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Cleveland Clinic medical oncologist Nima Sharifi, MD, is a recipient of two of the six 2015 Challenge Awards presented by the Prostate Cancer Foundation. Dr. Sharifi's research focuses on metabolic and molecular mechanisms of resistance to hormonal therapy in prostate cancer.
Cleveland Clinic medical oncologist and prostate cancer researcher Nima Sharifi, MD, is a recipient of two of the six 2015 Challenge Awards presented by the Prostate Cancer Foundation (PCF).
The peer-reviewed, highly competitive grants are intended to support innovative research that has the potential to make near-term, "game-changing" impacts on prostate cancer diagnosis and treatment.
Dr. Sharifi is the principal investigator on one of the 2015 Challenge Award-winning projects, and a co-investigator on the second, each of which provides the research team $1 million over two years. His research focuses on metabolic and molecular mechanisms of resistance to hormonal therapy in prostate cancer.
"These awards recognize the outstanding prostate cancer research at Cleveland Clinic and continue to build on our tradition of team science that has substantive benefits for patient care," said Eric A. Klein, MD, Chairman of Cleveland Clinic's Glickman Urological & Kidney Institute.
When patients with late-stage or aggressive prostate cancers undergo chemical or surgical castration, their tumors shrink due to testosterone deprivation. However, tumors often recur, forming ultimately lethal castration-resistant prostate cancer (CRPC).
CRPC tumors gain their resistance to androgen-deprivation therapy by reactivating the androgen receptor. Tumors accomplish this primarily by acquiring the ability to synthesize their own 5α-dihydrotestosterone (DHT) from adrenal precursor steroids. Dr. Sharifi's research has demonstrated the involvement of a previously underappreciated intermediate steroid metabolite – 5α-androstanedione – in prostate tumors' synthesis of DHT. In 2013, Dr. Sharifi's lab identified the first example of a mutation that increases DHT synthesis to promote hormone therapy resistance. This mutation can also be inherited as a variant of the enzyme 3β-hydroxysteroid dehydrogenase-1 (3βHSD1), which boosts the conversion of precursor steroids to DHT, thus enabling tumors to grow in the absence of gonadal testosterone.
The PCF Challenge Award-winning project for which Dr. Sharifi is the principal investigator aims to develop a diagnostic test to identify patients with the variant of 3βHSD1 that predisposes them to CRPC. This actionable biomarker could inform therapeutic decision-making and lead the way to tailored treatment, such as more intensive upfront hormonal therapy along with castration therapy, potentially increasing symptom-free and overall survival. Dr. Sharifi will lead a multidisciplinary team of basic scientists and clinicians at Cleveland Clinic and Mayo Clinic on the project.
Dr. Sharifi is a co-investigator on a second PCF Challenge Award-winning project that seeks to identify early biomarkers of anti-androgen treatment resistance. He will work with investigators from the University of Michigan and Washington University, using next-generation sequencing of prostatectomy specimens banked from a large clinical trial of radiation plus hormonal therapy to look for intrinsic resistance biomarkers and to define the clinical impact of the genetic alterations.
The PCF Challenge Awards go to high-risk, first-in-field and currently unfunded cross-disciplinary research projects that don't fit conventional funding organizations' requirements. Submissions undergo two rounds of peer review and are assessed for clinical relevancy and their potential to have near-term impact on standard of care. Fifty-five applicants representing 48 institutions in 13 countries competed for the 2015 awards.
Dr. Sharifi received a PCF Young Investigator Award in 2008 and was a co-investigator on a previous Challenge Award. He won the 2014 American Association for Cancer Research Award for Outstanding Achievement in Cancer Research, and previously received the Howard Hughes Medical Institute Physician-Scientist Early Career Award and the American Cancer Society Research Scholar Award.
Dr. Sharifi holds the Kendrick Family Endowed Chair for Prostate Cancer Research in Cleveland Clinic Lerner Research Institute's Department of Cancer Biology. He is an associate staff member of the Glickman Urological & Kidney Institute's Department of Urology and the Taussig Cancer Institute's Department of Hematology and Medical Oncology. He received his medical degree from the University of Pittsburgh School of Medicine. He completed his internal medicine residency at Yale-New Haven Hospital and his medical oncology fellowship at the National Cancer Institute.


After last week's Flipped, I decided a lightening of tone was in order.
Moving on to deeper issues, am I really the only one who cares that an all-male theater troupe is doing a stage version of Fruits Basket? Seriously?
You are currently browsing the The Manga Curmudgeon blog archives for the day Monday, February 23rd, 2009.


Peanut Sundal (or Groundnut Sundal or Verkadalai Sundal) is a popular and traditional sundal variety. It is often made during Navratri festival and is also made as an evening snack for kids.
1. Pressure cook the peanuts with salt until two whistles.
3. Fry the mustard seeds and dry red chillies for 30 seconds.
4. Add the asafoetida powder, boiled and drained peanuts and coconut.
6. Add green chillies, curry leaves and mix.
Feel free to comment or share your thoughts on this Peanut Sundal Recipe from Awesome Cuisine.


If you are like most adults, it is likely you will have a cavity that needs filling at some point of your life.
In the past, one of the most common ways to fill cavities, or dental caries, were amalgam fillings. Used for some 150 years, amalgam fillings were effective in preventing cavities from growing. However, with their dark gray color—a result of the combination of metals used to create these fillings—they were not terribly attractive.
In recent years, however, tooth-colored composite fillings have continued to improve to the point that not only are they made of materials that can match the color of your tooth but they offer excellent durability and resistance to fracture as well.
Dr. Brittaney Glazer of Glazer Family Dentistry offers tooth-colored fillings for patients who need to have their cavity filled. If you think you might have a cavity, give Dr. Glazer a call!
Also known as composite fillings, tooth-colored fillings are made of a mixture of tiny glass or quartz particles in a resin medium. One obvious advantage with tooth-colored fillings, of course, is that they match the color of your tooth and so they blend right in with your natural teeth. If you talk or laugh—even with your mouth wide open—no one will be able to tell you have any fillings because they so closely match your existing teeth.
If you have a cavity toward the front of your mouth, which is more readily visible, filling it with composite will also ensure that it blends in with the rest of your teeth. Tooth-colored fillings can also be used to fix teeth that are chipped or broken, again blending in with the rest of your teeth.
Filling preparation is easier and less invasive because in most cases not as much of the tooth needs to be prepared before the filling is placed.
Composite fillings have less of a tendency to expand and contract when they come into contact with hot or cold liquids, so there is less of a risk of fracture than with an amalgam filling.
If you experience any tooth sensitivity after the filling is placed, this is normal. It will almost always resolve itself if given a little bit of time. Meanwhile, just avoid anything that is causing the sensitivity. You can also try a desensitizing toothpaste. If the sensitivity doesn't go away after a few weeks, be sure to give us a call.
There is no difference in dental care after you get a tooth-colored filling. All you have to do is to continue to follow good oral hygiene practices, including brushing twice a day and flossing once a day. Continue to see your dentist twice each year for examinations and cleanings.
If you need a tooth filled, contact Glazer Family Dentistry for more information on tooth-colored fillings. We look forward to seeing you!


