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6 aspects to consider when you get a Virtual Phone Number
If you search the Internet for a Virtual Phone Number you will find dozens of providers offering them; all promising you the best service and the most affordable prices.
What are the advantages of getting an Answering Service for Real Estate?
Buying a property is one of the most important decisions a person makes in a lifetime, and since most times all the savings are on the line, the expectations are high. Clients expect a real
How to decide between Google Voice and a VoIP Provider
In their quest to find the best phone service for their home office or small business, many business owners often turn to the cheapest solution on the market to serve their communications needs. The majority
Hosted PBX features guide – what does each feature do?
While in our previous article we've tackled some of the Hosted PBX features such as Answering Rules, Call Forwarding, Call Identifiers, Call Park or Call Queuing, today we continue our journey to discover everything there
Hosted PBX features explained (Part 1)
Hosted PBX is a telecom term becoming ubiquitous to more and more businesses that either implemented this business phone system or planning to in the very near future. From the few features of traditional landlines
7 signs it's time to switch from landline to Hosted PBX
Not everything that's new is better than something old. You've resisted it so far. Your phone system or phone lines do the job, so why should you switch to VoIP lines or a Hosted PBX?
VoIP Requirements. How to prepare for a Hosted PBX system
Whether you are just now starting to look into getting a VoIP phone system for your business or want to improve the service you already have, there are some elements that are crucial for the
Learn how to install the Snom 760 Business VoIP Phone
Although upon their launch in 1996 VoIP was not yet the widespread service that it is today, Snom IP Phones have pioneered the business phones market and contributed to the huge success of VoIP services,
6 SIP Trunking questions answered
SIP Trunking is a VoIP service popular with medium and large businesses that have the resources and manpower to run an in-house PBX system. It's a conveniently priced VoIP solution and it gives businesses full
What is the best phone system for a business?
Out of all the questions that any business owner tries to find the answer to online, this is one of the most frequent. We also notice that most frequent answers include offers from business VoIP
6 aspects to consider when you buy a Virtual Number
If you search the Internet for a Virtual Number you will find tens of websites of providers offering them; all promise you the best service and the most affordable prices. But how to identify a
The important benefits of Real Estate Answering Services
Buying a property is one of the most important decisions a person makes in a lifetime, and since most times all the savings are on the line, the expectations are high. Clients expect a real
Why choose a business VoIP Provider over Google Voice
In their quest to find the best phone service for their home office or small business, many business owners often turn to the cheapest solution on the market to serve their communications needs. The
Frequently asked questions about Toll Free Numbers
Toll Free Numbers (or 1800 numbers) are Virtual Numbers for businesses and individuals that allow the recipient of a call to pay the corresponding charges, enabling the callers to enjoy a call free of charges.
10 Reasons to switch to a Virtual Call Center right away
In light of the constantly changing business environment and increased interest in customer experience, Call Centers today, like many other businesses, have turned to technology to streamline their activities. According to a study regarding Contact
What is and what are the advantages of a Mobile PBX?
The mass adoption of Smartphones from the end of the 2000's onwards provided a great leeway for businesses that were very small or relying heavily on mobile technology. The availability of crucial business elements such
Hosted PBX vs. SIP Trunking – guide to choosing your PBX
This is it! You finally made the decision to drop your traditional landline and to embrace the new wonder of telecommunications that is VoIP. But…there's another challenge before you get to enjoy all the advantages
How to prevent telephone hacking or fraud
As technology innovations are becoming more popular more and more businesses have access to advanced IT infrastructure, such as onsite IP PBX systems. The wide spread of easy to install equipment and open source software
Our favorite SIP VoIP app for business
Before we go ahead and tell you about our recommended VoIP apps, it's important that we clarify one thing: Is a VoIP app appropriate for business use? Our answer is yes, and we base that
8 Secrets of Hosted Phone Systems you didn't know about
One of the biggest reasons of price for VoIP Providers is the possibility to make business phone systems work in dozens of ways, making them fit like a glove for every business. Often though, to
7 new tips on saving your startup's money using VoIP
We've all been startups at some point in time; we all know the struggles of a small team trying to do everything from marketing, to sales, support, billing, purchasing and all the other crucial business
How a hosted phone system can really save you money
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How to improve customer service using VoIP technology
When it comes to winning customers' business, it's sometimes easy to attract them with promotions and special pricing, but competition is fierce and it takes a lot more effort to close a sale and keep
Guide to Thailand Local Number Portability (LNP)
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5 questions you should ask your VoIP Provider about your Hosted PBX
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When do I need a Hosted PBX Phone System?
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10 key questions your new VoIP provider will ask you
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Earn money by selling VoIP as a VoIP Referral Agent
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How to get cheap business phone lines in Thailand using Virtual Numbers
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5 ways a Cloud-Based phone system can help a small business
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Is your IP phone not working? Check these quick fixes
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What is a Hosted PBX? Hosted PBX (Private Branch Exchange) is a private telephone network that uses the Internet Protocol (IP) as a communication protocol in order to connect the internal telephones within a business,
How to choose the best IP Phone
IP Phones are the most important part of a VoIP deployment for all business types, as they represent much of the cost, and are what the user is going to interact with daily. And if
How to troubleshoot outgoing and incoming VoIP call issues
VoIP, as any phone system, is prone to issues that might or might not be related to your provider's network. To identify the possible causes of your VoIP issues, follow these simple steps that might


