INTRODUCTION — Vitiligo is a relatively common acquired chronic disorder of pigmentation characterized by the development of white macules on the skin due to loss of epidermal melanocytes [1,2]. The depigmented areas are often symmetrical and usually increase in size with time. Given the contrast between the white patches and areas of normal skin, the disease is most disfiguring in darker skin types and has a profound impact on the quality of life of children and adults [3,4]. Patients with vitiligo often experience stigmatization, isolation, and low self-esteem [5-8].
Although there is no cure for the disease, the available treatments may halt the progression of the disease and induce varying degrees of repigmentation with acceptable cosmetic results in many cases. This topic review will discuss the management of vitiligo
Goals of treatment — The goals of treatment for vitiligo should be set with the individual patient or parents in the case of children, based upon the patient’s age and skin type, the extent, location, and degree of disease activity, and the impact of the disease on the patient’s quality of life. An open discussion with the patient about the limitations of treatment may be helpful to create realistic expectations.
Nonsegmental vitiligo has an unpredictable course, and treatment is often challenging. However, multiple therapies, including topical agents, light therapies, and autologous grafting procedures, have demonstrated efficacy for repigmentation of vitiligo . The response to treatments is generally slow and may be highly variable among patients and among different body areas in the same patient. The best outcomes are often achieved in darker skin types (Fitzpatrick IV to VI), although satisfactory results are often seen also in lighter skin types (Fitzpatrick II, III). Facial and truncal lesions respond well to treatment, while acral areas are extremely difficult to treat.
APPROACH — Our approach to the management of patients with vitiligo is generally consistent with published guidelines [11,12]. Topical, systemic, and light-based therapies are available for the stabilization and repigmentation of vitiligo (table 1) [13-17]. Treatment modalities are chosen in the individual patient on the basis of the disease severity, patient preference (including cost and accessibility), and response evaluation. Combination therapies, such as phototherapy plus topical or oral corticosteroids, are usually more effective than single therapies . Despite treatment, however, vitiligo has a highly unpredictable course, and the long-term persistence of repigmentation cannot be predicted .
Stabilization of rapidly progressive disease — For patients who experience rapid progression of vitiligo, with depigmented macules spreading over a few weeks or months, we suggest low-dose oral corticosteroids as first-line therapy for the stabilization (cessation of spread) of the disease (table 1). Oral prednisone is given at the dose of 5 to 10 mg per day in children and 10 to 20 mg per day in adults for a maximum of two weeks. If needed, treatment can be repeated in four to six weeks.
In adult patients, alternatives to oral prednisone include oral mini-pulse therapy with dexamethasone 2.5 mg on two consecutive days weekly for an average of three months or intramuscular triamcinolone 40 mg in a single administration. Treatment with triamcinolone can be repeated in four to six weeks for a maximum of three injections. (See ‘Systemic corticosteroids’ below.)
Stabilization therapy can be given with or without concomitant narrowband ultraviolet B (NB-UVB) phototherapy. However, for patients with active disseminated disease affecting multiple anatomic sites, we suggest that systemic corticosteroids and NB-UVB phototherapy be initiated concomitantly. The disease is expected to stabilize in one to three months.
In both adults and children in whom systemic corticosteroids are contraindicated, NB-UVB phototherapy alone may be used to stabilize active vitiligo. NB-UVB is administered two to three times weekly.
Vitiligo envolvendo menos do que 10 porcento da Superfície Corporal Total
Localized disease — In patients with nonsegmental stable vitiligo (no increase in size of existing lesions and absence of new lesions in the previous three to six months) that involves <10 percent of the total body surface area (TBSA) and is limited to the face, neck, trunk, or extremities, mid- to high-potency topical corticosteroids (groups two to four (table 2) are the first-line therapy. High-potency and mid-potency topical corticosteroids are applied to the involved skin once and twice daily, respectively. Agents with negligible systemic or local side effects, such as mometasone furoate, are preferred .
There are no studies evaluating the optimal duration of treatment with topical corticosteroids. In the author’s experience, topical corticosteroids can be used safely for two to three months, interrupted for one month, and then resumed for an additional two or three months. Others suggest a discontinuous scheme (eg, once-daily application for 15 days per month for six months).
Patients must be monitored closely for adverse effects of topical corticosteroids, which include skin atrophy, telangiectasias, hypertrichosis, and acneiform eruptions. Limited quantities should be prescribed.
Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are the preferred first-line therapy in patients with limited disease involving the face or areas at high risk for skin atrophy. Topical calcineurin inhibitors are generally applied twice daily. They can also be used in combination with a topical corticosteroid for the first month or two, applying each one once daily.
Topical corticosteroids — Mid- to super-high-potency topical corticosteroids are commonly used as a first-line therapy for the treatment of limited vitiligo. Their efficacy is attributed to modulation of the immune response.
The efficacy of topical corticosteroids as monotherapy for the treatment of vitiligo is supported by a few small randomized trials . A systematic review of 17 randomized trials examined the effect of topical corticosteroids in combination with other therapies (eg, narrowband ultraviolet B [NB-UVB], psoralen plus ultraviolet A with sunlight [PUVAsol], excimer laser) . The combination of potent or super-potent topical corticosteroids (eg, betamethasone dipropionate, mometasone furoate, clobetasol propionate) with light therapies is more effective than light therapies alone in inducing repigmentation [27-29]. However, the quality of studies was generally poor, and the study results could not be pooled because of considerable heterogeneity in study design and outcome measure.
Adverse effects related to a prolonged use of topical corticosteroids, including folliculitis, mild atrophy, telangiectasia, and hypertrichosis, have been reported, generally in a small number of patients, in nearly all studies. Systemic absorption resulting in adrenal suppression is a concern when large areas of skin and areas with thin skin are treated for a prolonged time with potent steroids, especially in children .
Topical calcineurin inhibitors — Tacrolimus and pimecrolimus are topical immunomodulatory agents that affect the T-cell and mast-cell function and inhibit the synthesis and release of multiple proinflammatory cytokines, including interferon-gamma, tumor necrosis factor-alpha, interleukin (IL)-4, IL-5, and IL-10 [30-32]. In contrast with topical corticosteroids, topical calcineurin inhibitors do not induce skin atrophy, striae, or telangiectasias and are increasingly used for the treatment of facial vitiligo.
The efficacy of tacrolimus and pimecrolimus alone or in combination with other therapies for the treatment of nonsegmental vitiligo has been evaluated in several randomized trials including either adults or children with vitiligo .
●In a randomized trial, 100 children (55 children with facial vitiligo; 45 with nonfacial vitiligo) were treated with topical corticosteroid (clobetasol propionate 0.05%), tacrolimus 0.1%, or placebo for six months . Among children with facial vitiligo, the success rate (defined as repigmentation >50 percent) was the same in the topical corticosteroid and tacrolimus groups (58 percent); however, among children with nonfacial vitiligo, the success rate was higher in the topical corticosteroid group compared with the tacrolimus groups (39 versus 23 percent). The success rate in the placebo group was 7 percent.
●Another randomized trial including 44 adult patients with stable vitiligo compared 0.1% tacrolimus ointment twice daily, 1% pimecrolimus cream twice daily, and NB-UVB phototherapy three times a week for 24 weeks . At the end of the study, there was no significant difference among treatments in the repigmentation for any anatomical site.
●In a 12-week open, randomized study, 53 patients with vitiligo were treated with 308 nm monochromatic excimer light (MEL) twice weekly plus 0.1% tacrolimus and oral vitamin E daily, 308 nm MEL twice weekly plus daily oral vitamin E, or daily oral vitamin E alone . At the end of the study, good to excellent repigmentation was achieved in 70 percent of patients in the MEL plus tacrolimus and vitamin E group, 55 percent of those in the MEL plus vitamin E group, and in none of the patients in the vitamin E group.
●In an open trial, 40 children with nonsegmental, focal, or segmental vitiligo were treated with 0.1% mometasone furoate cream once daily or 1% pimecrolimus cream twice daily for three months . Moderate or marked responses were seen in 11 patients (55 percent) in the mometasone furoate group and in 7 (35 percent) in the pimecrolimus group, but the difference was not statistically significant.
Although the increased risk of skin cancer among transplant patients treated with systemic calcineurin inhibitors is well recognized, the use of topical calcineurin inhibitors does not seem to be associated with an increased risk for skin or systemic malignancies [37-39]. However, based upon animal studies documenting an increased risk of lymphoma and skin cancers associated with topical or systemic exposure to calcineurin inhibitors and to reports of cancer cases in children who used topical pimecrolimus or tacrolimus for atopic dermatitis, in 2006 the US Food and Drug Administration placed a boxed warning on the prescribing information for these medications. Labeling also recommends that these agents should not be used in combination with ultraviolet (UV) light therapy.
Unproven topical therapies — The benefit of topical vitamin D3 analogues in the treatment of vitiligo is controversial. A few small randomized trials evaluated the role of calcipotriol and tacalcitol in combination with psoralen plus ultraviolet A (PUVA), narrowband ultraviolet (NB-UV), or natural sunlight for the treatment of nonsegmental vitiligo with conflicting results [40-42].
●In a prospective right-left 24-week comparative study including 24 patients with vitiligo, there were no statistically significant differences between the sides treated with NB-UVB monotherapy and the sides treated with NB-UVB plus calcipotriol .
●In another right-left comparative study, 35 patients with generalized vitiligo applied calcipotriol 0.05 mg/g cream or placebo to the reference lesions one hour before PUVA treatment twice weekly . Lesions on the side treated with calcipotriol plus PUVA had a fourfold increase in the likelihood of achieving greater than 75 percent repigmentation sooner than the side treated with placebo plus PUVA (mean number of PUVA sessions 9 and 12, respectively).
Narrowband ultraviolet B phototherapy — NB-UVB involves the use of UV lamps with a peak emission of approximately 311 nm . These shorter wavelengths provide higher-energy fluences and induce less cutaneous erythema. NB-UVB induces local immunosuppression and apoptosis; stimulates the production of melanocyte-stimulating hormones, basic fibroblasts, growth factor, and endothelin I; and increases melanocyte proliferation and melanogenesis [43-45]. (See “UVB therapy (broadband and narrowband)”.)
Due to its lack of systemic toxicity and its good safety profile in both children and adults, NB-UVB phototherapy has emerged as the initial treatment of choice for patients with vitiligo involving >10 percent of the body surface area (BSA). NB-UVB can be used for both stabilization and repigmentation of vitiligo (picture 3).
A meta-analysis of three randomized trials comparing oral PUVA with NB-UVB found a 60 percent higher proportion of participants achieving >75 percent repigmentation in the NB-UVB group compared with the oral PUVA group . The additive effect of tacrolimus ointment (0.1%) applied once daily combined with NB-UVB in the treatment of vitiligo has been evaluated in one randomized trial . In this study, 40 patients with stable, symmetrical vitiligo were treated with tacrolimus ointment 0.1% on one side of their body and a placebo ointment on the other side plus whole-body NB-UVB two or three times weekly for at least three months. In 27 of 40 patients, a greater reduction in the target lesion area was seen in the side treated with tacrolimus compared with the side treated with NB-UVB alone (42 versus 29 percent). However, a possible increase in the risk of skin cancer with this combination therapy cannot be excluded.
A 2017 meta-analysis of 35 randomized and nonrandomized studies including 1428 patients compared the repigmentation rates of NB-UVB and PUVA by treatment duration . For NB-UVB, a ≥75 percent repigmentation was achieved by 13, 19, and 36 percent of patients at 3, 6, and 12 months of treatment, respectively. For PUVA, ≥75 percent repigmentation was achieved by 9 percent of patients at 6 months and 14 percent at 12 months. The results of this meta-analysis confirm the superiority of NB-UVB over PUVA and suggest that phototherapy should be continued for at least 12 months to achieve a maximal response.
Only a few small observational studies have evaluated the duration of repigmentation in patients with vitiligo treated with phototherapy. In a small observational study of 11 patients followed up for two years after treatment with NB-UVB phototherapy, five maintained areas of repigmentation and six experienced complete or partial relapse of vitiligo at previously repigmented sites . In another study including 15 children treated with NB-UVB phototherapy and followed up for a mean of 12 months after completing treatment, six showed stable repigmentation, four further improvement, and three complete or partial regression of the pigmentation achieved with treatment .
PUVA photochemotherapy — Historically, photochemotherapy with topical or systemic PUVA radiation was the “gold standard” treatment for the repigmentation of vitiligo but has been largely replaced by NB-UVB phototherapy. PUVA is associated with substantial adverse effects, including phototoxicity and gastrointestinal discomfort, and requires patients to use ocular protection for 12 to 24 hours following treatment. In addition, the long-term risk of skin cancer is well established for PUVA . (See “Psoralen plus ultraviolet A (PUVA) photochemotherapy”.)
Targeted phototherapy — Targeted phototherapy using 308 nm monochromatic excimer lamps or lasers has demonstrated efficacy for the treatment of localized vitiligo (picture 2) . These devices deliver high-intensity light only to the affected areas while avoiding exposure of the healthy skin and lowering the cumulative ultraviolet B (UVB) dose. (See “Targeted phototherapy”.)
A systematic review of six randomized trials (411 patients with 764 lesions) found that excimer lamps and excimer lasers were equally effective in inducing ≥50 percent and ≥75 percent repigmentation . Although the repigmentation may occur more rapidly with more frequent weekly treatments, the final result appears to be related to the overall number of treatment sessions rather than their frequency .
●In a study of eight patients with vitiligo, 24 symmetric vitiliginous areas were treated with the excimer laser three times per week for a total of 24 treatments . Topical tacrolimus ointment or placebo was applied to randomized affected areas twice daily throughout the length of the trial. Fifty percent of the areas treated with the combination excimer laser and topical tacrolimus achieved ≥75 percent repigmentation compared with 20 percent of the areas treated with placebo.