text:
Pemphigus Foliaceus
Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD
Pemphigus foliaceus (PF) is generally a benign variety of pemphigus. It is an autoimmune skin disorder characterized by the loss of intercellular adhesion of keratinocytes in the upper parts of the epidermis (acantholysis), resulting in the formation of superficial blisters. It is typified by clinical involvement of healthy-appearing skin that blisters when rubbed (the Nikolsky sign; commonly but incorrectly spelled Nicholsky), a finding named after Dr Piotr Nikolsky, who first described this sign in 1896.[1] Pemphigus foliaceus is characterized by a chronic course, with little or no involvement of the mucous membranes.
Pierre Louis Alphee Cazenave, founder of the first journal dedicated entirely to dermatology, documented the first description of pemphigus foliaceus in 1844 in this journal. The description was of a 47-year-old woman who consulted him at l'Hopital Saint Louis in Paris for a generalized eruption of several years' duration. Nikolsky described lateral extension of the preexisting erosion due to lifting up the collarette (and when applying a lateral pressure to the clinically intact skin), whereas Asboe-Hansen described extension of the intact blister due to pressure that is applied to its roof.
Pemphigus foliaceus has the following six subtypes: pemphigus erythematosus (PE), pemphigus herpetiformis (PH), endemic pemphigus foliaceus, endemic pemphigus foliaceus with antigenic reactivity characteristic of paraneoplastic pemphigus (but with no neoplasm), immunoglobulin A (IgA) pemphigus foliaceus, and drug-induced pemphigus foliaceus. See Pemphigus Erythematosus; Pemphigus Herpetiformis; Pemphigus, Paraneoplastic; and Pemphigus, IgA for more information.
Senear and Usher originally described PE in 1926 as an unusual type of pemphigus with features of lupus erythematosus. PE (also known as Senear-Usher syndrome) is best viewed as a localized form of pemphigus foliaceus. Chorzelski et al[2] determined its immunopathology in 1968.
Another pemphigus foliaceus variant with pruritic, flaccid vesicles in an annular pattern has been characterized as IgA pemphigus foliaceus, with antibodies of IgA class providing the basis for diagnosis.
Jablonska and associates[3] coined the term pemphigus herpetiformis for the pemphigus foliaceus variant that often begins as small clusters of pruritic papules and vesicles mimicking dermatitis herpetiformis.
Endemic pemphigus foliaceus, or fogo selvagem (formerly known as Brazilian pemphigus foliaceus because it is evident mainly in the river valleys of rural Brazil), has also been described in Columbia, El Salvador, Paraguay, Peru, and Tunisia. Fogo selvagem (Portuguese for wild fire) displays immunopathologic findings of pemphigus and a distinctive epidemiology suggestive of a disorder triggered by an infectious insect-borne agent (see Fogo Selvagem).[4] A focus of endemic pemphigus foliaceus also exists in El Bagre, Columbia and shares features with Senear-Usher syndrome but occurs in an endemic fashion.[5, 6] It also may have autoantibodies to optic nerve sheath envelope cell junctions, the clinical significance of which is unknown.[7] Heterogeneous antigenic reactivity was observed as in paraneoplastic pemphigus but with no evidence of association with neoplasia. This endemic pemphigus disease in El Bagre had immunologic features similar to pemphigus foliaceus or erythematosus.
Chorzelski et al in 1999[8] described paraneoplastic pemphigus with cutaneous and serologic features of pemphigus foliaceus in a patient with an underlying lymphoma. The authors are not aware of any similar patients with these highly unusual findings.
Drug-induced pemphigus foliaceus is mostly associated with penicillamine, nifedipine, or captopril, medications with a cysteinelike chemical structure.
A transition from pemphigus vulgaris (PV) to pemphigus foliaceus, or vice versa, is not likely. However, in the experience at the Medical University of Warsaw, PV in the remission period may resemble pemphigus foliaceus. About 7% of patients with pemphigus foliaceus may have the initial features of PH. This figure was 35% in patients with endemic pemphigus foliaceus in Tunisia (see Pemphigus Vulgaris). The pivotal contributions of Jean-Claude Bystryn have been summarized.[9]
Superficial blisters in pemphigus foliaceus are induced by immunoglobulin G (IgG) (mainly IgG4 subclass) autoantibodies directed against a cell adhesion molecule, desmoglein 1 (160 kd), expressed mainly in the granular layer of the epidermis. Desmoglein 1 is also a major autoantigen in cases of PH, suggesting that most cases of both PE and PH are clinical variants of pemphigus foliaceus. The mechanism of acantholysis induction by specific autoantibodies may involve phosphorylation of intracellular proteins associated with desmosomes. Complement activation does not play a pathogenic role in pemphigus foliaceus. A polyclonal mixture in pemphigus foliaceus patients of anti-Dsg1 IgG antibodies enhances pathogenic activity for blister formation, with not only pathogenic antibodies, but also nonpathogenic antibodies, contributing to blister formation.[10]
Antibodies against desmoglein 3 are also present in patients with paraneoplastic pemphigus (PNP), a severe condition associated with various antibodies against different components of the cell adhesion complex. Other target antigens, including the acetylcholine receptor, have also been postulated to be relevant in the pathogenesis of pemphigus foliaceus.[11, 12, 13, 14]
Cholinergic control of epidermal cohesion may be important.[15] The regulation of keratinocyte cell-to-cell and cell-matrix adhesion is an important biological function of cutaneous acetylcholine. Progress in therapy of pemphigus using cholinergic drugs supports this concept.
Precipitating factors include medications and ultraviolet light radiation. It has been suggested that both enhanced autoantibody epidermal binding and preferential neutrophil adhesion to UV-irradiated epidermis contribute to acantholysis development in photo-induced pemphigus foliaceus. Radiation therapy may also flare pemphigus foliaceus in those with it.[16, 17, 18]
Endemic pemphigus foliaceus seems to have an environmental cause. The prevalence of antibodies against desmoglein 1 is high in people residing in endemic areas of Brazil, with disease onset preceded by a sustained antibody response due to an as yet unknown environmental factor.
Genetic factors predispose to the development of pemphigus foliaceus. The HLA-DRB1*01:02 allele and the HLA-DRB1*01-DQA1*01-DQB1*05 haplotype had the strongest linkage among 86 pemphigus foliaceus patients from southeastern Brazil.[19] The role of genetic factors is evident in fogo selvagem in which a strong association exists with some human leukocyte antigen DRB1 (HLA-DRB1) haplotypes, including DRB1*0404, 1402, 1406, and 1401. In France, persons with DRB1*0102 and 0404 are at an increased risk of pemphigus foliaceus.
Pemphigus trigger factors have been meticulously analyzed by Ruocco and Ruocco,[20] who have delineated an exhaustive list and stressed the need to detect environmental provoking or precipitating factors. As a superb memory device to facilitate thorough patient evaluation, Ruocco[21] has cleverly observed that PEMPHIGUS should encourage the physician to consider pesticides (PE), malignancy (M), pharmaceuticals (P), hormones (H), infectious agents (I), gastronomy (G), ultraviolet light (U), and stress (S).
Rarely, a change in pemphigus subtype may occur, accompanied by qualitative and quantitative changes in the anti-Dsg autoantibody profile as detected using antigen-specific enzyme-linked immunosorbent assays (ELISAs). Thus, the antibody profile defines the clinical phenotypes of pemphigus, and that intermolecular "epitope spreading" may be the immunological mechanism underlying a shift between pemphigus foliaceus and PV.[22, 23]
It has been suggested that polymorphisms in the 2q33 and 3q21 chromosomal regions influence susceptibility to pemphigus foliaceus.[24]
Scientific evidence links interactions between thymoma function, thymoma, and pemphigus, often associating loss of self-tolerance and the presence of autoimmunity.[25] The association of pemphigus foliaceus and thymoma is noteworthy.
Endemic pemphigus foliaceus in Tunisia has merited analysis. Unlike in North America and Japan, in Tunisia IgG autoantibodies against Dsg1 are commonly detected in healthy individuals.[26] In a Tunisian study, these IgG autoantibodies against Dsg1 were generally against pre-Dsg1 and/or C-terminal domains of Dsg1 in healthy Tunisians.
Long noncoding RNA variants may play a pivotal role in the immunopathogenesis of both endemic and sporadic forms of pemphigus foliaceus.[27]
Endemic pemphigus foliaceus, or fogo selvagem, seems to be induced by a viral infection transmitted by insects. Pemphigus vulgaris in a recipient with pemphigus foliaceus in a donor after allogeneic peripheral blood stem cell transplantation between two siblings has been described.[28] Pemphigus foliaceus patients may have antibody responses against other keratinocyte adhesion molecules in addition to the main target autoantigen, Dsg1, and anti-Dsg1 monoclonal antibodies cross-reacted with an environmental antigen, LJM11, a sand fly saliva protein.[23]
In some patients, pemphigus foliaceus may be precipitated by extensive UV exposure or burns and by various drugs (eg, penicillamine,[29, 30] inhibitors of angiotensin convertase, nonsteroid anti-inflammatory agents).[31] Pemphigus foliaceus induced by bucillamine has been described.[32]
A topical ectoparasiticide containing fipronil, amitraz, and S-methoprene has been described as causing pemphigus foliaceus in dogs.[33]
Herbal supplements containing blue algae have also been linked with the induction of pemphigus foliaceus.[34]
The incidence of pemphigus foliaceus varies depending on the population studied. Pemphigus foliaceus is rare and sporadic worldwide. In contrast to PV, no predominance of pemphigus foliaceus is found in Jews and in people of Mediterranean descent. An increased incidence of pemphigus foliaceus was noted in Tunisian women (6.6 cases per million per year), whereas, in Western Europe, the incidence of pemphigus foliaceus is about 0.5-1 case per million per year.[35]
Endemic pemphigus foliaceus, or fogo selvagem, occurs with a high frequency in central and southwestern Brazil and in Colombia. The Terena reservation in Brazil has a prevalence of 3.4% of the population. In endemic regions of Brazil, as many as 50 cases per million per year are seen.[36] Other foci may be present in the Maghreb; one was described in Morocco.
Pemphigus foliaceus has been described in all races.
In general, the prevalence of pemphigus foliaceus in men and women is about equal; however, in the Sousse region of Tunisia, an overwhelming predominance of women are affected. The peak incidence of endemic pemphigus foliaceus in women aged 25-34 years in the Sousse region of Tunisia is 15.5 cases per million per year. In El Salvador, a similar female and age predisposition may also be evident.
The mean patient age at onset of pemphigus foliaceus is about 50-60 years; however, it may occur at any age, from infancy onward.[37] Fogo selvagem often occurs in children, young adults, and genetically related family members. The mean patient age at onset is about 20-30 years. The peak incidence of endemic pemphigus foliaceus occurs in women aged 25-34 years in the Sousse region of Tunisia. An increased incidence in genetically related family members does not appear to exist.
Pemphigus foliaceus tends to persist for months to years. Pemphigus foliaceus may coexist with thymoma, myasthenia gravis, lupus erythematosus, and other autoimmune bullous diseases.
The bullae usually start on the trunk. The course of the disease is long-term, with the patient's general health being satisfactory. Spontaneous remission sometimes occurs, but the lesions can persist for several years. A unique clinical pattern may occur in children, with individual lesions appearing as arcuate, circinate, or polycyclic.[38] Eyelid skin involvement without conjunctival changes occurs occasionally in patients with pemphigus foliaceus.[39]
The primary lesions are small, superficial blisters; however, these flaccid bullae are difficult to find because they are transient and transform into erosions. Typical pemphigus foliaceus has scaly, crusted erosions on an erythematosus base confined mainly to so-called seborrhoic areas (eg, face, scalp, upper part of the trunk).
The Nikolsky sign is the finding that physical trauma can shear the pathologic epidermis of the skin of patients with pemphigus foliaceus, resulting in clinical lesions. The Nikolsky sign should probably be regarded as a moderately sensitive but highly specific tool for the diagnosis of pemphigus.[40]
The erosions can become numerous, showing a tendency to generalize. Occasionally, erythrodermia develops. Thus, pemphigus foliaceus may be evident as a an erythroderma or a psoriasiform erythroderma.[37, 41] Atrophic changes of the nails and the hair are sometimes evident. The erosions may be accompanied by a burning sensation and local pain. In contrast to PV, in pemphigus foliaceus, little or no involvement of the mucous membranes occurs. Note the images below.
Middle-aged American woman of Mexican lineage with superficial bullae characteristic of pemphigus foliaceus.
Pemphigus foliaceus. Middle-aged American woman of Mexican lineage with superficial bullae formation.
A 41-year-old woman of Puerto Rican origin with a 9-year history of pemphigus foliaceus, often with erythroderma flares.
