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The Big Heart Disease Lie
Continue p-blockers, Dosage 0 if applicable Statins? Epiduralcatheter
Start p-blockers
Statins? Epiduralcatheter
Major surgery
Start p-bl ockers
No p-bt ockers
Perioperative arrhythmias are caused by physiologic and pathologic disturbances or by pharmacologic drug effects. Physiologic disturbances include hypoxemia, hypercapnia, acidosis, hypotension, hypovolemia, electrolyte imbalances, adrenergic stimulation (light anesthesia), vagal stimulation, and mechanical irritation (chest tube, pulmonary artery catheter). Pathologic cardiac disturbances include myocardial ischemia, infarction, acute heart failure, pulmonary embolism, and micro- or macrocirculatory shock. Therapy with proar-rhythmic drugs must also be considered when arrhythmias occur perioperatively.
The primary indications for antiarrhythmics are compromised hemodynamics due to critical tachycardias or bradycardias with impaired cardiac output. Another indication is the increased risk for cardiac death due to malignant or potentially malignant arrhythmias. Since all of the antiarrhythmic drugs also bear a proarrhythmic effect, treatment with antiarrhythmics may harm the patient, as was demonstrated in the Cardiac Arrhythmia Suppression Trial (CAST). Therefore, a thorough risk-benefit analysis is mandatory prior to long-term treatment with antiarrhythmics. Generally, the primary aim of antiarrhythmic therapy is to treat the underlying condition such as coronary heart disease or acute heart failure and not to cure symptoms.
In the perioperative setting, arrhythmias are observed quite commonly. Since in the operating room environment there are many reversible causes that predispose patients to arrhythmias, these conditions should be treated before considering pharmacological antiarrhythmic strategies. But in some patients perioperative arrhythmias pose the potential for rapidly developing life-threatening events necessitating immediate treatment.
Bradycardia is defined as a heart rate below 60 beats per minute. In trained athlete patients as well as in patients with excessive beta-blocker therapy, the heart rate can drop below 40 beats per minute with no symptoms. When low cardiac output is associated with bradycardia, the following stepwise therapeutic approach is indicated, where continuously the next step should be taken on failure of the previous step:
• Start with the administration of a parasympatholytic drug such as atropine up to 3 mg intravenously. Then administer a beta-adrenergic drug, e.g., epinephrine in boluses of 10 |g i.v.
• Thereafter consider the application of a transient pacemaker, either as an external transthoracic stimulation with pads or via an esophageal stimulation probe.
When an external pacemaker is not available, a defibrillator with its stimulation mode maybe used in case of emergency. Alternatively, internal stimulation with a temporary transvenous-inserted sterile stimulation probe is the treatment of choice in severe heart block.
Supraventricular Tachyarrhythmias
Various adverse physiological phenomena can evoke supraventricular tachyarrhythmias in anesthetized or critically ill patients. For management of the surgical patient, a thorough but rapid consideration of potential causes is required, because correction of reversible conditions may prevent life-threatening conditions. Antiarrhythmic therapy should only be considered after these etiologies have been excluded or in cases of extreme hemodynamic instability.
The origin of supraventricular tachyarrhythmias lies in the area of the atria, the sinus node, or the atrio-ventricular node (AV node).
• Paroxysmal supraventricular tachyarrhythmia with preexcitation is caused (most commonly) by congenital short-circuit conductive fibers leading to a bypass of the regular excitation from the sinus node over the atria to the AV node.
Wolff-Parkinson-White syndrome (WPW) is the most common preexcitation syndrome with the so-called Kent fiber being the accessory conductive fiber. In type A WPW syndrome, ECG recordings show a positive delta wave in V1 and Q waves in II, III, and aVF. In type B WPW syndrome, a negative delta wave is recorded in V1 of the ECG. The delta wave is defined as a slow up-slope of the R in the widened QRS complex. The PQ interval is below 0.12 s. WPW syndrome is potentially life-threatening, because an atrial fibrillation with the fast conducting accessory Kent fiber may lead to ventricular tachycardia or ventricular fibrillation. For treatment, a short trial of vagal stimulation may be attempted initially by the Valsalva maneuver or massage of the carotid sinus. On failure, the antiarrhythmic ajmalin 50 mg is administered by slow intravenous injection under ECG monitoring. As an alternative, amiodarone, procainamide, or flecainide should be considered.
It should be noted that patients with accessory pathways may also develop atrial fibrillation. These patients are at increased risk for developing ventricular fibrillation when treated with classic AV-nodal blocking agents (digitalis, calcium channel blockers, beta-blockers, adenosine), because these agents reduce the accessory bundle refractory period.
• A type of paroxysmal supraventricular tachyarrhythmia (PSVT) without preexcitation is the AV
node reentry tachycardia. In two-thirds of patients, it is caused by a congenital defect of the cardiac conductive system, in one-third of patients, it is caused by a prolapse of the mitral valve, hyperthyroidosis, or other cardiac diseases. The ECG trace shows a heart rate of 180-200 beats/min, small QRS complexes, and a missing P wave. The symptomatic therapy consists of adenosine (6 mg bolus, after 3 min 12 mg bolus), verapamil (5 mg slow intravenous injection over 10 min), or overdrive pacing in circulatory stable patients. In unstable patients with a threat of cardiogenic shock, an electroconversion is indicated with initially 200 J, on failure with higher energy of 360 J. If the patient is conscious, a short-acting hypnotic such as etomidate or propofol should be used for sedation during the electroconversion. Causal therapy is high-frequency catheter ablation. • Atrial fibrillation (AF) is the most common type of supraventricular tachyarrhythmia. The prevalence is about 0.5% of the adult population, but at age greater than 60 years, the prevalence is 4%. The etiology is primary or idiopathic in patients without cardiac disease or secondary due to a cardiac disease such as mitral valve disease, coronary heart disease, or due to extracardial causes such as arterial hypertension or alcohol-toxic effects on the heart ("holiday-heart"). The irregular conduction in the AV node leads to a tachyarrhythmia of the ventricles with frequencies of 100 -150 beats/min. Treatment strategies include frequency control, conversion into sinus rhythm, and prophylaxis of recurrence. The frequency control is achieved by administering digitalis and verapamil (calcium channel blocker). ECG-triggered cardioversion is performed under short sedation with an initial energy of 100 J. It may be advisable to first establish a therapeutic level of an antiarrhythmic agent that maintains sinus rhythm (i.e., amiodarone, procainamide) in order to minimize the risk of SVT recurrence following electrical cardioversion. It is important to anti-coagulate the patient before the cardioversion, if the AF persists longer than 48 h because intracardi-ac thrombi may have been formed. Thrombi formation can be checked by TTE (transthoracic echocardiography) or by TEE (transesophageal echocardiography). As an alternative, a drug-induced chemical cardioversion maybe considered.
For intraoperative and postoperative patients developing new-onset AF who are stable and rate-controlled, pharmacological cardioversion of SVT is questionable. The 24-h rate of spontaneous conversion to sinus rhythm exceeds 50% and many patients who develop SVT under anesthesia will remit spontaneously before or during emergence. Moreover, the antiarrhythmic agents with long-term activity against atrial arrhyth mias have limited efficacy when used for rapid phar-macologic cardioversion. Improved rates have been seen with amiodarone, but further studies have to confirm this because of the potential for undesirable side effects. Finally, it should be kept in mind that in recent-onset perioperative SVT, reversible causes should be excluded or resolved before considering pharmacological antiarrhythmic therapies.
Ventricular Tachyarrhythmias
Morphology (monomorphic vs polymorphic) and duration (sustained vs nonsustained) characterizes ventricular arrhythmias. Nonsustained ventricular tachycardia (NSVT) is defined as three or more premature ventricular contractions that occur at a rate exceeding 100 beats/min and last 30 s or less without hemody-namic compromise. The origin of ventricular premature beats is below the bifurcation of the HIS fibers. Usually the sinus node is not stimulated backwards. This leads to a compensatory pause, which is felt by the patient as an extra beat of the heart. These arrhythmias are routinely seen in the absence of cardiac disease and may not require drug therapy in the perioperative period. In contrast, in patients with structural heart disease, these nonsustained rhythms do predict subsequent life-threatening ventricular arrhythmias. However, antiarrhythmic drug therapies in patients with structural heart disease may worsen survival. When nonsustained ventricular arrhythmias occur during or after major operations, early or late mortality of patients with preserved left ventricular function is not influenced. These patients usually do not require antiar-rhythmic drug therapy. However, as in SVT, these arrhythmias may signal reversible etiologies that should be treated. For example, potassium- and magnesiumserum levels should be checked and elevated digitalis levels should be excluded.
Sustained ventricular tachycardia (VT) presents as monomorphic or polymorphic. In monomorphic VT, the amplitude of the QRS complex remains constant, while in polymorphic ventricular tachycardia the QRS morphology continually changes.
Ventricular tachycardia is characterized as a regular tachycardia of 100-200 beats/min with bundle-branch-block-like deformed, widened ventricular complexes. The underlying etiology is idiopathic, severe organic cardiac disease, intoxication of digitalis or treatment with other antiarrhythmics, or the Brugada syndrome (congenital mutation of the sodium channel). The underlying mechanism for monomorphic VT is formation of a re-entry pathway, e.g., around scar tissue from a healed myocardial infarction.
This is a life-threatening condition and immediate action is required. Although lidocaine has traditionally been the primary drug therapy for all sustained ventricular arrhythmias, i.v. amiodarone is now also recommended for treatment of perioperative-occurring monomorphic VT.
Treatment strategies for sustained polymorphic ventricular tachycardia depend on the duration of the QT interval during a prior sinus rhythm. In the setting of a prolonged QT interval (torsades de points), emphasis is taken at reversal of QT prolongation. In addition to QT-prolonging antiarrhythmic drugs (class IA or III), a number of other medications used in the perioperative period may evoke QT prolongation and torsades de points. The management of torsades de points includes i.v. magnesium sulfate (2-4 g), repleting potassium, maneuvers increasing the heart rate (atropine, temporary atrial or ventricular pacing). Hemodynamic collapse requires asynchronous DC countershocks. When antiarrhythmic therapy is deemed necessary, i.v. amiodarone may be considered, because it bears the lowest risk of triggering torsades de points.
Unstable ventricular tachycardia and ventricular fibrillation are life-threatening arrhythmias in the operating room. The most important first maneuvers in patients who experience VF perioperatively are nonphar-macological: rapid defibrillation (360 J monophasic or 200 J biphasic), and correction of reversible etiologies. Amiodarone i.v. (300 mg) should be considered as pharmacological intervention in addition to other measures taken during resuscitation (Thompson and Balser 2004).
A new therapeutic option for the treatment of VT is the implantation of antitachycardic pacemakers. The implantable cardioverter defibrillator (ICD) is used in patients with increased risk of sudden cardiac death due to ventricular fibrillation in recurrent ventricular tachyarrhythmias or history of VF (ventricular fibrillation) with significantly impaired ventricular function. For supraventricular tachyarrhythmia, termination of the reentry mechanisms can be achieved by overdrive pacing with a stimulation frequency above the tachy-
cardic frequency, programmable electrostimulation to terminate circulating impulses through premature impulses, or atrial high-frequency stimulation for the conversion of atrial flutter (Herold et al. 2006).
For an overview of the antiarrhythmic therapy, please refer to Fig. 3.2.
Acute Heart Failure
The acute heart failure (AHF) is defined as the rapid onset of symptoms and signs secondary to abnormal cardiac function. It may occur with or without previous cardiac disease. The cardiac dysfunction can be related to systolic or diastolic dysfunction, abnormalities in cardiac rhythm, or preload and afterload mismatch. It is often life-threatening and requires urgent treatment.
