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Section 1: Epidemiology and aetiology
Hypopituitarism evolves secondary to a spectrum of disorders which lead to insufficiency of pituitary hormones. Pathology may be intrinsic or extrinsic; either directly affecting the pituitary or indirectly via the hypothalamus.
Panhypopituitarism refers to the loss of secretion of at least three pituitary hormones. Several studies have demonstrated an increase in mortality by 1.3to 2.2-fold in hypopituitarism.1-3 Morbidity is variable and may result from the hormone deficiency or the underlying pathology.3 The incidence of hypopituitarism is around 2.5 per 100,000 with a prevalence of about 45.5 per 100,000 population.4
No age or racial predilection exists but pituitary failure is more common in women due to post-partum pituitary failure.
The causes of hypopituitarism vary with the age of onset and can be divided into sub-groups (see table left). Depending on the aetiology the syndrome can present acutely or insidiously and be either transient or permanent. There can be isolated (IPHD) or multiple pituitary hormone deficiencies (MPHD).
Disturbances in pituitary function commonly arise from a pituitary adenoma and dysfunction is usually proportional to tumour size (microadenoma <10mm diameter="" macroadenoma="">10mm).
The prevalence of pituitary adenomas is thought to be as high as 16.7 per cent5 and macroadenomas are estimated to occur in 1 in 600. 6
Pituitary dysfunction following radiotherapy is well researched in survivors of childhood cancer7 and is dependent upon the cumulative dose; doses less than 20Gy are rarely detrimental.
Typically the growth hormone (GH) axis is most sensitive followed by gonadotrophins and then the HPA (hypothalamic-pituitary-adrenal) axis. Hypothalamic damage can cause disturbances in thirst, appetite and temperature regulation, as well as aggressive behaviour and learning difficulties.
Cranial diabetes insipidus (DI) is seen more often in infiltrative conditions and traumatic brain injury. 8 Lymphocytic hypophysitis is an infiltrative disorder associated with pregnancy.9 It is characterised by headaches and visual field defects, and can cause MPHD.
|Source: www.endotext.com
Section 2: Making the diagnosis
Many symptoms and signs of hypopituitarism may be insidious or non-specific and may overlap with non-endocrine conditions, including depression, so careful clinical evaluation is essential.
Hypopituitarism during childhood may lead to delayed or deficient growth and upset in pubertal development, and may have lifelong consequences. Congenital syndromes associated with hypopituitarism, such as Bardet-Biedl syndrome, have distinct features (obesity, developmental delay, polydactyly, strabismus) that typically arouse suspicion.
Increased morbidity is correlated with earlier onset of disease and MPHD. Some symptoms of anterior pituitary dysfunction are summarised in the table.
Prolactin deficiency does not cause specific symptoms apart from a failure of lactation and hyperprolactinaemia is the more common abnormality seen. Hyperprolactinaemia may be secondary to a disruption of the hypothalamic pituitary connection with consequent lack of the normal dopamine suppression of prolactin.
Hyperprolactinaemia can cause breast congestion, galactorrhoea, oligomenorrhoea, secondary amenorrhoea, loss of libido, and sexual dysfunction.
Posterior pituitary dysfunction typically causes polydipsia and polyuria, resulting in weight loss, dehydration, hypernatraemia and renal impairment if untreated.
Symptoms that are variable or are mainly confined to the daytime are less consistent with a diagnosis of cranial DI (vasopressin deficiency).
Failure of lactation (the only symptom of oxytocin deficiency) may be one of the first indicators of post-partum pituitary insufficiency (Sheehan's syndrome).
|Hormones affected
|Signs and symptoms
|Postural symptoms, hypoglycaemia, hypotension and
shock, hypothermia, asthenia, poor appetite and
weight loss
|Low energy, fatigue, constipation, dry skin, hair
loss and cold intolerance
|Low libido/impotence, low energy, hot flushes,
reduced body hair (men), amenorrhoea/
olgiomenorrhoea, poor breast development, atrophy
and dyspareunia
|Growth hormone
|Poor growth in children, poor concentration and
memory, fatigue and somnolence
|Primary pathology related
|Headaches, double vision, weight loss, night
related sweats, visual field defects, nasopharyngeal
symptoms and neurological deficits
Investigations and diagnosis
Once pituitary insufficiency is suspected, then along with an examination which includes assessment of secondary sexual characteristics, investigations should include visual field testing and 'baseline' pituitary function: free thyroxine (fT4), TSH, prolactin, FSH, LH, estradiol (women), 9am testosterone (men), insulin-like growth factor 1 (IGF-1), and a 9am cortisol and/or synacthen test.
It is crucial to assess fT4, as TSH can be misleadingly 'normal'. It is important to be aware of the circadian rhythmicity of various hormones when arranging and interpreting tests and to appreciate that in hypopituitarism of acute onset early testing may be falsely reassuring.
Further dynamic testing is frequently indicated and early specialist input supports the selection and validity of testing.
Additional tests for the pituitary and to screen for underlying systemic disease include paired serum/urine osmolality and U&Es (hyponatraemia, DI); haemochromatosis-serum ferritin, sarcoid-serum ACE, Wegener's; MRI of the pituitary; an assessment of bone density (hypogonadism, GH deficiency, Cushing's disease or iatrogenic over-replacement of thyroid or adrenal axes); abdominal/pelvic ultrasound (fatty liver, gallstones, ascites, uterine and adnexal pathology); echocardiography (increased cardiovascular disease in acromegaly or possible increased risk of cardiac valvular fibrosis - long-term high dose dopamine agonist therapy), and colonoscopy (in acromegaly due to increased risk of colonic polyps and neoplasia).
Section 3: Managing the condition
The rationale behind HRT is to minimise morbidity, reduce long-term complications and to ensure good outcomes during fertility therapy, pregnancy and major illness or surgery.
In general, the relevant target hormone is replaced rather than the specific pituitary component of the feedback cycle. Patient choice and education is an integral feature of good management.
Steroid replacement
- Prompt replacement is essential as any significant deficiency is life-threatening.
- Current treatments poorly mimic normal physiology but hydrocortisone (10mg on waking, 5mg at midday and 5mg at approximately 5pm) is currently the most logical initial approach.
- Prednisolone is sometimes used but has a long duration of action and dexamethasone is less favoured due to varying rates of metabolism.
- It is vital that steroid replacement is commenced preferably 24 to 28 hours before the thyroid axis is replaced.
- Steroid replacement may unmask latent DI as cortisol is required for renal filtration and free water excretion.
- Patients should be advised to carry a 'steroid alert' card.
- Normal steroid doses should be doubled with comorbid illness or major stress. Parenteral administration may be necessary. A home-emergency pack (vial of 100mg of hydrocortisone and injection paraphernalia) should be available.
Thyroid hormone replacement
The typical adult replacement dose is 75-150microgram/day. Lower doses titrated slowly may be necessary in the elderly or in cardiac comorbidity. fT4 levels and symptomatology rather than TSH levels should guide replacement.
Treatment of GH deficiency
GH replacement is generally straightforward in children. Therapy is titrated against indices of growth until expected growth or peak bone mass is achieved. Subsequent GH withdrawal and confirmation of ongoing GH deficiency in adulthood is required before ongoing prescribing.10
GH therapy in adults is more controversial. Evidence supports beneficial effects on lean-to-fat mass ratio, lipid profile, and bone resorption but fracture, cardiovascular, or mortality endpoints remain elusive.
Prescribing is NICE governed and involves specialist assessment along with a quality of life assessment and a need to demonstrate benefit from any trial of therapy.10
Serum IGF-1 levels are used to guide therapy and nurse specialist input is needed. GH therapy is contraindicated in active malignancy.
Sex-hormone replacement
In women, estrogen replacement is a key area for GPs. Since deficiency is being replaced until age of menopause there is no increase in cancer risk.
In men, the intramuscular route is the most reliable. Treatment is guided by 'trough' testosterone levels (aim for lower third of the reference range), and clinical response. Testosterone gels can also be used.
Treatment of DI
Desmopressin is available in various forms. Drug therapy should be built up and weaned slowly. A 'drug holiday' is recommended once a week.