IgA pemphigus foliaceus begins as pruritic, flaccid vesicles in an annular pattern.
PH commences as intensely pruritic, grouped papules and vesicles suggestive of dermatitis herpetiformis. Erythematous patches with peripheral vesicles may be present. Sometimes, oral erosions are seen.
PE starts as erythematous patches with border vesiculation, often in a butterfly distribution on the cheeks and the forehead, with similar patches on the sternal and interscapular skin. Crusted plaques may appear in the healing phase.
PNP is a subset of pemphigus combining the clinical features of PV variably associated with those of erythema multiforme, bullous pemphigoid, and lichen planus. Chorzelski and associates[8] in 1999 described a most unusual case of PNP with the immunopathologic findings of pemphigus foliaceus. The clinical pattern appears to be correlated with that of the antibody profile; therefore, patients with antibodies directed against desmoglein 1 tend to have the clinical features of pemphigus foliaceus.
Monitor pemphigus foliaceus (PF) patients for other autoimmune disorders, particularly thymoma and myasthenia gravis.
New cutaneous pain or new constitutional symptoms, change in primary morphology, rapid disease progression, or failure to respond to appropriate therapies may suggest a concurrent cutaneous viral infection such as by herpes simplex or cytomegalovirus.[42]
Diagnostic Considerations
A mixed immunoblistering disorder exhibiting features of bullous pemphigoid and pemphigus foliaceus (PF), associated with the food supplement Spirulina, was described in an 82-year-old woman.[43]
Allergic Contact Dermatitis
Bullous Systemic Lupus Erythematosus (BSLE)
Dermatologic Manifestations of Glucagonoma Syndrome
Dermatologic Manifestations of Herpes Simplex
Drug-Induced Bullous Disorders
Drug-Induced Pemphigus
Drug-Induced Photosensitivity
Epidermolysis Bullosa Acquisita
Erysipelas
Erythroderma (Generalized Exfoliative Dermatitis)
Familial Benign Pemphigus (Hailey-Hailey Disease)
See Patel et al (2019).
Fogo Selvagem
IgA Pemphigus
Irritant Contact Dermatitis
Linear IgA Dermatosis
Papular Urticaria
Paraneoplastic Pemphigus
Pemphigus Erythematosus
Pemphigus Herpetiformis
Pseudoporphyria
Subacute Cutaneous Lupus Erythematosus (SCLE)
Subcorneal Pustular Dermatosis
Immunofluorescence using both direct techniques and indirect techniques is the most reliable method to diagnosis pemphigus.[44] Because of the rare occurrence of pemphiguslike antibodies, pemphigus cannot be diagnosed by indirect immunofluorescence (IIF) alone and must be confirmed by direct immunofluorescence (DIF). With the use of 2 appropriate substrates (ie, monkey esophagus [or human skin] and guinea pig esophagus and standardized conjugates), in IIF, PV and pemphigus foliaceus patterns are different; PV stains throughout the epidermis, and pemphigus foliaceus stains only in the upper epidermis, whereas, with DIF, the patterns are similar. With a DIF study, cell surface immune deposits are often present throughout the entire epidermis in both pemphigus foliaceus and PV. Using DIF on telogen hair outer root sheath may be beneficial for diagnosis and follow-up, irrespective of the presence of scalp lesions.[45]
Immunologic examination with DIF testing shows IgG in the intercellular space, mainly in the upper parts of the epidermis; an IIF study documents the presence of circulating pemphigus antibodies, especially with a guinea pig esophagus used as a substrate. One IIF study suggested that using both a monkey esophagus and the human skin increases the sensitivity and aids in distinguishing pemphigus foliaceus from PV. In PH, IgG deposits are evident in the upper epidermis, with circulating IgG to the epidermal cell surface. The subcorneal pustular dermatosis type of IgA pemphigus foliaceus has IgA deposition on the upper epidermal cell surfaces and circulating IgA antibodies to the epidermal cell surfaces. Desmogleins 1 and 3 are the major cell surface target molecules in patients with PH. In the unusual instance when PV becomes pemphigus foliaceus, or vice versa, the clinical alteration is associated with a shift in the antidesmoglein autoantibody profile.
Other methods, such as ELISA[46] and immunoblot assays,[47] can be used, but they require highly purified antigens to give similar results. The sensitivity for PV and pemphigus foliaceus antibodies is more than 98% in at least the renowned laboratory of Jarzabek-Chorzelska and associates,[44] with their many decades of experience. Histologic examination is useful, but it is not the preferred method for diagnosing pemphigus foliaceus because it cannot replace a highly reliable DIF method.
Another less experienced laboratory found ELISA to be superior to an IIF study for serodiagnosis of pemphigus foliaceus at various stages of disease activity.[48]
Pemphigus foliaceus arising during the administration of D-penicillamine was described in an elderly patient in whom withdrawal of D-penicillamine resulted in improvement of the skin lesions and ELISA scores for anti–desmoglein 1 antibodies revealed a rapid decline.[49]
The sensitivity and specificity of a novel multisubstrate immunofluorescence technique called BIOCHIP was evaluated in 35 patients, 21 with pemphigus vulgaris and 14 with pemphigus foliaceus, and the technique was found to be beneficial in differentiating these two types of pemphigus.[50]
Pemphigus foliaceus begins as acantholysis of the upper epidermis, often resulting in a subcorneal cleft. It usually enlarges and detaches without bullae formation, though a bulla may form showing acantholysis at both the roof and the floor. More established lesions may have acanthosis and mild-to-moderate papillomatosis. Hyperkeratosis and parakeratosis may also be evident, with dyskeratotic cells within the granular layer. These features may be particularly pronounced in long-standing PE. A mild dermal lymphocytic infiltrate occurs, often with the presence of eosinophils. Eosinophilic spongiosis may also be noted, especially in PH.
Histologic view shows the typical pattern of a detached stratum corneum without bullae formation. Pigmentary incontinence is prominent in the dermis, reflecting the patient's 9-year history of recurrent superficial bullae.
Present information is probably inadequate to ascertain the optimal therapy for pemphigus foliaceus (PF), including the optimal glucocorticoid dose, the role of adjuvant immunosuppressive medications, and long-term adverse events to improve the risk-to-benefit ratio.[51] Therapy for pemphigus foliaceus is usually less aggressive than that of PV because of lower morbidity and mortality rates.[52]
First results indicate that nonsteroidal treatment of pemphigus is possible. Mestinon may be used to slow down progression of the disease and to treat mild cases with chronic lesions on limited areas. Antimalarial therapy may be effective monotherapy in some patients. However, a major obstacle in comparing therapeutic outcomes is the lack of generally accepted definitions and measurements for the clinical evaluation of patients with pemphigus.[53] Common terms and endpoints of pemphigus are needed to accurately measure and assess disease extent, activity, severity, and therapeutic response.
Topical glucocorticosteroids may be sufficient in cases of limited involvement.[54]
In more extensive cases (similar to PV), adjuvant immunosuppressants, including systemic corticosteroids, azathioprine, mycophenolate mofetil, cyclophosphamide, and cyclosporin A, may be necessary.[55, 56]
In some cases, such as PE, combined therapy is beneficial with the use of corticosteroids and sulfones or antimalarial agents.
Topical treatment with antibiotics and corticosteroids, such as topical clobetasol cream or ointment 0.05% twice a day, is helpful. Other vehicles that may be useful are creams, foams, liquids (for scalp lesions), and aerosols. Antibiotics, such as minocycline 50 mg daily, may be effective. Nicotinamide 1.5 g/d and tetracycline 2 g/d have also been reported to be beneficial in a small number of patients. Antibiotics and nicotinamide are purported to have anti-inflammatory effects.[57]
Photoprotection is appropriate for some patients because UV-B may trigger acantholysis and cause a flare-up of the disease.
Successful anti-CD20 antibody treatment has also been described.[58]
Plasmapheresis is another therapeutic option in patients with recalcitrant disease. It may decrease autoantibody titers in some patients and favorably influence the clinical outcome, especially in patients with otherwise therapy-resistant pemphigus foliaceus. It is often used in conjunction with cytostatic agents, such as cyclophosphamide or azathioprine, to reduce a predictable rebound increase in autoantibody synthesis. Potential complications, including the need for maintaining venous access, a bleeding tendency, electrolyte shifts, pulmonary edema, fever, chills, hypotension, and septicemia, should be considered.
Amagai et al reported that a single cycle of intravenous immunoglobulin at 400 mg/kg/d for 5 days is effective and safe for patients with pemphigus that is relatively resistant to systemic steroid therapy.[59] Toth and Jonkman also reported on successful therapy with intravenous immunoglobulin (low dose).[60]
Numerous medications are used to treat patients with pemphigus foliaceus. They are often used in combination. However, a systematic review and meta-analysis according to the methodology of the Cochrane Collaboration showed that available evidence is inadequate at present to ascertain the optimal therapy for pemphigus foliaceus.[61]
Pemphigus is usually treated with systemic prednisone in combination with adjuvant immunosuppressants.[62] Refractory pemphigus foliaceus has been treated with the anti-CD20 monoclonal antibody rituximab.[63, 64, 65] Unfortunately, it increases the risk of infection with Pneumocystis jiroveci pneumonia, which may result in a fatal outcome.[66] Intravenous immunoglobulin (IVIg) may also be used because it lowers serum levels of pemphigus antibodies.[67, 68] Concurrent administration of a cytotoxic drug appears to be beneficial. Mycophenolate mofetil (MMF) and enteric-coated mycophenolate sodium may be considered.[69]
Corticosteroid agents
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Prednisone (Deltasone, Orasone)
Prednisone is a synthetic adrenocortical steroid with predominantly glucocorticoid properties. It is an immunosuppressant for the treatment of autoimmune disorders; it may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Prednisone stabilizes lysosomal membranes and suppresses lymphocyte and antibody production.
Antibiotic agents
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Minocycline (Dynacin, Minocin)
Minocycline is a semisynthetic derivative of tetracycline. It treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma species. Minocycline was found to be effective in some nontuberculotic mycobacterial infections.
Dapsone (Avlosulfon)
Dapsone is bactericidal and bacteriostatic against mycobacteria; its mechanism of action is similar to that of sulfonamides where competitive antagonists of PABA prevent formation of folic acid, inhibiting bacterial growth. Dapsone is used to control the dermatologic symptoms of dermatitis herpetiformis. It can be used for patients with pemphigus and may be the drug of choice for pemphigus foliaceus and IgA pemphigus foliaceus. It may be provided as monotherapy or in combination with systemic steroids and immunosuppressants.
Antimalarial agents
Hydroxychloroquine has immunosuppressive effects.
Hydroxychloroquine is a 4-aminoquinoline derivative active against a variety of autoimmune disorders. It inhibits chemotaxis of eosinophils, locomotion of neutrophils, and impairs complement-dependent antigen-antibody reactions. Hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base and 250 mg chloroquine phosphate.
Immunomodulatory agents
These agents have antiproliferative and immunosuppressive effects.
Azathioprine may be used alone or as steroid-sparing agent. It antagonizes purine metabolism and inhibits the synthesis of DNA, RNA, and proteins. Azathioprine may decrease the proliferation of immune cells, which results in lower autoimmune activity.
Cyclophosphamide (Cytoxan, Neosar)
Cyclophosphamide may be used as monotherapy or as a steroid-sparing agent. It is chemically related to nitrogen mustards. As an alkylating agent, the mechanism of action of the active metabolites may involve cross-linking of DNA, which may interfere with growth of normal and neoplastic cells.
Slawomir Majewski, MD Professor and Director, Department of Dermatology and Venereology, Warsaw School of Medicine, Poland
Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology
Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association
Julia R Nunley, MD Professor, Department of Dermatology, Virginia Commonwealth University Medical Center
Julia R Nunley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Nephrology, International Society of Nephrology, Medical Dermatology Society, Medical Society of Virginia, National Kidney Foundation, Phi Beta Kappa, Women's Dermatologic Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Board of Dermatology<br/>Author for: Up-to-date.
Robin Travers, MD Assistant Professor of Medicine (Dermatology), Dartmouth University School of Medicine; Staff Dermatologist, New England Baptist Hospital; Private Practice, SkinCare Physicians
Robin Travers, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Informatics Association, Massachusetts Medical Society, Women's Dermatologic Society, Medical Dermatology Society
Sebastian S Majewski †
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redpajama_set_name: RedPajamaCommonCrawl


