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Major Recommendations
Clinical Diagnosis
The diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is based on the patient's history, pattern of symptoms, and the exclusion of other fatiguing illnesses. A symptom-based diagnosis can be made with published criteria. This primer uses the 2003 Canadian clinical case definition for ME/CFS (see worksheet in the original guideline document), because of its emphasis on clearly described core symptoms of the illness. The 1994 Fukuda criteria for CFS (Appendix A in the original guideline document) are primarily used for research purposes, although they may be required for disability determinations in the US and elsewhere. The newly published 2011 International Consensus Criteria for ME are not yet in general use. No specific diagnostic laboratory test is currently available for ME/CFS, although potential biomarkers are under investigation.
The diagnostic criteria for the 2003 case definition are listed in the clinical worksheet in the original guideline document and can be copied and used for patient diagnosis. The second page of the worksheet includes diseases which must be excluded or fully treated before a diagnosis of ME/CFS can be established. A number of non-exclusionary co-morbid entities which commonly co-exist with ME/CFS are also listed. Patients with ME/CFS may have many symptoms in addition to those listed in the case definition.
Patient History
A thorough medical and social history is essential for accurate diagnosis. Obtaining a succinct and coherent history within one visit may not be possible given the cognitive difficulties in some patients. The information gathered should include pre-illness functioning (education, job performance, social and family relationships) and current living circumstances (daily activities, stressors, major life changes, and support sources). Assessment of functioning will reveal the significant life changes experienced by the patient as a result of the illness. A review of previous medical records, reports, and lab tests supplied by the patient may also provide useful information.
Physical Examination
Physical findings are often subtle and may not be clearly evident. Patients may look pale and puffy with suborbital dark shadows or shiners. Examination of the patient's pharynx may show non-exudative pharyngitis (often referred to as "crimson crescents"). Cervical and axillary lymph nodes may be palpable and tender.
Some patients have demonstrable orthostatic intolerance with neurally mediated hypotension or postural orthostatic tachycardia syndrome, characterized by lowered blood pressure and/or a tachycardia on prolonged standing. This may be associated with dependent rubor in the feet and pallor of the hands.
A neurological examination may reveal a positive Romberg test or positive tandem stance test. If widespread pain is reported, a concurrent diagnosis of fibromyalgia should be considered and confirmed with a tender point examination.
Laboratory Tests
A basic laboratory investigation (Table 1, below) should be followed with more specific tests (Table 2, below) depending on particular symptoms. For example, an electrocardiogram (EKG/ECG) should be performed if chest pain is present, a chest x-ray obtained for cough, and testing for celiac disease if gastrointestinal symptoms are reported. (An endoscopy is recommended if symptoms are severe.)
Results of routine tests in patients with ME/CFS are usually within the normal range even during severe relapses. If abnormalities are found (e.g., elevated erythrocyte sedimentation rate [ESR]), other diagnoses may be considered.
Specific tests from Table 2 (below) may show low morning cortisol, elevated antinuclear antibody (ANA), and/or immunoglobulin abnormalities. In addition, vitamin D levels are often low, which would suggest bone density testing for osteoporosis. Any abnormal finding warrants further investigation to exclude other diseases.
Research studies have reported a number of immune, neuroendocrine and brain abnormalities in patients with ME/CFS, but the clinical value of expensive and elaborate tests for these abnormalities has not been established.
Table 1. Investigation of ME/CFS: Routine Laboratory Testing
Table 2. Investigation of ME/CFS: Tests to Be Considered Depending on Symptoms
Differential Diagnosis
Although the symptoms of a number of diseases can mimic ME/CFS, the presence of post-exertional symptom exacerbation, a key feature of the illness, increases the likelihood of ME/CFS as the correct diagnosis. Table 3 in the original guideline document lists a number of medical conditions that need to be considered in the differential diagnosis.
Distinguishing ME/CFS from Depressive and Anxiety Disorders
Symptoms of depression or anxiety may result from or precede the illness as they do with other chronic medical conditions. Distinguishing depressive and anxiety disorders from ME/CFS may present a challenge. Depressive symptoms, including problems with sleep, cognition, and initiating activity as well as fatigue and appetite/weight changes may overlap with ME/CFS.
Differential diagnosis is based on the identification of ME/CFS features—in particular, post-exertional malaise (PEM)—as well as autonomic, endocrine or immune symptoms (see Diagnostic Worksheet in the original guideline document). PEM is the exacerbation of symptoms following minimal physical or mental activity that can persist for hours, days or even weeks. For instance, a short walk may trigger a long-lasting symptom flare-up. By contrast, patients with major depression generally feel better after increased activity, exercise or focused mental effort.
Furthermore, patients with ME/CFS (with or without co-morbid depression) generally have strong desires to be more active, but are unable to do so. In clinical depression, by comparison, there is often a pervasive loss of interest, motivation and/or enjoyment. Finally, diurnal fluctuations in ME/CFS tend to show symptom-worsening in the afternoon while in major depressive disorder more severe symptoms often occur in the morning.
Some patients with ME/CFS do develop major depressive disorder which is characterized by low mood (loss of interest is less likely) and additional symptoms such as feelings of worthlessness or guilt and suicidal ideation. The practitioner should conduct a suicide evaluation for all patients who appear to be clinically depressed or highly stressed.
Secondary anxiety can arise with the crisis of illness onset and persist as the illness affects the ability to work and family relationships. Secondary anxiety may be distinguished from generalized anxiety disorder (GAD). GAD is characterized by excessive worry and assorted physical symptoms. By comparison, panic disorder features unbidden panic attacks. Symptoms of ME/CFS not found in GAD and panic disorders include post-exertional malaise as well as autonomic, endocrine or immune symptoms (see Diagnostic Worksheet in the original guideline document). In addition, patients with primary anxiety disorders generally feel better after exercise whereas exercise worsens symptoms in ME/CFS. Finally panic disorder is situational and each episode is short-lived, whereas ME/CFS persists for years.
Exclusionary Medical Conditions (Table 3 in the original guideline document)
ME/CFS is not diagnosed if the patient has an identifiable medical or psychiatric condition that could plausibly account for the presenting symptoms. However, if ME/CFS symptoms persist after adequate treatment of the exclusionary illness, then a diagnosis of ME/CFS can subsequently be made.
Co-existing Medical Conditions (Table 4 in the original guideline document)
A number of other (non-exclusionary) conditions may co-exist with ME/CFS. A listing of these conditions appears in Table 4 in the original guideline document and includes fibromyalgia, multiple chemical sensitivity, irritable bowel syndrome, irritable bladder syndrome, interstitial cystitis, temporomandibular joint syndrome, migraine headache, allergies, thyroiditis, Sicca syndrome, Raynaud's phenomenon, and prolapsed mitral valve. These conditions should be investigated in their own right and treated appropriately.
The onset of ME/CFS impacts the individual's ability to work, to sustain family and social relationships, to provide basic self-care, and to maintain self-identity. These sudden losses may trigger confusion and crisis. Yet patients often receive little benefit from consultations with health practitioners due to (1) physician skepticism of individuals with ME/CFS who may not look ill and show normal findings on standard physical examinations and laboratory tests; and (2) the absence of a clear standard of care for these patients. These obstacles, in addition to significant illness limitations and unsupportive family and friends, may lead to patients feeling demoralized, frustrated and angry.
This section provides recommendations primarily for ambulatory patients who are able to attend office visits. Special considerations are offered in the "Related Clinical Concerns" section for the perhaps 25% of patients with ME/CFS who are bedridden, house-bound, or wheelchair dependent.
Approach to Treatment
Given the absence of curative treatments, clinical care of ME/CFS involves treating symptoms and guiding patient self-management. The goal is symptom reduction and quality of life improvement based on a collaborative therapeutic relationship. Although not all patients will improve, the potential for improvement, which ranges from modest to substantial, should be clearly communicated to the patient.
Acknowledging that the patient's illness is real will facilitate a therapeutic alliance and the development of an effective management plan. Thus, patients may be greatly relieved to hear that their bewildering symptoms have a diagnostic label—an important validation of their concerns. The practitioner can also assure the patient that normal findings on diagnostic tests do not negate the reality of the illness.
Once the diagnosis is established, a systems review will reveal the patient's most troublesome symptoms and concerns. These may include several of the following: debilitating fatigue and activity limitations; sleep disturbance; pain; cognitive problems; emotional distress; orthostatic intolerance; gastro-intestinal or urological symptoms; gynecological problems.
The clinical management plan in this section focuses on both non-pharmacologic interventions and medications. Written educational material for patients can also be helpful because they may have short-term memory problems.
To improve clinical management, the following are suggested:
- A patient support person to take down medical advice or a recording of the visit for later patient review
- Obtaining a written list of the patient's most troublesome symptoms
- Agreement with the patient to focus on a limited number of selected symptom(s) in order to avoid overloading the patient
- Medication doses that start low and go slow
- Ongoing assessments of the patient over multiple visits
The order of ME/CFS symptoms presented below starts with those considered most treatable.
The non-restorative sleep in ME/CFS indicates waking up feeling unrefreshed or feeling as tired as the night before. The unrefreshed feeling may be associated with morning stiffness or soreness and mental fogginess that may last for an hour or two. Disturbed sleep patterns include difficulty falling or staying asleep, frequent awakenings, or coma-like sleep. Hypersomnia may occur in the early stages of the illness. Many patients have a diagnosable sleep disorder that may require consultation with a sleep disorder specialist.
The following sleep hygiene suggestions may be helpful to patients:
- An hour of relaxing wind-down activities prior to bed time
- Regular sleep and wake times
- Pacing activities during the day to avoid symptom exacerbation that may interfere with sleep
- Avoiding naps after 3 pm and substituting rest
- Spending some morning time under full spectrum light either outdoors, by a window, or artificial light
- Reducing or eliminating caffeine-containing beverages and food
- Using earplugs or soundproofing for noise, or sleeping in a different bedroom without (a snoring) partner
- Ensuring the bedroom is very dark by using a sleep mask or black-out curtains
- If unable to sleep, getting up and moving to another room, and doing a quiet activity (reading, soft music, or relaxation tapes; not a computer, iPad, or TV) until sleepy
