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Adolescent Health Care: A Practical Guide
Chapter 58
Hirsutism and Virilization
Catherine M. Gordon
Lawrence S. Neinstein
Hirsutism is defined as increased growth of terminal (long, coarse, and pigmented) hair in a young woman, more than is cosmetically acceptable in a certain culture. The condition commonly refers to an increase in length and coarseness of the hair, in a male pattern, including predominantly midline hair of the upper lip, chin, cheeks, inner thighs, lower back, and periareolar, sternal, abdominal, and intergluteal regions. Virilization implies the development of male secondary sexual characteristics in a woman, and may include a deepened voice, increased libido, increased muscle mass, clitoromegaly (>5-mm diameter), temporal balding, and acne. Decreased breast tissue, oligomenorrhea, or amenorrhea may also accompany these physical signs.
Hypertrichosis implies the predominance of excessive vellus hair on the body, particularly the forehead, forearms, and lower legs.
Androgen excess, or hyperandrogenism, results in appearance changes in a young woman and can be associated with abnormal menstrual patterns, infertility, and metabolic disturbances that include decreased high-density lipoprotein cholesterol level, insulin resistance, decreased sex hormone–binding globulin (SHBG), and alterations in the balance between thromboxane and α2-prostacyclin (Haseltine et al., 1994). Polycystic ovary syndrome (PCOS), a common cause of hyperandrogenism, can increase a patient's risks for developing obesity, type 2 diabetes mellitus, and cardiovascular disease (Gordon, 1999; Ehrmann, 2005; Pfeifer, 2005). These young women can also have increased levels of plasminogen-activator inhibitor-1, which inhibits fibrinolysis and is a risk factor for myocardial infarction (Ehrmann et al., 1997).
Androgen disorders must be evaluated, particularly in female adolescents, because appropriate interventions are now available. The evaluation does not require complicated, expensive procedures; and if untreated, the hyperandrogenism will persist and can lead to excess morbidity and psychosocial dysfunction (Trent et al., 2002). It is also important to delineate the etiology of the hyperandrogenism so that an appropriate management plan can be developed around a specific diagnosis (e.g., PCOS and late-onset congenital adrenal hyperplasia).
Hair Physiology
Hair grows from follicles that develop at 8 weeks of gestation. All hair follicles are developed in utero, and no new follicles develop during life. The concentration of hair follicles per unit area of skin is similar in males and females, but differs between races and ethnic groups. Whites have a greater concentration than Asians, and Mediterranean individuals have a greater concentration than those of Nordic descent. Hair grows in cycles according to the following phases:
- Anagen phase: Growing phase
- Catagen phase: Rapid involution phase
- Telogen phase: Resting phase
Hair length is determined by the duration of the growing phase. Factors influencing hair growth include the following:
- Androgens: Androgens initiate hair growth and increase hair diameter and pigmentation. These changes occur secondary to dihydrotestosterone (DHT) conversion of vellus hair to terminal hair. Once hair growth is established, the pattern may continue despite androgen withdrawal, albeit at a slower rate. Once the androgen level is reduced, there may be a lag time of 6 to 9 months before a significant change is noticed, as old terminal hairs fall out and are replaced by new vellus hairs.
- Estrogens: Estrogens retard initiation and the rate of hair growth, and may prolong the anagen phase.
The effects of sex hormones and other factors on hair development and distribution can be more easily understood by considering the pilosebaceous unit (Fig. 58.1). The clinical manifestations of androgen excess vary depending on endorgan sensitivity to androgens, as is shown. Hirsutism can result either from overproduction or increased sensitivity of hair follicles to androgens (Azziz, 2003). Terminal hair growth is stimulated by the increased conversion of testosterone to DHT from excess 5α-reductase within this unit or the presence of more numerous hair follicles.
Androgen Physiology
Androgens are synthesized from the ovary or adrenals from steroidogenic pathways within each gland (Fig. 58.2).
- Circulating androgenic steroids in females
- 17-Ketosteroids (17-KSs)
- Dehydroepiandrosterone sulfate (DHEAS)
- Dehydroepiandrosterone (DHEA)
- Androstenedione
FIGURE 58.1 Effect of ovarian androgens on the pilosebaceous unit. Within the ovarian theca cell, insulin and luteinizing hormone (LH) may stimulate cytochrome P-450c17α activity, resulting in increased 17α-hydroxylase and 17,20-lyase activity, as denoted by asterisks above. These two enzymes comprise the P-450c17α complex. Ovarian testosterone, along with dihydrotestosterone (DHT) from 5α-reductase within the pilosebaceous unit, stimulates the androgen receptors at the hair follicle and sebaceous glands. Hirsutism and acne can result. (From Gordon CM. Menstrual disorders in adolescents: excess androgens and the polycystic ovary syndrome. Pediatr Clin North Am 1999;46:519–543, with permission.)
- 17β-Hydroxysteroids
- Testosterone
- Androstenediol
- 3β-Androstenediol
- Metabolism: Androgens originate in the adrenal gland and ovaries, either through direct secretion or peripheral conversion of precursors (Fig. 58.2). DHEAS, DHEA, and androstenedione, which are mainly produced in the adrenal gland, exert their androgenic activity after peripheral conversion to testosterone or its metabolites.
FIGURE 58.2 Sources of androgens in women. DHEA, dehydroepiandrosterone; DHEAS, dehydroepiandrosterone sulfate. (From Emans SJ. Androgen abnormalities in the adolescent girl. In: Pediatric and adolescent gynecology, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005:301, with permission.)
- Adrenal: Androgens are by-products of cortisol synthesis (Fig. 58.3).
- 17-KSs: Most of the 17-KSs are generated from adrenal sources. This includes a daily secretion of 7 mg of DHEAS (90% of total daily secretion), 5.5 mg of DHEA, and 1.8 mg of androstenedione (50% of total daily secretion). All of these compounds have low androgenic activity because they are precursors of testosterone.
- Testosterone: Twenty-five percent is derived from adrenal secretion, or a total of 0.06 mg/day is secreted from the adrenal gland. Testosterone is a potent androgen, although the most potent androgen is DHT, formed after conversion by 5α-reductase.
- Ovarian: Androgens from the ovary are metabolized as intermediates in the production of estrogen and progesterone. Androgenic hormones secreted by the ovary include the following (Fig. 58.2):
- Testosterone: Approximately 25% of total daily secretion (0.06 mg/day)
- Androstenedione: Approximately 50% of total daily secretion (1.7 mg/day)
- Peripheral conversion: Approximately 50% of testosterone is derived from peripheral conversion of androstenedione in liver, fat, and skin cells.
- Testosterone is 95.5% bound to SHBG in females; only the free portion is active. During pregnancy, approximately 99% is bound. In healthy males, 92.8% of testosterone is bound.
FIGURE 58.3 Major pathways of steroid biosynthesis. 21-OH, 21-hydroxylase; 11β-OH, 11β-hydroxylase; 18-OH, 18-hydroxylase; 3β-HSD, 3β-hydroxysteroid dehydrogenase; 17β-HSD, 17β-hydroxysteroid dehydrogenase (17-ketosteroid reductase); 17β-OH, 17-β hydroxylase; C-17,20 lyase also termed 17,20 desmolase. (From: Emans SJ. Androgen abnormalities in the adolescent girl. In: Pediatric and adolescent gynecology, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005:312, with permission.)
Differential Diagnosis
The relative prevalence of hirsutism is presented in Table 58.1 (Curran et al., 2005), with data obtained from an original sample of more than 1,000 women (Azziz et al., 2004). Note that PCOS is the most common cause of androgen excess and one of the most common endocrine abnormalities in female adolescents and young women.
- Idiopathic hirsutism: As the pathophysiology behind specific causes of hyperandrogenism is better delineated, the percentage of hirsute women with idiopathic hirsutism has continued to fall. This diagnosis represents between 4% and 15% of hirsute women (Azziz, 2003; Curran et al., 2005).
- Ovarian causes
- PCOS or functional ovarian hyperandrogenism (see Chapter 52), with or without insulin resistance
- Tumor: Sertoli-Leydig cell tumor, lipoid cell tumor, hilar cell tumor
- Pregnancy: Luteoma
- Adrenal causes
- Congenital adrenal hyperplasia: 21-hydroxylase or 11-hydroxylase deficiency, classic or nonclassic, late onset
- Tumors: Adenomas and carcinomas
- Cushing syndrome
- Nonandrogenic causes of hirsutism
- Genetic: Racial, familial
- Physiological: Pregnancy, puberty, postmenopausal
- Endocrine: Hypothyroidism, acromegaly
- Porphyria
- Hamartomas
- Drug-induced: Drugs that cause hirsutism by increasing androgenic activity include testosterone, DHEAS, danazol, corticotropin, high-dose corticosteroids, metyrapone, phenothiazine derivatives, anabolic steroids, androgenic progestin, and acetazolamide. Nonandrogenic drugs that can cause hirsutism include cyclosporine, phenytoin, diazoxide, triamterene-hydrochlorothiazide, minoxidil, hexachlorobenzene, penicillamine and psoralens, and minoxidil. Valproate is also associated with menstrual disturbances and hyperandrogenism (Isojarvi et al., 1993).
- Central nervous system lesions: Multiple sclerosis, encephalitis
- Congenital lesions: Hurler syndrome, de Lange syndrome
Indications for Evaluation
- Rapid onset of signs and symptoms
- Virilization
- Onset of hirsutism or virilism that is not peripubertal
- Symptoms suggesting Cushing syndrome (e.g., weight gain, weakness, or hypertension)
Consider hyperandrogenism in any female with premature pubarche, severe acne, hirsutism, or androgenetic alopecia. Girls with premature pubarche are at higher risk to develop PCOS and metabolic syndrome during adolescence (Ibanez et al., 2000). Insulin resistance can accompany the clinical picture with the potential to alter lipid profiles and glucose.
- Menstrual history, evaluating for amenorrhea or oligomenorrhea
- Drug history
- Ethnic background and family history of hirsutism, irregular menses, infertility, miscarriages, type 2 diabetes mellitus
- Rapidity of androgenizing or virilizing symptoms and signs: Most women with an androgen-producing ovarian or adrenal tumor have rapid onset of virilization.
Physical Examination
- Extent of hirsutism: Grading systems are available that enable a clinician to quantitate the degree of hirsutism in a patient. One method is illustrated and discussed by Hatch et al. (1981), based on grading the nine areas of the body from 1 to 4. The Ferriman-Gallwey hirsutism scoring system (Ferriman and Gallwey, 1961) is another frequently used system that enables clinicians to quantify the extent of hirsutism by circling an individual's appearance on a flow sheet and recording the total score on the patient's chart. These scores can be helpful for making comparative assessments between visits and for appraising the efficacy of a particular therapy. Some terminal hair on the lower abdomen, face, and around the areola is normal, but hair on the upper back, shoulders, sternum, and upper abdomen suggests more marked androgen activity.
- Stigmata of Cushing syndrome (e.g., truncal obesity, striae, posterior fat pad)
- Signs of virilization: Check clitoral diameter or index. A clitoral diameter >5 mm is abnormal and is a measurement that can be easily followed up. The clitoral index is the product of the vertical and horizontal dimensions of the glans. The normal range is 9 to 35 mm2; a clitoral index >100 mm2suggests a serious underlying disorder.
- Presence of ovarian or adrenal masses.
- Evidence of insulin resistance (e.g., acanthosis nigricans, as is seen in patients with PCOS).
Laboratory Evaluation
The goals of the laboratory evaluation include demonstrating androgen excess and locating the source of the excess.
- Measuring androgen excess
- Plasma testosterone is the most important measurement, although this is a subject of debate in the diagnostic work-up of these patients. Levels >150 to 200 ng/dL suggest significant hyperandrogenism and potentially, severe disease.
- Other important indicators
- DHEAS: Levels >700 µg/dL suggest significant adrenal androgen production. An adrenal tumor must be ruled out. Rarely, PCOS, congenital adrenal hyperplasia, or an ovarian tumor will result in levels this high.
- 17-Hydroxyprogesterone (17-OHP): This hormone should only be measured in the morning (ideally between 7 and 9 a.m.). This is characteristically elevated in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. One can also measure 11-deoxycortisol in the morning to rule out 11-hydroxylase deficiency.
- Free testosterone: Free testosterone may be elevated in the presence of normal total testosterone. However, free testosterone will be elevated in the presence of hirsutism, so it is not a specific test. Total testosterone tests are less expensive and may be sufficient to point the diagnosis toward an ovarian cause.
- 17-KS: This is a nonspecific test, because some 17-KSs are nonandrogenic and the potent 17β-hydroxysteroids are not measured.
- If the teen has either amenorrhea or oligomenorrhea, prolactin and thyroid-stimulating hormone should be measured and a pregnancy test performed.
Overall, in most individuals minimal laboratory testing is necessary because of the complete response to combination oral contraceptives, with or without spironolactone. This includes a total testosterone determination to eliminate the rare individual with a testosterone-secreting tumor. A baseline early morning level of 17-OHP is useful. DHEAS is also usually measured, but in many instances, a moderate increase is found in women with anovulation who have no adrenal disease.
- Locating the source of androgen excess
- If male levels of testosterone are obtained or a mass is felt on examination, perform an ultrasonography or computed tomography (CT) scan of adrenal glands and ovaries. Markedly elevated serum testosterone and DHEAS levels suggest an adrenal tumor and the need for a CT scan, whereas markedly elevated serum testosterone and normal DHEAS levels suggest an ovarian source and the need for ultrasonography of the ovaries.
- If any of the androgens' levels are elevated or signs suggest hypercortisolism, perform a dexamethasone suppression test.
- An ovarian source is suggested by cortisol suppression, but a lack of androgen suppression. An ultrasonography of the ovaries is helpful in this instance.
- Both adrenogenital syndrome and idiopathic hirsutism are suggested by suppression of cortisol and androgens after dexamethasone administration.
- Cushing syndrome or an adrenal tumor is suggested by lack of cortisol suppression.
Indicators of suppression after dexamethasone (0.5 mg q.i.d. for 5 to 7 days)
- –Free testosterone level <8 pg/mL
- –Total testosterone level <58 ng/dL
- –Free plasma 17β-hydroxysteroid level <42 pg/mL
- –Decrease in DHEAS level of at least 50%
- If 17-OHP level is elevated, perform an adrenocorticotropic hormone (ACTH) stimulation test. This is helpful in differentiating normal and idiopathic hirsute females from those with late-onset congenital adrenal hyperplasia due to incomplete 21-hydroxylase deficiency.
To perform the test measure a baseline 17-OHP and repeat a serum level 60 minutes after 0.25 mg of ACTH is administered intravenously. In a positive result, there is an increase in the serum level to >30 ng/mL, whereas in normal or idiopathic hirsute females, the levels are usually <5 ng/m This test can also be used to rule out less common forms of late-onset congenital adrenal hyperplasia due to 11-hydroxylase or 3β-hydroxysteroid dehydrogenase deficiency.
- Specific diagnoses
- Idiopathic hirsutism: These women generally ovulate regularly and have normal levels of androgens. 5α-reductase activity in the skin and follicle appears to be overactive in these young women, leading to hirsutism in the face of normal androgen (Azziz, 2003). The definitive underlying mechanism remains to be identified, with the following other possible causes of androgen excess:
- Altered gonadotropin secretory patterns
- Exaggerated adrenal androgen secretion
- Increased prolactin levels, augmenting adrenal androgen secretion
- Alteration of SHBG (decreased SHBG level, resulting in mild elevation of free testosterone level)
- Obesity
- Hyperinsulinism
- Ovarian tumors
- Palpable adnexal mass
- Testosterone level >200 ng/mL
- Nonsuppression of androgens after dexamethasone
- PCOS or functional ovarian hyperandrogenism (see Chapter 52)
- Hirsutism, infertility, menstrual irregularities, obesity
- Elevations in androgen levels (free and/or total testosterone; 50% or more may also have an elevated DHEAS level)
- Increase in luteinizing hormone (LH) level and LH: follicle stimulating hormone (FSH) ratio. LH and FSH have been suggested as markers for PCOS
with a high LH and low-normal FSH level (ratio >3:1), but this test is neither sensitive nor specific, because only approximately 50% of patients with PCOS exhibit these abnormalities.
- Adolescent girls with severe acne: High incidence of PCOS
- Congenital adrenal hyperplasia: Elevated 17-OHP, with large increase after ACTH administration is diagnostic of incomplete 21-hydroxylase deficiency. This condition is often recognized during adolescence with presentation similar to PCOS syndrome. Elevated 11-deoxycortisol or DHEAS and 17-hydroxypregnenolone levels are found in 11-hydroxylase and 3β-hydroxysteroid dehydrogenase deficiencies.
- Adrenal tumors
- Androgen-secreting tumors: Rare and associated with rapid defeminization
- Adrenal mass: Palpable in many individuals
- Elevated 17-KS, DHEAS, and DHEA levels
- Subnormal suppression with dexamethasone administration
- Mass on ultrasonography, intravenous pyelogram, or CT scan
- Drug-induced hirsutism: The cause of nonandrogen drug-induced hirsutism is not well understood. The pattern is not restricted to androgen-dependent areas, and the hair is usually vellus in nature.
- Anabolic steroid abuse
- Hyperandrogenic insulin-resistant acanthosis nigricans (HAIR-AN) syndrome: This includes the following characteristic features: hyper androgenism, insulin resistance, andacanthosis nigricans. This syndrome may lead to the clinical and metabolic features of PCOS, as well as myocardial hypertrophy. Insulin receptor mutations, circulating antibodies to the insulin receptor, and postreceptor signaling defects have been described in variants of this syndrome. These individuals have fasting basal insulin levels of >80 µU/mL compared with reference-range levels of approximately 7 to 8 µU/mL, as well as peaks of >1,000 µU/mL compared with approximately 60 µU/mL in healthy individuals.
- Tumor: Remove the androgen source
- Drug-induced: Stop medication
- Congenital adrenal hyperplasia: Replace cortisol and suppressive adrenal androgen precursors with oral hydrocortisone or prednisone. In rare instances, use low-dose dexamethasone (0.25 mg q.d.). Oral contraceptives may also be used to regulate menstrual bleeding and provide contraception.
- Functional ovarian hyperandrogenism (e.g., PCOS): Multi-faceted treatment directed at individual problems (e.g., hirsutism, menstrual irregularity, insulin resistance, hyperlipidemia, obesity)
- Specific therapies (hyperandrogenism)
- Hirsutism
- Cosmetic approaches: Standard treatments include camouflaging with heavy make-up, bleaching, and removal with physical methods such as rubbing, cutting, shaving, plucking, or waxing. Chemical depilatories are designed to use on specific body locations. Most of these methods last from hours to days. Electrolysis or thermodestruction of the hair follicle retards regrowth for days to weeks and can permanently remove hair. Electrolysis can be expensive, time-consuming, and uncomfortable. Photothermodestruction with a laser is a new hair-removal technique. It is expensive but can offer long periods between regrowth and can lead to permanent hair loss. All of these methods can cause skin irritation, folliculitis, and pigment abnormalities.
- Topical therapy: Eflornithine hydrochloride 13.9% cream has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of unwanted facial hair. The agent is an irreversible inhibitor of L-ornithine decarboxylase, an enzyme that is important in controlling hair growth and proliferation. The agent slows and miniaturizes hairs that are present. Side effects are mild, including rash and stinging, and occur in <10% of patients (Balfour and McClellan, 2001).
- Weight loss: Weight loss in obese girls with PCOS and hirsutism can reduce hirsutism. Weight loss reduces insulin resistance and therefore insulin levels, thereby reducing testosterone secretion.
- Estrogen/progestins: Oral contraceptives work in 60% to 100% of hirsute girls. Medical therapy is slow and requires 6 to 12 months before physical changes are evident. Lag time occurs because of the delay before terminal hair falls out and is replaced by thinner less-pigmented hair. Combination pills that contain low androgenic progestins, such as norethindrone or norgestimate, are optimally used. Oral contraceptives also provide contraception for women who are on other antiandrogenic medications that may be teratogenic. Combinations of oral contraceptives and antiandrogenic medications may enhance therapeutic effectiveness and prolong remission. A new estroprogestinic preparation is available containing the antimineralocorticoid progestin drospirenone and 30-µg ethinyl estradiol. In one study, hirsutism improved from the 6th cycle onward (Guido, 2004). All oral contraceptives decrease androgen production in the following ways:
- –Lowering LH levels, thus decreasing androgen production
- –Increasing SHBG, thereby lowering free androgens
- –Decreasing adrenal androgen production
- –Decreasing 5α-reductase activity
The above is an off-label use of oral contraceptives.
- Antiandrogenic agents: Antiandrogenic agents include drugs that block androgen cytochrome P-450 receptors, resulting in decreased testosterone, DHT, and DHEAS levels; and drugs that inhibit 5α-reductase, reducing conversion of testosterone to DHT. Spironolactone and cyproterone acetate (investigational) have been used. Spironolactone works primarily by competing at the androgen receptor peripherally, and also inhibits 5α-reductase. The starting dose is usually 50 mg/day and is typically effective between approximately 75 and 200 mg/day. The medication can be increased by 25 mg every 1 to 2 weeks. However, the maximal response is not seen for 6 months to 1 year. Side effects are minimal but can include dry mouth,
diuresis, fatigue, and menstrual spotting, and hyperkalemia on laboratory evaluation. The drug is contraindicated during pregnancy, because it can lead to feminization of the male fetus. Therefore, an oral contraceptive should be prescribed simultaneously. In Europe, flutamide (a nonsteroidal antiandrogen) and 5α-reductase inhibitors (such as finasteride) have been used, but reports of severe hepatotoxicity prohibit its use in teenagers.
- Combination therapy: The combination of low-dose oral contraceptives and spironolactone is very effective.
- Future directions: Therapies will probably include more widespread use of insulin-sensitizing agents, inhibitors of the enzyme 5α-reductase, and long-acting gonadotropin-releasing hormone (GnRH) agonists. The efficacy of insulin-sensitizing agents (e.g., metformin) in patients with PCOS is an area of intensive research, and efficacy and safety data from adolescent studies to date have been encouraging (Arslanian et al., 2002). One study of women showed effective treatment of moderate to severe hirsutism after 12 months of metformin (Harborne, et al., 2003). GnRH agonists are alternative agents for patients with PCOS, but should be reserved for severe cases of hyperandrogenism, because they are fraught with adverse side effects. Carr et al. (1995) compared the use of oral contraceptives alone, GnRH agonists alone, or the two in combination. They found that by 6 months, measurements of hirsutism were not different between the groups. GnRH agonists alone had a negative impact on bone density. For this reason, GnRH agonists are used only rarely in young women with PCOS.
- Menstrual abnormality
- Cyclic progestin
- Combined oral contraceptives
- Infertility (referral to infertility specialist)
- Clomiphene citrate
- Dexamethasone
- Human chorionic gonadotropin
- Insulin-sensitizing agents plus/minus clomiphene citrate (their use in adolescents is currently experimental
Web Sites
For Teenagers and Parents
http://www.obgyn.net/pcos/articles/hairissue_article.htm. OB-GYN net handout on hirsutism.
http://www.pcosupport.org. PCOS Association Web site includes facts and figures on PCOS, as well as on-line support.
http://www.obgyn.net/pcos/pcos.asp. PCOS Pavilion.
http://www.pcosupport.org/proteen. PCO Teenlist home page is dedicated to teenagers with PCOS. Includes a chat room and bulletin board so teens can share their thoughts on the disease.
http://www.noah-health.org/en/endocrine/endocrine/hirsutism.html. New York On-line Access to Health list of resources for hirsutism information.
http://www.hormone.org/Public/polycystic.cfm. A helpful overview of PCOS, including treatment options. Developed by the professional organization, The Endocrine Society.
http://www.youngwomenshealth.org/pcosinfo.html. A teen-friendly Web site developed at Children's Hospital Boston that is written using terminology that adolescents can easily understand.
For Health Professionals
http://www.postgradmed.com/issues/2000/06_00/bergfeld.htm. Postgraduate Medicine symposium on hirsutism.
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Rosenfield RI, Lucky AW. Acne, hirsutism, and alopecia in adolescent girls. Clinical expressions of androgen excess. Endocrinol Metab Clin North Am 1993;22:507.
Sane K, Pescovitz OH. The clitoral index: a determination of clitoral size in normal girls and girls with abnormal sexual development. J Pediatr 1992;120:265.
Trent ME, Rich M, Austin SB, et al. Quality of life in girls with polycystic ovary syndrome. Arch Pediatr Adolesc Med 2002;156:556.
Vetr M, Sobek A. Low dose spironolactone in the treatment of female hyperandrogenemia and hirsutism. Acta Univ Palacki Olomuc Fac Med 1993;135:55.
Wild RA. Obesity lipids, cardiovascular risk, and androgen excess. Am J Med 1995;98:275.
Wild RA, Demers LM, Applebaum-Bowden D, et al. Hirsutism: metabolic effects of two commonly used oral contraceptives and spironolactone. Contraception 1991;44:113.