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Staff at our Halifax branch today congratulated our very own Anthony Wannan on his 60th birthday during the morning fire drill - Enjoy your birthday Anthony!
Our very own 5-a-side squad took part in a charity tournament to raise money for Overgate Hospice. After a good 3 and half hours of sweating, we made it to the final and came in 2nd place. Well done lads!


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Michael Biehn Overview
Jul 31, 1956 Birth Place:
As a child, Michael Biehn moved from his Alabama hometown to Nebraska and finally Arizona, where he graduated high school. He went to college and later moved to Los Angeles to begin a film career, making his professional stage debut after two years of intensive training. In 1978, Biehn was cast as Mark Johnson, the hard-veneered but vulnerable ward of...
Altered Perception 2017
The Shadow Effect (2017) 2017
The Divide (2012) 2011
Puncture 2011
Take Me Home Tonight 2011
Bereavement 2011
Yellow Rock 2011
Saving Grace B. Jones 2009
They Wait 2008
Grindhouse: Planet Terror 2007
Grindhouse 2007
You Are Here (2000) 2007
That's Amore! 2004
Clockstoppers 2002
Megiddo: The Omega Code 2 2001
The Art of War 2000
Silverwolf 1999
The Rock 1996
Deep Red (1994) 1994
Tombstone 1993
The Abyss 1989
Aliens 1986
Hog Wild 1980
Grease (1978) 1978
See Michael Biehn's Full Filmography