●In a 12-week open randomized study, 53 patients with vitiligo were treated with 308 nm MEL twice weekly plus 0.1% tacrolimus and oral vitamin E daily, 308 nm MEL twice weekly plus daily oral vitamin E, or daily oral vitamin E alone . At the end of the study, good to excellent repigmentation was achieved in 70 percent of patients in the MEL plus tacrolimus and vitamin E group, 55 percent of those in the MEL plus vitamin E group, and in none of the patients in the vitamin E group.
Systemic corticosteroids — Low-dose oral corticosteroids are generally utilized for the stabilization of rapidly progressive vitiligo, often in combination with NB-UVB phototherapy. Evidence for their efficacy in halting the spread of vitiligo is limited to a few uncontrolled studies [56-58].
●In one study, 81 patients were treated with prednisolone 0.3 mg/kg per day for two months, and then the dose was progressively reduced in the subsequent three months . Control of disease progression was achieved in approximately 90 percent of patients and repigmentation in 74 percent.
●In another study, 40 patients with extensive or rapidly spreading vitiligo were treated with oral mini-pulses of betamethasone or dexamethasone (5 mg in single dose) on two consecutive days per week for several months. After one to three months, vitiligo progression was arrested in 32 of 36 patients with active disease .
Oral corticosteroids are not effective as a repigmenting therapy for stable vitiligo. In a small open-label trial, 86 patients with progressive nonsegmental vitiligo were treated with oral mini-pulses of betamethasone (0.1 mg/kg twice weekly on two consecutive days for three months followed by 1 mg every month for the following three months) alone or in combination with PUVA, NB-UVB, or broadband UVB . At six months, marked or moderate improvement was achieved in 15 percent of patients treated with corticosteroids alone versus 85 percent of patients treated with corticosteroids plus PUVA, 81 percent of those treated with corticosteroids plus NB-UVB, and 33 percent of those treated with corticosteroids plus broadband-UVB.
Complementary and alternative therapies — Oral supplementation with antioxidants and vitamins is often used as an adjunctive treatment for vitiligo, usually in combination with phototherapy. However, there is limited evidence from high-quality studies to support their use.
●Vitamins – A few small uncontrolled studies have reported stabilization and repigmentation in vitiligo patients treated with UVB phototherapy and high-dose vitamin supplementation, vitamin C, vitamin B12, and folic acid [60,61].
●Alpha-lipoic acid – Alpha-lipoic acid is an organosulfur compound derived from octanoic acid. It is widely available as an over-the-counter nutritional supplement and has been marketed as an antioxidant. The efficacy of alpha-lipoic acid in vitiligo was demonstrated in one randomized trial including 35 patients with nonsegmental vitiligo . In this study, twice-daily oral supplementation with alpha-lipoic acid, vitamin E, polyunsaturated fatty acids, and cysteine monohydrate combined with NB-UVB twice weekly for six months resulted in significantly more patients (47 versus 18 percent) achieving >75 percent repigmentation compared with phototherapy alone. In addition, repigmentation occurred earlier with lower cumulative UVB dose. Biochemical evaluations at two and six months showed increased catalase activity, decreased intracellular reactive oxygen species production, and reduced membrane peroxidation in the combination-treatment group. Despite these promising results, further studies are needed to confirm the benefit of alpha-lipoic acid supplementation in the management of vitiligo.
●Ginkgo biloba – Extracts from the Ginkgo biloba leaf have long been used in traditional Chinese medicine to treat various conditions, including cutaneous, neurologic, and vascular disorders. The two main groups of active constituents responsible for G. biloba’s medicinal effects are terpene lactones (ginkgolides and bilobalides) and ginkgo flavone glycosides, which are present in varying concentrations in the leaf of the ginkgo tree. (See “Clinical use of ginkgo biloba”.)
Only a few investigations have evaluated ginkgo’s use in the management of vitiligo.
•A small randomized trial reported that the spread of vitiligo was arrested in 20 of 25 subjects receiving 40 mg of G. biloba extract three times daily for six months but in none of 22 subjects in the placebo group . In addition, 10 patients in the active treatment group but only two in the placebo group showed >75 percent repigmentation.
•Another pilot study found significant improvements in total Vitiligo Area Scoring Index and Vitiligo European Task Force assessment in 12 participants following 12 weeks of supplementation with twice-daily G. biloba extract . In addition to repigmentation, active depigmentation ceased in all patients with acrofacial vitiligo.
●Polypodium leucotomos – In one randomized trial, NB-UVB in combination with oral extracts of Polypodium leucotomos, a tropical fern with antioxidant and immunomodulator properties, was more effective than NB-UVB alone in inducing repigmentation of vitiligo in the head and neck area (50 versus 19 percent) after 25 weeks . No difference was noted in other body areas.
Surgical therapies — Surgical therapies have been used for vitiligo for the past 25 years and remain viable options for patients with localized depigmented areas that have been unresponsive to medical intervention [66-69]. They include:
●Autologous suction blister grafts [70,71]
●Minigrafts or punch grafts [72-74]
●Split-thickness grafts [75,76]
●Autologous melanocyte cultures
●Cultured epidermal suspensions [77,78]
●Autologous noncultured epidermal cell suspension
●Hair follicle transplantation [80-82]
The scope of transplantation procedures is the transfer of a reservoir of healthy melanocytes to vitiliginous skin for proliferation and migration into areas of depigmentation. Transplantation procedures are contraindicated for patients with a history of hypertrophic scars or keloids.
A systematic review of randomized trials and observational studies of autologous transplantation methods for vitiligo concluded that maximal repigmentation occurred in patients treated with split-thickness grafting and epidermal blister grafting . Both treatment groups achieved success rates of 90 percent repigmentation.
Other studies have reported the benefits of transplantation of autologous melanocyte cultures and epidermal suspensions containing both melanocytes and keratinocytes [67,77,79]. In one randomized trial comparing autologous noncultured epidermal cell suspension with suction blister grafts in 41 patients, a repigmentation ≥75 percent was achieved in over 85 percent of lesions in both treatment groups . However, more lesions in the noncultured epidermal cell suspension group achieved a 90 to 100 percent repigmentation compared with those in the suction blister group (70 versus 27 percent).
Adverse effects of surgical therapies include cobblestoning, scarring, graft depigmentation, and graft displacement. Suction blister grafts and split skin grafts may be associated with the Koebner phenomenon at the donor site, a complication of major clinical importance since it results in the development of new vitiligo lesions . Other adverse effects include hypopigmentation, hyperpigmentation, scarring, and infection at both donor and recipient sites. Punch grafting or minigrafting adverse effects include lack of color blending and matching with the surrounding normal skin, cobblestoning, and “polka dot” appearance .
Factors influencing the outcome of transplantation techniques include age, site of lesion, and type of vitiligo. In a series of 117 patients, the best results were achieved for patients younger than age 20 and patients with segmental vitiligo, whereas the grafting site did not significantly affect the outcome .
Depigmentation — Since the 1950s, monobenzyl ether of hydroquinone (monobenzone) has been used as a depigmenting agent for patients with extensive vitiligo [84,85]. Monobenzone causes permanent destruction of melanocytes and induces depigmentation locally and remotely from the sites of application. Thus, the use of monobenzone for other disorders of pigmentation is contraindicated. The major side effects of monobenzone therapy are irritant contact dermatitis and pruritus, which usually respond to topical and systemic steroids. Other side effects include severe xerosis, alopecia, and premature graying.
●Afamelanotide – Afamelanotide, a potent and longer-lasting synthetic analog of naturally occurring alpha-melanocyte-stimulating hormone (MSH), is a novel intervention for vitiligo [86,87]. Its use is based upon the demonstration of defects in the melanocortin system in patients with vitiligo, including decreased circulating and lesional skin levels of alpha-MSH . Afamelanotide is delivered as a subcutaneous, bioresorbable implant that promotes melanocyte proliferation and melanogenesis.
The safety and efficacy of afamelanotide implants combined with NB-UVB were assessed in an observational study of four patients with generalized vitiligo . Patients were treated three times weekly with NB-UVB for one month and then administered a series of four monthly implants containing 16 mg of afamelanotide. Follicular and confluent areas of repigmentation were evident within two days to four weeks after the initial implant. Afamelanotide induced fast and deep repigmentation as well as diffuse hyperpigmentation in all cases. In a subsequent randomized trial including 55 patients with skin type III to VI and vitiligo involving 15 to 50 percent of the BSA, patients in the NB-UVB plus afamelanotide group achieved a greater repigmentation than patients in the NB-UVB monotherapy group at five months (49 versus 33 percent) .
●Prostaglandin E2 – Prostaglandin E2 (PGE2) is a potentially beneficial treatment for localized stable vitiligo. PGE2 controls the proliferation of melanocytes by means of stimulant and immunomodulatory effects. In a consecutive series of patients with stable vitiligo, repigmentation occurred in 40 of 56 patients treated with PGE2 0.25 mg/g gel twice daily for six months . The response was excellent in 22 of 40 patients, with complete repigmentation observed in eight patients.
●Bimatoprost – Bimatoprost, a synthetic analog of prostaglandin F2-alpha approved for the topical treatment of glaucoma and hypotrichosis of the eyelashes, is associated with hyperpigmentation of periocular skin caused by increased melanogenesis . The efficacy of bimatoprost in the treatment of vitiligo was initially evaluated in a preliminary study of 10 patients with localized vitiligo treated with bimatoprost 0.03% ophthalmic solution twice daily for four months . Of the 10 patients, three had 100 percent repigmentation, three had 75 to 99 percent repigmentation, and one patient had 50 to 75 percent repigmentation. The best responses were observed on the face.
A subsequent proof-of-concept randomized trial compared the efficacy of bimatoprost 0.03% ophthalmic solution alone and in combination with a topical steroid (mometasone) with mometasone alone in 32 patients with nonsegmental, nonfacial stable vitiligo involving <5 percent of the body surface area . At 20 weeks, none of the patients achieved the prespecified end point of 50 to 75 percent repigmentation. However, in a post-hoc analysis using a less stringent definition of response (25 to 50 percent repigmentation), patients treated with bimatoprost, either alone or with mometasone, achieved a greater repigmentation in the neck and trunk than patients treated with mometasone alone.
●Topical ruxolitinib – Ruxolitinib is a Janus kinase 1 and 2 inhibitor approved for the treatment of intermediate- or high-risk myelofibrosis and polycythemia vera. In a phase 2, proof-of-concept trial, topical ruxolitinib 1.5% cream was administered twice daily to 11 adult patients with vitiligo involving at least 1 percent of the body surface area for 20 weeks . Eight of 11 patients had some response to treatment, with a mean improvement of the Vitiligo Area Scoring Index of 23 percent. The best response was observed in patients with facial vitiligo. The main adverse effect was erythema over the treated lesion.
PSYCHOLOGIC INTERVENTIONS — There is a scarcity of high-quality studies evaluating the efficacy of psychologic interventions in the management of patients with vitiligo. One small randomized trial found that cognitive-behavioral therapy in addition to conventional therapies was effective in improving the quality of life, self-esteem, and perceived body image in adult patients with vitiligo and even influenced the course of the disease itself .
CAMOUFLAGE — Cosmetic camouflage can be beneficial for patients with vitiligo affecting exposed areas such as the face, neck, and hands. Camouflage products include foundation-based cosmetics and self-tanning products containing dihydroxyacetone (DHA). DHA-based products are most popular because they provide lasting color for up to several days and are not immediately rubbed off onto clothing. Tattooing or micropigmentation should be avoided, given the risk of koebnerization and oxidation of tattoo pigment causing further dyschromia. (See “Vitiligo: Pathogenesis, clinical features, and diagnosis”, section on ‘Koebner phenomenon’.)
PROGNOSIS — Vitiligo is a chronic disease with a highly unpredictable course. Early-onset vitiligo appears to be associated with involvement of a greater body surface area involvement and increased rate of disease progression . Despite treatment, most patients experience alternating periods of pigment loss and disease stability for their entire life. Occasionally, patients may experience spontaneous repigmentation.
Patients who have organ-specific autoantibodies have an increased risk of developing subclinical or overt autoimmune disease . (See “Vitiligo: Pathogenesis, clinical features, and diagnosis”, section on ‘Associated disorders’.)
SUMMARY AND RECOMMENDATIONS
●Vitiligo is a chronic, relapsing disease. The goals of treatment include the stabilization of active disease and the repigmentation of depigmented patches. However, the response to treatments is slow and may be highly variable among patients and among different body areas in the same patient. (See ‘Patient evaluation’ above and ‘Assessment of severity’ above and ‘Goals of treatment’above.)
●In patients with rapidly progressive vitiligo (ie, depigmented macules spreading over a few weeks or months), we suggest systemic corticosteroids as adjunct therapy to narrowband ultraviolet B (NB-UVB) phototherapy for stabilization (Grade 2C). (See ‘Stabilization of rapidly progressive disease’ above.)
●For patients with vitiligo involving <10 percent of the total body surface area (TBSA), we suggest topical corticosteroids as initial therapy (Grade 2C). Topical corticosteroids are applied once daily for two to three months and then interrupted for one month. Topical calcineurin inhibitors are preferred to topical corticosteroids for body areas at increased risk of atrophy. Targeted phototherapy is an option for patients with limited vitiligo who do not respond to topical therapies. (See ‘Vitiligo involving <10 percent of the TBSA’ above.)
●For patients with vitiligo involving 10 to 40 percent of the TBSA, we suggest phototherapy with NB-UVB (Grade 2B). Phototherapy is administered two to three times per week for 9 to 12 months or up to 200 treatments. Topical corticosteroids or topical calcineurin inhibitors may be intermittently used in combination with NB-UVB phototherapy. (See ‘Vitiligo involving 10 to 40 percent of the TBSA’ above.)
●Surgical therapies involving the autologous transplantation of healthy melanocytes in depigmented areas are an option for patients with localized, recalcitrant vitiligo and for patients with segmental vitiligo. (See ‘Localized recalcitrant vitiligo’ above and ‘Segmental vitiligo’ above.)
●Depigmentation of residual pigmented areas with monobenzyl ether of hydroquinone (monobenzone) can be considered for patients with extensive recalcitrant vitiligo that does not respond to repigmentation regimens and for those with extensive vitiligo who do not desire undergoing repigmentation treatments.
Fonte uptodate – atualizado em outubro de 2017