In the perioperative setting, AHF poses a serious threat to the patient, because these patients have a very poor prognosis. The 60-day mortality rate was 9.6 % and the combined rate for mortality and rehospitalization was 35.2% in the largest randomized trial to date (Cleland et al. 2003). The most common cause of AHF in the elderly is coronary heart disease, whereas in the younger population it is caused by dilatative cardiomyopathy, arrhythmia, congenital or valvular heart disease, or myocarditis (see Table 3.2).
188.8.131.52 Diagnosis
The diagnosis of AHF is primarily based on clinical findings, electrocardiogram (ECG), laboratory tests, chest x-ray, and echocardiography.
An impaired right ventricular function may be suspected if prominent jugular veins are present. To a cer-
Table 3.2. Causes and precipitating factors in acute heart failure
Decompensation of preexisting chronic heart failure (e.g., cardiomyopathy) Acute coronary syndromes: myocardial infarction/unstable angina with large extent of ischemia and ischemic dysfunction; mechanical complication of acute myocardial infarction; right ventricular infarction Hypertensive crisis
Acute arrhythmia (ventricular tachycardia, ventricular fibrillation, atrial fibrillation or flutter, other supraventric-ular tachycardia) Valvular regurgitation/endocarditis/rupture of chordae ten-
dineae, worsening of preexisting valvular regurgitation Severe aortic valve stenosis Acute severe myocarditis Cardiac tamponade Aortic dissection Postpartum cardiomyopathy
Noncardiovascular precipitating factors: lack of compliance with medical treatment, volume overload, infections, particularly pneumonia or septicemia, severe brain insult, after major surgery, reduction in renal function, asthma, drug abuse, alcohol abuse, pheochromocytoma High output syndromes: septicemia, thyrotoxic crisis, anemia, shunt syndromes
Modified from Nieminen (2005)
tain extent, measurement of the central venous pressure (CVP) allows quantification of the amount of congestion. The normal range of the CVP is 4-12 cm H2O. Caution is necessary in the interpretation of high measured values of central venous pressure in AHF, as this maybe a reflection of decreased venous compliance together with decreased right ventricular (RV) compliance even in the presence of inadequate RV filling. If the left ventricular function is impaired, wet rales in the lung fields are present during chest auscultation.
A chest x-ray confirms the diagnosis of left ventricular failure and allows the differential diagnosis to inflammatory or infectious lung diseases. Additionally the chest x-ray is used for follow-up of improvement or unsatisfactory response to therapy.
The ECG usually shows pathologic signs in patients with AHF. It determines the etiology of the AHF and may indicate strain of the left or right ventricle or the atria, acute coronary syndromes, arrhythmias, peri-myocarditis, and preexisting conditions such as left or right ventricular hypertrophy or dilated cardiomyopa-thy.
The recommended laboratory test in AHF include arterial blood gas analysis (BGA), venous oxygen saturation, plasma B-type natriuretic peptide (BNP), and standard tests such as blood count, platelet count, urea, electrolytes, blood glucose, and creatinine phosphoki-nase. The arterial BGA allows assessment of oxygenation (paO2), adequacy of respiratory function (pCO2), and acid-base balance (pH). Venous oxygen saturation is determined by oxygen supply, oxygen consumption of the body and regional circulation. It is useful as an estimate of the total body oxygen supply-demand balance. Another useful laboratory test is the plasma BNP, which is released from the cardiac ventricles in response to increased wall stretch and volume overload. The decision cut-off point is proposed as 100 pg/ml.
Echocardiography is used in AHF to evaluate the functional and structural changes of the heart and to assess acute coronary syndromes. Additional information is gathered by echo-Doppler studies, which can estimate pulmonary artery pressures (from the tricuspid regurgitation jet) and left ventricular preload.
Additional diagnostic procedures such as angiogra-phy, CT scan, or scintigraphy may be indicated according to the etiology of the AHF.
If the diagnosis of AHF is verified, the patient must be treated in specialized wards such as emergency units, chest pain units, or intensive care units. The physicians should be trained and should follow guidelines.
If immediate resuscitation is necessary, basic and advanced life support (BLS/ALS) is applied according to the applicable guidelines.
The patient in distress or pain requires treatment with a sedative or analgesic agent. In this context, morphine is recommended in the early stage of the treatment, when a patient is admitted with severe AHF presenting with the signs of restlessness and shortness of breath (dyspnea). Additional effects of morphine include venodilation, mild arterial dilation, and reduction of the heart rate. Intravenous boluses of 3 mg (2-5 mg) are recommended and may be repeated as needed.
To achieve adequate tissue oxygenation, an arterial oxygen saturation of greater than 95 % is favorable. It is important to realize that increased concentrations of oxygen to patients without evidence of hypoxemia may cause harm, because hyperoxemia can be associated with reduced coronary blood flow, reduced cardiac output, increased blood pressure, and increased systemic vascular resistance. When arterial oxygen saturation is too low, oxygen supply via a face mask with reservoir bag is effective to increase inspiratory oxygen concentration. In case of failure, ventilatory support without endotracheal intubation is supplied as noninvasive ventilation: continuous positive airway pressure (CPAP) or biphasic positive airway pressure (BiPAP). If acute respiratory failure by AHF-induced respiratory muscle fatigue does not respond to vasodilators, oxygen therapy and noninvasive ventilation, the trachea has to be intubated and mechanical ventilation of the lungs commenced.
During bradycardia-induced AHF, external or internal pacing restores an adequate heart rhythm. Cardiac arrhythmias or tachycardia can cause AHF. Since antiarrhythmic drugs and beta-blocking agents such as metoprolol have negative inotropic properties, they should be used with extreme caution in AHF. However, in patients with acute myocardial infarction, who stabilize after having developed AHF, beta-blockers should be initiated early.
In patients with AHF and absence of hypotension (mean blood pressure above 70 mmHg) vasodilators are indicated. The primary pharmacologic treatment options include nitrates such as glyceryl trinitrate or isosorbide dinitrate, sodium nitroprusside, and the new agent nesiritide (atrial natriuretic peptide). The nitrates relieve pulmonary congestion without compromising stroke volume or increasing myocardial oxygen demand in acute left heart failure, particularly in patients with acute coronary syndrome. Their effect is limited to 16 - 24 h primarily due to development of tolerance. Sodium nitroprusside is indicated in patients with severe heart failure and in patients with predominantly increased afterload such as hypertensive heart failure or acute mitral regurgitation due to ruptured papillary muscle as a complication of severe myocardial infarction. The substance should be used cautiously, invasive monitoring of blood pressure is usually required, and toxicity of the cyanide metabolites should be taken into account. The new drug nesiritide is a recombinant human brain peptide, which is identical to the endogenous hormone produced by the ventricle (see description above). Nesiritide has venous, arterial, and coronary vasodilatory properties, reducing preload and af-terload and thereby increasing cardiac output without direct inotropic effects. Calcium antagonists are con-traindicated in AHF; ACE inhibitors are not indicated in the early stabilization phase of patients with AHF.
If the patients show symptoms of AHF secondary to fluid retention, diuretics are indicated. Usually loop diuretics such as furosemide or torasemide are administered. Hydrochlorothiazide (HCT) or spironolactone is added to loop diuretics in patients that are refractory to loop diuretics alone; a concomitant alkalosis is treated with acetazolamide. In refractory renal failure, hemo-dialysis or hemofiltration is initiated.
If the preload is low, a fluid challenge is indicated, but should be administered with extreme caution.
After executing all of the therapeutic steps mentioned above, the adequacy of cardiac output is assessed by reversal of metabolic acidosis, venous oxygen saturation, and clinical signs of adequate organ perfusion. The application of catecholamines or phosphodi-
Fig. 3.3. Flow chart for immediate goals in treatment of the patients with acute heart failure. In coronary artery disease, the patient's mean blood pressure (mBP) should be higher to ensure coronary perfusion, mBP> 70, or systolic > 90 mm Hg. BLS basic life support, ALS advanced life support, CPAP continuous positive airway pressure, NIPPV noninvasivepositivepressureventila-tion. From Nieminen et al. (2005)
Fig. 3.3. Flow chart for immediate goals in treatment of the patients with acute heart failure. In coronary artery disease, the patient's mean blood pressure (mBP) should be higher to ensure coronary perfusion, mBP> 70, or systolic > 90 mm Hg. BLS basic life support, ALS advanced life support, CPAP continuous positive airway pressure, NIPPV noninvasivepositivepressureventila-tion. From Nieminen et al. (2005)
3.2 Deep Vein Thrombosis and Pulmonary Embolism
esterase inhibitors as inotropic agents is indicated in persistent heart failure, if tissue hypoperfusion does not suspend under the therapy described previously; but one must pay particular attention to these patients as catecholamines increase the oxygen consumption of the heart.
Dopamine incorporates dose-dependent properties of action on the receptors: it stimulates dopamine receptors at low doses (<2 |g/kg/min), beta-adrenergic receptors at medium doses (2-5 |g/kg/min), and alpha receptors at high doses (>5 |g/kg/min). Dopamine maybe used as an inotropic (> 2 |g/kg/min i.v.) in AHF with hypotension. Infusion of low doses of dopamine (<2-3 |g/kg/min i.v.) may be used to improve renal blood flow and diuresis in decompensated heart failure with hypotension and low urine output. However, if no response is seen, the therapy should be terminated, because no controlled trials regarding its long-term effects on renal function and survival have been conducted and concerns regarding its potential untoward effects on pituitary function, T cell responsiveness, gastrointestinal perfusion, chemoreceptor sensitivity, and ventilation have been raised.
Dobutamine stimulates betal receptors and beta2 receptors in a 3: 1 ratio. The effect is a positive inotropic and chronotropic action as well as peripheral vasodila-tion. To increase cardiac output, dobutamine is initiated with an infusion rate of 2 - 3 |g/kg/min, which can be increased up to 20 |g/kg/min. After 24-48 h, beta-receptor tolerance decreases the effect of dobutamine. The indication for dobutamine is evidence of peripheral hypoperfusion (hypotension, decreased renal function) with or without congestion or pulmonary edema refractory to volume replacement, diuretics, and vasodilators at optimal doses.
Phosphodiesterase inhibitors such as enoximone and milrinone have a site of action distal of the beta receptors, which results in persistent inotropic, lusitro-pic, and peripheral vasodilatory effects even in the presence of beta-blockers. Therefore, they are preferred to dobutamine in patients with concomitant beta-blocker therapy. In severe heart failure, a combination of phosphodiesterase inhibitors with epinephrine or norepinephrine is indicated in order to provide sufficient cardiac output with adequate perfusion pressure.
The new substance levosimendan (calcium sensitizer) has two main mechanisms of action: calcium sensitization of the contractile proteins, responsible for positive inotropic action, and smooth muscle potassium channel opening, responsible for peripheral vasodilatation. It is indicated in patients with symptomatic low cardiac output heart failure secondary to cardiac systolic dysfunction without severe hypotension.
If the combined administration of inotropic substances and a fluid challenge fail to relieve the symp toms of AHF, a potent vasopressor such as epinephrine is indicated. Norepinephrine may be considered in right heart failure or in combination with phosphodiesterase inhibitors (Fig. 3.3) (Nieminen et al. 2005).
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Giving you the Freedom to achieve your dreams and goals.
Freedom Fitness and Coaching offers endurance coaching of multisporters, kayakers and cyclists of all abilities. The design brief began with the development of logo and accompanying corporate stationary, and then moved into developing a Facebook presence, followed by the graphical development for a range of performance clothing, and later the design of a womens range. Further design projects have also included looking at branding for vehicles and kayaks.
Freedom Fitness aims to help participants 'let go of their fears and grab hold of their dreams'. N8 Creative aims to help it do that.

