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Partner with us
Together with our international partner institutions, we develop and run bespoke programs that allow students to examine and experience marine and terrestrial sciences in Australia and the Pacific's unique ecosystems and environments.
Our partners recruit and select program cohorts. Some institutions send experts to UQ with their students to offer support and to teach the courses they co-designed.
Blending practical fieldwork with laboratory, research and academic writing skills, our integrated programs equip participants with scientific knowledge and expertise to apply in the broader context throughout their further study and careers.
In Australia and the Solomon Islands, students gain a comprehensive insight into each country's iconic landscapes, diverse wildlife and local history and culture.
Some programs comprise a substantial research component, which offers the chance to conduct original supervised research in the field.
Partner with us
Contact Associate Professor Ian Tibbetts to discuss developing a program with your institution, or for general and institutional liaison information.
Current programs
We run programs with the HWS and Union College Partnership for Global Education, Stanford University and the University of California.
Find out about our partner programs, below.
HWS and Union College Partnership for Global Education
Integrating field and lecture components, this program focuses on the marine and terrestrial ecology of the Australian state of Queensland, as well as Australian culture.
Two directors from HWS and Union College accompany the students to UQ and teach one of the program's courses.
The program features field trips to several national parks, as well as UQ's world-renowned research stations on North Stradbroke Island in Moreton Bay and Heron Island on the Great Barrier Reef.
Find out more
Visit the HWS Global Education pages for more information.
Stanford University Bing Overseas Studies Program: Australia
Established in 2003, Stanford's Australia program remains one of the university's most popular study abroad options.
Comprising courses on terrestrial and marine science, and Australian studies, the program visits a variety of destinations, including capital cities, remote Far North Queensland, and UQ's world-renowned research stations on North Stradbroke Island in Moreton Bay and Heron Island on the Great Barrier Reef.
Students experience ecosystems first hand with lecture delivery alongside the physical experience.
A substantial research component also enables them to conduct original research in the field under the supervision of experts.
Participants develop skills through group labs, oral presentations, role play and scientific writing.
Find out more
Visit the Stanford University Bing Overseas Studies Program: Australia pages for more information.
University of California Education Abroad programs
UQ and the University of California enjoy a well-established collaboration on international partner programs, and currently offer two contract programs.
Australia Marine Biology & Terrestrial Ecology Education Abroad Program
Established in 2000, this long-running program comprises courses in marine biology, terrestrial ecology and Australian studies.
The marine biology component features lectures, laboratory work and intensive research-focused studies, and includes field trips to research stations on North Stradbroke Island in Moreton Bay and Heron Island on the Great Barrier Reef.
The terrestrial ecology component explores Australia's unique flora, fauna and ecosystems, with hands-on learning in field locations ranging from the outback to rainforests.
Pacific Island Environmental & Community Health: Australia & Solomon Islands Program
This program provides students with research skills and experience across a range of diverse and fragile ecosystems.
Participants explore urban and rural development, and their impacts on public health, while engaging with local students and members of remote communities.
After six weeks at UQ, the students complete the remainder of their semester abroad at the Solomon Islands National University.
Find out more
Visit the UC Education Abroad: Study Abroad in Australia webpages for more information on these programs.
Marine Biology & Terrestrial Ecology Program
Pacific Island Environmental & Community Health: Australia and Solomon Islands Program


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The days of putting your ear to the ground detect approaching cavalry are over. Now nations sport systems like the Iron Dome, THAAD radar, and these nine all-seeing early warning systems from our friends at Oobject. Really, there's no use hiding.
If you can't see them coming a mile away already, be sure to check out these 18 radio telescopes, these incredible listening devices, and these awesome astronomical aides.
In the original designs of these acoustic mirror, a curved recess in the concrete bounced sound towards a listener wearing a stethoscope.
The Woodpecker signal was a mysterious repetitive short wave radio frequency emanating from the Soviet Union during the Cold War. It later turned out to be part of a long range early warning system based in Ukraine.
One of 23 satellites in this system, which can detect the heat signature of missile launches. Shown here, being deployed from the Shuttle.
A floating radar platform that is used, among other things, to detect North Korean missile launches, from it usual home in the Pacific.
Part of the Distant Early Warning or DEW line, against a Soviet airborne or land based attack over Canada.

subset: commoncrawl


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Inning accordance with Wikipedia, sports shoes, or athletic shoes are "shoes mainly created for sports or other kinds of workout" There are ranges of sports shoes made from high quality toe puff and counter offered in the market, utilized for numerous functions. It's practically like each video game or activity has its own developed shoes. Here, in this short article, I will inform you about ways to pick an apt set of sports shoes made from high quality toe puff and counter for you, health advantages consisted of.
1. Know your feet well- The structure of feet, particularly the arc in the lower part, is various for each and everybody. Each sports shoe is developed to accommodate this issue. If you do not select the proper shoe for you, you will have feet issues like discomfort, rashes and so on. This is since of the irregular spread of your weight to your feet. You can likewise utilize insoles to conquer this issue.
2. Purchase it for the best usage- You ought to be clear about exactly what function you utilize the shoes for. Some shoes, like spike shoes, are created for particular functions just. Spike shoes, utilized for running, will not assist you in, for instance, a badminton video game, where you have to stabilize your feet for your motions forwards, in reverse or sideways. Utilize it for exactly what it is indicated for. Otherwise, not just will the shoe get ruined quickly, however likewise you may deal with health issue concerning the feet.
3. Constantly pick convenience above the cost of the item- Do not constantly jeopardize your alternatives concerning ho much you can pay. Even if you need to pay a bit more than your approximated spending plan, purchase the right, comfy shoe for you. You must not regret your choice later. By the time you recognize the error you have actually done, it may be late. So, constantly select your convenience and requirement prior to the rate.
4. Utilize the shoes inning accordance with your way of life- In some cases, you may utilize sports shoes made from high quality toe puff and counter in your daily life aside from sports activities. You may use it simply to secure your feet and even for your casual trips. There are sports shoes which can be utilized for a range of functions. Never ever limit your shoe collection into simply one. Know the function and usage appropriately.
Keep these 4 things into your mind prior to purchasing your shoes made from high quality toe puff and counter. It is much better if you take the best choice instead of taking the incorrect choice and later on regretting it. You can likewise purchase your shoes on the web. Due to the strong competitors you can get some fantastic discount rates in online shops.
If you are looking for more information on toe puff and counter, please visit: http://www.gastoneshoematerials.com.


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It's a Christmas tradition to have a fresh tree to decorate but what could be easier than loading it in the back of a truck? Maybe stamping it in the back of our Truck Tidings Cling Stamps and Die Set!
Debi Hammons created this tradition, shown above, by masking off the decorations making it look like a great, and easy, way to carry on the tradition through Christmas cards and scrapbook pages.
And more stamping fun with the same set is creating a truckload of presents to take to the family gathering or local charity. Capture the treasure of gift giving season with this stamp and die set and its loads of the possibilities!
For more inspiration, stop by our designer's blogs to see what they made for our Truck Tidings theme week!


