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AceShowbiz - %cAnna Faris% is back into the dating game, two months after announcing her split from her husband of eight years, %cChris Pratt%. The "What's Your Number?" star has reportedly been seeing cinematographer Michael Barrett, who according to his IMDb worked on Anna's upcoming movie "Overboard".
An eyewitness tells E! News that Anna and Michael dined at Italian restaurant Modo Mio in the upscale Los Angeles neighborhood of Pacific Palisades twice in a span of two days. During the first sighting, the pair reportedly sat on the patio and enjoyed a bottle of red wine.
The source describes the outing as looking "like a date." The source dishes, "They were laughing at the table. She looked very happy and had a smile on her face when she was leaving." Michael picked up the tab before they left the place.
The following day, they dined at Modo Mio again and enjoyed drinks and dinner on the patio. The eyewitness reveals that the pair had "several dishes of various pasta and salad" and shared a bottle of red wine.
"It was definitely a dinner date," the source gushes. "It seemed romantic in the way they were looking at one another and how they were laughing at the table... No one in the restaurant realized it was her, but she definitely looked to be on a date." Michael paid the check and they left together.
Anna and Michael were also caught on camera attending a family-friendly carnival in L.A. together on September 10. They tried to hide under baseball caps. The "Mom" star held a glass of wine, while the cinematographer had beer.
Anna and Chris announced their legal separation on August 6. They have a son together, 5-year-old Jack.
Anna tells PEOPLE about her relationship with the "Guardians of the Galaxy" actor since their split, "We'll always have each other and be incredible friends." She adds, "There is still so much laughter in our lives together, and he is so proud of me, still. We watched each other grow, and he still cracks me up all the time. And I think I crack him up - unless he's a really good actor and great at faking laughter."


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Living In Michigan Sucks!!!
Less than a week ago we had several inches of snow on the ground and I was wearing a parka. Two days ago I believe we hit 60 degrees and I was wearing my leather jacket again. These drastic weather changes suck. And because of these changes, I'm in a fight to keep from getting sick yet again. I hate Michigan weather!!!
3 years ago

subset: commoncrawl


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A West Australian man unwinding after work had his serenity rudely interrupted by the snap of a mouse trap — what was inside the rodent-catcher almost knocked him off his chair.
"I turned around, had a quick look and literally jumped off my stool because there was a snake about three metres away from me in the mouse-trap," Cascade local Anthony Parker told The Esperance Express.
"It was just trying to escape by trying to bite the trap off I think; I think it may have thought the trap was alive trying to get it."
A short video he posted to his Facebook page shows the serpent writhing to break free of the oversized trap and snapping at it with lightning speed.
Mr Parker said he and his wife has placed a number of traps around their home on Sunday after his wife thought she heard the rodents.
He said the snake may have also wanted to rid the house of the vermin.
"We were away over the weekend so there was probably mice running around the house which attracted the snake in," Mr Parker said.
Despite his initial reservations Mr Parker killed the snake, fearing that the reptile could lash out at his young son in its agitated state.
"I did feel sorry for it, but I couldn't risk moving it when it was like that," he said.


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text: Acasă Father of Peace (FP) (English) FP S01E02 Fr. Thaddeus – Spiritual Talks (Part 2/5) Father of Peace (FP) (English) FP S01E02 Fr. Thaddeus – Spiritual Talks (Part 2/5) ianuarie 6, 2016 Facebook Twitter Google+ Din păcate acest articol este disponibil doar în Engleză Americană. ARTICOLE SIMILAREDE LA ACELAȘI AUTOR (English) "Who can fight against love?" (Elder Thaddeus) (English) We are called to be children of light (Elder Thaddeus) (English) Fr. Thaddeus – "I don't want to think evil. I want only peace!" (Part 5/6) (English) Fr. Thaddeus – How to communicate with departed loved ones (Part 4/6) (English) Fr. Thaddeus – How to pray today (Part 3/6) (English) Fr. Thaddeus – Children trust us completely (Part 2/6) (English) Fr. Thaddeus – Advice to the Young (Part 1/6) (English) Fr. Thaddeus – Spiritual Talks [5/5] (FP, S01E05) (English) Fr. Thaddeus – Spiritual Talks [4/5] (FP, S01E04) LĂSAȚI UN MESAJ Renunțați la răspuns Please enter your comment! Please enter your name here You have entered an incorrect email address! Please enter your email address here Articole recente Esenta crestinismului dupa Sf. Nicolae Velimirovici decembrie 14, 2019 Biserica este raiul pe pamant (Pr. Ghelasie) decembrie 6, 2019 (English) A recent miracle performed by the Mother of God (Fr.... noiembrie 30, 2019 (English) Which partner should I choose? (real story of a young... noiembrie 22, 2019 Fiule, da-mi inima ta! (Pr. Ghelasie) noiembrie 15, 2019


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Product Description
Bestlite has been in continuous production since 1930. Winston Churchill is numbered amongst its many famous users. The Bestlite design was conceived by Robert Dudley Best who was highly influenced by the Bauhaus. Eighty years on, the Bestlite design stays close to its industrial roots and true to its original design. Bestlite is held in permanent collections at both the Victoria & Albert Museum and the Design Museum in London. Loved by architects, designers and design aficionados throught its 80-year history, today, Bestlite enjoys global iconic status.
The arm of the lamp is extendable and can be tilted 90 degrees from horizontal to vertical and the shade can be rotated 360 degrees. The textile cord matches the shade, except full chrome which is black.
Lamp height: 1160 mm, Tube length: 62 cm, Shade height: 14 cm, Shade diameter: ÕÉ16 cm
Cord: 2000 mm
Materials: The arm of the lamp is made of chrome and the shade is powder coated metal.
Finishes: Black/Chrome, Off-White/Chrome, Matt White/Chrome
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Greece Around is a worldwide search engine and a promoter of greek products and businesses. We started our action in October 2016 in Netherlands where the greek businessmen honoured us with their trust.
Our primary goal is to unite the Greek people working in the field of gastronomy and to promote their business with the most modern advertising media such as video, photography and social networking. Through educative actions full of new ideas, our vision is to create a renewed and consistent image of greek businesses and greek cuisine in its whole.
At the same time our mission is to educate and promote - through GreeceAround - the Greek businessmen and producers who are active in the country and want to export their products. Finally, our vision is to help create more vertically integrated units with greater export growth potential.
From a small village in England with only 10 Greek inhabitants, to Melbourne of Australia that counts more than 400.000, the Greeks living abroad are traditionally active in the field of gastronomy. Having two common points of reference, their country and their profession, they take good care of keeping the greek network alive.
But what happens when we bring a network into the internet? Take for example the Harvard University network of students who entered the internet and created the well-known Facebook. Greece Around, of course, is not one of the many social media networks, but uses them in order to have a huge dynamic that consists of thousandsgreek businesses around the world and millions of Greeks who work in these businesses. Combined with the world-known Greek-Mediterranean cuisine and the high quality Greek products, Greece Around's role is to bring together the Greek network and the internet and to promotethe action of the Greeks around the worldwith the best possible way.
Because of our experience in the advertisement field of work, a vast number of businesses abroad trust us for the promotion of their business throughout the world wide web! The efficiency and methodicalness of our work, is proved by the thousands of people that the Greece Around channel advertisements attract. Greece Around is a loyal partner to businesses for it ensures a plethora of services that cover all of their needs.
Greece Around's team consists of experienced people equiped with a contemporary view in matters of technology and advertisement. Covering a wide range of services, we provide to the collaborating businesses everything they need in order to reach the highest promotional and marketing level. Our services main aim is extroversion of the Greek businesses!
If you own a business in Greece and you want to start or strengthen your export activity, GreeceAround gives you the opportunity to promote your products with the most modern and effective advertising media.
If you have a greek business abroad, GreeceAround gives you the opportunity to acquire high-level advertising material (video, food-photos, GIF) and display it targeted (in your area) on the latest social media networks (Facebook, Instagram) through GreeceAround.
Greece Around presents you its new service, chef consulting. With this innovative step forward, Greece Around combines its forces with renowned chefs in order to revitalise the menus of Greek restaurants. We explore the new avenues of fine dining while maintaining the traditions that we so respect. Chef consulting is here to take Greek gastronomy to a higher level!
Greece Around in partnership with one of the biggest job search websites in Greece, Ergazomenos.gr, after considering your needs have created a new service: "Finding staff for Greek restaurants abroad"
One of the basic goals of this application, is to facilitate entrepreneurs who collaborate with Greece Around to concentrate and organise their reservations, staff program and product orders in a simplified way.
At the same time, it is a multi-tool for greek food import companies, both for the organisation of their orders and for the direct contact with their customers.
The most rewarding time for a creator is the recognition of his or her work.
Below you can read some of our customer's comments.
Bouillabaisse ofwel vissoep is een heerlijke volle maaltijdsoep uit het ...
Category: Hoofdgerecht met vlees
Cuisine: Griekse Keuken
Deze heerlijke kippensoep heb ik al vaak gemaakt en valt altijd goed in ...
Deze heerlijke kippensoep heb ik al vaak gemaakt en valt altijd goed in ...
Deze heerlijke kippensoep heb ik al vaak gemaakt en valt altijd goed in ...


