text:
But the microbes on your shoes are similar to the microbes on everyone else's shoes and the microbes on your phone are similar to the microbes on everyone else's phone. Read the rest
But the microbes on your shoes are similar to the microbes on everyone else's shoes and the microbes on your phone are similar to the microbes on everyone else's phone. Read the rest
Stick a thermal printer, a Game Boy and a camera into an Arduino-controlled gizmo and you've got ::vtol::'s 8-bit instant photo gun. Read the rest
It's more complicated than it seems: the functional elements of a 3D print can't be copyrighted, but they may be blended with decorative elements that can be; what's more, if we err on the side of caution by "open licensing" stuff that isn't even copyrighted, the effort to open up copyright ends up normalizing the application of copyright to new subjects. Read the rest
Microsoft has announced a relaxation of its "Secure Boot" guidelines for OEMs, allowing companies to sell computers pre-loaded with Windows 10 that will refuse to boot any non-Microsoft OS. Read the rest
The nonprofit, which created Writetothem, Fixmystreet, and other crucial, ground-breaking civil society projects, is looking for a new CEO to help it spend its £3.6m Omidyar Network grant. Read the rest
Unindexed is an online community that anyone can contribute to; it runs a back-end process that continuously scours Google for signs that it has been indexed, and securely erases itself once it discovers evidence of same. Read the rest
Joris Peels writes, "We've developed a license for sharing 3D printed things. We think it's important to have a good license that lets people remix, share and create in a 3D printed world. We'd like to ask the maker and 3D printing community to help us by giving us feedback on what about the 3DPL should be changed so we have a broadly accepted license for 3D printing." Read the rest
Dan Gillmor, who was the San Jose Mercury News's leading tech columnist during the dotcom years, and was one of the first reporters to go Mac, has switched over to using all free/open source software: Ubuntu GNU/Linux on a Thinkpad, Cyanogenmod on an Android phone. Read the rest
One of the most startling motifs of Citizenfour, Laura Poitras's Academy Award-winning documentary about Edward Snowden, is the use and abuse of cryptographic tools, which are at the center of the NSA's surveillance plans and Snowden's audacious act of whistleblowing. Read the rest
A year ago, the news that the world's biggest video site was abandoning proprietary software would have been incredible, but thanks to the World Wide Web Consortium's Netflix-driven DRM work, this changes very little. Read the rest
Bunnie Huang and his team have set out to fully reverse-engineer and document a cheap Chinese Mediatek MT6260. mobile-phone board -- licensed in the complex, informal regime of "gongkai," through which lots of theoretically confidential information is published, but some critical pieces are withheld. Read the rest
Al sends us the Fx0, a "beautiful mid-range phone running Firefox OS announced in Japan today by KDDI, one of Japan's largest mobile phone companies." Read the rest
Gnu Privacy Guard (GPG, the free/open version of PGP) relies on donations to pay developers to keep the project alive and viable; as one of its millions of users, I am grateful and indebted to the people who keep it alive and that's why I've just donated to the project. Read the rest
Dmytri writes, "Add a crypto wrinkle to your Kris Kringle! Make your Secret Santa even more secret with the magic of Onion Wrapping!" Read the rest
A reader writes, "The USB Armory is full-blown computer (800MHz ARM® processor, 512MB RAM) in a tiny form factor (65mm x 19mm x 6mm USB stick) designed from the ground up with information security applications in mind." Read the rest
Last spring, I gave the keynote address at the Museums and the Web conference in Florence, Italy, speaking in the glorious confines of the big room at the Palazzo Vecchio; the organizers were kind enough to put my talk online. It was very well-received at the time and lots of people have since asked where they could get it -- and here it is! Read the rest
Firefox Hello (a Webrtc implmentation) has debuted in the just-released v.34 of the browser, allowing users to conduct peer-to-peer video-chats without any plugins -- just create a chat, send the URL to your friend and start talking. Read the rest


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Apple iPod shuffle USB Cable
Apple iPod shuffle USB Cable
The Apple iPod shuffle USB Cable connects your iPod shuffle (3rd and 4th generation) to your computer's USB port for syncing and battery charging and to the Apple USB Power Adaptor for convenient charging from a wall socket.
Two cables are included, both with a 3.5-mm jack on one end and a USB connector on the other. The shorter cable is the same length as the USB cable that comes with the iPod shuffle. The longer cable is perfect for connecting the iPod shuffle to the back of a desktop computer or to a power adaptor plugged into a wall socket.
What's in the Box
One Apple iPod shuffle USB cable, 45 mm long
One Apple iPod shuffle USB cable, 1000 mm long
Tech Specs
Cable type: 3.5mm to USB
Get help buying.Call 800-1865-013
iPod Models
- iPod shuffle 3rd Generation
- iPod shuffle 4th Generation
Answers from the community
Wand to connect iPod shuffle to iPad 2. Will it download the music from my iPad to my iPod.
- Asked by Martino D from Aurora
- on 27 Oct, 2013
Best Answer:
you can't connect it "to" your iPad you have to sync both on iTunes and then connect your iPad and p you can't connect it "to" your iPad you have to sync both on iTunes and then connect your iPad and pick the songs from your iPod you want to put on your iPad.
- Written by David T from Wilmington
- on 8 Jul, 2016
I need to connect my ipod touch to the car aux jack. Would the ipod shuffle usb cable work for this?
- Asked by Clare D from East Kilbride
- on 8 Feb, 2012
how to connect ipod shuffle in car
- Asked by Lisa S from Rossland
- on 29 Dec, 2010
Best Answer:
You need to get a cable that has a male input to your shuffle, and either another male output to yo You need to get a cable that has a male input to your shuffle, and either another male output to your car audio's auxiliary input, or a cassette output.
- Written by VIET P from Springfield
- on 17 Jul, 2016
Can I use my charger for iPod 4th generation to charge my iPhone 5s?
- Asked by Isobel K from Randwick
- on 1 Aug, 2015
does the 4th generation iPod shuffle USB cable compatible with the iPod nano 5th generation
- Asked by kelly c from null
- on 5 Jun, 2015
- Written by Donald R from Liberty
- on 15 Jun, 2015
will this cable work on an iphone 5s
- Asked by Carl L from Groveton
- on 15 Apr, 2015
No. Only for iPod shuffles (see models on website).
- Written by Linda L from San Francisco
- on 28 Jun, 2016

subset: commoncrawl


text:
STARmeterSEE RANK
Down 271,651 this week
Pieter Schlosser
Pieter Schlosser was born on August 17, 1980 in Guatemala City, Guatemala. He is known for his work on Transformers (2007), Transformers: Dark of the Moon (2011) and The Hitcher (2007). See full bio »
Born:in Guatemala City, Guatemala
More at IMDbPro » Contact Info: View publicist
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Reload the page and try again.
Guys & Girls:
eh everyone is okay looking nothing fantastic or amazing
Guys & Girls:
People here are very friendly and down to earth they like to party learn and grow with you. The only downside is this school is very small so rumors are easily spread, situations often misjudged, and cliques seem to form towards the very end of the year. Haven't seen much bullying and hazing people stick up for each other and group together like a family. There's not a doubt in my mind that if I or anyone ever needed a friend on campus to go chat with in the late hours its almost always possible to find one.
Guys & Girls:
Everyone is unique and like to be themselves. Everyone dresses a different but in a nice way.
Guys & Girls:
Let Me Explain – Not to be mean but a lot of people at this school were most likely high school rejects who wanted to go to a safe place. I think its good though because everyone treats each other like a human being because they know how it feels to be rejected. I think this is the only place were a Jock will be saying high to that Nerd/loner in high school. They might even be good friends which most likely wouldn't happen at a different school. Overall I like this school because of this.
Guys & Girls:
A Well-Fitting Glove – The students at Warner at generally very nice and polite. People usually dress as they see fit, and while there is some clustering around certain subject areas, a sense of diversity is evident. It is a very comfortable environment.
