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Defence Policy
Meeting "Road to NATO Summit: Perspectives of Polish-Romanian cooperation"
Koncepcja działania satelity naprawczego DARPA. Ilustracja: Space Systems Loral / sslmda.com
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On 31st May 2016 the National Centre for Strategic Studies hosted a meeting "Road to NATO Summit: perspectives of Polish Romanian cooperation" with a special guest from Romania, Antonia Colibasanu PhD - partner, Regional Director for Eurasia at the US geopolitical analysis organisation Stratfor. Antonia Colibasanu PhD is also an Associate Professor at the Romanian National Intelligence Academy of the Bucharest University. The meeting was attended by experts from Polish think-tanks as well as representatives of the Ministry of Foreign Affairs and the National Security Bureau. The discussion was moderated by Adam Kowalczyk – Director of Analysis Division at the NCSS.
The meeting began with the opening speech by Antonia Colibasanu PhD in which she presented and assessed current security challenges facing Romania. Thereafter, the experts expressed their thoughts and remarks. Participants of the meeting addressed issues and potential approaches to the security challenges facing the Southern and Eastern NATO Flank. Furthermore, the issue of the Intermarium potential regional Alliance was raised and discussed at the meeting. The discussion was conducted under the Chatham House rules.
Romania is facing serious security challenges from both the South and East of Europe. Russia, due to its economic decline is becoming increasingly aggressive in its foreign policy. Furthermore, the current migration crisis is another challenge, which not only affects Europe as a whole, but is also rising to a high security threat in Bucharest. This crisis has to be resolved by the European Union on an institutional level. Moreover, the participants of the meeting highlighted the current situation in the Balkans as well as Turkey perceiving itself as a Southern European country rather than an Eastern European one as further concerns for Romania.. Lastly, it has been underlined that the United States continue to play the most significant role in Romania, even if it is perceived that there is a visible increase of German influence.
The participants agreed, that the Intermarium Alliance is a key factor in responding to the security threats which the Southern and Eastern Flanks must tackle. The experts underlined that strategic partnerships are necessary for securing and defending national interests of Poland and Romania, mainly because they provide a broader opportunity for future cooperation. Nevertheless, a number of issues remain unanswered, for example how to strategically connect countries of the Baltic Sea states and Black Sea, to take advantage of full operational capability or how do countries perceive achieving a fully operational Intermarium? These questions must be answered in the near future, while countries must define their common interests. Finally, a significant question remains of how countries should address Moldova and Ukraine, in terms of their potential participation in the Intermarium Alliance and whether Turkey should be treated as a connector or disruptor of this project?
Experts also assessed the position of Turkey and its main internal policies, which are problematic when it comes to the Intermarium. For instance, the issue of the Kurdish minority remains unresolved, while Turkey proceeds with its harsh politics towards the West. However, there were voices during the meeting that Ankara also recognises Russia and Iran as its main security challenges, therefore it is in its own interest to find common ground for the sake of cooperation with the West. The experts agreed that Turkey's main concern is Russia's role as a "peacekeeping nation" in the Caucasus region. Ankara could use NATO in order to block Moscow's actions in the region. One of the experts mentioned that Tukey's authoritarian direction is a significant problem as it creates destabilisation in the country rather than stability and predictability, therefore it would be difficult to include Turkey in the Intermarium initiative.
The discussion brought voices evaluating the possibility of changing the approach to core states forming the Intermarium. Some experts believe that the coalition should incorporate states from Norway to Turkey, in other words from the "Arctic to Aleppo", including strategic partnerships with Finland, Sweden and the Ukraine, which would play a significant role in the initiative.
Nevertheless, there were negative voices regarding the Intermarium initiative, as some experts perceive the project as not realistically operational (in terms of hard security) and believe that Poland should focus on the Northern countries.
The next conclusion from the meeting is that there is a significant potential for a further strengthening of cooperation, mainly in terms of hard security and "high politics", between Poland and Romania. The potential must be turned into real capabilities and capacities in upcoming years. Poland is spending over 2% of its GDP on defence of which 25% on modernisation while Romania is continuously increasing its military budget and undergoing significant modernisation processes, improving defensive capabilities. Thus, for instance, an important window of opportunity is surrounding the air space as both countries purchased F-16's, which seems to be a natural field of future cooperation. The main objective of this cooperation, should be the reduction of Russian influence in both Poland and Romania. These states have to play a greater role in reducing the Russian narrative of dependency of European states on Moscow. Lastly, experts underlined the challenge in terms of cohesion within the framework of the "Bucharest IX format" which must be resolved for the successful future cooperation.
Invited guests, also discussed upcoming US Presidential elections and how will that influence on the security of Europe, in particular Poland and Romania. Experts discussed the possibility of, so the called, "U-turn" in American foreign and security policy as well as the potential consequences of this change, for instance it might generate serious security threat to the European states as Russia could exploit this moment. Experts agreed that Poland and Romania must put all their efforts to further attract the US in order to intensify potential future political and military cooperation and US presence in the region. They also agreed that the new US reset policy with Russia is currently rather impossible to achieve. Poland and Romania should focus on the coming elections in France and Germany rather than the US elections. Elections in France and Germany may bring unexpected results which may change foreign and security politics of both countries.
Lastly, experts agreed that Greece may be a problem mainly due to its current economic state as its compliant to the Russian influence. Moscow can use and already has tried to use this situation to undermine the unity of the European Union and NATO by dividing European states. Regarding the Visegrad Group countries, participants agreed that the V4 states should at least present "passive support" in terms of regional politics towards security challenges, while not disrupting the current Polish and Romanian efforts to achieve security objectives.
Last but not least, in the perception of experts, Southern security challenges are not existential while Eastern Flank security challenges are existential, thus there exist differences within NATO members, which must be tackled and addressed during the Warsaw Summit.
Mateusz Krupczyński – NCSS Analysis Division
Adam Kowalczyk – NCSS Analysis Division (Director)
Defence24.pl


