text:
Interested in a career here at ScanSource? A great first step is participating in our Professional Internship Program. A ScanSource internship offers a way for students to prepare for their future after college. Paid internship opportunities are available for undergraduates who are rising seniors in the areas of sales, merchandising, marketing, accounting, finance, legal, or technical support. As a ScanSource Professional Intern, students will receive a dedicated mentor, an opportunity to explore career paths through our Walk-A-Mile program, and a celebration luncheon at the end of the summer - where they will have the opportunity to present to their mentors, managers, and the executive team. Other ScanSource Professional Internship advantages include participation in PULSE Talent Greenville to grow networking ties in the community, and free access to our on-site fitness center.
The ScanSource Professional Internship provides the ability for students to:
- Stephen Lukridge, 2016 Intern
Professional Intern candidates apply through all of the normal steps of any ScanSource candidate, including completing an application and interviewing for the internship during the spring semester. Internship opportunities are primarily available in the summer at the ScanSource headquarters in Greenville, SC - typically from the last week in May through the first week in August. Internship positions also may be available in our other US locations. Please contact Madison Skinner for those opportunities as well.


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Fantastic- who doesn't like the police raiding your house -around Christmas-Fantastic memories-And inbred cousins emptying their outhouse in your driveways-Comedy
Now, when did the General actually "marry" her current "wife"? If it was before DADT, she flat out lied. But, no matter, LGBTXYZLMNOPQ persons have donned the hood of "victimhood" and must be protected and promoted and you better fully accept and endorse their "lifestyle" or you are a bigot, racist, sexist, homophobe, and on and on it goes......YOUR beliefs be damned!! Even if one of your beliefs is the exact same belief nationally proclaimed by Hilary Clinton and Baraaak Obama: marriage is between a man and a woman!!
So now the Air Force and the Air Force Academy are going to hold up the General and "her wife" as totally wonderful role models for the 4,000 outstanding young men and young women cadets at my alma mater. I would bet that there are thousands of parents who thought they were sending the kids off to Colorado Springs to get a great moral education! Pity!
CongratulaionsGlad the word is spreading about you and your great cooking.
Hope you come to Arizona seasonally and grow your business even more. Spread that good food around
If my memory serves me correctly the original proposal for the street paving bid did include a 5 year warranty in the specs. What happened next is typical of a city that always puts the special interests before those of the citizens - the contractors raised a big stink and said they could not possibly make a big enough profit if they guaranteed the work for 5 years. City Council immediately caved to their demands. I don't need math to tell me if you let the bidders write your specifications and t.hen award to the lowest bidder the biggest winners are not the tax payers but the private contractors who have set themselves up with job security.
So, where does the process begin to remedy this awful situation at the Air Force Academy and likely the other Military Academies? While this problem "seems" more prevalent at AFA, how does anyone know if all sexual assaults are being reported at the USMA and USNA? We can be sure fear is a common denominator at each academy.
The next step MUST be taken to authenticate what is in this article which will not be easy. If, and I mean IF people's medical records have been falsified and cadets have been railroaded out of school, how can you trust anything coming from the AFA regarding any of this? You can be sure they will do everything to stonewall the release of information because of privacy laws, have records go missing, and anything else they can throw at you.
I am a retired Air Force NCO who was proud to serve so I'm no hater when it comes to the military. Do I take everything in this article as the gospel? No. But it's not totally fake news, either. This article absolutely sickened me because I have the highest regard for our military academies, warts and all, but this situation, if true, is way beyond warts and all. It's criminal and needs to be treated as such and needs to go back at least 10 years. You can be sure this attitude towards sexual assault and reporting sexual assault goes back much longer.
Ken Lucas
Actually Gary,I think many posed the same 'warranty' question you have asked. It was asked often.
The clue as to why the measure passed in what is basically a 'warranty free manner' is best found by logging onto the the City Website - going to Elections - going to "Nov 03 2015 Special Municipal Election" then - - going to Issue 2C - - going to "Springs Citizens Building the Future"
Why the hell would I want to offer a long-term warranty on my work when I know that the amount of my campaign contributions can sway the decision toward my NOT having to offer a warranty?
Councilman Bill Murray is right in asking for a longer warranty and he's also right that the city will never get ahead of the problem and mathematically it's impossible. The city will re-surface (note not re-build) 215 lane miles this season. Divide 215 into the total lane miles of the city and you'll arrive at the total numbers of years it will take to do one cycle of re-surfacing and not re-building roads. This will be longer than the life of the current tax and if extended, longer than the next tax. Also, that works out to $232,558/lane mile. Kind of pricey isn't it?
According to the Federal Highway Administration a two year "warranty" is the MINIMUM with no performance. In other words, the road can fail at anytime because a performance warranty was not required. Performance warranties begin at increments of 5, 10, 15, or 20 years. Detroit requires a 20 year performance warranty. The Europeans are going for 35 years. Why isn't Colorado Springs requiring a 20 year warranty?
I can understand the mayor's desire to stretch the dollars but what is gained if after year three the city has to go back and redo the roads of year one? i.e. No. Nevada between Fillmore and Garden of the Gods.
The question that arises now is, "Did the mayor get bad advice regarding road warranties or did he buy into a "tradition?" i.e. "We've alway done it that way." or "Two year is industry standard." If so, the driving public (aka taxpayers) got taken for a ride.
BTW The Centinnial extension is being built in a slide area. Look for that road to be a maintence nightmare because a 20 year performance warranty will not be part of the specifications.
The US Air Force has no mission. We spend gigabucks training people to do little or nothing to maintain our national defense. The Air Force jumps to address scandal after scandal because the troops are bored with nothing to do. Fold the Air Force back into the US Army from whence it came and we can save gigabucks scaling down an Air Force with nothing to do into an Army with lots to do. The only folks firing weapons at an enemy in the Air Force are the drone pilots sitting in air conditioned cubicles.
Last I heard is they'll be reopening in September. Super bummed, I only made it out there once and wanted to go back this weekend. Hope they had good insurance!
Kitty, You're exactly right. Stand by, everyone, for the demonization of everyone involved in the effort to shed light in this corrupt institution, just like they have done to the victims.
Davis, The only post without facts was yours. I wondered how long it would take for the 'pro-rape' team to rear its ugly head. Congratulations - it didn't take long at all.
You are so far on the wrong side of this issue you can't even see the truth from there.
What these government and agencies are doing is faulting chronic pain disease patients and our physicians for the overdoses and deaths of addicts.
With 100 million people who have a chronic pain disease, patients who become addicted to their medications is actually very low [.02-.6%]. We have legitimate prescription medications for diseases. The crisis is they are targeting patients and physicians. Physicians who still are trying to treat our chronic diseases. They are not allowing our physicians to treat us humanely, effectively and to the best of their ability. They are trying to doctor us all, without having a medical license. They are policing our physicians.
They need divert their efforts, from legitimate patients, to focus on the illegal fentanyl and heroin manufacturers and distributors, also, methamphetamine, cocaine and all other illegal drugs.
This distorted thinking and the false presumptions, that the cause of the opioid epidemic, is due to the overprescribing of much needed and beneficial medications, is causing havoc among physicians and patients. The hands of our physicians to treat us are being tied, due to the unfed imental and unfair laws they are trying to force upon them. We have our privacy invaded. There is no longer patient/doctor confidentiality.
The reports are stating how the number of prescription opioid medications have dropped, fairly significantly. Overdose deaths are on the rise. Logical thinking and knowledge at this point would tell you, this system is not working. It is the use of ILLEGAL opioids that are fueling this epidemic. Nowhere in the studies, headlines, reports or bills, are there talk, discussions or input, of the effects these laws will have on chronic pain disease of our physicians.
We pain disease patients are being abandoned, discriminated against and left to suffer with debilitating pain due to the stigma and laws being passed to condemn us and our physicians.
This targeting is wrong, it's discrimination against legitimate chronic pain disease patients, who use our MEDICATIONS responsibly.
Clearly using falsified records and mental diagnosis to control the narritive and provide a cover for the rape culture that seems to be a way of life at Air Force Academy. A whole system designed to discredit survivors and discourage reporting to protect attackers alnd obscure the Academy's real record of sexual assault means the institution itself is rotten. This is not a case of a few bad apples. This policy comes from the top. This fish stinks from the head.
The Academy continues to mistreat victims, and is now mistreating these whose job it is to care for and support them? What was reported in these articles is likely the tip of the iceberg, there is likely much more harm being done., all in the name of keeping the highly polished reputation of USAFA intact.