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Linea Integratori Salini
Linea Pneumologica
Linea Pediatrica
Linea Urologica
Linea Osteoarticolare
Linea Epatoprotettore
Lavora con Noi
Sai che...?
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October 19, 2013 - Regardless of your locality or career, odds are you will be involved in a real estate sales transaction at least once during your life. Continue reading to gather together knowledge about property, so that you can successfully sell property, as opposed to finding the whole process confusing.
When selling your home, be willing to negotiate with people making offers. Because housing prices fluctuate, your home may not be worth what you really are asking. Speak with your real estate agent and get their professional opinion on what should be the acceptable asking price.
When attemping to entice a purchaser into viewing your house as possibly theirs, remove your personal mark at home. It is as simple as putting away family pictures and other such personal items throughout the home's viewing. Audience won't be able to picture their particular family in your home if they only call at your family there. Furthermore, you should eliminate all of the clutter in your home so that its space could be shown off properly instead of your personal stuff.
Prepare your house for that market toward the close of winter or perhaps in the earliest weeks of spring. Lots of buyers just want a home or
stainless steel dog tag chain
they can settle into by mid summer, pay attention to this and plan ahead.
When you live in exactly the same house for a long period of time, it's easy for clutter to pile up without you realizing it. Many times it's hard to have an owner to get rid of the clutter since they became mounted on it. It may help to employ some other person to look through your home to identify locations that need tidying and elimination of distracting clutter before putting your property on the market.
Because potential customers like to envision themselves surviving in a house they're buying, you should try to eliminate all visible signs and symptoms of your personal imprint on the home. Move personal effects, especially family pictures and heirlooms away from sight. Buyers must be able to envision their own families living in your house, rather than yours. Also, remove any clutter at home because a spacious home looks much better than one crammed with stuff.
A well-manicured, tidy lawn will go a long way in adding charm of the entrance, so avoid heavy landscaping. Probably, the new buyers will take all the landscaping out and place new elements in. Keep the lawn mowed, by leaving mature trees set up.
The more time you're residing in a house, the greater clutter you are apt to have. Often people become so familiar with their clutter they do not even comprehend it is there. If you are trying to sell your property, have a friend walk through as if these folks were a potential buyer. Then ask them to point out the clutter that takes away from your home.
Once you plan to sell your home, it is a wise decision to perform some simple cleanup and straightening of your property before you work with a realtor or show your property. Apply a fresh coat of paint, clean the carpets and consider hiring a professional cleaners to give the entire house a comprehensive cleaning. The cash you expend on this endeavor pays off in the long run.
Before you place your home in the marketplace, make necessary renovations. This may increase its overall value. Among the easiest, most favored and effective renovations you possibly can make is a kitchen makeover. Updating your kitchen will increase your chances of a quick sell.
You might like to pay special focus on cleaning up under the sink, where things have a tendency to accumulate. This is also true for your kitchen junk drawer. Buyers is going to be checking out every nook and cranny, so take note of cleaning these little locations that tend to accumulate clutter.
When your buyer comes by, you should always be away. The purchaser needs the freedom to ramble about and find out whether he feels comfortable in your home on his own. When you're present, it will make it harder for the buyer to assume what it could be like to live there. This might lead to missing a sale.
When attemping to entice a purchaser into viewing your property as possibly theirs, remove your personal mark throughout the house. This can be
if you take away family photos and momentos. Buyers must be able to see themselves in the house, and your personality may block this vision. Also, pick up as much as you are able to, and de-clutter things. The home needs to be as open and spacious as you possibly can.
Use different ways of market your property. Use multiple channels to evaluate the real estate market locally, including websites like Zillow, real estate professionals, newspapers, and merely driving across the neighborhood. To function, you need to keep all of your options available to reach the widest audience you can.
To conclude, it can be wanting to listen to so-called experts offer you their opinion on selling real estate. The tips and tricks in this article have been widely proven time and time again. Hopefully this article will help to either clear up what you were unsure about, or offer you some new information.
co-blogger: Stefani M. Olmeda
Copyright © 2014 LaNovaFarmaceutici.com Partita IVA 03778700710. All Rights Reserved. Designed by Lucia M.


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Fresh Pineapple Festival Salsa
|3 cups fresh pineapple, chopped
|3 tsp fresh lemon juice
|3/4 cup red onion, chopped
|1-3 tsp jalapeno pepper, finely chopped
|3/4 cup jicama or water chestnut
|3 tsp fresh jinger, finely miinced
|1 cup frozen corn
|3 tbsp fresh mint, chopped
|6 tbsp granulated sugar
|3 tbsp cilantro, chopped
|Fresh Tomato (to taste)
|Salt & Pepper (to taste)
Mix all ingredients well in a glass bowl.
Adjust seasonings to taste.
Refrigerate at least 4 hours before serving.


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New construction modern masterpiece with 100' of waterfront in sought after Harbor Beach! Grand entrance with soaring ceilings leads to a stunning floor plan with the finest quality finishes. In addition to 6 bedrooms, 7 baths & 2 1/2 baths this home boasts a library, club room, wine room & bar. The master suite is located on the first floor and has enormous his and her closets & dual baths. Outdoor entertaining area features a covered patio, summer kitchen, patio bar, pool and spa. Elevator, 3 car garage
First Floor Entry, Bar, Built-Ins, Cooking Island
Automatic Garage Door Opener, Dishwasher, Dryer, Elevator, Icemaker, Microwave, Gas Range, Refrigerator, Washer
Central Cooling, Electric Cooling
Built-In Grill, High Impact Doors, Open Balcony
IDX information is provided by the Greater Fort Lauderdale REALTORS® exclusively for consumers' personal, non-commercial use and may not be used for any purpose other than to identify prospective properties consumers may be interested in purchasing.
The data relating to real estate for sale/lease on this web site come in part from a cooperative data exchange program of the multiple listing service (MLS) in which this real estate firm (Broker) participates. The properties displayed may not be all of the properties in the MLS's database, or all of the properties listed with Brokers participating in the cooperative data exchange program. Properties listed by Brokers other than this Broker are marked with either the listing Broker's logo or name or the MLS name or a logo provided by the MLS. Detailed information about such properties includes the name of the listing Brokers. Information provided is thought to be reliable but is not guaranteed to be accurate; you are advised to verify facts that are important to you. No warranties, expressed or implied, are provided for the data herein, or for their use or interpretation by the user. The Greater Fort Lauderdale REALTORS® and its cooperating MLSs do not create, control or review the property data displayed herein and take no responsibility for the content of such records. Federal law prohibits discrimination on the basis of race, color, religion, sex, handicap, familial status or national origin in the sale, rental or financing of housing.


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"Tre Corda brings together an awesome array of talent, performance wisdom and stylistic variations, from classical to pop and jazz. They are world ambassadors."
- Somerville Journal
Tre Corda CD Release show for Squeaky Toy
Featuring: Tim Ray, piano
Greg Hopkins, trumpet & flugelhorn
Eugene Friesen, cello
Tim Ray and Tre Corda are happy to present their latest recording "Squeaky Toy" with a special CD release event at the RegattaBar in Cambridge, MA on April 10th, 2013. This concert will feature many of the new tunes found on the disc, including Tim's new sonic journeys "Once Around the Block", "Nudgy" and of course "Squeaky Toy"; Eugene Friesen's sultry and grooving "ShadowPlay"; and Greg Hopkins' 3 movement opus "Sonata for Trumpet, Cello and Piano". And don't miss their arrangement and improvisations on three of Bela Bartok's "Improvisations for Piano". We hope to see you there!
Whether reinventing jazz standards, breathing fresh life into classical repertoire, or premiering their own original works, Tre Corda generates a compelling sound all its own. Their works blend composition and improvisation in new and unexpected ways, using the musical vocabulary of classical composers like Bartok and Stravinsky, as well as songs and ideas from the worlds of jazz and popular musics. Cellist Eugene Friesens dynamic rhythms and incredible array of bowing and plucking techniques, trumpeter Greg Hopkinss virtuosic leaps and outrageous genre-bending phrases, and pianist Tim Rays lyric melodicism and two-fisted pyrotechnics - these are just a few of the ways Tre Corda concerts have satisfied and delighted audiences with both jazz and classical expectations. The Boston Globe called this new group inventive, spirited, humorous..., and Downbeat Magazine's Fred Bouchard raved about their self-titled debut CD, giving it 3 1/2 stars.
Tim Ray piano
Perhaps best known as long-time pianist for Lyle Lovett, Tim Rays wide-ranging skills as a soloist and accompanist have afforded him the opportunity to perform with legendary performers from all walks of music. Appearing on over 70 recordings to date, Tim has performed in concert with an extensive list of pop music icons, notably Aretha Franklin, Bonnie Raitt, Willie Nelson, Jane Siberry and Soul Asylum. He regularly performs with leading figures in the jazz world, among them Gary Burton, Esperanza Spalding, Scott Hamilton, Dave Douglas, Brian Blade, Lewis Nash and Rufus Reid. Tims busy schedule has included frequent tours throughout the Americas, Canada, Mexico, Europe, Asia, and the Middle East, and has included performances at Carnegie Hall, the White House, the Kennedy Center and the 1992 Presidential Inauguration. He is a grant recipient from the National Endowment for the Arts, and is currently on the faculty of the Berklee College of Music. (AgitatedCatMusic.com)
Eugene Friesen - cello
A graduate of the Yale School of Music where he studied with Brazilian cellist Aldo Parisot, Eugene Friesen is active internationally as a concert artist, composer, conductor and teacher. In 1995, 2005 and 2006 Eugene won Grammy Awards for musical contributions to three Paul Winter Consort albums, Spanish Angel, Silver Solstice, and "Crestone." He has worked and recorded with such diverse artists as Dave Brubeck, Toots Thielemans, Betty Buckley, Will Ackerman, Joe Lovano and Dream Theater. Recording credits include six albums of original music: New Friend, Arms Around You, The Song of Rivers, In the Shade of Angels, Sono Miho and Colorful Transitions. Eugene is an artist-in-residence at the Cathedral of St. John the Divine in New York City, and on the faculty of the Berklee College of Music in Boston. (Celloman.com)
Greg Hopkins - trumpet
Performer, composer, and arranger Greg Hopkins first picked up the trumpet as a boy in Detroit, and to this day it would be hard to spot him without his horn. That symbiosis of man and musical instrument is evident throughout Gregs career, which began in 1965 freelancing in the Detroit area for such acts as the Temptations, Marvin Gaye, and Gladys Knight. Greg made a name for himself recording and touring for several years as soloist and arranger for the Buddy Rich Orchestra (he was called a real find by the London Times in 1974), but he has also performed with Dizzy Gillespie, Ella Fitzgerald, Frank Sinatra, Stevie Wonder, Joe Williams and Tony Bennett. A Professor of Jazz Composition at Berklee College of Music, Greg has developed and teaches several courses in composition and also directs the prestigious Berklee Concert Jazz Orchestra. (GregHopkins.net)


