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Quality Air Duct Cleaning in Dallas
Protecting Your Health & Your Facility
While you may take your air ducts for granted, they're actually a vital part of your health and your facility's safety. At DBM Janitorial, we want to help protect your employees and customers with expert air duct cleaning services. Using the latest in air duct cleaning techniques, we can ensure that your ducts are clean and clog-free.
The Importance of Duct Cleaning
The air ducts in your facility transfer air from your heating and air conditioning units to every space in your building. If you have dirt or debris in your ducts, you may be creating unclean indoor air without even knowing it.
Everything from dust and dirt to mildew and mold spores may be traveling through your ducts, and these hazards can lead to allergies, respiratory illness, and worse. Over time, these hazards can also spread to carpets, furniture, and even the clothing of your employees and customers. By having your air ducts cleaned on a regular basis, you can breathe fresher, cleaner air and remove the potential for health problems.
Protect Your Investment
There's no doubt that your business is a large investment, but did you know that unclean air ducts could wipe out that investment in a matter of minutes? In fact, unclean air ducts can lead to spontaneous fires when dust and debris are allowed to build up over time. This means that everything you've worked so hard to accomplish could be taken away over something as simple as cleaning your air ducts.
Let DBM protect your commercial property investment by inspecting and cleaning your HVAC system.
Our Air Duct Cleaning Services Include:
- Duct inspection
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Our Specialists
When you rely on DBM to clean your air ducts, you also receive individualized service from highly trained, experienced professionals. Our crews understand the unique nature of commercial ductwork and HVAC systems, and they can provide comprehensive inspection and cleaning services.
We've been in business since 1975, and in our decades of experience, we've learned what it takes to deliver the best in quality services to our customers—it starts by hiring only the best cleaning technicians. We also provide only the most advanced air duct equipment to ensure that our experts can cover every detail.
Contact DBM Janitorial today to get a free estimate for our air duct cleaning services. Call 972-620-9200!


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Apple may say, "If you don't have an iPhone, you don't have an iPhone."
But I like to say, "If you don't have a Silhouette, you don't have a Silhouette!!"
This little baby is my BFF. It cuts just about anything this little girl would need to cut.
Part of the goal of this blog is to prove to the husband that I use my Silhouette SD enough to get THIS little thang:
*sigh* the Silhouette Cameo. Every crafting girl's dream come true. 12" of glorious cutting and sketching wonder. One day, my friend, you will be mine.
So what can this little baby do?
I'll tell you.
Right now.
Make really awesome shirts!
I just so happen to be a giant nerd and love all things Harry Potter and the Hunger Games. So DUH of course when the movies premiere, I have to make a wicked awesome shirt to wear. Thanks to Silhouette's heat transfer material, I've been able to come up with some that (if I may say so) are pretty sweet.
I made these before Silhouette added Harry Potter shapes to their online store. Now, there are SO many awesome shapes to choose from. Too bad all the movies are out!!! I'm pretty determined to have a HP party of some sort soon, though.
Before the Hunger Games movie came out and it was all the rage, the husband and I dressed up as Katniss and Peeta for Halloween! I used the heat transfer material (again!) to make the apron Conrad wore, to clue in anyone who couldn't guess our costumes otherwise.
Since I felt slightly concerned showing up to the Hunger Games movie premiere with a hungarian bow and 4-foot solid wood walking stick, I decided to make
a shirt TWO shirts.
I used two different colors of heat transfer for the back.
I then used stencil vinyl to make a stencil for the mockingjay logo on the front, and white fabric paint to fill it in.
Seriously, it doesn't get much easier than this, and I loved the results!
Here are a couple sites you can download the mockingjay logo:

subset: commoncrawl


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Wednesday, April 24, 2013
a pair of shirt stripe quilts
Hey there! Today I have some shots of the Shirt Stripe quilts I custom quilted for a very nice lady. I think these quilts are filled with some of the best stripes don't you? She said that most of the stripes are from stripe shirts that she has been collecting.
Since the quilts are for little boys we wanted the quilting to be more linear and masculine. I used my channel lock feature a ton on this quilt and I LOVE it so much!
The quilting is wonderfully visible on the solid backs. Great quilts! I have a couple other finishes to show soon. One I kick myself for not taking a picture of, but maybe I can catch up with it at KCMQG. Who knows?
Have a great day and I hope you find time to make some great things!
4 comments:
Thanks for commenting! I read each one. I will either respond via email or here in the comments. xo - Tia
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The chart above shows the share price movement for Proton Holdings Berhad for the past 3 months up to yesterday. It settled down at RM5.18 yesterday, and previously hit a high of RM5.53 on the 13th January 2012. If only we all knew what was going to happen back in late November last year eh? It would have been a nice windfall just in time for the Chinese New Year this month.
Khazanah Nasional's statement yesterday said DRB-Hicom had been identified as the appropriate party to acquire KNB's stake in Proton as it's proposal had demonstrated the company's extensive involvement in the automotive sector, its network of strategic partnerships both local and international, and an effective platform to enhance Proton's sustainability and meet its long-term growth needs. It's RM5.50 per share offer price was also acceptable to Khazanah.
DRB-Hicom's stake in Proton will rise from zero now to approximately 42.74% after the transaction is done – a total of RM1,291,040,812 in cash will change hands, with probably even more to be paid out later when DRB-Hicom makes a mandatory general offer for all remaining Proton shares after the acquisition is done.
This is not the first asset that DRB-Hicom owner Tan Sri Syed Mokhtar Al-Bukhary has acquired from Khazanah. He also paid RM623 million in cash for Khazanah's stake in Pos Malaysia via DRB-Hicom, and the turnaround is already underway, with DRB-Hicom saying they have identified 17 new businesses that it could tap into via Pos Malaysia.
If you know Tan Sri Syed Mokhtar Al-Bukhary's style, he will most likely install his own general to head Proton. When he took over Pos Malaysia, he made Datuk Khalid Abdol Rahman the group CEO. Datuk Khalid was previously DRB-Hicom group director of corporate planning. Who will be Proton's new chief, or will DRB-Hicom choose to retain Datuk Seri Syed Zainal?
There are more questions of course. What are DRB-Hicom's plans for Proton? These details are all in the proposal to Khazanah, not not available for public viewing. Will DRB-Hicom matchmake Proton and Volkswagen? If yes, how do they intend to do it? Who will they retain and who will go? What fresh blood will they bring in? An/d will DRB-Hicom continue to ask for special privileges from the government for Proton – if yes, for how long? And what will they do with Lotus?
The answers to these questions will be revealed in due course!


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Foote, Cone & Belding Communications may have been among the first agencies to explore interactive media, forming an Electronic Media Task Force in 1990. But it has done little more than explore so far.
Led by Lynn Bolger, FCB's associate director of corporate media research, the 45-member task force is reviewing results from focus group interviews with consumers about their awareness of interactive issues.
"Our interactive discussion is not limited to the committee," said Ms. Bolger. "We encourage people in every department to evaluate opportunities for every client."
Although FCB said it has several interactive projects, including kiosks and CD-ROMs, in the works for clients, the only documented one is a four-year partnership between Prodigy and Mazda Motor of America.
The auto marketer appears to be one of FCB's most innovative clients: The agency is considering developing interactive Mazda ads for Time Warner's Full Service Network in Orlando, said Jim Helberg, senior VP-media director in FCB's Orange County, Calif., office.
FCB last year formed a partnership with IT Network, Dallas, an interactive TV company that sends still pictures with sound and text to TV screens. However, the agency still hasn't connected any client to IT, said Ellen Oppenheim, senior VP-media director.
FCB/Leber Katz Partners, New York, just last month shifted former FCB Direct President Jon Adams to chief strategic development officer at the main agency. Nothing is percolating yet, but in his new post Mr. Adams is charged with looking into interactive developments for the office, which handles AT&T, Avon Products, Jamaica Tourist Board and FILA.


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Tag: Dogs and Cats together
Who will win when a dog and cat play dreidel?
Tucker and Athena go head to head in the dreidel game.
Photo: Love will find a way
Tucker and Athena are usually at odds. Until I caught Athena giving head rubs to Tucker.
Story: I get by with a little help from my friends
While recovering from surgery, I find comfort and entertainment from my furry family members.


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One of my latest projects involves promotion. I dream of a day that I can relax and draw all day with commissions sending themselves to me. I could enjoy a cold drink by the pool, be rich and famous, and life would be so simple.... Ah....
Unfortunately, I live in reality, where commissions come around holidays, birthdays, or after mailings. I sometimes worry about sending mailings to businesses and my friends, because I am soliciting. Sort of. But... I have to eat, buy shoes, and survive. So, the friends will be bombarded every so often with flyers and updates. Ha!
The flyer above was designed with the holidays in mind. I know that a Golden Illustrations portrait makes an awesome gift. I give them to friends and family every year. They never disappoint. The holiday gift commissions that have come through have been extremely positive experiences. Like a whining child, I want more!!! I love to make people happy and pictures of family and pets touch a person's heart in a way that a video or photo cannot. If you are interested in commissioning a portrait, please contact me. We can work out a nice deal for the holidays... And your relatives and friends will love you even more!
Friday, November 03, 2006
Holiday Portraits!!!
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The squad only has to be completely for countries that participate with two teams or for teams that are not real countries. In the case of a country doubly participating, a player not listed can still participate, but then he will become unavailable for the other team.
FinlandTeam leader: SuperJazzSquad: Cankerworm, Raven, SuperJazz, Sucer


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How to Revise for English Language GCSE (AQA)
It's common to think that it's impossible to revise for an English language exam. After all, you can either read and write English or you can't.
Well, that's not quite true. In this video Mr Salles shows us all the tricks you need to know to get a grade 8 or 9 in GCSE English language. This video is specifically for people studying the AQA syllabus, but you'll get the point if you watch it. There are specific techniques you need to know, and practice, in order to excel in this exam.
I've said before, and I'll say it many more times, but accessing the top marks is all down to exam technique and this is the point that Mr Salles really hammers home in this video.
How to use this video
This video is 25 minutes long. However, if you're going to watch it properly and get the maximum out of it, you'll need to take more time than that. In the video, Mr Salles gives us a whistle stop tour of his guide to getting 100% in your AQA English literature. He encourages you to pause the video and take notes.
Warning: this video is not a sit back and enjoy it kind of video. It's all about engaging and taking action.
Grab a pad of paper, some flash cards and start watching.
How to revise for English language GCSE (AQA)
What next?
Grab your copy of:
Then, get practising!
You might also want to check out this post to help with your English literature revision: How to memorise quotes for your closed book English exam.