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Gut bacteria may play a preventive role in #MultipleSclerosis, according to new research. https://t.co/GwC2qvz
October 2016—Excessive Daytime Sleepiness Associated with Migraine
A new study has confirmed the link between excessive daytime sleepiness (EDS) and migraine. Investigating the prevalen…
October 2016—Emerging insights in the realm of sleep are shaping new understandings of neurological diseases.
October 2016—An emerging theory suggests possible new directions in harnessing the unique ability of REM sleep to prevent seizures.
October 2016—A Q&A with Alberto Rafael Ramos, MD and Clinton Wright, MD
September 2015—Purpose in life is one of the main components of Quality of Life.
March 2015—Sleep medicine's newest addition has a novel mechanism and an undecided future.
November/December 2014—The biggest news in sleep this year may have been the story that wasn't
June 2014—Understanding the condition and its effects is essential to patient care.
Multiple Sclerosis:Innovations and Advancements
For advertising rates and opportunities:
Wendy Terry
Steve Farrell
National Sales Manager
Launched in January 2002, Practical Neurology strives to enhance quality of care and improve the daily operation of neurology practices. Each month, our experts explain the real-world significance of recent advances in neurologic science and offer step-by-step advice on how to overcome the clinical and business challenges neurologists face. Our straightforward, how-to articles give neurologists tools they can put into practice right away.