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Fiona joined the Equine team in 2004 and now works at the practice two days a week since starting a family. She has a particular interest in sport horse work and is trained in acupuncture as well as veterinary chiropractic.
Along with her husband, Fiona runs Radway Equine Rehabilitation Centre with a cold salt water hydrotherapy spa.
Out of work hours, she enjoys spending time with her family.
Hook Norton Veterinary Group
Hook Norton Hospital
White Hills Surgery, Sibford Road
Hook Norton, Banbury, Oxon, OX15 5DG
Pets: 01608 730501
Equine & Farm: 01608 730085
For sat nav please use OX15 5DF


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The SF Chronicle had a great story by Ryan Kim about the escalating battle with HP and Apple. Everybody has a lot at stake. I love it.
P.S. Much thanks to Scott Budman from NBC 11 for covering Beyond Urban Branding's perspective on the latest tech battle between HP and Apple.
-Beyond Urban Branding


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Effective scheduling of resources with online plans and interactive job lists.
Your business. Planned.
Effective scheduling of resources with online plans and interactive job lists.
Planning and scheduling is a major challenge for many organisations. The variables within processes can make or break a company, and unsatisfactory production planning leads to high operating costs and customer delivery problems.
With LYNQ's comprehensive advanced, finite capacity based, planning and scheduling (APS), you can quickly and accurately schedule while minimising downtime. Deliver to your customers faster and in the most cost-effective way, by creating production plans that factor in constraints around machines, tooling, personnel and inventory to make smarter use of your materials and resources.
Real-time data collection and tracking of employees, equipment and jobs.
Automatic data capture from machines and other devices.
World-class factory performance analysis with loss visualisation.
Paperless shop floor with downtime alerts and collaborative messaging.
One solution to get more out of your resources.
Visual planning board
Define your resources and their available capacity by the shifts that they operate. Create, optimise and share your production schedule online. Publish job lists to your resources for easy data collection.
Balance equipment utilisation and order fulfilment to maximise factory output. View your most/least utilised resources, top orders by value and popular products by volume.
Production plan
View the agreed production plan. List and/or print shop packets. Review progress including hours reported, quantities produced and issues logged to expedite and/or provide delivery information.
Equipment plan
Review the impact of the production plan on your equipment. Drill into each equipment card to view loading detail and expected daily output.
Production status
Review open jobs to check their status. Use progress bars to gain visibility of hours booked, materials issued and overall progress at a glance. Drill to view specific job details including attached documents and issues recorded.
Material list
View specific material requirements by individual resources for today or this week designed to support cell manufacture and for use with mobile and/or tablet devices.
Job status
View job lists by resource groups for today or this week designed for use with mobile and/or tablet devices.
Production history
View activity history in relation to both open and closed jobs.
Your business.
One solution
Optimise manufacturing workflow by integrating your planning and production activities with an all-in-one solution.
Low cost
Starting from $20,000, avoiding time consuming and costly integration, for a low overall total cost of ownership.
Quick to deploy
Rapid, fixed priced implementation in less than 12 weeks.
Sophisticated, next-generation web-based technologies, easily configured for any industry and any device, providing any time access.
Gain instant insight with out of the box, world-class performance analysis and loss visualisation of your employees and equipment.
Machine connectivity
Automate data capture from your machines and other devices with more than 140 drivers to the most common PLC/IO devices supporting Industry 4.0.
Take a tour.
Take a virtual tour and explore how you can digitalise and drive factory performance with LYNQ.Take a tour
Unleash your potential.
One solution for effective resource management.


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Prices incl. VAT plus shipping costs
Delivery time approx. 5 working days
- Fully Intergrated
- Cutlery Basket
- Stainless Steel Interior
- 13 Place Setting
- Model Number HPT-LTF8B019CUK
Product information
The Hotpoint LTF8B019UK integrated full size dishwasher is functional and economically friendly and will make a smart addition to your kitchen. Boasting an A+ energy rating and an eco cycle rating, these innovative features will all work together to save you money on your energy bills.
Using 11 litres of water for a huge 13 place settings, this dishwasher is highly efficient. A total of 8 programmes, cover a range of washing requirements. An intensive wash is handy for removing stubborn food stains, an eco wash saves on time and money and a quick wash will do your dishes in no time.
A 12 hour delay timer and adjustable racking will make cleaning up after meals incredibly easy, whilst its integrated design will fit seamlessly into your kitchen.
|Energy Rating:
|Built In:


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Every day in November we will reveal the greatest stories ever told starring a particular character or written/drawn by a particular creator (and throughout the month, you'll get daily chances to vote for NEXT week's lists). These lists are voted on by YOU, the reader!
Here is the list of characters/creators featured so far (along with the rules on how to vote).
Today's list is the Greatest Joe Casey Stories Ever Told!
Sorry for the delay! In the rules, I noted that stories could be twelve issues long, so if I had a scenario where, say, the majority of the votes were for Intimates #1-12 while a handful of the votes were for a single issue of the Intimates, I just lumped the single issue in as a vote for Intimates #1-12.
10. Uncanny X-Men Annual 2001, Uncanny X-Men #407-409
It really is a shame that Casey's X-Men really "clicked" at this late point in his run. His last few issues, as well as the Annual that led to them, had Casey working with two stellar artists, Ashley Wood and Sean Phillips, as Casey takes a crack at turning Warren Worthington into the sort of crusading businessman that Casey later had so much success with with Jack Marlowe. The new take on Vanisher was quite compelling.
9. Intimates #1-12
This offbeat series following a school for superheroes opened up with very strong artwork by Giuseppe Camuncoli. Casey used a number of innovative narrative approaches in this clever and unusual series, which I believe was Casey's farwell to the Wildstorm universe that he did so much good with.
8. Cable #59-62 "The Nemesis Contract"
In this big, Kirby-esque adventure, Cable fights against SHIELD headhunter, Jack Truman. Paired with Ladronn, Casey tells a fun and engaging action romp that allows Casey to play with Cable's place within the Marvel Universe while also setting up stories that would later come into play during Casey's run on Deathlok (where Truman returns).
7. Adventures of Superman #612-616 "The Hollow Men"
In this inspired series of stories, Clark Kent comes across an old journalism mentor of his, whose fictional works are coming to life. Casey uses this plot device to compare and contrast modern Superman against how Superman originally appeared, showing just how different Superman is today, and more importantly, Casey shows us a Superman that does not use violence to solve problems. Engaging stuff.
6. Wildcats 3.0 #13-24 "Year Two"
Casey's finale of his Wildcats run is more or less split into two distinct elements (if it weren't for the fact that this was, indeed, released as a "Year Two" trade, I would think of it as two stories), with the first being the clever and cerebral examination of how Jack Marlowe's corporate endeavors are viewed by the United States government and the second being a re-visitation of older WildC.A.T.s stories with the return of Zealot and her warrior group, the Coda, in Coda War One. The series ends on a series of over-the-top dramatic fight sequences. Still an enjoyable ride.
5. Codeflesh
Originally appearing in a couple of different flip books, Codeflesh was eventually collected into a single collection. It is about a bail bondsman who continually offers bail to supervillains because he knows that they will skip bail and he will be able to take them down. Once a judge tells him he cannot do this anymore, he creates a costumed identity to continue doing it anyways. Casey does a sort of old school superhero riff here, in the sense that our "hero" is torn between his private life and his "superhero" life, only what he is doing is really not noble - it is driven more by his enjoyment of hunting down criminals. Charles Adlard did excellent artwork, especially on the final part of the original story where he and Casey do a very experimental story.
4. Wildcats 3.0 #1-12 "Year One"
This extremely ambitious series followed Jack Marlowe, the hero formerly known as Spartan, as he attempts to essentially save the world through his corporation (and his futuristic battery, of course). Meanwhile, Cole Cash trains one of Marlowe's accountants to become the new Grifter. Dustin Nguyen does the art on this
3. Wildcats Volume 2 #8-13 "Vicious Circles"
This was Joe Casey and Sean Phillips' first storyline on Wildcats, and this gave the hint of the great promise that they would achieve with taking the initial concept of Wildcats and pushing it into whole other areas. Casey plays with the idea that the Wildcats really do not have a reason for being on Earth anymore. By the end of the story, though, Spartan has taken on a new name and a new purpose. It is strong, character-driven work.
2. Wildcats Volume 2 #14-19 "Serial Boxes"
In their second storyline on Wildcats, Casey and Phillips use a super-powered serial killer to mold the cast of the book to the characters that they most want to write. A result of this is some shocking violence towards some of the regular members of the title. However, Casey introduces us to a bunch of new cast members as he continues his drive towards making this a moody, character-based comic book (having the great Sean Phillips on artwork certainly helps in that regard).
1. Automatic Kafka #1-9
This highly metafictional comic book shows us a washed-up superhero from the 1980s who is being pursued by the government to work for them. To avoid them, he becomes a celebrity game show host. The artwork by Ashley Wood is sublime and Casey has a number of stand-out issues, most famous being #4, an examination of what the Peanuts gang might be up to had they not been lucky enough to be stuck as kids forever and #9, where Casey and Wood break the news to their creation that his book has been canceled.
Agree? Disagree? Let me know! And go vote for the other characters and creators on the list!


