text: Effects of Folic Acid Fortification on Twin Gestation RatesSignore, Caroline MD, MPH*; Mills, James L. MD, MS*; Cox, Christopher PhD†; Trumble, Ann C. PhD‡Obstetrics & Gynecology: April 2005 - Volume 105 - Issue 4 - p 757-762 doi: 10.1097/01.AOG.0000154886.40318.5e Original Research Free Abstract In Brief Author InformationAuthors Article OutlineOutline Article MetricsMetrics OBJECTIVE: Previous studies have reported an increase in twinning of as much as 40% associated with folic acid–containing supplements, and folic acid fortification of enriched cereal grains was authorized in 1996. The purpose of this study was to investigate whether twinning rates have increased since that time. METHODS: We used United States birth and fetal death records to calculate twin gestation rates from 1990 through 2000. To eliminate the influence of fertility treatments, our analysis was limited to nulliparous women aged 16–19. We compared time trends in twin gestation rates before and after folic acid fortification in 1996. RESULTS: A total of 25,065 twin and 3,362,245 singleton pregnancies were included. Twin gestation rates were stable from January 1990 through December 1996, at 7.2 per 1,000, and then began a steady increase, averaging 2.4% (95% confidence interval 0.1–4.2%, P = .006) per year, which continued through 2000 and reached 8.2 per 1,000. This translates to 2 additional twin pregnancies per 10,000 gestations per year. Twin rates continued to increase well beyond 1998, when the maximal fortification effect on folate status had been reached. CONCLUSION: Although twin gestation rates in women not using fertility treatments increased after food fortification with folic acid, they rose by much less than the 40% rate previously reported; the observed pattern of increase in twin gestation rates is not consistent with a folic acid fortification effect. LEVEL OF EVIDENCE: II-2 Although twin gestation rates increased between 1990 and 2000, the pattern of increase is not consistent with a folic acid fortification effect. From the *Epidemiology Branch, †Biometry and Mathematical Statistics Branch, and ‡Computer Sciences Section, Division of Epidemiology, Statistics and Prevention Research, The National Institute of Child Health and Human Development, National Institutes of Health, Health and Human Services, Bethesda, Maryland. Reprints are not available. Address correspondence to: James L. Mills, MD, MS, Chief, Pediatric Epidemiology Section, 6100 Executive Boulevard, Room 7B03, DESPR, NICHD, NIH, Bethesda, MD 20892; e-mail: firstname.lastname@example.com. Received July 21, 2004. Received in revised form October 25, 2004. Accepted December 16, 2004. Abstract MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES Cited By Randomized trials have shown that periconceptional folic acid supplementation can decrease the occurrence of neural tube defects (NTDs) by as much as 70%.1,2 In response to this observation, the United States Public Health Service recommended that all women of reproductive age consume 400 μg of folic acid daily to reduce the incidence of NTDs.3 Unfortunately, most women did not follow the recommendation.4 To increase folic acid intake in women of reproductive age, the U.S. Food and Drug Administration mandated the fortification of enriched cereal grain products at 140 μg of folic acid per 100 g of grain.5 Voluntary fortification was started in March 1996; by January 1998, full fortification was mandatory. National data indicate that among women of reproductive age, serum folate levels have risen 171% since fortification.6 Ray7 showed that, in Canada, where the fortification plan is almost identical to that of the United States, serum folate levels rose quickly until late 1998, and then reached a plateau. Fortification has clearly brought population folate levels to protective range, as the incidence of NTDs has decreased by 19–54%.8–10 Several studies11–13 have reported an increase in twinning associated with use of multivitamin supplements containing folic acid. Because twin pregnancies are at greater risk for maternal morbidity and infant morbidity and mortality,14 an increase in the twinning rate caused by population-wide exposure to folic acid could have significant public health implications.15 In 1994, Czeizel et al11 reported a 40% increase in the number of twin births among Hungarian women randomized to treatment with periconceptional multivitamins that included 0.8 mg of folic acid, compared with women treated only with trace elements. Similar results were noted in observational studies in Sweden12 (odds ratio 1.45. 95% confidence interval [CI] 1.06–1.98) and the United States,13 although the increase in the U.S. study was not statistically significant. Other studies have shown no increase in twinning associated with food fortification in the United States.16,17 Because of the risks associated with twinning, a clinically significant folic acid-induced increase could stimulate a reconsideration of fortification policy. In this study, we used national natality and fetal death data to examine twin gestation rates before and after the introduction of folic acid fortification to the U.S. food supply to estimate 1) whether twin pregnancy rates increased after fortification and 2) if they had, whether the pattern of increase was consistent with a folic acid effect, ie, whether the twin rates increased as the maternal population's body folate stores increased, then reached a plateau as folate stores reached a plateau. Back to Top | Article Outline MATERIALS AND METHODS Natality data from the National Vital Statistics System/National Center for Health Statistics for the years 1990–2000 were used to determine the number and plurality of all live births in the United States. These data sets are compiled from 100% of all registered birth certificates from the 50 states and the District of Columbia.18,19 Fetal deaths were identified from fetal death files compiled by National Vital Statistics System/National Center for Health Statistics for the years 1990–1994.20 From 1995 on, fetal death data have been included as part of perinatal mortality data files.21 The number and plurality of stillbirths occurring between 1990 and 2000 in all states and the District of Columbia were abstracted from these sources.18–21 Pregnancies ending in spontaneous abortion and elective termination were not included. Reporting in natality and fetal death data sets is by infant, not by delivery. Triplet and higher-order births were excluded from this analysis (see below). A twin delivery is defined as delivery after 20 weeks of gestation of 2 clinically recognized fetuses, regardless of the vital status of either infant at birth. Each live and stillborn twin and singleton birth from 1990 to 2000 was categorized according to plurality, maternal age (15–44 years), race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, Asian), parity (0 or 1+), and month and year of birth. The number of twin deliveries for each year was calculated as the total number of first-born twin infants. The total number of deliveries was then calculated as the sum of the total number of singleton deliveries plus the calculated number of twin deliveries. Twin gestation rates were calculated as the number of live or stillborn twin deliveries/total number of deliveries for each age and racial group. Data on fertility treatments, an important cause of multiple gestations, are not collected on all women. Therefore, to minimize the influence of assisted reproduction (ovulation induction and/or assisted reproductive technologies [ARTs]) on multiple gestations, our initial target population was nulliparous women aged 15–19 years because this group is unlikely to be receiving fertility treatment. Using data compiled by the Society for Assisted Reproductive Technology and the Centers for Disease Control, Reynolds and colleagues22 reported that 0.0% of infants born to women younger than the age of 20 years were conceived using ART between 1997 and 2000. The 1988 National Survey of Family Growth data showed that 8.4% of nulliparous women aged 15–24 years reported impaired fecundity.23 Data from the same survey indicated that of the total number of women aged 15–19 with self-reported impaired fecundity, 2.1% had ever obtained specialized infertility services, such as ovulation induction, intrauterine insemination, or in vitro fertilization.24 Therefore, we estimated that less than 0.2% of teenagers receive fertility treatments. Additionally, records with plurality of triplet or greater were excluded because these high-order births are usually (∼80%) the result of fertility treatments.25 Because the numbers of twin pregnancies among all women aged 15 years (n = 831) and among Asian women aged 15–19 years (n = 347) were relatively small, making the twin gestation rates imprecise, these 2 groups are not reported. Therefore, our final analysis group consisted of nulliparous, non-Hispanic white, non-Hispanic black, and Hispanic women aged 16–19 years. Folic acid might increase twin pregnancy by increasing