of great things are going on there," he said.
There was a lot going on during a recent trip to the Power Plant. The parking lot was full, but there was no special program. Inside, there were brightly painted walls with dozens of inspirational quotes posted on them.
In contrast, there were also signs posted reminding people to throw away their trash and how to use the restrooms correctly.
Offices buzzed with chatter punctuated by occasional burst of laughter. In the DS MediaLab offices, however, it was quiet time as more than a half dozen young men sat in the dark in from of large computer screens.
It was well past 5 p.m.
"They'll be here until 2 o'clock in the morning," Reed said.
The company rents a room used specifically for power naps or to play video games.
The future
Despite the successes of the first 10 months, the Power Plant fell short in one key area: It was unable to find enough funding sources to invest in companies and ideas.
"Access to funding needs to improve," Reed said. "There are companies that, if they were funded, we'd love to have. They can't operate until they get some additional funding."
The incubator is currently working with two venture capital groups to start a fund for entrepreneurs who apply at the Power Plant, but nothing has been finalized.
The County Commission recently agreed to give the Power Plant an additional $100,000 to operate. The commission gave the incubator $100,000 in 2012 to get the operation going.
A project of the Ocala/Marion County Chamber and Economic Partnership, the incubator was not allowed to seek private sponsorships at first. With the hiring of Kevin Sheilley as the CEP's first president and CEO, that restriction is gone.
"The CEP team wanted to wait for the new CEO to launch a comprehensive capital campaign to support the three categories of economic development: business creation, business retention, and business recruitment," Reed said.
The incubator hopes to raise more than $400,000 in grants and sponsorships in 2013. That money will help fund the operations and salaries as well as allow for some marketing money.
"We spent virtually nothing on marketing this year. We simply did not have the budget for it," Reed said.
Reed also sees opportunities to lure other startups from around the country.
"There are a lot of incubators out there, but they can't support all the companies that come their way. If I can get the first five companies on a waiting list from Boston, they may jump ahead of an entrepreneur from Orlando," Reed said.
He said the city has agreed to let the incubator use two other nearby buildings to accommodate additional companies.
While the Power Plant has gotten off to a fast start, Reed hopes to continue attracting bigger and better companies that will stay in Ocala.
"Economic development isn't a one-step process. The end result that we are shooting for, to me, is that we have a whole bunch of companies with the best and brightest that can provide technology jobs for our children," Reed said.


text:
The law at one time treated all incorporated businesses alike. Even if they were small operations headed by one person, they were required to file extensive written documents and to hold board elections and annual meetings for shareholders and boards of directors as if they were IBM-like giants.
Small business owners who didn't comply or opted out of incorporating forfeited the protection of the corporate liability shield: If sued, an owner could personally lose everything. Partnerships, such as law firms and accounting firms, experienced similar detrimental legal effects.
Change started coming in the 1990s, with one of the leading catalysts being Suffolk Law Professor Carter G. Bishop, who for more than 20 years has served, pro bono, the Uniform Laws Commission, or ULC, a century-old organization that promulgates state laws intended to be uniformly adopted by all 50 states.
As a ULC reporter, Bishop has been the primary drafter of uniform laws governing limited liability companies, or LLCs, and limited liability partnerships, or LLPs. These laws enable the formation of unincorporated businesses that protect their owners from being personally liable for the business's debts and obligations while offering superior tax status. Because of these legal reforms, sole proprietors are no longer burdened with inefficient formalities and paperwork, and partners needn't fear losing their homes or pensions if they're sued.
Virtually every U.S. state has a law that Bishop drafted or remnants thereof, and the professor drafted many of the commercial business entity laws that students study in classrooms across the country.
Only a handful of states had LLC statutes when Bishop began teaching the subject at the William Mitchell College of Law in St. Paul, Minn. The dean recruited him to chair a committee to draft an LLC statute for Minnesota. After more states began adopting LLC laws, a publisher commissioned Bishop to co-author the two-volume treatise, Limited Liability Companies: Tax and Business Law. When legal inconsistencies began sprouting up from state to state, Bishop flagged the issue for the ULC and offered to serve as a reporter to draft uniform laws for unincorporated businesses.
The ULC took him up on it. Now, according to Bishop, more LLPs and LLCs are formed than corporations in every state.
"Limited liability not only facilitates the formation of capital; it facilitates and encourages the operation and development of a business," says Bishop.
"It tells the business owner that they can risk and lose their capital, but they won't lose their kids and their family and their dog and their house and everything else as a result. That encourages businesses to develop. That encourages jobs."