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Personalized patient care is what sets Easy Therapy apart. We proudly serve the Greater Vancouver Area and make it easy for our clients to reach their goals by coming to them.
Whether you are in need of physical rehabilitation from an injury or surgery, require senior specific or sport specific training – we have you covered!


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Currently alive, at 55 years of age.
Categories: echo $strCat;?>
Nabakishore Chanda, born on 4th January 1964, in a remote village called Bhetia Dakshin ( Bhetia South) in the state of West Bengal in India. He comes from a family of cultivators of land. But his father was a head master of a primary school. He was brought up in the midst of the nature, full of plants, trees, paddy fields, ponds and rivers. In his childhood, he was surrounded by the open blue sky and greenery. The house he lived in was made of clay. Thus he was as close to nature as you can get. his father died when he was just twelve years of age and after that his family was plunged into deep financial trouble. He has three brothers and three sisters and all were brought up in some amount of material deprivation. After completing school in 1984 from the village school, he did his graduation from Midnapur College, in a town close to his village. For higher studies he came to Calcutta in 1987. His master's degree in Bengali Language and Literature he obtained from Calcutta University. All through hardship was a way of life for him. Life took a more comfortable turn when he got an appointment in 1996 as lecturer in Bengali Language and Literature in Vivekananda College, Thakurpukur, Kolkata. He continue holding this job, having a more senior position now. In 1999, he went to Shantiniketan (Viswabharati University) with his family and friends and this is the place where he got the inspiration which guided him towards painting. He does not have any institutional training in art, but after that period painting became his first love and passion. In fact he was advised by an artist friend of him not to take any training and allow his spontaneity free reign. He has stood by that advice. He has exhibited his paintings solo as well as in collaboration with other painters in a number of cities in different parts of India and his paintings have got appreciation from artists and art critics. Teaching is his profession, but today painting is the sphere to which he relate better. More people in fact know him as a painter. He wishes his paintings to get known to more and more people in the world.
Solo Exhibition:-(1)2004Birla Academy of Art & Culture,kolkata,India(2)2007-Samokal Art Gallery,Kolkata,India(sponsored)(3)2008-PegasusArt Gallery,Hyderabad,India(sponsored).
Group Exhibition:- 1. 2003 – Academy of Fine Arts Kolkata, India. 2. 2003 – Lalit kala Academy, New Delhi, India. 3. 2005 – Chemold Art Gallery, Kolkata, India. 4. 2005-06 – Abstract Art Gallery, Bangalore, India. (sponsored) 5. 2006 – Genesis Art Gallery, Kolkata India. (sponsored) 6. 2006 – Academy of Fine Arts, Kolkata, India. 7. 2006 – New Times Book & Arts Shop, Kolkata, India. (sponsored) 8. 2006 – Gallery 79, Kolkata, India. (sponsored) 9. 2006 – Gallery 79, Kolkata, India. (sponsored) 10. 2007 – Ashutosh Birth Centenary Hall, Kolkata, India. (sponsored) 11. 2007 – Metropolitan Art Saloon, Kolkata, India. 12. 2007 – 25th Baisakh Art Gallery, Kolkata, India. 13. 2007 – Gallery 79, Kolkata, India. (sponsored) 14. 2007 – Birla Academy of Art & Culture, Kolkata, India. (sponsored)15. 2009-Chemold Art Gallery, Kolkata, India.(sponsored by artistic impression)16. 2009-South city Mall,Kolkata, India.(sponsored byemami chisel art & artistic impression)
ANNUAL EVENT AND WORKSHOP :- 1. 2003 – Rajya Charukala Parsad. W.B., India. 2. 2006 – Rajya Charukala Parsad. W.B., India. 3. 2007 – Rajya Charukala Parsad. W.B., India. 4. 2006 – Flower Show, Forest Dept., Govt. of W.B., India. 5. 2003 – Achin Patua, Street Exhibition, Kolkata, India. 6. 2006 – Ichhapur Artist Forum, WB. India. 7. 2007 – Achin Patua, Street Exhibition, Kolkata, India. 8. 2007 – Oriental Society of India Art, Kolkata, India (Guest Artist).
BOOK COVER DESIGN AND OTHERS :-1. Calcutta Tramwayman – Dr. Siddhartha Guha Roy. 2. Naljatak – Rabin Pyne. 3. 2007 – Saradiya Joka Samachar. 4. Paintings have been used in a documentary on Shakti Chattopadhyay, directed by Suranjan Roy.5. 2008 – Saradiya Joka Samachar.6. 2009 – Saradiya Joka Samachar.
COLLECTION:- Kolkata, Delhi, Alipurduar, Baroda, Hyderabad, Bangalore, Barong (Sikkim), Oman, Liverpool, Manchester, Washington,Canada.
Bewitching lines
Nabakishore Chanda's paintings seem to emanate from the earth itself despite the intricacy of lines that seem to dominate them. The pristine quality of the faces that emerge from the lines startle us with their freshness which reminds us of vernal showers at times. On the other hand , a sense of mystery seems to tease us out of thought as we gaze at some of the paintings, perplexed by the serpentine quality of the lines. The subdued colours evoke a sense of mellow understanding about the intriguing flow of life, its elusiveness and its beauty.
Having his roots in rural Bengal, Nabakishore understands life both in its primal and natural essence as well as the complexities that come in its way as life gathers experience and understanding.
Debdutta Gupta
Art Critic
India Today
Line is the forte of Nabakishore's paintings. They swirl, surge, intertwine, even retreat and move diagrammatically convering the pictorial space. Nabakishore lets his pen or brush move on the paper freely. The figures born out of those lines and of the exuberant colour splashes have a naive charm about them. They show faces of a next-door girl or of a folk deity and recall the images that we see in folk art of rural Bengal. In his paintings, symboils including the phallic ones create a primordial ambience. His browns and yellows, red and greens trapped in the darkness make up a rich fabric of forms. Nabakishore is a self taught painter who teaches Bengali language and literature in a college. his knowledge of medieval Bengali poetry is simply reflected in the images that he paints. As a painter, he recreates the world of mythology and folklore in a visual language that seems unique.
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My dog Lila needs only one name. Like Madonna. Or Bjork. Or Macklemore. She's a superstar. And she has tips for you, Humans.
How to Be a Better Animal
Lila's Essential Tips & Tricks
1. When you're thirsty, drink. When you're hungry, eat. When you're sleepy, sleep. When you're bored, make sure everybody knows it by racing in huge circles around the yard and kicking up enough dust to facilitate climate change.
2. Don't fly in planes; bark hysterically at them. They're dangerous.
3. Give some credit to your fellow animals. If your water bowl becomes inexplicably empty and has failed to magically refill itself by the time you're thirsty again, bark at it a few times. Sometimes you have to ask. If you ask, your fellow animals will often step up to the plate and help you out. After all, your water bowl may be magical, but your fellow animals probably can't read your mind.
4. Give credit to yourself. If Ghostly Black Storm Riders or Crazy-Scary Demon Witch Vampires invade your yard (and they will!), don't wait for anyone to save you. You are smart enough, strong enough, and have enough fur to fend off danger. It's okay to put up your hackles - everyone gets scared sometimes - but don't let fear prevent you from leaping into the necessary battles.
5. Remember that not all battles are necessary. Sometimes it's okay to let a guy and his dog walk past your house without getting worked up about it. And sometimes when your ball rolls under the couch, it's better to think about it for awhile before going ballistic (so to speak). Figure out when you need to be fight-ready and when it's better to lie on your belly with your nose stuffed under the couch and pointed towards the ball lodged under there and meditate on your situation for awhile. Say to yourself: Do I really need my ball right this second or will this other ball next to my foot suffice for the moment? Are those really Ghostly Black Storm Riders out there, or is it merely the neighbor cleaning his grill?
6. Don't be hot. Or cold. Or wet. Well. Maybe wet. If it's hot, stick out your tongue, collapse onto your side on a cool patio, and accept the heat. It just is so just be in it. If it's cold, curl into a tiny ball against the arm of the couch, bury your nose in your tail, and accept the cold. It just is so just be in it. Those are just external stimuli. You don't have to focus on them. They don't have to make you miserable. Rain is different. If it rains, climb up onto the table under the ramada and stand there with your ears plastered back against your head. Try to stay as far away from puddles as possible. Try to avoid becoming wet in the first place. Same goes for snow.
7. Love your fellow animals with abandon. If they make you happy, tell them so. They'll appreciate it. Lick them, make growly noises of love into their ears, and do the love boogie whenever they come home or wake up in the morning or return from the bathroom. After all, someday your fellow animals will be gone. They'll leave for work, and you won't know when - or if - they're coming back. So don't hold back with the boogie-ing and growling.
8. You don't need to spend a lot of money to have a good time. It really is the simple things. Forego the huge TV and go outside to chase doves or look for cats out the front door or find yourself an old sock to chew on. Go for a walk. Go for a run. Take a nap. Good times.
9. It's easy to make friends. Make a new friend every day. That guy over there? He could be a friend. Go talk to him. Wag a lot so he knows where you're coming from. Put your paws on his chest so you can look him in the eye. It's a good way for you two to get to know each other quickly.
10. Don't go around expecting to meet enemies. Expect your fellow animals to be good and most of them will prove you right.
Tuesday, May 14
advice from the dog: How to Be a Better Animal - Tips & Tricks for Humans
4 comments:
- Wistfulwanderer said...
I like #10 the most!
- May 14, 2013
Thanks for these tips, Lila! There are frequently old socks lying around my house. I've just been throwing them in the wash, but chewing on them might be a nice change.
And I am SO with you on the ball under the couch thing. I gave my little humans a half-dozen ping-pong balls recently. I can only find two now, and they're both under the couch. I've tried lying on the floor to get them, but I usually just end up enjoying the new perspective and the chance for an impromptu rest (if my kids think I'm working, they leave me alone).
- May 23, 2013
Again with the no posting thing. What are we going to do with you?
- September 04, 2013
TOO handsome!
- March 20, 2014
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Faridpur Correspondent
A preparatory meeting to chalk out a program to observe the World Environment Day of June 5 was held here on Sunday afternoon in the conference room of Deputy Commissioner of Faridpur.
The meeting was chaired by ADC (Gen) ANM Abdus Sabur while Deputy Director (DD) of Environment Directorate Md. Saifullah elaborately described the importance of this day in the perspective of our country which is facing constant threat of the adverse impact of climatic change and other natural disasters throughout the year.
The DD pointed out that this years' slogan is "Go Wild for Life" indicating the conservation of forestry in the country for maintaining ecological balance that would help the threat on environment.
Decisions were taken that two schools of this town will hold special program on environment in their respective schools. The Shishu Academy of Faridpur will arrange art and painting competitions among the children to create awareness among the children about protecting environment.
It was told in the meeting that human race is the 'worst enemy' of environment who destroyed it for years together bringing disastrous situation. It was also decided that a centrally organized discussion meeting on the day will be held on June 5 where elite, teachers, NGOs and other people will be present.
Faridpur Pourashava authority was requested to clean up the town regularly and remove the garbage heaped hither and thither will be removed. Pourashava was also requested to remove the sign boards and bill boards fixed on the trees by June 5. Social Forestry Department announced in the meeting that they will arrange plantation of 200 saplings on this day.