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Tag: The Danube
Drobeta Turnu Severin: Fin de Siècle architecture and Roman heritage in south western Romania
The Danube's Iron Gate gorge system separates the Carpathian and the Balkan mountain ranges, controlling the main waterway, and thus one of the important trade routes, between Central Europe and the Balkan peninsula. The city of Drobeta Turnu Severin sits immediately downstream from the Iron Gate and thus is excellently positioned to benefit from the traffic passing on the great river. Its history can be traced down to the period when the area was inhabited by Celtic and Dacian tribes, the place name "Drobeta" being probably, in my opinion, a Celtic origin toponym having similar roots with that of Drogheda in Ireland, which means "bridge of the ford". In fact one of the most audacious civil engineering and architectural master-works of the Roman Empire, the Emperor Trajan's bridge over the Danube (inaugurated in 105 CE), immortalised on the Trajan's Column in Rome, both built by the architect Apollodorus of Damascus, stood in the vicinity of the city at a place where the river has one of the lowest depths in the area, which tallies with the meaning of the word mentioned for the Irish case. The "Turnu Severin" part of the city's name came into use during medieval times and it means a northern ("Severin") located tower ("Turnu") provided fortification, originating probably in the old-Romanian language of early Middle Ages. An abstract depiction of the ancient Trajan's bridge is presented bellow on the reverse of a bronze Roman coin, sestertius (RIC 569-C), issued by the emperor to commemorate its inauguration.
Roman coin issued in 105 - 108 CE depicting the Trajan's bridge over the Danube, close to Drobeta Turnu Severin (Valentin Mandache collection).
After the fall of the Roman imperial rule in the region, Drobeta flourished again economically and as an urban centre comparable with the Roman times, only eighteen centuries later, in the reign of Prince, later King, Carol I of Romania (1866 -1914). That was the result of freeing the Danube navigation in the second part of the c19th both physically by the blowing up of the dangerous underwater rocks from the Danube's cataracts at Cazane, upstream Turnu Severin, and politically by wars against a dying out Ottoman empire, the erstwhile overlord of the region, and subsequent international treaties. Those circumstances allowed the navigation of large modern vessels on the river course, which allowed goods to easily travel from Vienna as far as the Aegean Sea or grains from the Wallachian plains to reach markets in the heartland of Europe.
Old warehouses (1890s - 1900s) that once stored goods from the Danube river trade, Drobeta Turnu Severin, south western Romania.
Drobeta Turnu Severin greatly profited from the important trading opportunities generated by its favourable geographical location and those auspicious political circumstances prevalent at the Fin de Siècle. A remnant of those glorious times is the large warehouse pictured in the photograph above, today left neglected as the region is currently adversely affected by the actual recession and government maladministration. The city was also endowed in that period with beautiful buildings, a very small sample being presented in the images bellow.
Little Paris style house, late 1890s, Drobeta Turnu Severin, south western Romania.
The usual architecture of those houses is the Little Paris style, which represents French c19th historicist styles, interpreted in a picturesque provincial manner in Romania from the "La Belle Époque" period.
Little Paris style house, dating from the late 1890s, Drobeta Turnu Severin, south western Romania
The edifices presented here are quite large by any standard and richly ornamented, more than positively comparable with the best houses in this style of the late 1890s Bucharest.
Neo-Gothic - early Renaissance style house dating from the late 1890s, Drobeta Turnu Severin, south western Romania.
There were also buildings in other styles as the one shown in the image above testifies, due to a diversity of increasingly sophisticated tastes among a very cosmopolite population that numbered Romanians, Germans, Serbians, Jews, Hungarians, Greeks, Italians and many other ethnicities.
Little Paris style house, late 189s, Drobeta Turnu Severin, south western Romania.
Turnu Severin, in 1906, together with the rest of Romania celebrated King Carol I's forty years of glorious and prosperous reign and eighteen centuries since the Roman conquest of Dacia (in 106 CE), a historical watershed moment that set into motion the formation of the Romanian people.
The bust statue of the Roman emperor Trajan, inaugurated in 1906; the cental park of Drobeta Turnu Severin.
As part of those celebrations, a bust of the emperor Trajan was inaugurated in the central park of the city, whose history and identity is so much linked to the events at the start of the second century of the Christian era.
The column shaft of the bust statue represnting the Roman emperor Trajan, inaugurated in 1906; the cental park of Drobeta Turnu Severin.
Trajan is also considered in the Romanian nationalist discourse and imagination as the founding father of the nation, a role shared with the Dacian king Decebalus whom he vanquished in two devastating wars. Those conflagrations represented the largest scale military engagements in Europe until the advent of the Great War, as stated by the historian Julian Bennett in his seminal biography of Trajan.
1906 Royal Jubilee Exhibition - "Expozitia Generala Romana" postcard decorated with Neo-Romanian motifs expressed in an Art Nouveau manner. (old postcard, Valentin Mandache collection)
The 1906 celebrations culminated with a great exhibition, "Expozitia Generala Romana", in Bucharest, where the country's achievements in arts, science and industry were presented to the wider public. The Neo-Romanian style, the new national architectural order has also been one of the main themes of that exhibition, seen in the graphic motifs of the postcard presented above, circulated with that occasion. The two personages whose deeds the country, including the people of Drobeta Turnu Severin, were then enthusiastically celebrating, the Emperor Trajan of the two millennia ago (on the left hand side) and King Carol I, were facing each other across an altar with the Roman She Wolf emblem inscribed on it, blessed by a woman figure personifying Romania, a veritable effusion of national identity symbolism, giving an idea about the ebullient atmosphere and pride felt by the people of that era.
The photographs containing examples of period architecture from Drobeta Turnu Severin were provided by Irina Magdalena Bivolaru, a native of the city and a keen reader of this blog.
I endeavor through this daily series of daily articles to inspire appreciation of the historic houses of Romania, a virtually undiscovered, but fascinating chapter of European architectural history and heritage.
Architectural Heritage, Industrial, Little Paris Danube, Eastern Europe, Fin de Siècle, History, Identity, Industrial, La Belle Epoque, Little Paris, Mehedinti, Modernisation, National Identity, Oltenia, Romania, South East Europe, The Danube, Turnu Severin, Victorian Era, Wallachia 1 Comment
100 years old Danube paddle steamer sold by the Romanian state for the price of a second hand car
"The Citadel" paddle steamer (1903) on the repair bank in Romania (Romania Libera, 28 July 2010)
In what looks like another brazen move by the corrupt Romanian officials, one of the most picturesque pieces of Romania's heritage, the Danube paddle steamer "Cetatea" ("The Citadel"), built in 1903 and used by the then European Danube Commission, has been sold in a so-called "public" auction for Euro 7,900, practically the price of a second hand car, to a grocer, a company probably linked with the gang infested scrap iron business or other unsavoury activities that are springing now up in crisis hit Romania. The story is detailed in the today edition of the newspaper Romania Libera. This is just another heritage loss, just as the continuous destruction of the country's architectural heritage, practically unnoticed or decried by a public that does not care about its identity after five decades of communist brain wash and subsequent two decades of Russian oligarchic style transition to a market economy. Romania's EU membership seems to be completely ineffectual in the face of these never punished broad daylight destructions and misappropriations of important pieces of European heritage.
Architectural Heritage Danube, Detruction of Heritage, Heritage Destruction, Paddle Steamer, Romania, Romanian Heritage, The Danube 2 Comments
17th c Transylvanian Mannerism ceiling decorations, found in Saxon houses from Kronstadt/ Brasov. They represent a very particular development in art in a culturally isolated region, a Protestant land surrounded and patronised by an Islamic power, threatened by a Catholic one and intertwined with the Balkan Orthodox world. The decorations somehow prefigure the Art Nouveau, of which Transylvania is so famous. #transylvania #saxontransylvania #kronstadt #brasov #renaissance #mannerism #southeasteurope #casedeepoca #valentinmandache

redpajama_set_name: RedPajamaCommonCrawl


In part 2 of this series, Host Tony Kramer continues his conversation with Jake Mauer, an agronomist with RDO Equipment Co., about the team's involvement with the Land Lab at North Dakota State College of Science.
To play this episode, look for Ep. 83 Field Trials at the NDSCS Land Lab Pt 2 in the podcast player below and select play.


Born and raised in Southern Germany, Claudia attended Regensburg University and spent a year at Wesleyan University in Middletown CT as an exchange student. She graduated in 2002 and holds Master's degrees in German and English literature and linguistics as well as a degree in Middle School Education. She is fluent in both English and German.
Claudia moved to Greenville, SC in 2007 and spent several years teaching German for Native Speakers for the German BMW students as well as German as a Second Language at Christ Church Episcopal School.
Having always had a strong interest in real estate, Claudia obtained her real estate license in 2014. Claudia Graupp-Sulak is a member of the Greater Greenville Association of REALTORS and is looking forward to assisting you in all your real estate needs.


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Jewish Blind and Disabled have provided that.
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So Tenants can live in their own homes.
So its Tenants could Live Worry-Free.
For a Flat ~ They'll have to pay.
Will Live Out their Lives in Peace.
So Please give this Cause your Rapport.