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Ways to Give
Harbor Country Day School is a non-profit 501 (c) (3) tax-exempt organization as recognized by the IRS; donations are tax deductible to the extent permitted by law. To receive a current year tax deduction for your gift, it must be received by December 31st.
- Cash/Check
- Credit Card by Mail or Phone
- Giving Levels
- Honorary and Memorial Gifts
- Matching Gifts
- Online
- Pledges
- Securities/Stock
Credit Card by Mail or Phone
If you would like to make a gift to Harbor Country Day School using your credit card please contact the Advancement Office at (631) 584-5555 or click here, which will bring you to a secure payment gateway.
We also accept credit card donations by mail, using our Harbor Fund donation envelope. You may pick up an envelope at the school, and simply check the appropriate box on the envelope, fill in the complete credit card information, and mail the envelope to:
17 Three Sisters Road
Saint James, New York 11780
Gifts by credit card may be made in a single payment or in installments.
Giving Levels
Honorary and Memorial Gifts
If you wish to honor or memorialize a loved one or another individual with a gift to the school, please indicate the name of person you wish to honor or memorialize when making your gift. A receipt will be sent to you for the gift, and the honoree or family of the memorialized individual will be notified of your donation.
Matching Gifts
Many employers are willing to match donations to Harbor Country Day School, which is a wonderful way to increase the impact of your gift. If your employer or your spouse's employer has a matching gift program, please indicate this when making your gift. You may enclose the employer's matching gift form with your gift. If you do not have a form, please contact the employer's human resources department for more information.
Making an online gift to Harbor Country Day School is easy. Simply visit the secure payment gateway at the Online Giving page on our website. VISA, MasterCard, and American Express are accepted. Your generous gift will be acknowledged electronically, and the school also will send you a written acknowledgement for tax purposes.
Please note: Online gifts made via credit card are subject to a processing fee imposed by credit card companies of between three and five percent of the donation amount; this fee is charged to Harbor. In other words, your net gift is less than the amount you are contributing. To help ease the financial burden on Harbor, we would be so grateful if you would consider adding a small amount to your gift to help Harbor defer the cost of these fees. The full amount of your gift, including this additional amount, will be considered a donation to Harbor Country Day.
If you would like to make a gift to Harbor Country Day School but are not in a position to do so right now, please contact the Advancement Office at (631) 584-5555 to phone in a pledge. If possible, indicate when you plan on making your gift to Harbor, and we will send you a friendly reminder. Pledges also may be made in the school office.
If you are pledging to the Harbor Fund, you may also mail your pledge, in a Harbor Fund envelope, to the address below. Harbor Fund pledges for the current campaign year must be paid by June 30th, but the sooner the gift is made, the sooner the donation goes to work for the school.
Harbor Country Day School
Advancement Office
17 Three Sisters Road
Saint James, New York 11780
A gift of securities or stock is an alternative to a cash gift to Harbor. It provides for an income tax deduction for the giver equal to the fair market value of the securities/stock at the date of transfer. Gifts of appreciated securities can provide great advantages.
Please contact the Advancement Office at (631) 584-5555 for more information.


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More About Arctic Fox Campers
Arctic Fox Campers – coverings are likewise referred to as caps or toppers. These stiff canopies or little real estates are primarily utilized as pick-up vehicle devices. arctic fox campers covering real estates are made from light weight aluminum or fiberglass. These are typically installed on the back bed's leading from the pickup. This completely covers the vehicle bed just like a roofing system.
The coverings are big and can in some cases be utilized for outdoor camping functions. As a matter of fact this was at first developed for outdoor camping. Nowadays, the coverings are utilized for storage space and energy functions. Some coverings can be big sufficient to overlap the taxi from the truck's leading.
arctic fox campers Trucks
Vehicle arctic fox campers is a call utilized in North America that describes any RV or leisure car brought in the pick-up truck's bed. It's likewise typically called TC as its resulting acronym. The kinds of leisure cars in North America are in some cases referred as cab-over or slide-in.
The call dismountable or demountable are often utilized in Europe. Slide-in is the call typically utilized in Australia when describing kinds that come from leisure cars.
Possibly one of the most versatile kind of leisure cars is vehicle arctic fox camperss. This kind of vehicle has the ability to go anywhere pickup can go. These are offered on the market because the very early 1950s. Throughout the years, these items had undergone advancements and improvements that make them at the exact same degree or kind regarding leisure car kinds.
In North America, the prominent and biggest producer for vehicle arctic fox camperss is the Lance arctic fox campers Producing Company. This company lies at Lancaster, California. The 2nd biggest producer is Frozen Fox situated at La Grande, Oregon. People in Canada and the western component from Unified Specifies still remain to usage and purchase vehicle arctic fox camperss. Additionally, Canada and the Unified Specifies are the head office from big vehicle arctic fox campers producers. Vehicle arctic fox camperss are likewise ending up being prominent in Australia because of its functionality and flexibility.
These are likewise an ideal option for fishermen, horseback bikers and seekers in addition to sporting activities lovers. The reason a great deal of outside type of people choices vehicle arctic fox camperss is that their equine trailers or watercrafts are quickly drew behind and they can camp off the roadway for family member convenience.
This expenses the like bigger leisure cars. All facilities should be crammed in a smaller sized bundle. Leisure cars should have the ability to birth the misuse from rough roads
Leisure Car Classes
Some leisure car courses are likewise thought about vehicle arctic fox camperss.
Very first is the Clamshell. The building from this kind of leisure car is used by 2 producers from Canada. Both producers are North Lite and Bigfoot. This car includes 2 fiberglass arctic fox campers coverings flat signed up with with each other at the facility.
Hardside Light weight aluminum is a kind of arctic fox campers that uses light weight aluminum or timber mounting. The arctic fox campers is do with a light weight aluminum exterior siding.
Hardside Filon uses timber mounting typically made from fir. It's do with Filon, a slim layer from fiberglass on the support from the timber.
The popup kind is typically reduced in account. It's developed to reduce wind resistance and weight. The building methods discussed over might be appropriate for this kind of arctic fox campers besides the Clamshell. This truck's roofing system is increased mechanically to include some elevation.


