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MARCH 31--Pointing to a supposedly "indecent" Howard Stern broadcast late last month, a Republican Senator has told Viacom boss Mel Karmazin that the King of All Media has already violated the media giant's new beefed-up decency policies. To support his claim, made in a March 30 letter, Senator Sam Brownback attached the below partial transcript from the offending Stern show, which featured a racy interview with Rick Salomon, who co-starred with ex-girlfriend Paris Hilton in the videotape seen 'round the world. In his letter to Karmazin, Brownback specifically asked, "can you explain how lines 5 through 11 are not indecent under the FCC rules." While we're waiting for Karmazin's response to the Kansas pol, at least this time Mel doesn't have to explain away talk about blumpkins and such. (3 pages)
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Why Aren’t There Stars In The Moon Landing Photos? -Explained
Newton October 23, 2017 Night Sky
On July 20, 1969, Apollo 11 astronauts Neil Armstrong and Buzz Aldrin climbed down from the Eagle lunar module (leaving behind poor Michael Collins) to put the first footprints on the moon. That’s the story, at least. A vocal minority believes that the moon landing was all an elaborate hoax filmed on a sound stage in Hollywood.
Among their evidence is the fact that photographs and video footage don’t show any stars in the sky. How could the Hollywood producers be so careless in their conspiracy? In fact, there’s a pretty mundane explanation. The camera settings weren’t adjusted to capture them.
If you wanted to take a picture of a friend in direct sunlight, you’d adjust your camera settings in two ways. You’d narrow the aperture, which keeps the light-collecting area on the lens small to avoid letting in too much light, the same reason your pupils constrict in bright sunlight.
You’d also speed up the shutter speed, so the camera sensor would only let in light for a brief moment. If you wanted to take a picture of that same friend at night, you’d probably slow down the shutter speed and widen the aperture so you could let in enough light for a good shot.
But what if your friend was illuminated at nighttime? Then you’d have to choose what you wanted in your photo. If you wanted to include the stars in the sky, you’d need to make sure your friend stood extra still to avoid blurring the shot while the slow shutter and wide aperture let in enough light.
If you kept the aperture small and the shutter speed fast, you’d capture a sharp, decently bright picture of your friend, but the sky would be dark because it wouldn’t send enough light into the lens.
That’s the trade-off the Apollo astronauts had to make. The sky on the moon is black as night not because it is night, but because there’s no atmosphere to scatter the daylight the way ours does on Earth.
But make no mistake, there is every bit as much sunlight at midday on the moon as there is on our home planet. That makes the lunar surface incredibly bright.
The scenery on the moon was the most important thing to capture in the Apollo photographs, so the camera was adjusted to make the most out of that scenery. As a result, the relatively dim stars in the background didn’t register in any of the shots. No hoax, just a trick of the camera lens
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14 comments
Anonymous 23 October 2017 at 18:13
Why does the shadow of the flag go in a different direction than the other shadows?
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Anonymous 23 October 2017 at 18:46
It´s not the shadow of the flag, it´s the shadow of an object or person to the left, outside the picture.
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Unknown 24 October 2017 at 16:13
because it's night time.. and they wanted to see. so they brought up multiple lights and depending on where you set up these lights it will cast shadows in different places... DUUUHHHHH
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Unknown 23 October 2017 at 19:19
Then how can the Hubble telescope see anything ?
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Unknown 23 October 2017 at 20:28
The Hubble telescope is not on the moon. Nor does it face the sun or the moon when taking readings. It uses a large aperture and a very long exposure while focusing on a small part of space. If you used a telescope on the moon when the sun is shining it would be about as effective as using one during the day on earth. The only advantage you would have is the almost non existent atmosphere.
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Unknown 20 December 2017 at 15:59
Why do you even bother explaining to morons?
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Anonymous 21 December 2017 at 05:54
Unknown, how did you get to be such a caring person?
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Anonymous 24 October 2017 at 00:30
I think it is a good idea then to send these non believers to use a telescope on the moon, they use too much of our atmosphere here anyway..
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Anonymous 26 October 2017 at 16:08
Why is there no shadow from the flag than?
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Imdyinhere 22 December 2017 at 11:48
its there, you just cant see it due to the uneven surface of the moon around where the flag has been placed.
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Moonbeams 20 December 2017 at 16:15
Why is the flag waving?
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Imdyinhere 22 December 2017 at 11:47
its not waving. technically its "floating". the top bar keeps the flag extended in zero/low gravity and the fabric is just kind of wrinkly and floating there.
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Unknown 21 December 2017 at 12:04
We spoofed it all just to fool all of you people! The moon rocks, measurement and monitoring instrumentation left behind, the data from these devices, astronaut training and lives lost, yes it was all done to jack with worthless morons like you folks. We are currently communicating with your bank and lending institutions through chips in your credit cards and those that we placed in your head after birth. NASCAR and Sunday Morning church broadcasts will be slowly terminated using our control of sunspots. We did it all because of you!
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Unknown 24 December 2017 at 18:55
The space telescopes have shades, screens, to block direct sunlight. Since there is no air to refract sunlight generally, the space telescope can take deep sky photos as long as it can block the photons of direct sunlight.
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Africa
Tanzanian PM rejects claims COVID-denying leader is unwell
TO
By Tom OdulaThe Associated Press
Fri., March 12, 2021timer3 min. read
NAIROBI, Kenya - Tanzania’s President John Magufuli is well, the country’s prime minister said Friday, rejecting opposition claims that the COVID-denying president, who’s been out of public view for nearly two weeks, is seriously sick with the virus.
Kassim Majaliwa said Magufuli is busy with office duties, and called on the public to ignore widespread reports that he is unwell. “He is fine and doing his responsibilities,” Majaliwa said, without disclosing the president’s whereabouts.
Magufuli had controversially claimed that Tanzania has defeated COVID-19 through prayer last year and that there were no more cases.
The prime minister said Magufuli, who has not been seen in public for 13 days, asked him to convey his greetings to residents in the country’s southern town of Njombe.
“The president has a lot to do,” he said, adding that the president had delegated some duties to his aides.
Magufuli’s absence is unusual as he is known for frequent public speeches and appearances on state television several times a week.
Opposition politicians also raised questions about the president’s health after at least one official close to him died recently.
Magufuli was last seen in public on Feb. 27 at the swearing-in ceremony of his chief of staff. The event was at the State House government offices in Dar es Salaam, the East African country’s largest city.
Exiled opposition leader Tundu Lissu, who lost the October presidential election to Magufuli, claimed in a series of Tweets since Wednesday that the president had been flown to India in critical condition after first being taken to neighbouring Kenya for COVID-19 treatment.
Lissu lives in Belgium due to fears for his life after a government crackdown on opposition politicians who were calling for peaceful protests over alleged massive voting irregularities.
He had returned to Tanzania in July to campaign in the election. Lissu started his self-imposed exile from exile following a failed assassination attempt in 2017 in which he was shot 16 times.
On Thursday, constitutional Affairs Minister Mwigulu Nchemba issued threats to those speculating on the president’s absence.
“A head of state is not a head of a jogging club who should always be around taking selfies,” Nchemba posted on his social media accounts.
“Those who are breaking the law, think about what the penal code says on cybercrime. The government is monitoring,” he said.
Magufuli announced last June that Tanzania had defeated COVID-19 through three days of prayer. The country, one of Africa’s most populous with 60 million people, in April stopped providing statistics about the numbers of people with confirmed cases of COVID-19 or deaths from the disease to the Africa Centers for Disease Control and Prevention.
The government has fired some officials who questioned Magufuli’s assertion that nobody was falling ill from COVID-19 in Tanzania. The government tried to encourage trade and foreign tourism, seeking to avoid the economic pain of neighbours who imposed lockdowns and curfews. It did not ban public gatherings or promote wearing masks, and Magufuli promoted herbal remedies for those who fell ill with what he called “breathing problems.”
However, people leaving Tanzania reported that hospital intensive care units were filled with patients with severe respiratory illnesses. Others said that burials were being held at night to hide the numbers of deaths. Migrants in other countries from Tanzania were found to have COVID-19.
In February, Magufuli appeared to acknowledge the existence of the disease after at least one top official in his administration died of it.
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Lavish Leasam
November 13, 2019
Section:
OPULENCE & SPLENDOUR
Vast Georgian mansion close to the East Sussex coast with garaging for nineteen cars for sale for just under £10 million
Built for a Rye based attorney and banker named Jeremiah Curteis (1735 – 1806) between 1798 and 1806 and altered in 1903 by Sir Reginald Blomfield (1856 – 1942) – best known for his work on Chequers between 1909 and 1912 – Leasam House at Playden in East Sussex is described as a “fine mansion” by British Listed Buildings.
Home to Sir George and Lady Warrender in the early 1900s, the Grade II listed building subsequently became the Leasam House School between 1956 to 1992 before being returned to use as a private residence in more recent years.
Consisting a total of 18,733 square foot of accommodation and 7 reception rooms, 11 bedrooms and 11 bathrooms in the three storey main residence, Leasam House also comes with a 3,592 square ancillary residence named Leasam Grange. Additional features number both a family and catering kitchens, a 10 seat cinema room, a gym and a steam room.
Standing on a picturesque plot of 56.67 acres that includes formal and informal gardens, parkland and woodland, there is also a tennis court, helicopter landing area and garaging for 19 cars – plainly something that attracted the company director and car enthusiast Matthew Le Breton, a collector of everything from 1937 Atalantas and Jaguar E-Types to Porsche GT Carreas, to the property.
Savills seek £9.5 million ($12.2 million, €11.1 million or درهم44.8 million) for Leasam House and laud the property as “beautifully refurbished” and having “elements of the contemporary.”
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8 COMMENTS
Fred Hanson November 13, 2019 At 11:44 am
The interior is not reflective of the grand exterior. A great pity but with some attention, it could be returned to something a little more in keeping with the style it should have.
Reply
Margaret November 13, 2019 At 1:03 pm
Fred’s comments have nailed it. A grand exterior but inside is 12, High Street, Hackney.
Reply
Fullarton November 13, 2019 At 2:37 pm
Oh my goodness, what a dreadful mess, however did that should be charged with vandalism
Reply
TRIA Maria September 10, 2020 At 6:48 am
it is George IV meets George Jetson….why did they destroy what was there previously?
Reply
Catherine November 13, 2019 At 4:24 pm
Fabulous exterior, disgraceful “elements of the contemporary” interiors! Whoever did that have a psych evaluation!
Reply
NB November 14, 2019 At 10:48 am
Stunning gounds and house exterior….interior vandalised by inappropriate ‘design’. So sad to see, disrespects the house rather than improves or enhancees it. Classic example of too much money and too little good taste.
Reply
Steve November 16, 2019 At 11:53 pm
This is someone’s family home. I don’t think these comments are very kind.
Reply
Jack December 28, 2019 At 5:51 pm
I think the interior looks awesome, think I might make a bid. Does anyone have 9.45 million they can lend me?
Reply
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Airtel Africa Launches Its Long-term Sustainability Strategy, Building On Its Corporate Purpose To Transform Lives - TheStreet
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INVESTINGPERSONAL FINANCERETIREMENTCRYPTOMARKETSHOW-TOVIDEOFINANCIAL ADVISOR CENTERTECHNOLOGY
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Publish date:
Oct 28, 2021 3:00 AM EDT
Airtel Africa Launches Its Long-term Sustainability Strategy, Building On Its Corporate Purpose To Transform Lives
Strategy sets out the Company's commitments and establishes medium and long-term goals NAIROBI, Kenya, Oct.
Author:
PR Newswire
Strategy sets out the Company's commitments and establishes medium and long-term goals
NAIROBI, Kenya, Oct. 28, 2021 /PRNewswire/ -- Airtel Africa, a leading provider of telecommunications and mobile money services, with a presence in 14 countries across Africa, today launched a comprehensive sustainability strategy ( www.airtel.africa/investors) which sets out its detailed plans to improve the lives of millions of people across Africa through digital and financial inclusion and access to education. The strategy also includes specific goals around environmental protection and the ongoing development of a rewarding, diverse and inclusive workplace.
We have worked hard to identify the technical programmes needed to respond to all our material topics and to have a genuine and positive impact on people and communities across Africa. Our strategy sets specific goals and commitments, and for each of these, we have identified exactly how we will achieve them and the milestones along the way. Our Board and Executive Committee have been integral to developing this strategy which is fully aligned with the Company's corporate strategy and plans. We have engaged with our stakeholders throughout the development of the strategy and undertook a detailed stakeholder consultation ahead of this launch.
Our strategy is delivered through four sustainability pillars: 'Our business' which reflects our operations and the expansion of our network, 'Our people' which sets commitments around employee engagement, development, diversity and inclusion, 'Our community' which details our dedication to improving access to education, and 'Our environment' which is focused on reducing the environmental impact of our operations. We have identified six of the United Nations Sustainable Development Goals to which we believe our work will make a genuine and tangible contribution- they are SDG 4: Quality education, SDG 5: Gender equality, SDG 8: Decent work and economic growth, SDG 9: Industry, innovation and infrastructure, SDG 10: Reduced inequalities, and SDG 12: Responsible consumption and production.
Segun Ogunsanya, CEO, Airtel Africa, said: "Today is a significant milestone in Airtel Africa's journey. Our new strategy provides a solid foundation for us to accelerate change for the communities we serve and the environment in which we operate. We have worked closely with our stakeholders to ensure that this strategy is ambitious, robust and credible. This partnership approach underpins all the work we will deliver through our strategy. We will look to collaborate across the industry, recognising that by working together, we will be able to drive a more significant impact for the people who need it most. We are more committed than ever to ensuring open and honest communication on our progress as Airtel Africa embarks on its long journey towards a more sustainable future.
Goals and commitments
The sustainability strategy includes nine goals and commitments, with corresponding programmes that address the business' material topics (identified through an extensive consultation at the beginning of the year) and enable the Group to continue delivering sustainable growth and uphold the best governance standards:
Data security goal: Establish industry-leading data security for our customers through investments in technology and expertise, updated processes and consumer awareness - with focus areas around confidentiality, integrity and availability.
Service quality goal: Provide underserved communities with access to reliable networks and connectivity through the rollout of new infrastructure and technology, improved fibre connectivity and capacity - with focus areas on service accessibility, delivery and reliability.
Supply chain goal: Ensure all our suppliers are aligned with our sustainability agenda through programmes to increase supplier disclosure and audit ESG performance - with focus areas on enhanced supplier due diligence and ongoing ESG compliance.
Commitments to our people: with our ongoing commitment to provide rewarding employment opportunities and to achieve genuine diversity and inclusion at all levels across the business through:
Delivering equality in our workforce through recruitment and programmes to provide training and advancement for everyone regardless of gender, nationality or disability;
Providing best practice training and development through upskilling and reskilling initiatives to ensure they can succeed in their future careers. And through supporting female entrepreneurs through training and increasing women's participation in the technology and engineering sectors;
Providing the highest standards of health and safety for our employees and contractors through the introduction of a best practice social and health and safety management system, improved policies and full compliance with all legislation and regulation; and,
Maintaining the highest levels of employee engagement through the introduction of additional channels that provide every one of our people with a voice.
Digital inclusion goal: significantly improve digital Inclusion across Africa by driving the penetration of mobile, smartphones and home broadband in rural areas through the provision of retail and support services.
Financial inclusion goal: significantly increase financial inclusion in Africa, with particular support for women through the development of affordable financial products to meet the needs of the un- and under-banked, a reliable service and financial confidence and literacy.
Access to education goal: helping transform the lives of over one million children through improving access to education - with programmes around connectivity, the provision of zero-rated education content under a five-year UNICEF partnership, connecting 1,400 schools to the internet by 2027, and the adoption and support of schools in all our markets.
Greenhouse gas emissions reduction goal: Our ambition is to achieve net zero greenhouse gas (GHG) emissions ahead of the 2050 deadline set out in the Paris Agreement. To do this we must fully identify, measure and reduce our GHG emissions which can only be achieved in partnership with our peers and the wider industry. We will establish and launch a sector leading and credible decarbonisation pathway in 2022, ahead of the publication of our first Sustainability Report.
Environmental stewardship: Eliminate hazardous waste from our operations, significantly reduce our non-hazardous waste and minimise our water consumption with programmes to replace damaging materials, expand recycling schemes and build employees' awareness around the protection of our natural resources.
About Airtel Africa
Airtel Africa is a leading provider of telecommunications and mobile money services, with a presence in 14 countries in Africa, primarily in East Africa and Central and West Africa.
Airtel Africa offers an integrated suite of telecommunications solutions to its subscribers, including mobile voice and data services as well as mobile money services both nationally and internationally.
The Group aims to continue providing a simple and intuitive customer experience through streamlined customer journeys.
www.airtel.africa
View original content: https://www.prnewswire.com/news-releases/airtel-africa-launches-its-long-term-sustainability-strategy-building-on-its-corporate-purpose-to-transform-lives-301410346.html
SOURCE Airtel Africa
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I am so excited to share with you a quick recap from my recent trip to NYFW and a look at my outfit for Day 1. While fashion week is exciting, February in New York is extremely cold. So planning your outfits is a little tricky, but definitely strategic. You want to be comfortable, yet “put together” and layering is a must!
I loved wearing these Radium Leggings from Carbon 38 to backstage at the Leanne Marshal show. You guys know how much I love Carbon 38 and I could not wait for these leggings to arrive in the mail just in time for me to take them on my trip. Not only are they extremely comfortable, but they have a shiny finish…almost like leather, but feel like fabric. I layered them with my favorite Ash Booties and Carbon 38 Parka over this top. It was the perfect combination for warmth and comfort. Would you judge me if I told you I wore these leggings more than once during this trip? You know how it goes when you find a pair that you love (plus they were so easy to pack)!
During our trip we were able to meet with some of my favorite brands and see a few shows and presentations. I absolutely loved meeting with the Birchbox Team (check out this dutch braid they gave me) and can’t wait to share with you an exciting project coming this summer. We also managed to pack in a few showroom visits with Alison Brod and Hunter Bell. I’ll be sharing more from our trip tomorrow!
Thanks for reading! xx
OUTFIT DETAILS: Carbon 38 Radium Leggings (Fit: True to Size), Parka (Fit: runs a little big, I am wearing a small. If you are in between sizes, I suggest sizing down) | Sweaty Betty Natha Yoga Long Sleeve Top (Fit: True to Size, this top is so soft!) c/o | Ash Booties | Goyard GM Tote | Grey Knit Scarf | similar Grey Gloves | Celine Audrey Sunglasses (similar version under $10 here)
MORE CARBON 38 FAVORITES
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images by: Jessa Kae
This post was sponsored by Carbon 38. As always, my opinions and selections are my own!
Related
Valentine’s Day in Pink
Snowday in New York City
Day 2 NYFW
Preparing for Fashion Week
9 Comments Filed Under: My Looks, Travel Diaries
Comments
stylemelauren says
February 26, 2016 at 11:16 am
YOu just cannot get any more chic in this all black look! Love it! xo
@stylemelauren
http://www.stylemelauren.com
Reply
Erin @ Her Heartland Soul says
February 26, 2016 at 12:09 pm
Cute look! I’m glad you enjoyed fashion week!
Reply
Monika says
February 27, 2016 at 9:44 am
Love this look!
Love,
http://www.thestyleventure.com
Reply
Anna White says
February 27, 2016 at 8:14 pm
Great look – cozy and warm! XO -Anna
http://www.parkavenueblogger.com
Reply
Jennifer says
February 28, 2016 at 12:08 am
Love this all black look! It’s refreshing to see this look on your blog. My boyfriend’s family lives in Texas, and I know you guys love color. In New England we definitely dress a lot darker. This look was perfect for NYC.
Reply
Catherine says
February 29, 2016 at 3:29 am
I love this clothes. Thanks for your recommend.
http://www.dressfashion.co.uk/browse/pink-prom-dresses-c-118/
Reply
Christina says
February 29, 2016 at 11:57 am
Love the Carbon38 pants! How do you like the zipper? Would it be awkward for someone who’s only about 5’2″?
Reply
Ashley Robertson says
February 29, 2016 at 1:51 pm
Hi Christina,
Thank you so much for your question! Based on their sizing chart, the inseam looks to be 29″. I am around 5’7, and they hit about an inch or 2 above my ankle. I’m afraid the zipper might cause a problem if you’re 5’2. Have you seen these http://bit.ly/1QocDMT I think they might be a better option 🙂
Hope that helps! Thanks for reading xx Ashley
Reply
Christina says
February 29, 2016 at 4:11 pm
Thank you so much!! I’m a new reader to your blog and I have to say I’m now obsessed! I love your style and your writing tone 🙂
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FEBRUARY half-term will see the return of the popular Football in the Community/Norwich City Soccer School to the Watton area.So if you are aged between five and 14 this could be the best way to spend your school holidays.
FEBRUARY half-term will see the return of the popular Football in the Community/Norwich City Soccer School to the Watton area.
So if you are aged between five and 14 this could be the best way to spend your school holidays. Soccer Schools are a great way for children to get active in the school holidays by enjoying the nations favourite sport.
The course is being held on Wednesday, February 18 at Watton Sports Centre.
Each Soccer School places the emphasis not only on fun, but each child regardless of ability learning new skills to take away with them, either to use either in the playground or for their local team.
Each venue provides a safe fun environment for the child to play, as long with all the top coaching from the FA-qualified coaches.
Lee Croft, Norwich City, winger said: “Soccer Schools are a great way for children to learn the game of football in a child friendly environment, and that's where I started playing and got picked up by Man City, so they can even help you make it as a professional.”
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Ian Thornton, FITC Director, added: “Our Soccer Schools allow many children to keep active in their holidays. Whilst the main aim is for them to attend, make friends, have fun and practice their skills under the guidance of our qualified staff we have also identified male and female players who have progressed to the relevant advanced programmes.''
All Soccer Schools run from 10am to 3pm with a cost of �17 for non-members and �16 for members.
Each child will go away with a NCFC signed certificate of attendance, and a free gift to remember the course, there is also the opportunity to be selected for one of the advanced Player Development Centres.
Also at some venues some NCFC players (subject to availability) might drop in to share their experiences, show their favourite skills and sign those all-important autographs.
To book on a course please either call the FITC office on 01603 761122 or download a booking form from the kids' course section at www.fitc.org.uk and remember to book early to avoid disappointment.
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How students get to class costs, too. Commuters with their own cars might pay a note on top of insurance, gas and parking passes, and others are paying bus fare.
And don't forget textbooks.
But students have to consider not only the cost of their education, but the value of their degree and whether it will pay for itself.
How students pay for college
With the popular TOPS scholarship fully funded for next year, some costs for more than 50,000 traditional college students are covered. TOPS goes toward tuition and fees for four semesters. Award amounts vary depending on GPA, ACT score and a student's classification.
Some receive more scholarships than what they owe for school and live off "refund checks" they receive at one time, usually in the middle of the semester.
But often scholarships, even TOPS, only cover so much, like for Beth Saida.
The sophomore nursing major from Alexandria is using TOPS and other financial aid to pay for classes at the University of Louisiana at Lafayette.
"Whatever's left over is out of pocket," she said.
That comes from tips and wages she earns as waitress at Tampico Restaurant in Lafayette.
She started there during the fall semester, working about 30 hours a week during the school year. With a lighter course load this summer, she is working full time.
"I'm trying to avoid loans as much as I can," said Saida, 19.
RELATED:When does school start again? | Where our taxes went
George Harrison, a senior at UL Lafayette, is thinking about the loans he's taken out as he enters his last year of college. He said it stresses him out a little.
"I'm fixing to graduate and will have to pay it back," he said.
Things already are tight. He works 50 hours a week at Target and is in the Army National Guard, which helps cover tuition.
But it's not enough.
"I actually have to look for a second job," said Harrison, 23.
The federal program Upward Bound is covering tuition and room and board for Oneisha Smith, this summer.
Are years of state cuts really to blame for tuition increases?
Smith, a freshman nursing student, doesn't have a job like her fellow Morrow native Harrison.
"I know I probably will have to get a job, just not this year," she said.
Major matters
Mary Fox Luquette, finance instructor at UL Lafayette, offered her philosophy when it comes to paying for school.
"If (students) get a scholarship, they can major in whatever they want," she said. "If they're taking out a loan, they need to be in a major that's going to provide a job that will allow them to pay back the loan."
She is referring to scholarships "in the broadest sense, which include, but not limited to: TOPS, trust funds, large savings, parental funding, rich grandma, patrons, benefactors and other resources that could fund a college education."
She's seen students in debt to the tune of hundreds of thousands of dollars in student loans for job fields that pay no where near that.
"There's never a way an educator's salary will pay off a degree at Tulane," she gave as an example.
"Education is fabulous," Luquette said. "... We're a family of teachers. Just go to a state or local university (for that path)."
Although she points out that "education is never a waste," she cautions students to consider the economics of different degree paths.
She says, "it's just my opinion, but, financially, it makes sense."
Thinking about college? Acadia Parish wants to help
Part of the problem is that often students and families aren't thinking about paying off loans when they're accruing debt.
"For them, it's all about the here and now," Luquette said.
Families should be realistic about the majors students choose.
"Some studies are very valuable," she said. "They have a place in society. The problem is being able to pay the loan back."
Luquette doesn't want to discourage students from choosing a major they want. If a lower-paying path is the one for you, just be practical about the college you attend to get it, she says.
In other words, private or Ivy League universities aren't the place to earn a teaching degree, in which you graduate to a starting salary that is less than one year of tuition.
Another thing to consider is the time it will take to complete a degree, which correlates to cost.
"A student goes in thinking it will take four years," she said. "Some take six. Every semester you're in college you're racking up debt."
How much does it cost?
Out-of-state and international students pay higher tuition rates than Louisiana residents, which is standard practice.
This chart breaks down the most recent rate of tuition and fees by state university published on each institution's website. Figures reflect tuition and fees for one year, excluding summer quarters or semesters, for an in-state, full-time student.
(Story continues below chart.)
Full-time is 12 or more credit hours per semester or at least 9 credit hours at Louisiana Tech University, which goes by quarters.
The school with the highest rate of tuition and fees is Louisiana State University, the flagship and largest public university in the state, at $11,318 a year, according to current full-time rates published on schools' websites.
Excluding two-year schools, the lowest rate can be found at LSU of Alexandria with $6,667.50 for two semesters.
In raw numbers, a year of tuition and fees at LSU, the highest in the state, equals 1,561 hours of work at minimum wage in Louisiana ($7.25 an hour) — if no taxes were taken out.
A year at LSUA, the cheapest, is just under 920 hours of minimum wage.
RELATED: How to succeed in college | What's driving students to community college?
Game plan
"There's got to be a plan in place," Luquette said.
And that planning starts before the first day off college. Many work in high school, apply for scholarships and pick a high-wage major, all before they graduate.
She knows a lot of parents can't afford to pay for college, she said, but with enough planning and hard work "it is possible to get a good down payment for college."
"See what you can do before you start," she said. "Plan ahead."
That also means knowing ahead of time how much school actually costs, said Jeff Massey, financial aid director at Louisiana State University of Alexandria.
"That's one thing that still surprises me is talking to students and finding most aren't aware of the cost," he said. "And then they wonder when they get the bill."
He said it's just a matter of putting in time to research that. Most schools post cost information online. Some even offer a calculator to give an estimate.
Massey encourages everyone to complete the Free Application for Federal Student Aid, commonly known as FAFSA, every year. Some students don't fill it out assuming they don't qualify or thinking it's only for loans.
"They're leaving money on the table possibly," Massey said.
And some schools are given funds from donors that include needs-based requirements. If a school doesn't have a FAFSA on file, they won't know you qualify, he said.
"It is possible (to pay for school)," Massey said. "It depends on what they qualify for. Some qualify for Pell grants and TOPS, and they can receive enough to cover everything and pay nothing out of pocket. That's typically the traditional students. They just have to keep up their academics."
Pell ranges from $600 to $2,900 a semester. Student loans range from $5,500 to $12,500 a year, depending on students' classification and whether they are dependents of their parents.
And then there are loans, of course.
"With student loans we always tell students they're there if you need them," Massey said. "They're an investment in your education."
But, he adds, don't over-borrow. The U.S. now has $1.44 trillion in total student loan debt.
"Take them only if you need them," he said. "Only get what you really need."
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This is a high quality Flavor West flavour concentrate, imported from the United States and packed into drip-tip bottles for your convenience. Please note that this is a flavour concentrate meant for DIY use, it is not ready-to-vape and must be diluted. We suggest a solution of 10% to 20% for best results. Flavor West concentrates are generally pre-sweetened and are great for single flavour mixes.
This is a flavour concentrate, meant for DIY mixing. It is NOT ready to vape and must be diluted before use.
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IMF Slashes Global GDP Forecasts, Warning Of An Economic Crisis ‘Like No Other’ | The Villages Home Search Blog | The Villages Florida Home Search
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IMF Slashes Global GDP Forecasts, Warning Of An Economic Crisis ‘Like No Other’
Back to blog
Thursday, August 20, 2020 / by The Villages Home Search
IMF Slashes Global GDP Forecasts, Warning Of An Economic Crisis ‘Like No Other’
The pandemic is causing an “unprecedented decline” in global economic activity.#thevillages #thevillagesfl #thevillagesflorida
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A scary moment during tonight's WWE Hall of Fame ceremony tonight; as Brett Hart and Natalya addressed the crowd for the Hart Foundation induction a fan jumped the barricade and tackled Hitman. A swarm of security, Hart family members, and current WWE roster members apprehended the man and led him away through the crowd. The sixty-one year old, pro wrestling icon was uninjured in the altercation and continued his speech.
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To ask the Secretary of State for Defence how many Royal Navy ships are currently in service; how many were in service in 2008; and if he will make a statement.
Tweet Share
Hansard source (Citation: HC Deb, 14 November 2011, c529W)
Peter Luff The Parliamentary Under-Secretary of State for Defence
Due to the difficult economic position this Government inherited, tough decisions have had to be taken to rationalise the fleet.
In 2008 the Royal Navy had 75 surface ships. The Royal Navy currently has 66 surface ships in service of the following types: Landing Platform Docks, Landing Platform Helicopters, Destroyers, Frigates, Mine Countermeasures ships, River Class Offshore Patrol Vessels, Inshore Patrol Craft and Survey Ships. In addition, the Royal Navy has 11 submarines in service (Ballistic and fleet).
The work done in the SDSR concluded that, despite these reductions, the Royal Navy retained sufficient assets to undertake the tasks required of it, as shown by the success of our operations in Libya.
Does this answer the above question?
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Would you like to ask a question like this yourself? Use our Freedom of Information site.
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Hansard source (Citation: HC Deb, 14 November 2011, c529W)
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Before digging around unikernels, I was just reading some updates in Are we web yet? for Rust web ecosystem, more specifically deployments, it triggered a whole new search subject.
Experimenting unikernels
April 06, 2021
Unikernels are specialised, single-address-space machine images constructed by using library operating systems. - unikernel.org
How I plan to use this weblog
January 21, 2021
Well, putting some of my thoughts in the open is one thing. I'll probably talk about web, a couple of programming languages if my knowledge of them let me. Apply some IndieWeb concepts as well.
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At the summer meeting of the National Association of Insurance Commissioners here, life actuaries updated regulators on how far along the massive principles-based reserving project has come.
During the discussion, it was noted that a new NAIC policy on model laws was not expected to impact the project.
The multi-pronged effort to transition from a formulaic approach to a principles-based approach, which many maintain will more accurately reflect the reserves a company should be holding, includes efforts to incorporate work done on life risk-based capital, make changes to the standard valuation law, and create a valuation manual adopted by states so that needed changes could more easily be incorporated into individual state regulation.
Discussions included both more general practical considerations and technical updates, and timeframes for completion of different aspects of the project presented by the American Academy of Actuaries, Washington. The academy is coordinating the work of numerous working groups and actuaries to realize the completion of the PBR project.
What Your Peers Are Reading
A major practical consideration for getting the PBR project adopted in states was raised by Paul Graham, a life actuary representing the American Council of Life Insurers, Washington.
Graham emphasized the importance of getting PBR uniformly adopted in all states, an effort that regulators on the Life & Health Actuarial Task Force supported. One reason he cited was a requirement that the appointed actuary sign a statement that actuarial requirements are being met in all states in which the company is doing business. If there are 2 sets of actuarial requirements, 1 PBR and 1 formulaic, then it will be very difficult for the appointed actuary to certify that all states’ requirements are being met, according to Graham.
There was also a discussion about having can do/must do effective dates as a way of phasing in PBR requirements.
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One regulator, Fred Anderson of New York, indicated that New York intends, at least initially, to require companies to calculate reserves using both PBR and formulaic approaches until there is a comfort level with the PBR approach.
Among the technical updates and timelines discussed by the academy’s different working groups are the following:
Completion of most of the work on a valuation manual by the fall NAIC meeting in September.
A simplified approach to non-guaranteed elements being developed by the life reserves working group for elements such as dividends on participating policies and UL interest crediting and mortality charges. This would only be available for policies that are determined not to have material tail risk at the time of issue. The idea would be to value only the guaranteed benefits using a conservative, deterministic greatest present value reserve. The method would automatically adjust for changes in experience.
Focus on life capital and continue working on a third phase of the C3 project, which looks at interest rate and market risk components of the current life risk-based capital framework.
On risk transfer, no penalty would apply if a risk transfer provision could be modeled, but may apply if a provision could not be modeled or if the provision presents a public policy concern.
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by Rich Collins | Nov 2, 2016 | Content Development, Featured, Marketing, Portsmouth NH, Social Media, Sustainability, Uncategorized, web design, web development, Wordpress, Writing
It’s 2016, My life in the Gig Economy is going well. I just hope my blog is still up to date? With so much going on professionally, it’s hard to stay on top of your own marketing game sometimes! But I’m still me, and working solo has been great to...
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Interview – Rich Collins, Kristi Baxter and Michael Cameron transcribed loosely from the New Hampshire Brand Project Radio Show. Michael Cameron- Rich Collins is the founder of Thirst Productions. Welcome to the New Hampshire Brand Project Radio Show! Rich...
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Most of us are jumping onto the WordPress bandwagon these days, I know i get misty eyed when I see the amazing level of control and capabilities the open source content management platform offers. And with all good things related to technology, with widespread...
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Passway is a lighting bollard with an abundance of unique features. The superior optics allow the Passway to be spaced further apart than conventional bollards, requiring fewer luminaires to light a space, whilst still achieving a high level of uniformity and just 2% upward light. The on-board optical selector switch provides on-site adjustment between area and pathway distributions providing flexibility and ease of installation. Slight knocks from parking vehicles can compromise the structure of a lighting bollard, so Passway features patent pending FlexBase technology, an innovative protection system that allows it to pivot up to 10° from vertical, gently returning to the upright position once the force is removed. Passway is designed to provide high performance and long life for a variety of different applications.
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Toronto-based Michael Vaughan's collection of historical wines from all over Canada, which includes some rare bottles, will be housed as part of Brock's Cool Climate Oenology and Viticulture Institute
ThoroldToday Staff
Sep 24, 2021 4:00 PM
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1 / 1 Toronto-based wine expert Michael Vaughan has donated his collection of rare, award-winning Canadian wines to Brock University’s Cool Climate Oenology and Viticulture Institute.Photo supplied by Brock University
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NEWS RELEASE
BROCK UNIVERSITY
*************************
Renowned wine expert Michael Vaughan has selected Brock University’s Cool Climate Oenology and Viticulture Institute (CCOVI) as the new home of his impeccably preserved collection of award-winning Canadian wines.
The Michael Vaughan Wine Collection contains 2,500 bottles of historical wines from across the country, including a number of extremely rare bottles that date back decades. The collection has been personally curated and preserved by Vaughan and contains some of the last-remaining bottles of their kind that are still in mint condition and drinkable.
Vaughan, who earned his PhD in International Economics from the University of Toronto, was a Professor of Economics at Ryerson University before becoming an award-winning national wine writer and critic. He said his collection was curated with intellectual pursuits in mind. As an educator himself, Vaughan said he felt CCOVI’s state-of-the-art facilities and reputation for research and educational excellence made it an ideal partner for both housing and utilizing his unique collection.
“I wanted to make sure the wines I have accumulated went somewhere where they could be a useful learning experience,” he said. “I wanted to share them with an academic institution. The most important one for me was Brock, because it made sense that it went to a place where the students, the faculty and the winemakers could experience the evolution of these wines and see how good they still were and how they had changed over all of these years.”
Brock University has become a trusted steward for unique, historically significant collections, including the Alexander Hamilton collection that was donated to the Brock Library’s Archives and Special Collections last year.
Debbie Inglis, Director of Brock’s CCOVI, said the Michael Vaughan Wine Collection is a prime example of how gifts of this kind and ongoing partnerships with donors can serve students, researchers and the community for years to come.
“This generous donation, coupled with Michael’s expertise, will be a valuable asset to the Institute as we work to address the evolving research and outreach needs of our industry and educate future generations of grape growers and winemakers,” she said. “This collection serves as a living history of the evolution of Canadian wine, allowing us to learn from the past and bolster the sustainability and success of our industry in the future.”
The collection will be housed in CCOVI’s 44,000-bottle capacity wine cellar, where the wines will be climate-controlled, archived and preserved as part of the Institute’s Canadian Wine Library.
“This donation contains wines from some of Canada’s top wine vintages, including 1998 and 1999, and to have these coming through our doors is very exciting,” said Barb Tatarnic, CCOVI’s Manager of Continuing Education and Outreach. “It opens up a treasure trove of opportunities for CCOVI to take a deep dive into these wines and to offer tastings and research opportunities that look at things like ageability, the impact that good vineyard practices have on the quality of wines, climate, weather impacts on vintage variation and much, much more.”
Vaughan has been studying, collecting and writing about wine for more than 50 years, documenting the 1970s resurgence of the Canadian wine industry first-hand. He is the publisher/editor and creator of Vintage Assessments, a not-for-profit publication dedicated to professional buyers, sommeliers and wine lovers, and has personally tasted and critiqued tens of thousands of the world’s top wines.
The value of the collection he is gifting to Brock lies in the health of the wines themselves, which he preserved in a climate- and humidity-controlled environment and routinely evaluated for quality using a time-honoured technique to preserve their integrity.
“I keep my wine very cold because I don’t want it to evolve, so my secret of having wines that are still drinkable after 50 years is the temperature,” Vaughan said. “The wines that have been donated to CCOVI had never moved out of my climate-controlled storage.”
Vaughan will continue to offer his breadth of expertise and collaborate with CCOVI on various outreach, research and educational opportunities involving the presentation of these wines going forward.
“This is the fun part,” he said. “I really want to continue working with Brock, including on some interesting projects I have in mind.”
CCOVI, which is poised to celebrate its 25th anniversary in October, is developing plans for hosting these opportunities, as well as an event to celebrate the donation, in the near future.
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XS / Fortress - $88.00S / Fortress - $88.00M / Fortress - $88.00L / Fortress - $88.00XL / Fortress - $88.00XXL / Fortress - $88.00XXXL / Fortress - $88.00
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This rusted locomotive once took tourists on a 62-mile journey through East Tennessee. Now, it sits at the end of its line tucked away in the hills it used to tour.
Author: Elizabeth Sims, Leslie Ackerson
Published: 9:39 AM CST November 16, 2021
Updated: 4:54 PM CST November 19, 2021
ANDERSON COUNTY, Tenn. — Hidden away among the trees in Anderson County are the remnants of a short-lived, but once beloved, tourist attraction.
The New River Scenic Railway was an idea brought to life by two East Tennesseans who wanted to start a tourism business.
They struck a deal with the coal company to use the railway for the operation. Then they bought the locomotive from a mine in Arizona and added a passenger car with a converted baggage car for a gift shop and snacks.
Passengers would wind along a scenic 62-mile trip deep into East Tennessee, and the little local operation’s popularity grew rapidly with its brochures scattered throughout the community.
Shortly after it started running, the owners had to add a second passenger car from Canada, complete with safety notices in French and English, so they wouldn’t have to turn guests away.
FULL SERIES: Explore Tennessee's Abandoned Places
While self-proclaimed train enthusiast John-David Ezell never got to take a ride while it was running, he has learned quite a bit about the locomotive’s history through a friendship with the owners.
“It was a pretty popular trip. It didn't last very long, but everybody wanted to come do it,” he said.
The short-lived stint lasted from 2008 to 2010 before things began to derail when the line changed hands and disputes about the rights to use the track brought the excursion to a screeching halt.
“They parked it here to keep it out of the way in case they ever needed to use the line for anything else, and here it's sat for going on probably 11 or 12 years now,” Ezell said.
Abandoned Places: New River Scenic Railway Train
1/15
Elizabeth Sims
This rusted-out locomotive once took tourists on a 62-mile journey over a river and through the hills of East Tennessee.
2/15
Elizabeth Sims
This rusted out locomotive once took tourists on a 62-mile journey over a river and through the hills of East Tennessee.
3/15
Elizabeth Sims
Inside the locomotive's engine
4/15
Elizabeth Sims
Inside the engine
5/15
Elizabeth Sims
Inside the first passenger car
6/15
Elizabeth Sims
Inside the second passenger car. It was bought from Canada so it has signs in English and French.
7/15
Elizabeth Sims
Inside the second passenger car. It was bought from Canada so it has signs in English and French.
8/15
Elizabeth Sims
Inside the second passenger car. It was bought from Canada so it has signs in English and French.
9/15
Elizabeth Sims
This rusted-out locomotive once took tourists on a 62-mile journey over a river and through the hills of East Tennessee.
10/15
Elizabeth Sims
This rusted-out locomotive once took tourists on a 62-mile journey over a river and through the hills of East Tennessee.
11/15
Elizabeth Sims
Inside the second passenger car. It was bought from Canada so it has signs in English and French.
12/15
Elizabeth Sims
This rusted-out locomotive once took tourists on a 62-mile journey over a river and through the hills of East Tennessee.
13/15
Elizabeth Sims
This rusted-out locomotive once took tourists on a 62-mile journey over a river and through the hills of East Tennessee.
14/15
Elizabeth Sims
This rusted-out locomotive once took tourists on a 62-mile journey over a river and through the hills of East Tennessee.
15/15
Elizabeth Sims
This rusted-out locomotive once took tourists on a 62-mile journey over a river and through the hills of East Tennessee.
1 / 15
×
Elizabeth Sims
This rusted-out locomotive once took tourists on a 62-mile journey over a river and through the hills of East Tennessee.
More
For a time, the owners and interested community members tried to keep the train in tiptop shape.
"One of the biggest reasons that it's in the state that it's in is it's just been too hard to keep up with,” Ezell said. “Every time something would get fixed or cleaned; something else would get broken, and it just ramped up to the point where it was hard to keep up."
Wind, rain and sunlight brought on layers of moss and rust outside and decay on the inside.
"A lot of the degrading is because of the windows being out. When they restored this car, all this upholstery and everything was brand new, and when the windows were still in, we kept the sunshades down or tried to because you can see where it got bleached sitting in the sun for so long,” Ezell said.
RELATED: Know of an abandoned place? Suggest a location for us to explore
People have also worn away at the little train. Thieves have picked apart the once beautiful green vintage diesel engine while vandals have left their own personalized messages throughout the conductor’s room and passenger cars.
“I'm kind of having a little giggle right now because that wasn't gone the last time I was up here not very long ago,” he said. "All kinds of interesting graffiti like some behind me that probably shouldn't be on TV."
Ezell said the owners are fine with visitors stopping by to take pictures, especially since it is a popular destination for ATVs coming from Wind Rock.
While the locomotive has lost its luster, a walk through the narrow and dully colorful aisles of the passenger cars gives subtle glimpses at the magic passengers felt aboard as the train chugged through the hills and over the New River of East Tennessee.
Advocates, like Ezell and the members of the Save The Tennessee Railway Facebook page, have pushed for a new life for the little tourist train.
At one point, the owners wanted to move it to another property they own as a stationary tourist attraction.
However, a one-way ticket out of the woods would come with a high price and difficult terrain.
“There's a couple of washouts on the railroad line so getting anything out of here or in here by rail would be a real challenge,” Ezell said. “Not only is it overgrown, in a couple places the track’s dangling over the river. So it's a long shot, but there are possibilities. I mean, stranger things have happened."
For now, Ezell said to visit with respect, hoping an ambitious vision might get the train back on the right track.
“It’d be nice to see anything happen with it really, whether it be restoration, static display,” Ezell said. “We could fix it back up a little bit, make it a little nicer for people to come see. Maybe it would lose the nickname as the abandoned train."
Reporter’s note: Though many of the buildings featured in this series are unused and empty, they sit on private property that is still actively used in some cases. DO NOT attempt to unlawfully enter any of these places without permission. Many of them are structurally unsound and pose potential health hazards, like asbestos and lead paint. WBIR contacted all owners prior to visiting.
For more stories from East Tennessee's Abandoned Places, check out our YouTube playlist:
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Dogpatch USA has been closed for almost three decades, but the memories of the iconic attraction between the cities of Jasper and Harrison are still vivid.
Author: Michael Aaron
Published: 5:33 PM CDT November 4, 2021
Updated: 2:04 PM CDT November 5, 2021
Along Highway 7 between Jasper and Harrison sits an iconic attraction, a place treasured by so many: Dogpatch USA.
The park has been closed for almost three decades, but the memories are still vivid. John Burton, a Branson-based travel blogger, recalls the scenery.
“It's different than driving into a giant parking lot, coming off the freeway somewhere and seeing all the big rides off in the distance,” Burton said. “It was different and even as a young kid, I remember that and I'm like, wow, this is really cool.”
The story of Dogpatch USA has more twists and turns than the rollercoasters that once stood there.
The park based on the popular “Lil’ Abner” comic strip opened in 1968 and welcomed 300,000 annual visitors at one point. It played host to thrill rides, a waterslide, trout pond, railroad, grist mill, and a downtown – ultimately closing 25 years later.
Michael Schwarz, president of the Abandoned Atlas Foundation, has researched and written extensively about the park.
“When Dogpatch opened in 1968 and then it closed in 1993, it wasn't just owned by one company,” Schwarz said.
“It changed owners several times, and each time an owner contributed to why that park ultimately didn't succeed. There was a lot of reasons why that park didn't succeed. A lot of it had to do with the themes and the principles that each owner would bring.”
The Abandoned Atlas Foundation highlights abandoned places and their potential for new life. Dogpatch USA is one of those places.
"For years, Dogpatch sat completely abandoned,” Schwarz said. “There was an old waterslide, all the buildings in the downtown, the train tracks, the train station, were still there. And it was just all grown up, there was just nothing.”
In the years that followed its closure, several investors made unsuccessful attempts at revitalizing the park. In 2020, it sold once again.
Billionaire conservationist and Bass Pro Shops owner Johnny Morris bought the 400-acre Dogpatch USA property for $1.12 million.
“Well, first, I said it was a lie. I didn't think that he was actually going to acquire it,” Matt Bell, executive director of Explore Harrison, said.
Explore Harrison is the marketing organization for the City of Harrison. Bell is among local leaders who share excitement about the future of the property that sits about five miles south of the city.
“Over the last couple of decades, it has been – for lack of better words – a roller coaster. You never knew what was going to come of Dogpatch USA,” Bell said. “We now know that Johnny Morris and his team are going to make it a relevant location for visitors to come.”
The park’s gates are locked, but the view from above shows a transformation underway. Details remain few and far between.
After reaching out to Bass Pro communications and requesting an interview, the company responded with the following email: “Unfortunately we do not have anyone available for an interview or an update to provide at this time, but we will gladly keep you informed when we have more to share.”
Credit: John Burton
During a September Buffalo River Conservation Committee meeting, Morris’ representatives shared the space will become Marble Falls Nature Park.
“The most important thing is that Mr. Morris, his goal is again, nature conserve natural conservancy, respecting the environment, creating opportunities for people to get outdoors and being engaged in nature,” Spencer Jones, an engineer on the project, said.
Morris is the brains behind several other Ozark nature projects, including Big Cedar Lodge, Top of the Rock, and Dogwood Canyon – the model for the Marble Falls park. It includes a restaurant, trout fishing, grazing livestock and wildlife.
In October, Burton visited the project site to see the progress for himself. He took photos from along Highway 7 to post on his Facebook page and YouTube channel.
“You see this old tram just sitting there and a waterwheel that's not moving anymore and train tracks, and I'm like, wow. And then you could just kind of put yourself back,” he said.
Although Burton is among people who originally hoped to see the return of a theme park, he looks forward to the future.
“We have all of these memories that were unique and special,” he said. “So is this new project going to create those types of memories for the next generation? I think that for Johnny Morris is a significant goal that I think that he needs to reach for.”
A timeline for the project has not been released, so community leaders and tourists are waiting in anticipation. Bell is hopeful the park’s natural beauty will serve as a draw.
“The fact that [Morris is] going to capitalize on that and preserve that property and allow tourists to come in and see what the Ozark Mountains our natural beauty is all about is awesome,” he said.
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Monday, November 30, 2009
Green From The Get-Go.
War Eagle Mill has operated in several different forms over the past 170 years. Hard to beat its longtime efforts to be green, organic, and local.
(this article appears in the December issue of Emerald City of the South)
The drive up to War Eagle is not one you take quickly. You might shave off a little time by hitching part of your ride on the interstate, but no matter where you come from, you end up on windy scenic two lane roads with miles of sky and fields (full of livestock and hay) aplenty.
Approaching from the south, you round a bend and suddenly you’re glancing out over a verdant plain below, green dotted
with the red of farm buildings and the far off site of a three story structure. That is your destination, that there yonder.
You snake down the side of the hill, roll out into a field, and wonder at the sign that states “War Eagle Craft Mill, next 10 exits.” Exits? You’re in a cow field, for heaven’s sake! Roll right with the road, down past a couple of barn-type buildings on the right and a couple of houses on the left, and then you’re at the bridge.
The bridge at War Eagle is nothing to sneeze at. It’s a 101 year old wood and steel framed monument to time, arching its single lane out over the greenish river below just down from the water break, coming to a landing beside the big red building you saw a mile back from on high. You have to slow down, to make sure no one’s coming from the other side, before you ease on over and back onto the security of the gravel.
You have arrived at War Eagle Mill.
The big gravel lot to the right is usually dotted with cars and motorcycles, sometimes with people just getting out of their vehicles, stretching their legs and visiting the facilities on the far side of the lot. Sometimes there will be children there with handfuls of corn from the converted candy machine, toddling after the ducks and geese that tend to wander up from the river below. Sometimes there’s just the hum of the afternoon and the swish-swish-swish of the waterwheel.
Up the stairs and past the “No Wet Feet” sign, you enter the Mill and are greeted with the everpresent churning and grinding of the millstone and machinery. Sometimes one of the folks working back in the rear will pour in whole grains to be busted apart and down by the stones. Or there will be a couple of people asking questions about the Mill’s operation. It always seems to smell good.
Shoppers come and go, checking out the calico-clad bags of flour and cornmeal and grains, or sampling some of the dips and jellies thoughtfully shared.
There are jams and salsas and cookies and all sorts of mixes and oven mitts and trivets and even fresh baked bread in tiny loaves to snack on, if you’re hankering for something to take with you. And there’s that smell… not just of the grains but of something else, something from the oven, that draws you upward.
You climb the stairs to the second floor, where all manners of cookware and quilts awaits. This is where you can find your non-edible souvenirs of the day, the knives and the stones and the honkin’ big cast iron Dutch ovens. And you can look out from a number of windows down on the water and the waterwheel and the bridge below.
But the scent drives you further upward, and you find yourself in the Bean Palace, the third floor of the Mill, with a hard-to-deny menu of simple things like beans and cornbread or a cornbread sandwich or, heaven help us, cobbler. Bits of history are tacked on angled ceilings and walls, bits of a past that’s embraced and treasured by those who work here and those who choose to make the trek, over and over again, to visit Arkansas’ only working grist mill.
***
The Green movement in Arkansas is not a new thing. It may be the flavor of the month, it may be “the new black” -- hell, it may be the vision of tomorrow for all that’s worthy. But as far back as our
grandparents’ grandparents ever recalled, this place has been operated by the harnessing of Mother Nature herself, not with coal or steam or lumber burning, but with the power of the War Eagle River.
Used to be, all the grain that came to the mill came from these parts. Farmers would bring bags and bushels of corn and wheat from their fields to the Mill to have the grain ground for their bread and sustenance. In those days there were no chemicals like Monsanto and Roundup and such to kill off the bugs and blight. The meal was pure.
Today, it still is, though the folks at War Eagle have to go further afar to find it. That surprised me, but once I heard TJ Young’s reasoning behind it, it made a lot of sense to me.
“Since we purchase organic grains, we go as far north as we can to find them. North and South Dakota, Minnesota, even Montana are all states where we find our grains. The reason for this has to do with the restrictions for insect control an organic farmer faces. The further north you go, the fewer varieties of insects there are for the farmers to defend against. That means cleaner grain for us and our customers.”
