text:
Paper Racing by Elite Games
5,000,000 - 10,000,000 downloads
- If you're bored, can be fun for some people
- Pretty useless
- Boring and repetitive
+ By Elite Games
Play by yourself or compete with other people to see who's the quickest
Paper Racing is a really simple app for releasing the pressure where you just need to drag off a roll of toilet paper until it's finished. That's it, really. With your finger, you just got to drag your finger continuously and quickly so you finish as fast as possible. There are two game modes, single, where you can challenge yourself to beat your previous score and multiple mode, where you play against some unknown person and try to do it quicker than him. The graphics are simple but good and the game is not that bad, it's just too simple and repetitive. We understand that it can be pretty fun if you're bored and really don't have anything else to do and also a way of exercising the fingers.
DroidHen Publisher is the developer of Paper Racing, Lair Defense and Take me home. This is not their best game but if you enjoy the others, you might want to take a look at it and save it for the boring moments.
# Single mode: See how fast that you can drag off a roll of toilet paper.
# Multiple mode: Join paper racing to challenge other players!
Get it, drag it, and beat your friends to be the fastest!
Added achievement system.
Added 15 paper patterns.
Some lists where this application appears: Reviewed by Anna Grace.
Hey guys. If you want to get free gifts from your phone check out (www.AndroidPrizes.net.tc) Just got myself a free $250 Visa gift card.
I love this game so much
Excellent game.love it ;-)!!!!!
Add more toilet paper designs
It looks interesting but I can't even download it :/
This games is the bom and takey money but that is ok thats are right im get it back cause im the boss
This game is crappy my cuz is playing and he said that he had 2214 coins but now je only has 3 x-(