What has happened to the reference type sub-process?
How do I get all references of a reusable sub-process?
I have reported this problem before, please refer to http://feedback.bizagi.com/en/responses/links-to-reusable-processes-disappear. Because that has been marked "Not a problem" I'm starting a new response.
We've upgraded to 2.4.0.8 and we still have this issue. However, we're finally able to reliably reproduce it.
At this moment, all the reusable processes in the diagram will have lost their linked process, they all point to nothing.
If user 2 closes Bizagi Process Modeler and reopens the model between steps 8 and 9, the links will be there, and it is safe to edit and save.
For now, we solve this in our team by closing the process modeler and reopening the model before starting to edit a diagram. This is not strictly necessary: if the reusable processes are ok while the diagram is read-only, it's safe to edit. But just always reopening is easier to remember.
Stricly speaking, step 3 is not necessary. It doesn't matter if user 2 is actually looking at the diagram or not, he needs to have the same model open in the process modeler. If a diagram gets edited by another user during your session, the reusable processes will disappear for you, and they will permanently disappear if you open and save the diagram in the same session. You're ok as soon as you start a new session.
Thank you very much for your detailed feedback.
We will analyze this subject and keep you posted.
We are working on this issue and it will be solved in our upcoming release this month (June 2013).
We gladly announce this issue has been resolved in our latest 2.5 release (June 2013).


How Much Time Does Cocaine Remain In Your System? Check it!
Have you utilized cocaine just recently? Do you make use of the medication when you party late into the evening? Do you use it on a regular basis to obtain with the day? Often people that abuse cocaine are worried concerning for how long it will remain in their system and how much time it will certainly continue to influence them.
According to the National Study on Drug Use and Health And Wellness, in 2009 alone, around 4.8 million young Americans (from age 12 and also up) had actually utilized cocaine in its different type which a million had actually used it at the very least when before the 2009 study was made.
The 2010 "Keeping an eye on The Future" research study exposed that 1.6 percent of the students in the eighth quality, 2.2% in the tenth grade and 2.9% in the twelfth quality had actually utilized cocaine in its different types. On top of that, one percent in the 8th quality and 10th grade and 1.4% on the 12th quality had actually utilized it a minimum of when.
In the U.S, concerning 14% of grownups have tried cocaine at the very least as soon as. Data reveal that from 40 adults at least one has attempted it throughout the previous year. The most significant age for cocaine use is 18-25 amongst boys. 8 percent of boys in this age group have used cocaine in the last 12 months.
Cocaine can be provided through three various paths: infusing, smoking cigarettes and also grunting (breathing in powdered cocaine through the nose). The period as well as strength of the results depend on just how the medicine was administered.
The faster absorption right into the bloodstream yields the most extreme result yet it has a minimal duration. Grunting the cocaine generates a "high' that would certainly last for fifteen to half an hour while smoking it decreases the period to about five to 10 mins.
This is why users usually take them simply put periods but with boosts in the dosage to lengthen the "high" feeling. When the fallen leaves are eaten the affect is reduced pain, exhaustion as well as hunger or thirst.
How Much Time Does Cocaine Remain In Your System?
Cocaine typically stays in the system for approximately 48 hours. Although the technique of administration as well as the dosage provided impacts for how long it takes for the body to metabolize this medicine. When coca leaves are eaten, absorption time is around Thirty Minutes.
If the drug is grunted, the peak results are most likely to manifest within the following 20 minutes as well as are maintained for approximately an hour. Infusing the medication straight to the blood stream enables the user to really feel the complete impacts within 3.2 minutes. This course is considered to be the one with biggest health danger. Cocaine is estimated to be in the system for around 72 hours since its first consumption.
Nevertheless, cocaine drug test is made to detect the metabolite of cocaine, benzylecgonine. When cocaine is metabolized in the body it undergoes hydrolysis.