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Clitoral Stimulation Techniques For Intense Orgasms
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Even in these modern times, one of the most elusive bedroom challenges would still be giving a person with a vagina an intense orgasm. You see, most pornographic videos are focused on male arousals which leads to most people having less to no idea on how to stimulate (or even locate) the clitoris. This is also why most vulva owners rarely experience intense orgasms.
In this article, we'll help you be more "clitoris literate" and find the best way to give or have the most intense clitoral orgasm.
Clitoral Orgasm vs. Vaginal Orgasm
People with vaginas can experience orgasms in different ways which may be confusing for most. Aside from the fact that G-Spots may be located differently inside the vagina, some can only orgasm through clitoral stimulation. But, how does clitoral orgasm differ from vaginal orgasm?
Let me start with vaginal orgasm. This is a common notion of achieving orgasm through penetration and stimulation of the vagina. In the past, Sigmund Freud said that female orgasm is only possible by entering the reproductive tract. He even referred to those who orgasm through the clitoris as "infantile."
However, this was just a misogynist claim and was repeatedly proved wrong as research shows only 25-30% of women experience orgasm through penetration. Meanwhile, approximately 70% of people with a vagina enjoy orgasms through clitoral stimulation. This is what we call a clitoral orgasm.
The Stages of Orgasm
To understand how clitoral orgasm happens, you must understand the different stages of it first. The sexual response cycle has four stages which are excitement, plateau, orgasm, and resolution. You should note that the intensity and timing of each stage may differ from person to person. By understanding them, you and your partner can get a better sexual experience.
First Stage: Excitement
Excitement or sexual arousal is the first stage of orgasm. It involves physical and psychological responses to erotic stimuli. For people with vaginas, this usually includes dilation and elevation of the genitals. As a person gets aroused, the heart rate quickens, blood pressure increases, and fluids pass through the vaginal walls. This, in effect, makes the vulva swollen, wet, and expanded.
Second Stage: Plateau
The second stage in the sexual response cycle is called the plateau phase. This is when you feel intense pleasure and continue to feel it for a prolonged period of time. When the blood flow in the vaginal opening reaches its limit, it becomes more firm. At this stage, you will notice that breasts are enlarged and nipples are less erect. The clitoris is also pulled back against the pubic bone and may seem hidden.
It's a critical point in sexual arousal because it can bring about an orgasm if properly stimulated during this phase or lead to frustration if not properly stimulated during this phase.
Third Stage: Orgasm
Orgasm is the third stage of sexual response in which there are intense muscle contractions at orgasmic peaks (or climaxes). The intensity can vary depending on the individual's preference, but generally, a vaginal or clitoral orgasm lasts between 20-35 seconds. After orgasm, a refractory period ensues where there are no further erections or orgasms until this time period has passed (usually between 30 minutes to an hour).
Although some people don't experience vaginal orgasms, we are actually blessed with no recovery period, unlike males. This means that we can have further orgasms through repeated stimulations.
Fourth Stage: Resolution
Resolution is the fourth stage of the sexual response cycle when muscles relax, heart rate and breathing return to normal levels, and endorphins flood your system to produce feelings of well-being.
What is Clitoris and Where is it Located?
(picture: Clue)
The clitoris is a small, sensitive part of the female reproductive system. It is also often referred to as the pleasure center. In fact, it's so sensitive that many women have trouble reaching orgasm from vaginal intercourse alone. It also has about 8,000 nerve endings — twice as many as the penis!
But, where can you see the clitoris? This is a crucial question that I must answer especially because a lot of people fail to locate this part. As a matter of fact, a survey of British people showed that 37% of them, regardless of gender, don't know where the clitoris is.
If you're one of the people who don't know where it is, let me help you.
The clitoris is located at the top of the labia minora (the inner lips), just below where they meet at the top of your pubic mound. It's made up of three parts: The glans and shaft are external, while the crura (or roots) are internal.
This is also known as the tip or head of the clitoris and is what most people think of when they think of "clitoris." It's a small bulb-shaped part about 1 cm long that swells with blood during arousal. This is where most of the sensation is coming from.
This part extends inside the body and connects to the glans at its base. The shaft becomes engorged during arousal and may also experience some sensation during intercourse or manual stimulation. The shaft contains many sensitive nerve endings, but it doesn't swell with blood as the glans do, so it's not as sensitive (but it still feels good!).
Crura
These are two elongated folds that extend down from each side of the pubic bone beneath your outer lips and flank on either side of your urethral opening (where urine comes out). They contain nerve endings that respond to pressure, which is why they can feel good when they're stimulated during sex or masturbation.
Clitoral Stimulation Techniques
Yes, the clitoris is highly erogenous and the center of vaginal pleasure. However, you still need to remember that it is not a button that magically turns on a vulva owner. A lot of people think that simply poking or stroking the clitoris will bring its owner to extreme ecstasy. The truth is, you need to know the right stimulation and consistency techniques to give the best clitoral orgasm.
Here are some of the clitoral stimulation techniques that will guarantee extreme orgasms.
1. Communicate with your partner.
Now, let's start with the most obvious and crucial technique that everyone should know and practice in every sexual practice–communication and consent. The most sensitive part of the clitoris is the glans but it can be difficult to find especially if it is your first time (or second, third, and fourth time.)
The best way to locate the right spot of the clitoris is by asking for your partner's guidance. Let the vulva owner place your fingers on the perfect spot. You can even ask what intensity or way of stroking is the most pleasurable. Remember, clits may look different from others and it's definitely not shameful to ask. Trust me, your partner will appreciate you asking about it.
2. Give complete control to your partner
If you're still unsure where you should start after asking for guidance, you can also give your partner complete control. Cup their vulva firmly and let them hump or grind against it, thus controlling the rhythm and pressure. You can ask them to move their hips against your hand and demonstrate the movement that works best for them.
3. Opt for indirect stimulation.
Preference for clitoral stimulation may differ from person to person, so it is best to ask or test the waters first. If your partner finds direct clitoral stimulation too intense, you can opt for indirect stimulation instead. Start by stroking the clitoral hood or the sides of the clitoral shafts to stimulate the area around the glans. This can also work as a starter for those who are not that sensitive.
4. Utilize your surroundings.
Feeling crafty? You can use your environment to get you or your partner in an optimal position. Whether you use the headboards, countertops, or sofa backs is entirely up to your preference, comfort level, and creativity.
For instance, you can use your headboard by resting your or your partner's back against it and having the other person straddle the hips. For support, the straddler can grab the back and this would be the perfect position to keep the clit within reach.
5. Ride and glide.
One of the best tools for clit stimulation is your pubic mound and thighs. They are firm yet not hard which makes them perfect for the sensitive clitoris. To do this, you just need to get yourself or your partner into a seated or reclined position and ask the other person to slide up and down the pubic bone, thigh, or belly.
In my experience, it would be better if you use your favorite lube or oil to avoid the uncomfortable friction of the surface to your clit. The additional sensation will feel ecstatic with the wonderful smooth glide.
6. Reverse the ride.
The reverse rider is another position that offers one of the best clitoris stimulation. To do this, let your partner straddle you while you are facing the other way.
If you have a penis or a strap-on available, you can use it to penetrate and stimulate the vagina of your partner. While thrusting, your partner can put their hands between their legs and rub their clit. The mixture of the simultaneous stimulation will make you and your partner feel wild!
But if there is no penis or strap-on available, you can put one or more pillows under your partner's pelvis. The alteration of your hips' angle will be enough for both clit to come in contact and create a highly arousing friction with each other.
7. Play the "Clit Clock" game.
Another clitoral stimulation that you should try is the "clit clock." Despite its playful name, this is actually pretty easy to do but guarantees your partner unstoppable moans. To start, imagine that the clit is a clock with the top point pointing to the belly button as twelve, and the spot close to your vaginal opening as six.
8. Make a peace sign.
Who says the peace sign is only for taking cute photos? If you want to experience better clitoris stimulation, you can put your finger in a peace sign or V-shape and slide them up and down the outer or inner lips of the clit. Make sure that you put lots of lube because it won't be as pleasurable without them.
In this technique, you are stimulating the extended internal structure or the highly sensitive erectile tissue of the clitoris. It also becomes engorged, hotter, filled with blood, and pulsing.
9. Stay consistent.
Everyone knows that in making you or your partner orgasm, consistency is the key. Once you find a movement, rhythm, or intensity that feels best, make sure that you stay consistent with it. There is nothing more frustrating than building your plateau only to feel disappointed when the pace changes. Continue whatever you are doing, let it build up, and just let your partner orgasm uncontrollably.
10. Practice pleasure calibration.
Yes, we said consistency is the key. However, there are also some people who find pleasure calibration more enticing. You just need to find the most sensitive part of the clit and try various ways of touching and playing with it. Change the pressure, speed, rhythm, and angle to keep surprising your partner with each touch.
To avoid discomfort, you can ask your partner to have a safe word, sound, or action when you do something that doesn't feel good. As I mentioned, communication is the key.
Toys You can Use for a Better Clitoral Orgasm
There are tons of external sex toys and clitoral vibrator options on the market. Wands, suction toys, and massagers are great if you're looking to get off. Whether you're a beginner to masturbation or looking to add some variety to partner play, there are plenty of styles out there to help you reach the big O.
Suction Vibrators
As the name suggests, this type of vibrator uses suction and pulsing sensations to stimulate the clitoris and mimic the sucking portion of oral sex. Suction vibrators can make its user feel like they are being eaten out–the most glorifying feeling ever.
Unlike other vibrators, the suction vibrator focuses on the external part of your vulva, meaning your clitoris. It sends out various intensities of pressure waves that feel amazing.
If you are looking for a more versatile option for clit stimulation, you can try wand vibrators. There are various wand sizes, designs, functionalities, and materials available in the market and you can just choose the one perfect for your comfort and needs. Because they usually have long handles and large heads, you can comfortably alter positions when using them.
It is very easy to spot bullet vibrators in the market. Aside from being one of the best sellers, it has a distinguishable bullet shape. Despite its elongated design, it is meant for external erogenous zone stimulation (meaning generally for the clitoris.) Still, you can find different sizes and forms of bullet vibrators with different pleasure purposes.
While some look simply like a bullet, other types can accompany penis rings or dildos for dual stimulation and a better orgasm experience. There are also some that you can on your underwear.
Are you the type of lover who loves sharing experiences and pleasure with your partner? If yes, then having couples vibrators is perfect for you. It has a unique design that helps in stimulating you and your partner simultaneously. This vibrator can stimulate the clitoris while penetrating your vagina and vibrating against your partner's penis at the same time.
Oral Sex Simulator
Every vulva owners love oral sex especially when it's done right. If you are looking for a sex toy that makes you feel like being eaten out, you should try oral sex simulators like Honey Play Box's Adele. This toy mimics licking sensation of the most delicate part of your clitoris. It also offers various intensities and patterns that help you build up pleasure and explode into an intense orgasm.
If you want to give or experience an intense vaginal orgasm, it is crucial to be clitoral literate. You should know how to locate and stimulate a clit with your body parts or sex toys. Despite being small, it actually resembles the tip of your pleasure iceberg. By following the techniques I mentioned above, you can assure a better sex orgasm experience.
Dirty Talk 101: A Complete Guide To Dirty Talking During Sexy TimeBack to Pleasure TipsMoaning during Sex: The Good, Bad and the Mind-Blowing
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Jerome Ropati is a professional rugby player who plays for the New Zealand Warriors team in the National Rugby League competition played in Australia. Before joining the New Zealand Warriors team in the year 2003, he played for the Marist Richmond Brothers till he made his first grade debut in the year 2003. Born on 14th July 1983, he has been re-signed by the New Zealand Warriors team for a 1 year period which extends up till the end of 2013 season. The 176 cm tall player prefers to play in the centre position in his teams formation on the field. He can also play as the five eighth based on his teams need for the match. Weighing 94 kilo grams, he has played 130 games so far scoring 49 tries in them.
This entry was posted in NRL and tagged Jerome Ropati, New Zealand Warriors. Bookmark the permalink.


