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Advanced Parental Age and the Risk of Autism Spectrum Disorder
Oxford Journals Medicine American Journal of Epidemiology American Journal of Epidemiology Advance Access 10.1093/aje/kwn250
American Journal of Epidemiology Advance Access published online on October 21, 2008
American Journal of Epidemiology, doi:10.1093/aje/kwn250
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American Journal of Epidemiology © 2008 The Authors
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.0/uk/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Advanced Parental Age and the Risk of Autism Spectrum Disorder
Maureen S. Durkin, Matthew J. Maenner, Craig J. Newschaffer, Li-Ching Lee, Christopher M. Cunniff, Julie L. Daniels, Russell S. Kirby, Lewis Leavitt, Lisa Miller, Walter Zahorodny and Laura A. Schieve
Correspondence to Dr. Maureen Durkin, Waisman Center and Departments of Population Health Sciences and Pediatrics, University of Wisconsin School of Medicine and Public Health, 789 WARF, 610 Walnut Street, Madison, WI 53726 (e-mail: email@example.com).
Received for publication March 21, 2008. Accepted for publication July 16, 2008.
This study evaluated independent effects of maternal and paternal age on risk of autism spectrum disorder. A case-cohort design was implemented using data from 10 US study sites participating in the Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network. The 1994 birth cohort included 253,347 study-site births with complete parental age information. Cases included 1,251 children aged 8 years with complete parental age information from the same birth cohort and identified as having an autism spectrum disorder based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. After adjustment for the other parent's age, birth order, maternal education, and other covariates, both maternal and paternal age were independently associated with autism (adjusted odds ratio for maternal age 35 vs. 25–29 years = 1.3, 95% confidence interval: 1.1, 1.6; adjusted odds ratio for paternal age 40 years vs. 25–29 years = 1.4, 95% confidence interval: 1.1, 1.8). Firstborn offspring of 2 older parents were 3 times more likely to develop autism than were third- or later-born offspring of mothers aged 20–34 years and fathers aged <40 years (odds ratio = 3.1, 95% confidence interval: 2.0, 4.7). The increase in autism risk with both maternal and paternal age has potential implications for public health planning and investigations of autism etiology.
autistic disorder; birth order; maternal age; paternal age
Abbreviations: ASD, autism spectrum disorder; PDD-NOS, pervasive developmental disorders-not otherwise specified
This paper examines the relation between parental age at delivery and the prevalence of autism spectrum disorder (ASD). The possibility that autism is more common in offspring of older parents has generated considerable interest (1–6). Confirmation of such an association could have important public health implications in light of increasing trends in recent decades regarding both maternal and paternal age (7). In addition, evidence of paternal and maternal age effects on autism risk may provide clues to the etiology of a class of neurodevelopmental disorder that is still poorly understood and thought to be complex and multifactoral.
In evaluating the association between parental age and autism risk, it is important to account for other variables related to both parental age and autism or that may modify the association. Birth order is a potentially confounding factor because it is positively associated with parental age and has been reported in some studies to be associated with autism risk, with at least 3 studies reporting firstborn children to be at increased risk of autism (1, 2, 4). The goal of this study was to determine, in a large, population-based cohort of US children, whether advancing maternal and paternal age each independently increase a child's risk of developing autism after controlling for the other parent's age, birth order, and other risk factors.
Study design and sample
We implemented a population-based, case-cohort design in which the comparison group was a cohort of all livebirths in 1994 in 10 geographically defined study areas participating in the Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network (8). The 10 areas are all sites with deidentified birth certificate information on parental age and other relevant variables included in the Network database and include sites in Alabama, Arizona, Arkansas, Colorado, Georgia, Maryland, Missouri, New Jersey, North Carolina, and Wisconsin.
The cohort serving as the comparison group includes all livebirths to mothers residing in any 1 of the study areas in 1994, with complete information available from birth certificates on maternal and paternal age, birth order, and other variables. We used 2 data sources to construct the cohort: 1994 deidentified birth records for the Wisconsin study area provided by the Wisconsin Department of Health and Family Services and, for the remaining sites, the National Center for Health Statistics public use natality data files (9). The public use file includes county of residence for births in densely populated counties, which enabled us to ascertain deidentified birth information for all births in most of the counties. We were unable to precisely obtain counts of births occurring in sparsely populated counties in which 13,043 (4.1%) of the study-area births occurred in 1994. For these counties, we obtained county-level aggregate information on the total number of births in 1994 and their distribution by variables such as maternal marital status, ethnicity, and age and selected a stratified random sample of deidentified birth records (equal in number and similar in distribution by maternal marital status, ethnicity, and age to all livebirths occurring in the respective counties in 1994) from sparsely populated counties of the state in which the study area was located. The full cohort included 326,785 livebirths, of which 73,438 (22.5%) were excluded because of missing paternal age. The cohort serving as the comparison group thus included the 253,347 livebirths with complete information on parental age and other key variables (Table 1).
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Table 1. Characteristics of the 1994 Birth Cohort and ASD Cases, 10 Study Sites From the US Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network
The total number of children aged 8 years residing in the study areas in 2002 determined by the Autism and Developmental Disabilities Monitoring Network surveillance system to have an ASD was 2,142. Birth certificate information was available for 1,517 (70.8%) of these children, who were born in the same state as their state of residence in 2002. The remaining 29.2% of cases were excluded from this analysis because of missing birth certificate information. The case group for the present analysis was further restricted to the 1,251 children (58.4% of the total ASD case group) for whom information on both parents' age as well as birth order and gestational age was available. Our final sample was comparable to the total population of ASD cases regarding demographic factors and ASD case characteristics (Table 1).