Please note I have been working on this post over the span of ~6 months, just adding to it a little everyday. The information regarding licensing and pricing may have changed since then. Please check the shop's policies for details. This is meant to be a guide, not an exhaustive list.
This is where I would look for someone just starting out and looking to make stickers for their own use. The artwork is not super unique, but it'll help you familiarize yourself with the design process. Plus, you can make some great kits compiling free images, and at the end of the day it's free, so you have nothing to lose.
This is one of the first places I looked to when I started making planner stickers. They have a great database of images that are mostly all free to use. If you use the images are used commercially, all they ask is that you credit the illustrator. For more information on this policy, visit them here.
Downloading is VERY easy. Let's say I am designing a summer-y tropical kit, and I search for tropical images. As you can see, there aren't a lot of organized themes, in that you mostly will not be able to download a set to use. However, it isn't too difficult to piece together items, as a lot of them are drawn by the same artist and have a similar look to them. I'll click on one I like to pull up the download screen. All you need to do is hit download, and it'll have you select one of two options. You can either credit the author by pasting html code into your site or you can upgrade to a premium plan and avoid having to credit altogether. I have personally tried both, and I think it'll depend on how often you plan on using their site. It is $9.99 a month and it was worth it for me when I was using this weekly, however I have since unsubscribed since I'm not designing as often.
They have great range on the website with lots of individual images you can piece together, or you can search for some of their sets. Here's an example. I often used this format, however it is very difficult to use in my opinion. You will need to purchase software to edit them– I used Adobe Illustrator. I had never used it before so extracting the pattern was a challenge for me, but if you are used to working with vector files, this should be no problem for you. Just keep in mind that the file download comes with exactly what you see. You don't get the 6 pattern files; rather you download the image with the title and the patterns arranged as seen.
For that reason, I would rate Freepik 3/5. While they have some great options, they don't download as jpegs making it more difficult to use in Silhouette Studio.
Flaticon is one of my favorite sites of all time for sticker designing. Flaticon comes from the makers of Freepik and has a very similar premise. They have a large database of icons characters that you can use as clipart for free, as long as you credit the author. They also have the option of purchasing a $9.99 membership for access to premium icons and to use without credit. To me, this is definitely worth it, and I'll show you why. Off to the side you'll see the set of images that pop up when you search "food". You'll notice a lot of icon style clipart where it's all one color. These are awesome because you can trace them in Silhouette, then fill them in with whatever pattern or color you'd like. When you click on them to download, you can also change the color there, but I prefer to download everything in black, then play around in Silhouette studio instead of downloading multiple colors. Lay them over a circle or a box and you've got labels and icons. You can also use the colored ones as clipart for more decorative stickers. Another reason why this site is great is that they group a lot of the icons for you. For example, if I don't want to pick out every single food, I can open up a gastronomy set that features icons of a similar theme and style, which is great for maintaining consistency. You can save sets or make collections of your own by saving icons into various folders, making downloading them very quick and easy. You can download the entire set or pick and choose your favorites.
A new feature that they've implemented that I absolutely love allows you to make patterns out of icons in a set. I never personally used this when designing, as it wasn't available at the time. Now after playing around in the pattern designer, I really wish it had been. It is so very easy to use– all you do is click on the icons you would like in the pattern and add a background. You can also choose to go for a random pattern created from icons of a particular set. This is really great for someone starting out as you can get great themed patterns very quickly. The top image is one that I created in about 15 seconds just by randomly clicking space themed icons and adding a colored background. The second image is one that they randomly put together, which I honestly like a lot more. There are a lot of options with this designer, and I would highly recommend checking it out.
Overall I give Flaticon a 5/5. I think they've got some great features built into the site that makes it so user-friendly. While they do have a lot of options, they all have a very cartoon-ish appearance so if you are looking for very realistic drawings, this may not be the site for you.
I've linked below some other websites where you may find some digital paper downloads for free. Just be sure to check the licensing information to ensure you are not violating any copyright rules. When in doubt, always contact the site administrator for more information.
The site has not been updated in a few years, but there are a lot of sets available for you to download. Usage is limited to personal use and small commercial use (i.e. small businesses only).
Once again, it hasn't been updated in a while, but you can still find some great sets here! Free for personal and commercial use!
I couldn't find anything about commercial use — I would email to be sure!
This section is intended for someone who has some experience with designing stickers and is looking to expand the quality of their kits. Just because something costs money does not mean it is better than something free, however I have generally found that these websites are very consistent in quality and are very affordable for those getting started. A lot of these shops (if not all) are based on Etsy, which is how I prefer to purchase digital items. There is some risk involved with digital purchases, but I have found Etsy's buyer protection to be reliable. Just make sure you read all the details in the description box and that you understand their licensing policy. The shops listed below all offer free licenses with purchase of their artwork, however this can change sometimes, so be sure to check every time you purchase and to message the seller with questions. I will also include each shop's Instagram page since that is where most will post about sales and coupons.
At the end of the description, I'll include a bolded number. That number is a rating out of 5. This rating is not a determination of that artist's skill or the quality of their business. It's simply my thoughts on pricing, ease of use, licensing, and how "planner-friendly" the patterns are.
I would only recommend going to this section once your shop/blog begins to take off, otherwise, I would stick to the first couple sections. Purchasing licenses for each set can add up quickly. This section will consist of shops that do not include free licenses, or the majority of the shop requires a license for any commercial use. Once again, there will be a bolded rating factoring in the price of the license and the value of the set. Any prices listed are as of the writing of the post, and can most definitely change later on. I will go through this list much quicker than others, just because I don't know how helpful it will be to beginners. Nonetheless, I had the list compiled and thought it may be useful in the future.
Elle P Studio has a more unique look to their shop, with a very distinctive character design. They offer lots of digital items, though the price is on the higher end. They offer a basic and large license. Basic ($25) covers 250 sales. Anything more necessitates a large license ($55). Once again, this shop does sell in bundles.
Alright! So we are to the end of a very lengthy post, and the last thing I want to discuss is the use of custom artwork for planner stickers. This is a way to differentiate yourself from other shops by using exclusive, custom artwork they won't find anywhere else. I idon'thave any specific links here to share with you, as I've never commissioned artwork before, but I would recommend checking Instagram and custom Etsy listings. These custom pieces can be expensive, so definitely don't jump in with the custom artwork.
Once again each list is not exhaustive. These are just shops that I found/ enjoyed using when I was making planner stickers many moons ago. This is just meant to be helpful and not critical or exclusive in any way!
If you have favorites that you use that weren't mentioned here, feel free to comment and let me know!
Thanks for checking in, and I hope to see you again soon!
Not using artwork, but real photographs for the full/half boxes. I'm not sure if creators use google images, or if there is another place recommended for getting photo images to use. Does that make sense?
Hmmm I'm not sure where they get them, but googling royalty free photographs should give you some sites to start off with.


KMS Solutions will support Code 25 with cybersecurity services. Credit: US Army photo by Michael L Lewis.
The US Navy has awarded a contract to federal government contractor KMS Solutions for cybersecurity services.
Under the deal, the company will be responsible for supporting US Naval Undersea Warfare Command Code 25 projects.
The range of projects includes assessment and authorisation, research, development, test and evaluation (RDT&E), as well as environment maintenance, and in-service engineer agent (ISEA) support.
KMS Solutions vice-president Michael Martino said: "KMS Solutions is pleased to provide Code 25 with these services and will bring a wide range of domain knowledge, mission experience, best practices, and next-generation capabilities to the navy.
The list of cybersecurity services being provided by the company will help in the development, assessment, modernisation, upgrade and sustainment of the US Navy's tactical and support systems.
KMS Solutions is a wholly owned subsidiary of US-based Subsystem Technologies and has been providing support to the Department of Defense (DoD) for more than 13 years.
In September last year, KMS secured a task order from the Naval Sea Systems Command (NAVSEA) and its Naval Undersea Warfare Center (NUWC) Division Newport under the US Navy's SeaPort-e programme.