I live in good old Great Britain, United Kingdom, England.
I have been a massive fan of this scanlation blog for while- mostly because you guys do Harlequin stuff which I can't seem to get enough of.
I will also admit I read a lot of Harlequin stuff though I really have only one favourite which I would to see get turned into a Manga.
In fact it's called "Mistress for a weekend" by Susan Napier so if they have done one.....please point me in the right direction.
I thought it would be a long shot for the book to be made into a manga so I am really surprised and happy to hear it has been.
Hopefully one day I'll get my hands on.


Day 3 of the Blogger's Beauty Brawl is Eyeliner and for this I have chosen to review the Glo & Ray Longwear Precision Liquid Eyeliner.
The Glo & Ray Longwear Precision Liquid Eyeliner is a liquid formula (obviously!) in a felt tip style pen. This means it is great for precise application. I found that this easily glides along my eyelid to create a smooth, neat line. It doesn't drag across the skin and the felt tip style applicator ensures that the perfect amount is applied. The actual eyeliner itself is a deep, dark, pigmented black – just how a black should be! I have scored this an 81 out of 100.
The packaging is pretty much what you would expect for this type of product – sleek black tube, white logo/writing and a felt tip style nib. There's not really much else to say about it except that it works! I have scored the Glo & Ray Longwear Precison Liquid Eyeliner an 85 for Packaging.
You can find this eyeliner on Glo-Ray.co.uk for £6.90 and in my opinion that is just about what I'd expect to pay. I think this is great value for money and for that reason I have scored this an 87.
Now head over to www.kimberlyjessica.co.uk and see what Kim chose and what she thought of it!
With thanks to Emma Drury, https://emmadrury.com/ who has very kindly provided all the graphics and branding you will see throughout the Brawl.


Check out the Pairings for Round 4!
68 Logan, Steven John vs. Poling, Zachary C.
174 Salgado, Ramiro vs. Quigley, Joshua J.
311 Barnett, Richard Gabriel CA vs. Steinhauer, Joseph T.
336 Riddle Jr., Stephen Dennis vs. Vivanh, Duncan P.
409 Xiong, Tony Na vs. Overbeck II, Douglas P.
464 Brown, Anton Dominick vs. Gagliardi, Joseph R.
480 Flores, Blair Edward G. vs. Lin, Ming Y.
539 Khoo, Jarrod Christopher vs. Goodrum Jr., Kevin H.
588 Mendoza, Mark A. IL vs. Grossman, Matthew B.
596 Hattie, Kyle Jon vs. Elmer, Dayton E.
614 Asta, Kory Richard vs. Puracchio, Nicholas J.


Today's POS* has a strong stylistic reminiscence of the phony credit card overdue notices described here and here. The crook's English isn't so good, and he obviously doesn't have an English spelling checker.
On July 26th, 2011 Hotel made wrong transaction writing-down from your account for an overall amount of $1944.
For noncompliance of the service contract this Hotel was divested accreditation in Moverick Company.
In the attachment you will find expense sheet with the sum of wrong transaction error of transaction.
As Company is not responsible for money transactions and acts as intermediary you can seize the court directly to return the funds from the Hotel.
Unfortunately, at this hour, the Trojan-laden attachment has extremely low coverage by antivirus applications (only 4 of 42 at VirusTotal's test). Recipients' greed for a free couple of grand may get the better of them...and the Trojan will do the same.
This message happened to really catch my eye because I went to college in Madison, Wisconsin, a city I'm truly fond of. I haven't been there in over ten years, so there was no other connection between the message and myself. But it does point to the fact that coincidences do happen frequently in the high-volume spam world. I suspect the template used for this malware bomb uses a placeholder for the city, and different recipients will see different cities in their versions. Although I have been around this country quite a bit, I can safely say that I have not been to the majority of cities. The spammer just got lucky this time, and I absolutely do not feel threatened that he or she is personalizing the message around my life's history.
I think it's good to be paranoid with respect to unsolicited email ("they" really are out to get you), but the chance that they're targeting you, specifically, is next to nil.
Following up on my earlier post about so-called Credit Card Overdue Notices, my email addresses have been hit by a new blast with slight variations of Subject: and message body. The sentiment is the same, however: you're supposedly late for some financial payment, and you have two days to open the attached file to get the details and settle the score.
Your Credit Card is one week overdue.
The details are attached to this e-mail.
Please read the financial statement properly.
If you pay the debt within 2 days, there will be no extra-charges.
In 2 days $25 late fee and a finance charge will be imposed on your account.
Please do not reply to this email, it's automatic mail notification.
The attachment for this particular email was titled Financial_Statement#98165.zip. Inside that zipped archive is a real oddball: a .cpzg file. This is a compressed Unix-style archive, indicating that it may be targeting Mac OS X and Linux users, but I think WinZip can also open these things.
In any case, if you try to open this file and have a problem, that's a GOOD THING! You've saved yourself from installing a Trojan loader onto your computer. Delete the email message and get on with your life. If you're late with a payment, you'll learn via snail mail soon enough.


From Heathrow Terminals 1, 2 or 3: - Take the 285 Bus (RailAir Link), available 24 hours a day, from the central bus station to Feltham station. - The lodge is just 200 yards from the station. From Terminal 4: - Take a bus (various routes available) to Hatton Cross station. - Take bus route 90, 285 or 490 to Feltham. - The lodge is just 200 yards away from the station. By Train: From Waterloo Station: Take a South West train to Feltham (travelling time approximately 20 -25 minutes). Feltham station is located 200 yards from the lodge. - Leaving Feltham station, turn left up the hill over the railway bridge. - Come further down the follow-up to the traffic junction; the lodge is clearly visible 20 metres just across, to the right-hand side of the road.