Trans-sphenoidal surgery can cure syndromes of hormone excess, restore pituitary function and protect vision depending on the size and location of the causative pathology but there is an associated risk of iatrogenic hypopituitarism.11
Cranial DI occurs in a small proportion of postoperative patients but may be transient.
Life-long specialist follow-up is required; the frequency of specialist review is determined by the complexity of the underlying problem, the treatment regimen and need for ongoing dynamic testing. The following are important aide memoirs:
- Hormone deficiencies may manifest many years after the initial diagnosis of pituitary pathology.
- Fertility issues should be reviewed periodically as appropriate.
- Imaging frequency is usually dictated by the underlying aetiology.
Section 4: Prognosis
A study in 2001 followed up 1,014 individuals with hypopituitarism over an eight-year period.3 The most common underlying aetiologies were non-functioning adenomas in 57 per cent of patients. Observed deaths (118) vs expected deaths (96.7) revealed a standardised mortality rate of 1.87 (99% CI 1.62-2.16, p<0.0001).
Mortality was higher in women with hypopituitarism, younger patients, those with craniopharyngiomas and those treated with radiotherapy.
The main causes of increased mortality included cardiovascular, respiratory and cerebrovascular disease in descending order. Untreated gondaotrophin deficiency contributed to excess mortality. The excess cardiovascular risk is not well characterised but further work has shown that after optimal correction of all anterior pituitary hormone deficiencies, adult GH deficiency can still lead to excess cardiovascular morbidity and mortality.12
Some expected advances in hormone formulation will allow more physiological HRT but much work still needs to be done to help minimise the morbidity and mortality associated with this condition.
The role of primary care
Given the chronicity of hypopituitarism, the primary care physician retains a critical role in co-ordinating care, appreciating whether hormone replacement is optimal and often may be better placed to explore fertility, sexual health, employment or other pertinent issues.
Given the varied pathology and the number of potential care-givers, clear communication between healthcare professionals, and careful patient education and empowerment is vital to a successful outcome.
Section 5: Case report
A 39-year-old vicar presented to his GP with headaches, lethargy, and blurred peripheral vision. Referral to ophthalmology led to confirmation of a bitemporal hemianopia.
An MRI scan demonstrated a 28x32mm pituitary lesion stretching the optic chiasm, extending into the cavernous sinuses bilaterally and eroding the sphenoid bone.
Following a baseline assessment, a non-functioning adenoma causing hypogonadism was diagnosed (testosterone: 4.6nanomoles/L). Trans-sphenoidal adenomectomy (TSA) restored his vision and postoperative biochemistry revealed an improvement in testosterone levels. Two years after his original presentation, annual imaging revealed enlargement of the residual tumour with renewed encroachment on the optic chiasm. The therapeutic options of further surgery or radiotherapy were considered and a revised TSA was undertaken.
Postoperative imaging revealed a reduction in tumour volume but the patient experienced transient DI. He was discharged on hydrocortisone replacement. A two-month postoperative short synacthen test was normal (peak cortisol 996nanomoles/L) and steroids were withdrawn.
Later problems
The patient presented three years later with headaches, nausea, vomiting, lethargy and flushing and sweating and he was admitted to hospital.
A low random cortisol of 53nmol/L prompted steroid replacement and reassessment of his pituitary profile. A repeat MRI showed a pituitary mass impinging on the optic chiasm and visual fields demonstrated a left upper temporal field defect.
Secondary hypogonadism and secondary hypothyroidism were diagnosed and the patient was treated with IM testosterone 250mg four-weekly and thyroxine 100 microgram daily.
Further pituitary surgery restored the patient's visual fields but established hypogonadism and hypothyroidism were confirmed. Conventional radiotherapy was administered for the indication of aggressive local tumour recurrence.
An assessment for adult GH deficiency was prompted by marked fatigue and arginine-GH releasing hormone stimulation confirmed severe GH deficiency with a peak GH of 1.4microgram/L. The patient had impairment in quality of life. This patient's testosterone, thyroxine and GH replacement are likely to be lifelong and appropriate dose titration and associated monitoring will be required. Careful monitoring for further enlargement of the tumour remnant is ongoing.
Section 6: Evidence base
Clinical trials
- Tomlinson JW, Holden N, Hills RK, et al. Association between premature mortality and hypopituitarism. West Midlands Prospective Hypopituitary Study Group. Lancet 2001; 357: 425-31.
- Abs R, Feldt-Rasmussen U, Mattsson AF, et al. Determinants of cardiovascular risk in 2589 hypopituitary GH-deficient adults - a KIMS database analysis. Eur J Endocrinol 2006; 155: 79-90.
- The Endocrine Society. Evaluation and treatment of adult growth hormone deficiency: An endocrine society clinical practice fuideline. J Clin Endocrinol Metab 2006; 91: 1621-34.
- Ghigo E, Masel B, Aimaretti G, et al, Consensus guidelines on screening for hypopituitarism following traumatic brain injury. Brain Inj 2005; 19: 711-24. Consensus on screening and treatment of pituitary insufficiency following traumatic brain injury.
- Cook DM, Yuen KCJ, Biller BMK, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for growth hormone use in growth hormone-deficient adults and transition patients - 2009 update. Endocr Pract 2009; 15 Suppl 2: 1-29. This is an updated version of the guideline which was published in 2003 by the American Association of Clinical Endocrinologists.
- BMJ Best Practice guide on hypopituitarism.
Key texts
- 'The pituitary' In: Turner H, Wass J. Oxford Handbook of Endocrinology and Diabetes. Oxford, Oxford University Press, 2009. This is a handy brief textbook reference.
- 'Neuroendocrinology and The Pituitary' In: De Groot LJ, Jameson JL. Endocrinology (5th Ed.). Philadelphia. Elsevier Health. 2005. This is a comprehensive textbook resource.
- www.endotext.com - Chapter 12 of the Endocrine Resource - Hypopituitarism - is a definitive review of the subject.
- www.endobible.com/condition/hypopituitarism. This has a focus on clinical assessment.
- www.endobible.com/condition/growth-hormone-deficiency
- www.pituitary.org.uk Information on hypopituitarism and a section for GPs
Reflect on this article and add notes to your CPD Organiser on MIMS Learning
These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.
Save this article and add notes with your free online CPD organiser at gponline.com/cpd
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1. Rosen T, Bengstsson BA. Premature mortality due to cardiovascular disease in hypopituitarism. Lancet 1990; 336: 285-8.
2. Bulow B, Hagmar L, Mikoczy Z, et al. Increased cerebrovascular mortality in patients with hypopituitarism. Clin Endocrinol 1997; 46: 75-81.
3. Tomlinson JW, Holden N, Hills RK. Association between premature mortality and hypopituitarism. West Midlands Prospective Hypopituitary Study Group. Lancet 2001; 357: 425-31.
4. Regal M, Paramo C, Sierra JM, et al. Prevalence and incidence of hypopituitarism in an adult Caucasian population in northwestern Spain. Clin Endocrinol 2001; 55: 735-40.
5. Ezzat S, Asa SL, Couldwell WT, et al. The prevalence of pituitary adenomas: a systematic review. Cancer 2004; 101: 613-19.
6. Nammour GM, Ybarra J, Naheedy MH, et al. Incidental pituitary macroadenoma: A population-based study. Am J Med Sci 1997; 314: 287-91.
7. Chemaitilly W, Sklar CA. Endocrine complications in long-term survivors of childhood cancers. Endocr Relat Cancer 2010; 17: R141-59.
8. Aimaretti G, Ambrosio MR, Di Somma C, et al. Traumatic brain injury and subarachnoid haemorrhage are conditions at high risk for hypopituitarism: screening study at 3 months after the brain injury. Clin Endocrinol 2004; 61: 320-6.
9. Gutenberg A, Hans V, Puchner MJ, et al. Primary hypophysitis: clinical-pathological correlations. Eur J Endocrinol 2006; 155: 101-7.
10. NICE. Human growth hormone (somatotrophin) in adults with growth hormone deficiency. TA64, London, NICE, 2003.
11. Webb SM, Rigla M, Wagner A, et al. Recovery of hypopituitarism after neurosurgical treatment of pituitary adenomas. J Clin Endocrinol Metab 1999; 84: 3696-700.
12. Abs R, Feldt-Rasmussen U, Mattsson AF,et al. Determinants of cardiovascular risk in 2589 hypopituitary GH-deficient adults - a KIMS database analysis. Eur J Endocrinol 2006; 155: 79-90.
Visit our GP Curriculum Centre for hundreds of articles linked to key topics in the RCGP curriculum.
- Contributed by Dr Rajeev Raghavan, specialist registrar, and Dr Karin Bradley, consultant endocrinologist, University Hospitals Bristol NHS Foundation Trust.