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text:
Toxic Waste Nuclear Sludge Bar Lives Up To Name
Candy Dynamics' Chewy bars are Worse than torture.04/16/2008
Orville Redenbacher SmartPop! Low Sodium Popcorn
Orville Redenbacher's SmartPop! with 30% Less Sodium04/16/2008
Haagen-Dazs Fleur De Sel Caramel Ice Cream04/16/2008
Stella D'Oro Introduces 100-Calorie Breakfast Treats
Stella D'oro Co. introduces a line of 100-Calorie items04/16/2008
Bija Healing Teas Promote Good Health
Flora Inc. adds four new flavors to its line of Bija Healing Teas to help promote optimal health.04/16/2008
Naked Juice Introduces Probiotic Juice Smoothie
Naked Juice introduces 100% probiotic juice smoothie04/16/2008
Kashi Whole Grain Frozen Pizza With Vegetarian Toppings
Kashi Co. expands its current all-natural frozen pizza family with three new All-Natural Thin Crust Frozen Pizzas.04/16/2008
SoBe Life Water Introduces Five New Flavors04/16/2008
Hormel Chili Meals
Hormel Foods debuts Hormel Chili Meals04/16/2008
Store Brand Sales Increase By $5.4 Billion In 200804/14/2008
Poll Shows Increasing Concern Over Meat Prices
Economic factors lead to more meals at home and more purchases of meat.04/14/2008
Luxury Chocolate At Three Calories A Piece
Godiva Chocoiste gives chocoholics not just a fix but an experience.04/13/2008
Why is our maintenance strategy so difficult?
MRO Q&A is a monthly problem-solving column for maintenance, repair and operational issues.04/13/2008
2007 Capital Spending Report
Economic uncertainty clouds 2008 capital forecast.04/11/2008
Software Helps Plants Integrate Cross-Functional Platforms
Islands of automation are giving way to plant-wide (even enterprise-wide) efforts that yield performance analysis and front-office profit maximization.04/11/2008
New Green Products And Techniques For Plant Sanitation
New products and techniques can effectively kill the bugs in environmentally friendly ways.04/11/2008
April 2008 Equipment Round Up: Cutting And Size Reduction
April equipment round-up features slicers and dicers, software, pneumatic scissors and more.04/11/2008
Advances In Packaging Deliver Fast Meals With Good Taste
Advances in microwavable and dual-ovenable packaging deliver meals fast and easy without surrendering taste or texture.04/11/2008
Nourish America Delivers Prenatal Vitamins To Needy Women
Nourish America launches new initiative to deliver prenatal nutrition to underprivileged pregnant women04/08/2008
Blue Pacific Flavors And HortResearch Collaborate
Blue Pacific Flavors Inc. announces strategic collaboration agreement with HortResearch04/08/2008


text:
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text:
Posted by ESPN.com's Tim Graham
New York Jets linebacker Bart Scott has opinions.
On Monday, a reporter asked him about second-year tight end Dustin Keller.
Scott suggested Keller is on the verge of becoming a star.
"I played against some pretty good tight ends," said Scott, a career Baltimore Raven before joining the Jets as a free agent. "Todd Heap was a tremendous athlete, great leaper.
"I would compare Dustin Keller to Kellen Winslow, and that's very high praise because other than Antonio Gates, I always knew Kellen Winslow was probably the best route-running tight end in the league.
"I think Dustin is well on his way to overcome that."
Keller, the 30th overall draft pick last year, got off to a slow start last year. Although two were for touchdowns, he had seven catches through his first six games, but then Brett Favre started to find him in late October. In a six-game span, Keller caught 33 passes for 370 yards and a touchdown.
Favre was going to Keller in clutch situations, too. In their thrilling Week 11 overtime victory over the New England Patriots in Gillette Stadium, Keller caught six passes for 55 yards -- and five of them for first downs -- in the fourth quarter and sudden death.
On the winning drive, Keller picked up three first downs, including a 16-yard gain to convert a third-and-15 situation.
Scott is impressed by how polished Keller already is.
"It's speed and sloppy route running," Scott said. "You have to be precise with your route running. You can be faster than somebody, but if you waste steps getting out of your break, it allows the defensive player to recover.
"[Keller] is crisp out of his break. He catches the ball at its highest point. I think he's a very athletic player."


text:
OSI-Approved Open Source (62)
- GNU General Public License version 2.0 (47)
- GNU Library or Lesser General Public License version 2.0 (6)
- Academic Free License (3)
- Open Software License 3.0 (3)
- BSD License (2)
- GNU General Public License version 3.0 (2)
- Apache License V2.0 (1)
- Common Development and Distribution License (1)
- IBM Public License (1)
- Microsoft Public License (1)
- NASA Open Source Agreement (1)
- Public Domain (7)
- Other License (3)
- Creative Commons Attribution License (2)
- Other Operating Systems (81)
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Top Apps
- Audio & Video
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World Of Battlezone
this expansion for the game combat commander battlezone2 the [wobz] or [zrfbz] thing brings wole active content in a battlezone2 gives the user play 26 races instead 2 as default note wole thing alredy made we here in try to impruve its sub sections
point of sales software
Londonpos Point of sales order processing system is a system to take orders. Post codes show up, daily sales records, caller id system, upto 5 numbers per customers, website integrated order system, map system integrated, sales records, inventory etc
Software to capture, organize and publish information (notes, text based data & graphic). The software is a "active" intelligent notepad, which help people to change information to knowledge.
vbGore Italia
Il progetto vbGore Italia consiste nel tradurre, migliorare e distribuire vbGore in lingua Italiana
i am vigneshwaran. i have done a project "web caching and authentication server for intranet" in linux environment using c/C++
myParser dbf2MySQL
myParser is an application based on Microsoft Visual Basic 6. The application transfer information between DbaseIV ( DBF ) Tables to MySQL. The application can be executed in a GUI form or as Command Line call. Example: c:\>myparser contacts.prj This wi6 weekly downloads


text:
|Home | About | Journals | Submit | Contact Us | Français
Since clinical and biological research and optimal clinical practice require stability of diagnoses over time, we determined stability of ICD-10 psychotic-disorder diagnoses, and sought predictors of diagnostic instability.
Patients (N=500) hospitalized for first-psychotic illnesses were diagnosed by ICD-10 criteria at baseline and 24 months, based on extensive prospective assessments, to evaluate the longitudinal stability of specific categorical diagnoses, and predictors of diagnostic change.
Diagnostic-stability averaged 90.4%, ranking: schizoaffective disorder (100%) > mania with psychosis (99.0%) > mixed-affective episode (94.9%) > schizophrenia (94.6%) > delusional disorder (88.2%) > severe, psychotic, depressive episode (85.2%) > acute psychosis with/without schizophrenia symptoms = unspecified psychosis (all 66.7%) acute schizophrenia-like psychosis (28.6%). Diagnoses changed by 24 months of follow-up, to: schizoaffective disorders (37.5%), bipolar disorder (25.0%), schizophrenia (16.7%) or unspecified non-organic psychosis (8.3%), mainly through emerging affective features. By logistic-regression, diagnostic-change was associated with Schneiderian first-rank psychosis symptoms at intake > lack of premorbid substance use.
We found some psychotic-disorder diagnoses to be more stable by ICD-10 than DSM-IV criteria in the same patients, with implications for revisions of both diagnostic systems.
