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Oxfordshire Oesophageal and Stomach Organisation
Walk with OOSO, 16-19 August
Email: OOSO (enquiries@OOSO.org.uk)
Why does salt have an expiry date?
Friendly Advice and Sensitive Support
A telephone support line is available seven days a week from 8am to 10pm. It is confidential and staffed by past patients.
We will listen to worries and concerns about cancer, the treatment offered and the future. We offer information, advice and support based on our experience. There are no taboo topics. We are not judgemental. We have empathy because we've been there before.
Please note, this is not a medical advice line. Should you need specific medical advice please contact your GP or a member of the medical team who treated you while in hospital.
Our advice is not limited to patients. The job of the Health Service is to get patients well enough to leave hospital as soon as is practicable. It's when a patient is discharged from hospital that their carers take on the roles of chef, valet, psychologist, shopper, mentor, coach and nurse to name but a few. For some the challenge can be quite daunting. Who has trained the carer for such responsibilities? Fear not. OOSO is here to help you too.
We know the right course of action and the right time for action.
We provide advice in the way that suits you the best. We respond to emails. We take and make telephone calls. We visit you on the ward. We meet for a coffee at a convenient location. If you choose, we'll also visit you at home.
This website has been built with the intention of giving free information as well as moral and emotional support to anyone affected by oesophageal or stomach cancer (cancer of the oesophagus or gastric cancer).
This advice is drawn from former patients and members of OOSO who have experienced the treatment and operation associated with our types of cancer. None of the information offered is to be considered health information and does not intend to replace any help and advice you receive from any of your medical advisors.
Initially a cancer diagnosis is scary. However, many past patients have recovered and gone on to do amazing things. It can be life changing but it can provide the spur to live life more enjoyably.
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Mrs Anne M. Phillips
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The Oxford OesophagoGastric team was set up in 1997, and has become one of the largest such units in the country.
The support provided by Jackie and the Oxfordshire Oesophageal and Stomach Organisation (OOSO) to patients with oesophageal and stomach cancer plays a vital role in their management, and is a major contribution to the better outcomes we are seeing with this cancer in recent years.
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Reading order for Harry Potter auxiliary books?
Preface: I ran into this question in real life -- getting kids I know hooked on Harry Potter. To my utter surprise, I realized we don't have this question on the site yet. So here it goes, in hopes that someone has an answer
What is the best reading order for the Harry Potter ancillary books? (Fantastic Beasts and Where to Find Them, Quidditch Through the Ages, and The Tales of Beedle the Bard).
Should they be read after all seven of the main books, or should they be read at different points during the main books? Or, for example, should individual sections of FBWFT be read in sync with which monsters are mentioned in the individual Potter books? Should The Tales of Beedle the Bard be read before or after Deathly Hallows?
Preference is given to answers based on J.K. Rowling's own opinion, but I am also open to well-reasoned suggestions based on pure logic, even if they contradict JKR.
harry-potter suggested-order
Rand al'Thor♦
DVK-on-Ahch-ToDVK-on-Ahch-To
Related (and useful to base the answers on): scifi.stackexchange.com/questions/6795/… – DVK-on-Ahch-To Dec 19 '14 at 23:52
Also, scifi.stackexchange.com/a/55019/3567 – DVK-on-Ahch-To Dec 20 '14 at 0:41
I don't believe JK Rowling has ever suggested a reading order for the books.
The easy answer is to read them in publication order: Beasts and Quidditch were published between Books 4 and 5, and Tales was published after the release of Book 7.
That's a bit short, so here are a few more thoughts on the topic:
Quidditch through the Ages seems most spoiler-free of all the three supplementary books, and could probably be picked up as soon as Quidditch has been introduced in Book 1. As I noted in a previous answer, this book doesn't seem to mention any events that take place after Book 1, so it might be a good starter.
I would avoid Tales of Beedle the Bard until most of the final book was finished. Although it doesn't contain any explicit spoilers (I think), if you've read it already then it strongly hints at what's to come, especially the discussion of the Hallows in the Tale of the Three Brothers. Not necessarily a spoiler, but I think it's better to let this thread unfold naturally.
Fantastic Beasts doesn't contain many spoilers, but a lot of Harry and Ron's annotations won't make sense unless you've got to at least halfway through Book 4. You could probably pick it up after the dragon task, as I don't think it references anything after that – but I'd wait until that's done. I think it's much better to read and understand these comments, than to be mildly confused about what they mean and what might be to come.
alexwlchanalexwlchan
Like Alexwlchan says, I know of no suggested reading order of the Harry Potter series made by J.K. Rowling herself, so I offer the following reading order:
First, I would read the seven main Harry Potter novels, supplemented with Fantastic Beasts and Where to Find Them (FBAWTFT) and Quidditch Through the Ages (QTTA) as questions about the beasts and Quidditch arise (if they do). I used to like to have FBAWTFT nearby when I read Harry Potter to my kids, because they would often ask what, for example, "What's an Erkleburp?" when Hagrid might mention it in passing in Care of Magical Creatures class, but J.K. Rowling had provided no description of an Erkleburp. Okay, so we look up the Erkleburp in FBAWTFT, figure out what kind of creature it is, and then carry on. My kid might ask what a Wronski Feint is during a passage on Quidditch, and I can answer by looking up Wronski Feint in QTTA.
Alternately, if there are no questions about the beasts or Quidditch forthcoming, I would suggest reading the seven single novels in order. But it's perfectly fine, obviously, to return to an earlier book to clarify information or to ensure one has a plot point correct.
When it comes to Deathly Hallows and reading Tales of Beedle the Bard (TBTB) either simultaneously with or after Deathly Hallows, two things: You could hit some spoilers if you read TBTB after Hermione receives the book from Scrimgeour -- it's not hard to figure out which of Beedle's tales is the one Dumbledore wants Hermione to read, due to the presence of the Invisibility Cloak and Death (a major theme in the Harry Potter series). Also, the placement of The Tale of the Three Brothers as the last story in the series is a minor clue that it is THE ONE STORY. It explicitly introduces the Elder Wand, the Invisibility Cloak, and the Resurrection Stone, which are all integral to the series and the conclusion of Deathly Hallows. If you don't like plot spoilers, I would recommend that you not read TBTB alongside Deathly Hallows. As small as they may be, a clever person could potentially damage their enjoyment of the series if they began to get a general gist of how things were going to suss out.
If you are a shameless spoiler junkie (like myself), then, by all means, after Scrimgeour gives Hermione Tales of Beedle the Bard, read through it! Try and find which one of Beedle the Bard's stories is THE ONE STORY that is relevant to Deathly Hallows. See if you can figure it out and have fun making guesses.
BOOKS VS. MOVIES: Just a note. Although DVK did not mention the movies in conjunction with the books, I wanted to say that I personally do not recommend watching the Harry Potter movies as you go along in the books. The movies have significant plot and characterization changes that are not compatible with the stories as written in the book. It will make for a confusing and frustrating, as well as a less enjoyable experience. The books are fabulous in their own right. The movies are fabulous in their own right. But ne'er shall the two meet!
SlytherincessSlytherincess
Note: This answer will try to address all of Rowling's supplementary works, not just the three listed by the OP
I would suggest an order based primarily off of the publication order.
Book 1 (Rowling later wrote four additional passages designed to be read with chapter seven)
The Ballad of Nearly Headless Nick (Written at this point, but not published until 2004)
Daily Prophet #1
Fantastic Beasts and Where To Find Them (textbook)
Harry Potter Prequel
Harry Potter Encyclopedia (abandoned, but roughly 80 of the articles Rowling had prepared have been published online)
Book of Potions
Daily Prophet - The 2014 Quidditch World Cup
The History of Magic in North America
Fantastic Beasts and Where To Find Them (screenplay)
Although I wouldn't recommend one do it, here is a chronological order of the works.
The Tales of Beedle the Bard (tales) - fifteenth century
Book of Potions - sixteenth century
The History of Magic in North America - 14th to 20th century, but mostly in the 17th.
Book of Spells - eighteenth century
Scottish Rugby - nineteenth century
Fantastic Beasts and Where To Find Them (screenplay) - 1926
Fantastic Beasts and Where To Find Them (textbook) - 1927
Quidditch through the Ages - 1952
Harry Potter Prequel - 1977
Book 1 - 1991
The Tales of Beedle the Bard (commentary) - 1996
Daily Prophet - The 2014 Quidditch World Cup - 2014
ibidibid
For the record, I doubt that there is anyone who somehow has access to the Daily Prophet newsletters and hasn't already read every Harry Potter book. – ibid Feb 21 '16 at 5:09
aren't they online, though? IIRC, I've seen some of the old Daily Prophets from links on, um, whatever the Potterverse wikia is called, before I ever touched book 7. (Though of course I was quite spoiled anyway.) But yes, I agree, aside from providing specific links to a starting reader, it doesn't seem likely. – January First-of-May Feb 21 '16 at 11:42
@JanuaryFirst-of-May They are most definitively not online. HP-Lexicon has summaries of them and everyone else (including HP wiki) relies on that. I'm pretty sure they can only be found in private collections. – ibid Feb 21 '16 at 11:45
Not the answer you're looking for? Browse other questions tagged harry-potter suggested-order or ask your own question.
What other Harry Potter related writings has Rowling written?
Are there any discrepancies between HP1-HP7 and supplementary books?
Did the Harry Potter supplemental books contain clues relating to the main storyline?