subset: commoncrawl


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A Guy Asked To Photoshop His Rainbow Model And The Internet Took Over
We all know the results when a guy asked the internet to photoshop his girlfriend's photo, as he got hilarious responses from people. And here this guy repeated the same mistake by asking the internet to photoshop his model.
He posted a majestic picture of a model in a rainbow swimsuit on Reddit and asked to make it more attractive as he was not satisfied by his editing. We can see what happened next, right here.


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November Restaurant Openings and Closings
Melissa McCart
Though November restaurant openings were not as prolific as earlier this year, a couple of restaurants that made their debut inspired speculation and commentary from readers, in particular Tundra and Tap 42 in Fort Lauderdale and Kapow! Noodle House. Have you visited yet? Let us know your thoughts in the comments. After the jump, this month's openings and closings.
D'Angelo Trattoria
. Delray Beach. (Nov 2)
Boca Burger Bar
. Boca Raton. (Nov 2)
Fort Lauderdale. (Nov 6)
. Fort Lauderdale. (Nov 11)
. Coral Springs. (Nov 15)
Tap 42.
Fort Lauderdale. (Nov 15)
West Palm. (Nov 23)
. West Palm. (Nov 23)
Frankie's Pier 5. Hallandale Beach
Maracas. Fort Lauderdale
On Deck
Tropical Acres. Fort Lauderdale. January
Josef's Table. Boca Raton. December/January
Energy Kitchen. Fort Lauderdale. April
S3. Fort Lauderdale. Mid-2012
Follow Clean Plate Charlie on Facebook and on Twitter: @CleanPlateBPB
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All righty-o, for those of you who read my fanon, firstly, I would like to say
CONGRATULATIONS. You have excellent taste.
Second, I would like to apologise.
If you have been reading the series, you may have noticed that I upload each chapter within a few days of each other. Now, I haven't uploaded chapter 3 yet, and theres a very good reason why. You know my editor? Origin? Well, he doesn't exist anymore. Not as such. He is now User:Omar067. And he is writing the next chapter, which I will be editing. So, I have no idea what it's about. Not really. I'm very excited.
Now, I can't remember if I mentioned that I have asked the Fanon Review Squad to do a review of my story. There will hopefully (fingers crossed) be two reviews by different people, but I can't be certain. If this is the case, then these two reviews will by Omashu Rocks and Mageddon725 on the 14th and 17th of June, respectively. I look forward to the review. I mean, no news is good news, but I don't want good news. Your feedback is the only thing keeping my story from going completely insane.