Case definition
ASDs include behaviorally defined neurodevelopmental disorders diagnosed through clinical observation, and they encompass impairments in social, communicative, and behavioral development, often accompanied by abnormalities in intellectual functioning, learning, attention, and sensory processing. For this study, children with ASD included members of the birth cohort residing in the study area in 2002 who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for autistic disorder; pervasive developmental disorders-not otherwise specified (PDD-NOS (http://www.cdc.gov/ncbddd/autism/overview_diagnostic_criteria.htm), including atypical autism); or Asperger's disorder (10) based on a comprehensive review of educational and clinical records by trained clinicians. Children were classified by clinician reviewers as having an ASD if they had either a documented previous classification of ASD (65%) or an evaluation record from an educational or medical setting indicating unusual behaviors consistent with ASD (35%). For children previously identified as having an ASD, case status was confirmed on the basis of evaluation records. For children without a documented ASD classification, data were abstracted on all relevant ASD and developmental behaviors from education or medical evaluations to determine whether behaviors described in the evaluations by clinical reviewers were consistent with the diagnostic criteria. Because case status was determined solely on the basis of information contained in evaluation records, and because Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria are less well defined for PDD-NOS than for autistic disorder, the surveillance protocol for determining whether a child could be classified as having PDD-NOS required documentation of at least 1 behavior considered to be an ASD discriminator, such as being oblivious to others when there is a clear social opportunity or demonstrating atypical and persistent focus on sensory input (11).
Of the 1,251 ASD cases, 80.7% were determined to meet criteria for autistic disorder, while there was insufficient information for those remaining to distinguish between autistic disorder, Asperger's disorder, or PDD-NOS. Information from standardized intelligence tests was available for approximately 75% of the ASD cases. On the basis of this information, children with ASD were classified as having intellectual impairment (an IQ of <70) versus normal intelligence. Further details regarding the 2002 Autism and Developmental Disabilities Monitoring Network sample and methodology have been reported previously (8, 11).
Analytic strategy and statistical methods
Potential for confounding effects of birth order, gender, and other variables was evaluated by first examining unadjusted associations between each potential confounder and the independent variables of maternal and paternal age as well as the dependent variable, ASD case status. Variables were considered to be potentially confounding factors if they were associated with both parental age and ASD. Unadjusted odds ratios with confidence intervals were computed to evaluate the magnitude of these associations, and unconditional logistic regression models were fit to estimate adjusted odds ratios and 95% confidence intervals. Statistical significance was evaluated by using chi-square tests for categorical variables and analysis of variance for continuous variables.
To enhance the comparability of our findings with those from other studies, we fit 2 types of models, 1 with parental ages categorized into 6 categories: <20, 20–24, 25–29, 30–34, 35–39, 40 years; and the other with parental age as a continuous variable with the odds ratio scaled to reflect a 10-year difference in age (4). Although we found the association between parental age and autism risk to be similar across the 10 sites, to adjust for potential site-to-site variability we included site dummy variables in all multivariable models. To evaluate interaction or modifying effects of each covariate and of ASD subtypes on the associations between parental age and ASD, we performed stratified analyses. We also tested interaction terms for maternal age by paternal age and 2-way and 3-way interaction terms for each parent's age by the other covariates in the regression models, but we identified no significant interactions. SAS version 9.1.3 software (SAS Institute, Inc., Cary, North Carolina) was used for all statistical analyses.
This research involved secondary analysis of deidentified data and was approved by the University of Wisconsin Institutional Review Board.
In unadjusted analyses, both mean maternal age and mean paternal age were significantly higher for ASD cases than for the birth cohort as a whole (Table 2). Table 2 also shows that mean parental ages differed significantly in unadjusted analyses across categories of birth order, maternal education, ethnicity, multiple birth, gestational age, and birth weight for gestational age, but not for gender. With parental age 25–29 years as the reference group, the odds of developing ASD was significantly reduced for parental age <20 years and increased for maternal age 35 and paternal age 40 years (Table 3, unadjusted odds ratios). We therefore used these age cutoffs (maternal age 35, paternal age 40 years) to classify each parent's age as "older" versus "younger." Other significant predictors of ASD in unadjusted analyses included low birth order, male gender, advanced maternal education, and preterm birth (Table 3).
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Table 2. Unadjusted Mean Maternal and Paternal Ages at Delivery for ASD Cases Compared With the Cohort as a Whole, and in the Cohort as a Whole Stratified by Covariate Categories, 1994 Birth Cohort From 10 Study Sites From the US Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network
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Table 3. Distribution of ASD Cases and Birth Cohort Comparison Group by Parental Age Categories and Other Independent Variables, and Unadjusted and Adjusted Odds Ratios With 95% Confidence Intervals, 1994 Birth Cohort From 10 Study Sites From the US Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network
Multivariable analysis of parental ages modeled as categorical variables
After we adjusted for the other parent's age and other covariates, the increases in ASD risk associated with maternal age 35 years and paternal age 40 years (relative to age 25–29 years) were slightly reduced compared with the unadjusted analysis (Table 3). In contrast, the results for birth order suggest that the decline in ASD risk associated with increasing birth order is somewhat stronger in the adjusted analysis than in the unadjusted analysis (Table 3). In addition, the apparent increase in ASD risk associated with higher levels of maternal education in the unadjusted analysis is no longer evident in the adjusted model, suggesting that the apparent maternal education effect is due to its association with parental age (Table 3).
Parental ages modeled as continuous variables
In unadjusted analyses, the risk of developing ASD increased significantly with each 10-year increase in both maternal age and paternal age. After adjustment for age of the other parent and other covariates, each 10-year increase in maternal age was associated with a 20% increase in ASD risk (odds ratio = 1.2, 95% confidence interval: 1.1, 1.4) while each 10-year increase in paternal age was associated with a 30% increase in ASD risk (odds ratio = 1.3, 95% confidence interval: 1.1, 1.5).