USAFA will justify their actions of course, and discredit the victims and those who speak up to support them rather than admit their wrongdoing, and fix what is so broken.
Mr. Davis,
You are incorrect in all your commentary. Per the FBI sexual assault is falsely reported no more than any other crime with about a 6 percent or less percent rate of false reporting. Your assertion regarding military rates of false reporting are not true. No such studies exist that show any findings of higher rates of false reporting in military populations.
The author has no "spin" on this article other than factual reporting. She has verified her story with carefully researched facts. This is a well written and thoughtful article..
Here is a researched fact for you, victims of sexual assault are frequently misdiagnosed with personality disorders. This often happens due to therapists who are not familiar with symptoms of trauma or the neurobiology of it., as well as intentional diagnosis given to have military members who are victims discharged from active duty. Neither of those are good outcomes. Thankfully there are therapies that are very effective in treatment of sexual assault and military sexual,assault,assault trauma., but it takes a skilled and educated provider to do so.
Thank you for your commentary as it is an opportunity to dispel misconceptions , myths, and untruths that are prevalent.
Correction: Sexual Assault Prevention and Response (SAPR).
Mr. Davis,
You have made a very strong accusation: "Study, after study, after study shows that the vast majority of accusations of sexual assault, especially in a military context, are false accusations."
The implication of that statement is that the premise of the Sexual Assault Response and Prevention (SARP) program is fraudulent. To make such a public claim, I challenge you to produce three citations of quality academic publications to support your allegation.
You have also claimed that "complaining accusers were diagnosed with personality disorders. This is significant." Did you not carefully read the articles? These diagnoses were made without proper evaluations. You publicly condemn these individuals without any valid evidence of their mental health. That is incredibly irresponsible and cruel.
You are the manifestation of the hatred and hostility that these victims face. No wonder they are petrified to come out publicly.
How far are we from the days when it took one person to accuse another of insanity to lock them away in an asylum?
R. David Mullin PhD CPA
What's the point in a voucher lottery when there is no affordable housing and the voucher promotes housing discrimination,racial profiling,and homelessness,equal opportunity housing means nothing when you are disabled living on section 8 and have a family,my house is being sold,we lived here 3 years,invested money in the yard ,because there was nothing but dirt and high weeds,we took care of the house as though it was ours, never ever late with rent and now no one will rent to us,I am stressed out to the max,we have money to move,but no one will rent to us.I can't sleep and barrel eat,I don't want my family to become another homeless statisic.
Well, I guess you don't really need honor and respect to be a drone pilot
This article is a demonstration of paranoid delusions on the part of the author.
There is not one single fact in this article that is not contaminated by the author's political "spin."
Study, after study, after study shows that the vast majority of accusations of sexual assault, especially in a military context, are false accusations.
Note that the complaining accusers were diagnosed with personality disorders. This is significant. People with Narcissistic personality disorder and Borderline Personality Disorder are highly likely to make false accusations. This is a scientific fact.

subset: commoncrawl


text:
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text:
It worked great. Thanks!
I have a 7 server openisp.net mysqlPostfix mail-gateway cluster and was having trouble knowing when a server was over-under loaded. Now it's easy!
Re: no images, just word "mailgraph" under every section
> OK. Just for the records, maybe others
> have Problems with this too...
> it's a Problem with syslog-ng
> Log-Files.
> There is a patch at bugs.gentoo.org but
> it does not work for me...
> Regards
> Niels
This is a known problem with the latest version of RRDtool and mailgraph. The author suggest that you downgrade to a 1.0x version of mailgraph until the issue is resolved. He said it is associated with COMMENT: not being escaped properly.
Re: no images, just word "mailgraph" under every section
OK. Just for the records, maybe others have Problems with this too...
it's a Problem with syslog-ng Log-Files.
There is a patch at bugs.gentoo.org but it does not work for me...
Re: no images, just word "mailgraph" under every section
I have the same Problem.
I have emerged it from gentoo-portage and compiled it by myself after the tutorial from:
I wonder what went wrong...
no images, just word "mailgraph" under every section
Hello all,
Any one have a tip for some one struggling a bit with this project.
I have what I think is this software up and running, well, almost, viewing the webpage gives me the word "mailgrph" two times under each section (ie: day, week, month, year). Why wouldnt it show the images?
Thanks so very much.
documentation, documentation, documentation
I love this project. I want to use it.
I have been a sysadmin for 6 years & using Linux for a only a couple years. I find the doc's for this project so very lacking that I can not figure out how to get this working on my system. This is only the second time in two years that I have been completely stumped on how to install something.
Please release a one page doc that says:
1. do this
2. then this
3. then this
4. then this
5. then this
6. done
Thank you very very much,
Jason Sjobeck
Unknown month 'ene'... my system is in Spanish...
I've copied the mailgraph.pl into my /var/www/cgi-bin directory.
Then chown'ed the file /var/log/syslog to root:apache and gave it read permission to the group.
Trying to browse http://192.168.0.1/cgi-bin/mailgraph.pl, I had errors.
Following is the result of
tail /var/log/httpd/error.log
[Wed Jul 10 22:07:18 2002]
[error] [client 192.168.0.5] Premature end of script headers: /var/www/cgi-bin/mailgraph.pl
unknown month ene
Parse::Syslog::next('Parse::Syslog=HASH(0x8081e50)') called at /var/www/cgi-bin/mailgraph.pl line 249
Parse::Syslog::main() called at /var/www/cgi-bin/mailgraph.pl line 416
[Wed Jul 10 22:09:21 2002]
[error] [client 192.168.0.5] Premature end of script headers: /var/www/cgi-bin/mailgraph.pl
I have Mandrake 8.1 running and my locales are es_UY.
ene is the abrrev. to 'enero' the month name of January in Spanish.
Re: mailgraph - initialization error
> Hello,
> maybe an outdated answer:
> Reinstall RRDtool from the .tar.gz
> sources and use
> 'make site-perl-install' too.
> Kind regards
That's it! It's already done - few weeks later from my first message - and now it runs! Thanks a lot. Maybe something to append at the "README" file in the future.... I have one more question: does "mailgraph" needs to run everytime - at boottime- to generate graphics for the .cgi/web page, or every hour/2hour, by cron? I did'nt figured out the relation between the rrd file and the availability of graphics update.
Re: mailgraph - initialization error
maybe an outdated answer:
Reinstall RRDtool from the .tar.gz sources and use
'make site-perl-install' too.
Kind regards
mailgraph - initialization error
I have already the linked packages - perl modules - needed, but i have a warning message saying: Can't locate RDS.pm in (mmany places where i have perl instaled. I'm using a RH 7.0 clone named Conectiva 7.0. Any sugestion would be appreciated.
An open, cross-platform journaling program.
A scientific plotting package.


text: Template:Sport Opinions and News Football Basketball Opinion Archive News Archive History member schools United States Air Force Academy Brigham Young University Colorado State University University of New Mexico San Diego State University Texas Christian University University of Nevada, Las Vegas University of Utah University of Wyoming 2006 football standings Template:Mountain West Conference Football Standings Small 2006-07 basketball standings Template:Mountain West Conference Basketball Standings Small Retrieved from "http://armchairgm.wikia.com/wiki/Mountain_West_Conference?oldid=28486" Ad blocker interference detected! Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers Wikia is not accessible if you've made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected.


text:
Let us know when your receive great advice so we can thank our lawyers and point others with similar questions in the right direction.Got it!
My wages are being garnished for $661 mo! Ive so far paid 1.5 months of payments. Am I entitled to the money I paid prior to filing, if so how do I obtain it. Also if I file and my employer still sends a payment, what steps do I take to retreive my money if I file pro se.
You need to contact the attorney for the creditor garnishing your wages and make sure they have notice of the bankruptcy so they can file a release of garnishment. You can also contact the court clerk where the garnishment was filed and find out how much money if any is the court registry in your case. You need to notify the court you filed for bankruptcy and see if they have any special procedure for getting the money back. You also need to make sure you disclose the money sitting in the registry on your schedules and exempt it if you can or the trustee could take it for the benefit of creditors.Ask a similar question
You would have to file an Adversary in the bankruptcy case to recover preferential payments but they may have to be surrendered to the chapter 7 trustee. You have to give notice of the bankruptcy filing to the local sheriff and your employer AND the creditor who filed the restraining notice to garnish your wages. Then, if they do not stop withholding, you may be able to sue them for contempt.