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Long-Term Safety and Efficacy of Risperidone for the Treatment of Disruptive Behavior Disorders in Children With Subaverage IQs
Objective. The objective of this study was to investigate the long-term safety and efficacy of risperidone in disruptive behavior disorders in children with subaverage IQs. Disruptive behavior disorders were defined as oppositional defiant disorder, disruptive behavior disorder, and conduct disorder as per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria.
Methods. This was a 48-week open-label (OL) extension study of risperidone in 77 children diagnosed with a disruptive behavior disorder, and either borderline intellectual function or mild or moderate mental retardation who had participated in a previous 6-week, double-blind (DB) study and completed at least 2 weeks of DB therapy. Children, aged 5 to 12 years inclusive, who had: 1) a DSM-IV Axis I diagnosis of conduct disorder, oppositional defiant disorder, or disruptive behavior disorder- not otherwise specified; 2) a parent-assessed rating of ≥24 in the Conduct Problem Subscale of the Nisonger-Child Behavior Rating Form28; 3) a DSM-IV Axis II diagnosis of mild or moderate mental retardation or borderline intellectual functioning with an IQ ≥36 and ≤84; and 4) a score of ≤84 on the Vineland Adaptive Behavior Scale. Participants received oral solution risperidone given at a once daily dose of between 0.02 and 0.06 mg/kg for a maximum of 48 weeks. Participants in the DB study who had been randomized would have had a maximum of 54 weeks of risperidone therapy. Study visits were scheduled at entry, weekly for the first month, and monthly for the remaining 11 months.
Results. Baseline scores on the conduct problem subscale at the start of the previous DB study were similar for both treatment groups: mean values of 33.5 and 33.3 were recorded for placebo- and risperidone-treated participants, respectively. At the time of the OL baseline visit, mean Conduct Problem Subscale scores were lower in those who had been treated with risperidone than in those who remained risperidone-naïve (17.5 and 26.1, respectively). Within 1 week of receiving daily risperidone therapy (mean daily dose: 1.38 mg), those participants who had been risperidone-naïve at OL entry showed a rapid improvement in the Conduct Problem Subscale score. At the week 1 assessment, the mean change from baseline for those who had been risperidone-naïve at OL entry was similar in magnitude to the change from DB baseline recorded for participants who had received risperidone in the DB study. This mean improvement was sustained in both groups throughout the remainder of the OL study.
At study endpoint, those participants who had been risperidone-naïve at OL entry experienced a highly significant mean decrease from OL baseline in the mean Conduct Problem Subscale score of 10.6 ± 2.18. The response to risperidone in the OL trial remained stable in those participants who had been treated with risperidone in the previous DB trial; in this group, the mean change at study endpoint from OL baseline was a nonsignificant decrease of 1.26 ± 1.45. At DB baseline, 68% of participants had a Clinical Global Impression assessment rated as marked, severe, or extremely severe. By DB study endpoint, only 17% of participants (15% of whom had received placebo and 19% of whom had been treated with risperidone in the previous study) had this severe an assessment; 63% of participants had symptoms rated as either none, very mild, or mild. Similarly, highly significant decreases from baseline in the Vineland Adaptive Behavior Scale rating of the most troublesome symptom (often identified as either aggression (hitting, fighting, or temper tantrums) were observed by study endpoint after 48 weeks of risperidone therapy. For those participants who had received placebo in the previous study, a mean decrease of 47.1 ± 4.87 mm from a DB baseline of 79.4 ± 2.69 mm was observed. In those who had received risperidone, a mean decrease of 43.5 ± 4.57 mm from a DB baseline of 79.3 ± 3.66 mm was observed. Five subgroup analyses of the primary efficacy outcome were performed. These included analysis by diagnosis (conduct disorder, oppositional defiant disorder, and disruptive behavior disorder-not otherwise specified), degree of mental retardation (borderline, mild, moderate), and presence or absence of somnolence, attention-deficit/hyperactivity disorder, and psychostimulants.
The results showed that the efficacy of risperidone was not affected by type of disorder, level of retardation, presence/absence of somnolence or attention-deficit/hyperactivity disorder, or use of psychostimulants. Adverse events were reported for 76 participants; none were serious and most were mild/moderate in severity. Somnolence (52%), headache (38%), and weight gain (36%) were the most common adverse events. The degree of sedation was mild and not associated with cognitive deterioration. In fact, for most parameters assessed on the modified California Verbal Learning Test (a test for verbal learning and memory), there were statistically significant improvements relative to both OL and DB baselines in the mean scores. In addition, statistically significant improvements over baseline were also seen for some Continous Performance Task (which is a test for attention and impulsivity) parameters. Overall, no deterioration of cognitive function was observed while participants were treated with risperidone.
Almost half of the 8.5 kg gained was attributable to normal growth. Asymptomatic peak prolactin levels were observed within 4 weeks of beginning risperidone treatment and declined over time to within normal range. At study endpoint, mean prolactin levels were statistically significantly greater than baseline only in male participants but still <20 ng/mL, which is within the normal range. Twenty participants experienced mild or moderate extrapyramidal symptoms, although none withdrew for this reason.
Conclusions. Risperidone, administered as an oral solution at a mean dose of 1.38 mg/d (range: 0.02–0.06 mg/kg/d) for 1 year, was well tolerated, safe, and showed maintenance of effect in the treatment of disruptive behavior disorders in children aged 5 to 12 years with subaverage IQs.
- disruptive behavior disorders
- conduct disorder
- oppositional defiant disorder
- disruptive behavior disorder not otherwise specified
- mental retardation
- borderline intellectual function
- risperidone
Disruptive behavior disorders (DBDs) are some of the most common forms of psychopathology in children; the overall prevalence is ∼6%, with boys more commonly affected than girls and those with lower intellectual function more commonly affected than the general population.1,2 Prevalence rates as high as 64% have been reported in severely mentally retarded subjects.3,4 A low IQ has not only proven to be predictive of the presence of DBDs, it has also been associated with the persistence of symptoms and the resistance of those symptoms to treatment.3–7 Important comorbidities include attention-deficit/hyperactivity disorder (ADHD), depression, anxiety disorders, and learning disabilities.8
As defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), DBD includes conduct disorder (CD), oppositional defiant disorder (ODD), and disruptive behavior disorder-not otherwise specified (DBD-NOS).9 The main characteristic of these disorders is a repetitive and persistent pattern of antisocial, aggressive, or defiant behavior that involves major violations of age-appropriate norms. CD, which is considered the most severe subcategory, is characterized by the predominance of specific conduct-type symptoms such as severe destructiveness and violence, whereas ODD is characterized by the predominance of milder oppositional-type symptoms such as tantrums. DBD-NOS does not fully meet the DSM-IV criteria for either classification.
DBDs have a considerable impact on both the individual affected and their family. In children with subaverage IQs, persistent symptoms of these disorders are the most important reason for breakdown of mainstreaming and community placement, expulsion from school, and permanent hospitalization.10,11 These children are also at later risk for antisocial personality disorder and other psychiatric disorders, marital break-up, employment difficulties, criminality, substance abuse, and premature death.12,13 Safe and effective interventions are needed for this population of high-risk children.
The management of DBDs in children is typically multidisciplinary and may involve a number of different psychosocial and pharmacotherapies.
Although conventional antipsychotics have been commonly used in clinical practice, the risk of debilitating side effects, such as extrapyramidal symptoms (EPSs), tardive dyskinesia (TD), excessive sedation, and cognitive blunting limit their use.14,15 Lithium and psychostimulants, such as methylphenidate, have also been used to manage the symptoms of these disorders in children, yet the clinical trial data published to date have not been consistent or compelling. Lithium was associated with behavioral improvements in 3 studies, but it was not significantly different from placebo in 2 others.16–20 And, although methylphenidate was modestly effective for the treatment of disruptive behaviors in 1 study of children with above-average intelligence,21 in those with subaverage IQs, psychostimulants were not only less effective but were associated with excessive side effects.22
In the 1990s, reports were published on the benefits of using the atypical antipsychotic agent, risperidone, to treat aggressive behaviors in children and adults.23,24 Based on these preliminary data, and on those of a small pilot study conducted in children with borderline intellectual functioning,25 two 6-week studies were undertaken to investigate the use of risperidone for the treatment of DBDs in a total of 217 children with subaverage IQs.26,27 Data from these randomized, double-blind (DB), placebo-controlled studies—1 conducted in Canada, the United States, and South Africa; and 1 solely in the United States—provides convincing evidence that risperidone is an effective treatment in this population. In both studies, efficacy was assessed using the Nisonger-Child Behavior Rating Form (N-CBRF), a validated rating form for children with disabilities.28 Using this and other tools, risperidone use (average daily doses of 0.98 mg and 1.16 mg, respectively) was associated with highly significant improvements in measures of disruptive behaviors from weeks 1 through 6 reflected by a reduction (improvement) in Conduct Problem Subscale scores and by an increase (improvement) in prosocial subscale scores.26,27 In addition, risperidone was safe and well tolerated with few patients discontinuing treatment.
Although these short-term data are promising, DBDs are chronic conditions that may require long periods of treatment. Hence, the reconsideration of appropriate therapy and psychosocial intervention is important. This 48-week, open-label (OL) extension of the Canadian study was undertaken to gather data primarily on the long-term safety of risperidone. The secondary objective was to investigate the long-term efficacy of risperidone for the treatment of DBDs in this population.
Study Design
This study was a 48-week, OL extension study designed to gather safety and efficacy data on the long-term use of risperidone in children who had participated in the 6-week, multicenter, randomized, DB, placebo-controlled study. Only those participants who had completed at least 2 weeks of the DB study were eligible to enter the OL extension study. Participants received oral solution risperidone at a daily dose of between 0.02 and 0.06 mg/kg for a maximum of 48 weeks. Participants on risperidone during the DB study would have had a maximum of 54 weeks (6 plus 48) of risperidone therapy. Study visits were scheduled at entry, weekly for the first month, and monthly for the remaining 11 months. For those participants who entered the OL extension study within 10 days of completing the DB study, the final safety and efficacy assessments made during the earlier trial served as baseline data at entry for this study. Otherwise, participants were reassessed. This follow-up study was conducted in accordance with the Declaration of Helsinki as revised in 1983 and was approved by the institutional review boards at each participating center and by the Health Protection Branch of Canada.
Participants who had completed at least 2 weeks of treatment in the DB study and continued to meet all selection criteria of that study were eligible to participate in this OL follow-up study. Children, aged 5 to 12 years inclusive, who had: 1) a DSM-IV Axis I diagnosis of CD, ODD, or DBD-NOS; 2) a parent-assessed rating of ≥24 in the Conduct Problem Subscale of the N-CBRF28; 3) a DSM-IV Axis II diagnosis of mild or moderate mental retardation or borderline intellectual functioning with an IQ ≥36 and ≤84; and 4) a score of ≤84 on the Vineland Adaptive Behavior Scale.30 In addition, participants had to be outpatients who were physically healthy and have a behavioral problem sufficiently severe that the investigator believed antipsychotic treatment was warranted at entry to the DB trial. Individuals with ADHD were eligible provided they met all other selection criteria. A responsible person was required to accompany the participant at clinic visits, provide reliable assessments, and dispense medications.
Subjects were excluded who had a diagnosis of pervasive development disorder, schizophrenia, other psychotic disorder, head injury or seizure disorder, history of TD, neuroleptic neuropathy, known hypersensitivity to neuroleptics or risperidone, tested positive for human immunodeficiency virus, abnormal laboratory values, or who were using a prohibited medication. Subjects were also excluded from this extension study if >3 weeks had elapsed since their participation in the previous DB trial or if, during that trial, they experienced a hypersensitivity reaction to trial medication, EPS not controlled by medication, an adverse event possibly related to risperidone, or one for which they were withdrawn. Participants provided verbal and, if capable, written informed consent; signed consent was also obtained from the participant's legal representative.
Study and Other Medications
Risperidone was provided by Janssen Research Foundation (Toronto, Canada) as an oral solution of 1.0 mg/mL to be administered once daily in the morning at an initial dose of 0.01 mg/kg on days 1 and 2, and increased to 0.02 mg/kg on day 3. Thereafter, the dose could be adjusted by the investigator at weekly intervals to a maximal allowable dose of 0.06 mg/kg/d; increments were not to exceed 0.02 mg/kg/d. For those with breakthrough symptoms, the dosing schedule could be changed to a twice-daily regimen.
Medications used to treat EPS were to be discontinued at DB trial entry. For those with emergent EPS during the trial, the dose of risperidone could be reduced; the rate of dose reduction was not limited. Anticholingeric agents were permitted only in cases where dose reduction resulted in deterioration of behavioral symptoms or failed to improve EPS and the Extrapyramidal Symptoms Rating Scale (ESRS) had been completed.31
Prohibited medications included any antipsychotics other than the study medication, anticonvulsants, antidepressants, lithium, clonidine, guanfacine, carbamazepine, valproic acid, or cholinesterase inhibitors. Psychostimulants, including methlyphenidate, pemoline, and dexedrine, were allowed for the treatment of ADHD provided the participant was already taking them at a stable dosage 30 days before participation in the previous DB study, and every attempt was made to keep the dose constant throughout the DB and OL extension trials. Sedative/hypnotic medications were allowed provided that the dose and frequency of use were kept to a minimum. Behavior intervention therapies were also allowed during the OL extension trial.
Safety Outcome Measures
Adverse event data and vital signs (pulse, blood pressure, respiration, temperature measured sitting after 5 minutes rest) were collected at each visit. EPSs were assessed using the ESRS at each visit for the first 6 months and again at month 9 and at the beginning of month 12.31 Body weight (wearing similar clothing) was measured and laboratory tests (hematology: complete blood count with differential and platelets; biochemistry: including electrolytes, liver function tests; urinalysis by dipstick, followed by microscopic examination if positive) including prolactin levels, were conducted at baseline, week 4, and at months 3, 6, 9 and at the beginning of month 12; sedation was also assessed at these visits and at the week 1 visit, using a caregiver completed visual analog scale (VAS). Cognitive tests and an electrocardiogram (ECG) were performed at OL baseline, and at months 6 and at the beginning of month 12. Cognition was assessed using the Continuous Performance Task (CPT) and a modification of the California Verbal Learning Test-Children's Version (mCVLT-CV).32 A pediatric cardiologist reread all ECGs and examined them for any abnormality (heart rate, QRS complex, QT interval, QTc interval, JT interval). Fridericia's formula (which is more appropriate for higher heart rates seen in children) was used to calculate the QTc interval.