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tag:blogger.com,1999:blog-153643705105259294.post1063805658173549472..comments2019-11-17T12:42:26.118+00:00Comments on Cocktails and Daydreams | Edinburgh Lifestyle Blog: You Go Glen Coco #email@example.com:blogger.com,1999:blog-153643705105259294.post-82312993812651547362013-02-20T09:56:12.988+00:002013-02-20T09:56:12.988+00:00SO glad Louise from Sprinkle of Glitter sent us al...SO glad Louise from Sprinkle of Glitter sent us all here :)
I can't pull away from your writing, and thanks for the mention of new reads!

Keep warm :)WanderBughttps://email@example.com:blogger.com,1999:blog-153643705105259294.post-2220952806009318662013-02-19T23:19:11.542+00:002013-02-19T23:19:11.542+00:00Ahh, thanks love!! What a lovely surprise, made my...Ahh, thanks love!! What a lovely surprise, made my day! I haven't been to Krispy Kreme yet but I'm kinda gagging to go. Whyyyyy is it drive through, though?? I cannae drive! Might wait in line anyway and just watch my step. Lots of other lovely blogs to check out too so will have a wee read :) xxKirsty Mhttps://email@example.com:blogger.com,1999:blog-153643705105259294.post-19573186223130398672013-02-19T23:00:58.259+00:002013-02-19T23:00:58.259+00:00I love finding new blogs to read, they all look gr...I love finding new blogs to read, they all look great :)

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Set2Survive Survival Blog
Learn everything about how to survive in the wild nature.
Kasamon YL, Jones RJ, Piantadosi S, et al. High-dose therapy and blood or marrow transplantation for non-Hodgkin lymphoma with central nervous system involvement. Biol Blood Marrow Transplant.2005;11 :93– 100
The primary benefit to cord blood banking is that it provides a type of medical insurance. This insurance is not from a financial perspective, but rather takes the form of having the necessary medical building blocks available should they be needed in the event of certain illnesses and diseases. Those medical building blocks are the stem cells found in umbilical cord blood.
Wall DA, Carter SL, Kernan NA, et al. Busulfan/melphalan/antithymocyte globulin followed by unrelated donor cord blood transplantation for treatment of infant leukemia and leukemia in young children: the Cord Blood Transplantation study (COBLT) experience. Biol Blood Marrow Transplant.2005;11 :637– 646
Properly preserved cord blood is long-lasting. Cord blood is stored in a nitrogen freezer (the same technology used to freeze donated sperm), so it can last for a long time. "The scientist who first developed cord blood preservation methods in 1990 has confirmed that some of the first specimens he stored 23 plus years ago are just as potent as fresh cord blood," says Mary Halet, Director, Central Region at Be The Match, which is operated by the National Bone Marrow Foundation.
Cord blood has been used for 20 years to treat more than 80 serious diseases.34 Successful treatments have paved the way for further research and today, FDA-regulated clinical trials are exploring the use of a child's own stem cells for conditions that currently have no cure.
There are two main types of cord blood banks: public and private. Public cord blood banks are usually nonprofit companies that store your donated cord blood for free, to be used for any sick child in another family or for research purposes, so accessing and using your own cord blood is not guaranteed. Private cord blood banks are companies that require a registration fee (plus annual storage fees) for your cord blood, but it is saved specifically for your own family, so you'll have ready access to it.
Compare costs and services for saving umbilical cord blood, cord tissue, and placenta tissue stem cells. Americord's® highest quality cord blood banking, friendly customer service, and affordable pricing have made us a leader in the industry.
Back in the 1980s, umbilical cord blood caught the attention of researchers who suspected that the often-discarded tissue could be a valuable source of shape-shifting stem cells. These cells, which can become several different types of blood cells, are similar to the specialized stem cells found in bone marrow that can churn out new blood cells. Such stem cells are found in adult blood, too, but not as abundantly.
A typical cord blood collection only contains enough stem cells to transplant a large child or small adult. This website has a page explaining the optimum transplant dose. At one time it was believed that cell dose limitations restricted the use of cord blood transplants to children. In recent years growing numbers of adults are also receiving cord blood transplants, either by growing the cells in a lab prior to transplant or by transplanting more than one cord blood unit at a time. More information about these trials is available on the web page about Research on Cord Blood Transplants.
As a trusted resource for families, CBR offers Genetic Counselors on staff to help families make informed choices about newborn stem cell banking. Our team of certified professionals are available to:
Your own cord blood will always be accessible. This applies only if you pay to store your cord blood at a private bank. The blood is reserved for your own family; nobody else can access or use it, and it will never be allotted to another family or be donated to research. If you donate your cord blood to a public bank, on the other hand, anyone who needs compatible cord blood can have it; there's no guarantee that it will be available if and when your family needs it.
Ozkaynak MF, Sandoval C, Levendoglu-Tugal O, Jayabose S. A pilot trial of tandem autologous peripheral blood progenitor cell transplantation following high-dose thiotepa and carboplatin in children with poor-risk central nervous system tumors. Pediatr Hematol Oncol.2004;21 :635– 645
## Payment Plan Disclosures for in-house CBR 12-Month Plan (interest free) – No credit check required. The 12-month plan requires a $15/month administrative fee. The plans may be prepaid in full at any time.
Bunin N, Aplenc R, Leahey A, et al. Outcomes of transplantation with partial T-cell depletion of matched or mismatched unrelated or partially matched related donor bone marrow in children and adolescents with leukemias. Bone Marrow Transplant.2005;35 :151– 158
Part of the reason for the dominance of these three companies in terms of the total number of units stored is that they are three of the oldest cord blood banks within the U.S., founded in 1992, 1993, and 1989, respectively. All three of these cord blood banks also support cord blood research and clinical trials.
One of the factors that influence engraftment time is cell dose (Gunning, 2007). Cell dose is directly related to the volume of umbilical cord blood collected. Cell dose refers to the amount of useful stem cells in the sample of blood. Because of the limited volume of cells collected from cord blood, the amount of stem cells in cord blood is approximately 10% less than the amount obtained from bone marrow (Moise, 2005). A single unit of umbilical cord blood usually contains 50 to 200 ml of blood (Gonzalez-Ryan et al., 2000). If an amount of cord blood is less than this minimum volume, the unit is discarded as being unsatisfactory because the cell dose of the sample would not be high enough. Collecting an insufficient volume of cord blood occurs in about 50% or more cases of cord blood collection (Drew, 2005). In general, fewer stem cells are needed for cord blood transplantation, and usually a volume of 50 to 100 ml of cord blood will provide enough of a cell dose for a child or small adult. However, should the recipient need additional stem cells, it is impossible to obtain more stem cells from the infant because the cord blood volume is a limited amount (Percer, 2009).
Regulatory agencies (eg, FDA, Federal Trade Commission, and state equivalents of these federal agencies) are encouraged to have an active role in providing oversight of the cord blood program. All cord blood–banking programs should comply with FACT or equivalent accreditation standards.
There are around 20 companies in the United States offering public cord blood banking and 34 companies offering private (or family) cord blood banking. Public cord blood banking is completely free (collecting, testing, processing, and storing), but private cord blood banking costs between $1,400 and $2,300 for collecting, testing, and registering, plus between $95 and $125 per year for storing. Both public and private cord blood banks require moms to be tested for various infections (like hepatitis and HIV).
We chose the site of our lab for one reason in particular: safety. As one of the safest cities in the US, Tucson ensures our families' samples will be protected from natural disaster. Natural disasters, such as hurricanes, tornadoes, and earthquakes, could interrupt consistent long-term storage of stem cells.
Laughlin MJ, Rizzieri DA, Smith CA, et al. Hematologic engraftment and reconstitution of immune function post unrelated placental cord blood transplant in an adult with acute lymphocytic leukemia. Leuk Res.1998;22 :215– 219
A history of releasing cord blood units for therapy. "This shows they're not just selling contracts to parents — there are doctors who are actually accepting units of cord blood that have been stored there for therapy," says Frances Verter, Ph.D., founder and director of Parent's Guide to Cord Blood Foundation, a nonprofit dedicated to educating parents about cord blood donation and cord blood therapists.
While some companies may advertise their cord tissue preservation service as "treatment-ready", this is a misnomer. In the U.S. there are currently no treatments available that use cord tissue cells. Without knowing what the treatment protocols may look like in the future, preserving the cord tissue sample whole today means that all of the available cell types in this precious resource may be available to your family in the future.
Prices subject to change until they are paid. Fees apply to single-birth, U.S. customers only. Cancellation fees may apply. All major credit cards accepted. Payment plans cover first-year fees only; future annual storage fees are not included. If not paying by credit/debit card, total first year fees are due at the time of enrollment.
You can also support your local research and academic institutions that are accepting cord blood donations. Stem cell research has become a provocative debate because of the ethical disagreements around embryonic stem cells. UCB avoids the debate entirely while still providing valuable stem cells in the quest to cure disease and mitigate human suffering.
Save by paying in advance for 21 years of storage through our long-term storage plan. This plan covers all the initial fees (collection kit, courier service, processing, and preservation) and the cost of 21 years of continuous storage. A lifetime plan is also available; call for details.
Finally, there is a significant lack of regulation for umbilical cord blood banking. The lack of quality control, in turn, affects the quality of the specimen available for transplant. Some cord blood banks have submitted to voluntary accreditation, but the process of accreditation varies from bank to bank, whether public or private (McGuckin & Forraz, 2008; Moise, 2005).
This means that family members, and possibly even strangers, may be able to use the cord blood stem cells for certain treatments. Siblings from the same biological parents have the highest chance of full or partial genetic match, followed by the biological parents who may be a partial match.
Blood naturally starts to clot when its outside the body. An anticoagulant is used to help prevent the cord blood from clotting while it is in transit to the laboratory for processing. CBR deliberately chose to use lyophilized (dry) heparin as the anticoagulant because of some potential advantages, including:


text: 2017 is the year that Gin is having a moment with the kids. Previously popular with the pensioners, this year it seems to be the millennial choice of tipple. Everywhere I look around Liverpool, there is some new and innovative way of enjoying the old herbal medicine. I was recently invited to attend an entire… Continue reading GIN-credible