- Using the bed for sleeping and sex only
- Avoiding attempts to force sleep
Medications (Table 5 in the original guideline document)
All sedating medications must be safe for long-term use and should be started at a low dose. The medication should be taken early enough so that sedation takes effect around bed time. Patients may initially feel thick-headed in the morning, but this usually improves as benefits become apparent. The risk of side effects and drug combinations which can produce serotonin syndrome should be explained. In some patients, tolerance may develop with medications. Rotating medications may be more effective than using a single drug.
Persistent pain in ME/CFS, whether widespread or localized, may range from mild to severe. In some cases the patient may feel pain from minimal stimulation such as a gentle touch. Headaches may be particularly troublesome and are often migrainous. If chronic widespread pain is a major complaint, a fibromyalgia evaluation may be indicated.
Helpful non-pharmacologic interventions for pain may include pacing of activity, physical therapy, stretches, massage, acupuncture, hydrotherapy, chiropractic, yoga, Tai Chi and meditation (relaxation response). Also consider hot or cold packs, warm baths or balneotherapy, muscle liniments, electrical massagers, TENS (transcutaneous electrical nerve stimulation), and rTMS (transcranial magnetic stimulation). These methods can be effective singly or in various combinations to reduce tension and pain. However, these interventions may also be poorly tolerated, inaccessible, or prohibitively costly. It is important to treat localized pain, e.g., arthritis or migraine, because it can amplify the generalized pain of ME/CFS.
Medications (Table 6 in the original guideline document)
For the treatment of pain in ME/CFS, the lowest effective dose should be prescribed and increased cautiously. Patients with severe pain may need the stronger analgesics and narcotics. Although opiates should be discouraged for the treatment of chronic pain states, they may be beneficial in some cases. Their use requires a clear rationale with documentation. Providers should consider referring such patients to a pain specialist.
Fatigue and Post-exertional Malaise
Patients with ME/CFS experience abnormal fatigue that is both more intense and qualitatively different from normal tiredness. The fatigue in ME/CFS may take several different forms: post-exertional fatigue (abnormal exhaustion or muscle weakness following minor physical activity), persistent flu-like feelings, brain fog (mental exhaustion from everyday cognitive effort), and wired fatigue (feeling over-stimulated when very tired).
The type of fatigue that is a core feature of ME/CFS is post-exertional malaise (PEM). PEM is the exacerbation of fatigue and other symptoms (e.g., cognitive difficulties, sore throat, insomnia) following minimal physical or mental activity that can persist for hours, days or even weeks. PEM may be related to abnormal energy metabolism.
Energy for physical activities is produced through two physiological systems: (1) Anaerobic metabolism is the predominant metabolic pathway during the first 90 seconds of exercise; (2) the aerobic/oxidative system is the primary source of energy during physical activities lasting longer than 90 seconds.
Because most daily physical activities exceed 90 seconds, the aerobic system is typically utilized to produce the energy-releasing nucleotide, adenosine triphosphate (ATP) at a steady rate in order to perform activities of daily living. In patients with ME/CFS, aerobic metabolism may be impaired. Thus, any physical exertion exceeding 90 seconds may utilize a dysfunctional aerobic system, which leads to increased reliance on anaerobic metabolism. This imbalance may be linked to the prolonged symptoms and functional deficits associated with PEM.
Simple and inexpensive physiological measures, such as heart rate monitoring, may be used to ensure that real-time cardiovascular responses remain below the threshold of aerobic impairment.
Managing Post-exertional Symptoms: Pacing and the Energy Envelope
Fatigue improvement can be facilitated by advising patients to pace or "spread out" activities so that ongoing exertion remains below the threshold of post-exertional symptom flare-ups (see Figure 2 in the original guideline document). For instance, rather than completing housework in one uninterrupted push, tasks may be divided into smaller pieces with rest intervals interspersed. Remaining as active as possible while avoiding fatigue-worsening over-exertion delineates an optimal zone of activity termed the "energy envelope." An activity log (Appendix D in the original guideline document) may be helpful to identify personal activities that stay within or exceed that optimal range.
Activity and Exercise
To stay within the energy envelope, some patients need to decrease their activity while others need to carefully and selectively do more. Many individuals with ME/CFS mistakenly over-exercise in an attempt to reduce fatigue and other symptoms. In addition, well-meaning healthcare providers may recommend exercise for patients with ME/CFS using guidelines intended for healthy people. Such guidelines are generally inappropriate and often counterproductive in this illness. Thus, practitioners may push patients too hard and patients may push themselves into activities that worsen symptoms. This symptom-worsening may be linked to underlying aerobic impairment.
Misdirected exercise usually results in post-exertional symptom flare-ups or relapses which discourage further exercise. In contrast, the optimal amount of individualized exercise is usually well below standard recommendations for healthy individuals, avoids post-exertional symptoms, and promotes improvement.
Exercise Recommendations
An individualized activity plan should be developed in collaboration with the patient. Consultation with rehabilitation professionals knowledgeable about ME/CFS may also be desirable. Any exercise or activity program should seek to minimize the negative effects of exertion on impaired aerobic function. Exercise should also not take priority over activities of daily living.
Initially, the patient's degree of activity limitation can be estimated using a functional status rating such as the Functional Capacity Scale (Appendix C in the original guideline document). This 10 point scale ranges from 10, for symptom free individuals, to 1, for patients who are bedridden and unable to perform activities of daily living.
Severely Ill Patients (Functional Capacity Rating 1-3; Appendix C in the original guideline document)
Homebound and bedbound patients may benefit from in-home services that provide assisted range-of-motion and strengthening exercises. Exercise lying down should be advised when exercise standing or sitting is poorly tolerated. Initially, interval training exercise should begin with gentle stretching to improve mobility utilizing intervals of 90 seconds or less. The patient should rest between intervals until complete recovery has occurred. Additional intervals can be added when the stretching exercises do not trigger post-exertional symptoms. Then, resistance training can begin (functional capacity rating 4-5) with elastic bands or light weights. As endurance improves, short-duration interval training such as leisurely-paced walking can be added.
Higher Functioning Patients (Functional Capacity Rating 5-9; Appendix C in the original guideline document)
Interval training can begin with leisurely paced walking, swimming, or pedaling on an exercise cycle. The initial duration may vary from 5-15 minutes a day depending on how much the patient can do without provoking symptom flares. These higher functioning patients may also benefit from adaptive yoga and Tai Chi.
Medications for Fatigue and Post-exertional Symptoms (Table 7 in the original guideline document)
Due to prescribing difficulties, cost, and limited effectiveness, medications for fatigue may need to be reserved for functional assistance at special, but potentially exhausting events in the patient's life (e.g., a wedding or a concert). If the medication is effective, patients should avoid exceeding their individual activity limit, as this is likely to provoke symptom-worsening. Thus, careful monitoring of activity is recommended.
Cognitive Problems
The patient's cognitive difficulties can be managed to some extent with the following suggestions:
- Using a "memory book" to write things down in one place (and attempt not to lose the book)
- Developing habits such as leaving keys or glasses or always parking in the same spot
- When possible, avoiding situations involving multisensory bombardment and fast-paced activity
- Limiting the duration and intensity of cognitive efforts (a form of pacing)
- Limiting or stopping cognitive efforts when cognitive symptoms flare up
Medications for Cognitive Problems (Table 8 in the original guideline document)
Stimulants seem to work best when the patient describes excessive "sleepiness" during the day as opposed to "tiredness." Sleepiness is suggested by a score of >10 on the Epworth sleepiness scale which may warrant a workup for primary sleep disorders.
Depression, Anxiety and Distress
The prevalence of clinical depression and/or anxiety in patients with ME/CFS is about 40%. This is similar to the rates of psychiatric symptoms in other chronic conditions such as arthritis. Patients may develop depression, anxiety, or stress reactions secondary to the illness or evidence a history of depression/anxiety prior to illness onset. The practitioner should conduct a suicide evaluation for all patients who appear to be clinically depressed or highly stressed.
Managing Depression, Anxiety and Distress: Support, Coping Skills and Pleasant Experiences
These types of interventions may be helpful:
- Educating family members about the illness so that they can provide useful assistance and support
- Identifying and scheduling pleasurable low effort activities (music, recorded relaxation, observing nature) which can generate well-being, reduce symptoms of anxiety, depression and distress and lessen fatigue as well
- Developing coping skills, such as cognitive strategies to reduce anger, worry, and catastrophizing, as well as skills to improve tolerance of this difficult illness. Good resources are available to guide ME/CFS patients with effective coping skills
- Referral, if needed, to supportive counseling, preferably to a professional familiar with ME/CFS
- Referral to a ME/CFS support group or volunteer services. Successful support groups have effective leadership and positive programming that avoids simply exchanging complaints
Medications for Depression
For patients who are clinically depressed, medication can sometimes improve mood and reduce fatigue. Medications should be started at a low dose. Improvement may take several weeks. Possible side effects of antidepressants, notably sedation and orthostatic hypotension, may worsen fatigue and autonomic lability in some patients. Drug choice is often based on side effects profile and the patient's response.
Cognitive Behavioral Therapy (CBT)
CBT is a much publicized and debated psychotherapeutic intervention for ME/CFS that addresses the interactions between thinking, feeling and behavior. It focuses on current problems and follows a structured style of intervention that usually includes a graded activity program. CBT may improve coping strategies and/or assist in rehabilitation, but the premise that cognitive therapy (e.g., changing "illness beliefs") and graded activity can "reverse" or cure the illness is not supported by post-intervention outcome data.
In routine medical practice, CBT has not yielded clinically significant outcomes for patients with ME/CFS. Furthermore, the lack of CBT providers who specialize in this illness (psychologist, social worker, or nurse) indicates that CBT may not be an option for many patients with ME/CFS. More detailed information on CBT protocols and the controversy surrounding its application in ME/CFS is presented elsewhere.
Management of Related Conditions
See section 5:8 of the original guideline for information on managing the following related conditions:
- Orthostatic intolerance (OI) and cardiovascular symptoms
- Gastrointestinal problems
- Urinary problems
- Allergies
- Multiple chemical sensitivity (MCS)