"The truth of aesthetically satisfying and didactically convenient classifications can be tested only in the actual application of them."Karl Jaspers 1
The importance of establishing sound, categorical or syndromal, clinical diagnoses of major psychiatric disorders with both cross-sectional validity and stability over time has long been recognized as clinically crucial and essential for progress in neurobiological as well as clinical research.1–3 International taxonomies represented by the World Health Organization's (International Classification of Diseases [ICD of WHO]) and American Psychiatric Association's (Diagnostic and Statistical Manual of Mental Disorders [DSM of APA]) systems involve standardized and operationalized descriptive criteria, and a longitudinal perspective.4,5 More objective, biologically-based methods to support psychiatric diagnoses continue to be sought, but are unlikely soon to displace clinical, descriptive, phenomenological diagnosis, or limit the need for biologists and nosologists to collaborate.6
Diagnosis of psychotic disorders may be especially unstable, owing to: [a] insufficient and potentially unreliable information, especially if elicited only from patients; [b] fluctuating manifestations or detection of psychopathology over time, and later emergence or change of initially unclear symptoms;7,8 [c] symptom-modifying effects of treatment, substance-abuse, co-morbid psychiatric or medical disorders, and prolonged disability or institutional care;8 premorbid temperamental characteristics or personality disorders,9 and developmental factors related to age;10,11 as well as [d] standardized diagnostic schemes of potentially limited validity,4,5 with simplified or arbitrary criteria for particular features, symptom-duration, and functional impairment that belie the richness, complexity, fluidity, and nuances of illness phenomena arising early in most disorders.11–19 In addition, some diagnostic concepts remain inadequately validated and may simply be unreliable, notably including transient acute-psychotic disorders and schizoaffective syndromes, or may be applied differently to particular clinical, ethnic, sex or age-groups, highlighting the need to consider cultural variations in psychopathological presentations and illness-stability over time.20–23
Given clinical and research requirements for more reliable diagnoses despite limited information and typically brief observation times, it is highly desirable that initial standardized, syndromal diagnoses remain longitudinally stable or follow predictable courses. It is therefore important to test diagnostic stability by systematic and prospective, long-term assessments, if only to document levels of longitudinal congruence of specific diagnoses and to identify early predictors of later diagnostic change. Several modern studies have considered the stability of some psychotic disorders followed from onset,11,14,18,24–38 but few have considered predictors of particular diagnostic changes over a wide spectrum of disorders.26,31,32,35–38 Specifically, studies of longitudinal stability of specific ICD-10 psychotic-disorder diagnoses include acute and transient psychotic disorder [ATPD] subtypes among acute polymorphic psychotic disorders [APPD],39–44 schizophrenia,45,46 or mood disorders.47–49 However, we found only two studies that investigated diagnostic stability over time in the broad range of ICD-10 functional psychoses, and neither explored factors predicting diagnostic change or stability over time.25,28
Based on these considerations and our previous findings on diagnostic stability and its predictors among DSM-IV psychotic disorders,38 we again evaluated diagnostic stability over two years, of a broad range of initially considered psychotic disorders based on ICD-10 criteria, among 517 patients enrolled in the McLean-Harvard International First-Episode Project. We hypothesized that stability of some initial ICD-10 diagnoses would vary over time, and that early clinical factors might predict later diagnostic instability. As secondary aims, we considered how initial affective and psychotic components of illnesses changed over time, and whether new diagnoses were more likely to emerge through newly-prominent affective versus non-affective features.
Subjects were among the first 517 patients entering the McLean-Harvard International First-Episode Project based at McLean Hospital and the University of Parma in 1989–2003. Project protocols were reviewed annually and approved by the McLean Hospital IRB and Ethical Committee of the University of Parma Medical Center, through 2008. For inclusion, all subjects presented in a first-lifetime episode of affective (manic, mixed, or depressive) or non-affective psychotic illness, and gave written informed consent for participation and anonymous, aggregate reporting of findings. Intake exclusion criteria were: [a] acute intoxication or withdrawal associated with drug or alcohol abuse, or any delirium; [b] previous psychiatric hospitalization, unless for detoxification; [c] documented mental retardation (WAIS-tested IQ <70) or other organic mental disorder; [d] index syndromal illness present >6 months, or any previous syndromal episode; or [e] prior total treatment with an antipsychotic agent for ≥4 weeks, or an antidepressant or mood-stabilizer for ≥3 months.
Diagnoses for analyses based on ICD-10 criteria, were made by a highly trained diagnostician with years of clinical-research experience (PS), employing historical prospective methods 50 and kept blinded to initial (baseline) and follow-up consensus and SCID-based diagnoses. All information on illness antecedents, prodromes, onset, presentation, and course was derived from medical records (including clinical narratives of hospital-course, and notes from initial and follow-up assessments, semi-structured interviews with patients, families and treating or primary-care clinicians) as well as research records (including psychopathological rating scales, and data derived from standardized clinical interviews including the SCID 51)—all with diagnostic formulations excluded for this study. This information was reviewed to define the most appropriate ICD-10 diagnosis in each case at baseline and again at two years. These 1000 assessments were made in random-order by the same expert-investigator (PS) over several months, with 3–6 weeks between individual assessments, making recollection bias unlikely. In addition, as a test of reliability of the assessments, we drew a random sample of 50 patients with two, categorical, ICD-10 diagnoses, and found agreement in 46 (92.0%), even without correcting for effects of natural diagnostic change over time. Diagnostic procedures of the First-Episode project for other studies applied DSM-IV criteria or updated diagnoses according to current DSM classifications based on SCID-P evaluations at baseline and at 24-months.37,38 We also estimated age-at-onset of primary illnesses, timing of premorbid features, and the presence and timing of lifetime co-morbid psychiatric or substance-use disorders (SCID-based), as well as general medical, neurological, and personality disorders determined clinically and recorded systematically according to DSM-IV requirements. Primary diagnoses met current ICD-10 criteria in 2008, based on the 1992 Clinical Descriptions and Diagnostic Guidelines,4 which were compared to DSM-IV-TR diagnoses.38 Clinical assessment methods have been detailed previously.37,38
We compared subjects with ICD-10-based, categorical diagnoses considered stable versus changed by 24 months to assess associated patient-characteristics, using one-way ANOVA (F) for continuous variables, and contingency tables (χ2 or Fisher exact-p) for categorical factors, with defined degrees-of-freedom (df). We entered measures with at least suggestive differences (p<0.10) in initial bivariate comparisons, stepwise, into a logistic regression model to identify factors independently associated with diagnostic change, reported as Odds Ratios (OR) with their 95% confidence intervals (CI). Averages are means with standard deviations (±SD). Analyses were based on commercial statistical programs (Stata-9®, Stata Corp., College Station, TX; Statview-5®, SAS Institute, Cary, NC).
Of 517 first-episode psychotic subjects assessed, 17 (3.3%) were lost to follow-up, leaving 500 (96.7%) for two (baseline and 2-year) diagnostic assessments (100%). Most subjects were men (55.0%) and estimated age-at-onset over the range of first-psychotic syndromes averaged (± SD) 31.7±13.7 years. Patients enrolled at McLean Hospital (n=406, 81.2%) and the University of Parma Medical Center (n=94, 18.8%), followed identical protocols. Initial diagnoses included affective-psychotic syndromes (mixed-affective episode, mania with psychotic symptoms, severe depressive episode with psychotic symptoms; n=309, 61.8%), and non-affective disorders (schizophrenia, APPD, delusional disorder, unspecified non-organic psychosis, and acute schizophrenia-like psychotic disorder; n=143, 28.6%), as well as schizoaffective disorders (n=48, 9.6%; Table 1). Among schizophrenia diagnoses at baseline (n= 56/500; 11.2%), the undifferentiated type was most prevalent (n= 22, 39.3%), hebephrenic (n=15, 26.8%) and paranoid types (n=11, 19.6%) intermediate, and catatonic (n= 4, 7.1%) and simple (n=1, 1.8%) types, uncommon.
At baseline, SCID-P based lifetime co-morbid diagnoses included: substance-use disorders (51.2%) and anxiety disorders (17.2%), and clinically determined Axis II lifetime co-morbidity with personality disorders recorded according to DSM-IV requirements reached 23.0% (Table 1). Substance-use disorders were associated (in descending incidence) with the following initial ICD-10 diagnoses: mixed affective episode (69.2%), mania with psychosis (57.6%), schizoaffective disorder (56.3%), severe depression with psychosis (51.8%), acute schizophrenia-like disorder (42.9%), schizophrenia (33.9%), unspecified non-organic psychosis (33.3%), APPD without symptoms of schizophrenia (23.8%), delusional disorder (11.8%), or APPD with symptoms of schizophrenia (11.1% of cases; χ2 [df=9] = 73.9 p<0.0001).
Based on initial diagnoses, mean onset-age was 31.7 years, and onset-age ranked by diagnosis as: delusional disorder (41.4) > severe depressive episode with psychotic symptoms (37.8) > unspecified non-organic psychosis (35.4) > APPD without symptoms of schizophrenia (33.3) > mania with psychotic symptoms (31.5) = mixed-affective episode (31.5) > APPD with symptoms of schizophrenia (28.8) ≥ acute schizophrenia-like psychotic disorder (28.0) ≥ schizophrenia (27.9) ≥ schizoaffective disorder (27.5 years; Table 1).
Initial ICD-10 diagnoses changed in 48/500 cases (9.6%), with a positive predictive value of initial diagnoses of 90.4%.52 This overall stability contrasts with 75.3% found with DSM-IV consensus diagnoses of the same cases.38 Positive predictive value was 1.2-times greater among subjects with ICD-10 schizoaffective (48/48, 100.0%) or major affective episodes with psychotic features (292/309, 94.5%) than those diagnosed with ICD-10 non-affective psychoses (112/143, 78.3%; χ2 [df=2] = 35.1, p<0.0001; Tables 2 and and33).