Young is the woman in the know at War Eagle. She’s in charge of groups and tours, and answers the questions that come into the website. She does say that there are some grains that do come from right here in Arkansas.
“There is one local farmer that grows a historic southern corn, known as Hickory Cane Corn, which he sells to us each year. We mill and sell this product, a semi-sweet white corn, only at our historic mill. Many of our senior customers say they remember seeing the corn in their father's field as a child.”
I mentioned earlier that the Mill’s been around for 170 years. That’s sorta true. It does span that length of time -- at least, the idea and presence of a mill structure on the river. But this is actually the fourth Mill. The first one was built in 1832. Young shares the narratives with groups that tour the Mill.
“The first Mill and Dam was built right around 1832-1834 by Sylvanus and Catherine Blackburn. This first Mill and Dam washed away in a flood in 1848 only to be immediately rebuilt by Sylvanus. By that time, the Mill had become a gathering place for the War Eagle community which had a sawmill (attached to the War Eagle Mill and stood where the road and on ramp for the bridge are now), blacksmith shop, church and school.
“The second Mill was burned by the Confederate troops, about three days before the battle of Pea Ridge in 1862. After the war, Sylvanus's son, James or J.A.C. as he was called, built the 3rd Mill in 1873. Only this time, instead of using water power as his father had in the previous two Mills, he used a steam powered turbine to operate the machinery. It was during the 3rd Mill's lifespan that the concrete dam was built, and still stands today.”
The third Mill burned in 1924. No one knows how it started. But the foundation sat baren for nearly 50 years. Young continues.
“A man name Jewell Medlin and his wife purchased a cabin on top of a hill that had the property with the Mill foundation included in the deed. Jewell contacted his daughter, Zoe, and asked if she would be interested in running a grist mill. Through time and trial and research, they successfully re-opened the War Eagle Mill, on the same foundation as the previous three, in 1973, 100 years after the opening of the third Mill.
“The current Mill is a replica of the third Mill with the exception of the annex on the side. However, this Mill is not steam powered. We have gone back to the natural and ‘green‘ way of doing things with water being the only source of power to our milling machine. We use the only working undershot, water goes under the wheel instead of over it, in the state of Arkansas and possibly the USA.”
Zoe and the man who would become her husband, Charlie Caywood, ran the mill for 30 years. They sold it in 2004 to Marty and Elise Roenigk of Eureka Springs, the owners of the Crescent and Basin Park Hotels. Today, Elise is the sole owner, Marty having been the victim of a car accident this past June.
Constructed in 1973 -- that makes the Mill as old as I am. It’s been in continual operation for 36 years now, and it’s in good shape. The wheel goes whenever it goes… all the time. That’s the nature of running water. The business of running the mill slows down during the winter months, and it’s open just a few days a week. During the summer and fall, though, it’s open every day.
Then there’s the Fair. Or Fairs, actually -- two of them. One in May, one in October, massive things that take over the landscape and bring thousands to the area. We’re not talking anything small here -- we’re talking colossal throngs of people.
“In the springtime we get about 90K here over 3 days. The spring fair is always the first weekend in May,” says Young. “The ‘biggie‘ as we call it here, is the Fall Arts & Crafts Fair, the third weekend in October, the 15th-18th this year. We turn into the largest town in Arkansas for four days. We see 250,000 plus over that four days. There is live entertainment, featuring a bluegrass group called Springstreet, on our front porch every day of the fair.”
It’s hard to imagine, looking out from the window on the third floor of the Mill, savoring a cornbread sandwich. You look out at the pastoral landscape across the bridge and take in the peacefulness of it all. It’s a quiet place. At least, right now it is.
I’ve been to the State Fair many times, and I know what sort of numbers that pass through those gates -- roughly 400,000 over ten days. Simple division tells me that War Eagle has to be larger. The fact that it runs concurrent to the State Fair… wow, that’s a lot of people. They come to see and purchase and experience. There are vendors that sell clothing, pottery, broken china jewelry, paintings, prints….
“(There’s) one gentleman named Peter Engler who hand carves Christmas Ornaments. There are many, many more that I cannot name, but between all three Fairs, we have close to 600 plus vendors,” Young tells me. Hence the “next 10 exits” sign on the way in. Ten exits, two lane roads, and a single lane bridge.
But I’ve gotten away for the reason I was sent up to the Mill. I was wondering how they fit into this picture, our modern world. The Mill is organic, sure -- and the waterwheel makes the grinding nature-powered and non-polluting. But how else is the Mill green? Looks red to me, from the outside.
Turns out, it’s everywhere. Everything that can be recycled is recycled, from the cardboard boxes that products are shipped in and out with, to the plastic and aluminum used on site. There are no chemicals used in food preparations, no chemicals, everything’s clean. The business purchases just about everything it sells that’s not produced at the Mill from local businesses in Arkansas and within the range of the Ozarks. It’s all available at the Mill, and a good amount of it all is available online as well.
I’d figure with the remote location that most of the business must come from the web. After all, how do you keep such an operation going when there aren’t but a half-dozen or so cars in the lot on a lazy Wednesday afternoon? Young has an answer for that, too.
“Even though our web business is growing by leaps and bounds, right now about 90% of our business still comes from visitors to the Mill and their purchases while they are here,“ she tells me. But there is a lot on the website that’s handy. “We have recently given our website a ‘facelift’ and that seems to have helped tremendously. There is now a recipe database that has recipes using our products. You can create your own account and save your favorites right there so you can use them later. If you forgot what you need to buy for them while you're here, we can pull it up for you.”
Considering the time of year, you may be wondering if this is the sort of place you want to choose for your holiday shopping. Perusing the online catalog, it seems most of the gifting baskets run in the neighborhood of $18 to $32. That’s pretty decent.
They managed to survive the big ice storm this past winter. While the Mill did go without power for a couple of weeks (the lights are still powered by the electric company), folks in the valley worked together to clear roads of downed trees. It did mean that the restaurant lost some food because there wasn’t power for the refrigerators, and the ice that paralyzed the area kept away customers. But good neighbors made a big difference.
“I do want to tell you that there is not a more hearty group of people than those here at War Eagle,” says Young. “People who could get out of their houses were grabbing their hand saws and chainsaws to help clear roads and driveways down to their neighbors houses and off the roads so emergency personnel could come if needed. From the moment trees started falling, all through the night, and for the next weeks, people all banded together to help.
“The loss was the greatest, of course, to all the trees we have here. Several were destroyed by the weight of the ice. Most of the damage is hidden by the leaves right now, but when they shed them, you'll be able to see the remnants of the disaster once again. A constant reminder to us all that we are at the mercy of the Lord and Mother Nature.”
Even with the lost trees, the area is gorgeous now. This fall the leaves will turn and the valley will erupt into a scale of colors from green to red, majestically crowning the river’s edges with flame like foliage.
***
I tend to be a target in the food community around these parts. I suppose that comes with the territory. You put your name out there and it’s attached to something, there’s bound to be someone passionate about it. It’s no secret that I review restaurants, and that I appreciate good old fashioned Arkansas fare to haute cuisine. I suppose it was how I was brought up.
The Bean Palace isn’t just an afterthought; it’s a restaurant all its own, certified USDA Organic. Not many places can make that claim. Bread, cornbread and pastry are all made from the grains ground downstairs; beans, smoked meats and fresh vegetables make up much of the rest of the menu.
I’ve had more than my share of Bean Palace cuisine. By the time you drive from Little Rock to the Mill, you tend to work up an appetite. First time I ate there, they had a daily special of Cornbread Chicken Pot Pie. Big hunks of chicken and vegetables in a slightly salty but somehow thick broth, with a big floating chunk of what they called Italian corn bread on top. Italian corn bread was just cornbread with spices in it, but
that was okay, it was splendid.
I spent one chilly late April afternoon in 2008 up on that top floor, thankfully nursing a bowl of cheese soup and a turkey sandwich on that fabulous white bread. At the time I was early on in my pregnancy, and the folks up there were kind and understanding. I must have sat up there for over an hour, praying away a little dizziness and then consoling myself with some of that seed-rich blackberry cobbler and Yarnell’s Vanilla Bean ice cream.
This latest trip, my husband and child came with me, along with another one of our traveling companions. South of us the sky was filled with rain-swollen pods
of pillow-thick clouds, dark against the horizon. But here the wind was sweet and the temperature for an August day a lazy 80 degrees. My husband tried out the meat-laden Chef’s Salad while I dithered over a turkey and cornbread sandwich, which held together just long enough for me to get halfway through before needing a fork. We handed the girl chunks of Southern fried potato, which she greedily tried to grab herself. Tea served up in Mason jars and some sugarless apple cobbler for dessert about topped us off.
It had taken us close to four hours to make it up here, to capture a bit of the story and to snag lunch on high above the river, but it felt like we were miles further away. The afternoon was passing by around us, yet there was no hurry here. It’d be harder to get further away from the busy lives we lead in the city.
But eventually the pull of the city drew us away again. We headed downstairs, picked up staples for our pantries and perused the jams and jellies. I picked up a 10 pound bag of organic whole wheat flour and a big pack of seven grain cereal for the bread I wanted to try out in the bread maker (as much as I wish I had time to hand-kneed, you don’t get to use that time when you have a small child) and white cornmeal for Johnnycakes for the next couple of weeks. We passed off our salutations and headed back on the road, savoring the last of the beautiful scenery and counting off in our minds how long it would be before we made the trek again.
War Eagle Mill is open throughout the year. From March through December it’s open every day from 8:30 a.m. to 5 p.m., with the exception of Thanksgiving, Christmas, and New Year’s. It closes at 2 p.m. Christmas Eve and 3 p.m. New Year’s Eve so its employees can spend time with their families. In January and February it’s open Thursday-Sunday. For more information, log onto the Mill’s website or call (866) 492-7324.
Told by Kat Robinson at 1:18:00 PM
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I saw Indiana Jones and the Kingdom of the Crystal Skull last night and I wasn't impressed. The opening action sequence made me realise how long it has been in watching a film in the cinema since I was last so aware that a stunt double was trying to ...
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My name is Eric McDermott and I am a lifelong resident of NEPA, along with my wife Jessica and four children. My journey began in 2014 when I obtained my real estate license and started my career working with clients to buy or sell homes. Over the years I would help my sellers liquidate a few items here and there. In the meantime, I began regularly attending auctions looking for items of value that would catch my eye, paying close attention to which items the buyers were most interested in and at what price point. On weekends I would periodically checkout estate sales and yard sales for items of value based on my experiences attending the auctions. The thrill of the hunt is always the most exciting part of finding an item that is of any interest of yours. There is definitely a buyer for every item. Being exposed to thousands of homes as a realtor, I discovered that there is a collector for just about every item imaginable. The following saying could not be more true - ‘One Man’s Trash Is Another Man’s Treasure.’ One night I had a conversation with my wife and we talked about taking the liquidation aspect to another level. It made perfect sense to become a full service liquidation company. Our clients would have the option to use one or both of our services of onsite estate liquidation, which would entail the sale of all the contents of the home and then also to sell the home itself. My wife brings a strong background in The Arts and can provide some great insights to clients looking to sell those items as part of their estate. Also, we have made some great contacts in the area through our mission to become more involved in the community as realtor and that would become an asset to our clients. We can help anyone located in either Luzerne or Lackawanna County. The Wilkes-Barre & Scranton area has a rich history and is made up of many wonderful surrounding cities including Dallas, Mountain Top, Kingston, Nanticoke, Pittston, Old Forge and Clark's Summit to name a few.
Contact
Timeless Treasures
Estate Sales Services
We are committed to helping our customers every step of the way by providing useful services to take care of all their needs. Read below to learn about the range of services we provide. We are constantly growing and expanding our service options, so if you have something in mind that we do not yet provide, we would love to hear about it!
Free Consultation
It is our goal to create a win-win situation with our clients. We highly recommend scheduling a free consultation to determine if an estate sale is the best fit for you. It is important to us to help you make the best decision for your and your family. We pride ourselves on our exceptional customer service, and guarantee you will love working with our team.
Estate Liquidation
We offer our service to liquidate the entire contents of your home. With this service, we ensure all details are simple, seamless and handled in a timely manner. Whenever you work with Timeless Treasures Estate Sales, you can trust that you are in great hands!
Real Estate Services
We can also help with the sale of your home. Our team has 2 licensed real estate agents with a track record of over 200 homes sold. We have built a strong reputation in our area as a trusted realtor team that has the ability to get the job done.
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If you require large amounts of oak planks/boards for a large project, we can source, and deliver oak direct to you. Our oak wood is imported and our lead times can vary to what oak is available.
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rock crushers spain Crusher plant manufacturer of SBM Company is good at stone mining crushing plant Our crushing plant manufacturers design and sale jaw crusher Get Price And Support Online Alibaba In Spain Mobile Cone Crusher For Sale In
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4 Cone crusher Cone crusher widely used in the metal and monmetal mines cement sand gravel aggregate quarry metallurgy and other industries it is suited for fine crushing all kinds of ores and rocks with hardness ≤5 16 such as iron ore Nonferrous metal ore granite limestone quartzite sandstone cobblestone etc
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1000 Maxtrak Portable Rock Crusher Powerscreen
1150 Maxtrak The high performance Powerscreen 1150 Maxtrak is a medium sized cone crusher which has been designed for direct feed applications without prescreening on clean rock At its heart is the Automax cone crusher which provides excellent reduction and product cubicity for the production of high quality aggregate and subbase material
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SYMONS Crusher Aggregate Equipment For Sale 22
Browse our inventory of new and used SYMONS Crusher Aggregate Equipment For Sale near you at Models include 3 FT STD 425 425 FT 425 STD 55 STD 3 FT SH 4 4 FT STD 425 FT SH and 55 Page 1 of 1
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New and Used Cone Crushers for Sale Savona Equipment
Cone Crushers A cone crusher breaks rock by squeezing the rock between an eccentrically gyrating spindle A cone crusher is suitable for crushing a variety of midhard and above midhard ores and rocks We sell brands by top cone crusher manufacturers including Nordberg Telsmith Symons Cedarapids Elrus Allis Chalmers Marcy Gyro and Raymond
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Crushers For Sale IronPlanet
Crushers for Sale Buy and sell unused and used Crushers at IronPlanet Whether looking for a Cone Crusher Impact Crusher Jaw Crusher or other various type IronPlanet offers several makes and models that can help efficiently and effectively complete your task Browse popular models from top manufacturers including Cedarapids Crushers Metso Crushers and others
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stone crusher in spain
China zenith Small Rock Cone Crusher Mini Stone Crusher for Sale zenith has offered types of Rock crushers for sale in Spain Stationary and portable crushing machine are widely used in
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Crusher in Spanish English to Spanish Translation
Spanish nouns have a gender which is either feminine like la mujer or la luna or masculine like el hombre or el sol F Marco was covered in dust after running the rock crusher
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Rock Crushing Rule of Thumb Mineral Processing
For example a 48 by 60 crusher will have a capacity in the order of 600 tph when crushing ore in a hard rock mine Source Jack de la Vergne The capacity of a jaw crusher selected for underground service should be sufficient to crush the daily requirement in 12 hours
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TERRY MICHAELIS is the owner of ProTeam Corvette and has bought and sold more than 10,000 Corvettes in his storied career. Michaelis began his Corvette love affair over 40 years ago on a local car lot. By the mid-1970’s, Michaelis was dubbed “King” of Corvette aftermarket parts. Michaelis and his brother, Fred, formed ProTeam Classic Corvette in 1987, where they assembled the largest most dynamic collection of classic Corvettes in the world. He has become such a world-renowned expert on Corvettes that his knowledge has been the focus of hundreds of radio interviews and newspaper articles, as well as a long list of industry publications. Terry continues to lobby for the collector Corvette community with the same passion and affection for over the top marketing that he first had when he parted out his ’61 in 1974.
Want more? In his own words:
"My name is Terry Michaelis and I and my brother, Fred Michaelis, have been in the Corvette business for over 40 years. We are the pioneers that helped jump start the popularity of Corvette collecting and the Corvette hobby phenomenon as we know it today. Few people know classic Corvettes better than Terry and Fred Michaelis as we strive to buy only authentic and legitimate classic Corvettes that possess much of their original unaltered DNA. Legitimate classic Corvettes are the benchmark for value and investment. We also are Corvette collectors and own many rare and hard to find classic Corvettes."
Michaelis oversees the daily operations, supplying Corvettes to customers around the globe. Through his in-depth knowledge of the Corvette market and his wealth of automotive passion, enthusiasm and extensive sales experience, he is able to search for just the right Classic Corvette to match each customer's personal and investment preferences.
Michaelis began his love affair with cars over 40 years ago when he began selling used cars at his cousin's Ohio dealership in 1971. On his 21st birthday, Michaelis applied for a used car dealer's license and was soon the owner of his own dealership. In 1974, he purchased a Corvette, a wrecked 1961, for a mere $250. Within a week, he sold the car's hardtop for $300, and soon provided parts to Corvette collectors and restorers across the U.S. By the mid-1970s, Michaelis was dubbed King of Corvette aftermarket parts, and was soon in charge of a company that had almost 200 employees and was grossing $500,000 a month in sales.
By the mid-1980s, the collector car market exploded and prices for Corvettes increased dramatically. As a result, it was more logical to repair and restore older models than part them out. With collectors hungry for restored and concours-quality Corvettes, Michaelis and his brother, Frederick, formed ProTeam Classic Corvette Collection and Sales in 1987. They began buying several Corvettes at a time, often 20 or more, and selling over 300 of the marque annually.
Since that time, Terry Michaelis has worked hard to position ProTeam as the source for investment-grade Corvettes, further positioning the Corvette market and serving as a consultant to the Corvette industry.He has become such a world-renowned expert on Corvettes that his knowledge has been the focus of hundreds of radio interviews and Associated Press newspaper articles across the U.S., as well as featured in such publications as: Automotive News, Wheels Magazine, AutoWeek, Old Cars Weekly, Auto Age Magazine, Vette Vues Magazine, Motor Trend, Cars & Parts, Super Chevy, Corvette Fever, Corvette Quarterly, Vette, Corvette Magazine, Automobile Magazine, Hot Rod Corvette. Corvette Enthusiast.
This blog serves as a look into the Corvette market through the eyes and experiences of the "General's Genuine Article".
Tags: Classic Corvettes, Corvette Top Tens, Corvette Market, Corvette Historical Facts, Corvette Buying 101, Corvette Info, NASCARCorvette, Used Corvettes for Sale, ProTeam Classic Corvette Collection
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Usain Bolt got a sweet welcome to Carnival in Trinidad & Tobago -- a human sacrifice ... on the dance floor!
The world's fastest man jumped onstage at a concert called TRIBE Ignite, and yelled ... "I love this country so much!" Trini obviously loves him back because the MC quickly offered him "something special" ... with much junk in her trunk.
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Fight back against Big Tech censorship by signing up for Todd’s free daily newsletter. Click here to subscribe!
The following is a transcript of Todd’s morning commentary heard daily on hundreds of radio stations around the nation. Click here to subscribe to Todd’s daily podcast.
Hello Americans, I’m Todd Starnes. Stand by for news and commentary next.
DC Comics has turned Superman into a woke, sexually confused, social justice warrior.
Most recently they announced that their newest incarnation of the Man of Steel was a bisexual 17-year-old in love with an older man.
And now comes word that Superman will no longer fight for the American way.
DC Comics says they are changing Superman’s mission statement.
Instead of Truth, Justice and the American Way, he will fight for Truth, Justice and a Better Tomorrow.
“Superman’s new motto of ‘Truth, Justice and a Better Tomorrow’ will better reflect the global storylines that we are telling across DC and to honor the character’s incredible legacy of over 80 years of building a better world,” said DC Chief Creative Officer and Publisher Jim Lee. “Superman has long been a symbol of hope who inspires people from around the world, and it is that optimism and hope that powers him forward with this new mission statement.”
The American Way is no longer kosher at DC Comics – ideals like faith and freedom, personal responsibility, helping your neighbor.
Even the pages of our beloved comic books have become propaganda tools for those who hate our nation.
I wrote a book about this, “Culture Jihad.” The Left wants to destroy our culture – the American way – so they can build a socialist super society on the ruins.
The Man of Steel is just their latest victim of this anti-American mob. He was defeated not by Lex Luthor or kryptonite. He was done-in by a bunch woke culture jihadists.
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Purchase a pass for Jacksonville Transit and send it directly to a phone. You can purchase a pass online and have it instantly sent to any phone number you choose.
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Home
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Hundreds of well-known U.S. restaurants hit by card-stealing malware
By Paul Wagenseil 02 January 2020
Bubba Gump, Joe's Crab Shack among dozens of brand names hit
Comments (0)
The sign outside a Bubba Gump Shrimp Co. restaurant at the Universal Studios Hollywood theme park in Universal City, California. (Image credit: Pe3k/Shutterstock)
Landry's, a Houston-based owner and operator of restaurant chains across North America, kicked off the New Year by disclosing Tuesday (Dec. 31) that its payment systems had been infected by credit-card-stealing malware for most of 2019.
However, the malware could have stolen the card data only if waitstaff mistakenly ran customer credit cards through restaurant food-and-drink order-placement systems instead of credit-card readers, Landry's said in a notice posted on the company website.
Both systems allow waitstaff to swipe magnetic-stripe cards through card readers, but Landry's said no card numbers could have been stolen from its payment-card system despite the infection. Landry's implemented a fully encrypted payment-card system in 2016 following an earlier spate of payment-card theft, according to the Houston Chronicle.
"The general timeframe when data from cards mistakenly swiped on the order-entry systems may have been accessed is March 13, 2019 to October 17, 2019," the company notice states. "At a small number of locations, access may have occurred as early as January 18, 2019."
What to do
The company did not estimate how many customer credit and debit cards may have been compromised, but anyone who dined or drank at a Landry's-owned establishment during that time period should check their card statements and immediately report anything unusual to the card issuer.
Landry's operates establishments under 60-odd brand names, including The Boathouse, Blue Water Grill, Bubba Gump Shrimp Company, Claim Jumper, Del Frisco's Double Eagle Steak House, Del Frisco's Grille, Dos Caminos, Joe's Crab Shack, McCormick & Schmick's, Mitchell's Fish Market, Morton's The Steakhouse, Rainforest Cafe and Vic & Anthony's Steakhouse. It also operates the Golden Nugget casinos in Las Vegas, Atlantic City, Laughlin, Nevada and Lake Charles, Louisiana. A full list of Landry's properties is here.
Concerned customers can call Landry's toll-free at 1-833-991-1538 from 8:00 a.m. to 8:00 p.m. Central Standard Time, Monday through Friday. The company has not said whether it will offer identity-protection services to affected customers.
Best identity-theft protection
What to do if your credit card is stolen
Identity theft vs. credit card theft: What's the difference?
Paul Wagenseil
Paul Wagenseil is a senior editor at Tom's Guide focused on security and privacy. He has also been a dishwasher, fry cook, long-haul driver, code monkey and video editor. He's been rooting around in the information-security space for more than 15 years at FoxNews.com, SecurityNewsDaily, TechNewsDaily and Tom's Guide, has presented talks at the ShmooCon, DerbyCon and BSides Las Vegas hacker conferences, shown up in random TV news spots and even moderated a panel discussion at the CEDIA home-technology conference. You can follow his rants on Twitter at @snd_wagenseil.
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Honeycomb: Navigation, Browser, And Music - Motorola Xoom: The First Android 3.1 (Honeycomb) Tablet | Tom's Hardware
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Home
Features
Motorola Xoom: The First Android 3.1 (Honeycomb) Tablet
By Andrew Ku 08 July 2011
Motorola's Xoom is the first Honeycomb-based tablet; but how does it fare against Apple's iPad 2? There's a lot to go over, from Google's new software platform to Nvidia's Tegra 2. Let's dig a little deeper to see how the tablet world is shaping up.
Comments (53)
Page 3 of 14:
Honeycomb: Navigation, Browser, And Music
Page 1: Motorola Xoom: Tablet Mania
Page 2: Motorola Xoom: The First Android Tablet
Page 3: Honeycomb: Navigation, Browser, And Music
Page 4: Honeycomb: Notifications And Multitasking
Page 5: Honeycomb: App Store, Data Transfer, And Screenshots
Page 6: Adobe Flash + Android: Certified, But Not Perfect
Page 7: Honeycomb 3.1: Small Enhancements
Page 8: Tegra 2: Nvidia Goes Mobile
Page 9: Honeycomb And Tegra 2: Gaming Spotlight
Page 10: Display Quality: Color Gamut
Page 11: Display Quality: White And Black Uniformity
Page 12: HDMI output And Camera Quality
Page 13: Real-World Performance And Battery Life
Page 14: Final Words
Honeycomb: Navigation, Browser, And Music
The move to tablets was fairly easy for Apple. It took the same underlying operating system and hardware powering the iPhone and applied the package to its iPad, which makes sense. Not surprisingly, then, the competition seems to be working from the same playbook.
Enter Google. In the world of smartphones, the company’s Android operating system is the only thing allowing companies like HTC to put up a fight against the iPhone onslaught. Ergo, the logic has always been to use Android as the basis for a competing tablet.
Image 1 of 2
Image 2 of 2
There have been a number of updates since Android first emerged, but version 3.0 (Honeycomb) is significantly different. Past builds were clearly designed for smartphones. That’s what you got from Android 2.3 (Gingerbread). It looked and felt like better version of Symbian S60. But Android 3.0 feels more like the jump from XP to Windows 7.
Unlocking
Image 1 of 2
Image 2 of 2
Previous Android users will find the changes in Honeycomb to be just as extreme. Once you complete the setup process, the lock screen pops up. But unlike iOS and Android phones, you don’t swipe to unlock the screen. Instead, you have to drag a circle and release it once it hovers over a white lock.
Home Screen
The home screen is unchanged. You can add contact cards, Gmail labels, widgets, and other icons for quick access, and there are a total of five panels that you can fill to your heart’s desire.
Navigation, Browser, And Email
If you own an Android-based phone, you generally enjoy the benefit of physical and on-screen buttons. Android tablets only have touchscreen buttons.
These buttons are in addition to the basic pinch, zoom, swipe, and scrolling gestures.
Back button: move to a previous screen or App
Home button: instantly takes you to home screen
Multitasking switcher: expose the multitasking switcher
My first experience with these buttons was a little confusing. With the exception of the Back button, the icons don’t exactly convey their exact function. They're certainly not as intuitive as pressing the iPad's Home button.
Image 1 of 2
Image 2 of 2
Here's an example: the built-in Chrome browser has its own dedicated Back button, which retrieves the previously-viewed Web page. Pressing the operating system's Back button doesn’t enable the same functionality while you’re browsing the Web. Instead, it returns you to the previous app. But if you’re browsing Gmail, the operating system's Back button does help you move between folders.
Music
Sort by Album
If you have a large music collection, management is a bit of a mess. You can sort music based on albums, artists, playlists, and genres, but CD covers represent all of that information in a 6x3 array. If you're trying to find one particular song, it's difficult because there is no column browser like the iPod app in iOS. You can browse for specific songs after you click on an item, but it's a slower process.
Third-party apps like doubleTwist operate in the same manner, which is a major disappointment. The main attraction of a tablet is its more immersive media experience. This interface needs a little fine-tuning if Google wants to compete at the same level as Apple.
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Current page: Honeycomb: Navigation, Browser, And Music
Prev Page Motorola Xoom: The First Android Tablet Next Page Honeycomb: Notifications And Multitasking
Topics
Android
Computers
Google
Laptops
Mobile
Motorola
Notebooks
Nvidia
Smartphones
Systems
Tablets
See all comments (53)
53 Comments Comment from the forums
dragonsqrrl
Very impressive review, especially the display quality page. A lot of in-depth information.
Reply
joytech22
Excellent! Covered everything I was interested in when comparing the iPad 2 to the Xoom.
Reply
tramit
Excellent review. I also agree that the excuse of Android coming later in the game does not mean it cannot have the same growth in apps in the same alotted time frame that it was released.
I personally feel that the iPad is a better device for gaming just by going through the app store and being able to find games ranging from Monopoly to FF3 and Infinity Blade. I have a Nexus S right now and the list of attractive games is not as long.
I like having both devices however. I plan to stay the course with continuing to purchase Android Nexus phones and having Apple supply me with their iPad. I get to enjoy the best of both worlds and not narrow my enjoyment of tech like most Droid and Apple fanboys.
Reply
Maziar
Excellent review.
I'm impressed with the honeycomb but I think it has 2 major drawbacks
1)UI is somehow laggy and not 100% smooth
2)Lack of apps.
If these 2 issues get fixed,then we're going to see a better competition
Reply
fstrthnu
A little late, but very good quality review. Very nice to see custom benchmarks, it really shows you guys put in the effort here.
I'd probably go for a Samsung Galaxy Tab 10.1, but that's just me.
Reply
Seems HD video playback was not tested. Nice to have a HDMI option, but not really useful if most HD movies cannot play smoothly as is the case with the XOOM.
Also, and probably related to the slow video, Tegra 2's CPU has no NEON extensions, limiting applications that use signal processing.
Yes, I do own a XOOM (also iPad 2 by the way)
Reply
acku
Seems HD video playback was not tested. Nice to have a HDMI option, but not really useful if most HD movies cannot play smoothly as is the case with the XOOM.
Also, and probably related to the slow video, Tegra 2's CPU has no NEON extensions, limiting applications that use signal processing.
Yes, I do own a XOOM (also iPad 2 by the way)
Check out page 13. We tested H.264 battery life using a ripped 1280x720 Blu-ray movie.
On page 12, we also show HD playblack when you're mirroring the display.
@Everyone else. Thanks for the comments guys. If there's anything else you guy want to see in future reviews please let us know.
Cheers,
Andrew Ku
TomsHardware.com
Reply
house70
Took quite a while to get this review done. Other tablets are already available that sport Honeycomb. Not to mention they are better than both contenders described in this article. I have a Transformer and no matter what I throw at it, it does it well. A review of that would be nice (maybe in another year or so...).
Good effort, but as others have said, late to the table.
Reply
house70
What the reviewer perceives as weaknesses, others perceive as strength. Example: the apps installation process. Not having to deal with iTunes is a bonus in itself, and having the option to make your own backups using whatever application you prefer is also a plus. The reviewer got a bit carried away by his personal bias towards iTunes/iOS environment. There are people that prefer to be led by hand while operating their tablet and there are others that prefer to pick and choose their options without limitations. It's a matter of personal preference. But this should not transpire into an objective review. Other than that, not too bad.
Reply
Wow - I couldn't disagree more with some of your views. Obviously you love you some Apple... I'm not an Apple hater - I have a Macbook Pro, I have an iPad, and I have a Xoom. I tell everyone the Xoom is 5X the tables the iPad is (Granted it's an iPad, not an iPad2 - but my beef with iPads are how much Apple controls what you can or can't do with it - that has not changed in the new generation of iPads). The iPad I can use as a toy, or as a cool media gadget - I actually basically gave it to my 6 year old son now bc that's all I can do with it. The Xoom I can use as so much more - it is was more useful on so many levels. Yes rendering takes a bit longer when you flip th screen, yes there are a few small quirks in it's behavior occasionally, but from an overall usefulness point of view I like it TONS betters than the iPad. Widgets - MultiTasking - OpenSource app development with an App store NOT controlled by Apple. Android IS the future for tablets. Apple needs to take note - they are just lucky at this point bc of their following, but Android will leave them in the dust. MS isn't even in the game and won't be even when Windows 8 hits. And you price comparison is off too IMO. $599 (now $499) for 32MB on the Xoom was in line (and is now better) than Apple's price point. Take it a step further and look the the Asus Eee Pad Transformer (very similar to Xoom with some things done even better) at $399. Android is taking hold, and will gain on Apple quickly, and eventually blow them away.
Reply
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Campbell the Swaggie Irving, unforgettable and fascinating. He's a bush poet extraordinaire, busker, author, writer, larrikin and swaggie all rolled into one, and to meet this remarkable human being is an experience that will be long remembered. There is no doubt that Campbell is one of Australia's best reciters, and it was a special treat to see him in concert, instead of busking at a market.
Review by ABC SA Country Hour: "It's a life filled with poetry, dust, flies and adventure - the modern day swaggie, true to historic views, comes complete with billy ready to boil, and a battered swag. 'Campbell the Swaggie' was the guest of honour at the Swagman Festival in Milparinka on the weekend. He is a performer but it's difficult to find anything forced in the way that he lives. He seems to walk straight out of the history books, and straight out the heart of Aussie culture. "I suppose it's more of a lifestyle keeping the spirit of 'Waltzing Matilda' alive and the character of the swagman. It has a lot to do with the cultural heritage of this country and being a part of that. Getting out onto the back roads - the old drover's stock routes - where the swagman once travelled. It's really good to get out - even amongst the flies. I'm a professional street performer, I've taken bush poetry out into the streets and I bring it alive."
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Published on November 18th, 2021 📆 | 5539 Views ⚑
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Palo Alto Networks modifies Technology Partner Program
Credit: Supplied
Palo Alto Networks has enhanced its Technology Partner Program, offering improved automation, partner portal and support within a new strategically tiered structure.
The cyber security vendor’s new four-tiered structure consists of Elite, Premier, Select and Self-Service.
The vendor’s technology partners are selected and invited into the Elite, Premier and Select tiers based on market research and assessment, if the technology is complementary to the Palo Alto Networks portfolio, they are put through to the product management board review for final evaluation.
Palo Alto Networks’ technology partners include the likes of Nutanix, Okta, Google Cloud and Amazon Web Services (AWS).
Some of the benefits of the new program update, according to Palo Alto, include development and go-to-market resources, certifications, training and technical support.
The Self-Service tier provides a pathway for emerging security partners to engage with Palo Alto Networks as they continue to grow their business.
“Partner program success is based on customer success, innovation and growth,” Palo Alto technology partnerships vice president Tana Rosenblatt said.
“The enhancements to our Technology Partner Program are designed to better equip our technology partners and give customers the confidence in choosing from an ecosystem of security partners committed to seamless integration and comprehensive security solutions to address the cyber threats today and into the future.”
Other new features of the program include improved automation for integration development purposes, flexible learning, automated validation and qualification.
Read more Enosys and Hacking Group merge in enterprise and Govt play
The vendor is also focused on continuous innovation and go-to-market support, along with its partner portal, which was revealed in August, providing a simplified application process, intuitive on-boarding experience and real time integration status updates.
During its Ignite ‘21 conference, Palo Alto took the wrappers off new solutions including its integrated platform, Prisma Cloud 3.0, and its next generation Cloud Access Security Broker (CASB), aimed at raising software-as-a-service (SaaS) security.
The vendor also revealed it had made its WildFire Advanced Malware Analytics a standalone application programming interface (API), introduced its Cortex eXtended Managed Detection and Response (XMDR) Partner specialisation and combined its Cortex XDR 3.0 solution with managed services offerings from more than 15 partners.
In addition, the company’s threat intelligence team, Unit 42, is also doubling down on its cloud incident response practice to provide an optimised approach for each stage of the cloud incident lifecycle, resulting in faster recovery for impacted organisations.
Read more Data#3 ramps up Wi-Fi tech for The Southport School
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For players wanting to improve their ability to body check, take a check properly and safely while building their overall strength, balance and agility.
They will learn proper body position, develop awareness and the ability to separate their opponent from the puck (or keep the puck!).
The camp will also focus on corner and small zone play (where much of the game is played)...being able to battle in small spaces while developing power, speed and balance.
Confidence is very important. Kids will be put into positions to succeed and gain confidence with both giving and receiving a check.
Camp Focus:
Power Skating
Body Checking
Angles and Body Positioning
1 on 1 Play (this includes Attacking / Defending skills)
Duration
The Peewee/Bantam Checking Camps include 1.75 hours of ice time per day and 1 hour of off-ice training.
Off-Ice Program
The off-ice program will focus on core strength, agility, balance and speed.
View our Off-Ice Program Page
Testimonial
Michael is frequently on the ice with older larger players as his birthday is in late December. Every day before your camp my wife reminded him to work hard and now one of his most prized possessions is the Torjager t-shirt he was awarded.
Thank you for sharing your knowledge in a fun environment, and for hiring such talented instructors to assist you. Thanks to you and your team Michael gained new skills and cherished memories.
Cheers
Brian
Summer 2021
Checking Power Camp Dates
COMBO WITH ANOTHER CAMP TO MAKE IT A FULL DAY!!
August 9 - 13, 2021
Springbank Arena
Checking Power Peewee/Bantam
FULL CAMP DETAILS »
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Dryland Training Program
Summer Camp Dates & Costs
Registration
© Copyright Torjager Hockey Ltd, 2001-2021. home | site map | contact us
Torgager Hockey offers a variey of hockey camps in and around Calgary—designed to improve your hockey game! Private training and team training is also available. P (403) 698-1751. E [email protected]. A 240-70 Shawville Blvd SE, Suite #1066 Calgary, Alberta T2Y 2Z3.
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Online campaign kicks-off in France
Online campaign kicks-off in France
19 Feb 2013
Tourism New Zealand has launched its first major advertising activity in over two years in France, partnering with the two largest online travel agencies Opodo.fr and GoVoyages.fr.
Combined, the sites receive over three million visits a month.
Launched this week, the campaign entices travellers already looking for a long-haul holiday to choose New Zealand.
A core part of the campaign is to build a significant amount of New Zealand destination content within the two sites alongside links to newzealand.com for those who want to discover more information.
"The French market is one of Europe's most prolific for using online channels to both research and book travel, so it makes sense for our first significant campaign in recent times to have a heavy online focus," says Gregg Anderson, General Manager Western Long Haul Markets.
"There has been solid growth in French arrivals since 2008. While arrivals were down last year this is due to the significant increase seen during the RWC 2011 which attracted over 11,000 arrivals alone. However, arrivals are up 1.5 per cent on two years ago - indicating strong underlying growth from the market.
"After elevating the importance of France in our business plans last year, we have undertaken a range activity at an industry level market.
"This campaign is the first to specifically engage with French travellers and aims to build on legacy growth from the RWC 2011 as well as leveraging New Zealand's increased profile since the release of The Hobbit: An Unexpected Journey last year."
Through the online booking sites, travellers looking for a long-haul holiday will be targeted with in-depth information on New Zealand and a variety of travel packages and offers designed to encourage them to book their holiday.
Activity is also underway to progressively translate the French market version ofnewzealand.com, with content prioritised based on the level of traffic being directed to various pages.
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Serbia is a common historic and naturally beautiful country, It is situated in the southern region of the European continent ad it is a member of the Balkan community. Serbia is a modernized state with its busy capital being the Belgrade City. Serbia promises many amazing, historic and natural attractions to its tourists. It has plenty of accommodation facilities for its tourists that are of high-quality wit dining centers that provide interesting Serbian cuisines.
There are three means of entertaining the state of Serbia. Serbia’s international airport called Belgrade Nikola Tesla Airport is some kilometers from Belgrade City center. Some of the airlines, Jet Airways, which is the national airline for Serbia, serves flights between Serbia and other European countries, North African states and the Middle East. From the airport, tourists can board a bus, taxi or minibus to reach Belgrade City. Tourists in Austria, Slovenia, Macedonia, Montenegro, Bulgaria, Croatia, Hungary, and Romania can use trains operating international train trips to be able to stop at Serbia’s train station in Belgrade. Buses can be boarded in Vienna’s international bus terminal to arrive at the southern part of the Belgrade City, as well as from Hungary.
Accommodation facilities in Serbia range from middle-class hotels, high c; ass hotels, apartments, guesthouses, and fine motels. Tourists can get the direct real appearance and descriptions of the facilities in the Serbia-Hotel Organization website to be able to select carefully the facility that meets their preference of the best place to spend their nights while touring Serbia.
One of the famous attractions of Serbia is the Belgrade Fortress. This fortress was constructed as a camp for Serbia’s defense forces in the first century A.D and since then it carries a huge collection of important history and wars that took place around the fortress.
Belgrade city is also a historic site. It is now a modernized city as a result of renovations and the recruitment of advanced technology into the affairs of the Serbia society. However, if taken back to the ancient period, Belgrade was still the capital center for Serbia but it had undergone several damages by numerous wars that took place in this region. The occurrence of these wars has left behind many layers of the wall that used to be replaced every time the wall was damaged by the wars.
Tara National Park is a fun place for all nature games. It has amazing mountain ranges, the large Drina River and gorge, as well as many animal and plant species. There is also a historic item: the Pancic Spruce that is more than a thousand years old. Many activities take place in this park-like boat-riding, water-rafting, visiting adventurous caves, interacting with wild animals, and discover the wide range of plant incredible, rare plant species growing in Serbia.
Devils Town is a site of one of the weirdest geographical phenomenon in the world. This site was created by a thrusting volcanic process that led to the making of two hundred and two large stones that are erected upright from the ground like pyramids that are up to fifteen meters high. Around the stones are volcanic springs whose water is highly acidic caused by the volcanic chemical products found in the area.
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The collaboration between Fortum and Chempolis, a biorefinery technology company, is becoming a tangible reality. They build a biorefinery in India together with a state-owned Indian oil company. Chempolis, partly owned by Fortum, uses Trailmaker to create and update the strategy and to ensure its systematic implementation.
With its strategic project Bio2X, Fortum aims to be a forerunner in resource efficiency – the straw refiner with superior material efficiency and the leading supplier of responsible textile fibers. In addition to its own development, Fortum utilizes external partners' new technologies.
"Fortum's goal is not to develop core technologies itself, but to find partners with the technological know-how. We are then the glue and implementer, the industrial player in the value chain", says Heli Antila, VP, Biobased Solutions at Fortum and chairman of the board at Chempolis.
Fortum invested in Chempolis in 2016. According to Antila, especially in the case of this kind of asset heavy business, ownership has been the right solution.
"In such a business, the customer has to invest hundreds of millions. Developing new technology and taking flight is possible when we are the owner and also carry some of the risk."
Through experiments towards common business models
Fractionation technologies are in the core of Bio2X, and Chempolis plays a key role in Fortum's Bio2X project as a fractionation technology expert.
The collaboration between Fortum and Chempolis has been research and development work including piloting at Chempolis biorefinery park in Oulu. Tomi Honkala, Chempolis CEO, appreciates Fortum's Bio2X team, an agile partner to build new business models together.
"With good cooperation and will, we can achieve a true win-win business model for both companies", Honkala says.
Also Antila sees mutual benefit.
"A huge factory project in India is extremely rewarding for both of us. We both see that we are building a pyramid, not just laying a stone on a stone", Antila sums up.
A joint venture between Numaligarh Refinery Limited, Fortum and Chempolis is now building the world's first bioethanol biorefinery, that uses bamboo as raw material – so now the EUR 160 million biorefinery investment becomes concrete. Target date for starting full commercial operations is set for year 2022.
Trailmaker keeps goals and milestones clear
Chempolis has clarified its strategic goals twice using the Trailmaker process.
"We created a strategy for Chempolis with Trailmaker in late summer 2018. A year later, we updated the strategy", says Honkala.
Following this strategy, Chempolis is now investing in selected customers and specific industries and continents. All strategic projects are in full swing. Trailmaker has guided the management team and the board to form a common view.
"With Trailmaker, we have systematically determined the company's strategic priorities. We use the Management View for keeping track of the key milestones", Honkala says.
"Trailmaker brings the various aspects of the strategy efficiently into a structured format. The best thing is that the concrete steps are taken in an ambitious manner and the progress can be easily followed up", says Antila.
TRAILMAKER is a concept for faster strategy execution:
- Concrete common view and commitment
- Identified capability needs
- Visibility
26.3.2020
≺ Takaisin
STRATEGY. EXECUTION. COMMON VIEW.
© 2019 Trailmaker Oy, All rights reserved.
Trailmaker OyKaisaniemenkatu 6
FI-00100 Helsinki+358 10 271 7490trailmaker(@)trailmaker.com
KonseptiAsiakkaatYritysUutisetBlogJohtamisnäkymä
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The maritime port of Matadi, on the river Congo in the Democratic Republic of the Congo (DRC), reported a major success recently. The door to a new opportunity was opened by the dredging of the river Congo by the Matadi Gateway Terminal (MGT), which is operated by ICTSI. This... more
06.03.2019
Wake-up call for a sleeping giant
One cannot say that Latin America has risen like a phoenix from the ashes of late, but at least the region’s trade has recently returned to ruder health. The maritime consultancy Dynamar has analysed the latest trends for the continent. more
05.03.2019
Dynamise the gateways
Saudi Arabia’s ports are successfully gearing up to face the future. Private initiatives are now being accorded more operational freedom, to help ensure that the strategy is effective. The largest terminal in the country’s biggest port is set to grow further. more
05.12.2018
Good prospects
General stagnation was the depressing order of the day for container throughput in West African gateways in the period 2013 – 2017. Dynamar’s Dirk Visser and Matthieu Neering are nevertheless optimistic that a strong surge of up to 5% annually is coming. more
29.08.2018
Western China to Europe
Predictions have it that trade between China and Europe will amount to approximately 170 million t by 2020, with the goods traded worth approximately USD 1.2 trillion. The EuroTransit Group is setting up its own logistics infrastructure to serve Eurasian overland passage on... more
05.07.2018
Africa going strong
Many African ports are powering ahead strongly, which has prompted PricewaterhouseCoopers to have a closer look at some of Subsaharan Africa’s large gateways. Its analysis concludes that Durban, Abidjan and Mombasa are the region’s outstanding performers. more
02.07.2018
Questions over questions
The growth rate of African airlines’ air cargo performance was larger than in any other region for 17 of the last 18 months. This trend was broken for the first time in March. Some of the continent’s inadequate airfreight infrastructure, in the meantime, has aroused the interest... more
28.06.2018
Record road bridge for goods
Africa’s longest suspension bridge straddles Maputo Bay. The major project by the China Road and Bridge Corporation will link up a suburb – and simultaneously dynamise road transport to and from South Africa. more
28.05.2018
Back – with a new perspective
A long, long time ago Emir Pineda began his career as an intern at Miami airport, working for the hub for ten years. He then pursued his professional path in private enterprise for almost 20 years, before returning to the aviation gateway that is so crucial to Latin America... more
17.05.2018
Expanding all its activities
Militzer & Münch, a company domiciled in the Swiss city of St Gallen, intends to further step up its activities in Morocco. Diversification occupies a prominent place in the investments it is making in order to effect this expansion. In a conversation with the ITJ’s Jutta Iten,... more
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The following stockholders' equity accounts, arranged alphabetically, are in the ledger of Kalmia... 1 answer below »
The following stockholders' equity accounts, arranged alphabetically, are in the ledger of Kalmia Corporation at December 31, 2017. Prepare the stockholders' equity section of the balance sheet at December 31, 2017.
Dec 18 2020 03:36 PM
1 Approved Answer
Subhrata R answered on December 20, 2020
0.5 Ratings,(11 Votes)
Kalmia Corporation Balance Sheet (Partial) 31-Dec-17 Stockholder's Equity Capital stock Preferred stock (8%, $100 par, noncumulative)...
solution.pdf
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Home / City Guide / Taiwan /
Keelung Travel Guide
Keelung Facts
Chinese Name: 基隆市 (jī lóng shì)
Population: 370,000
Area: 132.76 square kilometers (51.26 square miles)
Location: in the northeast of Taiwan Island, southeast China
Administrative Division: 7 districts (Jhongjheng, Cidu, Nuannuan, Renai, Jhongshan, Anle, Sinyi)
Area Code: 02
Zip Code: 200
GDP (2019): CNY 61.4 billion (USD 8.9 billion)
A Seafood Paradise Know as “Little Hong Kong"
Keelung is a port city located in the north end of Taiwan Island. Due to the special location, it was frequently attacked in ancient times; numerous emplacement groups were therefore built. They nowadays have become special scenery of the city. The prosperous city lies between seas and mountains with similar landscapes with Hong Kong, hence named “Small Hong Kong”.
It is also called “Rainy Port” because it rains a lot in winter, but winter is the best season to enjoy hot spring. Remember to bring rain gears if going there in winter. In spring, the rain decreases a lot and is not heavy to affect your travel. Typhoons pass once in a while from June to Auguest, so remember to notice the weather forecast. Except for the typhoon, summer scenery is very beautiful and the Hungry Ghost Festival Ceremony is held then every year.
Top Things to Do in Keelung
Taste yummy snacks at Miaokou Night Market: Miaokou Night Market is the best-known night market in the city, where almost 200 booths gather. Dingbiancuo, Tempura, bouillons, oyster omelets, and steamed rice with red-cooked pork must satisfy your taste buds. In addition, you cannot miss butter crabs, braised eel soups, eight-treasure noodles, rice wines, and many kinds of fruit ices. The night market is not closed until 02:00-03:00.
Appreciate native plants on Keelung Islet: It is a beautiful volcanic islet without resident. Cliffs are everywhere and the flat ground can hardly be seen. It is special for its rare igneous rocks and native plants. In spring, the islet is thick with charming wild lilies, which must impress you. To get there, you can take the speedboat at Bisha Harbor. It takes 40 minutes and costs TWD 500 for a round trip. You need to book the ticket in advance. Phone numbers for booking: Blue Sky: (+02) 2422 4471; Green Sea: (+02) 2469 1136; St. Fort William: (+02) 2469 2555.
Watch odd stones on Hoping Island: The island is famous for weathered rocks and marine abrasion topographies. There are square tofu rocks, Fanzi Cave in which ancient Dutch is carved on cliffs, and Million People Pile where lots of stones that look like heads scatter. In the seaside park, you can barbecue, camp, go boating, and ride an airbike.
Enjoy nature in Nuantung Canyon: There, steep cliffs are covered by dense trees, among which pen container trees are the majority. There is a bat cave on the cliff, and it is said that some bats inhabit it. The streams are so clear that you can catch fishes and shrimps as well as play the water. The canyon is also a good place to watch butterflies and spend the summer.
See artilleries at Uhrshawan Battery: The battery was built in 1840 to defend from enemies. The battery area is on the coastal mountain peak. There you can take a close look at the artilleries and the magazine. Two tombs are located at the foot of the mountain: one for national heroes, and the other for French generals.
Overlook Keelung in Jhongjheng Park: Apart from the pavilions, chess center, and recreation facilities, a 74-foot-high (22.5-meter-high) Guanyin statue sits in the park. There are five floors inside the statue, on which you can see the entire city. It is also the landmark of the city. The shuttle bus is available to travel around the park.
Attend the Hungry Ghost Festival Ceremony in Jhongjheng Park: The festival falls on the 15th of the seventh lunar month. During the festival, people float paper lanterns to release the ghosts’ souls from purgatory and pray for peace.
Eate seafood at Bisha Harbor: A fish market and a food street lie there. A number of shops selling various fresh fishes sit in the fish market. On food street, you can not only order dishes in the restaurant but also let the restaurant cook the fishes that you bought in the fish market.
Other Attractions: Keelung Mountain, Shiqiuling, Fairy Cave Rock…
How to get to Keelung
Train: You are recommended to take the train from Taipei to get there, which costs TWD 64 with the duration of 50 minutes.
See more about Taiwan Train
Long-distance Bus: Taipei West Bus Station, Banciao, Taoyuan, Taoyuan Airport, and Hsinchu stations all have buses to get there. The bus from Taipei takes less than 1 hour and about TWD 50. It departs every 10-20 minutes.
Ship: Keelung Harbor, next to the railway station, is the chief shipping hub of northern Taiwan. Xiamen in Mainland China has a ship to Keelung Harbor every Thursday. The ship named COSCO Star departs at 18:00 and arrives at 08:30 next morning. The ticket price is CNY 528 for a standard room and CNY 590 for a deluxe room.
How to travel around Keelung
City Bus: Most buses depart from the railway station or Chungyi Road. They cost TWD 15 for each trip. For convenience, you can buy Keelung Transportation Card, Easy Card, Taiwan Easy Go, I Pass or ETC Card to take the bus. Remember to wave to the driver when the bus is coming and ring when you want to get off, or the bus may not stop.
Taxi: The starting price is TWD 70. If you want to hire a taxi for a day tour, it costs about TWD 2,000.
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A very warm welcome to Plas Dinas, an award-winning historic Country House set in Snowdonia, North Wales. We offer you ten individually styled bedrooms with five star comforts in historic yet relaxed surroundings in beautiful grounds as well as a charming, two bedroom self-catering cottage.
Nestled between the Snowdonia mountains and the Irish Sea, the idyllic setting and stunning views are not to be missed. Whether you take a stroll round our 15 acres in the summer or sit by the roaring log fire in the Drawing room on a cold winter’s day, you’ll relax the minute you arrive.
Whilst having state of the art facilities such as free wireless internet access and on-demand movies, we retain a comfortable homely feel with many period antiques and original family portraits adorning the walls.