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Before I leave for Europe, I want to to leave you with this. I found this today, and apparently I posted it somewhere else - just months before I found out I needed a liver transplant. Today, these words ring so much truer today than when I posted them before. This is for me and you, everyone out there who is tired of waiting, feels it will never end, and is frustrated trying to see the purpose. Oh what I have learned in the waiting…
DESPERATELY, HELPLESSLY, LONGINGLY, I CRIED; Quietly, patiently, lovingly, God replied. I pled and I wept for a clue to my fate . . . And the Master so gently said, "WAIT." Wait? you say wait? my indignant reply. Lord, I need answers, I NEED TO KNOW WHY! Is your hand shortened? Or have you not heard? By faith I have asked, and I'm claiming your Word. My future and all to which I relate Hangs in the balance, and you tell me to wait? I'm needing a 'yes', a go-ahead sign, Or even a 'no' to which I can resign. YOU PROMISED, DEAR LORD, that if we believe, We need but to ask, and we shall receive. And Lord I've been asking, and this is my cry: I'm weary of asking! I need a reply." Then quietly, softly, I learned of my fate, As my Master replied again, "WAIT." So I slumped in my chair, defeated and taut, And grumbled to God, "So, I'm waiting for WHAT?" He seemed then to kneel, and His eyes met with mine . . . and He tenderly said, "I could give you a sign. I could shake the heavens and darken the sun. I could raise the dead and cause mountains to run. I could give all you seek and pleased you would be. YOU'D HAVE WHAT YOU WANT, BUT YOU WOULDN'T KNOW ME. You'd not know the DEPTH OF MY LOVE for each saint. You'd not know the POWER that I give to the faint. You'd not learn to SEE THROUGH CLOUDS OF DESPAIR; You'd not learn to TRUST just by knowing I'm there. You'd not know the JOY of RESTING in Me When darkness and silence are all you can see. You'd never experience the FULLNESS OF LOVE When the PEACE OF MY SPIRIT descends like a dove. You would know that I GIVE, and I SAVE, for a start, But you'd NOT KNOW THE DEPTH OF THE BEAT OF MY HEART. THE GLOW OF MY COMFORT late into the night, THE FAITH THAT I GIVE when you walk without sight. THE DEPTH THAT'S BEYOND getting just what you ask FROM AN INFINITE GOD who makes what you have last. You'd never know, should your pain quickly flee, What it means that My grace is sufficient for thee. Yes, your dearest dreams overnight would come true, But, oh, the LOSS, if you missed what I'm DOING IN YOU. So, be SILENT, my CHILD, and IN TIME you will see That the GREATEST OF GIFTS is to TRULY KNOW ME. And though oft My answers SEEM terribly late, My most precious answer of all is STILL . . . WAIT.Russell Kelfer, 1980 _Thank you to my precious donor family, whoever and wherever you are, for choosing to give the gift of life. Because of you and your sweet son, I am fulfilling my dreams all around the world. My heart is swollen with gratitude; I could never find the words to express it._
The time has come. As I'm nearing 3 years post-transplant and my incision has been cut open wide twice now, my transplant surgeon and the head of plastics/reconstructive surgery at the Cleveland Clinic have agreed to flip the green light on fixing the atrocity that has become my abdomen. As some of you know, it was badly infected after my first surgery, so the second surgeon tried to close it to look better when he was done, but there really wasn't much to make a large difference without gutting the whole thing and starting new. So that's what we're doing at the end of the summer. Yes, we are gutting my stomach just like a kitchen, ripping out the old, putting up the clean and new. I don't think this journey will be a fun one, especially as I'm not required to do it. You just go along with show when your life doesn't have a chance. But this is 100% my choice. I've looked forward to this day for so long, but now that it's here, I'm not sure if I want it. You see, my stomach boldly shows all of my battle scars. The staples, stitches, tubes, and drains. I trace them when I'm falling asleep sometimes. They are the only proof of my story, the only souvenir these past years of hell have left me with. I don't like what it is, but I like the idea of having it. I've come to learn to ignore it pretty well and have long stopped getting sick every time I get out of the shower and have to look at it. It's a nuisance and affects my clothes and my posture, and it's not pretty, so you'd think the decision would be easy. But all 90 gashes surrounding my bold Mercedes-Benz logo, and each big bump where a tube or drain once fell from… they each so fully tell my story. The agony, the pain, and the rising again. It's very symbolic to me. [Every time I say Mercedes-Benz I think of my friend Jenn S. who said, "Well at least its not a Hyundai." #transplantfunny] I will follow-through, but I'm sharing my mental process here as I know a lot of us are being transplanted younger and younger, these things are becoming issues. I have no indication that this surgery for this reason has ever been done before, so if you feel like me and hope someone has had good results from this , then I'm happy you're here reading along. I pray my experiences partially influence the future of transplants where you soon won't have to look like you've had a near-death experience from the lines and grooves of your abdomen. The memories are bad enough in my mind. I don't need them tattooed all over my skin.
Saw this in the Wall Street Journal, Weekend Edition March 16-17, 2013. Liver Preserver Holds Promise for Transplant Patients
Scientists from Britain's Oxford University have invented a device that preserves human livers outside the body for up to 24 hours, an advance that could potentially make more of the organs available for transplant at a time when demand is climbing.This has huge potential. The future of medicine is so exciting for transplant patients.
I learned of Chelsea last week and my heart broke in two reading of her story. I read every page on her website and took in each word. To refresh your memory, hepatocellular carcinoma, or HCC, is the adult form of liver cancer that my doctor discovered I had in May, 2010, which led me to transplant 3.5 months later. 21 year old Chelsea was diagnosed with HCC at age 4 and was treated with 40 chemo treatments and several surgeries. I don't know her story in detail, but I'm sure she dealt with much more, including the emotional agony of growing up in hospitals. Her mother gave her a partial liver transplant at age 7 and it lasted 7 years longer than it was projected (14 total). However, she endured some complications that left her liver damaged. All of the issues had caused strain on her kidneys, and she was forced onto dialysis. She lived at Cleveland Clinic in the ICU for a long period of time as she waited for a rare liver: intact (vs. partial), small (her years of illness caused her to be small), and O- blood type. As I know from my nursing experience, type O isn't the easiest type to match. Since Chelsea is my age, with my disease, with a history of several illnesses, and the same transplant team as I have, I felt an instant connection. We share so much in common. I wished I could do something to encourage or help her. _ My mom was watching late night news tonight, and then there it was - the newscaster said the words "liver transplant" so I instantly looked up. Chelsea's picture came onto the screen just as they said she lost her battle today. Chelsea had gotten a liver last night and from the times posted on her website, it seems as if her body succumbed during the actual transplant. Tears came to my eyes, and I gasped. I told my mom the whole story, and she was upset as well. Then she told me how blessed I am. When people like Chelsea are out there, I don't feel as blessed. I'm so caught up in the "Why me?" "Why her?" questions. Why did I live through the surgery while Chelsea didn't? She was a year or two younger than me at the time of her transplant so you'd think she'd have a better chance than me. I was small and needed a rare donor as well, yet I waited only 3.5 months. I never got to that point where I was in the ICU for days like Chelsea, or, like my hospital roommate last month, in end-stage liver failure, full of several liters of fluid that needed drained regularly. Who chooses who suffers most? Who chooses who gets it worse before some kind of intervention - supernatural, surgical, or otherwise? All transplant patients have unique bonds. We share each other's struggles and triumphs. We wish we could take the pain from any fellow one, whether we know them or just hear their story. We are all entered - involuntarily - into this club, the Transplant Club, and if death or complications harm any of our brothers or sisters, well that just won't work for us. We put up a fight because we have been there. The hit is too close to home. Who chooses who has tragic complications? Why can't we all triumph through? Why can't our youngest ones pull through to live happy, healthier lives? Doesn't it seem obvious? I'm grieving for a girl who I never knew. She's my transplant sister, so I love her anyways. I wanted to send her a card telling her my story and how I was pulling and praying for her. I was hoping my story would encourage her to keep pulling through, to give her more hope to keep going another day. Sadly, she'll never see my card. Rest in peace, sweet Chelsea. All of your transplant brothers and sisters are crying for you today. We pray for your family and friends and hope even in your death, your story will live on and continue spreading to thousands of people, giving everyone courage, strength, and perspective, inspiring each one to ultimately donate life.
It was a wonderful Saturday with my mentor, Rita, as we sat down for another quiet yet passionate discussion about the blessings we receive or the issues we face. Rita is special to me as she is the mother of a friend I grew up with at school since first grade, and she was my seventh grade science teacher. We had not seen each other in years, and we were purposefully matched together in a mentoring program. God had a hand in the match up as we have strikingly similar personalities, struggles, and challenges. Rita has gone through many relationship and health obstacles and has fought through everything with grace and beauty. She has much insight on suffering and living fully despite it, noticing God's blessings each step of the way. And so on this particular day, I mentioned to her how I've been in heightened realization of my physical weaknesses lately. I told her how I've felt opposition from a couple of individuals as they sometimes judge me independent of my pain and fatigue, my daily struggle to live as normal of a life as possible for a patient with fibromyalgia, chronic pain, and a past of 17 years of liver disease ending with a liver transplant and two subsequent surgeries. I bemoaned how I deeply wish they could see my point of view, how desperately hard I want them to realize what I deal with each day so they could tread more cautiously and deliberately. Of course, I meant it figuratively as in wishing they could just imagine what kind of physical and emotional pain I deal with and how my various thresholds can be so challenged at times. Pausing to choose her words and then in her gentlest voice, she said this to me.
At times, we so greatly wish for people to see where we walk, yet at the same time, we try harder to hide it from them and pray in the depths of our hearts that they will never truly know what we experience.As frustrating as it is, I am realizing it's a good thing these people cannot relate to me because to be able to fully do so, they would have had to not only journey _beside_ me through the years as they have done so diligently, but rather physically suffer through _exactly_ what I have over the years. My mind stopped immediately at this realization. I whispered intently, "I wouldn't wish this on my worst enemy." "Yes," she continued. "There are times I cannot even tell my daughter exactly what I'm going through. It would kill her to know." Oh how true. For example, I have been protecting my these loved ones, shielding them from the worst, ever since I was in elementary school. They don't know this, and I don't even want to tell them now. To hide things like this from people so close almost sounds like a punishable wrongdoing. Yet we continue on in order to protect our loved ones, and we hold our breath hoping and praying they will never go through what we have, no not possibly that. Not this. Not anyone, _but especially not them._ And so I proceed, journey on, more tolerant of their judgments, tempers, and inability to understand as _I strive to daily thank the Lord that they just can't comprehend what I've endured._ It's not easy; I will assure you of that. But when you love people, it's really the only option. May we take pleasure in our sufferings as they draw us nearer to our Lord and Him to us. He has willingly been through anything we could ever face in life just so He can truly, 100% understand what it feels like and in the meantime, guide us triumphantly to the other side.
I haven't said much lately because life has been pretty still for me. My heart has been _quiet_- there have been no major health scares and my loved ones are well. All is _quiet_ here. Yet isn't it funny how "_quiet_" and "normal" to people like me means sinus infections, shingles and its post-herpatic neuralgia, carpel tunnel, anesthesia treatments, and a few ER visits. And isn't it funny how when you're living your love, you just don't notice as much? I've spent so much time with my kids, my family, and my friends, and I've been so busy with my classes, commitments, and trying not to push my body off the deep end. But I have to give the most credit to my kids. They are the reason I get out of bed each day. They are the people who say the funniest things and make me smile from ear to ear. They give the best hugs and show me how important I really am and affirm my love is mutual. This is the _quiet_ balance that keeps my life running and my joy before my pain. For those wondering, up to bat after Christmas is Botox treatments for my migraines, a consult with an orthopedic surgeon about my carpal tunnel, my biannual tumor markers/CT scan in a few months, and maybe even abdominal reconstruction surgery. Those are my possibilities and I pray I get through what comes with grace and _quiet_. To some, that may sound scary or daunting, but when you have pain or issues, peace is getting it fixed. So with the best things present in my life, I will proceed with my plans. And with my family, friends, little loves, and Lord - I will transcend. Praise Jehovah Jireh!
United States' President Barack Obama officially signed November, 2012 as National Caregiver's Month. This is very special as all of us patients know how much caregivers truly sacrifice to _care_. And care _well_. It takes a special person to be not just a caregiver but a good caregiver, a caregiver who promotes health, wellness, comfort, and support in all he or she does. Caregivers are parents, children, doctors, nurses, friends, and even staff on the hospital's transport team or in the gift shop. They may be in unexpected places in unexpected positions, but we are completely grateful to them for sharing their smiles and hearts. In this month of Thanksgiving, honoring them seems almost obvious. For this month's international Patients for A Moment blog carnival, our topic - in honor of the month - is CAREGIVERS. Everyone is welcome to share a blog post about a caregiver, caregivers, or even being a caregiver. Please comment with a link to your post _and_ any special comments about your post OR send an email with the preceding information to agoodwin2010 (at) gmail (dot) com with the subject of PATIENTS FOR A MOMENT. Submissions are due November 24 so you have time to gather your thoughts after the US Thanksgiving holiday. The final edition will run live here on Crazy Miracle on November 30. Please write and submit! No submission is too small or insignificant. Share your voice - I know we all have something to say about this topic. Love to you all!
“If anyone would tell you the shortest, surest way to all happiness and all perfection, he must tell you to make a rule to yourself to thank and praise God for everything that happens to you. It is certain that whatever seeming calamity happens to you, if you thank and praise God for it, you turn it into a blessing. If you could work miracles, therefore, you could not do more for yourself than by this thankful spirit. It heals and turns all that it touches into happiness.”- William Law in A Serious Call to a Devout and Holy Life
What a response to our giveaway! The winners are KENDRA GILLILAN and RANDI so if you could please shoot me an email at agoodwin2010 (at) gmail (dot) com with your color preference and mailing address, I'll get your hair ties right out to you! Thanks to all who entered. Your comments were very touching and I enjoyed reading each one. We each have such a unique and special story to tell, and that's part of this crazy miracle. Love you all, Amanda