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A Dog Registration Amnesty will run for the month of May to combat a rising number of unregistered dogs in the region.
During the amnesty, Noosa residents can register their dogs free of charge (usually $160 or $40 for desexed dog) by popping into Council offices on Pelican Street or by submitting the online form.
Local Laws Manager Phil Amson said there's an alarming spike in the number of unregistered dogs in Noosa.
"Almost half of all dogs that come into our pound, are unregistered.
"Our officers have noticed an increase in the number of unregistered dogs in the region. In fact, both anecdotal and statistical evidence suggests that we have between 5000 and 8000 unregistered dogs in Noosa," he said.
According to the Animal Management (Cats & Dogs) Act 2008, dogs older than three months of age must be registered with Council.
Mr Amson said unregistered dogs affect the community in a number of ways.
"Dog owners mightn't realise that the maximum fines for owning an unregistered dog is $2610, so it can be quite costly. Further to that, dog registrations allow Council to identify and reunite pets with their owners.
"We are encouraging locals with unregistered dogs to register them for free during May as part of our no-questions-asked Dog Registration Amnesty."
This initiative is further supported by a joint venture with RSPCA Queensland to offer heavily discounted Microchipping Days at various locations around Noosa from June until the end of the year.
"We are also teaming up with RSPCA to provide $24.95 Microchipping Days so pet owners can easily drop in to a local park and microchip their cats and dogs.
"Once again, we need pet owners to take responsibility to register and microchip their animals. Fines for owners who fail to microchip their cats and dogs can be as high as $2600 and as a Council, we are making it easy for owners to do the right thing."


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Be a Delegate, and Meet and Associate with India's Best Support and Service Providers, and Key Specialists for Shopping Centres and Retail Ventures at One Place.
ISCF '19 is nation's biggest event that brings together companies providing impeccable services and products to shopping centres and most sought after experts from key industrial sectors. Delegates of ISCF will get an opportunity to network and engage with service and product providing companies and experts at a more personal level.
The event empowers retailers and delegates with innovative ideas, valuable insights and future scopes that enable sustainable growth and increased revenue.
As a delegate, you will get access to conference, meet with the exhibitors, network with key speakers over lunch and dinner, invitation for ISCF Awards and much more.


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These are just some of the things I have been working on this week to take to the Street Party on Sunday at Racecourse Rd, Hamilton.Small market totes...Say no to plastic bags...! Each one has a gorgeous Yo Yo decorating it.. $12New style pants with short fringing...You like ? Stocked up on lots of sizes.. Also available at Handmade Heaven and in my etsy store too...
Thursday, September 17, 2009
This Weeks Creations
Posted by bubbachenille at 8:06 PM
2 comments:
- The Handmade Expo and Handmade Heaven said...
Oh Mum, I am loving those little itty bitty bubba pants...with the fringe..SO SUPER CUTE
- September 18, 2009 at 9:14 AM
- Kris Meares - Tag Along Teddies said...
Hey Miriam! Those bags look fantastic - and you have my favourite colours - green and red! :0) What a shame I won't be in Brisbane to join the street party. For the first time in ages, we're home for Carnival of Flowers and are just taking it easy - walk up to see the parade, maybe head out to the Geham craft fair -and lots of relaxing in between! Hope the street party goes well for you! Bear Hugs! KRIS
- September 19, 2009 at 9:02 AM
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text: PARIS (Reuters) – French bank Natixis (CNAT.PA) said on Monday that it was not in talks over a possible takeover offer for Coface (COFA.PA), the credit insurance subsidiary in which Natixis has a stake of around 41.7%. "Natixis states that, as previously indicated, its investment in Coface is financial in nature and not strategic. In this context, Natixis regularly explores options for its holding in this asset," Natixis said in a statement. "Nonetheless, there is currently no discussion underway likely to give rise to the submission of an offer for this holding," added Natixis. Reuters reported on Friday that Apollo Global Management (APO.N) had approached Coface with an offer.


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Special Bunker for Doomsday
Vivos company, based in the City of Del Mar, Calif., claimed to have prepared a complex of underground rooms specifically for Doomsday. Located beneath the Mojave desert, bunkers were designed to make residents safer from nuclear attack and natural disaster while making their stay comfortable, like staying at home.
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What is Baseflash?
Baseflash, also spelt BaseFlash, is a browser extension, and, if you have it on your computer, you should remove the application right now. Baseflash is an adware program which replaces websites' advertisements with its own advertisements, which are supposed to match your interests. These changes are also expected to make your browsing experience unique; however, soon you may find that Baseflash is quite obtrusive and may decide to remove it from the browsers.
The application is compatible with Internet Explorer, Google Chrome, Mozilla Firefox, and some other browsers. Baseflash used to be available at baseflash.com/#; however, at the moment, the installer is inactive. However, baseflash.com/# is not the only source of the application. The browser plug-in may be bundled with freeware, which means that you can encounter Baseflash when installing some other browser plug-in, media player, or any other application promoted on freeware websites.
What does Baseflash do?
Baseflash monitors how use the Internet so that the information can be used to improve the quality of the service. It may arrive at your computer along with some cookies and other tracking files, whose function is to record your search terms, clicks, the URLs of the websites that you access, the type of the browsers that you have and their versions, operating system, Internet service providers, and so on. The same or similar information may also be used by the third parties to which you are exposed through Baseflash.
Bear in mind that Baseflash is not associated with the websites to which you are redirected. Baseflash does not control the activities of the third parties, which means that you interact with all those advertisements at your own risk. Stay away from advertisements that suggest installing or updating some computer applications, because the advertisements may be just a hoax to make you launch some unreliable installer. If you are dissatisfied with Baseflash advertisements, remove Baseflash from the computer as soon as you can.
How to remove Baseflash?
Our team at Anti-Spyware-101.com recommends using SpyHunter. This application can remove the adware program for you and also safeguard the system against multiple computer threats. If you have not computer security tool, your PC is highly prone to computer infections. Implement the recommended application and discover how easily you can get rid of Baseflash and shield the system from Trojan horses, rootkit, ransomware infections, etc. Do not hesitate to implement SpyHunter because your operating system may get afflicted any time; so act right now if you want to browse the Internet safely.
How to get rid of Baseflash
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- Press Alt+T and click Manage Add-ons.
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- Press Alt+F.
- Point to Tools and click Extensions.
- Remove the unwanted extension.
If you do not know how you have installed the adware program, it is worth scanning the system. If it contains some other unreliable programs, they should be removed from the computer, too. To find out what the security status of the computer is, click the button download, download and install the scanner and launch a system scan.
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What Is the Difference?
MyDifference.ca has 2 simple rules in selecting beautiful items to offer you. The product must be either 1. A Fair Trade Import or 2. Canadian Made.
MyDifference.ca began with an idea of mine a to create an online boutique catering to shoppers who are searching for eithically made or local fashions and accessories that are stylish and pretty while also helping local Canadian businesses or small artisans in other parts of the world. Every purchase you make has an impact!
I sincerely hope you enjoy shopping with MyDifference.ca. Please feel free to contact me with any questions, comments or concerns.
Thank You!
Deb Thompson
Click on the icons below to Follow MyDifference on Facebook & Instagram!