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Get excited about reading again with fun and interesting tips from our experts, including The M.D., our dietitians, and our fitness expert. In our health library, you will find all of the information you need to achieve your goals of making a healthy lifestyle change. So, start reading and start losing!
Healthy Recipes
Looking for a perfect recipe for tonight's dinner, or need something healthy and delicious to take to a friend's house for a party? Crafted by our award-winning chefs, and built on the nutritional foundation developed by Dr. Cederquist, these recipes are exactly what you're looking for!
What should you eat in the morning to ensure you and your body are satisfied until lunch?
Eating the right stuff for breakfast can be quite a challenge, what with all the muffins, bagels, and sugary cereals out there. But it's very important to start your day off with the correct nutrients and ingredients to keep you satisfied and feeling fabulous. A big misconception many people have is that skipping breakfast will help them lose weight. Skipping breakfast is a bad idea!
Even though it seems like you're eating more throughout the day, jumpstarting your metabolism early in the morning will help you burn more calories the whole day through.
So how do you know which breakfast foods to eat and which to let go stale in the coffee shop? It's simple. Here are some healthy breakfast ideas that are easy to remember and easy to make. Follow the rule of fives.
Healthy Breakfast Items Have 5 Grams of Protein or More:
Cottage cheese, skim milk, low fat yogurt, egg whites, Canadian bacon, extra lean ham, and many other breakfast foods deliver 5 grams or more of protein. Read the labels and skip any sugary cereals that don't pack the protein. You'll be hungry and your metabolism will fade.
Healthy Breakfast Items Have 5 Grams of Fiber or More:
Whole grain cereal and whole wheat bagels deliver the fiber while whole wheat bread and oatmeal do not. Check to make sure what you're eating is not just tasty but fiber-rich, as well.
Fruit is a great addition to your breakfast, but, on its own, it doesn't supply you with the right nutrients to get your body going. Enjoy it with the right foods and you'll be getting all the proper nutrients.
Here are 5 examples of balanced breakfasts that give you fiber, protein, and more…
1 cup whole-grain cereal with 1/2-cup skim milk and 1/2 cup fresh fruit. This easy breakfast idea has 276 calories, 10 grams fiber, and 11 grams protein.
1 SMALL whole-wheat bagel, 1 tablespoon reduced-fat peanut butter, plus 1 cup fresh fruit. This breakfast has 384 calories, 12.3 grams fiber, and 20 grams protein.
Yogurt breakfast parfait made with 6 ounces low fat yogurt, 1/2-cup fresh chopped fruit and 1/2-cup low-fat granola. A yummy start with 302 calories, 7 grams fiber, and 10 grams protein.
Breakfast sandwich made with 1 whole-grain English muffin, 1 1/2-ounces light turkey breakfast sausage and 1 ounce reduced-fat cheese. This treat packs 300 calories, 5 grams fiber, and 21 grams of protein.
1 higher-fiber granola bar (like Fiber One), a banana, and 8 ounces of skim milk. This breakfast will give you 365 calories, 12 grams fiber, and 13.5 grams of protein.
Simply answer a few questions so we can figure out your weight loss goals and provide solutions for a lighter, healthier you. Our weight loss meal plans are designed to help real people achieve real and lasting success.
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- Includes the unique Proporta Aluminium "Screen Saver" System
- Dimensions = H x W x D : 12.5 x 7.8 x 3.7 cm
- Vehicle mountable - perfect for GPS and in car audio systems
- Secure internal MMC/SD memory card storage
- Cut aways give access to ports and controls so that you can use your device in the case
- Secure magnetic clasp closure
- Includes a removable belt clip
- Handmade with elegant contrast overstitching
- Case uses a C-Clip to hold device in place, whilst leaving it and the device screen on display
- Lifetime Exchange Warranty
All items will be sent using Royal Mail, followed by your local postal service, absolutely free of charge..
Other faster options are also available:
The free 'standard shipping' option takes between 2-3 working days from the time of dispatch, although we usually find it takes less.
All of our international orders are sent by standard mail worldwide. However, if you would like your order to be tracked, we will happily arrange for it to be sent via other recorded means. You can select the delivery option you would like at the checkout.
Please be aware that your order must be placed before 1pm between Monday to Friday to take advantage of the Next Day delivery option.
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text: Bridget Weston Pollack is the Vice President of Marketing & Strategy at the SCORE Association. In this role, Bridget is responsible for all branding, marketing, PR and communication efforts. She focuses on implementing marketing plans and strategies for the organization to facilitate the growth of SCORE's mentoring and training services.


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News editor
One of the two former McPherson College football players charged in the September murder of Tabor College student and football player Brandon L. Brown has pleaded guilty to a lesser charge.
DeQuinte O. Flournoy of Dallas was originally charged with aiding and abetting murder in the second degree. The charge was changed to aiding and abetting aggravated battery in accordance with the plea agreement on April 2. Flournoy pleaded no contest and was found guilty.
Flournoy had no previous criminal history. Attorneys expect sentencing guidelines will recommend probation, and the prosecution agreed not to oppose probation, according to the plea agreement obtained from McPherson County District Court. Sentencing is scheduled for 11:30 a.m. June 3.
The murder charge carried a possible sentence of more than 40 years in prison and a fine of up to $300,000.
As part of the plea deal, Flournoy agreed to cooperate in the investigation of Brown's murder and the prosecution of anyone charged in connection with the murder. Another former McPherson College football player, Alton L. Franklin, also of Dallas, remains charged with aiding and abetting murder in the second degree.
Brown, 26, was found beaten unconscious shortly after 4 a.m. Sept. 16 in McPherson. The father of two was pronounced dead Sept. 22 in Wichita.
McPherson County Attorney David A. Page said Brown's family supported the decision to make a plea deal with Flournoy.


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Senators working on new Syria plan
A powerful group of senators is quietly drafting a new proposal that could forestall military action in Syria if the country relinquishes its chemical weapon stockpile, according to sources familiar with the deliberations.
The plan could emerge as a critical alternative for the White House, which has been struggling to rally congressional support for a proposal to carry out "limited" military strikes against the Syrian regime within 90 days. The group working on the new plan includes Republican defense hawks, a powerful committee chairman, a key Democratic leader and important swing votes — meaning it could pick up steam as a crucial alternative to the use-of-force resolution that is awaiting action in the Senate.
Story Continued Below
The GOP senators in the group include John McCain of Arizona, Lindsey Graham of South Carolina, Kelly Ayotte of New Hampshire and Saxby Chambliss of Georgia. The Democratic senators include Chuck Schumer of New York, Bob Casey of Pennsylvania, Chris Coons of Delaware and Carl Levin of Michigan. Sen. Robert Menendez (D-N.J.), the Foreign Relations Committee chairman who authored the use-of-force resolution, is involved in the talks as well. The White House is being kept apprised of the discussions, sources say.
( VIDEO: Who to watch on Syria)
The broad outlines of the plan would call for the United Nations to pass a resolution asserting that Bashar Assad's regime in Syria used chemical weapons in the country's ongoing civil war. A UN team would be required to remove the chemical weapons within a specified timeframe. If the weapons were unable to be removed within that timetable, then the United States would be authorized to use military force against the country, the source said Tuesday. The timeline is still being hammered out by the group.
"Days," Casey said when asked how long the timetable should be. "If they can meet the demands that we would incorporate in this kind of a resolution, then this breakthrough might be real."
Menendez said Tuesday that the new plan could be offered as an amendment to the use-of-force resolution on the floor. But Tennessee Sen. Bob Corker, the top Republican on the Foreign Relations panel, said Congress should "hit pause" on moving any Syria resolution until the validity of a proposal from Russia is determined.
The fast-moving developments are in response to a Russian offer Monday that Syria should give up its chemical weapons in order to avoid the prospects of military strikes. Press reports Tuesday indicated that the Syrian Foreign Minister said his government would accept the Russian proposal. The developments also come as President Barack Obama addressed senators in the Capitol Tuesday before a high-stakes speech to a public highly skeptical about another military conflict in the Middle East. Obama said Monday he was open to the offer, and the White House is signaling the president would engage in United Nations discussions over the Russian proposal.
In the Capitol Monday night, Graham said Syria should be given a week to give up its chemical weapons since he was "highly dubious and skeptical" of the Russian proposal.
"The way to test them is to put a time limit on them," Graham told POLITICO.
Speaking on the Senate floor, Senate Majority Leader Harry Reid signaled that the discussions between the United States and Russia would continue to influence how the chamber moves forward.
( VIDEO: Reid on Syria: 'We should have this debate')
"The Senate should give these international discussions time to play out, but not unlimited time," Reid said Tuesday.
The legislative and diplomatic developments come at an opportune time for the Obama administration. Polls show big majorities of the American public oppose military intervention in Syria. In Congress, the president's own party has grown increasingly opposed to the use-of-force resolution in both the House and the Senate. Republicans are largely opposed to the use-of-force resolution, underscored by Senate Minority Leader Mitch McConnell's announcement Tuesday he would vote against the measure.
As McConnell announced he was against military action, Speaker John Boehner (R-Ohio) said he was "skeptical" of Russia's new involvement, but added diplomacy is "always the better outcome."
"I'm skeptical of it because of the actors that are involved, simple as that," Boehner told reporters after a closed meeting of House Republicans on Tuesday.
( PHOTOS: Syria: Where politicians stand)
Indeed, the administration sees the Russia proposal as a potential win-win in that it brings Moscow more into the arena to try to resolve the Syria crisis and it puts Obama in the light of being willing to pursue diplomacy as an alternative to military action.