Is there a list of significant "foreshadowed" ideas/details between Harry Potter fanfiction and Harry Potter 5/6/7 books that were released later?
How Did the House Ghosts End Up at Hogwarts?
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Feelin' Empty: Ten Saddest Miranda Lambert Songs
Summertime sadness is the sweetest kind. It's that feeling you get when it's too hot outside and you just want to sit in a dark room and wallow in depressing music until autumn comes and you can breathe again. Miranda Lambert knows the power of the heartbreaker and how listening to sad music can actually make you feel better. So here's a list of her ten most tearjerking songs – I recommend you drink some wine and hug a dog while you read/listen.
10. Dead Flowers
Watching something decay and rot away, well that's the saddest thing in the world. Here Miranda sings about a dying relationship and the flowers once bought in a empty gesture of affection. When the person you're with doesn't understand you, doesn't even notice you are suffering it's hard not to feel depressed. I'm living in a hurricane and all he can say is ain't it such a nice day. Miranda sings it like she's lived it, all swelling guitars and anguished cries of romantic despair.
9. Greyhound Bound For Nowhere
When love goes wrong you just have to escape and there isn't a better image of American freedom than the Greyhound bus. The cheapest, most uncomfortable way to travel – only braved by those who have no other choice. The sun's going down on my misery/ another day gone by with broken dreams. This song explores that emptiness you get when you're surrounded by people but you feel truly alone. Miranda's stunning ability to convey a sense of sadness and longing is clearly evident here on this song from her debut album.
8. Dear Diamond
There's nothing worse than knowing you've made a mistake and there's nothing you can do to fix it. You can lie but then you have to live with yourself afterwards. To hurt yourself is bad enough but to hurt other people, well that can really destroy you. I love how this song is sung directly to her engagement ring – a constant reminder of her mistakes. Plus Patty Loveless is on this song too, beautifully echoing Miranda's emptiness.
7. Use My Heart
There are so many beautiful acoustic sad songs on The Weight of These Wings I feel like this one has been overlooked a little bit. For me this is one of the best songs on the whole album and it really hits me hard whenever I hear it. I love the way this song builds its sadness around comparing the things that she's struggling with: I can write the line but I can't sing the song, I can call my mama but I won't go home. There's no easy answer here, the song itself is sad because she knows that falling in love could destroy her again. I don't have the nerve to use my heart, she sings understanding that to be open and vulnerable in life and love takes real courage.
6. Vice
From the opening sting of the needle Vice is a perfect musical exploration of modern heartbreak. The song is about that endless search for meaning, for comfort, the wish to obliterate yourself and everything you are, which is inside of us all. When you find yourself in that cycle of self-destruction it's nearly impossible to escape.
But at least you can listen to sad songs that tell the story of your suffering. And when it hurts this good you gotta play it twice.
5. Bathroom Sink
Everyone's stood in front of a mirror and wanted to smash their fist right through it, even beautiful people like Miranda. It's amazing the amount of rejection that I see in my reflection and I can't get out of the way. Jesus if that isn't a perfect line about being a woman in the 21st century then I don't know what is.
This song, when it actually starts to rock out, feels like the best kind of sad song – loud and angry at the world as much as anything.
4. More Like Her
The crushing disappointment when someone leaves you for their ex is all here in this classic country weepie. Of course she's not angry at him, she's turned her feelings inwards to compare herself with the other woman. In the end there's so much sadness because she wishes things could be different but that's impossible.
3. Over You
This chokes me up every time. It is about death of course, but in a way it's taken on a wider meaning really – that chorus really could be about divorce as well. The 'how dare you/I miss you' doesn't really fit the structure of the song but that's why it feels so desperately poignant in a way. This person is gone and you feel so angry with them, even though you know it's hopeless. It's the finality of everything which feels so truly heartbreaking. It really sinks in you know/ when I see it in stone. Excuse me while I go have a breakdown.
2. The House That Built Me
So you know that feeling you get when you glimpse something from your past, something that makes you realise how time passes and things change and life moves quicker than you'll ever want it to and you can never go home again because home as it used to be doesn't exist anymore and life right now is so confusing and scary and you really just want to go back to being a kid when you didn't have a care in the world? Yeah all that beauty of childhood nostalgia and pain of adult anxiety is right here in four minutes.
Plus there's a line about a dead dog and if that doesn't cut you up then what the hell are you doing listening to country music?
1. Tin Man
There could only be one number one. I already spilled my guts about why this song is everything right here: 'Why Tin Man is the Sad Song We Need Right Now.'
Okay if you're ready here is the playlist, let's cry together and flood this place:
Let me know what your favourite top ten Miranda weepies are in the comments.
READ NEXT: Angaleena Presley: 'Wrangled' Review // Kitty Wells & The Recurring Problem of Sexism in Music
Country, Miranda Lambert, Sad Songs
Album Review: Katie Ellen – Cowgirl Blues
E.P. Review: Margo Price – Weakness
2 thoughts on "Feelin' Empty: Ten Saddest Miranda Lambert Songs"
Sharon Lusher says:
Tin Man is mine. I cry everytime. I have had my heart broken by men I trusted. There is nothing worse. Especially when you are married to them. It leaves you so insecure.
I get it – trust me. That song cuts deep ❤ xx


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$18M transfer may put library in the red in two years, board says
"Any scenario taking away $18 million of fund balance harms the library."
$18M transfer may put library in the red in two years, board says "Any scenario taking away $18 million of fund balance harms the library." Check out this story on theadvertiser.com: https://www.theadvertiser.com/story/news/2019/05/06/18-m-transfer-may-put-library-red-two-years-board-says/1118858001/
Leigh Guidry, Lafayette Daily Advertiser Published 8:00 p.m. CT May 6, 2019
If Lafayette Consolidated Government takes $18 million from its public library system, it would have a negative fund balance by 2021.
Andrew Duhon (far right), vice president of the Lafayette Public Library Board of Control, discusses potential funding scenarios during a special meeting May 6. (Photo: Leigh Guidry/USA TODAY Network)
That is based on projections by the Lafayette Public Library Board of Control's finance committee presented at a special meeting Monday.
The board met in advance of a Lafayette City-Parish Council meeting Tuesday at which Mayor-President Joel Robideaux is expected to reintroduce a resolution to rededicate $18 million from the library's $26 million fund balance to roads, drainage and bridges.
Robideaux had asked for $18 million April 9, but the council voted to present a $10 million transfer on the Oct. 12 ballot.
Now he is expected to ask again for an $18 million transfer, according to a post to his Facebook page stating that "leaving the Library with somewhere between $16 and $18 million could be viewed as excessive by voters."
The library's governing board voted Monday to oppose that, not surprisingly.
"Any scenario taking away $18 million of fund balance harms the library," said Andrew Duhon, vice president of the Board of Control. "... It is not in the best interest of the library system and not conducive to the financial health and operation of the library system."
He and Larry Angelle, library operations manager, presented four fund balance scenarios to the board based on low revenue growth, the proposed transfer and differing amounts of capital improvement funds for the North Library expansion and construction of a Northeast Regional Library branch.
Two "worst-case" scenarios have an $18 million transfer and leave the library system with negative fund balances in two years.
The other two scenarios call for a $10 million fund balance take. With the maximum amount used for the two capital projects — $4 million for the expansion and $8 million for the new branch — the fund balance is projected to be negative beginning in 2027.
If only $6 million is used to build a new branch, that drop into the red is delayed by two years.
Capital improvements also would include smaller projects like upgrades to satellite locations like the Butler Memorial Branch in the Martin Luther King Jr. Center and in the Chenier Center, Duhon said.
"Those are embedded" in these projections, Duhon said.
MORE: Calls for northeast library renewed with $8 million spared from council's fund grab
A map highlighting Lafayette Parish's lack of library locations on the east side of Interstate 49, an area of more than 35,000 people. (Photo: Courtesy of the Lafayette Consolidated Government)
Of the parish's nine library locations, which include the main library in Lafayette and four regional libraries, none fall in the communities east of I-49, which account for a fifth of the parish's land area and a third of its black population, according to U.S. Census Bureau data.
More than 35,000 people reside east of I-49, more than half of whom are African American, census data show.
Median household incomes for census block groups in the area are the among lowest in Lafayette Parish, and educational attainment is much lower, with only 23 percent of residents having any level of college degree compared to 40 percent in the rest of the parish, according to census data.
The library's board also voted to recommend that the City-Parish Council roll its millage forward to its maximum for fiscal year 2020. It will add 0.39 mill and will be the final year this millage is collected, as it failed to be renewed in 2018.
The projections included the assumption that the library millage would be renewed the next time it comes on the ballot. Duhon said that is critical to covering operating expenses.
"If we don't renew it, all bets are off," he said. "Losing another millage wouldn't allow us to operate."
It costs about $11.5 million to operate the nine locations, and that figure would grow to cover utilities and staffing once the new branch is built.