Most changes involved later-diagnosed schizoaffective disorders (18 cases, 37.5% of the 48 revised diagnoses: 8 from initial non-affective categories, and 10 initially affective cases including 8 initial mixed-episode diagnoses, one initially considered mania and another initially diagnosed as severe depression). New schizoaffective diagnoses involved emerging affective features in previously non-affective conditions, 1.8-times more often than the opposite (8/143 [5.6%] versus 10/309 [3.2%]; χ2 [df=2] = 771, p<0.0001).
The second-most prevalent changed diagnosis was bipolar affective disorder (12/48 [25.0%]: 6 initially diagnosed severe depressive episode with psychotic symptoms, 3 APPD with symptoms of schizophrenia, 2 APPD without symptoms of schizophrenia, and 1 initial unspecified non-organic psychosis). Third were new diagnoses of schizophrenia (8/48 changes, or 16.7%: 4 initially considered acute schizophrenia-like psychotic disorder, 3 initial APPD with symptoms of schizophrenia, and 1 with apparent severe depressive episode with psychotic symptoms). Fourth were shifts to unspecified non-organic psychosis (4/48 = 8.3%, all from APPD without symptoms of schizophrenia). These four final categories accounted for 42/48, or 87.5% of new ICD-10 psychotic-disorder diagnoses.
The remaining 6 new diagnoses (12.5%) included 2 cases of recurrent depressive disorder (one each from acute schizophrenia-like psychotic disorder and APPD with symptoms of schizophrenia), 2 delusional disorder (one each from unspecified non-organic psychosis, and APPD without schizophrenia symptoms), as well as one case each of mania with psychotic symptoms and severe depressive episode with psychotic symptoms, both being initially diagnosed as APPD with symptoms of schizophrenia.
Initial ICD-10 diagnoses of both mania with psychotic symptoms and mixed-affective episode held up best (99.0% [98/99] and 94.9% [148/156]), as only 1.0% (1/99) and 5.1% (8/156), respectively, changed to schizoaffective disorder at 2-year follow-up. These results were similar to our previous analyses of DSM-IV diagnoses.38 Also among affective-disorder diagnoses, 85.2% (46/54) of cases initially considered to have a severe depressive episode with psychotic symptoms remained stable, and 8 changed (6 to bipolar affective disorder, 1 each to schizoaffective disorder or schizophrenia). Among non-affective diagnoses, schizophrenia persisted in 94.6% of patients (with only 3 changes to schizoaffective disorder, including 2 from paranoid and 1 from undifferentiated subtypes), and delusional disorder remained stable in 88.2% of cases. Most short-duration or initially nonspecific syndromes, not surprisingly, changed to various alternatives, with moderate retention rates for APPD with and without symptoms of schizophrenia (66.7%) as well as unspecified non-organic psychosis (66.7%), and low persistence of initial acute schizophrenia-like psychotic disorder diagnoses (28.6%; Figure).
Of 48 total diagnostic changes, 31 (64.6%) involved diagnoses initially considered non-affective (31/143 = 21.7%; Tables 2 and and3),3), of whom, 8/31 (25.8%) shifted to schizoaffective disorders (from initial unspecified non-organic psychosis [n=3], schizophrenia [n=3], or delusional disorder [n=2]). Changes to alternative non-affective categories occurred in 13/31 (41.9%) of initially non-affective cases (4 from acute schizophrenia-like psychotic disorder to schizophrenia, 3 from APPD with symptoms of schizophrenia to schizophrenia, 5 from APPD without symptoms of schizophrenia to unspecified non-organic psychosis [n=4] or delusional disorder [n=1], and 1 from unspecified non-organic psychosis to delusional disorder). There were 10/31 shifts (32.3%) to new affective diagnoses (from APPD with symptoms of schizophrenia to bipolar affective disorder [n=3], mania with psychotic symptoms [n=1], recurrent depressive disorder [n=1], or severe depressive episode with psychotic symptoms [n=1], from APPD without symptoms of schizophrenia to bipolar affective disorder [n=2], from acute schizophrenia-like psychotic disorder to recurrent depressive disorder [n=1], and from unspecified non-organic psychosis to bipolar affective disorder [n=1]).
There were only 17/48 (35.4%) changes of initial affective-disorder diagnoses (of 309 initial affective cases, or 5.5%), including 10/17 (58.8%) new schizoaffective diagnoses arising from: initial diagnoses of mixed-affective episode (n=8), mania or severe depressive episode with psychotic symptoms (n=1 each). Shifts within affective categories (n=6) all involved new diagnoses of bipolar affective disorder from initial severe depression, owing to later manic (n=4) or mixed (n=2) episodes. The one new non-affective diagnosis was of schizophrenia, following an initial ICD-10 diagnosis of severe depressive episode.
Bayesian analyses 52 of final versus initial diagnoses (not shown) indicate that schizoaffective disorder (100%), mania with psychotic symptoms (99.0%), mixed-affective episode (94.9%), and schizophrenia (94.6%), delusional disorder (88.2%), and severe depressive episode with psychotic symptoms (85.2%), had relatively high levels of diagnostic stability or positive predictive value (>85%). In contrast, initial ICD-10-based acute schizophrenia-like psychotic disorder (28.6%), and diagnoses of unspecified non-organic psychosis and APPD with and without symptoms of schizophrenia (three categories, 66.7%) had lower predictive value (Table 2). Specificity (1.0 minus the false-positive rate) in all categories was ≥83% except for the acute and transient (50%) or unspecified psychotic disorders (64.3%). Sensitivity (1.0 minus the false-negative rate) exceeded 86% in all but 2 categories: acute schizophrenia-like psychotic disorder, and APPD with and without symptoms of schizophrenia (100%); bipolar affective disorder (95%); severe depressive episode with psychotic symptoms (94.1%); schizophrenia (86.9%); and delusional disorder (86.7%), but not unspecified non-organic psychosis (71.4%) and schizoaffective disorder (72.7%).
Initial bivariate regression modeling indicated that subjects with changed (n=48) versus stable (n=452) ICD-10 diagnoses ranked by statistical significance, as: [a] 4.7 years younger at onset, [b] more likely to present initial Schneiderian first-rank symptoms (FRS 53) of any type (audible thoughts, arguing, commenting, or imperative hallucinated voices; thought-withdrawal, broadcasting or insertion; external influences on bodily functions, arousal, sensations or volition; and delusional perception or attribution of abnormal meanings to real perceptions), [c] experiencing more initial auditory hallucinations, [d] less likely to have a previous substance-use disorder diagnosis, and [e] more likely to present with initial Schneiderian FRS of influence or hallucinations (Table 4A).
Two of these factors were independently associated with diagnostic change in multivariate logistic regression modeling, with factors ranking (by statistical significance) as: [a] any Schneiderian FRS at presentation > [b] lack of an earlier substance-use disorder diagnosis (Table 4B). Other demographic and clinical factors not associated with diagnostic changes included: sex; onset-type; latency of first-episode symptoms to full syndrome; specific Schneiderian FRS other than auditory hallucinations and experiences of influence; non-FRS visual, olfactory, gustatory, tactile, or somatosensory hallucinations; Capgras misidentification features; cycloid features; various pre-psychotic co-morbid DSM psychiatric disorders (including cyclothymia, dysthymia, post-traumatic stress disorder [PTSD], other anxiety disorders, eating disorders, or Axis II personality disorders, including clusters A–C), as well as medical or neurological illnesses or early learning disability, and study-site (see Table 4 footnote).
Based on categories considered comparable in the two leading, modern diagnostic systems, estimates of diagnostic stability were highly correlated. However, for nearly all categories of psychotic-disorder diagnoses, stability of ICD-10 diagnoses was consistently higher than with DSM-IV criteria (Table 5). A noteworthy exception was bipolar disorder, which yielded the same, highest stability of any diagnosis (96.5%). The greatest difference in diagnostic stability was found at the low end, between ICD-10 schizophrenia-like disorders (28.6%) and DSM-IV schizophreniform disorders (10.5% stability), although these diagnoses may not be directly comparable.