text:
Style # 211038
With waist-defining peplum and sharply tailored fit, this bebe blazer is sure to punch up your workweek. Throw it over a tee and pair of skinny jeans for weekend style.Ā
- 48% cotton, 45% polyamide, 7% elastane
- Center back to hem: 21" (53 cm)
- Imported
- Model is 5'9" and is wearing a US size S
Paula Peplum Jacket is rated out of 5 by 3.
Rated 5 out of 5 by Thequeengets from Very chic off-white jacket, a classic! I'm so happy with my purchase. I'm xs in bebe, I got this in 00 and fits perfect. Fabric does stretch a little bit which is nice and feels comfortable. The fabric wrinkles but not too much... color is not bright white but not cream either, is an off-white. Blazer looks feminine with the peplum kind of style and it accentuates the waist very nice. Looks great closed but open still gives a woman that femme sophisticated flair. It does not look cheap, nor it looks like a medical (doctor) robe at all like some others and the length of this jacket is perfect, not too short or too long. Sleeves are nice and fitted, again the fabric stretches a little. I'm 107 lb. and I get my jackets from bebe in 00 but I could do with a size 0, however I prefer it more fitted than not and I can say it runs true to bebe sizes.
Date published: 2013-07-23
Rated 5 out of 5 by Tbroc881 from Love! Beautiful fabric, bright white color, tailored to flatter both waist and bust! I'm 5'3'', 125 lbs, 34C and the size 4 fits perfectly. This is so versatile and great for spring/summer!
Date published: 2013-03-24
Rated 5 out of 5 by angelbabyboo67 from very feminine love the way it looks. this is now my favourite blazer/jacket. got it in 00
Date published: 2013-02-06