Huddersfield to Gatwick: IMPORTANT INFORMATION – PLEASE READ!
Heathrow Gatwick Cars suggest to Pre-Reserve Today!
You should know that every mini cabs service booking really should be purchased from the web-based store or office team. to make sure traveller private hire and chauffeur insurance policies are genuine; that's based on the TFL taxi & Private hire (Gatwick Minicab) rules. the Airport taxi Huddersfield driver ought not to take the transportation reservation direct aided by the traveller's. while avoiding to inform the Company in order to record and log the reservation. To carry-out the booking take the time to pre-order airport taxi Huddersfield to Gatwick on-line! or merely communicate with our very own representative's over the phone regarding assists.
Call Us Today | Gatwick Meet & Greet Services Attainable!
After your booking has been received, you shall be sent a confirmation e-mail in a matter of 12 hour's. (6 hour's for instant booking's).
This confirmation will summarize your LGW drive entirely, including the total fixed price, the reservation reference No. and payment received with thanks. Final yet not least, strategies to meet your TPH chauffeur. Remember that the above prices are Set cost per Vehicle, Not for each Individual commuting. "No Huddersfield to Gatwick taxi Meter" # "No Hidden Cost's". no matter what the route or even time obtained from Huddersfield to airport Gatwick, West Sussex RH6, U.K location.


text:
Cato Simons (Groningen, 24 januari 1878 - Amsterdam, 18 april 1967), bekend geworden als Cato Culp, was een Nederlands zangeres en actrice. Ze was soubrette.

Ze werd geboren binnen het gezin van broodbakker Elias Simons en Helena Culp. Helena Culp was tante van Julia Culp, Betsy Rijkens-Culp, Betsy Culp en Juliette Culp. Een aantal van Helena's  broers waren musicus bij De Harmonie in Groningen. Zelf huwde ze humorist Martin Kempinski, die in 1926 in Hamburg overleed. Ze overleed in De Joodse Invalide in Amsterdam. Ze werd begraven op de Joodse begraafplaats in Muiderberg.

Ze was actief binnen het variété en zong in die hoedanigheid ooit samen met Greetje Kauffeld. Ze trad vaak op in het Salon des Variétés in Amsterdam (Amstelstraat). Haar tante Emilie Culp was eveneens variété-artieste.

Nederlands zanger

redpajama_set_name: RedPajamaWikipedia


Check out our video above to see how easy it is to make these frozen raspberry yogurt snacks!
One of our all-time favorite and popular snacks readers love has been our strawberry yogurt bark. We took this same idea and made bite-sized frozen yogurt covered raspberries! You only need two ingredients to make this refreshing and healthy kid-approved snack.
Step 1. Place yogurt on a flat plate and skewer your raspberries. Let the kids help skewer the berries to get them involved in the kitchen!
Step 2. Gently roll the skewer in between the yogurt to get an even coating. Kids can also help with this step.
Step 3. Line up your skewers on a shallow pan so the yogurt doesn't touch the bottom. It's helpful to also move the berries a bit apart with another skewer before freezing so they don't all get stuck together.
Step 4. Place your pan in the freezer until frozen, at least an hour.
Step 5. Remove from the freezer and let them stand for about 5-10 minutes before gently popping them out of the skewers.
Enjoy your refreshing and healthy raspberry snack! This is a fun way to get kids eating more fruit and is a delicious summer treat. You can try this with other berries if you'd like. The kids couldn't stop popping several raspberry bites into their mouth.
What are your favorite berry snacks? Check out more easy 3 ingredient or less snacks for kids!


Removing old dams helps to restore migratory fish, clean water, and recreation.
Since the 18th century, dams constructed along the Millstone and Raritan Rivers have blocked American shad, striped bass, herring and other fish from swimming upriver to reproduce. Although these dams are relatively small and may seem insignificant, they prevent fish migrations and can also have a pronounced negative impact on water quality by blocking water flow, trapping sediment, and changing in-stream habitat. The dams can also be very dangerous for recreational users of these rivers, who can become trapped in the hydraulic jump at the base of the structures and drown.
Many low-head dams are now obsolete and crumbling before our very eyes, so it's a good time to remove them from our rivers. In 2008, the Watershed launched an effort to remove the Weston Mill and Blackwells Mills Dams on the Millstone River. We've completed feasibility studies and hydrologic analyses, secured a number of required permits and advocated with NJDEP and others to make this a priority.
The Watershed is a partner in the Raritan Basin Fish Passage Initiative. Since 2011, three dams have been removed from the Raritan River, restoring more than a dozen miles of migratory fish habitat and providing passage from Raritan Bay to the Millstone River for the first time in more than 80 years.