the number of twin conceptions. To examine this hypothesis, we assumed that infants born in December 1996 or after were likely to have been conceived on or after March 1996, the month that folic acid fortification was first authorized. We defined these births as exposed to fortification. We assumed that births before December 1996 were conceived before fortification was introduced, and defined these births as unexposed. Changes in the twinning rate over the course of time were adjusted for maternal age (in years) and race/ethnicity, as well as their interaction, using a log linear (Poisson regression) model. This is a standard method for the analysis of rates in which the numerator (number of twin pregnancies in a given category) serves as the dependent variable, with adjustment for the denominator (total number of pregnancies in the category) as an offset.26 The regression model included different time trends for the 2 time periods (before and after December 1996). The full model then consisted of, for each combination of age and race, a broken line with separate slopes for the prefortification and postfortification periods. The null hypothesis of interest was that the time trends in the 2 periods were identical (a single line rather than a broken line with 2 different slopes before and after December 1996), indicating no change in twin gestation rate associated with folic acid fortification. Statistical analysis was performed with SAS 8.2 software (SAS Institute, Cary, NC). Because the study used data that could not be linked to identifiable women or infants, the Office of Human Subjects Research of the National Institutes of Health granted it an exemption from the requirement for review and approval by the institutional review board. Back to Top | Article Outline RESULTS Maternal and infant characteristics for the analysis group pregnancies and for those of the entire U.S. cohort of mothers aged 15–44 for 1990–2000 are shown in Table 1. For both the young, nulliparous women and the entire U.S. cohort, twins were born at gestational ages 4 to 5 weeks earlier and birth weights 1,000 to 1,100 g smaller than singletons during the study interval. Among the 16- to 19-year-old study group, there were a total of 25,065 twin pregnancies and 3,362,245 singleton pregnancies, giving a total crude twin pregnancy rate of 7.4 per 1,000 pregnancies during the 11-year study period. The total crude twin pregnancy rate in the United States during the same period was 13.1 per 1,000. Table 1 Twin gestation rates increased between 1990 and 2000 (Fig. 1). The crude twin pregnancy rate in the group of interest (16- to 19-year-old nulliparous women) increased 13.9%, from 7.2 to 8.2 per 1,000 pregnancies from 1990 to 2000. Among older nulliparous women (aged 20 to 44), there was a much greater increase—43.8%—from 12.8 to 18.4 per 1,000 pregnancies, because of, we assume, the increasing use of fertility treatments by older women. By comparison, the entire population of U.S. women (all ages 15–44, all parity, all races) had a 38.4% increase, from 11.2 to 15.5 per 1,000 pregnancies. Fig We compared the pattern of changes over the course of time in twin gestation rates before fortification to the pattern after fortification. In the analysis group of 16- to 19-year-old nulliparous women, before fortification, there was a nonsignificant increase in twin gestation rates over the course of time (slope = 0.0052, standard error 0.0034, P = .13), ie, twin rates were essentially constant between January 1990 and November 1996 (Fig. 2). Fig After fortification, from December 1996 through December 2000, there was a small but statistically significant continuously increasing trend in twinning rates (difference in slope = 0.024, standard error 0.0088, P = .006), indicating that twin gestation rates have increased since the addition of folic acid to the food supply (Fig. 2). Regression analysis showed that since fortification, nulliparous white, black, and Hispanic women aged 16–19, in aggregate, have had a 2.4% (95% CI 0.1–4.2%) per year increase in twin gestation rates. This translates into 2 additional sets of twins per 10,000 deliveries per year. Back to Top | Article Outline DISCUSSION We examined the influence of folic acid fortification on twin gestation rates by looking for changes in rates among nulliparous 16- to 19-year-old women, a group that is almost never exposed to fertility treatments. If the effect of folic acid fortification were to increase twinning rates, one would expect to see an increase in the slope of the line describing the trend in twin rates after fortification was in effect. We detected a small but statistically significant increase in twin gestation rates among women who conceived after the introduction of folic acid into the food supply. However, the pattern of the increase is inconsistent with a fortification effect. After several months of exposure to folic acid, serum and red cell folate levels reach a plateau.7,27 If fortification were increasing twin gestation rates, one would expect to have observed a corresponding plateau in twin rates when folate levels reached their steady state in the childbearing population. Such a plateau in twin rates would certainly have been evident by early 2000, because folate stores in the entire maternal population were maximized by late 1998.7 In contrast, we observed a persistent increase that continued after the maximal fortification effect on folate status was reached. A number of other unmeasured factors may explain the increase in twin gestation rates observed in the late 1990s among young women who were not exposed to fertility treatments. There may have been changes in the accuracy or regularity of reporting infant plurality, particularly among stillbirths.28 Additionally, the use of technology in vital record collection, transmittal, and quality control increased during our study period and facilitated the correction of records, resolution of missing data, and improved reporting accuracy.29–31 It is conceivable that the small increase in twinning we observed is a reflection of better vital records reporting. Finally, a folate-related decrease in NTDs may contribute to improved survival of a small number of twin pairs. Previous studies of the impact of folic acid on twin gestations have had mixed results. Two international studies32,33 found no increase in twinning with the use of folic acid at doses of 400 μg to 4 mg per day. Two additional studies have examined the impact of the U.S. fortification program. In a population-based study in Texas, Waller and colleagues16 reported continuation of a 1–4% per year increase in twinning that began before fortification. In a similar study in California, Shaw and colleagues17 found no significant increase in twinning prevalence associated with fortification. Each of these studies, however, included in their "prefortification" groups women whose pregnancies had been exposed to folic acid fortification during the optional fortification period beginning March 1996. It is likely that a substantial amount of folic acid entered the food supply after fortification was authorized in 1996 but before the January 1998 deadline. For example, Jacques et al34 reported that most targeted products in New England were fortified by July 1997. The inclusion of women who were exposed to some folic acid in the unexposed population could have produced an underestimate of the effect of folic acid on twinning. Czeizel et al11 and Ericson et al12 reported significant increases in twinning in women taking folic acid. However, they counted twin births, which overestimates the rate of twin gestation. When Czeizel et al's11 data are reevaluated counting the number of twin pregnancies, the increased twinning rate is no longer statistically significant (44 of 2,198 compared with 29 of 2,170; relative risk 1.50, 95% CI 0.94–2.38; P = .09). Moreover, Czeizel et al's 1994 results are not statistically significant when women who had ovulation induction were excluded.11 When Ericson et al12 eliminated women with a history of involuntary childlessness, folic acid use was still associated with twin births (odds ratio 1.45, 95% CI 1.06–1.98), although it is not clear that excluding women with a history of involuntary childlessness eliminated all women receiving fertility treatments. Many limitations to our study exist. Because reported data on ARTs do not include specific maternal age, race/ethnicity, or parity, it is not possible to exclude specific ART conceptions from the pooled national data. Patterns of use of ovulation induction medications are not recorded systematically. Therefore, we cannot specifically account for the contribution of fertility treatments to national twin conception rates. We studied 16- to 19-year-old women to avoid confounding by fertility treatments. Between 1997 and 2000, 0.0% of infants conceived by ARTs were born to women younger than 20.22 We cannot exclude the possibility that a twinning response to fortification may be different among women aged 20 years or