text:
Safeguards Program
The Safeguards Program and staff are responsible for ensuring that federal, state and local agencies receiving federal tax information protect it as if the information remained in IRS's hands.
These agencies and their contractors receiving federal tax information must protect the confidentiality of return information and are periodically reviewed by Safeguards personnel to ensure they meet the safeguarding requirements of IRC 6103(p)(4). These requirements include employee awareness programs, proper disposal, secure storage and computer security among others.
Publication 1075, Tax Information Security Guidelines for Federal, State and Local Agencies (PDF)
This document contains specific requirements for safeguarding federal tax information. This revision becomes effective on Jan. 1, 2014.
Publication 1075, Tax Information Security Guidelines for Federal, State and Local Agencies (PDF)
This revision of 1075 became effective on Aug. 24, 2010 and is superceded by the Jan. 1, 2014 version.
Comments and suggestions on the revised Publication 1075 can be forwarded to the safeguards mailbox at: email@example.com.
Additional Requirements for Publication 1075
Safeguarding requirements may be supplemented or modified between editions of Publication 1075 by guidance issued by the Office of Safeguards.
See "Safeguards Alert Memorandums" below for trending security concerns.
Publication 1075
Recommendations on How to Become Compliant with the New Requirements
Given the significant changes in technical safeguards requirements found in Sections 4, 5 and 6, the IRS has some recommendations for agencies to become compliant with the new requirements.
Reporting Requirements
Publication 1075 requires agencies to use approved report templates and to transmit the reports electronically. These reports must be encrypted and submitted to the firstname.lastname@example.com mailbox.
Reporting Unauthorized Accesses, Disclosures or Data Breaches
Local, state and federal agencies receiving federal tax information must follow the revised provisions of Section 10 of Publication 1075 (PDF) upon discovering a possible improper inspection or disclosure of FTI, including breaches and security incidents. Agencies must contact Treasury Inspector General for Tax Administration and the IRS Office of Safeguards immediately, but no later than 24-hours after identification of a possible issue involving federal tax information. Agencies are not to wait until after their own internal investigation as been conducted.
Contacting TIGTA is critical to expedite the recovery of compromised data and identify potential criminal acts. The IRS Office of Safeguards investigation focuses on identifying processes, procedures or systems within the agency with inadequate security controls which led to the incident.
Internal Inspections Reports
Section 6.3 of Publication 1075, Tax Information Security guidelines for Federal, State and Local Agencies and Entities, requires that agencies receiving federal tax information (FTI) establish a review cycle for internal inspections of headquarters offices and all local/field offices that receive FTI. The Internal Inspections Report – Headquarters Office and Internal Inspections Report – Field Office are for these inspections.
In addition, these agencies must also include an internal inspection of IT operations, using the Internal Inspections Report – IT Operations. Internal inspections of contractors with access to FTI and any off-site storage facilities must also be completed. All scheduled and completed internal inspections should be provided to the IRS Office of Safeguards on the Internal Inspections Implementation Report.
Safeguards Technical Assistance by Topic
The IRS has recommendations and discussions on various Safeguards Program topics available for agencies to help stay in compliance. These documents may assist with preparation of reports, protecting federal tax information, and knowing the legalities of the Safeguards Program.
IRS Disclosure Awareness Videos
IRS Disclosure Awareness training videos are available for local, state and federal governmental agencies that receive federal tax information (FTI). The IRS Office of Safeguards created videos (with captions in English and Spanish) to help explain several key concepts in protecting the confidentiality of FTI.
Safeguards 1 Building New Systems - Safeguards Systems Development aids to comply with Publication 1075 security requirements when building a new application on which Federal Tax Information will reside or new process which will use FTI.
- Safeguards 2 Building New Processes or Procedures - Safeguards Process Procedure Development aids to comply with Publication 1075 security requirements when building a new application on which Federal Tax Information will reside or new process which will use FTI.
- Disclosure Awareness Training (Pub. 4711) / Spanish Captions
- Disclosure Awareness Training for State Child Support Agencies (Pub. 4712) / Spanish Captions
- Disclosure Awareness Training for State Human Services Agencies (Pub. 4713) / Spanish Captions
- Protecting Federal Tax Information: A Message from the IRS
- Safeguards 101 Webinar
References/Related Topics
Physical Security and Disclosure References/Related Topics
Publication 1075 requirements pertaining to the protection of FTI in a physical environment and the disclosure of FTI to other persons are available in the Safeguard Disclosure Security Evaluation Matrix.
Release Date
|Safeguard Disclosure Security Evaluation Matrix (SDSEM) (XLS)
Safeguards Alert Memorandums
The following resources address recent security trends regarding the protection of FTI.
Release Date
|Alert Memo – Multi-factor Authentication Implementation
|Alert Memo – Protecting FTI On Mainframes with Open Port 23
Computer Security Compliance References/Related Topics
The following Computer Security Evaluation Matrix (SCSEM) downloads are available for use in preparing an IT environment that will receive, process, or store FTI.


text: Buy some brown rice and cook up a pot. Brown Rice is like cheap as fuck. Buy some broccoli and chop it up. Broccoli is is around 3 bucks for 3 stalks. You can prob get it cheaper if you shop around. Chop up a boneless skinless chicken breast. 1 boneless skinless chicken breast is about a buck 50 if you get it on sale. Stir fry the broccoli with olive oil till it starts to brown. Add a little water and cover to let it blanch til the water evaporates like 2 or 3 minutes. (perfect chinese style broccoli every time.) Remove the broccoli and set aside. Fry up the cut up chicken until the juices run clear. Add some of this to the chicken. Mix to coat. This is the most expensive part of the meal. A jar cost around 4 bucks. You can use it sparingly though. Then add the cooked broccoli. Mix to coat. Serve over the brown rice. Add some of this for extra flavor. Soy sauce lasts for ever. Kikkoman is the best. Each batch you make is easily 2 meals so that makes a little over 3 dollars a meal. If you make a lot of rice you can feed a family of 4 for 5 bucks.