subset: commoncrawl


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UnNews:Navy initiates recruitment drive
This article is part of UnNews, your source for up-to-the-microsecond misinformation.
8 August 2012
SOMEWHERE IN THE PACIFIC – In a never-ending effort to boost recruiting rates, the military services continue to
deploy employ innovative approaches to get otherwise sane young men to sign their lives away on the dotted line. (Enough apparently sane young women have already enlisted to service serve the military brass' needs for the foreseeable future, it seems.)
The Army allows female soldiers to breastfeed in public. The Marine Corps permits Marines to march in gay parades. The Air Farce includes a rainbow combat badge exclusively for gay, lesbian, bisexual, and transgender airmen, to signify their service to their country. Now, the Navy has joined the other branches (except for the Coast Guard) in using innovative approaches to attract male, as opposed to female and transsexual, sailors.
According to Admiral Ima Dick, the Navy has "retrofitted some aircraft carriers," equipping the ships with a hotel-casino that rivals anything on the Las Vegas Strip. "We expect our boys to gamble their lives in combat," Admiral Dick said. "We believe we should let them gamble during rest and relaxation periods."
In addition, "the carriers boast two swimming pools, one with a waterfall; a wrap-around balcony that surrounds the deck amidships; a helipad, for V. I. P.'s, including celebrity performers whom the Navy engages to entertain swabbies; a matching pair of conventional. 150-foot yachts; valet parking facilities; an 18-hole golf course amid towering palm trees; and a host of other amenities," Admiral Dick said. "We're particularly proud of our Oasis on the Streets of Monaco, a lavishly landscaped plaza that features upper pools that cascade into a lagoon surrounded by Jacuzzis."
"We think young men would rather kick it in these lush, plush surroundings than watch some soldier breastfeed her brats, some jarhead march in a gay pride parade, or some flyboy get pinned with a rainbow badge," Admiral Dick said.
The ships also feature an "optional, detachable volcano," she observed.
If enlistment rates are any indication, the admiral is correct: Navy recruitment is greater than that of all the other military branches combined.
"When it comes to our men in uniform," Admiral Dick said, "no expense is too great, especially when civilian taxpayers are footing most of the bill." President Barack Obama agrees, she said. "In fact, as commander-in-chief, he and his family often enjoy their vacations aboard one or another of the Navy's six converted aircraft carriers."
The only drawback is that there is no longer any room for the combat aircraft that the ships used to carry. "You can't have everything," Admiral Dick said. "The Navy has chosen morale over combat readiness, and we think we've made the right decision."
"The Army may offer tits, the Marine Corps, gay pride, and the Air Farce rainbow badges, but the Navy is the only military service that lets its recruits see the world in style," Admiral Dick declared.


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I have published many pictures of The County in this site and have had many pleasing comments from old fans of the Somerton Park club. Because of their popularity I have decided to publish the whole County Archive, WARTS and ALL!
Over the years much information has been lost as has some of the picture quallity. These pictures were never meant to be kept for this length of time, being press and programme pictures. Where possible I shall give a caption but others will just have a season e.g 78/79. I am sure that many county fans will identify them for me. Please let me know I would love to hear from you. It will take many months to get through the thousands of negs, some will be good, some will be rubbish. For as many of the older photographers will tell, one often sat for 90 minutes looking at figures in the distance or the backs of heads whilst at the County. Enjoy and feel free to pass comment on the matches shown.
Page 1 Away at Torquay United
Page 2 Barnsley Home featuring Guests Lulu and Stan Stenett.
Page 3 Welsh Cup and Promotion winners parade in Newport
Page 4 As Above Part 2
Page 5 County 1975
Page 6 County Portraits
Page 7 Some behind the scenes pictures.
PAGE 8 Newport County Open Day 80/81 and Miss Newport County.
Newport County AFC Team Group 1980 County Page 5
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Do you remember the DIY 360 Camera that made headlines last year? Yeah, the one where this guy tied his smartphone on a string and swung it around?
Well, this guy is back and he has another trick under his sleeves. Nicolas Vuignier is back with what he calls the poor man's selfie drone. He calls it that because, well, you don't need a battery and a remote for it to work, you just need to throw it.
Yes, that's right. He throws his GoPro to the air and comes up with amazing shots, take a look at the video below.
To the GoPro's defense, Nicolas is not just throwing it up the air with the hopes of getting a good shot. A Redditor took a freeze frame from his video that shows that the GoPro is rigged into what looks like a makeshift drone, maybe to slow its drop when it's tossed.
Image is a screengrab from YouTube.


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Cruden's 'Movember' raises £4000
We are delighted to announce that Cruden Group's Movember campaign has raised over £4000 for the charity.
The staff at Cruden Group got fully behind the annual Movember drive, which raises funds for men's health, and have achieved their goal of raising over £2000 from donations and sponsorship which has been matched by a donation from the company resulting in just over £4000 being raised in total.
Movember focuses on three urgent issues - prostate cancer, testicular cancer and suicide prevention.
Cruden Group's Finance Director Simon Burrows led the way with his 'Shave Down' for the charity on 1st November and many colleagues registered themselves as a Mo Bros and grew a rather fetching array of 'Mo's' over the month. They were fully supported and encouraged by Cruden's 'Mo Sistas', who also acted as judges on the 30th November for the best 'Mo'.
The Judging Panel of Rachel Tetlow, Lisa Kennerly, Lorraine Armitage & Becky Edwards had a very difficult job of deciding on the winners, which were split into categories:
- 80's Throwback
- Crimewatch's Most Wanted
- Look-alikes
- Mr. Suave
The Movember winners were Peter Harrison-Johnson (80's Throwback), Paul Buttery (Crimewatch's Most Wanted), Stuart McCall (Look-alikes) and Dave Woodward (Mr. Suave).
Movember also saw the launch of Cruden's fitness awareness campaign, the C-Fit initiative, a series of health awareness events sponsored and promoted by the company on personnel wellbeing and preventive healthcare that will help staff members to stay well and to seek early advice and intervention on health issues.
Cruden's Mo Bros and Mo Sistas were first to positive action on this front, organising daily walks over lunchtime on each Movember day for everyone in the company to improve their daily exercise.


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This course teaches developers how to use Jenkins to automate the deployment of web applications to an application server. Automated deployments are a key feature of any deployment pipeline used for continuous delivery and deployment.
The course introduces a sample Java web application and focuses on deploying that application to an Apache Tomcat servlet container using Jenkins integration. By the end of this course, you'll understand how to automate the delivery of web applications by packaging them from a source code repository and ultimately deploying to an application server.