You filed Bankruptcy to get rid of debt and gain a "Fresh Start" but the creditors won't leave you alone even though you told them you filed! Here is what you should do! 1
Record the Communication
When you file Bankruptcy you are protected by a statute called the "Automatic Stay". Section "362" of the Bankruptcy Code is a 15 page statute that basically says that 1)No entity or person; 2) may commit any overt act (i.e. do anything) to; 3) gain possession or control of...4) property of the estate. All of your property is part of the bankruptcy so if someone violates your rights and communicates with you after you filed the case make sure you write down all of the information you can get from them. Name, real address and mailing address, website, corporate name and phone number and anything else your attorney needs to sue them!2
Check and Make Sure they are Listed!
Next, and before you contact your attorney, check the mailing matrix and especially Schedule F to make sure the creditor is listed! If the creditor is not listed then let your attorney know. The creditor will probably have to be added to the case!3
If the Creditor is Listed
If the creditor is listed write down a summary of the communication. Did the creditor threaten you? What did they say? Did you tell them you had filed Bankruptcy and did you give them the case number? How did all of this make you feel? Once you provide all of this information to your attorney they may have a basis to sue the creditor to enforce your rights! You spent a lot of time, effort, money and emotional capital to finally decide to file Bankruptcy. DO NOT allow abusive collection agencies or creditors take away the relief you felt during or after the case ended. Make a record and determine your rights!
Post bankruptcy discharge the same facts give rise to litigation because you are protected under section 524, or the discharge Injunction. Do all the things stated here and contact your attorney. You also have a right to go after the offender if you gave them actual notice of the bankruptcy and they ignored you.
REQUEST: Please give this answer a "thumbs up"(below) if you find it valuable.
Disclaimer: This answer does not constitute legal advice. I am admitted in the States of New York, New Jersey and Massachusetts only and make no attempt to opine on matters of law that are not relevant to those three States. This advice is based on general principles of law that may or may not relate to your specific situation. Facts and laws change and these possible changes will affect the advice provided here. Consult an attorney in your locale before you act on any of this advice. You should not rely on this advice alone and nothing in these communications creates an attorney client relationship. The opinions expressed herein are those of the author only and the fact that he has worked as an Assistant District Attorney; State Supreme Court Clerk; Special Assistant United States Attorney (Hawaii); Assistant Cornell University Counsel or Judge Advocate, United States Marine Corps should not be relied upon to assume that these statements reflect the policy of these organizations.Ask a similar question
Pro se cases almost never ever work. Ask the local Chapter 13 trustees about they feel about pro se cases. Your attorney fees for a bankruptcy attorney can be included in your Chapter 13 payment. At least take advantage of a free consultation with a local attorney and find out what your monthly payment would be if you filed.
I've posted a link to blog post I wrote about garnishments if you are interested.Ask a similar question
If you are pro se, you will likely never do the proper procedures to recover. If you have a lawyer, your odds get better, so call your lawyer on this.
Do NOT file a case pro se. That is almost always a disaster.Ask a similar question
Post a free question on our public forum.Ask a Question
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text:
|Message view
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|Johan Kok <j...@messianic.dyndns.org>
|Re: [NOTE] Skin status update
|Fri, 09 Jan 2004 09:52:19 GMT
Justus H. Piater wrote: >Marshall Roch <firstname.lastname@example.com> wrote on Thu, 08 Jan 2004 >16:48:01 -0500: > > > >>>- In the top part, could one separate the rounded-corner images from >>> the horizontal and vertical lines? This would remove the size limits >>> imposed by the current images (see the search box if you grow the >>> font size). >>> >>> >>I don't believe so. See the Sliding Doors[2] article on A List >>Apart. I don't think this is too big of a deal, since the images will >>be cached. I will make them longer to support more drastic font >>resizing. >> >> > >Good point. It drastically simplifies tab layout, and the images are >loaded only once. Moreover, the size difference is sub-proportional >with compressed PNG. > Just use SVG instead to get the autmatic sizing of the corners. > > > >>>- The menu bar has absolute width. It should be relative to font size. >>> >>> >>To get the background to go all the way down the side, you have to use >>a background image (which, obviously, is fixed-width). I agree, >>though, that it should be fluid, I just don't know if it's possible. >> >> > >Why not use a menu bar <div> with height=100% that is covered at the >top by whatever appears at the head of the page (header, tabs, ...)? >Then you don't even need an image. > There's cases where I would like to use an image, e.g. a watermark logo (even possibly using SVG) ... Just came across a site where I would like to do such, but has not ventured there yet. - Have an idea to try and use SVG. > >Justus > > >
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text:
Project Fame winner Monica Ogah teams up with Mr. Songz (formerly known as Harrysong) for a lovely romantic duet tagged "Obim Bunke Gi".
If you love good music and strong vocals this one is for you still we do not know what is happening to Ms. Ogah's project/album because we love talent so we are rooting for her.
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Upload ur songs @ waptrickmp3.peperonity.com


text:
Rush Hour (1998) Watch Movie Online on utvmovie.com. Quality :720p Bluray HD Director: Brett Ratner Stars: Jackie Chan, Chris Tucker, Ken Leung IMDb Ratings: 6,9/10 from 157.671 users Metascore: 60/100 Motion Picture Rating (MPAA) Rated PG-13 Genres:Action | Comedy | Thriller | Crime Country :USA Language: English | Cantonese | Mandarin Release Date: 18 September 1998 (USA)Subtitles: English Other Details: IMDb Rush Hour (1998) Plot:Cultures clash and tempers flares as the two cops named Detective Inspector Lee a Hong Kong Detective and Detective James Carter FBI, a big-mouthed work-alone Los Angeles cop who are from different worlds discovers one thing in common: they can't stand each other. With time running out, they must join forces to catch the criminals and save the eleven-year-old Chinese girl of the Chinese consul named Soo Yung.
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text:
Another Pirates of the Caribbean wallpaper including download.
One Article of Piracy stated: the captain shall have one full share and a half in all prizes. the Master, Carpenter, Boatswain, and Gunner shall have one share and quarter. This leaves it open how much everyone else got. It may be that every else got one share or may be that each person was instructed individually what they would get. Other things were also considered. Boarding parties might get a bonus share.


text:
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text:
This last week devoured me, luckily I came out alive. Let me explain, this past week has been finals week and I had a final project also due for one class. I don't understand the professors that have huge projects due on the day of the final AND a final on top of it. UGH> But now I'm done and officially on summer vacation! Yay!
I haven't been cooking anything lately since I've been studying for finals, but lets go back in time, shall we? To last weekend, my friends. I spent the weekend before my finals (not studying!) at my friend Megan's house up in Petaluma. She's one of my top five people. No joke. She's an amazingly loving person, AND she has amazing style. She takes my charity case shopping to find clothes that don't fit into these categories: jeans, t-shirts, sweats. Don't get me wrong, I'm not knocking anyone for wearing those things but it's seriously ALL I wear. I hate shopping, Megan loves it, so I make her pick out things for me to try on. It works out and I always end up with something adorable. The best part of this story is that she's married to my boyfriend's brother so she's kinda stuck with my horrific fashion-sense for the foreseeable future.
That weekend we cooked and watched a really really really old tv show, Roswell. Did anyone watch it besides us? I adore that tv show. I was so heart broken when it went off the air.
Anywhooo. We made this amazing pasta dish:I fully realize the picture isn't all that appetizing, but let me tell you the pasta itself was awesome. Angel Hair pasta with, basil, tomatoes, garlic, caramelized onions, and mozzarella. It was light and oh so flavorful. It would make a great summer dinner dish. The hot caramelized onions and warm noodles slightly wilted the basil making them even more fragrant and slightly warmed the fresh mozzarella. I happen to love balsamic vinegar so I poured some on top of mine as a sauce. If you like tangy, I'd go that route. Megan, however, doesn't like tangy, so she just ate the pasta by itself and said it was amazing that way too.
If summer would ever get here. It's only been reaching the high 60s low 70s here in California. I didn't sign up for this. Where'd my summer go?
Speaking of summer, this dish also makes an awesome cold pasta salad. Although, I might switch up the angel hair pasta for bow ties if I were going to use it as a cold pasta salad. Oh heck, I'd even put the bow ties in it if I were going to eat it hot. I like bow ties. They make pasta look classy and ready for a night out on the town.