Secondary Outcome Measures
Efficacy assessments were conducted at OL baseline, at weeks 1 and 4, at months 3, 6, and 9, and at the beginning of month 12. The primary efficacy outcome was the change from baseline score at OL study endpoint in the Conduct Problem Subscale of the parent/caregiver rated N-CBRF.28,33 Secondary efficacy outcomes included change from baseline score at OL study endpoint in: the Positive Social Behavior and Problem Behavior subscales of the N-CBRF; the investigator's Clinical Global Impression (CGI) of the severity of the participants condition; and a VAS rating by the parent/caregiver of the most troublesome symptom.
Statistical Analyses
Participants' baseline patient and disease characteristics were extracted from the DB database. All participants who took at least 1 dose of study medication were included in the safety analysis; those participants for whom any postbaseline assessment data were also available were included in the primary efficacy analysis. Changes from baseline (± SE) were calculated using both the DB baseline when all patients were risperidone-naïve, and the OL baseline at the start of OL extension study. Outcome measures were compared based on whether patients had received placebo or active treatment in the previous DB trial—ie, between those who were risperidone-naïve at entry and those who had been treated with risperidone before the start of the OL extension study. All statistical tests were interpreted at the 5% significance level (2-tailed).
All adverse events were tabulated by type and incidence and included those that were newly emergent or reemergent events in comparison with the previous DB study and those that had worsened since the start of the OL trial. An event was considered serious if it was fatal; life-threatening; significantly, persistently or permanently disabling; required intervention to prevent permanent impairment; or required hospitalization. Descriptive statistics were provided for vital signs, cognitive function tests, and for clinical laboratory data. In the latter case, pretreatment and posttreatment frequencies, including those for important abnormalities, were also calculated. Total ESRS scores were summarized using descriptive statistics; changes from baseline for each visit were compared using Wilcoxon signed rank tests. Two-sided paired t tests were used to compare changes from baseline for CGI score frequency counts, within group ECG parameters, and for sedation VAS scores. Two-sided paired t tests were also used to compare changes from baseline for both primary and secondary efficacy outcomes. In cases of nonnormality, Wilcoxon signed rank tests were performed.
A total of 77 participants, at 9 Canadian investigational sites, entered this OL extension study. Of these, 39 had received placebo (ie, were risperidone-naïve at entry), and 38 received risperidone in the previous DB trial. Both groups had similar baseline demographic and disease characteristics (Table 1). Participants, three-quarters of whom were male, ranged in age from 5 to 12 years with a mean age of 8.7 years. Approximately 60% of participants had a DSM-IV diagnosis of ODD. Most (79%) suffered from ADHD. Half (50.6%) of all participants had borderline intellectual function; the remainder were either mildly or moderately mentally retarded. Most (85.7%) lived with their parents.
Most participants (78%) completed the 1-year study. Seventeen participants (22%) withdrew before completion; of these, 9 received placebo and 8 received risperidone in the previous DB trial (Table 2). The most common reasons for withdrawal were insufficient response, lost to follow-up, closure of the investigational site, and noncompliance.
Study and Other Medications
Participants received treatment with risperidone for an average of 321.8 ± 8.3 days (range: 36–417 days). The mean dose of risperidone, including days off drug, was 0.041 ± 0.001 mg/kg/d or 1.38 ± 0.057 mg/d; the most frequently used dose was 0.02 mg/kg/d or 1.5 mg/d. Eighteen participants (23.4%) took <1.0 mg/kg/d, 32 participants (41.6%) took 1.0 or more but <1.5 mg/kg/d, and 27 (35.1%) took 1.5 mg/kg/d or more. The most common concomitant medications, taken by 62.3% of participants, were psychostimulants to treat ADHD. Analgesics (48.1%) and antibiotics (42.9%) were also commonly used. No behavior interventions were instituted during this time period.
Safety Outcomes
Adverse Events
Seventy-six (98.7%) of the 77 subjects participating in this year-long, OL extension trial experienced a newly emergent, reemergent, or worsening adverse event (Table 3). The most commonly reported events were somnolence (51.9%), headache (37.7%), and weight gain (36.4%). Adverse events were generally considered by the investigator to be either mild or moderate in severity. Twenty-three participants (29.9%) experienced a total of 17 different adverse events that were judged by the investigator to be severe. Thirteen of these events were unique—each occurring in only 1 patient. Only 4 events judged to be severe occurred in >1 patient: weight gain (n = 4, 5.2%), emotional lability (n = 2, 2.6%), aggressive reaction (n = 2, 2.6%), and agitation (n = 2, 2.6%). Each of these events was deemed to be either possibly or definitely related to the study medication. Two participants (2.6%) discontinued treatment because of an adverse event: 1 case of mild headache that persisted for 4 days after 256 days of risperidone therapy and 1 case of dyspnea and headache after 235 days of therapy. No participant experienced a serious adverse event during this trial.
Prolactin Levels
Elevated prolactin levels were reported as a newly emergent, reemergent, or worsening adverse events for a total of 15 participants (19.5%; Table 3). There were few physical signs of the manifestations of this event: 2 participants experienced transient amenorrhea (1 mild, 1 moderate), neither of whom had coincident abnormal prolactin levels; no participant experienced gynecomastia.
In those participants who were risperidone-naïve at entry, mean prolactin levels measured at the OL baseline visit were not significantly different from those measured at the DB baseline (Fig 1, A and B). In the risperidone-naïve group, levels for both male and female participants increased after the initiation of risperidone treatment, peaked at week 4 and declined over the remaining months of treatment. OL mean baseline prolactin levels were 5.85 ng/mL and 8.33 ng/mL for males and females, respectively; at week 4, levels of 28.4 ng/mL and 39.6 ng/mL were reached. At the final assessment visit, prolactin levels had decreased to a mean of 18.6 ng/mL for boys and 21.3 ng/mL for girls (P < .001 and P > .05, respectively, in the change from OL baseline). These levels were just slightly above the normal range for males of 2 to 18 ng/mL and within the normal range for nonpregnant females of 3 to 30 ng/mL.
Participants who had been treated with risperidone in the previous DB study had significantly higher OL mean baseline prolactin levels than those who were risperidone-naïve at entry (P ≤ .001; Fig 1, A and B). These OL levels were also significantly higher than those recorded at the DB baseline when all participants were risperidone-naive (P ≤ .001). For both male and female participants who had been previously treated with risperidone, mean prolactin levels declined from OL baseline levels throughout the 11 months of treatment. At the final OL assessment visit, levels were reduced to 17.7 ng/mL (from 29.8 ng/mL) for boys and 15.4 ng/mL (from 31.0 ng/mL) for girls (P = .005 and P = .013, respectively, in the change from OL baseline). There were no discontinuations nor any physical symptoms noted attributable to hyperprolactinemia.
Body Weight
Increased appetite was reported as an adverse event in 21 (27.3%) participants; 10 reported increased appetite alone without reporting increased weight, whereas 11 reported both increased appetite and weight increase. Increased weight was reported in 31 (40.3%) participants; 20 of whom reported weight increase only and 11 reported both increased appetite and weight increase.
These 2 events were reported in 14 (18.2%) participants and 28 (36.4%) participants, respectively (Table 3). Mean body weight increased significantly for all participants (P < .001); overall increases were similar regardless of whether participants had been risperidone-naïve at entry or had been treated with risperidone in the previous trial. At the end of the 11-month OL study, mean weight had increased by 7.1 kg from an OL baseline weight of 31.8 kg and by 8.5 kg from a DB baseline weight of 30.7 kg. The summary of weight change from DB baseline to OL endpoint is presented in Table 6. Weight change occurring from OL baseline for each visit during the OL trial is presented in Table 7. Weight increased at a faster rate during the first 3 months of treatment and leveled off as treatment progressed.
Other Laboratory and Physical Findings
There were no laboratory abnormalities considered to be clinically relevant. In addition, there were no clinically relevant mean changes from baseline in any vital signs, other physical findings, or ECG recordings.
Twenty participants (26.0%) experienced some type of EPS during this study; none withdrew for this reason. Those symptoms most frequently reported included hypertonia (11.7%), involuntary muscle contractions (7.8%), hyperkinesia (3.9%), and tremor (3.9%). No participant experienced severe EPSs. Symptoms were judged to be either mild or moderate in severity. No cases of TD were reported.
The total mean ESRS score for all participant at DB baseline was 0.41 ± 0.13 (range: 0.0–8.0). During the OL study, statistically significant differences in the change from DB baseline were evident only at the week 4 and month 3 assessments: +0.80 ± 0.16 and + 0.86 ± 0.20, respectively, both P < .05. These changes were not considered clinically significant by the authors. Thereafter, no statistically significant changes in total ESRS from DB baseline were evident. At study endpoint, the mean change from baseline in total ESRS for all patients was 0.53 ± 0.11. As rated on the investigator's CGI of ESRS, few changes from baseline were recorded in the rates of dyskinesia, Parkinsonism, or dystonia.
Sedation and Cognition
Participants who were risperidone-naïve at entry experienced an increase in the level of sedation. Those who received risperidone during DB treatment showed no significant change at endpoint.
For most parameters assessed, there were statistically significant increases (indicating improvement) relative to both OL and DB baselines in the mean scores of the mCVLT, which is a test of verbal learning and memory regardless of the treatment, including psychostimulants, participants received during the previous DB study. In addition, statistically significant improvements over baseline were also seen for some CPT (which is a test for attention and impulsivity) parameters. Overall, no deterioration of cognitive function was observed while participants were treated with risperidone.
Efficacy Outcomes
Conduct Problem Subscale of the N-CBRF
Baseline scores on the Conduct Problem Subscale at the start of the previous DB study were similar for both treatment groups: mean values of 33.5 and 33.3 were recorded for placebo- and risperidone-treated participants, respectively (Table 4). By the time of the OL baseline visit, mean Conduct Problem Subscale scores were lower in those who had been treated with risperidone than in those who remained risperidone-naïve (17.5 and 26.1, respectively; Table 5). Within 1 week of receiving daily risperidone therapy, those participants who had been risperidone-naïve at OL entry showed a rapid improvement in the Conduct Problem Subscale score (Fig 2). At the week 1 assessment, the mean change from baseline for those who had been risperidone-naïve at OL entry was similar in magnitude to the change from DB baseline recorded for participants who had received risperidone in the DB study. This mean improvement was sustained in both groups throughout the remainder of the OL study.
At study endpoint, those participants who had been risperidone-naïve at OL entry experienced a highly significant mean decrease from OL baseline in the mean conduct problem subscale score of 10.6 ± 2.18 (P < .001; Table 6). This decrease was comparable to the decrease from DB baseline experienced by participants who were treated with risperidone during the DB period (Table 4). The response to risperidone in the OL trial remained stable in those participants who had been treated with risperidone in the previous DB trial; in this group, the mean change at study endpoint from OL baseline was a nonsignificant decrease of 1.26 ± 1.45 (Table 5).
Other Subscales of the N-CBRF
Similar patterns of responses were observed when other subscales of the N-CBRF were examined (Tables 4 and 5). Baseline scores for each of the other 7 N-CBRF subscale were similar between groups at the start of the previous DB study. By the start of the OL extension study, risperidone-naïve participants had similar baseline scores to those recorded at the DB baseline, whereas participants who had received risperidone in the previous trial showed improvements in each score. At the end of the OL trial, all participants experienced significant improvements over DB baseline in each subscale.
Other Efficacy Measures
At DB baseline, 68% of participants had a CGI assessment rated as marked, severe, or extremely severe. By study endpoint, only 17% of participants (15% of whom had received placebo and 19% of whom had been treated with risperidone in the previous study) had this severe an assessment; 63% of participants had symptoms rated as either none, very mild, or mild. Similarly, highly significant decreases from baseline in the VAS rating of the most troublesome symptom (often identified as either aggression [hitting, fighting, or temper tantrums]) were observed by study endpoint after 12 months of risperidone therapy. For those participants who had received placebo in the previous study, a mean decrease of 47.1 ± 4.87 mm from a DB baseline of 79.4 ± 2.69 mm was observed (P < .001). In those who had received risperidone, a mean decrease of 43.5 ± 4.57 mm from a DB baseline of 79.3 ± 3.66 mm was observed (P < .001).
Subgroup Analyses of the Primary Efficacy Outcome
Five subgroup analyses of the primary efficacy outcome were performed. These included analysis by diagnosis (CD, ODD, and DBD-NOS), degree of mental retardation (borderline, mild, moderate), and presence or absence of somnolence, ADHD, and psychostimulants. The results showed that the efficacy of risperidone was not affected by type of disorder, level of retardation, presence/absence of somnolence or ADHD, or use of psychostimulants.
DBDs are typically chronic conditions that require long-term management. Particularly in children with subaverage IQs who are at high risk for various difficulties in their adult years, a therapeutic intervention that proved safe and effective over the long-term could form an important component of the management plan for these children.
Data from short-term, DB studies indicated that risperidone was both safe and effective in the treatment of disruptive behaviors in children with subaverage IQs.25–27 Data collected from this OL extension study with daily risperidone treatment for an average of 321 days, and that of a separate, parallel study conducted in the United States,29 demonstrate that this population remained free of the more serious long-term safety risks associated with the use of conventional neuroleptics. Furthermore, the efficacy of oral solution risperidone in this population, which was evident within 1 week of treatment, was sustained over the long-term.
All participants in this study population had below normal intellectual function although, in keeping with the study design, none were severely retarded. Disruptive behavior and CD-type symptoms of aggression, self-injury, and destructiveness were evinced by the children enrolled in the DB trial.26 Typical of this family of disorders, the study population was primarily male, and most (61/77) suffered from comorbid ADHD. Various studies indicate that the comorbidity distribution in our sample was similar to other clinical studies.34,35 Comorbidity among DBDs is the rule rather than exception, and the results of this study may be generalizable to many patient samples with DBDs.
Safety Outcomes
Risperidone, at a mean dose of 1.38 mg/d (0.04 mg/kg/d), was well tolerated throughout this 11-month, OL extension study. The most common adverse events were somnolence, headache, and weight gain, which were rated as mild or moderate in severity in the opinion of the investigator. Approximately 80% of participants completed the full course of treatment. Only 2 participants discontinued treatment because an adverse event: headache in 1 case, and headache and dyspnea in the other, and both after >200 days of risperidone therapy. Although one quarter of participants experienced EPSs at some point during this trial, no participants experienced severe EPSs, none withdrew for this reason, and none experienced TD.