Our warm and friendly atmosphere, attention to detail and attentive yet unobtrusive service sets us apart from our competition. For more information on the house and its hosts, click here.
We hope to welcome you to Plas Dinas very soon.
Neil, Marco, Malta & Blue
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Travel Republic Limited is an appointed representative of Rock Insurance Services Limited, which is authorised and regulated by the Financial Conduct Authority (their registration number is 300317).
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Kozuf is a mountain located near Gevgelija. A small city in the South of North Macedonia, just near the border with Greece. It is a worm city full of interesting people. Once I had the opportunity to have a nice ride around the mountain together with some friends, and I am willing to share some lovely pictures about the natural beauty of North Macedonia.
We drew for more than two hours I think, the ride was joined with a couple of stops and I really enjoyed it. The road was not good at all, and that scared me a bit. There were a lot of ruins and rocks, and the weather was very misty and creepy. We wanted to reach the top, but unfortunately, there was snow and ice on the road 5 km before we reached the top, so we had to give up and go back. The peak is Zelenbeg and is at 2171 meters above sea level.
I found out that the most specific thing about Kozuf is that it is the first natural barrier in our country, that is directly exposed to the influences of the Mediterranean and the Aegean Sea. The mountain can be also reached from Greece.
Misty mountain Kozuf
If any day the road brings you near Gevgelija and Kozuf, you can really think about visiting the places. Like any other mountain it brings purity and tranquillity, and it reminds you of how powerful nature is.
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Subscribe to our Youtube channel for all latest in-depth, on the ground reporting from around the world.
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Over the last year, we have changed the way we approach work and have moved to changing our homespace into our workspace which leaves us with very little or no movement. Tree of Life Workations - is a combination of constructive work balanced with a bit of vacation, in calm and serene surroundings.
Tree of Life brings to you properties across nine destinations that are handpicked — away from the hustle bustle of the city centre, limited inventories and open spaces offering an uninterrupted escape with nature.
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Mountain Escape Beachfront Wellness & Relaxation The Outdoors & Wildlife All Locations
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Perched on a hill-top with a 360 degree view of the surrounding mountain ranges — Tree of Life Highlands, Landour - Mussoorie is situated where Landour and Mussoorie meet. Away from the noise and hustle of the city and a convenient walk of 25 minutes to the quaint cantonment town — Landour.
Tree of Life Grand Oak Manor, Binsar
A stay inside the wildlife sanctuary — we welcome you to Tree of Life Grand Oak Manor, nestled atop the Kumaon hills of Uttarakhand takes you back to the time of the 1860s with its colonial charm spread over acres of land.
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Tucked away from the noise of the city centre, amidst the green forest reserve — Tree of Life Resort Dehradun Foothills makes for the perfect destination for those who are looking for solace in a calm and serene surrounding.
Tree of Life Highlands, Landour-Mussoorie
Perched on a hill-top with a 360 degree view of the surrounding mountain ranges — Tree of Life Highlands, Landour - Mussoorie is situated where Landour and Mussoorie meet. Away from the noise and hustle of the city and a convenient walk of 25 minutes to the quaint cantonment town — Landour.
Tree of Life Grand Oak Manor, Binsar
A stay inside the wildlife sanctuary — we welcome you to Tree of Life Grand Oak Manor, nestled atop the Kumaon hills of Uttarakhand takes you back to the time of the 1860s with its colonial charm spread over acres of land.
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Tree of Life Resorts & Spa, Jaipur
Spread over 7 acres of green space, away from the city centre with private pool villas with a garden, spa and sunken bath — at Tree of Life Resort & Spa, Jaipur we re-define luxury. Every villa takes its name from an Indian bearing flower tree and is reflective of Rajasthan's architectural history.
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Reflective of the local style of architecture, at Tree of Life Varanasi experience the city of spirituality and constant bustle with a sense of solace. Located away from the city centre, the resort with its Junior Suites offers you the luxury of space and privacy.
Tree of Life Resorts & Spa, Jaipur
Spread over 7 acres of green space, away from the city centre with private pool villas with a garden, spa and sunken bath — at Tree of Life Resort & Spa, Jaipur we re-define luxury. Every villa takes its name from an Indian bearing flower tree and is reflective of Rajasthan's architectural history.
The Tree of Life Resort & Spa, Varanasi
Reflective of the local style of architecture, at Tree of Life Varanasi experience the city of spirituality and constant bustle with a sense of solace. Located away from the city centre, the resort with its Junior Suites offers you the luxury of space and privacy.
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Built in stone and nestled amidst undulating forested hills, Tree of Life Resort, Udaipur with it’s 15 hideaway rooms set on 4 acres of land with lush green surroundings and a breathtaking view of the Aravali hills.
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A lodge built as cottages in natural stone with a wealth of floral, fauna and the wildlife — Tree of Life Kipling Lodge is a fusion of colonial and Rajasthani style of architecture, situated in close proximity to one of India’s most beautiful National Parks.
Tree of Life Homestead,
Corbett Country
A getaway on 170 acres of land with a 6 hole golf course, a private airstrip, fruit orchards — is an oasis of calmness and serenity. 12 hideaway rooms and cottages make it the perfect getaway destination for those who love nature and wildlife.
Tree of Life Kipling Jungle Lodge, Ranthambore
A lodge built as cottages in natural stone with a wealth of floral, fauna and the wildlife — Tree of Life Kipling Lodge is a fusion of colonial and Rajasthani style of architecture, situated in close proximity to one of India’s most beautiful National Parks.
Tree of Life Homestead,
Corbett Country
A getaway on 170 acres of land with a 6 hole golf course, a private airstrip, fruit orchards — is an oasis of calmness and serenity. 12 hideaway rooms and cottages make it the perfect getaway destination for those who love nature and wildlife.
Tree of Life Highlands, Landour-Mussoorie
Perched on a hill-top with a 360 degree view of the surrounding mountain ranges — Tree of Life Highlands, Landour - Mussoorie is situated where Landour and Mussoorie meet. Away from the noise and hustle of the city and a convenient walk of 25 minutes to the quaint cantonment town — Landour.
Tree of Life Grand Oak Manor, Binsar
A stay inside the wildlife sanctuary — we welcome you to Tree of Life Grand Oak Manor, nestled atop the Kumaon hills of Uttarakhand takes you back to the time of the 1860s with its colonial charm spread over acres of land.
Tree of Life Resort, Dehradun Foothills
Tucked away from the noise of the city centre, amidst the green forest reserve — Tree of Life Resort Dehradun Foothills makes for the perfect destination for those who are looking for solace in a calm and serene surrounding.
Tree of Life Marari Sands Beach Resort, Marari – Kerala
A private beach with clean sand, lush green palm trees and hammocks; surrounded by nature welcomes you to your private villas and cottages, where you wake up to clear blue skies and delectable local cuisine.
Tree of Life Resorts & Spa, Jaipur
Spread over 7 acres of green space, away from the city centre with private pool villas with a garden, spa and sunken bath — at Tree of Life Resort & Spa, Jaipur we re-define luxury. Every villa takes its name from an Indian bearing flower tree and is reflective of Rajasthan's architectural history.
The Tree of Life Resort & Spa, Varanasi
Reflective of the local style of architecture, at Tree of Life Varanasi experience the city of spirituality and constant bustle with a sense of solace. Located away from the city centre, the resort with its Junior Suites offers you the luxury of space and privacy.
Tree of Life Kipling Jungle Lodge, Ranthambore
A lodge built as cottages in natural stone with a wealth of floral, fauna and the wildlife — Tree of Life Kipling Lodge is a fusion of colonial and Rajasthani style of architecture, situated in close proximity to one of India’s most beautiful National Parks.
Tree of Life Homestead,
Corbett Country
A getaway on 170 acres of land with a 6 hole golf course, a private airstrip, fruit orchards — is an oasis of calmness and serenity. 12 hideaway rooms and cottages make it the perfect getaway destination for those who love nature and wildlife.
Tree of Life Resort, Udaipur
Built in stone and nestled amidst undulating forested hills, Tree of Life Resort, Udaipur with it’s 15 hideaway rooms set on 4 acres of land with lush green surroundings and a breathtaking view of the Aravali hills.
Tree of Life Highlands, Landour-Mussoorie
Perched on a hill-top with a 360 degree view of the surrounding mountain ranges — Tree of Life Highlands, Landour - Mussoorie is situated where Landour and Mussoorie meet. Away from the noise and hustle of the city and a convenient walk of 25 minutes to the quaint cantonment town — Landour.
Tree of Life Grand Oak Manor, Binsar
A stay inside the wildlife sanctuary — we welcome you to Tree of Life Grand Oak Manor, nestled atop the Kumaon hills of Uttarakhand takes you back to the time of the 1860s with its colonial charm spread over acres of land.
Tree of Life Resorts, Dehadun Foothilsx`
Tucked away from the noise of the city centre, amidst the green forest reserve — Tree of Life Resort Dehradun Foothills makes for the perfect destination for those who are looking for solace in a calm and serene surrounding.
Tree of Life Marari Sands Beach Resort, Marari – Kerala
A private beach with clean sand, lush green palm trees and hammocks; surrounded by nature welcomes you to your private villas and cottages, where you wake up to clear blue skies and delectable local cuisine.
Tree of Life Resorts & Spa, Jaipur
Spread over 7 acres of green space, away from the city centre with private pool villas with a garden, spa and sunken bath — at Tree of Life Resort & Spa, Jaipur we re-define luxury. Every villa takes its name from an Indian bearing flower tree and is reflective of Rajasthan's architectural history.
The Tree of Life Resort & Spa, Varanasi
Reflective of the local style of architecture, at Tree of Life Varanasi experience the city of spirituality and constant bustle with a sense of solace. Located away from the city centre, the resort with its Junior Suites offers you the luxury of space and privacy.
Tree of Life Kipling Jungle Lodge, Ranthambore
A lodge built as cottages in natural stone with a wealth of floral, fauna and the wildlife — Tree of Life Kipling Lodge is a fusion of colonial and Rajasthani style of architecture, situated in close proximity to one of India’s most beautiful National Parks.
Tree of Life Homestead,
Corbett Country
A getaway on 170 acres of land with a 6 hole golf course, a private airstrip, fruit orchards — is an oasis of calmness and serenity. 12 hideaway rooms and cottages make it the perfect getaway destination for those who love nature and wildlife.
Tree of Life Resort, Udaipur
Built in stone and nestled amidst undulating forested hills, Tree of Life Resort, Udaipur with it’s 15 hideaway rooms set on 4 acres of land with lush green surroundings and a breathtaking view of the Aravali hills.
An Ideal Workation?
As the name suggests, a Workation is about working while on a vacation. You need not be a nomad, traveling from place to place in search of your “balance”.
Tree of Life Workations offers you destinations of your preference — tranquility of the mountains, close to nature and wildlife, by your private pool or a beach resort.
Our Workations come with very comfortable and spacious accommodation, surrounded by nature; unlimited free hi-speed internet, gourmet meal plans based on your preference; discreet and caring service while following the highest standards of safety and hygiene and maintaining physical distance.
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Fantastic. The use o the ropes by both girls was awesome Suprrising ending, but I hope for a rematch.
clcl
2021-08-20 18:25:12
The way they used the top rope to hold onto while facing each other in a seated position trib reminded me of trib videos from 'back in the day' when the RED BED had a trapeze bar hanging down above it for just this technique :>) I also loved something you don't see much anymore which is the girls locking pussies in a scissors, lying back and rolling a few times while staying locked up. Best I saw of this was an old match between Eva and Lucille. This was fast paced and because I prefer slower paced matches, I just play it back at about half speed :>)
clcl
2021-08-04 16:44:27
I think I've seen Luna's bush even thicker / hairier in another review ... too bad there's no other girl at TD with a full bush she can be matched up with. How hot would be if Isabel sported an unshaven pussy and tribbed with Luna !! ??
roroy
2021-06-24 10:53:54
Bella beat Luna . Incredible . Super match very hot . I never thought that Luna can lose against Bella
ChChantel
2021-06-19 17:41:23
Amaging fight!!!!
GeGerry54
2021-06-16 15:37:42
Wow, amazing, best way I can describe this video is tremendous athletic pussy wrestling! Unique use of the ring ropes by both thruout the match ! Definitely one of my favorite TD videos of the last few years!
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Life can be unpredictable sometimes and Tri County Title Pawn is here to help you when you need it the most. By using your vehicle as collateral, you can get quick cash in a hassle free way. If you let us handle your case, you will have the friendliest customer service experience in the title pawn field! You don't have to use your car for a title pawn transaction. RV title pawn, motorcycle title pawn or boat title paw can be an option for you.
How Does a Title Loan work?
What you will need to bring:
The vehicle
Extra set of key for the vehicle
The clear Georgia title
Your state issued I. D.
Valid car insurance
A proof of residence dated within the last 30 days
Your paystub
Four Personal References with address and phone numbers
The Process:
Bring your car, clear title and all the required documents. Fill out an application for your Georgia title pawn while we appraise your vehicle. We will determine the pawn amount based on the value of your vehicle. We will hand you a check within 30 minutes or less. You can keep driving your car.
In Georgia you have 30 days to pay off your title pawn. If you need to extend your car title pawn beyond that, we are happy to discuss all available payment options with you. When you pay in full, Tri County Title Pawn will return your title to you. If you have any other questions, please call 706-420-0066.
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Customer Notice: A title pawn is a 30-day agreement, meant to be a short-term financial solution. However, borrowers often extend these pawns over a period of 2 to 24 months, which can be expensive. Title pawn customers have the option to extend their agreement at the maturity date, on the condition that finance charges have been satisfied for the period.
DISCLOSURE: This is a solicitation for a pawn transaction. This is not a guaranteed offer and requires approval. Amount subject to vehicle evaluation. Results and actual pawn amounts may vary. Certain limitations apply. Please see our FAQ page for more information.
|
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We noticed that you're using an unsupported browser. The Tripadvisor website may not display properly.We support the following browsers:
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Egyptian club Al Ahly beat South Africa's Kaizer Chiefs 3-0 in Casablanca, Morocco to become the first side in history to be crowned African football champions 10 times.
Mohamed Sherif, Mohamed Magdy and Amr El Solia scored the goals in the second half after Chiefs' Happy Mashiane was dismissed with a red card shortly before the break.
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Trucking Success partners with DAT to offer a special on the TruckersEdge Load Board to its members. Sign up for TruckersEdge today and get your first 30 days free by signing up at www.truckersedge.com/374122. This offer is available to new TruckersEdge subscribers only.
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DAT Trendlines™
powered by DAT RateView™
DAT Trendlines
Van
Flatbed
Reefer
Fuel Prices
Percent Change: +0.0%
Fuel Price: $3.06 /gallon
Freight volumes build ahead of Thanksgiving
National Spot Rates: Van, Flatbed, Reefer
Van and reefer rates up slightly
Nov 11-17 – Van and reefer load-to-truck ratios got a big boost last week, rising more than 20%. Vans are moving retail products in preparation for Black Friday and reefers are hauling fresh food ahead of Thanksgiving. Rates, however, have remained fairly stable. Van and reefer rates saw a slight increase, while flatbed rates declined.
For more info, read the Rate Trend of the Week.
Trendlines shows a weekly snapshot of the month-to-date for national average rates from DAT RateView. National average spot market rates for the past four months, including fuel surcharges, are shown in the three graphs, above.
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Trendlines last updated: 11/19/2019 12:00:00 AM
Next update: 12/03/2019 12:00:00 AM
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Spelunky
Her Favorite
Guide by Stiqe
View Solution
Spelunky
2,102
400
20
3.59
57,389
380 (1%)
80-100h
Her Favorite
Win the kapala from Kali.
0
3 guides
Stiqe201,404
06 Jul 2012 08 Jul 2012
18 2 3
for those looking for an extremely simple and easy way to get this one:
Simply play co-op and make your 2nd controller carry around any damsels you find. You can carry around your partner even while they're carrying a damsel, if you're going it alone. Once you encounter a shrine to Kali you simply sacrifice the damsel AND your friend! Alternatively, after sacrificing your friend, if you can't find a damsel but CAN manage to kill yourself and land your body on the shrine, that will work as well!
Kapala and Achievement = Yours. your friend gets the achievement, too! (assuming they've got their own profile)
Shrines are pretty hard to miss; they're blood-drenched altars below a large deity, and if you blow one up you'll spawn a load of spiders.
I guarantee you'll find a Kali shrine and damsel on the same map without having to leave the mines if you're patient/lucky enough.
TO THOSE UNAWARE: YOU USE THE KAPALA TO COLLECT BLOOD. Collected blood will add up, eventually filling the cup and giving you +1 heart. This can be done infinitely, as long as you can find blood!
It's also worth noting that sacrifices to Kali stack, so if you wanted to get this one in a legitimate playthrough you'd just want to make sure to sacrifice anything and everything (anything stunnable) at every opportunity and you'll get your Kapala soon enough.
Happy spelunking!
As a bonus, you can also sacrifice yourself even if you're not dead, as long as you're stunned and on the altar. I inadvertently got the achievement this way. To do it intentionally, try standing on the altar and throwing a rock straight up so it hits the ceiling and ricochets off of you.
Note that this isn't advised if you plan on beating the game.
Posted by Heffenffeffer on 08 Aug 12 at 23:32
Is it just random if you get the item? I just got this on literally my second ever damsel sacrifice
Posted by redjarman on 29 Aug 12 at 21:36
I tried for an hour and a half to find a Kali Shrine with a Damsel and an enemy who could be stunned on the same level with no success. Put on a second controller and got the achievement in 5 minutes. Thanks!
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Brand: Magictec
Color: Black
Features:
Premium quality, stainless steel, ultra-slim, windproof, travel Umbrella with easy open /close; 8-rib fortified frame; fiberglass flex clip; chrome plated metal shaft.
Durability-Tested up to 5000 times; frame is wind-resistant up to 55 mph; resin reinforced ribs will not bend or flip out in strong gusts; stainless steel frame will not corrode in constant presence of water or moisture.
Umbrella canopy is made with 210T polyester and coated; it will not soak through or leak, even in torrential downpours; rubberized grip keeps the handle secure and slip-free in your hand.
Auto open/close function allows for easy one handed operation. Measures just 13" long and weighs less than 11.8oz for easy storage in purses, briefcases, backpacks, luggage and more!
You are protected for life from the rain, sleet and snow, through our lifetime replacement program. If anything at all goes wrong with your umbrella, we will send you a replacement, no return required.
Details: Wind-Defying 8 Rib Construction Most umbrellas are made of 6 aluminum ribs but Repel is fortified with 8 resin-reinforced fiberglass ribs that flex slightly to withstand powerful gusts without turning inside out. Dupont Teflon Technology The Magictec Travel Umbrella gets its name from its ability to do just that - repel water and other elements through its waterproof and instantly drying canopy with state-of-the-art Dupont Teflon technology. Automatic, Compact, and Super Light Auto open/close function allows for easy one-handed operation. Measures just 13" long and weighs less than 11.8oz for easy storage in purses, briefcases, backpacks, luggage and more! Quality Workmanship Designed with a three-fold chrome plated metal shaft, and strong metal frame to allow for greater stability in high winds. The ergonomic, slip-proof, and rubberized handle with wrist strap allow for easy carrying.
EAN: 0756790006271
Package Dimensions: 13.8 x 2.6 x 2.5 inches
Shipping & Delivery
We offer standard & expedited shipping w/ status updates to 48 contiguous US states. We offer FREE Standard shipping on our items and Expedited shipping starting at $9.97. You may choose Free Standard shipping or Expedited shipping during checkout.
We do not ship outside the 48 contiguous states. We normally do not ship to PO Boxes. Please provide a physical address. We can not ship to Hawaii, Alaska, District of Columbia, and American territories.
Please allow up to 72 hours for order handling/processing. Once your awesome product leaves our warehouse, normal delivery time ranges from 3-10 business days (M-F) to reach your address, and all items ships from within United States. We send status updates for your shipment.
If you ordered more than one item, we may send them out in groups or separately. We provide tracking, and you may check the status of your order anytime by clicking on "Track Order" on our homepage, or click here. Our shipping partners also have the best people working round the clock to deliver your items to you on time. We use UPS, USPS, DHL, Fedex, & TBA.
Payments
PAYMENT OPTIONS
We accept all major credit cards (Visa, MasterCard, American Express, JCB, Discover, Diners Club), Google Pay, Apple Pay, and Paypal.
PRICING & CURRENCY CONVERSION
All prices listed on the website are in US dollars. For international orders, the bank that has issued your credit/debit card determines the exact exchange rate that you will be charged. The amount taken from the original funding source is returned in full when refunded by the seller. Please note we cannot be held responsible for any discrepancies caused by exchange rate fluctuations. In order to determine an estimated exchange rate for your currency, we recommend using an online currency converter
PAYMENT SAFETY
Shop with confidence. No card information is ever saved at TRVL Company and it remains the private property of the card holder at all times before, during, and after the product purchase. All transactions are processed though Stripe or Paypal and is a secure form of payment. Used by millions of people daily, Stripe is heavily encrypted third party-payment processors.
We take many active steps to ensure the absolute safety of your credit card and personal information. In addition to processing all credit card sales via a fully secured and reputable third party payment processor, your checkout experience is protected by industry standard 128 Bit SSL encryption to protect your private data. TRVL Company does NOT keep credit card information on record.
SHIPPING AND VERIFICATION
Please make sure that you enter the correct billing address and contact information as it appears on your bank or credit card statement. Transactions may not go through if the information entered does not match exactly what your bank or credit card provider has on file. Some transactions may also be held for further verification by our customer experience team. Make sure to also enter the correct shipping address (Street number and name, City, State, and Zip Code) as we are not liable for packages that are sent to the wrong address when the address information is not entered correctly.
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We hope you are all safe and well. Your order is our top priority. The TRVL Co. team are all working diligently and closely with our distribution centers and delivery companies to ensure a speedy fulfillment and delivery for your order. We ensure that our products are also handled in the best possible manner by taking appropriate steps to keep our customers and workers safe.
TRVL Company Products - What We Have to Offer
TRVL Company curates all sorts of products. We are a general curator that brings you tested, highly rated, and finest products at best prices. Your order is our top priority. We curate fashion products, hobbies & toy products for all ages, electronics, media storage, computers, home & office products, furniture, appliances, kitchen products such as for baking and cooking, food & personal care products, DVD & books, fitness & sports products, jewelry & watches, tools & hardware, phone accessories, pet supplies, travel bags, and travel accessories.
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TTM is pleased to announce and welcome its newest member Liomar De Leon, who will join the TTM team as a Design Consultant in our Gold Coast office.
Liomar is a recent graduate, and has a passion for designing and CAD work. He will also be assisting Tony Martyr in our Traffic Signal team with their numerous signals projects in Queensland, New South Wales, Victoria and Northern Territory.
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Web design has a love of all things retro. You can’t scan the web for long before you come across a site with faux wood textures or faded and breezy images influenced by the aesthetics of another time. These old styles are even large parts of current design trends such as flat design and the new found focus on typography. Designers are constantly taking the old and turning it new again.
Some choose to lean more heavily into the retro styles than others. While many flat designs owe debts of gratitude to minimalist styles of the 50’s and 60’s, you usually wouldn’t confuse the two. Others however do their best to emulate the styles of earlier times as closely as they can, but translated into a digital medium.
Going retro is a popular style for many brands and artists, and it isn’t any more difficult to achieve than most other current design aesthetics. Designrfix recently shared tips to really get the look and feel of older times, if you want to try it out for yourself.
Think Retro – The first step is getting inspiration. It can be difficult to detach yourself from your contemporary ideas of good style, and the best way to do that is go directly to the source. Search out old magazines and newspapers, any sort of graphic media from the time you can find. There is a huge amount of it online, and you’ll be able to get inspired within just a couple searches.
Focus on Simple Shapes – Vintage and retro styles are characterized by simplicity. Designs of the past relied on impact to grab attention, and this was usually achieved by using very simple shapes like circles which demand attention. Consider a circle surrounded by decoration, or blocky and heavy arrangements.
Limit Your Use of Color – Modern designers have it easy. We can use any assortment of colors we want on the web, even down to slight shading choices. Designers of the past were limited by the expense of full color printing, so they often relied on two-toned coloring to come up with colorful designs without breaking the bank. Using black-white, orange-yellow, or cream-brown color combinations will immediately make viewers think of older printing styles.
Retro Typefaces and Fonts – As previously mentioned, big typography in retro styles is an absolute necessity of a vintage site. The style has grown some legs on its own, but it still is a defining trait of older styles. You need to choose a font reflective of the era you want to reflect. Using the wrong typeface can seem anachronistic or lazy, so take your time and get it right. Check what designers were using in the era you’re emulating and find something similar online. It shouldn’t be hard to do so.
Borders – Borders have always been a big part of design, and ornamental borders were definitely a big part of making older designs attention grabbing. Frame your images and content in borders and simple shapes and you’re site will already look pretty retro.
Badges – Interestingly, if you look at websites with retro designs, you tend to see lots of badges as buttons, even though badges weren’t actually a big part of designs in the past. Still, these badges remind users of county-fair days and older times, while also standing out on the page and drawing attention. It is a simple addition that works better than it should.
Using the Right Texture – Well used textures can make a boring page feel stoic and formal. They can entirely define how a page feels, and can certainly make a page feel more retro. The trick is subtlety and integrating the texture into the layout, not simply laying it over things.
August 20, 2013 /0 Comments/by TMO
Tags: design tips, Designrfix, News, retro design, Web Design
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TMO https://www.tulsamarketingonline.com/wp-content/uploads/2018/07/TMO-Logo.png TMO2013-08-20 13:02:372013-08-20 13:02:37How to Make Your Website Look Retro
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Brezilya Hostels
Rio de janeiro Hostels
Gaia Hostel
Gaia Hostel
Rua Mena Barreto 18 - Botafogo, Rio de Janeiro - RJ , Rio de Janeiro, Brezilya
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Gaia Comfort Hostel has a very youthful yet relaxed atmosphere alongside friendly attentive service and plenty of fun! Our mission is to provide a traditional environment for our guests, giving them the chance to experience the Marvelous City as a local “Carioca”!
For us, it's about meeting people from all over the world, making lasting friendships and providing a unique experience, combining a low cost stay with comfort and good vibrations!
Gaia has X beds divided into several spacious shared dorms and private en-suites. We offer, free Wi-Fi and high speed internet, a communal kitchen, a cozy lounge (TV room), a really nice open-air area, free walking tours and maps, daily hostel parties and many more Brazilian activities!
In a great location, Botafogo, nestled comfortably between Copacabana and Flamengo, just a few minutes from Ipanema, the city centre and Lapa’s vibrant bars. 3 minutes walking from the metro station, and walking distance from the famous Sugar Loaf Mountain. There's transportation links just a stones throw away that will connect you to just about anywhere in the city. In close proximity also is Botafogo beach, Nelson Mandela Street and “Baixo Botafogo”, a famous area full of bars and restaurants, where many cariocas go to meet their friends, drink a nice cold beer and eat delicious local Brazilian cuisine!
Have fun, enjoy and discover all Rio has to offer by making Gaia Comfort Hostel your base!!
Check-In: 14:00 hs
Check-Out: 12:00 hs
* Half of the daily rate will be charged for late check out between 12:00 AM and 2:00 PM. After 2:00 PM a full daily rate will be charged. The hostel has luggage storage.
** Please, bring your own padlock for the locker
Cancellation Policy
Cancellations will result in a charge equal to the first night of your stay.
During special periods , Festivals, and holidays:
100% of the payment is required in advance upon your booking.
If the booking is cancelled 60 days before the check-in date, 70% of the deposit value will be refund.
If the booking is cancelled between 59 and 20 days before the check-in date, 50% of the deposit value will be refund.
If the booking is cancelled 20 days before the check-in date, there will be no refund.
For the World Cup, Olympic Games, Carnival And New Years 100% of non-refundable payment is required in advance upon your booking.
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https://www.turramurrauniting.org.au/wp-content/uploads/2018/09/180916am-Phil-ThanksgivingSunday-V2.mp3
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Sunday 16th September 9am Worship
Sermon Series: Extravagant Generosity
Title: Thanksgiving Sunday
Bible Reading: 2 Corinthians 9:6-12
Preacher: Rev Phil Swain
Sermon
As I have already mentioned before… I grew up in a church where we would have a yearly Harvest Festival Church Service … a time when everyone would bring in lots of produce and other crafty stuff and give thanks for God’s wonderful provision. Did you have that experience? I remember listening to lots of Harvest Festival sermons which encouraged me to give thanks to God for all God’s blessings … but I can’t remember ever hearing a sermon that explained why? Why is it good to give thanks to God? Has it got to do with just being “polite”? If God has given us all these provisions, then the least we should do is say thanks…
So … Why give Thanks to God?
The easy answer to this is that the Bible tells us so.
1 Thessalonians 5:16-18 – In everything give thanks, for this is God’s will for you in Christ Jesus
Philippians 4:6 – With thanksgiving, let your requests be made known to God
Psalms – Repeatedly say, “Give thanks to the Lord”
Hebrews 13:15 – Offer sacrifice of praise, the fruit of our lips that give thanks to his name
But that doesn’t answer the question of why??? Why are we instructed to do this? Does God “need” it? No. I don’t think that God needs anything from us. So, maybe thanksgiving has more to do with us than it does with God? If you have your bible’s here, turn to Romans 1:18-26. Here Paul is suggesting that God is really unhappy with some people. Paul explains that these people know God, they have received insight and revelation from God; and yet in verse 21 we read…
For although they knew God, they neither glorified him as God nor gave thanks to him, but their thinking became futile and their foolish hearts were darkened.
Paul is saying that these people missed the point. Although they knew God, knew God’s character and knew about the wonderful things God has done … they drifted from that and stopped honouring God in their words and actions AND stopped giving thanks. One of the commentaries I was read suggested that Paul is observing a practice that is very common in our modern world … these people started to take God for granted … that the goodness of God was seen as just the normal things of life … and therefore they could see the need to honour or give thanks to God.
I remember early in my ministry having a conversation with a man which went something like this. “I am frustrated that people like you think that God should get the credit for what I have got. I have this roof over my head and food on my plate because of my own hard work … not because of God’s blessing. I have good health because I look after myself … not because of God. If anyone should be getting the credit for my happy and comfortable life … it should be me, not God.” It is interesting if you hold that comment next to Romans 1:21. Yes, hard work often brings rewards … but that does not remove the need to pause and thank God. I want to suggest this morning that this practice of stopping, by giving God honour and, in particular, giving thanks to God actually does something helpful deep within us. Giving honour to God and being thankful is transformative.
Think about the story of the 10 lepers from Luke 17. Jesus heals all 10 and sends them off the priest to be verified. You know the story … only 1 comes back to say thank you. Jesus then says to the thankful one that his faith, his action of being thankful, has made him well. Sorry? He was already made well by Jesus 3 verses before. What is Jesus talking about? I think that Jesus implies to the one that returned that his act of giving thanks has brought an inner healing – a spiritual healing. That somehow in the act of coming back to give thanks to Jesus, this ex-leper was transformed.
Let’s jump to our bible reading for today – 2 Corinthians 9. The context of this passage is that it is about the “Jerusalem Offering”. Paul understood that his ministry was not separate but part of the wider ministry of the early church and as such he encouraged all the churches he established to financially support the work of the early church – its outreach, its charity work with the poor and its teaching ministry – both on a local level and on the regional level. This regional offering was called the “Jerusalem offering” and Paul not only refers to it here in our bible reading but also in 1 Corinthians 16, Romans 15 and it is mentioned numerous times in Acts.
In my sermon last week I used this passage to talk about the reality that the more people sow into the ministry of the church, the greater the harvest. I also highlighted Paul’s encouragement to be generous – not out of duty or reluctant obligation – but out of a cheerful heart. But that the amount is up to each person. That each person should give what they have decided in their hearts to give. But then in verse 11 it gets interesting. Paul says that in this act of giving, in the act of being generous, we will be made rich. I made it clear last week that am not a believer in a prosperity gospel … that if you give that God will bless you with even more money. Rather I think Paul is efering to the same ‘richness’ as Paul talks about in Chapter 8:9
“For you know the grace of our Lord Jesus Christ, that though he was rich, yet for your sake he became poor, so that you through his poverty might become rich.”
Paul is not talking about money here but something much more valuable. I believe Paul is talking about being spiritually rich … or as I mentioned before … inner transformation. So back in chapter 9:11 – through our generosity, we are made rich – or we are inwardly transformed – and this will result in “thanksgiving to God”. Can you see these threads coming together here? We are encouraged to give thanks to God not because God requires it but because it does something to us, it changes us, it is transformative. At the same time, we are encouraged to be generous with our support of the church, not because God requires it but because it does something to us, it changes us, it makes us spiritually rich, it is transformative … and results in giving thanks to God … which is transformative. And then in verse 12 we read that service we perform, when we use our hands and feet to serve God and serve others – that is not only meeting the needs of others but it does something to us, it changes us, it is transformative … and results in giving thanks to God … which is transformative.
We can’t separate these ideas… giving thanks to God, generously supporting the work of God, offering yourself to serve God and serve others. This is a foundation biblical principle, a way of life that we as followers of Jesus are called to follow. Not only because it is beneficial to the furthering of God’s kingdom, and beneficial to the poor and those in need, but it is also beneficial to us, it transforms us. We discover a different way of understanding what it means to “be rich”.
In response to this, I suggested a few months ago to our church council here at Turramurra that I would like to not only have a Thanksgiving Sunday but also a Thanksgiving Offering. Over the past few weeks you have received a brochure that explains the concept behind a Thanksgiving Offering. This is a special, one a year offering, for mission projects or innovations that are not part of our normal church budget. We as a church are extremely blessed for the regularly financial giving of people in the church – through our tithes and offerings, through regular direct giving, through other income such as rental income etc.
We are also blessed with … I am not extracting to say, over 100 people who regularly give of their time and skills and energy in serving on rosters or helping run groups or leading in worship etc. For which I want to say “Thanks be to God”. And this year we have been blessed with a great Vision and such positive energy as we have worked through five key mission priorities. But the reality is that we also have more ideas that what our resources allow us to do. And that is where the Thanksgiving Offering comes in. In consultation with different people and groups we have put together a short list of 5 projects that are not in the church budget and will only go ahead if we find some funding for it.
The criteria for the projects was things that we could implement now (or in the next few months), things that would make a clear difference or outcome to the ministry and mission of our church and I was also looking for a variety of things – not all property projects or not all internal projects. I was really impressed with the 5 projects that Church Council have put forward. Sure some of them are bold … like asking for $75,000 for air-conditioning (that is certainly not in our normal budget) … but imagine the difference that would make. We have some of our senior not coming to church in the heat of summer because it is too hot. We had someone faint last year in worship due to the heat. Christmas Eve is crazy. Imagine how much better we could communicate the gospel and help people grow spiritually and make this space welcoming and hospitable if we sorted out the cooling and heating. So yes, $75,000 is a lot – but it would make a clear missional difference.
The leaders involved in Children, Youth and Family ministry are also wanting to add to our property, but in a specific way that would have a big impact. The youth leaders want to build some cupboards on the stage to store all the youth group resources in one place and update the resources with some great items such as giant Jenga. They can’t afford to do that with the money that comes in each week from the kids – so they have put this idea forward to the Thanksgiving Offering. The kids church have been asking for a TV and DVD set up for the garden room – its never quite got into the budget – but we can make it happen in Thanksgiving Offering! The playgroup is looking to purchase some equipment as well. As you can see, all these projects have clear missional outcomes.
And some are not about property at all. Like the project that I put up about getting some short-term intensive leadership training for 6 leaders in our church (either young or older leaders). I have found an expert in leadership development and mentoring who is happy to help us out with this. Great idea, but it can only go ahead if we find some funding.
Project #4 is for those who are concerned that the church has debts. We are currently paying off a loan for some major work that we had done on this place several years ago. The beauty of debt reduction is that it is the gift that keeps on giving. By donating to this project this year, we save money every year moving forward.
Lastly, Thanksgiving offering is not just about us. So, project 5 “Raising Hope” is a great initiative by our sister church Parramatta Mission who are helping women affected by domestic violence and homelessness.
Let me be clear – in the spirit of last week – I hope that I am not sounding like a salesman and pressuring you to give in Thanksgiving Offering. I don’t want anyone to be guilted into giving. Rather, I know that people give in different ways and for some people, something like Thanksgiving Offering really connects with them. It is giving to a specific project to make a specific different – a real difference that will last. If we go back to our bible reading, I want to affirm verse 12:
This service that you perform [Or this initiative that you are invited to participate in] is not only supplying the needs of the Lord’s people but [I hope and pray will] also overflowing in many expressions of thanks to God.
I can imagine someone this year’s Christmas Eve saying, “Thank God for this air-conditioning” or in a few years’ time we will be saying, “Thank God for that leadership development in 2018. That has made such a difference in our church”. Our generosity – with our time, our gifts, our energy and our resources – will lead to many expressions of thanks to God.
So in summary… we should personal give our thanks to God because it changes us, it is good for us, it is transformative. But at the same time – and in a sense of gratitude and thanksgiving – we should also be generous with our support and in our service to God and others … and in doing so we find that we are changed, it is good for us, it is transformative.
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TUSC will oppose all cuts to council jobs, services, pay and conditions. Reject increases in council tax, rent and service charges to compensate for government cuts. Vote against the privatisation of council jobs and services.
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Sky News interviews TUSC's Dave Nellist on Jeremy Corbyn
Posted: 15 September 2015
Sky News interviewed Dave Nellist, chair of the Trade Unionist and Socialist Coalition on 13 September 2015 the day after socialist Jeremy Corbyn was elected leader of the Labour Party in a landslide victory for socialist ideas. Sky wanted to know what TUSC's reaction was.
Click here for more...
Steering committee re-sets TUSC conference agenda for new times ahead
Posted: 9 September 2015
The September meeting of the Trade Unionist and Socialist Coalition (TUSC) national steering committee has revised the agenda for the forthcoming TUSC conference to take account of the tremendous anti-austerity movement that has mobilised around Jeremy Corbyn's Labour leadership bid.
The TUSC conference is taking place on Saturday 26th September at Student Central, Malet Street, London WC1E 7HY, from 11am to 4-30pm.
The opening session, under the title 'The role of TUSC in the new situation', will be a chance to assess what needs to be done, after Jeremy Corbyn's hoped for success, to continue the process of re-building independent working class political representation.
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The TUSC 2016 local elections draft policy platform
Posted: 9 September 2015
The Trade Unionist and Socialist Coalition (TUSC) national steering committee has agreed a draft statement of core policies for the 2016 local council elections (see below).
First published at the start of the summer, the statement has been updated to take account of the tremendous anti-austerity movement that has mobilised around Jeremy Corbyn's bid for the Labour leadership.
The draft platform will be debated at the TUSC conference being held on September 26th. Local TUSC groups, constituent organisations or individuals who want to move amendments should send them to the TUSC national agent, Clive Heemskerk, at [email protected], by Friday 18th September to be included in the conference discussion.
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Fleetwood council opposes Lancashire gas storage plans as TUSC councillor calls for mass campaign
Posted: 26 August 2015
Fleetwood town council has voted to oppose controversial plans by the Halite Energy company to build a gas storage facility on the Fylde Coast.
The government Department of Energy and Climate Change has recently granted permission to Hailte to develop a huge underground gas storage scheme in salt caverns at Preesall (Over Wyre), in Lancashire, despite massive public opposition.
The Trade Unionist and Socialist Coalition (TUSC) Fleetwood town councillor Simon Roberts had organised a protest before the council meeting on August 25, which drew together members of the public including Preesall residents and anti-fracking campaigners.
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TUSC ex-councillor condemns Blairite manoeuvres against the Corbyn campaign
Posted: 10 August 2015
The Trade Unionist and Socialist Coalition (TUSC) today called on media outlets to name the sources for their stories that the Labour Party is being 'infiltrated' by TUSC members.
This follows the revelation that a former South London councillor who stood for TUSC in May was wrongly named in The Times as somebody who had signed up to support Jeremy Corbyn's leadership bid.
Last week The Times named Chris Flood, who stood as a TUSC candidate in the Lewisham Deptford constituency in May, as a new registered Labour supporter.
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TUSC chair interviewed in The Independent on the Jeremy Corbyn campaign
Posted: 3 August 2015
From The Independent on Sunday, 2nd August:
"If, as many Labour MPs believe, their party isn't having a leadership contest but a troubled convention of ghosts from socialists past, then Dave Nellist is among the haunting elite.
The former MP for Coventry South, now 63, was among those expelled from Labour in the early 1990s because of his links with the group centred around The Militant newspaper.
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TUSC councillor makes protest call against Lancashire gas storage plans
Posted: 2 August 2015
The Trade Unionist and Socialist Coalition (TUSC) Fleetwood town councillor Simon Roberts has added his voice of opposition to a recent government decision to allow a controversial gas storage facility on the Fylde Coast.
The Department of Energy and Climate Change (DECC) has granted the Halite Energy company permission to develop a huge underground gas storage scheme in salt caverns at Preesall (Over Wyre), in Lancashire, despite three rejections of the plan and massive public opposition.
The decision by the DECC to allow Halite to proceed follows last month's rejection by Lancashire county council of bids by the Cuadrilla energy company to test frack on the Flyde and bodes ill for the outcome if Caudrilla appeals.
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TUSC sets out draft policy platform for 2016 local elections
Posted: 20 July 2015
The Trade Unionist and Socialist Coalition (TUSC) national steering committee has agreed a draft statement of core policies for the 2016 local council elections, A councillors' revolt could stop the Tory cuts! (see below).
This will now go to the TUSC conference being held on September 26th, where local TUSC groups, constituent organisations or individuals will be able to move amendments to the statement for debate and decision. Amendments should be sent to the TUSC national agent, Clive Heemskerk, at [email protected], by Friday 18th September to be included in the conference discussion.
The platform, once it has been finalised, is the basis on which any prospective candidate can stand under the TUSC name in the elections taking place next May in 127 English councils.
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TUSC pledges opposition to new attack on workers' rights
Posted: 17 July 2015
The Trade Unionist and Socialist Coalition (TUSC) has added its voice to mounting opposition against the Conservative government's Trade Union Bill raising the threshold for union strike ballots, and allowing employers to bring in agency staff to break strikes.
The Trade Union Bill, introduced to parliament on Wednesday, 11th July, imposes a minimum 50% turnout in union strike ballots; for public sector strikes to be legal they would need the backing of at least 40% of those eligible to vote.
TUSC national chair, former Labour MP Dave Nellist, said:
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Scottish TUSC hears civil servants' union leader's call for industrial and political action
Posted: 8 July 2015
The Scottish Trade Unionist and Socialist Coalition (TUSC) meet in conference on June 27th to discuss plans to field the largest possible number of working class fighters as candidates in next May's elections for Scotland's Parliament.
The platform was dominated by those at the sharp end of fighting austerity, including speakers from the Glasgow School Buses campaign; Graham Nelson, a senior shop steward for Unite and a striking hospital porter from Dundee; and Chris Semani, Unison steward and striking Glasgow caseworker.
Another keynote speaker was Gordon Martin, the Scottish organiser of the RMT transport workers' union, whose members at CalMac are also on strike.
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TUSC steering committee debates coalition structures, the EU, and new election fund appeal
Posted: 5 July 2015
The June meeting of the Trade Unionist and Socialist Coalition (TUSC) national steering committee included a detailed discussion, the first in a series, on how to develop the coalition following the TUSC campaign in May's elections.
Also on the agenda was a plan for a TUSC National Election Fund appeal - with the aim being to meet the costs of election deposits for candidates in the 2016 contests for the Scottish Parliament, the Welsh Assembly, the Greater London Authority and the three council Mayoral elections taking place next year, in Liverpool, Salford and Bristol.
The meeting confirmed the date of the TUSC conference to discuss the 2016 elections as September 26th, to be held at London's Student Central venue, Malet Street, WC1E (11am to 4-30pm).
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TUSC North West conference keeps up the momentum
Kevin Bennett
Posted: 30 June 2015
Around 50 activists from across the region attended a Trade Unionist and Socialist Coalition (TUSC) North West conference on 27 June, to assess the post-election situation and make plans to build TUSC going forward. Meeting on the same day for their conference, Scottish TUSC sent us a message of solidarity which was well received.
TUSC councillor Kevin Bennett from Warrington introduced the discussion, with the memorable line that "it's like the Tories decided to usurp the tale of Robin Hood, except this time the Sheriff of Nottingham is the hero! And it seems Andy Burnham agrees!" The main theme to emerge from discussion was that TUSC has achieved significant momentum from our landmark election challenge this year, and must keep this up against a backdrop of international crisis, developments in Greece, and the Tories' war on the poor and organised workers while Labour remains in turmoil.
Daren Ireland, the regional organiser of the RMT transport workers' union, one of the constituent organisations of TUSC, outlined the essential organisational steps to take - building finance through standing orders with only ten months until next year's local elections; pushing TUSC in the trade union movement and winning the unions to a position of support for a new mass working-class party; building and strengthening local groups operating on an open and federal basis welcoming all individuals and groups; and standing at least 500 candidates in May 2016 when around 2,200 councillors face election across England.
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TUSC steering committee post-election meeting discusses future plans
Posted: 15 May 2015
The Trade Unionist and Socialist Coalition (TUSC) national steering committee held its first post-election meeting this week. Against the backdrop of a Tory-majority government committed to accelerated austerity, albeit one with the lowest ever share of support amongst the total electorate (24.4%), the need the build on the TUSC campaign to develop a socialist electoral alternative was recognised by all.
The meeting agreed a vote of thanks to all the 748 candidates - and their agents and campaign teams - who contested the elections on May 7th under the TUSC umbrella, polling a combined total of 118,125 votes.
A detailed report of the TUSC results was accepted and is now available, in PDF format, at www.tusc.org.uk/txt/338.pdf
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Results update - TUSC polls a thousand plus votes in over twenty councils
Posted: 9 May 2015
As predicted yesterday, over 100,000 votes were cast for TUSC candidates in Thursday's elections (see http://www.tusc.org.uk/17091/08-05-2015/results-still-coming-in-but-tusc-set-to-poll-100000-votes-for-bold-no-cuts-message ). We're currently at 108,416 votes but, with more local council election results to be collected in, we are still not able to give a final tally.
One thing is clear however - TUSC is making a mark in councils across the country, which will be vital in the anti-austerity struggles to come.
Leading the way is Leicester with 4,440 votes cast for TUSC council candidates, just ahead of Coventry on 4,389. While the Leicester rebel councillors Wayne Naylor and Barbara Potter were sadly unable to hold their seats in a contest overshadowed by the general election, the anti-cuts challenge has laid firm roots across the city. Barbara polled 3,028 votes in her stand for the directly-elected city mayor.
Click here for more...
Results still coming in but TUSC set to poll 100,000 votes for bold No Cuts message
Posted: 8 May 2015
With many councils not starting their local elections count until Friday morning, collecting in all the Trade Unionist and Socialist Coalition (TUSC) results has been a painfully slow task. But, while the figures are far from complete, we can confidently say that over 100,000 votes were cast for TUSC candidates in Thursday's elections.
The best TUSC parliamentary votes were recorded by Dave Nellist in Coventry North West, polling 1,769 votes, and Jenny Sutton in Tottenham, with 1,324 votes. There were also good scores recorded in Bethnal Green & Bow (949 votes), Liverpool Riverside (582), Barnsley Central (573), Walsall North (545), Leigh (542), Leicester East (540), Salford & Eccles (517), and the other Coventry seats, Coventry South (650) and North East (633).
But actually the parliamentary votes are just a small reflection of the support - including electoral support - for TUSC's socialist, anti-austerity message.
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After the polls close: election counts and reporting the TUSC results
Posted: 6 May 2015
The Trade Unionist and Socialist Coalition (TUSC) is standing in 135 parliamentary constituencies today and 619 candidates in the English local council elections. Gathering in the results will be a big job. How and when we plan to report them on this website is explained below. But there are also other things to look out for on election night, as the 2010 election showed.
TUSC was formed just twelve weeks before the 2010 general election, with the aim of providing a common banner for trade unionists, socialists and working class community activists to contest elections. One of the early pioneer candidates was Bill Rawcliffe, who was the RMT senior steward at the Jarvis Rail services company. Bill only decided to stand, after a mass meeting of rail engineering workers, when Jarvis went into administration on March 25th and made 1,200 workers redundant while the Labour government stood by.
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'One hundred percent anti-austerity' - Scottish TUSC media launch
Posted: 29 April 2015
The Scottish Trade Unionist and Socialist Coalition held its election manifesto launch on Friday - and got some decent coverage too.
BBC Scotland TV cameras filmed candidates campaigning in Glasgow (see https://www.youtube.com/watch?v=K1axZ5-ZWAU ), highlighting TUSC's £10 an hour minimum wage policy but also our stand for the public ownership of the banks, utility companies and major industries such as oil.
The need for public ownership of the major sections of the economy was also the theme of a more extensive interview with Scottish TUSC spokesperson Philip Stott on BBC Radio Scotland's Newsdrive programme (listen at https://www.youtube.com/watch?v=uW1tpbbzlS0 ) where TUSC's position in the election as the '100% anti-austerity, 100% socialist' alternative got through.
Click here for more...
Good luck message to TUSC candidates from Bob Crow's cousin
David Wallis
Posted: 27 April 2015
The Trade Unionist and Socialist Coalition (TUSC) has received the following message from David Wallis, Bob Crow's cousin and also a member of the RMT's London Taxi branch:
"I would just like to wish all the TUSC candidates good luck in your campaigns over the next two weeks.
"I have had lots of conversations in my London taxi discussing TUSC and it's been very reassuring that people have listened and taken away what we stand for. I hope that I have been able to turn some heads.
Click here for more...
TUSC's Dave Nellist on World At One
Posted: 23 April 2015
Chair of the Trade Unionist and Socialist Coalition, Dave Nellist, speaking on the BBC's World at One radio programme on the 21 April 2015.
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Rick Allred is a visual artist based out of Santa Fe,New Mexico. Allred's art captures the beauty that surrounds us and expresses the generosity of the human spirit.
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Better be careful Mouth. Last time you helped me, you got fired and now you're sitting out here at the River Court looking kinda creepy and stalker-ish.
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By joining TV Guide, you agree to our Terms of Use and acknowledge the data practices in our Privacy Policy.
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New York –Sirius Satellite Radio announced today that its service is now available in 11 states, with 17 more to receive service as of May 15.
Sirius has been deployed in Arizona, Colorado, Idaho, Iowa, Kansas, Montana, Nebraska, New Mexico, North and South Dakota and Wyoming. These are states which have a limited choice in radio programming and that include a large number of truck drivers who are potential customers for the service.
By May 1, seven more states are slated to receive Sirius service including Arkansas, Louisiana, Minnesota, Missouri, Nevada, Oklahoma and Utah. On May 15th, Alabama, Indiana, Kentucky, Michigan, Mississippi, Ohio, Tennessee, Texas, West Virginia and Wisconsin will come on line and Sirius will be available nationally on July 1, said the company.
Subscribe
For more stories like this, and to keep up to date with all our market leading news, features and analysis, sign up to our newsletter here.
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The Vikings’ Leslie Frazier is one of the NFL’s best defensive coordinators and should be given the opportunity to be a head coach somewhere. Maybe this will be the year it happens for him. He was scheduled to be interviewed Thursday for the Buffalo Bills’ opening. Though he’d like to get a shot at running his own team, Frazier also has a few other things on his mind. Like helping the Vikings advance in the playoffs. I talked to Frazier about the postseason and his head coaching aspirations.
BS: Is the defense where you want it to be heading into the playoffs?
LF: We finished strong in that last game (against the Giants). It was a great effort by our guys on defense. We had a few bumps in the month of December, but I feel like we’re heading in the right direction. It’s a totally new season once you get in the playoffs.
BS: How much preparation can you do for your game when you don’t know who you’ll play?
LF: It’s hard. There are three possibilities, so you can’t really hone in on one of those teams. You can take a glimpse at something, but you can’t begin to make plans.
BS: As you’ve noted, there are three teams you possibly can play in the first round. You’ve beaten the Packers. Lost to the Cardinals. And haven’t faced the Cowboys. Do any of those offenses present more issues than the other two?
LF: They’re all very good offenses and they do pretty good things and they all present some issues you have to deal with. We’ll just have to hone in when we find out who we have to play.
BS: Is Green Bay better than the last time you faced them? (The Vikings beat the Packers twice in the regular season — the last time 38-26 on Nov. 1 in Green Bay.) The Packers look to be an ascending team.
LF: It looks that way. It looks like they’ve really made some strides on the offensive side, doing some things a little bit better. So they’ll be a team to contend with.
BS: What gives you the most sense of serenity or security about your defense?