- Infections and immunological factors
Dietary Management
Although no evidence-based special diet is available for ME/CFS, dietary programs are popular with many patients. Good nutrition with a sensible, balanced diet is advisable. Excesses of specific foods as well as rich, fatty foods, sugars and caffeine are best avoided. Eating small meals with snacking in between can be helpful. To help counteract the risk of osteoporosis from lack of vitamin D, dairy products should be incorporated in the diet if lactose intolerance or an allergic reaction to milk and milk products is not present. In addition, because alcohol intolerance (causing sedation) may be reported, alcohol use should be minimized or avoided.
Some individuals who attribute their ME/CFS to food intolerances will carefully avoid certain foods. Gluten and/or lactose intolerances, not uncommon in ME/CFS, require a gluten- or lactose-free diet. Provided that these intolerances have been excluded, a rotational approach, rather than absolute avoidance, may lessen possible negative reactions to food.
Although there is no evidence that patients with ME/CFS suffer from systemic candidiasis, diets intended to combat candidiasis and allergies are quite popular and many patients believe that they are helpful. Finally, some patients with gastrointestinal symptoms have reported benefit from a "leaky gut diet" in combination with L-glutamine or butyrate.
Dietary Supplements
Patients with ME/CFS need to ensure that they obtain at least the recommended daily allowance (RDA) of vitamins and minerals. This is not always possible using dietary sources. A suitable multivitamin and a separate multi-mineral preparation will ensure that at least the RDA of vitamins and minerals are obtained in the correct proportions.
Vitamin D
Because vitamin D deficiency is often found in ME/CFS, additional vitamin D may be necessary to achieve an optimal level, which may reduce the risk of osteoporosis, cancer, heart disease, stroke, and other illnesses.
Vitamin B12 and B-Complex
Given that cerebrospinal fluid levels of vitamin B12 may be depleted in some patients with ME/CFS, a trial of a weekly injection of hydroxycobalamin 1000 μg for six weeks (or perhaps longer) may be helpful. There are no reports of serious risk or side effects, despite the high blood levels achieved. A supplement of B-complex will avoid concurrent B vitamin deficiency.
Essential Fatty Acids
Essential fatty acids supplementation in ME/CFS has yielded symptom improvement and greater shifts towards normal levels of cell fatty acids concentration in treated patients in some studies. Eicosapentaenoic acid, an essential fatty acid, is a major component of omega-3 fish oil. This substance has been beneficial in reducing symptoms for some patients. Additional vitamin and mineral cofactors, including biotin, niacin, folic acid, vitamin B6, vitamin B12, vitamin C, selenium, zinc, and magnesium, may be supportive in conjunction with essential fatty acids supplementation.
Inadequate zinc intake may contribute to decreased function of natural killer cells and cell-mediated immune dysfunction. A multi-mineral preparation may ensure the correct balance between zinc and copper.
Patient use of herbal/natural remedies should be identified to reveal likely side effects and avoid potential conflicts with prescribed medications. Patients may not know that "natural" does not necessarily mean "better" or "safe." As with medication, small doses should be used initially with warnings about adverse reactions. Some herbs with pharmacological effects have been traditionally incorporated in the diet, e.g., herbal teas of peppermint, ginger or chamomile for gastrointestinal symptoms or for improving sleep.
Warnings are appropriate for several largely unregulated products. Glyco-nutrients, olive leaf and pycnogenol (pine bark) have been touted as potential cures for ME/CFS, but neither clinical observation nor published evidence supports their use. Products claiming to be immune system boosters have not been shown, in the medical literature, to reduce symptoms in ME/CFS patients. Many of the so-called adrenal support concoctions contain steroids, which can have adverse effects in those who do not need them, especially when stopped suddenly. Steroids should only be prescribed by a physician.
Alternative and Complementary Approaches
Patients with ME/CFS often try costly alternative treatments in search of a cure. A review of a number of studies revealed generally poor methodologies and little evidence for more than modest effects. Equivocal evidence was found for homeopathy and biofeedback. Acupuncture, massage and chiropractic are relatively established treatments for pain, and thus are covered in the pain section. More detailed information may be found in recent reviews.
Follow Up
Patients with ME/CFS require regular reassessment and follow-up to manage their most disabling symptoms and to reconfirm or change the diagnosis. Although patients may assume that new symptoms are part of ME/CFS, other illnesses with symptoms not characteristic of ME/CFS can develop and should be investigated. Any patient who experiences a worsening of symptoms or the onset of new and/or additional symptoms should be encouraged to return to the physician's office. Additionally, an annual follow-up should be undertaken that includes a review of symptoms, a physical exam, a functional capacity evaluation, routine screening (Table 1, above), and a review of the patient's management/treatment plan.
Related Clinical Concerns
Low Functioning Patients: Special Considerations
Perhaps one in four patients are so disabled that they are confined to a bed or chair and rarely leave home. These individuals are unable to attend regular office visits. Assessments also reveal greater symptom severity, more comorbidities, limited mental activity, and very low levels of physical activity. A small minority of these patients may be totally bedbound and report constant pain as well as an inability to tolerate movement, light or noise and certain scents or chemicals (including prescribed drugs).
Home-based caregivers are essential to support patients with severe ME/CFS, and to participate in their ongoing management plan. Caregivers can also be subject to considerable stress in serving the needs of the patient.
These suggestions may be helpful for this severely ill group:
- Recommend a very quiet environment.
- Limit mental activity (such as reading, writing, computing, or concentrating) because mental exertion is as exhausting as physical activity in many of these patients.
- Minimize medications and supplements to those absolutely necessary.
- Prescribe medication in very low doses and titrate slowly, as tolerated.
- Proceed very slowly with any activity, perhaps starting with range of motion exercises lying down, followed by range of motion with light resistance and then very light aerobic activity.
In addition, low functioning patients may require more services and support with respect to:
- Follow up (perhaps via home visits, telephone contacts, or online communication)
- Social support, including home health services and aides
- Stress management and grief/loss counseling
- Modest expectations for themselves and from others
- Balanced nutrition and healthy foods (provided and prepared by caretakers)
Most mothers with ME/CFS have an uneventful pregnancy and deliver a normal child. During pregnancy, ME/CFS symptoms may improve for some, remain the same for some, and worsen for others. In many patients, symptoms return to pre-pregnancy levels within weeks of delivery. Pregnancy is not recommended in the early stages of ME/CFS, because the patient may be very ill and the diagnosis uncertain.
Some medications for ME/CFS can damage a growing fetus especially in the early stages of pregnancy. The effects of most herbal preparations on the fetus are unknown. Healthcare providers should advise which ongoing medications, given their risks to the fetus, should be stopped before a planned pregnancy. The patient can then determine if she can cope with possibly worsened ME/CFS symptoms without the medications. Some essential medications may need to be continued in smaller doses.
Obstetric problems, which may be more prevalent in women with ME/CFS, include lowered fertility, miscarriage, severe vomiting in pregnancy, exhaustion in labor, delayed post-partum recovery and post-partum depression. If labor is prolonged, surgical delivery of the child is recommended.
Lactation is not contraindicated. The advantages and disadvantages of breast-feeding should be discussed with the mother. Milk can be expressed for night feedings, to allow the mother adequate rest. Child-rearing is the biggest challenge for mothers with ME/CFS and many require a good support network.
The offspring of mothers with ME/CFS may have a higher risk of developing ME/CFS than the general population. One study showed a 5% risk of developing ME/CFS in childhood or early adult life. Another small study suggests that the offspring also may have an increased risk of developmental delays and learning difficulties.
Gynecological Problems
ME/CFS and some common gynecological conditions such as pre-menstrual syndrome and menopause show a significant overlap of symptoms. These conditions also frequently exacerbate symptoms of ME/CFS and vice versa.
A small number of scientific studies suggest that several gynecological conditions occur more frequently in women with ME/CFS. Some of these conditions may pre-date the onset of the illness. These disorders include: premenstrual syndrome; anovulatory and oligo-ovulatory cycles; low estrogen levels leading to a multitude of central nervous system (CNS) symptoms, loss of libido, and in later years, osteoporosis; dysmenorrhea; pelvic pain; endometriosis; interstitial cystitis; dyspareunia and vulvodynia; and a history of hysterectomy (for fibroids or ovarian cysts). The investigation and treatment of these conditions should follow standard gynecological practice.
Many peri-menopausal and postmenopausal patients with ME/CFS may benefit from hormone replacement therapy (HRT). Pre-menopausal patients with ME/CFS and low estrogen levels may also be helped by HRT. Estrogen may improve cerebral circulation, benefit cognition, and provide significant relief from hot flashes, insomnia, and fatigue. HRT also reduces the risk of osteoporosis.
Some women may be more responsive to a progesterone-only regimen such as a progesterone-only pill, or impregnated intra-uterine device. These approaches also address contraception, which may be vital for women with ME/CFS. Oral contraceptives may help patients who suffer from menstrual pain, particularly if bleeding is heavy.
Hormonal therapy should be limited in duration due to the increased risk of breast, ovarian and uterine cancer with HRT. Some women prefer to take "natural" hormones (e.g., phytoestrogens and wild yam products), but it should be pointed out that prospective randomized studies of their clinical effects and potential side effects have not been done.
Pediatric ME/CFS
ME/CFS can occur at any age but it is difficult to diagnose under the age of ten. Pediatric management can be especially challenging. Children and adolescents sometimes do not report symptoms and assume tiredness is normal. In addition, they are often misdiagnosed as lazy or having behavioral disorders, school phobia, attention deficit hyperactivity disorder (ADHD) or factitious disorder by proxy. The diagnosis of ME/CFS is often overlooked or delayed, but it can be established using a specific pediatric case definition (Appendix B in the original guideline document), which is based on the Canadian case definition. The diagnosis in children can be made after 3 months of illness. The prevalence of ME/CFS in children and adolescents varies greatly in different studies, but, overall, rates appear to be lower than in adults.
Management and treatment of children with ME/CFS is similar to that described above for adults. Any medications should be prescribed with great caution. As with adults, many pediatric patients with ME/CFS respond to much lower than standard doses of medications.
Many children with ME/CFS experience worsening of their school performance. In the USA, children and adolescents with cognitive deficits and physical limitations may qualify for special services under the Individuals with Disabilities Education Act (IDEA), because they are "health impaired." With physician documentation, eligible students can receive an individualized educational plan (IEP).