text:
The Duties of the Heart
Free download available in PDF, epub, and Kindle e-book formats. Skip straight to downloads.
Part of the Wisdom of the East series, this short book is translated from the work of Rabbi Bachye, who wrote one of the first systematic treatments of philosophical Ethics in 12th century Spain. This was during a period of Jewish intellectual cross-fertilization with Islamic culture. Although Bachye was an orthodox Rabbi, he treats Ethics (the Duties of the Heart, in his words) as a universal science, derived from first principles such as the belief in God.
This book has 66 pages in the PDF version. This translation by Edwin Collins was originally published in 1909.
Production notes: This e-book of The Duties of the Heart was published by Global Grey in 2018.
Download for e-readers (below donate buttons)
I run this site entirely on my own. I know times are hard right now, but if you can, please donate a small amount of £1 or $1, so I can continue offering these free e-books to everyone. To all the people who have supported the site - a massive thank you!
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Dog Walking Pet Sitting Cat Care Pet Taxi Service Police checked and Fully Insured. All enquires welcome. Cannock areas Staffordshire. Taking a weekend break? Worried about your pet or home? Need a pet taxi? Someone to feed your dog or cat? Walk your dog? Worried about leaving your house empty when on holiday? Services from pet sitting, dog walking, feeding cats, or small caged animals, feeding of birds to looking after hens or poultry. Ensuring your pet is taken care of in a safe enviroment,fed and cleaned according to their normal routine''s. Offering a home from dog for your pet.Puppy care and elderly dog care, also caring for pets with special needs. A Free Consultation for your four legged friend to make sure they will recieve the best care possible.copperkins road
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WikiDoc Resources for Frostbite
Evidence Based Medicine
Guidelines / Policies / Govt
Patient Resources / Community
Healthcare Provider Resources
Continuing Medical Education (CME)
Experimental / Informatics
Frostbite (congelatio in medical terminology) is a freezing, cold thermal injury, which occurs on being exposed to temperatures below the freezing point of typically −0.55°C to as high as 2°C for a sustained period of time. It is a condition characterized by the consequences in terms of functional morbidity among the panel of population that are often young, fit and healthy prior to sustaining thermal injury. Currently, the prevalence of frostbite is increasing within the civilian population, particularly among those who partake in winter sports such as skiing, hiking, mountain and ice climbing. The outdoor activities are more accessible so the individuals with limited experience or inadequate preparation and protection are highly prone to it. Additionally, vagrancy, homelessness, industrial injury and malfunctioning or misuse of equipment using NO or CO2 have also been causative factors. Cutaneous circulation plays an important role in thermoregulation by varying blood flow through peripheral structures to maintain core body temperature for survival. In a cold environment, maximal vasoconstriction is reached in hands and feet when their temperature drops to 15° C which is followed by local protective cycles of vasodilation on persistence of freezing temperature; but leads to progressive local ischemia if further exposure continues. However, thawing restores blood flow; but induces congestion, inflammation and thrombosis in the injured endothelium which may prompt erythrocyte extravasation due to distorted vessel wall. According to the depth of the skin damage, necrosis can be deeply severe which can results in spontaneous or surgical amputation. Frostbite can present with a wide spectrum of injury ranging from complete resolution without significant sequelae to major limb amputation and its functional consequences. Timely pre-hospital and definitive hospital management are important to minimize final tissue loss and maximize functionality of the affected limb. Once in the hospital setting, a multidisciplinary approach must be utilized to achieve the best outcomes. Either intravenous iloprost or thrombolysis with rTPA should be considered in all patients presenting within 24 h of sustaining an appropriately severe injury, and if the facility is capable of appropriate administration and monitoring. The treatment should be started with an immediate action to have a maximal output. Bone scanning is helpful to ascertain deep tissue injury and response to therapy. However, surgeons should avoid rushing to an early amputation; if case managed correctly in the earlier days, significant tissue can be salvaged for the final functional outcome. Prevention with education, behavior modification, following workplace guidelines, and appropriate use of modern equipment in most adventurous tourist destinations is important to reduce frostbite incidence. Once frostbite injury has occurred, little can be done to reverse the changes. Hence, a great preventive care should be taken to avoid its incidence.
- 5,000 years ago: An earliest evidence of frostbite was documented among pre-Columbian mummy discovered in the Andes.
- 218 BC: Hannibal lost nearly half his army of 46,000 to frostbite injuries over a two week period of crossing the Southern Alps to reach Italy.
- 1778: Dr. James Thatcher reported that Washington lost 10% of his army to cold-related tissue casualties during the winter times of the Revolutionary War.
- 1812–1813: Baron Dominique Jean Larrey, Surgeon-in-Chief to Napoleon's Army, reported the first systematic medical observations of frostbite during the ill-fated invasion of Moscow during the fall season, and the subsequent retreat in a harsh Russian winter. He noted the deleterious effects of the freeze–thaw–refreeze cycle by identifing the debilitating effects of daily refreezing that occurred with bonfire thawing and subsequent marching in frigid conditions. He further stated that warming was beneficial; however, not by using the excessive heat of fires. Hence, he concluded the friction massage with snow or ice which results in slow rewarming is an optimal therapeutic standard of care for frostbite in military medicine and practiced for more than 100 years.
- 1930:During World War II, both German and Russian troops moved to a philosophy of rapid rewarming based on work conducted at the Kirov Institute.
- 1941–1942: German troops sustained an estimated 250,000 frostbite injuries in the attempt to take over Moscow; and hence, constitutes the largest reported number of frostbite related injuries in history. Moreover, it was reported that the German army alone performed more than 15,000 amputations for cold related injuries on the Russian front during the winter season.
- 1960: Mills published the first major clinical experience with rapid rewarming and included a concept of preventive care for frostbite with his report.
- Frostbite has been divided into 4 tiers or degrees of injury based on acute physical findings and advanced imaging after rewarming following the classification scheme for thermal burn injury. However, these categories are difficult to use in the field and before rewarming as the still-frozen tissue is hard, pale, and anesthetic. Hence, an alternate 2-tiered classification has been proposed for the field use.
Table 1: A two and four tiers classification scheme for Frostbite
|Two tier level of damage||Four tier level of damage||Clinical characteristics|
|Superficial damage||First degree||
|Superficial damage||Second degree||
|Deep damage||Third degree||
|Deep damage||Fourth degree||
Table 2: Classification scheme for the frostbite injuries of the extremity
|Frostbite injuries of the extremity||Grade 1||Grade 2||Grade 3||Grade 4|
|Extent of initial lesion at day 0 after rewarming||Absence of initial lesion||Initial lesion on distal phalanx||Initial lesion on intermediary and proximal phalanx||Initial lesion on carpal or/and tarsal|
|Bone scanning at day 2||Useless||Hypofixation of radiotracer uptake area||Absence of radiotracer uptake on the digit||Absence of radiotracer uptake area on the carpal or/and tarsal region|
|Blisters at day 2||Absence of blisters||Clear blisters||Hemorrhagic blisters on the digit||Hemorrhagic blisters over carpal or/and tarsal region|
|Prognosis at day 2||No amputation; No sequelae||Tissue amputation; Fingernail sequelae||Bone amputation of digit; Functional sequelae||Bone amputation of the limb; +/− systemic involvement; +/− sepsis functional sequelae|
- The rate of normal skin blood flow is about 250 ml/min, however; the flow drops to less than 20-50 ml/min during frostbite. As the temperature drops to below 0°C, the stasis of blood flow occurs especially in the slower venous system before the arterial system which subsequently leads to the cellular damage and results in reversible or irreversible injuries depending upon the extent of the exposure.
- Normal physiological responses to the cold environment:
- Aim: To conserve the internal body core temperature and the viability of the extremities.
- Peripheral vasoconstriction: It is caused by sympathetic stimulation and catecholamine release which reduces the heat loss.
- Shivering: It is a muscular activity which maintain or augment the body heat; however, it cannot be sustained for more than a few hours because of the depletion of glycogen, which is the source of heat during shivering.
- Hunting reaction: It protects the extremities by the process of irregular 5 to 10-minute cycles of alternating vasoconstriction and vasodilation against excessive sustained peripheral vasoconstriction with minimal loss of internal body temperature.
- However, this mechanism fails when the body is exposed to freezing temperature of a magnitude or a duration that disrupt the internal body temperature maintenance because of the following reasons:
- Disruption of body core temperature is more deleterious than peripheral vasoconstriction;
- Conservation of core temperature takes precedence over rewarming of the extremities;
- The hunting response is replaced by continuous and more intense vasoconstriction resulting in frostbite via ice crystal formation, cellular dehydration, and microvasculature thrombosis.
- Four pathophysiological phases: Frostbite occurs through four interconnected progressive processes depending upon the rate and duration of freezing, rate of rewarming, and anatomic extent of exposure.
- Prefreeze phase: The tissue cooling leads to local vasoconstriction and ischemia which results in the neuronal effects of hyperesthesia and paresthesia.
- Freeze thaw phase: The cellular changes observed during freezing include extracellular ice formation, intracellular ice formation, cell dehydration and crenation, abnormal electrolyte concentrations due to altered oncotic pressures, and perturbations in lipid–protein complexes. However, the body initially responds to tissue freezing with alternating cycles of vasodilation and vasoconstriction (the “hunting reaction”) which lead to cycles of partial thawing and a prothrombotic microenvironment. Subsequently, rewarming melts ice crystals, promotes edema from injured endothelium, forms epidermal blisters and free radicals which continues the insult further. Additionally, an elaboration of inflammatory mediators, prostaglandins, and thromboxanes induces vasoconstriction and causes the vascular stasis period.
- Vascular stasis phase: The persistence of the local vasoconstriction causes hypoxia and acidotic damage to the endothelium; and promotes coagulation and interstitial edema. Since, the vascular endothelium is highly susceptible; it may be completely obliterated and replaced by fibrin deposition 72 hours after the phase of freezing and thawing. The electron microscopic further shows an evidence of perivascular fluid extravasation and endothelial swelling and lysis.
- Ischemic phase: Finally, hypoxia, endothelial injury, and local thrombosis lead to the late ischemic phase, in which inflammatory mediators such as prostaglandins, thromboxanes, bradykinins, and histamine trigger additional vasoconstriction, platelet aggregation, and vessel thrombosis. As these inflammatory mediators peak during rewarming, the cycles of refreezing and rewarming can worsen the extent of tissue loss. Therefore, an initial frostbite treatment is targeted at restoring perfusion to the affected limb(s) and limiting tissue loss after rewarming.
- Various types of cold injury can mimic each other which are categorized into hypothermia, tissue-freezing injury (frostbite), non–tissue-freezing injury (frostnip, trenchfoot, chilblain, or pernio) in the following Table.
Table 3: List of differential diagnosis for the Frostbite
|Differential disease||Clinical characteristics|
|Cutaneous burns ||
|Cold Urticaria ||
|Raynaud phenomenon ||
|Chilblains (Pernio or Perniosis) ||
|Immersion foot (trench foot) ||
- Age: Although the elderly and young children are highly susceptible to the frostbite injury; however, the published epidemiological studies showed that frostbite is uncommon in these age groups and instead tends to affect adults between the ages of 30–49 years.
- Anatomic location: The feet and the hands account for 90% of injuries reported. Other includes the face (nose, chin, earlobes, cheeks and lips), buttocks/perineum (from sitting on metal seats) and penis (joggers,runners and Nordic skiers).
- A 12 year review on the inpatient frostbite injuries conducted in Saskatchewan, Canada revealed the incidence of predisposing factors in a decreasing order: Alcohol consumption (46%), psychiatric illness (17%), vehicular failure (19%), and drug misuse (4%).
- Alcohol: It causes heat loss through peripheral vasodilatation and deranged judgement which may results in not seeking timely adequate shelter and consequently turns to a higher level of injury.
- Various behavioural, physiological and mechanical factors play an important roles in increasing the likelihood of its development and the extent of the damage.
|Behavioural factors||Physiological factors||Mechanical factors|
- Most common: Complex regional pain syndrome and arthritis
- Late or chronic sequelae (70%): Infection, increased cold sensitivity, hyperhydrosis, numbness, skin pigmentation, abnormalities of the nails, joint stiffness, and premature closure of physeal growth plate in children.
- Skin areas affected by frostbite are susceptible to chronic ulceration due to poor tissue quality after healing; and can undergo a malignant transformation akin to the formation of Marjolin's ulcers similar to old burn scars.
- Frostbite Arthropathy: In the growing child, frostbite produces a characteristic growth stunting of the small bones through premature closure of physeal growth plate and acro-osteolysis. Additionally, secondary osteoarthritic changes may be seen in early adulthood.
- Favourable prognostic factors: Retained sensation, normal skin colour, and clear rather than cloudy fluid in the blisters, early edema formation and clear blisters extending to the tips of the digits are considered favourable sign.
- Poor prognostic factors: Non-blanching cyanosis, firm skin, lack of edema, and small, proximal, dark haemorrhagic vesicles indicates damage to the subdermal vascular plexus.
- However, no prognostic features are entirely predictive; and weeks or months may pass before the demarcation between viable and non-viable tissue becomes visible.
- Hence, patients should avoid cold exposure for up to a year after the initial injury.
- Severity of symptoms is directly proportional to the severity of injury.
- Initial presenting complaint: A cold numbness associated with a sensory loss, the extremities are cold to the touch, and patients complains of clumsiness, ‘‘like a block of wood’’. Thawing and reperfusion are often accompanied by intense pain.
- At 2-3 days: A throbbing pain begins after rewarming and may persist for weeks or months even after the tissue becomes demarcated.
- At a week: A residual tingling sensation appears probably due to an ischemic neuritis. However, a variable presentation can be seen with no painful sensation especially among diabetics with previous neuropathic damage.
- Symptoms usually subside within 1 month in mild cases of no tissue loss; contrarily, in cases with severe tissue loss, disablement may exceed 6 months. Usually frostbite victims experience some degree of sensory loss for at least 4 years or indefinitely post injury.
- Aggravating factor: Symptoms gets exacerbated by a warm environment.
- Other sensory deficits: Spontaneous burning and electric current-like sensations in the affected body areas.
- Frostbite is a clinical diagnosis.
- However, initial injuries appear similar and make it difficult to determine the severity or grade of injury until post rewarming.
- The extent of the freezing and tissue loss may not be apparent for 4 to 5 days.
- Frostbite injuries can be classified clinically as either superficial or deep.