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Like your favorite restaurant with a drive-up window, coyotes have favored lunch stops for their comfort food and these hotspots change by the season. As you plan hunts throughout the year you need to explore your hunting sites for these seasonal food choices.
Here are some diners that may see increased coyote traffic in specific seasons.
During winter, especially the end of winter, coyotes turn their attention from scavenging refrigerator leftovers and breathe a collective sigh of relief as livestock birthing begins. Breeding is wrapping up and paired coyotes begin to establish territories. They need a constant food source and before spring blooms, livestock can provide a wealth of nutrition. Some coyotes may prey on young of the year; others capitalize on the occasional stillborn baby.
Near big livestock operations coyotes can actually relish in eating afterbirth, plus they'll dine on calf excrement, which is rich in cow milk and sports calories even after a trip through a calf. Your goal is to seek any livestock producer from cows to hogs and sheep to turkeys.
Coyotes cruise for these treats on the outskirts of a herd or flock, and you may see an uptick in your success by watching the flock and spiking curiosity with coyote howls. Get your Nikons ready for a security patrol!
Livestock producers have artificially pushed their birthing window back to ensure animals are ready for fall markets. Mother Nature still adheres to a stringent schedule of having babies when the weather is nice enough to support survival.
In spring deer, pronghorn and elk birthing spikes throughout much of the country. The research is irrefutable on this topic. From coast to coast the data is piling up that coyotes switch their diet from rodents to fawns in spring. Many studies indicate their fawn diet may run as high as 70 percent of their total intake in the month of June. In the Southeast, this may occur a bit later in summer as birthing times may be staggered.
Coyote pups demand that parents stock the refrigerator and coyote parents realize fawns can provide the meals for a short window as the countryside blooms. With this in mind, a bawling or dire bleat call imitating a fawn in distress draws the attention of most hunting coyotes. Set up near where you've heard coyote vocalizations and don't be afraid to add pup distress calls to ramp up the action.
Summer coyote hunting often drops off the radar screen of many predator hunters. If you're one of the diehards, keep in mind that coyotes are one of America's most adaptable wildlife species. They can swap nutritional needs faster than Donald Trump can fire off a tweet.
During late summer and into early autumn, coyotes habitually switch from an all-meat diet to more of an omnivore lifestyle. Gardens, vineyards and berry patches become hotbeds of coyote activity. In addition to fruits, berries and vegetables, melons shoot to the top of the list for coyote desirability.
Keep in touch with gardeners, large and small. They know when someone has been raiding their crops and if they water routinely the tracks will reveal the marauders. Nobody has included vegetable or fruit calls on their electronic callers so lean towards vocalizations and pup distress calls. You may even be able to take a sniper watch and never utter a peep until you send a Hornady V-Max downrange.
Whew! Autumn has arrived and you can begin to settle back into your typical fur-gathering habits. Coyotes will begin to disperse, but a few youngsters will hang close to den areas. If you don't find action by old dens, move your game to the most rodent-rich site you know.
Prairie dog towns, mouse-infested grasslands, rabbit-filled brush patches and others will be receiving the most attention from inexperienced young coyotes. Use simple prey in distress calls in these locations and you should score.
Coyotes have favorite drive-up windows just like you. As you map seasonal strategies consider where they may be dining during a particular time of the year.


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In accordance with the countrywide expansion of Daylight Saving Time, trading hours in Borsa Istanbul have been changed.
The announcement made by Borsa Istanbul Stock Exchange (BIST) indicates that following the Cabinet's decision to implement Daylight Saving Time throughout the whole year, the Borsa Istanbul administration conducted a survey to make the trading hours more compatible with foreign investors.
As a result of the survey, the opening sessions will start at 9:40 a.m. and end at 9:55 a.m. during both full and half days at the Equity Market. While the continuous trading will start at 10 a.m., there will be no changes on the closing time of the continuous trading on half days, but on full days, the closing time of the continuous trading will be extended from 5:30 p.m. to 6 p.m. Closing and single price transaction, on the other hand, will take place between 6 p.m. and 6:10 p.m. and close the session at 6:10 p.m.
At the Derivatives Exchange Market, the sessions will start at 9:30 a.m. on full days and end at 6:10 p.m. for single stock futures and at 6:15p.m. for other futures.
At the Debt Securities Market, the sessions will start at 9:30 a.m. and end at 5:30 p.m. on full days while at Equity Repo Market, the sessions will start at 10 a.m. on full days. New trading hours will be effective from Monday, Nov. 14, 2016.


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【十码中特今期_十码中特今期官网】China, EU should deepen comprehensive strategic partnership: Chinese state councilor
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BRUSSELS, March 18 (Xinhua) -- China and the European Union (EU) should continue to strengthen their comprehensive strategic partnership and enhance strategic communication and dialogue, Chinese State Councilor and Foreign Minister Wang Yi said here on Monday.
Wang made the remark when meeting with foreign ministers from the 28 EU member states. Wang said the meeting was the first of its kind since China and the EU established diplomatic ties 44 years ago and was a sign of increased mutual trust between the two sides, and would send a clear signal to the world that China and the EU would strengthen their strategic cooperation.
Wang pointed out that Chinese President Xi Jinping's upcoming visit to three European countries fully demonstrates the importance China attaches to Europe. "We have noticed that China-EU relations are becoming more stable, mutually beneficial and strategic, and the two sides share more common interests, a bigger common ground and more common goals," he said.
Although both sides have differences on some specific issues, cooperation has always been the mainstay of the China-EU relationship. In face of the complicated international situation, China and the EU should continue to strengthen their comprehensive strategic partnership, enhance strategic communication and dialogue, properly handle differences, demonstrate solidarity and mutual trust, and promote mutual benefit and win-win results. This is a shared responsibility for both sides, Wang said.
Wang emphasized China's firm support to the European integration process, the EU's unity and growth, and Europe's more important role in international affairs. These "three supports" are based on China's strategic grasp and long-term thinking of the evolution of the international situation. They are not an expedient measure, not targeted at any third party, nor will they affected by any momentary incidents that happen during the China-EU exchanges.
"We hope to see a multi-polar world, democratic international relations and more beneficial, inclusive and win-win globalization," Wang added.
During the dialogue, Wang briefed the European foreign ministers on the latest developments regarding the joint construction of the Belt and Road, the 16+1 cooperation format between China and Central and Eastern European Countries, China's development prospects and human rights protection, as well as the Venezuelan and Afghan issues.
The foreign ministers spoke enthusiastically and the two sides interacted actively, which enhanced mutual understanding.
The EU member states' foreign ministers praised the dialogue for being constructive and effective and affirmed the ten-point consensus between China and the EU.
Highlighting the importance of the EU-China comprehensive strategic partnership and the close attention they paid to China's rapid development and reform process, the foreign ministers expressed their willingness to work with China to cement strategic coordination and jointly cope with global challenges, so as to maintain multilateralism and promote world stability and development.


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Raising cattle means there are always times when you have to get your hands dirty. In mid-February I really got to get my hands dirty.
Normally I spend my weeks in the Kansas City-metro area working from the office, but for this week I was working from my family's ranch in the Flint Hills doing chores while my dad and brother were busy.
Going out to feed our cows one morning I found one of our fall calves stuck in a pond. He was nearly up to his neck in mud, so I wasn't able to drive him out of his predicament. I recruited my mother to drive a truck, and we were able to pull the steer out with a rope.
I cleaned the steer as best I could before we eventually took him to our machine shed to boost his temperature and monitor him more closely. It was a close call but he did survive.
Here are some photos that show the predicament we were in:
Like many ranches in our area we depend on ponds for stock water, but the current drought has dropped pond levels making mud a problem.
I struggled for 1.5 hours nearly submerged with my hip waders in almost freezing water before my mom and I could finally get him pulled past the pond bank.
After cleaning the mud off, we let the calf rest for 3 hours. He had a temperature of 88°F, so we took him to our heated machine shed to warm up. He was back on his feet again 12 hours later with a 99°F temperature.
Two days after rescuing the 450-lb. steer from the pond, we sent Calf #75 back to the pasture where he is now nursing his mother and eating in the feed line.


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Darwin man wears same trousers for 2.5 years
The fashion police have been https://www.goldengooseshoesit.com/ called in on a Darwin accountant who admits he has worn the same pair of trousers every work day for more than two years.
"Wayne" will not reveal his surname but is proud of wearing the same pants Monday to Friday, only washing them on the weekend.
The father of one says he sometimes gets another wear out of them on Golden Goose Saturday.
"I wear them all week, don't wash," he said.
"I do wash them at the end of the week and I sometimes wear them out on a Saturday night when I go to live theatre or wherever it may be.
"But nearly two-and-a-half years I've been wearing the same set of trousers."
Business etiquette specialist Patsy Rowe has told the ABC's Barry Nichols that Wayne's case is deeply troubling.
"I'm just a little concerned," she said.
"This is a personal matter Barry, and I wouldn't discuss it normally, about odour. One doesn't like to bring this up but is Wayne confident about his personal freshness?"


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BioMed Research International
Volume 2018, Article ID 4085298, 11 pages
Systematic Review of Appropriate Robotic Intervention for Gait Function in Subacute Stroke Patients
1Department of Physical Therapy, Graduate School, Sahmyook University, Seoul, Republic of Korea
2Department of Physical Therapy, Korea National University of Transportation, Chungcheongbuk-do, Republic of Korea
3Department of Physical Therapy, Sahmyook University College of Health Science, Seoul, Republic of Korea
Correspondence should be addressed to Wan-Hee Lee; rk.ca.uys@eelhw
Received 29 August 2017; Revised 12 December 2017; Accepted 25 December 2017; Published 6 February 2018
Academic Editor: Laura Guidetti
Copyright © 2018 Ji-Eun Cho et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to Cite this Article
Ji-Eun Cho, Jun Sang Yoo, Kyoung Eun Kim, et al., "Systematic Review of Appropriate Robotic Intervention for Gait Function in Subacute Stroke Patients," BioMed Research International, vol. 2018, Article ID 4085298, 11 pages, 2018. https://doi.org/10.1155/2018/4085298.