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Tuesday 19 July 2005
July 19, 2005
Central Asia: Is Regional Turbulence Return Of The Great Game?
Pressure mounts for the U.S. to pull out of Central Asia Just as the wildebeests migrate across the Serengeti, commentary on Central Asia periodically turns to talk of the Great Game. In its 19th-century variety, the Game pitted England against Russia in a scramble for control of Eurasia. Early 21st-century interpretations expand the number of players -- bringing in such regional heavyweights as Iran, Pakistan, and especially China -- but retain the central premise: big powers projecting their designs across Central Asia.
July 19, 2005
Central Asia: New EU Envoy A Familiar Face In The Region
By Khiromon Bakoeva http://gdb.rferl.org/F6DE9AEE-9512-4CF2-8EF2-552E42AA1D41_w203.jpg New EU envoy to Central Asia Jan Kubis Yesterday, the European Union appointed veteran Slovak diplomat Jan Kubis to be the EU's special envoy to Central Asia. Kubis is familiar with the region, having served as the UN special envoy to Tajikistan during the transitional period following the civil war there until the country held its first postwar elections. As the secretary-general of the Organization for Security and Cooperation in Europe (OSCE), Kubis continued to show his interest in the region, traveling often to Central Asia and Afghanistan. His appointment comes at a sensitive time following a popular revolt last March in Kyrgyzstan and violence in Uzbekistan in May when police and soldiers reportedly killed hundreds of demonstrators.
July 19, 2005
Uzbekistan: Leader Of Andijon Protests Speaks To RFE/RL
Uzbek troops in Andijon "Bloody Friday" is the name Uzbeks have given to the events in the eastern city of Andijon on 13 May. But despite the fact that a lot has been written and told about what happened that day, the truth remains unclear. Uzbek authorities tell their story; human rights activists, political oppositionists, and protesters give another account. Qobiljon Parpiev was among the protesters who seized the regional administration building in Andijon on 13 May and held negotiations with Uzbek Interior Minister Zakir Almatov. He escaped shootings by Uzbek forces that reportedly killed hundreds of civilians, and fled Uzbekistan. Parpiev recently spoke to RFE/RL with his version of events.
July 18, 2005
Afghanistan: Inconsistencies In The State Of The War On Terrorism
Almost immediately after Uzbek security forces fired on demonstrators in the eastern city of Andijon on 13 May, Russian officials, later supported by their Uzbek colleagues, began blaming elements infiltrating from Afghanistan for instigating the events and claimed that the combat capability of subversive elements in Afghanistan was not diminishing. However, the final declaration from the meeting of the heads of member states of Shanghai Cooperation Organization, held recently in Astana, Kazakhstan, called for the U.S. and its allies to withdrawal their military units from Central Asia. RFE/RL examines the contradiction in the two comments made by Moscow and some of its Central Asian allies.
July 18, 2005
EU: Foreign Ministers To Debate Iran, Uzbekistan, UN Reforms
EU headquarters in Brussels Brussels, 17 July 2005 (RFE/RL) -- The foreign ministers of the 25 European Union member states are meeting in Brussels today for the last time before September. The agenda of the monthly meeting is extensive, including nuclear talks with Iran, possible sanctions against Uzbekistan, and possible UN reforms.
July 15, 2005
Rights Group Claims Russians Arrested, Tortured Uzbeks
Andijon after the Uzbek government's crackdown 15 July 2005 -- A Russian human rights group today accused authorities in Russia of arresting and torturing 14 people of Uzbek origin following a request by Uzbek officials related to violence in eastern Uzbekistan in mid-May.
July 15, 2005
Uzbekistan: Is Russia Helping Tashkent Clean Up After Andijon?
The Uzbek opposition says more than 700 died in the Andijon events On 25 July, a criminal trial against two local employees of the U.S.-based nongovernmental organization Internews will begin in Tashkent. The two employees are accused of "conspiracy to engage in production of videos and publications of informational materials without the necessary licenses." According to the organization's press release of 5 July, the criminal charges followed "a year of harassment and 'fishing expeditions' by various branches of Uzbekistan's investigatory organs." If convicted they could spend six months behind bars, according to Reporters Without Frontiers.


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We are a small reptile business specializing in Leopard Geckos. Leopard Geckos have been our passion for over a decade. What once was a hobby, has grown into an everyday lifestyle for our whole family. Our focus is to breed healthy and quality lizards in order provide you with a special pet or addition to your collection.
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Gluten Free Graham Crackers with Bourbon and Honey
November 25, 2015 at 4:55 pm By Chef Eric
Back in August I posted a blog about making biscuits and told you it was a great stepping stone for more advanced baking. A few weeks ago I took that same recipe and adapted it to be gluten free. Today I will show you how easy it is to make gluten free graham crackers with just a few simple additions.
This recipe was originally adapted from Alton Brown's version of graham crackers. I scaled it down to fit in my mini food processor, and to also fit in a gallon-sized zip-top bag. I also used my homemade vanilla bourbon instead of milk. If you've run out, consider trying amaretto or spiced rum.
- 5 ounces Bob's Red Mill gluten free baking flour (about 1 cup)
- 1.5 ounces brown sugar (about 1/4 cup)
- 1/2 teaspoon baking powder
- 1/4 teaspoon baking soda
- 1/4 teaspoon kosher salt
- 1/8 teaspoon ground cinnamon
- 1.5 ounces unsalted butter (3 tablespoons)
- 1.5 ounces honey (2 tablespoons)
- 1.5 ounces vanilla infused bourbon* (3 tablespoons)
*can substitute 3 tablespoons whiskey + ½ tsp vanilla
In the bowl of a food processor, combine flour, sugar, baking powder, baking soda, and salt. Pulse a few times to combine.
Cut the butter into a few small cubes and add it to the flour mixture. Pulse a few times until the mixture looks like sand.
Add the honey and half of the bourbon. Pulse a few times, then add more bourbon if needed. Continue pulsing until the mixture pulls together.
Lightly grease the inside of a 1 gallon zip-top bag. Transfer the dough into the bag, being careful of the blade. Press the dough into a flat sheet, then chill for at least 1 hour or over night.
Preheat oven to 350F (175C). Line a sheet pan with lightly greased parchment paper.
Cut off the edges of the zip-top bag. Carefully peal back the top layer, flip the dough onto the sheet pan, then remove the back layer. Dock the dough with a fork, then cut into squares.
Bake for 18-25min, or until the edges begin to darken, turning the pan halfway through.
Let cool on the pan, then break apart and store in an airtight container.
You could eat this with cheese, or make them into s'mores, and you would probably enjoy it. But what I really want you to do is grind them up into graham cracker crumbs and store them in your cupboard, you'll thank me later.


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Opinion – Reinvention is a Necessity in Gaming
Franchises need to adapt or be passed.
Franchises need to adapt or be passed.
If there ever was a con about having been in the Navy for seven years, it's that I really didn't have a set sleep schedule. At sea, working hours can … Continue reading The Funny thing about Insomnia


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During the past five summers, a large number of cyclosporiasis cases have occurred in Texas. Therefore, the Texas Department of State Health Services is advising healthcare providers to consider testing patients for the parasite Cyclospora if they have diarrheal illness lasting more than a few days or diarrhea accompanied by severe anorexia or fatigue.
Previous outbreaks of cyclosporiasis have been associated with consumption of imported fresh produce, including: fresh cilantro, pre-packaged salad mix, raspberries, basil, snow peas, and mesclun lettuce. Although washing may not eliminate all risk of transmission since Cyclospora can be difficult to completely remove from produce, thorough washing of all fresh produce is recommended. Cyclospora does not appear to be spread through direct person-to-person contact.
Additional information about Cyclospora and it's symptoms can be found from the CDC, Here, or from the DSHS, Here.