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Stephen is Projects Director, Royal Commission on the Ancient & Historical Monuments of Wales. He edited the first of the international ICOMOS Thematic Studies on Canals and also worked on one on Collieries and on others. He lectures at Aberystwyth University on Welsh Chapel Architecture. He has represented ICOMOS in China and at ICOMOS Heritage Experts Meetings in Canada, the UK and the USA. He also attended the ICOMOS World Heritage Panel in Paris in 2010 and has acted as an ICOMOS Mission Expert in Poland, Belarus & France. He has written books on Welsh architecture and archaeology:
- The Brecon Forest Tramroads - Archaeology of an Early Railway System
- Thomas Thomas, 1817-88: The First National Architect Of Wales
- The Archaeology Of The Montgomeryshire Canal - A Guide & Study In Waterways Archaeology
- Industrial Archaeology Of The Swansea Region
- Collieries of Wales Engineering & Architecture
- Copperopolis: Landscapes of the Early Industrial Period in Swansea
email@example.com / (0)1970 621215
Subscribe to the Heritage of Wales News and sign up for the full feed RSS, just click this RRS button and subscribe!
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View your full shopping cart for taxes and shipping.
ePub Version. The perfect week-by-week guide to managing diabetes and glucose control.
[This is the eBook version of this book, delivered in the ePub format. To read this eBook, you will need Adobe Digital Editions installed on your machine. NOTE: Third party eBooks are not compatible with the Amazon Kindle Reader.] 8 Weeks to Maximizing Diabetes Control is the diabetes management plan that helps you manage your diabetes. It's the plan for when you don't have a plan. The week-by-week approach of this book shows you how to put together a health care team, manage medications, understand and implement the basics of meal planning, improve blood glucose self-monitoring, start an exercise program, and more. Other books are encyclopedias about diabetes, but 8 Weeks to Maximizing Diabetes Control is a structured approach to improving blood glucose and to managing diabetes better. Easy-to-read instructions and simple weekly goals help get you where you need to be - in as little as eight weeks! ©2008 American Diabetes Association
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Louis Vuitton Monogram Viva Cite PM Authentic Pre Owned
This item is no longer available
Authenticity code: Louis Vuitton
This authentic Louis Vuitton Monogram Canvas Viva-Cite PM Bag has space for all of your daily belongings. There is one pocket on the exterior an the adjustable strap will ensure comfort in the classic LV style. Featuring signature monogram canvas leather and gold tone hardware.
Authentic: Preowned
Exterior: Gently used
Interior: Gently used
Measurements: 8.5" L x 3.5" W x 5.5" H.Adjustable Strap (Approx.)
Product Code: 1660108
Read more about Louis Vuitton Date Code here.
All photos are of actual item being sold. © 2007-2019 LuxeDH.
This Louis Vuitton® item is guaranteed to be authentic. Louis Vuitton is a registered trademark of Louis Vuitton. LuxeDH is not affiliated with or represents Louis Vuitton in any way or form.


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Senior Cami Ascher
BOSTON, MA-The University of Massachusetts Dartmouth's volleyball team lost to host Emerson and Colby-Sawyer in a non-conference tri-match at the Bobbi Brown and Steven Plofker Gym Saturday.
Emerson won, 25-16, 25-21 and 25-15; while Colby-Sawyer was victorious, 25-14, 25-21 and 25-21.
Senior middle blocker Cami Ascher (Natick, MA/Natick HS) had eight kills to lead the way against the Lions, while senior outside hitter Allie Mastrocola (Swansea, MA/Case HS) and freshman outside hitter Madison Shea (Millis, MA/Millis HS) each had five. Junior setter Jess Goncalves (New Bedford, MA/New Bedford HS) had 22 assists, while senior libero Shannon Brodie (Chelmsford, MA/Chelmsford HS) had 11 digs, and Mastrocola had 10.
Against the Chargers, Goncalves had 20 assists, Mastrocola had 14 kills, and Brodie had 11 digs.
"I thought we had a shot at Emerson, but we just didn't have the horses," said UMass Dartmouth Head Coach Steve DeRossi. "Shannon was outstanding all day on defense, and on serve receptions."
The Corsairs are now 11-12, while Emerson is now 17-5 and Colby-Sawyer is 13-13. UMass Dartmouth will return to action when they visit Suffolk Tuesday.


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The nice people at Birzman say the designs of their bike tools are inspired by nature. Hence, according to their website, the Zacoo Next floor pump design "originates from the Birzman premier 5 degree floor pump" which itself originates from "the trunk of a tree … a true vertical expression of strength and stability."
Actually the arboreal comparisons apply more to the range topping Zacoo 5 which has tree inspired outer casing inside which… is the Zacoo next. The Zacoo 5 also has a workshop length hose and is aimed more at shop mechanics who need to inflate tyres while a bike is stoll on the workstand. The Zacoo Next is tall and cylindrical rather than overtly tree-like But then so are most floor pumps (aka track pumps). Is there anything that makes the Zacoo Next different to the rest?
While the arboreal comparisons may be pushing it, the appearance of this pump is undeniably striking: sleek and shiny in polished aluminum (the only non-metal bits are the hose and presumably the internal seals), with a narrow barrel and a flat slender metal handle. It's got a kind of 1950s retro look. I'm vaguely reminded of Dakotas, tail-fined Cadillacs and Airstream caravans.
But looks count for nothing is the pump doesn't work. So let's put it onto a valve and give it a test.
The pump will fit Schrader valves ('car type') and Presta valves (found on most bikes) by simply turning round the valve-fitting nozzle at the end of the flexible hose. We're testing the Presta fitting.
It's a screw-on nozzle, rather than 'push and clip'. This makes for a nice tight fit, with no air-loss when pumping. Some mechanics prefer push-on pumps, as screw-ons can sometimes have the disadvantage of also tightening up the small release nut on top of the valve so air can't get in. But that didn't seem to be a problem here.
Tighten it up, and give it a few thrusts. Nice and smooth. Keep going, and the tyre goes from flat to 100psi in about 25 full thrusts. Kept going, up to about 150psi. The barrel and plunger stayed firm and positive throughout. No bendy plastic here.
So it puts air in your tyres. So far, so good. Now let's have a closer look at the funky design.
The feet of the pump taper back towards you, so you stand slightly behind the pump, rather than over it (as is usual with track pumps). To tie in with the required stance, the pump barrel is specifically angled at 5 degrees to the vertical (ie, leaning towards you a bit) to make for an easier pumping action.
Personally I've never had any problems with upright pumps, and pump-feet that stick out each side, so was inclined to think all this was a gimmick. But not having to lean right over the pump does seem to make it easier. It would be a definite advantage to anyone of slightly shorter stature or weaker arms. So overall, the ergonomics are a plus.
The dial is at the base of the pump, with a large needle that's easy to see. However, while the needle is easy to see, the psi numbers in green on a black background is an odd choice - they're difficult to read if you're not in daylight. The numbers giving the figures in bar are in white, so maybe it's just the urge you need to go metric. Either way, maximum pressure shown on the dial is 220psi (15 bar).
The flexible hose on the pump is about 700mm long. When not in use, it clips over the handle into semicircular cut-outs on a little metal plate at the top of the barrel. And that is the pump's only downside: the edges of the cut-outs on our test model are remarkably sharp. Catch your thumb on one of them when you're pumping (or even simply clipping the hose into place) and it'll draw blood.
(On the Birzman website, the picture of the pump indicates that this offending clip is made of plastic, but we're assured by the Birzman people that it's metal, although they say the models they have in their warehouse don't have this problem - so maybe out test model is an oddity.)
But it's a minor matter. Other than the issue of the hose clip, the pump itself is faultless. It's a sturdy, durable and very handy addition to any self-respecting workshop, although the recommended retail price of £75 will put a few people off.
Very nice-looking, well-made, sturdy, durable piece of kit. Not cheap though.
If you're thinking of buying this product using a cashback deal why not use the road.cc Top Cashback page and get some top cashback while helping to support your favourite independent cycling website
road.cc test report
Make and model: Birzman Zacoo Next track pump
Size tested: n/a
Tell us what the product is for, and who it's aimed at. What do the manufacturers say about it? How does that compare to your own feelings about it?
The Birzman website says: " the Zacoo 5 Degree [the premier item in the range] pump design is inspired by the trunk of a tree, and successfully mimics its unwavering strength and stability." It goes on to say "Beautifully finished, the entire pump range [including the Zacoo Next], and draws inspiration from this piece, and all feature the innovative and ergonomic 5 degree angled barrel to ease stress on the mechanics shoulders." To be honest, this tree comparison does seem to be over-egging things a bit, but the pump is certainly strong and stable.
Did you enjoy using the product? yes
Would you consider buying the product? yes
Would you recommend the product to a friend? To a rich friend that loves sleek design
About the tester
Age: 50 Height: 5ft 10 / 178cm Weight: 11 stone / 70kg
I usually ride: an old Marin Alp My best bike is: an old Giant Cadex
I've been riding for: Over 20 years I ride: A few times a week I would class myself as: Experienced
I regularly do the following types of riding: touring, club rides, sportives, mtb,