more, although we know of no data suggesting such a difference. It is possible that women are exposed to additional folic acid in the form of supplements. Since the 1992 United States Public Health Service recommendation that women capable of becoming pregnant consume 400 μg of folic acid daily, numerous public health education campaigns have attempted to increase the proportion of women using daily supplements. Although awareness of folic acid has increased significantly, only a minority (30% in 1997, 31% in 2002) of women of childbearing age takes supplements regularly.4 Furthermore, teenagers are least likely to be aware of folic acid35 and are least likely to consume daily supplements (22% of ages 18–24, 36–37% of ages 25–45).4 Our study has several major strengths. It is nationally representative, population-based, and includes all 3.4 million twin and singleton births occurring in 16- to 19-year-old women in the United States from 1990 to 2000. Because of the large number of subjects, we were able to take into account the effects of age and race and limit the analysis to nulliparous women and still have sufficient data to detect even small shifts in twin gestation rates. Use of national data eliminates the potential problem that some parts of the country may have been exposed to fortified food before others. A search of PubMed (National Library of Medicine) from 1966 to September 2004 for the terms "twins," "twinning," or "multiple pregnancy" and "folic acid" or "fortified food" showed no other studies analyzing twin rates based on the actual date that fortified food was first introduced in the United States during March 1996. Our data show that in the entire United States, twin gestation rates in young women who were unexposed to fertility treatments have been slowly increasing since the introduction of folic acid fortification of grain. The increase is small, ie, 2 twin pairs per 10,000 deliveries per year in our study population, which is far less the 40% increase reported in those studies reporting that folic acid-containing multivitamins increased twin rates. Moreover, the increase is unlikely to be the result of food fortification because folic acid causes an increase in body folate stores that plateaus within months, and the twin rate continued to increase. Thus, fortification with folic acid does not appear to be causing a serious public health problem related to twinning.Back to Top | Article Outline REFERENCES 1. Czeizel AE, Dudas I. Prevention of the first occurrence of neural tube defects by periconceptional vitamin supplementation. N Engl J Med 1992;327:1832–5. Cited Here... | View Full Text | PubMed | CrossRef 2. Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research Group. Lancet 1991;338:131–7. Cited Here... | PubMed | CrossRef 3. Centers for Disease Control. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects [review]. MMWR Recomm Rep 1992;41(RR-14):1–7. Cited Here... | PubMed 4. March of Dimes. Folic acid and the prevention of birth defects: a national survey of pre-pregnancy awareness and behavior among women of childbearing age, 1995–2002. Washington, DC: March of Dimes Foundation; 2002. Cited Here... 5. Food and Drug Administration. Food standards: amendment of standards of identity for enriched grain products to require addition of folic acid. Federal Register 1996;61:8781–97. Cited Here... 6. Centers for Disease Control. Folate status in women of childbearing age, by race/ethnicity–United States, 1999–2000. MMWR Morb Mortal Wkly Rep 2002;51:808–10. Cited Here... | PubMed 7. Ray JG. Folic acid food fortification in Canada. Nutr Rev 2004;62(suppl):S35–9. Cited Here... | PubMed | CrossRef 8. Honein MA, Paulozzi LJ, Mathews TJ, Erickson JD, Wong LY. Impact of folic acid fortification of the U.S. food supply on the occurrence of neural tube defects [published erratum appears in JAMA 2001;286:2236]. JAMA 2001;285:3022–3. Cited Here... 9. Centers for Disease Control (CDC). Spina bifida and anencephaly before and after folic acid mandate: United States, 1995–1996 and 1999–2000. MMWR Morb Mortal Wkly Rep 2004;53:362–5. Cited Here... | PubMed 10. Mills JL, Signore C. Neural tube defect rates before and after food fortification with folic acid. Birth Defects Res A Clin Mol Teratol 2004;70:844–5. Cited Here... | PubMed | CrossRef 11. Czeizel AE, Metneki J, Dudas I. The higher rate of multiple births after periconceptional multivitamin supplementation: an analysis of causes. Acta Genet Med Gemellol (Roma) 1994;43:175–84. Cited Here... 12. Ericson A, Källén B, Åberg A. Use of multivitamins and folic acid in early pregnancy and multiple births in Sweden. Twin Res 2001;4:63–6. Cited Here... | PubMed | CrossRef 13. Werler MM, Cragan JD, Wasserman CR, Shaw GM, Erickson JD, Mitchell AA. Multivitamin supplementation and multiple births. Am J Med Genet 1997;71:93–6. Cited Here... | PubMed | CrossRef 14. Martin JA, Park MM. Trends in twin and triplet births: 1980–97. Natl Vital Stat Reps 1999;47:1–16. Cited Here... 15. From the Centers for Disease Control and Prevention. Use of assisted reproductive technology–United States, 1996 and 1998. MMWR Morb Mortal Wkly Rep 2002;51:97–101. Cited Here... 16. Waller DK, Tita AT, Annegers JF. Rates of twinning before and after fortification of foods in the U.S. with folic acid, Texas, 1996 to 1998. Paediatr Perinat Epidemiol 2003;17:378–83. Cited Here... | View Full Text | PubMed | CrossRef 17. Shaw GM, Carmichael SL, Nelson V, Selvin S, Schaffer DM. Food fortification with folic acid and twinning among California infants. Am J Med Genet A 2003;119:137–40. Cited Here... | PubMed | CrossRef 18. National Center for Health Statistics. Linked birth/infant death public use CD-ROMs; 1990 and 1991 birth cohorts. Hyattsville (MD): Public Health Service; 1996. Cited Here... 19. National Center for Health Statistics. Natality public use CD-ROMs; 1992–2000 natality files. Hyattsville (MD): Public Health Service; 1996–2002. Cited Here... 20. National Center for Health Statistics. Fetal death public use tapes and CD-ROM; 1990–1994. Hyattsville (MD): Public Health Service; 1994–1996. Cited Here... 21. National Center for Health Statistics. Perinatal mortality public use CD-ROMs; 1995–2000 numerator files. Hyattsville (MD): Public Health Service; 1998–2003. Cited Here... 22. Reynolds MA, Schieve LA, Martin JA, Jeng G, Macaluso M. Trends in multiple births conceived using assisted reproductive technology, United States, 1997–2000. Pediatrics 2003;111:1159–62. Cited Here... | PubMed 23. Mosher WD, Pratt WF. Fecundity and infertility in the United States, 1965–88: advance data from vital and health statistics; no. 192. Hyattsville (MD): National Center for Health Statistics; 1990. Cited Here... 24. Wilcox LS, Mosher WD. Use of infertility services in the United States. Obstet Gynecol 1993;82:122–7. Cited Here... | View Full Text | PubMed 25. Contribution of assisted reproductive technology and ovulation-inducing drugs to triplet and higher-order multiple births–United States, 1980–1997. MMWR Morb Mortal Wkly Rep 2000;49:535–8. Cited Here... | PubMed 26. McCullagh P, Nelder JA. Generalized linear models. 2nd ed. London (UK): Chapman and Hall; 1989. Cited Here... 27. Caudill MA, Cruz AC, Gregory JF 3rd, Hutson AD, Bailey LB. Folate status response to controlled folate intake in pregnant women. J Nutr 1997;127:2363–70. Cited Here... | PubMed 28. Centers for Disease Control (CDC). Racial/ethnic trends in fetal mortality–United States, 1990–2000. MMWR Morb Mortal Wkly Rep 2004;53:529–32. Cited Here... | PubMed 29. Starr P, Starr S. Reinventing vital statistics: the impact of changes in information technology, welfare policy, and health care. Public Health Rep 1995;110:534–44. Cited Here... | PubMed 30. American Medical Association Council on Scientific Affairs. Accuracy, importance, and application of data from the U.S. Vital Statistics System. Available at: http://www.ama-assn.org/ama/pub/category/13574.html. Retrieved January 4, 2005. Cited Here... 31. National Center for Health Statistics. Technical appendix: 2000 natality detail file. NCHS CD-ROM Series 21, No. 13H. Hyattsville (MD): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2002. Cited Here... 32. Mathews F, Murphy M, Wald NJ, Hackshaw A. Twinning and folic acid use. Lancet 1999;353:291–2. Cited Here... | View Full Text | PubMed | CrossRef 33. Li Z, Gindler J, Wang H, Berry RJ, Li S, Correa A, et al. Folic acid supplements during early pregnancy and likelihood of multiple births: a population-based cohort study. Lancet 2003;361:380–4. Cited Here... | PubMed | CrossRef 34. Jacques PF, Selhub J, Bostom AG, Wilson PW, Rosenberg IH. The effect of folic acid fortification on plasma folate and total homocysteine concentrations. N Engl J Med 1999;340:1449–54. Cited Here... | View Full Text | PubMed | CrossRef 35. Alozie Arole CN, Puder KS, Reznar M, Eby E, Zhu BP. Folic acid awareness in Michigan, 1996–1999. Obstet Gynecol 2003;102:1046–50. Cited Here... | View Full Text | PubMed | CrossRef © 2005 The American College of Obstetricians and Gynecologists