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NobleCircles Genealogy © Haceldama
NobleCircles Genealogy © Haceldama is a searchable genealogical relationship database consisting of more than 440,000 people and 165,000 families at 30,000 places worldwide all gathered in one single family tree; mapping their ancestors, descendants and various relatives and all of them somehow related to each other. The database also includes all European and some Middle Eastern royal families, many European noble families, 28 US Presidents, 33 British Prime Ministers and all 141 Danish Privy Councillors and Danish Prime Ministers and many of their relatives. You can follow NobleCircles Genealogy © Haceldama if you join our Facebook Page and our Facebook Group. You can at on the Log File see what other people latest looked at in the database, which were last updated on July 24 2019.
Family: Knud, Count of Danneskiold-Samsøe (Gyldenløve Moth - Danneskiold-Samsøe) / Alice Hasselbalch (F24005)m. 14 Nov 1906
Father | Male
Knud, Count of Danneskiold-Samsøe (Gyldenløve Moth - Danneskiold-Samsøe)
Born 26 Jun 1876 Christiansholm Palace, Klampenborg, Zealand, Denmark Died 22 Jul 1957 Frederiksberg, Copenhagen, Zealand, Denmark Buried Married 14 Nov 1906 Hoersholm, Zealand, Denmark Father Christian Conrad Sophus, Count of Danneskiold-Samsøe (Gyldenløve Moth - Danneskiold-Samsøe) | F63315 Group Sheet Mother Wanda Sophie Elisabeth Candia Zahrtmann (Zahrtmann) | F63315 Group Sheet
Mother | Female
Alice Hasselbalch
Born 23 Jul 1886 Copenhagen, Zealand, Denmark Died 7 Dec 1955 Copenhagen, Zealand, Denmark Buried 8 Dec 1955 Holmens, Copenhagen, Zealand, Denmark Father Christian Steen Hasselbalch | F8609 Group Sheet Mother Marie Mathilde Frederikke Helms (Helms) | F8609 Group Sheet
Child 1 | Female
+ Tove, Comtesse Danneskiold-Samsøe (Gyldenløve Moth - Danneskiold-Samsøe)
Born 31 May 1909 Rungsted Kyst, Hoersholm, Zealand, Denmark Died 25 Feb 1984 Copenhagen, Zealand, Denmark Buried Spouse Léon Charles Joseph, Count Moltke-Huitfeldt (Moltke) | F68002 Married 6 Feb 1929 St Andreas, Copenhagen, Zealand, Denmark
Child 2 | Female
+ Merete, Comtesse of Danneskiold-Samsøe (Gyldenløve Moth - Danneskiold-Samsøe)
Born 9 Nov 1911 Copenhagen, Zealand, Denmark Died 13 Oct 1997 Mogenstrup, Zealand, Denmark Buried Spouse Kield, Count Brockenhuus-Schack (Brockenhuus) | F23999 Married 15 Oct 1930 Citadels - Kastels, Copenhagen, Zealand, Denmark
Child 3 | Female
Helle, Comtesse Danneskiold-Samsøe (Gyldenløve Moth - Danneskiold-Samsøe)
Born 21 Dec 1918 Copenhagen, Zealand, Denmark Died 9 Jun 1987 Copenhagen, Zealand, Denmark Buried


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FINOS is a self-managed festival and offers the city of Seville a space for enjoyment and intercultural dialogue through diverse stories and from different regions of the world. What the organizers say: "This year we celebrate the eleventh edition of the festival of the stories of Seville, whose central days will be held at […] » read more
Alafresca Festival. Festival de cuentos, formas y colores
Amazing festival for the whole family, where you can let your emotions run free because everything here…. Counts! What the organizers say: " Alafresca festival is a unique event for everybody, young and old, that mixes storytelling and a little bit of circus." More information about Alafresca Festival here.
The Magic Word Festival
Come to a festival of narrative arts and engage in stories from different genres, in unusual formats and from unusual perspectives. This festival is organized every two years during epiphany time. What the organizers say: "Every two years on Epiphany, narrators from all over German-speaking countries and beyond come to Nuremberg and put their young […] » read more
Festival Interculturel du Conte de Chiny
The craziest tellers, as well as young talents come to put their stool in Chiny to the delight of greedy ears. Visit Chiny, which is called The City of Tales for a very good reason! What the organizers say: "Since 1990, the story is in the spotlight in the small rural town of Chiny. Every […] » read more
The New festival of Stories in Winter
Austria story lovers gather in this winter festival edition to warm up their spirits, join them and bring your own warm stories to share! What the organizers say: "Together with the Tourismusverband Region Bad Gleichenberg, high-quality narrative art will be presented in Bad Gleichenberg, Gnas, Kornberg Castle, and Straden: 16 artists from 11 nations will […] » read more
Austrian International Storytelling Festival
Austria opens like a book presenting the best stories of the region and around the world. Come, listen and let your imagination fly. What the organizers say: "For more than 30 years now, our festival has always been about telling stories, and in all the years of copying, expanding and, as a result, of constant […] » read more
The Amsterdam Storytelling Festival
An interesting festival that presents the best of the growing storytelling scene in the Netherlands and that has carefully curated the best performances of the year around the world. What the organizers say: "Whether you are addicted to love, alcohol, your own reflection or your smartphone… During The Amsterdam Storytelling Festival, you can confess it […] » read more
Settle Stories Festival
Come and join this wonderful event and help to change the world one story at a time. What the organizers say: "Expect a lot of magic and a good dash of mayhem! The Settle Stories Festival is returning to the idyllic Yorkshire Dales Market town of Settle. Be part of the story. " Read more about […] » read more
Sting in the Tale, A Festival of Stories
A biennial festival of wonder and imagination, suitable for the young and the old, the small and the tall, the… well for those who yearn for a life full of adventures and magic. What the organizers say: "Audiences of all ages enjoyed a variety of storytelling events and performances, from encounters with dragons to shapeshifting […] » read more
Stealing Thunder Storytelling Festival
Come an enjoy of myths, fables, folktales, wonder tales, fairytales, poetry, songs all of it at no better place to enjoy a story; around a campfire. What the organizers say: "Fairytales for grown-ups, myths for kids, puppetry shows, music, workshops and campfire. Welcome to the brand new Stealing Thunder Storytelling Festival… …A single field in […] » read more
The Fifth East Anglian Storytelling Festival
Festival at the Edge
A festival that can happen physically or virtually, organized by one of the oldest storytelling clubs in England, is here to share its story with you. What the organizers say: "At Festival at the Edge, we believe that storytelling is the most accessible of all art forms, both at an audience and at a participatory […] » read more
Oxford Storytelling Festival
A festival full of history and wonder, stories and magic, poetry and relaxing therapies. What the organizers say: "We are creating a beautiful space where a community of people can come together and connect to each other and the stories of our lands. The theme of this year's Oxford Storytelling Festival is 'home and […] » read more
Beyond the Border Festival
Every two years, the Castle of St. Donats opens its doors to magic and imagination in a family-friendly festival, participate in workshops, attend to circus acts, puppet performances and much more! What the organizers say: "Beyond the Border International Storytelling Festival is a magnificent weekend festival of stories and music from Wales and across the […] » read more
Mixed Reality Storytelling Festival
An experimental storytelling festival that mixes music, performance, and virtual reality, see how emerging artists combine old and new ways to tell their stories. What the organizers say: "The Festival is a variety of storytelling and mixed reality performances, workshops and talks with a focus on happiness in relation to identity, freedom and work.12 April […] » read more
Orkney Storytelling Festival
In Scotland when people congregate, they tend to argue, and discuss and reason; in Orkney, they tell stories. – George Mackay Brown. What a better place to tell your stories this October than Orkney. What the organizers say: "The Orkney Storytelling Festival is a celebration of the oral tradition in Orkney, with tales focusing on […] » read more
Samovafest Helsinki
A magical festival that promotes the art of storytelling in its many forms! What the organizers say: "International storytelling festival in Helsinki! The festival program consists of presentations, workshops and artists' meetings from different angles. There is a program for adults and children. Some events are free and tickets can be purchased separately for each show […] » read more
Scottish International Storytelling Festival
This fall, come to Edinburgh and experience a festival beyond words where Scottish and Canadian storytellers will take your imagination into a journey of tradition, dance, and music. What the organizers say: "The 31st Scottish International Storytelling Festival features 60 events in Edinburgh and 22 throughout Scotland, with 20 international guests joining 60 Scottish artists to share old traditions and new connections, […] » read more
Hastings Storytelling Festival
Chimères, Braine-le-Comte
The art of narration will never stop taking us far, far away to worlds yet to invent! Come and enjoy 4 days of fantastic stories. Will you dare to tell your tale? What the organizers say: "A new festival to show the diversity and creativity of our storytellers: from traditional tales to contemporary creation. What […] » read more


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Even a exceptional placement could be initiated by viewing the sinkand also the location in which we use to brush our teeth. We don't need to go everywhere when we set it there. We do not have to organize all things previous to going to brush our teeth. Discussing of this location or placement on the sink, this safe spa walk in showers will save more space and also give an alternative nuance in to the shower. We could add a little more color like citrus or baby green by a marijuana we now have back into your backyard. Find a single cabinet that's acceptable for the two purposes, the ribbon and the authentic use of the shower wall cabinet.
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It comprises with a very long string for dangling it into ceiling, and the mixture of black and orange formed the planet frame, and the triple Edison gentle inside. Beach front Florentine chandelier feature along with the ocean green and sea blue crystals, triple light-bulb in Italian style. The framework is write the almond drops and glass rings. When we put it to use for the shower, you'll receive the memory of the previous nighttime!
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The concept of showers. Decide on what kind of nuance you would like to attract on your shower! Inside this age, they are so many kind of themed and shower such like timeless, shore, antique, modern, and several much more.
This Safe Spa Walk In Showers the gallery form No Barrier Shower Stalls. Hopefully you can find the best inspiration from our gallery here.