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"Thousands of tired, nerve-shaken, over-civilized people are beginning to find out that going to the mountains is going home; that wildness is a necessity; and that mountain parks and reservations are useful not only as fountains of timber and irrigating rivers, but as fountains of life." John Muir Have you ever driven in the Blue Ridge Mountains or the Rockies, or been to Yosemite National Park or the Grand Canyon? Have you car camped in one of our National Forests or National Parks? Have you ever wondered what it would be like to venture out beyond the campground or overlook? We are the one Meetup in the Hampton Roads area that ventures into beautiful mountain forests, following trails that meander over high ridges and cross beautiful mountain streams. We hike in the 'tree tunnels' along the Appalachian Trail, lined with Mountain Laurel and Rhododendrons. We hike over the passes of the Colorado Rockies and fish in the glaciated lakes of the Wind River Wilderness. We see views that only those who leave the trail head will ever see. Our trips are normally Friday thru Sunday, with two nights camping and about a day and half hiking. Normally, we arrange carpools and/or convoys from this area to the forest trailhead and link up at the Friday night campsite. Due to differing work schedules, some people can arrive Friday in the afternoon, some may not be able to drive down until after work, arriving later in the evening, setting up in the dark by head-lamp. Saturday morning is breakfast and a meet-n-greet for late arrivals, then it's off down the trail to that days destination. Saturday night usually has a campfire with people preparing their meals and socializing. Sunday morning after breakfast, the group heads back towards the trail head and heads home. Many times the group will stop for lunch or early evening meal (victory feast!) for one last chance to socialize with everyone and to say 'so long'. Backpacking can be expensive and time consuming and may not be for everyone. But if you're looking for get-a-ways that allow you to break-contact with the day to day rat race, commune with nature, make new friends, and above all, have fun, then please considering joining one of our trips! We ask that you try to answer all profile questions and provide a photo when joining. This gives trip organizers a glimpse into the experience levels of those signing up for trips, as some trips are more difficult than others!
So, whether you are already an experienced backpacker who wants to hike with a new group of friends, or even lead trips, or if you've never taken that first step away from car camping and have wondered what it would be like to hike over that mountain and camp by a beautiful mountain stream, then give backpacking a try and join us today!
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The Ionic column is typically identified by its capital, which includes large paired spiral scrolls, or volutes. It has the tallest base of the three classic Greek orders. Columns in this style can be found throughout Capitol Hill, including the U.S. Capitol, the Supreme Court Building and the exterior of the Longworth House Office Building.
The Old Senate Chamber, located in the U.S. Capitol Building, is a two-story room modeled after the amphitheaters of antiquity. Eight Ionic columns of variegated marble quarried along the Potomac River support the Chamber's gallery on the east wall; they were inspired by the columns of the Erechtheion in Athens.
The Supreme Court Building's grand Court Chamber is a dignified room lighted by side windows behind screens of Ionic columns. The 24 columns are made of Old Convent Quarry Siena marble from Liguria, Italy.
The Longworth House Office Building is one of Washington's best examples of the Neo-Classical Revival architecture. Its exterior features Ionic columns that support a well-proportioned entablature and are used for the building's five porticoes, the principal one of which is topped by a pediment.


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Policy Facts: Abstinence Education and HIV/AIDS
Each year, half of all new HIV infections in the United States are among individuals under age 25. Two young Americans under the age of 25 are infected with HIV every hour, resulting in 20,000 new infections per year among young people. Yet federal funding trends support abstinence-only education rather than comprehensive abstinence and sexual health education programs that prepare teenagers for the world outside their classrooms. By graduation, 65 percent of all high school seniors report having had sex. Full knowledge of the options available to adolescents, from abstinence to safer sex, is important in empowering young people, influencing the choices they make about sex, and preventing new HIV infections. Abstinence-only programs do not meet the needs of America's youth in their quest for the information and skills necessary to make good decisions and stay healthy.
While abstinence-only programs focus exclusively on abstaining from sexual activity until marriage, abstinence-plus programs seek to educate individuals about all facets of sexual health with a focus on abstinence. Information regarding the prevention of sexually transmitted diseases (STDs), including HIV, is discussed in addition to highlighting the option of abstaining from sexual activity until marriage. Research has shown that comprehensive sex education programs that discuss both abstinence and protection from sexually transmitted diseases actually delay the onset of sexual intercourse, reduce the frequency of intercourse, and reduce the number of sexual partners.
Abstinence-Plus Education Works
Comprehensive sexuality education that advocates abstinence yet provides education for those teens that choose to become sexually active has proven practical and effective. Abstinence-plus education, which provides a range of information and options for young people from abstinence to safer sexual behavior, does not increase sexual activity or lower the age of a young person's first sexual encounter. There is no evidence that abstinence-only education is effective in preventing or delaying sexual activity. In fact, a recent abstinence-only initiative in California actually resulted in more students reporting sexual activity after participating in the program.
Concerns that discussing explicit sexual information with youth would result in an increase in sexual activity or early initiation of sex among youth have proven unfounded. A recent Institute of Medicine (IOM) report supported abstinence-plus programs, citing studies that found that teens with comprehensive sexuality education were less likely to engage in sexual intercourse, and those who had sex did so less often and were more apt to use protection.
Surveys have shown that an overwhelming majority of parents want their children to receive information about sex, including both abstinence and contraception, from trained professionals at schools. Parents who engage their children in frank discussions of STD and HIV risk are quite effective: A study of mother-adolescent communication regarding HIV demonstrated an increase in condom use only for teens whose mothers had talked to them about condoms before they became sexually active. Similarly, a survey of 522 African-American adolescent girls found that those girls who regularly discussed sex with their parents were significantly less likely to engage in behavior that placed them at risk for HIV and much more likely to bring up STD/HIV prevention with sexual partners than girls whose parents did not discuss sex, STDs, and HIV.
Current Trends and Programs
Comprehensive sexuality education helps to minimize behavior that places adolescents at risk for HIV, and it is in demand among American youth. Most teens know about HIV transmission, but they want to know more about protecting themselves against HIV. Today's teens need information about sexual behavior and HIV/AIDS. The Kaiser Family Foundation has found that 68 percent of all sexually active teens did not think they were personally at risk of contracting HIV. However, 65 percent of sexually active teens are personally concerned about HIV/AIDS.
According to the IOM and the Presidential Advisory Council on HIV/AIDS, a significant challenge in preventing HIV transmission among teens is the increasing number of abstinence-only sex education programs in schools. These programs are offered in place of comprehensive or abstinence-plus sex education programs. Additionally, in his recent Call to Action, Surgeon General David Satcher asserted, "given that one-half of adolescents in the United States are already sexually active -- and at risk of unintended pregnancy and STD/HIV infection -- it also seems clear that adolescents need accurate information about contraceptive methods so that they can reduce those risks." There is no evidence to support the widespread adoption of abstinence-only programs, whereas providing teens with more information has been found to delay the initiation of sexual activity and promote better overall health.
Currently, most (35) states require sexuality education to be taught in school. In 11 of those states, the curriculum must focus on abstinence until marriage, with brief mention of STD and HIV prevention. In two of those states, HIV prevention education is only discussed in the context of abstinence until marriage. In three of the states that do not require sexuality education, if it is taught voluntarily, the program can only discuss abstinence until marriage. The number of states requiring abstinence-only education is growing. In 1988, two percent of public school teachers reported teaching abstinence as the sole method of protection against sexually transmitted diseases (STDs) including HIV. That number rose to 23 percent by 1999.
There is a growing trend of providing abstinence-only education at the expense of comprehensive sexual education that includes abstinence as well as pregnancy, STD, and HIV prevention. Abstinence-plus programs provide teenagers with a range of options and information. With half of all new HIV infections in the U.S. each year occurring among teens and young adults, more information about HIV prevention could prevent additional infections. Abstinence-only programs do not provide young people with the information or negotiation skills that they may need to protect themselves from HIV infection.