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Just off the Wyoming border lies a land that is truly magnificent and magical. A land that is secluded from the busy, loud, obnoxious city bustle and void of any outside interference; a place entirely left alone by society and a place one can honestly call peaceful. It is a place that stretches endlessly in every direction until it kisses the sky on the horizon without the interruption or sight of a mountain, hill, house, tree or bush. In every direction, one can see only Endless Sky.
The beautiful private ranch (which is owned by a very generous and happy man who took pleasure in meeting everyone who was partying on his land) could have been on the Moon or Mars for all that mattered, that’s how wonderfully private and secluded the festival was. It was a beautiful piece of property that really made you feel. . . on another planet. No matter which direction you looked at, you couldn’t see anything except the endless sky.
On the beautiful property was a permanent stage that stood only twenty or so yards from a house, and adjacent to the stage towards the house was a boat which was where the bar tenders served. Above the stage were six beautiful color changing lanterns, and before the stage were several large and extremely comfortable chairs to lay in and relax in and enjoy the performances. There were also many wooden poles protruding from the ground which served as anchors for many hammocks to lay in.
Friday night ended somewhat early, but with the approaching 35 straight hours of amazing house music before me, I understood the reasoning; but the energy of the happy party-goers kept me up well into the early afternoon of 11am. It didn’t matter however, as the hot Wyoming heat kept me awake, which was followed by a rogue wind storm that uplifted my tent from its stakes and flapped about. I decided to cut my losses and join in the dance grooves once again.
Before I knew it the sun had set, me feet began to ache, and my ears were in the realm of euphoria when I saw the most bad-ass truck I’ve ever seen. I can only describe it as a ‘rave-truck’, as it had many triangular LED lights that altered patterns and colors on both sides of it and they stretched from the engine (this is a semi by the way) to the bed, and even above the vehicle. It was a marvelous piece of machinery that took an intelligent mind to create. And as it turned out, it was at the NYE 2015 Decadence party – which I was at! A dear friend of mine pointed it out after successfully recognizing it!
Saturday night came before I knew it and the sky was virtually crystal clear – so clear you could see the streak of the Milky Way. If you watched the night sky long enough you were bound to see a shooting star; I myself saw four that night. An omen of good things to come if ever there was one.
The night was full of mingling about, meeting new friends, dancing to the spectacular music, and losing yourself to the rhythm of the campout. As is the case with all Afterhours Anonymous / Mahesh Presents events, time seemed to be non-existent.
Until the sun rose.
I have never experienced such a beautiful sunrise in all my life. Aside from the endless sky and land that stretched in every direction imaginable, and the gorgeous sun reflecting its magnificent red, orange, yellow and every color in between in the clouds and illuminating the sky with beauty, Poland’s Catz n Dogz were playing their fantastic morning set. I couldn’t have asked for a more beautiful sunrise than what I experienced then – hearing Catz n Dogz before the vivid Wyoming sunrise. I knew what Nirvana was for a moment. The moment felt brief, but it felt endless at the same time.
Unfortunately, after having no real solid sleep since Thursday night my body and soul needed rest, and despite my best efforts to stay awake I was down for the count. I wish I could say I experienced the entire event, but starting a new job on Monday I felt it best to get some rest and recuperation.
I will never forget what my friends and I called the “Rave Ranch’ and the people we met, the music we heard, the displays we saw or the endless sky we witnessed.