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Words for this?
Sharesies investment funds | Geekzone broadband switch | Backblaze backup (Geekzone aff) | Amazon (Geekzone aff) | MightyApe (Geekzone aff) | My technology disclosure
Involuntary autocorrect in operation on mobile device. Apologies in advance.
c71931f:sunfolk: oooh look more Darwin awards candidates.
johnr:c71931f:sunfolk: oooh look more Darwin awards candidates.
have you not heard of the darwin awards?
jamesvini: He had this uncomprehending look on his face like he didn't under stand.
So i told him again. and he said "Oh"
Then i told him to "Get off my plane!"
and pulled his parachute cord and he got pulled out of the plane and went through the engine.
....that may have been Harrison Ford....Im a bit hazy on the details.


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There is always a pressure to be busy or appear busy. Everyone is involved in way too many things, volunteering, working, doing research, etc. The competition is fierce on the extracurricular involvement.
The fact that you can never have a moment's rest. Whenever you have free time, you think, "I could/should be doing some work," and you just feel so much anxiety. It's horrible.
There is considerable competition for grades. The beaurocracy is sometimes tedious when trying to get things done and the school is slow to adapt to a change academic landscape.
The worst thing is that it is not really a party school and your social life is focused on very toolish qualities like academic achievement and power in extra-curriculars.
I go to Harvard Extension School which is segregated from Harvard socially which I wish I took into account because social aspects of school is very important to me.
Pressure to succeed academically and career wise, and pressure to enter certain fields post graduation (law, medicine, business particularly).
The number of pretentious people around and the stressful enviroment given to learning, something which shouldn't be so hard and tiring to do.
The elitism. People believe they are better than others and try to impose their ways of life onto them. Never a fun thng to be around.
Limited resources for struggling students. This is the worst thing because this allows some students fall through the cracks.
Sometimes the political climate can be overwhelmingly liberal, and it can be difficult to find people to actually talk to.


text: Our reputation for the quality of our business advisory services speaks for itself. We can assist you in a series of areas, helping you prepare accounts, present forecasts, identify tax-saving opportunities to name just a few. We have vast experience in providing business advisory services for clients from various industries and have helped companies of all sizes over the years. Our services are designed to add value to your business and work with you to boost all financial aspects of your business to increase profits and reduce your outgoings whilst helping you remain fully compliant. Our commercial is something that goes way beyond the requirements of a basic accountancy firm. We go the extra mile for our clients to ensure their goals are met.


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Buy train and bus tickets for UK and Europe - the easy way
Hanover to Cologne by train
First train05:40
Last train23:31
Avg changes0
Fastest journey2hr 38m
Distance249 kilometres
Trains per Day27
Avg. journey time3hr 1m
Train Operators
Travelling from Hanover to Cologne by train
Fast trains from Hanover to Cologne take around 2 hours and 38 minutes, covering a distance of approximately 249 kilometres. There are frequent services on the rail route between Hanover and Cologne.
1. Are there direct trains from Hanover to Cologne?
Direct trains from Hanover to Cologne have been found.
We usually find around 29 direct trains on the route from Hanover to Cologne every weekday.
There are typically fewer departures at weekends, when we found around 26 departures.
2. How long is the train journey from Hanover to Cologne?
The Hanover to Cologne train travel time is normally about 2 hours and 38 minutes, whatever time you make the journey.
3. What are the Hanover to Cologne train times and schedule?
On weekdays the earliest direct train to Cologne is usually scheduled to depart Hanover around 05:40 and the last train is around 21:31. At weekends the first train of the day leaves Hanover around 05:33, and the last at 23:31.
What's the Hanover to Cologne train price?
The earlier you book the better, and the cheapest tickets we've found for trains from Hanover to Cologne are $23.58.
Trains departing 30 days in advance will cost around $33 while booking 7 days in advance the price is around $35. Booking on the day of travel is likely to be more expensive, so it is worth booking in advance if you can to save money.
When to book Hanover to Cologne train tickets?
Trains in Germany usually open for booking around 6 months in advance. If booking is not yet open for your dates then you can set a booking alert to receive an email on the day that the cheapest tickets are released for your journey from Hanover to Cologne by train.
Which train companies operate between Hanover and Cologne?
More than one train company operates on the route from Hanover to Cologne, so you'll be travelling with one or more of the following rail operators:
You can check which train you'll be travelling on by looking for the train name in search results.
Other journeys to Cologne View all journeys to Cologne
From London From $80.17
From Amsterdam From $23.58
From Brussels From $22.23
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From Munich From $23.58
From Hamburg From $23.58
From Mainz Hbf From $23.58
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Pay in EUR, GBP or USD
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KARACHI: Muttahida Qaumi Movement (MQM) on Friday, (MNA) Rashid Godil got critically injured after unidentified armed man tried to attack him at Bahadurabad area in Karachi.
According to reports, Godil received six bullets during gun attack, he has been shifted to private hospital in surgical ward.
The gun attack carried out by unknown attackers who were on motor-bikes, driver of MQM shot dead during attack.
Hospital spokesperson Dr Anjum Rizvi, while informing to the media says, Godil is severely injured, hospital is trying to treat him.
Before Tendering resignations, Rashid Godil was performing his duty in the assembly as an MQM's deputy parliamentary leader. In 2013 general elections, Godil claimed NA 252 seat with 90,827.
#MQM founder leader Altaf Hussain strongly condemned firing on MNA @RashidGodilMQM . appeal to public for pray pic.twitter.com/VhzmrSQLLW
— Mustafa Azizabadi (@azizabadi) August 18, 2015
QT #AltafHussain has strongly condemned attack on MQM Mna Rasheed Godil #PrayforRashidGodil #Pakistan
— Wasay Jalil (@WasayJalil) August 18, 2015Advertisements
Alhamdolillah he is stable. At CT Scan now. Prayers needed. His driver has expired. Please don't pay heed to false news being run.
— Syed Ali Raza Abidi (@abidifactor) August 18, 2015
Godil Latest snap , warning graphic pictures:


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Are you thinking of having a Neobux Golden Membership?
By Wismay
@Wismay (2038)
July 31, 2009 12:42am CST
Do you want to have Neobux Golden Mebmership? You really want it but not yet ready or contemplating? Then visit my site "Let us Grow Together", the link can be found on my profile. You will find how you can have it without much risk. Have a nice day!
3 responses
@meapas (2433)
• India
31 Jul 09
I am already a member in it but I am really frustrated with this site, so I am not active any more. They have a stock answer" too many failed attempts, try after some time"
@brienn (825)
• Philippines
31 Jul 09
Thats what I have planned since I have joined Neobux. So far I have invested $5.00 to get my first 20 referrals. And luckily I got 8 direct referrals. Right now I have earned $ 5.00 and have invested it again to rent another 20 referrals. All in all my referral are 48, i hope I can earn $90.00 from them so that I can be a Golden Member of Neobux.
@wizardrod (9)
31 Jul 09
I'm even planning to turn into an Ultimate member there but I cannot fund my paypal account. I got money to invest but the feature to fund my account in Paypal is not available in my country..
@brienn (825)
• Philippines
31 Jul 09
That's a great plan of yours. I hope you can make your plan come into action. And about funding your Paypal account, maybe you can ask someone in your country who have funds in their Paypal account to transfer it to your account, and then you will pay them with cash.


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TOP FENCE CO.LTD -We make and supply temporary fence according to AS687-2007 / Primer AS/NZS 3750.15.
|Place of Origin:
|Made In China ,Australia Design
|Brand Name:
|TOPFENCE™-Rubbish Cage
|Model Number:
|2100mm*2400mm*3.0mm3.8mm&4.00mm thick 1.4mm,1.3mm ,1.8mm,2.00mm
|Minimum Order Quantity:
|250 unit
|Packaging Details:
|Metal Pallet Wrapped with plastic film
|Delivery Time:
|3 days
|Payment Terms:
|TT30%deposit balance70% at sight finished products pictures
|Supply Ability:
|10000 pieces per month
|Rubbish Cage
Australian hot sale galvanized steel wire rubbish cage (Anping factory)
Dog kennel Packaing
Steel pallet + Cardboard box
1) Safety packing
2) Short lead time
3) Reasonable price
4) High quality
5) Long-life using
We usually accept T/T payment, and we also accept L/C payment.
The MOQ of our products is 50 pcs, sample is available, the delivery time is
About 15 days after receiving your down payment.
The rubbish cage is made of wire mesh panel, it's a temporary enclosure that acts as an alternative to the skip bin.
It most used for construction site, make building sites clean and a better place for workers and the environment.
|1. Rubbish cage kit consists of
|4 Wire Mesh Panels
|2 Lids
|2. Main Size:
|Wire dia: 3.0mm,4.0mm,5.0mm
|Mesh: 50x50mm,75x75mm,100x100mm
|LXWXH: 2200x2200x1500mm, 2000x2000x1500mm
|Surface treatment: Hot Dipped Galvanized
|Other size also can be accepted
|It also can be made with chain link fence
Our rubbish cage is without any other extra clamps. The cages are easy to assemble and move apart for emptying.You don't need to afraid that the cages can't be install if there are some accessories lost during delivery.