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|Privacy notice
UK data driving real-world evidence
Research using CPRD data has informed drug safety guidance and clinical practice and resulted in over 2,300 peer-reviewed publications.
The CPRD bibliography is updated on a monthly basis (last updated 4 December 2019) and papers are listed below and in the PDF below.
If you have published papers using CPRD data which are not included in this list, please contact us at email@example.com so that we can update the bibliography.
Export 4 results:Author Title Type [ Year]
Filters: Author is Bartels, D. B. [Clear All Filters]
"Measuring prevalence and incidence of chronic conditions in claims and electronic health record databases", Clin Epidemiol, vol. 11, pp. 1-15, 2019.,
"The Use of Telmisartan and the Incidence of Cancer", Am J Hypertens, vol. 29, pp. 1358-1365, 2016.,
"Population-based cohort study of warfarin-treated patients with atrial fibrillation: incidence of cardiovascular and bleeding outcomes", BMJ Open, vol. 4, p. e003839, 2014.,
"Long-term use of angiotensin receptor blockers and the risk of cancer", PLoS One, vol. 7, p. e50893, 2012.,


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Recession and a military emergency are handing all levels of government a unique challenge. Our most important trading partner, to whose fate we are inexorably tied, is trimming corporate taxes and accelerating tax rebates while throwing in spending for lots of guns and butter to boot.
We're not as wealthy and our political culture is generally reluctant to lower taxes. Moreover, it still ties its hands by insisting that key areas such as healthcare and education be run like the old post office, a monopoly whose costs constantly rose while service levels fell. We have much less room to manoeuvre because our government is already a third larger as a percent of the economy. More than ever, our public sector needs to tie itself to a framework of high performance and fiscal prudence.
This unusually turbulent scenario brings risk. Will governments dust off their 1960s economic textbooks and return to deficit spending and panicky job-creation programs? That would be a pity because quality policy options are available.
What if we pour money into the public trough and it doesn't work? Japan has tried this approach for more than a dozen years, and its economy remains flat on its back, in a semi-permanent stupor. Besides ultra-expensive bridges to nowhere, it is left with little growth, a ballooning debt and increasingly non-competitive tax levels. Nobody, save the odd university professor and a shrinking minority of government-stimulus advocates, still believe deficits can magically produce prosperity.
Manitoba's big temptation might be the construction of dams up north, to take advantage of last year's energy market. These types of government projects are too time consuming. A Canadian recession, especially Ontario's, translates into falling equalization payments for Manitoba, a form of easy money that troublingly makes up a third of the provincial budget. The crunch is coming.
What can Finance Minister Greg Selinger otherwise do? He might profit by reading the annual report of a program he controls, the Special Operating Agencies Finance Authority.
SOAs are operations within government where the civil service is separated from the ponderous regulations and archaic operating systems that characterize the traditional public sector. They focus on results, setting performance goals and then systematically developing strategies to attain them. While they lack the more extensive flexibility afforded the world's most innovative models of high performance government, they are relatively free to use best methods in an environment where output is measured and excellence is rewarded. Their track record as quasi-independent business units within government speaks for itself.
They have garnered international recognition for the province. (Take a look at the World Bank's web site). Greg Selinger and company could easily build on their demonstrated, if low profile, success.
The program began with the Fleet Vehicles Agency, which was converted into an SOA in 1992. It now includes 17 other government operations, incorporating such varied services as the Fire Commissioner's Office, the property registry and the Manitoba Securities Commission. All told, SOAs represent 5% of the Manitoba civil service and $112 million in business activity. The latest annual report documents significant improvements in efficiency and service quality, including a 21% reduction in costs, faster response times and a doubling of clientele. The old way of doing things was not the best way.
In spite of this encouraging record, there appear to be no immediate plans to expand this hotspot of public sector innovation. This is too bad. The other 95% of provincial spending would benefit from the principles that govern SOAs. From the outset, the program was restricted to public sector niches that had existing or potential revenue streams, but its values have application across the board.
If a general lesson can be taken from this performance-oriented model, it is that we can benefit by operating services on a more personalized, customer-connected scale. Instead of government's easy, slightly soviet tendency to centralize and amalgamate service activities and organizations in the elusive quest for so-called economies of scale, the SOA script goes in the opposite direction, decentralizing control and pushing responsibility and accountability down to the client level. Get the central agencies, notorious for micromanagement, creating burdensome paperwork, hidden costs and delays, out of the way. Let front-line workers use their brains. Focus on results and forget about rigid processes that smother front-line employees. Use concrete performance measures to benchmark progress and tie it to employee rewards. Know the costs, including those hidden or ignored in a bewildering maze of internal subsidies.
The tough spot ahead for governments should be seen as a marvellous opportunity to try new things. In the stifled Canadian context the SOA philosophy is truly a breath of fresh air. More than ever, the public sector has to be affordable and at the same time do a first-rate job. A little SOA magic gives civil servants that chance.


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Thursday, February 26, 2009
At the brink of global ruin, many Americans suddenly seem willing to consider sensible ideas that were always deemed unthinkable, and to reject foolish notions that were once deemed brilliant. Soon we may be mature enough to observe how other developed countries address problems that have baffled us for generations.
Nationalizing major banks, temporarily at least, is a radical notion that today looks far more prudent than handing over hundreds of billions of additional dollars to the clowns and crooks who wrecked the financial system. Privatizing Social Security, which meant turning over another trillion dollars to the Wall Street geniuses whose reckless greed drove us into penury, no longer appears so alluring. Even a few repentant right-wingers -- notably including Alan Greenspan, the former "maestro" of money -- now gaze dolefully into the mirror and wonder where they went so wrong. (Here's a hint: The trouble began during those lonely evenings spent perusing the addled works of Ayn Rand.)
So as President Obama convened his "fiscal responsibility summit" and then delivered his first address to Congress, the voices of free-market fundamentalism were muted in Washington, if not on cable television. The anticipated onslaught against Social Security from those claiming to represent future generations did not materialize at the Obama summit -- and neither did the presidential capitulation that liberals had feared. Instead, the White House wonks insisted on discussing the actual threat to America's future solvency, namely the swelling price of health care for the retiring generation of baby boomers and its effect on Medicare and Medicaid.
The problem with these programs, which have done so much to improve the health of America's poor and elderly, is neither the size of the boomer cohort nor even their impending geezerhood. The problem is the rate of cost increase per beneficiary, according to a landmark study released two years ago by the Center on Budget and Policy Priorities (and described with admirable clarity by Ezra Klein on the American Prospect website on Feb. 23).
Respected across the political spectrum for the accuracy and relevance of its data, that liberal think tank happens to be the former professional home of Peter Orszag, the Obama administration's budget director. The center's insights into federal spending will inform policy at the highest level -- which means that reforming the way we finance and deliver medicine will be central to this government's fiscal planning. Although there are many other matters that must be addressed if we are ever to regain control of deficits when economic growth resumes -- from the abuse of tax shelters by the super-rich to the absurd rip-offs by military contractors -- the biggest money is in the health sector.
But how can we cope with rising costs when we have yet to achieve the basic national goal of providing universal coverage? Perhaps now Americans will look abroad and notice that other countries provide quality care to all of their citizens, spending less than half what we do and achieving better outcomes.
In the coming decades, countries in Europe, as well as Canada and Japan, will be able to invest their resources in energy and education, while we try to figure out how to borrow enough to keep our hospitals open. What they all have in common is that they do not devote a huge proportion of their health spending to the profits of insurance companies -- and they negotiate budgets with health providers, such as pharmaceutical companies.
The superior performance of these alternatives is at long last coming to the attention of the mainstream media, which has so long ignored it.
As always, Congress will resist change on behalf of the insurance and pharmaceutical lobbies, preferring to do nothing. But perhaps in the coming years, the public will realize that such feckless politicians should be told to go do nothing somewhere else.
Joe Conason writes for the New York Observer.
See Other Political Commentary.
See Other Commentary by Joe Conason.
Views expressed in this column are those of the author, not those of Rasmussen Reports.
Rasmussen Reports is a media company specializing in the collection, publication and distribution of public opinion information.
We conduct public opinion polls on a variety of topics to inform our audience on events in the news and other topics of interest. To ensure editorial control and independence, we pay for the polls ourselves and generate revenue through the sale of subscriptions, sponsorships, and advertising. Nightly polling on politics, business and lifestyle topics provides the content to update the Rasmussen Reports web site many times each day. If it's in the news, it's in our polls. Additionally, the data drives a daily update newsletter and various media outlets across the country.
Some information, including the Rasmussen Reports daily Presidential Tracking Poll and commentaries are available for free to the general public. Subscriptions are available for $4.95 a month or 34.95 a year that provide subscribers with exclusive access to more than 20 stories per week on upcoming elections, consumer confidence, and issues that affect us all. For those who are really into the numbers, Platinum Members can review demographic crosstabs and a full history of our data.
To learn more about our methodology, click here.


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Robust services in support of global health.
A team of librarians and a vast array of resources are available to you. If you need help, please contact one of the librarians for your area:
The list of global health links from Perkins Library offers a thorough list of resources to help your academic and research work in global health and is linked as a tab from this guide. It is an excellent starting point for those beginning research in global health.
The Medical Center Library is staffed from 8:00 am - 6:00 pm, Monday - Friday.
Your Duke ID card is required for after hours and weekend access.
Duke Medicine badge holders: study spaces are available 24/7.
Duke University badge holders: bring your ID card and ring the doorbell for access:
Questions? (919) 660-1100 or email us at firstname.lastname@example.com


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White cotton sweatshirt
Code: FS6864A1VPF0ZNM
Long-sleeved sweatshirt customised with metal cut-out Fendi logo. Straight-cut garment with side slits and dipped hem at the back. Ribbed collar and cuffs. Symmetrical zips on the shoulders. Made of white cotton jersey. Decorated with appliqués embroidered on the back that make up the FENDI lettering. A small contrasting Fendi logo is inlaid on the right cuff. Palladium-finish metalware.
Made in Italy
More details
- Product Code:FS6864A1VPF0ZNM
- Composition:100%cotton, trim:65%polyester,30%polyamide ,5%elastane, embroidery:100%polyester, abs
- Additional details:The model is wearing a size 40 and is 178 CM tall
May we help?
Our Customer Care is at your disposal for any information or assistance you may require. Call us at +39 0633450130 or send us an email.
We're available Monday to Friday, 10am to 7pm CET.
Buy online
Enjoy shopping online when and where you want, and have your order delivered at a personal address or pick it up at one of our stores.
You can also place your order by phone with our Customer Care.
Shipping and Returns
We offer free Standard shipping on all orders. The parcel will be delivered in 4 to 6 working days. Express shipping is available if you want to receive your order in 2 to 3 working days.
Returns are always free and can be requested within 14 days from delivery. Please note it is not possible to return personalised items..
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The Riverside County District Attorney's office announced today in a press release that a consumer protection lawsuit against the Boston-based insurance company has resulted in a settlement. The civil complaint alleges violation of California's false advertising laws by failing to disclose to consumers in the ads that "accident forgiveness" was in fact not available in the state yet countless advertisements had been running in California for over two years. State law requires that all advertising must clearly and conspicuously disclose any material facts that viewers need to avoid being misled. It is alleged in a complaint filed in the case that the disclaimers in the Liberty Mutual ads were unlawful because these ads could convey "an overall impression that California consumers would receive this benefit as part of Liberty Mutual car insurance," which was not true.
The advertising campaign was launched in 2014 with great fanfare by the insurer. In a press release about the campaign launch Liberty's CMO said "In a category where trivial humor can often distract from substance, we saw an opportunity to talk honestly with consumers about providing the right protection for what they value most in their lives."
Well that backfired. I wonder how many other states will follow California's lead?
The ads were created by Liberty's AOR Havas Worldwide New York and Optimedia, part of Publicis Groupe, handled media planning and buying. Under the terms of the judgment, which will be entered without admission of liability, Liberty Mutual will be subject to an injunction requiring full compliance with California's advertising laws in its "Accident Forgiveness" advertising, including clear and conspicuous disclosure of the fact that such programs are not available in California.
So who's to blame here? The agency? Liberty's Marketing team? Liberty's legal team? I'd say all of the above. In a highly regulated industry like insurance, marketing leadership needs to always review everything for legal compliance – that's marketing 101.