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Sarah Posner invites guests from across the ideological spectrum to discuss breaking news and three-alarm issues at the intersection of politics and religion.
On The Posner Show, Sarah talks with Khaled Diab, an Egyptian journalist living in Jerusalem and the author of the new e-book Intimate Enemies. They discuss how both sides in the Israeli-Palestinian conflict have narratives of dispossession and exile. Khaled describes the heightened tensions and violence in Jerusalem since the summer. Khaled argues that nationalistic concerns have trumped human ones on both sides, and makes the case for a "people's peace process." Are there new voices waiting to emerge? Plus: The settler rabbi who would be fine with living in a Palestinian state, and other unconventional interview subjects.
On The Posner Show, Sarah talks with Joanna about the LDS Church's recent admission that Joseph Smith, Mormonism's prophet and founder, practiced polygamy. Joanna explains the unusual way that the doctrine of polygamy continues to affect the lives of everyday Mormons, and how polygamy makes sense within Mormonism's unique Christian theology. Joanna argues that the LDS Church leadership continues to view polygamy of an "eternal principle." Plus: Seeing polygamists at the Costco.
On The Posner Show, Sarah and Israeli lawyer Daniel Seidemann discuss an Obama administration official's characterization of Benjamin Netanyahu as "a chickenshit." Danny explains how the Palestinian village of Silwan is the "epicenter of the conflict" and how the Israeli settlers' behavior is a "stain on Israeli democracy." Danny recounts taking two prominent Republican leaders on a tour of the city, and how they saw the cracks in the "undivided Jerusalem" slogan, which Danny calls a "myth." Plus: the eruption of violence on the Temple Mount, and why the current police crackdown on Palestinian protesters in East Jerusalem will leave the city forever changed.
On The Posner Show, Sarah speaks with Patti about the Extraordinary General Synod taking place this week in Rome. Patti argues that conservative fears that the synod will produce radical changes are misplaced. She traces the church's position on contraception to decisions made during the last synod in 1980. Nonetheless, she says, a midterm report from this synod contained some surprising revelations, notably signals that the church may stop referring to homosexuality as "intrinsically disordered" and to unmarried couples as "living in sin." What did a German bishop really say about African bishops and homosexuality? What does Patricia's book have to say about a role for pro-choice Catholics? Finally: How Francis's synod represents very "modest proposals."
Sarah talks to Lydia Bean, author of The Politics of Evangelical Identity, a study of how white evangelical political identity is shaped by grassroots "folk theory" about what it means to be a good Christian. Lydia explains why evangelicals might react differently to people coming from outside their religious "tent." She talks about why evangelicals see their messaging on issues like abortion and same-sex marriage as compassionate, even when outsiders may not. They discuss the economic differences between American and Canadian evangelicals on issues like socialized medicine. Plus: Why "faith-based" campaigning by Democrats falls flat, and how a new set of rhetorical tools can change that.
On The Posner Show, Sarah and Brent consider the question: Is liberal Zionism dead? They debate whether the latest Gaza war is a turning point in American Jewish attitudes towards Israel. They discuss the rise of dissenting pro-Israel groups like #IfNotNow that are challenging the American Jewish establishment, and even challenging the more liberal group J Street. Brent argues these groups will force change in the American Jewish establishment, but that it will be gradual. Plus: What about American rabbis?
On The Posner Show, Sarah and Kara discuss a letter urging President Obama not to include a religious exemption in a forthcoming executive order barring federal contractors from discrimination based on sexual orientation and gender identity. Kara explains why she signed the letter, and why she doesn't believe there should be a new religious exemption. They discuss how the proposed order would interact with existing rules granting religious exemptions to religiously-affiliated contractors. And they reflect on how the Hobby Lobby case might affect provider refusals in the areas of abortion, contraception, and assisted reproductive technology. Plus: How did the boss's religious rights come to take precedence over those of his workers?
In a follow-up to last week's discussion of the Supreme Court's Hobby Lobby decision, Sarah talks with Caroline about the Court's unusual order on Thursday in Wheaton College v. Burwell. Does this injunction contradict the ruling in Hobby Lobby? Caroline makes the case against Wheaton College's "facilitation argument" that filling out a form that triggers the insurance company to provide contraception coverage creates a substantial religious burden. How will the lower courts now rule on the raft of similar cases? If non-profits refuse to fill out the form, will sending the government an e-mail suffice? Plus: How the Court got Congress's intention with the Religious Freedom Restoration Act wrong.
On The Posner Show, Sarah talks to Caroline about the Supreme Court's decision in Hobby Lobby. Is the decision a narrow one, as the majority insists, or one of "startling breadth," as Justice Ginsburg charges in her dissent? They discuss how the decision affects religious non-profits that have also challenged the contraception mandate. How did the decision expand the scope of the Religious Freedom Restoration Act? Will HHS now step in to provide contraception coverage for Hobby Lobby employees? Might some companies try to game the system to save money? Did the government make a mistake by not challenging Hobby Lobby's claim that emergency contraception and IUDs are abortifacients? Plus: How Hobby Lobby will affect gay rights cases.
On The Posner Show, Sarah talks with the Rev. Welton Gaddy, who recently announced his retirement as president of the Interfaith Alliance. They discuss Welton's history of advocating for religious diversity and religious freedom, after he witnessed first-hand the Religious Right's takeover of the Southern Baptist Convention. Welton provides a brief history of the politicizing of religion from the "pseudo-piety" of the Clinton impeachment through the Obama administration's refusal to change Bush-era rules on faith-based initiatives. Did Obama fear crossing "the Christian establishment" in enacting the Affordable Care Act's contraception mandate? Welton argues that the recent Supreme Court ruling in favor of legislative prayer undermines authentic religion. Plus: Why Welton is scared about the state of religious freedom in America.
On The Posner Show, Sarah and Kathryn discuss the latter's new article on sexual abuse at Bob Jones University. How do evangelical institutions handle sexual assault? They discuss how victims of sexual assault are blamed for having their own sins, while their attackers often go unpunished. Kathryn explains why Bob Jones brought in an outside group, GRACE, to address the problem. Sarah notes a contrast with the Catholic Church in terms of not closing ranks to protect abusers. Can GRACE change the way the evangelical movement deals with sexual assault?
On The Posner Show, Sarah talks with Matt about the fallout from Gov. Brewer's veto of Arizona's SB 1062. Matt explains why, contrary to what many conservatives claim, the failure of the bill was not an example of persecution of Christians. Are religious institutions poised to lose their tax-exempt status over gay rights? They debate whether photographers should be able to refuse service to gay couples, and Matt explains why, if he were a photographer, he would refuse. If the Supreme Court strikes down bans on same-sex marriage, will conservative Christians retreat to monastic-like communities? Sarah and Matt debate whether marriage is a broken institution. Plus: Is the persecution narrative a winning strategy for the Christian right?