LF: The fact that we have Jared Allen and Kevin Williams gives me peace of mind, as much as anything. And just the way our guys play hard. Things aren’t always perfect, but they play hard. That’s all you can ask for as a coach.
BS: Anything that worries the heck out of you?
LF: You like to avoid those injuries. I don’t worry about it. It’s just a part of our game. You just like to keep your best guys on the field.
BS: Speaking of injuries, do you expect Antoine Winfield to be 100 percent, or close to it, by game time?
LF: This time off should help him. We’ll just have to monitor and see where he is when we get back.
BS: Which of your players have been ascending?
LF: One new guy who seems to be improving every time he gets out there is (middle linebacker) Jasper Brinkley. I think he’s making some improvements, which helps our defense. There’s a big void when you’re trying to fill E.J. Henderson’s shoes. To see Jasper make some strides is a plus. (Defensive end) Ray Edwards is making some strides, as well. And I think (safety) Madieu Williams has begun to make some improvements in some areas that are important to our defense. Another young guy who is beginning to get a little more playing time, Jamarca Sanford, is a guy we’re keeping on eye on who is making some improvements, as well.
BS: That young man can hit.
LF: (Smiles.) He can hit. He’ll knock you out, which is what we want from a safety.
BS: Brinkley seemed to have a tough time on passing downs a few games back. On running plays, there is no hesitation and he seems to play well. Have you seen advancements in the way he plays the pass?
LF: That’s where he’s making the majority of his strides. He’s always been pretty good against the run, which is why we drafted him.
BS: How much better does the defense play at home than on the road?
LF: I think if you look at any sport, home-field advantage is huge, whether you’re the Minnesota Twins, the L.A. Lakers, the Indianapolis Colts. And if you’re a dome team, it’s even bigger because of the noise in the dome compared to outdoors. We should be a better team at home. And we are.
BS: Does your gut tell you this will be the year you’ll become a head coach?
LF: If there are (limited) openings, it’s going to be real tough. It may be one of those years.
BS: The Rooney Rule is, in theory, a good one (for mandating that NFL teams interview minority candidates for head coaching openings). But do you think some teams just go through the motions?
LF: I hope not. I hope when they bring in a minority candidate they legitimately are looking at that candidate as a potential head coach as opposed to satisfying the Rooney Rule. I’m hoping that’s the case, that they are legitimately believing that this guy has a chance.
BS: I asked Brad Childress this the other day, and he brushed if off. So I’ll try with you. I’m predicting a Vikings-Packers NFC championship game. How about you?
LF: Hey, I don’t care. As long as the Vikings are in the championship game, I’m a happy camper. Bring ’em on, whoever it is. Bring ’em to the Metrodome.
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What qualifies you to hold this position? I feel being involved in the community is essential. I coached youth sports in the Roseville/Falcon Heights area for 19 years. I served on the FHFD for 13 years and two as the Fire Marshal. Being self-employed since 1996. I work with a diverse customer base and understand problem solving is a team effort that needs involvement and transparency.
What would your top priorities be if elected? Community involvement in civic decisions. Transparency of information to our community. Fiscal Responsibility of City Funds.
What do you think is the primary role of government? The role of government in Falcon Heights is to responsibly watch over our city funds. To make sure we continue to have an inclusive attitude toward our residents in the decisions our council makes. To be transparent with the information that is used to make decisions.
How would you rate Minnesota’s response to the coronavirus? What would you do differently? Minnesota’s response to the Covid-19 crisis has been consistent with our nation’s response. At the local level we are required to follow the State policies and procedures.
Website or contact information: arcandforfhcouncil.com
Melanie Leehy
Melanie Leehy
Age: 57
What qualifies you to hold this position? I’ve served successfully for 4 years on the City Council, chaired the Community Engagement Commission for 8 years, and co-chaired the Inclusion & Policing Task Force. My professional experience is 40 years in nonprofit community leadership, banking, and public schools. I am known for being a responsive listener who seeks positive action with unity.
What would your top priorities be if elected? It is important to our city’s viability and uniqueness to have a balanced budget that covers current and long range financial stability, meet our public safety needs, and honor residents and guests of all ages and backgrounds. This includes stewardship of our environment, infrastructure and amenities like our present need of a new park building.
What do you think is the primary role of government? I believe it is to provide servant leadership that seeks the best interest of the community within the scope of municipal parameters. This means operating with fiscal responsibility, seeking creative means for city growth, being responsive and transparent to concerns, and encouraging community involvement.
How would you rate Minnesota’s response to the coronavirus? What would you do differently? I am mindful of the challenge State leadership had to respond to something they have never experienced before. I am grateful for the quick answers and solutions. As someone serving in the community it was helpful to have the daily media communication. I sensed there was a desire to work compassionately with people of color and in urban communities.
Website or contact information: [email protected] or https://www.facebook.com/MelanieLeehy4u.
Sue Majerus
Sue Majerus
Age: 66
What qualifies you to hold this position? My work passion for my city and volunteer experience. BA in Public Administration and lifelong learner. Grew up in Falcon Heights. 40+ years Social Services, technology and business improvement in Ramsey County. Using my knowledge and experiences with many many volunteer and appointments within the city.
What would your top priorities be if elected? We have very talented educated residents with busy life’s so think how best to engage with them and there is no 1 single solution that will fit all. Create opportunity for a meet and greet in the community with those affected to engage in a conversation, acquire information, be educated, be heard, and come to an informed decision.
What do you think is the primary role of government? To provide a safe community environment and process for services to the community. The city is built and grows based on community input and engagement. It’s the community that makes the City of Falcon Heights unique. Ensure a fiscal responsible budget and acquire alternative funding whenever possible.
How would you rate Minnesota’s response to the coronavirus? What would you do differently? The State response Very Good. Communication needs to flows from State-County-City level to the people! It’s the impacts on the community as it relates to jobs, services, housing, food, emotional well-being, isolation, and overall safety of the community that is important. Continue to communicate new program assistance during this difficult time.
Website or contact information: https://votemajerus.org
Eric Meyer
Eric Meyer
Age: 34
What qualifies you to hold this position? At TakeAction MN and the Minnesota Nurses Association, I organized volunteers and workers to fight for paid family leave and better healthcare. At Generation Atomic, I organize advocates to fight for clean energy and good jobs. My entire career has been focused on bringing people together for the greater good. I want to do that for Falcon Heights.
What would your top priorities be if elected? We need a new community center, and while we’re at it, we must ensure all public buildings, walkways, and parks are accessible, safe, and ADA compliant. In general, I want to make our community safer, more connected, and welcoming to workers, businesses, and residents.
What do you think is the primary role of government? I believe the role of government is to be responsible and responsive to the people that elect it. From what I’ve been hearing in the community that’s keeping our city safe with sensible ordinances, expanding housing opportunities, and strengthening our business community with innovative ideas. Overall I’m here to serve the needs of the citizens.
How would you rate Minnesota’s response to the coronavirus? What would you do differently? As far as deaths per 100,000 people, Minnesota is 12th least in the nation. We’re doing a pretty good job, but we need to act decisively to beat this virus. The science is clear that vaccines are safe and they work. I would support making them more available at community events and mandating them at indoor businesses moving forward.
Website or contact information: http://voteericmeyer.com
Nicole Porter
Candidate responses not available.
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Tags:
Falcon Heights
Minnesota Elections
Ramsey County races
Pioneer Press elections team
As you comment, please be respectful of other commenters and other viewpoints. Our goal with article comments is to provide a space for civil, informative and constructive conversations. We reserve the right to remove any comment we deem to be defamatory, rude, insulting to others, hateful, off-topic or reckless to the community. See our full terms of use here.
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In this concluding article of our series on "Big Data & Issues & Opportunities", we want to start looking beyond the issues and opportunities that were identified in the 17 articles that make up the series.
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Growing up the son of an attorney in Silicon Valley, I've spent my entire life at the intersection of technology and law. After I became an attorney, I saw the need to automate my law and motion practice, and created TypeLaw to enable others in the legal field do the same. TypeLaw's goal is to help attorneys spend less time on the formatting and technical aspects of a brief and more time focused on crafting legal arguments.
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ON LINKEDIN
– Christopher T. Dralla, Esq., Founder & CEO
About TypeLaw
TypeLaw was founded by Chris Dralla and Andrew Baker in 2014. Chris is an attorney and saw in his own practice that there was a need to improve the way attorneys write and edit their arguments. By reducing the time he needed to spend on the technical details of a brief, Chris found that he could better focus on the substance of his brief. Chris decided to transition out of working as an attorney so he could build and share TypeLaw with the rest of the legal community. Since the company was founded, over 500 attorneys have used TypeLaw for over 3500 briefs in cases filed in trial and appellate courts at the state and federal level in the United States.
TypeLaw is based in San Francisco and is Bloomberg Beta’s first investment in the future of legal work.
Who Uses TypeLaw?
Prompt service. Great support. Saves me hours instead of using the Word or Word Perfect TOA and TOC software.
Alan Charles Dell'Ario, Esq.
Certified Specialist, Appellate Law
State Bar of California Board of Legal Specialization
TypeLaw relieves the last-minute stress of creating tables and formatting per local court rules. Speedy, efficient turnaround, great feedback on questions, and a perfect result. For a solo practitioner, it's indispensable.
Nancy Brandt, Esq.
TypeLaw Customer
TypeLaw provides a terrific service at a reasonable price. Completely reliable, fast turnaround when needed, and the formatting is perfect.
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TypeLaw Customer
TypeLaw fills a need that could only otherwise be filled with hiring someone to do the work in office. In my practice I don't have enough work to support a full-time or part-time assistant, so this is the perfect solution.
Tanya Dellaca, Esq.
TypeLaw Customer
A TypeLaw brief is very professional looking, done well, timely, and for a reasonable price. The answer to a sole practitioner's prayers!
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In addition to searching for product resources, you can visit our customer portal to ask members of the customer community product‑related questions.
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COVID-19 Regulations and Required Vaccination Policy approved by UFS Council on 26 Nov 2021. Policy to be implemented as from 14 Feb 2022: www.ufs.ac.za/vaccinepolicy
COVID-19 Regulations and Required Vaccination Policy approved by UFS Council on 26 Nov 2021. Policy to be implemented as from 14 Feb 2022: www.ufs.ac.za/vaccinepolicy
UFS to present December 2021 graduation ceremonies virtually
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Urgent Announcement
COVID-19 Regulations and Required Vaccination Policy approved by UFS Council on 26 Nov 2021. Policy to be implemented as from 14 Feb 2022: www.ufs.ac.za/vaccinepolicy
COVID-19 Regulations and Required Vaccination Policy approved by UFS Council on 26 Nov 2021. Policy to be implemented as from 14 Feb 2022: www.ufs.ac.za/vaccinepolicy
Latest News Archive
Please select Category, Year, and then Month to display items
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News Items
2019-08-08 UFS study turns ‘Zama Zamas’ into legal artisan miners
2019-08-08 UFS study turns ‘Zama Zamas’ into legal artisan miners
News Archive
SAMWOP creates space for sharing research
2016-12-06
Dr Kristina Riedel, Head of the UFS Department of
Linguistics and Language Practice; middle:
Prof Nancy Kula, of the University of Essex; back:
from left, Dr Elias Malete, lecturer at the UFS
Department of Linguistics and Language Practice,
Prof Andy Chebanne, from the University of Botswana;
and Lesoetsa Motsamai, from the University of Stellenbosch,
at the SAMWOP workshop on 24 November 2016.
Photo: Rulanzen Martin
“The Southern African Microlinguistics Workshop (SAMWOP) creates space for sharing the latest research, networking and building stronger collaboration amongst linguists.”
This is what Dr Kristina Riedel, Head of the Department of Linguistics and Language Practice at the University of the Free State (UFS), said of the 5th SAMWOP hosted by her department. The workshop, hosted from 24 to 26 November 2016, also provided linguists who work on theory and language description in South Africa, the opportunity to network. “As a free conference it is very important, particularly for students and junior scholars.”
International delegates attend workshop
Participants at the workshop were from eight countries including the US, Botswana, Mozambique, Brazil and the UK. Prof Nancy Kula (University of Essex, UK), who was recently appointed as research associate to the department, presented jointly with Xiaoxi Liu, work on depressor effects (consonants which lower tones) in Bantu languages. Other presenters discussed Bantu languages, Khoisan languages and Afrikaans.
Microlinguistics analyses language and sound
“Microlinguistics focuses on analysing language data that deals with language sounds, structures and meaning, rather than language in society,” Dr Riedel said. “The range and diversity of the research on African languages presented at SAMWOP5 were a true highlight. There is a need for more research into African languages and SAMWOP presents the opportunity to scholars in the field to share their work, including in the accredited open-access proceedings.
“We are happy that we were able to hold a very successful and well-attended workshop despite the disruptions to the academic calendar this year,” the professor said.
The Linguistics Society of Southern Africa supported the cause in the form of a grant with additional support from the Office of Dean of Humanities at the UFS.
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Give your taste buds the ol’ razzle-dazzle with Slush Bucket, Razzbub. This delicious slush e-liquid has been created to taste just like a blue raspberry candy bubble gum slush!
200ml eliquid
250ml bottle
70/30 VG/PG
Add 4x 18mg Nic Shots to make 3mg
QUICK LINKS
HOME
ASPIRE PRESTIGE
ABOUT US
CONTACT US
ASPIRE UK TERMS & REFUNDS
SHIPPING & ORDERS
SITE MAP
WHOLESALE
About Us
You must be 18 years or older to browse and shop from this site. We may authenticate your age after placing your order.
As a licensed distributor of Aspire products we have spent time and effort into developing a company that provides a solution for stores and retail customers in the UK e-cigarette market.
UK Aspire Vendor is the trading name of UK Ecig Vendor LTD registered in England and Wales, Company No. 9379830.
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If you are considering replacing your windows, you have lots of options when it comes to new windows for home use in Ardfernal. The selections that you make regarding the styles, insulation and materials can have an impact on your energy and maintenance costs for many years to come. When you have finally found a window that is to your liking, take a peek at the energy label on it so that you can see how it holds up in comparison with other windows.
Will Installing New Windows Help You Save Money?
Be smart when comparing the windows to see if they will save you money on your energy bills. The total amount of money that can be saved in Ardfernal will depend on a few factors:
The climate where you live
How much shade is around your home
How large your home is
How many windows your home has
How well your home might be insulated
What material your windows are made from
When you are trying to figure out if your new windows will save you more money in the long run, it is also critical to consider what they will cost you up front. Prices for windows can range from inexpensive to considerably more expensive depending on things like the features they have and materials they are made from as well as how much it will cost to have them installed.
You can easily get quotes from more than 120 installers across the country when you use our Window Quote tool. All of the installers we quote for are trusted window companies. All that you need to do is to fill out the simple form with your pertinent information and then wait for the window companies that are local to you to get in touch with you. Once you have talked to them, then just choose the quote that interested you the most.
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Other Benefits
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Will Installing New Windows Help You Save Money?
Be smart when comparing the windows to see if they will save you money on your energy bills. The total amount of money that can be saved in Acol will depend on a few factors:
The climate where you live
How much shade is around your home
How large your home is
How many windows your home has
How well your home might be insulated
What material your windows are made from
When you are trying to figure out if your new windows will save you more money in the long run, it is also critical to consider what they will cost you up front. Prices for windows can range from inexpensive to considerably more expensive depending on things like the features they have and materials they are made from as well as how much it will cost to have them installed.
You can easily get quotes from more than 120 installers across the country when you use our Window Quote tool. All of the installers we quote for are trusted window companies. All that you need to do is to fill out the simple form with your pertinent information and then wait for the window companies that are local to you to get in touch with you. Once you have talked to them, then just choose the quote that interested you the most.
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Other Benefits
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Holden Commodore VE Wagon 6.0 i V8 2010 RWD Petrol 6.0L 8cyl 260kW L76,L77(364CUV8) 5967cc 260kW (Petrol)
Covid Update - Opens for pick ups & shipping orders normally. Freight delays are occurring in Covid affected states
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VE Wagon 6.0 i V8
2010
RWD Petrol 6.0L 8cyl 260kW L76,L77(364CUV8)
5967cc 260kW (Petrol)
5967cc 260kW (Petrol)
$1,699.99
or 4 payments of $425.00 with Info
SKU: kitexhvevfsdnextractors
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gd2Vic2l0ZS4gSWYgeW91IGNvbnRpbnVlIHRvIGJyb3dzZSBhbmQgdXNlIHRoaXMgd2Vic2l0ZSwgeW91IGFyZSBhZ3JlZWluZyB0byBjb21wbHkgd2l0aCBhbmQgYmUgYm91bmQgYnkgdGhlIGZvbGxvd2luZyB0ZXJtcyBhbmQgY29uZGl0aW9ucyBvZiB1c2UsIHdoaWNoIHRvZ2V0aGVyIHdpdGggb3VyIHByaXZhY3kgcG9saWN5IGdvdmVybiBVbHRyZXggUGVyZm9ybWFuY2UncyByZWxhdGlvbnNoaXAgd2l0aCB5b3UgaW4gcmVsYXRpb24gdG8gdGhpcyB3ZWJzaXRlLiBJZiB5b3UgZGlzYWdyZWUgd2l0aCBhbnkgcGFydCBvZiB0aGVzZSB0ZXJtcyBhbmQgY29uZGl0aW9ucywgcGxlYXNlIGRvIG5vdCB1c2Ugb3VyIHdlYnNpdGUuIFRoZSB0ZXJtIOKAmFVsdHJleCBQZXJmb3JtYW5jZScgb3Ig4oCYdXMnIG9yIOKAmHdlJyByZWZlcnMgdG8gdGhlIG93bmVyIG9mIHRoZSB3ZWJzaXRlIHdob3NlIHJlZ2lzdGVyZWQgb2ZmaWNlIGlzIDkgQ3V0dGluZyBXYXksIFlhbmdlYnVwIFdlc3Rlcm4gQXVzdHJhbGlhIDYxNjQuIE91ciBBQk4gaXMgNTg2MDE3NjMyODIuIFRoZSB0ZXJtIOKAmHlvdScgcmVmZXJzIHRvIHRoZSB1c2VyIG9yIHZpZXdlciBvZiBvdXIgd2Vic2l0ZS4gVGhlIHVzZSBvZiB0aGlzIHdlYnNpdGUgaXMgc3ViamVjdCB0byB0aGUgZm9sbG93aW5nIHRlcm1zIG9mIHVzZTogVGhlIGNvbnRlbnQgb2YgdGhlIHBhZ2VzIG9mIHRoaXMgd2Vic2l0ZSBpcyBmb3IgeW91ciBnZW5lcmFsIGluZm9ybWF0aW9uIGFuZCB1c2Ugb25seS4gSXQgaXMgc3ViamVjdCB0byBjaGFuZ2Ugd2l0aG91dCBub3RpY2UuIE5laXRoZXIgd2Ugbm9yIGFueSB0aGlyZCBwYXJ0aWVzIHByb3ZpZGUgYW55IHdhcnJhbnR5IG9yIGd1YXJhbnRlZSBhcyB0byB0aGUgYWNjdXJhY3ksIHRpbWVsaW5lc3MsIHBlcmZvcm1hbmNlLCBjb21wbGV0ZW5lc3Mgb3Igc3VpdGFiaWxpdHkgb2YgdGhlIGluZm9ybWF0aW9uIGFuZCBtYXRlcmlhbHMgZm91bmQgb3Igb2ZmZXJlZCBvbiB0aGlzIHdlYnNpdGUgZm9yIGFueSBwYXJ0aWN1bGFyIHB1cnBvc2UuIFlvdSBhY2tub3dsZWRnZSB0aGF0IHN1Y2ggaW5mb3JtYXRpb24gYW5kIG1hdGVyaWFscyBtYXkgY29udGFpbiBpbmFjY3VyYWNpZXMgb3IgZXJyb3JzIGFuZCB3ZSBleHByZXNzbHkgZXhjbHVkZSBsaWFiaWxpdHkgZm9yIGFueSBzdWNoIGluYWNjdXJhY2llcyBvciBlcnJvcnMgdG8gdGhlIGZ1bGxlc3QgZXh0ZW50IHBlcm1pdHRlZCBieSBsYXcuIFlvdXIgdXNlIG9mIGFueSBpbmZvcm1hdGlvbiBvciBtYXRlcmlhbHMgb24gdGhpcyB3ZWJzaXRlIGlzIGVudGlyZWx5IGF0IHlvdXIgb3duIHJpc2ssIGZvciB3aGljaCB3ZSBzaGFsbCBub3QgYmUgbGlhYmxlLiBJdCBzaGFsbCBiZSB5b3VyIG93biByZXNwb25zaWJpbGl0eSB0byBlbnN1cmUgdGhhdCBhbnkgcHJvZHVjdHMsIHNlcnZpY2VzIG9yIGluZm9ybWF0aW9uIGF2YWlsYWJsZSB0aHJvdWdoIHRoaXMgd2Vic2l0ZSBtZWV0IHlvdXIgc3BlY2lmaWMgcmVxdWlyZW1lbnRzLiBUaGlzIHdlYnNpdGUgY29udGFpbnMgbWF0ZXJpYWwgd2hpY2ggaXMgb3duZWQgYnkgb3IgbGljZW5zZWQgdG8gdXMuIFRoaXMgbWF0ZXJpYWwgaW5jbHVkZXMsIGJ1dCBpcyBub3QgbGltaXRlZCB0bywgdGhlIGRlc2lnbiwgbGF5b3V0LCBsb29rLCBhcHBlYXJhbmNlIGFuZCBncmFwaGljcy4gUmVwcm9kdWN0aW9uIGlzIHByb2hpYml0ZWQgb3RoZXIgdGhhbiBpbiBhY2NvcmRhbmNlIHdpdGggdGhlIGNvcHlyaWdodCBub3RpY2UsIHdoaWNoIGZvcm1zIHBhcnQgb2YgdGhlc2UgdGVybXMgYW5kIGNvbmRpdGlvbnMuIEFsbCB0cmFkZW1hcmtzIHJlcHJvZHVjZWQgaW4gdGhpcyB3ZWJzaXRlLCB3aGljaCBhcmUgbm90IHRoZSBwcm9wZXJ0eSBvZiwgb3IgbGljZW5zZWQgdG8gdGhlIG9wZXJhdG9yLCBhcmUgYWNrbm93bGVkZ2VkIG9uIHRoZSB3ZWJzaXRlLiBVbmF1dGhvcmlzZWQgdXNlIG9mIHRoaXMgd2Vic2l0ZSBtYXkgZ2l2ZSByaXNlIHRvIGEgY2xhaW0gZm9yIGRhbWFnZXMgYW5kL29yIGJlIGEgY3JpbWluYWwgb2ZmZW5jZS4gRnJvbSB0aW1lIHRvIHRpbWUsIHRoaXMgd2Vic2l0ZSBtYXkgYWxzbyBpbmNsdWRlIGxpbmtzIHRvIG90aGVyIHdlYnNpdGVzLiBUaGVzZSBsaW5rcyBhcmUgcHJvdmlkZWQgZm9yIHlvdXIgY29udmVuaWVuY2UgdG8gcHJvdmlkZSBmdXJ0aGVyIGluZm9ybWF0aW9uLiBUaGV5IGRvIG5vdCBzaWduaWZ5IHRoYXQgd2UgZW5kb3JzZSB0aGUgd2Vic2l0ZShzKS4gV2UgaGF2ZSBubyByZXNwb25zaWJpbGl0eSBmb3IgdGhlIGNvbnRlbnQgb2YgdGhlIGxpbmtlZCB3ZWJzaXRlKHMpLiBZb3VyIHVzZSBvZiB0aGlzIHdlYnNpdGUgYW5kIGFueSBkaXNwdXRlIGFyaXNpbmcgb3V0IG9mIHN1Y2ggdXNlIG9mIHRoZSB3ZWJzaXRlIGlzIHN1YmplY3QgdG8gdGhlIGxhd3Mgb2YgQXVzdHJhbGlhLiBDbG9zZSDDlyBQcml2YWN5IFBvbGljeSBUaGlzIHByaXZhY3kgcG9saWN5IHNldHMgb3V0IGhvdyB3ZSB1c2VzIGFuZCBwcm90ZWN0cyBhbnkgaW5mb3JtYXRpb24gdGhhdCB5b3UgZ2l2ZSB1cyB3aGVuIHlvdSB1c2UgdGhpcyB3ZWJzaXRlLiBXZSBhcmUgY29tbWl0dGVkIHRvIGVuc3VyaW5nIHRoYXQgeW91ciBwcml2YWN5IGlzIHByb3RlY3RlZC4gU2hvdWxkIHdlIGFzayB5b3UgdG8gcHJvdmlkZSBjZXJ0YWluIGluZm9ybWF0aW9uIGJ5IHdoaWNoIHlvdSBjYW4gYmUgaWRlbnRpZmllZCB3aGVuIHVzaW5nIHRoaXMgd2Vic2l0ZSwgdGhlbiB5b3UgY2FuIGJlIGFzc3VyZWQgdGhhdCBpdCB3aWxsIG9ubHkgYmUgdXNlZCBpbiBhY2NvcmRhbmNlIHdpdGggdGhpcyBwcml2YWN5IHN0YXRlbWVudC4gV2UgbWF5IGNoYW5nZSB0aGlzIHBvbGljeSBmcm9tIHRpbWUgdG8gdGltZSBieSB1cGRhdGluZyB0aGlzIHBhZ2UuIFlvdSBzaG91bGQgY2hlY2sgdGhpcyBwYWdlIGZyb20gdGltZSB0byB0aW1lIHRvIGVuc3VyZSB0aGF0IHlvdSBhcmUgaGFwcHkgd2l0aCBhbnkgY2hhbmdlcy4gV2hhdCB3ZSBjb2xsZWN0IFdlIG1heSBjb2xsZWN0IHRoZSBmb2xsb3dpbmcgaW5mb3JtYXRpb246IG5hbWUgYW5kIGpvYiB0aXRsZSBjb250YWN0IGluZm9ybWF0aW9uIGluY2x1ZGluZyBlbWFpbCBhZGRyZXNzIGRlbW9ncmFwaGljIGluZm9ybWF0aW9uIHN1Y2ggYXMgcG9zdGNvZGUsIHByZWZlcmVuY2VzIGFuZCBpbnRlcmVzdHMgb3RoZXIgaW5mb3JtYXRpb24gcmVsZXZhbnQgdG8gY3VzdG9tZXIgc3VydmV5cyBhbmQvb3Igb2ZmZXJzIFdoYXQgd2UgZG8gd2l0aCB0aGUgaW5mb3JtYXRpb24gd2UgZ2F0aGVyIFdlIHJlcXVpcmUgdGhpcyBpbmZvcm1hdGlvbiB0byB1bmRlcnN0YW5kIHlvdXIgbmVlZHMgYW5kIHByb3ZpZGUgeW91IHdpdGggYSBiZXR0ZXIgc2VydmljZSwgYW5kIGluIHBhcnRpY3VsYXIgZm9yIHRoZSBmb2xsb3dpbmcgcmVhc29uczogSW50ZXJuYWwgcmVjb3JkIGtlZXBpbmcuIFdlIG1heSB1c2UgdGhlIGluZm9ybWF0aW9uIHRvIGltcHJvdmUgb3VyIHByb2R1Y3RzIGFuZCBzZXJ2aWNlcy4gV2UgbWF5IHBlcmlvZGljYWxseSBzZW5kIHByb21vdGlvbmFsIGVtYWlscyBhYm91dCBuZXcgcHJvZHVjdHMsIHNwZWNpYWwgb2ZmZXJzIG9yIG90aGVyIGluZm9ybWF0aW9uIHdoaWNoIHdlIHRoaW5rIHlvdSBtYXkgZmluZCBpbnRlcmVzdGluZyB1c2luZyB0aGUgZW1haWwgYWRkcmVzcyB3aGljaCB5b3UgaGF2ZSBwcm92aWRlZC4gRnJvbSB0aW1lIHRvIHRpbWUsIHdlIG1heSBhbHNvIHVzZSB5b3VyIGluZm9ybWF0aW9uIHRvIGNvbnRhY3QgeW91IGZvciBtYXJrZXQgcmVzZWFyY2ggcHVycG9zZXMuIFdlIG1heSBjb250YWN0IHlvdSBieSBlbWFpbCwgcGhvbmUsIGZheCBvciBtYWlsLiBXZSBtYXkgdXNlIHRoZSBpbmZvcm1hdGlvbiB0byBjdXN0b21pc2UgdGhlIHdlYnNpdGUgYWNjb3JkaW5nIHRvIHlvdXIgaW50ZXJlc3RzLiBTZWN1cml0eSBXZSBhcmUgY29tbWl0dGVkIHRvIGVuc3VyaW5nIHRoYXQgeW91ciBpbmZvcm1hdGlvbiBpcyBzZWN1cmUuIEluIG9yZGVyIHRvIHByZXZlbnQgdW5hdXRob3Jpc2VkIGFjY2VzcyBvciBkaXNjbG9zdXJlLCB3ZSBoYXZlIHB1dCBpbiBwbGFjZSBzdWl0YWJsZSBwaHlzaWNhbCwgZWxlY3Ryb25pYyBhbmQgbWFuYWdlcmlhbCBwcm9jZWR1cmVzIHRvIHNhZmVndWFyZCBhbmQgc2VjdXJlIHRoZSBpbmZvcm1hdGlvbiB3ZSBjb2xsZWN0IG9ubGluZS4gSG93IHdlIHVzZSBjb29raWVzIEEgY29va2llIGlzIGEgc21hbGwgZmlsZSB3aGljaCBhc2tzIHBlcm1pc3Npb24gdG8gYmUgcGxhY2VkIG9uIHlvdXIgY29tcHV0ZXIncyBoYXJkIGRyaXZlLiBPbmNlIHlvdSBhZ3JlZSwgdGhlIGZpbGUgaXMgYWRkZWQgYW5kIHRoZSBjb29raWUgaGVscHMgYW5hbHlzZSB3ZWIgdHJhZmZpYyBvciBsZXRzIHlvdSBrbm93IHdoZW4geW91IHZpc2l0IGEgcGFydGljdWxhciBzaXRlLiBDb29raWVzIGFsbG93IHdlYiBhcHBsaWNhdGlvbnMgdG8gcmVzcG9uZCB0byB5b3UgYXMgYW4gaW5kaXZpZHVhbC4gVGhlIHdlYiBhcHBsaWNhdGlvbiBjYW4gdGFpbG9yIGl0cyBvcGVyYXRpb25zIHRvIHlvdXIgbmVlZHMsIGxpa2VzIGFuZCBkaXNsaWtlcyBieSBnYXRoZXJpbmcgYW5kIHJlbWVtYmVyaW5nIGluZm9ybWF0aW9uIGFib3V0IHlvdXIgcHJlZmVyZW5jZXMuIFdlIHVzZSB0cmFmZmljIGxvZyBjb29raWVzIHRvIGlkZW50aWZ5IHdoaWNoIHBhZ2VzIGFyZSBiZWluZyB1c2VkLiBUaGlzIGhlbHBzIHVzIGFuYWx5c2UgZGF0YSBhYm91dCB3ZWJwYWdlIHRyYWZmaWMgYW5kIGltcHJvdmUgb3VyIHdlYnNpdGUgaW4gb3JkZXIgdG8gdGFpbG9yIGl0IHRvIGN1c3RvbWVyIG5lZWRzLiBXZSBvbmx5IHVzZSB0aGlzIGluZm9ybWF0aW9uIGZvciBzdGF0aXN0aWNhbCBhbmFseXNpcyBwdXJwb3NlcyBhbmQgdGhlbiB0aGUgZGF0YSBpcyByZW1vdmVkIGZyb20gdGhlIHN5c3RlbS4gT3ZlcmFsbCwgY29va2llcyBoZWxwIHVzIHByb3ZpZGUgeW91IHdpdGggYSBiZXR0ZXIgd2Vic2l0ZSBieSBlbmFibGluZyB1cyB0byBtb25pdG9yIHdoaWNoIHBhZ2VzIHlvdSBmaW5kIHVzZWZ1bCBhbmQgd2hpY2ggeW91IGRvIG5vdC4gQSBjb29raWUgaW4gbm8gd2F5IGdpdmVzIHVzIGFjY2VzcyB0byB5b3VyIGNvbXB1dGVyIG9yIGFueSBpbmZvcm1hdGlvbiBhYm91dCB5b3UsIG90aGVyIHRoYW4gdGhlIGRhdGEgeW91IGNob29zZSB0byBzaGFyZSB3aXRoIHVzLiBZb3UgY2FuIGNob29zZSB0byBhY2NlcHQgb3IgZGVjbGluZSBjb29raWVzLiBNb3N0IHdlYiBicm93c2VycyBhdXRvbWF0aWNhbGx5IGFjY2VwdCBjb29raWVzLCBidXQgeW91IGNhbiB1c3VhbGx5IG1vZGlmeSB5b3VyIGJyb3dzZXIgc2V0dGluZyB0byBkZWNsaW5lIGNvb2tpZXMgaWYgeW91IHByZWZlci4gVGhpcyBtYXkgcHJldmVudCB5b3UgZnJvbSB0YWtpbmcgZnVsbCBhZHZhbnRhZ2Ugb2YgdGhlIHdlYnNpdGUuIExpbmtzIHRvIG90aGVyIHdlYnNpdGVzIE91ciB3ZWJzaXRlIG1heSBjb250YWluIGxpbmtzIHRvIG90aGVyIHdlYnNpdGVzIG9mIGludGVyZXN0LiBIb3dldmVyLCBvbmNlIHlvdSBoYXZlIHVzZWQgdGhlc2UgbGlua3MgdG8gbGVhdmUgb3VyIHNpdGUsIHlvdSBzaG91bGQgbm90ZSB0aGF0IHdlIGRvIG5vdCBoYXZlIGFueSBjb250cm9sIG92ZXIgdGhhdCBvdGhlciB3ZWJzaXRlLiBUaGVyZWZvcmUsIHdlIGNhbm5vdCBiZSByZXNwb25zaWJsZSBmb3IgdGhlIHByb3RlY3Rpb24gYW5kIHByaXZhY3kgb2YgYW55IGluZm9ybWF0aW9uIHdoaWNoIHlvdSBwcm92aWRlIHdoaWxzdCB2aXNpdGluZyBzdWNoIHNpdGVzIGFuZCBzdWNoIHNpdGVzIGFyZSBub3QgZ292ZXJuZWQgYnkgdGhpcyBwcml2YWN5IHN0YXRlbWVudC4gWW91IHNob3VsZCBleGVyY2lzZSBjYXV0aW9uIGFuZCBsb29rIGF0IHRoZSBwcml2YWN5IHN0YXRlbWVudCBhcHBsaWNhYmxlIHRvIHRoZSB3ZWJzaXRlIGluIHF1ZXN0aW9uLiBDb250cm9sbGluZyB5b3VyIHBlcnNvbmFsIGluZm9ybWF0aW9uIFlvdSBtYXkgY2hvb3NlIHRvIHJlc3RyaWN0IHRoZSBjb2xsZWN0aW9uIG9yIHVzZSBvZiB5b3VyIHBlcnNvbmFsIGluZm9ybWF0aW9uIGluIHRoZSBmb2xsb3dpbmcgd2F5czogd2hlbmV2ZXIgeW91IGFyZSBhc2tlZCB0byBmaWxsIGluIGEgZm9ybSBvbiB0aGUgd2Vic2l0ZSwgbG9vayBmb3IgdGhlIGJveCB0aGF0IHlvdSBjYW4gY2xpY2sgdG8gaW5kaWNhdGUgdGhhdCB5b3UgZG8gbm90IHdhbnQgdGhlIGluZm9ybWF0aW9uIHRvIGJlIHVzZWQgYnkgYW55Ym9keSBmb3IgZGlyZWN0IG1hcmtldGluZyBwdXJwb3NlcyBpZiB5b3UgaGF2ZSBwcmV2aW91c2x5IGFncmVlZCB0byB1cyB1c2luZyB5b3VyIHBlcnNvbmFsIGluZm9ybWF0aW9uIGZvciBkaXJlY3QgbWFya2V0aW5nIHB1cnBvc2VzLCB5b3UgbWF5IGNoYW5nZSB5b3VyIG1pbmQgYXQgYW55IHRpbWUgYnkgd3JpdGluZyB0byBvciBlbWFpbGluZyB1cy4gV2Ugd2lsbCBub3Qgc2VsbCwgZGlzdHJpYnV0ZSBvciBsZWFzZSB5b3VyIHBlcnNvbmFsIGluZm9ybWF0aW9uIHRvIHRoaXJkIHBhcnRpZXMgdW5sZXNzIHdlIGhhdmUgeW91ciBwZXJtaXNzaW9uIG9yIGFyZSByZXF1aXJlZCBieSBsYXcgdG8gZG8gc28uIFdlIG1heSB1c2UgeW91ciBwZXJzb25hbCBpbmZvcm1hdGlvbiB0byBzZW5kIHlvdSBwcm9tb3Rpb25hbCBpbmZvcm1hdGlvbiBhYm91dCB0aGlyZCBwYXJ0aWVzIHdoaWNoIHdlIHRoaW5rIHlvdSBtYXkgZmluZCBpbnRlcmVzdGluZyBpZiB5b3UgdGVsbCB1cyB0aGF0IHlvdSB3aXNoIHRoaXMgdG8gaGFwcGVuLiBJZiB5b3UgYmVsaWV2ZSB0aGF0IGFueSBpbmZvcm1hdGlvbiB3ZSBhcmUgaG9sZGluZyBvbiB5b3UgaXMgaW5jb3JyZWN0IG9yIGluY29tcGxldGUsIHBsZWFzZSB3cml0ZSB0byBvciBlbWFpbCB1cyBhcyBzb29uIGFzIHBvc3NpYmxlIGF0IHRoZSBhYm92ZSBhZGRyZXNzLiBXZSB3aWxsIHByb21wdGx5IGNvcnJlY3QgYW55IGluZm9ybWF0aW9uIGZvdW5kIHRvIGJlIGluY29ycmVjdC4gQ2xvc2Ugw5cgU2hvcCBOb3cuIFBheSBMYXRlci4gQWx3YXlzIGludGVyZXN0LWZyZWUuIEFkZCB5b3VyIGZhdm91cml0ZXMgdG8gY2FydCBTZWxlY3QgQWZ0ZXJwYXkgYXQgY2hlY2tvdXQgTG9nIGludG8gb3IgY3JlYXRlIHlvdXIgQWZ0ZXJwYXkgYWNjb3VudCwgd2l0aCBpbnN0YW50IGFwcHJvdmFsIGRlY2lzaW9uIFlvdXIgcHVyY2hhc2Ugd2lsbCBiZSBzcGxpdCBpbnRvIDQgcGF5bWVudHMsIHBheWFibGUgZXZlcnkgMiB3ZWVrcyBBbGwgeW91IG5lZWQgdG8gYXBwbHkgaXMgdG8gaGF2ZSBhIGRlYml0IG9yIGNyZWRpdCBjYXJkLCB0byBiZSBvdmVyIDE4IHllYXJzIG9mIGFnZSwgYW5kIHRvIGJlIGEgcmVzaWRlbnQgb2YgY291bnRyeSBvZmZlcmluZyBBZnRlcnBheSBMYXRlIGZlZXMgYW5kIGFkZGl0aW9uYWwgZWxpZ2liaWxpdHkgY3JpdGVyaWEgYXBwbHkuIFRoZSBmaXJzdCBwYXltZW50IG1heSBiZSBkdWUgYXQgdGhlIHRpbWUgb2YgcHVyY2hhc2X//z/g"
] | true |
[
431989689
] |
2,606,218 |
Covid Update - Opens for pick ups & shipping orders normally. Freight delays are occurring in Covid affected states
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Holden
Commodore
VF Ute 3.6 i SV6
2013
RWD Petrol 3.6L 6cyl 210kW LFX
RWD Petrol 3.6L 6cyl 210kW LFX
3564cc 210kW (Petrol)
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$399.99
or 4 payments of $100.00 with Info
SKU: m4-064
HOLDEN COMMODORE VE VF MUFFLERS EXHAUST SS SSV SV6 HSV UTE
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$1,299.99
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There have been a number of articles recently on the aging of the population of developed countries. Some, such as the Manchester Guardian’s, below, focus on the economic consequences of declining birth rates and restrictive immigration policy, such as in Australia; while others, such as the New York Times’, discuss the more far-reaching changes in society caused by a distortion of the normal age distribution, such as in Japan. Few discuss the major issue underlying the persistent and increasingly xenophobic demands for cultural purity. Members of the old guard – the French who have for centuries viewed the country as a cultural and spiritual leader of Europe; traditional Japanese who have retained the ancient traditions of the Shoguns, strong family and societal structures, and Shinto and Buddhist principles; white, Anglo-Saxon Americans who trace their cultural lineage back to the Puritans and the Calvinist fundamentals of the new nation – all resist the changes that would result from a more pluralistic society.
The anti-immigration movement uses three arguments, two understandable, the other not so. The first is economic. Illegal Mexican immigration, it is often repeated in the United States, is depressing wages, adding to welfare roles, increasing public service costs, and increasing taxpayer burden. This same scenario is played out in Europe with different dimensions. France, Denmark and even socially tolerant Netherlands are realizing that the labor market can be, at least in the short run, altered, often with negative consequences for the native population.
The second argument is that the rapid influx of immigrants will cause social unrest. This has been especially true in Europe where Muslim immigrants from North and Sub-Saharan Africa are from vastly different cultures. Worse, because of radical Islam, the demands of these marginalized and ghettoized populations become aggressive and dangerous. They will not abide by white European traditions of assimilation and homogenization, and have been empowered to demand what they see are their civil rights. While this is indeed a problem, countries have been slow to realize the dimensions of the problem.
Africans in France were largely concentrated, isolated, and mostly forgotten in the suburbs of Paris and other major cities. Unlike in the United States where urban ghettoes are close, visible, and frightening, these poor and increasingly dysfunctional communities were far from the majority’s view. Old-school French families in the tony 7th arrondissement went about their business shopping for fashion, wine, baguettes and cheese with little thought to the turmoil raging in Neuilly-sur-Marne, Aulnay-sous-Bois, and Trembley-en-France, neighborhoods with traditional names evoking a pastoral existence on the banks of rivers or under shading elms. The French government ignored the simmering resentment and hostility until it was too late, and the suburbs erupted. After a token expression of regret and conciliation, France is back to measures which will only further isolate, enrage, and harden these communities.
The third and most compelling argument is that immigration will destroy ‘traditional culture’ – our American way, our French way. But what exactly is the culture that these diminishing majorities want to extend? And how will a more diverse population diminish it? Few people have convincing answers. America is the hardest to understand, since we are a country of immigrants, easily and quickly assimilated, and within one or two generations speak English and more importantly subscribe to the American work ethic. The sons and daughters of Mexican, Guatemalan, Salvadoran, and Honduran immigrants want the same thing as ‘traditional’ citizens – to get ahead, to make money, to be a success. No argument makes sense. Most first or second generation Americans speak English. All are Christian. Few practice barbarous rites. Yet the idea of a largely Hispanic population is still threatening.
The French cultural resistance is easier to understand but just as hard to accept. France has always considered itself ‘The Elder Sister of the Catholic Church’ thanks to the valiant efforts of Charlemagne to keep the Muslim hordes out of France. Because of its strong intellectual traditions, it has ascribed to itself a certain intellectual and cultural supremacy; and because of the past elegance and luxury of the French courts, it has preserved its national talents for fashion and cuisine. When the French say that their culture is being perversely altered, it is likely to be comprised of these elements. At least the French of the 7th arrondissement who have the money and social status to preserve them. Not so for the vast majority of French who work in factories, ports, railroads, farms, and post offices throughout the nation. For them – if they think about it – culture is more indefinable. A café-cognac at the neighborhood bar, perhaps; or two- or three-stop shopping at the butcher, grocer, and baker. In any case, both classes revolt in their own ways.
In any case French primacy in culture and the arts has long since suffered a decline. The arts have moved across the Atlantic, futuristic innovations occur from California to India. When one thinks of fashion, it is the runways of New York, Italy, or the boutiques of hipster San Francisco that first come to mind. The world is smaller, more competitive, more integrated and more flexible. The traditional French have not yet learned this lesson.
So, again, what is this culture that the French are trying to preserve? The current received wisdom is as old as the Revolution – “We are all French citizens, equal in being and opportunity”. Within that official worldview, there are no boxes for race or ethnicity to be checked on census forms; no affirmative action; no cultural preferences. The current policies to forbid hijabs and non-‘French’ cultural practices in public institutions are an extension of this principle. Yet no one – except traditional French – accept this principle any more. Racial and ethnic differences, far from diminishing or dissipating, are increasing. Only countries like Britain and the United States have realized this and accepted it.
What the French have not realized is that it is almost impossible for cultural traditions to expire because immigration is gradual. If you travel to some of the ethnically diverse outlying neighborhoods of Paris you will find both boulangeries, charcuteries, and epicieries alongside felafel, couscous, and pita. Second generation immigrants read Le Monde and Arab weeklies.
The point is that French cultural traditions will not disappear. Many will be changed to incorporate non-European perspectives, and many will simply co-exist with newcomers. Countries all have certain characteristics which guide if not propel newcomers without their realizing it, or without banners being waved about cultural values. America is and will always be ‘The Land of Opportunity’. Regardless of who comes or goes, what political party is in office, the business of America is business. All else – our fashion, cuisine, and artistic and intellectual endeavors – are secondary. France – regardless of who come and who goes – should retain its high valuation of intellectualism and the high arts as necessary and welcome contributions to society (I say should because its radicalized Muslim immigrants hold views antithetical to even this generic principle). Germany will always be fundamentally Protestant in outlook.
Yet, the older powers that be in the Elysee still retain an old-fashioned gestalt of Jean-Paul Sartre sitting at Le Café des Deux Magots – the Paris recently limned in Woody Allen’s recent Midnight In Paris. As Allen concludes, every generation thinks the present one is worse than those past, and that there is greater sanity, value, and heroics then rather than now. Immigration – refreshing the cultural and gene pool – is out. Backward-looking, unrealistic policies are in.
The problem is made infinitely more difficult because of the demographic profile of the very countries which are most defending conservative cultural values.
Ross Douthat writes in the New York Times http://www.nytimes.com/2012/04/29/opinion/sunday/douthat-incredible-shrinking-country.html?_r=1 about Japan which because of extreme xenophobia and the almost insurmountable barrier of language continues to be hermetically sealed:
“THE Children of Men,” P. D. James’s 1992 novel, is set in a future where the world’s male population has become infertile, and an aging Britain is adapting to the human race’s gradual extinction. Women push dolls in baby carriages. Families baptize kittens. There are state-run “national porn shops” to stimulate the flagging male libido. Suicide flourishes. Immigrants are welcomed as guest laborers but expelled once they become too old to work. The last children born on earth — the so-called “Omegas” — have grown up to be bored, arrogant, antisocial and destructive.
James’s book, like most effective dystopias, worked by exaggerating existing trends — the plunge in birthrates across the developed world, the spread of voluntary euthanasia in nations like the Netherlands and Switzerland, the European struggle to assimilate a growing immigrant population.
“Gradually but relentlessly,” the demographer Nick Eberstadt writes in the latest issue of The Wilson Quarterly, “Japan is evolving into a type of society whose contours and workings have only been contemplated in science fiction.”
The expressions of this phenomenon are indeed scary:
These trends are forging a society that sometimes evokes the infertile Britain in James’s dystopia. Japan has one of the highest suicide rates in the developed world, and there were rashes of Internet-enabled group suicidesin the last decade. Rental “relatives” are available for sparsely attended wedding parties; so-called “babyloids” — furry dolls that mimic infant sounds — are being developed for lonely seniors; and Japanese researchers are at the forefront of efforts to build robots that resemble human babies The younger generation includes millions of so-called “parasite singles” who still live with (and off) their parents, and perhaps hundreds of thousands of the “hikikomori” — “young adults,” Eberstadt writes, “who shut themselves off almost entirely by retreating into a friendless life of video games, the Internet and manga (comics) in their parents’ home.”
Douthat suggests reasons for this phenomenon:
Japan is facing such swift demographic collapse, Eberstadt’s essay suggests, because its culture combines liberalism and traditionalism in particularly disastrous ways. On the one hand, the old sexual culture, oriented around arranged marriage and family obligation, has largely collapsed. Japan is one of the world’s least religious nations, the marriage rate has plunged and the divorce rate is higher than in Northern Europe.
Even despite these frightening trends, Japan refuses to admit immigrants. In other words, the dark, foreboding handwriting is on the wall, and no one is willing to even look at it, let alone read it.
Other countries like France and Australia have offered incentives to the native population to reproduce. A recent article in the Guardian http://www.guardian.co.uk/commentisfree/2012/apr/28/ageing-australia-young-immigrants reports:
Policymakers in Australia have to balance the public's desire for continued tightening of immigration controls versus maintaining a steady population growth against a background of an ageing population. It is predicted that by 2036 more Australians will be retiring from the labour force than joining it. By 2050 there will only be 2.5 working Australians for every citizen over 65 – in the 1970s that figure was 7.5. The main solution policymakers seem to have come up with is to throw money at the problem.
In 2002, perhaps in response to Australia's Total Fertility Rate (TFR) reaching an all time low, the government introduced a baby bonus scheme. For every child born or adopted by a citizen or permanent resident of Australia the government will award them $5,000. Australia's TFR has risen since then, yet it still remains below replacement levels of 2.1 births per woman. If the baby bonus wasn't enough, the government is now introducing a jobs bonus, where employers will be offered $1,000 for each employee they hire and retain over 50 years of age. These seem like desperate measures from a government running out of ideas.
Desperate measures indeed, and not even well-conceived. Anyone who has had children and who takes childrearing seriously knows that the $5000 is nothing compared to the lifetime investment in a child; and for those who have children indiscriminately, the money is wasted.
In conclusion, the battle over immigration is superficially one about jobs, tax burdens, and social divisiveness; but it is really about preserving a perceived way of life, a Woody Allenesque romantic dream of Le Temps Perdu. Yet the greatest vitality of cultures comes from their inclusiveness; and for those who are worried about making a buck or where to get their baguettes, those timeless truths will never change.
Posted by Ron Parlato at 7:22 AM
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Labels: Politics and Culture
3 comments:
Robert September 2, 2015 at 8:04 AM
focus on the economic consequences of declining birth rates and restrictive immigration policy. work permit application
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If you are planning a trip to USA and searching the map of USA State, then you are at right blog. Here we are providing the various type of Vermont Map. These map of Vermont are very useful in your trip to Vermont State because all detail of roads, highways and streets are given on it. So you can easily visit all places in Vermont State. You can also see the location of Vermont State in this given map of USA.
Vermont on USA Map
Map of Vermont
Vermont is a state in the northeastern United States, known for its natural landscape, which is primarily forested. The capital of Vermont State is Montpelier and the area of this city is around 24,923 km square. Vermont population is around 626,562 and this is very beautiful State of USA. There are many interesting point in Vermont State like Lake Champlain, Montshire Museum of Science, Shelburne Museum, Marsh-Billings-Rockefeller National Historical Park, Hildene, ECHO Lake Aquarium and Science Center and many other places. This Vermont map will help you to visit all beautiful places.
Vermont Road Map
Vermont Cities
There are many cities in Vermont State of USA, but here we are providing you some largest and beautiful cities map with their picture. These Vermont cities map will help you in your trip to Vermont State and with the help of these map you can easily visit all places in this state.
Map of Burlington
Burlington is the largest city in the Vermont State of USA. The population of this city is around 42,284 and there are many visiting points which are Lake Champlain, ECHO Lake Aquarium and Science Center, University of Vermont, Lake Champlain Chocolates, Ethan Allen Homestead Museum, Robert Hull Fleming Museum, Mount Mansfield, Battery Park, Lake Champlain Maritime Museum, Saint Anne’s Shrine, Henry Sheldon Museum of Vermont History, Round Church, Rokeby museum, Vermont State House, Birds of Vermont Museum, Wilson Castle and Fisk Quarry Preserve. It is located 45 miles south of the Canada–United States border and 94 miles south of Montreal. The area of this state is 40.1km square and the University of Vermont, University of Vermont, Champlain College, Burlington College, Trinity College, Burlington Technical Center and Woodbury Institute at Champlain College are some famous colleges which are located here. The map of Vermont Burlington are given here, it will help you in your visit to Vermont State of USA.
Map of Essex
Essex is the beautiful city in Vermont State of USA. Essex’s area is 101.8 km square and the population of this city is around 19,587. Essex Town, Pages Corner, Essex Center and Butlers Corners are some beautiful places which are located here. Thousands of visitor come here to see its beauty and they also enjoy the lovely weather of Vermont State. Essex is located in central Chittenden County, bordered on the south by the Winooski River. The village of Essex Junction is located in the southwestern part of the town. Here we are providing the map of Essex with a beautiful picture of this city.