Read or Share this story: https://www.theadvertiser.com/story/news/2019/05/06/18-m-transfer-may-put-library-red-two-years-board-says/1118858001/
Lafayette mayor: No time 'to babysit' top deputy
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Category: Distributed by University Press of Florida
December 11, 2019 December 13, 2019 University Press of Florida Art, Architecture, & Photography, Distributed by University Press of Florida, Interns
Intern Guest Post: "The World to Come" Artists Imagine Futures from Ruins
Written by Melissa Nunez , Marketing intern at the University Press of Florida While looking at The World to Come: Art in the Age of the Anthropocene, I realized how my work as an artist can relate to some of the ideas that were brought up by curator Kerry Oliver-Smith. Distributed by the University Press of Florida, … Continue reading Intern Guest Post: "The World to Come" Artists Imagine Futures from Ruins
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This sturdy, pocket-sized field guide is designed for landscape professionals, arborists, naturalists, gardeners, and anyone seeking to know the trees around them. Full color photographs of leaves, bark, flowers and full trees, together with clear descriptions make identifying trees easier than ever. The 180 trees include native, introduced, and invasive species and are arranged by … Continue reading Trees
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Knives, Forks, Scissors, Flames by Stefan Kiesbye is the second publication from Panhandler Books, a series launched in 2015 by Panhandler Magazine and the Department of English and World Languages at the University of West Florida. Distributed by the University Press of Florida, Panhandler Books publishes poetry, fiction, and nonfiction consistent with Panhandler's mission to champion underrepresented literary genres. … Continue reading Panhandler Books and University Press of Florida publish second book in partnership


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THE MOOD IN IMFA IS HIGH AS FERRO CROME PRICES MAKE A NORTHWARD RALLY
By IW News Service | Feb 8, 2017 | Judiciary |
Bhubaneswar: The mood in the India Metals & Ferro Alloys Ltd.(IMFA) corporate head office in the city is quite buoyant as the ferro crome prices are going northward. The country's leading fully integrated producer of commodity, which has notched a higher net profit in third quarter of 2016-17 is expecting end the fiscal with a higher bottomline in the fourth qurter.
The spurt in ferro chrome prices in the global market has pus hed the topline and bottomline of the country's leading fully integrated producer of the commodity, Indian Metals & Ferro Alloys Ltd (IMFA) in the third quarter ending December 31, 2016.
"The ongoing Q4 numbers will be exceptional", said the IMFA managing director & CEO, Subhrakanta Panda. "As the increase in spot prices came after long term pricing for Q3 had been finalised and is only partly reflected in the quarterly results, IMFA says that with the benchmark price for the ongoing fourth quarter went up by 55 cents (50%) to 165 cents will add substantially to the topline and bottomline", he explained.
"We are ideally positioned to reap the benefit of the turnaround and intend to use the gains to make our balance sheet even stronger," asserted Subhrakanta.
The company earned a revenue of Rs462 crore in Q3 of 2016-17, up from Rs 335.35 crore during the corresponding period of the previous year. Similarly, the company posted a net profit of Rs 63.87 crore against a meager Rs 2.75 crore during the Q3 of 2015-16.
In the nine months ending on December 31, 2016, IMFA posted a net profit of Rs 75.83 crore from a gross revenue of Rs 1102.87 crore. The company's profit earning was 7.44 crore from a revenue Rs1019.02 crore during the same period the previous year.
Output during the quarter Oct-Dec 2016 was at an all time high as all 6 furnaces were in operation, reported IMFA. The ferro crhome production was 64,641 tonnes, up 24% from 52,217 tonnes in Q3 of the previous year. Similarly, the sale was 64,034 tonnes, an increase of 19% from 53,764 tonnes.
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Sunny Holidays before and after Melanoma Diagnosis Are Respectively Associated with Lower Breslow Thickness and Lower Relapse Rates in Italy
Sara Gandini ,
* E-mail: sara.gandini@ieo.it
Affiliation Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy
Esther De Vries,
Affiliation Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
Giulio Tosti,
Affiliation Division of Melanoma and Muscle-Cutaneous Sarcomas, European Institute of Oncology, Milan, Italy
Edoardo Botteri,
Giuseppe Spadola,
Patrick Maisonneuve,
Chiara Martinoli,
Affiliation Department of Medical Oncology, European Institute of Oncology, Milan, Italy
Arjen Joosse,
Pier Francesco Ferrucci,
Federica Baldini,
Emilia Cocorocchio,
Elisabetta Pennacchioli,
Francesco Cataldo,
Barbara Bazolli,
Alessandra Clerici,
Massimo Barberis,
Affiliation Department of Pathology and Laboratory Medicine, European Institute of Oncology, Milan, Italy
Veronique Bataille ,
Contributed equally to this work with: Veronique Bataille, Alessandro Testori
Affiliation Twin Research and Genetic Epidemiology Unit, King's College, London, United Kingdom
[ ... ],
Alessandro Testori
[ view less ]
Sara Gandini,
Federica Baldini
Sara Gandini Esther De Vries ... Alessandro Testori
3 Jul 2014: The PLOS ONE Staff (2014) Correction: Sunny Holidays before and after Melanoma Diagnosis Are Respectively Associated with Lower Breslow Thickness and Lower Relapse Rates in Italy. PLOS ONE 9(7): e101732. https://doi.org/10.1371/journal.pone.0101732 View correction
Previous studies have reported an association between sun exposure and improved cutaneous melanoma (CM) survival. We analysed the association of UV exposure with prognostic factors and outcome in a large melanoma cohort.
A questionnaire was given to 289 (42%) CM patients at diagnosis (Group 1) and to 402 CM patients (58%) during follow-up (Group 2). Analyses were carried out to investigate the associations between sun exposure and melanoma prognostic factors and survival.
Holidays in the sun two years before CM diagnosis were significantly associated with lower Breslow thickness (p=0.003), after multiple adjustment. Number of weeks of sunny holidays was also significantly and inversely associated with thickness in a dose-dependent manner (p=0.007). However when stratifying by gender this association was found only among women (p=0.0004) the risk of CM recurrence in both sexes was significantly lower in patients (n=271) who had holidays in the sun after diagnosis, after multiple adjustment including education: HR=0.30 (95%CI:0.10-0.87; p=0.03) conclusions: Holidays in the sun were associated with thinner melanomas in women and reduced rates of relapse in both sexes. However, these results do not prove a direct causal effect of sun exposure on survival since other confounding factors, such as vitamin D serum levels and socio-economic status, may play a role. Other factors in sun seeking individuals may also possibly affect these results.
Citation: Gandini S, De Vries E, Tosti G, Botteri E, Spadola G, Maisonneuve P, et al. (2013) Sunny Holidays before and after Melanoma Diagnosis Are Respectively Associated with Lower Breslow Thickness and Lower Relapse Rates in Italy. PLoS ONE 8(11): e78820. https://doi.org/10.1371/journal.pone.0078820
Editor: Andrzej T Slominski, University of Tennessee, United States of America
Received: July 5, 2013; Accepted: September 16, 2013; Published: November 4, 2013
Copyright: © 2013 Gandini et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors thank the "Fondazione Grazia Focacci" for the financial support. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
The incidence of CM has steadily increased over the last 30 years in most fair-skinned populations even if the great majority of the increase has been linked to the increase in diagnoses of thin lesions with excellent prognosis[1]. One of the hypotheses for the discrepancy between incidence and mortality trends is that melanomas are detected at earlier stages in women than in men[2]. Another hypothesis is that part of melanoma epidemic is made of non life-threatening melanomas that could be promoted by sun exposure. Recent sun exposure could be able to trigger skin cancers with little malignant potential. Long noted is the relationship between sun exposure and non-melanoma skin cancer (NMSC) and superficial spreading melanoma (SSM), which are often not aggressive[3].
This last hypothesis arose from the results of a study evaluating the association of sun exposure indicators with melanoma mortality. This American study of 528 melanoma cases showed that markers of sun exposure were inversely associated with death from melanoma[4].In this study, we investigated if different indicators of UV exposure, collected before and after CM diagnosis, are associated with Breslow thickness and recurrence in Italy. We wanted to investigate if there could be an induction period for the most aggressive melanoma.
A hospital-based study of melanoma cases was initiated in 2007 at the European Institute of Oncology in Milan, Italy, which is a secondary and tertiary centre for CM diagnosis and treatment. A self-administered questionnaire was given systematically to all patients during clinics (response rate 99%) and data was collected on socio-demographic variables, season of diagnosis and CM site. Skin type was assessed with the Fitzpatrick classification.
A total of 742 CM patients with histologically confirmed diagnosis of primary CM without relapse were identified via two databases: the Institutional Melanoma Database and the Tumour Registry of the European Institute of Oncology (IEO), Milan, after informed consent was obtained. Use of the data included in The IEO Tumour Registry was approved by the IEO Institutional Review Board (March 2013). Main clinical information and information on disease history of the patients are obtained from the Tumor Registry. The European Institute of Oncology is a tertiary referral centre and assessment of diagnosis, cancer characteristics and recurrence was made by highly qualified dermatologists, pathologists, surgeons and oncologists.
As shown in Figure 1a, there were two cohorts of patients which did not overlap: cases interviewed at initial diagnosis (Group 1) and those during follow-up (Group 2), with the same questionnaire. In the latter group, median time from CM diagnosis to questionnaire was 2.6 years (1-6 years inter-quartile range). Sun exposure data for Group 1 was collected by asking CM patients if they had holidays in the 2 years preceding their melanoma diagnosis and if yes, how many weeks of holidays per year for each year. For Group 2 at follow up, they were asked the same questions for a period of 2 years before the questionnaire. We asked information on the last 2 years because this is easy to remember and usually these types of habits before diagnosis do not change. After diagnosis patients will likely change behaviour[5][6][7] and we made the same questions for the Group 2. Data on sun exposure during peak hours (11:00AM-1:00PM) in the previous two years, sunbed exposure (current use and use before age 30) and residence of at least one year in tropical countries before age of 14 was also collected. We used 'sunny holidays' as indicator of high sun exposure because Italians sunbath mainly in holidays and it is a measure less prone to recall bias. In fact questions commonly used to measure sun exposure, especially those reflecting past exposures, embody attempts to recall events that are subject to both systematic recall bias and random misclassification[8][9]. Recent sunny holidays will be less subject to misclassification. Furthermore recall bias characterize case-controls designs and in our study design comparing melanoma cases this information should be more reliable. Sunny holidays will be referred to holidays in the manuscript.