Strengths of this study include prospective and systematic follow-up of a large cohort of 500 first-episode patients assigned categorical, syndromal diagnoses using standardized and reliable methods with a broad range of both ICD-10 affective and non-affective psychotic disorders, based on initial hospitalization and repeated, prospective, systematic, clinical and rating-scale based assessments over 24 months of follow-up, evaluated with formal SCID-P assessments at baseline and 24 months. During follow-up, there was only 3.3% loss due to consistent and intensive pursuit of all subjects. Study-limitations include assignment of ICD diagnostic categories at baseline and 24 months by one expert diagnostician, using extensive, prospectively acquired data, held blind to consensus DSM-IV diagnoses and interpretations of SCID assessments, and considering cases in random-order over many weeks. In addition, there were relatively small samples (n<30) in several categories at intake (especially acute schizophrenia-like psychotic disorder, unspecified non-organic psychosis, and APPD with and without schizophrenia-like symptoms), reflecting their limited prevalence. Such power-limitations precluded statistical analysis of predictive factors for specific diagnostic changes, and overall analyses reported may not apply to all disorders. Also, these findings for initially hospitalized patients in first psychotic episodes may not apply to samples obtained in other settings (outpatient clinics, community samples, or others).
Overall, diagnostic stability of first-episode ICD-10 psychotic disorders in the first two years of follow-up from initial major episodes (90.4%) was significantly greater than previously reported for DSM-IV categories in the same patient-sample (75.3%).38 This superior stability was sustained for all seven psychotic-disorder diagnoses considered to be similar in both classification systems (Table 5). A second main finding was that all 48 initial ICD-10 schizoaffective diagnoses remained stable for two years. In addition, mania with psychotic symptoms remained stable in 99.0% of 99 cases; only one case of mania later changed to schizoaffective disorder, and 14 (14.1%) initially manic patients did not experience a major recurrence within two years. Of 156 cases diagnosed initially as mixed-affective episode, 94.6% remained stable; all 8 changes (5.1%) involved later-emerging psychotic features, with new schizoaffective diagnoses. Another 14.1% had no further episodes within 24 months (Figure, Table 2). Previous studies have reported prevalence of single-episode manic or mixed-states at 0%–55% of cases (usually ≤8%).54,55 Schizophrenia was the fourth-most stable diagnosis (94.6% of 56 unchanged); all changes (5.4%) involved new schizoaffective diagnoses, mostly from the paranoid subtype. Only 4 ICD-10 psychotic-disorder diagnoses (schizoaffective disorder, mania with psychotic symptoms, mixed affective episode, and schizophrenia) remained stable for two years in ≥95% of cases.
The uncommon ICD-10 diagnosis delusional disorder (3.4%) remained stable in 88.2% of cases (Table 2). Such conditions often evolve into schizophrenia or schizoaffective diagnoses, with emergence of hallucinations or formal thought disorder, or of affective features,29 although their relationship to schizophrenias and paraphrenias has been ambiguous for a century.2 Severe depressive episode with psychotic symptoms (54 cases) was similarly stable (85.2%), shifting to bipolar affective disorder as later manic or mixed episodes arose (6/8 changes), or to one each of new schizoaffective or schizophrenia diagnoses. Also, among 46 subjects initially diagnosed with severe depressive episode at both intake and two years later, 15 (32.6%) had only a single episode.
Of initial acute polymorphic psychotic disorder (APPD) diagnoses with and without symptoms of schizophrenia (n=32 initially), 33.3% changed to other categories (Tables 1 and and2,2, Figure). Diagnostic instability was anticipated among psychotic disorders expected to be acute, time-limited, and prognostically favorable, particularly acute schizophrenia-like psychotic disorder. Initially, this diagnosis was uncommon (n=7 cases), and 71.4% changed to other diagnoses, particularly schizophrenia (Table 2). Diagnostic-instability rates of ICD-10 acute and transient psychotic disorders (ATPD; n=55 or 11.0%, including APPD [n=48] and acute schizophrenia-like psychotic disorder [n=7]) averaged 46.0% overall, and 33.3% of APPD underwent diagnostic changes. These disorders, in the same patients, may compare best to DSM-IV categories of schizophreniform (89.5%) and brief psychotic disorders (38.9% involved changed diagnoses; 64.2% overall).38 Accordingly, ICD-10 diagnoses of ATPD, particularly the APPD subtypes, may be somewhat more stable, and potentially more reliable and valid constructs than DSM-IV schizophreniform and brief psychotic disorder. Several studies 21,25,39,41,43,44 investigated the incidence, characteristics, and diagnostic stability of ICD-10 acute, transient psychoses, alone or within the broad range of first-episode functional psychoses, generally finding low to moderate overall stability rates (34.4%–57.9%), though relatively high positive predictive power was found among such diagnoses in developing countries (64.4%–73.3%),28,40,42 particularly for the APPD subtypes.40
The present and previous findings 38 indicate limitations of both ICD-10 and DSM-IV diagnostic categories, particularly in attempting to account for acute, non-affective, remitting psychoses.56 Notably, several criteria, including 1–3 months duration required for acute psychoses in both systems, the schizophrenia Criteria-A required for DSM-IV schizophreniform disorder, and lack of negative symptoms for DSM-IV brief psychotic disorder, all seem limited, arbitrary, and fail to capture the complexity of many psychotic disorders. As acute onset is not a criterion for DSM-IV brief psychotic or schizophreniform disorders, but ICD-10 considers onset-type to be crucial, remitting psychoses with non-acute onset and typical cases of schizophrenia and other persistent psychoses, as well as non-affective acute remitting psychoses, may be misclassified, especially by DSM-IV criteria. As highlighted in ICD-10, initial acute-versus-non-acute onset and a remitting-versus-chronic course, as well as prolonged stability during follow-up may be relatively robust criteria for differentiating psychotic-disorder subtypes.56 Also, the relatively high instability of undifferentiated/unspecified psychoses may reflect their possible status as prodromes of more stable conditions such as schizophrenia and schizoaffective disorder.57
The present finding of diagnostic stability of ICD-10 APPD diagnoses with and without symptoms of schizophrenia (both 66.7%) might be related partly to the higher prevalence of cycloid features at presentation (64.3% and 66.7%) among longitudinally stable cases of APPD than for other categories (0%–50% stability; not shown), including schizophrenia (1.6%) and schizoaffective disorders (9.1%). Some recent reports comment on the presence of cycloid phenomena, including rapidly-changing moods and activity levels, delusions, confusion or perplexity, anxiety or ecstasy, not only to distinguish APPD from chronic psychotic illnesses, but also to predict a more favorable course and outcome.41,58–60
Schizoaffective disorder is of particular interest owing to variance in both concepts and criteria. With ICD-10 criteria, its prevalence increased from 9.6% to 13.2% within two years, and it accounted for 37.5% of new diagnoses; moreover, this diagnosis remained stable in 100% of the 48 patients initially so-diagnosed, to represent the most stable ICD-10 psychotic disorder diagnosis (Table 2). In contrast, based on DSM-IV criteria, schizoaffective disorder was rare initially.38 Such striking differences probably reflect: [a] allowance in ICD-10 of broad temporal relations between schizophrenia-like (psychotic) and affective symptoms;4 [b] narrow definitions of psychotic phenomena in DSM-IV Criterion-B; and [c] the required meeting of criteria for a major mood episode in DSM-IV.5 John Kasanin's 61 concept of the schizoaffective syndrome as the acute admixture or rapid succession of schizophrenia-like and mood features anticipated the ICD-10 concept,4 whose essential criterion is prominence of both affective and psychotic symptoms in the same episode or within a few days. The more restrictive DSM-IV 5 Criterion-B required for schizoaffective disorder ("during the same period of illness there have been delusions or hallucinations for ≥2 weeks in the absence of prominent mood symptoms") extends the requirement of "an uninterrupted period of illness of at least 1 month, during which at some time there is a 1–2-week major mood episode as well as symptoms meeting DSM-IV Criterion-A for schizophrenia," and narrowly limits potential psychotic phenomena to the occurrence of delusions or hallucinations alone.
Later emergence of affective features led 5.6% of initial ICD-10 non-affective cases to be diagnosed later as schizoaffective, whereas 3.2% initially considered affective-disorders later manifested sustained psychotic features, indicating that new affective features were the more likely route to ICD-10 schizoaffective diagnoses (Table 3), similar to DSM-IV criteria.38 In other studies, relative contributions of late affective versus psychotic features were not specified.18,25–27,62 From a clinical and nosologic viewpoint, later emergence of affective components within initially psychotic conditions might reflect the phenomenological nature of acute psychoses in which affective expression is overwhelmed by pervasive positive psychotic symptoms, or affective features are quantitatively or temporally insufficient to meet diagnostic criteria for an affective psychotic disorder.21,25,39–44 In addition, from the perspective of clinical psychopathology, as pointed out by Kurt Schneider,53 subsequent appearance of affective components in initial non-affective psychotic states might be triggered by the profound existential catastrophe of first-rank symptoms (FRS), which undermine the unity of the self as the center of thought, perception, volition, bodily experience and action, and its impact on the basic affective substratum.