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The newly established PTI government plans to introduce a uniform education system in Pakistan in collaboration with private educational institutions. According to local media reports, the PM Imran Khan has emphasized the need for new modifications in the education system. He has also stressed that there should be a uniform education curriculum throughout the country.
The PM also criticized various educational systems in the nation as they are becoming the basis of discrimination in Pakistan. Previously, the federal minister for education Shafqat Mahmood had also mentioned that the Ministry of Education is focussing to form a uniform education policy.
Read Also: This girl comes forward to break the patriarchal system of Pakistan
O-level & A-level Education System
However, if the government introduces the uniform and the modified educational system is imposed in Pakistan; it would raise some questions about the continuation of O and A level education system. But, so far, no confirmation has been shared in this regard.
Not only that, the PTI government is also considering to improve the Madrasa system. The government has recommended for including Science, Maths and English Language as compulsory subjects for the students getting Madrasa education.
Do you think that a uniform education system would bring positive development in the education sector of Pakistan? Let us know in the comments sections.


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According to Bruce Rogers, Chief Insight Officer at Forbes, "Content marketing can be defined as the creation and distribution of meaningful insights, perspectives, and best practices that are valuable to a specific audience. The aim is to retain existing clients including doing more business with them and to attract new high-quality clients."
Content Writing simply has to do with creation and distribution of creative and engaging articles across digital platforms with the purpose of marketing goods/services, engaging relevant targets/customers, customer relationship building, creating publicity/awareness about certain causes, and so on.
Sequel to this article on top 8 resourceful websites for content writers and editors, here is a list of seven other web resources content marketers (Content Writers/Editors) can utilize to optimize their content marketing activities.
1. CoSchedule
This web tool basically does content planning, execution, and promotion. It has a calendar feature that can be used to plan editorial content, social media scheduling and analytics features. CoSchedule is available on www.coschedule.com.
2. Searchenginereports.net
This tool is used for checking the uniqueness of an article. Grammarly is integrated with this platform and makes it easy for users to also edit their articles after checking.
3. Pixabay.com
A good content needs to be properly illustrated and accompanied with relevant pictures. Pixabay.com provides users with free high-quality photos, illustrations, and vector graphics. The good thing about pixabay.com photos is that they are free to use, even for commercial purpose, without attribution.
4. Hubspot.com
Creating quality article title is not only desirable, it's very important! No matter how resourceful and good your article is, if the title is not creatively attractive enough, chances are that your article won't be read. If it's a suitable title to go with your already written articles, or title ideas to start your articles, hubspot.com is a go-to website.
5. Google Keyword Planner
While this tool is mainly for digital marketers that use Google Adwords, content writers can also use it to determine relevant keywords to creatively insert in their articles to enhance search engine optimization.
6. Google Alerts
Writing good articles is important. But what is much more important is writing relevant, fresh and up-to-date articles. Google alert enables users to "monitor the web for interesting new content" which can give them a "push-start" on what next to write about. Google Alerts is available here: www.google.com.ng/alerts.
7. GrammarBase
This web tool is an online grammar editor. It is free to use and doesn't require signing up. GrammarBase is available on www.grammarbase.com.


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SPRINGFIELD, Ohio – The No. 12 Marymount University men's volleyball team opened the Jim Coleman Invitational on Friday night, falling to No. 9 University of California, Santa Cruz, 3-1, at Wittenberg University.
The Saints took the first set of the match, 25-22, after opening the match on a 20-11 run.
Seniors Eric Wiles and Remington Shahan each put down four kills in the stint to lead the way.
The Banana Slugs came back strong, cutting the Marymount lead to only two with an 11-4 run, however, the Saints were able to hold on for the 1-0 lead.
Wiles tallied five kills, in all, in the first set, as he finished with nine in the match.
UC Santa Cruz returned the favor, opening the second set on a 16-6 run. After grabbing control of the set, the Banana Slugs didn't look back, tying the match, 1-1.
They again started hot in the third set with an 11-5 run and, eventually, pushed the lead to seven, 17-10.
The Saints got back to within five points, but the Banana Slugs were able to grab the lead in the match, 2-1.
The fourth set played closer, as a kill and service ace by junior Sam Safley helped the Saints grab an early 7-3 lead.
That would be the biggest lead by either team in the frame, as the Banana Slugs continued to keep the set close. With the score tied, 20-20, UC Santa Cruz was able to take the match with a 5-2 run.
Safley finished with a match-high 14 kills, while Shahan added 11. Junior Joseph Zanelotti posted 42 assists and two service aces, while freshmen Kyle Marcolla-Gattasse and Miles Olson paced the defense with 14 and 10 digs, respectively.
The Saints will be back in action on Saturday, January 19 to continue the tournament, squaring off with the Milwaukee School of Engineering at 11 a.m.


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We have had a lot of discussion lately about the concept of missional community and this has brought much excitement and also struggle. In many ways, our struggle with the idea of community is one of doubt. More than anything else, we looks at our past experiences in "small groups" and we question whether authentic missional community is anything different than what we have experienced in the past. Because of the failure or struggles that we have experienced with small groups in the past, we ultimately doubt whether missional community really works at all. For the sake of addressing the error of this conclusion, I want to compare one area of traditional small group ministry with the dynamic reality of missional communities and that is outreach.
In the traditional small group paradigm, outreach is often left with the individual. In this view, small groups exist to teach people the Bible in order to send them out in the world to reach people for Christ. In contrast to this, missional community formed around the commission that Jesus gave presents outreach as a shared responsibility for the entire group to embrace together, not merely an individualistic endeavor.
This became very evident this last week as the topic of outreach came up in our last missional community gathering. One of the ladies in our group began to share her current frustration in making inroads into her neighbors lives. She has tried, but the results just aren't where she would like them to be. Another lady chimed in and shared her frustrations with the same issue. The question was then asked of the group, "Is this issue of outreach a personal responsibility or a group responsibility? How can we tackle this challenge in community?" Within 5 minutes, three other group members shared of friends that God had given them the opportunity to share with. These friends were interested but needed to be "immersed" in the love of Jesus through our community so we began to plan follow-up parties, hangouts, and social events to interact with them in community together.
What we found was this – missional community works when we go about it God's way. When we reject the formalistic tendencies of our traditional views of things and embrace the biblical model, we find that we can align to God's Story together. We are empowered to realize that when we embrace the mission of God in community we have strength in numbers rather than defeat in isolation.
Consider today your commitment to your missional community. Don't allow your doubts to keep you from experiencing what life is meant to be as you live in community together following Jesus. Missional community works!


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Just when I start to feel really good about the progress that I have made, seeing that I am half way in fact to my personal goal, I am reminded that people still view me as the "fat kid". When I was out running today, a run that ended up being one cut short due to circumstances beyond my control, some man driving past me had to yell out the window of his jalopy "Look at you fat ass!" I normally can't hear much of what is going on around me because of the music, but I was running on a busier street not near my house, a lot more traffic I felt it was smart to turn it down a little, at home I wouldn't have heard him. But those 5 words cut me. I have spent the rest of today battling the emotions that it stirred up.
I know what I am. I know what I'm not, I know what I never will be and what I don't want to be. I like my curves, it's womanly, motherly…what that man stole from me today will take months to rebuild. For he crept in with 5 words and stole the confidence that progress had built up over the past 7 months.
This journey has been so much harder, personally I have had to face more set backs due to life events than I ever have before, I have had to adopt and learn, teach and teach myself again how to eat, what to eat, how to exercise, to not feel guilty when I take time for me to do these things. It's taken me 7 months to drop 30#, in my head I would have been within pounds of my goal by now based on my past successes. But, I'm not 27 this time, I have children and I have accepted that losing this weight slowly, in the long run will lead to loss that is more permanent. The mindset is so much harder to reshape than the body.
In my head I am always going to be the "fatkid" I am always going to think about what I looked like before, what I want to look like, what I look like in comparison to other women around me. I am always going to think about every bite I take, and what people think about what I am eating. I am not certain that I will ever overcome completely the emotional aspects of food, it's who I am.
In 5 words that man, who I will never see again, will never know how his few words brought me down so much. I am disappointed in the fact that I let it bother me that much, but it did. I know what I am, I didn't need a reminder, and he doesn't know that 7 months ago I was bigger, softer, weaker; he doesn't know what I have accomplished, it doesn't matter to him, for 15 seconds he got to be cruel to a total stranger (and let that be a lesson when I have negative thoughts about anyone else because certainly I don't know their journey and have no right to think anything about them over me).
So, tomorrow I will approach the day with a better attitude. Start my climb back up, reach for that goal that isn't so far away, and tonight hope that the man who brought me down, thinks twice before he does it again.
Confidence is so fragile.


text: She's A DJ Entertainment provides professional DJ services, with a variety of entertaining options to please any crowd. From our basic DJ packages, weddings, corporate events, to Video & Karaoke etc., no one is left out! At She's A DJ Entertainment our ultimate goal is to completely satisfy and meet the expectations of our clients. We strive to provide an entertainment package that matches each client's vision, desires, and budget so that we can build relationships and create the absolute best environment for your event!