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A brand new Low Rider style pack, perfectly sized and equipped for single day missions.
Perfectly sized and equipped for single day missions, the new Sparta™ includes over 30L of cargo, laser-cut Mountain™ MOLLE and our new 3L, 100oz Mil Spec Crux™ Lumbar Reservoir, which delivers 25% more water per sip. Low Rider™ technology uses a lumbar reservoir to move the water weight low for increased stability and a lower center of gravity. It is constructed of 500D Double-Rip Cordura® fabric for long lasting durability.
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Dual antenna ports on top of pack
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Adjustable sternum strap
Hook-and-loop strap management
MOLLE attachment system integrated to bottom of boot
Zippered mesh pocket for keys, clips, etc.
Add or remove name tags and unit badges quickly with integrated hook-and-loop panel
Top webbing hanger loop
Grommet drain holes located at bottom of main compartment
Uses 500D Double-rip Cordura® Fabric for the ultimate combination of strength and durability


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Self adhesive
The self adhesive coinholder gives the best protection to your coins, because the coin is 100 % closed from the outside-air. The outside of the coinholder offers the most space to write on.
Available window sizes (outside 50x50 mm):
and extra large size (outside 67x67 mm):
There are Hartberger coin holders without hole (blind) 50 x 50 mm, to fill unused pockets. Can also be used as text cards. These can be found by the non-adhesive coin holders in the packaging of 100 and 1000 pieces.
Also available assorted boxes (50x50 mm) and (67x67 mm) with 25 pieces of all sizes and a box for only Euro coins.
The coin holders are packed per 25, 100 en 1000 stuks.
Pages for coin holders you find here.
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Our HARTBERGER adhesive coin holders are improved with "EASY LIFT TAPE".
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SALEM, Va. – The Emory & Henry College Softball Team (26-16) saw its run in the 2019 Old Dominion Athletic Conference Tournament come to an end just before 11:00 p.m., on Saturday evening. The Wasps dropped a 4-1 decision to top-seeded Virginia Wesleyan University to exit the tournament with a 2-2 record, finishing fourth in postseason play.
The Basics
GAME EIGHT – #3 Lynchburg 12, #3 Emory & Henry 3
GAME NINE – #2 Emory & Henry 4, #8 Shenandoah 2
GAME TWELVE – #1 Virginia Wesleyan 4, #2 Emory & Henry 1
LOCATION – Salem, Virginia
VENUE – James I. Moyer Sports Complex
RECORDS – Emory & Henry (26-16)
Game Eight – #3 Lynchburg 12, #2 Emory & Henry 3
The Wasps dropped a 12-3 decision to the Hornets in their first game of the day. Lynchburg opened the game with two runs in the first and pushed its lead to 6-1 midway through the fourth as Taylor Mabry hit a three-run home run to left field to highlight the frame.
A two-run double to left-center by E&H sophomore first baseman Kendall Varner (Bassett, Va.) closed the gap to 6-3, but the visitors scored six unanswered to take the contest 12-3.
Game Nine – #2 Emory & Henry 4, #8 Shenandoah 2
Emory & Henry picked up a win in the elimination bracket, 4-2 over eighth-seeded Shenandoah University. The Wasps got out to a 1-0 lead early, but the Hornets responded with single runs in the second and fifth to go up 4-2.
E&H put up a three-run sixth highlighted by a go-ahead two-run homer by senior Madison McClanahan (Abingdon, Va.). Senior centerfielder Erin Anderson (Aylett, Va.) also had a RBI-base knock in the frame to tie things up.
Junior Tiffany Cole (Wise, Va.) picked up the win in the circle, scattering two runs on nine hits with two strikeouts over seven innings.
Game Twelve - #1 Virginia Wesleyan 4, #2 Emory & Henry 1
VWU got things started with a run in the bottom of the second as Maria Weddle singled down the left field line, scoring Jessica Lindsay. The Marlins pushed the lead to 4-0 after the sixth, putting up three runs to break things open. Lindsay and Katelyn Biando drove in runs in the inning.
Emory & Henry showed life during its final three outs as junior designated player Alex Thomas (Orlando, Fla.) and junior second baseman Lyndsay Boyd (Abingdon, Va.) hit back-to-back doubles to make the score 4-1. The Wasps got two runners in scoring position with one out but were unable to make any extra noise as the two-time defending national champions moved on to Sunday's action.
Up Next
As the No. 7-ranked team in the Atlantic Region, Emory & Henry will now await the announcement of the field of teams for the NCAA Division III Tournament which will occur on Monday, May 6.


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Krishna Janam Ashtami celebrated in Mathura
Mathura: Krishna Janam Ashtami was celebrated with great fervour and fanfare as devotees thronged temples in birth place of Lord Krishna, Mathura, and adjoining areas of Goverdhan and Vrindavan today.
Pilgrims flocked to various temples in the Sri Krishna `Janmasthan`, where special religious discourses, kathas, hymns and community kitchens were held in the decorated temples.
Bathing ceremony of the deity `Abhishek` was performed with milk, curd, honey, ghee and Khandsari amidst chanting of vedic hymns in Bhagwat Bhawan and Keshav Deo temples.
Several pilgrims paid obeisance in the main temples of Mathura, Vrindavan, Nandgaon, Mahaban and Baldeo, while others performed circumambulation of hillock Goverdhan.
Meanwhile, security in the main temples was beefed up today. Beside police and para-military forces, police in plain clothes were posted at sensitive points of the birthplace.


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Having a business is part of many people's dream. America is full of stories about self-made business owners who started from nothing but were able to parlay perseverance, hard work, and a good idea into successful businesses. The funding part is what trips up many people, causing them to put their dreams on hold. However, instead of letting the lack of a few thousand dollars crush the spirit of your entrepreneurial, you should consider car title loans as an alternate source of capital.
Read more about debt from https://en.wikipedia.org/wiki/Debt.
Some of the largest corporate successes in America? They were built up from humble beginnings. This should serve as a reminder not to abandon business ideas due to lack of money. If other avenues are not open to you, check out car title loans as a means of getting cash for your startup. You can obtain car title loans from TFC Title Loan today!