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I wear skirts and dresses alot, not for any religious reason, just because theyre comfy and pretty haha.
they're not long at all. most of the time mid-thigh length to about an inch above knee length. many times they're mini-length too.
so guys, do you like this or would you prefer girls just wearing shorts and pants? I'm curious.
thanks for all your answers in advance:)
Most Helpful Girl
A male mate of mine said to me "All girls look good in a dress, no matter what they look like!" and it was while we were shopping for his mum. I thought it was so sweet.. that day I was wearing a dress as well. I never used to wear them much but we're female, we're born with curves for a reason so why not show them off at their best? Dresses and skirts are deffinately in style, and can be used for any occasion but pants are good at times as well! Depends on the look your going for.11|00|0
Awww, that's really sweet of him. I've heard that from a couple guys, too.
Yeah he really is a sweetheart :)


text: So I'm sitting here all loaded up with two skids behind my new Ford(don't give me crap). This is my first real load with this truck and I'm anxious to see how she'll do. I have a little over 300 miles to drive tonight to drop them off, hopefully everything goes good.


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Products/Services for Worm Gear Calculation
Gears - (589 companies)...gear is offset, and can best be considered a hybrid between a bevel gear and worm drive. Rack and pinion gears' change rotational movement into translation by the use of an infinite circumference, toothed mechanism. Spur gears transmit power amongst...Show MoreGear TypeNumber of TeethDesign Units
Gear Manufacturing Services - (400 companies)How to Select Gear Manufacturing Services. Worm Gear. Image Credit: Howstuffworks.com Spur Gears. Image Credit: Promark Offroad. Gear manufacturing services design and fabricate gears to customer specifications. They differ in terms of product...Show More
Worms and Worm Gears - (198 companies)Worms and worm gears are gear sets that offer high gear reduction and torque multiplication with a small footprint. A worm drive is a cylindrical gear with a shallow spiral thread that engages the worm gear in a non-intersecting, perpendicular axes...Show More
DC Motors - (1165 companies)...may include spur, planetary, harmonic, worm, or bevel gears. Environmental Considerations. Finally, buyers of DC motors may need to consider environmental conditions or application requirements when sourcing products. Operating temperature should...Show More
AC Motors - (1307 companies)...gearheads include one or more sets of pinion-gear sets, in which one pinion drives one gear. These sets can be stacked or cascaded to achieve higher reduction ratios. Worm -- Worm gearing uses right-angled drives in which a worm drives a wheel coupled...Show More
Metric Gears - (79 companies)Types. Any type of gear can be a metric gear, including: Differential end gears. Gear stock or pinion wire. Hypoid gears. Miter and bevel gear sets. Racks and pinions. Spur gears. Worm drives and worm wheels. Specifications. More than just module...Show More
Herringbone Gears - (40 companies)Herringbone gears, also called double helical gears, are gear sets designed to transmit power through parallel or, less commonly, perpendicular axes. The unique tooth structure of a herringbone gear consists of two adjoining, opposite helixes...Show More
Stepper Motors (rotary) - (417 companies)...gearing. This step mode can, however, affect the motor's repeatability. Specifications. Performance. The key performance specifications for sourcing a stepper motor are voltage, speed, torque, rotor inertia and step angle. Terminal voltage refers...Show More
Hypoid Gears - (42 companies)...are helical, and the pitch surface is best described as a hyperboloid. A hypoid gear can be considered a cross between a bevel gear and a worm drive. A hypoid gear is a style of spiral bevel gear whose main variance is that the mating gears' axes do...Show More
Helical Gears - (192 companies)Helical gears are cylindrilical gears whose teeth are not parallel to the axis of rotation. The teeth are angled and appear as a segment of a helix. Helical gears can transmit power between parallel or right angle axes. Helical gears are cylindrical...Show More
Product News
QTC Metric Worm Gear Pairs These worm gears and worm wheels from Quality Transmission Components - QTC provides over 403 ways to transmit motion at a 90 angle to the shaft as an ideal solution to many power transmission design applications. These hobbed worm gears, identified as the KWG... (worm shafts) and AG... Series (worm wheels) are stocked in 4140 alloy steel for the worms and CAC702 aluminum bronze for the worm wheels. Bore diameters for worm gears range from 4 mm to 250 mm and worm shaft lengths range from 13 mm... (read more)Browse Worms and Worm Gears Datasheets for QTC METRIC GEARS
KHK USA, Inc.
Economical Plastic Worm Gears (DG) Meeting the needs for small and lightweight components. Economical sintered gears and injection-molded gears are offered in fine pitch products. Specifications. Precision grade: KHK W 002 grade 5. Heat treatment: -. Reference section of gear: Normal plane. Surface treatment: -. Gear teeth: Standard full depth. Surface finish: Cut. Normal pressure angle: 20. Datum reference surface for teeth cutting: Bore -0.05, -0.10. Material: Polyacetal. Modifications: Possible (read more)Browse Worms and Worm Gears Datasheets for KHK USA, Inc.
Stock Drive Products & Sterling Instrument - SDP/SI
Custom or Standard Molded Worms & Molded Gears SDP/SI offers a variety of different worms and their mating worm gears both metal and molded. These can be made custom with different numbers of teeth, custom bores, and passivation for stainless steel. SDP/SI consistently provides high quality precision gears, gear assemblies, and mechanisms in quantities for prototype to production for OEM's. We make what others can't. (read more)
Hangzhou Chinabase Machinery Co., Ltd.
WJ Series Worm Gear Speed Reducer WJ series worm-gear speed reducer is new, the appearance is beautiful, small, heavy to output moment, has steady transmission, and has little noise. Can unite with electrical machinery or a stepless derailleur of awl of UD series planet directly, the structure is compact. Worm gear output for hole, user mix incline and exert oneself axle only, too can mix pair incline and exert oneself axle, there is greater flexibility. (read more)Browse Worms and Worm Gears Datasheets for Hangzhou Chinabase Machinery Co., Ltd.
Stock Drive Products & Sterling Instrument - SDP/SI
Metal Right Angle Bevel Gear & Worm Gear Drives Hicksville, NY -- These right angle ratio drives manufactured by Stock Drive Products / Sterling Instrument feature non-corrosive all metal construction for use in a wide variety of instrumentation applications. A total of 6 worm and bevel gear types are stocked. The 3 worm gear types are offered as standard with 5:1, 10:1 and 20:1 ratios. The worm gears are made of bronze and the worm is steel. The 3 brass bevel gear types are offered as standard with 1:1, 2:1 and 3:1 ratios. The housings... (read more)Browse Bevel and Miter Gears Datasheets for Stock Drive Products & Sterling Instrument - SDP/SI
KHK USA, Inc.
Worm Gears Large Speed Reduction w/Small Volume KHK worm gear pairs are offered in many materials, modules, numbers of teeth and reduction ratios. All of the worm wheels that we offer allow for secondary operations such as opening the bore, adding of keyways, adding of tapped holes, and the reduction of the hub diameter to be performed. Most of the worms that we offer allow for secondary operations such as opening the bore, adding of keyways, adding of tapped holes, and the reduction of the hub diameter or shaft diameter to be performed. Our... (read more)Browse Worms and Worm Gears Datasheets for KHK USA, Inc.
Pittsburgh Corning (FOAMGLAS® insulation)
FOAMGLAS® INSULATION Thickness Calculations is buried, in a culvert or on a roof top? These are just a few of the many things that must be considered, and having such a wide range of parameters means that insulation thickness calculations cannot be made reliably without expert assistance. Fortunately, Pittsburgh Corning has developed a unique range of tailored insulation thickness calculation programs, unrivalled in the industry. Estimates of insulation thickness can be made using online tools, but these programs may not take into account... (read more)
DieQua Corporation
Backlash Measurement in Worm Reducers . This is when we suggest some our hybrid solutions that include a gearbox more typically used for standard power transmission applications and an adapter for accepting a servo motor. Especially for lighter duty applications, our Varvel series of worm reducers is a common consideration. It is relatively lower in cost than other gear technologies, has a compact right angle configuration, is shaft mountable and has a unique input coupling and flange system that lends itself to accommodating a variety... (read more)Browse Gearmotors Datasheets for DieQua Corporation
Branham, W.C. Inc.
Series 4 Worm Gearboxes Three model configurations of W.C. Branham Series 4 Right Angle Worm Gearboxes include: Hollow Bore, Single Shaft; Hollow Bores Only; and Hollow Bore, Double Shafts - all in 10:1 and 20:1 ratios. Select models with .625 inch diameter shaft x either .625, .750, 1.00 inch diameter hollow bores. Each model is designed around a 1.333 inch center distance. All models are constructed with double sealed, heavy duty ball bearings and case hardened worm gears. ----------. 8/28/16 --- RECEIVE A 15%... (read more)Browse Gearboxes and Gearheads Datasheets for Branham, W.C. Inc.
Calculation of wing-fuselage-nacelle combinations Product Announcement from IHS ESDU - New. Aerodynamics. ESDU 13009. This methodology describes the construction of input files for the program ESDUpac A1309, which combines the prediction methods of three individual ESDU Data Items (ESDU 76015, ESDU 77012 and ESDU 78013) to evaluate the chordwise position of the aerodynamic centre of wing-fuselage-nacelle combinations at subsonic speeds. The nacelles can be mounted either on pylons below the wings of wing-fuselage combinations of medium-to-high... (read more)Browse Modeling and Simulation Software Datasheets for IHS ESDU
The review of existing theory carried out in Chapter 1 found several different methods for calculating worm gear form and contact position.
Computer-Aided Design, Manufacturing, Modeling and Simulation II
primary geometry parameters, z1 = 1 , z2 = 50 。. calculation worm gear and worm drive efficiency and worm input torque .
Efficiency prediction of worm gear with plastic worm wheel
W. Cheng and W. Tu8 measured the efficiency of a plastic worm gear and calculated the friction coefficient of the worm gear.
Forming a modification involute line of teeth of a cone worm gear drive with conical worm on CNC milling machine
Geometric model of a cone worm gear for calculate position of an edge trace tool independent of line, view cross-section of partition surface .
The effects of load-sensitive behavior on the operability margins of motor-operated gate valves
Histories of the apparent worm gear radius calculated from three tests conducted on the MOVLS.
New Advances in Mechanisms, Transmissions and Applications
Bolotovskaya, T., Bolotovsky, I., Bocharov, G., et al.: Involute and worm gearings geo- metric calculation guide (1962) (in Russian .
Cylindrical worm gear module calculation based on hydrodynamic lubrication .
Springer Handbook of Mechanical Engineering
381 6.5.14 Projection Calculation for Worm Gearings ......................
Contact rigidity of metal-polymer worm transmissions
Hence, in design and check calculations of worm gears with caprolon teeth, it is expedient to use CAE systems based on the finite- element method—in particular, the DEFORM 3D sys- tem.
Robotic endoscope motor module and gearing design
Calculations for worm gearing and efficiency are discussed.