Is It a Mistake to Diagram Your Own Processes?
Resolved Is It a Mistake to Diagram Your Own Processes?
A point brought up at last week's [url=http://bpmandcasemanagement.com/]BPM and Case Management Summit[/url]: Is it a mistake to try to diagram your own processes? What do you think?
As a business owner, your processes are your children. You should get to know them intimately. Yes, you will occasionally need the advice of experts(and capital BPM can provide those experts ;), but you really should spend time with them and know them inside and out.
Diagramming your own processes is by itself an interesting question; it actually implies that the process has an owner... Which is then again a good thing :-).
I was diagramming processes in early 70s as auditor and found fraud inefficiencies etc; truly revealing! Now with next generation software which supports BPM the "diagram" is the application back to basics how business really works!
If you see a reason to model your processes, you should always do it yourself.
But actually I am writing a boring story about this subject for Linkedin. It's too long to post here. Hopefeully will be ready this week.
In a nut shell; a process model is not 'a small version of reality' and it misses the dynamics of execution. A thing you definitely need, in my opinion, to understand wh y a process doesn't perform.
So, the main question still remains; why spend the time, money and effort on modeling your processes?
If you're not sure. Don't do it.
By diagramming your own processes, you have no other choice but to analyze them and really understand how they work, which individuals are involved, etc.
Translating a process into a diagram can be very hard because you have to see the main picture and simplify the whole process. Sure, it's easier if someone else does it but if you are able to achieve a good diagram, you will understand which aspects of the process are vital and which ones don't. Later one, if you have to explain the process to someone (a new employee, client, etc.) you will recognize what is the core of the process and which aspects you should emphasize on.
If you need someone else to explain your business to you, something isn't quite right.
Of course you can ask for help from a consultant or other experienced employees. Be sure to use a diagramming language that is well known and facilitates the hard steps. The most common one is [url=http://www.flokzu.com/en/documents-and-processes/bpmn/]BPMN[/url].
It's typically never a mistake, the resulting visibility, sharing of knowledge and revelations about, "do we really do that" are invaluable. However organisations must have a specific goal in mind, ideally a burning platform, time and budget. Process mapping just for the sake of it it can be a huge and costly effort and in the past these diagrams lived on a floppy disk or worse still in a paper file on a shelf, gathering dust and quickly forgotten. As Walter says with cloud based repositries there is at least the capability to share more widely, maintain and update maps more easily. BPMN also means that we have a shared language for defining and reading maps which makes them truly a global asset.
However going back to constraints unless an organisation has a specific business objective, it can be meaningless exercise, mapping the entire organisations proceses just for the sake of it can be career limiting. One organisation I've worked with recently is using Blueworks live as the enterprise tool, with BPMN the enterprise standard. The business objective is to create a library of processes to identify the low hanging fruit and move on to redesign onceall the processes are mapped This initiative has senior sponsorship but what it lacks, in my view, and therefore still likely to fail, are some early successes.
I would suggest breaking up any enterprise mapping initiatives into discrete projects, map an area and then move immediately to redesign / automation initiatives picking off the low hanging fruit. Ohterwise the endless mapping, showing no results quickly becomes a chore with little to show for your efforts. The question will soon be asked, what's the point and when the sponsor, moves on the intiative will most likely be axed. However,if you are able to show early and repeated successes, no matter how small, there is a much stronger case for the continued effort.
diagramming my own processes, including operational ones - full BPMN 2.0 compliant, including boundary events, role modelling and data modelling. And then I deploy them, just for validation sake, onto my process engine. Those processes that can be contained only to my process engine domain (so excluding processes that span across systems - I am not ready for that) get to see the light of day on the company intranet as full-fledged web applications, accompanied by communication of new process and full verbatim description of objectives, roles, and process steps.
. But then again - I'm not perfect.
Even if your modeling "language" is only readable by you, you always can specify them better after knowing your processes.
, convincing (not forcing) people to use them.
(not threats), if you have modeled them at the first time.
Of course, this all is even more powerful if you use a BPM Suite providing automatic "model to implementation" capabilities. If it is the case, you can execute several improvement cycles (model, automate, measure, and start again) quickly.
And yet we've had so many here and elsewhere say it's a waste of time, don't do it. Including, I think (going to have to go rummage back through archives now) a couple of respondents to this thread who have poo-poo'ed it in the past. This should be fun.
In any event, as one of the presenters from #BPMCM15 correctly pointed out last week, they did it because they didn't know what they had and needed that insight before undertaking any initiative to make things better.
manner is a good thing.
One would assume that the exercise was being done as part of a larger project to improve efficiency in the areas of interest. Given that assumption then a collaboration between the process users, management and process improvement experts to create a map between where you are and where you want to go has worked best for us.
Having the customer initially attempt to map their processes gives us a good starting point. This often allows the customer to see that many of the people involved have viewpoints that vary greatly as to how the process works. Having a process consultant help the team uncover exactly what is happening today also helps determine what changes need to be made to reach the desired process state.
This is an important step in the Business Process Management.... it brings acknoledgement about the execution of the process, it brings alignment of the people involved in the operation and clear meaning of why the process is executed... as stated by some of us here.... the diagram must be clear and must represent the reality of the things...moreover, the diagram modeling, must involve experts of the execution of process to increase the knowledge of some aspects that one can not understand alone and also to engage the team and make them feel as part of the BPM's effort.
Absolutely fascinating answers to another deceptively simple question.
whenever we look at as-is. Reality is messy and Platonic or Soviet-style top down modelling can only take one so far.
2. Re "You", imagine the same question applied to accounting.
Should you or I do our own books? For sure all business people should understand accounting. But right now I'm with my accountant for year end; this is also a good thing. Lots of implications. BPM applies to "you" differently depending on your role as developer, process jockey, business analyst, business executive, C-level etc.
Everyone will eventually understand process modeling and process mining etc., just as everyone understands debits and credits and receivables and cash flow and days sales outstanding. But not everyone can design a chart of accounts appropriately or close the books or fix an accounting error.
1. The documentation process will make development personnel more knowledgeable about the enterprise's business. Users often complain that the systems people are ignorant or naive about the business, and usually there is some justification in this complaint. The process of capturing current systems will educate Systems Engineers in the business of the company.
- What information is being produced.
- Who is using the information and how.
- What data resources are being used (data, records, files, inputs, outputs).
- What processing is being executed, and what is not.
Quite often, user personnel do not use existing systems simply because they do not understand the purpose of the system or how it is to be used. If a system has been properly documented, perhaps only a few modifications are required as opposed to a major new development effort. Unless we understand clearly what the old system is doing, how can we design a new system to replace the old? How can we plan the conversion from the old to the new? Most of the current system contains resources that will be reusable for the new system. Data, records, files, inputs, outputs - most, if not all of these can be reused in systems development.
Weaknesses and misusages of current systems will also be uncovered. Because of inadequate documentation, it is not unusual to see a good system be misinterpreted by users, including operations personnel. As a consequence, the system is only partially utilized and the benefits not fully realized.
3. Programs and files which only serve the purpose of unnecessarily occupying computer storage space can be identified and removed.
Capturing current systems can be a huge undertaking. A single company can have hundreds of systems and sub-systems, and thousands of procedures and programs, some of which are very old. It is important to remember that the intent here is to ONLY IDENTIFY AND DESCRIBE THE CURRENT SYSTEM, NOT TO CORRECT DEFICIENCIES. Quite often, there is a temptation to try to correct an obvious problem at this stage. As a consequence, the task of capturing current systems takes longer and longer. When errors or problems are spotted they should be documented as future Modification/Improvements and not corrected as part of this effort.
How much definition is enough? Ultimately it is based on the organization's needs. No two companies will approach the problem in the same way. Their requirements will vary. However, simplicity is recommended when describing the various information resources.
Capturing current systems is an exercise in reverse engineering. Whereas, system design is a top-down effort, current systems analysis begins with an examination of the procedural flow and works up and down the system hierarchy.
What systems or sub-systems do you begin with? Start with those that provide operational information - those that are at the heart of the business operations. Those parts of the systems that provide policy and control information can be delayed until the operational systems have been captured, since they will require the same data created in the operational systems.
A significant challenge addressed by both case management and (warning: shameless plug) Process Timeline is precisely that not all processes are diagram-friendly. Indeed, a key failure of BPMN and related standards is that they assume otherwise. Processes are often more easily modeled as checklists, or workback schedules, or Gantt-style project plans, or perhaps even in other ways we haven't really thought much about yet.
By the time you've decided to diagram your process, therefore, you should first have considered the question of whether a diagram makes sense in the first place.
This question is phrased in an interesting way--it's asking if an individual should diagram his/her own processes. The pitfalls of diagramming a process alone are numerous. You are in danger of getting lost in the weeds, becoming paralyzed by detail, or creating a hopeless spaghetti monster of a diagram that only you can decipher. You could also fall prey to skimming over necessary details, over-simplifying multi-step actions, forgetting possible alternatives, or just having limited knowledge of what "actually" happens each step of the way. Is it a mistake to undergo the exercise alone, regardless? Eh, probably not. Just thinking about what's going on and why is a valuable exercise.
Diagramming processes for the purpose of documenting what exists is best done by a group of SMEs who are intimately familiar with most, if not all of the steps. If nothing else, they can confirm with each other that the as-is process is truly understood and clearly identified so that more than one person can follow it. To identify improvements to the existing process or if the process can/should be removed/replaced/revamped, a group of people with varying ranges of knowledge (of an existing system) should participate in the process analysis that will likely generate a new diagram. Having non-SMEs participate in the analysis will provide fresh points of view that are not immersed in the current process. They will be able to ask questions that reveal options and possibilities for improvements that may not occur to someone "on the inside."
- you cannot be impartial / avoid politics.
It is actually a mistake to do any kind of business if any of those are true.
Everything you do more than once is a process.
Working it through - whether in a process diagram, decision tree or timeline - will help you see where you are doing it wrong. It is invaluable and anyone who doesn't have their own processes mapped is deluding themselves that they're in control of their business.
But we've been trained to see the diagram as the endgame, not the first iteration.
We draw our pretty diagram - perhaps even have a razzmatazz session onthe whiteboard - then the meeting finishes and everyone goes away thinking - "Done that, what's next?"
The result is that we fix the process in time and make it impossible to change. We've just left the future of our business, quite literally, on the table.
What should the process be doing? What could it do? And why isn't it?
Where has it been optimised to the detriment of other processes? Where has it accepted other processes compromising its speed or deliverables?
Why are the compromises being made? And what can be done to remove them?
We can get lost in our own metrics and think we're doing the right thing, while actually we are haemorrhaging customers, giving away profit or alienating users. We need a rounded 3D view, weighting soft factors as well as hard ones.
From this we can create a 4D model, not just a 2D diagram.
It can be seen from a host of different viewpoints. It has a timeline.
Now we can draw the real process diagram.
One which takes where we are and draws a line to where we want to be.
Which works out what metrics we need to measure and how those change over time.
Which allows us to constantly revisit and revise plans in the light of new stats.
A Dynamic Process to reflect a dynamic business.
In some enterprises everyone sees the same process differently and all departments understand an end-to-end process differently. In other (rare) enterprises the work is already properly planned and it is ready to be expressed as processes.
1) within a small group: processes may be done by process owners; inter-groups: processes must be done by an architect. See last three illustrations in REF1.
2) teach people to use process patterns – see REF2.
3) understanding of process "nature" of an enterprise or an organisational unit always helps: straight-through processes and ad-hoc work must be modelled differently.
Is it a mistake to send your own emails or create your own documents?