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Comparison of different strategies in prenatal screening for Down's syndrome: cost effectiveness analysis of computer simulationBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b138 (Published 13 February 2009) Cite this as: BMJ 2009;338:b138
- Jean Gekas, chief of prenatal diagnosis unit, consultant in medical genetic, and professor1,
- Geneviève Gagné, research assistant2,
- Emmanuel Bujold, consultant obstetrician and professor3,
- Daniel Douillard, research assistant2,
- Jean-Claude Forest, chief of medical biochemistry service, director of CHUQ medical research centre, and professor4,
- Daniel Reinharz, professor2,
- François Rousseau, professor4
- 1Centre de recherche du CHUQ, Service de Génétique Médicale, Unité de Diagnostic Prénatal, Faculté de Médecine, Université Laval, Québec city, Québec, Canada
- 2Centre de recherche du CHUQ, Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Cité universitaire, Québec city
- 3Centre de recherche du CHUQ, Unité de Diagnostic Prénatal, Département d'Obstétrique-Gynécologie, Faculté de Médecine, Université Laval, Québec city
- 4Centre de recherche du CHUQ, Département de biologie médicale, Faculté de Médecine, Université Laval, The CanGèneTest research consortium on genetic laboratory services, Québec city
- Correspondence to: J Gekas, Centre Hospitalier de l'Université Laval (CHUL), 2705, boul. Laurier, bureau RC-9300, Sainte-Foy, Québec city, G1V 4G2, Québec, Canada jean.gekas{at}mail.chuq.qc.ca
- Accepted 12 December 2008
Objectives To assess and compare the cost effectiveness of three different strategies for prenatal screening for Down's syndrome (integrated test, sequential screening, and contingent screenings) and to determine the most useful cut-off values for risk.
Design Computer simulations to study integrated, sequential, and contingent screening strategies with various cut-offs leading to 19 potential screening algorithms.
Data sources The computer simulation was populated with data from the Serum Urine and Ultrasound Screening Study (SURUSS), real unit costs for healthcare interventions, and a population of 110 948 pregnancies from the province of Québec for the year 2001.
Main outcome measures Cost effectiveness ratios, incremental cost effectiveness ratios, and screening options' outcomes.
Results The contingent screening strategy dominated all other screening options: it had the best cost effectiveness ratio ($C26 833 per case of Down's syndrome) with fewer procedure related euploid miscarriages and unnecessary terminations (respectively, 6 and 16 per 100 000 pregnancies). It also outperformed serum screening at the second trimester. In terms of the incremental cost effectiveness ratio, contingent screening was still dominant: compared with screening based on maternal age alone, the savings were $C30 963 per additional birth with Down's syndrome averted. Contingent screening was the only screening strategy that offered early reassurance to the majority of women (77.81%) in first trimester and minimised costs by limiting retesting during the second trimester (21.05%). For the contingent and sequential screening strategies, the choice of cut-off value for risk in the first trimester test significantly affected the cost effectiveness ratios (respectively, from $C26 833 to $C37 260 and from $C35 215 to $C45 314 per case of Down's syndrome), the number of procedure related euploid miscarriages (from 6 to 46 and from 6 to 45 per 100 000 pregnancies), and the number of unnecessary terminations (from 16 to 26 and from 16 to 25 per 100 000 pregnancies).
Conclusions Contingent screening, with a first trimester cut-off value for high risk of 1 in 9, is the preferred option for prenatal screening of women for pregnancies affected by Down's syndrome.
In the past 10-15 years, major advances have been made in prenatal screening for Down's syndrome,1 2 the foremost known genetic cause of mental retardation.3 It has been suggested that maternal age alone as a screening strategy should be abandoned,4 but there is still no consensus on the most cost effective alternative, and thus no national strategy exists in the United States or Canada.5 6
New strategies that allow a relatively high detection rate combine analyses from first and second trimesters of pregnancy.7 8 Different approaches have been proposed6 7 9 such as
The integrated test, in which the results from first trimester screening tests are not analysed until the results from second trimester tests are evaluated, when both sets are assessed together1
Sequential screening, in which first trimester screening results determine whether second trimester testing is indicated: women with a positive first trimester result are offered invasive testing (chorionic villous sampling), whereas those with a negative result are offered another serum test10
Contingent screening, in which the first trimester screening results are used to categorise women as high, intermediate, or low risk.11 High risk women are offered early diagnosis (chorionic villous sampling), low risk women are reassured and do not undergo second trimester testing, and intermediate risk women are offered second trimester testing. The cut-off values between the risk categories vary depending on how the groups are defined.
Published evaluations of screening programmes for Down's syndrome have primarily focused on the detection rates of the different strategies used.6 Although the detection rate is important for individuals, the cost effectiveness ratio and similar end points of screening strategies are needed for the development of optimal public health strategies.6 In that respect, only contradictory and limited data exist on the three above methods of combining first and second trimester tests.6 9 Using a decision analysis model based on data from the First and Second Trimester Evaluation of Risk (FASTER) trial,12 Ball et al reported that contingent screening dominated (lower costs with better outcomes) the integrated test.6 In contrast, Wald et al—summarising the modelling of integrated, sequential, and contingent screening strategies from data derived from the Serum Urine and Ultrasound Screening Study (SURUSS)13—concluded that integrated screening had the best screening performance.9 However, recent reports underline the insufficiency of data on these three screening strategies.5 9 14 For sequential and contingent testing, there is no consensus on cut-off levels, resulting in variations in performance measured.8 A workshop of experts convened by the National Institutes of Health concluded that the contingent screening strategy needed further study before its widespread implementation could be recommended.8
Given the countless screening strategies available,7 15 regional differences in local resources,5 16 and the costs of prospective clinical studies,17 no empirical study can be foreseen that would compare all options available for the three approaches to combining first and second trimester analyses. There are indeed too many possible combinations of tests, sequences, cut-off values, and schedules to be handled in a single study. Only computer simulations can compare all the options to identify the most cost effective.6 9 17 18 19
In the current analysis, we performed computer simulations to compare 19 different screening options based on the three screening approaches (integrated test and sequential and contingent screenings) with various cut-off levels and using real data from the SURUSS trials.9 13 Our aims were to
Analyse the cost effectiveness ratio of the different screening options from a public health perspective
Compare their performance estimates for an overall 90% detection rate by evaluating seven other relevant end points that cover the main outcomes in prenatal screening for Down's syndrome9 17:
1) False positive rate that defines the number of scheduled amniocentesis procedures
2) Number of procedure related miscarriages of normal (euploid) fetuses
3) Number of live births with Down's syndrome
4) Number of unnecessary terminations
5) Proportion of pregnancies affected by Down's syndrome that were screened by a first trimester test
6) Proportion of patients reassured early in gestation by first trimester testing
7) Proportion of continuing pregnancies that proceed to a second trimester test
Compare the effects of eight different first trimester cut-off values in contingent and sequential screening strategies to determine the optimal value.
Material and methods
Screening strategies and tests
The screening strategies considered were the integrated test, sequential screening, and contingent screening compared with maternal age alone (≥35 years), which has been the standard since antenatal diagnosis guidelines for invasive testing were established in the US in the late 1970s,20 and the triple test, which has been widely available in Europe and Canada since 1991.8 16 21 The box gives further details of the screening strategies and the tests used.
Definitions of screening procedures
Integrated test
Measurements performed at different times of pregnancy are integrated into a single test result. Unless otherwise qualified, it refers to the integration of nuchal translucency measurement (by ultrasound scan of the width of an area of translucency at the back of the fetal neck) and measurement of pregnancy associated plasma protein A (PAPP-A) in the first trimester with the quadruple test markers in the second trimester (measurement of maternal serum concentrations of α fetoprotein, unconjugated oestriol, free or total β human chorionic gonadotrophin, and inhibin A) together with maternal age.
Sequential screening
First trimester tests are performed (nuchal translucency measurement and PAPP-A) and interpreted immediately. If the result is positive, the mother is offered a diagnostic test (chorionic villous sampling), but if it is not positive, second trimester serum markers (quadruple test markers) are measured and the results combined with the first trimester results to form an integrated test.
Contingent screening
First trimester tests (nuchal translucency measurement and PAPP-A) are used to categorise pregnant women as high, low, or intermediate risk. High risk women (positive result) are immediately offered a diagnostic test (chorionic villous sampling), low risk women (negative test result) receive no further screening, and intermediate risk women (lower risk positive result) undergo second trimester screening (quadruple test markers) for an integrated test to be done.
Triple test
Second trimester test based on the measurement of maternal serum α fetoprotein, unconjugated oestriol, and free or total β human chorionic gonadotrophin, together with maternal age.
Sequential and contingent screening strategies consist of a sequence of tests with many possible cut-off values for the risk of the fetus having Down's syndrome, but screening performance has been reported for only eight different cut-off points for first trimester tests (1 in 6, 1 in 9, 1 in 30, 1 in 58, 1 in 114, 1 in 175, 1 in 237, and 1 in 307).9 We compared 19 screening algorithms comprised possible screening scenarios resulting from the three screening strategies (integrated test and sequential and contingent screening), different cut-off values for contingent and sequential screenings, the triple test, and maternal age alone. For contingent screening, we also used a lower risk cut-off of 1 in 2000.