Tutoring at home, correspondence schooling or home schooling allows students who are debilitated with ME/CFS to pace themselves and reduce symptom flares. When appropriate, a graduated schedule of return to school can be successful in conjunction with school personnel who are willing to work with the child and family. This might involve the child initially attending a single class on a daily basis and gradually increasing the number of classes attended over several weeks or months.
To enhance the chances of recovery, competitive sports are best avoided. If the patient is subject to stress-related symptom flare-ups, it may be desirable to limit academic examinations to those that are deemed essential. Family counseling may be recommended if family conflicts related to the child's illness are evident. The prognosis for children with ME/CFS is considerably better than for adults, although they may initially be severely ill.
Patients with ME/CFS should consider avoiding all but essential immunizations particularly with live vaccines, as post-vaccination relapse has been known to occur. Usual medical practice is not to vaccinate a normally healthy person when unwell. However, during a flu epidemic, patients should balance the health hazards of becoming ill against the possibility of symptom-worsening due to immunization.
Blood and Tissue Donation
The American Red Cross requires that blood donors "be healthy," i.e., feel well and be able to perform normal activities. Since people with ME/CFS are not healthy by this definition, they should not donate blood. Furthermore, based on the possible link between ME/CFS and xenotropic murine leukemia virus-related virus (XMRV), a number of national blood banks adopted measures to discourage or prohibit individuals diagnosed with ME/CFS from donating blood.
Recommendations Prior to Surgery
For individuals with ME/CFS approaching surgery, discussion with the surgeon and anesthesiologist/anaesthetist about this illness is important. Issues such as depleted blood volume, orthostatic intolerance, pain control, and sensitivity to anesthetic medications should be addressed. Further recommendations for persons with ME/CFS who are anticipating surgery are given in Appendix E in the original guideline document.
Clinical Algorithm(s)
None provided
Chronic fatigue syndrome, also known as myalgic encephalomyelitis
Guideline Category
Clinical Specialty
Family Practice
Internal Medicine
Obstetrics and Gynecology
Physical Medicine and Rehabilitation
Intended Users
Advanced Practice Nurses
Physical Therapists
Physician Assistants
Psychologists/Non-physician Behavioral Health Clinicians
Guideline Objective(s)
To provide the information necessary to understand, diagnose, and manage the symptoms of chronic fatigue syndrome—also known as myalgic encephalomyelitis (ME/CFS)
Target Population
Patient suspected of having or diagnosed with chronic fatigue syndrome—also known as myalgic encephalomyelitis (ME/CFS)
Interventions and Practices Considered
- Medical and social history
- Physical examination
- Measuring severity and frequency of symptoms (pathological fatigue, post-exertional malaise, sleep problems, pain, two neurocognitive symptoms, and at least one symptom from two of the following categories: autonomic, neuroendocrine, immune)
- Routine laboratory tests, electrocardiogram, chest x-ray
- Differential diagnosis
- Distinguishing myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) from depressive and anxiety disorders
- Identifying and treating exclusionary and co-existing medical conditions
- Treating symptoms and guiding patient self-management
- Management of sleep disorders (sleep hygiene and medications)
- Management of pain (nonpharmacologic interventions and medications)
- Management of fatigue and post-exertional malaise (pacing activities, activity logs, exercise and activity programs, medications for fatigue)
- Management of cognitive problems
- Management of depression, anxiety and distress (providing support, coping skills, engaging in pleasant experiences, medication)
- Cognitive behavioral therapy
- Management of related conditions (orthostatic intolerance and cardiovascular symptoms, gastrointestinal problems, urinary problems, allergies, multiple chemical sensitivity, infections and immunological factors)
- Dietary management (e.g., supplements)
- Alternative and complementary approaches
- Regular follow-up and reassessment of symptoms
- Special considerations for low-functioning patients
- Management of pregnant women and women with gynecological problems
- Management of children with ME/CFS
- Avoiding all but essential immunizations, particularly with live vaccines
- Discouraging or prohibiting individuals diagnosed with ME/CFS from donating blood
- Preparing for surgery
Major Outcomes Considered
- Symptom reduction
- Quality of life
Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
Ovid/Medline was searched for articles from the time period of 1984 to May 2012 using the search term "chronic fatigue syndrome."
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
The text was developed by consensus of the primer committee. The authors have made considerable efforts to ensure that the information provided is accurate and up to date. Where published studies are lacking, the recommendations are based on the clinical expertise of the committee's experienced practitioners.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Not stated
Description of Method of Guideline Validation
Not applicable
Evidence Supporting the Recommendations
Type of Evidence Supporting the Recommendations
The type of evidence supporting the recommendations is not specifically stated for each recommendation.
Where published studies are lacking, the Writing Committee's recommendations are based on the clinical expertise of the Committee's experienced practitioners.
Benefits/Harms of Implementing the Guideline Recommendations
Potential Benefits
Accurate diagnosis and appropriate treatment and management of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)
Potential Harms
- Medications for sleep: Patients may initially feel thick-headed in the morning, but this usually improves as benefits become apparent. The risk of side effects and drug combinations which can produce serotonin syndrome should be explained. In some patients, tolerance may develop with medications. See Table 5 in the original guideline document for specific potential side effects of medications for sleep.
- Non-pharmacologic interventions for pain: These interventions may be poorly tolerated, inaccessible, or prohibitively costly.
- Medications for pain: See Table 6 in the original guideline document for specific potential side effects of medications for pain.
- Medications for fatigue: Due to prescribing difficulties, cost, and limited effectiveness, medications for fatigue may need to be reserved for functional assistance at special, but potentially exhausting events in the patient's life (e.g., a wedding or a concert). See Table 7 in the original guideline document for specific potential side effects of medications for fatigue.
- Medications for cognitive problems: See Table 8 in the original guideline document for potential side effects of medications for cognitive problems.
- Medications for depression: Possible side effects of antidepressants, notably sedation and orthostatic hypotension, may worsen fatigue and autonomic lability in some patients. Drug choice is often based on side effects profile and the patient's response.
- Herbs: Patient use of herbal/natural remedies should be identified to reveal likely side effects and avoid potential conflicts with prescribed medications. Patients may not know that "natural" does not necessarily mean "better" or "safe." As with medication, small doses should be used initially with warnings about adverse reactions.
Qualifying Statements
Qualifying Statements
This primer was developed by consensus among members of the primer committee who have made considerable effort to ensure that the information is accurate and up to date with the caveat that the physiological basis of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) has not yet been established. Statements, opinions and study results published in this primer are those of the individual authors and the studies cited, and do not necessarily reflect the policy or position of the International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (IACFS/ME). The IACFS/ME provides no warranty, express or implied, as to the accuracy or reliability of all the contents of this primer. The recommendations contained in any part of this primer do not indicate an exclusive course of treatment or course of action. Nothing contained in this primer should serve as a substitute for the medical judgment of a treating provider.
Implementation of the Guideline
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Chart Documentation/Checklists/Forms
Institute of Medicine (IOM) National Healthcare Quality Report Categories
IOM Care Need
Living with Illness
IOM Domain
Identifying Information and Availability
Bibliographic Source(s)
|International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (IACFS/ME). Chronic fatigue syndrome/myalgic encephalomyelitis. A primer for clinical practitioners. Chicago (IL): International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (IACFS/ME); 2012. 41 p. [121 references]
Not applicable: The guideline was not adapted from another source.
Date Released
Guideline Developer(s)
International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis - Nonprofit Organization
Source(s) of Funding
The International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (IACFS/ME) Primer Writing Committee acknowledges the generous support of Chase Community Giving and Hemispherx Biopharma in the production of this primer.
Guideline Committee
International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (IACFS/ME) Primer Writing Committee
Composition of Group That Authored the Guideline
Writing Committee: Fred Friedberg, Ph.D. (Chairperson), Stony Brook, New York, USA; Lucinda Bateman, B.S., M.D., General Internal Medicine, Salt Lake City, Utah, USA; Alison C. Bested, M.D., F.R.C.P.C., Haematological Pathologist, Toronto, Ontario, Canada; Todd Davenport, D.P.T., O.C.S., Physical Therapy, Stockton, California, USA; Kenneth J. Friedman, Ph.D., Physiology/Natural Sciences, Castleton, Vermont, USA; Alan Gurwitt, M.D., Psychiatry, Newton Highlands, Massachusetts, USA; Leonard A. Jason, Ph.D., Clinical-Community Psychology, Chicago, Illinois, USA; Charles W. Lapp, M.D., Primary Care, Charlotte, North Carolina, USA; Staci R. Stevens, M.A., Exercise Physiology, Stockton, California, USA; Rosemary A. Underhill, M.B., B.S., Physician, Upper Saddle River, NJ, USA; Rosamund Vallings, M.B., B.S., Primary Care, Howick, New Zealand
Financial Disclosures/Conflicts of Interest
The International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (IACFS/ME) received a $10,000 donation from Hemispherx, the maker of Ampligen® (a possible treatment for ME/CFS), which supported this primer. Charles Lapp is a Hemispherx principal investigator in Ampligen® studies and has a small amount of stock in the company. Lucinda Bateman has been a principal investigator in Hemispherx Ampligen® studies for 10 years. All other authors declared no conflicts of interest.
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (IACFS/ME) Web site .
Availability of Companion Documents
The following items are available in the original guideline document :
- Myalgia encephalomyelitis/chronic fatigue syndrome (ME/CFS) clinical diagnostic criteria worksheet
- 1994 international research case definition worksheet
- Pediatric case definition worksheet
- Functional capacity scale
- Activity log
- Recommendations prior to surgery
A variety of other resources, including a quick start guide to diagnosis and diagnosis questionnaires for adults and children, are available from the International Association for Chronic Fatigue/Myalgic Encephalomyelitis (IACFS/ME) Web site .
Patient Resources
None available
NGC Status
This NGC summary was completed by ECRI Institute on September 10, 2012.
Copyright Statement
This NCG summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.
NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.