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Though both schools have faced off against each other several times in their National Schools season, this year's Squash Boys' Final was no less exhilarating! Our Boys team put up a tough fight for the team championship title, eventually concluding their season as 1st Runners Up!
All matches are played in Singles format and each match consists of 5 games. The Point a Rally scoring system is adopted, whereby the winning team is the first to score 11 points, or the first to score 2 consecutive points when both players have scored 10 points.
The first player to win 3 out of 5 games in each individual match wins, and the team that wins 3 out of 5 matches will be crowned the overall champions!
In the spirit of the National Schools Games, all school teams are required to complete all five of the squash matches.
In a rally, each player has to ensure that his ball hits the front wall within the boundaries of the court marked on all the walls. The side-walls and even the glass wall are surfaces that the players may use to direct their return to the front wall. Only one bounce is allowed on the ground before a return is to be made. The player may also choose to return the ball before it hits the ground, which constitutes as a volley.
A "let" can be played when there is interference in the opponent reaching the ball. It is also applicable to the situation when the opponent is in the way when a return is to be made or the opponent is in danger of being hit in the process. In such cases, both the striker and the opponent must make every effort to clear the ball or get to the ball.
Here are some common terminologies:
- Boast — ball bounces off either side-wall or the back wall before the front wall
- Volley — to hit back a ball before it touches the floor
- Drive — a shot that hits the front wall and travels deep to the back of the court
- Drop — to hit the ball lightly such that it drops in the front half of the court
- Let — to replay a point because you were in the way of opponent
- Stroke — a point given to the person whose way was obstructed
- Cross-court — to hit across the court to the other side
The Team
Chua Man Chin 14S64
Lee Ming En 14A16
Gunn Wei Lim 14S6P
Lee Ming An 15S62
Jonathan Jiang 15S6P
Liau Chi De 15S66
Tan Hua Shin 15S79
Match 1 [HCI 0-3 RI]
Player: Lee Ming En
Round 1: HCI 8-11 RI
Our player, Ming En, started off with a strong start, scoring the first point of the match. A series of drive and cross-court shots played by Ming En drove the balls to the corner of the court, making it hard for our opponent to return the balls. Thus, this resulted in Ming En gaining a 3 point lead, with the score standing at 3-0. Our opponent quickly retaliated with a series of cross-court shots, which Ming En tried his best to return. However, our opponent nevertheless managed to level the score at 3-3. Our opponent remained in good form and managed to score a series of points, bringing the score to 5-8. Ming En was not fazed and delivered several skilful drop shots, bringing the score to 8-8. However, the game was eventually won by RI with a score of 8-11, after our opponent executed several low shots, which caught Ming En off-guard.
Round 2: HCI 7-11 RI
Ming En returned our opponent's first serve with a well-executed cross-court shot, scoring the first point of this round. However, our opponent caught up soon after, scoring the subsequent points with several lethal cross court shots, as well as drop shots, which Ming En valiantly attempted to return. This brought the score to 2-6. Ming En's quick-wittedness resulted in him executing and scoring the subsequent 2 points, narrowing the point margin and bringing the score to 4-6.
Thereafter, both sides engaged in exciting rallies, which saw Ming En deflecting the opponent's shots with a series of drop shots and volleys. One interesting point in the match was when Ming En managed to deflect our opponent's shot with a drop shot, such that our opponent could not react in time and could only deliver a weak return. In the end, it was a close fight and the game concluded with a score of 7-11.
Round 3: HCI 3-11 RI
As it was the game which would potentially decide RI's win for the first match, it was an intense round which was a feast for the eyes of the spectator. The round started off with RI securing a two-point lead against HCI, however, Ming En managed to demolish the two-point lead by scoring 2 consecutive points, one by returning a deadly drop shot executed by our opponent, and another by returning the ball such that it just touched the bottom boundary line. This brought the score to 2-2. However, our opponent proved not to be trifled with, and while Ming En did his best to deflect the shots delivered, the game concluded with a score of 3-11 to RI.
Match 2 [HCI 1-3 RI]
Player: Lee Ming An
Round 1: HCI 7-11 RI
Ming An started the match extremely well, making several low and tricky shots that made it difficult for our opponent to return the balls. As the crowd roared Ming An on, he secured a 4-1 lead into the first game. However, our opponent began to deliver longer shots that forced Ming An to the corners of the court. Ming An tried his best to return, however our opponent eventually managed to level the score at 4-4. Determined, Ming An was not ready to back down. He managed several cross court shots, making it hard for our opponent to return his shots. This brought the score to 6-4. Our opponent remained unfazed and executed some impressive boasts that made it hard for Ming An to return, albeit some miraculous and impressive saves on his part. Eventually, the game ended with a score of 7-11.
Round 2: HCI 11-6 RI
This was an extremely intense round to watch, as it started with RI gaining a 3 point lead, with the score standing at 1-4. However, Ming An remained composed, and managed to catch up the lead by executing a series of boasts, driving the ball to corners of the court or the side walls, and thus making it hard for the opponent to return his shots.
This resulted Ming An scoring 7 consecutive points, bringing the score to 8-5. This boosted his morale, and while our opponent managed to score another point due a missed return, Ming An continued to secure the subsequent 3 points with spectacular kill shots, which caught our opponent off guard. The round concluded with Ming An securing a convincing win, acknowledged by the roaring crowd of Hwa Chong supporters.
Round 3: HCI 9-11 RI
The opening three balls went to RI, as our opponent constantly remained on form, constantly trying to catch Ming An off guard and to score. Despite the 3-point lead, Ming An played on, managing to secure a nerve-wrecking save to return the cross court shots delivered by our opponent. This brought the score to 3-3. Ming An continued to impress with his tactical play, delivering drop shots, which made it difficult for our opponent to return as the ball was merely lightly bounced on the front wall. However, our opponent proved to be of calibre as well, and the scores were neck to neck. The highlight of the game was when both players tied 7-7, and the score could easily go both ways. Both players were on their toes, as they tried to outwit each other. Eventually, RI managed to regain the lead, and won with a score of 9-11.
Round 4: HCI 3-11 RI
Although Ming An managed to score the first ball, RI proved to be a strong contender, scoring 8 consecutive points, despite valiant attempts by Ming An to return the ball. Eventually, Ming An managed to secure a chance to deliver a drop shot, making it hard for our opponent to return the ball. This brought the score to 2-8. Eventually, despite efforts by Ming An to narrow the score margin, the game concluded with a score of 3-11.
Match 3 [HCI 2-3 RI]
Player: Tan Hua Shin
Round 1: HCI 14-16 RI
This round was an incredibly close one, as neither player was willing to succumb to the other, and it consisted of intense rallies, as each player attempted to outwit the other with unexpected cross court shots as well as drop shots. The highlight of the match was when it reached the 10-10 deuce, and both sides remained on form and tried to secure the two-point margin win. One notable point Hua Shin scored was when he attempted a nick, which resulted in the ball hitting the junction between the floor and the side wall, resulting in the ball having less bounce. This brought the score to 14-13. However, our opponent eventually managed to win 3 points in a row, concluding this fast-paced game at 14-16.