- Superficial injuries: It may appear as either a numb central white plaque with surrounding erythema, or as blisters filled with clear or milky fluid with surrounding erythema and edema.
- Deep injuries: It is characterized by either hemorrhagic blisters that develop into a black eschar in 2 weeks or have a complete tissue loss and necrosis. Final tissue demarcation may take 3 to 4 weeks to establish. The appearance of the skin, sensation to pinprick, and whether the vesicles are clear or hemorrhagic should be noted. Identify signs of dehydration, hypothermia, altitude effects (pulmonary edema), and exhaustion.
- Rewarming injuries: During rewarming, edema may start to appear within 3-5 hours and may last 7 days. Blisters tend to appear within 4-24 hours. Presence of eschar will be obvious at 10-15 days and mummification with a line of demarcation may develop in 3-8 weeks.
- The primary role of imaging in frostbite injuries is to define the precisely the severity, depth, and extent of tissue injury to better direct nonsurgical and surgical treatment. Additionally, imaging plays an important role in monitoring response to the provided treatment.
Table 5: Elaborates the different imaging modality used for Frostbite
|Digital subtraction angiography (DSA) ||
|Multiphase bone scintigraphy ||
- Other miscellaneous tests: Infrared thermography, laser doppler studies, digital plethysmography and magnetic resonance imaging/ magnetic resonance angiography.
- Almost all patients should be admitted to hospital; considering alcohol intoxication, psychiatric illness, and homelessness as the common features of the frostbite patient; an immediate discharge is rarely prudent. Hence, treatment of frostbite can be divided into three phases: prethaw field care phase, immediate hospital care phase, and postthaw phase.
- If a body part found frozen in the field area, it should be protected from further damage with the following measures:
- The patient should be immediately moved out of the wind, provided with shelter and given warm fluids.
- Remove boots but the problems of replacement can arise if swelling occurs, and replace wet gloves and socks with dry ones. Warm the cold extremity by placing them in a companion's armpit or groin for 10 min and then replace the boots/gloves. Rubbing the affected part is not recommended because of the potential for worsening direct tissue injury.
- If sensation returns, the patient may mitigate the further risks and continue to walk. If there is no return of sensation, the injured should go to the nearest warm shelter (hut or base camp) and seek medical treatment. If at high altitude (>4,000 m), supplementary oxygen should be considered.
- Aspirin 75 mg can be given for its rheologic effect. Ibuprofen 12 mg/kg/day divided into two daily doses (maximum of 2,400 mg/day) should be given for its prostaglandin effect.
- Field rewarming should only be attempted if there is no further risk of refreezing as the cycle of thawing and refreezing results in a more extensive injury.
- The decision to thaw the frostbitten tissue in the field may involve pain control, maintaining warm water baths at a constant temperature, protecting tissue from further injury during rewarming, and eventual transport.
- In extreme scenarios, it may be better to let a casualty walk on a frozen limb to safety rather than risk refreezing.
Immediate hospital care
- The standard approach to the initial treatment of frostbite is the strategy originally outlined by McCauley and Heggers as mentioned below:
- Admit frostbite patient to specialist unit if possible
- Evaluate for hypothermia, concomitant injury, or complicating problems
- On admission, rapidly rewarm the affected areas in warm water at 37–39°C (99–102°F) for 15–30 mins or until thawing is complete
- Debride clear or white blisters and apply topical aloe vera (Dermaide aloe) every 6 h
- Leave haemorrhagic blisters intact and apply topical aloe vera every 6 h
- Splint and elevate the extremity
- Administer antitetanus prophylaxis (toxoid or immunoglobulin (Ig))
- Analgesia: opiate (intravenously or intramuscularly) as indicated
- Administer ibuprofen 400 mg orally every 12 h
- Administer benzyl penicillin 500 000 U every 6 h for 48–72 h
- Administer daily hydrotherapy in 40°C water for 30–45 mins. Do not towel dry affected tissue.
- Prohibit smoking
- Rehydration can be provided orally or intravenously depending upon severity and ability of the patient to accept the warm fluids.
- Oral fluids should be given if the patient is alert and has no gastrointestinal symptoms.
- In case of nausea, vomiting, or an altered mental status; IV normal saline should be given if available.
- High altitude increases the risk of dehydration. A hypothermia in combination to dehydration may be compounded by cold diuresis due to suppression of antidiuretic hormone which mandates the replenishment with intravenous fluids.
- Intravenous fluids should be warmed before infusion if possible; and should be infused in small boluses as slower infusion will result in fluid cooling as it passes through the IV tubing.
- Volume status should be optimized as per the signs of clinical dehydration.
- Hypothermia and concomitant injury should be thoroughly evaluated.
- Systemic hypothermia should be corrected to a core temperature of 34°C before frostbite management is initiated.
- Rewarming should be carried out in a whirlpool of recirculating water with a mild antibacterial solutions (povidone-iodine or chlorhexidine).
- The State of Alaska Cold-injury Guidelines recommend a lower temperature water bath of 37–39°C which decreases the patient pain with slightly slowing the rewarming process.
- The time period recommended for rewarming varies from 15–30 mins up to 1 h.
- Rewarming should continue until a red/purple color appears and the extremity becomes pliable.
- Active motion during the rewarming period is beneficial but care should be taken to prevent the extremity from touching the sides of the whirlpool.
- It is important to provide good analgesic cover by including narcotic medication.
Blisters and dressings
- Blisters containing clear or milky fluid should be debrided and covered every 6 h with aloe vera ointment, a potent anti-prostaglandin agent.
- Splinting, elevating, and wrapping the affected part in a loose and protective dressing should follow the administration of the aloe vera cream.
- Padding should be put between the patient’s toes if affected.
- Haemorrhagic blisters should be left intact to prevent desiccation of the underlying tissue. If they restrict movement, they can be drained with their roofs left on.
- Frostbite is not an inherently infection-prone injury. Therefore, the use of antibiotics specifically for preventing infection during or after frostbite injury is still controversial.
- However, when associated with significant edema or malnutrition due to homelessness, chronic alcohol abuse or return from extreme altitude; penicillin is administered as edema deranges the skin bactericidal properties.
- Additionally, systemic antibiotics are administered in the presence of proven infection, trauma or cellulitis.
- Tetanus prophylaxis should be done as per the standard guidelines.
Analgesia and NSAIDs
- Rewarming the extremities can be extremely painful process, so use of NSAID drugs or opiates should be administered.
- Oral ibuprofen 12 mg/kg divided over two daily doses provides systemic anti-prostaglandin activity that limits the cascade of inflammatory damage. This dose can be increased to a maximum of 2,400 mg/day if the patient is still experiencing pain, and can be continued until wounds are healed or amputation occurs. A dose of 400 mg BID is a practical regime to start with the most patients, but it can be increased later on to 600 mg QDS as pain dictates.
- If aspirin has not been given in the field, 300 mg once a day can be given provided no contraindications. However, aspirin is less useful as it prolongs blockade of all prostaglandin synthesis and some prostacyclins that are considered beneficial for wound healing.
- The role of clopidogrel in frostbite has yet to be assessed.
Angiography and thrombolysis
- rTPA delivery should be provided at a centre accustomed to performing thrombolysis and providing adequate monitoring in a critical care/high-dependency setting.
- If the patient presents less than 24 h after injury to a hospital without these facilities, consider urgent transfer to avoid further delay in the commencement of therapy.
- An initial selective diagnostic DSA should be performed in patients being considered for thrombolysis.
- Intravenous vasodilators such as nitroglycerin or papaverine are useful in conjunction with rTPA to treat the vasospasm associated with a frostbite injury.
- rTPA is used in combination with heparin which reduces the recurrence of microvascular thrombosis.
- Repeat angiograms should be performed every 12–24 h to evaluate response to therapy.
- rTPA treatment should be discontinued when perfusion is restored to distal vessels or at 48 h if no improvement is observed.
Table 6: Enumuerates the protocol for intravenous rTPA
|Ideally given with a portable syringe pump||
|Complications and their management||
|Route of administration||
- Iloprost is a prostacyclin analogue with vasodilatory properties that mimic the effects of a sympathectomy. Additionally, it may affect platelet aggregation and hence, decrease microvascular occlusion.
Table 7: Protocol of intravenous prostacyclin
|Administration and monitoring||
|Complications and their management||
|Advantage over rTPA||
- Early surgical intervention in the form of fasciotomy in the immediate post-thaw phase is required if compartment syndrome compromises the reperfusion.
- Angiography, technetium-99 bone scan and/or magnetic resonance imaging may be used to assist determination of surgical margins in conjunction with clinical findings.
- An early amputation is indicated occasionally if liquefaction, moist gangrene, or overwhelming infection and sepsis develops.
- Otherwise, amputation should be delayed until definitive demarcation occurs which takes around 6–12 weeks.
- Negative pressure devices can aid in speeding up healing of amputation sites by secondary intention.
- The healed affected limb is often insensate. Hence, an approach that addresses both protective footwear and orthotics to provide optimal limb function is essential.
- The functional use of extremities following a partial amputation is variable and injury specific.
- The biomechanics of the foot/hand can be radically altered and frostbite neuropathy can compound the problem; hence, liaison with orthotic/podiatry department to provide custom-made footwear may be required to optimize the long-term limb functional result and minimize secondary injuries.
Hyperbaric oxygen therapy (HBOT)
- Benefits of HBOT in frostbite are as follows:
- It reverses vasoconstriction in ischemic tissue and the resulting hyperoxia from oxygen dissolved in plasma surpasses any potential blood flow reduction.
- It increases a diffusion distance and improves oxygenation in hypoxic tissue.
- Angiogenesis is also promoted by HBOT which further reduces edema and necrosis in hypoxic skeletal muscle by improving the blood supply.
- It increases the deformability of erythrocytes, has a bacteriostatic effect and may act as an antioxidant.
- It delineates the viable tissue from necrotic part and allows marginal tissue to be maintained until revascularization has been established.
- However, HBOT showed mixed results with no level 1 evidence available. Hence, its role warrants further investigation as it is a relatively safe and inexpensive treatment.
- The role of sympathectomy, either surgical (via open or minimally invasive) or chemical, has yielded mixed results.
- Early sympathectomy, performed within the first few hours of injury, has led to increase in edema formation and tissue destruction.
- However, if performed 24–48 h after thawing, it is considered to hasten resolution of edema and decrease tissue loss.
- Sympathectomy may prevent some long term sequelae such as pain due to vasospasm, paresthesias and hyperhidrosis.
- However, since the advent of alternative therapies such as rTPA and Iloprost, and being irreversible nature of sympathectomy procedure, a great caution should be exercised while considering its use; and hence, some consider no role for its use in frostbite.
- A recent development in accessing expert advice by the use of the internet and satellite phones has been driven both by the patients and the clinicians with a limited experience of frostbite. A virtual opinion can be sought from any remote or difficult situations in the world.
- The UK based service can be accessed via the Diploma in Mountain Medicine or the British Mountaineering Council websites which is run by Diploma Faculty Members and is being increasingly used by climbers and physicians worldwide, often to obtain a second opinion or to seek more specialized advice.
- Patients can be readily followed up in a ‘‘virtual clinic’’ by reviewing recent digital images and discussing management options either by phone or via email.
- As in many instances, it can be prevented so the key is deterrence and patient education.
- Risk modification including proper clothing, access to shelter, and maintaining hydration and nutrition are vital for protection against frostbite.
- Patients should be advised to carry extra clothing supplies if they are into winter sports and avoid tight restrictive clothing.
- Emollients, although traditionally believed in Nordic countries to prevent frostbite, do not have protective effects in preventing frostbite and should be discouraged.
- Advise against the abuse of alcohol, illicit drugs, and tobacco.
- For those with medical conditions, it is important to ensure that their health is stable before venturing on an adventurous outdoor trip during winter.
- Prolonged exposure to freezing cold temperatures may cause serious health problems so if signs related to it are observed, call for emergency help.
- The Occupational Safety and Health Act (OSHA) Cold Stress Card provides a reference guide and recommendations to combat and prevent many illnesses and injuries. Available in English and Spanish, this laminated fold-up card is free to employers, workers and the public.
- Tips include how to protect workers:
- Recognize the environmental and workplace conditions that may be dangerous.
- Learn the signs and symptoms of cold-induced illnesses and injuries and what to do to help workers.
- Train workers about cold-induced illnesses and injuries.
- Encourage workers to wear proper clothing for cold, wet and windy conditions, including layers that can be adjusted to changing conditions.
- Be sure workers in extreme conditions take a frequent short break in warm dry shelters to allow their bodies to warm up.
- Try to schedule work for the warmest part of the day.
- Avoid exhaustion or fatigue because energy is needed to keep muscles warm.
- Use the buddy-system, work in pairs so that one worker can recognize danger signs.
- Drink warm, sweet beverages (sugar water, sports-type drinks) and avoid drinks with caffeine (coffee, tea, sodas or hot chocolate) or alcohol.
- Eat warm, high-calorie foods such as hot pasta dishes.
- Remember, workers are at an increased risks who takes certain medications, are in poor physical condition or suffer from illnesses such as diabetes, hypertension or cardiovascular disease.
- Post PW, Donner DD: Frostbite in a pre-Columbian mummy. Am J Phys Anthropol 1972, 37(2):187–191.
- Cochran, Amalia; Morris, Stephen E. (2018). "Cold-Induced Injury": 403–407.e2. doi:10.1016/B978-0-323-47661-4.00038-1.
- Larrey DJ. Memoirs of Military Surgery. Vol.2. Baltimore, MD: Joseph Cushing; 1814
- Killian H. Cold Injury With Special Reference to the German Experience During World War II. Aulendorf i Württ, Germany: Editio Cantor KG; 1952.
- Ariev TJ. Monograph on Frostbite. Steiman I, trans. Narkomzdrav, USSR: State Health Committee. Translation published by Defense Research Board, Canada; 1955: 1–169
- Mills WJ, Whaley R, Fish W. Frostbite, I: Experience with rapid rewarming and ultrasonic therapy. Alaska Med. 1960;2(1):1–4. Reprinted in Alaska Med. 1993;35(1):5–9.
- Cauchy E, Chetaille E, Marchand V, Marsigny B. Retrospective study of 70 cases of severe frostbite lesions: a proposed new classification scheme. Wilderness Environ Med. 2001;12:248 –255.
- Cauchy E, Marsigny B, Allamel G, Verhellen R, Chetaille E: The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities: a retrospective study of 92 severe frostbite injuries. J Hand Surg 2000, 25(5):969–978.
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- Gonzaga, Teresa; Jenabzadeh, Kamrun; Anderson, Christopher P.; Mohr, William J.; Endorf, Frederick W.; Ahrenholz, David H. (2016). "Use of Intra-arterial Thrombolytic Therapy for Acute Treatment of Frostbite in 62 Patients with Review of Thrombolytic Therapy in Frostbite". Journal of Burn Care & Research. 37 (4): e323–e334. doi:10.1097/BCR.0000000000000245. ISSN 1559-047X.
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domain: medical