text:
Pyoderma gangrenosum – a review
Uwe Wollina1
Pyoderma gangrenosum (PG) is a rare noninfectious neutrophilic dermatosis. Clinically it starts with sterile pustules that rapidly progress and turn into painful ulcers of variable depth and size with undermined violaceous borders. The legs are most commonly affected but other parts of the skin and mucous membranes may also be involved. Course can be mild or malignant, chronic or relapsing with remarkable morbidity. In many cases PG is associated with an underlying disease, most commonly inflammatory bowel disease, rheumatic or haematological disease and malignancy. Diagnosis of PG is based on history of an underlying disease, typical clinical presentation, histopathology, and exclusion of other diseases that would lead to a similar appearance. The peak of incidence occurs between the ages of 20 to 50 years with women being more often affected than men. Aetiology has not been clearly determined yet.
The treatment of PG is a challenge. Randomized, double-blinded prospective multicenter trials for PG are not available. The best documented treatments are systemic corticosteroids and ciclosporin A. Combinations of steroids with cytotoxic drugs are used in resistant cases. The combination of steroids with sulfa drugs or immunosuppressants has been used as steroid-sparing modalities. Anti-tumor necrosis alpha therapy in Crohn's disease showed a rapid response of PG. Skin transplants and the application of bioengineered skin is useful in selected cases as a complement to the immunosuppressive treatment. Topical therapy with modern wound dressings is useful to minimize pain and the risk of secondary infections. Despite recent advances in therapy, the prognosis of PG remains unpredictable.
Pyoderma gangrenosum
Definition/Diagnostic criteria
Pyoderma gangrenosum (PG) is a primarily sterile inflammatory neutrophilic dermatosis. It is characterized by recurrent cutaneous ulcerations with mucopurulent or hemorrhagic exudate. These very painful ulcers present with undermined bluish borders with surrounding erythema. In many cases, PG is associated with inflammatory bowel disease, rheumatic disorder or neoplasia [1–3].
Powell et al. [4] suggested a classification of PG into four major clinical types [see Table 1].
Table 1 The different clinical types of PG
Accurate epidemiological data on PG are missing. The peak of incidence occurs between the ages of 20 to 50 years with women being more often affected than men [2, 6]. Cases in infants and adolescents account for only 4% of PG. PG in elderly people has occasionally been reported [7]. The general incidence has been estimated to be between 3 and 10 per million per year [8].
PG occurs most commonly on the lower legs with preference for the pretibial area [Fig. 1 &2]. PG has been reported on other sites of the body as well, including breast, hand, trunk, head and neck, and peristomal skin [Fig. 3 &4]. Extracutaneous manifestations include involvement of upper airway mucosa, eye [9–12], genital mucosa [13], sterile pulmonary neutrophilic infiltrates [14] or spleen infiltrates [15], and neutrophilic myositis [16]. Sterile cortical osteolysis has been observed adjacent to PG ulcers as another extracutaneous manifestation of the disease [17].
Acute rapid growing pyoderma gangraenosum with undermined violaceous borders.
Postsurgical pyoderma gangraenosusm [a] before treatment; [b] after immunosuppressive treatment with oral prednisolone and mesh-graft transplantation.
Ecthyma-like pyoderma gangraenosum.
Peristomal pyoderma gangraenosum in ulcerative colitis.
The development of PG is a feared complication after breast surgery and other surgical procedures [18–20]. It seems to me that areas rich in subcutaneous fat tissue bear a somewhat higher risk than others but systematic investigations in this field are missing.
The ulcer starts as a follicular pustule with rapid growth, tissue necrosis and enlargement of the area. The surrounding skin is erythematous with infiltration end oedema. The ulcer borders are typically undermined and violaceous or bluish [Fig. 1]. The ulcers develop a purulent cover, which rapidly becomes malodorous due to secondary infection. A strong sensation of pain often is associated to PG [1, 2, 10].
In larger series, about 50% of patients show an underlying disorder. Ulcerative colitis is found in 10–15% of cases. Another associated disease is Crohn's regional enteritis with a frequency close to that of ulcerative colitis [2, 21, 22]. On the other hand, less than 3% of patients with Crohn's disease or ulcerative colitis develop PG [23, 24]. Hepatitis C, seronegative rheumatoid arthritis, spondylitis, and a broad spectrum of lymphoproliferative disorders including monoclonal gammopathies, leukaemia, lymphoma, and myelodysplastic syndrome have been described in association with PG [2, 4, 25, 26].
The PG-ulcers associated with arthritis seem to have a poorer prognosis than others. In a study covering 2 years 78.9% of PG-ulcers in general healed versus only 23.4% in arthritis-associated PG [27]. In such cases PAPA syndrome has to be considered [28]. PG involvement of the hands shows a higher percentage of lymphoproliferative than chronic inflammatory bowel disease [29].
PG is a typical clinical presentation of the PAPA syndrome also known as familial recurrent arthritis [28]. The autosomal dominant inherited disease is characterized by nonaxial destructive arthritis, severe cystic acne and PC. PAPA syndrome is caused by mutations in the PSTPIP1 gene on chromosome 15 involved in regulation of inflammatory response [30].
PG can arise as a consequence of drug therapies. Recent examples of drug-induced PG include compounds such as propylthiouracil [31], pegfilgastrim – a granulocyte-stimulating factor [32], and gefinib – an inhibitor of epidermal growth factor receptor [33].
Etiology and pathogenesis
PG was initially thought to be caused by bacterial infection in the immunocompromised host [1]. Fulbright et al. [20] hypothesized that PG results from an aberrant immune response to yet unidentified factors. Depositions of proteins in skin vessels in PG lesions have suggested an Arthus-like reaction [34]. Since inflammatory bowel disease is the most common underlying disorder, cross-reacting antigens in the bowel and the skin could be responsible for secondary cutaneous manifestation [2].
Cellular analysis in PG demonstrated aberrant integrin oscillations on neutrophils and aberrant neutrophil tracking of patients with PG [35, 36]. Pathways to protect the epidermis from neutrophil infiltration seem to be insufficient in PG resulting in tissue necrosis.
Diagnosis of PG relies on clinical signs first and is supported by biopsy for histopathology. Knowledge of the patient's history for possible underlying disease and specific investigations based on that background are necessary. Therefore diagnosis is made by exclusion of other possible disorders. No laboratory parameter for PG is available. The histopathology of PG is nonspecific and changes with the stage of lesion. The initial lesions show a deep suppurative folliculitis with dense neutrophilic infiltrate. In about 40% of cases, leukocytoclastic vasculitis is present. PG with [necrotizing] granulomatous inflammation has been described [3, 34, 37]. These reports illustrate the difficulties of a diagnosis based solely on histopathology since concomitant occurrence of PG and systemic necrotizing vasculitis has been observed.
Six disease categories may imitate the clinical appearance of PG [38]:
(a) Vascular occulusive or venous disease including calciphylaxis which is particular painful and rapidly evolving.
(b) Vasculitis. That is a particular challenge when PG develops in a patient with vasculitic rheumatoid arthritis. Differential diagnoses of this topic include Wegener's disease, phospholipid syndrome, or in Adamantiades-Behcet's disease etc.
(c) Cancer. Again the differential diagnosis is most complicated in patients with lymphomas or leukaemia. Where the specific cutaneous lesions may present as suppurative ulcers.
(d) Infectious disease. Ecthymata and deep [tropical] mycoses like sporotrichosis may resemble PG. The rapid onset of post-surgical PG often reminds of acute deep skin infection such as erysipelas or gangrene [18]. Late syphilis has become more common again and may develop suppurative ulcerations. Deep viral herpetic infections can resemble PG.
(e) Exogenous tissue injury. Facticious panniculitis as a part of the Münchhausen syndrome may masquerading as PG [39]. Insect or spider bites can cause necrotizing skin ulcers.
(f) Drug reactions. Pustular drug reactions may masquerade as pustular PG.
Systemic therapy
For patients with a more widespread disease or rapidly progressive course, systemic treatment is mandatory. Corticosteroids, like prednisolone, 1 to 2 mg per kg per day, are widely used for initial therapy [2, 4, 25]. Trying an initial high-dose therapy aims to prevent progression and rapidly stop inflammation. Action of pulse therapy with suprapharmacological doses of corticosteroids [1 g of methylprednisolone] is faster [40]. Since this treatment may cause fatal side effects in patients with cardiovascular disease on diuretics, patients have to be carefully selected.