Round 2: HCI 11-5 RI
In the second round, Hua Shin gaining a convincing lead of 4-1 a few minutes into the game. Throughout this game, Hua Shin remained on top of his form, showing much agility and quick-wittedness as he executed his strokes. Never once did he allow our opponent to catch up with him, as he even scored 5 consecutive points, bringing the score to 8-2. Though our opponent managed to secure a few points due to certain lapses on Hua Shin's part, it was overall a convincing win of 11-5 to HCI!
Round 3: HCI 11-9 RI
This was a nerve-wrecking round, as RI had initially secured a 1-4 lead by continually forcing Hua Shin to hit the ball below the bottom boundary. However, Hua Shin remained undeterred and bounced back, slowly gaining the lead. Even midway through the game, the score was 4-7 and it looked very in RI's favour. However, Hua Shin was quick to think on his feet, and delivered several drop shots which caused the ball to fall to the floor in the front corner, making it extremely difficult for RI to return the ball. Eventually, the score levelled at 9-9. Hua Shin continued to press on and managed to score the remaining 2 points, winning 11-9 to RI!
Round 4: HCI 1-11 RI
With the overall score of the match 2-1 in HCI's favour, a win in this game would allow Hua Shin to win his match! He managed to secure his first point by hitting a cross-court shot into the corner of the court, resulting in his opponent unable to return it and he levelled the score at 1-1.Seemingly exhausted from the second and third games where Hua Shin fought hard for his wins, he succumbed to his opponent's strategically placed shots which were constantly sent to the right side of the court, forcing Hua Shin to execute his backhand shots. Several errors made by Hua Shin, coupled with our opponent's improvement in form for this game, allowed RI to gain a huge lead and winning consecutive points. Hua Shin did not give up and worked hard, but our opponent proved to be a tough nut to crack, with the game ending in RI's favour with a score of 1-11.
Round 5: HCI 9-11 RI
In an especially crucial game which determined the result of the match and whether RI would manage to secure championship status in the finals, both players pushed themselves to their limits in the final game of this gruelling match. Our opponent started off well, initially securing a 3-0 lead. Hua Shin remained undeterred, despite trailing at 1-6. It appeared that the game would be another straightforward fight for RI, however Hua Shin made a comeback and gained nearly consecutive points as he caught up with his opponent. By executing long and consistently accurate shots, Hua Shin attempted to tire his opponent out, and forced our opponent to deliver weak returns to Hua Shin's excellent corner drop shots. Both players took turns to score points, and when the score levelled at 9-9, the crowd was ecstatic as the match would be concluding on a very close fight, with a mere 2 points to victory for either side. However, our opponent made some impressive strokes and secured the next two points, winning with a score of 11-9 in this game. Nevertheless, there was huge applause reserved for Hua Shin, who had fought extremely hard in this long match!
Match 4 [HCI 3-0 RI]
Player: Chua Man Chin
Round 1: HCI 11-8 RI
Man Chin, the Boys Captain, was up next in the fourth match! Although the championship title results have already been determined, Man Chin was eager to do his best for the team in the fourth match. Our opponent won the first few points as Man Chin's returns went offside, thus ahead in the lead at 5-1. However, this was the turning point of the game where Man Chin began to find his momentum, and started to execute cross-court shots that drove the ball to the back of the court, forcing our opponent to run for the ball. The long rallies seemed to tire our opponent out, as Man Chin slowly increased his points to level at 6-6! Man Chin's brilliant cross-court smashes allowed him to retain his lead at 8-6, and while our opponent strived to narrow HCI's lead to 9-8, Man Chin remained focused to win the game at 11-8!
Round 2: HCI 11-7 RI
The second round featured exciting rallies as both players were determined to not lose any crucial points, with the score level at 1-1. Our opponent maintained his form as he led by a narrow margin at 4-3. However, Man Chin's skilful shots, featuring a well-played boast, allowed him to level the score at 5-5 yet again! Man Chin persisted in challenging his opponent with cross-court shots and capitalising on his opponent's uncharacteristic errors, to narrowly edge out his opponent at 8-7. Man Chin's consistent performance helped him secure another win, concluding the game with a score of 11-7.
Round 3: HCI 11-3 RI
Man Chin started off in stellar form, only allowing his opponent to win the first point and then proceeding to capture the next 5 consecutive points! A series of excellent shots displayed his experience and agility as while he drove the ball to the various corners at the back of the court, he then contrasted it with drop shots that caught our opponent off-guard. This brought the score to 5-1. Our opponent did not give up and attempted to catch up, however Man Chin retained his lead with his powerful strokes. Man Chin's high smash towards the corners of the front wall wrapped up the game with a score of 11-3, and this marked the first match where our Boys emerged victorious!
Match 5 [HCI 0-3 RI]
Player: Gunn Wei Lim
Round 1: HCI 2-11 RI
Wei Lim found himself committing several errors due to our opponent's extremely skilled cross-court shots, thus unable to secure the points and giving RI the lead at 7-0. As his team and supporters encouraged and cheered him on, he managed to win his first point with a drop shot that resulted in our opponent failing to deliver a good return. Wei Lim then gained his second point afterwards, following a powerful stroke that sent the ball towards the leftmost corner of the front wall. Nevertheless, the relatively more experienced RI player forced further errors on Wei Lim's part, and the first game concluded with a score of 2-11.
Round 2: HCI 9-11 RI
Wei Lim, determined to do even better in this game, improved tremendously in form as he delivered a low shot that our opponent missed, levelling the game at 1-1. Both Wei Lim and our opponent fought hard for every single point and were neck-to-neck in terms of points, with the score at a draw at 2-2 and later 4-4. A spectacular shot that sent RI's return too low below the boundary line allowed Wei Lim to be in the lead for the first time, at a score of 5-4! However, our opponent did not allow Wei Lim to hold on to the lead for long, as he managed to win consecutive points and bringing the score to 8-5. Wei Lim did not give up and continued to push himself on, by regaining some consistency in his form and levelling the game at 9-9. As the crowd became incredibly excited, they cheered Wei Lim on in the hope of him succeeding in his comeback and winning this game! Eventually, our opponent held on and emerged stronger, winning the game 11-9 in a very close fight.
Round 3: HCI 2-11 RI
A visibly drained Wei Lim remained focused on doing his best, as despite our opponent winning the first point of this game, he took the next point and levelled at 1-1. However, our opponent's agility forced Wei Lim into making weak returns and unable to end our opponent's lead. Wei Lim earned his second point through a drop shot at the front wall that resulted in our opponent hitting the ball out. While Wei Lim did his best in attempting to deflect the powerful shots by our opponent, our opponent still emerged victorious in this final game, winning 11-2. Kudos to Wei Lim for pressing on!
This marked the end of the Boys' Squash Finals with an overall score of 1-4 to our opponents, RI. With that, the A Division Squash Season came to a close. Our Squash Boys have certainly done our school proud by putting up a strong fight and improving on their performance from last year! Good job to our Boys team and we wish them all the best in their future competitions!