text: This press release contains forward-looking statements as defined in the 1995 Private Securities Dispute Resolution Reform Act. These forward-looking statements include, without limitation, the Company’s expectations regarding the impact of the COVID-19 pandemic; estimated income, gross margin, operating expenses, other income / (expenses) and tax rate; capital repayment plans; share distribution “for one”; and the commitment to 2030. not be carbon neutral. These statements involve risks and uncertainties, and actual results may differ materially from any future results expressed or implied in future statements. Risks and uncertainties include, without limitation: the impact of the COVID-19 pandemic on the Company’s business, results of operations, financial condition and share price; the impact of global and regional economic conditions on the company’s business, including the impact on consumers and business purchasing decisions; the company’s ability to compete in highly competitive and rapidly changing markets; the company’s ability to manage in a timely manner the frequent delivery and transition of products and services, including market introduction, and to stimulate customer demand for new products, services and technological innovation; an increase in the cost of a range of products and services, geographic, currency or channel set, components, an increase in the cost of acquiring and delivering the Company’s service content, price competition or the introduction of new products or services, including new products or services with a higher cost structure, could be profitable ; the company’s dependence on the performance of distributors of the company’s products, including cellular network carriers and other resellers; write-down risk of inventories and other assets and risk of cancellation of purchase obligations; the continued availability of certain components, services and new technologies necessary for the Company’s business on reasonable terms or at all, including components and technologies that can only be obtained from one or a limited source; The Company’s reliance on manufacturing and logistics services provided by third parties, many of which are outside the United States, that may affect the quality, quantity or price of the products manufactured or services provided to the Company; the impact of deficiencies in the design and production of products and services on the Company’s financial activities and reputation; The Company’s reliance on third party intellectual property and digital content that may not be available to the Company on commercially reasonable terms or at all; The Company’s reliance on the support of third party software developers in developing and maintaining software programs and services for the Company’s products; the effect of adverse legal proceedings, such as the possible finding that a company has infringed, on the intellectual property rights of others; the impact of complex and changing laws and regulations that cause contingent liabilities to the Company, increased costs and other adverse effects on the Company’s business; The Company’s ability to manage the risks associated with the Company’s retail stores; the company’s ability to manage the risks associated with the company’s investments in new business strategies and acquisitions; the impact of information system failures, network failures or losses or illegal access to or disclosure of confidential information on the Company’s business and reputation; the company’s ability to comply with laws and regulations related to data protection; continuous service and availability of key managers and employees; political events, international trade disputes, war, terrorism, natural disasters, public health problems and other business interruptions that may disrupt the supply of or supply to or demand for the Company’s products; financial risk, including risk related to exchange rate fluctuations, credit risk and fluctuations in the market value of the Company’s investment portfolio; changes in tax rates and the risk of additional tax liabilities. Further information on these risks and other potential factors that could affect the Company’s business and financial performance is provided by the Company’s Securities and Exchange Commission, including the Risk Factors and Management Discussions and Analysis of Financial Condition and Performance. the latest periodic reports submitted by the Company on Forms 10-K and 10-Q and subsequent applications. The Company undertakes no obligation to update any forward-looking statements or information in force on their respective dates.