text:
Schools cancelled
The recent ice storm was persistent. On three successive nights, a new layer of freezing rain fell. School was cancelled for three days in a row.
To be precise, during the last week before Christmas, school was held on Monday and school is planned for Friday (tomorrow). It will be a wild day with the kids super-excited for Christmas. I'm glad I won't be there.


text:
2 days ago
Kearney named NZ coach, Bennett advisor
Former Kiwis skipper Stephen Kearney has been appointed coach of the New Zealand rugby league team, with former Australia mentor Wayne Bennett to be a team advisor.
Kearney is currently an assistant with NRL premiers Melbourne and assumes the position after Gary Kemble quit following a horror European tour last year.
Brisbane coach Bennett had been expected to be named New Zealand head coach today, but has instead assumed a role advising the team ahead of the 2008 World Cup in Australia.
Bennett, who confirmed last week that he would leave the Broncos at the end of this year's season, his 21st in charge of the club, coached Australia 16 times between 1998 and 2005.


text:
We are pleased to present this hairy busty babe Kitty.
We have many more pics of Kitty and other natural babes in our Natural and Hairy members' area and more scheduled for
future updates. We also have over 2,400 other beautiful, natural models in our
ATK - NATURAL and HAIRY members' area.
Come see the Best Hairy Pussy!
Click Here For FREE Sample Pictures!


text:
Steve Jenkins Workshop - What Animal is This?
Place:The Depot - across the river from the Library on 13th Street
KIds' Workshop: What Animal is This?
Come join the award-winning author Steve Jenkins, who has given us a close-up look at the animal world through his amazing books. Mr. Jenkins will work with students to create their own animal guessing game with cut- and torn-paper collage.
Limited to 30 kids ages 8 and up.
Reserve your workshop slot here.


text:
American Honda Motor Co., Inc., announced today a new voluntary program to provide important safety information to consumers. Monroney labels (window stickers) on all 2006 model year Honda and Acura cars and light-duty trucks will include a listing of government crash test ratings. Honda will be the first company to make this safety information available to consumers on the important window labels, show pricing, vehicle features, point of origin, Environmental Protection Agency numbers, domestic content, emissions and other information.
In keeping with Honda's 'Safety for Everyone' initiative, all vehicle window stickers will display the star ratings awarded under the National Highway Transportation Safety Administration's (NHTSA), New Car Assessment Program (NCAP) for frontal, side and rollover crash safety test ratings.
"Honda's commitment to safety goes beyond conventional measures with our 'Safety for Everyone' initiative," said John Mendel, senior vice president, automobile operations, American Honda Motor Co., Inc. "Honda's initiative is just one of several actions we are taking to advance motor vehicle safety and to educate consumers."
Honda's action to revise its window labels to include safety rating information is modeled after the 'Stars on Cars' initiative sponsored by U.S. Senator Mike DeWine (R-OH). Senator DeWine's provision in the Highway bill would require manufacturers to post NHTSA crash tests "star" ratings on vehicle pricing stickers.
"I would like to congratulate Honda on this announcement. As with its 'Safety for Everyone' initiative, Honda has shown again today that it is willing to innovate and take voluntary action to protect the driving public. I look forward to a time when all new cars will come standard with 'Stars on Cars' labels," stated Senator Mike DeWine (R-Ohio).
"This common-sense legislation is included in the Senate's version of H.R. 3, yet is not in the House's, and I urge the Conference Committee to include it in the final report. Vital safety information needs to be accessible to the consumer when they need it most, at the dealership when purchasing decisions are made," Senator DeWine said.
NHTSA's New Car Assessment Program provides consumers with vehicle safety information on front and side crash tests, as well as rollover ratings. The test results are publicized through a recognizable star rating system - from 1 to 5 stars, with 5 being the best score. The star ratings, are accessible on the safercar.gov website but may not be readily available on the showroom floor.
"Honda is setting a good example for other manufacturers by getting safety information to the customer at the point of sale," said NHTSA Administrator, Jeffrey W. Runge, M.D. "This voluntary action helps the market work for the safety of consumers."
Honda has more vehicles than any other brand that achieve a top rating for both frontal and side impacts under the federal government's NCAP and SINCAP crash rating programs.
Through Honda's industry-leading 'Safety for Everyone' initiative, all Honda and Acura vehicles, with the exception of a small number of specialty vehicles, will feature a suite of advanced safety technologies. By the end of calendar year 2006, front side airbags with an Occupant Position Detection System (OPDS), side curtain airbags and anti-lock brakes will come as standard equipment. Most Honda and all Acura light-duty trucks, including all SUVs and minivans, will also be equipped with Vehicle Stability Assist (VSA¿) and rollover sensors for side curtain airbag deployment.
Honda's 'Safety for Everyone' initiative is based on the company's commitment to leadership in safety and to providing a high level of occupant and pedestrian protection in all its cars and trucks, as well as increased crash compatibility with other vehicles, regardless of size or price. In addition to having two of the world's most advanced crash test research centers, Honda has conducted industry-leading research into increased pedestrian safety and car-to-car crash compatibility, two critical issues in the quest to further reduce traffic-related injuries and deaths.