Hello, I am Sahra. I am young body with an old soul. I smoke cannabis medically. I tend to remember everything that happens, every moment, and everything I learn. I care about things that mean nothing to others. I think about things like this everyday. I have friends all ages, shapes, styles, genders, and colors. I've had my life saved by a poet who is often more judged for being a rapper that having a message. (Watsky) I believe in every way a person could believe that it is NOT on the outside that counts. I don't ever want you to let anyone tell you that you aren't beautiful and that you aren't worth the world. If you need anything, ask away. Advice, a friend, want to tell me about your day, send a poem, say hello, anything. Anything.


I am not going to assume everyone knows the title for this post is from a Clash song The Magnificent Seven If you do not know the song, take a listen, I will wait…..
It is time for me to become unstuck from the past. All too often people are trapped in their bubble or loop. They take the same route to the same job, see the same people, read the same things, listen to the same music, and on I could go.
Not that there is anything specifically wrong with these things. There are very good reasons to have a job, a group of friends you see all the time, like the music you like, these things can bring great joy and comfort to our lives.
But, it is good sometimes to try something totally different. I like to think of it as rediscovering what it was like when we were kids, everything was new and exciting. Every experience was novel. That feeling can be recreated when we let go of our past habits and just try something new. It can be terrifying. I have had several people tell me I should try stand up comedy (one person said I would need a LOT of work on my material first, fair enough), and the idea of standing on a stage telling others what I think is funny is so far from my comfort zone. I do not want to do stand up professionally, but the idea of getting in front of a bunch of strangers and doing something that makes me feel that uncomfortable is an intriguing one for sure.
I probably won’t do it, I have other things that terrify me more and I think I need to do first anyway. Writing these postings is part of this process, as I type these words I have to turn off that part of my brain that is imagining you and others reading this and them imagining what on earth you must think of this rambling mind of mine. But, I try to turn that off, and just write, it is useful to me, if anyone else likes it I get bonus points.
My first real photography mentor/ teacher John Gray always would write on the board and tell anyone who would listen COMFORT IS YOUR ENEMY. When I read it as a 19-year-old punk rock kid I assumed it was referred mostly to material comfort. If you have too many nice things you can’t be a good photographer. You know, suffering artist type bullshit. There is an element to that in what he meant, but I think now the way I see it is, if you are doing what makes you comfortable all the time, if you stay in your box, or silo, comfort zone, small town, large town, neighborhood, car, your own head, you will never grow as a person and if you are trying to do any sort of creative work you will be stuck in a creative rut.
These are not at all original ideas, many people have articulated them much better than I am or ever could, but as I have said before, these writings are for me. I need to remind myself every day that the only way to grow as a person and photographer is to push myself into those uncomfortable places, to do something every day that I have never done before.
There is a podcast called Invisibilia that I have been listening to lately as I edit photos. One of the episodes was quite interesting and prompted me to write this post. The main character of the story lived a comfortable life working for a tech company, making a good living, he had good friends, and all was good. But, sensed something was missing, so he wrote a program that searched Facebook events in his area and would choose at random one of the events, and he went. A few times it was awkward, but most of the time it ended up being a really awesome adventure. He met people he never would have encountered in his normal life, it expanded so much of his life, brought him a joy that so many of us are lacking. At the end of the podcast they said he is working on an app that will do this so we can all try this novel way to get out of our own bubbles. However they did not say when it will be done, nor where to look for it. I think they want me to go to their website to look for it, so why am I resisting?
And that reminds me of one other story I heard the other day. People somewhere found a way to capture monkeys of some type. They would get a large piece of wood, an cut small holes in it. Inside the small holes they places something shiny which would attract the attention of the local monkeys. The monkeys would reach into the hold to grab the shiny object, but in creating a fist to grab onto the object their hands could not fit through the small hole and the monkey was trapped. All the monkey had to do is let go of the shiny object and he would be free, but he really wanted that shiny object, so stayed there until the humans came along and captured the monkey.
I am trying to let go of that shiny object today.