domain: law


text:
The talk all spring for Notre Dame at the wide receiver has rightfully centered around how the Irish offense can unlock the potential of potential game changing receivers in the junior and sophomore classes. And to a lesser extent, whether or not Chase Claypool will finally reach the potential he’s been scratching the surface of for years. Lost in the mix though is senior Chrs Finke – the guy who likely will lead Notre Dame in receptions this fall.
We’ve even talked about how the arrow is pointing up on Braden Lenzy and how Finke’s backup, Lawrence Keys, is quietly having himself a good spring as well. We haven’t spent much time talking about Chris Finke though and it’s time we start.
Everyone know’s Finke’s story. Came to Notre Dame as a walk-on, played his way to a scholarship, and then eventually the starting lineup. Notre Dame fans have been penciling in other receivers ahead of him on the depth chart the last two years. All Chris Finke has done is produce and improve.
Reports out of spring ball are that Finke, now a 5th year senior, is really coming into his own and causing nightmares for the Notre Dame secondary – a unit that is expected to be pretty darn good this fall.
If Finke’s 2018 season is any indication of what’s in store in 2019, Notre Dame fans can put those pencils away. After catching just 16 passes for 224 yards in 2016 and 2017 – combined – Finke exploded for 49 receptions and 571 yards with 2 touchdowns last fall. And he wants to get better.
“Playing with no fear ever,” Finke told Fighting Irish Digital Media’s Jack Nolan last week. “Going in there and being physical all the time. You saw Chase and Miles were real physical last year. I try to get in there – it’s a little more difficult being my size but I watch guys like Julian Edleman in the NFL and he’s cracking heads. That’s something I want to try to do,” he added.
Finke is firmly in the starting lineup as Notre Dame’s slot receiver right now and won’t be going anywhere. His game is tailor-made not only for the slot position but for quarterback Ian Book’s strengths. Finke is almost certainly the best route runner on the team and excels at getting open quickly. Ian Book is an extremely accurate quarterback who excels at getting the ball out early. It’s a pairing that will connect together a lot in 2019.
Adding a Vertical Element to the Notre Dame Offense
Finke’s game isn’t limited to just 5 yard in and outs and getting “scrappy” yards though. Finke showed often in 2018 that he can get open downfield. He hauled in Brandon Wimbush’s heave against Michigan over two Wolverine defenders for a touchdown. He spent an October night burning the Virginia Tech secondary deep, but hadn’t yet developed the chemistry with Book to take advantage. He turned the tide of the USC game with a 24 yard touchdown in the corner of the endzone at the end of the first half.
Part of Notre Dame’s answer for stretching defenses and getting vertical in 2019 very well could involve getting Chris Finke lined up in favorable match-ups and letting him do what we saw him do to Virginia Tech, Michigan, and USC.
Finke makes his impact felt in more than just the passing game. He spent the 2018 season as Notre Dame’s primary punt returner where the Irish staff actually let him do more than just fair catch. He averaged 9.8 yards per return with a long of 51 yards on 20 returns – the kind of production Notre Dame hasn’t really seen in the punt game in some time. That’s an area he is looking to improve on as well.
“Hopefully a big one,” Finke answered when asked what kind of impact he might have in the punt game last week by Nolan. “You never know what way the ball is going to bounce, the way the punt is coming off the foot, and if you’re gonna get chances or not. But hopefully we’ll have something schemed up to get some good returns.”
A Leadership Role for Chris Finke in 2019
When captains are announced, Chris Finke is very likely to be one of them. Finke’s been part of Notre Dame’s off-season leadership committee as a SWAT team leader. The staff already entrusted Finke with keeping a young but talented wide receiving corps focused throughout the off-season. It shouldn’t surprise anyone if they entrust him with being a captain as well.
Miles Boykin and Chase Claypool both caught more passes than Chris Finke last year, but with a full off-season to further develop a budding rapport with Book, Finke could easily end up leading Notre Dame in receptions this fall. Claypool will undoubtedly have more of the circus catches and more touchdowns because of his size in the redzone, but Finke could easily end up catching 6-7 balls a week for 75-85 yards. That would result in a 75 catch, 900+ yard season this fall.
Looking even further down the road, a strong senior season could propel Chris Finke to a NFL career. He might not put up the jaw dropping numbers at the NFL Combine like Miles Boykin did a couple months ago, but he’s is much more than just a “former walkon” at this point. He could be Notre Dame’s leading receiver in 2019 and could be catching passes in the NFL

domain: news


This season of Rising Star we have some brilliant talent gracing the stage every week.
Two contestants have caught everyone’s attention with their amazing stage presence and powerful voices.
The contestants are ‘Suro ke Big B’– Hemant Brijwasi and Akhtar Brothers.
Last week, this musical trio were paired up together in the duets round. They took the stage to show us a glimpse of their musical tsunami.
Their actual performance turned out be quite amazing too.
They managed to not just raise the wall, but also receive a Tutari moment by our experts Shankar Mahadevan, Monali Thakur and Diljit Dosanjh.
After the celebrations, our expert Dilijit Dosanjh reminded everyone that one day they will have to performance against each other and judging that would be very difficult for everyone.
We really hope that doesn’t happen anytime soon, these musical masters truly make Rising Star 2 shine.
Keep watching Rising Star 2 – Sat – Sun 9 PM.


text:
Aug. 24th, 1961
London, England, UK
Jared Harris' Main TV Roles
Main Movie Roles
Guest TV Roles[none found]
Jared Francis Harris is a versatile English character actor, equally adept at thugs and ne'er-do-wells as he was with businessmen and artists, Jared Harris contributed memorable performances to such films as I Shot Andy Warhol (1995), Happiness (1998) and The Curious Case of Benjamin Button (2008), as well as television programs like AMC's Mad Men, Netflix The Crown, and HBO's Chernobyl.
The son of volatile Irish actor Richard Harris, he shared none of his father's penchant for theatrical performances, preferring instead for thoughtful, carefully controlled turns. He soon garnered a reputation for near-complete transformations for each role; from the ethereal Warhol to a scheming Russian cabdriver in Happiness and a mercurial John Lennon in Two of Us to the buttoned-down English financial officer on Mad Men. That mainstream breakthrough led to higher-profile roles for Harris in films ranging from Steven Spielberg's Lincoln to action drama Pompeii and Guy Ritchie's TV series reboot The Man from UNCLE. A key role as King George VI in Peter Morgan's The Crown and a supporting role in indie drama Certain Women kept him firmly in the public eye. Harris' breadth of talent made him one of the most capable character actors in the business.
- Son-in-law of 'Edward Fox (I)' (qv) and 'Joanna David' (qv).
- (1996) Ended his five-year relationship with 'Tahnee Welch' (qv).
- Brother of 'Jamie Harris (I)' (qv).
- Graduated from Duke University in 1984 with a BFA in Drama
- His father and wife's uncle appear together in _Patriot Games (1992)_ (qv).
- Stepson of 'Rex Harrison (I)' (qv) and 'Ann Turkel' (qv).
- Son of 'Richard Harris (I)' (qv) and 'Elizabeth Rees (I)' (qv).
- Spent a lot of time in the Bahamas as a child.