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… Search is traffic. We need traffic. But what's better? More traffic? Better traffic? Both? Confused yet? Grant Simmons, vice president of search marketing at Homes.com, wants us to define "better." Personas are a tool to help in strategy development, tactical execution and measurement of outcomes. They help us inform who we want to reach…


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The Grupotel Los Principes Hotel is on the Muro beach in the centre of the Las Gaviotas area. The hotel guests can access the beach through the attractive hotel gardens. The resort has one of the best beaches on the island and the shops, bars and restaurants are only a short walk away.
Distance from Airport:
40 miles
All have * private bathroom / shower * WC * balcony / terrace * air conditioning * TV * telephone * safety deposit box * (certain amenities may be payable locally)
Transfer time:
90 minutes
Location and Resort:
The hotel has a modern style, inside and out. There are over 200 rooms in this 5 storey property and the nearby beach has a good selection of watersports including sailing and diving.
Eating and Drinking:
There is a restaurant, lobby bar and a lounge bar with a terrace. The hotel also has a small seafront bistro.
Swimming pools:
The hotel has a swimming pool and a children`s pool. There is also a heated and covered swimming pool in April, May and October.
Right choice:
This hotel will appeal to couples and families looking for a convenient position for a holiday in Mallorca with direct beach access and plenty of facilities in and around the property for all ages.
Suitable for:
Couples and Families


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Doctor insights on:
Is Erb Palsy Painful
Is erb palsy painful?
It can be: The nerve damage can result in discomfort. We do occasionally need to treat the children with codeine. Watch http://www.Youtube.Com/watch?V=b68jtv0-teo to learn a little more. ...Read moreSee 1 more doctor answer
Palsy (Definition)
...is a corruption of French "paralise" from Latinized Greek "paralysis." In the old days it meant any kind of persistent weakness. To this day Parkinson's disease is also called "paralysis agitans" which is a Latin translation of Dr. Parkinson's original name for it, the "shaking palsy." We've obviously reborrowed the full form "paralysis" into English as well; today ...Read more
How long is erb palsy treated?
Erb Palsy: It is really based on how severe the palsy is and age at the time its occur. Erb's palsy is most common in infancy and the physical and occupational therapy is given for at least the first two years and often times even longer. In the adult the pt/ot is usually given up to 18 months to two years and in some cases surgical exploration might be recommended. ...Read more
Why do some babies recover from erb palsy while others do not?
Imaging: Cervical mri's can give a better answer as to the extent of cervical injuries. Those that recover tend to have nerves that are stretched and show inflammatiry responses. These tend to recover with physical therapy. A pediatric neurosurgeon can help delineate what is the best therapy. ...Read moreSee 2 more doctor answers
Could erb palsy be cause short-term memory loss?
No relationship: Erb palsy is the result of a stretching and or tearing of the nerves to the arm due to shoulder dystocia. It should not have anything to do with memory difficulty, unless the diagnosis of Erb palsy is confused with an upper extremity diosrde due to brain injury. ...Read moreSee 2 more doctor answers
Can unexplained arm paralysis be caused by erb palsy?
Erb's palsy: This refers to an injury of the upper part of the brachial plexus, which results in problems with the fifth and sixth nerve roots in the neck. Most commonly, this occurs after birth trauma or motorcycle accidents. ...Read more
What are the tests for erb-duchenne paralysis?
Thorough exam first.: A thorough physical and neurological exam is a must; radiological and electrodiagnostic tests may also be needed. ...Read more
My son has erb-duchenne paralysis. Is that something serious?
Most are transient: Occasionally the forces of delivery & position of the head & shoulder during the final moments of delivery put stress on the nerves exiting the neck to supply the shoulder & arm. Swelling around these nerves, will lead to changes in the position & movement of the affected arm in a pattern called erbs palsy.Most cases are transient & resolve in < 48hrs..Some will need therapy if persisting. ...Read moreSee 1 more doctor answer
Is there a way to prevent the symptoms of erb-duchenne paralysis?
Difficult to answer: Erb's palsy (erb-duchenne palsy) is a paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the upper trunk c5-c6 is functionally severed. The best way to prevent the symptoms is to avoid the injury in the first place. ...Read more
What is the treatment for erb-duchenne paralysis?
Lots of PT.: Erb-duchenne paralysis, or neonatal brachial plexus palsy (bpp), usually is treated with extensive physical therapy (including a home regimen) and sometimes electrical muscle stimulation, splinting or taping. ...Read more
How long does treatment for erb duchenne paralysis take?
Erb Palsy Recovery: The treatment time depends on the type of recovery. Most erb's palsies will heal with therapy over 6-12 months. If surgery is required to improve function, the final result may take 2-3 years. Continued rehabilitation may be required for a lifetime if continued deficits are present. ...Read moreSee 1 more doctor answer
Erb Duchenne Paralysis (Definition)
Erb-Duchenne paralysis is a medical condition in which there is paralysis of the arm caused by injury to the nerves responsible for innervation of the arm. These nerves run along the side of the neck and can be damaged during birthing process or traumatic injuries of ...Read more
Paralysis (Definition)
A paralyzed limb cannot be voluntarily moved, and the term reflects leg involvement, paraplegia, full body, quadriplegia, and less than full, tetraplegia. Causes can be many, including stroke, trauma, ...Read more


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Publisher:Scholastic (Orchard)
Publication Month:
Publication Date:2017
2017 Nomination (not yet selected):With his lively art and careful prose, Reynolds creates a dreamer who is quiet, loud, colorful, unique. Not always happy or in step with expectations, his lively child always finds a way back, letting us know "I'm really good at being me". The main character is "unisex" and almost always in motion. While there is clearly a message her, it is an important one and you can't finish this book without feeling good about the character and hopefully yourself. Edie Ching (up to 7)


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- Wei-Ta Fang, Bai-You Cheng, Shang-Shu Shih, Jui-Yu Chou, Marinus L. Otte
- Paddy and Water Environment
- 2015
Farm ponds provide a home for birds and numerous species of aquatic animals in Taoyuan, Taiwan. Urbanization and development of infrastructure resulted in the gradual disappearance of these ponds. Currently, only 3800 ponds originally approximately 15.4 % remain, and 84.6 % of the surface area of the ponds has vanished. Aiming to protect avian diversity,… (More)
- Hwey-Lian Hsieh, Hsing-Juh Lin, Shang-Shu Shih, Chang-Po Chen
- International journal of environmental research…
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The present study examined a mangrove ecosystem in northern Taiwan to determine how the various components of ecosystem function, ecosystem services and human wellbeing are connected. The overall contributions of mangrove services to specific components of human wellbeing were also assessed. A network was developed and evaluated by an expert panel… (More)
Constructed ponds and wetlands are widely used in urban areas for stormwater management, ecological conservation, and pollution treatment. The treatment efficiency of these systems is strongly related to the hydrodynamics and hydraulic residence time. In this study, we developed a physical model and used rhodamine-WT as a tracer to conduct flume… (More)
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Give us a call to get our secret deals 1-800-468-3578
Property Location
Located in Serrekunda, Calabash Residence is by the ocean and convenient to Kololi Beach and Bijilo Forest Park. This apartment is within close proximity of Bijilo Beach and Independence Stadium.
Make yourself at home in one of the 15 air-conditioned rooms featuring kitchens with full-sized refrigerators/freezers and microwaves. Rooms have private balconies. Complimentary wireless Internet access keeps you connected, and satellite programming is available for your entertainment. Conveniences include safes, and housekeeping is provided daily.
Rec, Spa, Premium Amenities
Take in the views from a terrace and a garden and make use of amenities such as gift shops/newsstands. Additional features include a television in the lobby and tour/ticket assistance.
Enjoy a satisfying meal at a restaurant serving guests of Calabash Residence. Quench your thirst with your favorite drink at a bar/lounge.
Business, Other Amenities
Featured amenities include a business center, dry cleaning/laundry services, and multilingual staff.
You must present a photo ID when checking in. Your credit card is charged at the time you book. Bed type and smoking preferences are not guaranteed.Your reservation is prepaid and is guaranteed for late arrival. The total charge includes all room charges and taxes, as well as fees for access and booking. Any incidental charges such as parking, phone calls, and room service will be handled directly between you and the property.


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Dating back to 1609, this charming manor is believed to be the oldest dwelling house in Keynsham Village. It retains period features like oak beams, and offers free Wi-Fi and free parking on site.
You can check in between 14:00 - 21:00. You can check out between 07:30 - 10:30.


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What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
what happens after 1000 views in the free version?Asked by pfeilstein on April 23, 2016 at 01:40 PM
And are alle the testing views from my own IP-adress to be counted as well?
I noticed a strange behaviour: New fields are shown in the builder, but not in my site.
Is there a connection?
To get a better understanding of form views please see this guide here https://www.jotform.com/help/355-Form-View-Limits-What-is-it-all-about.