text:
|> Introducing filesFLASH.net
|29th May 2011, 02:40 AM
Join Date: 2nd October 2004
Posts: 831
Introducing filesFLASH.net
Allow me to present to you a new player on the filehosting scene - filesflash.net
As you all know, filesquick has not had a payment processor for a long time. Also, as the site is growing, we are finding it difficult to buy more servers for storage of so many files. Therefore, we have decided to store all our videos at filesflash.net.
filesflash.net is no different from the various file hosting services prevalent on the internet nowadays. What this means, among other things, is that:
1. You can buy time based subscriptions for very little money and download as much as you want in that time.
2. People who are on slow connections and do not want to download too many files can opt for the free option which is slower and has less features, but is more than adequate for sparse usage.
3. Uploaders can now earn not only the facility of downloading other files but also some money.
4. Uploaders can use remote upload to directly transfer files from other websites to FF. They are also testing a multi-upload client (think FQ uploader on steroids, inside a browser) but that is not publicly enabled yet.
I am sure you will find this change to be beneficial all around.
Let me anticipate a few questions and answer them:
Tell me 'this' or 'that' about FilesFlash.net?
FilesFlash is a new file hosting site. They are a general file host not restricted to videos only, but we will be using them only for videos. You may upload all kinds of files and post their links on other sites, but please post only videos at FQ.
You can read more about their terms and schemes on their site. We can probably answer many of your queries about their service, so feel free to ask, but we cannot replace their support team. For specific help and support, you will need to use their contact form.
So I cannot upload videos to FQ anymore?
You can continue to post videos like always, but you must upload the file to FF. Video file uploading at FQ will be disabled. You will only be able to upload jpeg, gif and png files to FQ.
How will FQ change to accommodate this?
The only change at FQ is that FF url's are allowed (earlier all url were disabled). Thus, you can now upload your videos at filesflash and post the links at filesquick. Images can be posted via attachments as always. As always, threads will be viewable by all only after you post at least one image and one video.
All the other things like categories, search, moderations, rules etc will remain the same.
What about the old videos which already exist at FQ?
These videos will also be transferred to FF shortly. The process will be automatic and you need not do anything except tell FQ about your FF account. You can do this in the UserCP at FQ. We expect this process to start in 3 days.
Hey, if there are no videos at FQ, what use will be my bandwidth balance?
The videos at FQ are not gone as yet. You can continue to download them while they are here. No downloads in progress will be interrupted during the transfer. All downloads which have already started will be allowed to finish.
Moreover, you can get FF subscriptions in exchange of FQ bandwidth at the rate of 1 month FF subscription for 15 GB bandwidth or a 1 day subscription for 1 GB bandwidth. The process will be controlled by you and you can do this when you wish. This is obviously a very fair exchange as you can download much more than 1 GB in a day at FF.
Sounds good for the uploaders, downloaders and freeloaders, but what does FQ get out of this?
FQ gets a commission on every subscription sold through FQ.
Automatic file transferring from FQ to FF is now live.
To transfer your files,
1. Register at filesflash.
2. Go to FilesQuick->userCP->edit options. Scroll down to the bottom and enter your FF username.
3. relax.
To Register At FilesFlash
Transfer FQ bandwidth to FilesFlash Premium
To transfer your bandwidth into corresponding FF subscriptions visit *url removed*
Once you generate a coupon code, go to My Account page on FilesFlash.net and click on Apply Coupon. Copy the coupon code given above and paste it into the 'Enter coupon code:' field at FilesFlash.net and click the Submit button. Your FilesFlash account's 'premium upto' time will be extended.
Feel free to ask more questions. You can also give suggestions and feedback which we will pass on to the FF team.
Cannot think of anything witty right now.
Last edited by Suzane007; 23rd April 2015 at 07:51 PM.
|Post in any Forum
|29th May 2011, 02:49 AM
XP Super Moderator
Join Date: 4th July 2008
Posts: 57
Last edited by avs1984avs; 29th May 2011 at 03:31 AM.
|29th May 2011, 08:41 AM
MD SuMo
Join Date: 14th August 2007
Location: XP & MD
Posts: 405
Wow superb
Search before uploading and avoid posting duplicate videos.
Posting vdo takes more then 10min. Searching for duplicates takes only 1min and Removing your duplicate vdo's takes only 10sec for MDTF's.
So pls avoid posting duplicates and save your time.
Last edited by manikbasa; 29th May 2011 at 08:41 AM.
|29th May 2011, 12:19 PM
Join Date: 13th April 2007
Posts: 44
Honestly You Screwed It .. For The Downloaders In FilesQuick Who Love To Download Often Only and Specially For Indian Users as they do not accept payments from India Currently .. !!
|29th May 2011, 12:28 PM
Join Date: 22nd January 2006
Location: /search.php
Posts: 669
Power belongs to those who take it.
|29th May 2011, 12:34 PM
Join Date: 13th April 2007
Posts: 44
Kal Kisney Dekha ?? !! FQ was looking for payment processor since so long but finally ended up colaborating .. !!
and free users sucks 2 videos per day : P lolzzzz.. FQ was the best Thing There were so many other ways to accept payment to be Honest .. Colaborating is not a solution until you own that website too !!
Anyways its done .. !! Phewww.. Lets c but it will be just like you are posting your pics on a pic hosting service and uploading your video on any other file hosting like rapidshare filesonic and placing in it a forum .. So How Unique Will FQ be From Now !!
|29th May 2011, 12:45 PM
Join Date: 22nd January 2006
Location: /search.php
Posts: 669
Power belongs to those who take it.
|29th May 2011, 12:59 PM
Join Date: 2nd October 2004
Posts: 831
Cannot think of anything witty right now.
|29th May 2011, 04:10 PM
Join Date: 13th April 2007
Posts: 44
Argument never ends you know .. I just wanna enlight that FQ was a file upload and download forum in itself and from now on its just another forum .. what will stand out fq from now on ??
Do You Own FF ?? If yes then its cool and if now whats the guarantee thats it wont shut down like every other new file hosts gets after few months or year or two ..
Getting My Point ??
And Me Myself ..
* Members with zero bandwith cant download ( agree ) but can we gift bandwith now in FF ??
* Options Colaborating is never an Option ..
* Every Forums Gets Moderated ...
And GodFather.. i agree with your point .. it was to be an Hour Instead Of Day My Mistake ..
But there are always other options instead of what FF got implemented.. Anyways I am finishing My Bandwith Now Because it will get wasted as there were no time limit in FQ and FF will Have Time Limit ..
Therefore whats the use of the current Bandwith ..
Also How Will You Balance out the features earn bandwith
|Thread Tools