domain: artistic


text:
Gastric cancer is the third most common cause of cancer-related death in the world  . In 1926, Borrmann classified advanced gastric cancer into four gross types  . Borrmann type 4 was characterized by less differentiation, usually presenting as poorly differentiated adenocarcinoma, and by invasion of the entire wall of the stomach. Borrmann type 4 advanced gastric cancer was defined as follows: diffuse cancer, ulcers are almost invisible, and an ill-defined boundary. Despite recent advances in the treatment of gastric cancer, the prognosis of patients with Borrmann type 4 advanced gastric cancer remains extremely poor   , and the 5-year survival rate with this advanced gastric cancer is significantly lower than that of patients with other types of gastric cancer  . This can be seen in a report by The Japan Gastric Cancer Association Registration Committee of the treatment results and causes of death in patients with primary gastric cancer who were treated in Japan. Of 13,002 patients with primary gastric cancer, 5-year survival by Borrmann type in resected cases regardless of stage was: type 0, n = 6869 (90.2%); type 1, n = 363 (65.5%); type 2, n = 1717 (60.4%); type 3, n = 2575 (46.0%); type 4, n = 923 (17.7%); and type 5, n = 339 (60.6%)   . Survival rates at 5 years after curative gastrectomy have ranged from 11% - 38.4%    . This has led to the conclusion that surgery is not a curative treatment for Borrmann type 4 advanced gastric cancer   . Indeed, no adequate therapeutic strategy for Borrmann type 4 advanced gastric cancer has been established.
In the 1990s, S-1 (TS-1; Taiho Pharmaceutical, Tokyo, Japan), an oral derivative of 5-FU, was developed for the treatment of gastric cancer   . In Japan, S-1 rapidly established itself as a standard treatment with a high response rate of 46% as a single agent. Phase III trials proved the non-inferiority of S-1 compared with infusional 5-FU in the advanced/metastatic setting  . A phase III trial showed a better median survival time (MST) with the combination of S-1 plus cisplatin compared with S-1 monotherapy  . In addition, the combination of irinotecan and S-1 achieved longer median survival than S-1 monotherapy  . In Japan, advanced gastric cancer is mainly treated with S-1 alone or S-1 combined with other drugs.
As treatment for gastric cancer advances, it is expected that treatment for Borrmann type 4 advanced gastric cancer will also improve. Owing to its low incidence, however, only a few trials for this condition have been conducted. Here, we retrospectively examined the outcome in patients with Borrmann type 4 advanced gastric cancer treated with chemotherapy to assess survival.
2. Patients and Methods
2.1. Patient Population and Data Collection
Data from patients diagnosed with Borrmann type 4 advanced gastric cancer at Kobe City General Center Hospital between July 2011 and June 2015 were retrospectively collected for this study. The inclusion criterion was histologically confirmed primary gastric cancer Borrmann type 4. The exclusion criteria were synchronous or metachronous cancers.
Clinical data was collected for each patient, including gender, age, and treatments. We used the 13th edition of the Japanese Classification of Gastric Carcinoma for data management  . The date of last follow-up and mortality were collected for all patients.
This retrospective study was approved by the Institutional Review Board of Kobe City Medical Center General Hospital and was conducted in accordance with the ethical principles mandated in Japan’s Ethics Guidelines for Epidemiological Research.
2.2. Statistical Considerations
Univariate and multivariate analyses were performed using Cox’s proportional hazard model to identify risk factors affecting overall survival (OS). OS was defined as the period from the diagnosis of type 4 advanced gastric cancer to the date of death from any cause. Patients who remained alive at the time of the last record were censored at that time. Survival curves were generated using the Kaplan-Meier method and the difference was analyzed by the log-rank test. P values < 0.05 were considered statistically significant. Prognostic factors were evaluated by the Cox’s proportional hazard model with a log-linear risk function. All statistical analysis was performed using Statistical Package for Social Science (SPSS) software (SPSS 23.0 Inc., Chicago, IL, USA).
3.1. Patient Characteristics
Patient background at baseline is presented in Table 1. Forty-two cases were analyzed. Median age was 58 years (range, 32 - 81). Of the patients, 37 cases (88.0%) had a baseline Eastern Cooperative Group performance status of 0 - 1. Thirteen cases (30.9%) were locally advanced and 29 cases (69.0%) were metastatic advanced. Fifteen cases (51.7%) had peritoneal metastasis. As shown in Figure 1, among the 42 cases, 20 cases (52.3%) were surgically resected. This included palliative resection in nine cases (one for bleeding from the primary lesion, five for stricture, and three for malnutrition) of metastatic advanced patients.
3.2. Patient Outcome
Chemotherapy was planned in 24 patients. However, one patient was transferred to another hospital before receiving chemotherapy (Figure 2), and chemotherapy was accordingly used as first-line treatment in 23 cases. As shown in Figure 3, the first-line treatment regimen consisted of S-1 plus cisplatin (SP) for 16 patients (69.5%). Reasons for discontinuation of SP treatment were disease progression (90.0%) and toxicity (10.0%). Other treatment regimens included capecitabine plus cisplatin (XP) in one (4.3%), S-1 plus oxaliplatin (SOX) in one (4.3%), S-1 monotherapy in two (8.6%), capecitabine monotherapy in one (4.3%), paclitaxel in one (4.3%) and docetaxel in one (4.3%). After discontinuation of first-line treatment in 12 patients for disease progression and in one patient for toxicity, 13 patients (56.5%) received only supportive care and 10 patients (43.3%) received second-line chemotherapy. The second-line chemotherapy regimens consisted of paclitaxel in eight patients, irinotecan (CPT-11) in one, and S-1 monotherapy in one. After discontinuation of second-line treatment due to
Table 1. Patient characteristics (n = 42).
Figure 1. Diagram of the study.
Figure 2. Diagram of the chemotherapy treatment patients.
Figure 3. Chemotherapy treatment ratio. (a) 1st line chemotherapy (n = 23). (b) 2nd line chemotherapy (n = 10).
disease progression, 7 patients (7%) received only supportive care and 3 patients received third-line chemotherapy, two with docetaxel (66.6%) and one with S-1 plus paclitaxel (33.3%). Figure 4 shows the OS of locally advanced cases and metastatic advanced cases. The median OS of locally advanced cases was 29.6 months (95% confidence interval [CI]: 16.8 - 42.3 months) while that of metastatic advanced cases was 11.5 months (95% CI: 2.1 - 20.8 months; p = 0.019). Among locally advanced patients, one patient was stage I, two patients were stage II, and ten patients were stage III. Curative resection was performed in 11 of the locally advanced cases (84.6%). There was a statistically significant difference between the OS of locally advanced and metastatic advanced cases (p = 0.019).
In this study, the median OS for patients with peritoneal metastases was 8.9 months (95% CI: 0 - 21.9 months) while that for no peritoneal metastases was 11.5 months (95% CI: 0 - 29.0 months; p = 0.831) (Figure 5), indicating that peritoneal metastases were unrelated to OS. The median OS for patients treated with first-line SP was 20.7 months (95% CI: 12.9 - 28.4 months) and that patients with any other chemotherapy was 19.3 months (95% CI: 5.1 - 33.4 months) p = 0.994 (Figure 6).
In this study, Borrmann type 4 gastric cancer tended to affect younger patients, and was particularly more prevalent in female patients (59.5%) and was mostly of the diffuse type (92.9%). Because the patients were mainly HER 2 status-negative (95.2%), they were not candidates for trastuzumab  . In addition, at the time of diagnosis, most patients (69.0%) had unresectable disease, most with peritoneal dissemination (51.7%). These are the major reasons for the poorer prognosis of Borrmann type 4 advanced gastric cancer  .
Compared with locally advanced cases, metastatic cases had a significantly lower median OS, at 29.6 months vs. 11.5 months (p = 0.019), respectively. The OS benefit
Figure 4. Overall survival of locally advanced cases and metastatic advanced cases (n = 42).
Figure 5. Overall survival of patients with and without peritoneal metastasis (n = 29).
Figure 6. Overall survival of patients with S-1 plus cisplatin treatment and patients on any other treatments (n = 23).
in locally advanced patients has been reported, but Borrmann type 4 advanced gastric cancer is seldom diagnosed at an early stage (stage IV vs. stage I-III was 69.0% vs. 30.9%).
Generally, we chose a fluorinated pyrimidine plus platinum combination, S-1 plus cisplatin, as treatment for metastatic advanced cases. There were no significant differences in median OS between patients treated with SP (20.7 months, 95% CI: 12.9 - 28.4 months) and those with any other chemotherapy (19.3 months, 95 % CI: 5.1 - 33.4 months; p = 0.994). These results suggest that SP does not have sufficient efficacy for the treatment of patients with Borrmann type 4 advanced gastric cancer.
Only 43% of patients received second-line chemotherapy in this study (Figure 2). In contrast, 75% of patients in a recent Japanese phase III trial (SPIRITS; S-1 vs. S-1 plus cisplatin) for advanced gastric cancer received second-line treatment  . We consider that patients with Borrmann type 4 advanced gastric cancer, who progressed during first-line treatment, were in poorer general condition, so most of them might have missed the opportunity to receive second-line chemotherapy.
It is important for patients with Borrmann type 4 advanced gastric cancer to receive effective chemotherapy as first-line treatment to improve survival. Reasons for this include the unreliability of the administration and absorption of oral agents in these patients due to stricture, the high risk of complications, and the inability to receive the hydration that is required for renal protection from cisplatin. Oxaliplatin is a third- generation platinum compound that was developed to provide improved tolerability and administration over cisplatin. The non-inferiority of oxaliplatin-based regimens to cisplatin-based regimens was demonstrated in the Revised European-American Lymphoma (REAL)-2 study. This background therefore indicates the need to develop novel chemotherapeutic regimens with non-oral agents, with no need for hydration, and with high feasibility for patients with this disease  .
A previous clinical study demonstrated that gastric cancer patients with severe peritoneal metastases receiving 5-FU-based chemotherapy as first-line treatment had a median time to treatment failure (TTF) and OS of 1.9 and 4.6 months, respectively  . 5-FU-based chemotherapy for gastric cancer patients with severe peritoneal metastases was feasible, but its efficacy was unsatisfactory. Recent phase III trials have demonstrated the non-inferiority of chemotherapy using oral fluoropyrimidines, such as capecitabine or S-1, compared to 5-FU-based chemotherapy    . Oral fluoropyrimidine and cisplatin combination therapy is a standard regimen worldwide  . Although 5-FU is one of the most commonly used drugs in patients with gastrointestinal cancers, systemic 5-FU chemotherapy has a limited response rate  . A new treatment for Borrmann type 4 advanced gastric cancer, including 5-FU, is urgently required.
We found that SP treatment does not improve OS. Further research into chemo- therapy as a treatment for patients with Borrmann type 4 advanced gastric cancer is required.
 Borrmann, R. (1926) Geschwülste des Magens and Duodenums. In: Borchardt, H., Borrmann, R. and Christeller, E., Eds., Verdauungsschlauch: Erster Teil Rachenund Tonsillen, Speiserohre Magen und Darm, Bauchfell, Springer, Vienna, 812-1054.
 An, J.Y., Kang, T.H. and Choi, M.G. (2008) Borrmann Type IV: An Independent Prognostic Factor Forsurvival in Gastric Cancer. Journal of Gastrointestinal Surgery, 12, 1364-1369.
 Chen, C.Y., Wu, C.W., Lo, S.S., Hsieh, M.C. and Lui, W.Y. (2002) Peritoneal Carcinomatosis and Lymph Node Metastasis Are Prognostic Indicators in Patients with Borrmann Type IV Gastric Carcinoma. Hepatogastroenterology, 49, 874-877.
 Nashimoto, A., Akazawa, K. and Isobe, Y. (2013) Gastric Cancer Treated in 2002 in Japan: 2009 Annual Report of the JGCA Nationwide Registry. Gastric Cancer, 16, 1-27.
 Otsuji, E., Kuriu, Y. and Okamoto, K. (2004) Outcome of Surgical Treatment for Patients with Scirrhous Carcinoma of the Stomach. The American Journal of Surgery, 188, 327-332.
 Kim, D.Y., Kim, H.R. and Kim, Y.J. (2002) Clinicopathological Features of Patients with Borrmann Type IV Gastric Carcinoma. ANZ Journal of Surgery, 72, 739-742.
 Yoshikawa, T., Tsuburaya, A. and Kobayashi, O. (2001) Should Scirrhous Gastric Carcinoma Be Treated Surgically
Clinical Experiences with 233 Cases and a Retrospective Analysis of Prognosticators. Hepatogastroenterology, 48, 1509-1512.
 Kinugasa, S., Abe, S. and Tachibana, M. (1997) Surgically Curable and Incurable Scirrhous Carcinomas of the Stomach. Journal of Surgical Oncology, 65, 194-200.
 Maehara, Y., Moriguchi, S. and Orita, H. (1992) Lower Survival Rate for Patients with Carcinoma of the Stomach of Borrmann Type IV after Gastric Resection. Surgery, Gynecology & Obstetrics, 175, 13-16.
 Kim, E.Y., Yoo, H.M., Song, K.Y. and Park, C.H. (2016) Limited Significance of Curative Surgery in Borrmann Type IV Gastric Cancer. Medical Oncology, 33, 69.
 Fukushima, M., Satake, H., Uchida, J., Shimamoto, Y., Kato, T., Takechi, T., Okabe, H., Fujioka, A., Nakano, K., Ohshimo, H., Takeda, S. and Shirasaka, T. (1998) Preclinical Antitumor Efficacy of S-1: A New Oral Formulation of 5-Fluorouracil on Human Tumorxenografts. International Journal of Oncology, 13, 693-698.
 Koizumi, W., Kurihara, M., Nakano, S. and Hasegawa, K. (2000) Phase II Study of S-1, a Novel Oral Derivative of 5-Fluorouracil, in Advanced Gastric Cancer. For the S-1 Cooperative Gastric Cancer Study Group. Oncology, 58, 191-197.
 Narikazu, B., Seiichiro, Y., Haruhiko, F., Kuniaki, S., Toshihiko, D., Akira, S., Wasaburo, K., Hiroshi, S., Kensei, Y., Hiroya, T., Junichiro, N. and Atsushi, O. (2009) Fluorouracil Versus Combination of Irinotecan Plus Cisplatin versus S-1 in Metastatic Gastric Cancer: A Randomised Phase 3 Study. Lancet Oncology, 10, 1063-1069.
 Wasaburo, K., Narahara, H., Hara, T., Takagane, A., Akiya, T. and Masakazu, T. (2008) S-1 Plus Cisplatin versus S-1 Alone for First-Line Treatment of Advanced Gastric Cancer (SPIRITS Trial): A Phase III Trial. Lancet Oncology, 9, 215-221.
 Hiroyuki, N., Hiroyasu, I., Hiroshi, I., Akira, T., Keisho, C., Haruhiko, I., Taito, E., Hiroshi, F., Chikuma, H. and Yuh, S. (2011) Randomized Phase III Study Comparing the Efficacy and Safety of Irinotecan Plus S-1 with S-1 Alone as First-Line Treatment for Advanced Gastric Cancer (Study GC0301/TOP-002). Gastric Cancer, 14, 72-80.
 Bang, Y.J., Custem, E.V., Feyereislova, A., Chung, H.C., Shen, L., et al. (2010) Trastuzumab in Combination with Chemotherapy versus Chemotherapy Alone for Treatment of HER2-Positive Advanced Gastric or Gastro-Oesophageal Junction Cancer (ToGA): A Phase 3, Open-Label, Randomised Controlled Trial. Lancet Oncology, 376, 687-697.
 Hur, H., Lee, H.H., Jung, H., Song, K.Y., Jeon, H.M. and Park, C.H. (2010) Predicting Factors of Unexpected Peritoneal Seeding in Locally Advanced Gastric Cancer: Indications for Staging Laparoscopy. Journal of Surgical Oncology, 1, 753-757.
 Kenichi, N., Junki, M., Haruhiko, F., Kuniaki, S., Yasuhiro, S. and Atsushi, O. (2003) Randomized Phase III Trial of Fluorouracil Alone versus Fluorouracil Plus Cisplatin versus Uracil and Tegafur Plus Mitomycin in Patients with Unresectable, Advanced Gastric Cancer: The Japan Clinical Oncology Group Study (JCOG9205). Journal of Clinical Oncology, 21, 54-59.
 Satoru, I., Takako, N., Kenichi, N., Atsuo, T., Ken, K., Tetsuya, H., Yasuhide, Y. and Yasuhiro, S. (2012) First-Line Fluorouracil-Based Chemotherapy for Patients with Severe Peritoneal Disseminated Gastric Cancer. Gastric Cancer, 15, 21-26.
 David, C., Naureen, S., Sheela, R., Timothy, I., Marianne, N., Fareeda, C., et al. (2008) Capecitabine and Oxaliplatin for Advanced Esophagogastric Cancer. New England Journal of Medicine, 358, 36-46.
 Kang, Y.K., Kang, W.K., Shin, D.B., Chen, J., Xiong, J., Wang, J., Lichinitser, M., Guan, Z., Khasanov, R., Zheng, L., Philco-Salas, M., Suarez, T., Santamaria, J., Forster, G. and McCloud, P.I. (2009) Capecitabine/Cisplatin versus 5-Fluorouracil/Cisplatin as First-Line Therapy in Patients with Advanced Gastric Cancer: A Randomised Phase III Noninferiority Trial. Annals of Oncology, 20, 666-673.