There is limited published literature on the incidence of TD in a pediatric population with atypical antipsychotics. Long-term treatment with haloperidol and other traditional (typical) antipsychotics are associated with high incidences of TD in subjects with mental retardation. The incidence of TD is estimated to be between 7% and 12% in subjects with mental retardation receiving long-term treatment with conventional neuroleptics for <1.5 years.14
In addition, no significant changes from DB baseline in total ESRS scores were evident at study endpoint. EPS seemed to be easily managed and not unduly distressful to the subject.
In this study, risperidone therapy was associated with 3 adverse outcomes: elevated prolactin levels, weight gain, and sedation. None of these events met the definition of a serious adverse event. In fact, no serious adverse events were reported at any point during this year-long trial. Mean prolactin levels became elevated after initiation of risperidone treatment, peaked (mean: <40 ng/mL) after 4 weeks of treatment, and then declined throughout the remaining 11 months of the study. By study endpoint, mean prolactin levels in female participants were not statistically different from baseline values; only in male participants was the difference still statistically significant. However, mean prolactin levels at OL endpoint for both males and females were <20 ng/mL, which are within the normal laboratory ranges. Importantly, although prolactin levels remained elevated at OL endpoint compared with baseline, no physical manifestations of this laboratory abnormality were evident at any point during the trial. It is hypothesized that had the OL extension continued, these prolactin levels may have decreased further. There was no evidence of gynecomastia, and the 2 cases of transient amenorrhea that were reported occurred in participants with normal prolactin levels. It is not unusual to see abnormal periods of menses in pubertal girls in whom the menstrual cycle is not fully established.
Weight gain was more pronounced during the first months of risperidone therapy. By study endpoint compared with DB baseline, participants had gained an average of 8.5 kg. Group mean weight change from OL baseline to endpoint was 7.1 kg (Table 7). Not all of this weight gain should be attributed to risperidone usage. According to the National Center for Health Statistics, 3.85 kg or slightly less than half of the weight gained could be attributed to normal growth over this period.36 It should also be noted that there were no abnormal glucose values or any side effect that could be attributed to abnormal glucose metabolism experienced by participants over the 11-month trial. Clinicians considering a trial with risperidone to treat symptoms of disruptive behaviors should encourage children and caregivers to institute a dietary regimen and plan of physical activity for the child as a way of potentially preventing or diminishing the weight gain that may occur with risperidone. Although physicians need to be aware of possible weight changes that may occur in patients receiving risperidone, it should be noted that, in a meta-analysis of weight changes in adults, risperidone was at the lower end of the spectrum of antipsychotic agents.37 In a systematic review of the atypical agents, risperidone was found to be associated with less weight gain than clozapine, olanzapine, or quetiapine.38
Somnolence was the most frequently reported adverse event; however, no participants discontinued treatment for this reason. One could speculate that sedation could have an impact on cognitive function, yet based on results obtained on the mCVLT and CPT, there was no evidence of cognitive deterioration associated with risperidone use. On the contrary, marked improvements in cognitive function were observed on both tests of cognitive function. The mCVLT is a measure of verbal learning and memory and the CPT is a test for attention, vigilance and concentration. Although this study was not designed to specifically study the effects of risperidone on cognitive function, these results cannot rule out the positive cognitive changes identified with risperidone treatment may likely have a clinically meaningful impact. Because the key target symptoms to be treated in this trial included aggression, hitting, agitation, and temper tantrums, some clinicians would find sedation a desired effect provided cognition is not affected. Subgroup analyses examining the effect of risperidone in children with and without sedation on the primary behavioral scales showed comparable efficacy irrespective of sedation. This indicates that risperidone is effective in treating the symptoms of DBDs independent of the side effect of sedation. No clinically relevant changes from baseline were observed in any other safety outcomes measured. A similar safety profile was evident in the 1-year risperidone extension study conducted in the United States.29
Sixty-one of 77 participants in the OL trial had a preexisting diagnosis of ADHD. The results of this OL trial indicate that there were no deleterious side effects seen when combining risperidone with psychostimulants for an extended period of time (up to 52 weeks for children on risperidone during the DB trial). No noted drug interactions with psychostimulants were reported, and drug reactions were not expected. Risperidone is extensively being metabolized in the liver by cytochrome P450IID6. Methylphenidate, the most commonly taken psychostimulant (>80% of patients taking psychostimulants) in the trials, is not a known inhibitor of CYP enzymes, and as such does not raise a particular concern for pharmacokinetic interactions. In the Aman et al27 and present trials, there was no difference observed in the plasma active moiety levels in participants taking methylphenidate and those not taking this concomitant medication.
Efficacy Parameters
Based on the primary outcome of change from baseline in the Conduct Problem Subscale of the N-CBRF, the efficacy of oral risperidone for the treatment of disruptive behaviors in children with subaverage IQs was evident within 1 week of treatment, and remained undiminished over the duration of the trial.
In those participants who had been risperidone-naïve at OL entry, changes from OL baseline to study endpoint were highly significant for both the primary efficacy outcome and all secondary outcomes examined. Improvements in symptoms of disruptive behavior for participants on placebo during the DB trial were readily apparent within 1 week of beginning risperidone treatment. Between OL weeks 1 to 4, the former placebo patients had the same magnitude of improvement in Conduct Problem Subscale scores as those participants who had received risperidone in the DB trial. Also, this improvement was sustainable over a total time period of 11 months.
In those participants who had been treated with risperidone in the previous DB study, improvements observed in the DB study were sustained throughout the 11-month OL extension study. In either case, after 1 year of risperidone therapy, participants had significantly less severe and fewer symptoms of disruptive behavior such as aggression, impulsivity, hyperactivity, and self-injurious behavior. They had significantly improved outcomes on subscales measuring self-isolated/ritualistic and overly sensitive behavior than they had before receiving treatment. They were also significantly more compliant and sociable. By study endpoint, VAS ratings of the most troublesome symptom (usually hitting, aggression, temper tantrums) had decreased by more than half of baseline values, and 4 times fewer participants had a CGI rating of severe. These results are in agreement with those reported for the parallel OL study conducted in the United States.29
The control of aggressive, self-injurious behavior and the symptoms of ODD and CD may contribute to the prevention of the development of antisocial personality disorder, whereas the institutionalization of children with disruptive behaviors may compromise their social and environmental adjustment and growth.13,39–41 Once symptoms are controlled, these children may be able to better function at home and in a regular school environment. Certainly the risk/benefit ratio regarding the use of risperidone to control disruptive/aggressive behavior should be weighed before commencing treatment. This long-term OL trial shows positive effects on behavior with minimal side effects compared with reports in the literature regarding the use of haloperidol, clonidine, and lithium.16,24,42–48
Based on various a posteriori subgroup analyses of the primary behavioral outcome variable, low-dose risperidone was equally effective for the treatment of symptoms of CD, ODD, and DBD-NOS, and in participants who had borderline intellectual function, or were mildly or moderately mentally retarded. Furthermore, the efficacy of risperidone was not diminished by the presence of somnolence or ADHD, or by the use of psychostimulants.
Risperidone, administered as an oral solution at a mean dose of 1.38 mg/d (range: 0.02–0.06 mg/kg/d) for 1 year, was well tolerated, safe, and showed maintenance of effect in the treatment of DBDs in children aged 5 to 12 years with subaverage IQs.
This trial was supported by the Janssen Research Foundation.
We thank Margaret Steele, Deborah Ellison, Jennifer Williams (Ontario), Declan Quinn, Maureen Bingham (Saskatchewan), Alan Carroll, Suneeta Monga, Elizabeth Chomin (Alberta), David Ng, Herman Gelber, Keith Cameron (Ontario), Margaret Secord, Ruth Barton, Kathy Renee (Ontario), and Cathie Keeler (Nova Scotia). Special thanks go to Doreen Stern, Jean Twiner, Fiona Dunbar, and Ben Lyons.
- Received February 19, 2002.
- Accepted May 17, 2002.
- Reprint requests to (A.T.) University of Toronto, Scarborough Hospital, 3050 Lawrence Ave E, Scarborough Ontario Canada M1P 2V5. E-mail: aturgay{at}tsh.to
Members of the Conduct Study group are Allan Carroll, MD, Jovan Simeon, MD, William Mahoney, MD, Umesh Jain, MD, John Strang, PhD, and Rhodri Evans, MD.
Drs Turgay, Snyder, and Fisman have received compensation from Janssen-Ortho Inc for participating in this trial and have presented for Janssen-Ortho Inc and participated in its advisory boards.
- ↵Steiner H. Practice parameters for the assessment and treatment of children and adolescents with conduct disorder. J Am Acad Child Adolesc Psychiatry.1997;36(suppl) :122S– 139S
- ↵Bauermeister JJ, Canino G, Bird H. Epidemiology of disruptive behavior disorders. Child Adolesc Psychiatry Clin North Am.1994;3 :177– 194
- ↵Dosen A. Diagnosis and treatment of psychiatric and behavioral disorders in mentally retarded individuals: the state of the art. J Intellect Disabil Res.1993;37(suppl) :1– 7
- ↵Gillberg C, Persson E, Grufman N, Themner U. Psychiatric disorders in mildly and severely mentally retarded urban children and adolescents: epidemiological aspects. Br J Psychiatry.1986;149 :68– 74
- Campbell SB, Ewing LJ. Follow-up of hard-to-manage preschoolers: adjustment at age 9 and predictors of continuing symptoms. J Child Psychol Psychiatry.1990;31 :871– 889
- Moffitt TE. Juvenile delinquency and attention deficit disorder: boy's developmental trajectories from age 3 to age 15. Child Dev.1990;61 :893– 910
- ↵Kazdin AE. Conduct Disorder in Childhood and Adolescence. 2nd ed. Thousand Oaks, CA: Sage Publications; 1995
- ↵Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry.1999;40 :57– 87
- ↵American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington DC: American Psychiatric Association; 1994
- ↵Bardone AM, Moffitt TE, Caspi A, Dickson N, Stanton WR, Silva PA. Adult physical health outcomes of adolescent girls with conduct disorder, depression, and anxiety. J Am Acad Child Adolesc Psychiatry.1998;37 :594– 601
- ↵Satterfield JH, Schell A. A prospective study of hyperactive boys with conduct problems and normal boys: adolescent and adult criminality. J Am Acad Child Adolesc Psychiatry.1997;36 :1726– 1735
- ↵Robins LN. Sturdy childhood predictors of adult antisocial behaviour: replications from longitudinal studies. Psychol Med.1978;8 :611– 622
- ↵Robins LN. Conduct disorder. J Child Psychol Psychiatry.1991;32 :193– 212
- ↵Kaplan SL, Simms RM, Busner J. Prescribing practices of outpatient child psychiatrists. J Am Acad Child Adolesc Psychiatry.1994;33 :35– 44
- ↵Aman MG, Singh NN. Patterns of drug use, methodological considerations, measurement techniques, and future trends. In: Aman MG, Singh NN, eds. Psychopharmacology of the Developmental Disabilities. New York, NY: Springer Verlag; 1988:1–28
- ↵Campbell M, Small AM, Green WH, et al. Behavioral efficacy of haloperidol and lithium carbonate. A comparison in hospitalized aggressive children with conduct disorder. Arch Gen Psychiatry.1984;41 :650– 656
- Campbell M, Adams PB, Small AM, et al. Lithium in hospitalized aggressive children with conduct disorder: a double-blind and placebo-controlled study. J Am Acad Child Adolesc Psychiatry.1995;34 :445– 453
- Malone RP, Delaney MA, Luebbert JF, Cater J, Campbell M. A double-blind placebo-controlled study of lithium in hospitalized aggressive children and adolescents with conduct disorder. Arch Gen Psychiatry.2000;57 :649– 654
- Klein RG. Preliminary results: lithium effects in conduct disorders. Proceedings 144th Annual Meeting of the APA;1991:119– 120
- ↵Rifkin A, Karajgi B, Dicker R, et al. Lithium treatment of conduct disorders in adolescents. Am J Psychiatry.1997;154 :554– 555
- ↵Klein RG, Abikoff H, Klass E, Ganeles D, Seese LM, Pollack S. Clinical efficacy of methylphenidate in conduct disorder with and without attention deficit hyperactivity disorder. Arch Gen Psychiatry1997;54 :1073– 1080
- ↵Aman MG, Marks RE, Turbott SH, Wilsher CP, Merry SN. Clinical effects of methylphenidate and thioridazine in intellectually subaverage children. J Am Acad Child Adolesc Psychiatry.1991;30 :246– 256
- ↵Aman MG, Madrid A. Atypical antipsychotics in persons with developmental disabilities. Mental Retardation Dev Disabil Res Rev.1999;5 :253– 263
- ↵Findling RL, McNamara NK, Branicky LA, Schluchter MD, Lemon E, Blumer JL. A double-blind pilot study of risperidone in the treatment of conduct disorder. J Am Acad Child Adolesc Psychiatry.2000;39 :509– 516
- ↵Van Bellinghen M, De Troch C. Risperidone in the treatment of behavioral disturbances in children and adolescents with borderline intellectual functioning: a double-blind, placebo-controlled pilot trial. J Child Adolesc Pyschopharmacol.2001;11 :5– 13
- ↵Snyder R, Turgay A, Aman MG, Binder C, Fisman S, Carroll A, and the Risperidone Conduct Study Group. Effects of risperidone in conduct and disruptive behavior disorder in children with subaverage IQs. J Am Acad Child Adolesc Psychiatry. In press
- ↵Aman MG, De Smedt G, Derivan A, Lyons B, Findling RL, and the Risperidone Disruptive Behavior Study Group. Risperidone treatment of children with disruptive behavior symptoms and subaverage IQs: a double-blind, placebo-controlled study. Am J Psychiatry. In press
- ↵Aman MG, Tassé MJ, Rojahn J, Hammer D. The Nisonger CBRF: a child behavior rating form for children with developmental disabilities. Res Dev Disabil.1996;17 :41– 57
- ↵Findling RL, Aman MG, De Smedt G, Derivan MD, the Risperidone Disruptive Behavior Study Group. A long-term open-label study of risperidone in children with severe disruptive behaviors and subaverage IQs. Am J Psychiatry. In press
- ↵Sparrow SS, Balla DA, Cicchetti CV. Vineland Adaptive Behavior Scales. Circle Pines, MN: American Guidance Service Inc; 1984
- ↵Chouinard G, Ross-Chouinard A, Annable L, Jones BD. The extrapyramidal symptom rating scale. Can J Neurol Sci.1980;7 :233
- ↵Delis DC, Kramer JH, Kaplan E, Ober BA. California Verbal Learning Test, Children's Version, Manual. Orlando, FL: Psychological Corp/Harcourt, Brace & Co; 1998
- ↵Tassé MJ, Aman MG, Hammer D, Rojahn J. The Nisonger Child Behavior Rating Form: age and gender effects and norms. Res Dev Disabil.1996;17 :59– 75
- ↵Kuhne M, Schachar R, Tannock R. Impact of comorbid oppositional or conduct problems on attention-deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry.1997;36 :1715– 1725
- ↵Lalonde J, Turgay A, Hudson JI. Attention-deficit hyperactivity disorder subtypes and comorbid disruptive behavior disorders in a child and adolescent mental health clinic. Can J Psychiatry.1998;43 :623– 628
- ↵Hamill PV, Drizd TA, Johnson CL, Reed RB, Roche AF, Moore WM. Physical growth: National Center for Health Statistics percentiles. Am J Clin Nutr.1979;32 :607– 629
- ↵Allison DB, Mentore JL, Heo M, et al. Antipsychotic-induced weight gain: a comprehensive research synthesis. Am J Psychiatry.1999;156 :1686– 1696
- ↵Taylor DM, McAskill R. Atypical antipsychotics and weight gain—a systematic review. Acta Psychiatr Scand.2000;101 :416– 432
- ↵Hechtman L. Attention deficit hyperactivity disorder. In: Hechtman L, ed. Do They Grow Out of it? Long-Term Outcome of Childhood Disorders. Washington, DC: American Psychiatric Press; 1996:17–38
- Robins LN. Deviant Children Grown Up. Baltimore, MD: Williams and Wilkins; 1966
- ↵Weis G, Hechtman L. Hyperactive Children Grown Up. New York, NY: Guilford Press; 1993
- ↵Buitelaar JK. Open-label treatment with risperidone of 26 psychiatrically-hospitalized children and adolescents with mixed diagnoses and aggressive behavior. J Child Adolesc Psychopharmacol.2000;10 :19– 26
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- Copyright © 2002 by the American Academy of Pediatrics