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This piece was inspired by the marathon dances of the1920s and 1930s in the USA. In these events couples competed for cash prizes and celebrity in dances that went on for days. The last couple standing would win. These brutal competitions were a way out for people suffering the century's worst economic crisis. However for most it was a futile exercise that would not lead anywhere. The phenomenon was made famous by the 1969 film They Shoot Horses, Don't They?.
The sculpture is a floor piece which floats just above normal floor level to set it apart. A pair of worn out men's and women's shoes face each other as if their occupants are dancing together. Frenetic and Impossible dance patterns are marked out on the dance floor. However the shoes are nailed to the floor. This couple aren't going anywhere, neither literally nor metaphorically.

subset: commoncrawl


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Full description
This assessment and related data examines water resources in the Carpentaria Coast region in 2009–10 and over recent decades. Seasonal variability and trends in modelled water flows, stores and levels are considered at the regional level. Details for selected rivers, wetlands, groundwater, urban areas and agriculture are not addressed. At the time of writing, suitable quality controlled and assured surface water quality data from the Australian Water Resources Information System (Bureau of Meteorology 2011a) were not available. It begins with an overview of key data and information on water flows in the region in recent times followed by a description of the region.
Key data and information
The assessment presents the 2009–10 annual landscape water flows and the change in accessible surface water storage in the Carpentaria Coast region. The region experienced above average rainfall and evapotranspiration for 2009–10 and the high rainfall resulted in very much higher than average modelled landscape water yield1. The reported surface water storage in this region is Lake Julius (only 26 per cent of the total storage capacity in the region). Other main storages in the region that are not reported include Lake Mitchell and Lake Moondarra. The decrease in accessible volume, over the year given that this was a wetter than average year, was due to some deliberate releases from storage during May 2010.
Data time period: 08 07 2009 to 08 06 2010
Spatial Coverage And Location
text: Carpentaria Coast
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The iconic Armada ARV 116 JJ continues to carve its name into ski lore, coming with a poplar and ash wood core for an increased responsibility for steep lines and tight terrain. The ARV 116 also adds confidence with a revamped flex profile to stiffen up tip and tail in tight conditions. 3D beveling on the tips/tails of the base is brought to you through Smear Tech, allowing limitless directions of drifting/pressing and smearing as you put your signature on the mountain.
Riding Style
Backcountry freestyle for intermediate to advanced level riders - You consider the backcountry as a snowpark with unlimited possibilities? Then this ski is the right choice for you.
This ski comes with a directional twin shape, the nose is a few millimetres wider than the tail with a central binding position. Thus, the ski offers the same riding characteristics forward and switch. However, due to the slightly wider nose, you get a bit more float in the soft snow.
This ski comes with a classic camber under the binding and a rocker in the nose and tail. The enormous float of the rockered tips improves manoeuvrability in deep snow while the camber underfoot provides edge hold, pop and response.
The medium-stiff flex provides you with a lively ski that allows you to stay in control at all speeds and pop over everything.
The AR75 Sidewall construction features a Cap construction in the tip and tail with a sidewall underfoot. The Cap construction in the tip and tail reduces the swing weight while the sidewall makes the ski more durable. The Pop-Lite core combines lightweight wood with a higher density, stiffer wood in a horizontal laminate to create an impossibly lively ski that has all the power needed for boosting to new elevations. The S7 Base is durable and requires low maintenance, and comes with a speed additive for quickness.
Tyto lyže jsou dodávány bez vázání. Doporučujeme vázání s brzdičkami o 5 až 10 mm širší než jsou tyto lyže. Prosíme, neváhejte ohledně kompatibility vázání s lyžemi kontaktovat náš zákaznický servis.
Pokud si zakoupíte zároveň lyže i vázání, můžeme vám vázání namontovat zdarma. Pro další informace se podívejte na stránku nejčastějších dotazů FAQ.
Prosíme, berte na vědomí, že vázání pro dospělé nemůže být kombinováno s lyžemi pro děti (a naopak).
Armada - what skiing will become - the famous quote from Chris O'Connell, one of the brands' founding fathers. A freeski company created by athletes for athletes, developed out of the pure passion for skiing and earning huge success in its key demographic. With a big all-star team, Armada continues to dominate both the freestyle and the freeride scene with high-quality ski gear. "


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AUSTIN, Texas (AP) - The Texas Education Agency is laying off
178 employees this week as part of budget cuts ordered by the state
TEA spokeswoman Debbie Ratcliffe said the agency is reducing its
operating budget by $48 million, or 36 percent, most of which will
come from the layoffs since payroll and benefits are the bulk of
their costs.
The state education agency oversees pre-kindergarten to
12th-grade education and allocates billions of dollars to school
The cuts are being made to deal with reduced state tax revenue
caused by the nation's economic downturn. The Legislature chose to
cut spending by $15.2 billion rather than increase taxes or spend
all of the $9.7 billion rainy day fund.
Thousands of state government layoffs are expected in the coming


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Linear Audio 3
Linear Audio Vol 3 is the fourth issue of a series of printed bookzines dedicated to technical audio and perception. The international team of authors for this issue again offers technical audio articles on a wide ranging number of subjects, from tutorials to circuit design to projects and concepts to book reviews:
Guest Editorial:
Renowned designer Richard Burwen explains why Audible tweaks that cannot work in your system can nevertheless cause audible differences at listening tests.
Richard Lyons explains How Discrete Signal Interpolation Improves Digital-to-Analog Conversion, while Patrick K. walks us through the Design Considerations for a Class A Amplifier Enclosure with regards to thermal and vibrational aspects.
Circuit Design:
Richard Marsh develops a high-quality buffer and amplifier for headphones and en passant tells how to equalize it for your ears with simple means in A Headphone Buffer/Amp and Auto-EQ for headphones; Steven van Raalte has a very clever design for compensating for mechanical resonance in both replay cartridges and loudspeaker drivers in Correcting transducer response with an inverse resonance filter; Sigurd Ruschkowski, motivated by Erno Borbely, shares his Passive, Discrete, DC coupled, Open Loop IV Converters. Finally, Scott Wurcer is back with his long-awaited DIY Low-noise Microphone Preamplifiers Part II.
Robert Munnig Schmidt details how to design a THX©-conforming subwoofer in A Mechatronic Approach to active subwoofer design.
Instrumentation/Test Equipment:
Ramkumar Ramaswamy is back with A Universal Simulated Power Inductor for quick and easy filter and cross-over development; Samuel Groner designed A low noise laboratory-grade measurement preamplifier for very low level signal and noise measurements.
The Way I see it:
Stan Curtis, who for decades has shown that he knows how to design audio equipment that excels at that ultimate test – Good Sound, chimes in with the first installment of a regularly column. In Audio Design moves forward – or does it he highlights the different states of the art between analog and digital design – and notes that still lots of work has to be done.
Book reviews:
Stuart Yaniger reviews Morgan Jones' latest tome, the 4th edition of Valve Amplifiers, while Ovidiu Popa reviews the 2nd edition of Burkhard Vogel's The Sound of Silence. While very different books, both reviewers conclude that each deserves a spot on the serious designer's book shelf.
|Linear Audio
|Jan Didden
|17 x 23.5 cm (Paperback)


text: I tried to cut the elastic thread but made a small hole in the fabric. I decided to cut my loses and proceed with a different strategy. So, I cut off the top ruffled edge, hemmed under and inserted elastic. This took maybe 10 minutes. Now it will be more comfortable and easier to wear as a skirt.