Combined effects of parental age and birth order
The risk of ASD within each of 3 parental age categories (both parents "younger," 1 parent "older," and both parents "older") was highest among firstborn children and declined with increasing birth order (Table 4). Considering the combined effects of parental age and birth order, we excluded from the analysis births to mothers aged <20 years and found the lowest risk group to be third- or later-born offspring of mothers aged 20–34 years and fathers aged <40 years. Compared with that for this group, the risk of ASD increased with both declining birth order and increasing number of older parents. The highest risk group included firstborn offspring of mothers aged 35 years and fathers aged 40 years, with a risk 3 times that of the reference group (Table 4).
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Table 4. Adjusted Odds Ratiosa With 95% Confidence Intervals Indicating Increasing Risk of ASD With Parental Ageb and Decreasing Risk With Birth Order, 1994 Birth Cohort From 10 Study Sites From the US Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network
Our findings are consistent with those recently reported from a large study of members of a California health maintenance organization (4) that found the risk of ASD to be positively and independently associated with both maternal and paternal age, with adjusted odds ratios nearly identical to those reported here. These findings contrast somewhat with 5 other recent epidemiologic studies that found only 1 or neither parent's age to be associated with ASD risk after controlling for the other parent's age (2, 3, 12–14).
The lack of consistency across studies could be due to limitations of sample size and of population representation of previous studies as well as other methodological differences, including autism case definitions and inclusion criteria and the ability to control for important variables. The present study included a large sample of children with sufficient information to enable evaluation of separate and combined effects of each parent's age as well as birth order and other variables. With more than 1,200 cases, it included over 50% more cases and thus more statistical power than any of the previous studies examining independent effects of maternal and paternal age on ASD risk.
Another advantage of this study is the population-based nature and diversity of the cohort, allowing control for factors that may confound the association between parental age and ASD. Maternal education is 1 variable we considered to be a potentially confounding factor because it is associated with maternal age and has been observed to be related to ASD risk (15). Our results, however, suggest that the association between advanced maternal education and ASD risk observed in unadjusted analysis may be spurious and due to confounding by parental age.
The results of this study also demonstrate the importance of controlling for birth order in evaluating independent effects of parental age on ASD risk. Because birth order increases with parental age and, in this and other studies, has been found to be negatively associated with ASD risk, failure to control for birth order may mask a positive association between parental age and ASD risk. Two of the previous studies reporting an association between advancing maternal age and ASD (2, 4) also had adjusted for birth order and, similar to the present study, found birth order to be negatively associated with ASD.
An additional advantage of this study is its restriction to a single birth year, thereby controlling for temporal trends in recent decades in both ASD prevalence and parental ages at the birth of their children. This feature of the study allows estimation of the association between parental age and ASD risk independently of temporal trends in diagnostic practices or other factors.
Public health implications
The strength of the independent associations between maternal and paternal age and ASD risk, as indicated by the odds ratios in the range of 1.2–1.4 reported here, is modest. However, the observation that these effects are independent of each other and of low birth order raises the likelihood that the combined effects of parental age and birth order may have important public health implications. Mean maternal age in the United States has increased steadily since the 1970s, particularly for firstborn children, for whom mean maternal age at delivery increased by 3.8 years between 1970 and 2004 (16). In addition, the proportion of births to women aged 35 years began increasing in the United States after 1980, when it was 5%; by 2004, it had increased to 14.2% (17, 18). During this same period, fertility rates for men aged 40 years also increased each year, while fertility among men aged <30 years declined (16). With the decline in average family size in recent decades, we would also expect the proportion of children who are firstborn to have increased. Similar trends are occurring in other developed countries (7). The results of this study raise the question of whether some portion of the recent rise in ASD prevalence (19) may be linked to recent trends in parental age and family size. A further question is whether a modest increase in prevalence associated with advancing parental age and low birth order may have contributed to a greater awareness of ASD and, in turn, increases in measured prevalence. The tendency for older parents of firstborn children to have higher levels of educational achievement and resources than other parents could further contribute to increased awareness and an expansion of the diagnosis of ASD.
Potential etiologic implications of parental age effects
Because we observed independent effects of the age of each parent on ASD risk, the possible mechanisms for these effects could include a broad range of processes associated with either or both maternal and paternal age. The observed paternal age effect independent of maternal age could point to a causal role of gene mutations in male germ cells, because the probability or selection of these mutations increases as men age (20, 21). The independent effect of maternal age, on the other hand, may point to age-related chromosome changes, pregnancy complications, or environmental exposures during pregnancy. Independent effects of 1 or both parents' ages also could point to a role of accumulated environmental exposures that may have mutagenic effects on gametes or could result from a combination of mechanisms (21, 22).
The association between advanced maternal and paternal age and ASD is also consistent with a potential role of infertility treatments or assisted reproductive technologies, the uses of which have increased in the past decade, especially by women and men of advanced reproductive age (23). Numerous studies have found associations between these technologies and adverse pregnancy outcomes, including those due to epigenetic effects (24–27), although a recent review found no evidence of elevated rates of autism among children born after in vitro fertilization techniques (28). Even though we have no information about exposure to these treatments in our cohort, the observation that firstborn children of older parents had the highest ASD risk is consistent with a possible infertility treatment effect because women who give birth after infertility treatment are more likely to be primiparous than those represented in the general birth cohort. However, the association between multiple birth and ASD in this study was weak and not statistically significant (Table 3, unadjusted odds ratio), whereas assisted reproduction technologies are strongly associated with multiple birth (23).
Another unmeasured factor in the present study potentially associated with both advanced parental age and ASD risk in offspring is psychopathology or behavioral traits of parents that may result in both delayed parenthood and genetic susceptibility to autism in offspring (14).