text:
phone view phone(609) 610-1976 Address 4525 Comanche Trail Blvd
Jacksonville, Florida 32259
United States
Jacksonville, Florida 32259
United States
|Law School
|Florida Coastal School of Law
|Admitted Year
|Most recent firm
|Barrasso Consulting (through Kelly Law Services
|Relevant Jobs
City Attorney
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A. Harrison Barnes is a well-known attorney throughout the United States. As a member of the Malibu community, Harrison is committed to serving the needs of Malibu residents and businesses in legal matters.

subset: commoncrawl


text:
Jonathan KING
Office: Division of Behavioral and Social Research (DBSR)
Phone: 301-402-4156
Jonathan W. King received his Ph.D. in Cognitive Psychology from Carnegie Mellon University. His post-doctoral work in cognitive neuroscience at the Department of Cognitive Science at UCSD focused on language processing and working memory in both younger and older adults. Dr. King later joined the faculty in the Department of Psychological Sciences and the Interdisciplinary Neuroscience Program at the University of Missouri-Columbia. He joined the Biobehavioral and Behavioral Processes IRG at the Center for Scientific Review at NIH in 2006, and is currently working as the Program Director for Cognitive Aging and Human Factors in the Division of Behavioral and Social Research (BSR) at the NIA. While at BSR, he has coordinated new initiatives in cognitive interventions to remediate age-related cognitive decline and the use of behavioral economic approaches both to promote health behavior change in older adults and to increase the uptake of comparative effectiveness research. Dr. King is also the Roadmap Coordinator for the NIH Science of Behavior Change Roadmap Project effort.
- Cognitive aging and cognitive interventions
- Human factors in older adults, especially driving
- Technology use by older adults
- Science of Behavior Change (Common Fund)
- Statistical methods for aging research
- Genetics of social behavior
- Interplay of genetics and social, psychological and behavioral processes across the lifespan


text:
You should have just bought mine when you bought the pipes .. all I wanted was 300 bucks.
Thanks sweet, thats the cheapest I have seen!
It was 14 bucks shippin. I got it from Dennis Kirk. Beat it by a buck. 435.65 today. Be in here Wednesday. Be a late Birthday present/ Amazons are higher right now . That was cheapest website i found.


text:
Who won the greatest game ever pitched?
Can't believe Volquez didn't throw over...he was obviously running lol.
I still say Phillips would hit .315+ with that approach. Seems like he gets a hit every time he goes oppo on that outside strike. Would love to see his BABIP on balls pulled vs balls hit oppo
The Reds offense will be fine once they get back to GAB. Just to hard to hit in these large parks.
Frasier with a bad pitch hit.
Yonder and BP getting a room later???... too much
Aggressive baserunning tonight.
If evolution is outlawed, only outlaws will evolve!
Lets see if we can hit a sac fly
Put Stubbs in...
Board Moderators may, at their discretion and judgment, delete and/or edit any messages that violate any of the following guidelines: 1. Explicit references to alleged illegal or unlawful acts. 2. Graphic sexual descriptions. 3. Racial or ethnic slurs. 4. Use of edgy language (including masked profanity). 5. Direct personal attacks, flames, fights, trolling, baiting, name-calling, general nuisance, excessive player criticism or anything along those lines. 6. Posting spam. 7. Each person may have only one user account. It is fine to be critical here - that's what this board is for. But let's not beat a subject or a player to death, please.


text:
Address: http://www.EvilInstincts.com/
Game Name: Evil Instincts
Game Description: A browser game based on the old style Internet MUDs (Multi-User Dungeon), which focuses on the MUDS fast action, highly interactive experience.
Publisher: Sergio Camarena
Genre: Text Fantasy
Status: Open Beta
Browser Based
Game is still in development, but it's playable.
I'm developing a classic, old-school MUD (Multi-User Dungeon) that is identical to their old TELNET counter-parts, but instead of typing commands, you just use the web interface.
I'm confident it's highly entertaining due to it's very interactive nature. Most RPG games on the web are not real-time combat or play. I have actually accomplished this using javascript techniques, and the result is quite nice.
If you have played a MUD before, it will be very familiar.
Please try it out at www.EvilInstincts.com.
Do not be taken aback by the sparseness and low-graphics feel of it. Most of the development has been on game-play and functionality.
I would love to hear your comments on it!


text:
Posted by Augie Ray on August 18, 2010
Today Facebook revealed its long-anticipated geolocation offering called "Places." In many respects, Facebook's offering doesn't expand on the functionality you can find in current location-based services such as foursquare — you can check in at a place, share your location with friends, see who is nearby, and add a place. In fact, the most important contribution Facebook is making to the geolocation social space is not in form but scale. While foursquare counts around 2.5 million users in its base, Facebook has 500 million. This means that Facebook is positioned to introduce the benefits of location sharing to a new and much wider audience.
Of course, providing users with a new feature is one thing, but getting them to adopt a new sort of social behavior is another. Facebook has done much to ease the adoption process for users, starting with some smart decisions about privacy. It is evident that Facebook has learned from past privacy missteps. By default, when users check into a place, this information will only be shared with friends and not the whole world. This reflects a different and more user-centric approach than Facebook has taken in the past.
Of course, it's nearly impossible to launch any new social feature without some level of privacy concern, and it remains to be seen whether users will like or dislike the fact that they can be checked in by their friends. Facebook says this is intended as an advantage — since not every person has an advanced smartphone, not every Facebook user can check himself or herself into a location for the time being; by allowing people to check in their friends, more Facebook users can participate. People can turn off the ability for friends to check them in, but by default this is permitted.


text: The Panda, Mogilny, Walter and Pass99 basically summed up what would have been my reply. I guess the only other thing I would add is that if the players played the defense you categorized each of them as, our record would probably not be bottom 4. I would also disagree with one thing that Walter said and it relates to Calderon's defense. Personally, I think his defense is terrible. I guess the only saving grace is there are not many lock down defenders at the PG position to begin with. Pass99, who is the guy you want drafted? Based on your description I will assume it is either Noel, Zeller or Bennett. Without overvaluing Monroe, if you were JD, who would you trade him for? Keeping in mind the trading partner 1) needs a C/PF 2) willing to give up the asset you are trading for 3) makes sense for both teams. I ask because I can't think of a team that has a player we could use and could use Monroe (assuming each team gets equal value).


text:
Lewiston, N.Y. – The Canisius College women's lacrosse team cruised to a 14-4 win over Battle of the Bridge rival Niagara on Wednesday night. The Griffs won their sixth-straight contest to improve to 8-3 on the season and 2-0 in MAAC play, while the Purple Eagles drop to 4-8 and 0-2 in league play.
"We got off to a fantastic start again and that was the difference," said Canisius head coach Scott Teeter. "We made the most of our shots early in the game and took advantage of our opportunities to build a big lead at the half. However, we need to play better in the second half if we want to reach our potential this season."
Senior Lindsey Morgan and sophomore Tori Quinn both led the Griffs with a game-high five points in the win. Morgan netted four goals to go along with one assist, while Quinn recorded two goals and three helpers.
Senior Morgan Leonard also netted four goals to go along with a game-high five caused turnovers, while junior Maria Kotas chipped in four points on two goals and two assists. Sophomore Meghan Cuddy and freshman Caroline Ogden rounded out the scoring for Canisius with a goal each.
Sophomore Kayla Scully anchored the Canisius defense with four saves to earn the victory before giving way to senior netminder Gina Molfetta, who recorded two stops in relief.
The Griffs scored early and often in the contest, taking the lead and never looking back. Quinn opened the scoring 3:08 into the contest with Leonard following with three of the team's next four tallies as Canisius grabbed a 5-0 lead, forcing an early Niagara timeout.
Overall, the Griffs scored the first seven goals of the game and outscored Niagara, 10-1, in the opening 30 minutes of action. Canisius also outshot the Purple Eagles, 18-4, and forced Niagara into 11 first-half turnovers.
The Griffs continued to control the action in the second stanza and their lead reached as high as 13 goals, 14-1, before the Purple Eagles netted the final three tallies for the 14-4 final.
Canisius finished the game with a 30-14 advantage in shots, while forcing the Purple Eagles into 19 turnovers.
Four different players scored for Niagara with Paige Sasser finishing with 10 saves in net.
Canisius continues MAAC play on Saturday, playing at Manhattan. First draw is scheduled for 5 p.m.
Game Notes: Canisius has now won the last nine meetings against Niagara … The Griffs have outscored opponents, 94-36, during the team's six-game winning streak(average of 15.7 to 6.0) … The six-game winning streak is now the second-longest in school history and the longest since Canisius won eight-straight during the 2011 season … The Griffs now lead the Battle of the Bridge series, an annual all-sports competition between the two schools, 16-11.