Also, only 6.4% of initial ICD-10 schizophrenia cases were later considered schizoaffective (Table 2), perhaps as a manifestation of early-illness fluidity 7–11 and a need for 12–24 months of observation for confident diagnosis of schizophrenia.63,64 In contrast, almost all DSM-IV schizoaffective cases were not diagnosed before 2 years of follow-up.38 Indeed, schizoaffective disorder, as currently conceived in the US, is similar to schizophrenia in severity, chronicity, and disability, high rates of co-morbidity and relatively young onset.14,24 This concept differs sharply from Kasanin's 61 original concept of acute admixtures of features, and other recent formulations that include both an episodic course 31 and a favorable long-term outcome.22
Several prospective studies considered stability of first-episode psychotic-illness diagnoses, although large, broad samples followed-up for a year or longer,14,18,25,26,30–32,34,35,38 and evaluations of factors associated with diagnostic stability are rare.26,31,32,35,38 Several studies specifically considered longitudinal stability of individual, ICD-10 acute psychotic-disorder diagnoses,39–44 schizophrenia,45,46 mania or severe depression with psychotic features,47–49 but only two 25,28 considered diagnostic stability over time in a broad range of functional psychoses, and neither explored factors predicting stability.25,28
These studies 25,28 averaged with our findings (Table 2) indicated that ICD-10 schizophrenia was a particularly stable initial diagnosis (92.2±9.2%), mania with psychotic symptoms similarly stable (90.8±8.4%), delusional disorder and severe depressive episode with psychotic features less stable (75.4±21.2%), ATPD moderately unstable (63.7±32.6%), and the pool of unspecified acute psychoses even less stable (40.1±24.1% of cases remaining stable for at least one year). Compared with our findings of 100% longitudinal diagnostic stability among initial ICD-10 schizoaffective cases (Table 2), one comparable study found that only 20% of cases initially considered schizoaffective (2.9%) remained so at 36 months,25 and the other did not identify any subject as schizoaffective at baseline or at 12-months.28
Factors associated with diagnostic instability included any type of Schneiderian FRS 53 at presentation and lack of previous substance-use disorders (Table 4B). Comparable studies are rare, and none used ICD-10 criteria. Schwartz et al.26 found that diagnostic change between 6 and 24 months to DSM-IV schizophrenia or schizoaffective categories was associated with: poor adolescent adjustment, lack of early substance-abuse, psychosis lasting ≥3 months before hospitalization, more initial negative symptoms, prolonged hospitalization, and antipsychotic treatment at discharge. For Schimmelmann et al.31 higher initial global impression (CGI) and lower premorbid functional (GAF) scores predicted shifts from DSM-IV schizophreniform disorder to schizophrenia or schizoaffective diagnoses. Whitty et al.32 associated diagnostic change generally with less education, milder initial DSM-IV psychopathology, and co-morbid substance-abuse. Relationships of substance-use disorders to risk or timing of new psychotic disorder diagnoses remain particularly unclear, as the evidence is inconsistent.26,32,33,65
Subramaniam and colleagues 35 found duration of untreated psychosis to be the only significant predictor of diagnostic shifts towards a DSM-IV "schizophrenia-spectrum." Fraguas et al.36 reported that diagnostic concordance of 54.2% between baseline and 1-year diagnoses rose to 95.7% by 2-years, highlighting the importance of prolonged follow-up to stable diagnosis. Our previous study 38 with the same 500-patient-sample diagnosed by DSM-IV criteria, found that diagnostic instability was predicted by initial non-affective diagnoses and auditory hallucinations, younger age at syndromal-onset, male sex, and gradual onset.
The finding that Schneiderian FRS predicted diagnostic instability while also representing important anchors for the relatively stable ICD-10 diagnosis of schizophrenia, seems paradoxical. It may be that FRS are also core descriptive features for ATPD, especially its highly unstable subtypes, namely acute schizophrenia-like, and APPD with schizophrenia symptoms. Peter Berner 66 hypothesized that FRS emerging during acute psychosis may represent continuously fluctuating impulses, drives, emotions, feelings, and mood states (the so called "dynamic instability") that disrupt basic, innate behavioral schemes, ideas, mental images, and personal values ("structural components"). Since specific interactions between dynamic and structural components might facilitate emergence of mainly affective, non-affective, or schizoaffective psychoses, FRS might well be associated with diagnostic changes that reflect the premorbid psychobiological substratum from which psychotic illnesses develop.
Associations of early features with later diagnoses encourage further study of the potential predictive value of early phenomenology,21 to guide earlier diagnosis and therapeutic interventions aimed at limiting morbidity and disability, as well as to limit adverse effects and costs of unnecessary treatments.67,68 However, challenges of evaluating early or premorbid phenomena are great, especially in young patients. Early symptoms can obscure or delay diagnosis of psychotic disorders, particularly when prominent nonspecific features suggest neurotic, personality, conduct, cognitive, or substance-use disorders.14,16,17,21,24,26,33,69–75
Our findings underscore the wide diversity of diagnostic stability among initial ICD-10 psychotic-disorder diagnoses, based on two years of observation from onset. They suggest four major nodes of stability: [a] very high stability (95%–100%) in ICD-10 schizoaffective disorder, mania with psychotic symptoms, mixed affective episode, and schizophrenia > [b] moderately high stability (85%–88%) in delusional disorder and severe depressive episode with psychotic symptoms > [c] limited stability (67%) in APPD and unspecified non-organic psychosis [d] low stability (29%%) of acute schizophrenia-like psychotic disorder. ICD-10 schizoaffective disorder and mania with psychotic symptoms were particularly stable diagnoses, and somewhat more robust as initial diagnoses than mixed-affective episode, schizophrenia, or other psychotic disorders. Early allocation of individual patients to a particular diagnosis or to such diagnostic nodes might usefully consider the details of early psychopathology as well as presenting clinical features, including their timing and plasticity over time.
Most diagnostic changes were to schizoaffective diagnoses, usually anticipated by initial mixed-affective episodes or later-emerging affective components of initially non-affective psychotic illnesses, and typically with unfavorable outcomes. This category challenges the standard psychotic versus affective Kraepelinian dichotomy underlying both DSM-IV and ICD-10, and requires further study. Despite the higher sensitivity and stability of an ICD-10 schizoaffective diagnosis than the corresponding DSM-IV category in this same cohort of 500 patients,38 the diagnosis of schizoaffective disorders in general may require more than 12 months of follow-up, and may include acute and episodic, as well as chronic forms.
In light of the high diagnostic stability of ICD-10 ATPD and its polymorphic subtypes, we also recommend critical re-evaluation of the DSM-IV categories of "schizophreniform," "brief psychotic" disorders, and related concepts. Developing improved diagnostic criteria for such supposedly good-prognosis and time-limited disorders may require integrating categorical and dimensional approaches, with consideration of early features, type of onset, as well as long-term outcomes.1,76–80 Finally, we specifically encourage continued efforts to devise diagnostic methods and criteria to identify patients with psychotic disorders of favorable course as early as possible, if only to avoid unnecessarily pessimistic prognoses and overuse of antipsychotic medications and other costly or risky interventions.67,81
Supported by grants from NARSAD (to PS); by NIH grants MH-04844, MH-10948 and a grant from the Atlas Foundation (to MT); by grants MH-47370 and MH-73049, and from the Bruce J. Anderson Foundation, and the McLean Private Donors Research Fund (to RJB); and by the Spanish Ministry of Education & Science and CIBERSAM (to EV). Statistical advice was provided by Theodore Whitfield, D.Sc., and the late John Hennen, Ph.D. Dr. Francesca Stefani provided valuable assistance with data collections in Parma.