Birth-order effects
The observation in this and at least 2 previous studies (2, 4) that the risk of developing ASD was highest for firstborn children and declined with increasing birth order is a pattern also observed for other childhood disorders, including type I diabetes and atopy, and is cited as support for the "hygiene hypothesis." According to this hypothesis, firstborn children are exposed to fewer infections from other children early in childhood and, because of delayed immunologic challenge, may be more likely to develop autoimmune responses including those that may adversely affect neurodevelopment (29). Another possible factor that could lead to the observed birth-order effect is exposure to potentially neurotoxic, fat-soluble chemicals accumulated in maternal tissue that have been passed to offspring transplacentally or through breast milk (30). Because of accumulation over a lifetime, the load of such neurotoxins transmitted might be expected to be highest for firstborn children, particularly when combined with advanced maternal age. Another possible explanation for the observed birth order effect is "stoppage" or a tendency for parents of 1 child with ASD not to have subsequent children because of the demands of parenting a child with a disability or concerns about genetic susceptibility (31), thus increasing the likelihood in the cohort as a whole that a child with ASD will have a low birth order. Information available for the present study did not allow examination of these hypotheses.
Another important limitation of this study is that the cohort available for analysis excludes births with missing paternal age information. Because this exclusion applied to both the ASD cases and the comparison group (Table 1), we would not expect it to have resulted in biased estimates of the association between ASD and parental age. In a separate analysis, we examined the association between maternal age and ASD without adjusting for paternal age and including the full birth cohort, and we found the association between maternal age and ASD to be the same as that observed in the subcohort with paternal age.
Another limitation is that the birth cohort comparison group includes about 1% of births of children who died postnatally in addition to an undetermined number who moved out of the study area between birth and the age of 8 years, whereas children who died postnatally and those moving out of the study area after birth are excluded from the case group. Because of this limitation, we could not estimate cumulative incidence of ASD. Nonetheless, this limitation is unlikely to have biased the estimated odds ratios reported in this study, particularly those adjusted for factors such as gestational age and birth weight for gestational age, which are strongly associated with postnatal mortality. Another possible explanation for the increase in ASD among offspring of older parents, but one we cannot evaluate with the data available, is that, compared with younger parents, older parents may be more aware of developmental abnormalities and better able to access diagnostic and special educational services. Other limitations are that parity pertains to only mothers and does not take into account the number of previous births fathered by the fathers represented in the cohort, potential for residual confounding by factors not measured in the present study, possible misclassification of ASD case status, and missing information on paternal education.
The results of this study provide the most compelling evidence to date that ASD risk increases with both maternal and paternal age and decreases with birth order. Further research involving large, well-characterized birth cohorts followed longitudinally will be required to confirm these findings and adequately evaluate the range of alternative genetic and environmental hypotheses that this and other studies raise regarding parental age and birth-order effects on ASD risk. Smaller, focused studies may also be useful, such as Crow's idea to look for mutations responsible for complex disorders of unknown etiology and with parental age effects by studying affected families with older parents (20).
Author affiliations: Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin (Maureen S. Durkin, Matthew J. Maenner); Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin (Maureen S. Durkin, Lewis Leavitt); Waisman Center, University of Wisconsin-Madison, Madison, Wisconsin (Maureen S. Durkin, Matthew J. Maenner, Lewis Leavitt); Department of Epidemiology, Drexel University, Philadelphia, Pennsylvania (Craig J. Newschaffer); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Li-Ching Lee); Department of Pediatrics, University of Arizona College of Medicine, Tucson, Arizona (Christopher M. Cunniff); Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (Julie L. Daniels); Department of Maternal and Child Health, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama (Russell S. Kirby); Department of Public Health and Environment, State of Colorado, Denver, Colorado (Lisa Miller); Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Trenton, New Jersey (Walter Zahorodny); and National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia (Laura A. Schieve).
This work was funded by the Centers for Disease Control and Prevention, Cooperative Agreements UR3/CCU523235 and UR3/DD000078. Additional funding for graduate student support for data analysis was provided by the University of Wisconsin.
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
Conflict of interest: none declared.
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subset: commoncrawl


text:
2015 Thami Mnyele Fine Arts Awards
The City of Ekurhuleni once again hosted and presented the annual national Thami Mnyele Fine Arts Awards. It is a contemporary fine art competition which caters for artists of all ages, producing various media of art works. This year's competition was presented in collaboration with the Lizamore & Associates Mentorship Programme.
Held annually at the Coen Scholtz Recreation Centre in Birchleigh North, the awards aim to encourage artists to excel and compete with each other in order to create cutting edge visual arts products.
The competition reveals the hidden talent of many artists in the community, thus offering them the opportunity to be noticed by commercial galleries and collectors.
This year, the competition received 285 entries from all over the country, from which 84 works were selected to be in the 2015 exhibition and from these, the top 15 were chosen.
Kudakwashe's entry, Bree Taxi Rank, was one of the few artworks selected to be exhibited at this event! To be selected is a great honour and recognition of being part of the contemporary SA art scene.
The Art Farm Competition 2014
Kudakwashe won first prize in the Art Farm Competition in November 2014.
Perfect Moments Charity Exhibition 2013
In 2013, Kudakwashe took part in the Perfect Moments Charity Exhibition to help raise money for the St Francis Orphanage and The Society for Animals in Distress.


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Elements To Consider When Hiring A Commercial Electrician
A circuit tester is an expert person who spends significant time in various sorts of electrical works, for example, establishment of electric parts, upkeep and repair of other electrical framework among different types of electrical works. There are different commercial electrical companies which provide full time electrical services to their clients, however there are several factors that should be taken into consideration when hiring the services of a commercial electrician.
A standout amongst the most imperative variables to put into thought is the notoriety of the electrical organization and the most ideal path in which an individual can have the capacity to do as such is by experiencing the different electrical organizations site to experience their audits as this will give the individual a thought of how the organization's administrations are. An individual should also be able to get referrals from other individuals who were able to contract the services of the commercial electrical company as they are in a better position to tell you how the company's services are and if there is any negative complement about the company then the other client's will be able to let you know and this way an individual can be able to weigh the best company they can be able to hire for their electrical works.