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Imagine yourself as a regular commentator on public affairs — maybe a paid pundit, maybe a supposed expert in some area, maybe just an opinionated billionaire. You weigh in on a major policy initiative that's about to happen, making strong predictions of disaster. The Obama stimulus, you declare, will cause soaring interest rates; the Fed's bond purchases will "debase the dollar" and cause high inflation; the Affordable Care Act will collapse in a vicious circle of declining enrollment and surging costs.
But nothing you predicted actually comes to pass. What do you do?
You might admit that you were wrong, and try to figure out why. But almost nobody does that; we live in an age of unacknowledged error.
Alternatively, you might insist that sinister forces are covering up the grim reality. Quite a few well-known pundits are, or at some point were, "inflation truthers," claiming that the government is lying about the pace of price increases. There have also been many prominent Obamacare truthers declaring that the White House is cooking the books, that the policies are worthless, and so on.
Finally, there's a third option: You can pretend that you didn't make the predictions you did. I see that a lot when it comes to people who issued dire warnings about interest rates and inflation, and now claim that they did no such thing. Where I'm seeing it most, however, is on the health care front. Obamacare is working better than even its supporters expected — but its enemies say that the good news proves nothing, because nobody predicted anything different.
Go back to 2013, before reform went fully into effect, or early 2014, before the numbers on first-year enrollment came in. What were Obamacare's opponents predicting?The answer is, utter disaster. Americans, declared a May 2013 report from a House committee, were about to face a devastating "rate shock," with premiums almost doubling on average.
And it would only get worse: At the beginning of 2014 the right's favored experts — or maybe that should be "experts" — were warning about a "death spiral" in which only the sickest citizens would sign up, causing premiums to soar even higher and many people to drop out of the program.
What about the overall effect on insurance coverage? Several months into 2014 many leading Republicans — including John Boehner, the speaker of the House — were predicting that more people would lose coverage than gain it. And everyone on the right was predicting that the law would cost far more than projected, adding hundreds of billions if not trillions to budget deficits.
What actually happened? There was no rate shock: average premiums in 2014 were about 16 percent lower than projected. There is no death spiral: On average, premiums for 2015 are between 2 and 4 percent higher than in 2014, which is a much slower rate of increase than the historical norm. The number of Americans without health insurance has fallen by around 15 million, and would have fallen substantially more if so many Republican-controlled states weren't blocking the expansion of Medicaid. And the overall cost of the program is coming in well below expectations.
One more thing: You sometimes hear complaints about the alleged poor quality of the policies offered to newly insured families. But a new survey by J. D. Power, the market research company, finds that the newly enrolled are very satisfied with their coverage — more satisfied than the average person with conventional, non-Obamacare insurance.
This is what policy success looks like, and it should have the critics engaged in soul-searching about why they got it so wrong. But no.
Instead, the new line — exemplified by, but not unique to, a recent op-ed article by the hedge-fund manager Cliff Asness — is that there's nothing to see here: "That more people would be insured was never in dispute." Never, I guess, except in everything ever said by anyone in a position of influence on the American right. Oh, and all the good news on costs is just a coincidence.
It's both easy and entirely appropriate to ridicule this kind of thing. But there are some serious stakes here, and they go beyond the issue of health reform, important as it is.
You see, in a polarized political environment, policy debates always involve more than just the specific issue on the table. They are also clashes of world views. Predictions of debt disaster, a debased dollar, and Obama death spirals reflect the same ideology, and the utter failure of these predictions should inspire major doubts about that ideology.
And there's also a moral issue involved. Refusing to accept responsibility for past errors is a serious character flaw in one's private life. It rises to the level of real wrongdoing when policies that affect millions of lives are at stake.


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Services in the area from Sunday, July 9, 2017.
8am Communion at Lissington; 10am Communion with Children's Church and Young People's group at Market Rasen; 11.30am Communion at Linwood.
July 10: 9am Morning Prayer at Market Rasen.
July 11: 9am Morning Prayer at Market Rasen.
July 12: 9am Morning Prayer at Market Rasen; 10am-11.30am Mini Messy Church picnic in Market Rasen Church Room or Rectory garden.
July 13: 9.30am BCP Communion at Market Rasen.
July 14: 9am Morning Prayer at Market Rasen; 7.15pm Choir practice at Market Rasen.
July 15: 2pm - 4pm Church Garden Party at the Rectory.
Market Rasen Catholic Church
9.15am Mass at Caistor; 11am Mass at Holy Rood; 5.30pm at Osgodby.
Monday - Thursday: 10am Mass at Holy Rood.
Friday: 6pm Mass at Caistor.
Saturday: 5.30pm Vigil Mass at St Francis De Sales, Hainton.
Market Rasen and Caistor
Methodist Circuit
Brookenby: 10.30am the Rev Sarah Parkin.
Caistor: 10.15am John K Ramm.
Glentham: 6pm Cafe Church, the Rev Elizabeth Childs.
Market Rasen: 10.45am Timothy Smith.
Middle Rasen: 10.45am Communion, the Rev Anne Coates; 6pm Dr Don Owen.
Nettleton: 2.30pm Chapel Anniversary, Malcolm Boot.
North Kelsey: 10.45am Jane Lloyd.
Market Rasen New Life
10.30am All Age Service in the Festival Hall; 2.30pm Summer Strolls (lifts 2.15pm). Details: 01673 849941.
The Salvation Army
10.30am Morning Worship; 5.30pm Evening Fellowship, informal meeting, followed by a cup of tea.
Middle Rasen Group
9am Communion at Faldingworth; 10.30am Communion at Middle Rasen; 3pm Evening Prayer at Friesthorpe.
July 12: 9.30am Service at Middle Rasen.
Walesby Group.
9am BCP Communion at Normanby; 9am Morning Prayer at Stainton; 10am Communion at Thoresway; 10.30am Methodist-led service at Brookenby; 10.30am Summer Celebration Service at Walesby.
July 11: 6.15pm Communion and Prayer at Walesby.
9.30am Communion.
8am Said Communion; 10.15am Communion; 6pm Evensong.
July 10: 9.30am Morning Prayer.
July 12: 10am Communion.
July 13: Communion at 7pm.
Barkwith Group
10am Communion at Sixhills.
Binbrook Group
10am Communion at Binbrook; 11.15am Communion at Ludford.
Waddingham with Kirton Lindsey
9am Communion at Kirton Lindsey; 11am Morning Prayer at Kirton Lindsey.
July 12: 7pm Evening Prayers at Waddingham.
Owmby Group
8.30am Communion at Spridlington; 9.30am Communion at Hackthorn.
July 12: 8.30am Morning Prayer at Spridlington.
July 14: 4pm Evening Prayer at Spridlington.
Wragby Group
9.30am Communion at Wragby; 6pm Evensong at Rand.