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Benedict XVI, the pope who resigned in 2014, has written an essay on the sexual abuse crisis in the Roman Catholic Church. It has a curious section about what the church should now do:
What must be done? Perhaps we should create another Church for things to work out? Well, that experiment has already been undertaken and has already failed. Only obedience and love for our Lord Jesus Christ can point the way. So let us first try to understand anew and from within [ourselves] what the Lord wants, and has wanted with us.
That looks like a conclusion that the Protestant Reformation was a failure. And if Protestantism failed, what does that say about Protestants' salvation? It does not look good.
But then Benedict talks about redemption in ways that make it look like Protestants, at least liberal ones, could qualify as a success:
If we really wanted to summarize very briefly the content of the Faith as laid down in the Bible, we might do so by saying that the Lord has initiated a narrative of love with us and wants to subsume all creation in it. The counterforce against evil, which threatens us and the whole world, can ultimately only consist in our entering into this love. It is the real counterforce against evil. The power of evil arises from our refusal to love God. He who entrusts himself to the love of God is redeemed. Our being not redeemed is a consequence of our inability to love God. Learning to love God is therefore the path of human redemption.
That is a lot of love and makes me wonder if Fred Rogers, a Presbyterian pastor, and star of "Mr. Rogers" could well have written those lines. Granted, Benedict contrasts evil with love. But where are the categories of God's law, God's holiness, human sinfulness, punishment for sin, and salvation by faith?Of course, justification by faith alone is not a doctrine that Benedict could affirm. But his idea of redemption doesn't even sound like faith working through love.
Worst of all, he doesn't sound like Paul:
10 For all who rely on works of the law are under a curse; for it is written, "Cursed be everyone who does not abide by all things written in the Book of the Law, and do them." 11 Now it is evident that no one is justified before God by the law, for "The righteous shall live by faith." 12 But the law is not of faith, rather "The one who does them shall live by them." 13 Christ redeemed us from the curse of the law by becoming a curse for us—for it is written, "Cursed is everyone who is hanged on a tree"— 14 so that in Christ Jesus the blessing of Abraham might come to the Gentiles, so that we might receive the promised Spirit through faith. (Galatians 3)
I understand that Protestants and Roman Catholics differ on saving faith and on the supremacy of Scripture. But if one of the apostles himself says the contrast is between law and faith, why would a person who used to be head of the biggest church in the world substitute a contrast of evil and love?
Benedict may want to rescue Protestants from the bins of failure.


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Patrick Ibarra – Opening Session (Getting Better All the Time); Closing (Still.. Getting Better All the Time)
Don Bishop – General Session (Health Care Reform: What the Future Holds)
Julie Burch – General Session (Going the Distance)
Darrell Adkerson – How to Mitigate Risk Through Human Resources Best Practices
Joseph Black – The Immigrations and Customs Enforcement (ICE) IMAGE Certification Process
Samuel Friedman – Employee Assistance Program: A Benefit Times Two
Sheila Gladstone – Social Media and City Employment: A Tricky Balance
Melinda Galler – Electronic Information, HIPAA, and the HITECH Act
Susan Hampton – Leadership Development: Building Self Awareness and Authenticity
Tom Hart – Developing World Class Leadership
Jill McAdams – Best Practices in Wellness
Darrel Noga – Accident Review Policies: Help or Hindrance?
Elizabeth Prevencio – Meet & Confer: Run & Hide, or Get Prepared?
Julie Ross – The Guts and Glory of Managing FMLA, ADAAA, and Workers' Compensation


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Cadila healthcare LTD Supply zone b/w 190-220 Buy at that zone with SL 188 on Weekly closing basis target 295-300 Risk:reward = 1:2.3
Buy Raymond with sl 785 on closing basis (Near to 20 days Exponential moving average) for target of 824-830 CMP 796
Break out with volume. if It may touch 42 level its buy opportunity. it may touch 51 level.
Upward movement in nifty still intact. Nifty may be touch 11210-11250 with sl of 10700.
Marksans pharma consolidated from last 3 years. On 01 March its jump near 12%. Its bottom fishing out. Now it may touch 45 rs. within one year time.
RSI may get support here and bounce back. BSE may be bounce up to 800-825 level.
As per chart Cup and Handle pattern to be created. My target for Indostar is 500 initial within a week.
-Trend of NDTV indicated range bound movements. -RSI indicator indicate the fresh break out. - My target is 74.
Fed bank may support @86 on closing basis. Buy at deep with sl 86 on closing. target 92-95 within short time. LTP 88.5.
Stock may fire once if RSI break out +40. Waiting for break out.
Head and shoulder pattern creat at that point. take advantage and short at that level with sl 365 target 290-260
Today petronet lng gave just baounce back. its move within the range.
Short petronet at every rise up to 257 sl 265 Target 240
RSI reversal with volume, stock can support from 95 level Buy sequent scientific at CMP sl 90 target 120-125 good fundamental BET
Short Nifty fut Jan cmp : 10492 Target : 10200-10000-9900 Strict SL: 10556
Petronet LNG take a support at 240 Now on uptrend till 275 Buy at every dip.
Arihant superstructure has support at 142. Buy at dip til 142 sl 138 on closing, target 177-185


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Max Allegri complained the media "wants Paulo Dybala on the pitch and then can't wait to tear him apart. There will be room for everyone."
The game with Sassuolo kicks off on Sunday at 14.00 UK time (13.00 GMT), click here for a match preview.
The first question was inevitably about Dybala, who has been dropped for recent Juve and Argentina games, raising doubts on his future.
"He didn't play because I had to make tactical choices. Paulo's quality is not up for debate, but I have to pick 11 players plus another three to come off the bench," said the Coach in his Press conference.
"Fortunately, we can now begin to play three games per week. Paulo has to prove he deserves his place in the starting line-up. That is true for everyone and I know of no other way. When you have this much talent in the squad, someone has to sit out.
"However, I do not like the pressure people are putting on Dybala, because if he plays tomorrow and doesn't have a great performance, you in the media are going to destroy him. You are the ones who want him on the pitch and can't wait to tear him apart.
"I am very happy with the way he came off the bench in Parma for the last 15 minutes, as he already had a completely different approach. He just has to do like everyone else, train hard and find his form. There will be room for everyone, as from here to December 30 our objective is to qualify for the Champions League knockout rounds and stay on top of Serie A, so we can be geared up for the final push from March onwards.
"Let's not forget that two years ago the team went all the way because everyone joined in and gave their contribution. The important thing is to find the right balance."
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text: Awesome couple, beautiful venue, fantastic vendors, amazing weather…what more could you ask for? This wedding was gorgeous! Khaki and Elliot are so much fun to be around. We started out with Khaki and the ladies getting ready at the Hilton downtown while Elliott and the guys hung around the Mill and Mine. They held their ceremony at the Church of the Ascension and then came back to the Mill and Mine for an unforgettable reception. Thanks to all the great vendors: Bradford Catered Events, Samuel Franklin, Darla Walker, Evoke Story Group. Congratulations Khaki and Elliott! Take a look at the images below!