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The Strange Beauty of Khewra Salt Mines Pakistan
The Khewra Salt Mine (or Mayo Salt Mine) is located in Khewra, north of Pind Dadan Khan,[1] an administrative subdivision ofJhelum District, Punjab, Pakistan. It is Pakistan's largest and oldest salt mine[2] and the world's second largest.[3][4][5] It is a major tourist attraction, drawing up to 250,000 visitors a year.[6][7] Its history dates back to its discovery by Alexander's troops in 320 BC, but it started trading in the Mughal era.[8] The main tunnel at ground level was developed by Dr. H. Warth, a mining engineer, in 1872 during British rule. After independence, the Pakistan Mineral Development Corporation took over the mine, which still remains the largest source of salt in the country, producing more than 350,000 tons per annum[9] of about 99% pure halite.[6] Estimates of the reserves of salt in the mine vary from 82 million tons[10] to 600 million tons.


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You can only message people who are following you. If you'd like to message this person, simply join our Recruiter Pro Plan.
Do you really want to delete project Fishguard on Film?
Do you really want to delete project Abandoned?
Day to day I'm a design engineer craving an escape into a more creative role. I'm currently working on a couple of graphic projects for a few friends whilst looking to find the next big thing. I co-run www.objectbags.com. Please get in touch if you've got an exciting project that I could get involved with!
Key design function required to design and develop high accuracy hand held measurement device, taking product from concept study to full product launch.
Tasked to explore emerging technologies, understand application requirements and undertake competitor analysis to design, test and develop innovative styli products. Manage custom quotation and product change processes. Check design work undertaken by draughtspersons. Mentor graduates and apprentices during placements. Work with customers on application problem solving and developing products for specific high value applications, including aerospace and automotive.
Responsible for producing accurate designs of quotation concepts ready for production. Undertake prototyping and testing of custom iterations of standard product for small volume production runs. Tooling and jig design, development and testing for electrical and mechanical assembly operations.
Modular course placed emphasis on attention to detail and problem solving through individual and teamwork produced coursework, both research and academia based. Main themes of the course included Product Design, Computer Aided Engineering Design, Materials Science, Manufacturing Processes and Industrial Design.
One of three finalists to design platform seating for the new TFL Crossrail railway in London


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Using Contex's Xenforo API http://xenforo.com/community/resources/xenapi-xenforo-rest-api.902/ we can easily add a secondary usergroup when someone purchases an upgrade from our site. However, we would like to also add a User Upgrade in Xenforo so that when the time expires, the user is downgraded and the secondary usergroup is removed.
The requested User Upgrade API should have the same functionality as the Manually Upgrade User within adminCP.
We offer recurring billing, so the API should be able to update an existing User Upgrade to extend the end date.
Finally, the API should allow to Downgrade and active User Upgrade in the same way as can be done in adminCP.
Please get in touch with an estimate of cost, and let me know if you have any questions.
Thank you for reading.


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Narrative essay assignments are a fun way to showcase your personality and past experiences to readers, but when the time comes to write the conclusion, your creativity can come to a grinding halt. Without a good ending, readers will be left confused about your story's significance and be frustrated with its lack of completion. Brainstorming, creativity and reflection can all help you write a conclusion that conveys a powerful message.
Reread your essay draft to get an overview of your narrative's plot. Pay special attention to the way the story begins, noting key images, phrases or ideas that you might be able to incorporate into your conclusion.
Choose a creative approach for your ending. Review the observations you made on your opening and look for a way to echo its elements in the ending. For example, if your essay begins with a memory of spending time with your grandmother in the kitchen, it might end with your preparing a favorite dish she taught you to make. You can also end with an important image from the story, or by reflecting on what your experience taught you.
Write a draft of your conclusion. Don't be too critical of the initial product; just like a complete essay, your ending will need to be revised and reworked. Read the paragraph that comes before the conclusion to come up with a natural transition into your ending.
Read your essay a second time to see how the new conclusion enhances it. The ending is where you show readers why what they've just read matters, writes the University of North Carolina at Chapel Hill Writing Center. Therefore, think about how effectively your ending brings the narrative's events to an end and makes a lasting impression on readers. Show your conclusion to a classmate or teacher to get another opinion on its effectiveness.
Items you will need
- Draft of your essay
- Pen
- Your conclusion may actually be buried somewhere in your essay's final pages. Read through the last few paragraphs to see if one of them naturally brings your story to a close.
- Avoid beginning with the phrase "In conclusion." It's redundant because readers can see from the final paragraph that the essay is drawing to a close. Rather than rely on trite phrases, be creative as you wind your narrative down.
Photo Credits
- Leonard Mc Lane/Digital Vision/Getty Images


text:
Please use this identifier to cite or link to this item:
|The Not So Perilous Sea: An Optimization Model for Fleet Positioning of Liquefied Natural Gas Carriers in Future Energy Commodity Markets
|Fongaard, Tharald
|Kornhauser, Alain
|Operations Research and Financial Engineering
|Class Year:
|The need for energy is constantly increasing in the wake of global demand and population growth. This increase in demand has so far been met with nuclear energy, renewables, and above all, fossil fuels. Economic and human development growth has been particularly aggressive in regions such as India, Southeast Asia and China - all heavily dependent on energy import. As a result, an increasing seaborne fossil fuel transportation gap has to be filled to meet the need for energy. Seaborne fossil fuel transportation growth and trade patterns have remained relatively predictable from the end of the Second World War until the beginning of the 21st century, excluding the 1967-75 Suez Canal closure and the 1973/1979 oil crisis. Over the last decade, however, with increasing production of energy fuels in North America due to the ongoing shale revolution, and erratic production and export levels in several leading OPEC countries such as Libya, Iran and Iraq, as well as increasing energy demand in both Asia and Africa, trade patterns are changing and becoming increasingly complex. From 2003 - 2014, world trade in oil increased from approx. 46 million barrels per day to 56 million barrels per day, or approx. 2% p.a, and liquefied natural gas export increased from approx. 110 million tonnes per annum to 220 million tonnes per annum or approx. 7.2% p.a. In the same period, we experienced a financial crisis, several geopolitical crisis', as well as increasingly unstable oil, gas and coal markets with extreme growth in price differentials across regions. Looking into the future, projections from several leading energy analysts and demographics experts indicate continued ramifications for the global energy market. With the increasing complexity and volume of energy trade, in particular trade of fossil fuels, this thesis attempts to create a robust model to optimize the positioning of hydrocarbon carriers, in particular liquefied natural gas carriers, in global markets. The model is developed from a combination of highly accurate statistics and projections established by leading independent energy consultants on both sides of the Atlantic, as well as stochastic models developed by the author, alumni and faculty at Princeton University.
|197 pages
|Type of Material:
|Princeton University Senior Theses
|Appears in Collections:
|Operations Research and Financial Engineering, 2000-2017
Files in This Item:
|Adobe PDF
|Request a copy
Items in Dataspace are protected by copyright, with all rights reserved, unless otherwise indicated.


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Mila Kunis Finally Acknowledges Pregnancy, Discusses Cravings on 'Ellen'
Mila Kunis stopped by The Ellen DeGeneres Show and confirmed what we've all known for quite some time: she and her fiancé Ashton Kutcher will welcome a baby "some time this year." While the Jupiter Ascending actress remained coy about the baby's gender, she discussed her pregnancy cravings, and how her husband-to-be is helping to satisfy them.
Mila, who met Ashton, 36, when the two starred on That '70s Show, has been mum on her engagement to the Two and a Half Men star until now. She told Ellen, "We were able to keep this private for two months. Two months without anybody knowing. I think everybody assumed we've been engaged for so long that I was wearing the ring in public for two months and … nobody ever commented on a single photograph. They just decided not to acknowledge it for two months. It was amazing."
The Black Swan star told Ellen she has been craving sauerkraut, and of course, pickles. The 30-year-old Ukraine-born actress also revealed that Ashton has been learning her native tongue, Russian, (awww) and she plans on having a natural child birth.
Check out the interview above.
Mila appears on "Ellen's Mother's Day Show," airing today.


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[change region]
You are here:Home >
Solutions >
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Cisco Webinar Recordings >
2015 is an exciting time, as we see many organisations aspire to build upon their employee's soft skills and job related competences, underpinned by business- and technical certifications.
During this webinar, you will get a market place update and explore together with Jeff and Mel industry changes and the future of Cisco education. Furthermore, you will receive information on upcoming new training.
This webinar will include the following elements:
Jeff Wheeldon
Jeff is Global Knowledge's Director of Cisco Business EMEAR. He has worked in the datacomms industry for over 20 years and brings an extensive understanding of Cisco and its markets. Originally trained as a Network Engineer, his focus turned to education and Jeff developed a strong understanding of the Cisco Systems business and the importance of education as the foundation for an evolving technology world.
In a previous job role, Jeff Wheeldon led the market launch of Cisco Systems Voice Over IP solution before joining Global Knowledge in 2007 to manage the UK Cisco Business and qualifying as a Cisco instructor before moving to Global Knowledge's European headquarters to take responsibility for the Cisco Business across EMEAR.
Melanie Jones
Melanie Jones is the Cisco Product Manager for Global Knowledge EMEAR and has been responsible for Global Knowledge's Cisco training portfolio for many years.
Experienced in launching new Cisco Certifications, Melanie is ideally placed to update on the latest additions to the Cisco portfolio.
Technical Requirements:
Internet connection and computer speakers for audio.
Watch the webinar recording


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What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
Preview Before Submit Widget - Does Not Show Photo AdditionsAsked by markashton on June 12, 2014 at 11:41 AM
Ok, this may not be possible ... but it is the reason I cannot use it.
A lot of my forms have users adding photos. if they cannot review the photos they have added then unfortunately it is not much use i.e. its purpose is incomplete.
The photo fields are not even shown?
I do not see them even being referenced....
JotForm Support
Hi Mark,
Great idea. I actually think about that too and I think the image preview is a good addition. Though, I think it's a little complicated since when you use single file upload tool, the file won't be uploaded without getting the form to be submitted so I'm not sure how it's possible to preview the image. Maybe or unless you're using multiple file upload.
By the way, single file upload actually shows the file name as text on the review page, FYI.
Anyway, we'll see if this is possible with this widget. I have raised your request to our developers for a review.
They will surely reply here once the feature has been added or if there's any complexity on implementing this in the said widget.
What did the developers think? i.e. Nicholas Westley
Thanks Mark
I'm also agree with this feature !
JotForm Support
Hi Mark,
Our developer Nicholas have not provided any update on the status of this yet.
I'll let him now also of your latest message.
@ Wtfuck
We have taken note of your agreement on the feature.
Perhaps if you have more details to add, you can create a separate thread about it here also.
If Wtfuck has extra details to add I'd like to know about them ... and would like them on this thread. It's ridiculous to suggest he creates a different thread for the same issue.
How do any of us know who is contributing what if people are all creating their own threads.
thanks Mark
JotForm Support
Hi Mark,
The submitted ticket about this thread was a feature request not a bug or issue.
If more similar tickets will be submitted from different post about a feature requested, it will eventually be more convincing that the feature is needed or important.
I apologize if I was not clear about it the previous time around.