Map of South Burlington
South Burlington is the second largest city in the Vermont State of USA. The area of this city is 76.6 km square having the population of 18,612. Advanced Welding Institute is the famous college in South Burlington City. Vermont’s largest airport, the Burlington International Airport, is located within the city limits. There are many visiting places which are Red Rocks Park, Overlook Park, Veterans Memorial Park, Jaycee Park, Wheeler Nature Park. The map of South Burlington has been given here, it will help you to visit these above beautiful places.
Map of Rutland City
Rutland City is the peaceful city in the Vermont State of USA. There are many interesting points to visit like American Precision Museum, Montshire Museum of Science, Billings Farm & Museum, Chaffee Art Center and Hildene. The population of this city is approx 17,292 and it’s area is 19.87 km square. College of St. Joseph is the famous college of Rutland City in Vermont State. Rutland is the third largest city in Vermont, after Burlington and South Burlington. Rutland Regional Medical Center is Vermont’s second-largest health care facility with 188 inpatient beds and 120 physicians. You can visit all places with the help of Rutland City Map.
Map of Colchester
Colchester is the city in the Vermont State of USA. The population of this city is around 121,859 and Colchester was also a named line of lathe machinery. There are many interesting points which are Hollytrees Museum, Colchester Castle, Firstsite, Beth Chatto Gardens, Colchester Zoo, Layer Marney Tower, East Anglian Railway Museum, Jumbo Water Tower and Wivenhoe Park. The map of Colchester is also given here with a beautiful picture of this city.
Map of Rutland
The population of Rutland is 16,126 and this is the very beautiful city in Vermont State having greenery and many lakes. Rutland city has many interesting points which are Rutland Water, Barnsdale Gardens, Oakham Castle, Rutland County Museum and Rutland Railway Museum. There also some beautiful areas like Oakham, Rutland Water, Uppingham, wing, Hambleton, Cottesmore, Lyddington, Rutland Water Nature Reserve, Whissendine, Caldecott, Whitwell, and Normanton.
Map of Bennington
Bennington is the city in the Vermont State of USA. The population of this city is around 15,764 and its area is 110.1 km square. Thousands of visitors come here to see its beauty and they enjoy its lovely weather. There are many visiting points Bennington Battle Monument, Park-McCullough House, Wilson Castle, Bennington Battlefield State Historic Site and Vermont Backroad Tours. You can easily visit each place with the help of the Bennington Map.
Map of Brattleboro
Brattleboro city population is around 12.046 and its area is 84 km square. SIT Graduate Institute, Marlboro College Graduate School, John Woolman College are some famous colleges here and you can see this location in this given map of Brattleboro city. Vermont Artisan Designs, Pisgah State Park, Fort Dummer and Vermont Center for Photography are the beautiful places in Brattleboro City.
Map of Essex Junction
Essex Junction is the city in the Vermont State of USA. The population of the Essex Junction is around 9,695 and the village of Essex Junction is one of three voting districts in the town of Essex. We are providing you the map of Essex Junction with the beautiful picture of this city.
I hope you will like this article and map of vt. You can share your ideas about this blog and let me know that what you more want from this blog. You can answer us througgh the comments and we shall try to provide more Vermont map as soon as possible and also try to fulfill your requirement. Thank You.
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From vlogging to organising seminars: students of Italian put their skills into practice - Leiden University
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From vlogging to organising seminars: students of Italian put their skills into practice
From vlogging to organising seminars: students of Italian put their skills into practice
18 October 2021
Do you gain enough practical experience in an academic language and culture study programme? Certainly, proved the bachelor students of Italian this summer. For the Transfer IT programme, they combined their own interests with the knowledge they gained during their studies. This resulted in vastly different activities, varying from a vlog series about the Giro d’Italia to a course on creative writing that can be taken worldwide, interviews with people from the work field (such as translators, editors, writers), and the creation of knowledge clips for an online museum.
Tatum Paauwe
Tatum Paauwe organised an online course on creative writing
‘I really like creative writing, so when I found out about Transfer IT, I wanted to do something with that. First, the plan was to organise one online workshop with one author, but that quickly turned into a series with ten Italian authors. The first one, for example, discussed the fear of a white, empty page. Halfway through, the topic was visual writing and we just finished with a class on professional publication opportunities.
It was a bit of a puzzle to arrange everything. Which authors wanted to participate? Who can be understood by people whose native language is not Italian? And prior to the courses, we wanted to interview the authors to determine what kind of seminar would best suit the participants. I ended up working on it from January to September. A whole pregnancy, yes. Fortunately, I received a lot of support from my lecturer, Carmen Van den Bergh. She used her network to recruit authors. That was very nice, because people are less likely to respond to a student.
During some sessions, as many as 130 people participated, from all corners of the world. One man from Toronto even got up at 4 in the morning to participate. It gives me a very powerful feeling that I managed to lead this project. My love for writing has only grown. I would love to do something with it in the future.’
Daan Kessens
Daan Kessens made daily vlogs about the Giro d’Italia
‘A couple of years ago I got interested in bicycle racing through the Tour de France. That is the most accessible race because it airs during the summer. Later on, I started watching the Giro d’Italia as well and started doing some things related to bicycle racing. I translated for a YouTube series on bicycle racing, for example, and now I also spend some time on a bike myself – I just had my first fall. So when my lecturer, Carmen Van den Bergh, approached me with the question whether I wanted to vlog about the Giro d’Italia, I was immediately excited.
But it was also a nice excuse to watch the entire race. I even vlogged every day of the Giro, even though the original plan was to make only five videos.
At the beginning, it felt uncomfortable to appear on screen myself, and also having to look at myself when editing the videos. Luckily, I was able to quickly flip a switch and I already knew a little bit about editing, so that didn’t take too much time. I would like to continue with the channel, although I would maybe prefer to make videos that have more to do with Italian culture.’
What is Transfer IT?
University lecturer Carmen Van den Bergh explains: ‘The educational innovation project Transfer IT offers students of Italian language and culture a way to showcase their skills through nice projects and internships. This way, a ‘practical’ element is added to education, in addition to the theoretical an intellectual components. Why would you, as a student, wait until after your studies to start finding out about possible job opportunities? You can immediately apply the knowledge you have gained in practice: the early bird does catch the worm, right?’
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Every time you will believe of unlocking the locking mechanism, the very first name in which will come to your own thoughts is the Locksmith in Kannapolis NC. The locksmith professional services not really only unlock the doors of autos, home and organizations, it also assists to replace the damaged lock. The Kannapolis locksmith professional provides support anytime where ever you are caught in. We undertake many advanced strategies to handle the problem.
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The finest portion of us is our instant support. We offer some helpline numbers which remains online all throughout the evening and night for offering assistance to the individuals in the course of their emergency. The consumer care official thus after acquiring the phone informs the neighborhood locksmith service Service provider to take attention of the matter. Thus for having such a quick and excellent services, we are considered to become the best emergency locksmith professional services in Kannapolis, North Carolina.
Our own targets and services
Our main aim is to assist our clients with fantastic being humble. The different services supplied by us all are usually
Free advice and guidance
Skilled team associates
Members having knowledge on insurance coverage and fire regulations
Removing the lock on of the doors of car, home and business enterprise
Alternative of destroyed lock
As we are the only insured, bonded and licensed company in Kannapolis, North Carolina, we are trustworthy. We offer our assistance to all classes of people at a very affordable price just for $15 and we act in response to your call within 15 minutes.
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Omeprazole can cause kidney problems. Tell your doctor if you are urinating less than usual, or if you have blood in your urine.
Diarrhea may be a sign of a new infection. Call your doctor if you have diarrhea that is watery or has blood in it.
Omeprazole may cause new or worsening symptoms of lupus. Tell your doctor if you have joint pain and a skin rash on your cheeks or arms that worsens in sunlight.
You may be more likely to have a broken bone while taking this medicine long term or more than once per day.
What is omeprazole?
Omeprazole is a proton pump inhibitor that decreases the amount of acid produced in the stomach.
Omeprazole is used to treat symptoms of gastroesophageal reflux disease (GERD) and other conditions caused by excess stomach acid. Omeprazole is also used to promote healing of erosive esophagitis (damage to your esophagus caused by stomach acid).
Omeprazole may also be given together with antibiotics to treat gastric ulcer caused by infection with Helicobacter pylori (H. pylori).
Over-the-counter (OTC) omeprazole is used in adults to help control heartburn that occurs 2 or more days per week. This medicine not for immediate relief of heartburn symptoms. OTC omeprazole must be taken on a regular basis for 14 days in a row.
Omeprazole may also be used for purposes not listed in this medication guide.
What should I discuss with my healthcare provider before taking omeprazole?
Heartburn can mimic early symptoms of a heart attack. Get emergency medical help if you have chest pain that spreads to your jaw or shoulder and you feel sweaty or light-headed.
You should not use omeprazole if you are allergic to it, or if:
you are also allergic to medicines like omeprazole, such as esomeprazole, lansoprazole, pantoprazole, rabeprazole, Nexium, Prevacid, Protonix, and others; or
you also take HIV medication that contains rilpivirine (such as Complera, Edurant, Odefsey, Juluca).
Ask a doctor or pharmacist if this medicine is safe to use if you have:
trouble or pain with swallowing;
bloody or black stools, vomit that looks like blood or coffee grounds;
heartburn that has lasted for over 3 months;
frequent chest pain, heartburn with wheezing;
unexplained weight loss;
nausea or vomiting, stomach pain;
liver disease;
low levels of magnesium in your blood; or
osteoporosis or low bone mineral density (osteopenia).
You may be more likely to have a broken bone in your hip, wrist, or spine while taking a proton pump inhibitor long-term or more than once per day. Talk with your doctor about ways to keep your bones healthy.
Ask a doctor before using this medicine if you are pregnant or breast-feeding.
Do not give this medicine to a child without medical advice.
How should I take omeprazole?
Follow all directions on your prescription label and read all medication guides or instruction sheets. Use the medicine exactly as directed.
Use Prilosec OTC (over-the-counter) exactly as directed on the label, or as prescribed by your doctor.
Read and carefully follow any Instructions for Use provided with your medicine. Ask your doctor or pharmacist if you do not understand these instructions.
Shake the oral suspension (liquid) before you measure a dose. Use the dosing syringe provided, or use a medicine dose-measuring device (not a kitchen spoon).
If you cannot swallow a capsule whole, open it and sprinkle the medicine into a spoonful of applesauce. Swallow the mixture right away without chewing. Do not save it for later use.
You must dissolve omeprazole powder in a small amount of water. This mixture can either be swallowed or given through a nasogastric (NG) feeding tube using a catheter-tipped syringe.
Use this medicine for the full prescribed length of time, even if your symptoms quickly improve.
OTC omeprazole should be taken for only 14 days in a row. It may take 1 to 4 days before your symptoms improve. Allow at least 4 months to pass before you start a new 14-day course of treatment.
Call your doctor if your symptoms do not improve, or if they get worse.
Some conditions are treated with a combination of omeprazole and antibiotics. Use all medications as directed.
This medicine can affect the results of certain medical tests. Tell any doctor who treats you that you are using omeprazole.
Store at room temperature away from moisture and heat.
What happens if I miss a dose?
Take the medicine as soon as you can, but skip the missed dose if it is almost time for your next dose. Do not take two doses at one time.
What happens if I overdose?
Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.
What should I avoid while taking omeprazole?
This medicine can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is watery or bloody, call your doctor before using anti-diarrhea medicine.
What are the possible side effects of omeprazole?
Get emergency medical help if you have signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Stop using omeprazole and call your doctor at once if you have:
severe stomach pain, diarrhea that is watery or bloody;
new or unusual pain in your wrist, thigh, hip, or back;
seizure (convulsions);
kidney problems --little or no urination, blood in your urine, swelling, rapid weight gain;
low magnesium --dizziness, irregular heartbeats, feeling jittery, muscle cramps, muscle spasms, cough or choking feeling; or
new or worsening symptoms of lupus --joint pain, and a skin rash on your cheeks or arms that worsens in sunlight.
Taking omeprazole long-term may cause you to develop stomach growths called fundic gland polyps. Talk with your doctor about this risk.
If you use omeprazole for longer than 3 years, you could develop a vitamin B-12 deficiency. Talk to your doctor about how to manage this condition if you develop it.
Common side effects may include:
stomach pain, gas;
nausea, vomiting, diarrhea; or
headache.
This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
What other drugs will affect omeprazole?
Sometimes it is not safe to use certain medications at the same time. Some drugs can affect your blood levels of other drugs you take, which may increase side effects or make the medications less effective.
Tell your doctor about all your current medicines. Many drugs can affect omeprazole, especially:
clopidogrel;
methotrexate;
St. John's wort; or
an antibiotic --amoxicillin, clarithromycin, rifampin.
This list is not complete and many other drugs may affect omeprazole. This includes prescription and over-the-counter medicines, vitamins, and herbal products. Not all possible drug interactions are listed here.
Where can I get more information?
Your pharmacist can provide more information about omeprazole.
Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.
Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist.
Copyright 1996-2021 Cerner Multum, Inc. Version: 20.01. Revision date: 4/11/2019.
Your use of the content provided in this service indicates that you have read, understood and agree to the End-User License Agreement, which can be accessed by End-User License Agreement, which can be accessed by clicking on this link.
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omeprazole
NOTICE: This health information was not created by the University of Michigan Health System (UMHS) and may not necessarily reflect specific UMHS practices. For medical advice relating to your personal condition, please consult your doctor. Complete disclaimer
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Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®): Supportive care - Health Professional Information [NCI] | Michigan Medicine
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Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®): Supportive care - Health Professional Information [NCI]
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Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®): Supportive care - Health Professional Information [NCI]
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Overview
Aggressive treatment of malignant disease may produce unavoidable toxicities to normal cells. The mucosal lining of the gastrointestinal tract, including the oral mucosa, is a prime target for treatment-related toxicity by virtue of its rapid rate of cell turnover. The oral cavity is highly susceptible to direct and indirect toxic effects of cancer chemotherapy and ionizing radiation.[1] This risk results from multiple factors, including high rates of cellular turnover for the lining mucosa, a diverse and complex microflora, and trauma to oral tissues during normal oral function.[2] Although changes in soft tissue structures within the oral cavity presumably reflect the changes that occur throughout the gastrointestinal tract, this summary focuses on oral complications of antineoplastic drugs and radiation therapies.
It is essential that a multidisciplinary approach be used for oral management of the cancer patient before, during, and after cancer treatment. A multidisciplinary approach is warranted because the medical complexity of these patients affects dental treatment planning, prioritization, and timing of dental care. In addition, selected cancer patients (e.g., status posttreatment with high-dose head-and-neck radiation) are often at lifelong risk for serious complications such as osteoradionecrosis of the mandible. Thus, a multidisciplinary oncology team that includes oncologists, oncology nurses, and dental generalists and specialists as well as dental hygienists, social workers, dieticians, and related health professionals can often achieve highly effective preventive and therapeutic outcomes relative to oral complications in these patients.
While oral complications may mimic selected systemic disorders, unique oral toxicities emerge in the context of specific oral anatomic structures and their functions.
Frequencies of oral complications vary by cancer therapy; estimates are included in Table 1.
Table 1. Prevalence for Oral Complications with Cancer Therapies: Oral Care Study Group Systematic Reviews, MASCC/ISOO
Complication
Reference Citation
Weighted Prevalence
CT = chemotherapy; EORTC QLQ-C30 = European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30; HNC = head and neck cancer; IMRT = intensity-modulated radiation therapy; MASCC/ISOO = Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology; RT = radiation therapy; VAS = visual analog scale.
a Pain is common in patients with HNCs and is reported by approximately half of patients before cancer therapy, by 81% during therapy, by 70% at the end of therapy, and by 36% at 6 months posttreatment.
Bisphosphonate osteonecrosis [3] 6.1% for all studies (mean)
Studies with documented follow-up = 13.3%
Studies with undocumented follow-up = 0.7%
Epidemiological studies = 1.2%
Dysgeusia [4] CT only = 56.3% (mean)
RT only = 66.5% (mean)
Combined CT and RT = 76% (mean)
Oral fungal infection [5] Of clinical oral fungal infection (all oral candidiasis):
Pretreatment = 7.5%
During treatment = 39.1%
Posttreatment = 32.6%
Of oral candidiasis clinical infection by cancer treatment:
During HNC RT = 37.4%
During CT = 38%
Oral viral infection [6] In patients treated with CT for hematologic malignancies:
Patients with oral ulcerations/sampling oral ulcerations = 49.8%
Patients sampling oral ulcerations = 33.8%
Patients sampling independently of the presence of oral ulcerations = 0%
In patients treated with RT:
Patients with RT only/sampling oral ulcerations = 0%
Patients with RT and adjunctive CT/sampling oral ulcerations = 43.2%
Dental disease [7] For dental caries in patients treated with cancer therapy:
All studies = 28.1%
CT only = 37.3%
Post-RT = 24%
Post-CT and -RT = 21.4%
Of severe gingivitis in patients undergoing CT = 20.3%
Of dental infection/abscess in patients undergoing CT = 5.8%
Osteoradionecrosis [8] In conventional RT = 7.4%
In IMRT = 5.2%
In RT and CT = 6.8%
In brachytherapy = 5.3%
Trismus [9] For conventional RT = 25.4%
For IMRT = 5%
For combined RT and CT = 30.7%
Oral paina [10] VAS pain level (0–100) in HNC patients:
Pretreatment = 12/100
Immediately posttreatment = 33/100
1 mo posttreatment = 20/100
EORTC QLQ-C30 pain level (0–100) in HNC patients:
Pretreatment = 27/100
3 mo posttreatment = 30/100
6 mo posttreatment = 23/100
12 mo posttreatment = 24/100
Salivary gland hypofunction and xerostomia [11] Of xerostomia in HNC patients by type of RT:
All studies
Pre-RT = 6%
During RT = 93%
1–3 mo post-RT = 74%
3–6 mo post-RT = 79%
6–12 mo post-RT = 83%
1–2 y post-RT = 78%
>2 y post-RT = 85%
Conventional RT
Pre-RT = 10%
During RT = 81%
1–3 mo post-RT = 71%
3–6 mo post-RT = 83%
6–12 mo post-RT = 72%
1–2 y post-RT = 84%
>2 y post-RT = 91%
IMRT
Pre-RT = 12%
During RT = 100%
1–3 mo post-RT = 89%
3–6 mo post-RT = 73%
6–12 mo post-RT = 90%
1–2 y post-RT = 66%
>2 y post-RT = 68%
The most common oral complications related to cancer therapies are mucositis, infection, salivary gland dysfunction, taste dysfunction, and pain. These complications can lead to secondary complications such as dehydration, dysgeusia, and malnutrition. In myelosuppressed cancer patients, the oral cavity can also be a source of systemic infection. Radiation of the head and neck can irreversibly injure oral mucosa, vasculature, muscle, and bone, resulting in xerostomia, rampant dental caries, trismus, soft tissue necrosis, and osteonecrosis.
Severe oral toxicities can compromise delivery of optimal cancer therapy protocols. For example, dose reduction or treatment schedule modifications may be necessary to allow for resolution of oral lesions. In cases of severe oral morbidity, the patient may no longer be able to continue cancer therapy; treatment is then usually discontinued. These disruptions in dosing caused by oral complications can directly affect patient survivorship.
Management of oral complications of cancer therapy includes identification of high-risk populations, patient education, initiation of pretreatment interventions, and timely management of lesions. Assessment of oral status and stabilization of oral disease before cancer therapy are critical to overall patient care. Care should be both preventive and therapeutic to minimize risk for oral and associated systemic complications.
Future research targeted at developing technologies is needed to:
Reduce incidence and severity of oral mucositis.
Improve infection management.
Protect salivary gland function.
Minimize risk of chronic sequelae.
Development of new technologies to prevent cancer therapy–induced complications, especially oral mucositis, could substantially reduce the risk of oral pain, oral and systemic infections, and number of days in the hospital; and could improve quality of life and reduce health care costs. New technologies could also provide a setting in which novel classes of chemotherapeutic drugs, used at increased doses, could lead to enhanced cancer cure rates and durability of disease remission.
As has been noted, it is essential that a multidisciplinary approach be used for oral management of the cancer patient before, during, and after cancer treatment. This collaboration is pivotally important for the advancement of basic, clinical, and translational research associated with oral complications of current and emerging cancer therapies. The pathobiologic complexity of oral complications and the ever-expanding science base of clinical management require this comprehensive interdisciplinary approach.
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.
References:
Lalla RV, Brennan MT, Schubert MM: Oral complications of cancer therapy. In: Yagiela JA, Dowd FJ, Johnson BS, et al., eds.: Pharmacology and Therapeutics for Dentistry. 6th ed. St. Louis, Mo: Mosby Elsevier, 2011, pp 782-98.
Keefe DM, Schubert MM, Elting LS, et al.: Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer 109 (5): 820-31, 2007.
Migliorati CA, Woo SB, Hewson I, et al.: A systematic review of bisphosphonate osteonecrosis (BON) in cancer. Support Care Cancer 18 (8): 1099-106, 2010.
Hovan AJ, Williams PM, Stevenson-Moore P, et al.: A systematic review of dysgeusia induced by cancer therapies. Support Care Cancer 18 (8): 1081-7, 2010.
Lalla RV, Latortue MC, Hong CH, et al.: A systematic review of oral fungal infections in patients receiving cancer therapy. Support Care Cancer 18 (8): 985-92, 2010.
Elad S, Zadik Y, Hewson I, et al.: A systematic review of viral infections associated with oral involvement in cancer patients: a spotlight on Herpesviridea. Support Care Cancer 18 (8): 993-1006, 2010.
Hong CH, Napeñas JJ, Hodgson BD, et al.: A systematic review of dental disease in patients undergoing cancer therapy. Support Care Cancer 18 (8): 1007-21, 2010.
Peterson DE, Doerr W, Hovan A, et al.: Osteoradionecrosis in cancer patients: the evidence base for treatment-dependent frequency, current management strategies, and future studies. Support Care Cancer 18 (8): 1089-98, 2010.
Bensadoun RJ, Riesenbeck D, Lockhart PB, et al.: A systematic review of trismus induced by cancer therapies in head and neck cancer patients. Support Care Cancer 18 (8): 1033-8, 2010.
Epstein JB, Hong C, Logan RM, et al.: A systematic review of orofacial pain in patients receiving cancer therapy. Support Care Cancer 18 (8): 1023-31, 2010.
Jensen SB, Pedersen AM, Vissink A, et al.: A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life. Support Care Cancer 18 (8): 1039-60, 2010.
Etiopathogenesis
Oral complications associated with cancer chemotherapy and radiation result from complex interactions among multiple factors. The most prominent contributors are direct lethal and sublethal damage to oral tissues, attenuation of immune and other protective systems, and interference with normal healing. Principal causes can be attributed to both direct stomatotoxicity and indirect stomatotoxicity. Direct toxicities are initiated via primary injury to oral tissues. Indirect toxicities are caused by nonoral toxicities that secondarily affect the oral cavity, including the following:
Myelosuppression.
Loss of tissue-based immune cells.
Loss of protective salivary constituents.
Understanding of mechanisms associated with oral complications continues to increase. Unfortunately, there are no universally effective agents or protocols to prevent toxicity. Elimination of preexisting dental/periapical, periodontal, and mucosal infections; institution of comprehensive oral hygiene protocols during therapy; and reduction of other factors that may compromise oral mucosal integrity (e.g., physical trauma to oral tissues) can reduce frequency and severity of oral complications in cancer patients (refer to the Oral and Dental Management Before Cancer Therapy and the Oral and Dental Management After Cancer Therapy sections of this summary for further information).[1]
Complications can be acute (developing during therapy) or chronic (developing months to years after therapy). In general, cancer chemotherapy causes acute toxicities that resolve following discontinuation of therapy and recovery of damaged tissues. In contrast, radiation protocols typically cause not only acute oral toxicities, but induce permanent tissue damage that result in lifelong risk for the patient.
Chemotherapy-induced Complications
Risk factors for oral complications (see Table 2) derive from both direct damage to oral tissues secondary to chemotherapy and indirect damage due to regional or systemic toxicity. For example, therapy-related toxicity to oral mucosa can be exacerbated by colonizing oral microflora when local and systemic immune function is concurrently compromised. Frequency and severity of oral complications are directly related to extent and type of systemic compromise.
Table 2. Oral Complications of Cancer Chemotherapy
Complication
Direct Risk Factor
Indirect Risk Factors
DIC = disseminated intravascular coagulation; HSV = herpes simplex virus.
Oral mucositis Mucosal cytotoxicity Decreased local/systemic immunity: local infections, reactivation of HSV
Physical/chemical trauma
Oral infections:
Viral Decreased systemic immunity
Fungal Decreased oral mucosal and/or systemic immunity
Salivary gland dysfunction
Altered oral flora (decreased bacterial flora)
Bacterial Inadequate oral hygiene Decreased oral mucosal and/or systemic immunity
Mucosal breakdown Salivary gland dysfunction
Acquired pathogens
Taste dysfunction Taste receptor toxicity
Xerostomia Salivary gland toxicity Anticholinergic drugs
Neuropathies Vinca alkaloid, thalidomide, bortezomib drug use; risk for specific drug toxicity varies Anemia, dental hypersensitivity, temporomandibular dysfunction/myofascial pain
Dental and skeletal growth and development (pediatric patients) Specific drug toxicity Stage of dental and skeletal maturation
Gastrointestinal mucositis causing secondary changes in oral status including taste, hygiene, and dietary intake Mucosal cytotoxicity: radiation, chemotherapy Nausea and vomiting
Hemorrhage Oral mucositis Thrombocytopenia
Physical trauma Decreased clotting factors (e.g., DIC)
Infections (e.g., HSV)
Ulcerative oral mucositis occurs in approximately 40% of patients receiving chemotherapy. In approximately 50% of these patients, the lesions are severe and require medical intervention including modification of their cytotoxic cancer therapy. Normal oral mucosal epithelium is estimated to undergo complete replacement every 9 to 16 days. Intensive chemotherapy can cause ulcerative mucositis that initially emerges approximately 2 weeks after initiation of high-dose chemotherapy.[2,3,4]
Chemotherapy directly impairs replication of basal epithelial cells; other factors, including proinflammatory cytokines and metabolic products of bacteria, may also play a role. The labial mucosa, buccal mucosa, tongue, floor of mouth, and soft palate are more severely affected by chemotherapy than are the attached, heavily keratinized tissues such as the hard palate and gingiva; this may be caused by relative rate of epithelial cell turnover among high-risk versus low-risk oral mucosal tissues. Topical cryotherapy may ameliorate mucositis caused by agents such as 5-fluorouracil (5-FU) by reducing vascular delivery of these toxic agents to replicating oral epithelium.[5]
It is difficult to predict whether a patient will develop mucositis strictly on the basis of the classes of drugs that are administered. Several drugs are associated with a propensity to damage oral mucosa:
Methotrexate.
Doxorubicin.
5-FU.
Busulfan.
Bleomycin.
The platinum coordination complexes, including cisplatin and carboplatin.
Mammalian target of rapamycin (mTOR) inhibitors (a new class of targeted cancer therapeutic agents).[6,7]
Anecdotal evidence suggests that patients who experience mucositis with a specific chemotherapy regimen during the first cycle will typically develop comparable mucositis during subsequent courses of that regimen.
Other oral complications typically include infections of the mucosa, dentition/periapices, and periodontium. Prevalence of these infections has been substantiated in multiple studies.[8,9,10,11] Specific criteria for determining risk of infectious flare during myelosuppression have not been developed. Guidelines for assessment primarily address both degree of severity of the chronic lesion and whether acute symptoms have recently (i.e., <90 days) developed. However, chronic asymptomatic periodontitis may also represent a focus for systemic infectious complications since bacteria, bacterial cell wall substances, and inflammatory cytokines may translocate into the circulation via ulcerated pocket epithelium.[10] In addition, poor oral hygiene and periodontitis seem to increase the prevalence of pulmonary infections in high-risk patients.[12]
Resolution of oral toxicity, including mucositis and infection, generally coincides with granulocyte recovery. This relationship may be temporally but not causally related. For example, oral mucosal healing in hematopoietic stem cell transplantation patients is only partially dependent on rate of engraftment, especially neutrophils.
Head/Neck Radiation–induced Complications
Head and neck radiation can cause a wide spectrum of oral complications (refer to the list of Oral Complications of Radiation Therapy). Ulcerative oral mucositis is a virtually universal toxicity resulting from this treatment; there are clinically significant similarities as well as differences compared with oral mucositis caused by chemotherapy.[2] In addition, oral mucosal toxicity can be increased by use of head and neck radiation together with concurrent chemotherapy.
Head and neck radiation can also induce damage that results in permanent dysfunction of vasculature, connective tissue, salivary glands, muscle, and bone. Loss of bone vitality occurs:
Secondary to injury to osteocytes, osteoblasts, and osteoclasts.
From a relative hypoxia due to reduction in vascular supply.
These changes can lead to soft tissue necrosis and osteonecrosis that result in bone exposure, secondary infection, and severe pain.[11]
Oral Complications of Radiation Therapy
Acute complications:
Oral mucositis.
Infection:
Fungal.
Bacterial.
Salivary gland dysfunction:
Sialadenitis.
Xerostomia.
Taste dysfunction.
Chronic complications:
Mucosal fibrosis and atrophy.
Xerostomia.
Dental caries.
Soft tissue necrosis.
Osteonecrosis.
Taste dysfunction:
Dysgeusia.
Ageusia.
Muscular/cutaneous fibrosis.
Infections:
Fungal.
Bacterial.
Unlike chemotherapy, however, radiation damage is anatomically site-specific; toxicity is localized to irradiated tissue volumes. Degree of damage depends on treatment regimen-related factors, including type of radiation utilized, total dose administered, and field size/fractionation. Radiation-induced damage also differs from chemotherapy-induced changes in that irradiated tissue tends to manifest permanent damage that places the patient at continual risk for oral sequelae. The oral tissues are thus more easily damaged by subsequent toxic drug or radiation exposure, and normal physiologic repair mechanisms are compromised as a result of permanent cellular damage.
References:
Larson PJ, Miaskowski C, MacPhail L, et al.: The PRO-SELF Mouth Aware program: an effective approach for reducing chemotherapy-induced mucositis. Cancer Nurs 21 (4): 263-8, 1998.
Sonis ST: Mucositis as a biological process: a new hypothesis for the development of chemotherapy-induced stomatotoxicity. Oral Oncol 34 (1): 39-43, 1998.
Lalla RV, Brennan MT, Schubert MM: Oral complications of cancer therapy. In: Yagiela JA, Dowd FJ, Johnson BS, et al., eds.: Pharmacology and Therapeutics for Dentistry. 6th ed. St. Louis, Mo: Mosby Elsevier, 2011, pp 782-98.
Schubert MM, Peterson DE: Oral complications of hematopoietic cell transplantation. In: Appelbaum FR, Forman SJ, Negrin RS, et al., eds.: Thomas' Hematopoietic Cell Transplantation: Stem Cell Transplantation. 4th ed. Oxford, UK: Wiley-Blackwell, 2009, pp 1589-1607.
Rocke LK, Loprinzi CL, Lee JK, et al.: A randomized clinical trial of two different durations of oral cryotherapy for prevention of 5-fluorouracil-related stomatitis. Cancer 72 (7): 2234-8, 1993.
Pilotte AP, Hohos MB, Polson KM, et al.: Managing stomatitis in patients treated with Mammalian target of rapamycin inhibitors. Clin J Oncol Nurs 15 (5): E83-9, 2011.
de Oliveira MA, Martins E Martins F, Wang Q, et al.: Clinical presentation and management of mTOR inhibitor-associated stomatitis. Oral Oncol 47 (10): 998-1003, 2011.
Sonis ST, Peterson DE, McGuire DB, eds.: Mucosal injury in cancer patients: new strategies for research and treatment. J Natl Cancer Inst Monogr (29): 1-54, 2001.
Akintoye SO, Brennan MT, Graber CJ, et al.: A retrospective investigation of advanced periodontal disease as a risk factor for septicemia in hematopoietic stem cell and bone marrow transplant recipients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94 (5): 581-8, 2002.
Raber-Durlacher JE, Epstein JB, Raber J, et al.: Periodontal infection in cancer patients treated with high-dose chemotherapy. Support Care Cancer 10 (6): 466-73, 2002.
Myers RA, Marx RE: Use of hyperbaric oxygen in postradiation head and neck surgery. NCI Monogr (9): 151-7, 1990.
Paju S, Scannapieco FA: Oral biofilms, periodontitis, and pulmonary infections. Oral Dis 13 (6): 508-12, 2007.
Oral and Dental Management Before Cancer Therapy
Poor oral health has been associated with increased incidence and severity of oral complications in cancer patients, hence the adoption of an aggressive approach to stabilizing oral care before treatment.[1,2] Primary preventive measures such as appropriate nutritional intake, effective oral hygiene practices, and early detection of oral lesions are important pretreatment interventions.
There is no universally accepted pre–cancer therapy dental protocol because of the lack of clinical trials evaluating the efficacy of a specific protocol. A systematic review of the literature revealed two articles on oral care protocols prior to cancer therapy.[3] One study examined the benefits of a minimal intervention pre–cancer therapy (mostly chemotherapy) dental protocol, and the other examined the impact of an intensive preventive protocol on patients undergoing chemotherapy. Both studies had several flaws, including small sample size or the lack of comparison groups.[3]
The involvement of a dental team experienced with oral oncology may reduce the risk of oral complications via either direct examination of the patient or in consultation with the community-based dentist. The evaluation should occur as early as possible before treatment.[4,5] The examination allows the dentist to determine the status of the oral cavity before cancer treatment begins and to initiate necessary interventions that may reduce oral complications during and after that therapy. Ideally, this examination should be performed at least 1 month before the start of cancer treatment to permit adequate healing from any required invasive oral procedures. A program of oral hygiene should be initiated, with emphasis on maximizing patient compliance on a continuing basis.
Chemotherapy Patients
Oral evaluation and management of patients scheduled to undergo myeloablative chemotherapy should occur as early as possible before initiation of therapy (refer to the list on Oral Disease Stabilization Before Chemotherapy and/or Hematopoietic Stem Cell Transplantation). To maximize outcomes, the oncology team should clearly advise the dentist as to the patient's medical status and oncology treatment plan. In turn, the dental team should delineate and communicate a plan of care for oral disease management before, during, and after cancer therapy.[5]
Oral Disease Stabilization Before Chemotherapy and/or Hematopoietic Stem Cell Transplantation
Data provided by oncology team to dental providers:
Underlying disease:
Cancer: type, stage, prognosis.
Aplastic anemia status, complete blood count (CBC).
Other.
Type of transplant:
Autologous.
Allogeneic donor types:
Matched related and unrelated.
Mismatched related.
Mismatched unrelated.
Syngeneic.
Hematopoietic stem cell source:
Bone marrow.
Peripheral stem cells.
Cord blood stem cells.
Conditioning regimen:
Myeloablative.
Reduced-intensity conditioning (including nonmyeloablative regimens).
Planned date of transplant.
Conditioning regimen:
Chemotherapy.
Total-body irradiation.
Radioactive antibodies.
Current hematologic status and immunologic status.
Present medications.
Other medical considerations:
Cardiac disease (including murmurs).
Pulmonary disease.
Indwelling venous access line.
Coagulation status.
Splenectomy.
Data provided by dental providers to oncology team:
Dental caries (number of teeth and severity, including designation of number of teeth that should be treated before cancer treatment begins).
Endodontic disease:
Teeth with pulpal infection.
Teeth with periapical infection.
Periodontal disease status.
Number of teeth requiring extraction.
Other urgent care required.
Time necessary to complete stabilization of oral disease.
The overall goal is to complete a comprehensive oral care plan that eliminates or stabilizes oral disease that could otherwise produce complications during or following chemotherapy. Achieving this goal will most likely reduce risk of oral toxicities with resultant reduced risk for systemic sequelae, reduced cost of patient care, and enhanced quality of life. If the patient is unable to receive the medically necessary oral care in the community, the oncology team should assume responsibility for oral management.
It is important to realize that dental treatment plans need to be realistic relative to type and extent of dental disease and how long it could be before resumption of routine dental care. For example, teeth with minor caries may not need restoration before cancer treatment begins, especially if more conservative disease stabilization strategies can be used (e.g., aggressive topical fluoride protocols, temporary restorations, or dental sealants).
Specific interventions are directed to:
Mucosal lesions.
Dental caries and endodontic disease.
Periodontal disease.
Ill-fitting dentures.
Orthodontic appliances.
Temporomandibular dysfunction.
Salivary abnormalities.
Guidelines for dental extractions, endodontic management, and related interventions (see Table 3) can be used as appropriate.[6,7] Antibiotic prophylaxis prior to invasive oral procedures may be warranted in the context of central venous catheters; the current American Heart Association (AHA) protocol for infective endocarditis and oral procedures is frequently used for these patients.
Table 3. Management Guidelines Relative to Invasive Dental Procedures
Medical Status
Guideline
Comments
CBC = complete blood cell count; IV = intravenous.
a Assumes that all other coagulation parameters are within normal limits and that platelet counts will be maintained at or above the specified level until initial stabilization/healing has occurred.
Patients with chronic indwelling venous access lines (e.g., Hickman). AHA prophylactic antibiotic recommendations (low risk). There is no clear scientific proof detailing infectious risk for these lines following dental procedures. This recommendation is empiric.
Neutrophils Order CBC with differential.
>2,000/mm3 No prophylactic antibiotics.
1,000–2,000/mm3 AHA prophylactic antibiotic recommendations (low risk). Clinical judgment is critical. If infection is present or unclear, more aggressive antibiotic therapy may be indicated.
<1,000/mm3 Amikacin 150 mg/m2 1 h presurgery; ticarcillin 75 mg/kg IV ½ h presurgery. Repeat both 6 h postoperatively. If organisms are known or suspected, appropriate adjustments should be based on sensitivities.
Plateletsa Order platelet count and coagulation tests.
>60,000/mm3 No additional support needed.
30,000–60,000/mm3 Platelet transfusions are optional for noninvasive treatment; consider administering preoperatively and 24 h later for surgical treatment (e.g., dental extractions). Additional transfusions are based on clinical course. Utilize techniques to promote establishing and maintaining control of bleeding (i.e., sutures, pressure packs, minimize trauma).
<30,000/mm3 Platelets should be transfused 1 h before procedure; obtain an immediate postinfusion platelet count; transfuse regularly to maintain counts >30,000–40,000/mm3 until initial healing has occurred. In some instances, platelet counts >60,000/mm3 may be required. In addition to above, consider using hemostatic agents (i.e., microfibrillar collagen, topical thrombin). Aminocaproic acid may help stabilize nondurable clots. Monitor sites carefully.
Assessment of Hematopoietic Stem Cell Transplant Patients
Stages of assessment have been described relative to the hematopoietic stem cell transplant patient (see Table 4).[5] This model provides a useful classification for neutropenic cancer patients in general. Type, timing, and severity of oral complications represent the interaction of local and systemic factors that culminate in clinical expression of disease. Correlating oral status with systemic condition of the patient is thus critically important.
Selected conditioning regimens characterized by reduced intensity for myelosuppression have been used in patients. These regimens have generally been noted to significantly reduce the severity of oral complications early posttransplant, especially for mucositis and infection risk. The guidelines listed in Table 4 can be adjusted to reflect these varying degrees of risk, based on the specific conditioning regimen to be used.
Table 4. Oral Complications of Hematopoietic Stem Cell Transplantation
Transplant Phase
Oral Complication
GVHD = graft-versus-host disease.
Phase I: Preconditioning Oral infections: dental caries, endodontic infections, periodontal disease (gingivitis, periodontitis), mucosal infections (i.e., viral, fungal, bacterial).
Gingival leukemic infiltrates.
Metastatic cancer.
Oral bleeding.
Oral ulceration: aphthous ulcers, erythema multiforme.
Temporomandibular dysfunction.
Phase II: Conditioning Neutropenic Phase Oropharyngeal mucositis.
Oral infections: mucosal infections (i.e., viral, fungal, bacterial), periodontal infections.
Hemorrhage.
Xerostomia.
Taste dysfunction.
Neurotoxicity: dental pain, muscle tremor (e.g., jaws, tongue).
Temporomandibular dysfunction: jaw pain, headache, joint pain.
Phase III: Engraftment Hematopoietic Recovery Oral infections: mucosal infections (i.e., viral, fungal, bacterial).
Acute GVHD.
Xerostomia.
Hemorrhage.
Neurotoxicity: dental pain, muscle tremor (e.g., jaws, tongue).
Temporomandibular dysfunction: jaw pain, headache, joint pain.
Granulomas/papillomas.
Phase IV: Immune Reconstitution Late Posttransplant Oral infections: mucosal infections (i.e., viral, fungal, bacterial).
Chronic GVHD.
Dental/skeletal growth and development alterations (pediatric patients).
Xerostomia.
Relapse-related oral lesions.
Second malignancies.
Phase V: Long-term Survival Relapse or second malignancies.
Dental/skeletal growth and development alterations.
Phase I: Before Chemotherapy
Oral complications are related to current systemic and oral health, oral manifestations of underlying disease, and oral complications of recent cancer or other medical therapy. During this period, oral trauma and clinically significant infections, including dental caries, periodontal disease, and pulpal infection, should be eliminated. Additionally, patients should be educated relative to the range and management of oral complications that may occur during subsequent phases. Baseline oral hygiene instructions should be provided. It is especially important to note whether patients have been treated with bisphosphonates (e.g., patients with multiple myeloma) and to plan their care accordingly.
Phase II: Neutropenic Phase
Oral complications arise primarily from direct and indirect stomatotoxicities associated with high-dose chemotherapy or chemoradiotherapy and their sequelae. Mucositis, xerostomia, and those lesions related to myelosuppression, thrombocytopenia, and anemia predominate. This phase is typically the period of high prevalence and severity of oral complications.
Oral mucositis usually begins 7 to 10 days after initiation of cytotoxic therapy and remains present for approximately 2 weeks after cessation of that therapy. Viral, fungal, and bacterial infections may arise, with incidence dependent on the use of prophylactic regimens, oral status prior to chemotherapy, and duration/severity of neutropenia. Frequency of infection declines upon resolution of mucositis and regeneration of neutrophils. This phenomenon appears to be more a temporal relation than a causative one, based on the predominant evidence. Despite the initial marrow recovery, however, the patient may remain at risk for infection, depending on status of overall immune reconstitution.
Salivary gland hypofunction/xerostomia secondary to anticholinergic drugs and taste dysfunction is initially detected in this phase; the toxicity typically resolves within 2 to 3 months.
In allogeneic transplant patients, while uncommon, hyperacute graft-versus-host disease (GVHD) can occur and can result in significant oral mucosal inflammation and breakdown that can complicate the oral course for patients. Clinical presentation will often not be sufficiently distinct to diagnosis this lesion. The clinical assessment is typically based on the patient experiencing more-severe-than-expected mucositis that will often not heal within the time line for mucosal recovery associated with oral mucositis caused by chemotherapy.
Phase III: Hematopoietic Recovery
Frequency and severity of acute oral complications typically begin to decrease approximately 3 to 4 weeks after cessation of chemotherapy. Healing of ulcerative oral mucositis in the setting of marrow regeneration contributes to this dynamic. Although immune reconstitution is developing, oral mucosal immune defenses may not be optimal. Generally stated, immune reconstitution will take between 6 and 9 months for autologous transplant patients and between 9 and 12 months for allogeneic transplant patients not developing chronic GVHD. Thus, the patient remains at risk for selected infection, including candidal and herpes simplex virus infections.
Mucosal bacterial infections during this phase occur less frequently unless engraftment is delayed or the patient has acute GVHD or is receiving GVHD therapy. Most centers will use systemic infection prophylaxis throughout this period (and, in many instances, longer) to reduce the risk of infections in general, a practice that positively influences the rate and severity of both systemic and local oral infections.
The hematopoietic stem cell transplant patient represents a unique cohort at this point. For example, risk for acute oral GVHD typically emerges during this time in allogeneic graft recipients.
Phase IV: Immune Reconstitution/Recovery from Systemic Toxicity
Oral lesions are principally related to chronic conditioning regimen–associated (chemotherapy with or without radiation therapy) toxicity and, in the allogeneic patient, GVHD. Late viral infections and xerostomia predominate. Mucosal bacterial infections are infrequent unless the patient remains neutropenic or has severe chronic GVHD.
Risk exists for graft failure, cancer relapse, and second malignancies. The hematopoietic stem cell transplant patient may develop oral manifestations of chronic GVHD during this period.
Phase V: Long-term Survival
Long-term survivors of cancer treated with high-dose chemotherapy alone or chemoradiotherapy will generally have few significant permanent oral complications.
Risk for radiation-induced chronic complications is related to the total dose and schedule of radiation therapy. Regimens that incorporate total body irradiation may result in permanent salivary gland hypofunction/xerostomia,[8] which is the most frequently reported late oral complication. Permanent salivary gland dysfunction can occur in autologous transplant patients in addition to nonautologous recipients. Other significant complications include craniofacial growth and developmental abnormalities in pediatric patients, and emergence of second malignancies of the head/neck region.
References:
Sonis ST, Woods PD, White BA: Oral complications of cancer therapies. Pretreatment oral assessment. NCI Monogr (9): 29-32, 1990.
Epstein JB: Infection prevention in bone marrow transplantation and radiation patients. NCI Monogr (9): 73-85, 1990.
Hong CH, Napeñas JJ, Hodgson BD, et al.: A systematic review of dental disease in patients undergoing cancer therapy. Support Care Cancer 18 (8): 1007-21, 2010.
Lalla RV, Brennan MT, Schubert MM: Oral complications of cancer therapy. In: Yagiela JA, Dowd FJ, Johnson BS, et al., eds.: Pharmacology and Therapeutics for Dentistry. 6th ed. St. Louis, Mo: Mosby Elsevier, 2011, pp 782-98.
Schubert MM, Peterson DE: Oral complications of hematopoietic cell transplantation. In: Appelbaum FR, Forman SJ, Negrin RS, et al., eds.: Thomas' Hematopoietic Cell Transplantation: Stem Cell Transplantation. 4th ed. Oxford, UK: Wiley-Blackwell, 2009, pp 1589-1607.
Williford SK, Salisbury PL, Peacock JE, et al.: The safety of dental extractions in patients with hematologic malignancies. J Clin Oncol 7 (6): 798-802, 1989.
Overholser CD, Peterson DE, Bergman SA, et al.: Dental extractions in patients with acute nonlymphocytic leukemia. J Oral Maxillofac Surg 40 (5): 296-8, 1982.
Jensen SB, Pedersen AM, Vissink A, et al.: A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life. Support Care Cancer 18 (8): 1039-60, 2010.
Oral and Dental Management After Cancer Therapy
Routine systematic oral hygiene is important for reducing incidence and severity of oral sequelae of cancer therapy. The patient must be informed of the rationale for the oral hygiene program as well as the potential side effects of cancer chemotherapy and radiation therapy. Effective oral hygiene is important throughout cancer treatment, with emphasis on oral hygiene beginning before treatment starts.[1]
Management of patients undergoing either high-dose chemotherapy or upper-mantle radiation share selected common principles. These principles are based on baseline oral care (refer to the list of suggestions for Routine Oral Hygiene Care) and reduction of physical trauma to oral mucosa (refer to the list of Guidelines for Management of Dentures and Orthodontic Appliances in Patients Receiving High-Dose Cancer Therapy).
Routine Oral Hygiene Care
Toothbrushing. Electric and ultrasonic toothbrushes are acceptable if the patient is capable of using them without causing trauma.
Soft nylon-bristled brush (two to three rows).
Brush 2 to 3 times daily with Bass sulcular scrub method.
Rinse frequently.
Foam toothbrushes:
Use only when use of a regular toothbrush is not feasible.
Use with antimicrobial rinses when routine brushing and flossing are not possible.
Brush teeth 2 to 3 times a day.
Rinse frequently.
Dentifrice:
Patient preference, as tolerated.
(Note: Non–mint-flavored products are typically better tolerated than mint-flavored products when oral mucositis or oral graft-versus-host disease [GVHD] is present).
Fluoride recommended.
Use 0.9% saline or water if toothpaste causes irritation.
Flossing:
Once daily.
Atraumatic technique with modifications as needed.
Bland rinses:
Varieties:
0.9% saline.
Sodium bicarbonate solution.
0.9% saline plus sodium bicarbonate solution.
Use 8 to 12 oz of rinse, hold a mouthful, and expectorate until total volume is used; repeat every 2 to 4 hours or as needed to ameliorate discomfort.
Fluoride:
1.1% neutral sodium fluoride gel.
0.4% stannous fluoride gel.
Brush on gel for 2 to 3 minutes.
Expectorate and rinse mouth gently.
Apply once a day.
Topical antimicrobial rinses:
0.12% to 0.2% chlorhexidine oral rinse for management of acute gingival lesions.
Povidone iodine oral rinse.
Rinse, hold 1 to 2 minutes, and expectorate.
Repeat 2 to 4 times a day, depending on severity of periodontal disease.
Guidelines for Management of Dentures and Orthodontic Appliances in Patients Receiving High-Dose Cancer Therapy [1]
Minimize denture use during first 3 weeks posttransplant.
Wear dentures only when eating.
Discontinue use at all other times.
Clean twice a day with a soft brush and rinse well.
Soak in antimicrobial solutions when not being worn.
Perform routine oral mucosal care procedures 3 to 4 times a day with the oral appliances out of the mouth.
Leave appliances out of mouth when sleeping and during periods of significant mouth soreness.
Dentures may be used to hold medications needed for oral care (e.g., antifungals).
Discontinue use of removable appliances until oral mucositis has healed.
Remove orthodontic appliances (e.g., brackets, wires, retainers) before conditioning.
Considerable variation exists across institutions relative to specific nonmedicated approaches to baseline oral care, given limited published evidence. Most nonmedicated oral care protocols use topical, frequent (every 4–6 hours) rinsing with 0.9% saline. Additional interventions include dental brushing with toothpaste, dental flossing, ice chips, and sodium bicarbonate rinses. Patient compliance with these agents can be maximized by comprehensive overseeing by the health care professional.
Patients using removable dental prostheses or orthodontic appliances have risk of mucosal injury or infection. This risk can be eliminated or substantially reduced prior to high-dose cancer therapy. (Refer to the list of Guidelines for Management of Dentures and Orthodontic Appliances in Patients Receiving High-Dose Cancer Therapy.)
Dental brushing and flossing represent simple, cost-effective approaches to bacterial dental plaque control. This strategy is designed to reduce risk of oral soft tissue infection during myeloablation. Oncology teams at some centers promote their use, while teams at other centers have patients discontinue brushing and flossing when peripheral blood components decrease below defined thresholds (e.g., platelets <30,000/mm3). There is no comprehensive evidence base regarding the optimal approach. Many centers adopt the strategy that the benefits of properly performed dental brushing and flossing in reducing risk of gingival infection outweigh the risks.
Periodontal infection (gingivitis and periodontitis) increases risk for oral bleeding; healthy tissues should not bleed. Discontinuing dental brushing and flossing can increase risk for gingival bleeding, oral infection, and bacteremia. Risk for gingival bleeding and infection, therefore, is reduced by eliminating gingival infection before therapy and promoting oral health daily by removing bacterial plaque with gentle debridement with a soft or ultra-soft toothbrush during therapy. Mechanical plaque control not only promotes gingival health, but it also may decrease risk of exacerbation of oral mucositis secondary to microbial colonization of damaged mucosal surfaces.
Dental brushing and flossing should be performed daily under the supervision of professional staff:
A soft nylon-bristled toothbrush should be used 2 to 3 times a day with techniques that specifically maintain the gingival portion of the tooth and periodontal sulcus, keeping them free of bacterial plaque.
Rinsing the toothbrush in hot water every 15 to 30 seconds during brushing will soften the brush and reduce risk for trauma.
Oral rinsing with water or saline 3 to 4 times while brushing will further aid in removal of dental plaque dislodged by brushing.
Rinses containing alcohol should be avoided.
A toothpaste with a relatively neutral taste should be considered because the flavoring agents in toothpaste can irritate oral soft tissues.
Brushes should be air-dried between uses.
While disinfectants have been suggested, their routine use to clean brushes has not been proven of value.
Ultrasonic toothbrushes may be substituted for manual brushes if patients are properly trained in their use.
Patients skilled at flossing without traumatizing gingival tissues may continue flossing throughout chemotherapy administration. Flossing allows for interproximal removal of dental bacterial plaque and thus promotes gingival health. As with dental brushing, this intervention should be performed under the supervision of professional staff to ensure its safe administration.