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So I have a lot of updating to do- trip to Park City, Jonathan's birthday, Abigale's birthday and Dora party, Halloween, pumpkin patch, etc. but blogger is not letting me upload my pictures. We just got a new camera (the main reason I have been missing from blogger- no camera so no pictures for a few weeks) and it is having a hard time recognizing the pictures or something. So stay tuned for lots of updates soon including our trip this weekend to Utah and Lydia's first birthday!
Tuesday, November 3, 2009
We are Alive I Promise
Posted by Carley and Jonathan at 3:24 PM 2 comments
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Upton Massachusetts car repair: All
makes and models including classics and antiques!
We utilize state-of-the-art computer diagnostic equipment to diagnose and service your automobile efficiently.
Time Auto Sales
located in Milford, Massachusetts
Go to our Service Center home page.
We employ ASE Certified Master Technicians
West St.
Milford MA, 01757
508.478.6907 | Get Directions
of Operation
8AM - 6PM Mon -Thurs
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Saturday 8AM-3PM
Complete light truck automotive repair
changes Brakes Exhaust Tires Tune-up Batteries Shocks Suspension and Under Car Service
Engine and Emission Diagnostics and Automotive Service Center Servicing Upton Massachusetts


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Parade Magazine has come out with a pollrevealing the most annoying celebrities. Kim Kardashian wins with 29 percent of the vote, two points ahead of Charlie Sheen. Winning! You have to be really annoying to fare worse than Charlie Sheen.
Snooki from "The Jersey Shore" comes in third with 21 percent of the vote, followed by Lindsay Lohan at 16 percent—hey, people still know who she is!—with Donald Trump in fifth place at five percent, and, finally, former Bachelor Brad Womack in last with one percent of the vote.
I'm sure Paris Hilton is either breathing a sigh of relief because she did not make the list, or she is concerned because she's no longer making any lists. My own personal "most annoying" celeb is Zooey Deschanel. She's beautiful, talented, quirky, and a star. I hate her.
The Parade poll got me thinking. Who is the most annoying CEO? Not necessarily the worst, but the most annoying. I posed the question on Twitter.
Suggestions included:
Brian Harrison of Solyndra "for costing taxpayers a half billion dollars."
Michael Parness at TrendTrade.com for "most annoying commercial."
Lloyd Blankfein at Goldman Sachsfor "doing God's work" while trading against client accounts.
The most obscure suggestion: Dan Gilbert at Quicken Loans over the use of Comic Sans—"Take his font choices away."
However, after thoughtful consideration, here are my top six choices:
Donald Trump
Why the Donald?
As @jrs111 says, "Just because."
Hey, if he can qualify as an annoying celebrity in the Parade poll, he automatically qualifies as annoying CEO here.
While you can't argue with Trump's success, you also can't argue with him at all. Ask Simon Hobbs.
Mark Zuckerberg
MZ, if it ain't broke, don't fix it. Facebook changes format more often than Katy Perry changes hairstyles, yet the site's "innovating" increasingly feels like "change for the sake of change." I also can't shake this feeling that I'm being sucked into this free, fabulous social networking site only to be invaded by aliens who will reprogram me.
Reed Hastings
The apology to Netflix customers for being arrogant smacked of arrogance.
Steve Ballmer
One word: Zune . Also, if you want to jump up and down and get all excited, get the share price moving after a decade of going nowhere.
Andrew Mason
The CEO of Groupon is funny, quirky and offbeat. However, he also has an odd grasp of numbers. It appears he doesn't know much about accounting, like realizing when a portion of a daily deal goes to a vendor, you can't book the whole amount as revenue. Even if an IPO eventually happens, one reader suggested, "I wouldn't buy Groupon stock, unless I could buy it for 50-90% off."
Kris Jenner
She runs the Kardashian empire. On the one hand, you've got to admire someone who has done so much with so little. On the other hand...it's the Kardashians.
Questions? Comments? Funny Stories? Email firstname.lastname@example.com


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Our Education Fund invests in companies that are improving the quality of teacher instruction and student achievement across the globe using cutting-edge education technology and methods.
Our Health Fund invests in companies that provide better and affordable services on maternal health and chronic illnesses using cutting edge approaches in managing health facilities, diagnosis and treatment.
Our Housing Fund invests in companies that help fulfill the global demand for inclusive housing or use technology that helps lower the costs of housing for low-income dwellers including energy and water and sanitation.
Our Trade Fund invests in improving access to markets for companies that have technology, products and services that create quality jobs en-masse or that uplift incomes for the global poor.
Our AgriBusiness Fund invests in a world where every smallholder farmer has access to good technology and methods, economically viable harvests and retains more of their earnings.
Our Smart Cities Fund invests in companies improving quality of life with the lowest environmental footprint, whilst ensuring that the needs of future generations are not compromised.


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May 28, 2013 Gillum House Bed & Breakfast Shinnston, West Virginia: Each year WV Metro News works with many sponsors to create a WV Scholar Scholarship – a 4-year ALL-Expenses PAID scholarship to West Virginia Wesleyan College.
This year, Johnna Akers of Shinnston's Lincoln High School has made the Finalists. She needs YOUR help. You can vote once PER e-mail address until June 9, 2013.
Please got to: http://www.wvscholar.com/vote.cfm
Choose Johnna Akers from the drop-down menu
Enter your e-mail address (you can vote once per e-mail address)
Click vote
Then Go to your e-mail and confirm your vote
Thank you for helping Johnna Akers try to win a Full ALL expenses paid scholarship to West Virginia Wesleyan
Tags: Johnna Akers, Lincoln High School, Shinnston, West Virginia Scholar, West Virginia Wesleyan College, WV Metro News, WV Scholar, WV Scholarship, WV Wesleyan College


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Ben Elton is to return to stand-up with his first major tour in over a decade.
Elton promises to try and make sense of a world which appears to have gone stark raving mad in the new show.
The veteran comic says: "The last time I toured I was still smarter than my phone. Things have definitely taken a funny turn."
The 53 date tour starts in Dublin on 27 September and currently finishes in Torquay on 30 November.
Elton first made his name in the 1980s as an angry stand-up comic and also as a writer, co-writting both The Young Ones and three series of Blackadder. He has recently returned to form as a sitcom writer with Shakespearean spoof Upstart Crow starring David Mitchell.
Elton is also the writer of All Is True, a new movie due out in February starring Kenneth Branagh, Judi Dench and Ian McKellen about the final years of William Shakespeare.
Tickets for all shows will go on sale on Monday 10 December. Presale Friday December 7 at 10am here.