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Hot Flash Remedy report
Hot Flash Remedy report
Heres what youll discover in The Hot Flash Remedy report: The herb from central Asia that can stop hot flashes in one week! (page 17) How your brain gets tricked into firing up the furnace and how to recalibrate it. (page 6) 7 lifestyle factors that increase your odds of suffering from hot flashes. (page 19) 9 food items that bring hot flashes on fast and furious! (page 10) The bean that actually makes hot flashes non-existent for women in other countries. (page 12) The secret ingredient in your fruit bowl that extinguishes the flame. (page 17) Why 6 meals a day are better than 3 and eating more often wont make you gain weight! (page 10) How common wildflowers hold the key to shutting down hot flashes. (page 16)
Hot Flash Remedy report Summary
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Hot Flashes
Botanicals such as soy and black cohosh are promoted to reduce treatment-related hot flashes in cancer patients. However, evidence suggests that they are not effective. Randomized, placebo-controlled trials show no benefit for black cohosh118 or soy119,120 in reducing the frequency of hot flashes in breast cancer patients. Vitamin E decreases hot flashes only minimally,121 but its low cost and lack of toxicity have led at least some authorities to recommend its use.122
Hormonally Mediated Events
Menopause may cause uncomfortable symptoms in many women and can be controlled to a great extent by HRT. Some of these symptoms, hot flashes, fatigue, and bone thinning (leading to osteoporosis) can intensify symptoms and problems related to MS. Osteoporosis has been linked to the treatment of MS with steroids, and this condition may worsen during the peri-menopausal or menopausal state of life.
Ovulation suppression
Ovarian suppression with GnRH agonists induces menopause. PMS symptoms will be relieved, but patients experience menopausal side effects, including irritability, insomnia, hot flashes, and vaginal dryness. To prevent osteoporosis, add-back therapy with estrogen and progesterone is required.
Central nervous System symptoms
Changes in neurologic function such as increased irritability, mood disorders, mild depression, hot flushes, and sleep disturbances may arise during the perimenopausal transition. Estrogen replacement therapy is the most effective treatment for hot flushes. Hormone replacement with estrogen may help to reverse cognitive changes and improve function.
Hormonal Influences on the Pelvic Floor
Reproductive hormones, especially estrogen, have a significant impact on pelvic floor function. Hormonal changes that occur during a woman's lifespan impact many aspects of female physiology. With the onset of menopause, it becomes evident that estrogen sensitivity is greatest in the central nervous system and the genital tissues. The most frequently occurring initial symptoms of estrogen deprivation include hot flushes, mood changes, and emotional irritability. These central nervous system symptoms are promptly reversible with systemic estrogen replacement. More prolonged duration of estrogen deprivation will lead to other known consequences such as osteoporosis and urogenital atrophy. It is estimated that 80 of postmenopausal women have hot flushes, and that not all women will develop osteoporosis. However, urogenital atrophy occurs universally. Interestingly, many women with urogenital atrophy are asymptomatic.1 Many treatments are currently available for prevention of and therapy...
Adverse Reactions to SERMs
Nausea, vomiting, and hot flashes may accompany tamoxifen administration. Tamoxifen may cause a transient flare of tumor growth and increased pain due to bone metastases. These reactions are thought to be due to an initial estrogenic action of this drug. Mild or tran Raloxifene and clomiphene use is associated with an increased frequency of vasomotor disturbances (hot flashes) and thromboembolism formation.
Synthetic Agents Acting Via Estrogen And Progesterone Receptors
Tamoxifen, clomiphene, and raloxifene are orally active. The primary route of excretion of all three drugs is in the feces. The undesirable effects common to all three of these SERMs are increased frequency of hot flashes and increased risk of thromboembolism. Both effects are attributable to their estrogenic activity.
Buserelin and Leuprolide
Leuprolide is a potent LH-RH agonist for the first several days to a few weeks after initiation of therapy, and therefore, it initially stimulates testicular and ovarian steroidogenesis. Because of this initial stimulation of testosterone production, it is recommended that patients with prostatic cancer be treated concurrently with leuprolide and the antiandrogen flutamide (discussed earlier). Leuprolide is generally well tolerated, with hot flashes being the most common side effect.
Hormone Replacement Therapy
The four most common symptoms associated with menopause are vasomotor disorders, or hot flashes urogenital atrophy osteoporosis and psychological disturbances. A varying proportion of women may have one or more of these symptoms. Vasomotor disorders (hot flashes) are common, affecting 70 to 80 of postmenopausal women. The cause of the vasomotor changes appears to be associated with the release of LH after normal female estrogen levels have fallen. These symptoms occur with variable frequency but generally disappear without treatment within 2 to 3
Panic disorder
Most patients with panic disorder experience at least one sleep-related panic attack, and one-third or more of patients have recurrent nocturnal panic attacks. (2D Data from the few sleep panic attacks that have been recorded suggests that they occur more commonly during NREM sleep, at the transition to SWS. (22,23,) Symptoms of sleep panic attacks are essentially the same as those which occur during daytime attacks. Typically, patients report waking in a state of intense fear or anxiety, commonly with palpitations, shortness of breath, choking sensation, chest discomfort, and chills or hot flushes. They do not usually report dreaming just before the attacks. Unlike night terrors, which are characterized by incomplete arousal from sleep, patients having a sleep panic attack are awake and alert immediately after the attack begins. Patients with frequent sleep panic attacks may become fearful of going to sleep, which can contribute further to their insomnia.
Menopause is a natural life transition for women and usually occurs between the ages of 45 and 55. Hormonal changes result in a decline of estrogen and some women experience symptoms such as hot flashes, mood swings, and vaginal dryness. These changes may begin 4 to 6 years before the cessation of menstruation. Low-dose estrogen creams are effective for vaginal dryness. Antihistamines, diuretics, caffeine, and alcohol have a tendency to dry mucous membranes including those in the vagina. Regular exercise reduces hot flashes and other meno-pausal symptoms.
Those found in soy products, as a potential alternative to the synthetic estrogens in HRT (24,36,42,43). Together with lig-nans, coumestans, flavones, and flavanones, isoflavones belong to the larger group of nonsteroidal phytoestrogens. Interest in phytoestrogens has been fueled by observational studies showing a lower incidence of menopausal symptoms, osteoporosis, cardiovascular disease, and breast and endometrial cancers in Asian women who have a diet rich in soy products. Consistent with epidemiological studies are the findings that soy phy-toestrogens prevent mammary tumors and bone loss in rodents and atherosclerosis of coronary arteries in monkeys. Soy protein relieves hot flashes in postmenopausal women and attenuates bone loss in the lumbar spine of perimenopausal women. Furthermore, a high intake of dietary phytoestrogens is associated with a lower incidence of cancers of the colon, breast, and prostate. Isoflavones and other phytoestrogens have been considered to exert...
Flutamide (Eulexin) is a nonsteroidal antiandrogen (see Chapter 63) compound that competes with testosterone for binding to androgen receptors. The drug is well absorbed on oral administration. It is an active agent in the hormonal therapy of cancer of the prostate and has been shown to complement the pharmacological castration produced by the gonadotropin-releasing hormone (GnRH) agonist leuprolide. Flutamide prevents the stimulation of tumor growth that may occur as a result of the transient increase in testosterone secretion after the initiation of leuprolide therapy. The most common side effects of flutamide are those expected with androgen blockade hot flashes, loss of libido, and impotence. Mild nausea and diarrhea occur in about 10 of patients.


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While news of the pairing of Betfair and Trump Plaza in New Jersey was leaked months ago, the official announcement finally arrived yesterday.
Category: Poker Reviews
Pennsylvania Hosts Online Gambling Conference
An online gaming conference will be held in Pennsylvania today and tomorrow that will include participation from gaming industry leaders worldwide.
Trump Plaza & Trump Taj Mahal Receive Online Gambling Permit
Trump Entertainment Resorts two Atlantic City casinos, Trump Plaza and Trump Taj, were the third and fourth New Jersey casinos awarded Internet gaming permits.
Online Poker New Jersey November 26 Launch Confirmed
On Friday, New Jersey´s Gaming Enforcement Division announced that a five day period of soft play will precede the launch of online poker on November 26.
California Symposium to Discuss Online Gambling Legislation
Many Californians cite the state's powerful Indian tribes' desire to exclude horse racing interests as the main hindrance to advancing online poker legislation.
Black Chip Poker Introduces On Demand Tournaments
Black Chip Poker has introduced "On Demand" poker tournaments into its portfolio of games during another upgrade to its online poker software.
Nevada GCB Meeting Reviews Interstate Compacts
The Nevada Gaming Control Board (GCB) met on Wednesday to further discuss regulations concerning interstate online poker partnerships.
Zone Poker Launched by Bovada, Fast Fold for US Players
US poker players are being invited to "Step Inside the Zone" by Bovada Poker, who yesterday launched their fast-fold poker product – Zone Poker.
ACR Says Happy Birthday to The Beast with $51,000 Bonus
Americas Cardroom is celebrating the first anniversary of its Beast progressive rake promotion by offering $51,000 in added prizes throughout August.
UK-based 2UP Eyes New Jersey Market
Foreign-based gaming companies can readily see that regulated online poker and gambling in the U.S. is likely to boom in the near future.
Ultimate Poker Guarantees $100,000 in Summer Series
With its "Million Dollar Summer" promo already in full swing, Ultimate Poker has added a Summer Series of 11 tournaments that guarantee $100,000 in prize money.


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Activating the Automatically accept new senders option offers several advantages:
- You no longer need to accept new senders manually*. The acceptance is done automatically as soon as a sender offers you a new document via Zoomit (invoices, salary slips, …).
- You will be notified by email each time a new sender has been added to your Zoomit.
You are still able to refuse a Sender if you do not wish to receive his documents via Zoomit and you can at any time disable this setting to return to the manual acceptation of a sender.
Since the implementation of our new Zoomit version in July 2019, you can now choose, among the bank accounts to which you have access. By selecting account numbers, you indicate that you want to receive documents for these bank accounts numbers digitally.
To enable this option
- Start your Internet Banking application and go to the Zoomit section.
- In the Zoomit Settings, the option Automatically accept new senders is disabled by default.
- To activate the option, click on Yes next to Automatically accept new senders
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If you have previously refused an sender, your choice to not accept this sender will be respected: this sender will not be accepted automatically.
If the select account numbers option is not available, please contact your bank and check with their support if their implementation allows this choice.