Interceptive treatment is performed on young, growing children in order to deal with issues such as misaligned jaws, severely overcrowded or protruding teeth or to correct harmful oral habits as early as possible. Delivered between the ages of 7 and 9, treatment typically lasts between 8 and 12 months. It often makes later treatment much less complicated.
Moira Wong is a leading consultant trained orthodontist and specialist in interceptive treatment.
Moira recommends that the initial orthodontic evaluation should occur at the first sign of orthodontic problems or no later than age seven. At this early age, orthodontic treatment may not be necessary, but careful examination can anticipate the most advantageous time to begin treatment. This early treatment is aimed at preventing or "intercepting" more serious problems.
Early evaluation provides both timely detection of problems and greater opportunity for more effective treatment. Prudent intervention guides growth and development, preventing serious problems later. When orthodontic intervention is not required in the short term, an orthodontist can carefully monitor growth and development and begin treatment at the ideal time.
By the time your child is seven years old the first adult molars will have erupted, establishing the back bite. At this time, we can evaluate front-to-back and side-to-side tooth relationships. For example, the presence of erupting incisors can indicate possible overbite, open bite, overcrowding or "gummy" smiles. Timely screening increases the chances for a wonderful smile and the avoidance of braces during the teen years.


text:
TWENTY-SECOND EDITION
VIRTUAL (web-based) and IN-PERSON Options!
Contact Us about CQ Certification!
Want to Experience CQ
in action and hear Barbara speak?
AUTOMOTIVE SUPPLIER QUALITY CONFERENCE
December 11-12, 2014 Detroit, MI
ADVANCED PROFIT INNOVATION CONFERENCE
> Visit www.ChangeCatalysts.com
> Watch CQ webinar recorded with the Human Capital Institute
How can my team /organization develop our collective CQ to lead successful and sustainable change?Check out the CQ Certification Process, and email me at btrautlein@
Interested in having Barbara speak for your company or organization?
Visit www.ChangeCatalysts.com/
What's YOUR style of leading change?
Knowing your CQ (Change Intelligence) style can make all the difference for your ability to influence others and overcome resistance to change!
Just as each of us communicates, collaborates and handles conflict in our own unique ways, so do we each have our own style of leading change. And, just as we are much more effective in working with others when we understand ourselves and how we are similar and different than others - and can adjust accordingly - so we are much more confident and competent in influencing and partnering with others towards challenging goals when we understand the various change leader styles.
Our Change Leader style is comprised of our tendencies to lead with our Heart versus our Head versus our Hands. Powerful Change Leaders "start with the heart," "engage the brain," and "help the hands" move in positive new directions. Of course, none of us leads only, all the time, in every instance with the Head or Heart or Hands. We are each a blend of all three. It is this unique combination that represents our Change Leader Style. There are seven possible styles, depending on how strong you are on heart, head and hands.
If you're a Coach, you're all about Heart. You love engaging your colleagues whenever you get a chance, and you find great reward in supporting people around you as you all move through a change process.
If you're a Visionary, you are the one who's always looking forward to an inspiring future. Thanks to your Head focus, you have a gift for seeing opportunity and planning for new situations, and you tend to get excited about what lies on the other side of a change.
If you're an Executer, you focus primarily on the Hands. You like to get things done, and people know they can rely on you to not just talk but take action. Often your execution is backed up by comprehensive, step-by-step plans.
If you're a Champion, you use a combined strength in Head and Heart to get people pumped about a change. Like a Visionary, you see abundant possibilities for the future and, adding the people skills of a Coach to the mix, you're able to energize and excite your colleagues as you all work to bring about change.
If you're a Driver, you're strong on both Head and Hands. You see an enticing vision before you, and you use your executional abilities to drive toward that vision, laying out clear strategies and tactics along the way.
If you're a Facilitator, you focus on specific people and specific activities you need to support on a day-to-day basis to lead the change, thanks to your strong Heart and Hands capabilities. You know the tasks that need to be accomplished to make measurable progress, and you succeed in motivating others to work together on those tasks.
If you're an Adapter, you're about even on Head, Heart, and Hands. You can employ all three approaches as necessary, and you're generally flexible, politically savvy, and willing to collaborate with others.
The relationship between the seven styles can be represented as a triangle, which, incidentally, is also the Greek symbol for change:
We enhance our influence and impact when we learn how to shift our leadership strategy to more meaningfully connect with people of different styles. We all know the Golden Rule, "do onto others as YOU want to be done unto." To optimally partner with others through change, follow the Platinum Rule, "do onto others at THEY want to be done unto."
Depending on the circumstances, sometimes we lead in one way and sometimes in another. No style is better or worse, right or wrong. However, at any given time one style may be more effective in leading change. Awareness of our style can help us adapt to different people and situations and ultimately take action to become more powerful change leaders.
By building Change Intelligence, Change Leaders are able to overcome what looks like resistance, but is really either confusion over the goal (no "Head"), lack of connection to the goal (no "Heart"), or lack of tactics and training to partner together to work toward the goal (no "Hands"). That's CQ!
What to learn more?
Join our FREE
"Change Leader Styles" webinar
on November 20
from 1-2 p.m. Central time.
(Can't attend live? No worries!
By registering you'll receive a link to the recording
so you can listen at your convenience!)


Derby Fire & Rescue has been operating as a full-time city department since 2005 after more than 50 years of service from the volunteer department. Fire Chief Brad Smith came on board in 2004 to help establish the groundwork for full-time staff. In addition to the fire chief and deputy fire chief, there are 26 full-time firefighters, 13 part-time firefighters, and five volunteer firefighters serve the growing Derby community (pop. 24,000).
The department continues the tradition of outstanding service to the citizens of Derby by delivering fire protection, medical first response service, fire prevention education, and fire safety inspections at businesses and in the community. The department ensures the highest level of training needed to keep fire personnel prepared for any event. In addition, volunteer and part-time firefighters provide service in a backup capacity to full-time staff.
Learn more about the department in the 2018 Annual Report.