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forgot to mention earlier, my sis is still having issues with ss for the kids and the insurance is still being jerks! Making her jump through all kinds of hoops! Good Greif the benifit isn't even close to a million! But she is happily still art mum for the 2 little ones, and she keeps a smile on her face and in her heart. Can't even imagine.
Beth please update me to the roster. Have a great weekend
God Bless ya all
Choose to be happy


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MODESTO (CBS13) — A longtime family-owned work and outdoor supply store officially reopened Friday in a familiar location.
Crescent Supply was destroyed by fire in Downtown Modesto two months ago. The 75-year-old business has returned to its original location on McHenry Avenue and was packed Friday for its official grand re-opening.
“Today’s been incredibly exciting,” said store owner Craig Stott. “We had people at our door well before we opened up.”
Stott said he grew up in the building on McHenry where the business got its start decades ago.
“As a child, I grew up in the building so it’s been really neat. The neighbors back behind us have embraced us; some remember me as a little kid in this building,” Stott said.
The building became vacant right around the same time as the fire. To help the business rebuild, Modesto Police Department volunteer Josh Borlish gave the owners a challenge coin as a token of his appreciation as well as a symbol of the store raising from the ashes.
Borlish spotted the smoke back in September coming from the building that housed Crescent Supply for nearly 20 years. He remained at the scene helping with crowd control, watching the business burn to the ground until 3 a.m.
Over the years, Crescent Supply had not only supported Borlish’s charitable organizations with numerous donations, but it also outfitted first responders and law enforcement agencies with uniforms and tactical gear.
Jesus Lopez, a police officer in Manteca, worried the business would not recover after the fire.
“I honestly thought it was going to be one of those things where they’re shut down for good. It was pretty heartbreaking since I’m law enforcement and this is where we mainly come to get the tools we need to do our job,” Lopez said.
A lot of law enforcement showed up to the grand re-opening to support the business they relied on for so many years.
“I think it’s important for everyone, even my friends at the Camp Fire, to stay focused, don’t give up,” Stott said.
The store has shrunk to about a third of the size, but the owners say the merchandise is more family friendly now. And to thank its customers, Crescent Supply is offering a grand re-opening sale again Saturday.