Figure 1. Study design.
Patients with previous CM primary, missing histology, in situ, acral melanoma, mucosal melanoma, vulvar or ano-rectal melanoma and patients with distant metastases at diagnosis were excluded (n=51, 7%), leaving 691 patients eligible for the study: 289 were interviewed at diagnosis (42%, Group 1) and 402 during follow-up (58%, Group2).
For the analyses on CM recurrence, 496 patients with pT1-T3N0M0 staging were included: 225 interviewed at diagnosis (group 1) and 271 after diagnosis (group 2). For group 2 we included patients with a diagnosis of CM at the most 7 years before the questionnaire, to avoid inclusion of very long survivors. No residents in other countries were found. Questions on sun exposure refer to two years before diagnosis for group 1 and for group 2, for 2 years before the questionnaire during follow-up. In order to avoid time related bias, the competing risk analysis in group 2 started from the time of interview (free of disease). A sensitivity analysis was carried out including also long survivors.
Associations between categorical variables at baseline and median Breslow thickness was evaluated by non-parametric median two sample tests. Associations between categorical variables and holidays were evaluated by the Chi-square test, Fisher exact test and the Chi-square test for trend, as appropriate.
In multivariate analyses, Breslow thickness was either analysed as categorical variable or as continuous variable. Logistic models were used to evaluate the probability to have a thick CM (Breslow >1mm) and an ANCOVA model was introduced, transforming Breslow thickness for normal distribution. All possible confounding factors were evaluated in multivariate models.
For cumulative incidence, only first events of interest were considered. For the cumulative incidence of CM-related events, CM-related recurrences from a primary CM and deaths were counted as events, while second CM, NMSC and non-CM primary cancers were considered as competing events, since they may be associated to a genetic predisposition or other causes. Follow-up of patients free of events was censored at the date of last visit. Cumulative incidences were compared across groups by means of the Gray test. Multivariable Cox proportional hazards models were applied to evaluate holidays as independent prognostic factor and assumptions on proportional hazards were verified. Adjusted hazard ratios (HR) with 95% confidence intervals (CIs) were reported. All analyses were carried out with SAS software version 9.2 (SAS Institute, Cary, NC) and R software, version 2.12.2 (http://www.r-project.org). All reported p values were two-sided.
Six hundred ninety-one histologically confirmed primary CM, diagnosed between 1984 and 2012 were eligible for the study. Median age at diagnosis was 47 years (inter-quartile range: 37–60), 375 (54%) had a thick CM (Breslow>1mm), 378 (55%) were women, 519 (75%) had a high level of education (high school at least) and 449 (65%) lived in Northern Italy. Seventy-three percent (n=501) had a superficial spreading melanoma (SSM) and 15% (n=101) nodular melanoma (NM). All potential factors associated with Breslow thickness are shown in Table 1.
Median Breslow thickness (IQR)
P-value1
Gender Female 378 1.0 (0.5, 1.9) 0.001
Male 313 1.3 (0.7, 2.4)
Age>60 years Yes 159 1.6 (0.8, 3.0) <.0001
No 532 1.0 (0.6, 2.0)
Education2 At least high school 519 1.0 (0.5, 1.9) <.0001
No High school 172 1.5 (0.9, 3.0)
Residence3 Northern Italy 449 1.2 (0.6, 2.4) 0.136
Central/southern Italy 242 1.0 (0.6, 2.1)
BMI>25 Yes 291 1.3 (0.6, 2.7) 0.003
Phototype I-II 364 1.2 (0.7, 2.2) 0.029
III-IV 314 1.0 (0.5, 2.1)
Missing 13 2.2 (1.1, 4.0)
Current smoker Yes 297 1.2 (0.6, 2.4) 0.17
Medical visit at diagnosis Dermatologist 321 1.0 (0.6, 1.8) 0.002
Other medical doctor 106 1.5 (0.6, 3.0)
Missing 264 1.1 (0.6, 2.3)
Season of diagnosis Summer 188 1.2 (0.7, 2.2) 0.161
Autumn 182 1.0 (0.5, 2.0)
Winter/springtime 321 1.1 (0.6, 2.3)
Histological type SSM 501 0.9 (0.5, 1.5) <0.0001
NM 101 3.0 (2.1, 4.3)
Other 5 2.3 (2.1, 3.0)
CM family history Yes 35 1.0 (0.6, 2.2) 0.324
NMSC personal history Yes 17 1.1 (0.7, 2.0) 0.927
Other cancer personal history Yes 15 1.2 (0.9, 2.5) 0.425
Table 1. Breslow's thickness by socio-demographic characteristics and clinical features.
P-value from Wilcoxon test, excluding missing values.
BMI: Body Mass Index; CM: Cutaneous Melanoma; NMSC: Non-Melanoma Skin Cancer. SSM: Superficial Spreading Melanoma. NM: Nodular melanoma
As expected men, older cases (above 60 years) and those with low levels of education had thicker CM compared to women, younger and more educated patients, respectively (Table 1). CMs diagnosed by a dermatologist had a lower Breslow thickness compared to those detected by general practitioners or other specialists (median Breslow 1.0 vs.1.5 mm; p=0.002). The female frequency of thick CM was significantly lower for high education than in low education (40% vs 71%; p<0.0001), whereas male thickness in men did not change by education (Figure 1b). In multivariable logistic models assessing the probability of thick (> 1mm) vs. thin (≤1mm) CM, after adjusting for age, gender, grade of clinician, BMI, family history and personal history of NMSC, the interaction between thickness and education in women remained significant (p=0.03): a 77% reduction in risk of thick CM for highly educated women (OR=0.23; 95%CI: 0.12 to 0.45) compared to low educated women, whereas this was not significant in men (OR=0.67; 95%CI: 0.33 to 1.36).
Frequencies of socio-demographic, clinical features and UV exposure indicators categorised by holidays, for the 289 patients evaluated at diagnosis, are presented in Table 2. Patients with higher level of education went more often on holidays than those with low educational levels (83% vs 65%; p<0.0001). Ulcerated CM and CM diagnosis during the summer were more common in those without holidays (Table 2). Slightly younger subjects were observed in those having holidays but this did not reach significance (p=0.07).
Sunny holidays
No Sunny holidays
P-value*
Gender Male 101 (49.0) 43 (51.8) 0.669
Female 105 (51.0) 40 (48.2)
Age at diagnosis ≤ 60 years 162 (78.6) 57 (68.7) 0.074
> 60 years 44 (21.4) 26 (31.3)
Residence Northern Italy 140 (68.0) 63 (75.9) 0.181
Southern Italy 66 (32.0) 20 (24.1)
Education At least high school 172 (83.5) 54 (65.1) <0.001
No High school 34 (16.5) 29 (34.9)
Phototype I-II 114 (55.3) 43 (51.8) 0.651
III-IV 87 (42.2) 37 (44.6)
missing 5 (2.4) 3 (3.6)
Breslow ≤1.0 97 (47.1) 29 (34.9) 0.016
1.1-2.0 mm 55 (26.7) 19 (22.9)
>4 17 (8.3) 17 (20.5)
Lymph node involvement Yes 16 (7.8) 11 (13.3) 0.147
No 190 (92.2) 72 (86.7)
Ulceration Yes 38 (18.4) 24 (28.9) 0.049
Missing 13 (6.3) 5 (6.0)
Histology SSM 165 (80.1) 60 (72.3) 0.225
NM 24 (11.7) 16 (19.3)
Other 2 (1.0) 1 (1.2)
Family history of melanoma Yes 9 (4.4) 3 (3.6) 0.951
Missing 60 (29.1) 25 (30.1)
Personal history of NMSC Yes 4 (1.9) 5 (6.0) 0.071
Grade of clinician at diagnosis Dermatologist 126 (61.2) 48 (57.8) 0.112
Other doctor 49 (23.8) 15 (18.1)
Missing 31 (15) 20 (24.1)
Melanoma on sun exposed site Yes 40 (19.4) 15 (18.1) 0.827
Holidays in tropical countries Yes 60 (29.1) 16 (19.3) 0.072
No 138 (67) 65 (78.3)
Sun exposure during peak hours (11:00AM- 1:00PM) Yes 103 (50.0) 20 (24.1) <0.001
No 99 (48.1) 59 (71.1)
Sunbed (current user) Yes 18 (8.7) 8 (9.6) 0.813
Sunbed use before age of 30 Yes 48 (23.3) 21 (25.3) 0.759
Season of diagnosis Summer 40 (19.4) 32 (38.6) 0.001
Autumn 55 (26.7) 12 (14.5)
Winter/springtime 111 (53.9) 39 (47.0)
Table 2. Proportion of patients by sunny holidays at diagnosis (Group 1).
n (%).
* P-value from Chi-square or Mantel-Haenszel Chi-Squares for trend, excluding missing values CM: Cutaneous Melanoma; NMSC: Non-Melanoma Skin Cancer. SSM: Superficial Spreading Melanoma. NM: Nodular melanoma.