The oral cavity should be cleaned after meals:
If xerostomia is present, plaque and food debris may accumulate secondary to reduced salivary function, and more frequent hygiene may be necessary.
Dentures need to be cleaned with denture cleanser every day and should be brushed and rinsed after meals.
Rinsing the oral cavity may not be sufficient for thorough cleansing of the oral tissues; mechanical plaque removal is often necessary.
Care must be exerted in the use of the varied mechanical hygiene aids that are available; dental floss, interproximal brushes, and wooden wedges can injure oral tissues rendered fragile by chemotherapy.
Toothettes have limited ability to cleanse the dentition; however, they may be useful for cleaning maxillary/mandibular alveolar ridges of edentulous areas, palate, and tongue.
Preventing dryness of the lips to reduce risk for tissue injury is important. Mouth breathing and/or xerostomia secondary to anticholinergic medications used for nausea management can induce the condition. GVHD of the lips can also contribute to dry lips in allogeneic transplant patients. Lip care products containing petroleum-based oils and waxes can be useful. Lanolin-based creams and ointments may be more effective in moisturizing/lubricating the lips and thus protecting against trauma.
References:
Schubert MM, Peterson DE: Oral complications of hematopoietic cell transplantation. In: Appelbaum FR, Forman SJ, Negrin RS, et al., eds.: Thomas' Hematopoietic Cell Transplantation: Stem Cell Transplantation. 4th ed. Oxford, UK: Wiley-Blackwell, 2009, pp 1589-1607.
Oral Mucositis
The terms oral mucositis and stomatitis are often used interchangeably at the clinical level, but they do not reflect identical processes.
Oral Mucositis:
Describes inflammation of oral mucosa resulting from chemotherapeutic agents or ionizing radiation.[1,2,3]
Typically manifests as erythema or ulcerations.
May be exacerbated by local factors.
Stomatitis:
Refers to any inflammatory condition of oral tissue, including mucosa, dentition/periapices, and periodontium.
Includes infections of oral tissues as well as mucositis.
Risk of oral mucositis has historically been characterized by treatment-based and patient-based variables.[4] The current model of oral mucositis involves a complex trajectory of molecular, cellular, and tissue-based changes. There is increasing evidence of genetic governance of this injury,[5,6,7,8] characterized in part by upregulation of nuclear factor kappa beta and inflammatory cytokines (e.g., tumor necrosis factor-alpha) and interleukin-1 in addition to epithelial basal cell injury. Comprehensive knowledge of the molecular-based causation of the lesion has contributed to targeted drug development for clinical use.[9] The pipeline of new drugs in development (e.g., recombinant human intestinal trefoil factor [10] may lead to strategic new advances in the ability of clinicians to customize the prevention and treatment of oral mucositis in the future.[11]
Erythematous mucositis typically appears 7 to 10 days after initiation of high-dose cancer therapy. Clinicians should be alert to the potential for increased toxicity with escalating dose or treatment duration in clinical trials that demonstrate gastrointestinal mucosal toxicity. High-dose chemotherapy, such as that used in the treatment of leukemia and hematopoietic stem cell transplant regimens, may produce severe mucositis. Mucositis is self-limited when uncomplicated by infection and typically heals within 2 to 4 weeks after cessation of cytotoxic chemotherapy.
Systematic assessment of the oral cavity following treatment permits early identification of lesions.[12,13,14,15,16] Oral hygiene and other supportive care measures are important to minimizing the severity of the lesion.
In an effort to standardize measurements of mucosal integrity, oral assessment scales have been developed to grade the level of stomatitis by characterizing alterations in lips, tongue, mucous membranes, gingiva, teeth, pharynx, quality of saliva, and voice.[12,13,14] Specific instruments of assessment have been developed to evaluate the observable and functional dimensions of mucositis. These evaluative tools vary in complexity.
Chemoradiotherapy and Hematopoietic Stem Cell Transplantation Patients
Management of mucositis
Prophylactic measures and treatment options should be employed by practitioners for patients in the appropriate clinical settings. Specific recommendations for minimizing oral mucositis include the following:
Good oral hygiene.
Avoidance of spicy, acidic, hard, and hot foods and beverages.
Use of mild-flavored toothpastes.
Use of saline-peroxide mouthwashes 3 or 4 times per day.
Updated guidelines from the American Society of Clinical Oncology for the prevention and treatment of mucositis were published in 2007 [17] and include the following:
Palifermin for oral mucositis associated with stem cell transplantation.
Amifostine for radiation proctitis.
Cryotherapy for high-dose-melphalan–induced mucositis.
Specific recommendations against specific practices include the following:
No systemic glutamine for the prevention of gastrointestinal mucositis.
No sucralfate or antibiotic lozenges for radiation-induced mucositis.
No granulocyte-macrophage colony-stimulating factor mouthwashes.
Oral mucositis in hematopoietic stem cell transplantation patients produces clinically significant toxicities that require multiprofessional interventions.[18,19,20,21,22,23,24,25] The lesion can increase risk of systemic infection,[1] produce clinically significant pain,[26][Level of evidence: II] and promote oral hemorrhage. It can also compromise the upper airway such that endotracheal intubation is required. Use of total parenteral nutrition is often necessary because of the patient's inability to receive enteral nutrition.
Once mucositis has developed, its severity and the patient's hematologic status govern appropriate oral management. Meticulous oral hygiene and palliation of symptoms are essential. Some established guidelines for oral care include oral assessments twice daily for hospitalized patients and frequent oral care (minimum of every 4 hours and at bedtime) that increases in frequency as the severity of mucositis increases.
Oral care protocols generally include atraumatically cleansing the oral mucosa, maintaining lubrication of the lips and oral tissues, and relieving pain and inflammation. Several health professional organizations have produced evidence-based oral mucositis guidelines. These organizations include but are not limited to the following:
Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology [17]
National Comprehensive Cancer Network [27]
European Society of Medical Oncology [11]
European Oncology Nursing Society
The Cochrane Collaboration [28,29]
In many cases, there is similarity in recommendations across the organizations. The Cochrane Collaboration, however, uses a meta-analysis approach and thus provides a unique context for purposes of guideline construction.
Palifermin (Kepivance), also known as keratinocyte growth factor-1, has been approved to decrease the incidence and duration of severe oral mucositis in patients with hematologic cancers undergoing conditioning with high-dose chemotherapy, with or without radiation therapy, followed by hematopoietic stem cell rescue.[9][Level of evidence: I] The standard dosing regimen is three daily doses before conditioning and three additional daily doses starting on day 0 (day of transplant). Palifermin has also been shown in a randomized, placebo-controlled trial to reduce the incidence of oral mucositis in patients with metastatic colorectal cancer treated with fluorouracil-based chemotherapy.[30][Level of evidence: I] In addition, a single dose of palifermin prevented severe oral mucositis in patients who had sarcoma and were receiving doxorubicin-based chemotherapy.[31][Level of evidence: I]
In two randomized, placebo-controlled trials conducted in head/neck cancer patients undergoing postoperative chemoradiotherapy and in patients receiving definitive chemoradiotherapy for locally advanced head/neck cancer, intravenous palifermin administered weekly for 8 weeks decreased severe oral mucositis,[32,33][Level of evidence: I] as graded by providers using standard toxicity assessments and during multicycle chemotherapy.[31] Patient-reported outcomes related to mouth and throat soreness and to treatment breaks or compliance were not significantly different between arms in either trial. In one study, opioid analgesic use was also not significantly different between arms.[33]
Evidence from several studies has supported the potential efficacy of low-level laser therapy in addition to oral care to decrease the duration of chemotherapy-induced oral mucositis in children.[34][Level of evidence: I][35][Level of evidence: I]
Mucositis Management
Bland rinses:
0.9% saline solution.
Sodium bicarbonate solution.
0.9% saline/sodium bicarbonate solution.
Topical anesthetics:
Lidocaine: viscous, ointments, sprays.
Benzocaine: sprays, gels.
0.5% or 1.0% dyclonine hydrochloride (HCl).
Diphenhydramine solution.
Mucosal coating agents:
Amphojel.
Kaopectate.
Hydroxypropyl methylcellulose film-forming agents (e.g., Zilactin).
Gelclair (approved by the U.S. Food and Drug Administration [FDA] as a device).
Analgesics:
Benzydamine HCl topical rinse (not approved in the United States).
Opioid drugs: oral, intravenous (e.g., bolus, continuous infusion, patient-controlled analgesia [PCA]), patches, transmucosal.
Growth factor (keratinocyte growth factor-1):
Palifermin (approved by the FDA in December 2004 to decrease the incidence and duration of severe oral mucositis in patients undergoing high-dose chemotherapy with or without radiation therapy followed by bone marrow transplant for hematologic cancers).
Management of oral mucositis via topical approaches should address efficacy, patient acceptance, and appropriate dosing. A stepped approach is typically used, with progression from one level to the next as follows:
Bland rinses (e.g., 0.9% normal saline and/or sodium bicarbonate solutions).
Mucosal coating agents (e.g., antacid solutions, kaolin solutions).
Water-soluble lubricating agents, including artificial saliva for xerostomia.
Topical anesthetics (e.g., viscous lidocaine, benzocaine sprays/gels, dyclonine rinses, diphenhydramine solutions).
Cellulose film-forming agents for covering localized ulcerative lesions (e.g., hydroxypropyl cellulose).
Normal saline solution is prepared by adding approximately 1 tsp of table salt to 32 oz of water. The solution can be administered at room or refrigerated temperatures, depending on patient preference. The patient should rinse and swish approximately 1 tbsp, followed by expectoration; this can be repeated as often as necessary to maintain oral comfort. Sodium bicarbonate (1–2 tbsp/qt) can be added, if viscous saliva is present. Saline solution can enhance oral lubrication directly as well as by stimulating salivary glands to increase salivary flow.
A soft toothbrush that is replaced regularly should be used to maintain oral hygiene.[17] Foam-swab brushes do not effectively clean teeth and should not be considered a routine substitute for a soft nylon-bristled toothbrush; additionally, the rough sponge surface may irritate and damage the mucosal surfaces opposite the tooth surfaces being brushed.
On the basis of nonoral mucosa wound-healing studies, the repeated use of hydrogen peroxide rinses for daily preventive oral hygiene is not recommended, especially if mucositis is present, because of the potential for damage to fibroblasts and keratinocytes, which can cause delayed wound healing.[36,37,38,39] Using 3% hydrogen peroxide diluted 1:1 with water or normal saline to remove hemorrhagic debris may be helpful; however, this approach should only be used for 1 or 2 days because more extended use may impair timely healing of mucosal lesions associated with bleeding.[40]
Focal topical application of anesthetic agents is preferred over widespread oral topical administration, unless the patient requires more extensive pain relief. Products such as the following may provide relief:
2% viscous lidocaine
Diphenhydramine solution
One of the many extemporaneously prepared mixtures combining the following coating agents with topical anesthetics:
Milk of magnesia.
Kaolin with pectin suspension.
Mixtures of aluminum.
Magnesium hydroxide suspensions (many antacids).
The use of compounded topical anesthetic rinses should be considered carefully relative to the cost of compounding these products versus their actual efficacy.
Irrigation should be performed before topical medication is applied because removal of debris and saliva allows for better coating of oral tissues and prevents material from accumulating. Frequent rinsing cleans and lubricates tissues, prevents crusting, and palliates painful gingiva and mucosa.
Systemic analgesics should be administered when topical anesthetic strategies are not sufficient for clinical relief. Opiates are typically used;[26][Level of evidence: II] the combination of chronic indwelling venous catheters and computerized drug administration pumps to provide PCA has significantly increased the effectiveness of controlling severe mucositis pain while lowering the dose and side effects of narcotic analgesics. Nonsteroidal anti-inflammatory drugs that affect platelet adhesion and damage gastric mucosa are contraindicated, especially if thrombocytopenia is present.
Although mucositis continues to be one of the dose-limiting toxicities of fluorouracil (5-FU), cryotherapy may be an option for preventing oral mucositis. Because 5-FU has a short half-life (5–20 minutes), patients are instructed to swish ice chips in their mouths for 30 minutes, beginning 5 minutes before 5-FU is administered.[41][Level of evidence: I] Oral cryotherapy has been studied in patients receiving high-dose melphalan conditioning regimens used with transplantation;[42,43] further research is needed.
Many agents and protocols have been promoted for management or prevention of mucositis.[44,45,46] Although not adequately supported by controlled clinical trials, allopurinol mouthwash and vitamin E have been cited as agents that decrease the severity of mucositis. Prostaglandin E2 was not effective as a prophylaxis of oral mucositis following bone marrow transplant, although studies indicate possible efficacy when prostaglandin E2 is administered via a different dosing protocol.
Current Clinical Trials
Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.
References:
Sonis ST: Mucositis as a biological process: a new hypothesis for the development of chemotherapy-induced stomatotoxicity. Oral Oncol 34 (1): 39-43, 1998.
Lalla RV, Brennan MT, Schubert MM: Oral complications of cancer therapy. In: Yagiela JA, Dowd FJ, Johnson BS, et al., eds.: Pharmacology and Therapeutics for Dentistry. 6th ed. St. Louis, Mo: Mosby Elsevier, 2011, pp 782-98.
Sonis ST, Elting LS, Keefe D, et al.: Perspectives on cancer therapy-induced mucosal injury: pathogenesis, measurement, epidemiology, and consequences for patients. Cancer 100 (9 Suppl): 1995-2025, 2004.
Barasch A, Peterson DE: Risk factors for ulcerative oral mucositis in cancer patients: unanswered questions. Oral Oncol 39 (2): 91-100, 2003.
Ezzeldin HH, Diasio RB: Predicting fluorouracil toxicity: can we finally do it? J Clin Oncol 26 (13): 2080-2, 2008.
Schwab M, Zanger UM, Marx C, et al.: Role of genetic and nongenetic factors for fluorouracil treatment-related severe toxicity: a prospective clinical trial by the German 5-FU Toxicity Study Group. J Clin Oncol 26 (13): 2131-8, 2008.
Werbrouck J, De Ruyck K, Duprez F, et al.: Acute normal tissue reactions in head-and-neck cancer patients treated with IMRT: influence of dose and association with genetic polymorphisms in DNA DSB repair genes. Int J Radiat Oncol Biol Phys 73 (4): 1187-95, 2009.
Hahn T, Zhelnova E, Sucheston L, et al.: A deletion polymorphism in glutathione-S-transferase mu (GSTM1) and/or theta (GSTT1) is associated with an increased risk of toxicity after autologous blood and marrow transplantation. Biol Blood Marrow Transplant 16 (6): 801-8, 2010.
Spielberger R, Stiff P, Bensinger W, et al.: Palifermin for oral mucositis after intensive therapy for hematologic cancers. N Engl J Med 351 (25): 2590-8, 2004.
Peterson DE, Barker NP, Akhmadullina LI, et al.: Phase II, randomized, double-blind, placebo-controlled study of recombinant human intestinal trefoil factor oral spray for prevention of oral mucositis in patients with colorectal cancer who are receiving fluorouracil-based chemotherapy. J Clin Oncol 27 (26): 4333-8, 2009.
Peterson DE, Bensadoun RJ, Roila F, et al.: Management of oral and gastrointestinal mucositis: ESMO clinical recommendations. Ann Oncol 20 (Suppl 4): 174-7, 2009.
Schubert MM, Williams BE, Lloid ME, et al.: Clinical assessment scale for the rating of oral mucosal changes associated with bone marrow transplantation. Development of an oral mucositis index. Cancer 69 (10): 2469-77, 1992.
Sonis ST, Eilers JP, Epstein JB, et al.: Validation of a new scoring system for the assessment of clinical trial research of oral mucositis induced by radiation or chemotherapy. Mucositis Study Group. Cancer 85 (10): 2103-13, 1999.
McGuire DB, Peterson DE, Muller S, et al.: The 20 item oral mucositis index: reliability and validity in bone marrow and stem cell transplant patients. Cancer Invest 20 (7-8): 893-903, 2002.
Larson PJ, Miaskowski C, MacPhail L, et al.: The PRO-SELF Mouth Aware program: an effective approach for reducing chemotherapy-induced mucositis. Cancer Nurs 21 (4): 263-8, 1998.
Schubert MM: Oro-pharyngeal mucositis. In: Atkinson K, ed.: Clinical Bone Marrow and Blood Stem Cell Transplantation. 2nd ed. Cambridge, UK: Cambridge University Press, 2000, pp 812-20.
Keefe DM, Schubert MM, Elting LS, et al.: Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer 109 (5): 820-31, 2007.
Elting LS, Cooksley C, Chambers M, et al.: The burdens of cancer therapy. Clinical and economic outcomes of chemotherapy-induced mucositis. Cancer 98 (7): 1531-9, 2003.
Elting LS, Cooksley CD, Chambers MS, et al.: Risk, outcomes, and costs of radiation-induced oral mucositis among patients with head-and-neck malignancies. Int J Radiat Oncol Biol Phys 68 (4): 1110-20, 2007.
Lalla RV, Sonis ST, Peterson DE: Management of oral mucositis in patients who have cancer. Dent Clin North Am 52 (1): 61-77, viii, 2008.
Peterson DE, Lalla RV: Oral mucositis: the new paradigms. Curr Opin Oncol 22 (4): 318-22, 2010.
Rosenthal DI: Consequences of mucositis-induced treatment breaks and dose reductions on head and neck cancer treatment outcomes. J Support Oncol 5 (9 Suppl 4): 23-31, 2007.
Sonis ST, Oster G, Fuchs H, et al.: Oral mucositis and the clinical and economic outcomes of hematopoietic stem-cell transplantation. J Clin Oncol 19 (8): 2201-5, 2001.
Sonis ST: Regimen-related gastrointestinal toxicities in cancer patients. Curr Opin Support Palliat Care 4 (1): 26-30, 2010.
Trotti A, Bellm LA, Epstein JB, et al.: Mucositis incidence, severity and associated outcomes in patients with head and neck cancer receiving radiotherapy with or without chemotherapy: a systematic literature review. Radiother Oncol 66 (3): 253-62, 2003.
Pillitteri LC, Clark RE: Comparison of a patient-controlled analgesia system with continuous infusion for administration of diamorphine for mucositis. Bone Marrow Transplant 22 (5): 495-8, 1998.
Bensinger W, Schubert M, Ang KK, et al.: NCCN Task Force Report. prevention and management of mucositis in cancer care. J Natl Compr Canc Netw 6 (Suppl 1): S1-21; quiz S22-4, 2008.
Clarkson JE, Worthington HV, Furness S, et al.: Interventions for treating oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev (8): CD001973, 2010.
Worthington HV, Clarkson JE, Bryan G, et al.: Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev 12: CD000978, 2010.
Rosen LS, Abdi E, Davis ID, et al.: Palifermin reduces the incidence of oral mucositis in patients with metastatic colorectal cancer treated with fluorouracil-based chemotherapy. J Clin Oncol 24 (33): 5194-200, 2006.
Vadhan-Raj S, Trent J, Patel S, et al.: Single-dose palifermin prevents severe oral mucositis during multicycle chemotherapy in patients with cancer: a randomized trial. Ann Intern Med 153 (6): 358-67, 2010.
Henke M, Alfonsi M, Foa P, et al.: Palifermin decreases severe oral mucositis of patients undergoing postoperative radiochemotherapy for head and neck cancer: a randomized, placebo-controlled trial. J Clin Oncol 29 (20): 2815-20, 2011.
Le QT, Kim HE, Schneider CJ, et al.: Palifermin reduces severe mucositis in definitive chemoradiotherapy of locally advanced head and neck cancer: a randomized, placebo-controlled study. J Clin Oncol 29 (20): 2808-14, 2011.
Kuhn A, Porto FA, Miraglia P, et al.: Low-level infrared laser therapy in chemotherapy-induced oral mucositis: a randomized placebo-controlled trial in children. J Pediatr Hematol Oncol 31 (1): 33-7, 2009.
Schubert MM, Eduardo FP, Guthrie KA, et al.: A phase III randomized double-blind placebo-controlled clinical trial to determine the efficacy of low level laser therapy for the prevention of oral mucositis in patients undergoing hematopoietic cell transplantation. Support Care Cancer 15 (10): 1145-54, 2007.
National Institutes of Health Consensus Development Conference on Oral Complications of Cancer Therapies: Diagnosis, Prevention, and Treatment. Bethesda, Maryland, April 17-19, 1989. NCI Monogr (9): 1-184, 1990.
Bavier AR: Nursing management of acute oral complications of cancer. NCI Monogr (9): 123-8, 1990.
Takahashi A, Aoshiba K, Nagai A: Apoptosis of wound fibroblasts induced by oxidative stress. Exp Lung Res 28 (4): 275-84, 2002.
Bennett LL, Rosenblum RS, Perlov C, et al.: An in vivo comparison of topical agents on wound repair. Plast Reconstr Surg 108 (3): 675-87, 2001.
Schubert MM, Peterson DE: Oral complications of hematopoietic cell transplantation. In: Appelbaum FR, Forman SJ, Negrin RS, et al., eds.: Thomas' Hematopoietic Cell Transplantation: Stem Cell Transplantation. 4th ed. Oxford, UK: Wiley-Blackwell, 2009, pp 1589-1607.
Rocke LK, Loprinzi CL, Lee JK, et al.: A randomized clinical trial of two different durations of oral cryotherapy for prevention of 5-fluorouracil-related stomatitis. Cancer 72 (7): 2234-8, 1993.
Mori T, Yamazaki R, Aisa Y, et al.: Brief oral cryotherapy for the prevention of high-dose melphalan-induced stomatitis in allogeneic hematopoietic stem cell transplant recipients. Support Care Cancer 14 (4): 392-5, 2006.
Ohbayashi Y, Imataki O, Ohnishi H, et al.: Multivariate analysis of factors influencing oral mucositis in allogeneic hematopoietic stem cell transplantation. Ann Hematol 87 (10): 837-45, 2008.
Lugliè PF, Mura G, Mura A, et al.: [Prevention of periodontopathy and oral mucositis during antineoplastic chemotherapy. Clinical study] Minerva Stomatol 51 (6): 231-9, 2002.
Cheng KK, Molassiotis A, Chang AM, et al.: Evaluation of an oral care protocol intervention in the prevention of chemotherapy-induced oral mucositis in paediatric cancer patients. Eur J Cancer 37 (16): 2056-63, 2001.
Wardley AM, Jayson GC, Swindell R, et al.: Prospective evaluation of oral mucositis in patients receiving myeloablative conditioning regimens and haemopoietic progenitor rescue. Br J Haematol 110 (2): 292-9, 2000.
Orofacial Pain in Cancer Patients
Pain in cancer patients may arise from onset of the disease through survivorship and may be:[1]
Caused by the malignant disease.
Caused by acute or chronic complications of cancer therapy.
Coincidental and unrelated to the cancer.
Cancer pain causes increased morbidity, reduced performance status, increased anxiety and depression, and diminished quality of life (QOL). Dimensions of acute and chronic pain include the following:
Sensory
Physiologic
Affective
Cognitive
Behavioral
Sociocultural
Management of head and neck pain and oral pain may be particularly challenging because eating, speech, swallowing, and other motor functions of the head and neck and oropharynx are constant pain triggers.
Orofacial Pain due to Cancer
Acute and chronic pain in cancer can result from several factors, including the following:
Pain due to malignant disease:
Local/regional cancer.
Oral involvement in systemic/hematopoietic cancer.
Metastatic disease.
Pain due to treatment:
Surgery.
Radiation.
Chemotherapy.
Pain unrelated to malignancy.
Pain at diagnosis is often low intensity but typically becomes more frequent and severe with advancing disease. Cancer pain may be caused by local and distant tumor effects. Direct invasion by cancer may cause pain and may result from inflammatory and neuropathic mechanisms. Effective prevention and management of pain in cancer requires knowledge of the factors and mechanisms involved.
It is estimated that 45% to 80% of all cancer patients have inadequate pain management. Seventy-five percent to 90% of patients with terminal or advanced cancer may have pain. Pain may be present in up to 85% of patients with head and neck cancers (HNCs) at diagnosis.
Orofacial pain associated with cancer management is a well-recognized adverse effect of treatment. Pain due to oral mucositis is the most frequently reported patient-related complaint during cancer therapy. Severe and painful mucositis is associated with additional hospital admissions and prolonged periods in hospital, leading to delayed, interrupted, or altered cancer therapy protocols that may affect prognosis, QOL, and cost of care. Graft-versus-host disease (GVHD) is a common complication of allogeneic hematopoietic cell transplant (HCT), occurring in 25% to 70% of patients; oral lesions are often painful.
In addition to HNCs, oral manifestations of leukemia and lymphoma may cause pain and loss of function. Lymphomas and leukemias may induce pain by infiltration of pain-sensitive structures and if secondary oral infection occurs. Multiple myeloma frequently presents with pain and, when associated with teeth, presents a diagnostic challenge. Intracranial malignancies may give rise to orofacial pain and headache. Even in diagnosed cancer patients, the prediction of intracranial metastases with new or changed headache is difficult.
Pain may present similarly to classical trigeminal neuralgia. Jaw pain may be caused by metastatic cancer, and tumors arising from the breast, prostate, thyroid, lung, and kidney have a propensity to spread to bone in the head and neck, most commonly seen in the posterior mandible. Metastasis in the oral region may be the first indication of a distant undiscovered malignancy in up to 60% of patients. Patients with nasopharyngeal cancer report pain that may be referred to the temporomandibular joint region and masquerade as temporomandibular disorder. Orofacial pain has been reported in patients with a distant nonmetastasized cancer, most commonly in the lungs.
The mechanism of pain is thought to be involvement of the vagus or phrenic nerve. Paraneoplastic processes may present with peripheral neuropathies, particularly in patients with lung cancer and lymphoma. Neuropathies are commonly reported in patients with malignancy (1.7%–5.5%) because of the direct effects of the tumor, paraneoplastic syndromes, and treatment-related toxicities.
Orofacial Pain due to Cancer Management
The most common acute oral side effect of radiation therapy and/or cancer chemotherapy is oral mucositis. Oral mucositis and associated pain are the most distressing symptoms reported by patients receiving head and neck radiation therapy and aggressive neutropenia-inducing chemotherapy regimens. Combined chemotherapy and radiation therapy results in increased frequency, severity, and duration of mucositis. (Refer to the Oral Mucositis section of this summary for more information.)
Mucositis pain may interfere with daily activities in approximately one-third of patients, interfering with social activities and mood in more than half. Mucosal pain may persist long after the mucositis resolves. Reports of mucosal sensitivity at 1-year follow-up are common, suggesting that chronic symptoms may be related to tissue change, including epithelial atrophy and/or neuropathy.
Orofacial pain after HNC therapy can be caused by musculoskeletal syndromes, including temporomandibular disorders associated with muscular fibrosis, scar formation, and discontinuity of the jaw. Ablative surgery may lead to tissue defects that may cause significant loss of orofacial function. Resection of the maxilla and mandible leads to sensory impairment, and more than half of patients experience regional hyperalgesia or allodynia. Pain scores after surgery for HNCs are highest for oral cavity cancers, followed by cancers of the larynx and oropharynx.
At more than 6 months postsurgery, impairment due to moderate to severe pain may be seen in approximately one-third of patients. Analgesics and physiotherapy are commonly used in pain management in these patients. Long-term HNC survivors (>3 years) continue to suffer from more pain and functional problems. Surgery-related pain involves inflammatory and neuropathic pain mechanisms.
Postradiation osteonecrosis and bisphosphonate-associated osteonecrosis are recognized oral complications that may cause pain; clinical presentation may include pain, swelling, and bone exposure. Oral GVHD represents a local manifestation of a systemic disease post-HCT that may result in mucosal and arthritic pain. Viral reactivation of herpes viruses may cause pain. Postherpetic neuralgia may result in chronic pain causing painful dysesthesias in the affected area that may persist for years.
Treatment of Pain in Cancer Patients
Pain management should be directed at the diagnoses of etiologic factors, pain mechanisms involved, and pain severity. (Refer to the PDQ summary on Cancer Pain for more information.) Pain mechanisms in cancer include the following:
Inflammation.
Malignant disease.
Complications of treatment.
Infection.
Tumor invasion, pressure on structures, or ulceration of mucosal surface.
Nociceptive pain.
Neuropathic pain.
Management of pain due to oral mucositis
Oral mucositis pain is associated with release of proinflammatory cytokines and neurotransmitters that activate nociceptors at the site of injury and may be increased by secondary mucosal infection. Pain experience is influenced by anxiety, depression, sociocultural variation, and quality and quantity of sleep.
Topical approaches for mucosal pain relief
Topical anesthetics have a limited duration of effect in mucositis pain (15–30 minutes), may sting with application on damaged mucosa, and affect taste and the gag reflex. Some patients will apply local anesthetics directly to specific sites of ulceration, but no controlled studies have been reported.
Topical anesthetics are often mixed with coating and antimicrobial agents such as milk of magnesia, diphenhydramine, or nystatin but have not been subjected to controlled studies. However, these mixtures result in dilution of each component, which may limit the therapeutic effect. In addition, various agents in the mix may interact, reducing the effect of the components.
Topical benzydamine (not available in the United States), an anti-inflammatory and analgesic/anesthetic agent, has been shown in randomized controlled studies to reduce pain in oral mucositis and reduce the need for systemic analgesics.[2] Other topical approaches include the following:
A single application of topical doxepin, a tricyclic antidepressant, in cancer patients produces analgesia for 4 hours or longer.[1] Besides producing an extended period of pain relief, application of topical doxepin to damaged mucosa is not accompanied by burning.
Topical morphine has been shown to be effective for relieving pain,[1] but there is concern about dispensing large volumes of the medication.
Topical fentanyl prepared as lozenges administered in a randomized placebo-controlled study showed relief of oral mucositis pain.
Topical capsaicin has been studied for the control of oral mucositis pain [3] but is poorly tolerated by patients. Pretreatment initiation of capsaicin may represent an approach to desensitize patients before the onset of mucositis.
Topical coating agents may reduce pain in mucositis. Coating agents such as sucralfate may have a role to play in mucosal pain management but not in reducing tissue damage.
Systemic medications
Pain management strategies directed at diagnoses and pain mechanisms include the following:
Topical anesthetics/analgesics.
Topical before systemic therapies; if topicals are effective, continue while adding systemic analgesics.
Systemic analgesics.
Adjuvant medications (muscle relaxants, anti-inflammatories, antianxiety medications, antidepressants, anticonvulsants).
Adjuvant therapies (physiotherapy, relaxation, cognitive-behavioral therapies, counseling).
Palliative radiation therapy.
Additional and nonpharmacologic pain management techniques in oncology include the following:
Transcutaneous electrical nerve stimulation.
Cold/moist heat applications.
Hypnosis.
Acupuncture.
Psychological approaches:
Distraction.
Relaxation/imagery.
Cognitive/behavioral therapy.
Music therapy, drama therapy.
Counseling.
Suggestions for the use of opioids in cancer pain include the following:
Use the lowest effective dose.
Base time-contingent prescription on drug characteristics.
Provide analgesics for breakthrough pain.
Combine with nonopioid analgesics.
Provide prophylaxis/treatment for constipation.
Conduct regular pain assessment and modify management, depending on pain control.
Follow steps in World Health Organization (WHO) analgesic ladder.
The WHO analgesic ladder is a three-step strategy for managing pain in cancer patients.[4] Pain management must be directed at the severity of pain; the lowest dose of strong opioids (step 3 in the WHO ladder) may be chosen instead of weak opioids for better pain control.[5,6]
Analgesics should be provided on a time-contingent basis to provide a steady state of analgesia; when needed, medication should be available to manage breakthrough pain. Adjuvant medications such as tricyclic antidepressants, gabapentin, and other centrally acting pain medications should be considered, particularly in light of the developing understanding of the common neuropathic mechanisms involved in cancer pain (see list of pain mechanisms).[6,7,8] Regular assessment of pain and modification of pain medications are necessary.
Transdermal fentanyl is widely used for extended duration therapy in the management of pain in the outpatient setting. Cyclooxygenase-2 (COX-2) is upregulated in mucositis; therefore, COX-2 inhibitors represent potential agents that may affect pain and evolution of mucositis.
Adjuvant medications should be used in addition to analgesics. Patients who experienced neuropathic cancer pain and received amitriptyline in addition to morphine were studied in a randomized controlled trial.[9][Level of evidence: I] Limited additional analgesic effect and increased drowsiness, confusion, and dry mouth were observed; however, the central actions of amitriptyline may improve sleep.
Gabapentin is a voltage-sensitive sodium and calcium channel blocker that is used for management of a variety of pain conditions and may improve pain control when used in addition to morphine in cancer patients. Drugs that affect the N-methyl-D-aspartate receptor may affect neuropathic pain; gabapentin is one of these and is well tolerated. Other agents that may be used in pain management include the following:
Cannabinoids.
Alpha-2 adrenergic receptor agonists.
Nicotine.
Lidocaine.
Ketamine.
Addiction in opioid therapy is not generally a concern for cancer patients; the focus should be on escalating to stronger opioids as needed (based on assessment) and using adjuvant approaches to provide adequate pain relief. However, the clinician always should be cognizant of potential drug-seeking behavior by the patient.
Tolerance and physical side effects such as constipation, nausea, vomiting, and mental clouding occur with opioids and should be managed prophylactically, if possible. Stool softeners and other approaches to bowel management should be initiated along with the initial opioid prescription. Adequacy of the approach should be assessed regularly.
Nonpharmacologic pain management strategies
In randomized trials, hypnosis has been shown to be a useful pain management strategy for cancer patients. Additional psychological techniques such as counseling, distraction, relaxation techniques, and other cognitive and behavioral training programs have been described (see list of psychological approaches to pain management techniques).
Physical management of orofacial pain includes the use of ice chips for oral cooling, cold compresses, and physical therapy. Acupuncture (refer to the PDQ summary on Acupuncture for more information), transcutaneous nerve stimulation, group therapy, self-hypnosis, relaxation, imagery, cognitive behavioral training, and massage therapy have been considered to alleviate pain in cancer patients. Relaxation and imagery may alleviate pain due to oral mucositis.[1,3];[10][Level of evidence: I][11]
Orofacial Pain Summary
Orofacial pain is common in cancer patients and may be caused by the cancer or its treatment. Orofacial pain is frequently associated with locoregional cancer, but it can also be a sign of systemic and distant cancer.
Pain management requires diagnosis of the various causes and mechanisms of pain in cancer patients. Practitioners must obtain regular pain ratings during the treatment of patients with cancer-related pain. Because pain is frequently multifactorial, addressing each of the dimensions of a patient's pain can improve pain control. Attention should be paid to the patient's overall medical status and oral status.
It is important to recognize and manage the side effects of analgesic therapy, especially those induced by opioids and adjuvant medications. Use of effective topical pain therapy with the initial mucosal injury may allow for reduced duration or reduced doses of systemic medications. Awareness of adjuvant approaches to management is essential; both medications and complementary management with evidence of effect should be considered.
References:
Epstein JB, Elad S, Eliav E, et al.: Orofacial pain in cancer: part II--clinical perspectives and management. J Dent Res 86 (6): 506-18, 2007.
Kazemian A, Kamian S, Aghili M, et al.: Benzydamine for prophylaxis of radiation-induced oral mucositis in head and neck cancers: a double-blind placebo-controlled randomized clinical trial. Eur J Cancer Care (Engl) 18 (2): 174-8, 2009.
Berger A, Henderson M, Nadoolman W, et al.: Oral capsaicin provides temporary relief for oral mucositis pain secondary to chemotherapy/radiation therapy. J Pain Symptom Manage 10 (3): 243-8, 1995.
Meuser T, Pietruck C, Radbruch L, et al.: Symptoms during cancer pain treatment following WHO-guidelines: a longitudinal follow-up study of symptom prevalence, severity and etiology. Pain 93 (3): 247-57, 2001.
Eisenberg E, Marinangeli F, Birkhahn J, et al.: Time to modify the WHO analgesic ladder? Pain: Clinical Updates 13 (5): 1-4, 2005. Also available online. Last accessed January 5, 2018.
Benedetti C, Brock C, Cleeland C, et al.: NCCN Practice Guidelines for Cancer Pain. Oncology (Williston Park) 14 (11A): 135-50, 2000.
Ripamonti C, Dickerson ED: Strategies for the treatment of cancer pain in the new millennium. Drugs 61 (7): 955-77, 2001.
Rankin KV, Jones DL, Redding SW, eds.: Oral Health in Cancer Therapy: A Guide for Health Care Professionals. 3rd ed. Austin, Tex: Dental Oncology Education Program, 2008.
Mercadante S, Arcuri E, Tirelli W, et al.: Amitriptyline in neuropathic cancer pain in patients on morphine therapy: a randomized placebo-controlled, double-blind crossover study. Tumori 88 (3): 239-42, 2002 May-Jun.
Mercadante S, Fulfaro F, Casuccio A: A randomised controlled study on the use of anti-inflammatory drugs in patients with cancer pain on morphine therapy: effects on dose-escalation and a pharmacoeconomic analysis. Eur J Cancer 38 (10): 1358-63, 2002.
Epstein JB, Hong C, Logan RM, et al.: A systematic review of orofacial pain in patients receiving cancer therapy. Support Care Cancer 18 (8): 1023-31, 2010.
Infection
The multiple protective-barrier functions associated with normal oral mucosa directly affect risk of acute infection. Normal oral mucosa reduces levels of oral microorganisms colonizing the mucosa by shedding the surface layer; it also limits penetration of many compounds into the epithelium by maintaining a chemical barrier.[1] Normal salivary gland function promotes mucosal health.
Oral mucositis can be complicated by infection in the immunocompromised patient. Specific organisms may play a role in upregulating proinflammatory cytokines via bacterial metabolic products such as liposaccharides. Also, oral organisms can disseminate systemically in the setting of ulcerative oral mucositis and profound, prolonged neutropenia.[2,3,4,5]
Both indigenous oral flora and hospital-acquired pathogens have been associated with bacteremias and systemic infection. As the absolute neutrophil count falls below 1,000/mm3, incidence and severity of infection rise.[6] Patients with prolonged neutropenia are at higher risk of developing serious infectious complications.[7,8] Compromised salivary function can elevate risk of infection of oral origin.
Other oral sites, including the dentition, periapices, and periodontium, can also become acutely infected during myelosuppression secondary to high-dose chemotherapy.[9,10,11,12] A systematic review of the MEDLINE/PubMed and EMBASE databases for articles published between January 1, 1990, and December 31, 2008, reported (from three studies) that the weighted prevalence of dental infection/abscess during chemotherapy was 5.8% (standard of error, 0.009; 95% confidence interval [CI], 1.8–9.7).[13] Dental management before cytoreductive therapy is initiated can substantially reduce the risk of these infectious complications.[14,15,16]
Bacterial Infection
Changes in infection profiles in myelosuppressed cancer patients have occurred over the past three decades. This evolving epidemiology has been caused by multiple factors, including the use of prophylactic and therapeutic antimicrobial regimens and decreased depth and duration of myelosuppression via growth factor therapy.[17] Gram-positive organisms, including viridans streptococci and Enterococci species, are associated with systemic infection of oral origin. In addition, gram-negative pathogens, including Pseudomonas aeruginosa, Neisseria species, and Escherichia coli, remain of concern.
Myeloablated cancer patients with chronic periodontal disease may develop acute periodontal infections, with associated systemic sequelae.[3,9,10,11,12] Extensive ulceration of sulcular epithelium associated with periodontal disease is not directly observable yet may represent a source of disseminated infection by a wide variety of organisms. Inflammatory signs may be masked by the underlying myelosuppression. Thus, neutropenic mouth care protocols that reduce microbial colonization of the dentition and periodontium are important during myelosuppression. Topical therapy may include the following:
Oral rinses with 0.12% chlorhexidine digluconate.
Irrigation with effervescent (peroxide) agents, which may affect anaerobic bacteria colonizing the periodontal pocket.
Gentle mechanical plaque removal, including dental brushing and flossing.
Pulpal/periapical infections of dental origin can cause complications for the chemotherapy patient.[14] Such lesions should be eliminated before chemotherapy begins. Prechemotherapy endodontic therapy should be completed at least 10 days before chemotherapy begins. Teeth with poor prognoses should be extracted, using the 10-day window as a guide. Specific management guidelines are delineated in the NIH Consensus Conference statement.[14,15]
Ill-fitting, removable prosthetic appliances can traumatize oral mucosa and increase the risk of microbial invasion into deeper tissues. Denture-soaking cups can readily become colonized with a variety of pathogens, including P. aeruginosa, E. coli, Enterobacter species, Staphylococcus aureus, Klebsiella species, and Candida albicans. Dentures should be evaluated before chemotherapy begins and adjusted as necessary to reduce risk of trauma. Denture-cleansing solutions should be changed daily. In general, dentures should not be worn when the patient has ulcerative mucositis and is neutropenic (i.e., absolute neutrophil count <500 cells/mm3).
Fungal Infection
Candidiasis
Candidiasis is typically caused by opportunistic overgrowth of C. albicans, a normal inhabitant of the oral cavity in a large proportion of individuals. Several variables contribute to its clinical expression, including drug- or disease-induced immunosuppression, mucosal injury, and salivary compromise. In addition, use of antibiotics may alter the oral flora, thereby creating a favorable environment for fungal overgrowth.[18]
A systematic review indicated that the weighted mean prevalence of clinical oral fungal infection during chemotherapy is 38%.[19] The most common forms of intraoral candidiasis reported in oncology patients are pseudomembranous and erythematous candidiasis.[20,21] Pseudomembranous candidiasis can usually be diagnosed on the basis of its characteristic clinical appearance and may be accompanied by burning pain and taste changes. The appearance of erythematous candidiasis is relatively nonspecific, and laboratory testing may be needed to confirm the diagnosis. It may be accompanied by a burning sensation of the affected tissues.
Topical oral antifungal agents such as nystatin rinse and clotrimazole troches are often used but appear to have variable efficacy in preventing or treating fungal infection in neutropenic patients.[22,23] Patients who wear removable dental prostheses (e.g., partial or full denture) should remove them before the oral antifungal agents are used. Dentures can also be treated by soaking them overnight in the antifungal solution.
Although topical agents may be helpful for superficial oral candidiasis, systemic agents should be used for persistent fungal infections and in patients with significant immunosuppression. Systemic fluconazole is highly effective for prophylaxis and treatment of oral fungal infections in the oncology population.[19]
Noncandidal fungal infections
An increasing number of different fungal organisms are being associated with oral infection in immunocompromised cancer patients, including infection by species of Aspergillus, Mucormycosis, and Rhizopus.[3,23] The clinical presentation is not pathognomonic; lesions may appear similar to lesions caused by other oral toxicities. Microbiologic documentation is essential. Systemic therapy must be instituted promptly because of the high risk of morbidity and mortality.
Viral Infections
Herpes virus
Herpes group viral infections, including those caused by oral lesions, can cause a variety of diseases that range from mild to serious conditions in patients undergoing treatment for cancer.[24] The severity and impact of these lesions and systemic sequelae are directly related to the degree of immunocompromisation of the patient. Comorbid oral conditions such as mucositis or graft-versus-host disease can dramatically increase the severity of oral lesions and significantly increase the difficulty of diagnosis.
In most instances, herpes simplex virus (HSV), varicella-zoster virus (VZV), and Epstein-Barr virus (EBV) infections result from reactivation of latent virus, while cytomegalovirus (CMV) infections can result from either reactivation of a latent virus, or via a newly acquired virus. The viral infections can cause oral mucosal lesions. The prevalence of HSV infection was found to be higher when oral ulcers existed than when no oral ulcers were present.[25]
A systematic review was conducted by the Mucositis Study Group (MSG) of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology.[25] One of the aims of this review was to evaluate studies conducted since 1989 that considered the prevalence of oral viral infections. The reported prevalence of oral HSV infection was 49.8% (95% CI, 31.3–68.2%) among neutropenic cancer patients. The prevalence was much lower in head and neck cancer (HNC) patients who were treated with radiation therapy (0%); however, it rose to 43.2% (95% CI, 0–100%) in irradiated HNC patients who were treated with radiation therapy combined with chemotherapy. This finding is not surprising because neutropenic patients—mainly patients with hematological malignancies—develop deeper immunosuppression during cancer treatment than do other groups of cancer patients. However, the addition of chemotherapy to the conventional radiation therapy increased risks for HNC patients.
With the recognition of the increased risk of HSV and VZV reactivation in seropositive patients who are expected to become profoundly immunosuppressed during cancer therapy, prophylaxis with antiviral medications has drastically reduced the incidence of disease, primarily in patients receiving high-dose chemotherapy and undergoing hematopoietic stem cell transplant (HSCT). The MSG systematic review identified a series of randomized controlled trials testing various antiviral prophylactic protocols.[25] It concluded that there was a significant benefit to using acyclovir to prevent HSV oral infection (at 800 mg/d).[26][Level of evidence: I] In addition, the systematic review pointed out that HSV reactivation was reported in a similar prevalence whether acyclovir or valacyclovir was prescribed [27] and that the prevention of HSV reactivation was achieved in various dosing protocols of valacyclovir (500 or 1,000 mg/d).[27]
The Centers for Disease Control and Prevention (CDC), the Infectious Diseases Society of America (IDSA), and the American Society for Blood and Marrow Transplantation (ASBMT) have published guidelines for the prevention of opportunistic infections in HSCT recipients, which have become a benchmark in this field.[28,29] This significant body of literature presents a global perspective on the prevention of viral infections. CDC, IDSA, and ASBMT concluded that acyclovir prophylaxis is recommended for all HSV seropositive allograft recipients. Valacyclovir instead of acyclovir has been ranked moderately as an effective prevention for HSV in HSCT; foscarnet was mentioned as a drug to avoid for routine HSV prophylaxis because of substantial renal toxicity.
These guidelines extend beyond the MSG systematic review, which failed to provide sufficient evidence (e.g., regarding CMV, VZV, and EBV infections) because the evidence available is not specific for infections with oral involvement. The guidelines of these three U.S. societies are in line with the recommendations of the German Society of Hematology [30] and the European Group for Blood and Marrow Transplantation.[31]
Early diagnosis and prompt therapy remain hallmarks of management. Unfortunately, the available literature [25] and the CDC and ASBMT guidelines [28,29] do not refer to treatment recommendations once a viral infection is diagnosed. As with other infections, risk of systemic dissemination and morbidity/mortality increases with degree and duration of immunocompromisation. The infections can be fatal, depending on degree of immunosuppression.
Herpes simplex virus
Oral herpetic lesions can range from routine herpes labialis to severe stomatitis causing large, painful ulcerations throughout the mouth. The severity of lesions dramatically increases with increasing degrees of immunosuppression. The incidence of recurrent oral HSV lesions in myelosuppressed cancer patients has been considerably reduced with the use of prophylactic acyclovir and valacyclovir regimens.[32,33,34] Additionally, the severity and duration of actual HSV lesions have been reduced by antiviral therapies.
Breakthrough infections are uncommon but can occur. While true resistance to antivirals occurs, clinical infection in the face of antiviral therapy is more likely caused by insufficient dosing or compromised gastrointestinal absorption of oral acyclovir. The introduction of valacyclovir appears to have reduced the incidence of breakthrough oral HSV infections. Topical therapy alone is generally not efficacious in the immunocompromised patient.
In patients who are not receiving antiviral prophylaxis, oral lesions typically emerge concurrent with chemotherapy or chemoradiation therapy during the period of most significant immunosuppression (white blood cell nadir). Typically, in HSCT patients, this represents the period a few days pretransplant through day 35 posttransplant. The risk of HSV reactivation remains higher than normal until immune reconstitution occurs. Similar patterns of risk are noted in patients who are receiving high-dose (immunosuppressive) chemotherapy.
Recurrent oral HSV infections occurring simultaneously with cancer therapy–induced oral mucositis can result in the development of extensive, confluent mucosal ulcerations clinically similar to primary herpetic stomatitis. As such, HSV stomatitis can be confused with cancer therapy–induced ulcerative mucositis. Viral cultures from lesions in HSV seropositive patients are essential for accurate diagnoses. Assays that produce more rapid results, including direct immunofluorescence, shell vial testing, and specific immunoassay for HSV antigen and/or biopsy, may also be useful.
Unlike in myelosuppressed cancer patients, incidence of HSV reactivation in patients undergoing head and neck radiation is very low.[25] Therefore, HSV prophylaxis in patients scheduled to receive head and neck radiation is not recommended.
Varicella-zoster virus
VZV infection classically distributes via dermatomes, although the clinical manifestations can be altered in immunocompromised patients, and multiple dermatomes or more widespread distribution of lesions can be seen. In patients who are receiving high-dose chemotherapy, orofacial VZV lesions are typically observed several weeks after cessation of chemotherapy—unlike HSV, which often occurs within 2 to 3 weeks after chemotherapy is discontinued. For reasons that are not entirely clear, the period of increased risk of VZV reactivation essentially extends from approximately 3 to 12 months posttransplant, with allogeneic transplant recipients being at highest risk. Acyclovir, valacyclovir, and famciclovir are the primary drugs used for treatment.[35]
Cytomegalovirus
Oral lesions associated with CMV have been documented in immunocompromised patients, including those who have undergone marrow transplantation.[3]
Appearance is not pathognomonic and is characterized by multiple mild to moderate ulcerations with irregular margins. The lesions initially present during early periods of marrow regeneration (e.g., 3 weeks after chemotherapy is discontinued) and are characterized by nonspecific pseudomembranous fibrin exudate-covered ulcerations with a granulomatous-appearing base. Surface swab cultures may yield false-negative results, perhaps because of viral propensity for infecting endothelial cells and fibroblasts, with resulting low levels of free virus.
Shell vial cultures can enhance identification of CMV, but CMV-specific immunohistochemical staining of biopsy specimens remains the gold standard. Ganciclovir is the treatment of choice for acute CMV infection. Improved prophylactic measures have reduced the incidence of both primary and recurrent CMV infections.[36][Level of evidence: I][37]
Epstein-Barr virus
EBV is linked to tumor development.[38] In addition, oral hairy leukoplakia has been attributed to EBV infection in immunocompromised patients, as seen in HIV-infected patients and solid organ transplant patients. The lesion does not appear to be clinically significant in chemotherapy recipients, however. In contrast, HSCT patients who are immunocompromised for a prolonged period may be at risk of developing EBV-related lymphomas of the head and neck region, especially when T-cell–depleted grafts are used for allogeneic transplant. As such, risk of EBV infection typically emerges months after cessation of myeloablative therapy used for transplant conditioning.
EBV has been associated with nasopharyngeal carcinomas.[39] After treatment (surgery and/or radiation therapy), anti-EBV antibody titers are often noted to decrease; subsequent increases in titers can be associated with recurrence.
Non–herpes group virus infections
Infections caused by non-herpes viruses are more common in immunocompromised patients, with the risk of infection apparently increasing with the depth and duration of immunosuppression. Oral lesions caused by adenovirus and oral human papilloma virus (HPV) have been described.[3] Often, patients with increased cutaneous HPV lesions will demonstrate oral lesions. These lesions can present as hyperkeratotic verrucoid lesions or as flat acuminata-like lesions.
Restoration of immune function will often result in a digression and, possibly, the disappearance of the oral mucosal lesions. Laser surgery or cryotherapy are typically used to remove oral HPV lesions when medically or cosmetically required; intralesional injections of interferon-alpha may prove effective for recurrent lesions. Infection with Coxsackie viruses can occur but is generally viewed as uncommon. Although adenovirus infections are often implicated as a potential cause of oral lesions, their true incidence is not known.[3]
References:
Squier CA, Kremer MJ: Biology of oral mucosa and esophagus. J Natl Cancer Inst Monogr (29): 7-15, 2001.
Lalla RV, Brennan MT, Schubert MM: Oral complications of cancer therapy. In: Yagiela JA, Dowd FJ, Johnson BS, et al., eds.: Pharmacology and Therapeutics for Dentistry. 6th ed. St. Louis, Mo: Mosby Elsevier, 2011, pp 782-98.
Schubert MM, Peterson DE: Oral complications of hematopoietic cell transplantation. In: Appelbaum FR, Forman SJ, Negrin RS, et al., eds.: Thomas' Hematopoietic Cell Transplantation: Stem Cell Transplantation. 4th ed. Oxford, UK: Wiley-Blackwell, 2009, pp 1589-1607.
De Pauw BE, Donnelly JP: Infections in the immunocompromised host: general principles. In: Mandell GL, Bennett JE, Dolin R, eds.: Mandell, Douglas, and Bennett's Principles and Practices of Infectious Diseases. 5th ed. Philadelphia, Pa: Churchill Livingstone, 2000, pp 3079-90.
Kennedy HF, Morrison D, Kaufmann ME, et al.: Origins of Staphylococcus epidermidis and Streptococcus oralis causing bacteraemia in a bone marrow transplant patient. J Med Microbiol 49 (4): 367-70, 2000.