Ciclosporin A is an inhibitor of T-lymphocyte activation. Immunosuppressive therapy with ciclosporin A has become an accepted treatment for widespread PG after initial steroids or in combination with steroids. In many cases, steroids can be completely be replaced by ciclosporin A [41, 42]. Doses of 2 to 3 mg ciclosporin A/kg body weight and day show efficacy in PG [43]. During therapy with ciclosporin A it is necessary to control blood pressure and creatinine. The drug induces an early response but has no impact on the incidence of recurrences [44]. Therefore, combination with other drugs can become necessary even after initial response to ciclosporine A monotherapy.
Sulfa drugs are useful in milder cases of PG. The combination of steroids with diaminodiphenylsulfone [dapsone] up to 200 mg daily [only for patients with a normal glucose-6-phosphate dehydrogenase level] is the most popular. Dapsone inhibits neutrophil migration and production of reactive oxygen species and exerts a variety of other anti-inflammatory activities [4, 45]. Formation of met-hemoglobin needs regular monitoring during this treatment.
Clofazimine is a scavenger of hypochlorus acid, thus reducing the chlorination of proteins by neutrophils. It stimulates phagocytosis and superoxide production and has a direct antibacterial activity as well. In my opinion the efficacy of clofazimine 300 to 400 mg/day is comparable to that of sulfa drugs as dapsone. A common side effect is hyperpigmentation [46].
Thalidomide shows immunomodulatory activity such as suppression of tumour necrosis factor-alpha, basic fibroblast growth factor and neutrophil chemotaxis. It was used in combination with steroids [47]. Thalidomide is teratogenic and therefore absolutely contraindicated in fertile women.
Colchicine, an inhibitor of the spindle-apparatus with anti-inflammatory properties, was employed in two patients with PG from Greece [48]. It may be used as a single agent or in combination with prednisolone depending on the severity of disease. Gastrointestinal adverse effects may limit its use.
Azathioprine [100–150 mg/day] is a cytotoxic drug usually administered for its steroid-sparing effects. Its action is delayed of at least about 2 to 4 weeks. Blood counts and transaminases should be monitored [2, 4, 45]. There is a wide inter-individual variability in azathioprine metabolism due to a common genetic polymorphism of thiopurine methyltransferase, a major metabolizing enzyme of azathioprine. Azathioprine and sulfasalazine are a good choice when the underlying disease is ulcerative colitis or Crohn's disease.
Another cytotoxic drug that has been used in PG is cylophosphamide. Cyclophosphamide pulse therapy followed by either azathioprine or methotrexate is an effective treatment in steroid-refractory Crohn's disease. In cases of Crohn's associated PG may achieve long term remissions with this regimen lasting for up to 30 months [49].
Mycophenolate mofetil is an inhibitor of the purin synthesis selectively reducing the proliferation of T- and B-lymphocytes. With the dosage of 2 g/day there is a very low risk of renal and hepatic side effects. Mycophenalate mofetil was used in peristomal PG and other refractory cases [50, 51]. Recently, a case of staphylococcal and pseudomonal sepsis has been reported in a mycophenolate mofetil treated PG-patient [52].
Enteric-coated mycophenolate sodium [ECMPS] is an advanced formulation delivering mycophenolic acid. At a dosage of 720 mg ECMPS exhibits equivalent mycophenolate acid exposure to mycophenolate mofetil 1000 mg. Recent trials demonstrated that ECMPS has a similar safety profile than mycoephenolate mofetil [53].
Tumour necrosis alpha inhibitor infliximab was reported to be effective in PG associated with inflammatory bowel disease at a dosage of 5 mg/kg body weight. Infliximab is given by infusion at weeks 0, 2 and 6, and every 8 weeks thereafter. The chimeric antibody is usually combined with low-dose methotrexate for Crohn's disease [54, 55]. In a small series including 4 patients with fistulating Crohn's disease and PG infliximab was given either as a single infusion or a series of three infusions at a dosage of 5 mg per kg body weight/day. All patients demonstrated a rapid healing of PG within 4 weeks after starting the treatment. Healing was complete and relapses were not observed [56]. In another study four patients with PG-ulcers and Crohn's disease showed a marked improvement after a single infusion of infliximab [57]. Since infusion reactions can occur in 3% to 17% of patients with Crohn's disease that are antibody associated the concurrent administration of steroids and the use of immunosuppressant like methotrexate or azathioprine has been recommended [58].
The positive effect on PG has also seen with another tumour-necrosis factor alpha antagonist etanercept, a fusion protein [59]. Etanercept is applied by subcutaneous injections of 50 mg twice weekly. Because there is a risk of reactivation of tuberculosis during anti-tumour necrosis alpha therapy patients have to be screened for tuberculosis before and during treatment [58].
Tacrolimus, a selective calcineurin inhibitor, was used at low dosages of 0.1 mg per kg body weight/day. The treatment was monitored to maintain a serum level of between 4 and 6 ng/L. Complete clearance of skin lesions was observed in two patients with underlying ulcerative colitis [60].
Since PG is a neutrophilic disease, removal of activated neutrophiles should improve the symptoms. Leukocytapheresis, where white blood cells are removed extracorporeal, and granulocyte adsorptive apheresis, a more selective procedure, have been used in single cases with success. These methods have been used in single cases unresponsive to systemic standard therapy with success [61, 62].
Topical treatment is important in any case when ulcers have developed. Moist wound management is a cornerstone of wound management. Since most ulcers show heavy exudates, foam dressings or laminate dressings composed of different layers are recommended. In case of sloughy or purulent covered lesions, semiocclusive dressings are contraindicated. In such cases, wet compresses with sterile saline solution or Ringer-lactate solution and alginate dressings are useful. Pain relief and improvement of odor have also been observed with compresses [25].
For small flat lesions without secondary infection, topical high potent corticosteroids are in use. They are rarely capable of inducing remissions except in peristomal PG [4, 10, 11]. Topical calcineurin inhibitors like tacrolimus or pimecrolimus were used in some cases with success [4, 63, 64]. Dramatic improvement has been observed in particular in peristomal PG [65, 66].
Surgical therapy
Surgery has to be used with caution since it can be trigger PG [19]. Any surgical procedure has to be done as an adjunct to immunosuppression only in patients with stable disease or partial remission. Autologous split-skin grafts have been used with variable outcome [[67] Fig. 3]. A significant disadvantage of split-skin grafts is the necessity to create a new wound at the donor site. New developments include the use of bioengineered skin, like the dermal regeneration template Integra®, hair follicle stem cell-derived autologous keratinocyte sheets Epidex® or hyaluronic acid-based autologous keratinocyte delivery system Laserskin® [18, 25, 50, 68–70]
Despite advances in management, the long term outcome of PG remains unpredictable. We have seen one young patient who did not respond to intense drug therapy anymore. There fore because of intractable apin and toxicity of the large wound a lower limb amputation was performed eventually [Fig. 5]. Even in those patients who respond to drug therapy relapses occur. They are seen in about 70% of patients treated with prednisolone and 66% of patients treated ciclosporine A [44]. In cases where long term treatment is justified a careful monitoring of possible adverse effects is mandatory [5, 25]. In those cases with a complete clinical remission the internal treatment dosage should be tapered down. PG is still a potentially life-threatening with a mortality rate of up to 30% in some series [70].
Deep purulent ulcerations due to pyoderma gangraenosum. In this patient later on a lower limb amputation was necessary, since he did not response to drug therapy.
Our knowledge about pathogenesis and individual risk factors for the development of PG is still rather limited. This hampers the efforts for prevention. In the treatment of PG controlled, prospective and randomized trials have yet not been established. Such an approach would be possible only in a multinational trial because of the rareness of this disease. It would further been limited by the various clinical types and courses of this disease. A major point for further investigations is the calculation of prognosis. The course of this disease is unpredictable and the manifestations range from very limited and superficial ulcerations to widespread disease with extracutaneous manifestations and life threatening course. The new attempts of treatment with biologics needs careful investigation since this could provide a new understanding of the disease.
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Department of Dermatology & Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Friedrichstrasse Dresden, Germany
Uwe Wollina
Correspondence to Uwe Wollina.
Wollina, U. Pyoderma gangrenosum – a review. Orphanet J Rare Dis 2, 19 (2007). https://doi.org/10.1186/1750-1172-2-19
Infliximab
Sporotrichosis