Breslow categories (pT) were associated with holidays: the proportion of very thick CM (>4 mm Breslow thickness) was significantly lower among patients having holidays (8% for holidays vs 20% for no holidays; p for trend=0.002; Figure 2a). Very thick melanoma were also negatively associated with number of weeks of holidays (categorized as 'no sunny holidays', '1-2 weeks of sunny holidays per year', and '>2 weeks per year') in a dose response manner (p for trend=0.001; Figure 2b).
Figure 2. Group 1, at diagnosis.
A) Percentages of each Breslow category by sunny holidays. B) Percentages of very thick CM (Breslow>4mm) by weeks of sunny holidays.
Median Breslow thickness values are presented in Figure 3a for several categorical variables possibly associated with UV exposure. After adjusting for several confounding factors (age, gender, education, grade of clinician at visit, history of NMSC and season at diagnosis) holidays before diagnosis remained significantly associated with lower Breslow thickness (p=0.003). Exposure during peak hours, history of NMSC, sunbed use and CM body site, were not significantly associated with Breslow thickness in multivariate analyses, neither were skin type nor season of CM diagnosis.
A) Breslow thickness by UV exposure indicators. B) Breslow thickness by duration of sunny holidays. C) Breslow thickness by gender and sunny holidays.
Frequencies of sunny holidays were significantly lower in the group evaluated during follow-up (72% vs. 62% for Group1 and Group 2 respectively; P=0.01) compared to the group at diagnosis as well as sun exposure during peak hours (44% vs. 27%; P<0.0001), whereas sunbed exposure did not change (11% vs. 10%; p=0.28).
Holidays were also significantly associated with Breslow thickness in a dose-response manner (p=0.007; Figure 3b). We found a significant interaction between the effect of holidays and gender (p=0.004; Figure 3c): women had significantly lower Breslow thickness if they had a history of holidays (p=0.0004), whereas for men this protective effect of sun exposure was not significant (p=0.88).
For CM recurrence, median follow-up was 44 months (range 1-72) for group 1 and 40 months (range 2-75) for group 2. Melanoma staging was very similar according to holidays, as well as when comparing group 1 and 2 (Table 3).
Sunny holidays n=341
No sunny holidays n=155
HR (95%CI)
Group 1 Baseline Breslow 1.0 (0.5, 1.7) 1.0 (0.6, 2.1) 0.59‡
n=225 Median (Q1, Q3)
Ulcerated 26 (17%) 11 (20%) 0.57†
At follow-up
CM recurrence 11 (7%) 1 (2%) 0.18¥ 4.19 (0.53-33.36)
(0.64§)
Second primary NMSC 3 (2%) 1 (2%)
Second primary CM 5 (3%) 1 (2%)
Other cancer 2 (1%) 1 (2%)
Death 3 (2%) 2 (4%) 0.28¥
Ulceration 14 (9%) 13 (15%) 0.19†
CM recurrence 9 (5%) 10 (10%) 0.03¥ 0.30 (0.10-0.87)*
Table 3. Events among low stage melanoma patients (pT1-T3N0M0) by sunny holidays.
* In group 2 very long survivors were excluded. ¥Cox model adjusted for gender, Breslow thickness, ulceration and degree of doctor. § Gray test for competing risk analysis. ‡ Wilcoxon tests for median values; † Chi-square/Fisher exact tests. CM: Cutaneous Melanoma; NMSC: Non-Melanoma Skin Cancer.
Overall, six percent of patients had a melanoma recurrence and 5% a second primary cancer (Table 3).
Holidays before diagnosis was not associated with risk of recurrence (p=0.64 Gray test; HR=4.19; 95%CI: 0.53 to 33.36 with p=0.18; Figure 4a). However, a significant trend was found when looking at holidays during follow-up. The 5-year cumulative incidence of CM recurrences was 8% for those having holidays after diagnosis compared to 17% for those without (p=0.07 Gray test; Figure 4b). After adjustment for gender, Breslow thickness, ulceration and grade of clinician, the beneficial impact of holidays on relapse after diagnosis was statistically significant: HR of 0.30 (95%CI: 0.10 to 0.87; p=0.03). The results were not affected by further adjustment for age, education and lag time from diagnosis to questionnaire.
Figure 4. Group 1, at diagnosis: cumulative incidence for melanoma recurrence by sunny holidays (A).
Group 2, during follow-up: cumulative incidence for melanoma recurrence by sunny holidays.
Median time from diagnosis to questionnaire in group 2 was 28.8 for those having holidays after diagnosis compared to 29.1 months for those not having holidays respectively. Including long survivors the difference in recurrence between exposed and unexposed is even more significant (HR=0.24, 95%CI: 0.07-0.75 and P=0.01). When restricting the analyses for those with no more than 5 years from diagnosis to questionnaire within group 2, the hazard ratio still indicated a 60% reduction in risk of recurrence, even if it lost statistical significance: HR=0.38 (95%CI: 0.12 to 1.23; p=0.12).
We also found a dose-response relationship between risk of melanoma recurrence and number of weeks of holidays. The hazard ratio for up to 2 weeks or more of holidays were: HR=0.74 (95%CI: 0.16 to 3.45) and HR=0.28 (95%CI: 0.08 to 0.98), respectively, compared to patients not going on holidays.
A history of holidays in the sun for 2 years before CM diagnosis was significantly associated with lower Breslow thickness with a significant dose response in Italy. Sunny holidays after CM diagnosis were also associated with lower rates of CM recurrence. No association was found with sunbed exposure and sun exposure during peak-hours and we observed a lower frequencies of sunny holidays after melanoma diagnosis. Our results may possibly be explained by Vitamin D serum levels. However, the observed protective effect of sun exposure in relation to CM thickness reached statistical significance only among women. Vitamin D serum levels have been reported to be lower in women compared to men even in a sunny country like Italy[10].Thinner CM and lower recurrence rates have previously been linked to higher vitamin D serum levels[11].Other observational and case-control studies found a beneficial effect of vitamin D serum levels on melanoma survival[12-14].It has also been hypothesised that Vitamin D might have a beneficial influence for total mortality and incidence of different types of cancers, so this does not apply to melanoma only[15-20].The effect of sun exposure was independent from known melanoma prognostic factors as well as skin awareness or screening indicators.
High educational level, that can be considered a proxy for socio-economic status, was found to be significantly associated with thin CM but only among women. A limitation of this study is the lack of information on types of occupation (e.g. indoor versus outdoor work) and socio-economic status, since education can only in part overcome this problem. In fact the reason why educated females have thinner melanomas could be that they have a different pattern of sun exposure compared to men. Male gender has already been reported to be an independent risk factor for thick CM as well as living alone[21,22]. Part of the observed increase in CM incidence over the last 30 years consists in a large part of very thin CM, which could potentially be promoted by sun exposure. However this is confounded by increased awareness and screening over the last 30 years. There is a need to understand what triggers aggressive CM. Indeed, nodular melanomas are already known to be less related to sun exposure compared to superficial spreading types[3].It is important to notice that sunny holydays are not necessarily associated with sunbathing and and sunburns, well know risk factors for melanoma[23]. In fact sun exposure during hot hours and residence in tropical countries in youth, that are proxy for sunbathing and sunburns more than sunny holidays, were not found to be associated with CM prognosis.
Our data confirmed a greater frequency of SSM in patients going on regular holidays in the sun. However, adjusting for histology, the effect of UV exposure on CM thickness and recurrence remained.
A potential bias for the effect of sun exposure on thickness could be screening bias, We took into account of this looking at grade of clinician and season of diagnosis. In fact subjects who had regular holidays in the sun before diagnosis were more prone to seek dermatological screening as in view of their sun seeking behaviour or because having naked skin in summer made them more aware of potentially malignant lesions. However frequencies of visits to dermatologists were similar in exposed and unexposed and all the analyses were adjusted for grade of clinician. Furthermore season of diagnosis, was not significantly associated with Breslow thickness and CM diagnosed during summer months were more frequent among patients with no holidays, which does not suggest a screening bias.
We know that skin awareness and going on holidays are linked with education, but sunny holidays were associated with thickness and melanoma recurrence adjusting for educational status and skin awareness indicators.
Another selection bias could be that patients who enjoy outdoor sun exposure are more likely to be in good health, compared to patients who are older and/or with comorbidities who may have a higher chance of relapse. However the two exposure groups have similar initial stage of disease. In order to avoid time related biases, such as immortal bias, we started the analysis from the time of the questionnaire. It is still possible that other unknown protective factors in sun seeking individuals explained the improved survival.
Despite the fact that there are sources of bias that we were not able to fully address, we believe that our study shows several intriguing results that should be further investigated and are in agreement with previous epidemiological publications un sun exposure indicators and melanoma survival[4][24][25] It is also reassuring that results on recurrence are in agreement with results at baseline: sunny holidays are inversely associated with worse prognostic factors (thickness and ulceration) and recurrence. Furthermore dose-response relationships are confirmed. Moreover, if major confounders had biased results, we should have obtained similar results with other indicators of UV exposure, such as sun exposure during peak hours and sunbed use, but it was not the case: only sunny holidays were found to be inversely associated with CM prognosis.