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Grass Green - Glitter Dust 10ml
Write a review
| Ask a question
Nail art glitter dust is approx. 0.2mm in diameter, smaller than mini, chunky or super chunky nail art glitter. 10ml Pots can be mixed into your pot to UV Nail Gel and Clear or coloured Acrylic Powder to create a custom blend unique to you. Only want enough to create a single design? You can pick up your glitter with a tiny bead of acrylic or gel and apply it straight on to the nail then cap it with clear or blush pink acrylic powder.


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When the signs of potty training readiness begin to emerge in your child, you have an important decision to make: which potty chair? There are plenty of models available on the market, but we recently had the opportunity to review the the Fisher-Price Learn-to-Flush Potty that I think you will all agree is a really unique and fun tool to help us through this sometimes difficult process.
Using M&Ms and stickers is popular way of providing incentive to get your kids to use the potty, but the folks at Fisher Price have come up with another idea: how about some music? The Learn to Flush potty is even more deluxe than our their very popular cheer for me potty. The real fun is in the flushing action. When the child flushes the potty, the tank water feature lights up and pretend water twirls around to a real flushing sound and cheerful yay. Moreover, there are musical ditties and sound effects that reward the child for going in the potty bowl, thus encouraging toilet training. There is a grow with me element as the removable potty ring can be used on the adult toilet as baby grows. There is a built in potty guard and smooth contours for easy cleaning and is just the right height for a potty training child. Finally, the design is styled with realistic colors and shapes and is the perfect gender neutral potty.
Some recent parental reviews say:
(5 Stars: Good for Boys!)
I like this potty because the seat is made well, there no where that a little boy can get pinched. There is enough room for his little bottom and it is a nice height for a just turned 3yr old. The reward system is very encouraging. I laughed at my son's first expression when he did #1 in it. His face went from shock to awe to giggles. He even did a little dance to the song while he sat on the seat. It was so cute. Now he wants to bring his potty EVERYWHERE! lol.
He was partially trained before on the adult toilet (can do #1 but having a little trouble with the #2 part); as the adult toilet is still too difficult for him to get on and off. Plus I think the big bowl kind of scares him even with a trainer seat on. The other potties I tried were too small or narrow, more designed for girls I think.
So this little potty that looks just like the adult one is much more encouraging. It is sturdy and well made. I am so glad we decided to get it.
As I wrote this little review, he just went all by himself! I can hear the little tune playing and he came to me for a High-Five! Yay! lol.
We are still in the early stages of training with Lily, as she has just recently started showing signs of readiness (letting me know when she has to go, staying dry for 2 + hours) but so far she really does like her potty. She enjoys pushing the button herself to make her music play, and it also has a spot to affix your favorite photo. We have a picture of our dog, which she also loves. Anything we can do to make it a fun and happy experience for her is completely worth it!
To order on Amazon and delivery straight to your door:


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Website Design
We have over ten years of experience designing websites.
Digital Marketing
Getting new leads and sales to your site is our speciality.
Logo & Branding
Building a brand that speaks to your customers is what we do.
We're experts at the world's most trusted web platform.
Print Design
Business cards, brochures, posters and much much more.
Responsive Design
We build websites that work on all kinds of devices.
Meet the Team
Nathanael HubbardManaging Director | Founder
Nathanael HubbardManaging Director | Founder
Nathanael is our co-founder and Managing Director, who along with Scott Maynard has built Excite Media into one of Brisbane's premier agencies over the past 12 years. Leading a team of 35 close-knit digital experts, Nathanael is passionate about helping people and businesses discover what they want, why they want it, and how to achieve it.
- Nathanael enjoys nudging things one pixel at a time until they look 'perfect'
- Nathanael thinks he can predict the weather better than the professionals
- Nathanael has a Masters of Information Technology and a Bachelor of Popular Music.
Scott MaynardManaging Director | Founder
Scott MaynardManaging Director | Founder
Scott, Excite Media's Technical Director is a qualified engineer with 16 years programming experience. Scott jumps into support calls when needed to ensure we continually better our service and solutions.
- Scott once drank a whole bottle of mint sauce
- Scott (along with 3 other Excite team members) broke a Guinness World Record for the longest ever darts marathon
- Scott's "Useless Skill" is catching items that fall out of the fridge
- Scott's hobbies include, drums, guitar, soccer, golf and speed-clicking.
- Scott's car was once used in an ad! It was the 'before' image for a lottery advertisement.
- Scott has a Bachelor of Electrical/Computer Systems Engineering with First Class Honours
Andrew PitchfordDirector of Client Engagement
Andrew PitchfordDirector of Client Engagement
Andrew has a knack for solving complex business challenges through digital. He was the Director of a NZ web agency and leverages years in broadcasting, advertising and community services for our clients.
A true early adopter that loves swimming in the technology space, Andrew is highly regarded as a public speaker across marketing and non-profit interests.
- Andrew is a movie addict and the original "Family Guy" who built his first website in '95.
- With his four children now grown up, his new brood is a collection of Pop Culture Pop Vinyl collectibles.
Chris TaylorDirector of Operations
Chris TaylorDirector of Operations
Chris is our Operations Manager, with a degree in business and experience with companies like CBA and Ricoh, Chris is the first to fill in for a sick colleague or take on extra work to support the team.
- Chris is part of the Excite Media team that broke the Guinness World Record for the longest ever game of darts.
- Chris is the founder of the office saying: "a splash of flash"
Benjamin MaynardCreative Director
Benjamin MaynardCreative Director
Ben's our Creative Director with 17 years experience in web, UI/UX and digital marketing for companies like MTV, Seagate, SAP and eBay. Ben has founded numerous successful startups, and knows how to get results through design.
- Ben has over twenty guitars, a collection that doesn't seem likely to stop anytime soon.
- Ben is tragically addicted to Formula One, and one day dreams of following the championship around the world for a year.
Lee WallisHead of Digital Marketing
Lee WallisHead of Digital Marketing
Lee brings over 10 years of digital marketing experience to Excite Media, with 4 of those years spent running his own digital agency. Lee is our CRO expert and has helped multi-million dollar property companies like Diamond Resorts grow their sales.
Lee, our very own British expatriate (yep, he's a pom), understands how to transform an under-performing website into an online lead generating machine! With over 10 years experience in the digital marketing industry, Lee spends his time amongst our webIQ team, continuously optimising websites to generate more leads and sales for our clients.
- Lee knows when you're bluffing at the poker table.
- Lee's travels have taken him to Spain, Turkey, Cyprus, Italy, India, Japan, Indonesia and of course his new home, Australia. Next stop… Las Vegas!
- Lee is obsessed with the digital currency Bitcoin and believes one day his Bitcoin stash will be worth millions. As of September 2017, 1 Bitcoin is worth $5,170 AUD.
Polina ShileninaAccount Planner
Polina ShileninaAccount Planner
Polina has launched more than 70 websites, working with global players like REIQ, Nike EMEA and Sberbank, Russia's largest investment bank. Polina's remarkable abilities also see her working with the WebIQ team.
- Polina has only come off her scooter once, which she considers a great personal achievement.
- Polina has visited exactly 32 countries.
- Polina's office duty is to 'make everyone feel like they are funny'.
- Polina has a Bachelor of Management, Master of Project Management and is Google Analytics Certified
Shane RoseAccount Lead
Shane RoseAccount Lead
Shane is our Online Marketing Manager who has been working in digital marketing for 8 years, helping 100's of Australian SME businesses get top Google rankings and maximum ROI from their PPC campaigns.
- On the weekends, if he's not donning some lycra and hitting the roads on his bicycle then you'll probably find him camping or at the beach
We're a friendly bunch of peeps, why not get to know all of us?
How would you rate the quality of your finished project?
We're absolutely thrilled with the site and the entire collaborative experience with Excite Media. In fact, I've been singing their praises whenever an opportunity presents itself.
How did you feel about working with the team at Excite Media?
Excite Media gave a professional front to my small business. They are the only organisation I know that actually deliver when they say they will.
Is there anything that Excite Media could have improved during your project?
To make cakes push through the screen every time I hit the home button. Other than that, nothing. Although, I have no doubt that if anybody could have made the cake thing happen, it would be Excite Media.
Web Design and Digital Marketing Brisbane
Excite Media are Brisbane based web designers that have been producing high quality website design, Search Engine Optimisation (SEO) and Google AdWords campaigns for over 10 years. With over 1,200 websites being professionally designed and built, the Excite Media team of web designers and fellow professionals can offer the perfect solution for your next website design project.
We are based in Petrie Terrace, Brisbane but if you can't make it to our office for a website consultation, don't worry! Whether your business is based in Indooroopilly, Kenmore, Taringa, Toowong, Milton, Brisbane CBD or beyond, we can bring our web design expertise to you.
Case StudyOz Wardrobes
Wordfence Plugin: Saving the Internet One Security Flaw at a Time
On the second of September this year, without most of the world knowing, one of the most significant threats to internet security was discovered. While business continued as most for most, the good folks over at Wordfence uncovered a major security flaw that had the potential to throw a significant portion of the internet into complete disarray.
Five days after the Wordfence security plugin identified the vulnerability, a solution was issued to tackle the problem immediately. By the 21st of September, threats were no longer present to sites and the investigation was concluded.
Only recently this information has been disclosed, but consumers want to know how they can protect themselves against a similar attack. Read the full article…
Site Speed – Making or Breaking Your Website
It's a very rare person who would tell you that a slow website doesn't grind their gears.
In fact, there is absolutely no one in the Excite Media Team who would happily twiddle their thumbs and watch wheels spin while a website loads. We live in a fast-paced world where we want things sooner rather than later. That's why page speed is so critical to a good user experience (UX).
It doesn't matter how great the content is, how flashy the graphics are, or even if you have an ace video playing – speed is key. Read the full article…
Going the Distance for our Remote Clients
Learning our client's business through complete immersion, Web Project Manager Polina, travelled to the Northern Territory
A couple of weeks ago I had the unique opportunity to steal away from my desk at Excite and head to the outback for one of my clients. I was invited by the Laynhapuy Homelands Aboriginal Corporation (Laynha) to visit a number of their remote sites in the Northern Territory. To say I jumped at the opportunity is a bit of an understatement!
The type of project Laynha had in mind posed some real challenges and understanding precisely how the group integrated with the local community was critical to fully comprehending what they were trying to achieve. Read the full article…