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Movies should move you; company movies should do even more.
They must instantly capture the attention and clearly communicate their message; but – most of all – they should conquer hearts and inspire change.
Get in touch and tell us your message you want to share with the world – let us take care of the rest.


text:
Acquaintance is scanty on primaquine (PQ) efficacy and Plasmodium vivax recurrence in Udupi district, Karnataka, India. We assessed the efficacy of 14 days PQ regimen (0.25 mg/kg/day) to prevent P. vivax recurrence. Microscopically, aparasitemic adults (≥18 years) after acute vivax malaria on day 28 were re-enrolled into 15 months' long follow-up study. A peripheral blood smear examination was performed with participants at every 1–2 month interval. A nested PCR test was performed to confirm the mono-infection with P. vivax. Of 114 participants, 28 (24.6%) recurred subsequently. The median (IQR) duration of the first recurrence was 3.1 (2.2–5.8) months which ranged from 1.2 to 15.1 months, including initial 28 days. Participants with history of vivax malaria had significantly higher risk of recurrence, with hazard ratio (HR) (95% CI) of 2.62 (1.24–5.54) (P=0.012). Severity of disease (11.4%, 13/114) was not associated (P=1.00) with recurrence. Of 28 recurrence cases, the nPCR proved that P. vivax mono-infection recurrence rate was at least 72.7% (16/22) at first recurrence. In Udupi district, PQ dose of 0.25 mg/kg/day over 14 days seems inadequate to prevent recurrence in substantial proportion of vivax malaria. Patients with a history of vivax malaria are at high risk of recurrences.
Of the 5 Plasmodium spp. malariogenic to humans, P. vivax and P. ovale have distinction to cause 'relapse'. The relapse feature is indeed one of the trickiest hurdles to be outmanoeuvred to control/eliminate the P. vivax malaria that asserts the widest global geographic range and utmost burden in Southeast Asia [1]. Primaquine (PQ) is the sole antimalarial in clinical practice for the radical cure of P. vivax and P. ovale malaria worldwide. Although P. vivax resistance to PQ has never been reported, a relapse is believed to occur due to suboptimal cumulative dosage or impaired pharmacokinetics of PQ [2]. Tailoring PQ regimen is a function of body weight, glucose-6-phosphate dehydrogenase (G6PD) activity, and natural relapse rates in a given population. It is vital to measure the natural relapse prevalence in P. vivax malaria in a geographic region. It is said that a relapse prevalence over 50% would account for majority of vivax malaria burden and serve as prime reservoir [3].
P. vivax comprises ~50% malaria burden in India [4] and the national guideline recommends a PQ dosage of 0.25 mg/kg body weight daily over 14 days in all non-pregnant adult vivax malaria patients with normal G6PD activity [5]. Chloroquine (CQ) and artemisinin combination drugs remain the companion antimalarials to PQ for uncomplicated and complicated vivax malaria, respectively [5]. There have been reports describing P. vivax relapse from different parts of India [6–10]; however, there lacks one such from Udupi district, which remains one of the most fiercely active malaria transmission zones of Karnataka, India, having annual parasite incidence (API) of >2 per 1,000 risk population and about 90% P. vivax prevalence. Also, some previous reports indicated low relapse rates [11,12] which appear to be underestimated due to a short follow-up length. We undertook this study to determine the efficacy of PQ (0.25 mg/kg body weight daily over 14 days) for preventing recurrences of P. vivax across 15 months duration, including participants from a tertiary and 5 primary health centres of Udupi taluk in Karnataka, India.
Study design and population
Light microscopically proven P. vivax mono-infected adults (≥ 18 years) from 1 tertiary care hospital, Kasturba Hospital (KH), Manipal, Udupi, and 5 primary health centres (PHCs) of Udupi taluk (Hiriadka, Kolalagiri, Malpe, Pethri, and Shirva), pre-enrolled in a CQ-PQ combined therapeutic trial [13,14], upon convalescence on 28th day were requested to participate in another 15 months long follow-up study. All participants had 'adequate clinical and parasitological response' and were microscopically aparasitemic at recruitment on the day 28. All voluntarily consenting participants were recruited from September 2012 through October 2014. Participants were followed to check parasitemia at every 1–2 month's duration and additionally if anyone had fever. All participants from PHCs and 125 participants from KH, Manipal were treated previously with CQ 25 mg/kg body weight over 3 days and PQ 0.25 mg/kg body weight daily for 14 days. Patients with G6PD deficiency, i.e., activity less than 30% of the normal mean [15], who could not be treated with PQ, 0.25 mg/kg body weight daily for 14 days, were excluded. Adherence to the prescribed CQ-PQ was not observed directly, rather on each follow-up till day 28, participants were reminded to comply with the regimen and emptied drug stripes were documented. Besides, 37 out of total 162 patients at KH, Manipal were treated with artesunate combination therapy (ACT) along with PQ as per clinicians' decision (Fig. 1).
Ethical approval (no. IEC 86/2013) for the study was obtained from the institutional ethics committee of Kasturba Medical College and Kasturba Hospital, Manipal University, Manipal, Karnataka, India. A written informed consent was obtained from all participants before their enrolment into the study.
Study setting
Fig. 2 depicts the geographical location of the KH, Manipal and the PHCs. Udupi district harbours tropical monsoon climate and over 4,000 mm rainfall is recorded per annum during the month of June to October. The malaria incidence occurs throughout a year in Udupi taluk, and the mean annual parasite incidence was estimated as 2.5 per 1,000 risk population during the year 2012 to 2014. The catchment area of the KH, Manipal encompasses both rural and urban population of coastal and interior Karnataka, Goa, and Kerala. The KH, Manipal records malaria incidence across the year with over 200 malaria cases per annum, comprising > 55% P. vivax cases. By contrast, the catchment areas of the 5 PHCs are largely rural, except Hiriadka PHC wherein rapid urbanization and mega-construction projects are in-progress, mainly around Manipal.
Blood sample collection and processing
Both thin and thick peripheral blood smears were obtained by capillary puncture from every participant on each follow-up. Smears were stained using Leishman's stain, then examined individually by 3 microscopists to ascertain P. vivax mono-infection and to determine the parasite index (PI) per μl blood [16]. On every instance of P. vivax reappearance, another 1 ml venous blood was obtained from participants in a K2EDTA anticoagulated vacutainer for total leukocyte count and DNA extraction. Participants' total leukocyte count per μl was estimated by Beckman Coulter® LH 750 Hematology Analyzer (Fullerton, California, USA) and used for PI calculation. Further, DNA extraction was carried out from 200 μl of K2EDTA anticoagulated blood using QIAamp DNA Blood Mini Kit (Hilden, Germany) as per the manufacturer's instructions and stored at −20°C until the conduct of nested PCR (nPCR) test for confirmation of the mono-infection with P. vivax malaria.
Exposure variables
Axillary temperature and history of fever within last 1 week was recorded on each follow-up. Pertinent clinical and laboratory variables were assessed and recorded in a proforma.
Outcome variables
Anytime during the study period, reappearance of P. vivax parasitemia as confirmed by light microscopy was considered the primary outcome. All reappearances were considered 'recurrence' as molecular investigations to differentiate cases into either 'relapse' or 'reinfection' was not performed. Demographic, clinical, and laboratory variables were compared between 'no-recurrence' and 'recurrence' groups to determine mutual associations. Severity of P. vivax malaria was the secondary outcome. Severity was determined as per the WHO's guideline for management of severe malaria [17].
Patients' treatment
Specific anti-malarial medications were prescribed to recurrent cases as per the clinicians' decision and the national guideline for treatment of malaria [5]. CQ-PQ was the most frequently prescribed anti-malarial regimen. However, ACT, i.e., artesunate plus doxycycline, along with PQ was given to cases befitting so as per the attending clinicians. Activity of G6PD enzyme (U/g hemoglobin) was estimated by spectrophotometric kinetic 'gold standard' method.
CQ-PQ regimen at Kasturba Hospital, Manipal
Resochin (chloroquine phosphate 250 mg; CQ, 25 mg/kg body weight over 3 days) manufactured by Bayer Pharmaceuticals Private Ltd. (Bayer House Central Avenue, Maharashtra, India) and Malirid (primaquine phosphate 7.5 mg; PQ, 0.25 mg/kg body weight daily over 14 days) manufactured by IPCA Laboratories Pvt. Ltd. (Mumbai, Maharashtra, India) was administered to the study cohort. Notably, PQ was administered only after estimation of G6PD activity, but immediately after completion of CQ dosage.
CQ-PQ regimen at PHCs, Udupi taluk
CQ (25 mg/kg body weight over 3 days) and PQ (0.25 mg/kg body weight daily over 14 days) as supplied and procured by the National Vector Borne Disease Control Programme (NVBDCP), India were dispensed among participants by the staffs of respective PHCs as per the national guideline [5]. CQ and PQ were started together before the estimation of G6PD activity. However, G6PD results were available by 48 hr after the onset of CQ-PQ regimen.
Confirmation of Plasmodium vivax mono-infection by nPCR test
Small sub-unit ribosomal RNA was amplified using genus and species-specific oligonucleotide primers separately for P. vivax and P. falciparum [18] with modifications in the amplification conditions of the second step [13]. DNA extracted from the reference samples procured from the National Institute of Malaria Research (ICMR), Dwarka, Delhi-110077, India served as positive controls in every batch of nPCR tests. Whereas, DNA extracted from a healthy volunteer was used as negative control.
Statistical analyses
Continuous variables were summarized as mean with SD or median with interquartile range (IQR). Categorical variables were summarized as frequency with proportion. No-recurrence and recurrence groups were compared by independent sample t-test or Mann Whitney U test and chi-square test or Fischer's exact test. Furthermore, variables of recurrence cohort at initial presentation and at first recurrence were compared using paired t-test or Willcoxon sign rank test and McNemar chi-square test. All tests of significance were 2-tailed with a P-value <0.05 indicating statistical significance. Parasite index was summarized as geometric mean with 95% confidence interval (CI). Cox regression analysis was performed to determine the hazard ratio (HR) of history of P. vivax malaria for recurrence. Furthermore, a Kaplan-Meier survival plot was generated to determine the survival function of recurrences till 15 months follow-up duration for independent variables. Log rank test was used to compare the survival function of independent variables. Data analysis was done using Statistical Package for the Social Sciences version 15.0 (SPSS, South Asia, Bangalore, India).
Baseline characteristics of the study cohort