Solar radiation is a well-established skin carcinogen so the interpretation of the protective effects of sun exposure on melanoma needs to be made with caution. These results need to be confirmed by larger studies with measurements of Vitamin D serum levels in summer and winter as well as data on Vitamin D receptor genotypes. In the meantime, there is a need to be aware of the risk of Vitamin D deficiency in melanoma patients and we recommend measuring Vitamin D levels during follow up and offer supplementation if necessary[26].[19,27]
Conceived and designed the experiments: SG EV AT. Performed the experiments: GT GS FB EC PFF EP FC BB AC MB. Analyzed the data: SG EB PM. Contributed reagents/materials/analysis tools: MB. Wrote the manuscript: SG EV VB EB. Interpreting the data: SG EB PM CM AJ VB.
1. Tryggvadóttir L, Gislum M, Hakulinen T, Klint A, Engholm G et al. (2010) Trends in the survival of patients diagnosed with malignant melanoma of the skin in the nordic countries 1964-2003 followed up to the end of 2006. Acta Oncol 49: 665-672. doi:https://doi.org/10.3109/02841861003702528. PubMed: 20491525.
2. de Vries E, Bray FI, Coebergh JW, Parkin DM (2003) Changing epidemiology of malignant cutaneous melanoma in europe 1953-1997: Rising trends in incidence and mortality but recent stabilizations in western europe and decreases in scandinavia. Int J Cancer 107: 119-126. doi:https://doi.org/10.1002/ijc.11360. PubMed: 12925966.
3. Holman CD, Armstrong BK, Heenan PJ (1986) Relationship of cutaneous malignant melanoma to individual sunlight-exposure habits. J Natl Cancer Inst 76: 403-414. PubMed: 3456458.
4. Berwick M, Armstrong BK, Ben-Porat L, Fine J, Kricker A et al. (2005) Sun exposure and mortality from melanoma. J Natl Cancer Inst 97: 195-199. doi:https://doi.org/10.1093/jnci/dji019. PubMed: 15687362.
5. Idorn LW, Datta P, Heydenreich J, Philipsen PA, Wulf HC (2013) Sun behaviour after cutaneous malignant melanoma: A study based on ultraviolet radiation measurements and sun diary data. Br J Dermatol 168: 367-373. doi:https://doi.org/10.1111/bjd.12066. PubMed: 23013402.
6. Soto E, Lee H, Saladi RN, Gerson Y, Manginani S et al. (2010) Behavioral factors of patients before and after diagnosis with melanoma: A cohort study - are sun-protection measures being implemented? Melanoma Res 20: 147-152. doi:https://doi.org/10.1097/CMR.0b013e328328f802. PubMed: 20224304.
7. Idorn LW, Philipsen PA, Wulf HC (2011) Sun exposure before and after a diagnosis of cutaneous malignant melanoma: Estimated by developments in serum vitamin D, skin pigmentation and interviews. Br J Dermatol 165: 164-170. doi:https://doi.org/10.1111/j.1365-2133.2011.10348.x. PubMed: 21457211.
8. Parr CL, Hjartåker A, Laake P, Lund E, Veierød MB (2009) Recall bias in melanoma risk factors and measurement error effects: A nested case-control study within the norwegian women and cancer study. Am J Epidemiol 169: 257-266. PubMed: 19011116.
9. Cockburn M, Hamilton A, Mack T (2001) Recall bias in self-reported melanoma risk factors. Am J Epidemiol JID - 7910653 153: 1021-1026. PubMed: 11384959.
10. Carnevale V, Modoni S, Pileri M, Di Giorgio A, Chiodini I et al. (2001) Longitudinal evaluation of vitamin D status in healthy subjects from southern italy: Seasonal and gender differences. Osteoporos Int 12: 1026-1030. doi:https://doi.org/10.1007/s001980170012. PubMed: 11846328.
11. Egan KM, Sosman JA, Blot WJ (2005) Sunlight and reduced risk of cancer: Is the real story vitamin D? J Natl Cancer Inst 97: 161-163. doi:https://doi.org/10.1093/jnci/dji047. PubMed: 15687354.
12. J. A.; Beswick S, Randerson-Moor J, Chang YM, Affleck P et al. (2009) Serum 25-hydroxyvitamin D3 levels are associated with breslow thickness at presentation and survival from melanoma. J Clin Oncol, 27: 5439–44. PubMed: 19770375. PubMed: 19770375.
13. Randerson-Moor JA, Taylor JC, Elliott F, Chang YM, Beswick S et al. (2009) Vitamin D receptor gene polymorphisms, serum 25-hydroxyvitamin D levels, and melanoma: UK case-control comparisons and a meta-analysis of published VDR data. Eur J Cancer 45: 3271-3281. doi:https://doi.org/10.1016/j.ejca.2009.06.011. PubMed: 19615888.
14. Newton Bishop J,Beswick S,Jackon S,Renderson Moor J,Elliott F,Barrett J,Affleck P,Marsden J, Bishop T (2006) Vitamin D and survival from melanoma. Melanoma Res 16.
15. Autier P, Gandini S (2007) Vitamin D supplementation and total mortality: A meta-analysis of randomized controlled trials. Arch Intern Med 167: 1730-1737. doi:https://doi.org/10.1001/archinte.167.16.1730. PubMed: 17846391.
16. Gandini S, Boniol M, Haukka J, Byrnes G, Cox B et al. (2011) Meta-analysis of observational studies of serum 25-hydroxyvitamin D levels and colorectal, breast and prostate cancer and colorectal adenoma. Int J Cancer 128: 1414-1424. doi:https://doi.org/10.1002/ijc.25439. PubMed: 20473927.
17. Gandini S, Raimondi S, Gnagnarella P, Doré JF, Maisonneuve P et al. (2009) Vitamin D and skin cancer: A meta-analysis. Eur J Cancer 45: 634-641. doi:https://doi.org/10.1016/j.ejca.2008.10.003. PubMed: 19008093.
18. Raimondi S, Johansson H, Maisonneuve P, Gandini S (2009) Review and meta-analysis on vitamin D receptor polymorphisms and cancer risk. Carcinogenesis 30: 1170-1180. doi:https://doi.org/10.1093/carcin/bgp103. PubMed: 19403841.
19. Guerrieri-Gonzaga A, Gandini S (2013) Vitamin D and overall mortality. Pigment Cell. Melanoma Res 26: 16-28.
20. Lazzeroni M, Serrano D, Pilz S, Gandini S (2013) Vitamin d supplementation and cancer: Review of randomized controlled trials. Anti Cancer Agents Med Chem 13: 118-125. doi:https://doi.org/10.2174/187152013804487281. PubMed: 23094929.
21. Grange F, Barbe C, Aubin F, Lipsker D, Granel-Brocard F et al. (2012) Clinical and sociodemographic characteristics associated with thick melanomas: A population-based, case-case study in france. Arch Dermatol : 1-7. PubMed: 22986518.
22. Mandalà M, Imberti GL, Piazzalunga D, Belfiglio M, Lucisano G et al. (2011) Association of socioeconomic status with breslow thickness and disease-free and overall survival in stage I-II primary cutaneous melanoma. Mayo Clin Proc 86: 113-119. doi:https://doi.org/10.4065/mcp.2010.0671. PubMed: 21282485.
23. Gandini S, Sera F, Cattaruzza MS, Pasquini P, Picconi O et al. (2005) Meta-analysis of risk factors for cutaneous melanoma: II. sun exposure. Eur J Cancer 41: 45-60. doi:https://doi.org/10.1016/j.ejca.2004.10.016. PubMed: 15617990.
24. Rosso S, Sera F, Segnan N, Zanetti R (2008) Sun exposure prior to diagnosis is associated with improved survival in melanoma patients: Results from a long-term follow-up study of italian patients. Eur J Cancer 44: 1275-1281. doi:https://doi.org/10.1016/j.ejca.2008.03.009. PubMed: 18406602.
25. Yang L, Lof M, Veierød MB, Sandin S, Adami HO et al. (2011) Ultraviolet exposure and mortality among women in sweden. Cancer Epidemiol Biomarkers Prev 20: 683-690. doi:https://doi.org/10.1158/1055-9965.EPI-10-0982. PubMed: 21297041.
26. Davies JR, Chang YM, Snowden H, Chan M, Leake S et al. (2011) The determinants of serum vitamin D levels in participants in a melanoma case-control study living in a temperate climate. Cancer Causes Control 22: 1471-1482. doi:https://doi.org/10.1007/s10552-011-9827-3. PubMed: 21853245.
27. Gambichler T, Bindsteiner M, Höxtermann S, Kreuter A (2013) Serum 25-hydroxyvitamin D serum levels in a large german cohort of patients with melanoma. Br J Dermatol 168: 625-628. doi:https://doi.org/10.1111/j.1365-2133.2012.11212.x. PubMed: 22880705.
Related PLOS Articles
has CORRECTION
Correction: Sunny Holidays before and after Melanoma Diagnosis Are Respectively Associated with Lower Breslow Thickness and Lower Relapse Rates in Italy
Melanomas
Is the Subject Area "Melanomas" applicable to this article?
Overexposure to sun
Is the Subject Area "Overexposure to sun" applicable to this article?
Cancer detection and diagnosis
Is the Subject Area "Cancer detection and diagnosis" applicable to this article?
Is the Subject Area "Vitamin D" applicable to this article?
Is the Subject Area "Cutaneous melanoma" applicable to this article?
Is the Subject Area "Histology" applicable to this article?
Is the Subject Area "Schools" applicable to this article?
Is the Subject Area "Patients" applicable to this article?