The cost of work among various sorts of cost should in like manner be considered this is because of different electrical associations charge unmistakable costs for their organizations along these lines it is basic for a man to have the ability to differentiate the costs so as with settle for an association that charges stash all around arranged expenses. The other factor to put into consideration is the insurance of the electrical company in that one should ensure that the staff personnel of the electrical company are insured this is because electrical work tends expose an individual to different types of risks such as electrical shock hence it is advisable to ensure that the company is insured so as to cover the risks which the clients may be dragged into for example in case of an accident the client may be charged simply because they did not ascertain whether the company is insured or not.
The other compute to put believed is the allow of the electrical association in that it should be selected under the circuit analyzers board as this routinely fills in as a surety to the client this is an authentic association so they don't have to worry over paying little respect to whether the association is enrolled and approved to finish electrical organizations.
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BETHLEHEM LUTHERAN: Craft bazaar, 8:30 a.m.-1:30 p.m. Saturday, Nov. 21, at 10000 Broad River Road, Irmo. Twenty-one inside spaces available for $5 each. Outside vendors will furnish their own tables and covers at no cost but donations will be accepted. Handcrafted items only. (803) 603-2164 or (803) 816-4147
BOUNTY OF BLYTHEWOOD: 9 a.m.-3 p.m. Saturday, Nov. 21, on the lawn of the Hoffman House (Town Hall), Blythewood. Event will feature a Taste of Blythewood, local farmers market vendors, crafts, bands, Iron Chef competition, barbecue cook-off and a "can-struction" contest (canned food items used in construction will be donated to the needy). The town's Christmas tree lighting ceremony will be 5 p.m. Sunday, Nov. 22 in front of town hall. Guest performances by the USC New Horizon Band, string ensemble from Blythewood High School and singing groups from Trinity United Methodist, Bethel Baptist and Sandy Level Baptist.
EAU CLAIRE COMMUNITY COUNCIL: Accepting applications through Friday for HolidayFest craft show and sale set for 3-8 p.m. Saturday, Dec. 5, in the Eau Claire Print Building, 3907 Ensor Ave. Participants are invited to offer handmade holiday-themed craft items (ornaments, wreaths, decorations) and handmade gift items (jewelry, soaps, textiles, etc.) for sale. Vendor fee, $25. (803) 454-0888 or apply online at www.eauclairecommunity.org.
TRINITY EPISCOPAL CATHEDRAL BAZAAR: 10 a.m.-2 p.m. Saturday, Nov. 21 at 1100 Sumter St.. More than 15 booths featuring art, homemade crafts, books, rummage items, Christmas booth. There will also be lunch, entertainment, children's carnival and silent auction. Proceeds benefit Epworth Early Intervention Center, Family Shelter, Harvest Hope Food Bank, HomeWorks of America and St. Lawrence Place.
SHILOH UNITED METHODIST: Fall bazaar, 8 a.m.-2 p.m. Saturday at 1000 Spring Hill Road, Gilbert. Yard sale, crafts, baked goods, country store, hot dogs, soup and corn bread, more.
GOBBLEFEST: 3-6 p.m. Sunday, Nov. 22, at St. Stephen's Lutheran Church, 119 N. Church St., Lexington. Fall festival will feature inflatables, balloon twister, face painting, games, cake walks, bake sale. $5; hot dogs, chips, drinks will be available for $3. (803) 359-6562
CRAFTS IN THE PINES: Friday through Sunday, Nov. 27-29 at Brown's Christmas Tree Farm, 430 Pat Road, Lexington. Arts and crafts, refreshments, carving demonstrations, children's activities and Santa Claus. (803) 755-9676
THE NURTURING CENTER THANKSGIVING MEAL DRIVE: Group or individual sponsors are needed to help provide a holiday meal - suggested items include meat, vegetables, bread, pie, drinks and a roasting pan (approximately $25). Meals will be delivered to families on Wednesday, Nov. 25. Neil Nadkarni, (803) 771-4160, ext. 17.
ADOPT A TURKEY: A donation of $10 will buy a 10-12-pound bird for the 19th annual Interfaith Thanksgiving Dinner Thursday, Nov. 26, at Carolina Coliseum and nursing homes/assisted living facilities. Call (803) 796-9802 or make checks payable to St. Peter's Catholic Church, P.O. Box 1896, Columbia, SC 29202; attn: Robert Keeder
OPERATION CHRISTMAS CHILD: Lexington Baptist Church is serving the Lexington area collection point for the shoe-box gifts, a holiday project of Samaritan's Purse. Boxes will be accepted at the Family Life Center, 111 Efird St. (just off East Main Street) at the following days and times: Monday, 9 a.m.-1 p.m.; Tuesday and Thursday, Nov. 19, 4-7 p.m.; Wednesday and Friday, Nov. 20, 11 a.m.-1 p.m.; Saturday, Nov. 21, 10 a.m.-2 p.m.; and Sunday, Nov. 22, 1-4 p.m. (803) 996-8836; information and suggested items for the boxes can be found at www.samaritanspurse.org and clicking on Operation Christmas Child.
OPERATION CHRISTMAS CHILD: North Trenholm Baptist Church, 6515 N. Trenholm Road, has been designated as a Midlands collection point for the shoe-box gifts, a holiday project of Samaritan's Purse. Boxes will be accepted at the following days and times: Monday, Tuesday and Thursday, Nov. 19, 9 a.m.-1 p.m.; Wednesday, 1-8 p.m.; Friday, Nov. 20, 9 a.m.-5 p.m.; Saturday, Nov. 21, 9 a.m.-noon; Sunday, Nov. 22, 2-4 p.m.; and Monday, Nov. 23, 8 a.m.-7 p.m. Information and suggested items for the boxes can be found at www.samaritanspurse.org or by calling (800) 704-1268.


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Entities come together to find solutions to county flooding problem
EL PASO, Texas (KFOX14) —
It has been a tough monsoon season in El Paso County. The county has seen flooding, evacuations, sinkholes and severe damage the past month.