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2006 @ inc
|Once North carolina debt consolidation credit account balances are zero, homeowners simply submit one monthly payment to repay the debt consolidation loan.
Personal Small business grants savings and credit cards are the primary sources of start-up capital for 70 percent of the surveyed businesses. |
Home improvement loan lenderneed to use your banks online bill payment option, make sure your account has over draft protection and set it up to make your payment automatically. |


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Experience you can trust.
Based in Monroe, Michigan, Solomon Diving, Inc. is a commercial diving firm with the knowledge, equipment,
and capabilities to accomplish nearly any task. Solomon Diving, Inc.,
with its owner Bret A. Solomon and his son Bret A. Solomon II, provide services to marine contractors, municipalities,
golf course associations and government agencies.
Below is a brief list of tasks successfully performed by our firm:
Design, installation, and maintenance of chemical feed lines for Zebra Mussel control
Sludge and/or sediment removal from pipelines and basins
Irrigation system inspection, maintenance, and repairs
Inspection and maintenance of potable water systems
Repair and replacement of traveling screen assemblies
Video or still photography for documentation of inspections
Underwater demolition
Concrete repairs both above and below water using all forms of repair techniques including chemical grout injections.
Underwater welding and cutting
Pipeline penetrations
Clear well inspection and cleaning
Trash rack inspection and cleaning
Confined space work
With our varied experience and up-to-date equipment, we can complete projects in a timely manner with nominal expense.
We would appreciate the opportunity to further discuss how our company can benefit your organization. Please feel free to contact us should you require any information.


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I would like to submit the card I made last Christmas which is in neither red nor green traditional colours.
I used my snowflake CB embossing folder on the Not Quite Navy cardstock then lightly rubbed my glue pad over it and covered with glitter.
Unfortunately this photo does not show up the glitter as it should.
I then mounted the word 'sparkle' and using my round punches attached the silver thread and ribbon around then mounted on the Whisper White cardstock.
Very easy to make and quite effective.


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South Central PA Area Courses
Carroll Valley
Links at Gettysburg
Mountain View
Penn National
Royal Manchester
You would be hard pressed to find a region more connected to American history than the Gettysburg area of South Central Pennsylvania. With history and small-town charm blending so flawlessly together, you have the makings for the perfect golf getaway. Besides incredible golf, you'll find craft beverages and culinary delights in fine dining establishments and historic taverns in downtown Gettysburg.
You can explore the Civil War battlefields in several ways from a full-fledged guided tour to retracing the steps of military commands by foot. Spend time strolling the streets of the downtown Gettysburg area and visit eclectic shops with handmade artistic offerings, amazing art, Civil War artifacts, and tasting rooms. From historic taverns to ethnic cuisine, farm-to-table dining to unique edibles, the tastes of Gettysburg are sure to please every palate. The countryside has plenty of farm markets to stock the car for the trip home.
Play some of the most popular and recognized courses this part of the Pennsylvania countryside offers. Set among the rolling hills and mountains of Adams County, The Links At Gettysburg is the area's most iconic golf battleground. Prepare for sensory overload when you engage in this challenging layout managed by Raspberry Golf. The closing nine leaves a lasting impression on all golfers. The perfect combination of traditional and modern golf can be found in nearby Fayetteville at Penn National Golf Club & Inn, home of two four-star, 18-hole championship courses. The Founders Course, a classic Northeastern-style masterpiece, features large contoured greens, tree-lined rye/bluegrass fairways, sculpted bunkers, and a 7-acre lake. Iron Forge at Penn National reveals a contemporary design with links characteristics and well-placed mounding and tall native grasses. Carroll Valley Golf Course at Liberty Mountain has grown leaps and bounds under the ownership of the adjacent Liberty Mountain Resort. Set amidst picturesque rolling hills, surrounded by the inspiring Catoctin Mountains, Carroll Valley offers 18 holes of Pennsylvania's best golf and now has the spectacular new Highland Lodge to accommodate guests. Their sister course, Whitetail Golf Resort is located about 30 minutes west in Mercersburg. This Rick Robbins spectacular design brings "golf with a view." Quite simply, Whitetail can boast being one of the area's most beautiful golf courses with several holes on the back nine carved into the side of a heavily wooded mountain. Mountain View Golf Club has a pre-Civil War clubhouse, picturesque views of the Catoctin Mountains, and 18 well-manicured holes on a fair, challenging, and gratifying layout that always achieves high marks for playability and value. Royal Manchester Golf Links would make an excellent addition to your South Central Pennsylvania golf getaway. This gem from Raspberry Golf Management is located in northern York County bordering the banks of the Susquehanna River. The course resembles something from Scotland or Ireland and is just a delight to play.
An incredible golf journey adjacent to the fairways of American history await you in South Central Pennsylvania.
Distances to Gettysburg, Pennsylvania (miles)
Travel Destinations
Winchester/Front Royal VA
Harrisonburg VA
Northern VA
Eastern Panhandle WV
Frederick/Hagerstown MD
Baltimore/Harford County MD
South Central PA
Destination Amenities
Winchester/Front Royal VA
Harrisonburg VA
Northern VA
Eastern Panhandle WV
Frederick/Hagerstown MD
Baltimore/Harford County MD
South Central PA
Golf Guide Mid-Atlantic Golf Getaways
206 Morlyn Drive
Stephenson, VA 22656
Phone – 1-540-431-5034
Toll Free – 1-888-306-3673
Content ©2019 Golf Guide Mid-Atlantic Golf Getaways
Designed by ©2019 Site Schemes


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Episode Eight « The Caliente Affairs
#1TCA08: Mortimer Goth hosts a dinner at the Caliente house and invites his daughter Cassandra, who brings along her new fiancé Darren Dreamer and his son, Dirk. Will Dina, Nina, and Alex put their complicated lives on hold and try and get on with the house-guests for his sake, or could events be about to take a turn for the worst?
Act 1
The Dinner, Part One
Act 2
The Dinner, Part Two
Act 3
The Dinner, Part Three