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Home Product Directory Manufacturing & Processing Machinery Agricultural Machinery Other Agricultural Machinery
Goat Manure Organic Fertilizer Production Line
|FOB Price:
|US $10,000-99,999 / Piece
|Min. Order:
|1 Piece
|Min. Order
|FOB Price
|1 Piece
|US $10,000-99,999/ Piece
|Production Capacity:
|Transport Package:
|Wooden Case
|Payment Terms:
Basic Info
Product Description
- Model NO.: EF
- Guaranteed: 12months
- Origin: Zhengzhou, Henan Province, China
- Condition: New
- Trademark: Easy Farming
- HS Code: 8479820090


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What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
How can edit mobile number field width in feedback form?Asked by carplus on May 30, 2016 at 03:28 AM
JotForm Support
You can change the width of your text box field as you see below:
If you have any question or issues, please do not hesitate contacting us. We will be glad to assist you.


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About the Book
197 x 248 mm ed:open
In 2007 I took part in the Regenerator project- available at www.bookarts.uwe.ac.uk/regen/regener8.htm, I received a book called 'Exhibition Design', as an altered book it became 'Ex Design' and was swopped with another book artist. I made a further artist's book 'Exhibits Unseen' for we love your books ABC exhibition in 2007, but I had more images I wanted to record. 'Ex' brings the project to closure.
Features & Details
- Category Arts & Photography
Standard Portrait, 8×10 in, 20×25 cm
70 Pages
- Publish Date May 23, 2009
- Tags artist's book, altered book. art, graphic design, book arts, collage
About the Creator
Melanie Bush is a UK book artist, previously having been a senior lecturer in graphic design and illustration at the University of Northampton and a packaging designer in London. She is co-founder of Book Arts collaborative 'we love you books', which holds annual exhibitions in the UK of experimental international artists' books. Melanie has had her books exhibited and acquired for collections both nationally and internationally
Log in or create an account to post a comment.


text:
What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
form quotaAsked by crystald on August 31, 2016 at 08:05 AMReceived an error message for a form- what does this mean and how do we fix it?Page URL:This form has exceeded its allocated quota
JotForm Support
I checked your account and it seems to be active. I also see that you currently have no form in your account, except those that are shared to you.
Based on this thread - https://support.jotform.com/answers/921093 - that you opened, you have already deleted your submissions but you now have issues with your forms being lost. We will attend to your issue on that thread.


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A former Mississippi circuit clerk says that transparency is lacking in the Magnolia State's civil asset forfeiture system.
Angie McGinnis, who was the circuit clerk for Oktibbeha County for 16 years and retired in 2011, told Mississippi Watchdog that there is no accountability on forfeited funds and property and no way for an auditor to track the property and its disposition through court records.
Law enforcement agencies are not legally required to keep records of forfeitures, something that would change under a bill awaiting Gov. Phil Bryant's signature. It would require law enforcement agencies to keep records of their forfeitures and submit them to the Mississippi Bureau of Narcotics, which would build a website to track all forfeitures.
But the legislation wouldn't change any of the procedural elements of the forfeiture process, and also wouldn't guarantee that the Legislature will appropriate the money necessary to build and maintain the database.
"This will keep the honest officers out there honest about inventorying the stuff and giving that list to the district attorney for forfeiture of those items," McGinnis said. "It's more a procedural bill for the agencies than anything. In my experience, you're going to have to provide some funds for a venture like this, because money doesn't just magically appear."
According to Mississippi law, the only requirement for a law enforcement agency to seize property is to connect property to a crime, even if there is no conviction on the owner. Those whose property is seized have to prove in a civil court that their property was not involved with a crime.
RELATED: Mississippi Senate passes civil asset forfeiture reform
A Mississippi circuit clerk keeps court records, tracks money from fines and court costs, and maintains the voter rolls as registrar, among other duties.
In cases of civil asset forfeiture, the paper trail is scant.
"There'd be two sheets of paper, a petition (by the district attorney) for forfeiture and there may or may not be an order forfeiting it," McGinnis said. "That's it. That's really not much to go on in those particular cases."
She noticed a trend as she maintained the Oktibbeha County Circuit Court docket. Starting in the mid-1990s, there would be many cases of the state of Mississippi vs. a dollar amount. Or a car, down to the year, make and model, she said.
A recent analysis by Mississippi Watchdog of electronic court records shows that little has changed.
Property owners are given 30 days to file an answer requesting the return of their seized property, which is done through a civil proceeding. Under state law, if a property owner doesn't file a motion, the court hears evidence on whether the property is subject to forfeiture.
While a criminal conviction in Mississippi requires proof beyond a reasonable doubt, civil asset forfeiture requires only a preponderance of evidence, a lower standard.
The bill awaiting Bryant's signature would also establish:
- A new warrant system that would require a county or circuit judge to issue a civil seizure warrant within 72 hours, excluding weekends and holidays. The law enforcement agency would have to tell the judge what was taken and why it was seized, and explain to the judge the probable cause to justify the seizure. If the judge didn't issue a seizure warrant, the property would be returned.
- A requirement that the local district attorney or the Bureau of Narcotics prosecute all forfeitures, which would eliminate outside counsel from being hired by law enforcement agencies.
Steve Wilson reports for Mississippi Watchdog. Contact him at [email protected] and on Twitter.


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Question: Assume that your organization wants to retain senior employees who
Assume that your organization wants to retain senior employees who might otherwise want to retire. What incentives and other retention techniques should you use to keep these valued employees? Explain.
View Solution:
View Solution:
Answer to relevant QuestionsWhy are skills inventories important to an organization? Explain. Explain the difference between competency modeling and job analysis? Why do some companies prefer to use competency modeling? What guidelines should be followed to make sure that recruitment advertising does not violate equal employment laws? 1. Why is there a need for companies to offer work-family balance programs, such as flextime, telecommuting and job sharing? 2. Some organizations do not believe in offering work-life balance programs. What do you think ...What is the Employee Polygraph Protection Act? What alternatives to polygraphs are organizations using? Are these alternatives effective?
Post your question


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These documents examine the economic characteristics and workplace role and function of the Camden Council Local Government Area (LGA) in the state of New South Wales.
Understanding the economic and demographic processes that exist within the Camden LGA provides a framework for understanding what role the industries and workforce of the area play in the context of the Macarthur area and the Greater Sydney region.
The Camden Economic Key Findings Reports are intended to guide economic development in understanding what policy responses to put in place to enhance the local economy:


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God Dragon by DavidAlvarezArtWatch
©2012-2017 DavidAlvarezArt
Illustrations for "Lord of the Dragons"
Copyright Klab Global Pte. Ltd.
Copyright Klab Global Pte. Ltd.
Hi! I wanted to know if I could use this piece of art for an RP I will be making on a SIM game called Lioden. I will be giving you full credit for the piece of work, I will put an attachment on the photo that will lead to your DA account that you can click. I love the dragon...It's so beautiful by the way
You are one of those who managed to grasp what a dragon should be: a phisical god.
Been looking at a lot of dragons on deviant art.This is the first to be favorized! i honestly cant find one little thing i dont like about it. It is thought through and really skillfully made. It is not a picture of a dragon to me but a window to another world with its own story. thank you for sharing
sorry-bad english.
sorry-bad english.
What a beautiful Guardian Dragon! ♥ Literally great defender!
Then why is he on earth......................*gasps* HAS HE COME TO BRING US THE GOOD NEWS?!?!?!?!?!
Pfft, it's only a model...
This piece is so epic!
Oh how great is this dragon's appetite? Lol.......
Just, waw...
Just, waw...
I feel like he needs to be bigger if he is going to be a god. Like one foot could crush that Kingdom.
Still pretty awesome picture.
Still pretty awesome picture.
Wow, this guy is immense.
Just a big target. Now,go get the 20-inch Battleship Railguns!
Why stop there? I'll fetch a UNSC Mark V super-MAC. Let see how well a living mountain takes a 3000 ton ferric-tungsten round at 12,000 kilometres per second!
...Wait, why do we want to kill him, again?
Dragon: [Towering over us, his head alone the size of an aircraft carrier] "I'd like to know that myself, gentlemen...."
...Wait, why do we want to kill him, again?
Dragon: [Towering over us, his head alone the size of an aircraft carrier] "I'd like to know that myself, gentlemen...."
"Emm... it's purely theoretical?"
Dragon: [Cocks head, snorting smoke out his nostrils] "...Truly? Well, I suppose you wouldn't discuss ways of slaying me within earshot if you actually planned on doing it...and what's the harm with humans engaging in some idle speculation, hmm? Carry on, gents. Oh, and some of my brood may be coming soon; I'd suggest hiding and keeping your talk quiet. My daughter finds humans; well, adorable. I'd rather save you two the humiliation of having a fire-breathing dragoness who could swallow a whale whole coo over you and...nuzzle you like a schoolgirl with a new kitten."
Very well done!
so thats the dragon that torched Harranhall
You know, I hate leaving one word comments. But there's really no other way to say how good this is besides "Wicked Cool"
Humongously awesome!
The only true god for me.
Completely amazing!
beautiful. incredible detail, angles and setting! love it!
Amazing work!
Congrats :3
Congrats :3
I <3 it *.*


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Our Guesthouse Service:
We're very happy to announce that Riviera Fashion House [RFH] is offering free accommodation for our visiting foreign buyers in Bangladesh. Our buyers will get following facilities in fully free of cost:
> Full furnished & decorated room with attached bathroom & balcony
> 24 hrs Wi-Fi internet connectivity
> Safe locker for hard cash or other valuable things
> 23 Inch LED TV with satellite cable connection
> Tea, Coffee, Cigarette on demand
> 24 hrs support stuff
> Airport pickup & drop
> Necessary factory visit
> Local shopping support
> 100% guarantee of safety & security
> Friendly business environment
> Nearby Pizza Hut, KFC, Chinese, Turkish, Indian, Pakistani & Bengali restaurants.
About us [Riviera Fashion House/RFH]:
RFH is a government registered buying house for readymade garments export. We're dealing with all kinds of knit & woven overruns / stock lots / canceled...