Rolston KVI, Bodey GP: Infections in patients with cancer. In: Hong WK, Bast RC Jr, Hait WN, et al., eds.: Holland-Frei Cancer Medicine. 8th ed. Shelton, Conn: People's Medical Publishing House-USA, 2010, pp 1921-40.
Giamarellou H, Antoniadou A: Infectious complications of febrile leukopenia. Infect Dis Clin North Am 15 (2): 457-82, 2001.
Zambelli A, Montagna D, Da Prada GA, et al.: Evaluation of infectious complications and immune recovery following high-dose chemotherapy (HDC) and autologous peripheral blood progenitor cell transplantation (PBPC-T) in 148 breast cancer patients. Anticancer Res 22 (6B): 3701-8, 2002 Nov-Dec.
Peterson DE, Minah GE, Overholser CD, et al.: Microbiology of acute periodontal infection in myelosuppressed cancer patients. J Clin Oncol 5 (9): 1461-8, 1987.
Graber CJ, de Almeida KN, Atkinson JC, et al.: Dental health and viridans streptococcal bacteremia in allogeneic hematopoietic stem cell transplant recipients. Bone Marrow Transplant 27 (5): 537-42, 2001.
Akintoye SO, Brennan MT, Graber CJ, et al.: A retrospective investigation of advanced periodontal disease as a risk factor for septicemia in hematopoietic stem cell and bone marrow transplant recipients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94 (5): 581-8, 2002.
Raber-Durlacher JE, Epstein JB, Raber J, et al.: Periodontal infection in cancer patients treated with high-dose chemotherapy. Support Care Cancer 10 (6): 466-73, 2002.
Hong CH, Napeñas JJ, Hodgson BD, et al.: A systematic review of dental disease in patients undergoing cancer therapy. Support Care Cancer 18 (8): 1007-21, 2010.
Peterson DE: Pretreatment strategies for infection prevention in chemotherapy patients. NCI Monogr (9): 61-71, 1990.
Sonis ST, Woods PD, White BA: Oral complications of cancer therapies. Pretreatment oral assessment. NCI Monogr (9): 29-32, 1990.
Peters E, Monopoli M, Woo SB, et al.: Assessment of the need for treatment of postendodontic asymptomatic periapical radiolucencies in bone marrow transplant recipients. Oral Surg Oral Med Oral Pathol 76 (1): 45-8, 1993.
Myers RA, Marx RE: Use of hyperbaric oxygen in postradiation head and neck surgery. NCI Monogr (9): 151-7, 1990.
Böhme A, Karthaus M, Hoelzer D: Antifungal prophylaxis in neutropenic patients with hematologic malignancies. Antibiot Chemother 50: 69-78, 2000.
Lalla RV, Latortue MC, Hong CH, et al.: A systematic review of oral fungal infections in patients receiving cancer therapy. Support Care Cancer 18 (8): 985-92, 2010.
Nicolatou-Galitis O, Athanassiadou P, Kouloulias V, et al.: Herpes simplex virus-1 (HSV-1) infection in radiation-induced oral mucositis. Support Care Cancer 14 (7): 753-62, 2006.
Nicolatou-Galitis O, Velegraki A, Sotiropoulou-Lontou A, et al.: Effect of fluconazole antifungal prophylaxis on oral mucositis in head and neck cancer patients receiving radiotherapy. Support Care Cancer 14 (1): 44-51, 2006.
Epstein JB, Vickars L, Spinelli J, et al.: Efficacy of chlorhexidine and nystatin rinses in prevention of oral complications in leukemia and bone marrow transplantation. Oral Surg Oral Med Oral Pathol 73 (6): 682-9, 1992.
Ellis ME, Clink H, Ernst P, et al.: Controlled study of fluconazole in the prevention of fungal infections in neutropenic patients with haematological malignancies and bone marrow transplant recipients. Eur J Clin Microbiol Infect Dis 13 (1): 3-11, 1994.
Schubert MM: Oral manifestations of viral infections in immunocompromised patients. Curr Opin Dent 1 (4): 384-97, 1991.
Elad S, Zadik Y, Hewson I, et al.: A systematic review of viral infections associated with oral involvement in cancer patients: a spotlight on Herpesviridea. Support Care Cancer 18 (8): 993-1006, 2010.
Bergmann OJ, Ellermann-Eriksen S, Mogensen SC, et al.: Acyclovir given as prophylaxis against oral ulcers in acute myeloid leukaemia: randomised, double blind, placebo controlled trial. BMJ 310 (6988): 1169-72, 1995.
Warkentin DI, Epstein JB, Campbell LM, et al.: Valacyclovir versus acyclovir for HSV prophylaxisin neutropenic patients. Ann Pharmacother 36 (10): 1525-31, 2002.
Centers for Disease Control and Prevention, Infectious Disease Society of America, American Society of Blood and Marrow Transplantation: Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Recomm Rep 49 (RR-10): 1-125, CE1-7, 2000.
Sullivan KM, Dykewicz CA, Longworth DL, et al.: Preventing opportunistic infections after hematopoietic stem cell transplantation: the Centers for Disease Control and Prevention, Infectious Diseases Society of America, and American Society for Blood and Marrow Transplantation Practice Guidelines and beyond. Hematology Am Soc Hematol Educ Program : 392-421, 2001.
Krüger WH, Bohlius J, Cornely OA, et al.: Antimicrobial prophylaxis in allogeneic bone marrow transplantation. Guidelines of the infectious diseases working party (AGIHO) of the german society of haematology and oncology. Ann Oncol 16 (8): 1381-90, 2005.
Apperley J, Carreras E, Gluckman E, et al., eds.: The EBMT Handbook: Haematopoietic Stem Cell Transplantation. 6th ed. Paris, France: European School of Haemtology and European Group for Blood and Marrow Transplantation, 2012. Also available online. Last accessed January 5, 2018.
Leflore S, Anderson PL, Fletcher CV: A risk-benefit evaluation of aciclovir for the treatment and prophylaxis of herpes simplex virus infections. Drug Saf 23 (2): 131-42, 2000.
Reusser P: Management of viral infections in immunocompromised cancer patients. Swiss Med Wkly 132 (27-28): 374-8, 2002.
Naesens L, De Clercq E: Recent developments in herpesvirus therapy. Herpes 8 (1): 12-6, 2001.
Jubelt B: Valacyclovir and famciclovir therapy in herpes zoster. Curr Neurol Neurosci Rep 2 (6): 477-8, 2002.
Burns LJ, Miller W, Kandaswamy C, et al.: Randomized clinical trial of ganciclovir vs acyclovir for prevention of cytomegalovirus antigenemia after allogeneic transplantation. Bone Marrow Transplant 30 (12): 945-51, 2002.
Zaia JA: Prevention of cytomegalovirus disease in hematopoietic stem cell transplantation. Clin Infect Dis 35 (8): 999-1004, 2002.
Kanegane H, Nomura K, Miyawaki T, et al.: Biological aspects of Epstein-Barr virus (EBV)-infected lymphocytes in chronic active EBV infection and associated malignancies. Crit Rev Oncol Hematol 44 (3): 239-49, 2002.
Kumar S, Wairagkar NS, Mahanta J: Demonstration of Epstein-Barr virus antibodies in serum of patients with nasopharyngeal carcinoma. Indian J Cancer 38 (2-4): 72-5, 2001 Jun-Dec.
Hemorrhage
Hemorrhage may occur during treatment-induced thrombocytopenia and/or coagulopathy and is a concern for patients who are receiving high-dose chemotherapy or undergoing hematopoietic stem cell transplantation.[1] Spontaneous gingival oozing may occur when platelet counts drop below 20,000/mm3, especially when there is preexisting gingivitis or periodontitis. Even normal function or routine oral hygiene (brushing and flossing) can induce gingival oozing in the face of preexisting gingivitis and periodontitis.
Although rarely serious, oral bleeds can be of concern to the patient and family. Oral bleeding may be mild (e.g., petechiae located on the lips, soft palate, or floor of the mouth) or severe (e.g., persistent gingival hemorrhage or bleeding from herpes simplex virus ulcers in the face of severe thrombocytopenia).
It is not uncommon for oncology patients to be told specifically to not use toothbrushes and dental floss when their platelet counts drop below 40,000/mm3. This is generally poor advice unless there are extenuating circumstances. Healthy gingival tissues do not bleed unless traumatized. Discontinuation of routine oral hygiene can increase the risk of infection that could not only promote bleeding but also increase the risk of local and systemic infection due to accumulation of bacterial plaque, leading to periodontal infections and tissue breakdown. Such issues further support the utility of pre–cancer therapy dental treatments to reduce or eliminate gingival or periodontal conditions.
The degree of health professional oversight of thrombocytopenic patients is an important consideration relative to risk of mechanical hygiene procedures. With comprehensive monitoring, patients can often safely use dental brushing and flossing throughout the thrombocytopenic episode. Foam brushes are recommended by some practitioners. However, studies have shown that foam brushes cannot adequately remove dental plaque along gingival margins, thus promoting gingival infection and bleeding.
Management of oral bleeds revolves around the use of vasoconstrictors, clot-forming agents, and tissue protectants:
Epinephrine or cocaine can be used topically to reduce blood flow rates through bleeding vessels.
Topical thrombin and/or hemostatic collagen agents can be used to organize and stabilize clots.
Application of mucosal adherent products (including cyanoacrylate products) help seal bleeding sites and protect organized clots.
Patients who tend to form friable and easily dislodged clots will benefit from topical application of aminocaproic acid; in some instances, intravenous administration can be considered to improve coagulation and the formation of stable clots.
Application of 3% hydrogen peroxide and 0.9% saline (1:2 to 1:3 by volume) can aid in wound cleansing and removal of superficial blood debris. Care must be taken not to disturb clots, which might promote bleeding.[1]
References:
Schubert MM, Peterson DE: Oral complications of hematopoietic cell transplantation. In: Appelbaum FR, Forman SJ, Negrin RS, et al., eds.: Thomas' Hematopoietic Cell Transplantation: Stem Cell Transplantation. 4th ed. Oxford, UK: Wiley-Blackwell, 2009, pp 1589-1607.
Neurotoxicity
Selected classes of chemotherapy, including the vinca alkaloids, vincristine, and vinblastine, can cause direct neurotoxicity. Additionally, drugs such as thalidomide and lenalidomide are associated with peripheral neuropathies that can affect the face and jaw. Deep-seated, throbbing mandibular pain can occur. Because this symptom is also consistent with acute dental pulpal disease, it is important that a thorough history and oral physical examination be performed when oral pain is present; radiographs and vitality testing of the dental pulp are typically necessary. After neurotoxicity is appropriately diagnosed, management includes pain support and patient counseling. The symptom generally resolves within a week of discontinuing the causative chemotherapy.
Dental hypersensitivity may occasionally arise in patients weeks or months after they discontinue chemotherapy. Additionally, it has been observed that patients being treated with cyclosporine for treatment of graft-versus-host disease will report increased thermal sensitivity. The mechanisms of this response are not known. Fortunately, thermal stimuli are self-resolving after discontinuation or withdrawal of therapy, though they can persist for several months. Topical application of fluorides and/or desensitizing toothpaste may ameliorate the discomfort.
Patients may experience temporomandibular dysfunction pain involving muscles of mastication, temporomandibular joints, or teeth. This condition is not unique to cancer patients, and it correlates with stress and dysfunctional habits including bruxism and clenching of the jaws. Stress and sleep dysfunction appear to be the most frequent etiologic factors. Judicious use of muscle relaxants or anxiety-reducing agents plus physical therapy (moist heat applications, massage, and gentle stretching) are standard approaches for management. For patients with a propensity for clenching or bruxism during sleep, customized occlusal splints for use while sleeping may be of value.
Graft-versus-Host Disease
Patients who have received allogeneic or matched unrelated transplants are at risk of developing graft-versus-host disease (GVHD).[1,2] A related condition referred to as pseudo-GVHD is occasionally reported in autologous hematopoietic stem cell transplant recipients. GVHD can affect oral tissues and often mimics naturally occurring autoimmune diseases such as erosive lichen planus, pemphigus, scleroderma, and Sjögren syndrome. Oral GVHD has also been linked to oral precancerous and malignant lesions.[3]
Acute GVHD can occur as early as 2 to 3 weeks posttransplant; mucosal erythema and erosion/ulceration are typical manifestations. Chronic oral GVHD changes can be recognized as early as day 70 posttransplant.[4] The pattern and types of lesions seen in acute GVHD are also seen in chronic GVHD, but manifestations can also include raised white hyperkeratotic plaques and striae and persistent reduced salivary function. Oral symptoms of oral GVHD include xerostomia and increased sensitivity and pain with spices, alcohols, and flavoring agents (especially mint flavors in toothpaste and oral care products). Patients may also suffer from odynophagia and dysphagia due to gastrointestinal involvement.[5] All of these symptoms of GVHD may lead to weight loss and malnutrition.[6]
Biopsy of oral mucosa, including both surface epithelium and minor labial salivary glands, may be of value in establishing a final diagnosis.[7,8] Presence of a lymphocytic infiltrate (grade I) with epithelial cell necrosis (grade II) provides the diagnostic basis for oral GVHD. As clinical criteria for recognition of oral signs and symptoms of GVHD have become more established, dependance on the oral biopsy to diagnose oral involvement has lessened. In cases of equivocal examination findings, the biopsy can improve the recognition of oral involvement.
Topical management of mucosal lesions may include steroids, azathioprine, and/or oral psoralen and ultraviolet A (PUVA) therapy (refer to the list on Management of Oral GVHD).[4,9] While topical cyclosporin has been suggested as therapeutically beneficial, its effectiveness is less predictable than that of other treatments—which, when coupled with increased cost of care, usually decreases its utility. The use of FK506 and mycophenolate mofetil to topically treat oral GVHD remains anecdotal and of uncertain efficacy. Systemic therapy (e.g., prednisone, budesonide, cyclosporine, mycophenolate mofetil, and other immunosuppressive agents) is routinely necessary, primarily to treat the condition. Topical treatment can be used to specifically manage oral sensitivity and help heal ulcerations. Patients with clinically significant xerostomia may benefit from pilocarpine (5 mg 3 or 4 times a day) or cevimeline (10 mg 4 times a day) if native salivary gland function remains partially intact.
Submucosal and/or dermal fibrosis can occur in persistent cases of chronic GVHD. This scleroderma-like complication can be subtle and appear as slight mucosal or skin tightness, or it can progress to skin thickening and fibrosis. Intraoral submucosal fibrotic bands have been noted to significantly restrict the oral opening. Successful management of GVHD with systemic therapy will usually see resolution and/or significant resolution of this problem. However, in rare instances, surgical or chemical techniques to disrupt fibrotic bands can be required to improve the oral opening.
Management of Oral GVHD
Topical steroids:
Rinses: dexamethasone elixir (Decadron 0.1 mg/mL).
Gels, creams:
fluocinonide (Fluonex)
clobetasol (Temovate)
halobetasol (Ultravate)
betamethasone (Celestone)
Powders: beclomethasone (Beclovent) (inhalers applied to mucosa).
Other topical immunosuppressants:
azathioprine rinse (Imuran; 5–10 mg/mL)
cyclosporin (Neoral)
Antifungals (when concomitant oral fungal infection is documented):
Topical preparations:
nystatin (Mycostatin)
clotrimazole (Mycelex)
amphotericin solution (Amphocin; in the United States, this is compounded)
Systemic agents:
fluconazole (Diflucan)
itraconazole (Sporanox)
PUVA.
Sialogogues:
cevimeline (Evoxac)
pilocarpine (Salagen)
bethanechol
Topical anesthetics:
lidocaine (Xylocaine)
dyclonine (Dyclone)
diphenhydramine (Benadryl)
doxepin (Zonalon)
Dental caries prevention:
Oral hygiene (dental plaque removal)
Fluorides:
Adult patients: brush-on products, rinses, home-use trays
Pediatric patients: brush-on gel (if patient can dependably expectorate the fluoride gel after application)
If drinking water does not contain enough fluoride to prevent tooth decay, oral fluoride (e.g., drops or vitamins) should be provided to children younger than 12 years.
Remineralizing solution (calcium phosphate ± fluoride preparations)
References:
Schubert MM, Sullivan KM: Recognition, incidence, and management of oral graft-versus-host disease. NCI Monogr (9): 135-43, 1990.
Demarosi F, Bez C, Sardella A, et al.: Oral involvement in chronic graft-vs-host disease following allogenic bone marrow transplantation. Arch Dermatol 138 (6): 842-3, 2002.
Abdelsayed RA, Sumner T, Allen CM, et al.: Oral precancerous and malignant lesions associated with graft-versus-host disease: report of 2 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 93 (1): 75-80, 2002.
Schubert MM, Peterson DE: Oral complications of hematopoietic cell transplantation. In: Appelbaum FR, Forman SJ, Negrin RS, et al., eds.: Thomas' Hematopoietic Cell Transplantation: Stem Cell Transplantation. 4th ed. Oxford, UK: Wiley-Blackwell, 2009, pp 1589-1607.
Schima W, Pokieser P, Forstinger C, et al.: Videofluoroscopy of the pharynx and esophagus in chronic graft-versus-host disease. Abdom Imaging 19 (3): 191-4, 1994 May-Jun.
Jacobsohn DA, Margolis J, Doherty J, et al.: Weight loss and malnutrition in patients with chronic graft-versus-host disease. Bone Marrow Transplant 29 (3): 231-6, 2002.
Loughran TP, Sullivan K, Morton T, et al.: Value of day 100 screening studies for predicting the development of chronic graft-versus-host disease after allogeneic bone marrow transplantation. Blood 76 (1): 228-34, 1990.
Yamada H, Chihara J, Hamada K, et al.: Immunohistology of skin and oral biopsies in graft-versus-host disease after bone marrow transplantation and cytokine therapy. J Allergy Clin Immunol 100 (6 Pt 2): S73-6, 1997.
Epstein JB, Nantel S, Sheoltch SM: Topical azathioprine in the combined treatment of chronic oral graft-versus-host disease. Bone Marrow Transplant 25 (6): 683-7, 2000.
Posttransplantation Dental Treatment
Caution should be exercised when considering dental treatment for transplant patients until immune reconstitution has occurred; the time frame for this reconstitution can vary from 6 months to 12 months. Although hematologic parameters, including complete blood count and differential, may be documented as within normal limits, functional immune abnormalities may still be present. Patients should not resume routine dental treatment, including dental scaling and polishing, until adequate immunologic reconstitution has occurred; this includes recovery from graft-versus-host disease. The aerosolization of debris and bacteria during the use of ultrasonic or high-speed rotary cutting instruments can put the patient at risk for aspiration pneumonia; additionally, bacteremias often occur as a result of dental treatment, and their impact can be noticeable.
For patients who need urgent or emergency dental treatment, prophylactic antibiotics and strategies to reduce the potential influence of aspirating dental aerosols should be used. Additional administration of antibiotics should be determined by the patient's risk of infection caused by the presenting condition or as a sequela of treatment.
Appropriate supportive care—including antibiotics, immunoglobulin G administration, adjustment of steroid doses, and/or platelet transfusions—should be comprehensively considered before invasive oral procedures are undertaken.
Relapse and Second Malignancy
Gingival infiltrates, oral infection, and/or bleeding disproportionate to local etiology can indicate possible relapsed disease, especially in patients treated for leukemias or lymphomas. Additionally, localized oral plasmacytomas have been observed in patients relapsing early post–autologous transplantation for multiple myeloma. Painless unilateral lymphadenopathy can also represent relapse in patients with previously treated lymphoma. Lymphoproliferative diseases occurring as second primary malignancies posttransplant must be considered for soft tissue masses and lymphadenopathy noted in transplant recipients.
Incidence of second malignancy steadily increases as cancer patients survive longer posttransplant. Previous exposure to chemotherapy and radiation therapy and alterations in immune function, graft-versus-host disease (GVHD), and GVHD therapy collectively contribute to risk of second malignancy. Oral squamous cell carcinoma is the most frequently occurring secondary oral malignancy in transplant patients, with the lips and tongue being the most frequently reported sites.
Dysgeusia
In stem cell transplant patients, dysgeusia can occur secondary to either chemotherapy/chemoradiation conditioning or graft-versus-host disease. Refer to the Dysgeusia section in the Conditions Affected By Both Chemotherapy and Head/Neck Radiation section of this summary for management recommendations.
Oral Toxicities Not Related to Chemotherapy or Radiation Therapy
Osteonecrosis of the Jaw Associated With Medications (ONJ)
The first reported cases of osteonecrosis of the jaw associated with medications (ONJ) were seen in patients taking bisphosphonates.[1,2,3] Bisphosphonates are potent inhibitors of osteoclasts. They are used in cancer patients with skeletal metastasis, including breast, prostate, or lung cancer; and in patients with multiple myeloma. Bisphosphonates are also used to treat hypercalcemia of malignancy. Bisphosphonates reduce the risk of fracture and skeletal pain, improving the quality of life of patients with malignant bone disease.[4] (Refer to the PDQ summary on Cancer Pain for more information.)
Evidence in the medical and dental literature reveals several cases of ONJ reported with the use of drugs other than bisphosphonates, including the following:[5,6]
Denosumab, a human monoclonal antibody that inhibits the receptor activator of nuclear factor kappa beta ligand (RANKL).
The antiangiogenic drugs being tested in advanced cancer cases, including bevacizumab, sunitinib, and possibly sorafenib.
Table 5. Drugs and Biologics Used in Oncology and Reported to Be Associated With ONJ
Drug Generic (Trade Name)
Manufacturer (Indication)
Class of Drug
Mode of Action
Reported to Cause ONJ?
GIST = gastrointestinal stromal tumor; ONJ = osteonecrosis of the jaw associated with medications; RANKL = receptor activator of nuclear factor kappa beta ligand; VEGF = vascular endothelial growth factor.
Zoledronic acid (Zometa, Reclast) Novartis (bone metastasis; bone loss from cancer therapy) Bisphosphonate (antiresorptive) Inhibition of osteoclasts Yes
Pamidronate (Aredia) Novartis Bisphosphonate (antiresorptive) Inhibition of osteoclasts Yes
Alendronate (Fosamax) Merck (bone loss from cancer therapy) Bisphosphonate (antiresorptive) Inhibition of osteoclasts Yes
Denosumab (Prolia, XGeva) Amgen, Inc. (bone metastasis; osteoporosis; bone loss from cancer therapy) Humanized monoclonal antibody (antiresorptive) Suppression of bone remodeling by inhibition of RANKL Yes
Bevacizumab (Avastin) Genentech BioOncology (advanced cancers: metastatic colorectal cancer; nonsquamous non-small cell lung cancer; metastatic breast cancer; glioblastoma; metastatic renal cell carcinoma) Antiangiogenic Inhibition of angiogenesis by blocking the action of VEGF Yes
Sunitinib (Sutent) Pfizer Oncology (advanced renal cell carcinoma; GIST) Antiangiogenic Inhibition of angiogenesis by blocking VEGF tyrosine kinase Yes
Sorafenib (Nexavar) Bayer Health Care Pharmaceuticals (renal cell carcinoma; hepatocellular carcinoma) Antiangiogenic Inhibition of angiogenesis by blocking VEGF tyrosine kinase Yes, when combined with antiresorptives
With the approval of a new antiresorptive medication, denosumab, a fully humanized monoclonal antibody that targets RANKL and that has indications similar to those of the bisphosphonates, additional reports confirmed that this new drug can also cause ONJ. Subsequently, the introduction of antiangiogenic medications in clinical trials in oncology revealed that these agents can also be associated with ONJ development, either as single drugs or when used in combination with antiresorptives. When antiangiogenics are used in combination with bisphosphonates, the risk of ONJ increases significantly.[7]
Thus, osteonecrosis of the jaw is no longer a problem exclusively associated with the use of bisphosphonates; it is also associated with the use of other drugs such as the monoclonal antibody denosumab and antiangiogenics such as bevacizumab and sorafenib. For this reason, it is proposed that the nomenclature that refers to this pathology be changed to ONJ, meaning osteonecrosis of the jaw that is associated with medications.
ONJ is an oral complication of antiresorptive therapy in cancer patients.[8] First reported in 2003,[1,2,3] ONJ is defined as the unexpected appearance of exposed necrotic bone anywhere in the oral cavity of an individual who is receiving drugs that have been associated with ONJ (bisphosphonates, denosumab, and antiangiogenics) and who has not received radiation therapy to the head and neck. The exposed bone persists for at least 6 to 8 weeks, despite the provision of standard dental care. It is also possible that symptoms of dental disease, periodontal disease, or both may be present, without visible exposed bone.[9] The occurrence of ONJ is based on cases reported in the literature, and occurrence ranges from between 1% and 10% for patients receiving the intravenous formulation (pamidronate and zoledronic acid) to less than 1% for patients taking oral bisphosphonates.[10,11]
A study evaluating the literature until December 2008 found that the prevalence of ONJ can vary according to study design and the type of bisphosphonate used. For example, studies in which patient evaluation and follow-up are conducted by dental professionals have an overall prevalence of 7.3%, whereas survey studies of large populations of patients have a prevalence of less than 1%. If the prevalence is calculated on the basis of type of bisphosphonate used, then the prevalence of cases of ONJ in which a combination of zoledronic acid and pamidronate is used over the course of therapy can be as high as 24.5%.[12] The mandible is affected in approximately 68% of cases, the maxilla in about 28% of cases, and both jawbones in approximately 4% of cases.[13] However, there have been reports of evidence of ONJ in other parts of the head and neck and skeleton.[14,15,16]
ONJ incidence, risk factors, and outcomes were assessed in an analysis of three phase III trials in patients who had metastatic bone disease secondary to solid tumors or myeloma and who were receiving antiresorptive therapies.[17] Patients were assigned to receive either subcutaneous injections of denosumab (120 mg) or intravenous administration of zoledronic acid (4 mg) every 4 weeks. Oral examinations were performed at baseline and every 6 months. Oral adverse events were adjudicated by a panel of dental experts. Of 5,723 patients enrolled, 89 (1.6%) were diagnosed with ONJ; 37 received zoledronic acid, and 52 received denosumab. Tooth extraction was reported for two-thirds of patients with ONJ. As of October 2010, ONJ resolved in 36% of patients (29.7% for zoledronic acid and 40.4% for denosumab). A combined analysis of these trials found that ONJ was an infrequent event, management was mostly conservative, and healing occurred in more than one-third of the patients. Bone-targeted therapy may help reduce the rate of ONJ and improve outcomes.[17]
When denosumab was compared to placebo in a study of men with nonmetastatic, high-risk, castration-resistant prostate cancer in which patients received treatment for at least 24 months, ONJ incidence was 4.6% in patients treated with denosumab; there were no cases of ONJ in the placebo group.[18] Therefore, time on medication can be a factor in the development of ONJ.
Risk factors for ONJ include the following:
Dental extractions.[19][Level of evidence: II][20]
Ill-fitting dentures.[19]
Intravenous bisphosphonate (zoledronic acid, denosumab).[19,20][Level of evidence: I][12];[21][Level of evidence: I]
Time on medication.[12,18,20]
Multiple myeloma.[12]
The incidence of ONJ may be reduced by the implementation of dental preventive measures before bisphosphonate therapy is initiated in solid-tumor patients with bone metastases.[22,23]
Diagnosis of ONJ
Diagnosis of ONJ can be clinically challenging. The most common clinical presentations are as follows:
Classical: a cancer patient with skeletal metastasis who is receiving intravenous bisphosphonate or denosumab therapy and who presents with visible necrotic bone in the oral cavity. The site may be infected and painful; these conditions are the typical reason for referral to a dentist. Pain results both from inflammation of the soft tissues contiguous to the necrotic bone and from infection. Other symptoms typically occur in more advanced cases (e.g., paresthesia secondary to local neurologic involvement). Purulent secretion at the exposed area indicates active infection. Radiographic examination may demonstrate typical radiolucent and radiopaque areas associated with a bone sequestrum. Bone trabeculation may present with a moth-eaten appearance, suggesting ongoing bone destruction. Lesions can arise secondary to surgical dental treatments (e.g., dental extractions or periodontal surgery), significant dental infections, or trauma. Alternatively, ONJ can arise spontaneously, without any detectable trauma or predisposing treatment.
Less common: a cancer patient receiving intravenous bisphosphonate or denosumab therapy who complains of pain that mimics periodontal or pulpal pathology. There is no clinically visible exposed necrotic bone, but a draining fistula or purulent secretion from the periodontal sulcus may exist. The involved teeth will typically be symptomatic upon palpation and percussion.
Occasional: a cancer patient who complains of oral pain and discomfort, but a definitive diagnosis of ONJ cannot be made because no clinically exposed bone is evident. In these patients, the most likely clinical diagnosis should be addressed first. It is important to recognize that antiresorptive administration can result in bone pain, including to areas of the head and neck and jaws; this possible etiology for jaw symptoms should be considered as additional dental diagnoses are pursued. Routine clinical pulp testing and assessing for signs and symptoms of periodontal disease (e.g., pocket depths, bone loss, and bleeding on probing) should be performed. Radiographic examination should also be conducted. Although not yet definitively confirmed in the literature, the radiographic finding of sclerosing or absence of the lamina dura of the involved teeth may indicate the early presence of ONJ.[13][Level of evidence: III]
Endodontic and periodontal therapy should be performed first. The patient should be advised about the possibility of ONJ and should be educated about oral hygiene procedures. If dental extraction is indicated, the possibility of subclinical ONJ should be considered and explained to the patient. Thus, delay or absence of healing postextraction must be considered as risk for ultimate development of ONJ. Before the invasive procedure is performed, the risk of excessive bleeding and/or infection due to bone marrow suppression must be discussed with the patient's physician, and proper preventive measures should be formulated.
Management of ONJ
Confirmed ONJ with exposed bone in the oral cavity should initially be managed conservatively with local debridement and removal of sharp margins of bone; this reduces the risk of trauma to soft tissue, including the tongue. Systemic antibiotics should be administered when active infection with purulent secretion, swelling and inflammation of the surrounding soft tissues, and pain are present. Initial therapy can be implemented with a single antibiotic, but there is no agreement regarding drug of first choice. Options include the following:
Amoxicillin, 500 mg 4 times a day for at least 14 days.
Metronidazole, 250 mg 3 times a day for at least 14 days.
Clindamycin, 300 mg 4 times a day for at least 14 days.
Amoxicillin and clavulanic acid, 500 mg 4 times a day for at least 14 days.
In addition, topical oral therapy can be implemented via 0.12% chlorhexidine mouth rinses or tetracycline rinses (62.5 mg/oz) twice a day. The need for oral hygiene with meticulous brushing and flossing after meals should be emphasized.[4,10,11,13,24,25]
The patient should be reevaluated in 2 weeks. Systemic antibiotics can be discontinued when clinical signs and symptoms improve. The local measures should be maintained, however, as part of the routine oral hygiene procedures consisting of brushing and flossing.
In ONJ cases refractory to therapy, patients may need to be maintained on long-term antibiotic therapy. With these patients, a combination of different antibiotic agents such as penicillin and metronidazole can be considered. Another possibility is to use clindamycin or the combination of amoxicillin and clavulanic acid in place of amoxicillin. When the infectious process extends to more critical areas of the head and neck, the patient may need hospitalization and intravenous antibiotic therapy, culminating in the need for extensive surgical resection of the affected areas.[25]
Reports suggest that ONJ can be successfully managed by surgical resection and primary wound closure, especially in cases refractory to conservative therapy.[26,27,28] The use of radical surgery is increasing, and it appears that the initial paradigm that surgery should not be done in ONJ cases is no longer true. However, patients must be advised that surgery may result in treatment failure and that not all cases are treated successfully. With surgery as a treatment option, clinicians are now performing bone biopsies to confirm ONJ diagnoses. In cancer patients, there is always a possibility of metastatic disease to the jawbones mimicking ONJ; the final diagnosis should be confirmed by histopathological examination.[29] The use of surgical lasers has also been suggested as an alternative for ONJ patients who do not respond to conservative management.[30]
The use of hyperbaric oxygen therapy (HBO) to treat cases of established ONJ does not appear to be effective.[4,13,24,25] However, evidence indicates that HBO in addition to discontinuation of bisphosphonate therapy may benefit patients with ONJ.[31] Definitive evidence is pending while research in this area continues.[32]
Another possible approach involves surgical manipulation and uses bone labeling with tetracycline. In this modality, the patient is treated with a standard dose of tetracycline a few days presurgery. During the surgery, when bone is exposed, the Wood's lamp is shone over the bone. Necrotic bone does not fluoresce and is removed. The procedure continues until fluorescence is seen, suggesting the presence of vital bone.[33]
The American Association of Oral and Maxillofacial Surgeons proposed a staging system for ONJ and suggested treatment strategies (see Table 6, adapted from the guidelines paper [34]).
Table 6. ONJ Staging System
BRONJ (ONJ) Staging
Treatment Strategies
BRONJ = bisphosphonate-related osteonecrosis of the jaw; IV = intravenous; ONJ = osteonecrosis of the jaw associated with medications.
At-risk category: No apparent necrotic bone in patients who have been treated with either oral or IV bisphosphonates. No treatment indicated; patient education.
Stage 0: No clinical evidence of necrotic bone, but nonspecific clinical findings and symptoms. Systemic management, including the use of pain medication and antibiotics.
Stage 1: Exposed and necrotic bone in patients who are asymptomatic and have no evidence of infection. Antibacterial mouth rinse; clinical follow-up on a quarterly basis; patient education and review of indications for continued bisphosphonate therapy.
Stage 2: Exposed and necrotic bone associated with infection, as evidenced by pain and erythema in the region of the exposed bone, with or without purulent drainage. Symptomatic treatment with oral antibiotics; oral antibacterial mouth rinse; pain control; superficial debridement to relieve irritation of soft tissue.
Stage 3: Exposed and necrotic bone in patients with pain, infection, and one or more of the following: exposed and necrotic bone extending beyond the region of alveolar bone (i.e., inferior border and ramus in the mandible, maxillary sinus and zygoma in the maxilla), resulting in pathologic fracture, extraoral fistula, oral antral/oral nasal communication, or osteolysis extending to the inferior border of the mandible of sinus floor. Antibacterial mouth rinse; antibiotic therapy and pain control; surgical debridement/resection for longer-term palliation of infection and pain.
Discontinuation of bisphosphonate therapy
The literature does not support discontinuing bisphosphonate therapy to enhance the healing process. Bisphosphonates accumulate in a patient's skeleton and could remain active for several years, especially in patients who have been treated with an intravenous bisphosphonate for longer than a year. There is anecdotal evidence that even with discontinuing zoledronic acid therapy for patients who develop ONJ, the osteonecrotic process clinically progresses and can extend to contiguous sites. However, discontinuing bisphosphonate therapy is advocated by some authors, especially when a procedure to treat ONJ is planned.[10,13]
Some clinicians believe that discontinuing the drug for patients scheduled for surgery to treat the necrotic area may be beneficial, although this belief is not supported by scientific study. It is recommended that such a drug holiday be maintained until clinical evidence of healing is observed.[10] However, controversy surrounds this issue,[11][Level of evidence: IV] and further research is needed.
In summary, a potential drug holiday for patients on bisphosphonates must be considered in the context of presence or absence of osteonecrosis. In view of the lack of scientific evidence from randomized controlled studies, risk and benefits of drug discontinuation must be determined by the prescribing physician. In patients who are being treated with bisphosphonate therapy and who need invasive procedures, there is no scientific information that supports a drug holiday and that this will prevent the development of ONJ. In patients with osteonecrosis who need invasive procedures, a drug holiday may be beneficial.[35] On the other hand, there is emerging evidence that patients with multiple myeloma and osteonecrosis may be maintained on bisphosphonate therapy without the risk of progression of the osteonecrotic process.[36]
It is advisable to discuss with the patient's physician whether discontinuing bisphosphonate therapy will not put the patient's general health at risk. Obtaining an informed consent from the patient before execution of the proposed drug discontinuation and therapy is important.
Spontaneous and asymptomatic ONJ
Patients may present with asymptomatic exposed necrotic bone anywhere in the oral cavity, although the mylohyoid plate on the posterior mandible and the mandibular tori are the most frequently affected sites. In this case, local measures and effective oral hygiene are important, as is systematic reevaluation of the patient to ensure resolution.
Effects on quality of life
The number of patients who develop ONJ is small compared with the large number of people who take bisphosphonates. However, some lesions can progress to large sizes and cause severe changes in a patient's quality of life.[4,8] Advanced mandibular lesions, for instance, can cause necrosis of the cortical bone, increasing the risk of fractures.[4] Advanced and nonresponsive infections may require hospitalization and intravenous antibiotic therapy.[4] Advanced cases of ONJ may require extensive jawbone resection.[37] Therefore, this adverse effect of bisphosphonate therapy may negatively affect quality of life.
Tobacco use and ONJ
The discontinuation of tobacco use to favor the healing process has been recommended.[38] However, the role of tobacco and other comorbidities in the process of ONJ formation is still under investigation.[13]
References:
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Marx RE: Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 61 (9): 1115-7, 2003.
Migliorati CA: Bisphosphanates and oral cavity avascular bone necrosis. J Clin Oncol 21 (22): 4253-4, 2003.
Migliorati CA, Casiglia J, Epstein J, et al.: Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. J Am Dent Assoc 136 (12): 1658-68, 2005.
Migliorati CA, Covington JS: New oncology drugs and osteonecrosis of the jaw (ONJ). J Tenn Dent Assoc 89 (4): 36-8; quiz 38-9, 2009.
Yarom N, Elad S, Madrid C, et al.: Osteonecrosis of the jaws induced by drugs other than bisphosphonates - a call to update terminology in light of new data. Oral Oncol 46 (1): e1, 2010.
Smidt-Hansen T, Folkmar TB, Fode K, et al.: Combination of zoledronic Acid and targeted therapy is active but may induce osteonecrosis of the jaw in patients with metastatic renal cell carcinoma. J Oral Maxillofac Surg 71 (9): 1532-40, 2013.
Migliorati CA, Siegel MA, Elting LS: Bisphosphonate-associated osteonecrosis: a long-term complication of bisphosphonate treatment. Lancet Oncol 7 (6): 508-14, 2006.
Ruggiero SL, Dodson TB, Fantasia J, et al.: Medication-Related Osteonecrosis of the Jaw—2014 Update. Rosemont, Ill: American Association of Oral and Maxillofacial Surgeons, 2014. Available online. Last accessed January 5, 2018.
Woo SB, Hellstein JW, Kalmar JR: Narrative [corrected] review: bisphosphonates and osteonecrosis of the jaws. Ann Intern Med 144 (10): 753-61, 2006.
Khosla S, Burr D, Cauley J, et al.: Bisphosphonate-associated osteonecrosis of the jaw: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res 22 (10): 1479-91, 2007.
Migliorati CA, Woo SB, Hewson I, et al.: A systematic review of bisphosphonate osteonecrosis (BON) in cancer. Support Care Cancer 18 (8): 1099-106, 2010.
Marx RE, Sawatari Y, Fortin M, et al.: Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg 63 (11): 1567-75, 2005.
Polizzotto MN, Cousins V, Schwarer AP: Bisphosphonate-associated osteonecrosis of the auditory canal. Br J Haematol 132 (1): 114, 2006.
Khan AM, Sindwani R: Bisphosphonate-related osteonecrosis of the skull base. Laryngoscope 119 (3): 449-52, 2009.
Longo R, Castellana MA, Gasparini G: Bisphosphonate-related osteonecrosis of the jaw and left thumb. J Clin Oncol 27 (35): e242-3, 2009.
Saad F, Brown JE, Van Poznak C, et al.: Incidence, risk factors, and outcomes of osteonecrosis of the jaw: integrated analysis from three blinded active-controlled phase III trials in cancer patients with bone metastases. Ann Oncol 23 (5): 1341-7, 2012.
Smith MR, Saad F, Coleman R, et al.: Denosumab and bone-metastasis-free survival in men with castration-resistant prostate cancer: results of a phase 3, randomised, placebo-controlled trial. Lancet 379 (9810): 39-46, 2012.
Vahtsevanos K, Kyrgidis A, Verrou E, et al.: Longitudinal cohort study of risk factors in cancer patients of bisphosphonate-related osteonecrosis of the jaw. J Clin Oncol 27 (32): 5356-62, 2009.
Hoff AO, Toth BB, Altundag K, et al.: Frequency and risk factors associated with osteonecrosis of the jaw in cancer patients treated with intravenous bisphosphonates. J Bone Miner Res 23 (6): 826-36, 2008.
Stopeck AT, Lipton A, Body JJ, et al.: Denosumab compared with zoledronic acid for the treatment of bone metastases in patients with advanced breast cancer: a randomized, double-blind study. J Clin Oncol 28 (35): 5132-9, 2010.
Ripamonti CI, Maniezzo M, Campa T, et al.: Decreased occurrence of osteonecrosis of the jaw after implementation of dental preventive measures in solid tumour patients with bone metastases treated with bisphosphonates. The experience of the National Cancer Institute of Milan. Ann Oncol 20 (1): 137-45, 2009.
Fusco V, Galassi C, Berruti A, et al.: Decreasing frequency of osteonecrosis of the jaw in cancer and myeloma patients treated with bisphosphonates: the experience of the oncology network of piedmont and aosta valley (north-Western Italy). ISRN Oncol 2013: 672027, 2013.
Migliorati CA, Schubert MM, Peterson DE, et al.: Bisphosphonate-associated osteonecrosis of mandibular and maxillary bone: an emerging oral complication of supportive cancer therapy. Cancer 104 (1): 83-93, 2005.
Ruggiero SL, Fantasia J, Carlson E: Bisphosphonate-related osteonecrosis of the jaw: background and guidelines for diagnosis, staging and management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102 (4): 433-41, 2006.
Carlson ER, Basile JD: The role of surgical resection in the management of bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg 67 (5 Suppl): 85-95, 2009.
Stockmann P, Vairaktaris E, Wehrhan F, et al.: Osteotomy and primary wound closure in bisphosphonate-associated osteonecrosis of the jaw: a prospective clinical study with 12 months follow-up. Support Care Cancer 18 (4): 449-60, 2010.
Williamson RA: Surgical management of bisphosphonate induced osteonecrosis of the jaws. Int J Oral Maxillofac Surg 39 (3): 251-5, 2010.
Gander T, Obwegeser JA, Zemann W, et al.: Malignancy mimicking bisphosphonate-associated osteonecrosis of the jaw: a case series and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol 117 (1): 32-6, 2014.
Vescovi P, Manfredi M, Merigo E, et al.: Surgical approach with Er:YAG laser on osteonecrosis of the jaws (ONJ) in patients under bisphosphonate therapy (BPT). Lasers Med Sci 25 (1): 101-13, 2010.
Freiberger JJ, Padilla-Burgos R, Chhoeu AH, et al.: Hyperbaric oxygen treatment and bisphosphonate-induced osteonecrosis of the jaw: a case series. J Oral Maxillofac Surg 65 (7): 1321-7, 2007.
Freiberger JJ: Utility of hyperbaric oxygen in treatment of bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg 67 (5 Suppl): 96-106, 2009.
Pautke C, Bauer F, Tischer T, et al.: Fluorescence-guided bone resection in bisphosphonate-associated osteonecrosis of the jaws. J Oral Maxillofac Surg 67 (3): 471-6, 2009.
Ruggiero SL, Dodson TB, Assael LA, et al.: American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaw - 2009 update. Aust Endod J 35 (3): 119-30, 2009.
Dickinson M, Prince HM, Kirsa S, et al.: Osteonecrosis of the jaw complicating bisphosphonate treatment for bone disease in multiple myeloma: an overview with recommendations for prevention and treatment. Intern Med J 39 (5): 304-16, 2009.
Berenson JR, Yellin O, Crowley J, et al.: Prognostic factors and jaw and renal complications among multiple myeloma patients treated with zoledronic acid. Am J Hematol 86 (1): 25-30, 2011.
Chaudhry AN, Ruggiero SL: Osteonecrosis and bisphosphonates in oral and maxillofacial surgery. Oral Maxillofac Surg Clin North Am 19 (2): 199-206, vi, 2007.
Yarom N, Yahalom R, Shoshani Y, et al.: Osteonecrosis of the jaw induced by orally administered bisphosphonates: incidence, clinical features, predisposing factors and treatment outcome. Osteoporos Int 18 (10): 1363-70, 2007.
Head / Neck Radiation Patients
Head and neck radiation patients are a significant challenge relative to both intratherapy and posttherapy oral complications resulting from radiation therapy. Unlike the oral complications of chemotherapy that are of shorter duration and significant for only a short period (a few weeks to 2 months) after the cessation of therapy, the oral complications of head and neck radiation are more predictable, are often more severe, and can lead to permanent tissue changes that put the patient at risk for serious chronic complications.
Preradiation Dental Evaluation and Oral Disease Stabilization
Elimination of oral disease and implementation of oral care protocols designed to maintain maximum oral health must be components of patient assessment and care before radiation therapy begins. During and after radiation therapy, oral management will be dictated by the following:
Specific needs of the patient.
Specifics of the radiation therapy.
Chronic complications caused by radiation therapy.
Ongoing oral assessment and treatment of complications are essential because radiation to oral tissues typically conveys a lifelong risk of oral complications. In addition, invasive oral procedures can cause additional sequelae. Dental care typically needs to be altered because of underlying chronic radiation-induced tissue damage.
Patients should receive a comprehensive oral evaluation several weeks before high-dose upper-mantle radiation begins. This timing provides an appropriate interval for tissue healing in the event that invasive oral procedures, including dental extractions, dental scaling/polishing, and endodontic therapy, are necessary. The goal of this evaluation is to identify teeth at significant risk of infection and/or breakdown that would ultimately require aggressive or invasive dental treatment during or after the radiation that increases the risk of soft tissue necroses and osteonecroses. The likelihood of these lesions occurring postradiation increases over the patient's lifetime as the risk of significant dental disease (restorative, periodontal, and endodontic) increases. Salivary gland hypofunction and xerostomia frequently occur postradiation. It is thus especially important that preradiation dental care strategies are instituted to reduce the impact of the complications of severely decreased saliva secretion and the associated high risk of dental caries.
In addition, three radiation-specific issues emerge:
Radiation injury is oral tissue–specific and dependent on dosage and portals of therapy.
Radiation-induced oral mucositis typically lasts 6 to 8 weeks, versus the approximate 5 to 14 days observed in chemotherapy patients. The extended radiation treatment protocols are chiefly responsible for this difference.
The primary cause of oral cancer is tobacco use; alcohol abuse further escalates risk. It is therefore critical that head/neck cancer patients permanently cease tobacco use.
Most patients with smoking-related cancer appear motivated to quit smoking at the time of cancer diagnosis.
Continued smoking substantially increases the likelihood of recurrence or occurrence of a second cancer in survivors, particularly in those who previously received radiation therapy.
A stepped-care approach to tobacco cessation is recommended, including direct physician advice to quit and provision of basic information to all patients at each contact during the first month of diagnosis, followed by more intensive pharmacologic treatment or counseling for those having difficulty quitting or remaining abstinent.
Oral Complications of Head and Neck Radiation
The oral complications of head and neck radiation can be divided into two groups on the basis of the usual time of their occurrence:
Acute complications occurring during therapy.
Late complications occurring after radiation therapy has ended.
Acute complications include the following:
Oropharyngeal mucositis.[1]
Sialadenitis and xerostomia.
Infections (primarily candidiasis).
Taste dysfunction.
Occasionally, tissue necrosis can be seen late during therapy, but this is relatively rare.
Chronic complications include the following:
Mucosal fibrosis and atrophy.
Decreased saliva secretion and xerostomia.[1]
Accelerated dental caries related to compromised saliva secretion.
Infections (primarily candidiasis).
Tissue necrosis (soft tissue necrosis and osteonecrosis).
Taste dysfunction (dysgeusia/ageusia).
Muscular and cutaneous fibrosis.[1]
Dysphagia.[2]
Management of oral mucositis
The etiopathogenesis of mucositis caused by head and neck radiation appears to be similar but not identical to mucositis caused by high-dose chemotherapy.[3,4,5] Management strategies described for chemotherapy/hematopoietic stem cell transplantation are generally applicable to the head/neck radiation patient.[6,7] (Refer to the Management of mucositis section of this summary for more information.) In one study, gabapentin appeared promising in reducing the need for narcotic pain medication for patients with head and neck malignancies treated with radiation therapy.[8][Level of evidence: III]
The extensive duration and severity of radiation mucositis combined with the treatment of most radiation patients as outpatients results in pain management challenges. As mucositis severity increases and topical pain management strategies become less effective, it becomes increasingly necessary to depend on systemic analgesics to manage oral radiation mucositis pain:[9]
Because there is generally no risk of bleeding for head and neck radiation patients, analgesic treatment begins with nonsteroidal anti-inflammatory drugs (NSAIDs).
As pain increases, NSAIDs are combined with opioids, and patients can be made relatively comfortable.
Doses for NSAIDs are titrated up to their recommended dosing ceiling; on the other hand, opioids are titrated to effective pain relief. Systemic analgesics are given by the clock to achieve steady-state blood levels to provide adequate pain relief.
Additionally, adjunctive medications are given to provide adjuvant analgesia and manage side effects of NSAIDs and opioids. Zinc supplementation used with radiation therapy may improve mucositis and dermatitis.[10][Level of evidence: I] The use of alcohol-free povidone-iodine mouthwash may reduce the severity and delay the onset of oral mucositis caused by antineoplastic radiation therapy.[11][Level of evidence: I]
Early infections
A systematic review indicated that the weighted mean prevalence of clinical oral candidiasis during head and neck radiation therapy is 37.4% and may be significantly higher in patients who receive concurrent chemotherapy.[12] Factors promoting clinical fungal infection in this population include the following:
Hyposalivation resulting from radiation damage to the salivary glands.
Tissue damage caused by radiation-induced oral mucositis.
Resulting dietary impairment.
Inability to maintain oral hygiene.
Because these patients are usually not significantly neutropenic, topical antifungal agents such as nystatin rinse/pastilles and clotrimazole troches can be effective. The use of a troche may be limited by significant xerostomia. Patients who receive topical antifungals should be asked to avoid eating, drinking, or rinsing for at least 30 minutes after use. Patients with removable dentures should remove the dentures before using the topical antifungals and should also treat the dentures to avoid repeat colonization of the oral tissues by fungal organisms that are colonizing the dentures.
For persistent lesions, systemic agents such as fluconazole are very effective.
Taste dysfunction
As oral and pharyngeal mucosa are exposed to radiation, taste receptors become damaged, and taste discrimination becomes increasingly compromised.[13,14] After several weeks of radiation therapy, patients commonly complain that they have no sense of taste. It will generally take 6 to 8 weeks after the end of radiation therapy for taste receptors to recover and become functional. Zinc sulfate supplements (220 mg 2 or 3 times a day) have been reported to help with recovery of the sense of taste.[15,16][Level of evidence: I]
References:
Vera-Llonch M, Oster G, Hagiwara M, et al.: Oral mucositis in patients undergoing radiation treatment for head and neck carcinoma. Cancer 106 (2): 329-36, 2006.
Caudell JJ, Schaner PE, Meredith RF, et al.: Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys 73 (2): 410-5, 2009.
Sonis ST: Mucositis as a biological process: a new hypothesis for the development of chemotherapy-induced stomatotoxicity. Oral Oncol 34 (1): 39-43, 1998.
Sonis ST, Peterson DE, McGuire DB, eds.: Mucosal injury in cancer patients: new strategies for research and treatment. J Natl Cancer Inst Monogr (29): 1-54, 2001.
Barasch A, Peterson DE: Risk factors for ulcerative oral mucositis in cancer patients: unanswered questions. Oral Oncol 39 (2): 91-100, 2003.
Demarosi F, Bez C, Carrassi A: Prevention and treatment of chemo- and radiotherapy-induced oral mucositis. Minerva Stomatol 51 (5): 173-86, 2002.
Shih A, Miaskowski C, Dodd MJ, et al.: A research review of the current treatments for radiation-induced oral mucositis in patients with head and neck cancer. Oncol Nurs Forum 29 (7): 1063-80, 2002.
Bar Ad V, Weinstein G, Dutta PR, et al.: Gabapentin for the treatment of pain related to radiation-induced mucositis in patients with head and neck tumors treated with intensity-modulated radiation therapy. Head Neck 32 (2): 173-7, 2010.
Wong PC, Dodd MJ, Miaskowski C, et al.: Mucositis pain induced by radiation therapy: prevalence, severity, and use of self-care behaviors. J Pain Symptom Manage 32 (1): 27-37, 2006.
Lin LC, Que J, Lin LK, et al.: Zinc supplementation to improve mucositis and dermatitis in patients after radiotherapy for head-and-neck cancers: a double-blind, randomized study. Int J Radiat Oncol Biol Phys 65 (3): 745-50, 2006.