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This guideline covers the care and support of adults receiving social care in their own homes, residential care and community settings. It aims to help people understand what care they can expect and to improve their experience by supporting them to make decisions about their care.
This guideline covers services for children, young people and adults with a learning disability (or autism and a learning disability) and behaviour that challenges. It aims to promote a lifelong approach to supporting people and their families and carers, focusing on prevention and early intervention and minimising inpatient admissions.
This guideline covers care and support for adults with learning disabilities as they grow older. It covers identifying changing needs, planning for the future, and delivering services including health, social care and housing. It aims to support people to access the services they need as they get older.
This guideline covers recognising and responding to abuse and neglect in children and young people aged under 18. It covers physical, sexual and emotional abuse, and neglect. The guideline aims to help anyone whose work brings them into contact with children and young people to spot signs of abuse and neglect and to know how to respond. It also supports practitioners who carry out assessments and provide early help and interventions to children, young people, parents and carers.
This guideline covers referral and assessment for intermediate care and how to deliver the service. Intermediate care is a multidisciplinary service that helps people to be as independent as possible. It provides support and rehabilitation to people at risk of hospital admission or who have been in hospital. It aims to ensure people transfer from hospital to the community in a timely way and to prevent unnecessary admissions to hospitals and residential care.
This guideline covers medicines support for adults (aged 18 and over) who are receiving social care in the community. It aims to ensure that people who receive social care are supported to take and look after their medicines effectively and safely at home. It gives advice on assessing if people need help with managing their medicines, who should provide medicines support and how health and social care staff should work together.
This guideline covers decision-making in people 16 years and over who may lack capacity now or in the future. It aims to help health and social care practitioners support people to make their own decisions where they have the capacity to do so. It also helps practitioners to keep people who lack capacity at the centre of the decision-making process.
Evidence-based recommendations on rapid tests for group A streptococcal (strep A) infections in people aged 5 and over with a sore throat
Evidence-based recommendations on point-of-care coagulometers (the CoaguChek XS system) to self-monitor blood clotting
Evidence-based recommendations on integrated multiplex polymerase chain tests for identifying gastrointestinal pathogens in suspected gastroenteritis
Evidence-based recommendations on new generation computed tomography (CT) scanners for cardiac imaging for suspected or known coronary artery disease
Evidence-based recommendations on virtual chromoendoscopy (VCE) using NBI, FICE or i-scan to assess colorectal polyps of 5 mm or less during colonoscopy
Evidence-based recommendations on multi frequency bioimpedance devices to guide fluid management for people with chronic kidney disease having dialysis
Evidence-based recommendations on quantitative faecal immunochemical tests (OC Sensor, HM-JACKarc and FOB Gold) to guide GP referral for colorectal cancer
Evidence-based recommendations on biomarker tests (Actim Partus, PartoSure, Rapid fFN 10Q Cassette) to diagnose preterm labour in women with intact membranes
Evidence-based recommendations on DYSIS colposcope with DYSISmap and ZedScan I for assessing suspected cervical abnormalities in people having colposcopy
Evidence-based recommendations on tests (IOTA ADNEX, Overa, RMI I, ROMA, IOTA Simple Rules) in secondary care to identify people at high risk of ovarian cancer
Evidence-based recommendations on lead-I ECG devices for detecting symptomatic atrial fibrillation using single time point testing in primary care
Evidence-based recommendations on immunohistochemistry/microsatellite instability testing to guide tests for Lynch syndrome in people with colon cancer
Evidence-based recommendations on enzyme-linked immunosorbent assay (ELISA) tests for therapeutic monitoring of TNF-alpha inhibitors in rheumatoid arthritis
Evidence-based recommendations on tumour profiling tests to guide adjuvant chemotherapy decisions in early breast cancer
Evidence-based recommendations on point-of-care creatinine devices to assess kidney function before CT imaging with intravenous contrast
This guideline covers diagnosing and managing gastro-oesophageal reflux disease in children and young people (under 18s). It aims to raise awareness of symptoms that need investigating and treating, and to reassure parents and carers that regurgitation is common in infants under 1 year.
This guideline covers the care and treatment of people aged 18 and over with generalised anxiety disorder (chronic anxiety) or panic disorder (with or without agoraphobia or panic attacks). It aims to help people achieve complete relief of symptoms (remission), which is associated with better functioning and a lower likelihood of relapse.
This guideline covers the assessment and early management of fever with no obvious cause in children aged under 5. It aims to improve clinical assessment and help healthcare professionals diagnose serious illness among young children who present with fever in primary and secondary care.
This guideline covers prescribing of cannabis-based medicinal products for people with intractable nausea and vomiting, chronic pain, spasticity and severe treatment-resistant epilepsy.
This guideline covers the assessment and early management of head injury in children, young people and adults. It promotes effective clinical assessment so that people receive the right care for the severity of their head injury, including referral directly to specialist care if needed.
This guideline covers diagnosing and managing multiple sclerosis in people aged 18 and over. It aims to improve the quality of life for adults with multiple sclerosis by promoting symptom management, comprehensive reviews and effective relapse treatment.
This guideline covers diagnosing and managing community- and hospital-acquired pneumonia in adults. It aims to improve accurate assessment and diagnosis of pneumonia to help guide antibiotic prescribing and ensure that people receive the right treatment.
This guideline covers diagnosing and managing ectopic pregnancy and miscarriage in women with complications, such as pain and bleeding, in early pregnancy (that is, up to 13 completed weeks of pregnancy). It aims to improve how early pregnancy loss is diagnosed, and the support women are given, to limit the psychological impact of their loss.
This guideline covers care and support for people with advanced (stage 4) breast cancer. It aims to help them and their healthcare professionals make shared decisions about tests and treatments to improve outcomes and quality of life.
This guideline covers the diagnosing and managing of myeloma (including smouldering myeloma and primary plasma cell leukaemia) in people aged 16 and over. It aims to improve care for people with myeloma by promoting the most effective tests and treatments for myeloma and its complications.
This guideline covers assessing and managing cancers of the upper aerodigestive tract in people aged 16 and over. These are cancers of the airways of the head and neck, including the mouth, throat, larynx (voicebox) and sinuses. It aims to reduce variation in practice and improve survival.
This guideline covers assessing and managing pelvic fractures, open fractures and severe ankle fractures (known as pilon fractures and intra-articular distal tibia fractures) in pre-hospital settings (including ambulance services), emergency departments and major trauma centres. It aims to reduce deaths and long-term health problems by improving the quality of emergency and urgent care.
This guideline covers identifying and managing familial hypercholesterolaemia (FH), a specific type of high cholesterol that runs in the family, in children, young people and adults. It aims to help identify people at increased risk of coronary heart disease as a result of having FH.
This guideline covers diagnosing and managing peripheral arterial disease (PAD) in people aged 18 and over. Rapid changes in diagnostic methods, endovascular treatments and vascular services associated with new specialties in surgery and interventional radiology have resulted in considerable uncertainty and variation in practice. This guideline aims to resolve that uncertainty and variation.
This guideline covers the signs of possible child maltreatment in children and young people aged under 18 years. It aims to raise awareness and help health professionals who are not child protection specialists to identify the features of physical, sexual and emotional abuse, neglect and fabricated or induced illness.
This guideline covers preventing and controlling healthcare-associated infections in children, young people and adults in primary and community care settings. It provides a blueprint for the infection prevention and control precautions that should be applied by everyone involved in delivering NHS care and treatment.
This guideline covers identifying people who wish to donate their organs after their death. It offers advice on how to approach families and carers of people who are nearing the end of life and how to seek consent for organ donation. It aims to promote discussion of organ donation as part of end-of-life care and to increase the number of organs available for people waiting for a transplant.
This guideline covers identifying and caring for adults who are malnourished or at risk of malnutrition in hospital or in their own home or a care home. It offers advice on how oral, enteral tube feeding and parenteral nutrition support should be started, administered and stopped. It aims to support healthcare professionals identify malnourished people and help them to choose the most appropriate form of support.
This guideline covers diagnosing and managing irritable bowel syndrome (IBS) in people aged 18 and over. It details how to accurately diagnose IBS, and aims to improve the quality of life for adults with IBS by promoting effective management using dietary and lifestyle advice, pharmacological therapy and referral for psychological interventions.
This guideline covers recognising and managing antisocial behaviour and conduct disorders in children and young people aged under 19. It aims to improve care by identifying children and young people who are at risk and when interventions can prevent conduct disorders from developing. The guideline also makes recommendations on communication, to help professionals build relationships with children and young people and involve them in their own care.
This guideline covers assessing and managing psoriasis in adults, young people and children. It aims to improve long-term disease control and quality of life for people with psoriasis.
This guideline covers diagnosing and treating fertility problems. It aims to reduce variation in practice and improve the way fertility problems are investigated and managed.
This guideline covers diagnosing and treating delirium in people aged 18 and over in hospital and in long-term residential care or a nursing home. It also covers identifying people at risk of developing delirium in these settings and preventing onset. It aims to improve diagnosis of delirium and reduce hospital stays and complications.
This guideline covers assessing and managing chronic hepatitis B in children, young people and adults. It aims to improve care for people with hepatitis B by specifying which tests and treatments to use for people of different ages and with different disease severities.
This guideline covers diagnosing and managing constipation in children and young people up to 18. It provides strategies to support the early identification and timely, effective treatment of constipation which will help improve outcomes for patients. It does not cover constipation caused by a specific condition.
This guideline covers assessing the risk of fragility fracture in people aged 18 and over with osteoporosis. It aims to provide guidance on the selection and use of risk assessment tools in the care of adults at risk of fragility fractures in all NHS settings.
This guideline covers recognising and diagnosing autism spectrum disorder in children and young people from birth up to 19 years. It also covers referral. It aims to improve the experience of children, young people and those who care for them.
This guideline covers diagnosing and managing idiopathic pulmonary fibrosis in people aged 18 and over. It aims to improve the quality of life for people with idiopathic pulmonary fibrosis by helping healthcare professionals to diagnose the condition and provide effective symptom management.