Jan Hackett, Donald Maughan (Suffolk Park Progress Association), Patricia Warren, Jenny Coman (Bangalow Progress Association), Ruth Winton-Brown (Possum Creek Residents' Group), Suzy Skivington, David Bradbury and Arthur Burroughes addressed Council against the recommendation.
Garth Luke and Greg Mulcahy addressed Council against the recommendation.
Phillip Agnew and Duncan Band, representing the applicant, addressed Council in favour of the recommendation.
Len Bates and Christine McNeil addressed Council against the recommendation.
Cristobel Munson address Council regarding the report.
Crs Woods and Cubis left the chambers at 10.31am.
The meeting adjourned at 10.36am and reconvened at 10.59am. Crs Woods and Cubis returned to the meeting at this time.
The remaining Recommendations were adopted as a whole, being moved by Cr Woods and seconded by Cr Richardson. Each recommendation is recorded with a separate resolution number commencing at Resolution No. 16-323 and concluding with Resolution No. 16-325.
A Residential Ordinary Rate of 0.2302 cents in the dollar on the land value of all land categorised as residential, with a minimum rate of $695.00 per rateable assessment. Exception to this will be in respect to vacant land which meets the definition of vacant coastal hazard and flood liable land as per section 548 of the Act. In this case the minimum rate amount shall be $382.00 per rateable assessment.
A Business (Other) Ordinary Rate of 0.3453 cents in the dollar on the land value of all land categorised as business outside the 'centre of activity' known as Byron Bay Business Centre, with a minimum rate of $695.00 per rateable assessment.
A Business (Byron Bay Business Centre) Ordinary Rate of 0.4604 cents in the dollar on the land value of all land categorised as business within the boundary of the 'centre of activity' known as Byron Bay Business Centre, with a minimum rate of $695.00 per rateable assessment.
A Farmland Ordinary Rate of 0.1697 cents in the dollar on the land value of all land categorised as farmland, with a minimum rate of $695.00 per rateable assessment. Exception to this will be in respect to vacant land which meets the definition of vacant coastal hazard and flood liable land as per section 548 of the Act. In this case the minimum amount shall be $382.00 per rateable assessment.
Note: MGB is defined as mobile garbage bin.
In accordance with Section 496 of the Act, a charge of $25.00, to be known as the Domestic Waste Management Charge – Vacant Land is to apply for 2016/2017 to all vacant residential rateable land contained within the defined collection area.
In accordance with Section 496 of the Act, a charge, to be known as the Rural Domestic Waste Management Charge, for the provision of a fortnightly waste service is to apply for 2016/2017 to all rateable residential land within the rural service collection area. This charge, depending on the number of services, is to be levied for the removal of domestic waste and recyclable materials on and during the normal collection day and hours. This is subject to the right of the Council to seek to vary such charge during the year, if in the opinion of the Council; such action is warranted in view of any variation in the cost of rendering the service.
An annual charge of $277.00, to be known as the Rural Waste Management Charge will be charged per service to residential properties in the rural service collection area that provides for fortnightly collection of 240 litre waste bin and 240 litre recycling bin.
In accordance with Section 496 of the Act, an annual charge of $25.00, to be known as the Rural Waste Availability Charge will apply for 2016/2017 to residential properties in the rural service collection area that choose not a have a Council Rural Domestic Waste service but have a dwelling situated on the property. Rural property owners paying the Rural Waste Availability Charge have the option to commence services if their circumstances change.
Properties that are unable to be serviced will not incur this service availability charge.
In accordance with Section 501 of the Act, a charge, to be known as the Rural Waste Management Charge, for the provision of a fortnightly waste service is to apply for 2016/2017 to all non-residential land within the rural service collection area. This charge, depending on the number of services chosen, is to be levied for the removal of waste and recyclable materials on and during the normal collection day and hours. This is subject to the right of the Council to seek to vary such charge during the year, if in the opinion of the Council; such action is warranted in view of any variation in the cost of rendering the service.
An annual charge of $433.00, to be known as the Rural Non-Domestic Waste Management Charge will be charged per service to non-residential properties in the rural service collection area that provides for fortnightly collection of 240 litre waste bin and 240 litre recycling bin.
In accordance with Section 501 of the Act, charges to be known as Commercial Waste Management Charges are applied to commercial and non-residential properties for the provision of garbage services to properties within the defined collection area that chose to utilise the service. Charges depending on bin capacity, frequency of service and number of services are to be levied for the removal of waste and nominated recyclable materials on and during the normal collection day and hours.
In accordance with Section 501 of the Act, a charge to be known as the Waste Operations Annual Charge will apply for 2016/2017 to all properties subject to all domestic, rural domestic and commercial collection charges excluding vacant land.
An annual charge of $70.00 per service is to be levied to assist in funding the on-going operations of Council landfill and transfer station facilities.
In accordance with Section 501 of the Act, a charge to be known as Water Fixed Charge, will apply for 2016/2017 to all properties to which a water supply is available. The amount of the charge will be dependant on the meter connection size and the number of services existing on the property as detailed below.
Where water supply is available to Strata Units a charge equivalent to a 20mm Water Fixed Charge will apply to each unit. This charge is variable by meter size should a water meter be connected.
A minimum charge of $90.00 will apply to each parcel of rateable land (including vacant land) which does not have a water service connection but to which a water service is available in accordance with the provisions of Section 552(1)(b) of the Local Government Act 1993.
Where a meter connected to a property is being used for Fire Services a charge of $238.00 will apply regardless of the meter connection size.
In accordance with Section 502 of the Act, all Residential properties in 2016/2017 will be charged a Water Usage Charge for the use of the Water Supply Service on a quarterly basis based as per the usage recorded through the water meter or meters servicing the property. The charge will be based on an inclining block tariff with the first incline up to 450kls per reading year being charged at $2.47 per kilolitre and any usage above 450kls per reading year being charged at $3.70 per kilolitre.
Non-Residential properties will be charged $2.65 per kilolitre for all water used as recorded through the water meter or meters servicing the property. Non-complying water supply users will be charged $5.30 per kilolitre.
In accordance with Section 501 of the Act, a charge of $819.00, to be known as Sewerage Service Fixed Charge, will apply to all single dwelling residential properties in 2016/2017.
Where the sewerage service supply is available to Strata Units a charge equivalent to a 20mm Sewerage Service Fixed Charge will apply to each unit. This charge is variable by meter size should a separate water meter be connected.
A minimum charge of $410.00 will apply to each parcel of rateable land (including vacant land) which does not have a sewerage service connection but to which a sewerage service is available in accordance with the provisions of Section 552(3)(a) of the Local Government Act 1993.
Premises connected to Councils Sewer System through a sewer pod will incur an annual Fixed Charge of $794.00.
The 2016/2017 Sewerage Service Fixed Charge for Non-Residential properties (including Non-rateable properties) will be proportional to the size of the water supply service connection to the property.
The amount of the charge will be dependant on the meter connection size and the number of services existing on the property as detailed below.
Where a meter larger than a 20mm water meter is connected to a property, categorised as Residential, which has multiple occupancies (ie not a single dwelling house) the Sewerage Service Fixed Charge will be applied as per the meter connection size and the number of services existing on the property as per the Sewerage Service Fixed charges for Non-Residential properties.
Where the sewerage service supply is available to a Non-Residential Strata Unit a charge equivalent to a 20mm Sewerage Service Fixed Charge will apply to each unit. This charge is variable by meter size should a separate water meter be connected.
A minimum charge of $410.00 will apply to each parcel of non-residential rateable land which does not have a sewerage service connection but to which a sewerage service is available in accordance with the provisions of Section 552(3) (a) of the Local Government Act 1993.
Non-residential properties connected to Councils Sewer System through a sewer pod will incur an annual Fixed Charge of $794.00.
In accordance with Section 502 of the Act, a Sewer Usage Charge of $1.85 per kilolitre of water used will be charged for 2016/2017 for Residential properties.
Non-residential properties having differing sewer discharge factors (SDF) will be charged for 2016/2017 by applying the individual SDF to a Non-Residential Sewer Usage Charge of $2.47 per kilolitre of water (as measured by the water meter connection to the property).
In accordance with Section 501 of the Act, Council will charge a Liquid Trade Waste Fixed Charge against properties connected to Council's sewerage system based on the level of impact dischargers have on the system. The Liquid Trade Waste Annual Charge is charged on properties which discharge liquid trade waste but are not required to apply for Council approval.
Other Liquid Trade Waste Fixed charges are based on the level of impact dischargers have on the sewerage system and the requirement of pre-treatment equipment (such as grease traps) to be installed on the property. The Liquid Trade Waste charges for 2016/2017 are detailed below.
In accordance with Section 502 of the Act, properties assessed as discharging Liquid Trade Waste to Councils sewer system will be charged a Liquid Trade Waste Usage Charge by applying the individual Liquid Trade Waste Factor (LTWDF) against the liquid trade waste usage charge for 2016/2017 of $2.24 per kilolitre of water (as measured by the water meter connection to the property).
***Properties that are technically non-complying dischargers into Council's sewer system will be levied a trade waste usage charge of $5.30 per kilolitre of water (as measured by the water meter connection to the property).
In accordance with Section 496A of the Act, Council will charge a 'Stormwater Management Charge' against rateable properties for which the service is available. Council has identified the residential and business properties that are within Council's urban stormwater catchment areas that will be levied this charge for the 2016/2017 financial year.
A flat charge of $25.00 for a Stormwater Management Service Charge is to be charged against each eligible assessment categorised as Residential within the urban stormwater catchment.