text:
Question: How can you play a bullish gold outlook while reducing the risk of an uncertain and volatile marketplace?
Answer: A bull 1x2 call spread.
Athough the presidential election will be settled by the time you read this, there still will be a lot of uncertainty regarding the economy and volatility in the metals sector.
Efforts to discern what the next few weeks or months may hold, while always difficult, have been intensified by the recent uptick in realized volatility. Oscillations are exacerbated by program trading, polling data, central banks, jobs numbers and questions regarding the fiscal cliff.
President and General Dwight D. Eisenhower said: "In preparing for battle, I have always found that plans are useless, but planning is indispensable."
While we are traders, not soldiers or politicians, Eisenhower's statement rings true. Absent a plan, you are more likely to fail in whatever you do, so here is some background and a plan for trading metals in the coming weeks.
On Nov. 2, the Bureau of Labor Statistics (BLS) reported that the economy added 171,000 jobs in October, beating expectations by about 40k. The BLS also revised the August and September data considerably higher (50k and 34k respectively). The release caught a fairly directionless short-term metals market flat-footed.
The board was blood red on the number as traders pushed gold lower by $40, 2.35%. Silver sold off by $1.39, 4.3%. The week ended in fairly classic "risk-off" fashion with the U.S. dollar and the VIX higher, and just about the entire commodity complex closing at or near multi-week lows.
The weakness in metals may present attractive entry points as the market nears the end of a healthy correction where outside forces still are very supportive of higher prices.
While the election is days away as of press time, the results will not change the overall outlook that higher prices are likely into the end of the year.