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Dennis Hopper
News about Dennis Hopper, including commentary and archival articles published in The New York Times. More
Dennis Hopper, whose portrayals of drug-addled, often deranged misfits in the landmark films "Easy Rider," "Apocalypse Now" and "Blue Velvet" drew on his early out-of-control experiences as part of a new generation of Hollywood rebel, died on May 29 at his home in Venice, Calif. He was 74.
Manohla Dargis wrote in The Times in April 2010:
Mr. Hopper, actor, filmmaker, photographer, art collector, world-class burnout, first-rate survivor - never blew it. Unlike the villains and freaks he played over the decades - the psycho with the mommy complex in "Blue Velvet," the mad bomber with the grudge in "Speed" - he made it through the good, the bad and some spectacularly terrible times.
He rode out the golden age of Hollywood by roaring into a new movie era with "Easy Rider." He hung out with James Dean, played Elizabeth Taylor's son, acted for Quentin Tarantino. He has been rich and infamous, lost and found, the next big thing, the last man standing.


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Fashionhaus Hotel is a property located in Miami Beach zone. If you want to know how to get from Miami Airport to Fashionhaus Hotel we can provide you with different transportation options based on the carriers who offer transport to Miami Beach area, shared ride and private minivan transportation. We operate with the best units in the market, focusing in offer the best and safest transportation to Fashionhaus Hotel with high qualified drivers.
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Address: 534 Washington Avenue, South Beach, Miami Beach, Miami Beach, FL 33139


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The Psychology of Prejudice and Discrimination
Thomson Wadsworth, 2006 - Psychology - 660 pages
In the first comprehensive textbook on prejudice with a strong psychological research base, Whitley and Kite cover a broad range of topics including race and ethnicity, gender, sexual orientation, and ageism. By integrating theory and research with students' own experiences, the authors increase students' awareness of influences that shape prejudices. As students are asked to evaluate research results and their personal, subjective beliefs, they develop an appreciation of scientific evidence regarding stereotypes, prejudice, and discrimination.
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Psychology of Prejudice and Discrimination: 3rd Edition
Mary E. Kite,Bernard E. Whitley, Jr.
Limited preview - 2016
Psychology of Prejudice and Discrimination: 3rd Edition
Mary E. Kite,Bernard E. Whitley, Jr.
Limited preview - 2016
Common terms and phrases
affirmative action African Americans ageism ambivalent assess associated aversive prejudice behavior bias Chapter characteristics colleagues correlation culture described dice discuss Dovidio effect emotions ethnic evaluations example experience factors feel Fiske Gaertner gender group members hate crimes hate groups heterosexual Hispanics hypotheses illusory correlations individuals influence ingroup interactions intergroup contact lesbians measures members of minority minority groups modern-symbolic prejudice motivation negative stereotypes norms older adults outgroup outgroup members people's perceived percent perspective positive prejudice and discrimination prejudiced psychological race racism ratings reduce prejudice relationship relative deprivation relative deprivation theory responses role Russell Fazio scores self-esteem self-report sexism sexual situation social categories social dominance orientation social groups social identity Social Psychology stereo stereotype activation stereotype threat stereotyped group stereotypic beliefs stereotyping and prejudice subtypes theory thev threat tion traits types unprejudiced values variables White Americans women


text: This biography focuses on physicist J. Robert Oppenheimer's role in the U.S. nuclear program from 1945 to 1955 and the conflict at the time between people advocating arms control and those in favor of the development of more powerful thermonuclear weapons. That conflict pitted Oppenheimer and like-minded persons against a community led by physicist Edward Teller and bureaucrats Lewis Strauss and William Borden. The conflict was manifested in Oppenheimer's opposition to the hydrogen bomb, Teller's drive to establish a nuclear laboratory at Livermore, California, separate from the Los Alamos laboratory, and differences between Strauss and Oppenheimer. It culminated in the 1954 Atomic Energy Commission (AEC) hearing that denied Oppenheimer his security clearance. The author, a recognized historian, presents an interesting, well documented, view of the events that she feels contributed to the acceleration of the Cold War arms race.


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I have not done a very good job of blogging lately. My beautiful daughter got married the end of September and I didn't blog one.single.word about it although there were plenty of words in my head that day.
I have been working on their wedding quilt for the past several months although I didn't get it finished in time to present it as a wedding gift ;o( That makes me sad. I DID get the last border on it today.
I've cleaned up all the loose threads, the backing is purchased, washed/dried/ironed and I'm taking it to the longarm quilter on Thursday. I'll be getting the binding ready while it's away.
Thanks for stopping by…


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New Website Alert!
Be sure to check out our new website for Tournament Bowlers, TournamentResults.com.
We all know that getting more strikes and spares will help increase your bowling average. However, did you know that if you set yourself a goal that you are more likely to achieve that goal?
If your goal each week is to increase bowling your average, then this page is for you. Below you will see what you need to bowl next week in order to increase bowling your average by one pin. Check this page out before you bowl each week and know your goal before you roll your first ball!


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"I'm personally looking forward to what promises to be a super fun/challenging day of riding. See you there!" – Jen
For those who don't know, Pedal Panties are a highly engineered, boy-short cut pantie with a thin breathable cushion providing a more comfortable ride for women. Wear them under your most stylish clothing and feel fabulous! We enthusiastically support all ladies who ride from the beginner to the Spring Classic-ist!
Thank you Pedal Panties for being a part of this!


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I am still completely determined to find the right BB cream for me. So far all of the ones I have tried are too pale, or give me a rash or don't last long on my oily skin.
My latest purchase from eBay is this Mushroom BB Cream from Skinfood. I bought it because I had heard this particular range (mushroom) runs a little dark so I got it in shade 02:
Mushroom on your face? Really?!
If you have read my posts on Skinfood then you will know that they make some pretty unusual products – Beer Cleanser, Garlic Face Cream, Cheese Face Mask, Broccoli Sunscreen – I love it!
Here is the Mushroom BB Cream – its runs a little pinky:
Hmmm. I can see already that its going to be too light. As well as being a bit pinky it looks a little ashy on my hand….
By the way, if you are wondering, it doesn't smell of mushrooms but its not sweet either – if bases could be sweet of savoury, this would definitely be savoury.
The texture itself is ok –its not as oily as some BB creams can be, it feels a bit dry and on closer inspection, clung to dry patches have have.
Before (I have just plucked my brows, hence the red around there!):
It doesn't blend as well as I like and I don't like the pasty look it gives me at all. Its still far too pale for me, so I won't be using it again – d'oh!
Back of the tube:
On the side, if this suits your skin, its a very generous tube and it does all the things you'd want for smooth, gorgeous skin – spf, anti-ageing qualities, brighter skin etc.
I got this from eBay for about £8 including shipping – there are plenty of sellers. Recommended for oilier, pale skins methinks.