Diagnostic tests
The diagnostic procedures included in our simulation were conditional on the stage of pregnancy in accordance with best practice in prenatal care. Thus, amniocentesis was used for prenatal diagnosis only after second trimester screenings results, whereas women with a positive result at the first trimester screening were considered for transabdominal chorionic villous sampling for caryotyping. Timing of procedure-related euploid miscarriages is dependent on the test undergone. Our computer model also accounted for the performance characteristics of the diagnostic tests (amniocentesis and chorionic villous sampling).
Decision model
We developed a computer program in C11 language that simulates all 19 screening scenarios. The program was devised to
Generate a virtual population with characteristics related to the prevalence and clinical course of pregnancies affected by Down's syndrome and unaffected pregnancies, as well as maternal age distribution
Construct the various screening algorithms for the screening and diagnosis options for Down's syndrome
Simulate screening of this virtual population with each algorithm and measure pregnancy outcomes
Establish the direct healthcare costs of each screening option using costs of procedures and of complications provided by the Ministry of Health.
Figure 1⇓ shows a simplified version of the decision model. The model includes several possible outcomes of screening and diagnostic testing decisions, including birth of a baby with no chromosomal disorder, birth of a baby with Down's syndrome, miscarriage, elective abortion after positive test results, and whether a pregnancy loss occurs after a diagnostic test.
Data used in analysis
Table 1⇓ lists all the input variables and their data sources. Table 2⇓ shows the demographic characteristics of the virtual population used in our computer simulation and the most critical assumptions. Our virtual population of 110 948 pregnancies corresponded to all pregnancies in Québec province in year 200122 23 with the same maternal age distribution. This population was of mixed origins, mainly white, and table 2 contains details of maternal ages.
Pregnancies affected by Down's syndrome and risk of miscarriage—We estimated the risk of a pregnancy being affected by Down's syndrome by multiplying the specific odds by maternal age of having an affected live birth24 25 (corrected for the spontaneous miscarriage of fetuses with Down's syndrome26 27) by the likelihood ratio (for a given set of marker values) obtained from the overlapping multivariate Gaussian distributions of marker levels in affected and unaffected pregnancies.9 If a woman chooses to undergo amniocentesis, she is at risk of a miscarriage before she has the test and either before or after the test results are given.
Test performance—We used the distribution of marker values in pregnancies affected by Down's syndrome and in unaffected pregnancies reported in the SURUSS trials to determine the parametric values (means, standard deviations, correlation coefficients, and truncation limits).9 13 We included rates of false positive and false negative test results in the calculations.
Other probabilities—Our simulation included the level of compliance previously estimated in the Québec population28—that is, the proportion of women who consent to participate in prenatal screening for Down's syndrome and to a diagnostic test after a positive screening result. We also included the chance that a woman will choose elective abortion after a positive diagnostic test.28
In Canada, in accordance with the Canadian Health Care Act, all services considered as medically necessary are generally provided exclusively inside the public healthcare system and are free of charge. We considered only direct costs under the Ministry of Health and the Public Medical Assurance perspectives. Unit prices were averages for Quebec province calculated from government databases (financial and operative databank SIFO and APR-DRG). Costs for laboratory and imaging tests were from technical units for Quebec province.29 30 31 32 33 These unit prices include the costs of necessary support services (such as administration, security, cleaning, etc).34 Items considered for costing comprised screening costs and medical services related to the following outcomes—birth, spontaneous miscarriage, elective abortion after positive test results, or pregnancy loss after a diagnostic test. Costs are expressed in Canadian dollars ($C) at 2007 values (exchange rate: $C1.0748=$US1.00).
Cost effectiveness analysis
Our approach follows guidelines for cost effectiveness analysis in prenatal diagnosis.17 The analyses were run to evaluate global costs, cost effectiveness ratios (costs per case of Down's syndrome diagnosed), and incremental cost effectiveness ratios comparing all 19 screening options. Incremental cost effectiveness ratio was calculated by dividing the difference in cost between each screening strategy and screening based on maternal age only (amniocentesis for women aged ≥35 years) by the difference in the number of cases of Down's syndrome detected by the two strategies. The incremental cost effectiveness ratio therefore represents the additional cost or savings per additional abnormality detected. All measured costs occurred within one year; and so there was no need to discount costs and effects over time.17
Sensitivity analyses
In order to test the robustness of our findings, we performed a series of simulations (univariate sensitivity analyses) in which we varied the major assumptions of the modelling with values proposed in the AETMIS report22 and recalculated the cost effectiveness ratios.17 Apart from the values shown in tables 1⇑ and 2⇑, we also tested the effects of
Rates of consent to participate in prenatal screening of 65% and 80%22
Rates of fetal loss from chorionic villous sampling of 0.5%, 1%, and 2%, and from amniocentesis of 1% and 1.5%22
The proportion of couples with a fetus with confirmed Down's syndrome who would undergo pregnancy termination, namely 70% and 80%
Varying the sensitivities and false positive rates of the screening strategies over the ranges achieved in the SURUSS trial.9 13
Estimation of confidence intervals
In order to generate 95% confidence intervals for our estimates of cost effectiveness ratios, we used the method of replications.35 This consisted of simulating each screening option 100 times on a virtual population of 110 948 pregnancies (100×110 948 individuals). It resulted in more than 11 million individuals being screened for computing the mean cost effectiveness ratios for each screening scenario.
Cost effectiveness analysis
Table 3⇓ summarises the results of our cost effectiveness analysis. The most cost effective screening strategy seems to be contingent screening (cost effectiveness ratio $C26 833 per case of Down's syndrome with a high risk cut-off value of 1 in 30). These results were robust in sensitivity analyses: none of these different models yielded a different relative rank of the various screening scenarios analysed. Compared with the reference screening strategy (maternal age only), the incremental cost effectiveness ratio of contingent screening (with cut-off value of 1 in 6) is −$C30 963 per averted birth with Down's syndrome. The estimated costs per prevented birth with Down's syndrome were $C35 215 for sequential screening, $C38 944 for integrated screening, and $C43 809 for the triple test. Consequently, the contingent screening strategy seems to be most cost effective. As expected, amniocentesis based on advanced maternal age only is the least cost effective option, with a cost effectiveness ratio of $C74 037 per case of Down's syndrome.
Screening strategies outcomes
Depending on the specific end points that are considered, different screening approaches may seem more appropriate. The most appropriate screening test for Down's syndrome should have the lowest false positive rate (to minimise the number of invasive procedures required and their related complications), the highest detection rate, and the best cost effectiveness ratio.16 The screening procedure (non-invasive screening and diagnostic technique) may also interfere with the number of live births with Down's syndrome. Figure 2⇓ shows the effects of the different screening strategies on these major end points—false positive rate, number of procedure-related euploid miscarriages, and number of live births with Down's syndrome.
Early diagnosis of pregnancies affected by Down's syndrome may result in unnecessary terminations since some of the affected fetuses would be spontaneously aborted before term.9 Some studies have suggest that, in order to avoid this problem, women prefer a lower false positive rate,36 37 but others suggest that women want early diagnosis.38 39 We evaluated the effect of the different screening strategies on this issue by calculating the number of unnecessary terminations, the proportion of pregnancies affected by Down's syndrome screened by a first trimester test, and the proportion of continuing pregnancies that proceed to a second trimester test (fig 3⇓).
Contingent and sequential screening strategies produced similar results on the major outcomes—respectively, 1.43% and 1.55% for false positive results (fig 2⇑), six procedure related euploid miscarriages each (fig 2⇑), 16 unnecessary terminations each (fig 3⇑), and 43.71% and 44.13% of affected pregnancies with a positive first trimester test (fig 3⇑) (these results are those achieved with the most favourable cut-off value). However, contingent screening was unique in permitting 77.81% of patients to be reassured at the first trimester and 77.95% of women to avoid retesting in the second trimester (proportion of continuing pregnancies that proceed to a second trimester testing, fig 3⇑). Indeed, contingent screening (whatever the cut-off value) allowed about 78% of women (77.75% to 78.51%) to be reassured with a negative screening result early in gestation, which was obviously not possible integrated, sequential, or triple test screening strategies.
In the same manner, we found that integrated screening was associated with a low number of procedure related euploid miscarriages (n=6, fig 2⇑) and, in conjunction with the triple test, gave the best result for unnecessary terminations (n=6 for both, fig 3⇑). Moreover, the integrated test's false positive rate is close to those achieved by sequential and contingent screening (1.82%, 1.43%, and 1.55% respectively, fig 2⇑).
Impact of cut-off values in first trimester screening
We simulated the use of different cut-off values for the risk of a fetus having Down's syndrome in the first trimester tests of the contingent and sequential screening strategies. For both contingent and sequential screening, these had significant effects on
Cost effectiveness ratios (from $C26 833 to $C37 260 and from $C35 215 to $C45 314 per case of Down's syndrome respectively, table 3⇑)
False positive rate (1.55% to 3.69% and 1.43% to 3.66%, fig 2⇑)
Number of procedure related euploid miscarriages (6 to 46 and 6 to 45, fig 2⇑)
Number of unnecessary terminations (16 to 26 and 16 to 25, fig 3⇑)
Proportion of affected pregnancies with a positive result from the first trimester test (44.1% to 86.1% and 43.7% to 86.3%, fig 3⇑).