text:
Motorola impressed us a year or so ago when it introduced the Defy. It was a rugged, waterproof smartphone that actually looked quite sleek and had all the smartphone essentials. It then followed this up with the slightly faster Defy+ at the tale end of 2011, and we liked that model too. Now it's expanded the line further with the Defy Mini, which is a smaller even cheaper version available for around £150. But while Motorola has got some things right, this handset is also deeply flawed.
Waterproofing and Toughness
Perhaps the biggest failing of the Defy Mini is that it isn't all that tough, or more specifically waterproof. Where the original Defy could survive a dunking, it would appear from our testing that the Defy Mini cannot. The key here is that the Defy was rated to IP67, which means it is completely sealed against dust and can survive in up to metre of water. On the Defy Mini, however, this official stamp of approval has disappeared.
Not at first realising this we put the phone to the same mild dunking test as we did with both the Defy and Defy+, and the result was a rather soggy phone – inside and out. After drying the phone out all seemed well until we tried to interact with the touchscreen, whereupon it simply failed to respond.
Clearly this is a little embarrassing for us, as we didn't read the small print, but it's a worse situation for Motorola. The distinction on Motorola's website between the toughness of the Defy Mini and its larger siblings is absolutely minimal and the page title of the official site proudly proclaims the phone water-resistant, so the likelihood many punters will mistakenly buy this phone thinking it offers the same protection as the Defy and Defy+ seems high. The result? Potentially many unhappy customers.
So perhaps the key question is just what can the Defy Mini survive? Well, it doesn't have an official IP rating that we know of so it's hard to nail down but we would hazard that this device actually conforms to the IP65 standard. This infers the device is resistant to jets of water hitting the phone from any angle, but not complete submersion. Essentially, it's rain and shallow puddle proof – not a device for taking kayaking.
As for its actual toughness, the body is finished in rugged plastic that certainly seems capable of surviving a few bounces on concrete. The battery cover also has a latch, which should prevent it flying off and exposing the innards when dropped. The final piece of the puzzle is that the screen uses scratch and crack resistant Gorilla Glass.
Design and Features
So the Motorola Defy Mini isn't the toughest phone in the world but otherwise it just about fits the camping-phone bill. It is indeed smaller and lighter than your average handset, making it perfect for keeping your camping clobber as small and lightweight as possible. It's also potentially easier for children to handle, so if you're looking for a cheap, tough phone that'll survive play time in the sand pit, it's a possible option. That said, it is actually 2mm taller than the Defy and Defy+, so presumably its mini claims come from the fact it's 0.8mm thinner.
Style wise, it's not ugly but hardly inspiring either. It's a device of function, not form.
Round the sides, completing the rugged credentials are rubber flaps covering the headphone and microUSB ports. It's a bit of a pain having to flip these out the way all the time to plug in your headphones or put your phone on charge but needs must. Elsewhere you've got a 3megapixel camera on the back with an LED flash, and there's even a hardware button on the side for taking snaps. You also get volume buttons on the left and screen lock/power on the top edge. As the phone's small it's nice and easy to reach all these controls and the full expanse of the screen, which is more than can be said for most phones these days.
One let down here, though, is the use of touch buttons underneath the screen. These work well in normal conditions but can become a bit sporadic in the wet, as indeed can the touchscreen (even when still working). The larger Defys also suffered with this but the Sony Ericsson Xperia Active gets round this, so that may be your best choice if this is a major concern.
Motorola Defy Mini XT320 Unlocked GSM Phone with Android 2.3 OS - Black$49.99 View Item
Motorola Defy Mini XT320 - Black (Unlocked) Smartphone Cell Phone AT&T T-Mobile$138.49 View Item
UNLOCKED MOTOROLA DEFY MINI XT320+3G WIFI+WATER & SHOCK RESISTANT+ANDROID+FM+MP3AU$129.00 View Item
Optus Motorola Defy Mini XT320 3.2"LCD 3MP Android Dust Scratch Water ResistantAU$69.99 View Item
Motorola DEFY MINI - Smartphone- NEW !!! EU version , Full BOX !!!$99.00 View Item
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text: Metro Trouser Pants Style: prod7519278 Out of Stock Love it? Everyone else did too. This item sold out! Use our search tool, chat online or call 1.888.855.4986 to find something equally desirable. Perfect-fitting trouser pants are a must-have style staple. In our soft, smooth, refined fabric, the sophisticated crease down the front leg streamlines the silhouette for a city-chic look. Hidden slide-clasp and zipper closure. Slanted hand pockets and welted back pockets. 70% polyester, 27% rayon, 3% spandex. Unlined. Machine wash. Imported. Read More… Share on Facebook Tweet Pin


text:
Peripherals: Simulation
Look to RIA for a Revitalized Robotics Industry
There is no sugar coating the fact that the robotics industry suffered from the Great Recession but there are some bright spots. RIA's Director of Market Analysis, Paul Kellett, presented detailed statistics during the Robotics Industry Forum and they show the industry has contracted. However, he also highlighted areas where
KUKA RoboCoaster is Sum of All Thrills at Disney's Epcot
Until recently, few people could boast they had strapped themselves to a robot and gone for a ride (although quite a few did this at 2005 International Robots & Vision Show when KUKA brought an early version of their RoboCoaster). Now you can go


text:
What would be the Pali for Wherever you throw me I will stand?
thanks in advance
Moderator: Mahavihara moderator
Dhammanando wrote:yattha katthaci tvaṃ maṃ khipeyyāsi, tatth'āhaṃ tiṭṭheyyuṃ.
Or more poetically:
yena maṃ khipeyyāsi, tena ṭhassām'ahaṃ.
But I wonder, is it the Latin motto quocunque jeceris stabit that you have in mind? If so, then that would be simply:
yattha naṃ khipeyyāsi, tattha ṭhassati.
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text:
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text:
[Date Index]
[Thread Index]
[Author Index]
how put Manipulate-like automatic action control in a Panel?
I have a Panel with various Manipulator objects, each a function of a
Dynamic variable. How can I put a control on the Panel that does the
same thing as is done by the little +shaped control on a Manipulate that
accesses Manipulate autorun actions?
Murray Eisenberg murray at math.umass.edu
Mathematics & Statistics Dept.
Lederle Graduate Research Tower phone 413 549-1020 (H)
University of Massachusetts 413 545-2859 (W)
710 North Pleasant Street fax 413 545-1801
Amherst, MA 01003-9305


text:
So allegedly the holsters for the Sig P239 fit the Bersa Thunder 9/40/45 pistols, both UC and HC, Pro and non-Pro.
Ive called every retailer, local and online, Cheaper than Dirt, Holsterland.com, Eagle Imports/Condors Flight.. I even called Fobus themselves..
I understand that the picture may not represent the actual item number.. and only the style of holster. However the Sig P239 has a rounded smooth trigger guard.. and the Thunder series has the flat front trigger guard with the finger rest, just like a Glock.
So how well does a round bottom but squared off trigger guard fit into a smooth fully round molded holster for the Sig?!?!?!?!
No one has one in stock that I can go test fit.. everyone I spoke with is just assuming it will fit.. I have also read multiple times that holsters for a Glock 19/23/32 fit this pistol... Does anyone know for sure, or can they test fit for me!? PLEASE? ... and thank you.
Here are some links of holsters I am referring to.. you'll notice the differences in the molded trigger guards:
Fobus Bersa, Sig, S&W Evolution Paddle Holster - FOBUS HOLSTERS by Gun Gear Usa
BS2BERSARP - Fobus Roto Paddlebelt Holster With Bersa Logo
Bersa Thunder 9 mm UC Belt Holster By Fobus [SG239RB] - $35.99
Fobus Evolution Standard Belt Holster SIG Sauer 239 9mm Right Hand Black
According to retailers and manufacturers, ALL of those will fit.. but i dont see how with the trigger guard differences. And for the record, I cant yet afford a custom made or higher priced holster.. just need something that my brother can get me for Christmas to replace my stupid $6 Wal-Mart nylon airsoft gun holster.


text:
Regardless of the type of diapers you're using, you'll need a healthy stash of wipes. Wipes are a must-have for diaper changes, drool-soaked chins, runny noses, sticky hands... babies require a lot of wiping up!
Our Cotton Wipes are made of 100% unbleached cotton flannel. They are 1-ply, and at 8" x 8", tiny enough to tuck into your pocket. They're soft and practical, with just a touch of whimsy in the rainbow stitching.
Cotton Wipes are sold in packs of 6.
2013-12-12 16:38:22
Fantastic Wipe!
I purchased a set of these to try out cloth wipes. I have since purchased several other kinds, but these are hands down my favorite! They are very soft and do a great job cleaning up! They wash wonderfuly and the rainbow edging is delightfully adorable :)
2013-05-01 14:22:04
Best wipes ever!
I am so sold on these wipes. They are thin, but sturdy. They grab, but they are soft. They don't curl up in the wash and they are just so perfect. I can't wait to buy more!
Do you want to review this Bummis product ?


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Eight years of rule by the authoritarian minded Vladmir Putin has left the nation's judiciary system in a shamble of corruption and inefficiency. Newly elected President Dimitry Medvedev, who comes from a legal background, said the establishment of an independent judiciary was the central plank of planned reofrms to the judicial sytem. "Our main goal is to achieve independence for the courts as a reality. The principle that courts should be guided only by the law is well-known, and this, as a matter of fact, forms the basis for the courts and trust in a fair justice." Medevev pledged he will fight to protect judges from outside pressure or bribery. He was particularly upset at the lack of proper legal credentials on the part of many judges.
Prominent lawyer, Mikhail Barschchevsky, said any reform woould require at least ten years to achieve any kind of results and it all came down to "a question of political will" on the part of Medvedev. He noted: "the judicial system is completely corrupt, and to reverse this, what is necessary is a change of the ruling elite and not just the judges."
During his campaign for the presidency, Medvedev referredd to Russia as a "country of legal nihilism" with a "disregard for the law." The president now has an historic opportunity to bring about change and end the nihilism which pervades. Of course, in so doing, Medvedev may well run straight into opposition from his mentor, Vladmir Putin.