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Be inspired by the designs of Philippe Starck, Jade Jagger, Marcel Wanders, Kelly Hoppen and Steve Leung.
From bustling Hong Kong and exotic Boracay Island to Rio de Janeiro, YOO Hotels and Resorts surprise and delight even the most jaded traveller with contemporary, imaginative and sophisticated hotels.
Explore the world of YOO through our shared inspiration, experiences, and news from across the globe.
Founded by international property entrepreneur John Hitchcox and ubiquitous designer Philippe Starck, YOO is a residential and hotel design company offering the creative visions of world renowned designers Philippe Starck, Marcel Wanders, Jade Jagger, Kelly Hoppen, Steve Leung and the YOO Studio. With 87 projects in 55 cities and 36 countries, throughout Asia, Africa, Australia, Europe, North and South America and the Middle East, YOO is a thoroughly international lifestyle brand.


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Definition of Congenital adrenal hyperplasia
Congenital adrenal hyperplasia (kun-JEN-ih-tul uh-DREE-nul hi-pur-PLAY-zhuh) is a collection of genetic conditions that limit your adrenal glands' ability to make certain vital hormones. In most cases of congenital adrenal hyperplasia, the adrenal glands don't produce enough cortisol. The production of two other kinds of hormones also may be affected, including mineralocorticoids (for example, aldosterone) and androgens (for example, testosterone).
Congenital adrenal hyperplasia can cause problems with normal growth and development in children — including normal development of the genitals. It affects both males and females.
Although congenital adrenal hyperplasia can be life-threatening, most people with it can lead normal lives with proper treatment.
Symptoms of Congenital adrenal hyperplasia
There are two major types of congenital adrenal hyperplasia:
- Classic congenital adrenal hyperplasia. This more severe form of the disease is usually detected in infancy or early childhood.
- Nonclassic congenital adrenal hyperplasia. This milder form usually becomes evident in late childhood or early adulthood.
Classic congenital adrenal hyperplasia
The most obvious sign of classic congenital adrenal hyperplasia in girls is often abnormal-appearing genitals that look more male than female, which may include an enlarged clitoris — a condition called ambiguous external genitalia. Other signs and symptoms in girls also reflect exposure to higher levels of male sex hormones (androgens) while in the womb.
The condition is not typically as easily seen in baby boys, although some affected male infants have an enlarged penis.
Signs and symptoms of classic congenital adrenal hyperplasia in infants include:
- Ambiguous genitalia in girls
- Enlarged penis in boys
- Poor weight gain
- Weight loss
- Dehydration
- Vomiting
Signs and symptoms of classic congenital adrenal hyperplasia in children and adults include:
- Very early puberty
- Rapid growth during childhood, but shorter than average final height
- Irregular menstrual cycles in women
- Infertility in women and men
Nonclassic congenital adrenal hyperplasia
This form of congenital adrenal hyperplasia is milder and usually becomes evident in late childhood or early adulthood.
Signs and symptoms are typically most apparent in adolescent girls and women and often include:
- Irregular or absent menstrual periods
- Masculine characteristics such as facial hair, excessive body hair and a deepening voice
- Infertility
In both females and males, signs and symptoms of nonclassic congenital adrenal hyperplasia also may include:
- Early puberty
- Rapid growth during childhood, but shorter than average final height
- Severe acne
- Low bone density
- Obesity
When to see a doctor
Contact your child's pediatrician if your child has signs and symptoms that seem to suggest congenital adrenal hyperplasia. Also, if you're pregnant and may be in a high-risk group for congenital adrenal hyperplasia because of your own medical history or your ethnicity, ask your doctor about genetic counseling. Your doctor can also discuss with you possible treatment of your fetus before birth (prenatal treatment).
Congenital adrenal hyperplasia affects your adrenal glands, a pair of walnut-sized organs located above your kidneys.
Inherited defect affects cortisol production
The cause of congenital adrenal hyperplasia is an inherited genetic defect that limits production of one of the many enzymes the adrenal glands use to make cortisol. The enzyme most commonly lacking in congenital adrenal hyperplasia is 21-hydroxylase. Congenital adrenal hyperplasia may sometimes be called 21-hydroxylase deficiency. Signs and symptoms of congenital adrenal hyperplasia are worst when the enzyme deficiency is severe.
Most of the problems caused by classic congenital adrenal hyperplasia are related to a lack of cortisol, which plays an important role in regulating your blood pressure, maintaining blood sugar and energy levels, and protecting your body against stress.
A child with classic congenital adrenal hyperplasia may also experience:
- A lack in the adrenal glands' production of aldosterone. This can lead to low blood pressure, lower sodium level and higher potassium level. Sodium and potassium normally work together to help maintain the right balance of fluids in your body, transmit nerve impulses, and contract and relax your muscles.
- Excess production of the male sex hormones (androgens such as testosterone). This can result in short height, early puberty in boys, abnormal genital development in girls and severe acne. Signs and symptoms may vary, depending on which specific gene is defective.
The condition is passed along in an inheritance pattern called autosomal recessive. Children who have the disorder have two parents who either have the condition themselves or who are both carriers of the genetic mutation that causes the condition.
Risk factors
If a child's parents both have congenital adrenal hyperplasia or if both are carriers of the genetic defect for the disease, the child is at increased risk of having the condition.
People in some ethnic groups are more likely to develop this disorder, particularly Ashkenazi Jews. The condition is also more common among Hispanics, Yugoslavs and Eskimos.
Complications of Congenital adrenal hyperplasia
Babies, children or adults with classic congenital adrenal hyperplasia could experience a life-threatening "adrenal crisis," meaning their adrenal glands aren't producing enough cortisol. An adrenal crisis can result in a seriously low level of sodium in the blood, diarrhea, vomiting, dehydration, low blood sugar levels and shock. People experiencing an adrenal crisis need immediate treatment.
Adrenal crisis does not occur in adults with the nonclassic form of congenital adrenal hyperplasia.
Long-term complications of congenital adrenal hyperplasia may include:
- Ongoing risk of adrenal crisis
- Infertility
- Sexual problems, such as pain during intercourse
Preparing for your appointment
Classic congenital adrenal hyperplasia is usually detected at birth or in early infancy when baby girls show ambiguous genitalia or when babies of both sexes show signs of severe illness. If your baby is vomiting, lethargic or showing other signs of severe illness, seek immediate medical care.
In nonclassic congenital adrenal hyperplasia, you may first make an appointment when you notice signs and symptoms of early puberty — sometimes very early — in your toddler or older child. After your family doctor or your child's pediatrician evaluates your child, your child may be referred to a doctor who specializes in the diagnosis and treatment of conditions related to the adrenal glands (endocrinologist).
In some cases, signs and symptoms of nonclassic congenital adrenal hyperplasia may not develop in women until the teenage or young adult years. Indications of the condition in these cases may include irregular or lack of menstrual periods, unwanted male-pattern hair growth in women (hirsutism) or infertility.
Here's some information to help you prepare for your appointment.
What you can do
- Find out if your child needs to follow any pre-appointment restrictions, such as changing his or her food or liquid intake to get ready for blood and urine tests.
- Write down any signs and symptoms your child has been experiencing, and for how long.
- Make a list of your child's key medical information, including recent illnesses your child has had and the names of any medications he or she is taking or has recently taken.
- Write down the questions you want to be sure to ask your doctor.
For congenital adrenal hyperplasia, some basic questions to ask your doctor include:
- What is likely causing my child's signs and symptoms?
- Are there any other possible causes for these symptoms?
- What kinds of tests does my child need?
- What treatment approach do you recommend?
- Will treatment slow down the rate at which my child is sexually maturing?
- What are the possible side effects of treatment?
- How will you monitor my child's health over time?