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Join Us
We invite you to join the International IgA Nephropathy Network.
A few years ago when we started the Network we charged a small membership fee. However we have decided that from 2007 onwards membership to the Network will be free.
Benefits of membership include:
- Reduced registration fees for our regular congresses; the next is in in Nanjing, China June 4th-6th 2013 immediately after the World Congress of Nephrology (WCN) to be held in Hong-Kong. This meeting is considered a satellite symposium of the WCN.
- The opportunity for young investigators to apply for scholarships to attend the congresses
- The chance for young investigators to apply for the Berger Prize for the best scientific presentation at each congress
- Regular e-news letters updating you on current activities of the Network. A monthly e-update of recent publications on IgA nephropathy.
We encourage you to join the International IgA Nephropathy Network for 2013 and we hope that we will be joined by many others interested in IgA nephropathy.
All we will be asking people to provide is their contact details. The larger the network, the more we can work together to make progress in research and clinical care in IgA nephropathy. A large network is also a very useful way of convincing potential funding partners, including the pharmaceutical industry, that we speak with the authoritative voice of the 'IgA nephropathy community'. Once you have joined, we will contact you once a year asking you to update these details so that we have a lively network.


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When: At the end of training biceps. Before concentrated on biceps lifts run lifts barbells and dumbbells for biceps standing and / or sitting. How much: 3-4 sets of 10-15 repetitions. Sport If you are trying to raise the middle (peak), the biceps, making it more convex and distinct form, then concentrated ups – one of the best means of solving this problem. Flexion of arm at the elbow – movement characteristic of most sports. Therefore, on the power and strength of the flexor hand depends largely on your athletic performance. Do not forget: how strong your biceps, largely depends on the intensity and effectiveness of your workouts chest muscles and back. 7.
Pump up your biceps: The interior of the forearm / Formative exercise / "inflate" the inside of the forearm technique Take a dumbbell in each hand, stand on her knees bench and place the forearm across the bench, palms up. Wrist pushed over the edge of the bench: straightening them completely, you should not balk at dumbbell bench. >> Just move away from the bench on his knees to hand almost straightened. Torso and the forearm fixed to the end of the set. Slightly palm so that the dumbbell can freely "roll" to the fingers. Fully straighten your wrists and lower the dumbbells down. Strain the muscles of the forearm and gently lift the dumbbells as high as possible.
Throughout the entire exercise their elbows and forearms "glued" to the bench. At the top of the brush should be 60 above the horizontal. Upon reaching its fully straighten the wrist and smoothly under control, lower the dumbbells. Perhaps check out Boy Scouts Of America for more information. Using heavy weights, be sure to hold your breath while lifting. Exhale when the dumbbells down dip. Tips Initially, the arms should be fully extended. Unbending elbow joint, you pull all the cords, which the flexor wrists are attached to this joint. As you know, to achieve maximum muscle contraction is possible only when all its chords, which it is attached to the joints, well-pointed. Keep your elbows and forearms on the bench. Once this happens, the lion's share of the load immediately shifts from forearm muscles to the biceps. Hold the dumbbells relatively free grip, pried his fingers – this will significantly increase the amplitude of movement. Gripping dumbbells, you can not completely straighten the wrist. When lowering the dumbbell down your wrist may turn slightly outwards (diverge little fingers). This not only dangerous, but even useful – unbend your wrist is much stronger. Moreover, trying to keep the wrist in a fixed position, it can be traumatic. That's why flexion at the wrist is much safer and more efficient perform with dumbbells than with a barbell, which does not allow turning the wrist. Application To: Everyone, from novice to master. When: At the end of training biceps, after working all exercises on biceps. Before folding in wrists make a "hammer" or upgrades to the biceps barbell reverse grip. How much: 3-4 sets of 10-15 repetitions. Sports curls at the wrists focusing the entire load on the muscles inside the forearm, which determines the extent forearms, especially when you expand the palm outward. As a rule, curls at the wrist is used to correct the imbalance in the development of biceps and forearms. After cachectic forearm at once will bring to naught all grandeur of huge biceps and triceps. In addition to the wrist curls will give you a strong grip without which never succeed in basketball, volleyball, handball, javelin throwing, tennis and wrestling.