text:
2010-01-14 / General
Spencer Adventist Christian School Accepting Applications
Offering quality Christian education for grades kindergarten through eighth, Spencer Adventist Christian School is currently accepting applications for enrollment in second semester. Open to all, bus spots are limited. Located on State Road 43, one mile south of State Road 46, Spencer Adventist Christian School is part of the second largest private education system in the world. Find out more by calling 812-829-2485 or 812-821-1582.
© 2009-2018 Spencer Evening World, Inc. | Privacy Policy
No commercial reproduction without written consent.
Electronic reproduction of any kind forbidden without written consent.


text:
Players, Coaches, Referees, Administrators and Their Parents
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Latest Activity: Oct 30, 2016
We are players and coaches looking to join a team. To post, in the Subject post where you want to play or coach, like: "College in U.K."
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text:
oh little fire (Rhapsody) [Digital Download]
With a sound reminiscent of her acclaimed album You Were Here (which Time Magazine hailed as "The year's best debut"), but also showcasing a bit of her folk and country side, oh little fire may be the strongest batch of songs Sarah Harmer has ever released. Co-produced by Sarah and Gavin Brown (Metric, Sarah's All of Our Names), oh little fire is Sarah's first new album in 4 years and is full of the same hooky melodies, insightful lyrics, and lovely, plaintive singing which attracted so many fans to her music from the start of her career. Featuring a duet with Neko Case on "Silverado."


text:
Transnational education at a juncture: Sociological futures post-Brexit2 May, Keele University
· To what extent can the symbolic capital of a British degree continue to travel across space, post-Brexit?
· Within the complex modes of mobilities of transnational education (TNE), will Brexit trigger new or stifle current forms of mobilities? Should there be a theoretical re-definition of the mobilities within TNE? If yes, how?
· What are the embodied experiences of TNE institutional agents and the students in situ?
· In relation to Early Career Researchers who are engaged in TNE teaching and research, to what extent might their career / research trajectories be impacted by the uncertainties/opportunities brought about by Brexit?
· To what extent are the TNE students'/academics' interests represented?
Nearly one in every three students of UK's universities is a TNE student, i.e. they earn their British degrees while they are partially or entirely based in a different country from the UK. In 2012, the UK's TNE export amounted to £18 billion, with a projected increase to £30 billion by 2020 (HEGlobal, 2016). However, the recent events of Brexit seem to have brought this into question, raising practical, empirical and theoretical concerns.
This one-day seminar seeks to serve as a platform for these questions to be debated and to make important theoretical, empirical and methodological contributions to TNE as manifest in the cogent disciplines of sociology, anthropology, human geography, education, political science and others.
We are delighted to announce our keynote speakers:
· Dr Johanna Waters, University of Oxford
· Professor Catherine Montgomery, University of Bath
Call for abstracts
We invite both established and early-career (including postgraduate) researchers who would like to present at the event to submit titles and abstracts of max. 250 words. In your abstract, please tell us about how your research contributes to one or more of the above questions. Abstracts will be used as the basis for a selection for a special issue.
Travel Bursaries
Two bursaries (£150 each) are available for early career researchers, including PhD students and PhD holders not in established positions. To apply, send a one-page CV and a statement of interest of no more than 200 words to the organisers.
· Deadline for abstract submission/travel bursary application: 10 March 2017
· Presenters/bursary winners will be notified by 24 March 2017
For more information or to submit an abstract, or apply for travel bursaries please email Cora Lingling Xu and Reza Gholami using 'BSA Early Career Forum: Transnational Education post-Brexit' in the subject line.
Registration costs £10 for BSA members and £25 for non-members, and will open in April 2017 at:http://portal.britsoc.co.uk/public/event/events.aspx