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American forces are stretched thin as they fight both in Iraq and Afghanistan, but there is increasing evidence of a possible new third front situation on the border area that connects Afghanistan and Pakistan. Three congressmen recently visited Pakistan where they met with President Musharraf and discussed American concerns about what was happening in tribal areas of Pakistan. Congressmen Gene Green, Michael McCaul, and Henry Cuellar, told the Houston Chronicle, US commandos are prepared to stage raids into Pakistan's volatile tribal areas if Pakistan does not not action to halt Taliban and al-Qaeda militancy. They told President Musharraf failure to disrupt terrorist attacks which have led to a rise in US casualties in Afganistan will require new American military action in the border region. Musharraf has so far rejected resumption of joint operations with the American military that ended in 2003.
There is little doubt comments by the Congressmen were cleared with the Bush administration. McCaul openly said Pakistan's failure to contain militancy makes it "imperative that US forces be allowed to pursue the Taliban and al-Qaeda inside Pakistan." Even as they spoke, General David McKiernan was complaining of the growing number of militant actions that arise from their ability to cross over into Afghanistan.
There is no doubt militancy is growing in Afghanistan. However, US strikes into Pakistan will only create a new front which must be manned and will undoubtedly become a permanent center of new American military action. Is this a possible reality in light of growing concerns by the American public for continued fighting in Asia?


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Bearcats Student-Athletes Honored for Classroom Performance
Jan. 24, 2014
Fall 2013 Dean's List | Fall 2013 Bearcat Honor Roll
The average halftime presentation at a men's basketball game does not include 226 participants, but that is exactly the number of Bearcats student-athletes who were recognized at Fifth Third Arena for posting a grade-point average of at least 3.0 during the Fall 2013 semester.
At halftime of Thursday night's men's basketball game versus Temple, the group was recognized before 10,000-plus fans for their achievements off the field. The group making the Bearcat Honor Roll for achieving at least a 3.0 represented 52% of all UC student-athletes, while 34% of all student-athletes earned a spot on the Dean's List for posting at least a 3.4 GPA.
Included in the 226 Bearcat Honor Roll members were 25 student-athletes who were recognized as TopCat Scholars for posting a perfect 4.0 GPA last semester.
Overall, the athletic department posted a fall grade-point average of 3.016. Head coach Angela Farley Wilson's tennis squad had the highest team GPA at 3.556, while Ty Neal's first full semester at UC saw his baseball team post the highest by a men's program at 3.232.
TopCat Scholars
Mitch Patishall - Baseball


text: Maybe it's just me, but it seems like more skaters are injured this year than ever. What do you think this can be attributed to? Perhaps everyone trying to up their technical ante the year before the olympic season? 3 of the top 5 US men have been dealing with injuries (Lysacek, Weir, Abbott) as well as big US names Alissa and Rachael among others. Tons of people pulling out of the GPs from all nations in every discipline. The pairs field has run out of possible competitors for the GP series. Hopefully this all gets sorted, i prefer a competition where all are healthy and at the top of their game.


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The CACFP meal pattern varies according to age and the type of meal served. Please review the documents below for additional information.
Infant Feeding
- Infant Meal Pattern
- Infant Meal Pattern (Spanish)
- Sample Infant Menu
- Infant Menu Form
- Obligation of Offer Infant Meals in the CACFP(policy)
- Obligation to Serve Infants in the CACFP(form)
- Creditable/Non-Creditable Infant Foods
- Is this infant meal reimbursable?
- Indiana Infant Feeding (Power Point Presentation)
Meal Pattern Requirements for Children
- Meal Pattern for Children
- Meal Pattern Chart for Children Ages 1 - 12
- Recommendations to Improve Your Menus


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Minka Kelly gets watched by people after lunch.
Michelle Rodriguez has got her traveling hat on. It seems like it would be, right?
Natalie Portman picking up a few bucks from Dior.
The new King and Queen of Spain. Actual emotion there. Must have had something inn their teeth.
Ashley Tisdale takes her niece and mom shopping.
Tim McGraw would like you to know he works out. I would like you to know, I do not.
Tom Hardy and a dog on the set of his new movie.
The Rock promoting Hercules in Australia.
Taylor Swift looking very summer like in NYC.


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Knowing how to get rid of spiders is essential, as these creepy pests can strike fear into the hearts of homeowners. The giant house spider, the domestic house spider, and the hobo spider are the most common spider species found in homes in North America.
Although most spiders are not aggressive toward humans, hobo spiders will bite if provoked, and homeowners need to know how to get rid of spiders. Domestic house spiders lay eggs sacs containing about 50 eggs at undisturbed places around the house. Call a pest exterminator today to discover safe ways of how to get rid of spiders.
Terminix® stands behind its professional service. That's why we offer the strongest guarantee in the business. We call it Ultimate Protection®. You may come to call it ultimate peace of mind.


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IntelliScanner mini's sleek and ultra-portable design makes it easy to scan items anywhere -- in your home office, wine cellar or even at your favorite store. It's built to travel, and small enough to fit in your pocket or purse. Simply scan the barcode, then plug it in to download and start organizing. IntelliScanner automatically stores your scans until you plug it into your computer -- just like a digital camera.
Organize everything with IntelliScanner mini's included home organization software. The intelligent software organizes your collections automatically and instantly fills in the details -- so you don't have to! By scanning the barcode, the software will automatically download detailed product information on your item, like a book title, CD track, wine varietal, comic book cover art, or cereal brand.
IntelliScanner mini includes everything you need to organize, track and share your collections automatically. IntelliScanner mini and our easy-to-use software comes packaged in one box. It's a complete home organization solution in one place, for your PC or Mac.


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'It all begins with selecting the right players. They address needs and always seem to have players ready at different positions. You also have to give them ice time and allow them to develop. As a coach I always wanted to make sure ice time got spread around as evenly as possible. It didn't help anyone to only play a few minutes a game. That's not what I wanted to see. You want players to develop and play in different situations and you have to spread ice time around in order to do that.'
Randy Cunneyworth Talks Sabres
October 18, 2008 Submitted by
Via: AtlantaThrashers.com


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Program for International Legal Studies announces Fall 2010 Speaker Series
DETROIT (Aug. 26, 2010) — Representatives of the Program for International Legal Studies at Wayne State University Law School are pleased to announce the Fall 2010 Speaker Series.
"Wayne Law is proud to host a series that features such a remarkable group of internationally known experts," said Gregory Fox, Wayne Law professor and director of the Program for International Legal Studies. "Each of the talks will be on an issue very much in the news, and the speakers will offer an exciting mix of scholarly insight and provocative commentary."
The Fall 2010 Speaker Series features the following events:
Thursday, Sept. 9
"Prosecuting international crimes: The cases of Abu Ghraib and Chuckie Taylor"
Christopher Graveline, assistant U.S. attorney in the Eastern District of Michigan
Wednesday, Sept. 22
"In search of a just settlement of the Israel-Palestine conflict: The relevance of international law"
Tom Farer, former dean of the Josef Korbel School of International Studies at the University of Denver and former president of the Inter-American Commission on Human Rights of the Organization of American States
Wednesday, Oct. 6
"Miranda rights for terrorism suspects?"
Mark Denbeaux, professor and director of the Center for Policy and Research at Seton Hall Law School
Wednesday, Oct. 13
"The new Strategic Arms Reduction Treaty with Russia"
Jeffrey Pryce, an attorney with Steptoe and Johnson LLP in Washington, D.C.
Wednesday, Nov. 3
"The new crime of aggression before the International Criminal Court"
Sean D. Murphy, Patricia Roberts Harris Research Professor of Law at The George Washington University Law School
These events will take place in the Law School's Spencer M. Partrich Auditorium at 12:15-1:30 p.m. on the dates noted above. They are free and open to the public and lunch will be served. Parking is available for $4.25 in WSU Structure #1 across from the Law School on West Palmer Street in Detroit. For directions to the Law School or to view a campus map, visit campusmap.wayne.edu/location/LAW.
For more information about the Speaker Series or the Program for International Legal Studies, visit Wayne Law online at law.wayne.edu/international-studies or contact Fox at firstname.lastname@example.com.
Program for International Legal Studies
Wayne Law created the Program for International Legal Studies in recognition of the breadth of the faculty's international engagements and expertise and the fact that nearly all aspects of law now have an international component. From regulation of cross-border financial transactions to controlling pollution that recognizes no boundaries to human rights treaties that regulate how governments treat their citizens, law is now an interconnected global phenomenon.
The program coordinates all activities at Wayne Law related to international law. These activities include hosting the Speaker Series, sponsoring conferences and symposia featuring leading international scholars and practitioners, promoting research on international and comparative law topics, and providing important resources for Wayne Law students, alumni and friends interested in international law.
The program capitalizes on the Law School's world-renowned faculty members, who teach and write on a wide variety of international legal issues.
- ### -
Wayne State University is a premier urban research university offering more than 400 academic programs through 13 schools and colleges to nearly 32,000 students.
For more information about Wayne State University Law School, visit law.wayne.edu.