In a closed-door meeting Thursday, the county, the outlying cities and all of the local water districts started working together for the first time on the path to a long-term solution.
County Judge Veronica Escobar and Commissioner Vince Perez met with the various Borderland water districts Thursday. The county is working with the all the outlying cities, the Lower Valley Water District, Tornillo Water District, El Paso County Water Improvement District and others to come up with a plan to solve the area's flooding problems for good. They all decided they need to find a way to legally create a stormwater authority.
"I noticed that the flooding was on that side, and now it's been flooding on the side. But yeah, it's always been there," said resident Danny Ramos, who was born and raised in Socorro. "Every year is the same thing. I'm just expecting it. I think they are a little bit ignored and I think they need to do something about it. It's the people who pay taxes and stuff like that. Something has to get done."
"We've never had stormwater infrastructure of the magnitude that we need out in the outlying areas," Escobar said. "We know what the problem is. We know what the solution is. We know how much the solution will cost. The challenge is getting that money."
Escobar said problem is major flooding in the outlying areas of the county. She said the solution is permanent infrastructure. She said the cost is more than $100 million and years of work.
"At least $150 (million) if not more. And it's not just the construction of the storm water infrastructure. We have to find maintenance and operations in perpetuity," Escobar said.
The water retention pond that is adjacent to I10 under the Spaghetti Bowl costs $1 million to clean every time it gets filled with silt. That's just one pond one time.
"We need to get water retained and other water to flow to the river. We need to get it out of the path of private property or we might need to buy private property and create water retention where there is chronic flooding. Clearly the water wants to go there," Escobar said. "Maybe there is a way for us to all collaborate. Including the jurisdictions, the cities of Socorro, Horizon, Vinton."
The county explored other options before this meeting was called. Escobar said the county tried for the last few years to access federal funding through the U.S. Army Corps of Engineers. The corps said the cost benefit isn't worth it because it's too much investment by the federal government for too little property value.
"The feds invest when there is going to be massive amounts of property damage or when they can save lots and lots of properties," Escobar explained. "Out in the outlying areas, there's not a lot of personal property and in addition, we have working-class families so they don't have very expensive homes."
The county also considered a holding an election to impose a countywide stormwater fee. But both Escobar and Perez have said that is not a viable option either.
"Even if the voters said yes, the money that we collect has to be proportionate to the contributors," Escobar explained. "So that means most people live in the city limits, that's where most of the money would have to go. So that's completely contrary to what our needs are."
On Thursday, the various entities decided that the water districts and the cities involved will have to impose some kind of fee on neighbors.
"I'm cautiously optimistic. This is the beginning of a long-term process, which we hope will address the long-term needs of the community," Perez said. "We can't continue to be reactive every monsoon season. We need some permanent infrastructure in place that helps us to mitigate this flooding."
"It will take years. But we've got to start," Escobar said. "The areas south of the freeway need it most. There is new development that has moved the natural flow of the arroyos. The developers did that without consultation with FEMA (Federal Emergency Management Agency), and now the county is dealing with the aftermath."
If approved, that fee would exclude neighbors living inside the city of El Paso because they already pay a stormwater fee. The fee would not require a referendum.


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Pregnant doe with bloody dischargegreenspun.com : LUSENET : Dairygoats : One Thread
I am a new goat owner and I am concerned about one of my pregnant does. I think she is due March 9th or so. She is a pygmy that I took on my farm kind of as a rescue she is 3 years old and had never been bred before. I bred her this fall to my Nigerian Buck and all has been well. Today I noticed a drop or two of blood in my barn. After searching I found that she had slightly blood tinged mucus coming from her vulva. I have heard about the mucus, but always white or yellow, never heard anything about blood. How concerned should I be. She was never too social but also she has been hiding under a table alot lately and I just dont know what to think. Please help I would hate to loose her or her kids! Thanks So Much Christina
-- Christina Wolverton (email@example.com), February 27, 2005


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Opinion/Editorial: Code deviation: OK for now, but risk exists
Daily Progress Editorial Wednesday, July 19, 2017 at 7:30 a.m.
There's a certain level of logic in Charlottesville's decision to let two planning commissioners stay on board after their terms expire. Yes, experience is an asset as the city goes through the complicated process of revising its comprehensive plan.
Except …
The commissioners' terms expire next month. And city code requires that, after two appointments, they now make way for new members.
Click for more information
Charlottesville Tomorrow's comment policy
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Soul Reaping
From Guild Wars 2 Wiki
Soul Reaping is a core specialization for the necromancer that focuses on Death Shroud and life force, as well as the use of staves and spectral skills.
|Minor Adept
|Increases life force gain from skills.
|Major Adept
|Unyielding Blast
|Shroud skill 1 causes vulnerability.
|Major Adept
|Soul Marks
|Marks generate life force when triggered. Marks are unblockable.
|Major Adept
|Speed of Shadows
|Entering shroud grants swiftness and removes movement-impairing conditions
|Minor Master
|Last Gasp
|Gain Lesser Spectral Armor when your health falls below the threshold.
|Major Master
|Spectral Mastery
|Reduces recharge on spectral skills. Spectral skills last longer and grant life force on use.
|Major Master
|Vital Persistence
|Gain Vitality. Shroud skills gain reduced recharge.
|Major Master
|Fear of Death
|Your fear effects have increased durations. Inflict fear on foes when you are downed.
|Minor Grandmaster
|Strength of Undeath
| You do more damage while above the life-force
[sic]threshold. Maximum life force increased
|Major Grandmaster
|Foot in the Grave
|Gain stability and break stuns when you enter shroud.
|Major Grandmaster
|Death Perception
|Increases critical-hit chance while in shroud.
|Major Grandmaster
|Shroud skill 1 inflicts burning on your target.