text:
CHARLOTTE, N.C. (AP) — Freezing rain and sleet have closed schools and offices and caused hundreds of wrecks across North Carolina, Tennessee and Kentucky.
The icy weather snarled traffic across much of western and central North Carolina. The Department of Transportation reported traffic moving under 30 mph on much of Interstate 40 from Winston-Salem to Raleigh and Interstate 85 from Charlotte to Durham.
Charlotte Police were responding to dozens of calls of cars overturned as the heaviest freezing rain moved through.
The storm has caused no deaths, and only scattered power outages have been reported.
Tennessee had declared a state of emergency as a precaution and the eastern part of the state is seeing significant icing.
An ice storm warning was issued from the Smoky Mountains, northward through Knoxville, Cumberland Gap and well into Kentucky.


text:
- Visit
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About This Artwork
Irving Penn
American, 1917–2009
Two Cholas (Mestizas) From Puno, Cuzco, 1948, printed 1949
Gelatin silver print, edition of 8
20.2 x 19 cm (image/paper); 35.5 x 28.4 cm (mount)
Inscribed verso: "172724-273/MLY"; stamped verso: "COPYRIGHT / NOT TO BE REPRODUCED WITHOUT / WRITTEN PERMISSION FROM / THE CONDE NAST PUBLICATIONS, INC."; stamped verso: "PHOTOGRAPH / BY / PENN"; inscribed verso: ".."; inscribed verso: "TWO CHOLAS (MESTIZAS) FROM PUNO / CUZCO, DEC. 1948 [in a box]"; stamped and inscribed verso: "PHOTOGRAPH BY IRVING PENN / Copyright © 1960 by Irving Penn, / COURTESY OF VOGUE / Not to be reproduced without / written permission of the / copyright owner and / THE CONDE NAST PUBLICATIONS INC."; stamped and inscribed verso: "SIGNED, SILVER PRINTS OF / THIS NEGATIVE NOT EXCEEDING 8."; signed and stamped verso: "Irving Penn / IRVING PENN [in a circle]"; inscribed verso: "Print made 1949. / IP."
Gift of Irving Penn, 1996.262
Not on Display
Exhibition, Publication and Ownership Histories
Exhibition History
Chicago, Art Institute of Chicago, "Irving Penn, A Career in Photography," November 22, 1997–February 1, 1998; traveled to St. Petersburg, Russia, State Hermitage Museum, March 1–May 16, 1998; Hamburg, Germany, Deichtorhallen, June 18–September 6, 1998; Munich, Germany, Müchner Stadtmuseum, October 6, 1998–February 21, 1999; San Francisco, California, Friends of Photography/Ansel Adams Center for Photography, November 11, 1999–January 23, 2000; Museum of Fine Arts, Houston, March 25–June 4, 2000; Paris, France, Maison Européenne de la Photographie, September 13–November 5, 2000 (Chicago only). (Colin Westerbeck)
Publication History
Penn, Irving. 1960. "Moments Preserved." Simon and Schuster. p. 100. (other print of this image)
Westerbeck, Colin. 1997. "Irving Penn: A Career in Photography." Exh. cat. Art Institute of Chicago/Bulfinch Press. p. 178, cat. 41.
Ownership History
Given by the artist to the Art Institute, 1996.