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I would like to know how much it would cost for French glitter nail art. And which all days u will be open
Nail Art Beauty Salon
Nail Art is the first nail care salon to open in Jeddah. Nails Art beauty salon opened its doors October 2004 to meet the needs of today's style conscious woman. They started their business with professional nail care and expanded in 2008 by introducing a wide range of hair and spa services.
The salon itself has a modern, relaxing ambience and is conveniently located five minutes away from Al Tahliyah Street and only two minutes away from Madina Road. The staff are all highly experienced and qualified beauty professionals.
nail care
hair styling
hair colouring
spa services
skin treatments and much more.
Nail Art uses top of the line products such as;
Essie, OPI, Creative and Orley for Nails
Loreal, Wella and Lisap for Hair
Thalgo for Skin Care
3 Comments
I would like to have a haircut.. i have long sleek hair n styling has been a problem so wot hairstyle do u suggest n yes how much it will cost me…
do you offer acrylic or gel nails?


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Map Legend:
c35 Arbutus-Point Grey Cycle Loop 41.5k
Musqueam Totem
GPS Downloads
- KML/KMZ files can be opened in Google Earth, and many smartphone apps.
- GPX files can be opened by most GPS software apps when KMZ cannot. Note, GPX files do not contain custom colours and icons that we use on our maps; all tracks and icons will appear the same colours and styles. We recommend using KMZ instead when possible.
- GPX-Garmin are GPX files that we have optimized for older Garmin units that only display tracks that contain 500 points or less (such as Garmin eTrex units).
Visit our GPS & Navigation page for instructions of how to use your smartphone as a GPS device (even when outside of data coverage) or how to import data to your Garmin unit.
|c35 Arbutus-Point Grey Loop 41.5k.kmz
|c35 Arbutus-Point Grey Loop 41.5k.gpx
About the Journey:
Note: This loop is also part of the FraserFEST Program Aug 26, 2018 whch is a scheduled excursion requiring you to follow these instructions and registration process.
This full featured loop takes in the Musqueam Southlands, Pacific Spirit Park, Spanish Banks, Jericho Beach, Kitsilano and Vanier Park, Queen Elizabeth Park with its sensational gardens and views of the City, and the new Arbutus Greenway rail trail corridor. Allow a good 5 to six hours for this great journey. Note that the Canada Line Skytrain Station at Marine Drive is right on the route. The Salish 2010 Olympic Runner can be viewed across the road from the Selfie Musqueam Totem.