Summer Pasta
4-6 servings
1 pound of pasta (angel hair, bow ties. Whatever floats your boat).
12 oz fresh mozzarella
1 bunch fresh basil
1 large onion
1 head of garlic (use as much or as little as you like. Megan and I loooooove garlic so I think we put about 3/4 of a head of garlic in our pasta :P)
3-4 Roma Tomoates
2 tbsp olive oil
Bring a large pot of salted water to a boil. While waiting for the water to boil, chop the onions and garlic. Heat up a the two tablespoons of olive oil in a pan. Cook the onions until they start to become translucent and then add in garlic. Continue cooking onions until they are delightfully caramelized. Add the pasta to the water once it boils.
While waiting for the pasta to cook and the onions to caramelize, chop up the tomatoes and mozzarella into chunks. Small, large, whatever floats your boat. If you want, mince some more garlic to throw in to the mix. If you like raw garlic that is. Rip the basil in to pieces. You could also use a knife.
Drain the pasta. Mix the pasta, basil, tomatoes, mozzarella, and caramelized onions together. Serve in bowls and dig in! You can also drizzle balsamic vinegar over it for a caprese salad kind of feel.


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|AJ ...@dude.podzone.net>
|Re: Strong Consistency with ONE read/writes
|Sat, 02 Jul 2011 23:58:49 GMT
On 7/2/2011 6:03 AM, William Oberman wrote: > Ok, I see the "you happen to choose the 'right' node" idea, but it > sounds like you want to solve "C* problems" in the client, and they > already wrote that complicated code to make clients simple. You're > talking about reimplementing key<->node mappings, network topology > (with failures), etc... Plus, if they change something about > replication and you get too tricky, your code breaks. Or, if they > optimize something, you might not benefit. > I'm only asking if this is possible working within the current design and architecture and if not, then why. I'm not interested in a hack; just exploring possibilities.
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SAM says...
Design advice from Susan Drover and the SAM Team
We had some fun today decorating the @OutoftheFogTV set for Halloween ! Tune in to @OutoftheFogTV to check it out!
It is the LAST WEEK for the @EQ3_Furniture 15% off upholstery sale at @SamDesignInc . You don't want to miss this! https://t.co/4tPpZsUuey


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Attempting suicide is not worth it. Just imagine how different your life would be in say a year and a half..even this time next year you might have even got some conditional offers to become a vet?
I just think you haven't give it much of a chance for you to show yourself your capabilities because you owe yourself that!
Hope your feeling much better now
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- 26-06-2010 01:14
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- 26-06-2010 01:26
To the OP, if you haven't already you need to discuss these feelings and events with your GP sooner rather than later. The sooner you mention it the sooner this can be dealt with.
In the mean time if you're feeling suicidal I urge you to either contact:
Samaritans: 08457 90 90 90
Papyrus: 0800 068 41 41
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- 26-06-2010 01:30
I am praying for you. Please put things into perspective and realise that suicide is a permanent solution to temporary problems.
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- 26-06-2010 01:34
Most painful slowest agonising way to go... Please dont put yourself through that...
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- 26-06-2010 01:35
Sorry, but untill you have experienced suicidal thoughts yourself you have no idea how hellish it can be for someone. How dare you accuse the OP of being selfish, you have no idea what you are talking about! If the OP decides not to take the overdose, it shouldn't be because he/she is worried about the remaining friends and family, instead it should be because he/she has realised that there is hope for a better future and that they should not give up. Even if the future doesn't seem bright and doesn't turn out that way, I still think that suicide is not the way to go, giving up is letting yourself fail. Give yourself a chance OP.
Personally what helps me is to have faith that God will bring me through. He gives me strength.
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- 26-06-2010 01:46
if you dont get the grades you were hoping for then dont lose faith! my friend really wanted to do vetinary but her grades werent good enough, and another for dentistry. they applied to do bio-med and then plan on switching to their preferable courses after a year or two
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- 26-06-2010 01:52
OP please get in touch with the Samaritans or go to A&E. You'd be wasting your life for one maths grade. Your parents would be losing a child for one maths grade.
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- 26-06-2010 03:10
Why the **** you need math to become a vet?
If you kill yourself, you would never become a vet anyways, so stop thinking about that. Think of examples mate, Abraham Lincoln failed so many times but ultimately achieved his goal and was respected, get inspired.
Talk about this and make up your mind that you won't kill yourself PLEASE!
Math is all about learning from basics, take separate extra class with your teacher and master the basics first, it will take some time but you'll get the hang of it sooner than later.
best of luck, keep us updated with your math progress and I am sure you'll become a fantastic vet
Keep yourself occupied to keep those suicidal thoughts off, do some veryyyy basic math, don't be ashamed to pick up a low level book to improve your level
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- 27-06-2010 09:42
I am sorry to hear that you are having such a tough time at the moment and that things are so difficult for you. You mention that you are worried that you won't be able to achieve your goal of becoming a vet and that you are having problems at school especially with the maths department. Is there anyone that you can talk to? Friends, family or teachers about how you are feeling, I know this can be very hard but they might be able to get you some help. You could also go to see your GP as there maybe things that they can suggest that you can help. If you don't feel that you can speak to anyone that you know would you be willing to contact the samaritans? Their details can be found here: http://www.samaritans.org/ and you can phone, text or email them. If you would like someone at the samaritans to call you if you get in touch with me via the PM system I can pass on your details to them.
If you have done anything which could harm yourself please contact NHS direct on 08457 4647 or go to A&E.
This thread is going to remain closed now. This is not because we don't care or we don't want to help you but because sometimes people make insensitive or dangerous replies to threads like this. We are not in the best position to help you with this but please talk to someone about how low you are feeling and if you would like me to call the samaritans and give them your details please get in touch
Updated: June 27, 2010
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What's so special about Boston couples?
Singles flock to Boston from across the country because of its educational and job opportunities, building up careers before making the commitment to a life partner.
hard to talk about
at a time when they are
expected to be
~Mimi Licht, "Before I do"
The Boston Globe, 12/16/07
Mimi Licht, LICSW, BCD, sees a pattern in the way people in Boston approach married life.
Young Bostonians tend to establish a professional identity before finding the one, moving in together and, when the biological clock starts ticking really loudly, getting engaged and setting the date.
Your ultimate goal is walking down the aisle together and, very often, setting the stage for parenthood. How to juggle two-career families, or how to handle career changes that may accompany parenthood after both of you have invested many years in your education and career, needs to be figured out.
Learning to share financial plans can be difficult for couples who have built up their own individual assets. And of course, giving up your life as you know it, as a single person, requires a major adjustment.
With Mimi, you will be able to share your premarital worries and get clearly focused feedback and help. By sharing this counseling experience, you will feel more confident when you become husband and wife, and you will establish a greater sense of trust in each other by the time you arrive at the altar.
Your engagement is the culmination of many years of studying, working, and planning. You want to savor every aspect of arriving at your special day. Saying I do should be so sweet, particularly if you have taken many years to turn the page to this next chapter in your lives.


text:
|No image available
|Tom Lingard
|Carrie Lingard
|Nellie Preston
| Ada Lingard (1913)
Mary Lingard (1921)
|First appearance
Tom Lingard moved into 13 Coronation Street with his wife Nellie and their daughter Ada in 1919. The house was let to the Lingards by Charles Hardcastle as a thank-you to Nellie for her faithful service at Hardcastle's Mill. A second daughter, Mary, was born in 1921.
Tom was a gardener and usually worked on council contracts. His biggest job was the re-development of the old Weatherfield Main Colliery site into a park surrounding the new Town Hall. The project wasn't completed until 1928. After this, Tom was due to begin a new landscaping job when he went missing on his way to work. On 30th January 1929, his body washed up at Blackpool's Central Pier, without any indication of what had happened to him.
- Tom first appeared in Daran Little and Bill Hill's "Weatherfield Life", published in 1992. Other information is derived from Little's follow-up book, "Around the Coronation Street Houses".