It’s been a long time since I updated my blog. A lot has happened. But sometimes when I sit down to write, the pain of typing the emotion is just too great. It’s one thing to walk through the grief and try to survive it; it’s another to relive it by recounting details by putting words on a paper. But, I’ve come to realize, it’s through narrating my journey that I truly can fully grieve.
Grief has been described to me as a flood, ruining lives. Grief has been described to me as a tornado, destroying everything in its path. But to me, loosing Carter has been a lot like a series of thunderstorms. Some days the rain is gentle. I’m able to wake in the morning, go through my daily routine, and make it through the day. The rain is soft and a reminder of new life, sweet smells, and rainbows. Other days, the rain is so blinding I can’t even catch my breath, struggle to see in front of me, and stop in fear of what will happen next.
Maggie lost her first tooth last week. Cooper helped pull it which was so exciting for him! Todd is the expert tooth puller in the Mayes household. I sit back and cheer everyone on! This time it was different. I smiled and cheered Maggie on. She was so excited. Cooper was so excited. I fought to hold back the tears. I gripped my stomach as the physical pain was so intense I was scared I might get sick. I struggled to maintain normalcy. Carter should be here. He should.
Cooper’s team is in the middle of playoffs. He has worked so hard this year to improve as a ball player. I have seen him so proud of his accomplishments. Todd has helped coach which has been good for him (and Cooper). Cooper’s games are so intensely entertaining. I sit back and cheer everyone on! Each game, as Cooper #8 (Carter’s old number), stands at the plate to bat, I fight to hold back the tears. I find myself gripping my stomach as the physical pain is so intense I am scared I might get sick. I struggle to maintain normalcy. Carter should be here. He should.
We attended Cooper’s Cub Scout bridge ceremony a week ago. It’s a ceremony where the Cub Scout crosses the bridge to the next level of scouting. Before the ceremony in a moment of confusion we couldn’t find Cooper’s Cub Scout belt. We were pressed for time so I did the only thing I knew to do. I reached deep in my closet for my box of special Carter memories and pulled Carter’s Cub Scout belt out for Cooper to wear. As I laced the belt through the loops, I look up and Cooper’s eyes are filled with tears. I watch Carter’s Cub Scout den cross the bridge (before Cooper's den), each smiling proudly as the ‘graduate’ to the next scouting level. I fight to hold back the tears. I find myself gripping my stomach as the physical pain is so intense I am scared I might get sick. I struggle to maintain normalcy. Carter should be here. He should.
As I write this I receive a call from Cooper’s summer camp director, Clinton. I called him this morning to give him a heads up on Cooper’s family dynamic before Coop arrives at camp. I can’t even get the words out of my mouth. I start crying as I begin to talk. My tongue gets stuck in my throat and I can’t say anything. Its times like this I realize the thunderstorm is at its worst. I can’t see through the rain. My heart beats so hard I feel like it might fall out of my chest. I can’t do this, I think. It hurts too much, I just want the pain to stop. Then, the rain passes. Clinton begins to pray with me on the phone. I feel at peace and I know I will once again be ‘ok’.
Daily I pray that there will be a day when I won’t cry. Daily I pray that there will be a day that I don’t fall asleep praying I won’t wake up. Daily I pray that the guilt in my heart will lesson. Each day I pray that it will get easier. And, some moments, are easier….and for those ‘gentle rains’, I will forever be grateful.
10 hours ago


The Last Resort
Jane Goes to Graduate School
West Texas is a barren land in the heart of the “bible belt”. My family has strong ties to the land they work. For a hundred years they have been ranchers and farmers and leaders of community. Over the years, I have often felt like a square peg trying to fit into a grid of round holes. I first moved away from West Texas when I was 17 and returned there to live when I was 35. I am the only one in my family and my extended family who has ever moved away. My family has never understood why I would ever want to leave, for them there is no other place to live. My southern heritage is rich in story and experience at the same time it is tarnished by violence and pain. But it is my home and a land that has a permanent hold on my soul.
After my children grew up I found myself entertaining the idea of going back to school for my self to study art and photography. It took me three years to work up to the idea that I could go back to school and two more years to apply and actually come to Arizona to study photography. I left West Texas for a second time.
My husband Dan is a bit older than I am. When we moved to Arizona we chose the most affordable living option, which happened to be a trailer park for senior citizens. The idea of a community for people 55 and over was a completely new concept for both of us, I was by far the youngest resident and soon after we got here I realized that I was living in an old folks home. It was depressing and a little scary. But I responded to my new environment by telling stories. I had found another place rich and complex.
The Last Resort is a place that exists in my head as much as does in my environment. It is a reflection of my experience both in the park and at home in West Texas. Personally it is both terrifying and redeeming.
I found out the Corner decided She died of a heart attack in her sleep. The way most of us would like to die. It turned out She was beloved after all. She was beloved by the other side.


💜Ridonculously long post of hope and possibility:
10 months ago my husband was offered a job overseas: less than 2 years after moving into the house we’d built after losing our old one and pups to fire a year prior. Losing them, our darling Mastador, Ziba, and our big mama’s boy Dane, Hagrid, prompted our search for new loves to *try* to fill the holes left in our hearts. We found them. EM Guinness, and Dane Fezzik. Of course we learned along the way that the holes aren’t filled. Our hearts just grow with the love for our new babies.
7 months ago we had to rehome Fezzik. He couldn’t travel in the car to be able to have house showings and we needed to sell our house to be able to make this move. That was an albeit AGONISING blessing in disguise. He and Guinness loved each other dearly, but their behaviour and energy cycled in a negative and unmanageable way, making him more anxious, and her seemingly aggressive. Which she’s not. At all. But we innocently and mistakenly read it as such. As hard as it was to know I’d never get to kiss that big nose again, and be kept up at night anthropomorphising his confusion, it had to be done. I realised though, when 2 weeks after the transition I met him with his new owners at our vet to have him neutered, he now just had a bigger family! His new dad sat in the waiting room and cried, worrying about something happening to “his boy” while under anaesthesia. The love these folks had for him was more than I could’ve ever hoped for. And there wasn’t a void for Fezzik. Any longing. He’d just gained a new mum and dad. He still had us in his heart. And his new family has become OUR family, and he is so content there. On a road out in the country without traffic (the root of his deep fears), with a Dane sister, duck buddies on a pond, and even a C A T! Hard as it all was, it couldn’t have been better or more providential, and we could begin to move forward with our plans.
3 months ago, after finally selling our dream house, we were told we couldn’t bring Guinness. My heart shattered. Everything I loved and had worked so hard to build and repair felt as though it was being taken from me. My house, my garden, my sense of safety and security; being in a place I’d called home for over a third of my life...my darling Dane, and now my Mastiff who, in the absence of little brother Dane’s energy, had come into her own, revealing the most perfect dog in the universe. I’d always loved her, but I felt that I’d just gotten to know her. I didn’t want to go. But things were in motion.
I let the grief pass through me, and then I said “no.”
We were going, but dammit we were taking our dog.
I’m giant ball of feels today. It’s been nothing but feels for the last 10 months. Every bit of good news we’ve received in the last 3 months about Guinness; hopeful news: a house that said yes to her, or a big enough crate for travel, etc., was then deflated in one way or another, throwing us back to the starting line. We found several amazing families in Virginia who offered her a loving home. I tried to make peace with that. But I just couldn’t do it. I don’t know what it is about her that turned me into this unrelenting, determined warrior. If all of the loss over the last 3.5 years culminated in the thought of losing her? If she was just my limit? My big NO. I can’t imagine that I actually love her any more than I do Fezzik. (I have 4 human kids, and I have the same amount of love for each of them). Or maybe she’s connected to me in some cosmic way that we’re just not meant to be apart? Who knows. But it’s always been a hard NO for me where she was concerned. Even to the point of causing some pretty epic discussions with my husband. 😉
So...yes...I’m a giant ball of feels today. A month after arriving, and a week after moving into a house that finally said yes to her, I am shouting my cheesy woo-woo proclamation that if you are a mastiff parent, you have mastiff-sized love, mastiff-sized determination, which means that mastiff-sized things are possible!!!
Our girl is home!!!
(And she traveled like a freaking ROCK STAR!)
Roman Gottfried working with you was so empowering and enlightening. You opened my eyes to possibilities I always felt were way out there for *other* people to enjoy. That I just couldn’t “do it.” And that “it” was something to learn, somehow. Trainers got “it,” but it required a discipline and authority I just didn’t have. 🤔
You and Barbara helped to point me in the direction of the innate wisdom we ALL share: human AND canine. While I’m still honing my energy in relation to her, I feel like we communicate on a different plane than before. Which is truly beautiful. And she’s so much happier for it.
We are all so grateful for what you do!!!
SO much gratitude to Roman Gottfried who was there for us at every stage of this roller coaster, guiding us with his wisdom through education and insight, helping me see the power of energy and the importance of understanding what means what in dog speak. 🙏 - Marnie Walsh - Germany / USA


Medden have been critical to the development and launch of our lifestory business Book of You. We came to Clare with a concept and she immediately understood what we were trying to achieve and came up with suggestions to make it possible.
Book of You is a demanding web design project, involving managing memberships, uploading media, allowing the collaborative authoring of multi-media online books, and the export of print-quality PDFs for real books as gifts. It has necessitated a huge amount of new thinking and problem solving, and Clare has been absolutely brilliant in doing this, and explaining technical issues in language that we could understand. She has been highly flexible in dealing with the demands of an evolving project, and very patient when we have taken her down development cul-de-sacs!
Clare has a tremendous ability to problem solve, has high quality standards, and understands the needs of clients and the people who will end up using the website. These have been essential in the development of our unique business model, which was launched in July 2012. We would highly recommend her work.