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Seven Seas Explorer
As soon as guests step aboard Seven Seas Explorer they know they have arrived somewhere special. She is the most luxurious cruise ship to ever grace the seven seas and at every turn her designer touches astound, just as her professional crew delights guests by tending to their every need at a ratio of 1 to 1.36. She is intimately spacious, boasting the highest space ratios ever seen in the cruise industry, the largest suite balconies at sea, and the exclusive top-of-the-ship residence with a private in-suite spa, called the Regent Suite among her 375 suites.
Activities on Seven Seas Explorer
At the Culinary Arts Kitchen, guests learn how to prepare a variety of exquisite dishes in a welcoming environment reminiscent of the most prestigious cooking schools in the world.
Our optional Gourmet Explorer Tours, offered exclusively aboard Seven Seas Explorer, allows guests the unique opportunity to experience the culinary culture of the world's most delicious destinations. They revel in the chance to shop at local markets in the company of a knowledgeable local expert and their Chef Instructor from the Culinary Arts Kitchen
At the Canyon Ranch SpaClub® guests can choose from an array of experiences such as signature massages and therapeutic bodywork, aromatherapy, ayurvedic and seaweed treatments, as well as facials. Guests may also choose from an extraordinary selection of luxurious beauty treatments, including hair care, manicures, pedicures and more available in the salon.
State-of-the-art Fitness Center features Lifecycles, free weights, striders, StairMasters, treadmills, weight benches, a Nautilus machine, workout mats and step benches.
Well-stocked and exceedingly comfortable, the Library offers a calm setting for reading and relaxing. The beautifully decorated Card Room is an inviting and tranquil oasis where guests may gather their favorite board games.
Guests can lounge their day away under the warm sun on the Pool Deck. Outfitted in teak accents, it is one of the most elegant at sea featuring a lavish pool and two whirlpools.
Dining / Food on Seven Seas Explorer
Guests choose from five exquisite dining options, including the exclusive Pan-Asian restaurant Pacific Rim and they may learn to prepare their own masterful meals at the Culinary Arts Kitchen – Regent Seven Seas Cruises' first cooking school at sea.
Entertainment on Seven Seas Explorer
the Constellation Theater features an intricate entry-way mosaic, table-top Murano glass lamps and comfortable cabaret-style seats. Enjoy thrilling shows such as Paradis, our bohemian cabaret featuring a sophisticated collection of vignettes that showcase a distinctive French style, and My Revolution, an enthralling, original musical that takes the audience back to when Beatlemania and the British invasion hit North America.
Guests delight in the exciting gaming offerings inside our elegant, Monte Carlo-style casino. Games include Blackjack, roulette, poker, and a full craps table, as well as slot machines.
For cocktails, and to sit back and relax, there are the elegantly appointed Meridian Lounge, the Explorer Lounge with rich mahogany wood columns, where our resident musicians entertain with familiar tunes and special requests from an intimate stage, the Observation Lounge with floor to ceiling windows to provide guests with incredible ocean vistas, and the Connoisseur Club to enjoy a fine cigar or imbibe a favorite libation in comfortable leather armchairs and a club-like atmosphere.
|Seven Seas Explorer Fast Facts
|Maiden Voyage
|Ships Registry
|Marshall Islands
|Tonnage (GRT)
|735 feet
|102 feet
|Passenger Capacity
|Number of Crew
|Passenger Decks
Seven Seas Explorer Reviews
0.0 out of 5 based on 0 reviews
Overall Rating
Ship Quality
Stateroom Quality
Dining & Food Quality
Staff Quality
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2013 Ferrari 458 Italia Niki Lauda Edition
The launch of Ferrari's Tailor Made personalization program has given way to some pretty interesting creations over the years.
Recently, the Italian automaker added another project to its list and this one pays homage to Formula One legend Niki Lauda. Thanks to the always-ingenious work by a personal designer from the Maranello Style Center, this Ferrari 458 Italia received the treat of a host of styling upgrades.
The red body of the supercar is accentuated by a white roof that features a longitudinal image of the Italian flag. Adding to the exterior touch is the new set of gold alloy wheels that brings out the unique look of the Lauda-inspired 458 Italia.
Inside, there are plenty more distinctive touches, highlighted by the Italian flag motif on both the seats and the center tunnel. Matching red stitching was also applied on numerous parts of the cabin, including the dashboard, the seats, the steering wheel and the instrument panel.
The program is impressive in a lot of ways, but one thing we noticed was the lack of details attributed to Lauda's home country of Austria. It's true that the Austrian racer won two of his three world championships with Ferrari, but a simple tribute to his homeland would've been pretty nice.
Other than that, there aren't a whole lot of complaints coming from us with this 458 Italia Niki Lauda Edition.
Click past the jump to read more about the 2013 Ferrari 458 Italia Niki Lauda Edition
2013 Ferrari 458 Italia Niki Lauda Edition
Horsepower @ RPM:570
Torque @ RPM:398
Displacement:4.5 L
0-60 time:3.2 sec.
Top Speed:201 mph
car segment:
body style:
2013 Ferrari 458 Italia Niki Lauda Edition
The white roof with the colors of the Italian flag running down its length is a nice contrast to the piercing red of the 458 Italia's body.
Gold wheels always look good on a supercar, including the 458 Italia.
The Italian colors are clearly evident on the interior.
This baby always looks great from whatever angle.
2010 Ferrari 458 Italia
Ferrari unveiled the 458 Italia at the 2009 Frankfurt Motor Show as the replacement for the F430. The model introduced a design language never seen before on a Ferrari model, plus, as expected, it comes with tons of punch under its hood.
We are talking about a 4.5-liter, V-8 engine that delivers a total of 570 horsepower at 9,000 rpm and a peak torque of 398 pound-feet at 6,000 rpm. This output is enough to sprint the car from 0 to 60 mph in under 3.4 seconds, while top speed goes up to an impressive 201 mph.
Press Release
A 458 dedicated to Lauda
In the year the film "Rush" has been released, directed by Oscar winner Ron Howard and telling the story of the rivalry between Niki Lauda and James Hunt, a Prancing Horse owner has decided to personalise his new 458 Italia in the livery that featured on the Maranello cars back in the golden age that covered the mid-Seventies. In those days, the Scuderia took three consecutive Constructors' titles and two Drivers' both of them thanks to the Austrian driver.
In red with a white roof, featuring the Italian flag going longitudinally across it, with gold rims, the car was prepared with this exclusive design by the Commercial Department at Ferrari as part of the Tailor Made personalisation programme, with the collaboration of a personal designer from the Maranello Style Centre. The interior has not been neglected with the seats and central tunnel reprising the italian flag motif and the racing aspect is accentuated by the type of seats and the red motif on their stitching, the dashboard and instrument panel and the steering wheel with LEDs, as well as the F1 type gear shifts.
The 458 Italia represents the perfect synthesis of technological innovation, style, creativity and passion, all qualities that are a byword for Italy in the world. The owner of this two seater berlinetta, powered by the multi award winning V8 engine, wanted to make it unique by paying tribute to one of the happiest and most productive eras in the history of the Scuderia.


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"It was the Worst Christmas Ever!" says Connor while he is screaming and crying. Silly me, and I thought it was the best Christmas ever. You see, this year we stayed home. It was as low stress as possible with shopping done 10 days before Christmas, cards mailed in the first week of December and little cooking to be done. Caskey and I had even gone to bed at a decent hour since we got the wrapping done in a timely fashion.
This morning was fabulous. It was slightly rainy with low clouds. The perfect day to stay indoors. Connor tore through all this gifts yelling, "WOW. I have wanted this forever. WOW!" Lainy Ann was in heaven sorting the gifts and reading all the tags. 45 minutes into gift-opening and Lainy Ann had only opened one gift (2 pairs of jammies from me - she hugged me and said, "thank you for the jammies mommy, they are my favorite") and Connor has opened nearly all of his. She had so much fun just sorting and helping. William wandered around the living room stealing everyone's candy and playing with already opened toys - none of them were his. And Alexander thankfully sat quietly and watched it all while Caskey and I ran back and forth rescuing toys from their prison-boxes.
It went better than I hoped. No complaints of 'he got more toys than me' or 'santa forgot to bring me something'. They were very happy to unwrap presents and ooh and aah.
I have some really wonderful pictures of all the boys involved in various Jedi fights throughout the day. We had 3 light sabers and even a custom jedi-robe to play with. Papa even got into the action fending off attacks from both Connor and William. Later I found Papa on the kitchen floor with William playing with monster trucks. And Grandma was found 'organizing' Lainy Ann's box of craft supplies. Caskey got light sabers of his own, to use on the Wii.
It was a lazy Christmas day. The kids ate too much candy. Watched too many movies and played too many video games. Because it was a rainy day they chased each other through the house with light sabers and Nerf guns. I'm even missing some silly putty, but the day was just too great to be worried about a mess I will find later.
So we skipped naps and never had a proper lunch. Then we rushed out of the house at 2 pm to have Christmas Dinner at my mother's house with extended family. More craziness ensued as the kids chased through her house of 25+ guests and fine china and crystal while waving their light sabers. Nothing was broken and only the kids got bopped on the head.
Suddenly, the magic disappeared. TEARS! CRYING! SCREAMING! It all ended with a hasty exit to the car and Connor screaming, "It was the worst Christmas ever." The good news is that tomorrow when he remembers all his cool gifts and the few that are still unopened he will forget about tonights tantrum.


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Rogers Dance Center Fairfield
Owned by America's first World Champions - Gary & Diana McDonald
Rogers Dance Centers are New Jersey's 2 most beautiful Ballrooms. Rogers Dance Center, Fairfield has everything you are looking for in Ballroom Dancing, Latin Dancing, Performing Arts, and Fitness.
-Free Dance Evaluations are offered to help find the best type of lessons for you.
-12,000 square foot dance floor split to 3 rooms.
-On-Site Parking.
-Friday Night Dance Party 8PM-10PM (students free, public $10).
-Social Dancing; Salsa. Swing, Waltz, Argentine Tango.
-Competitive American and International Dance Styles.
-Jazz, Tap, Ballet, Hip Hop, Latin Fitness, Flex and Tone, Stretch Classes.
Contact us today to see for yourself why Rogers Dance Center is the place for you to learn and enjoy.
Click the image below to take a virtual tour
Who Is Roger?
So many people have asked "Who is Roger?" or "Where did the name Rogers come from?" Here's some background information you all may find interesting.
Fran Rogers was the founder of the first Rogers Dance Studio which started in a fire house in Wayne, NJ in 1960. After spending many years traveling from location to location, Fran Rogers bought a building in Upper Montclair that she made her permanent location from the early 1970's - 1997. During her career as a teacher and competitor, she was very successful overseas as well as being a top representative of the USA and Canada for many years. Fran was also responsible for bringing the first overseas coaches to America with legendary names such as Eric Hancox and Bill & Bobbie Irvine traveling regularly to New Jersey.
A pioneer in the training of professionals in International Style Ballroom Dancing, Fran's efforts and expertise have produced many of North America's leading coaches and judges including: Mario & Elena Battista, Marie Rose & Emil Nepveu, Andre & Danielle Lachappelle, Pierre Morin, Meryem Pearson, Vernon Brock, Glennis Dee, Yvon Quintal, Pierrette Chartier, Sandra Fortuna, Bill Davies, John DePalma, Angelo Calia, Pat Traymore, Al Franz, Ron Bennett, Roger Nepveu, Lison Nepveu, Roger & Helen Picard, John Adams, Marianne Nicole, Sam Sodano, Rufus Dustin, Beverly Donahue, Gary & Diana McDonald to name a few.
Fran along with her son in-law and daughter Gary & Diana McDonald joined forces officially and opened a larger facility Rogers Dance Center in Fairfield in September of 1997.
In the Summer of 2011 Katusha Demidova added to the legacy of Rogers by purchasing Battista Dance Studio which is now Rogers Dance Center Hackensack.
Both studios are owned and operated by World Champion dancers who are committed to upholding the strong fundamentals in teaching which have turned out successful dancers for over 50 years.
Fran Rogers will forever be an icon in the world of ballroom dance.


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Stories of transformation
Made possible by donors
Jacksees came to the village hospital with a cleft-lip that had caused pain and suffering in his life. Ridicule, poor nutrition, unable to attend school. He used his hand to cover his face. A relatively short surgery by the Fargo-Moorhead Haiti Medical Mission changed his life forever.
Edmond came to know the Fargo Moorhead Haiti Medical Mission team as a patient. He and his mother were brought in to the hospital, badly burned. The team worked for days to save Edmond's mother but she died. Edmond was saved and is now part of our life while we are in Haiti, and team members see that the orphan boy is enrolled in school and gets a daily meal.
When Nelta came to the village hospital, most thought we needed to prepare for triplets. But we soon learned, Nelta had a huge non-cancerous tumor. The Fargo Moorhead medical team worked for hours to remove the 15-pound growth.


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$ 3,300 per Integration
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We provide an easy-to-use API for integration as an alternative to connect to additonal systems.
No, Savision can be deployed on-prem or in your cloud. You are in full control of your data and none of it is pushed to our servers.
No, our price is based on number of integrations exclusively. Every integration can transfer unlimited amounts of data without any extra costs.
No, multiple instances of the same product are counted as multiple integrations, but additional integrations are sold at a discounted price.
Yes, MSP pricing is available upon request.
Yes, please get in touch with us to discuss permanent licensing options.