text:
Related Information
Additional Resources
Volume 18, Number 11—November 2012
CME ACTIVITY - Research
Invasive Pneumococcal Disease and 7-Valent Pneumococcal Conjugate Vaccine, the Netherlands
On This Page
Technical Appendices
Highlight and copy the desired format.
|van Deursen A, van Mens SP, Sanders E, Vlaminckx B, de Melker HE, Schouls LM, et al. Invasive Pneumococcal Disease and 7-Valent Pneumococcal Conjugate Vaccine, the Netherlands. Emerg Infect Dis. 2012;18(11):1729-1737. https://dx.doi.org/10.3201/eid1811.120329
|van Deursen A, van Mens SP, Sanders E, et al. Invasive Pneumococcal Disease and 7-Valent Pneumococcal Conjugate Vaccine, the Netherlands. Emerging Infectious Diseases. 2012;18(11):1729-1737. doi:10.3201/eid1811.120329.
|van Deursen, A., van Mens, S. P., Sanders, E., Vlaminckx, B., de Melker, H. E., Schouls, L. M....van der Ende, A. (2012). Invasive Pneumococcal Disease and 7-Valent Pneumococcal Conjugate Vaccine, the Netherlands. Emerging Infectious Diseases, 18(11), 1729-1737. https://dx.doi.org/10.3201/eid1811.120329.
Medscape, LLC is pleased to provide online continuing medical education (CME) for this journal article, allowing clinicians the opportunity to earn CME credit.
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and Emerging Infectious Diseases. Medscape, LLC is accredited by the ACCME to provide continuing medical education for physicians.
Medscape, LLC designates this Journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
All other clinicians completing this activity will be issued a certificate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 70% minimum passing score and complete the evaluation at www.medscape.org/journal/eid; (4) view/print certificate.
Release date: October 19, 2012; Expiration date: October 19, 2013
Learning Objectives
Upon completion of this activity, participants will be able to:
• Analyze previous research into the effects of 7-valent pneumococcal conjugate vaccine (PCV7)
• Compare the effects of PCV7 on different continents
• Distinguish age groups most affected by PCV7
• Evaluate the clinical presentation and outcomes of IPD after introduction of PCV7.
CME Editor
Claudia Chesley, Technical Writer/Editor, Emerging Infectious Diseases. Disclosure: Claudia Chesley has disclosed no relevant financial relationships.
CME Author
Charles P. Vega, MD, Health Sciences Clinical Professor; Residency Director, Department of Family Medicine, University of California, Irvine. Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.
Disclosures: Anna M.M. van Deursen; Suzan P. van Mens, MD; Bart J.M. Vlaminckx, MD, PhD; Hester E. de Melker; Leo M. Schouls; and Sabine C. de Greeff, MSc, have disclosed no relevant financial relationships. Elisabeth A.M. Sanders, MD, PhD, has disclosed the following relevant financial relationships: served as an advisor or consultant for Pfizer, GSK; received grants for clinical research from Pfizer, GSK. Arie van der Ende, PhD, has disclosed the following relevant financial relationships: served as an advisor or consultant for Pfizer, GSK; received grants for clinical research from Pfizer, GSK.
In the Netherlands, the national immunization program includes 7-valent pneumococcal conjugate vaccine (PCV7) for all newborns born after April 1, 2006. We compared the incidence of invasive pneumococcal disease (IPD) and patient and disease characteristics before PCV7 introduction (June 2004–June 2006) with those after PCV7 introduction (June 2008–June 2010). Culture-confirmed IPD cases were identified by 9 sentinel laboratories covering ≈25% of the Dutch population. Significant declines in overall IPD incidence were observed in children <2 (60%) and in persons >65 (13%) years of age. A trend toward gradual increases in non–PCV7 serotype IPD infections was observed in all age groups; the largest increases were among persons 50–64 (37%) and >65 (25%) years of age. In adults, the proportion of immunocompromised persons increased among IPD patients. Overall, deaths from IPD decreased from 16% to 12% because of a lower case-fatality rate for persons with non–PCV7 serotype IPD.
Streptococcus pneumoniae is a major cause of severe invasive infections, such as meningitis, invasive pneumonia, and other bloodstream infections. The highest incidence rates for such infections are for infants and elderly persons (1).
Since 2001, many high-income countries included the 7-valent pneumococcal conjugate vaccine (PCV7; Prevenar; Pfizer Pharmaceuticals, Pearl River, NY, USA) in their national immunization programs for newborns (2). In general, within a few years after the introduction of PCV7, the age group targeted for vaccination and unvaccinated adults showed a dramatic decrease in invasive pneumococcal disease (IPD) caused by the 7 vaccine serotypes (2–5). However, at the same time, the incidence of non-PCV7 serotype IPD increased (3,4,6,7).
The overall benefit of PCV7 varies by country, perhaps as a result of differences in surveillance methods and the maturity of vaccination programs (8). For all age groups, the overall reduction in IPD incidence is greater in the United States than in European countries; the great reduction in the United States is a result of a decrease in PCV7-serotype IPD in adults and less replacement of PCV7-serotype by non–PCV7 serotype IPD in children and older adults (3,4,7). The United States began using PCV7 in 2000, but many European countries did not begin using the vaccine until after 2005–2006, and they have experienced less protection from indirect herd protection (herd immunity). Furthermore, not all European countries implemented a catch-up program for children <5 years of age; catch-up programs speed up eradication of vaccine serotypes. Geographic variations in circulation of PCV7 serotypes before the implementation of routine vaccination also caused differences in the relative proportion of IPD covered by the vaccine (7,8).
In addition, the benefits of vaccination with PCV7 may have been biased, for example, by changes in the directive for blood culture after 2000, as in the United States (9,10), and by enhanced surveillance, as reported for England and Wales (4). Unlike studies in the United States, studies in Europe, particularly Dutch surveillance studies, have focused almost exclusively on patients requiring hospitalization for severe IPD and who often had other underlying illnesses (11,12). This difference in reporting leads to different baseline incidence rates and may affect the observed net benefit of vaccination (13). For example, compared with healthy persons of the same age, US adults with comorbid conditions benefited less from the indirect effects of PCV7 because of an increase in non–PCV7 serotype IPD after introduction of the vaccine (14). Differences in the directive for blood culture and patient populations under surveillance can partly explain the differences in results from use of PCV7.
The invasive disease potential of S. pneumoniae and the population at risk for IPD differs by serotype (12,13,15). Therefore, shifts in circulating serotypes may change the clinical manifestations of IPD, the population segment most at risk for infection, and the disease course and outcome. We investigated these issues and changes in IPD incidence in the Netherlands 4 years after a PCV7 vaccine program was implemented and compared our findings with those from the years just before introduction of the vaccine.
Pneumococcal Vaccination in the Netherlands
PCV7 was introduced into the Dutch national immunization program in June 2006 and was recommended for children born after April 1, 2006, at 2, 3, 4, and 11 months of age (16). Vaccination uptake is 94%–95% among Dutch infants (17). Use of the 23-valent pneumococcal polysaccharide vaccine is restricted to persons at high-risk for IPD (e.g., persons with asplenia or Hodgkin lymphoma); uptake in elderly persons is negligible (<1%) (18).
Surveillance Data
For this study, we registered all persons with a diagnosis of culture-confirmed IPD during June 1, 2008–May 31, 2010 (late post-implementation period) and all case-patients from previous Dutch IPD surveillance studies during June 1, 2004–May 31, 2006 (pre-implementation period) (1) and June 1, 2006–May 31, 2008 (post-implementation period) (11). All study procedures were the same as those used in the previous studies (11).
Nine sentinel laboratories identified IPD case-patients, which were defined as patients for whom S. pneumoniae was isolated from blood or cerebrospinal fluid (CSF) samples. The laboratories submitted all invasive pneumococcal isolates to the Netherlands Reference Laboratory for Bacterial Meningitis (NRLBM, Academic Medical Center, Amsterdam, the Netherlands) for typing and characterization. We selected the laboratories on the basis of their geographic distribution throughout the country and their reliability for submitting isolates (1,11). The laboratories were estimated to cover a representative cohort of ≈25% of the Dutch population (≈4.1 million inhabitants, including ≈0.6 million adults >65 years of age). In addition, ≈25% of the other meningitis-causing bacterial isolates that were submitted to NRLBM during the study period were submitted by the 9 sentinel laboratories.
At the NRLBM, co-agglutination was used to type the pneumococcal isolates and the capsular swelling method (Quellung reaction), using antisera (Statens Serum Institute, Copenhagen, Denmark), including serotype 6C, was used for serotyping. For isolates collected before June 2008, serotype 6C was determined by using PCR and antisera. The serotypes were grouped in either PCV7 serotypes (4, 6B, 9V, 14, 18C, 19F, 23F) or non–PCV7 serotypes (all other serotypes, including 6A).