text:
Blog do escritor Luís Soares
Virá a morte e terá os teus olhos
John Koch (American, 1909–1978) - The Reader (c.1955)
John White Alexander - Repose,1895
Alexander, who lived in Paris during the 1890s, achieved international success with his studies of female figures gracefully posed in elegant interiors. In this example, the provocative facial expression and supple curves reflect the contemporary French taste for sensual images of women as well as the undulating linear rhythms of Art Nouveau. With its model decoratively attired in a sweep of white fabric, "Repose" was lampooned in a French magazine as a portrayal of Loïe Fuller (1862–1928), the American dancer famous for manipulating swirling folds of silk in her performances at the Folies Bergère in Paris.
Dahye Choi
From "It's Nice That":
For a lot of artists, the first brush with paint usually comes at an early age. This was not too dissimilar for Seoul-based artist Dahye Choi, who graduated from art college and "rarely thought about anything other than art." At this time, 2009, she was exhibiting her first solo show and worked across both illustration and painting. She thought that "without a doubt" painting was the best thing she could do – but little did she know that she would come to regret it.
Concerning Pollock
The Nerdwriter - How Art Arrived At Jackson Pollock
There's an overlooked reason for Pollock's fame. Even if you love him, you might not know the name of the man who made him famous.
Jackson Pollock is one of the 20th century's most famous artists. But do you know the critic who made his reputation?
Clement Greenberg is a well-known name in the art world, but not necessarily to art fans. However, he earned a reputation as one of the most influential art critics in the 20th century, whose legacy included the canonization of Jackson Pollock.
Abstract expressionist art needed vocal champions to support challenging, unique work, and Greenberg was the most powerful and vocal in his defense of the art and, in particular, Jackson Pollock. Greenberg went from tie salesman to intellectual in less than a decade, thanks to strongly worded arguments for a new artform. Jackson Pollock was one of his favorite artists, and the two spent time together socially as they simultaneously climbed in the art world.
Is Clement Greenberg the reason that Jackson Pollock is so famous? He's definitely a part of it — and understanding the role of Greenberg and critics like him can be a useful tool to understanding art in the 20th century.
Overrated is a series that takes a look at the things we all know — the books, the trends, and the ideas that have become iconic — and answers the question: "Why is this so famous"?
Vox.com is a news website that helps you cut through the noise and understand what's really driving the events in the headlines. Check out http://www.vox.com.
Subscribe to our channel! http://goo.gl/0bsAjO
Jarvis Cocker on Monet and Feist on Bruegel
Claude Monet - La Gare Saint Lazare, hosted at The National Gallery, London narrated by Jarvis Cocker
Discover why Cocker compares Claude Monet's La Gare Saint Lazare (The National Gallery, London) to an 80's horror movie and an ACDC concert, and listen to him explain why Impressionism is called what it is.
Find out more on https://g.co/ArtZoom Listen and keep your eyes peeled as iconic music figures take you on a tour of some of the greatest masterpieces of the world in Art Zoom. Zoom into La Gare Saint-Lazare here: http://bit.ly/2XiMBsN
Listen to more from Pulp: https://www.youtube.com/user/PulpVEVO
Pieter Bruegel the Elder - The Tower of Babel, hosted at Kunsthistorisches Museum Wien narrated by Feist
As well as telling us the story behind Pieter Bruegel the Elder's The Babel Tower (Kunsthistorisches Museum Wien), discover why Feist compares the renaissance artist and his contemporaries to the indie folk-pop duo Kings of Convenience and singer, songwriter and activist, Chance the Rapper.
Find out more on https://g.co/ArtZoom Listen and keep your eyes peeled as iconic music figures take you on a tour of some of the greatest masterpieces of the world in Art Zoom. Zoom into the Tower of Babel here: http://bit.ly/2XJHPRU
Listen to more from Feist here: https://www.youtube.com/channel/UCmZIr7Mf7kek8tFQOddI5DA
Jonathan Wateridge
Jonathan Wateridge's paintings are elaborately crafted 'non-events' that have the trappings of a real occurrence but for the most part are entirely fabricated.
A significant part of his work over recent years has been to reconfigure or re-make a given scenario or found image. This involves building full-scale sets and using performers to enact roles, within the context of the studio, in order to set up questions about the way we frame and understand notions of the real.
His work initially employed painterly realism as a 'default setting' by which to view the world, curbing any excesses of style to emphasise not only the often fleeting, banal and everyday quality of the scenes depicted but also the nature of their construction.
More recently, this has given way to an increasingly lyrical use of paint which explores the tension between the social dimension of the figuration and the more formal and expressive qualities of the work.
Shadow Head
Jenny Saville - Shadow Head (2007-13)
Human perception of the body is so acute and knowledgeable that the smallest hint of a body can trigger recognition.
—Jenny Saville
Daniel Richter, Tarifa, 2001
Clyfford Styll - 1953 (1953)
'My paintings have no titles because I do not wish them to be considered illustrations or pictorial puzzles', Still wrote. 'If properly made visible they speak for themselves.' In a letter discussing this work, he explained that the red at the lower edge was intended to contrast with and therefore emphasise the depths of the blue. He saw the yellow wedge at the top as 'a reassertion of the human context - a gesture of rejection of any authoritarian rationale or system of politico-dialectical dogma.'
Gallery label, November 2005
I'm out of here.
Illustrator Dean Rohrer has been playing around with an American classic. Using Photoshop, he has been taking the figures out of Edward Hopper paintings. His thinking is formal--do the paintings work when you take the supposed subject out? It turns out they do.


Alaska Campground Owners Association membership directory lists privately owned RV Parks, cabin vacation rentals, restaurants, fishing charters, adventure companies.
Find the Best Wasilla, AK Insurance on Superpages. We have multiple consumer reviews, photos and opening hours.
The Community Clean-Up program is designed solely for Borough roadsides, right-of-ways, and public lands. This clean-up program is NOT meant for private property.
Local Insurance Agents & Brokers in Wasilla,AK with maps, local business reviews, directions and more.
Car Insurance Wasilla, Alaska Agents. Jola Robbennolt At a plus auto insurance, our experienced insurance agents offer car, motorcycle, rv, Wasilla, AK 99654.


Spices are used in different forms: whole, chopped, ground, roasted, sautéed, fried, and as topping. They blend food to extract the nutrients and bind them in a palatable form Lighter spices are added last, and spices with strong flavour should be added first. "Curry" is not a spice, an exotic blend of a few spices in correct proportions to get delicious and different gravies.
Apart from adding colour, flavour and taste, consumption of spices provide infinite health and medical benefits.
This bright orange spice is great for adding color to your dish, since thousands of years, Ayurvedic medicine has used turmeric for a variety of health reasons- turmeric aids in helping to treat arthritis, heartburn, stomach pain, diarrhea, intestinal gas, stomach bloating, and loss of appetite. Turmeric is also used as a topical treatment for issues like skin inflammation, infected wounds, and ringworm.
Is one of the most traded spices in the world and are commonly found in many European dishes, often paired with salt. needs to be toasted before blending. For the best flavor, however, fresh black pepper can also be ground directly into dishes. Black pepper aids in digestion, congestion, an upset stomach and can also help to stop the bleeding on a cut when applied topically.
these green pods are used also in Chai—Indian tea. It can be used to counteract a number of digestive problems including, bloating, gas, heartburn and loss of appetite—treat bad breath and also as an after-meal breath freshener.
In cosmetic uses, cloves is found in toothpastes, soaps, and perfumes, Clove oil can also help with pain when applied topically, is very effective especially for toothache.
Helps regulate treatment for people with type 2 diabetes. The theory is that cinnamon increases insulin action.
Chillies (mirch):Your eyes may start watering just with the name of it, but you would be surprised to know that. They have been used externally to relieve pain and internally to cure anything from yellow fever to the common cold. The active ingredient in hot red peppers is a compound called capsaicin, which gives it that unique sting. Capsaicin triggers the release of endorphins in the brain, which has a pain relieving effect similar to that of morphine. Their high vitamin C content can also substantially increase the absorption of non-heme iron from other ingredients in a meal, such as beans and grains.
The most expensive spice in the world, saffron is actually more valuable by weight than gold, due to the fact that it is one of the most labor-intensive spices to produce. Saffron is an intense spice, and is used in small quantities, usually dissolved in warm water or milk before being added to dishes.
Though these spices provide innumerable benefits they should be used sparingly. The excessive use of spices in food can cause harm to the health. Try to make specific use of these spices. This will help you to make optimal use of the resources provided by nature. Strike the right balance and add some spice to your life.
These are a just a few of a whole big variety of spices used in Indian cooking !
This article has been provided by Delhi Durbar, a one of its kind, Authentic Indian Cusine Restaurant in Vientiane, Laos !!
21/01/2011 Stephan Comments Off on Nice Buns!