About Maha kavi Rathnakaravarni Adhyayana Peetha
Mahakavi Rathnakaravarni Adhyana Peeta
The Kadamba,Rashtrakuta,Ganga,Chalukya and Hoysala dynastries gavestrenght to the Jaina in South Indiya. These dynastries patronized many great Jaina poets including Pampa, Nagachandra,Chavundaraya,Nemichandra,Nayasena,Brahmashiva,Nagavarma the second,Janna, Rathnakaravani and Inspired their scholarly work. The Jaina tradition and Thulunaadu , covering the revenue districts of Dakshina Kannada and Udupi have had a longstanding relationship. Rathnakaravarni of Moodubidri is one of the great poets of Tulunaadu.He is also the foremost among the ‘Sangatya’ poets of Kannada .Four major works are attributed to this poet of the sixteenth century; Bharatheshvaracharita(Bharathesha Vaibhava),Trioka Shathaka, Rathnakara Shathaka and Aparajitha Shathaka. As per the direction of the government, a propsosal was sent to State Government to start a Chair for study in the of name Jainakavi Rathnakaravani. The Government of Karnataka has released a sum of Rupees One Croee during the year 2014-15 as an endowement for Establishment of “Mahakvi Rathnakaravarni Adhyana peeta’’ in Mangalore University, Hence, it has becomes necessary to frame a state in this regard.
Objective Of the Centre
- To bring together complete information on Rathnakaravarni and to pulish his work though popular, low priced edition.
- To research into the literacy works Rathnakaravarni and to organization level seminars and workshops.
- To instill in students a love and enthusiasm for the works of Rathnakaravarni by initiating a Lecture series and audio visual.
- TTo establish a library and museum housing complete information released to Jainsism and its literature and to develop them as an archival local, state and national levels.
Coordinator: Prof. somanna Hongalli
Research assistant: Prasad. S
Office Staff: Latha Shenoy


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Beach boys: behind the scenes
Ah, the beach. Where troubles are few and less is more. In the dead of winter, the promise of soft sand between your toes and warm sun on your face may seem like a world away. But with spring around the corner, it’s a world that will soon again be at your sockless, tanned feet.
So it’s time to start packing. Because this summer we’re going places. From palm lined beaches to snazzy rooftop parties under sweltering night skies. And you’re coming with us. Travel light, go with the flow and be ready to scramble at a moment’s notice. As the mercury rises, so do the chances of great things happening.
But wherever you’re going or might unexpectedly end up, there’s no need to sweat it. On the contrary. Because there’s nothing like the perks of summer to make you feel larger than life.


Recently, Overwatch’s Twitter account presented us with a new Short Story “What you left behind”.
In this short story, we discover Mauga, the Talon Tank. Now I’m not going to spoil the story for you, but I will say that Mauga is heavily hinted as a hero in the near future!
The reason I say this is because they’ve already given us too many details about Mauga, enough details to build a Solid Tank out of. That, and the fact that he has 3 pictures of himself already:
His abilities were already hinted at throughout the story! In short, He holds up 2 Miniguns along with having a Coolant attached to his back. It is also stated that he has a shield!
Doesn’t that remind you guys of a previous event that occurred in Overwatch?


Everything—regardless of how innocuous or dated—had its use. It was a mantra he lived by. Born in 1946 to an Irish immigrant father and an American mom of French-Canadian descent, his mother and father’ coming of age was marked by the Great Depression plus many years of conflict.
Unsurprisingly, this meant that his mother and father, Pat and Stella, had been extra than sensible when it got here to purchases and investments. They had been intentional. They had been frugal. It was “waste not, want not.” And they by no means threw something away—a lifestyle that he held on to lengthy into maturity.
But someday, Pat and Stella’s hoarding and his ensuing perception that all the pieces was helpful, modified my life.
After considered one of his routine check-ins with Pat and Stella, Dad arrived residence with what seemed like a small, hardcover suitcase. It was a shiny metal blue. He swung the case onto the kitchen desk and known as me over. He unlatched the quilt and pushed it again to reveal the contents.
My eyes widened. He smiled. We hugged. And I ran my fingers over the black keys of the outdated typewriter as I contemplated which story I might write first …
This is a bit of my story. And everybody has a narrative to inform; a glimpse to present—together with your B2B model.
The Intersection of Storytelling & B2B Content Marketing
Storytelling is civilization’s oldest type of communication, serving to us train, entertain, protect our histories and cultures, and instill our values. We’re programmed for tales. Our brains mild up once we hear and see tales unfolding.
This starvation for narrative mixed with our want and talent to information our personal quest for solutions, storytelling has naturally grow to be a basic staple of B2B content material advertising. As Ursula Ringham, Global Head of Influencer Marketing for SAP, says: “In advertising, story is all the pieces.”
But the problem for a lot of B2B entrepreneurs is to weave a narrative internet that’s all the pieces to their prospects and prospects. It wants to present that significant glimpse. It wants to be acquainted. It wants to be genuine. And it wants to resonate.
“Every content creator should consider themselves a storyteller,” Nick Nelson, Senior Content Strategist at TopRank Marketing, declares in his piece on constructing belief by storytelling. “When we write, we are invariably sharing a story: about our solution, about our customers, about the pains we can help solve.”
He provides: “Tying a number of items of knowledge collectively in a coherent, chronological, and—above all—relatable means makes the message much more affecting. The content material abruptly turns into experiential as an alternative of merely academic.”
In #advertising, story is all the pieces. @ursularingham #B2BContenMarketing #Storytelling Click To Tweet
The backside line? It’s now not sufficient to inform patrons. Instead, you should present story-driven content material that connects on each mental and emotional ranges.
Read: Creating Content Connections: 10 Lessons in Resonance from Content Marketing Pros
How to Create B2B Content Connections Through Storytelling
Whether you’re constructing a large-scale model narrative or pulling at story threads, right here are some things to take into account as you commit to storytelling in your B2B content material advertising initiatives.
#1 – Commit to storytelling by doubling-down on what’s already acquainted.
Contently co-founder and acknowledged journalist Shane Snow is broadly recognized in advertising circles for his knack for storytelling and his dedication to serving to different entrepreneurs harness their storytelling skillset.
A few years in the past, I had the privilege of seeing Shane converse on this very matter at MarketingProfs B2B Forum. At that point, he laid out a three-step framework for telling higher tales and it resonated with me.
- Create well timed, seasonal, and evergreen content material that tells a narrative at each stage of the funnel.
- Connect your viewers together with your tales by figuring out the best distribution channels and content material varieties—primarily based in your viewers’s preferences and your aims.
- Optimize and refine your tales to guarantee your creating content material that undoubtedly connects.
The ideas outlined in his framework ought to really feel actually acquainted—they’re meant to, from my perspective. (Familiarity is a trademark of fine storytelling.) The swap is defining the way you present and inform tales your patrons will care about, somewhat than merely creating extra content material.
For a extra in-depth look, try Shane’s storytelling course that outlines the science of nice tales, the weather of efficient storytelling, and rather more.
#2 – Introduce your viewers to new characters.
Content is completely all over the place. And belief in advertising—amongst customers and your C-suite—is low. As a outcome, patrons are trying to these they know or these they think they know for insights, solutions, and suggestions. And this implies there’s by no means been an even bigger alternative to accomplice with different “storytellers” to add new dynamics to your content material.
“In order to tell a compelling story, you have to be immersed,” Ursula Ringham states. “Bring empathy and understanding, convey goal, and produce perception—the latter of which influencers can definitely assist with.
When you co-create content material with influencers, you not solely present influential consultants with a medium to share worthwhile insights, however you can too present your viewers with a mixture of views—considerably upping your storytelling capabilities and credibility.
“Partnering with an influencer allows you to highlight your brand’s own existing narrative in a new way, so that you can reinforce the proof points you really want your customers to know,” Whitney Magnuson, Global Head of Social Media and Influencer Programs for IBM, instructed us not way back.
Partnering with an #influencer permits you to spotlight your model’s personal current narrative in a brand new means, with the intention to reinforce the proof factors you actually need your prospects to know. @whitneymagnuson @IBMSystems Click To Tweet
#three – Steer away from fantasy or fiction.
With belief in advertising low, authenticity and transparency are more and more vital. As my colleague Nick Nelson so eloquently mentioned:
“Storytelling backfires when it strikes people as false or disingenuous. Share real anecdotes and back them with third-party evidence or quotes. Telling hard truths, even if it means acknowledging a shortcoming in your business, can be tremendously beneficial in the long run. Even more than being true to the facts, you must be true to yourself, and your brand.”
Storytelling backfires when it strikes folks as false or disingenuous. Even greater than being true to the information, you have to be true to your self, and your model. @NickNelson #B2BContentMarketing #Storytelling Click To Tweet
Read: Be Honest Like Abe: How Content Marketers Can Build Trust Through Storytelling
The nostalgic story I opened with is greater than a fond reminiscence. It’s a glimpse into who I’m, the place I got here from, and the way I received right here. It’s my reality. It’s my context. It’s a bit of my story.
Every model has the chance to discover, present, and inform their very own tales. Stories about who they’re, what they stand for, and the way they clear up issues. Stories that convey reality and add context. Stories that resonate and encourage.
So, mud off your model’s outdated hand-me-down typewriter and get to work. It’s storytime.
Senior Director of Digital Strategy Ashley Zeckman and Content Strategist Annie Leuman are on the bottom at Social Media Marketing World in San Diego from March 20-22, 2019. And as all the time, you’ll be able to rely on us to ship you first-hand learnings and tales from the convention ground. Follow @azeckman, @annieleuman, and @toprank on Twitter to get stay updates.