Clinical Characteristics
Trained medical students, using a standardized data collection form, retrospectively extracted the following information for all case-patients from hospital records, as described (1,11): patient characteristics, clinical syndrome, comorbidity, and disease course and outcome. We subdivided comorbid conditions as immunocompromising or nonimmunocompromising and categorized clinical syndromes as meningitis, invasive pneumonia, bacteremia with other focus, and bacteremia without focus, as described (1). Information on disease course and outcome included the length of hospital stay, admission to an intensive care unit, and death (i.e., in-hospital death and/or death within 30 days after first reported blood/CSF culture positive for S. pneumoniae). Cases without clinical information were excluded from all analyses.
Statistical Analyses
National population coverage was ≈25% by the sentinel laboratories; thus, we estimated annual IPD incidence rates per 100,000 inhabitants by dividing the total number of IPD cases in a specific epidemiologic year by 25% of the total Dutch population. Epidemiologic years were defined as June 1st–May 31 of the succeeding year. We used the population on January 1 of each consecutive year as the population at risk for infection (StatLine, www.cbs.nl/en-GB/menu/cijfers/statline/zelf-tabellen-maken/default.htm), assuming a stable population throughout the year.
We assessed the effect of vaccination by determining the incidence rate ratio. The assessment was done by comparing incidences in the late post-implementation period (2008–2010) with those in the pre-implementation period (2004–2006); we also determined 95% CIs.
To evaluate any changes in population at risk, we compared the proportion of patients with comorbid conditions in the pre- and late post-implementation periods. We also determined changes in disease course (intensive care unit admission, median length of hospital stay, and death). Differences in percentages were compared by using the χ2 test, and differences in median length of hospital stay were compared by using the Mann-Whitney U test.
All analyses were stratified by age group (<2, 2–4, 5–17, 18–50, 50–64, and >65 years) and by serotype group (PCV7/non–PCV7). All p values <0.05 were considered statistically significant.
In the late post-implementation period (June 1, 2008–May 31, 2010), a total of 1,196 pneumococcal isolates from CSF and blood samples were submitted to the NRLBM by the 9 sentinel laboratories; this number compares with 1,297 and 1,352 isolates submitted during the pre- and early post-implementation periods, respectively. In the late post-implementation period, clinical characteristics were available for 1,144 (96%) case-patients, compared with 1,216 (94%) in the pre-implementation period and 1,304 (96%) in the early post-implementation period (Table 1).
IPD Incidence and Serotype Distribution
The overall incidence of IPD declined from 14.9 to 13.8 cases/100,000 persons during the pre- and late post-implementation periods, respectively (Table 1). A 60% decline in overall IPD incidence (from 35.0 to 14.1 cases/100,000 persons) was observed in children <2 years of age (i.e., children age-eligible for PCV7 vaccination). A similar but nonsignificant decline was seen in children 2–4 years of age. In the age group with the highest incidence rate, i.e., persons >65 years of age, the overall IPD incidence had a significant decline of 13% (from 57.7 to 49.9 cases/100,000 persons). IPD incidence rates remained unchanged in persons 5–64 years of age.
The overall decline of IPD incidences seen among persons <2 and >65 years of age from the pre- to the late post-implementation period resulted from declines in the incidence of PCV7-serotype IPD of 100% and 55%, respectively (Table 1); in children <2 years of age, no PCV7-serotype IPD cases were reported after June 1, 2008. Of 3 children (2–4 years of age) with PCV7-serotype IPD after June 1, 2008, 2 were born before April 1, 2006 and had not received PCV7. The third patient (2 years of age) experienced a vaccine failure; PCV7–serotype 19F IPD developed even though the child was fully vaccinated with 4 doses of PCV7. The child was previously healthy, without any comorbidity. Overall, infections with all PCV7 serotypes declined significantly, except for infection with serotype 18C, which was already low (Figure).
However, from the pre- to the late post-implementation period, the overall incidence of non–PCV7 serotype IPD increased by 33% (from 8.0 to 10.6 cases/100,000 persons) (Table 1). IPD incidence due to non–PCV7 serotypes showed an increasing trend in all age groups, and the increase was significant in patients 50–64 and >65 years of age. Non–PCV7 serotypes 1, 19A, 22F, and 23B increased significantly (Figure), although absolute numbers remained relatively small.
Clinical Characteristics
During all 3 study periods, surveillance data were primarily (97%–98%) for hospitalized IPD patients; the few exceptions were data for patients who visited a hospital emergency department and went home the same day. The distribution of clinical IPD manifestations among patients in different age groups did not change between the pre- and late post-implementation period (Table 2). In children <5 years of age, there was no decline in the incidence of meningitis because of an increase in non–PCV7 serotype meningitis in the late post-implementation period. In older children and adults, invasive pneumonia remained the most prevalent manifestation. The incidence of invasive pneumonia declined in the late post-implementation period in persons >65 years of age despite a significant increase in invasive pneumonia caused by non–PCV7 serotypes (Table 2).
Although the overall number of IPD cases declined from 1,216 in the pre-implementation period to 1,144 in the late post-implementation period, the number of IPD patients (all ages) with an immunocompromising condition increased from 216 to 255 (Table 3). This increase mainly occurred among persons >5 years of age, particularly among those >65 years of age. The number of PCV7-serotype IPD cases declined from 565 in the pre-implementation period to 268 in the late post-implementation period (all ages), and the number of patients with any comorbidity also showed a clear reduction. However, the number of immunocompromised persons with PCV7-serotype IPD declined only marginally (Table 3), indicating that persons with immunocompromising conditions may benefit less than others from herd immunity against PCV7-serotype IPD. This relatively marginal decline was seen for all PCV7 serotypes (data not shown). For non–PCV7 serotype IPD cases, there were similar increases in the number of infected immunocompromised patients and patients with any comorbidity. Moreover, at baseline a smaller proportion of immunocompromised (41%) than nonimmunocompromised (47%) persons had PCV7-serotype IPD (Table 4). Before and after introduction of PCV7, few children <5 years of age had a comorbid condition along with IPD (Technical Appendix Table [PDF - 136 KB - 3 pages]).
Despite the relative increase in immunocompromised patients with IPD, the overall death rate for IPD decreased significantly from 2.4 to 1.6 cases/100,000 persons. This decline in IPD-related deaths appears to be the result of 1) an overall decrease in the incidence of PCV7-serotype IPD and 2) a lower case-fatality rate among persons with non–PCV7 serotype IPD (Table 3). The lower death rate was seen in all age groups, but the decrease was significant only for patients >65 years of age. Moreover, a decrease in the case-fatality rate for non–PCV7 serotype cases was seen not only among otherwise healthy persons (decrease from 10% to 4%; p = 0.02), but also among immunocompromised persons (from 27% to 16%; p = 0.03) and/or persons with other comorbidities (from 19% to 14%; p = 0.03). Likewise, the median length of hospital stay for children >5 years of age and adults was significantly lower during the post-implementation period than in the pre-implementation period (Technical Appendix Table [PDF - 136 KB - 3 pages]).
Our findings show that 4 years after introduction of PCV7 in the Netherlands, the overall annual incidence of IPD decreased by 60% (from 35.0 to 14.1 cases/100,000 persons) among children <2 years of age, the age group targeted for vaccination; the decrease was a result of virtually complete eradication of PCV7 serotypes. In children 2–4 years of age, a 48% reduction was seen in IPD cases overall. A significant decline of 13% was also observed in persons >65 years of age. No significant decline in overall IPD was seen in persons 5–64 years of age because the decline in PCV7-serotype IPD was offset by a similar increase in non–PCV7 serotype IPD. The proportion of immunocompromised patients within PCV7-serotype IPD also increased. Despite these findings, the length of hospital stay and case-fatality rates declined over the last years. Our findings indicate that use of PCV7 in the Netherlands resulted in a major decrease in PCV7-serotype IPD among all age groups.