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A beloved Jesuit priest who was well known for bringing people back to Confession and inspiring conversions has died aged 83.
Fr John Edwards passed away on Wednesday evening last week. Following his death, Fr Andrew Cameron-Mowat, parish priest at Farm Street church in London, said: "Fr John was greatly loved by an enormous number of people. His dynamic preaching and his mission work will live long in the memory of all who met him. He brought numerous people into the Church.
"In my short time so far as parish priest it was a blessing to have his presence at daily Mass in the church, and to receive his frequent words of support and encouragement. He was a remarkable example of a faithful and compassionate priest and a generous companion of Jesus. We will all miss him very much, but rejoice that he is now in the arms of our Blessed Lord. May he rest in peace."
A priest for 49 years, and a member of the Jesuit Community at Mount St for 32 years, Fr Edwards was known to be an excellent confessor who was very successful in encouraging people to attend Confession. He was also a devoted advocate of the practice of receiving indulgences.
Fr Anthony Symondson, a fellow Jesuit priest and a friend of Fr Edwards, said his death was a "perfect end to a very fine Jesuit vocation".
He said: "He had a very attractive personality in the sense that people warmed to him. Most of his life, since about 1972, was spent trudging around the country in mission, to large churches and small churches, well-known and obscure churches. His missions took a week and ended with an appeal, and he knew how successful he was by the amount of money raised."
He continued: "John was a holy man, a wonderful confessor. He regularly gave his Confession, he preached brilliantly, and he made the faith something worth believing in. He had a great effect on individual people, he was delightful company and most of all a Jesuit priest."
After Fr Edwards was diagnosed with lung cancer, Fr Symondson said that he had described it as "a gift from God".
"He was radiant. I couldn't believe it. He told me: 'I've just been given a death sentence, and I've never been so happy.' He became radiant with the love of God. He said he never prayed so well."
Fr Symondson continued: "The heart of John's genius lay in his ability to make the Catholic faith attractive to people. He changed people's lives. He had a great sense of humour, he saw the sardonic side of life… I'm going to miss him more than I can say."
Fr John Edward's funeral Mass was due to take place at the church of the Immaculate Conception, Farm Street in Mayfair, London, on December 20 at 11am.
Writing on his blog Fr Tim Finigan, parish priest in Blackfen, south-east London, said Fr Edwards preached about purgatory and the importance of praying for dead. "So let us return that kindness by praying for him," he said.


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Tufts Public Health » Prenatal Health, Prevention, Reproductive Health, Sex Education » The importance of access to reproductive health care
The importance of access to reproductive health care
"We need to ensure that the next generation is as healthy as possible," says Odilia Bermudez, PhD, MPH, Associate Professor of Public Health and Community Medicine, Tufts University School of Medicine and Associate Professor of Nutrition, Tufts Friedman School of Nutrition Science and Policy. "And that their children and their grandchildren are also coming into this world healthy and happy." Public health professionals have an important role to play in education and policy work surrounding reproductive health, including contraception, fertility, pregnancy, and birth.
Nearly half of pregnancies in the U.S. are unplanned, with higher rates among ethnic minority groups and low-income populations. Unintended pregnancies are associated with low birth weight, later initiation of prenatal medical care, and other health concerns for women and fetuses. In addition, they correlate with lower income and education levels for women, as well as more arguments, depression, and anxiety for women and their partners.
Reproductive health concerns are not limited to a single gender or sexual orientation. Individuals who identify as transgender, gender non-conforming, lesbian, gay, or bisexual are at higher risk for a variety of health issues and may face challenges in accessing care. These challenges include acts of discrimination ranging from uninformed or malicious communication by doctors or nurses to refusal of care. In recent years, some states have passed laws targeting people based on their gender identity. However, a recent regulation related to the Affordable Care Act bars federally funded health facilities from discriminating against individuals on the basis of gender identity and may provide some protection from discrimination related to sexual orientation. While this post discusses reproductive care for cisgender men and women in general terms, it is important to note that gender identity may interact with reproductive care in a variety of ways; for example, an individual who identifies as a transgender man may seek contraceptive options to prevent pregnancy.
Contraception reduces rates of unplanned pregnancies and their impact on population health and wellbeing, but access to effective methods such as birth control pills has changed over time and still varies by location within the U.S. Federal regulation of contraception dates back to the 1873 Comstock Act, which prohibited interstate commerce involving contraception and sparked similar laws at the state level. In some states, for years or decades after oral contraception (also called "the pill") was first approved in 1960, young unmarried women needed parental consent for a prescription. Over time, restrictions were lessened through court rulings and new laws.
Even when care is legal, individuals must have the education to understand their options, the independence and support system to make decisions, and a trusting environment to seek out a provider and ask questions about their care. "When we talk about reproductive health, we focus on women," but we need to focus on family members, partners, and society as a whole, says Bermudez. Parents play a key part in determining whether adolescents are able to access care. In addition, violence against women and human trafficking are often overlooked as risk factors for harmful health effects, unintended pregnancy, and poor pregnancy outcomes.
The price of reproductive health care can also affect access. Many community health centers offer low-cost or free care. With certain religious exemptions, the Affordable Care Act mandates that insurance companies fully cover the cost of folic acid supplements and some screening and counseling services for maternal and prenatal health. It also requires complete coverage of many forms of contraception. However, insurance companies may limit coverage to certain types or brands, and are not required to cover fertility treatments, abortion, or interventions for men such as vasectomies.
One increasingly popular intervention is long-acting reversible contraception, or LARC. These methods include intrauterine devices (IUDs), apparatuses with hormones or copper that are placed in the uterus to deter pregnancy, as well as hormonal implants placed under the skin of a woman's arm. They last for years and can be removed at any time. "Perhaps the biggest advantage of these types of birth control is that they are highly effective," said Danielle Roncari, MD, Director of Family Planning at Tufts Medical Center to Boston Magazine, although they do not prevent sexually transmitted infections (STIs). Unlike some options, these methods do not require a woman to remember an action such as taking medication or using a device.
Researchers continue to explore new methods of contraception. A recent promising but unsuccessful trial of male contraception drew media attention in part because some men dropped out of the trial after experiencing side effects, such as acne and severe mood changes that were more common than those associated with approved forms of contraception for women. Men have their own reproductive health needs, including fertility and prevention of STIs. They play their own role in unintended pregnancy, and many participants in the trial they would want to use male contraception. However, about three times as many couples use female sterilization for contraception as compared with vasectomies, although both methods are safe and effective. This raises important questions about balancing the risks and benefits of contraception choices and about who takes responsibility for contraception.
With the future of the Affordable Care Act in question, it remains to be seen what will happen to measures related to reproductive health. Bermudez notes, "We have to educate both girls and boys about the responsibility they have." Educating individuals about their options and providing accessible, quality care allows people to make the decisions about their health that are right for them.
by Cayla Saret, MPH Candidate '17


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A collection of personal textures made in Substance Designer. I also havesome Free Substance Tutorials available that I hope you find useful for making some of these!
I had a lot of fun making these in my spare time! Especially the Muddy Walk one, which was created to help test the Alpha Version of Marmosets Toolbag 3.


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Bulldogs' Gleason signs with Stars
FRISCO, Texas — Dallas Stars General Manager Jim Nill announced today that the club has signed defenseman Ben Gleason to a three-year, entry-level contract.
Gleason, 20, finished ninth among all OHL defensemen with 48 points (9-39=48) in 63 regular-season games with Hamilton in 2017-18. He also ranked eighth among League blueliners with 39 assists in 2017-18, while his six power play goals were good for sixth among OHL defensemen. The defenseman registered 18 points (3-15=18) in 21 postseason contests, helping Hamilton win the OHL championship. Gleason's 18 points in the postseason shared first among OHL defensemen and were tied for fifth among all team skaters.
The 6-foot-1, 185-pound native of Ortonville, Mich. has recorded 125 points (22-103=125) in 236 career regular-season contests over four OHL seasons with Hamilton and London. Gleason has also appeared in 32 games in the OHL Playoffs, recording 20 points (3-17=20).
For more information visit nhl.com/stars.
The Dallas Stars have signed defenseman Ben Gleason to a three-year, entry-level contract. https://t.co/75wgx908DL
— Dallas Stars (@DallasStars) September 13, 2018


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Bubis(redirected from Ignatz Bubis)
Also found in: Wikipedia.
(also, Ediye), a people living on the island of Fernando Póo, in the Gulf of Guinea. Population, more than 30,000 (1967 estimate). The Bubi language belongs to the northwestern group of the Bantu language family and is very similar to the language of the Duala people, who are related to the Bubis. The religion is Christianity (Catholicism). The chief occupations are farming and gathering the fruit of the African oil palm; some of the Bubis work on plantations owned by Europeans (cacao, coffee, peanut, and so forth).


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text: About SPC The Southwestern Pennsylvania Commission is the regional planning agency serving the 10-county Southwestern Pennsylvania region. The official Metropolitan Planning Organization (MPO), SPC directs the use of state and federal transportation and economic development funds allocated to the region---approximately $35 billion through 2045. SPC helps counties, cities, municipalities, and townships access state and federal transportation funds. [ more . . . ]


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Yes, LORD, walking in the way of your laws, we wait for you; your name and renown are the desire of our hearts. Isaiah 26:8
Wednesday, April 7, 2010
Sweet Leftovers
OK - so I know you are all falling off your chairs now because I am posting two days in a row, but don't be shocked. I am loving our week at home and enjoy sharing it here with you. Today, I wanted to share my great idea (I am quite certain I am not the first to do this, but it is the first time I have done it quite to this extent!)
In spite of the fact that my children did not get baskets full of candy from us on Easter morning, there still seemed to be lots in the house (thanks to loving grandmas!) So...today I had my older boys help me sort the loot. Fruity candy went into the candy jar to go in lunch boxes one piece at a time. All chocolate got unwrapped and tossed into a bowl. Then we chopped and cut it up (even the four inch crispy bunny!) and used the chocolaty pile instead of chocolate chips in our favorite cookie recipe. The results were sweet. Sweet! I also remembered that I had a partial half-gallon of vanilla ice cream (Edy's Slow Churned) in the freezer, so I made four ice cream sandwiches. Those will go with a meal tonight to friends from church who just had a baby. Fun!
It makes me giddy to take something of which I'd rather not have in my house and turn it into
a) a fun project and
b) a tasty treat
Enjoy your day. May it be as sweet as ours!
3 comments:
- Anonymous said...
Love, Love, Love this idea! thanks!
- April 8, 2010 at 9:13 PM
- Anonymous said...
Love, Love, Love this idea. Thanks!
- April 8, 2010 at 9:14 PM
- chris ann dykstra said...
love it!!
- April 14, 2010 at 7:45 PM
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