Disclosures: Dr. Salvatore, Ms. Khalsa, and Drs. Perez Sanchez-Toledo, Zarate and Maggini have no relevant disclosures. Dr. Baldessarini has recently been a consultant or research collaborator with Auritec, Biotrofix, Eli Lilly, IFI, Janssen, JDS-Noven, Luitpold, NeuroHealing, Novartis and Pfizer Corporations, but is not a member of speakers' bureaus, nor does he or any family member hold equity positions in pharmaceutical or biomedical companies. Dr. Tohen was an employee and stockholder of Eli Lilly & Co to 2008, as is his wife currently. Dr. Vieta consults to or receives research support from Astra-Zeneca, Bristol-Myers-Squibb, Eli Lilly, Forrest, Glaxo-SmithKline, Janssen-Cilag, Jazz, Merck, Novartis, Organon, Otsuka, Pfizer, Sanofi, and Servier Corporations.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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The number of new National Board Certified Teachers in Illinois grew by 37% last year, and educators say the process of examining their own teaching was beneficial. Studies show that National Board Certification also benefits students, with reports showing that students taught by NBCTs outperform their peers who are not.
Full Story:Daily Herald (Arlington Heights, Ill.)


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Betcha Liquor Overview
This profile for Betcha Liquor is located in Colorado Springs, CO.Betcha Liquor industry is listed as Ret Alcoholic Beverages.
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text:
iHerb Customer Reviews
Savings of: $3.33 (30% off)
Sorry, this product is no longer in stock.
Yummie and Healthy
Posted by sunnysuperfood on Aug 21, 2011
Yummie and Healthy Yummie and Healthy Yummie and Healthy!
Great alternative to artificial sweetners.
Posted by Reviewer1986221 on Aug 23, 2011
This is a good stevia, especially with the added inulin and chromium.
Posted by Reviewer2744802 on Jun 22, 2011
Very good
Review of Now Foods, Stevia Balance
Posted by Reviewer1268089 on Jul 19, 2011
I like this product, only down side is that it is hard to disolve in cool liquid. Works well in Coffee.
Very Strong
Posted by aromatherapy on Dec 20, 2010
This Stevia is very strong and a little goes a long way. I use it in my iced coffee as it melts perfectly. If you use too much it will taste bitter. Keep some in your purse and you can use it at Starbucks!
Posted by 4817415181269878326 on Mar 24, 2013
Still not sure how to calculate exactly the amount needed but this stuff is really sweet. Friends warned me that stevia can have a bitter aftertaste but I have not noticed that with this one. Would give it 5 stars but I have never tried stevia before so I am not sure how it compares.
Good smooth taste
Posted by Reviewer3253087 on Apr 15, 2012
This stevia is smoother and less saccharine-like, compared to other brands I've tried.
so good!
Posted by Reviewer3203632 on Jul 20, 2013
so good! but its not so sweet.(my mistake) but useful.
nice priduct
Posted by 4841053370452449638 on Aug 14, 2013
Strong taste
Better Stevia
Posted by 5009927467533989003 on Jun 13, 2013
I liked this product, but I do like NuNaturals better.


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Heavy Duty Grinder
55 Suppliers
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Fornnax Technology Pvt LtdVerified Supplier with TrustSEAL
Manufacturer & trader of rubber grinder & scrap tyre grinder. Also offering grinding mill, used tire granulator & waste tyre more........Thaltej Road, Ahmedabad
B-908, Titanium Square, Thaltej Cross Road,
Ahmedabad - 380054, Gujarathttp://www.fornnax.net/rubber-process-machinery.htmlGet Best Quotes 8586925911Ahmedabad
Fein Power Tools India Private LimitedVerified Supplier with TrustSEAL
Specialized exporter & supplier of high frequency heavy duty grinding & heavy duty grinding machine. We also offer high frequ more........Kodambakkam, Chennai
No. 69, Arcot Road, Kodambakkam,
Chennai - 600024, Tamil Nadu
Essen EngineersVerified Supplier with TrustSEAL
Reputed manufacturer & exporter of essen heavy duty grinders, 1001, essen heavy duty grinders, 1006, essen heavy duty grinder more........Jogeshwari West, Mumbai
No. 9, Prashant, Opposite Patel Engineering Patel Estate, Jogeshwari West,
Mumbai - 400102, Maharashtra
Suresh Machine ToolsVerified Supplier with TrustSEAL
Supplier and manufacturer of heavy duty grinders such as heavy duty grinder for plastic, industrial heavy duty grinders and h more........Surat
B-11-12, Ambica Nagar Society, Opposite Trikamnagar-2 Near- Radhakrishna Temple, L.H. Road,
Surat - 395010, Gujarat
- Gajjar Engineering & Fabrication Works
Gajjar Engineering & Fabrication WorksVerified Supplier with TrustSEAL
Manufacturer & exporter of heavy duty grinder - out put 800kg. Also offering cable compounding mixer, high speed cooler mixer more........Ahmedabad
No. 163, Pushkar Industrial Estate, Opposite Macon Industry,
Ahmedabad - 382445, Gujarat
- Ruchak Enterprise
Ruchak EnterpriseVerified Supplier with TrustSEAL
Manufacturer & exporter of grinder. Also offering finishing and fabrication tools, fuel and lubrication dispensing, hydraulic more........Ahmedabad
No. 411, Sudarshan Complex, Near Mithakhali Underbridge, Navrangpura,
Ahmedabad - 380009, Gujarat
- G. S. Engineers
G. S. EngineersVerified Supplier with TrustSEAL
Established in 1990 we are a leading manufacturer of heavy duty grinder. Also deals in heavy duty grinder from India. more........New Delhi
No. 3026/7, A - 9, Shiv Chowk, Ranjeet Nagar N-129 Sec 1 Bawana,
New Delhi - 110008, Delhihttp://www.geeplastindia.in/granulator-machines.htmlGet Best Quotes 8048078964New Delhi
- Vikas Machinery & Automobiles
Vikas Machinery & AutomobilesVerified Supplier
Trader & supplier of rajlaxmi extra heavy duty bench grinder with wheel, rhg-2, rajlaxmi single phase heavy duty bench grinde more........Rajkot
Shop No. 5/6, Lotus Arcade, Opposite Automotive Showroom, Gondal Road,
Rajkot - 360004, Gujarat
Walia Engineering CompanyVerified Supplier
We are a leading manufacturing & trading of heavy duty grinder. These are widely acknowledged for its easy installation & les more........Janta Nagar, Ludhiana
No. 10385, Street No. 4, Baghwan Chowk, Janta Nagar Ludhiana,
Ludhiana - 141003, Punjabhttp://www.indiamart.com/welton/die-grinder.htmlGet Best Quotes 8049676661Ludhiana
Murali Pneumatics, CoimbatoreVerified Supplier
We are exporter & trader of heavy duty grinder, heavy duty grinders. We also offer ace gas springs, accura pulse wrenches, dr more........Kattoor, Coimbatore
183/2, Mangammal Building, Ranga Konar Street Kattoor,
Coimbatore - 641009, Tamil Naduhttp://www.indiamart.com/murali-pneumatics/grinders.htmlGet Best Quotes 8079450900Coimbatore
Sai Krupa TradersVerified Supplier
Exporter & trader of heavy duty grinder. Also offering construction adhesive, cutting & grinding machine, digital laser meter more........Hansol, Ahmedabad
No. 22, Shiv Shopping Center, Near Avsar Party Plot,.opp Chandrabhanu Airport Road Hansol,
Ahmedabad - 382475, Gujarat
Aditya RetailVerified Supplier
Specialized trader & supplier of heavy duty grinder. Also offering angle grinder, construction tool, demolition hammer, diamo more........Malleswaram, Bengaluru
No 21/1,16 Cross,sampige Road,Malleshwara,
Bengaluru - 560003, Karnataka
- Royal Corporation, Chennai
Royal Corporation, ChennaiVerified Supplier
Wholesaler & trader of heavy duty grinder, heavy duty grinders. Also offering crimp height micrometer, tool boxes & dew point more........Malleswaram, Chennai
No. 14/4, Mclean Street,
Chennai - 600001, Tamil Nadu
- Aar Kumar & Co.