Madan PD, Sequeira PS, Shenoy K, et al.: The effect of three mouthwashes on radiation-induced oral mucositis in patients with head and neck malignancies: a randomized control trial. J Cancer Res Ther 4 (1): 3-8, 2008 Jan-Mar.
Lalla RV, Latortue MC, Hong CH, et al.: A systematic review of oral fungal infections in patients receiving cancer therapy. Support Care Cancer 18 (8): 985-92, 2010.
Nelson GM: Biology of taste buds and the clinical problem of taste loss. Anat Rec 253 (3): 70-8, 1998.
Zheng WK, Inokuchi A, Yamamoto T, et al.: Taste dysfunction in irradiated patients with head and neck cancer. Fukuoka Igaku Zasshi 93 (4): 64-76, 2002.
Silverman S Jr: Complications of treatment. In: Silverman S Jr, ed.: Oral Cancer. 5th ed. Hamilton, Canada: BC Decker Inc, 2003, pp 113-28.
Ripamonti C, Zecca E, Brunelli C, et al.: A randomized, controlled clinical trial to evaluate the effects of zinc sulfate on cancer patients with taste alterations caused by head and neck irradiation. Cancer 82 (10): 1938-45, 1998.
Late Complications of Head and Neck Radiation
Late oral complications of radiation therapy are chiefly a result of chronic injury to vasculature, salivary glands, mucosa, connective tissue, and bone.[1,2,3,4] The types and severity of these changes are directly related to radiation dosimetry, including total dose, fraction size, and duration of treatment.
Mucosal Lesions
Mucosal lesions include epithelial atrophy, reduced vascularization, and submucosal fibrosis. These changes lead to an atrophic, friable barrier. Fibrosis involving muscle, dermis, and the temporomandibular joint results in compromised oral function. Salivary tissue changes include loss of acinar cells, alteration in duct epithelium, fibrosis, and fatty degeneration. Compromised vascularization and remodeling capacity of bone leads to risk of osteonecrosis.
Salivary Gland Hypofunction and Xerostomia
Ionizing radiation to salivary glands results in inflammatory and degenerative effects on salivary gland parenchyma, especially serous acinar cells. The early salivary gland tissue response to irradiation results in decreased salivary flow rates within the first week of treatment, and xerostomia (the subjective feeling of oral dryness) becomes apparent when doses exceed 10 Gy.
The degree of dysfunction is related to the radiation dose and volume of glandular tissue in the radiation field. Doses larger than 54 Gy are generally considered to induce irreversible dysfunction. Serous parotid glands may be more susceptible to radiation effects than are nonserous submandibular, sublingual, and minor salivary gland tissues. Management strategies described for late salivary gland complications are generally applicable to the acute complications in the head/neck radiation patient. (Refer to the Oral and dental management of the xerostomic patient section of this summary for more information.)
Salivary gland hypofunction (decreased salivary gland secretion) and xerostomia are among the most frequent and severe long-term side effects of radiation therapy to the head and neck region. The adverse effects will have a significant impact on a patient's quality of life in a lifelong perspective after radiation treatment.[5]
Xerostomia is caused by salivary gland hypofunction. Saliva is necessary for the normal execution of oral functions such as taste, swallowing, and speech. Unstimulated whole salivary flow rates lower than 0.1 mL per minute are considered pathologic low (normal salivary flow rate = 0.3–0.5 mL/min).[6]
Late salivary tissue changes induced by radiation therapy include loss of acinar cells, alteration in duct epithelium, fibrosis, and fatty degeneration. The early response to irradiation resulting in markedly decreased salivary flow rates within the first week of treatment is followed by a further decline in saliva secretion and worsening of xerostomia after radiation therapy (1–3 months posttreatment), whereafter salivary secretion and xerostomia gradually recover over time (maximum recovery, 1–2 years posttherapy), depending on the total radiation dose to the gland tissue.[6] Recovery of salivary gland function is usually incomplete, and the overall degree of dryness can range from mild to severe.
It should be noted that salivary gland hypofunction and xerostomia may also be sequelae of other radiation regimens, e.g., radioactive iodine treatment of thyroid cancer and preconditioning total body irradiation in hematopoietic stem cell transplantation for the treatment of hematologic malignancies—although to a much lesser severity.[7,8]
Symptoms and signs of salivary gland hypofunction include the following:
Xerostomia.
Lip dryness/crusting.
Fissures at lip commissures.
Atrophy of dorsal tongue surface.
Atrophic and fragile oral mucosa.
Difficulties in speech, chewing, and swallowing.
Difficulty in wearing dentures (edentulous patients).
Oral burning sensation.
Taste disturbances.
Increased thirst.
Sensitivity/pain in response to spicy foods and strong flavorings.
Salivary gland tissues that have been excluded from the radiation portal may become hyperplastic, partially compensating for the nonfunctional glands at other oral sites.
Salivary gland hypofunction also alters the mechanical cleansing ability and the buffer capacity of the mouth, thereby contributing to a high risk of accelerated dental caries (cavities) and periodontal disease. Also, the progression of dental caries is accelerated by the reduction in antimicrobial proteins normally contained in saliva.
In summary, salivary gland hypofunction produces the following changes in the mouth that collectively cause patient discomfort and increased risk of oral lesions:
Increase in salivary viscosity, with resultant impaired lubrication of oral tissues.
Decrease in flushing/clearance of acid production after sugar exposure, resulting in demineralization of the teeth and leading to dental decay.
Compromise of buffering capacity and salivary pH, with increased risk for dental caries and erosion.
Increase in pathogenicity of oral flora.
Accumulated bacterial plaque levels caused by patient difficulty in maintaining oral hygiene (caused by soreness of oral mucosa and/or muscular fibrosis/trismus).
Oral and dental management of the xerostomic patient
Patients who experience salivary gland hypofunction and xerostomia must maintain excellent oral hygiene to minimize the risk of oral lesions. Periodontal disease can be accelerated and caries can become rampant unless preventive measures are instituted. Multiple preventive strategies should be considered.
Oral hygiene protocol
Perform systematic oral hygiene at least 4 times per day (after meals and at bedtime):
Brush teeth (if soreness of oral mucosa and trismus are present, use small ultrasoft toothbrush).
Use a fluoridated toothpaste when brushing.
Floss once daily.
Apply a prescription-strength fluoride gel at bedtime to prevent caries.
Rinse with a solution of salt and baking soda 4 to 6 times a day (½ tsp salt and ½ tsp baking soda in 1 c warm water) to clean and lubricate the oral tissues and to buffer the oral environment.
Sip water frequently to rinse the mouth and alleviate mouth dryness.
Avoid foods and liquids with a high sugar content. (Refer to the PDQ summary on Nutrition in Cancer Care for more information.)
Fluorides
Prescription-strength fluorides should be used because nonprescription fluoride preparations are inadequate for moderate to high risk of dental caries. If drinking water does not contain enough fluoride to prevent dental decay, oral fluoride (e.g., drops or vitamins) should be provided.
Use of topical fluoride has demonstrable benefit in minimizing caries formation. During radiation treatment, it has been recommended that mouth guards be filled with topical 1% sodium fluoride gel and placed over the upper and lower teeth. The appliances should remain in place for 5 minutes, after which the patient should not eat or drink for 30 minutes.
Remineralizing solutions:
Fluoride and calcium/phosphates.
Topical high-concentration fluorides.
Children: topical and systemic.
Adults: topical.
Management of xerostomia
Prevention of salivary gland hypofunction and xerostomia
To prevent or reduce the extent of salivary gland hypofunction and xerostomia, parotid-sparing intensity-modulated radiation therapy (IMRT) is recommended as a standard approach in head and neck cancer (HNC), if oncologically feasible. In addition, treatment should focus on approaches to further reduce the radiation dose to the submandibular and minor salivary glands, as these glands are the major contributors to moistening of oral tissues.[9]
Another preventive strategy to reduce radiation-induced salivary gland hypofunction and xerostomia is surgical transfer of one submandibular gland to the submental space not included in the radiation portal in selected oropharyngeal and hypopharyngeal/laryngeal cancer patients.[10];[11][Level of evidence: I]
Amifostine is an organic thiophosphate approved for the protection of normal tissues against the harmful effects of radiation or chemotherapy, including reduction of acute or late xerostomia in patients with HNC. Studies have reported varying degrees of effectiveness.[12,13][Level of evidence: I] One randomized prospective study reported that intravenous amifostine administered during head and neck radiation therapy reduces the severity and duration of xerostomia 2 years after amifostine treatment, without apparent compromise of locoregional tumor control rates, progression-free survival, or overall patient survival.[14][Level of evidence: I] The intravenous administration of amifostine may cause severe adverse effects such as hypotension, vomiting, nausea, and allergic reaction. These adverse effects might be reduced by subcutaneous administration of amifostine. The possible risk of tumor protection by amifostine remains a clinical concern.[15]
Alleviation of xerostomia
Treatment of salivary gland hypofunction and xerostomia induced by radiation therapy is primarily symptomatic. Alleviation of xerostomia includes frequent sipping or spraying of the oral cavity with water, the use of saliva substitutes, or stimulation of saliva production from intact salivary glandular tissues by taste/mastication, pharmacological sialogogues, or acupuncture.[9]
Saliva substitutes or artificial saliva preparations (e.g., oral rinses or gels containing hydroxyethylcellulose, hydroxypropylcellulose, carboxymethylcellulose, polyglycerylmethacrylate, mucin, or xanthan gum) are palliative agents that relieve the discomfort of xerostomia by temporarily wetting the oral mucosa.[9]
Sugar-free lozenges, acidic candies, or chewing gum may produce transitory relief from xerostomia by stimulating residual capacity of salivary gland tissue (acidic products can result in demineralization of the teeth and may not be recommended in dentate patients).[9]
Pilocarpine is the only drug approved by the U.S. Food and Drug Administration for use as a sialogogue (5-mg tablets of pilocarpine hydrochloride) for radiation xerostomia. Treatment is initiated at 5 mg by mouth 3 times a day; the dose is then titrated to achieve optimal clinical response and minimize adverse effects. Some patients may experience increased benefit at higher daily doses; however, incidence of adverse effects increases proportionally with dose. The patient's evening dose may be increased to 10 mg within 1 week after starting pilocarpine. Subsequently, morning and afternoon doses may also be increased to a maximum 10 mg per dose (30 mg/d). Patient tolerance is confirmed by allowing 7 days between increments.
The most common adverse effect at clinically useful doses of pilocarpine is hyperhidrosis (excessive sweating); its incidence and severity are proportional to dosage. Also reported, typically at doses higher than 5 mg 3 times a day, are the following:
Nausea.
Chills.
Rhinorrhea.
Vasodilation.
Increased lacrimation.
Bladder pressure (urinary urgency and frequency).
Dizziness.
Asthenia.
Headache.
Diarrhea.
Dyspepsia.
Pilocarpine usually increases salivary flow within 30 minutes after ingestion. Maximal response may occur only after continual use (>8 weeks).[16][Level of evidence: I]
It has been suggested that pilocarpine given during radiation therapy may reduce salivary gland impairment and xerostomia both during and after treatment. However, in a randomized study of 249 patients with HNC, the concomitant use of pilocarpine during radiation did not have a positive impact on quality of life or patient assessment of salivary function, despite the maintenance of salivary flow.[17][Level of evidence: I] It has been indicated that the efficacy of pilocarpine depends on the radiation dose distributed to the parotid glands during treatment, i.e., in patients in whom the mean parotid dose exceeds 40 Gy, pilocarpine may spare parotid gland function and reduce xerostomia—particularly significant after 12 months.[18][Level of evidence: I]
Cevimeline (30 mg 3 times a day) also appears anecdotally to have efficacy in managing radiation-induced xerostomia.[19];[20][Level of evidence: I] Although cevimeline is approved for use only in the management of Sjögren syndrome, appropriate clinical trials are under way, and its efficacy should be established soon. While cevimeline has greater selective affinity for M3 muscarinic receptors than pilocarpine, whether this can prove advantageous for treating radiation xerostomia remains unclear.
Acupuncture appears to offer an intervention for the treatment of radiation-induced xerostomia in patients with a residual functional capacity of the salivary glands and is a treatment modality without serious adverse effects.[21,22,23] Further randomized controlled clinical trials, including sham acupuncture, are warranted.
Intraoral electrical stimulation devices delivering a low-intensity electrical current to the oral mucosa—thus stimulating salivary gland secretion by innervating afferent neurons of the salivary reflex and efferent neurons (e.g., the lingual nerve)—is under development and has been tested, with promising initial results in the palliation of xerostomia.[24];[25] Special considerations appear to be indicated when electrostimulation devices are used in head and neck radiation patients.[26][Level of evidence: I] Further studies are needed.
Caries
The risk of dental caries increases secondary to a number of factors, including shifts to a cariogenic flora, reduced concentrations of salivary antimicrobial proteins, and loss of mineralizing components.[3] (Refer to the Conditions Affected By Both Chemotherapy and Head/Neck Radiation section of this summary for more information.) As reported in a systematic review, the overall count of decayed, missing, or filled teeth (DMFT) in patients who were post–antineoplastic therapy was 9.19 (standard deviation [SD], 7.98; n = 457). The DMFT for patients who were post–radiation therapy was 17.01 (SD, 9.14; n = 157), which was much higher than that in patients who were postchemotherapy (DMFT, 4.5).[27]
Treatment strategies must be directed to each component of the caries process. Optimal oral hygiene must be maintained. Xerostomia should be managed whenever possible via salivary substitutes or replacements. Caries resistance can be enhanced with the use of topical fluorides and/or remineralizing agents. Efficacy of topical products may be enhanced by increased contact time on the teeth by application using vinyl carriers. Patients unable to effectively comply with use of fluoride trays should be instructed to use brush-on gels and rinses.
Increased colonization with Streptococcus mutans and Lactobacillus species increases caries risk. Culture data can be useful in defining level of risk in relation to colonization patterns. Topical fluorides or chlorhexidine rinses may lead to reduced levels of S. mutans but not Lactobacilli. Because of adverse drug interactions, fluoride and chlorhexidine dosing should be separated by several hours.
Remineralizing agents, which are high in calcium phosphate and fluoride, have demonstrated salutary in vitro and clinical effects. The intervention may be enhanced by delivering the drug via customized vinyl carriers. This approach extends the contact time of active drug with tooth structure, which leads to increased uptake into enamel.
A systematic review of managing dental caries in post–radiation therapy patients produced the following conclusions:[27,28]
Fluoride: The use of fluoride products reduces caries activity in patients who are post–radiation therapy. The type of fluoride gel or fluoride delivery system used did not significantly influence caries activity.
Chlorhexidine: The use of chlorhexidine rinse reduces plaque scores and oral streptococcus mutans scores. This reduction was not seen with lactobacillus counts.
Dental restorative materials: There is evidence suggesting that conventional glass ionomer restorations performed more poorly than did resin-modified glass ionomer, composite resin, and amalgam restorations in patients who had been treated with radiation therapy.
Osteoradionecrosis
Risk of osteoradionecrosis (ORN) is directly related to radiation dose and volume of tissue irradiated. The unilateral vascular supply to each half of the mandible results in postradiation ORN most frequently involving the mandible, compared with the maxilla. Presenting clinical features include:
Pain.
Diminished or complete loss of sensation.
Fistula.
Infection.
Pathologic fracture can occur because the compromised bone is unable to appropriately undergo repair at the involved sites. Risk of tissue necrosis is in part related to trauma or oral infection; however, idiopathic cases can also occur. Patients who have received high-dose radiation to the head and neck are at lifelong risk for ORN, with an overall risk of approximately 15%.
Ideally, postradiation management or ORN is based on prevention that begins with comprehensive oral and dental care before radiation therapy begins. The dentition, periodontium, periapices, and mucosa should be thoroughly examined to identify oral disease, which could lead to serious odontogenic, periodontal, or mucosal infections that could necessitate surgical therapy postradiation. Oral disease should be eliminated pretreatment. Dentition that exhibits poor prognosis and is within high-dose fields should be extracted before radiation therapy begins. Ideally, at least 7 to 14 days should be allowed for healing before initiation of radiation; some have suggested allowing up to 21 days. Surgical technique should be as atraumatic as possible and use primary wound closure.
Patients who develop ORN should be comprehensively managed to:
Eliminate trauma.
Avoid removable dental prosthesis if the denture-bearing area is within the osteonecrotic field.
Ensure adequate nutritional intake.
Discontinue tobacco and alcohol use.
Topical antibiotics (e.g., tetracycline) or antiseptics (e.g., chlorhexidine) may contribute to wound resolution. Wherever possible, coverage of the exposed bone with mucosa should be achieved. Analgesics for pain control are often effective. Local resection of bone sequestra may be possible.
Hyperbaric oxygen therapy (HBO) is recommended for management of ORN, although it has not been universally accepted. HBO has been reported to increase oxygenation of irradiated tissue, promote angiogenesis, and enhance osteoblast repopulation and fibroblast function. HBO is usually prescribed as 20 to 30 dives at 100% oxygen and 2 to 2.5 atmospheres of pressure. If surgery is needed, ten dives of postsurgical HBO are recommended. Unfortunately, HBO technology is not always accessible to patients who might otherwise benefit because of lack of available units and the high price of care.
A systematic review regarding treatment-dependent frequency, current management strategies, and future studies has been published.[29] A total of 43 articles published between 1990 and 2008 were reviewed. The weighted prevalence for ORN included the following:
Conventional radiation therapy, 7.4%.
IMRT, 5.1%.
Chemoradiation therapy, 6.8%.
Brachytherapy, 5.3%.
HBO may contribute a role in management of ORN. However, no clear recommendations for the prevention or treatment of ORN could be established on the basis of the literature reviewed. The review concluded that new cancer treatment modalities such as IMRT and concomitant chemoradiation therapy have had minimal effect on prevalence of ORN. No studies have systematically addressed the impact of ORN on either quality of life or cost of care. Research addressing these collective issues is needed.
Partial mandibulectomy may be necessary in severe cases of ORN. The mandible can be reconstructed to provide continuity for esthetics and function. A multidisciplinary cancer team that includes oncologists, oncology nurses, maxillofacial prosthodontists, general dentists, hygienists, and physical therapists is appropriate for management of these patients.
Tissue Necrosis
Necrosis and secondary infection of previously irradiated tissue is a serious complication for patients who have undergone radiation therapy for head and neck tumors.[3] Acute effects typically involve oral mucosa. Chronic changes involving bone and mucosa are a result of the process of vascular inflammation and scarring that in turn result in hypovascular, hypocellular, and hypoxic changes. Infection secondary to tissue injury and osteonecrosis confounds the process.
Soft tissue necrosis can involve any mucosal surface in the mouth, though nonkeratinized surfaces appear to be at moderately higher risk. Trauma and injury are often associated with nonhealing soft tissue necrotic lesions, though spontaneous lesions are also reported. Soft tissue necrosis begins as an ulcerative break in the mucosal surface and can spread in diameter and depth. Pain will generally become more prominent as soft tissue necrosis becomes worse. Secondary infection is a risk.
Mandibular Dysfunction
Musculoskeletal syndromes may develop secondary to radiation therapy and surgery. Lesions include soft tissue fibrosis, surgically induced mandibular discontinuity, and parafunctional habits associated with emotional stress caused by cancer and its treatment. Patients can be instructed in physical therapy interventions such as mandibular stretching exercises and the use of prosthetic aids designed to reduce the severity of fibrosis. It is important that these approaches be instituted before trismus develops. If clinically significant changes develop, several approaches can be considered, including the following:
Stabilization of occlusion.
Use of trigger-point injection and other pain management strategies.
Use of muscle relaxants.
Use of tricyclic medications.
Trismus
Trismus has been associated with significant morbidity post–radiation therapy, with significant health implications, including reduced nutrition due to impaired mastication, difficulty in speaking, and compromised oral hygiene.[30] Limitations in jaw opening have been reported in 6% to 86% of patients who received radiation to the temporomandibular joint and/or masseter/pterygoid muscles, with frequency and severity that are somewhat unpredictable.[31]
The loss of function and range of mandibular motion from radiation therapy appears to be related to fibrosis in and damage to the muscles of mastication. Studies have demonstrated that an abnormal proliferation of fibroblasts is an important initial event in these reactions. Additionally, there may be scar tissue from radiation therapy or surgery, nerve damage, or a combination of these factors. Regardless of the immediate cause, mandibular hypomobility will ultimately result in degeneration of both muscle and temporomandibular joint.
Radiation therapy involving the temporomandibular joint, the pterygoid muscles, or the masseter muscle is most likely to result in trismus.[30] Tumors related to this type of radiation can appear in the following locations:
Nasopharynx.
Oral cavity.
Oropharynx.
Base of tongue.
Salivary gland.
Maxilla or mandible.
The prevalence of trismus increases with increasing doses of radiation, and levels in excess of 60 Gy are more likely to cause trismus.[5] Patients who have been previously irradiated and who are being treated for a recurrence appear to be at higher risk of trismus than those who are receiving their first treatment.[32,33] This suggests that the effects of radiation are cumulative, even over many years. Radiation-induced trismus may begin toward the end of radiation therapy or at any time during the subsequent 24 months. Limitations in opening the mouth often increase slowly over several weeks or months. The condition may worsen over time or remain the same, or the symptoms may reduce over time, even in the absence of treatment.
Limited mouth opening frequently results in reduced nutritional status. These patients may experience significant weight loss and nutritional deficits.[34] It is generally accepted that weight loss of more than 10% of initial body weight is considered significant. This is of particular importance at a time when the patient is recovering from surgery, chemotherapy, and/or radiation therapy. Additionally, it lowers the ability for social eating and thereby increases the risk of social isolation and decrease in quality of life in patients with HNC.
Finally, limited mouth opening can result in compromised oral hygiene. Patients who have undergone radiation therapy involving the salivary glands must maintain excellent oral hygiene to prevent dental caries. Deficits in oral hygiene can aggravate mucosal and dental problems, with the subsequent risk of mandibular ORN. Also, dental work and other professional oral care measures such as surgery can be made more difficult, which might even result in compromised oncologic follow-up.
The weighted prevalence of trismus with conventional radiation is estimated to be 25%, but 5% with IMRT only. Trismus prevalence in studies of chemoradiation is approximately 30%.[35]
Prevention strategies
Early treatment of trismus has the potential to prevent or minimize many of the consequences of this condition. If the clinical examination reveals the presence of limited mouth opening, and diagnosis determines the condition to be trismus, treatment should begin as soon as is practical. As restriction becomes more severe and likely irreversible, the need for treatment becomes more urgent.
Over the years, clinicians have attempted to prevent or treat trismus with a wide array of appliances. These devices include the following:
Cages that fit over the head.
Heavy springs that fit between the teeth.
Screws that are placed between the central incisors.
Hydraulic bulbs placed between the teeth.
These devices range widely in cost. Some devices, such as continuous passive motion devices, must be custom made for each patient; others are rented on a daily or weekly basis, at rates of up to several hundred dollars per week. The least expensive option is the use of tongue depressors, which has been used for many years to mobilize the jaw. A search of the literature, however, failed to reveal any studies that demonstrated significant improvement in treating trismus with tongue depressors.
Curative approach
Some therapeutic interventions seem to show some efficacy in decreasing the intensity of cancer treatment–related trismus (e.g., pentoxifylline,[36,37] Botulinum toxin,[38] exercise using the Therabite device,[39] and the Dynasplint Trismus System [40]). However, this proposed efficacy must be confirmed by randomized controlled studies, which are lacking in this area.
Recommendations for future research directions
Radiation oncology textbooks often fail to mention trismus as a sequela of radiation therapy for HNC patients, contributing to a lack of recognition of the prevalence and significance of this condition. There has been an ongoing attempt by the Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer to develop LENT (late effects in normal tissue) morbidity scales. The National Cancer Institute consensus conferences introduced the SOMA (subjective, objective, management, analysis) classification for late toxicity. However, both scales are focused on major organ and dermatological injuries, and trismus is not addressed. This should be corrected in future revisions of these scales.
Considering the high prevalence of trismus in published studies and the deficits in quality of life associated with trismus, increased efforts for patient education, prevention, and early treatment options are warranted. Larger prospective trials that include the prevention and treatment of trismus are needed to improve management and to confirm the benefit of IMRT in the reduction of radiation-induced trismus and the quality-of-life and economic impact of this common oral sequela of radiation.
Current Clinical Trials
Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.
References:
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Epstein JB, Wong FL, Stevenson-Moore P: Osteoradionecrosis: clinical experience and a proposal for classification. J Oral Maxillofac Surg 45 (2): 104-10, 1987.
Silverman S Jr: Complications of treatment. In: Silverman S Jr, ed.: Oral Cancer. 5th ed. Hamilton, Canada: BC Decker Inc, 2003, pp 113-28.
Jensen SB, Pedersen AM, Vissink A, et al.: A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life. Support Care Cancer 18 (8): 1039-60, 2010.
Teguh DN, Levendag PC, Voet P, et al.: Trismus in patients with oropharyngeal cancer: relationship with dose in structures of mastication apparatus. Head Neck 30 (5): 622-30, 2008.
Jellema AP, Slotman BJ, Doornaert P, et al.: Impact of radiation-induced xerostomia on quality of life after primary radiotherapy among patients with head and neck cancer. Int J Radiat Oncol Biol Phys 69 (3): 751-60, 2007.
Hyer S, Kong A, Pratt B, et al.: Salivary gland toxicity after radioiodine therapy for thyroid cancer. Clin Oncol (R Coll Radiol) 19 (1): 83-6, 2007.
Dahllöf G, Bågesund M, Ringdén O: Impact of conditioning regimens on salivary function, caries-associated microorganisms and dental caries in children after bone marrow transplantation. A 4-year longitudinal study. Bone Marrow Transplant 20 (6): 479-83, 1997.
Jensen SB, Pedersen AM, Vissink A, et al.: A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: management strategies and economic impact. Support Care Cancer 18 (8): 1061-79, 2010.
Seikaly H, Jha N, Harris JR, et al.: Long-term outcomes of submandibular gland transfer for prevention of postradiation xerostomia. Arch Otolaryngol Head Neck Surg 130 (8): 956-61, 2004.
Jha N, Seikaly H, Harris J, et al.: Phase III randomized study: oral pilocarpine versus submandibular salivary gland transfer protocol for the management of radiation-induced xerostomia. Head Neck 31 (2): 234-43, 2009.
Buentzel J, Micke O, Adamietz IA, et al.: Intravenous amifostine during chemoradiotherapy for head-and-neck cancer: a randomized placebo-controlled phase III study. Int J Radiat Oncol Biol Phys 64 (3): 684-91, 2006.
Sasse AD, Clark LG, Sasse EC, et al.: Amifostine reduces side effects and improves complete response rate during radiotherapy: results of a meta-analysis. Int J Radiat Oncol Biol Phys 64 (3): 784-91, 2006.
Wasserman TH, Brizel DM, Henke M, et al.: Influence of intravenous amifostine on xerostomia, tumor control, and survival after radiotherapy for head-and- neck cancer: 2-year follow-up of a prospective, randomized, phase III trial. Int J Radiat Oncol Biol Phys 63 (4): 985-90, 2005.
Brizel DM, Overgaard J: Does amifostine have a role in chemoradiation treatment? Lancet Oncol 4 (6): 378-81, 2003.
Rieke JW, Hafermann MD, Johnson JT, et al.: Oral pilocarpine for radiation-induced xerostomia: integrated efficacy and safety results from two prospective randomized clinical trials. Int J Radiat Oncol Biol Phys 31 (3): 661-9, 1995.
Scarantino C, LeVeque F, Swann RS, et al.: Effect of pilocarpine during radiation therapy: results of RTOG 97-09, a phase III randomized study in head and neck cancer patients. J Support Oncol 4 (5): 252-8, 2006.
Burlage FR, Roesink JM, Kampinga HH, et al.: Protection of salivary function by concomitant pilocarpine during radiotherapy: a double-blind, randomized, placebo-controlled study. Int J Radiat Oncol Biol Phys 70 (1): 14-22, 2008.
Chambers MS, Jones CU, Biel MA, et al.: Open-label, long-term safety study of cevimeline in the treatment of postirradiation xerostomia. Int J Radiat Oncol Biol Phys 69 (5): 1369-76, 2007.
Jham BC, Teixeira IV, Aboud CG, et al.: A randomized phase III prospective trial of bethanechol to prevent radiotherapy-induced salivary gland damage in patients with head and neck cancer. Oral Oncol 43 (2): 137-42, 2007.
Blom M, Lundeberg T: Long-term follow-up of patients treated with acupuncture for xerostomia and the influence of additional treatment. Oral Dis 6 (1): 15-24, 2000.
O'Sullivan EM, Higginson IJ: Clinical effectiveness and safety of acupuncture in the treatment of irradiation-induced xerostomia in patients with head and neck cancer: a systematic review. Acupunct Med 28 (4): 191-9, 2010.
Cho JH, Chung WK, Kang W, et al.: Manual acupuncture improved quality of life in cancer patients with radiation-induced xerostomia. J Altern Complement Med 14 (5): 523-6, 2008.
Strietzel FP, Martín-Granizo R, Fedele S, et al.: Electrostimulating device in the management of xerostomia. Oral Dis 13 (2): 206-13, 2007.
Strietzel FP, Lafaurie GI, Mendoza GR, et al.: Efficacy and safety of an intraoral electrostimulation device for xerostomia relief: a multicenter, randomized trial. Arthritis Rheum 63 (1): 180-90, 2011.
Lafaurie G, Fedele S, López RM, et al.: Biotechnological advances in neuro-electro-stimulation for the treatment of hyposalivation and xerostomia. Med Oral Patol Oral Cir Bucal 14 (2): E76-80, 2009.
Hong CH, Napeñas JJ, Hodgson BD, et al.: A systematic review of dental disease in patients undergoing cancer therapy. Support Care Cancer 18 (8): 1007-21, 2010.
Brennan MT, Elting LS, Spijkervet FK: Systematic reviews of oral complications from cancer therapies, Oral Care Study Group, MASCC/ISOO: methodology and quality of the literature. Support Care Cancer 18 (8): 979-84, 2010.
Peterson DE, Doerr W, Hovan A, et al.: Osteoradionecrosis in cancer patients: the evidence base for treatment-dependent frequency, current management strategies, and future studies. Support Care Cancer 18 (8): 1089-98, 2010.
Dijkstra PU, Kalk WW, Roodenburg JL: Trismus in head and neck oncology: a systematic review. Oral Oncol 40 (9): 879-89, 2004.
Louise Kent M, Brennan MT, Noll JL, et al.: Radiation-induced trismus in head and neck cancer patients. Support Care Cancer 16 (3): 305-9, 2008.
Dijkstra PU, Huisman PM, Roodenburg JL: Criteria for trismus in head and neck oncology. Int J Oral Maxillofac Surg 35 (4): 337-42, 2006.
Yeh SA, Tang Y, Lui CC, et al.: Treatment outcomes and late complications of 849 patients with nasopharyngeal carcinoma treated with radiotherapy alone. Int J Radiat Oncol Biol Phys 62 (3): 672-9, 2005.
Hsiung CY, Huang EY, Ting HM, et al.: Intensity-modulated radiotherapy for nasopharyngeal carcinoma: the reduction of radiation-induced trismus. Br J Radiol 81 (970): 809-14, 2008.
Bensadoun RJ, Riesenbeck D, Lockhart PB, et al.: A systematic review of trismus induced by cancer therapies in head and neck cancer patients. Support Care Cancer 18 (8): 1033-8, 2010.
Chua DT, Lo C, Yuen J, et al.: A pilot study of pentoxifylline in the treatment of radiation-induced trismus. Am J Clin Oncol 24 (4): 366-9, 2001.
Grandi G, Silva ML, Streit C, et al.: A mobilization regimen to prevent mandibular hypomobility in irradiated patients: an analysis and comparison of two techniques. Med Oral Patol Oral Cir Bucal 12 (2): E105-9, 2007.
Hartl DM, Cohen M, Juliéron M, et al.: Botulinum toxin for radiation-induced facial pain and trismus. Otolaryngol Head Neck Surg 138 (4): 459-463, 2008.
Melchers LJ, Van Weert E, Beurskens CH, et al.: Exercise adherence in patients with trismus due to head and neck oncology: a qualitative study into the use of the Therabite. Int J Oral Maxillofac Surg 38 (9): 947-54, 2009.
Shulman DH, Shipman B, Willis FB: Treating trismus with dynamic splinting: a cohort, case series. Adv Ther 25 (1): 9-16, 2008.
Conditions Affected By Both Chemotherapy and Head / Neck Radiation
Salivary Gland Hypofunction and Xerostomia
Radiation therapy can damage salivary glands, causing salivary hypofunction and xerostomia. (Refer to the Oral Complications of Head and Neck Radiation section of this summary for more information.) In addition, selected chemotherapeutic agents (singly or in combination) have been implicated in causing salivary dysfunction and xerostomia.[1] However, it has not been possible to draw consistent conclusions about the effects of cancer chemotherapy on salivary gland function.[2]
Dysphagia
Dysphagia and odynophagia are common in cancer patients and can exist before, during, and after treatment:
Dysphagia predisposes to aspiration and potentially life-threatening pulmonary complications.[3]
Swallowing disorders may lead to unfavorable dietary changes and decreased oral intake, which may result in dehydration, malnutrition, delayed wound healing, and decreased resistance to infection.
Tube feeding may become necessary, which may further compromise swallowing.
Opioids administered for the management of odynophagia may cause xerostomia and constipation.
Difficulties with speaking, eating and drinking, or drooling may affect mental health and put patients and family members in social isolation.
All of these problems, plus the patient perception of swallowing difficulties, significantly decrease health-related quality of life.[3,4]
Dysphagia is most prominent in patients with head and neck cancers but may also develop in patients with other malignancies as a symptom of oropharyngeal or esophageal mucositis or infection. In addition, dysphagia can be associated with graft-versus-host disease.
The prevalence and severity of pretreatment dysphagia associated with head and neck tumors depend on tumor stage and localization.[5] Pretreatment dysphagia is most prevalent in patients with pharyngeal and laryngeal cancers.[6] Surgical interventions for head and neck tumors result in anatomic or neurologic insults with site-specific patterns of dysphagia.[7] In general, the larger the resection, the more swallowing function will be impaired.
The severity of radiation-induced dysphagia depends on the following:[8]
Total radiation dose.
Fraction size and schedule.
Target volumes.
Treatment delivery techniques.
Concurrent chemotherapy.
Genetic factors.
Feeding status (via percutaneous endoscopic gastrostomy [PEG] tube or nil per os [NPO, nothing by mouth]).
Smoking status.
Psychological coping factors.
Intensified schedules and the use of chemoradiation therapy have been shown to improve locoregional control and survival but come at the cost of more severe acute and chronic side effects. Intensity-modulated radiation therapy (IMRT) has emerged as an effective technique to deliver the full radiation dose to the tumor and regions at risk while reducing exposure of surrounding healthy tissues. However, the preservation of anatomy does not necessarily translate into the preservation of swallowing function.[9]
Mucositis induced by chemoradiation therapy or chemotherapy alone, edema, pain, thickened mucous saliva and hyposalivation, radiation dermatitis, and infection may all contribute to acute dysphagia. The use of epidermal growth factor inhibitors seems not to be associated with increased mucositis and acute dysphagia.[10]
By 3 months posttreatment, acute clinical effects have largely resolved, and normal swallowing function starts to return in most patients. Unfortunately, in head and neck cancer patients treated with chemoradiation, a continuing cascade of inflammatory cytokines triggered by oxidative stress and hypoxia may damage exposed tissues, and dysphagia may develop even years after the completion of treatment. Late sequelae that may contribute to chronic dysphagia include the following:
Reduced capillary flow.
Atrophy and necrosis.
Lymphedema.
Neuromuscular fibrosis leading to trismus and stricture formation.
Hyposalivation.
Infection.
Successful management of dysphagia requires the following:
Interdisciplinary collaboration.
Accurate and early diagnostic workup.
Effective preventative and therapeutic strategies.
An individual approach geared to unique patient characteristics.
Dysphagia- and aspiration-related structures have been identified, and minimizing radiation to these bystander tissues results in better swallowing outcomes.[11] Because hyposalivation affects swallowing function, strategies aimed at sparing salivary glands such as IMRT and the use of amifostine may improve swallowing outcomes.[12,13]
A predictive model for persistent swallowing dysfunction following chemoradiation therapy for head and neck cancer has been developed.[14] Early involvement of a speech and language therapist is critical to assess swallow function and aspiration risk and to generate a treatment plan that includes patient education and swallow therapy.[15] Cooperation with a dietician is important to ensure adequate and safe nutrition. Prosthodontic interventions may improve swallowing performance, and patients may benefit from psychological support.
Dysgeusia
Dysgeusia can be a prominent symptom in patients who are receiving chemotherapy or head/neck radiation.[16,17] Etiology is likely associated with several factors, including direct neurotoxicity to taste buds, xerostomia, infection, and psychologic conditioning. In addition, taste dysfunction can be associated with damage caused by graft-versus-host disease to the taste perception units. (Refer to the Graft-versus-Host Disease section of this summary for more information.)
Patients receiving chemotherapy may experience unpleasant taste secondary to diffusion of drug into the oral cavity. In addition, chemotherapy patients often describe dysgeusia in the early weeks after cessation of cytotoxic therapy. This symptom in general is reversible, and taste sensation returns to normal in the ensuing months.
By comparison, however, a total fractionated radiation dose higher than 3,000 Gy reduces acuity of sweet, sour, bitter, and salt tastes. Damage to the microvilli and outer surface of the taste cells has been proposed as the principal mechanism for loss of the sense of taste. In many cases, taste acuity returns in 2 to 3 months after cessation of radiation. However, many other patients develop permanent hypogeusia. Zinc supplementation (zinc sulfate 220 mg 2 times a day) has been reported to be useful in some patients; the overall benefit of this treatment remains unclear.[18];[19][Level of evidence: I]
Nutritional Considerations
Patients with head and neck cancer are at high risk for nutritional problems. Contributing to malnutrition are the following:[20]
The malignancy itself.
Poor nutrition before diagnosis.
Complications of surgery, radiation therapy, and chemotherapy.
In cancer patients, loss of appetite can also occur secondary to mucositis, xerostomia, taste loss, dysphagia, nausea, and vomiting. Quality of life is compromised as eating becomes more problematic. Oral pain with eating may lead to selection of foods that do not aggravate the oral tissues, often at the expense of adequate nutrition. Nutritional deficiencies can be minimized by modifying the texture and consistency of the diet and by adding more frequent meals and snacks to increase calories and protein. Ongoing nutrition assessment and counseling with a registered dietitian should be part of the patient's treatment plan.[21]
Many patients who receive radiation therapy alone are able to tolerate soft foods; however, as treatment progresses, most patients must transition to liquid diets using high-calorie, high-protein liquid nutritional supplements, and some may require enteral feeding tubes to meet their nutritional needs. Almost all patients receiving concurrent chemotherapy and radiation therapy will become fully dependent on enteral nutritional support within 3 to 4 weeks of therapy. Numerous studies have demonstrated the benefit of enteral feedings initiated at the onset of treatment, before significant weight loss has occurred.[22,23]
Oral nutrition is reinstituted after treatment has concluded and the radiated site has adequately healed. Oral nutrition often requires a team approach. The assistance of a speech and swallowing therapist to assess for any swallowing dysfunction resulting from surgery or treatment is often necessary and beneficial in easing the transition back to solid foods. The number of tube feedings can be decreased as a patient's oral intake increases, with tube feeding being discontinued when 75% of a patient's nutrition needs are being met orally. Although most patients will resume adequate oral intake, many will continue to experience chronic complications such as taste changes, xerostomia, and varying degrees of dysphagia that can affect their nutritional status and quality of life.[20,21]
Fatigue
Cancer patients undergoing high-dose chemotherapy and/or radiation therapy can experience fatigue related to either the disease or its treatment.[24] These processes can produce sleep deprivation or metabolic disorders that collectively contribute to compromised oral status. For example, the fatigued patient will likely have impaired compliance with mouth care protocols designed to otherwise minimize risk of mucosal ulceration, infection, and pain. In addition, biochemical abnormalities are likely involved in many patients. The psychosocial component can also play a major role, with depression contributing to overall fatigue. (Refer to the PDQ summary on Fatigue for more information.)
References:
Jensen SB, Mouridsen HT, Reibel J, et al.: Adjuvant chemotherapy in breast cancer patients induces temporary salivary gland hypofunction. Oral Oncol 44 (2): 162-73, 2008.
Jensen SB, Pedersen AM, Vissink A, et al.: A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life. Support Care Cancer 18 (8): 1039-60, 2010.
Nguyen NP, Moltz CC, Frank C, et al.: Dysphagia following chemoradiation for locally advanced head and neck cancer. Ann Oncol 15 (3): 383-8, 2004.
Langendijk JA, Doornaert P, Verdonck-de Leeuw IM, et al.: Impact of late treatment-related toxicity on quality of life among patients with head and neck cancer treated with radiotherapy. J Clin Oncol 26 (22): 3770-6, 2008.
Logemann JA, Rademaker AW, Pauloski BR, et al.: Site of disease and treatment protocol as correlates of swallowing function in patients with head and neck cancer treated with chemoradiation. Head Neck 28 (1): 64-73, 2006.
Pauloski BR, Rademaker AW, Logemann JA, et al.: Pretreatment swallowing function in patients with head and neck cancer. Head Neck 22 (5): 474-82, 2000.
Kronenberger MB, Meyers AD: Dysphagia following head and neck cancer surgery. Dysphagia 9 (4): 236-44, 1994.
Platteaux N, Dirix P, Dejaeger E, et al.: Dysphagia in head and neck cancer patients treated with chemoradiotherapy. Dysphagia 25 (2): 139-52, 2010.
Mittal BB, Pauloski BR, Haraf DJ, et al.: Swallowing dysfunction--preventative and rehabilitation strategies in patients with head-and-neck cancers treated with surgery, radiotherapy, and chemotherapy: a critical review. Int J Radiat Oncol Biol Phys 57 (5): 1219-30, 2003.
Curran D, Giralt J, Harari PM, et al.: Quality of life in head and neck cancer patients after treatment with high-dose radiotherapy alone or in combination with cetuximab. J Clin Oncol 25 (16): 2191-7, 2007.
Eisbruch A, Schwartz M, Rasch C, et al.: Dysphagia and aspiration after chemoradiotherapy for head-and-neck cancer: which anatomic structures are affected and can they be spared by IMRT? Int J Radiat Oncol Biol Phys 60 (5): 1425-39, 2004.
Sasse AD, Clark LG, Sasse EC, et al.: Amifostine reduces side effects and improves complete response rate during radiotherapy: results of a meta-analysis. Int J Radiat Oncol Biol Phys 64 (3): 784-91, 2006.
Büntzel J, Glatzel M, Mücke R, et al.: Influence of amifostine on late radiation-toxicity in head and neck cancer--a follow-up study. Anticancer Res 27 (4A): 1953-6, 2007 Jul-Aug.
Langendijk JA, Doornaert P, Rietveld DH, et al.: A predictive model for swallowing dysfunction after curative radiotherapy in head and neck cancer. Radiother Oncol 90 (2): 189-95, 2009.
Murphy BA, Gilbert J: Dysphagia in head and neck cancer patients treated with radiation: assessment, sequelae, and rehabilitation. Semin Radiat Oncol 19 (1): 35-42, 2009.
Bartoshuk LM: Chemosensory alterations and cancer therapies. NCI Monogr (9): 179-84, 1990.
Garrick R: Neurologic complications. In: Atkinson K, ed.: Clinical Bone Marrow and Blood Stem Cell Transplantation. 2nd ed. Cambridge, UK: Cambridge University Press, 2000, pp 958-79.
Silverman S Jr: Complications of treatment. In: Silverman S Jr, ed.: Oral Cancer. 5th ed. Hamilton, Canada: BC Decker Inc, 2003, pp 113-28.
Ripamonti C, Zecca E, Brunelli C, et al.: A randomized, controlled clinical trial to evaluate the effects of zinc sulfate on cancer patients with taste alterations caused by head and neck irradiation. Cancer 82 (10): 1938-45, 1998.
Robinson CA: Enteral nutrition in adult oncology. In: Elliott L, Molseed LL, McCallum PD, eds.: The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, Ill: American Dietetic Association, 2006, pp 138-55.
Kagan SH, Sweeney-Cordes E: Head and neck cancers. In: Kogut VJ, Luthringer SL, eds.: Nutritional Issues in Cancer Care. Pittsburgh, Pa: Oncology Nursing Society, 2005, pp 103-16.
Beer KT, Krause KB, Zuercher T, et al.: Early percutaneous endoscopic gastrostomy insertion maintains nutritional state in patients with aerodigestive tract cancer. Nutr Cancer 52 (1): 29-34, 2005.
Tyldesley S, Sheehan F, Munk P, et al.: The use of radiologically placed gastrostomy tubes in head and neck cancer patients receiving radiotherapy. Int J Radiat Oncol Biol Phys 36 (5): 1205-9, 1996.
Visser MR, Smets EM: Fatigue, depression and quality of life in cancer patients: how are they related? Support Care Cancer 6 (2): 101-8, 1998.
Psychosocial Issues
Oral complications of cancer, including oral mucositis [1] and salivary gland hypofunction/xerostomia,[2] are among the most devastating of both short- and long-term problems encountered by people with cancer because they affect eating and communication, the most basic of human activities. Patients with these problems can become withdrawn, socially avoidant, and even clinically depressed as a result of the difficulties and frustrations they encounter living with oral complications.
When psychotropic drug interventions are employed in the treatment of such patients, it is important that the drugs chosen will improve, or at least not worsen, their oral complications. For example, in the treatment of depression, highly anticholinergic drugs should be avoided in patients with xerostomia and salivary problems. (Refer to the PDQ summaries on Adjustment to Cancer: Anxiety and Distress and Depression for more information.)
Supportive care, including education and symptom management, are important for patients experiencing oral complications related to cancer therapy. It is important to closely monitor each patient's level of distress, ability to cope, and response to treatment. This approach provides a setting for the health professional to demonstrate concern for the patient's complications and to educate the patient and family caregivers. Comprehensive supportive care from staff and family can enhance the patient's ability to cope with cancer and its complications.
References:
Dodd MJ, Dibble S, Miaskowski C, et al.: A comparison of the affective state and quality of life of chemotherapy patients who do and do not develop chemotherapy-induced oral mucositis. J Pain Symptom Manage 21 (6): 498-505, 2001.
Langendijk JA, Doornaert P, Verdonck-de Leeuw IM, et al.: Impact of late treatment-related toxicity on quality of life among patients with head and neck cancer treated with radiotherapy. J Clin Oncol 26 (22): 3770-6, 2008.
Special Considerations in Pediatric Populations
Altered dental growth and development is a frequent complication in long-term cancer survivors who received high-dose chemotherapy and/or head/neck radiation for childhood malignancies.[1,2,3,4,5,6,7,8] Radiation doses as low as 4 Gy have been shown to cause localized dental defects in humans.[9,10]
Developmental disturbances in children treated before age 12 years generally affect size, shape, and eruption of teeth as well as craniofacial development:
Abnormal tooth formation manifests as decreased crown size, shortened and conical shaped roots, and microdontia; on occasion, complete agenesis may occur.
Eruption of teeth can be delayed, including increased frequency of impacted maxillary canines.
Shortened root length is associated with diminished alveolar processes, leading to decreased occlusal vertical dimension.
Conditioning-induced injury to maxillary and mandibular growth centers can compromise full maturation of the craniofacial complex.
Because the changes tend to be symmetric, the effect is not always clinically evident. Cephalometric analysis is typically necessary to delineate the scope of the condition.
The extent and location of dental and craniofacial anomalies largely depend on the age at which cancer therapy was initiated and the cancer regimen used. Children younger than 5 or 6 years at the time of treatment (particularly those who undergo treatment that involves concomitant chemotherapy and head and neck radiation) appear to have a higher incidence of dental and craniofacial anomalies than do older patients or those who undergo only chemotherapy.[11,12]
The role and timing of orthodontic treatment for patients who have transplant-related malocclusions or other alterations of dental growth and development are not fully established. The number of successfully managed orthodontic interventions appears to be increasing; however, specific guidelines for management, including optimal force and pace with which teeth should be moved, remains undefined. The influence of growth hormone relative to improved development of maxillary and mandibular structures is yet to be comprehensively studied. Such studies may well influence recommendations for orthodontic treatment. (Refer to the PDQ summary on Late Effects of Treatment for Childhood Cancer for further information.)
Management of oral complications in pediatric patients is additionally challenging because of the relatively limited research base directed to oral toxicities. New, comprehensive research studies are thus needed.
References:
Cohen A, Rovelli R, Zecca S, et al.: Endocrine late effects in children who underwent bone marrow transplantation: review. Bone Marrow Transplant 21 (Suppl 2): S64-7, 1998.
Dahllöf G, Barr M, Bolme P, et al.: Disturbances in dental development after total body irradiation in bone marrow transplant recipients. Oral Surg Oral Med Oral Pathol 65 (1): 41-4, 1988.
Dahllöf G: Craniofacial growth in children treated for malignant diseases. Acta Odontol Scand 56 (6): 378-82, 1998.
Dahllöf G, Forsberg CM, Ringdén O, et al.: Facial growth and morphology in long-term survivors after bone marrow transplantation. Eur J Orthod 11 (4): 332-40, 1989.
Uderzo C, Fraschini D, Balduzzi A, et al.: Long-term effects of bone marrow transplantation on dental status in children with leukaemia. Bone Marrow Transplant 20 (10): 865-9, 1997.
Lucas VS, Roberts GJ, Beighton D: Oral health of children undergoing allogeneic bone marrow transplantation. Bone Marrow Transplant 22 (8): 801-8, 1998.
Dahllöf G, Heimdahl A, Bolme P, et al.: Oral condition in children treated with bone marrow transplantation. Bone Marrow Transplant 3 (1): 43-51, 1988.
Rosenberg SW, Kolodney H, Wong GY, et al.: Altered dental root development in long-term survivors of pediatric acute lymphoblastic leukemia. A review of 17 cases. Cancer 59 (9): 1640-8, 1987.
Fromm M, Littman P, Raney RB, et al.: Late effects after treatment of twenty children with soft tissue sarcomas of the head and neck. Experience at a single institution with a review of the literature. Cancer 57 (10): 2070-6, 1986.
Goho C: Chemoradiation therapy: effect on dental development. Pediatr Dent 15 (1): 6-12, 1993 Jan-Feb.
Näsman M, Forsberg CM, Dahllöf G: Long-term dental development in children after treatment for malignant disease. Eur J Orthod 19 (2): 151-9, 1997.
Hölttä P, Hovi L, Saarinen-Pihkala UM, et al.: Disturbed root development of permanent teeth after pediatric stem cell transplantation. Dental root development after SCT. Cancer 103 (7): 1484-93, 2005.
Changes to This Summary (12 / 16 / 2016)
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.
Editorial changes were made to this summary.
This summary is written and maintained by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® - NCI's Comprehensive Cancer Database pages.
About This PDQ Summary
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the pathophysiology and treatment of oral complications of chemotherapy and head/neck radiation. 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 Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
be discussed at a meeting,
be cited with text, or
replace or update an existing article that is already cited.
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 NCI website's Email Us. 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 Supportive and Palliative Care 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:
PDQ® Supportive and Palliative Care Editorial Board. PDQ Oral Complications of Chemotherapy and Head/Neck Radiation. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/treatment/side-effects/mouth-throat/oral-complications-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389320]
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Health Library
Topic Contents
Overview
Etiopathogenesis
Oral and Dental Management Before Cancer Therapy
Oral and Dental Management After Cancer Therapy
Oral Mucositis
Orofacial Pain in Cancer Patients
Infection
Hemorrhage
Neurotoxicity
Graft-versus-Host Disease
Posttransplantation Dental Treatment
Relapse and Second Malignancy
Dysgeusia
Oral Toxicities Not Related to Chemotherapy or Radiation Therapy
Head / Neck Radiation Patients
Late Complications of Head and Neck Radiation
Conditions Affected By Both Chemotherapy and Head / Neck Radiation
Psychosocial Issues
Special Considerations in Pediatric Populations
Changes to This Summary (12 / 16 / 2016)
About This PDQ Summary
Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ®): Supportive care - Health Professional Information [NCI]
NOTICE: This health information was not created by the University of Michigan Health System (UMHS) and may not necessarily reflect specific UMHS practices. For medical advice relating to your personal condition, please consult your doctor. Complete disclaimer
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| 660.2 | 225,880 |
https://www.uofmhealth.org/health-library/ncicdr0000062870
|
www.uofmhealth.org
| 0 |
[] |
[] | false |
[] |
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