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Student Case Report Contest
Our Student Case Report Contest is intended to enhance professional development and research skills
2020 Student Case Report Contest Now Open
Are you a current massage therapy student with a case report to share? Student Case Report submission dates have changed in order to accommodate students who graduate between June and September. Students must still submit before their graduation date, but the contest will accept applications year-round. Applications will be reviewed once per year.
Submission deadline is June 1st, 2020
2020 Student Case Report Contest guidelines
Student Case Report Contest checklist
Authorship form
Client informed consent form
2020 Student Case Report Contest rubric
Case reports play an important role in scientific and professional literature. Writing a case report helps develop communication skills, critical thinking skills, and could contribute to future research and clinical practice.
Since 2006, Massage Therapy Foundation has offered the Student Case Report Contest to provide an opportunity for students to develop research skills and enhance their ability to provide evidence-informed massage to the public. Cash prizes are available to contest winners contingent on publication of the case report.
View past Student Case Report Contest winners
Resources for Writing a Case Report
Writing Case Reports: Free Five-Part Webinar Series
The Massage Therapy Foundation, in collaboration with Associated Bodywork & Massage Professionals (ABMP), is pleased to bring you a free webinar series on writing a case report. This five-part series dissects the essential sections of a case report and demystifies the writing process, making it easy for you to write your own case report.
Article: Adaptation of the CARE Guidelines for Therapeutic Massage and Bodywork Publications: Efforts to Improve the Impact of Case Reports
Published in the International Journal of Therapeutic Massage & Bodywork, this article discusses efforts to improve the impact of case reports and includes a detailed checklist of what components comprise a case report.
Student & Faculty Tools
For additional case report writing resources, visit our Student and Faculty Tools page.
Students submitting a report must do so prior to their graduation date.
For more information please contact:
Christine Daskais, Program Manager, at email@example.com or 847-905-1667


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Please use our contact information above or fill in the form below and we'll get back to you as soon as possible. Thanks.
Your Name (required)
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Hot Wired IT Solutions, Lonsdale Avenue, South Bents, Sunderland, Tyne & Wear, SR6 8AY
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After a week where he's managed to offend people with mental health problems not just once, but twice, Harrow East Tory politician Bob Blackman has done it again.
According to the Harrow Times, Blackman, who hopes to take on incumbent Labour MP Tony McNulty, called his rival 'mad'.
McNulty had been rather quick to criticise Blackman for his slips, telling Stanmore Politics yesterday that he should apologise.
But it seems clear that Blackman didn't mean the remarks offensivly, he just needs to follow the maxim of 'think before you speak'.
Stern talk necessary from Conservative HQ?


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Painting the Metal Roof on Your Home
Does your Metal Roof Require a New Paint Job?
When traveling to Nebraska, Cocoona Baby recently had a client ask about painting his metal roof. Repainting your metal roof is a wonderful way of giving your home a new fresh look without investing in new tiles or shingles. If you want a new roof color or if the old color lost its initial brightness, all you have to do is buy some new metal roofing paint and learn a few tips on how to paint a metal roof!
But here you may have a question: How much will the new color of my metal roof cost? The simplest solution is to go online and browse for the available metal roof paints. You will find a large variety of special paints especially created for protecting your metal roof and giving it a fresh bright look. You'll also see the cost of metal roofing paints, thus being able to choose the product that suits you best, both by quality and price.
Acylic Resin Paint for Metal Roofs
My advice is to look for a paint with acrylic resins. These products provide a good protection for your metal roof, offering it extra resistance against water infiltration, peeling, corrosion and fading. The price for a good metal roofing paint can range between 30 and 300 dollars per bucket. Whether you need a fresh coat of paint or new metal roofing in Minneapolis, we suggest you speak with a local contractor.
Top Coatings & Sealants for Metal Roofs
You can also find many versions of metal roofing top coatings, sealants and adhesives. Their price depends on their quality, on the strength of the protective formula and so on. A good coating will protect your metal roof against the heat coming from the sun rays, moisture, algae and mildew, giving your roof durability and helping you to reduce your energy expenses.
If you already painted your roof and you want to give it an extra shine, there are also many shining top coatings that you can choose from. Most of them also include all the protecting functions I wrote above.
Nowadays, especially thanks to the online market, we have the opportunity of finding everything we want at a good price. The field of metal roofing colors is not an exception. Just turn on your computer and don't be lazy – browse all the available offers until you find that perfect product that totally satisfies you, offering you quality, guarantees, fast delivery and a convenient price! Have questions? Contact Cocoona Baby Travel!


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Style: Polycarbonate Nano CaseInterior: 5.20" x 3.00" x 1.10"
Dust-proof and water resistant, the Nano 310 case is perfect for all your pocket-sized valuables. A protective web and Powerclaw Latching System will keep your goods safe while you're on the go.
Authorized Distributor:
Authorized Dealer:
Toll Free: 1-888-357-8882
Fax: (613) 836-6401
P.O. Box 969
Stittsville, ON Canada


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This project builds on previous work done for the RUC West Consortium during the study of Financial Impacts of a RUC on Drivers in Rural and Urban Counties. That project looked at replacing the gas tax with a flat per-mile rate that would be revenue-neutral and provided EDR Group with expertise in assessing vehicle and household data at a high level of geographic detail that carried over to this work.
For this project, EDR Group investigated additional dimensions of the RUC rate structure. After exploring a wide variety of potential parameters, formulas were developed to investigate three types of parameters in more detail research – fuel type and fuel efficiency, as well as an initial mileage allowance under which all vehicles got 2,000 free miles. Fuel type and fuel efficiency are both parameters that affect household payments under the gas tax and are major motivations for considering new revenue policies. The new RUC rate formulas were used to carry out financial analysis, both of a revenue-neutral policy (for 7 states) and at a more sustainable level of revenue (for 3 states). This analysis showed that a RUC policy could be tailored to meet many different policy objectives and its incidence made more or less similar to the current gas tax, while still being more sustainable from a revenue perspective than current policy.
In collaboration with partners at EBP, the project also investigated the technological constraints of using a single system to collect road user charges, facility tolls, and congestion fees. The public perception of these different charges was investigated in partnership with PRR.
Please contact RUC West if you wish to view the final report


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This Saturday, May 24th 2014, 52 events will take place in 21 countries to protest the captivity of whales and dolphins. And in case you are wondering what the fuss is about, CNN is airing the critically acclaimed film that exposes the dark side of captivity, Blackfish, again on Thursday (6 and 8 pm EST) and Saturday (6 pm EST).
[Jeff Ventre]: You've participated directly at The Cove [in Taiji, Japan], and I presume you've seen Blackfish. Can you speculate how these two movies have "moved the bar" forward in regard to the animal justice movement?
Most people are so busy with everyday life and they do not stop to consider something as basic as the unethical decision to watch orcas doing circus tricks in a glorified swimming pool. They just see it as a family day out at the amusement park. Once they see these films their eyes are opened up to the truth. They see the dirty and bloodly truth behind the dolphin slaughters in Japan and they see what really goes on behind closed doors at the most well-known marine park in the world. These movies have inspired so many people to speak out against the dolphin slaughters and the captivity industry. They have created a movement towards ridding our world of marine mammal captivity.