Limitations of study
Our results are based on mathematical modelling and not on prospective observational data. However, we used empirical data and true healthcare costs as input parameters for the simulations. Given geographical limitations, resource differences between regions, and the many possible screening strategies for Down's syndrome, it is unlikely that a large scale, comprehensive, prospective, clinical trial could be organised across North America. Our approach was useful in allowing 19 different strategies to be assessed and compared simultaneously.18 40 41 42
Our reported cost effectiveness ratios were based on Québec province's healthcare system and costs. However, given the robustness of our findings observed in the sensitivity analyses (in which we varied the values of the major assumptions of the modelling), our conclusions are likely to be applicable to other jurisdictions. The demographic characteristics of the population we simulated are similar to those of other Western countries. In particular, the mean maternal age and the proportion of women aged ≥35 years were similar to those of the populations of the SURUSS and the FASTER trials, which represented women in the UK and US.12 13 The effect of the maternal age distribution on the detection rate of Down's syndrome is reported to be limited and unlikely to be large enough to influence screening policy decisions.43 Also, pregnancy outcomes are likely to be similar across different populations. With respect to healthcare costs, they could be estimated for other provinces by using other costs units in the simulation model.
Most improvements in overall cost effectiveness attained with a screening strategy are due to the reduction in live births with Down's syndrome.18 An important drawback of studies that incorporate the future costs of caring for a child with Down's syndrome into their cost effectiveness or cost utility analyses6 44 is that they do not incorporate commensurate benefits of having such a child.45 In accordance with previous reports,9 46 47 48 we decided not to consider the cost of caring for a child with Down's syndrome. However, computing the cost per case of Down's syndrome detected allows us to compare different screening strategies on a common ground.
Our study did not consider the logistical problems and costs of implementing a screening strategy that includes nuchal translucency measurement or chorionic villous sampling in North America.8 15 Neither technique is universally available throughout the US and Canada,15 18 and the cost of establishing a screening programme with mandatory use of the techniques, including its administrative and technical challenges, is unknown.15 50 Because of this, some have speculated that such a screening programme is not justifiable15 or has serious implications for resource use.16
Cut-off values for contingent and sequential screening options
There is no consensus on what are the most appropriate cut-off values for high risk in the first trimester tests for contingent and sequential screening strategies,8 even though they could have a major effect on screening performance.6 9 Our data show the impact of modulating the cut-off values and confirm that, for risk assessment to be successful, a careful choice of cut-off is required.
The first aim of using non-invasive screening is to reduce the number of procedure related euploid miscarriages.50 Our analysis suggests that first trimester cut-off values for high risk of 1 in 6 and 1 in 9 are most appropriate because they lead to the same number of procedure-related euploid miscarriages as occurs with the integrated test (which is considered the optimum screening option for limiting the procedure related euploid miscarriages9). With these cut-off values, contingent screening remains more cost effective than the integrated test and sequential screening. Our results are consistent with those of Wald et al,9 who reported that, with a first trimester cut-off point for high risk of 1 in 30, the number of procedure-related euploid miscarriages was greater in contingent and sequential screening options than in the integrated test, and that contingent screening, but not sequential screening, was more cost effective than the integrated test.9
For contingent screening, the optimal cut-off value seems to be 1 in 9 cut-off with regard to cost effectiveness. The cut-off value of 1 in 30 showed the best cost effectiveness ratio, whereas the value of 1 in 6 produced the best incremental cost effectiveness ratio: hence, an in between value of 1 in 9 should achieve the best balance between these performance measures.
This value has important implications because the first trimester cut-off values traditionally used by healthcare professionals are much lower. Before the development of new screening strategies that combine first and second trimester tests,7 8 only the combined test (first trimester measurement of nuchal translucency, pregnancy associated plasma protein A, and β human chorionic gonadotrophin) used a first trimester cut-off value. The value for this test, which has become the de facto standard of care in the UK and may spread in North America,6 51 is 1 in 670 for obtaining a 90% detection rate.13 With strategies that combine first and second trimester tests,7 8 healthcare workers would have to be prepared (and trained) for the use of the much higher level of 1 in 9, and appropriate information would be needed for patients. Risk levels are often misunderstood by patients,52 and it may be difficult to refuse a diagnostic test at first trimester for an anxious woman with a calculated risk close to the 1 in 9 cut-off point because some women want an early diagnosis.38 39 However, the use of inappropriate cut-off values in the first trimester may produce an excess in iatrogenic losses and costs.
Different screening strategies
Contingent screening
Our results confirm previous reports6 that contingent screening dominates all other options:
Best cost effectiveness for achieving a lower overall false positive rate leading to better outcomes
Fewer procedure related euploid miscarriages and unnecessary terminations
Lowest cost per case of Down's syndrome detected
Best incremental cost effectiveness ratio.
Contingent screening also offers early testing to those most likely to have an affected pregnancy (as does sequential screening), and it is the only option that allows the majority of women to be reassured early in gestation. Furthermore, it minimises costs by limiting retesting at the second trimester. Avoiding such repeat blood tests is a major reduction in unneeded clinic visits and their attendant costs. In our model, starting with 110 948 pregnancies, the removal of about 86 484 second clinic visits, blood draws, and reagent costs, results in major cost savings. Additionally, savings to the patients in terms of travel and time off work, are not to be ignored.5
It has been proposed that all women who screen negative at the first trimester will still require screening at the second trimester for neural tube defects8 and that this may affect the cost effectiveness of contingent screening.9 However, this is not applicable in our study since the standard practice in Canada and similar countries is that all women undergo a fetal ultrasound assessment at 20 weeks of gestation,5 50 so that a second trimester test for serum α fetoprotein seems to be unnecessary.5
Sequential screening
In accordance with reported data,6 9 we found sequential screening to be outperformed by contingent screening. This is probably due to the high proportion of women who proceed to a second trimester test under the sequential screening scenario. However, the contingent and sequential screening options are very similar with regard to other outcomes.
Integrated test
Our results confirm reports that the integrated test results in few procedure related euploid miscarriages9 and that its principal advantage is the low number of unnecessary terminations (because this screening option allows a diagnostic test only in the second trimester). However, the integrated test does not allow identification of affected pregnancies at the first trimester, nor reassurance for women with unaffected pregnancies. This could be a disadvantage given that women seem to want an early diagnosis.38 39
Triple test
Considering cost effectiveness and outcomes, triple test has too many limitations to be maintained as a desirable Down's syndrome screening strategy. But a screening option that starts in second trimester should also be available because one third of women seek prenatal care after the first trimester.7
Amniocentesis for women aged ≥35 years
We show here that scheduling an amniocentesis for women aged ≥35 years is not a cost effective strategy and should be abandoned rapidly. Also, this approach may produce seven times more procedure related euploid miscarriages than contingent screening.
What screening option?
We conclude that, depending on local conditions,16 contingent screening is the preferred screening strategy for Down's syndrome with a first trimester cut-off value for risk of 1 in 9. Obviously, if it becomes possible to perform non-invasive prenatal diagnosis of Down's syndrome by means of fetal DNA or cells in maternal blood new cost effectiveness studies will be needed.12 53 54
What is already known on this topic
Prenatal screening for Down's syndrome is widely used, with many different screening strategies but still no consensus on the most cost effective approach
New strategies that provide a relatively high detection rate combine tests at both first and second trimesters
What this study adds
For strategies that combine first and second trimester tests, the choice of cut-off value for risk in the first trimester test significantly influences the cost effectiveness ratios and outcomes
Contingent screening, with a first trimester cut-off value for high risk of 1 in 9, is the preferred option. This cut-off value is much higher than those generally used in screening programmes
Cite this as: BMJ 2009;338:b138
Contributors: JG was principal investigator and was responsible for the study design and coordination, analysis of data, and drafting the manuscript. DR, GG, and DD made the computer simulations of screening procedures and contributed to the data analysis and drafting the manuscript. EB validated the clinical design of the study and contributed to drafting the manuscript. JF and FR were responsible for analysis of pregnancies' characteristics and screening options applicable in Québec and interpretation of results and contributed to drafting the manuscript. JG is the guarantor for the study.
Funding: This study was funded by the CanGèneTest research consortium on genetic laboratory services through a team grant from the Institute of Genetics of the Canadian Institutes for Health Research, the Heart and Stroke Foundation of Canada, the Canadian Agency for Drugs and Technologies in Health, and the Canadian Genetics Diseases Network of Centres of Excellence. EB holds a clinician-scientist award from the Canadian Institute for Health Research and the Jeanne et Jean-Louis Lévesque Perinatal Research Chair at Laval University.
Competing interests: None declared.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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