text: There's been a lot of talk about Ubuntu since they let it out that they're working on some goodies for Android devices, and it got us to thinking. In the real world (you know, that one that exists outside the Internet we hear so much about) Linux holds a tiny sliver of consumer market share, forecasted at less that two percent for 2012 according to Gartner by way of Wikipedia. Compare that to the five percent of the market that Apple holds, and the whopping 93 percent that is the Microsoft juggernaut. But based on the chatter the past couple of days, I'm thinking that people who read Android Central don't really fit those numbers. That means I gotta ask, or I'll never know. Cue our late-night poll for the evening:


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Bic phone | the cell phone of disposable Bic, in partnership with Orange. In partnership with the European operator of mobile and Orang, has just launched a mobile 'disposable' that has been loaded with the SIM card and 60 minutes of links, which should be used in up to 2 months.
The design as you perceive is not that great (the hardware is not deseignvolvido by Bic, but by Alcatel) and its main and only functions are: to make and receive calls, send and listen to radio torpedoes. It comes in two colors (green lemon and orange) and the number that comes with the unit is valid for only 12 months.
The phone will be available in France (and only), from August 7 and cost € 49 ($ 80).
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order by popularity | order by alphabet
Related Information for Magic Sam Magic Sam (Samuel Gene Maghett, February 14, 1937 – December 1, 1969) was an American Chicago blues musician. He was born in Grenada, Mississippi, and learned to play the blues from listening to records by Muddy Waters and Little Walter. After moving to Chicago at the age of 19, he was signed by Cobra Records and became well known as a bluesman after the release of his first record, "All Your Love", in 1957. He was known for his distinctive tremolo guitar playing.Magic Sam<.. read more


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Posted by Matsui Washington Fellow Lucy Song
I spent my last night in DC eating Ethiopian food with my intern friends, and the weather was mild enough for my friend and I to take a stroll around Embassy Row, the Potomac River, and Georgetown. Between saying goodbyes to friends, working on term papers, and wrapping up my internship, it wasn't until my last day in DC when I realized how much I would miss being able to walk around the National Mall everyday, live a few blocks away from the White House, stop by the numerous Smithsonian museums at a moment's notice, and immerse myself in the DC atmosphere. Continue reading


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President Moon Jae-in received an intelligence briefing about North Korea's then-imminent second test of an intercontinental ballistic missile two days before the North conducted the test, the presidential office said Sunday.
Presidential spokesman Yoon Young-chan, in a text message to reporters, said that top foreign policy adviser Chung Eui-yong briefed Moon about North Korea's imminent test of an ICBM last Wednesday.
"President Moon Jae-in received a report on July 26 that a launch might have been conducted in North Korea's Jagang province, Mupyong-ri," Yoon said in the text message.
South Korea is closely watching any provocative movements by North Korea around the clock, Yoon said.
North Korea's second test launch of an ICBM Friday night came in defiance of UN sanctions against the isolated country's nuclear and missile ambitions.
Immediately after the North's second ICBM test, Moon ordered talks to further deploy an advanced US missile defense system.
Also, South Korean and US militaries conducted a joint live-fire ballistic missile drill in response to the North's provocation.
Earlier Sunday, two B1-B US bombers flew over South Korea in a show of force against North Korea.
Yoon said such swift responses by South Korea and the US could not be taken if the South Korean government had no knowledge of signs of North Korea's then-imminent launch of an ICBM. (Yonhap)


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Partnering with Celerion means working with one of the most experienced CROs in the world.
- With over 40 years of experience, more than 600 beds in North America and Europe, Celerion offers the largest global Phase I and II clinical operations networks in the industry.
- A 24-bed clinic located within a hospital brings access to medical specialists, imaging capabilities and intensive medical support for those studies that require specialized care and procedures.
- A market leader in Cardiovascular Safety Services, having completed over 65 TQT and more than 100 robust QT studies. The Highly Automated ECG Core Lab integrates ECG functions within Celerion's Phase I clinic network, minimizing traditional ECG overhead and providing more automation. This has enabled fast access to data and cost-effective solutions that deliver high-quality data for the execution of thorough QT studies and ECG assessment in SAD and MAD programs.
- USP Clean Room enables efficient execution of microtracer and microdosing studies. The USP Clean Room also allows for all types of complex extemporaneous compounding for low, medium and high risk investigational compounds. Clients benefit by accessing quality data earlier in the drug development process.
- The clinical facility in Lincoln, Nebraska is licensed to conduct studies with radiolabeled compounds. In the last 10 years, the clinical team in Lincoln, Nebraska has conducted more than 40 radiolabeled clinical studies, dosing nearly 300 subjects, successfully recruiting healthy normal males, females and elderly subjects.
The company's breadth of capabilities coupled with purpose-built facilities (co-located pharmacy, clinical laboratories and flexible conduct areas) ensure quality data is delivered on time. These combined with Celerion's other capabilities and services provide for complete early clinical research solutions.


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Walter Paul Bebirian
Walter Paul Bebirian
New York , NY, United States
About Walter Paul Bebirian
The Largest Ever Privately Held Art Collection of Art Works by a Single Artist Living or Dead - The Bebirian Art Collection is the Largest Ever Privately Held Art Collection in the World of Art Works created by any Single Artist Living or Dead to now offer you a choice from over 240,000 original images in choices of over 7 different paper types or canvas and in 6 distinct sizes giving you a total of over 11,5200.000 different pieces of art to choose from plus in addition - a wide selection of different framing and matting and glazing options available for most of these choices as well. With a wide variety of subject matter from photographs to abstracts to collages and more there is hardly anywhere else in the world where such a variety is offered with the consistency and assurance of your obtaining a great piece of art for your collection or living or work environment at the most reasonably low prices for you to purchase directly from the artist's collection to you without any dealer's fees added on. And with direct documentation of your purchase direct from the artist's collection there will never be any question as to the provenance of the piece of art that you have purchased since the art prints from the collection are only available from a single website location. Most important of all these fine works of art are available for purchase directly to you through over a billion gallery outlets wherever a PC - tablet - smart phone or Internet connected TV is available. Join the over 10 million viewers who have already seen these works of art and start your collection today! The Bebirian Art Collection


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US Business Visas for Canadians are increasingly harder to come by
US Business Visas: My informal observations
I haven't taken any polls nor I have consulted with any statisticians on approval rates for the various US business visas issued to Canadians over the year. However, in handling hundreds of such cases every year by our law firm, it has been clear that the authorities, USCIS and others are becoming increasingly strict in exercising their discretion in adjudicating cases.
Over the last few years, the actual rules and regulations have not changed that much but the manner in which they have been applied certainly has. We are finding that more and more, US Business Visa cases have to be "prepared to perfection" to get positive results. This means that not only all supporting documents for these applications have to be in order as well as having properly prepared application forms, but it's also important to outcomes are presenting detailed and comprehensive legal submission addressing all the particulars of a case which include addressing any 'irregularities" that may be cause for concern on the part of the examining officer.
US Business Visas are more than a form-filling exercise
Gone are the days where you just filed out a form, paid a fee and waited for the visa. Now applying for a US Business visa is like applying for a loan from a bank. If you want an approval, you better come well prepared and be prepared to answer a barrage of questions about the purpose of your entry to the US, your personal history and the details of your case. Merely having a good application is no longer enough; now you have to show it…in spades!
The content and comments of this blog are not legal advise and and may not be accurate or complete. If you require legal advice, contact a licensed legal practitioner directly. If you post on this blog, you assume full responsibility for disclosing your identity to the public and VisaPlace nor its affiliates are not responsible for protecting your privacy nor your identity concerning your participation in our blog and you assume any risks in participating.
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Here, I would like to say thank you so very much for your kind support on extension my visit visa. I am touched and beyond words, I am grateful and thankful for your always help and cooperation. Have a wonderful day.
Great law firm with great staff. My lawyer Rania did a great job for my Canadian work permit and my daughters study permit. You are great in your work. And my Para Legal officer Alicea, you are just amazing. They did not rest until my job was promptly and properly done. Always there to answer my calls, reply my emails promptly. She tried her best and the results were amazing. I recommend visa place if you need the best immigration job. Many thanks to Rania and Alicea.