Of total 323 participants in 28 days CQ-PQ therapeutic trial, 114 participated in 15 months follow-up study (Fig. 1). The study cohort included 105 (92.1%) male and 9 (7.9%) female participants. The mean (±SD) age of cohort was 38.9 (±12.4) years which ranged from 18 to 76 years. The mean (±SD) G6PD enzyme activity of study cohort was 14.5±3.8 U/g hemoglobin ranging from 5.5 to 27.2 U/g hemoglobin. No PQ related adverse effects were noted among the study cohort. All cases with subsequent recurrence were retreated using CQ-PQ combined regimen as described above except 1 case that was treated with ACT-PQ at first recurrence (Fig. 1).
Study outcomes
Of 114 participants, 28 (24.6%) recurred subsequently, including 2 participants with 2 recurrences and 1 participant with 3 recurrences through 16 months (since the date of recruitment in the 28 days CQ-PQ combined efficacy trial). One patient did present with P. falciparum malaria after 3 months of initial presentation. Cumulative proportion of recurrence across 15 months was significantly higher (P=0.03) in PHCs' cohort than KH, Manipal cohort (Fig. 3A). Through 16 months of follow-up, the median (IQR) duration of first recurrence was 3.1 (2.2–5.8) months and ranged from 1.2 to 15.1 months. Sub-groups treated with antimalarial regimens viz. CQ-PQ and ACT-PQ at KH, Manipal did not show any significant (P=0.08) difference in their respective recurrence proportions (Table 1).
Recurrence proportion did not vary by age, gender, clinical symptoms, and vital signs on presentation (Table 1). Except total leucocyte count and serum alanine aminotransferase, there was no difference observed in the laboratory profile between recurrence and no-recurrence groups (Table 2). In recurrence group, proportion of cases managed on ambulatory care rose significantly (P=0.02) at first recurrence than initial presentation (Table 3). In recurrence group, none of the variables except hemoglobin and hematocrit showed a significant difference between initial presentation and first recurrence (Table 4).
Participants with history of P. vivax malaria did recur in significantly higher (P=0.02) proportion and had a higher HR for recurrences of 2.62 (95% CI; 1.24–5.54) (P=0.012; Fig. 3B). There was no significant difference (P=0.10) in the duration of past malaria between recurrence and no-recurrence groups. The proportion of severe malaria cases did not vary (P=1.00) between recurrence and no-recurrence groups. Of 28 cases in recurrence group, 3 (10.7%) had severe malaria initially; however, none developed severe malaria during subsequent recurrences.
Fig. 4 is a flow diagram depicting results of nPCR test in recurrence cohort at different recurrence stages. At all recurrence stages, including R0, i.e., at initial presentation, while light microscopy test showed mono-infection with P. vivax, nPCR test did reveal subpatent mixed infections. Adjoining lines do indicate nPCR test results with the corresponding group of participants across all recurrence stages. At R0, of all 28 P. vivax mono-infections as diagnosed by light microscopy, only 22 did have P. vivax mono-infections as confirmed by the nPCR test. At R1, of 22 nPCR proven P. vivax mono-infections, only 16 were found to have nPCR proven mono-infections. Hence, the nPCR proven P. vivax mono-infection recurrence rate was at least 72.7% (16/22) at first recurrence. All mixed infections at R0 did have nPCR proven mono-infection at R1. Revelation of nPCR proven mixed infection at subsequent recurrence indicated possible new infection with P. falciparum and/or simultaneous inoculation of new P. vivax strain as well. There was no significant (P=0.76) difference in the cumulative recurrence hazard function between nPCR diagnosed P. vivax mono-infection and mixed malaria groups at initial presentation (Fig. 3C).
In recurrence cohort, the initial infection occurred across the year except in the month of February and April. Subsequently, their first recurrence was noted throughout the year except in the month of May. There was no distinct seasonality noted for recurrences (Fig. 3D).
This study was conducted to assess the anti-recurrence efficacy of PQ regimen (0.25 mg/kg body weight daily over 14 days) in P. vivax malaria. During acute P. vivax illness, patients were treated with CQ-PQ combined regimen as mentioned in the methods section. Convalescent and microscopically aparasitemic voluntary participants after acute P. vivax malaria on day 28 were re-enrolled into the 15 months' long follow-up study.
Male predominance in this study is a reflection of the gender ratio in cohort of preceding CQ-PQ combined therapeutic trials [13,14]. However, the male preponderance in malaria have also been reported previously [19–21] from the current study setting.
Duration of follow-up considerably influences the observed recurrence proportion in studies involving therapeutic assessment of PQ in P. vivax malaria [2]. Differences in the length of follow-up, antimalarial regimen, PQ dosage, and participants' age in studies [2] pose a challenge of heterogeneity to the comparison of their observed recurrence proportions. In unsupervised therapeutic studies with CQ, 1,500 mg over 3 days and PQ 210 mg over 14 days, P. vivax recurrence was reported to have varied from 8.1% across 6 months to 38.0% across 15 months [2]. The recurrence proportion (24.6%, 28/114) over 16 months as observed in this study was less than the proportion (38.1%, 16/42) observed by Kim et al. [10] over 15 months in Kolkata, India for the same CQ-PQ regimen as described in this study.
Similar to the findings of this study (Table 3), previously Adak et al. [8] did observe comparatively milder disease manifestation in recurring P. vivax cases than their initial presentation. It seems plausible that severity of disease does not determine the subsequent recurrences of P. vivax, rather subsequent episodes are likely to be clinically milder due to acquired immunity [22]. However, development of acquired immunity for P. vivax and its impact on the course of clinical illness in this low transmission intensity study area remains elusive and needs a thorough validation. In this study, history of P. vivax malaria has surfaced as a sole independent predictor of subsequent recurrences. Of note, an empiric evidence of intact CQ-PQ therapeutic efficacy for subpatent P. falciparum infection has surfaced in this study. All 6 participants having nPCR proven mixed infections at R0, did show nPCR proven P. vivax mono-infection at R1 (Fig. 4). This indicates that CQ-PQ combined regimen at R0 did effectively cleared subpatent P. falciparum parasitemia along with patent P. vivax parasitemia. However, this empiric evidence needs to be verified further. Conversely, nPCR proven mixed infections (patent P. vivax and subpatent P. falciparum) cases from KH, Manipal and PHCs, Udupi taluk did have adequate clinical and parasitological responses to the CQ-PQ combined regimen [13,14].
Rationally long follow-up duration (16 months), robust study design, statistical analyses, microscopic and nPCR confirmation of P. vivax mono-infection render the outcomes of this study valid and comparable with other similar studies. To the best of our knowledge, this is the first report of its kind from the study region, i.e., Udupi district.
This study has certain limitations as well. Firstly, we cannot rule out the possibility of intermittent self-limiting asymptomatic recurrences, thus it remains plausible that there would have been even higher rate of recurrences than observed in this study. Because the study setting is malaria endemic and recurrences occurred across the year, proportion of recurrence having 'reinfection' needs to be determined. As about 50% of recurrences did occur during regional rainy season between the months of June to October (Fig. 3D), a substantial proportion could be 'reinfection', and its confirmation requires further genetic investigations [2,10]. Also, a higher cumulative recurrence propensity (Fig. 3A) in P. vivax cohort of PHCs' than KH, Manipal could be due to 'reinfection' rather than 'relapse', and further genetic analyses are required for confirmation [2,10]. This notion of reinfection arose by the circumstance wherein the majority (83.3%, 10/12) of the recurrence participants of PHCs were from Hiriadka PHC, and all of them were workers of various mega-construction sites around which local malaria transmission is intensely confined. Conversely, differences in proportion of participants complying with the PQ regimen and underlying CYP2D6 metabolizer phenotypes [2] between PHCs and KH cohort could also explain the observed differences in cumulative recurrence between the cohorts of 2 settings. As the CQ-PQ regimen was unsupervised, non-compliance with 14 days long PQ could not be ruled out among participants. Further, like findings of Kim et al. [10] from Kolkata, India both short and long interval latency P. vivax phenotypes have been found in the present study (Fig. 3D). However, further genetic analyses are required to describe the individual parasite strains and their temporal association with recurrence. Also, it would be interesting to study the clonal variations among P. vivax genotypes in both nPCR proven mono-infection and mixed cases through all recurrence stages.
In Udupi district, PQ dose of 0.25 mg/kg/day over 14 days seems inadequate to prevent recurrences in substantial proportion of P. vivax malaria. Patients with a history of P. vivax malaria are at high risk of recurrences. Further, molecular investigations are required to determine the true rate of 'relapse' and its determinants.
This work was supported by an extramural research grant (no. AMR/46/2011-ECD-I) and a Senior Research Fellowship Grant (no. 80/93/2015-ECD-I) from the Indian Council of Medical Research, New Delhi, India. The funding council had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors are immensely grateful to all the participants of this study. Much of the field work carried out by Mr. Satish Kitta Madivala and Mr. Prashantha Prabhu, Laboratory Assistants, is thankfully acknowledged.
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16. Rishikesh K, Madivala SK, Prabhu P, Kamath A, Ashok H, Vidyasagar S, Shastry AB, Saravu K. Surmised total leucocyte counts miscalculate the parasite index of Plasmodium vivax malaria patients of tertiary and primary care settings in South-Western India. Malar J 2015;14: 163.
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18. Snounou G, Viriyakosol S, Zhu XP, Jarra W, Pinheiro L, do Rosario VE, Thaithong S, Brown KN. High sensitivity of detection of human malaria parasites by the use of nested polymerase chain reaction. Mol Biochem Parasitol 1993;61: 315-320.
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21. Saravu K, Rishikesh K, Kamath A. Determinants of mortality, intensive care requirement and prolonged hospitalization in malaria-a tertiary care hospital based cohort study from South-Western India. Malar J 2014;13: 370.
Table 1
a Categorical variables are summarized as frequency with proportion whereas continuous variables are summarized as either mean (±SD) or median (IQR). χ2-test or Fischer's exact test and independent sample t-test or Mann Whitney U test was performed.
c As per the WHO's guideline for management of severe malaria in the year 2012 [17].
Table 2
Table 3
Table 4


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