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Liam Gallagher saved by girlfriend
Liam Gallagher's girlfriend "saved" him.
The former Oasis frontman began dating Debbie Gwyther after his marriage to Nicole Appleton broke down in August 2013 when it emerged he'd fathered a child with another woman, and he credits his lover for expanding his world beyond his local neighbourhood.
He said: "Debbie saved me. No bulls**t. Debbie swooped me up as I was falling, she just said, 'Stop being a d**khead.' She got me out of the house, introduced me to all kinds of people outside my world, got me doing new things. I've lived in London a long time, but I only really knew Hampstead. She took me to new places. I've been to Dalston, man."
Following the breakdown of his marriage and the demise of his band Beady Eye, 43-year-old Liam - who has four children from past relationships - admits the last few years have been "emotional".
He told Q magazine: "These last few years have been emotional. Eye-opening. Mind-bending. But emotional."
Liam lives close to a number of other famous people, comparing the area to satirical comedy series 'Stella Street', and once got told off for bothering chef Jamie Oliver and begging him for breakfast.
He admitted: "It's like 'Stella Street', round here: Jamie Oliver lives up the road. I got told off for throwing stones at his windows p***ed-up, asking him to chuck down some bacon rolls."
Despite his legendary partying, the 'Live Forever' hitmaker tends to lead a much healthier lifestyle these days - most of the time.
He said: "I run around seven miles every day, leaving about 5am. Unless I've been out on the sauce, then I'm getting in at 5am. Normally, though, seven miles.
"Climb the odd tree too. Climbed one the other day. I was running on the Heath and I thought, 'That looks like a nice tree, I'm going to climb that f**king tree.' Climbed it and sat there with my hood up for about 10 minutes."
Liam's full interview is available to read in the new issue of Q magazine, which is out now. Visit www.qthemusic.com for more.


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Gary Kurtz
Birthday Number 9
Gary Kurtz is a male celebrity.
He was born on Saturday July 27th 1940, in Los Angeles, CA, USA,.
Gary Kurtz is broad-minded, idealistic, and compassionate. He should obtain a wide education, especially in the arts. Kurtz is highly creative. Many great artists are found under this number.
Gary must come to truly understand life to be of greater service to society. He has a greater social role to play that will require a blend of the practical and the humanitarian. Gary Kurtz must have a keen sense of what will work, but at the same time directing those efforts toward some greater good.
His challenge is to find a place for himself that has some direct benefit to others. The more Kurtz can be of service to humanity, the greater will be his personal reward on all levels - from the material to the spiritual.
Gary Kurtz is socially oriented and has a gift of charm. He is well-liked and even admired by others. Gary can relate to people in all walks of life. He has also a broad vision of the world and can see the grand scheme of things, including international politics and great social movements.
Gary Kurtz expresses his feelings well, but sometimes can be a bit dramatic. He has a strong interest in philosophy and metaphysics.
Nines tend to attract money from other sources, such as inheritance or a stroke of "luck". Also, there is an element of sacrifice in the number 9 that demands that Kurtz learns forgiveness and unconditional love. He must avoid negative attachments. Gary Kurtz must not hold on to people or situations just because he feels that justice has not yet been done, or that someone still owes him something. Gary Kurtz's task in life is to truly let the universe judge such situations, and rely on his own forward-moving life path to bring him the necessities and rewards he deserve.
You and Gary
About Gary's Birthday number
Gary's day of birth is one of his four core numbers - the Life Path, Expression, and Heart's Desire being the other three. It is the least significant of the four core numbers, but perhaps the most finite, in that it reveals a specific ability Gary Kurtz possesses in a marked degree.
Read more about our numerological interpretation of Gary Kurtz's


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"My excellent experience with the Orthopedic..."
About: Freeman Hospital Freeman Hospital Newcastle Upon Tyne NE7 7DN
Posted by NHS Feedback Line8
Anything else?
I seen a consultant for my knee as I have been having trouble with it, they operated on my knee (new knee fitted) and every thing went well. Before I had the operation I was given the opportunity to see a film with other patients due for a similar procedure describing what would be entailed in the operation and this was very helpful, the consultants did answer any questions after the film.
It doesn't feel like I had an operation on my knee.
I seen a consultant.
Response from Freeman Hospital 4 years ago
Thank you very much for the time taken to record your positive feedback on the NHS choices website regarding the care and treatment you received from the Orthopaedic Team at the Freeman Hospital prior to and after your recent knee operation. We would like to take the opportunity to thank you for your extremely kind comments which we have shared with the staff involved in your care. It is always rewarding to receive positive feedback from patients.
- {{helpful}} of {{total()}} people think this response is helpful
- Was this response helpful? Yes | No
Thank you for your feedback.
See more responses from Freeman Hospital


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Screamfest LA
If you haven't made it out yet to the 2011 Screamfest Film Festival that's currently under way, then Los Angeles-area horror fans, you have been missing out!
This past Monday, October 17th, writer/director Eric England's Madison County made its world premiere during the fest to a sold-out crowd, and due to the overwhelming demand for the flick, Screamfest is bringing it back for an encore screening. Kick-ass!
So if you missed out on this little indie gem about a madman in a pig's mask that likes to hunt down hotties in rural Arkansas, Madison County's encore screening is happening this Thursday, October 20th, at 10:15 pm at the Mann's 6 Theater located at the Hollywood & Highland Complex in Los Angeles!
Make sure to get your tickets here!
For more visit the official Madison County website, follow @MadisonCoFilm on Twitter, and befriend Madison County on Facebook.
Got news? Click here to submit it!
Do some digging in the comments section below!


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I got this really super cute swim suit a few months ago. Its a one piece, though. I was tired of feeling sooo self conscious in a two piece... and also, I finally realized that many (not all) two pieces do a good job at making a girl look trashy. I thought it was really cute...
here is a link...
Im about the same size as this girl, but none of my features are like her, really.
My boyfriend doesn't like it... he says I need to go get another 'less modest" one just for him.
My real question... is:
If you see a girl at the beach/ pool wearing a one piece swim suit... what do you think?
Is he right? Are one pieces not attractive at all?
Most Helpful Girl
That really is a cute swimsuit. If you aren't comfortable with showing so much skin, then don't. Have you told your boyfriend it makes you feel uncomfortable? If you have, and he is still pressing you, then he is just a perv. Lols. Go with what you want.00|00|1


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If you love computers and technology, there are plenty of careers in the Creative Industries for you. You could find your work on everyone's smartphone as an App Developer or bring big animations to life as Render Wrangler. You could even bring whole new technology products to life as a Creative Technologist.
News story
Are you one of our future creatives?
We're teaming up with Creative & Cultural Skills to let you know that there is so much more to the creative and cultural industries than you may think
Job role
A skilled programmer, the developer is responsible for any kind of custom software technology needed by the creative team.
How can I start a career in the Creative Industries?
- From:
- Creative Skillset
- Date:
- 23 March 2016
Job role
Broadcast Engineer
Broadcast Engineers work in a television studio or on location, making sure programmes are broadcast at the right time and without interference.


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HOTTTTT: Haykan Dandy – Successful
January 4, 2017 | Music, Nigerian Music | No Comments|
Download and listen to Haykan Dandy – Successful
After several months of silence, AfroBeat r&b HAYKAN DANDY is out with another banging dope tune, single titled SUCCESSFUL is said to have been produced by Mega-X who has worked with other talented artists in the industry. Download and listen he Rebirth of AfroBeat. Enjoy
AfroBeat R&B Haykan Dandy also know as Haykan _D, Born and raise in Surulere, Lagos, he is from south-south Nigeria of Akwa ibom state, born on December 15 in the 80's.
Listen Below
DOWNLOAD Mr. Ben – Saga Dance
Call +2348110941865 or Chat with us +2348167937916 on whatsapp For Music Promo Only
Follow @Tapoutmusic on Twitter
Like Tapoutmusicdotcom on Facebook
Follow @Tapoutmusic1 on Instagram
Add Us 2AFD3C82 On BBM
Join Our Channel C00237A36 On BBM


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- Description
- Tags
- Reviews
Furniture of America Broadus Coffee Table Set in Dark Oak Finish
Vamp up your home with a little rustic décor. This bold straight panel table is accented with straight wood paneling, unique weathered grain details, and corner fine points to best amplify the unique design.
Broadus Coffee Table Set Offer:
1 x Broadus Coffee Table
1 x Broadus End Table
1 x Broadus Sofa Table
Style: Transitional
Color/Finish: Dark Oak
Material: Metal, Solid Wood/Wood Veneer & Others
Metal Corner Accents
Metal Castors
Weathered Grain
Coffee Table: 48"L X 26"W X 18 1/2"H
End Table: 22"L X 22"W X 24"H
Sofa Table: 48"L X 16"W X 30"H