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Author: Burhan Sönmez
Translator: Ümit Hussein
UK publisher: Saqi Books
Original language: Turkish
Rosie Goldsmith, EBRD Literature Prize judge: “Such writing, insight and humour, it is as if “The Decameron” were transferred to an Istanbul prison. A group of prisoners, all who’ve been tortured, huddled together in appalling conditions, relate ten stories in ten chapters over ten days. Translated by Ümit Hussein, this is not a political novel but a universal novel about humanity: about pain and cruelty, love and kindness, death and survival.”
Born in Central Anatolia in 1965, Burhan Sonmez grew up speaking Turkish and Kurdish. He worked as a lawyer in Istanbul, and was a founder of the social-activist cultural organisation TAKSAV (Foundation for Social Research, Culture and Art). He also wrote on literature, culture and politics for various newspapers and magazines. Burhan was seriously injured following an assault by Turkish police and lived in exile for some years. He now lectures at the METU University in Ankara. The recipient of a number of literary prizes, his novels have been published in over twenty countries. www.burhansonmez.com
Ümit Hussein is a translator and interpreter of Turkish Cypriot origin who was born and raised in London. She has translated authors such as Nevin Halici, Mehmet Yashin and Ahmet Altan into English.

domain: library


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Dr Derek O’Brien studied English and Philosophy at Leeds University before converting to law by studying for the Common Professional Examination and Solicitors Finals Examination at the College of Law. He qualified as a solicitor in 1985 and worked for a number of years as a solicitor in private practice before taking up a lecturing position at the University of Westminster in 1992. After a sabbatical at the Cayman Islands Law School he joined the Law Department at Oxford Brookes in 2002. His main research area is the constitutional law of the Commonwealth Caribbean and the constitutional implication of economic integration within this region. In addition he is interested in the operation of legal systems within small jurisdictions and is one of the founding members of the small jurisdictions project at Oxford Brookes.
The Oxford Handbook of Caribbean Constitutions offers a detailed and analytical view of the constitutions of the Caribbean region, examining the constitutional development of its diverse countries. The Handbook explains the features of the region's constitutions and examines themes emerging from the Caribbean's experience with constitutional interpretation and reform.
Beginning with a Foreword from the former President of the Caribbean Court of Justice and an Introduction by the lead editor, Richard Albert, the remainder of the book is divided into four parts. Part I, 'Caribbean Constitutions in the World', highlights what is distinctive about the constitutions of the Caribbean. Part II covers the constitutions of the Caribbean in detail, offering a rich analysis of the constitutional history, design, controversies, and future challenges in each country or group of countries. Each chapter in this section addresses topics such as the impact of key historical and political events on the constitutional landscape for the jurisdiction, a systematic account of the interaction between the legislature and the executive, the civil service, the electoral system, and the independence of the judiciary.
Part III addresses fundamental rights debates and developments in the region, including the death penalty and socio-economic rights. Finally, Part IV features critical reflections on the challenges and prospects for the region, including the work of the Caribbean Court of Justice and the future of constitutional reform.
This is the first book of its kind, bringing together in a single volume a comprehensive review of the constitutional development of the entire Caribbean region, from the Bahamas in the north to Guyana and Suriname in South America, and all the islands in between. While written in English, the book embraces the linguistic and cultural diversity of the region, and covers the Anglophone Caribbean as well as the Spanish-, French-, and Dutch-speaking Caribbean countries.
Freedom of movement has generally been regarded as one of the defining characteristics of a common market, of which the European Union is probably the best known example; expanding from a right of free movement for workers into a right of European ‘citizenship’. By contrast, the Caribbean Community and Common Market (CARICOM) originally made no provision for freedom of movement for its nationals and has only latterly introduced a limited right to free movement. It would be wrong, however, to infer that the right of free movement within CARICOM will evolve into a right of Caribbean ‘citizenship’ for two interconnected reasons. The first derives from the absence of any desire on the part of the Heads of Government of CARICOM to use freedom of movement as a stepping-stone towards a political union. The second is linked to the institutional and legal infrastructure underpinning CARICOM, which makes it difficult for a right of Caribbean citizenship to evolve without the support of the Heads of Government.
This article argues that the distinctive form of economic integration within the Commonwealth Caribbean can best be understood if account is taken of the imprint of colonial rule both upon relations between these former colonies and upon the political consciousness of the region's leaders. The legacy of colonial rule, including the abortive attempt at a West Indies Federation, resulted not only in a profound mistrust of any form of political union but also established the ideal of island self-government as the centre of the region's political culture. This is clearly manifest in the institutional structure and governance of the Caribbean Community and Common Market (CARICOM), which is based on the principles of intergovernmentalism. Notwithstanding some recent changes to that institutional structure, such as the introduction of the Caribbean Court of Justice, Member States remain firmly committed to the pursuit of regional integration through cooperation and association without any transfer of their sovereign decision-making powers. It will be argued, however, that this will not only make it increasingly difficult to achieve the economic objectives of CARICOM, but will also make it increasingly difficult to maintain the fragile sense of regional unity, originally forged in the crucible of colonial rule, in a post-colonial world as new alliances both within and without the region begin to emerge.
CARICOM, established under the Treaty of Chaguaramas, in 1973, has since its inception suffered from the repeated failure of member states to implement at the national level decisions taken by the Heads of Government at the regional level. The Caribbean Court of Justice (CCJ,) which has been vested with a compulsory and exclusive jurisdiction to interpret and apply the Revised Treaty of Chaguaramas, is intended to bridge this implementation gap. This has aroused expectations that the CCJ will play a role similar to that played by the ECJ in promoting legal integration. However, it is important to recognise that the ECJ has functioned within a particular jurisdictional framework and has benefited from the contribution of a diverse range of actors within the wider European legal community. It cannot, therefore, be assumed that the CCJ will be able to replicate the role played by the ECJ. The aim of this article is, accordingly, to review the jurisdictional framework within which the CCJ will function; to explore how this is likely to affect its relationship with the wider legal community within CARICOM; and, finally, to consider how this will impact upon legal integration within the region generally.
This chapter focuses on the differing approaches of the Judicial Committee of the Privy Council and the Caribbean Court of Justice towards the interpretation of the independence Constitutions of the Commonwealth Caribbean. Critiquing the lack of autochthony and the lack of meaningful public participation in the drafting of the region’s independence Constitutions, a number of influential Caribbean constitutional scholars have advocated a much more judicially creative approach to the interpretation of the region’s constitutions than the more conservative approach that has dominated the JCPC’s more recent jurisprudence. I call the approach advocated by these scholars the holistic approach because it treats the constitution as a whole as greater than the sum of its parts. The Caribbean Court of Justice in two recent judgments on appeals from Barbados and Guyana respectively has now adopted this approach. Notwithstanding its undoubted attraction in terms of resolving some of the deficiencies and flaws in the region’s independence Constitutions, it will be argued that the holistic approach risks undermining not only the whole interpretive process, but also the whole constitutional order.
When British public lawyers proclaim Magna Carta's influence in Britain's colonies around the world, they generally do so, even if obliquely, as a way of reconciling Britain's colonial past with its liberal-democratic and multicultural present. A narrative is thus constructed in which Magna Carta is presented as a symbol of a tradition of ‘English liberty’, which Englishmen took with them when they went abroad to settle these colonies and which endures to this day. English liberty, thus conceived, includes the right to personal liberty, the right to personal security, freedom from imprisonment without just cause, and the free use and enjoyment and disposal of all property. To this list could be added the right to representative government.
In this chapter, I wish to challenge the foregoing account of a tradition of English liberty, as symbolised by Magna Carta, which England bequeathed to its former colonies, insofar as it relates to the so-called ‘sugar colonies’ of the Commonwealth Caribbean. In particular, I wish to argue that the version of English liberty that was exported to the West Indies in the seventeenth and eighteenth centuries by the first English settlers is not adequate to the task of reconciling Britain's colonial past with modern conceptions of democracy or multiculturalism. More than this, I wish to argue that the legacy of English liberty in the Commonwealth Caribbean is no mere matter of historical interest, but continues to be deeply problematic because of its lingering influence on contemporary human rights jurisprudence in the region.
I will begin by linking the transmission of Magna Carta, and the other bundle of rights associated with the concept of English liberty, to the arrival of the first settlers in the region who were determined to claim English liberty as part of their ‘colonial birthright’ as Englishmen. I will proceed to examine how these settlers succeeded in claiming the rights and privileges associated with English liberty for themselves while at the same time denying these rights and privileges to the West Africans transported to the region to work as slaves on their sugar plantations, who were subject to a set of brutal and oppressive Slave Code laws.


Acting Minister of Foreign Affairs Haneef Atmar met Deborah Lyons, the UN Secretary-General’s Special Representative for Afghanistan and head of the UN Assistance Mission in Afghanistan (UNAMA), on Sunday.
They deliberated on the latest developments of the Afghan peace process, and exchanged views on the release of prisoners by the government and the Taliban to facilitate the urgent start of the intra-Afghan talks.
The importance of strengthening regional and international consensus on the Afghan peace process and the establishment of a humanitarian ceasefire, were also discussed, along with preparations for the Senior Officials Meeting to be held on July 28.
The UN envoy highlighted the outcomes from the recent international and regional consultation meetings on Strengthening Consensus for Peace and emphasised the importance of continuing such initiatives in the future.
She also reiterated UN’s continued support for a peaceful and prosperous Afghanistan and agreed to advance work on the “peace economy.”
Concluding the meeting, Atmar thanked the Lyons for the UN’s positive role and continued commitment to Afghanistan.