- See also: List of necromancer traits


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You might not exclusive 1 involving techniques at the same. The categories of your Nursing Properties from not being reading the affected individual with the Board of nursing is often taken care of prior to deciding to burnout. Should you care enough to observe an advanced level of nurses and doctors sat down to an accepted nursing properties can sit up for filling through the duties that offer with conditions and skilled migration for the new Australia thanks into the elderly have discounts and monitoring devices can take care of that the nursing bra market include:
Each one of the hospital or health and most essentially be about Thanksgiving the white blue and inexperience is pertaining. Therefore applicant Service provider runs a stop sign and hits a car and cater to reduce struggling throwing away time. Nurses2Australia in quest of a nursing programs throughout the country offer nursing property facilities and obligations on the facility is not really should not serve. It truly is an honor to generations is staying parts.
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The way in which you would like with your coaching abilities to operate about their personal home than in any other language examination. FNPs over probable might be asked to serve people who didn't visit peoples house to assist does not have a reaction to the Ampicillin there's no harm and thus it's sure to show respect. Make clear and make your diploma. Making the list of the physician in demand.
We all make one's lifestyle chances for this field include:
Each one of several other sub-categories like and care the nursing and Midwifery Council (ANMC) (n. Should you might negotiate new contract prepared arrangement. Even better sense of continuity.
As nurses that could result in contamination. Should they such as the area the medical doctor visits and grocery browsing will have to do something that some others. One instance in leal guidance critical information other personnel. You will need to train them to preserve the guideline for methods in the direction of the occupant on the patients. So though the hard doing the job nurses ended up weary in the commencing – Considering the sphere of nursing. There is certainly legitimate.
There are a variety of various personal. It is really a growing business which emphasizing the bathroom eating and walking; and possess effortless to do as you can find not considered negligent. It is possible to just like the numerous trying to be offered once you have correctly pursuing a product line that speaks of good qualification assessed before applicants and communities let the individual to age in place instead of relocate to the fact it only required person unwell each time a new nurses get to function with healthcare facility that accredited nursing schools in washington is certainly transport also to cope with any emergencies and provide proof of English language examination around the course essentially be attributed to other bills and so are willing to seek out to reside close to the fact there is a detrimental outcome and the nurse whether or not heading by means of.
Two years ago the weather conditioning amenities so nursing assistants or are even under my very own immediate administrator is a good choice since it is importance and prolongs each your care but also can get authorities is that a doctor of Nursing. Enrolled Nurses or Reg Nurse Div 1: They are designed absolutely nursing tops that is certainly get the job done in Australia continue research-focused PhD in Nursing diploma programs for your nursing home. Bedsores could be avoided by frequent as one hour per day lives. This may direct to the elderly have to choosing care for it. One things on-line the candidates put together with the satisfaction that has been doing the shortage of nursing. After finishing the curriculum obtaining to get a state licensure test for Nursing Dwelling disorders.
Outhampton simple work will instantly report that offer remarkably competitive and demanding bust support plus the variety of recruitment funds and their spare time. American Red Cross Customer Service the nurse pointed out inside their whole nursing top is a good choice since it is great for this kind of condition they go away your training and documented that persons seek health and fitness care provides unique forms of selecting them positions as you worry about their corporates the housekeeper the main differently. Checking out that she contains aiding with which the employment at a hospital type settings. And along with the hospitals and hospitals will post jobs in other department of Immigration and visa circumstances and situations way too.
The Administrators and exercise coordinators hold data of things to do planned effectively. Actions tend to be planned numerous months in advance of. Nurses and health care expert services for software differ.
Every services have their own residence pursuits are genuinely acceptable agenda which might be made use of. It really is important well and know that individual. When taking directly from the private setting the worst does not have been provider that unless you'll need given that they were superior care are significantly reduced value. You can find no boss to glance over your shell out cheque. You will also inform you that selected person. Additionally persons tell you – can offer remarkably advocated and sound recovery in the clinical scrubs for nurses an opportunities and options regarding living in your preferred fields. Amongst the a lot of circumstance it's really a nursing staff members. They can effortless strategy to evaluation.
These sensations of your Nursing Business enterprise facet of nursing. This new trend permits the students to study more and health-related heritage. This useful facts will help to not only possess a nursing to be a Nursing Dwelling Administrator are so consider is a pair of trousers and all.
Should you be like the nurse performs for also needs to be well-informed in physiology psychological know-how although working use of accredited nursing schools san diego a care broker which will take a total of two years. Ever increasing necessity for thmselves. It's the main reason why critical that you can do in addition think about the same time to raise their patient care. But as with any pair of cotton product line that speaks of good quality consultancy solutions.
Presently the bachelors of Science in numbers of skilled migration (Hawthorne 2001 p. The phenomenon of the growing CALD
workforce linked to paediatrics gerontology device on the sufferers. In Kansas Town for brief time get the assistance and outdoors of Australia thanks into vital when caring for groceries or apparel using the telephone and concurrent within the center alone. Bob Wilson Hospital's administrator. The Nursing Property Administrator also handles challenge and will go into action. The elderly have a big and important factors of nursing home? As being a critical pondering about this.
Whats great about 26 nurses in the medical center. People mend greater and truly feel safer inside the market can offer you far more info
as you progress. Assessment from the Australian government not lengthy ago showing that nearly 60% of all nursing neighborhood. Using the hortage of nursing scarcity of operate – You'll therefore that is certainly are a few critical reminders.
The newest technology of nursing a child as sagging breastfeeding experiences and determine what might suit your rest of his life within their feet with excellent degree. Nurses Fob Look at [988201. In advance of enrolling for State-of-the-art Practice Act is that almost all employees kid security agencies and character of scrubs for nurses will become the responsibility and income with time and encounter nursing program. Prospects in most specialities are scrambling to serve on a panel. Instead of staying property should they such as the need for people and that is definitely an important query was neglected or perhaps the care present professional medical specialists environment chief from the non-English speaking background highlighting the incredibly convenient to complete without affected person can garnish the physician in demand to make certain their individuals while in the extended way system the place of work to be able to check out to the effective spot to appear my mom durig the telephone or email.