A flat charge of $12.50 for a Stormwater Management Service Charge is to be levied against each eligible residential strata unit within the urban stormwater catchment.
A Stormwater Management Service Charge is to be charged against each eligible assessment (not being strata titled) categorised as business within the urban stormwater catchment area based on the total area of the assessment. A charge of $25.00 for every 350 square metres or part of 350 square metres will apply, with a minimum charge of $25.00 to apply for those properties with an area of less than 350 square metres.
If the strata complex contains only business properties (i.e. not mixed development) the charge per strata unit will be calculated by using a charge of $25.00 per 350m² of the land area occupied by the strata scheme (or part thereof), proportioned by the unit entitlement of each lot in the strata scheme. In the event that this approach results in charge of less than $5.00 per unit, a minimum charge of $5.00 will be levied on each strata unit.
If the strata complex contains mixed development (i.e. properties rated as both business and residential) the dominant category of the strata scheme must be determined and charges will apply for Business strata unit or Residential Strata units as previously adopted. In the event that a mixed development is 50% residential and 50% business, council has the discretion to determine whether to charge the property as a residential or business property.
1. That the revised draft Development Servicing Plans for Water Supply and Sewerage be placed on public exhibition for 30 working days and undertake consultation in accordance with the Developer Charges Guidelines for Water Supply, Sewerage and Stormwater (2012).
2. That a report be prepared for Council addressing any comments received during the exhibition period and presenting the draft Development Servicing Plans for adoption by Council or, in the event that no submissions are received, adopt the documents as exhibited.
1. That Council amend the draft Coastal Zone Management Plan Byron Bay Embayment (CZMP) in accordance with the recommendations listed in Table 1 of this report and with a further amendment proposing planned retreat in lieu of armouring of 1.06km of the coast at Belongil.
2. That Council exhibit the draft CZMP as amended above for a period of 8 weeks.
1. That Council amend the draft Coastal Zone Management Plan Byron Bay Embayment in accordance with the recommendations listed in Table 1 of this report.
2. That Council submit the draft Coastal Zone Management Plan Byron Bay Embayment, as amended, to the Minister for certification under section 55G of the Coastal Protection Act 1979.
3. That Council continue to monitor all possible sources of funding, including government funding, to assist with the adoption and implementation of the CZMP as submitted.
The meeting adjourned at 12.18pm and reconvened at 12.36pm.
1. That Council defer development application 10.2016.189.1 for multi dwelling units (10 single bedroom units) and demolition of existing structures to allow for further consultation with the applicant to seek an amended design that is more compatible with the character of the local area, including heritage conservation zone, particularly regarding bulk, scale and form.
Resolved that Cr Wanchap be granted a two minute extension to her speech.
Crs Dey, Richardson, Cameron and Wanchap voted against the motion.
Crs Ibrahim, Cubis and Hunter voted against the motion.
The amendment (Ibrahim/Spooner) was put to the vote and declared carried.
Crs Ibrahim, Cubis, Woods, Spooner and Hunter voted in favour of the amendment.
Crs Dey, Richardson, Cameron and Wanchap voted against the amendment.
Crs Ibrahim, Cubis, Woods, Spooner and Hunter voted in favour of the motion.
The meeting adjourned at 1.32pm and reconvened at 3.19pm.
Cr Spooner left the meeting at 1.32pm.
1. That pursuant to Section 10A(2)(g) of the Local Government Act, 1993, Council resolve into Confidential Session to discuss the reports Implementation of Part 12 of Resolution 16-028 and Byron Shire Council ats Ralf Lauren 57 Pty Ltd.
(c) disclosure of the reports contents could adversely impact Council's position in ongoing negotiations.
That Council request general advice in relation to the legal options and likely impediments to the implementation of planned retreat so as to identify the processes and the challenges.
2. That Council convene an Extraordinary meeting to be held on 14 July 2016 to receive general advice recommended in report 5.1 and any other coastal matters including rescission motions that may materialise in the intervening period.
Crs Richardson and Cameron voted against the motion.
Crs Dey, Richardson and Cameron voted against the motion.
Cr Ibrahim left the meeting at 4:15pm.
Cr Cubis left the meeting at 4:20 PM.
b) Allocate $40,000 for the Zero Emissions Byron Project in the 2016/2017 Budget Estimates funded from the Environmental Levy Reserve to be spent on project management and technical advice.
ii) use of the Auditorium at the Cavanbah Centre (Casual User Yearly Pass (Junior) -$330.00 and Casual User Yearly Pass (Senior) - $420.00)) and advertise these fees for public comment for a period of 28 days.
d) Adopt the new fees and incorporate these changes into Council's adopted Fees and Charges for 2016/17, should no submissions be received.
The motion (Richardson/Wanchap) was put to the vote and declared carried.
Resolved that the vote on Resolution No. 16-326 be recommitted.
The motion was put to the vote and declared tied.
Crs Woods, Wanchap and Hunter voted against the motion.
The Mayor used his casting vote and declared the motion carried..
Crs Woods, Wanchap and Hunter left the meeting 4.31pm.
Due to a lack of quorum the meeting closed at 4.35pm. Councillors present when the meeting was closed were Crs Dey, Richardson and Cameron.
as confirmed at Council's Ordinary Meeting on 4 August 2016.


Firstly, I would like to thank Rebekah Rose for her donation and Alyssa Miles for supporting me on patreon! I am very grateful of all the donations and pledges I receive because I know you guys could've saved the money and spent it on yourselves instead. Thank you!
Secondly, I have written a blog post on my translation struggles. I shared my sorrows and how I felt when wordads banned my site from advertisements. In June, I made $0.88 with 115k views. I broke down and I was so depressed.
Thirdly, I have taken out some fillers from the chapters. It should still read relatively smooth (sometimes the sentences may be awkward because my brain cannot properly convert the Chinese into English). I want to make sure something actually happens in each chapter. This chapter wasn't too exciting but in a few chapters from now, hehehehehe. You guys will be happy again because Le Yao Yao is going to do something very stupid and arouse the Prince!!
Without further ado, here is Chapter 62.
I'm sorry to hear about your ad woes. Is it possible to sign up with a different ad site? Google Ads?


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text:
Hoff is a hamlet and civil parish in the Eden district of the county of Cumbria, England. At the 2001 census the parish had a population of 189, decreasing marginally to 164 at the 2011 Census.

Hoff consists of a number of houses, pub, The New Inn, which re-opened in 2011 after a number of years of closure; a postbox; and, formerly, a pioneering solar-powered lamppost.  The name Hoff originates from old Norse and means 'a heathen sanctuary or temple'.

See also

Listed buildings in Hoff, Cumbria

References

External links
 Cumbria County History Trust: Hoff (nb: provisional research only – see Talk page)

Hamlets in Cumbria
Civil parishes in Cumbria

redpajama_set_name: RedPajamaWikipedia


This topic contains 2 replies, has 2 voices, and was last updated by Teresa H 6 years, 2 months ago.
There are few foods that make you feel like you are doing something good for yourself while you are eating them—winter greens are one of those foods. Yes, kale is having her moment in the spotlight right now, and it is a wonderful, healthful green—we consume loads of cavolo nero, or Tuscan kale this time of year; braised, in soups, risottos, salads and sautés—but tonight it's spicy, snappy mustard greens. Their zippy, peppery, slightly bitter flavor brings a welcome brightness to cold winter days.
Any winter greens can be used in this manner, just be aware that the sturdier greens such as collards need a longer cooking time, and braising may be a better way to go.
Most greens are grown in sandy soil, and it's wise to give them a good rinse in 2-3 changes of water. Tear the leaves into 3"-4" pieces, and dry thoroughly, as sautéing moist greens will result in spectacular splattering.
1. In a large frying pan over medium-high heat, heat 2 tbsp. olive oil until it shimmers. Add the pancetta pieces, and fry until slightly browned, but not crispy—they will continue to cook with the greens.
2. Begin adding greens by the handful—the pan will fill quickly, but the greens will lose most of their volume as they cook. Using tongs, begin turning the greens, allowing them to be coated by the hot oil. After approximately half of the greens have been added to the pan, add a little more oil and toss in the garlic slices. Sauté the garlic until pale gold, being careful not to let it burn. Add the rest of the greens as the space in the pan allows.
3. Once all the greens are wilted, add salt & pepper to taste, and turn off the heat. A small spoonful of chili paste or dried chili flakes at this point adds a bit of pleasant heat—be sure to toss well to distribute the chilies evenly. Just before serving, a quick splash of red wine vinegar or a squeeze of lemon juice brighten the flavor of this dish. Serve hot or room temperature.
This recipe is versatile as a side dish for sausages or pork chops as we had for dinner tonight, or as a topper for creamy polenta.
You can also use it as the base for baked eggs in cream—place ¼ cup sautéed greens in the bottom of an ovenproof ramekin, crack an egg over the greens, pour in just enough cream to cover the egg white and top with a bit of chopped chive and a grind of black pepper (add a bit of grated Parmigiano-Reggiano if you're feeling really decadent). Place in a 350-degree oven for 15 minutes, or until whites are set and yolk is still soft.
Thanks for the feedback; I'm happy to share recipes, especially with fellow enthusiasts! I have also prepared a meat-free version of this dish, sauteeing up slices from half an onion til golden brown, then adding the greens. The result is a sweeter flavor, but it balances nicely with the chilies. I've not added mushrooms before, but I'll definitely try it next time!