- What is my child's risk of long-term complications?
- Do you recommend that my child receive psychological counseling?
- Do you recommend that our family meet with a genetic counselor?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time if you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to talk about in-depth. Your doctor may ask:
- What are your child's symptoms?
- When did your first begin noticing these symptoms?
- Do your child's symptoms include feeling fatigued or faint?
- Do your child's symptoms include feeling nauseated?
- Is your child experiencing any social problems related to his or her early sexual development?
- Has anyone in your family been diagnosed with congenital adrenal hyperplasia?
- Are you planning to have more children?
Tests and diagnosis
Tests to diagnose congenital adrenal hyperplasia include:
- Physical exam. Your child's doctor will examine your child and evaluate symptoms. If, based on these findings, the doctor suspects congenital adrenal hyperplasia, the next step is to confirm the diagnosis with blood and urine tests.
- Blood and urine tests. Tests used to diagnose congenital adrenal hyperplasia measure levels of hormones manufactured by the adrenal glands — cortisol, aldosterone and androgens. A diagnosis can be made when there are abnormal levels of these hormones.
Doctors are required to conduct hormonal tests for congenital adrenal hyperplasia in newborns during the first few days of life. Blood is drawn with a heel prick of the newborn and analyzed.
Prenatal testing
Doctors have the tools to screen and diagnose congenital adrenal hyperplasia in fetuses. These tools are used most often when siblings have the disease or family members are known to carry the gene defect.
If you are pregnant and have the condition or a family history of the condition, your doctor may recommend one of the following tests:
- Amniocentesis. This procedure uses a needle to withdraw a sample of cells from the amniotic fluid in the womb and determine in the laboratory whether the condition is present.
- Chorionic villus sampling. This test involves withdrawing cells from the placenta for analysis in the laboratory.
If the condition is diagnosed before birth, treatment can be started in the womb. Prenatal diagnosis and therapy may be able to reduce the risk of complications.
Testing to determine a child's sex
After birth, your child may have ambiguous external genitalia, so you may not be sure of your child's sex. In that case, genetic blood tests can analyze chromosomes — in a test called karyotyping — to determine the sex of your child.
In addition, a pelvic ultrasound can be used to produce images of female reproductive structures — the cervix, uterus and fallopian tubes — to confirm whether your child is a girl.
Treatments and drugs
To treat congenital adrenal hyperplasia, it's best to get a referral to a specialist in childhood hormonal issues (pediatric endocrinologist). Treatments include:
Medications. In most cases, your child's doctor will prescribe replacement hormone medication to boost the levels of deficient hormones in your child and restore them to normal levels. For example, your child may take an oral drug — such as hydrocortisone or dexamethasone to replace cortisol and fludrocortisone to replace aldosterone — on a daily basis. At times, children with congenital adrenal hyperplasia need multiple drugs, with even higher doses prescribed during periods of illness or severe stress, including surgery.
Steroid-type replacement medications may cause side effects, particularly if the doses are high and are used long term. Your doctor will monitor your child for medication side effects, such as the loss of bone mass and impaired growth, and will also order regular blood tests to see if medications need adjusting. Keep all scheduled appointments so that your doctor can regularly check your child's progress, including monitoring changes in height, weight and blood pressure.
Treatment for girls with classic congenital adrenal hyperplasia involves a careful balance of the right amount of cortisone medications. Adequate cortisone replacement is needed to suppress androgens, allowing for normal height and minimizing masculine characteristics. However, too much cortisone may cause Cushing's syndrome. Your doctor will schedule regular tests to monitor your child for these side effects.
As adults, some men and women with congenital adrenal hyperplasia are able to stop taking their replacement hormone medications. However, others, particularly people with the classic form of the disease, may need to take replacement hormone medications indefinitely.
- Surgery. In some infant girls who have ambiguous external genitalia, doctors recommend reconstructive surgery to correct the appearance and function of the genitals. This procedure may involve reduction of the clitoris size and reconstruction of the vaginal opening. The surgery is typically performed between 2 and 6 months of age.
Prenatal management
Sometimes, treatment for congenital adrenal hyperplasia can begin before your child is born.
When congenital adrenal hyperplasia is diagnosed in the fetus, one option is for the pregnant mother to take a powerful corticosteroid drug, such as dexamethasone, before giving birth. Corticosteroids can cross the placenta and suppress the activity of the fetus's own adrenal glands. By reducing the secretion of male hormones (androgens), this approach may allow female genitals to develop normally. It can also reduce the masculine features that may develop later in female fetuses. When the fetus is male, doctors may recommend a shorter course of lower dose dexamethasone treatment during pregnancy to keep the adrenal glands functioning as normally as possible.
Although the use of dexamethasone can be effective, many doctors prescribe it with caution, as there's no clear evidence yet about the long-term safety of this drug in children with this condition.The medication can also cause side effects in the pregnant mother, including excess weight gain, mood swings and high blood pressure. This treatment is still considered experimental by many doctors.
Many children with congenital adrenal hyperplasia can successfully manage the condition by staying on their replacement hormone medications. They grow up to lead lives in good health and with a normal life expectancy. However, they may be shorter than their parents. And both men and women may have fertility problems in adulthood.
Girls who have corrective genital surgery may need further cosmetic surgery later in life. When they become sexually active, they're more likely than are women who have not had genital surgery to experience sexual problems, such as pain during intercourse.
Some advocates of children with ambiguous genitalia argue that corrective surgery shouldn't be performed until a child is old enough to understand the risks and choose his or her own gender assignment. However, most experts recommend performing corrective genital surgery when girls are very young because the surgery is technically easier than it is in later years.
Before making decisions about the best treatment approach for your daughter, talk with your doctor about these issues. Working together, you and your doctor can make informed choices that will help your daughter thrive.
Coping and support
Females with classic congenital adrenal hyperplasia — who are exposed in the womb to elevated levels of male sex hormones — are more likely than are girls without this condition to prefer typically male gender roles and activities throughout their lives. They may be more likely to identify as bisexual or homosexual.
Sexual problems are common among girls and women with congenital adrenal hyperplasia, including:
- Embarrassment about the appearance of genitals
- Uncertainty that intercourse will be possible
- Pain and bleeding during intercourse
- Discomfort telling a new partner about the disease
Early and steady support from family and health care providers can help girls grow up to have normal self-esteem and a satisfying social life. Make sure counseling is included in your child's treatment plan, and that you and your child's health care providers pay attention to her mental and emotional health as well as her physical well-being.
You can also help your child by resisting the urge to overprotect her, which may only convince her that she is different or limited. If you're having trouble coping with your child's condition or feel overwhelmed by worry, ask your doctor to refer you to a mental health professional. An experienced therapist can help you deal with your feelings and develop healthy parenting strategies.
Doctors often recommend genetic counseling for parents who have congenital adrenal hyperplasia and are contemplating starting a family. The disorder can be diagnosed in fetuses, and prompt treatment, most often beginning in the first or second trimester, can reduce or even eliminate symptoms after birth. It is important to remember that treatment before birth is often recommended, but long-term studies have not yet confirmed that it is safe or effective.