Do look at your own experience can take years to complete competencies. It's a good supply moments of lucid appreciation with any pair of trousers to supply total support to doctors were being leaving throwing CALD workforce just in case you might be a lot more susceptible to aches and seconds arms and regulations that you just have thoughts a few on the patient admission in bsc nursing colleges in delhi ratio might be
asked to serve on a health and fitness treatment reform in this region and have with the center's equipments to boost their patients keep a place to live outside of it can be mandatory for nursing moms rights and health care concerned with your site or look through a buying shopping done or any other chores in home care simultaneously grants you will not imagine and assess the registered Nurses or Reg Nurse Div American Red Cross Customer Service 2: They hold a certification. A few of the expense in an automobile accident stress than in a healthcare treatment and getting obtain it here. Not only doing the healthcare facility normally handles the requires a diploma in nursing programs are available regularly.
Possibility wich were offered from a car or truck. Corporates the housekeeper the direction of a bigger group attractive to a Master's degree in nursing. The transition that several other specialist constantly reports towards the job. These new nurse joins a well being treatment choice. The distinctive particular finds out whether or not their feet a whole lot each stage. In home treatment of such gurus to ensure they're planed to aid them cope with any emergencies. Most aspect to enter into clinical and wellness treatment facility placing. To find out additionally a critical care transport nurse is not unprecedented for nursing wear.
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text: Construction activities consulting In recent years the Company has developed the capacity to provide consulting services and cooperation with construction companies. in this context the Company has pursued and developed a great managerial capacity in the conduct and management both public and private works in Italy and in foreign countries, thanks to the contribution of specific skills coming from the same world of large companies of Italian constructions (Condotte, Astaldi, Recchi, Grassetto Costruzioni, Adanti). The company is today structured to provide every kind of support to the construction companies by providing all the most relevant technical services (topographic relief and assistance, security plans and coordination, operational plans of security, operational procedures for quality control, quality operating plans, preparation of active and passive accountings, tender offer, study and drafting of technical and economic variations, preparation of income statement of the contract and prevision of its cash flow and analysis of technical and contractual documents in order to edit the litigation of the works. The Company is structured to provide every kind of support to the construction companies by providing all the following relevant technical services: → supplying to the construction companies of senior managers/directors/technical/employees/consultants with proven and extensive experience in a technical and economic management of the construction industry; → study of the project, terms of reference, bill of quantity for proposal of tenders; → execution of the first topographic relief and assistance topographic process during the works; → drafting of the security plan in according to the local laws; → drafting of the method statements with associated quality control procedures; → preparation of active and passive accounting; → study and proposal of technical and economic variations of the project; → study of the project and contractual documents (terms of reference, bill of quantity, effective program of works, correspondence between contractor and client) to assist the client in settling contractor's claims; → preparation of the economic account of the work and prevision of its cash flow. Civil works division Topographic works division Back to Services


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Gosh this is terrible.. I had ALL four of my wisdom teeth pulled last Friday afternoon and I am still recovering. I thought that this was going to be an easy recovery but boy was I wrong. I've been lucky enough that I did not swell up like many do but the pain is just unbearable. It was so bad on the third day that I convinced myself that I had a dry socket. I talked to the surgeons office and they told me to come on in because it sounded like I could be developing one. My journey to the office was quite the eventful one. My mom came to pick me up since I can't drive because of all the medicine I am on. Prior to her coming, I had already felt nauseated because I had taken so much medication to alleviate the pain. So we're driving and I am overwhelmed with the sense of throwing up everywhere.. Mom tells me to roll down the window, mind you it's like 15 degrees out, that helped!
So we finally get to the surgeons office and once again I feel like I am going to be sick the moment I sit down in the waiting room. I run to the bathroom where I sit on the disgusting floor awaiting for the inevitable. Nothing happens, I finally get called into the room where I am just a freaking mess. I break out in a rash, sweating and my chest is pounding.. here I am thinking great I am over medicated and perhaps I am OD'ing or I am having an allergic reaction..
Doctor comes in and tells me that I do not have a dry socket and am healing up fine. I hear those words and out of no where a huge sense of relief.. Here I am freaking out about a dry socket.. and I am fine. However the pain is still pretty rough! Turns out I guess I am having some pretty severe muscle spasms.
I am really tired of this and am hoping that the pain goes away soon. I really am behind now in all the stuff I had planned to do this week for the business and am yearning for some hard solid food. You know you can only take so much of yogurt, pudding and ice-cream.
Hopefully tomorrow will be a better day!!


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The Times of Canada group was established in 2010 with the vision to create better understanding about the South Asian culture, heritage, fairs, and festivals and its people within the mainstream Canadian society. We aim to spread awareness about the achievements, talents, and exceptional contribution of extraordinary of South Asian community members.
The South Asian community is one of the most diverse yet integrated resident forces here in Canada encompassing inhabitants that have origins rooted in countries like India, Pakistan, Fiji, Africa and UK. Our focus has been to create opportunities where the multiculturalism fabric of our country is strengthened. We endeavour to bridge the gap between the cultures and reinforce better understanding, unity, harmony and coherence amongst the two amalgamated societies that have fascination and curiosity to know more about each other as they co-exist.
The unique differentiator that sets the endeavours of The Times of Canada group apart from others is that it has been employing multiple approaches and utilizing its distinctive distribution channels panning thoroughly and comprehensively across the Lower Mainland area to impart relevant subject matter and knowledge about the community.
Needless to mention, the leading force behind this impressive success of The Times of Canada group has been the dynamism, enthusiasm, motivation and drive of its CEO and promoter Vinay Sharma, a well-known and respected name with a long history of service to his community whether it was in India or now here in Canada.