Our results for children are in line with those in England and Wales (4). However, among persons 5–65 years of age, the effect of herd immunity was less pronounced in the Netherlands than in England and Wales (4), where PCV7 was introduced around the same time as in the Netherlands (summer 2006), or in the United States 4 years after the introduction of PCV7 in 2000 (14). This difference can be partly explained by the absence of a catch-up campaign for children <2 years of age in the Netherlands. Young children are a primary reservoir for carriage and transmission of pneumococci because of prolonged colonization episodes related to their immature immune systems. Vaccination of toddlers in addition to newborns has a major effect on the speed of onset of herd immunity in the population. Therefore, by continuing surveillance in the Netherlands, we will likely see more reduction of PCV7-serotype IPD in the years after 2010. A major issue will be the rise in non–PCV7 serotypes, which is estimated by Choi et al. (19) to be ≈90% in England and Wales. Despite this large increase in non–PCV7 serotype IPD, it is expected that this will not offset the decrease in PCV7-serotype IPD in infants and elderly persons.
The decline of IPD cases among persons with immunocompromising conditions was limited compared with the decline among nonimmunocompromised persons. This result may be biased because the number of PCV7-serotype IPD cases in this group was relatively small before introduction of PCV7. However, the case-fatality rate for non–PCV7 serotype IPD in the post-implementation period declined among otherwise healthy persons and among those with comorbid conditions, suggesting a less severe course of disease, even in patients with serious immunocompromising conditions. Thus, even if the incidence of IPD decreased less in immunocompromised persons than in the general population, persons with immunocompromising conditions still appear to benefit from the vaccination program because of a reduction in case-fatality rates.
The reduced case-fatality rate for non–PCV7 serotype IPD since the introduction of PCV7 can be partly explained by a large increase in serotype 1 IPD. This invasive serotype is associated with a low case-fatality rate (12,15,20), which remained low (6%–8%) in the Netherlands during the study period. Case-fatality rates for the other individual serotypes also did not change significantly after introduction of PCV7. In line with a lower case-fatality rate, we also found a reduced length of hospital stay for patients with PCV7-serotype IPD and those with non–PCV7 serotype IPD. However, in the Netherlands, there has been a tendency toward shorter hospital stays, which along with other factors (e.g., improved hospital efficiency) may affect the finding of a reduced length of hospital stay for patients with IPD (21). For example, in 2006 a new financial system was introduced in the Netherlands that encourages shortening of the length of hospital stay.
In children, the increase in non–PCV7 serotype disease was most pronounced among patients with meningitis. Although the numbers were too small to yield significant differences, these data indicate that surveillance should be continued and special attention should be paid to patient characteristics and the evolution of serotype circulation over time.
The incidence of IPD caused by nonvaccine– S. pneumoniae serotypes 1, 19A, 22F, and 23B increased significantly after introduction of PCV7 in the Netherlands. The increase in serotype 19A has been consistently reported worldwide, especially increased carriage among children (22,23) and increased cases of serotype 19A–associated invasive disease (24) and otitis media (25–27). The role of PCV7 in promoting serotype 19A carriage in vaccinated children compared with unvaccinated controls has been shown (22,28). In many countries, the increase in serotype 19A disease is associated with high levels of penicillin resistance (24). In the Netherlands, only 1.8% of pneumococcal strains are reported to be resistant (29). The increase in serotype 22F was also seen in the United States and in England and Wales (3,4). The occurrence of serotype 1 was also shown to fluctuate and decline in presence of PCV7 (4). We did not see an increase in IPD caused by serotypes 6C and 15B/C, although increases have been reported elsewhere (3,4). On May 1, 2011, the Dutch government switched from the 7-valent to the 10-valent pneumococcal conjugate vaccine, which includes serotypes 1, 5, and 7F in addition to those in PCV7 (30). The 13-valent pneumococcal conjugate vaccine, which has not been introduced in the Netherlands, adds protection against serotypes 3, 6A, and 19A.
Surveillance artifacts resulting from enhanced surveillance and increased awareness after the introduction of the vaccine should be considered when evaluating the effects of the PCV7 vaccination program (4). However, adjustments for these artifacts can introduce new biases leading to over- and underestimation of the true effects of the vaccine. We believe there are no indications for enhanced surveillance and increased awareness in our study. The laboratory-based surveillance system remained unchanged during the study period, 2004–2010. Unlike the situation in England and Wales (4), the number of pneumococcal isolates obtained from CSF samples in the Netherlands remained stable during the years before PCV7 was introduced (Technical Appendix Figure 1 [PDF - 136 KB - 3 pages]). Moreover, the incidences of IPD caused by a great majority of non–PCV7 serotypes remained stable during the entire study period; the exceptions were for IPD caused by serotypes 1, 19A, 22F, and 23B (Technical Appendix Figure 2 [PDF - 136 KB - 3 pages]). If enhanced surveillance had taken place, one would expect an increase in the reported number of IPD cases caused by any of these serotypes. Thus, we made no corrections for increased case ascertainment or awareness in this study.
Our study does have limitations. First, the study periods before and after implementation of the vaccine program were relatively short; this may have caused an overestimation or underestimation of our results. To account for a proper transition period, we did not include June 2006–May 2008 in our comparisons because no clear conclusions could be drawn from this period. Second, changes in IPD epidemiology could have been influenced by variations in the seasonal influenza and the influenza A(H1N1)pdm09 virus epidemics in 2009 (31,32). Last, no data were available on the national prevalence of comorbidities/diseases. Thus, we could not evaluate IPD incidence rate ratios for the 3 patient groups in our study: otherwise healthy persons, persons with any comorbidity, and persons with immunocompromising conditions.
The results of this study show that PCV7 use has reduced the number of IPD cases and deaths in children <2 years of age (the age group targeted for vaccination) and in persons >65 years of age. However, after introduction of PCV7, cases of IPD caused by non–PCV7 serotypes increased significantly among elderly persons, and the proportion of immunocompromised persons with IPD increased. Despite these increases, the overall IPD case-fatality rate among patients >65 years of age decreased, which seems to be a positive consequence of shifts in circulating serotypes after introduction of a pneumococcal conjugate vaccine for infants.
Ms van Deursen is a doctoral candidate at Utrecht University; this manuscript was part of her doctoral research project. Her research interests include the effectiveness of pneumococcal conjugate vaccinations on invasive pneumococcal disease and more common respiratory infections in vaccinated and unvaccinated populations.
We thank all involved medical students for making data collection possible and all participating hospitals and sentinel laboratories for their cooperation.
This study was supported by an unrestricted research grant from Pfizer Pharmaceuticals. The sponsor played no role in the study design, data-analyses, and preparation, review, or approval of the manuscript.
E.A.M.S. has received grant support from Pfizer and GlaxoSmithKline for research on pneumococcal infections for pneumococcal vaccine studies; grant support from Baxter for research on immunodeficiency disease; consulting fees from Pfizer and GlaxoSmithKline; and lecturing fees from Pfizer and GlaxoSmithKline. E.A.M.S. is involved in Independent data monitoring committees for Pfizer and GlaxoSmithKline vaccine studies. A.v.d.E. has received grants from Pfizer for research on pneumococcal infections.
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- Brueggemann AB, Peto TE, Crook DW, Butler JC, Kristinsson KG, Spratt BG. Temporal and geographic stability of the serogroup-specific invasive disease potential of Streptococcus pneumoniae in children. J Infect Dis. 2004;190:1203–11. DOIPubMed
- Lexau CA, Lynfield R, Danila R, Pilishvili T, Facklam R, Farley MM, Changing epidemiology of invasive pneumococcal disease among older adults in the era of pediatric pneumococcal conjugate vaccine. JAMA. 2005;294:2043–51. DOIPubMed
- Weinberger DM, Harboe ZB, Sanders EA, Ndiritu M, Klugman KP, Ruckinger S, Association of serotype with risk of death due to pneumococcal pneumonia: a meta-analysis. Clin Infect Dis. 2010;51:692–9. DOIPubMed
- van Oosten M, de Greeff SC, Spanjaard L, Schouls LM. Introduction of pneumococcal conjugate vaccine into the Dutch national immunisation programme. Euro Surveill. 2006;11:E060608.2.PubMed
- van Lier EA, Oomen PJ, Oostenbrug MWM, Zwakhals SLN, Drijfhout IH, de Hoogh PAAM, Vaccinatiegraad rijksvaccinatie programma Nederland; Verslagjaar 2009 [cited 2012 Jan 5]. http://www.rivm.nl/bibliotheek/rapporten/210021010.pdf
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- Figure. . . . . . Serotype distribution of invasive pneumococcal disease in the Netherlands before and after (early and late) introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). The 7...