Aar Kumar & Co.Verified Supplier
Manufacturer of heavy duty grinder, internal grinding machine, universal milling machine, sharpening machine, internal grinde more........Malleswaram, Panchkula
No.465 & 417- A, Industrial Area, Phase 1,
Panchkula - 134113, Haryanahttp://www.indiamart.com/aarkumarcompany/Get Best Quotes 9953358640Panchkula
Micro Protect Engiequipments Pvt. Ltd.Verified Supplier
Trader & supplier of heavy duty grinder. Also offering air compressors, air dryer, air line accessories, automotive pneumatic more........Naroda, Ahmedabad
C 1- 6A, G.I.D.C. Estate, Near Deep Premises, Near Parry Steel, Naroda,
Ahmedabad - 382330, Gujarat
- Fusion Technical Services (india) Private Limited
Fusion Technical Services (india) Private LimitedVerified Supplier
Trader & supplier of heavy duty grinder. Also offering balancers, battery operated tools, eco friendly anti-spatter spray, el more........Naroda, Chennai
No. 126, Buvana Commercial Complex, Poonamalle High Road, Velapanchavadi,
Chennai - 600077, Tamil Nadu
Pneumatic EquipmentsVerified Supplier
We are a leading manufacturer of heavy duty vertical grinders. Also offering heavy duty straight grinder & air grinders. more........Kolkata
B- 59A/H/3, Madan Mohan Burman Street,
Kolkata - 700007, West Bengal
Rb Pneumatic Tools Pvt. Ltd.Verified Supplier
Manufacturer & exporter of venus grinder. Also offering breaker demolition tools, chippers and scalers, chisel sets & drill m more........Ghatkopar West, Mumbai
C/15, Ghatkopar Industrial Estate, L.B.S. Marg, Ghatkopar(West),
Mumbai - 400086, Maharashtra
- B & B Engineering Works
B & B Engineering WorksVerified Supplier
We are a leading manufacturer & supplier of heavy duty grinder. Also offering bench grinder, electric motor, electric motor m more........Ghatkopar West, Ahmedabad
L- 458/ 459, G. I. D. C., Near Water Tank, Odhav,
Ahmedabad - 382415, Gujarathttp://www.indiamart.com/bbengineering-works/Get Best Quotes 9953353538Ahmedabad
- Sri Kathyayeni Enterprises
Sri Kathyayeni EnterprisesVerified Supplier
Leading trader & supplier of heavy duty die grinder dw887, heavy duty grinder, angle grinder, blowers, chopsaws, corded drill more........Ghatkopar West, Chennai
H-23, Central Avenue, Korattur,
Chennai - 600080, Tamil Nadu


text:
19 Listings:
Business Solutions for every ANGLE from every ANGLE.
John Rowley Team
Angle Business Services
Rahway, NJ
Full service auto and tire center business, with over $775,000 in annual sales. This facility has been in existence for 50 years, with the present owners operating it for over 30 years. This business is located on a well- traveled county road just a few hundred yards away from the main entrance to one of NJ's largest companies. Building on the existing profitability would be easy for an ambitious person, due to the fact that various auto services such as heavy engine or transmission work are not performed. The annual sales DON'T include any customizing work, stereo and security systems, remote starts, or any other add-on devices. There is obviously great room for expansion into these areas if desired! We have a considerable customer base due to the unique location and years in business. We have an excellent reputation for honest work, superior customer service, name brand products, and competitive prices. We have a consistent flow of business and have very little advertising costs! This facility is also unique due to the fact that a separate car wash/detail center and separate used car sales business also exist at this location. These operations complement each other and truly make this a full service center. The business has 2 service bays with lifts, as well as an outside service area. All equipment is included in the sale with items such as portable lift, hydraulic jacks and bumper jack, 2 tire machines, wheel balancer, diagnostic scanners, brake lathe machine, various tools and all office equipment. The building is approximately 1500 sq. ft. with 2 offices, 2 baths, (1 Handicap accessible), and storage. THIS SALE IS FOR BUSINESS AND EQUIPMENT. PROPERTY MAY BE AVAILABLE.* WITH PROPERTY PURCHASE, THE RENTS COULD EXCEED $10,000.00 ! Owner would stay on for a considerable time in order for a smooth transition! Call 732-547-5528
Union County, NJ
4 MPDS & Canopy located on a corner of a major road. No brand and average margin is 14-18 cents per gallon. Does average if 125,000 g/ month and kiosk does an average of $300-400 a day. Very lucrative location and very reasonable rent. The Station will be sold only the gas part not the mechanic .The office area is for the gas part of the lease. Station has long lease and cheap rent. Has 3 tanks of 6 k each.don't miss this opportunity .
Independent Gas Station and C-Store with the real estate, located in Northern New Jersey on US State Highway 1 & 9, in Union County and in the Elizabeth / Linden area. The business has gross sales of 1,250,000 gallons yearly which includes gas and diesel. The business assets have an estimated value of approximately $550,000 which consists of a fully equipped commercial gas station and retail C-Store, including, four fuel pumps, three underground tanks, displays, shelving, POS system, canopy, two islands, four fuel pumps, computers, software including all the necessary equipment to maintain the day to day business operation and a list of assets will be supplied to purchaser upon request. This particular business has two employees who are unaware of the pending sale and fully expected to remain post-closing, monthly payroll $3,400. This sale transaction will not include a lease, the property is included in the sale. The business consists of a free stranding facility with two islands, four pumps with a capacity for ten vehicles at one time. The facility has appropriate private mall parking on site as part of the commercial lease. The business is active seven days per week, with hours from 6:00 am to 10:00 pm. The sale includes a certificate of occupancy from the particular municipality and the required state or city licenses to conduct its day to day business. This is a dependable business opportunity and based on the asking price, required down payment and yearly net income, this business expects to supply a consistent investment return to the owner operator prior to debt service. The 2015 yearly gross income is $212,000 and the business has a yearly net income of approximately $110,000 based on an owner operator and prior to debt service. This business transaction has been valued at $1,300,000 based on a multiple of the net yearly income, real estate value of approximately $650,000 and the value of the specific business assets and seller financing has been approved to a qualified buyer with an appropriate down payment, collateral and credit rating. Please do not disturb business, this sale is absolutely confidential, the employees are Unaware of the pending sale, all viewings are by appointment only and photo does Not represent this particular business opportunity.
Branded Gas Station with very busy mechanic shop. Current owner is not a mechanic so he is renting the shop but current mechanic has no lease. The fact sheet is only reflecting how much your cash flow will be if you run the station with mechanic shop. The mechanic shop will be a part of the whole business when the station is sold. Gas deposit is required in the amount of 25K. Franchise approval is also required. Station has 4 MPDs (New) and also brand new tanks.
No Brand Gas station with 4 MPDS and canopy .Does around 100,000 G/M as an average. Located on a busy road and busy corner. Tanks are double wall fiber glass and the station is in very good shape. Has c-store that used to be 7-11 . But previous owner elect not to renew his FA WITH 7-11. station does work on high margin. No supply agreement. Has 3 tanks 20 k regular, 10 k diesel, 10 k super. Station sell diesel as well, new owner can get home accounts and increase the business lease 8 years PLUS 2x5 years option and property is for sale as well .
Note: This Gas Station is available without convenience store as well. Please call the broker for more information.
Join Dunkin Donuts in a newly remodeled 76 Gas station. Station has 3 MPDs and sell diesel. Around 1200 s/f Convenience store with good volume and good lottery commission. Current owner is working on high margin at least 25 cents /gallon. ATM also does very well. Current owner is going back overseas for good. Very good opportunity for family business owner operator. Good corner and there is Dunkin Donuts on the premises but not including in the sale.
Roselle Park, NJ
Unbranded gas station for sale
Union, NJ
This independent-unbranded Gas and Diesel dispensing station is prominently located on one of NJ's heavily traveled major highway in Union County. A break down of the amount shown as Gross Income is actually a combination of Gross Margin (gas/diesel) and Gross Income from other sources. Monthly Average Profits from Gasoline and Diesel sales are approx. $20,950. There is no fuel supply agreement to deal with. Supplementary income of $5,200+ represents sales of soft drinks, motor oil, air pump charges, etc.) This station features an extremely busy 3-bay repair facility, rented on a month-to-month basis to a local popular mechanic for $3,500 per month.
This advantageous location, on an approx. 0.75 acre lot, enjoys an exceptionally low overhead. Total monthly rent of $5,500 is offset by the 3-bay lease, which requires the mechanic to also share other operating expense (i.e., utilities and taxes). The result is that Average Monthly Operating Expense will run a bit over $11,000, thus contributing to a remarkably high net cash flow to the owner. Bottom line - this owner enjoys almost a quarter of million dollars per year.
This station must be viewed to realize its unique business qualities.
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What does NHRHS stand for?
NHRHS stands for Northern Highlands Regional High School
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posted on: 4/19/13
I'm urgently seeking someone fluent in Illustrator who can help me with a project *this weekend*.
This involves a simple layout and graphics for a health communication booklet, which will be tested with a focus group early next week. I've had some help and have made a decent start, but continuing alone is too time consuming as I'm really learning Illustrator from scratch.
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