Lecture 9: Constraint Resolution
In this lecture we study constraint resolution, constraint semantics, and unification.
Hendrik van Antwerpen, Pierre Néron, Andrew P. Tolmach, Eelco Visser, Guido Wachsmuth. A constraint language for static semantic analysis based on scope graphs. In Martin Erwig, Tiark Rompf, editors, Proceedings of the 2016 ACM SIGPLAN Workshop on Partial Evaluation and Program Manipulation, PEPM 2016, St. Petersburg, FL, USA, January 20 - 22, 2016. pages 49-60, ACM, 2016. This paper develops a constraint language for description of type system using scope graph constraints for the definition of name binding. These constraints are the basis for the NaBL2 language.
Baader, Franz, Wayne Snyder, Paliath Narendran, Manfred Schmidt-Schauss, and Klaus Schulz. “Chapter 8 - Unification Theory.” In Handbook of Automated Reasoning, edited by Alan Robinson and Andrei Voronkov, 445–533. Handbook of Automated Reasoning. Amsterdam: North-Holland, 2001. https://doi.org/10.1016/B978-044450813-3/50010-2.


Author: James Taylor
Publisher: Crowood Press (August 27, 2019)
Hardcover: 176 pages
Item Weight: 1.8 pounds
Dimensions: 8.79 x 0.68 x 10.59 inches
James Taylor remembers very well the disappointment among his pretrol-head friends when the XJ-S was announced in 1975. It was not a replacement for the legendary E-type; its colours were uninspired; and its interior was drab. All credit, then, to those people at Jaguar who truly believed in the car and, over a period of nearly 20 years, turned the ugly duckling into a swan. From the moment the XJ-S HE arrived in 1981, there seemed to be renewed hope, and from then on, the car went from strength to strength to become the much-admirred grand tourer it always should have been. The book contains a timeline of the key events in the history of the XJ-S and an overview of the evolution of the XJS from the XJ27 prototype. There are Appendices covering identification/serial numbers, UK showroom prices through the years and sales in the US by year.


Hi! I’m Maxwell Cloe (they/he), an oral historian and American Studies scholar with an MA from the College of William & Mary. My research centers on LGBTQ+ histories and cultures in the Appalachian Mountains, particularly artistic and archival networks. I’m also interested in oral history methodology, twentieth-century Southern literature, environmental activism, and radical labor movements. My recent dissertation project focuses on the intersections of LGBTQ+ Appalachian art and environmental justice.
When I’m not conducting research, you can find me in the shelves of antique stores and bookshops, looking for rare and first edition books to add to my collection. I photograph and document these books on a dedicated Instagram page, which you’re welcome to peruse and follow.
I play old time Appalachian fiddle, regularly enjoy walks in the woods, and distract myself by arguing with my black cat, Corduroy.


When I take the decision
Not to follow you in that far country
with its wealthy sweet ways,
I still love you more than my life,
But I’m afraid of being cut off
In such a spectacular world.
That valley of silver would prevent me
From visiting Rosoanilaina whom I need so much,
She who dresses my hair in Marina tresses,
So easy to do and which honour me
like a lady with a newborn child.
And now, so our parting begins
You leave for gain and I leave for life,
Your courtesy is not enough to live Malgache-style
I grind the rice; I plant the paddy;
With pistachio I cook the cassava.
I die losing you. You’re off to your fate,
To plant yourself anew on the soil of sweat,
Foreign soil where I’d never find
My own sense of belonging,
My negress skin, my frizzy hair,
My beauty would would wither away in that
land of riches.
and he wasn’t taller than three apples
exactly as they should be
to give taste to life
he was no higher
than three fruit
plucked from the tree of paradise
to make heads turn
such that life tasted of cider
he wasn’t tall enough
too much of a child
to be making war
but still they involved him
in their warrior games
now there are gaps
in the apples
because they dared to trample
over God’s orchard!
the innocence of childhood!
Of this world you are the witness,
From the dust you question
The sphere of the sky
Limbs stripped of flesh,
on the edge of nothingness,
what image will you keep
of men, your brothers?
My Somali, fortunately
you cannot see yourself through
the television watching you.
Fortunately you are unaware of
Neither can you hear the laughter
Over the dinner table and wine
Nor the excellent discourse
Which constructs a life over the tomb.
For you none of that exists,
Nothing but that land cursed
By the sun and the rain,
That soil once blessed by the god
And today beyond the hope of man.
Perish, my brother,
Perish without regret,
Die in peace,
The world is so.
You sons of the night,
is it the eternal stubborness
of your eternal manliness?
Agree to look.


“There is simply no way to describe the past without lying. Our memories are not like fiction. They are fiction.” This is the main theme of Marcel Proust’s ideas on memories. Jonah Lehrer writes this chapter about “Proust’s fiction, which is mostly nonfiction.” He explains throughout the chapter that our memories lie to us and how “our recollections are phony.” Sometimes depending on our experiences we remember certain situations to be better or worse than what they actually are. We warp memories to fit “our own personal narrative” and sometimes our memories are bias. He describes our memoires as imperfect. But why are our memories imperfect? According to Lehrer our recollections are designed by the brain to always feel true whether or not they actually happened. Our memories are formed by neurons connecting. If neurons don’t touch gaps form. These empty spaces are the parts of memories that change. Another thing that causes memories to change memories is time. According to Proust “time mutates memory.” As time goes on they become a vaguer and vaguer portrait of what actually happened. “They are imperfect copies of what actually happened.” Our brains are not designed to remember every single detail of our memories and what exactly happened. From the video that we watched in class, it explained that men remember jists of things are women remember things in more detail. After reading this chapter it has become clear to me that woman must have more neurons connection in the brain. While men have more gaps. Proust’s ideas about memory and how they are “fictional” become very clear after reading this chapter.
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What Should I Do?
Now that you have heard this Good News, God wants you to respond to Him. You can talk to him using words like these:
"My life is broken - I recognize it's because of sin. I need you."
"I believe Jesus the Christ came to live, die and was raised from the dead - to rescue me from my sin."
"Forgive me. I turn from my selfish ways and put my trust in you"
"I know that Jesus is Lord of all, and I want to follow Him."
Becoming a Follower of Jesus Christ
The Bible says:
"if you confess with your mouth, 'Jesus is Lord', and believe in your heart that God raised him from the dead, you will be saved" (Romans 10:9)
"For everyone who calls on the name of the Lord will be saved" (Romans 10:13)


When you lose a large quantity of weight after present process the Gastric Bypass Weight-Loss Surgical procedure, it’s difficult to alter our mindsets and the way we incorporate our new way of life habits. As we slim down, it is crucial that we start to “suppose as a skinny individual” or reasonably let’s all observe this tongue-twister collectively “thinking as the skinny think.”
Why should we do that?
As a result of if we fail to do this, we will run the chance of simply falling into these unhealthy and dangerous habits that strolled us down the paths of weight problems in the first place. It doesn’t matter what stage alongside your weight-loss journey you might be currently experiencing, in the end you’ll fall prey to these nasty life-long ugly companions (aka habits). They may devour your positive ideas and urge you to glutinously devour all the wrong issues so that you’ll succumb to your meals bondage once more. However DON’T DO IT! Put in your armor of THIN THINKING shortly to thwart all advances
I recall as a younger teenager, I knew many friends who, even at a young age, have been obsessive about watching their weight, counting energy, apprehensive about getting sufficient physical exercise, and monitoring the snugness of their clothes. I believed this was very weird since I didn’t have any weight points then. I might nearly eat something and it might never present a pound on the dimensions. In fact, pondering again, I used to be a high-level physically lively particular person, and so for this reason weight-watching was not a crucial consider my life on the time. I didn’t must suppose like a skinny individual.
Nonetheless, when I step by step turned very heavy 317 pounds, I spotted that I obtained that method partially as a result of I didn’t have the inspiration of “pondering as the skinny think.” And with out that basis to make the most of, I missed nice opportunities to alter a few of my dangerous habits. Think about that morbid weight problems is way deeper than simply succumbing to unhealthy habits… morbid weight problems has many aspects to it; however for this writing, I wish to focus on one factor, and that’s how we “suppose” we’re.
After I discover the rationale of how skinny individuals think, I uncover some attention-grabbing behaviors. Skinny individuals think about:
“Thinking Thin” Will Help You Lose Weight. Please, Must you like this publish, don’t overlook to share this publish and kindly adjust to us on Fb, Pinterest, and Twitter.


Canada / 2020 / 105 min
Dark dreams plague Sarah. She’s an intelligent, thoughtful, rebellious teenager. These are all hard things to be at the age of 18, and it has landed her in trouble at school and unable to go home. With nowhere left to turn, she notices an advertisement posted on the wall of her local coffee shop – for a sleep study. The lure of a safe place to rest, and the added bonus of getting paid to do it, are impossible for her to shun. After only a single evening of sleeping under the watchful eye of a small group of scientists, Sarah begins to see things from her dreams in her waking life. Her visions worsen as she continues to take part in the nightly studies, and before she, or any of the scientists can effectively react… Sarah becomes the unknowing conduit to a horrifying new discovery.


Matthew Goode and Ben Whishaw by Steve Harries, 2008.
A Clockwork Orange by Crysse
Even though I’m no better than a beast, don’t I have the right to live?
"I wish we could stay here forever… and ever… and ever."
More new stills from The Desolation of Smaug (x)


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He lived in England from 1968-1972 and studied philosophy at the University of Nottingham, then medicine at the University of Amsterdam. He qualified as a doctor in 1981 and then worked shortly in Kenya. Since 1985 he has been a geriatrician in Amsterdam.
As a physician in a nursing home he has written about physician assisted suicide (which has been legal in the Netherlands for some years), most notably in his book Het refrein is Hein, which was translated into English (by Keizer himself) as Dancing with Mr D and published by Transworld-Doubleday in 1994. The book was also translated into German, Spanish, Japanese, Danish, Swedish and French.
His style is contemplative, with an undercurrent of realism (or some would say pessimism) about the limits of medicine which most people prefer not to think about, and a remarkable intellectual honesty about the emotions of the patient as well as the physician.
While the topic of euthanasia and assisted suicide was the most salient point for the literary criticism, it is not a very large part of the book.
- https://publications.parliament.uk/pa/ld200405/ldselect/ldasdy/86/86we14.htm Select Committee on Assisted Dying for the Terminally Ill Bill Written Evidence, Memorandum by Dr Bert Keizer, from the UK Parliament, House of Loards, 2008.