- Table 1. Incidence of invasive pneumococcal disease before and after implementation of a PCV7 vaccination program, the Netherlands, June 2004–May 2010
- Table 2. Incidence of invasive pneumococcal disease manifestations before and after implementation of a PCV7 vaccination program, the Netherlands, June 2004–May 2010
- Table 3. Characteristics for persons with invasive pneumococcal disease before and after implementation of a PCV7 vaccination program, the Netherlands, June 2004–May 2010
- Table 4. Proportion of vaccine-type and nonvaccine type invasive pneumococcal disease cases before and after implementation of a PCV7 vaccination program, the Netherlands, June 2004–May 2010
Technical Appendix
Follow Up
Earning CME Credit
To obtain credit, you should first read the journal article. After reading the article, you should be able to answer the following, related, multiple-choice questions. To complete the questions (with a minimum 70% passing score) and earn continuing medical education (CME) credit, please go to www.medscape.org/journal/eid. Credit cannot be obtained for tests completed on paper, although you may use the worksheet below to keep a record of your answers. You must be a registered user on Medscape.org. If you are not registered on Medscape.org, please click on the New Users: Free Registration link on the left hand side of the website to register. Only one answer is correct for each question. Once you successfully answer all post-test questions you will be able to view and/or print your certificate. For questions regarding the content of this activity, contact the accredited provider, firstname.lastname@example.com. For technical assistance, contact email@example.com. American Medical Association's Physician's Recognition Award (AMA PRA) credits are accepted in the US as evidence of participation in CME activities. For further information on this award, please refer to http://www.ama-assn.org/ama/pub/category/2922.html. The AMA has determined that physicians not licensed in the US who participate in this CME activity are eligible for AMA PRA Category 1 Credits™. Through agreements that the AMA has made with agencies in some countries, AMA PRA credit may be acceptable as evidence of participation in CME activities. If you are not licensed in the US, please complete the questions online, print the certificate and present it to your national medical association for review.
Article Title:
Invasive Pneumococcal Disease and 7-Valent Pneumococcal Conjugate Vaccine, the Netherlands
CME Questions
1. You are seeing a 2-month-old infant whose parents have multiple questions regarding the effects of the 7-valent pneumococcal conjugate vaccine (PCV7). What does previous research demonstrate regarding the efficacy of PCV7?
A. PCV7 primarily reduces the risk of otitis media among children
B. PCV7 has no effect on the rate of invasive pneumococcal disease (IPD) among adults
C. PCV7 has no effect on the rate of IPD among young children
D. The rate of non-PCV7-serotype IPD increased after introduction of PCV7
2. What else should you consider as you discuss PCV7 with these parents?
A. IPD incidence has declined to a greater degree in Europe vs the United States
B. Catch-up vaccination programs for children under 5 have sped up eradication of vaccine serotypes
C. The greatest indirect benefit of PCV7 is found among older adults with comorbid conditions
D. PCV7 contains serotype 1, which is the most common serotype implicated in IPD
3. As you continue your conversation regarding PCV7, which age groups from the current study can you tell these parents experienced the greatest decline in the incidence of IPD?
A. 2 to 4 years of age and 5 to 12 years of age
B. 0 to 2 years of age and middle-aged adults
C. 0 to 2 years of age and 65 years or older
D. 21 to 35 years of age and 50 to 64 years of age
4. What can you tell these parents regarding characteristics of IPD in the current study?
A. IPD incidence due to non–PCV7-serotypes increased among young children but fell among adults
B. Pneumonia was the most common infection related to IPD among children less than 5 years of age
C. PCV-7 appeared particularly effective in reducing IPD among immunocompromised individuals
D. The overall mortality rate associated with IPD declined during the study period
Activity Evaluation
1. The activity supported the learning objectives.
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2. The material was organized clearly for learning to occur.
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3. The content learned from this activity will impact my practice.
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4. The activity was presented objectively and free of commercial bias.
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DOI: 10.3201/eid1811.120329
1These authors contributed equally to this article.
2These authors contributed equally to this article.
3Additional members of the Invasive Pneumococcal Disease Sentinel Surveillance Laboratory Group are listed at the end of this article.
Members of the Invasive Pneumococcal Disease Sentinel Surveillance Laboratory Group: Karola Waar, Izore, Centre for Infectious Diseases Friesland, Leeuwarden, the Netherlands; Bert Mulder, Laboratory of Medical Microbiology Twente Achterhoek, Enschede, the Netherlands; Caroline Swanink, Department of Medical Microbiology and Medical Immunology Hospital Rijnstate, Arnhem, the Netherlands; Bram Diederen, Regional Laboratory of Public Health, Haarlem, the Netherlands; Niek Arents, Laboratory for Pathology and Medical Microbiology, Veldhoven, the Netherlands; Ine Frénay, Regional Laboratory for Medical Microbiology and Infectious Diseases, Dordrecht–Gorinchem, the Netherlands; Hans Wagenvoort, Atrium Medical Center, Heerlen, the Netherlands; Bartelt de Jongh, St. Antonius Hospital, Nieuwegein, the Netherlands; Lodewijk Spanjaard, Academic Medical Center, Amsterdam, the Netherlands
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text:
S'Lek Varen was a corporation that resided on Vulcan.
Founded on Stardate 1/1212.17 and based at Shuridar, the organization was chartered by the Securities and Exchange Commission with its CEO being Sehrtor. S'Lek Support Systems chief product was starship auxilliary systems production and its division head was Sheriv. Its products were intended for both civilian and military use though S'Lek Varen tended to contract only through the Vulcan government. However, it did also work as a sub-contractor for other less specialized ship builders on cooperative projects. (FASA RPG module: The Federation)


text:
G7 sell yen to help Japan
The G7 nations have agreed to help Japan lower its soaring currency by selling yen, in an effort to aid its disaster-hit industries.
The US, UK, European Central Bank and Canada have agreed to off-load some of their yen holdings to help the Bank of Japan bring the yen down from its highest level against the greenback since World War II.
The move started at 11:00am (AEDT) and had immediate effect - the US dollar rose from being worth 79.18 to 81.04 Japanese yen, while the Australian dollar also surged from 77.85 to 79.9 Japanese yen shortly after the concerted intervention started.
The Bank of Japan's governor Masaaki Shirakawa issued a statement, expressing confidence that the coordinated action would return stability to foreign exchange markets.
"The Bank of Japan strongly expects that Japan's concerted action with G7 member countries in the foreign exchange market will contribute to the stable formation of foreign exchange rates," he noted.
"The Bank of Japan will pursue powerful monetary easing and, to ensure stability in financial markets, will continue to provide ample liquidity."
However, Japan's foreign minister, who was on the conference call with his G7 counterparts, has refused to reveal the size of the currency market intervention.
The Australian dollar has also risen above the greenback, to 98.5 US cents.
The bechmark Nikkei share index was up 2.5 per cent by 11:13am as Japanese exporters welcomed the intervention, which will help make their products more competitive.
TD Securities' Singapore-based senior strategist Roland Randall says it is vital for Japan to successfully stabilise its currency at a lower level to prevent further financial damage to manufacturers that have already suffered physical damage and disruptions.
"Japan is a trading nation, so it does rely on exports for much of its gross domestic product, and exports are made more expensive when your currency appreciates, so a weaker currency means that your customers get a better deal, and they want to buy more from you rather than from your competitors," he explained.
He says the coordinated approach was vital, as even the Bank of Japan did not have enough clout to successfully take on global financial markets by itself.
"Anything that was attempted by the Bank of Japan unilaterally would probably have been very expensive and very ineffective," Mr Randall told ABC News Online.
"So it's a very strong statement, it's a psychological boost to the Bank of Japan and the Japanese Government's efforts to try and stabilise its currency and financial markets and return confidence to those markets."
He says it is most likely the Bank of Japan itself that kicked-off the yen sell-off, but it is likely other central banks will join in later as part of the coordinated approach.
"At this stage we believe it's only the Bank of Japan doing this, but we think it will be a fairly relentless process through the Asia session and then onto the London and North American sessions," he said.
"So we'll probably see waves of selling of the yen throughout the next 24 hours, and that should push the yen much weaker against most of the major currencies, particularly of course against the US dollar."
Topics: currency, business-economics-and-finance, money-and-monetary-policy, international-financial-crisis, japan
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text: Going on a Rim to Rim, South Kaibab to Bright Angel Loop or Indian Garden Trip? If you are hiking along any of the main trails Grand Canyon National Park calls the "corridor" trails, this is the map for you. Ths map includes South Kaibab, Bright Angel and North Kaibab Trails.


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