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Do you have questions on how to use our products?
Our manuals for Nero BackItUp & Burn certainly help you!
Download information: To view PDF-documents (Portable Document Format), you must have Adobe Reader 5.x or higher. If you don't have Adobe Reader, click here to download it from Adobe.
Please begin by selecting your language:


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Hi all,
I'm enquiring to see if any other ESOL teachers can give me advice how to do an Individual Learning Plan for my class. I studied the assessment cycle when I did my Cert Trinity TESOL, eg. needs analysis, diagnostics etc. But we did not cover ILPs.
I'm a fairly newly qualified TESOL teacher, and I have been asked to teach a level 1 class. I work as a volunteer and my organisation have asked me to do ILPs included with the diagnostics, needs assessments etc. Ideally I would like to interview my students first (individually) to assess them. But I have been asked to do all the assessments, then teach all in the same day.
I would be grateful if anybody can give me advice on how what approach to use and how to do ILPs.
Thank you,


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Cinnamon Schultz drops by to discuss her role in the Oscar-nominated film, "Winter's Bone" with Randy Mason; KCPT visits the WWI Museum and takes a closer look at the Liberty Memorial structure itself and the important role it plays in the Museum, and David Hawley, of the Steamboat Arabia Museum, discusses what's ahead for the Museum and its treasure trove of artifacts recovered from a steamboat discovered over 130 years after its sinking, buried in a cornfield with KCPT's Nick Haines.
Watch the full episode. See more The Local Show.
Learn more : visit thelocalshow.org


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Winnner Named - 2011 Slingshot Of The Year Competition
Posted by NightKnight, in Other Stuff 17 December 2011 · 21,113 views
Thanks for all of the votes for the Slingshot of the Year competition! It was hard to make a decision with so many good nominees, but a winner has been selected! Congratulations to Nathan Masters and Flippinout Slingshot for winning the 2011 SOTY with their Axiom slingshot!


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Anyone need parts for an 80s model Bronco?
I have an 1982 Bronco that a guy droped a rod bearing and just didnt fix it. It has sat for 5 years but everything is still in working order(not the motor) The 302 is rebuildable ( I have the 300 6 in mine). Auto trans, rear end ,front end, transfer case, ect.
Load of good parts. My 83 is like new now and I dont need any of the other parts.


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Granola Cereal Bars RecipeRead Reviews Be the first to add a review
4 4 5
These sweet peanut butter bars are perfect for breakfast, dessert or anytime as a quick snack. You can add raisins instead of chocolate chips if you prefer. —Helen Velichko, Kansas City, Missouri
Featured In: 14 Recipes for Cereal Bars
- 1/2 cup packed brown sugar
- 1/2 cup creamy peanut butter
- 1/4 cup light corn syrup
- 1 teaspoon vanilla extract
- 2 cups old-fashioned oats
- 1-1/2 cups crisp rice cereal
- 1/4 cup miniature chocolate chips
- In a microwave-safe bowl, combine the brown sugar, peanut butter and corn syrup; cover and microwave on high for 2 minutes or until mixture comes to a boil, stirring once. Stir in the vanilla; add oats and cereal. Fold in chocolate chips. Press into a 9-in. square pan coated with cooking spray. Cool and cut into bars. Yield: 1 dozen.
Editor's Note: This recipe was tested in a 1,100-watt microwave.
Originally published as Granola Cereal Bars in Light & Tasty February/March 2005, p29
Reviews for Granola Cereal Bars
Please Log In or Join to add a rating and review.
Click stars to rate
Any changes to your rating or review will appear where you originally posted your review
Reviewed Mar. 25, 2014
"5 stars with some changes. I had trouble getting this recipe to set and also wanted add more protein so I made some changes. I make it about every week because cereal bars are my breakfast of choice. Here is the revision:2 cups old-fashioned oats2 cups Kashi Go Lean cereal (with fiber twigs, soy protein grahams, and honey puff cereal) 1/4 cup chopped nuts (your choice)1/4 cup packed brown sugar1/2 cup creamy peanut butter1/4 cup honey1 cup miniature marshmallows1 teaspoon vanilla extractDirections Mix cereal, oats and nuts in large mixing bowl and set aside. In a microwave-safe bowl, combine the brown sugar, peanut butter, marshmallows and honey; microwave on high for 1 1/2 minutes stirring every 30 seconds. Stir in the vanilla; fold hot mixture into cereal. Press into a 9-in. square pan coated with cooking spray. Cool and cut into bars."
Reviewed Jul. 25, 2011
"These bars were okay. They were sweet and crunchy, but didn't have any distinct flavor."
Reviewed Mar. 16, 2011
"Had no problems with these hardening whatsoever! My husband thinks they're just glorified cereal bars, but my sons love them. Will make again."
Reviewed Jun. 23, 2009
"I could not get these bars to harden. They seemed very dry so I added more of the peanut butter & corn syrup mixture but still did not work well."


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Alumni Staff
Marcy Stryker
|Director of Development
If you were to ask Marcy Stryker what she enjoys most about her job, she'd tell you it's the relationships she is able to develop with alumni.
"I hear wonderful success stories from alumni whose degrees have transformed their lives," she explains. "It's inspiring to hear how Excelsior helped so many and to work with the many who now want to give back themselves."
In her role as Director of Development, Marcy manages the College's initiatives aimed at alumni, including career services, alumni awards and elections. She also oversees activities to grow the base of support for the College.
Marcy comes from United Jewish Federation where she directed programs for young adults, and was previously the director of marketing for WMHT Public Broadcasting. Now directing development and alumni affairs, she looks forward to building strong connections with the College's alumni and donors.


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Arsenal welcome Montpellier to the Emirates on Wednesday for what is shaping up to be a crucial Champions League clash.
You can find out more about our opponents below.
Full name: Montpellier Herault Sports Club
Manager: Rene Girard
Club colours: Blue shirts, orange shorts, blue socks
Nickname(s): La Paillade
Three facts about Montpellier:
- Arsenal signed striker Olivier Giroud from the club
- They stand no chance of qualifying for the knockout stages of the tournament
- The club won the Ligue 1 title last year - the first time in their history they have done so
Remy Cabella
Talented playmaker Cabella has impressed despite Montpellier struggling in Ligue 1 this season. Blessed with speed and skill, the midfielder will pose a threat to the Arsenal defence. Still only 20 years of age, Cabella is a regular in the French Under-21 side.


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Posted by Alex Cullen on June 4, 2010
Consider the following scenario. You have realized that your firm can benefit from having a documented business architecture – perhaps based on business capabilities – not for any one issue or need but rather as a general framework for planning, strategic execution and coordination by different parts of business and IT. You are in a meeting with your CIO, making the case, when the CIO says, "In a couple of minutes our CEO is dropping by. You can make your case to him. If he's interested, we'll go ahead."
OK – that scenario may seem like kind of a stretch – after all, how often does the CEO drop in on the CIO and want to listen to a pitch on business architecture? Well, something like this happened to me recently, and I'd like your thoughts on how to make the case. I was visiting a client – the head of EA at this client (a medium-size financial services firm) – when he said, "I've started to lobby with our business management that we need a business capability map. The CEO is dropping by and would like to hear the reasons from you. I think you'll have about 15 minutes."
Talk about a challenge! When CEO arrived, after initial introductions, this is the case I made:


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Before and after photos, most of the work done by my 14 year old son.
This is a Golden Armour jet pack that ran 185 delivered in the rough..
Before and after photos, most of the work done by my 14 year old son.
This is a Golden Armour jet pack that ran 185 delivered in the rough..
Thats a nice kit!
Is the rocket one piece or did you have to screw it together?
The rocket, mounted on top of the jet pack, is separate as shown in the lower photo.
It did not come with thruster cones, so I used air freshener tops. Please note that the air fresheners have caps that can be removed. Instead of just glue, these were screw mounted to the thrusters as shown.
I would recomend phillips head screws, instead of the flat head seen here. They were very difficult, even with a drill, to install. The phillips head would have made this much easier.
Last edited by lorenreale; Oct 29, 2006 at 4:00 PM.
Quick question...did your GA kit come with the piece I circled in the pic? Of not what did you use?
Ive seen a lot of people use a Covertech clip circle thing. It's what the Jedi use to keep their lightsabers on their belts.
How much does that thing weigh lorenreale?
Okay, it seems to weigh about 6-8 pounds. The rpg is the heaviest. The silver piece on the thrusters is silver paint.
Last edited by lorenreale; Nov 7, 2006 at 11:58 PM.
yes, large wood dowels
are they still selling that kit? and where did you find it?
Just go to www.goldenarmor.com and email the guy. He'll reply with a price likely within the day. I've ordered from him a few times.
Just thought I'd post a pic...JUST finished my Jet Pack today!!
Nice packs guys!! Ingenious on the removable cones!
very sexy
Hi! Is this jetpack kit from Golden Armor sturdy/high quality? Any problems with it? Good value compared to other kits? I might be looking at getting one. Thanks for any info.
You might check the dates when you post. This thread has been dead for four years.
Stay away far away!!!!!! you are better off looking at a Man of War pack or a BFUK pack.
Really? Does golden armor have a bad rep? Problems?
Look at the kit its very shoody just looking at it...the missile is pretty inaccurate its shape is not very crisp i could go on and on but you get the picture


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|Topic Review (Newest First)
|I think the leather will hold up better, and will be easier to keep clean, but I don't like suede (or fake suede) in a car interior, so I'm very biased on the issue.
leather or alcantara
I bought a car that had a cheap ebay steering wheel. The plastic covers have fallen off, the leather wrap is coming undone and the foam is crumbling onto my legs. I decided I need a better wheel if I am going to drive this car much. I wouldn't call it a DD but it isn't a show car or anything. I ride a bike most of the time and use this when the weather is bad and getting groceries.
I knew alot of people with Grant wheels in high school but most of the them had the foam come loose around the top of the wheel. My car has manual steering and I want a good secure feeling wheel. I am interested in a Momo wheel. It comes in both leather or alcantara. I kinda like the idea if the suede feel. It might not be some hot in the summer. I know the put in the interiors of high end cars so the question is. Will the alcantara hold up under semi-regular use on the steering wheel? I would hate to spend 180 bucks on a steering wheel that will turn to crap in a short while.
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text: If the only difference between languages was the words we use then there would be no need for translators. It would only be a matter of switching from one language to another in the same way that we convert from the metric system to the English system of weights and measures. Software programs designed to convert documents into different languages would be cheap and 100% accurate. Unfortunately it's not what we say but how we say it that makes each language unique. The difference between the Spanish verbs "ser" and "estar" are lost when translating to English. The double negative, commonly used in Spanish, sounds terrible in English. The verb "to look" means "mirar" but be careful with look out, look into, look over, look after, look for, look up, and look up to. "Esta noche" could be last night or tonight depending on how and when you use it.