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Flower - Rotational Puzzle - Hryahlavolamy
Product Information
|Mix up the pieces and put them back to the start
|Level 10 - Mind Boggling
|Other Rotational Puzzles
|3 in x 3 in x 3 in / 7.5 cm x 7.5 cm x 7.5 cm
|Plastic Clamshell
Product Description
The Flower is made from with a hard white plastic core. The object of this puzzle is to scramble up all 12 colors and then organize them back to the starting position. This puzzle is unique because any piece can be interchanged with any other piece, as they are all the same shape. The Flower is manufactured by Hryahlavolamy.
Customer Reviews |Write your own review!
Disclaimer: These reviews are written by our customers. Puzzle Master makes every attempt to keep these posts informative and relevant. If you find a post objectionable or inappropriate, please let us know by sending an email to email@example.com
On Tuesday February 28th Luke wrote,
I don't actually own this, but I can easily get it by taking the edges out of my Pyraminx Crystal. You don't need to spend $17 on this when the Pyraminx Crystal is only around $8.
On Monday November 2nd Griffin wrote,
Fun little puzzle, emphasis on little. It's basically a miniature centreless edgeless megaminx. Very stiff until you mess around with the tension, but then it turns quite nicely. A little small fro my hands but a fun puzzle nonetheless.

subset: commoncrawl


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Trick Bolt #2
Product Information
|Remove the Ring
|Level 7 - Challenging
|Puzzle Master
|Other Wire / Metal Puzzles
|3.9 in x 1.2 in x 1.2 in / 9.9 cm x 3 cm x 3 cm
Product Description
Yet another variation of the Trick Bolt #1, this new design is also made from solid brass and looks just like the real thing. Can you remove the ring by finding out how to take the nut from the bolt? If you solved the previous version, it won't help you in solving this one, since both mechanisms are completely different. This one is in fact a bit easier, but don't let that fool you, as you might be in for a surprise. Produced by our own brand PuzzleMaster.
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It is a clever idea but this puzzle is too easily solved by just wiggling things about at random. You will find more satisfaction if you spend time observing it and trying to mentally figure it out before physically manipulating it.


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Other Proposed Uses
- Acute Anterior Uveitis
- Aging Skin
- Allergies
- Asthma
- Autism
- Bedsores
- Bladder Infections in Pregnancy
- Cancer (Prevention)
- Cancer (Treatment)
- Cataracts
- Colds (Treatment, Not Prevention)
- Easy Bruising
- Gallbladder Disease (Prevention)
- Glaucoma
- Heart Disease (Prevention)
- HIV Support
- Hypertension
- Insomnia
- Low Sperm Count
- Macular Degeneration
- Maintaining Effectiveness of Nitrate Drugs
- Menopausal Symptoms
- Minor Injuries
- Muscle Soreness after Exercise
- Osteoarthritis
- Photosensitivity
- Pneumonia
- Preeclampsia (Prevention)
- Reflex Sympathetic Dystrophy (RSD) (Prevention)
- Sunburn (Prevention)
- Vascular Dementia (Prevention)
- Ulcers
- Weight Loss
Probably Not Effective Uses
Although most animals can make vitamin C from scratch, humans have lost the ability over the course of evolution. We must get it from food, chiefly fresh fruits and vegetables. One of this vitamin's main functions is helping the body manufacture collagen, a key protein in our connective tissues, cartilage, and tendons.
From ancient times through the early nineteenth century, sailors and others deprived of fresh fruits and vegetables developed a disease called scurvy . Scurvy involves so-called scorbutic symptoms, which include nonhealing wounds, bleeding gums, bruising, and overall weakness. Now we know that scurvy is nothing more than vitamin C deficiency.
Scurvy was successfully treated with citrus fruit during the mid-1700s. In 1928, when Albert Szent-Gyorgyi isolated the active ingredient, he called it the anti-scorbutic principle, or ascorbic acid. This, of course, is vitamin C.
Vitamin C is a powerful antioxidant that neutralizes damaging natural substances called free radicals. It works in water, both inside and outside of cells. Vitamin C complements another antioxidant vitamin, vitamin E , which works in lipid (fatty) parts of the body.
Vitamin C is the single most popular vitamin supplement in the United States and perhaps the most controversial, as well. In the 1960s, two-time Nobel Prize winner Dr. Linus Pauling claimed that vitamin C could effectively treat both cancer and the common cold. Subsequent research has mostly discounted these claims, but hasn't dampened enthusiasm for this essential nutrient. The vitamin C movement has led to hundreds of clinical studies testing the vitamin on dozens of illnesses; at present, however, no dramatic benefits have been discerned.
Vitamin C is an essential nutrient that must be obtained from food or supplements; the body cannot manufacture it. The official US and Canadian recommendations for daily intake are as follows:
- 0-6 months: 40 mg
- 7-12 months: 50 mg
- 1-3 years: 15 mg
- 4-8 years: 25 mg
- 9-13 years: 45 mg
- 14-18 years: 75 mg
- 19 years and older: 90 mg
- 14-18 years: 65 mg
- 19 years and older: 75 mg
Pregnant Women
- 18 years old or younger: 80 mg
- 19 years and older: 85 mg
Nursing Women
- 18 years old or younger: 115 mg
- 19 years and older: 120 mg
Note : Smoking cigarettes significantly reduces levels of vitamin C in the body. 1 The recommended daily intake for smokers is 35 mg higher across all age groups.
Vitamin C supplements are available in two forms: ascorbic acid and ascorbate. The latter is less intensely sour.
Most of us think of orange juice as the quintessential source of vitamin C, but many vegetables contain as much or even more. The National Institutes of Health's Office of Dietary Supplements offers this list of foods that are high in vitamin C: 188
One great advantage of getting vitamin C from foods rather than from supplements is that you will get many other potentially healthful nutrients at the same time, such as bioflavonoids and carotenes. However, vitamin C in food is partially destroyed by cooking and exposure to air, so for maximum nutritional benefit you might want to try freshly made salads rather than dishes that require a lot of cooking.
Vitamin C Deficiency
Scurvy, the classic vitamin C deficiency disease, is now a rarity in the developed world, although a more subtle deficiency of vitamin C is fairly common. 2-6 According to one study, 40% of Americans do not get enough vitamin C. 7 In fact, vitamin C deficiency sufficient to cause bleeding problems during surgery turns out to be more common than previously thought. 141
Aspirin and other anti-inflammatory drugs might lower body levels of vitamin C, 8-10 as might oral contraceptives . 11-15 Supplementation may be helpful if you are taking any of these medications.
Therapeutic Dosages
Ever since Linus Pauling, proponents have recommended taking vitamin C in enormous doses, as high as 20,000 mg to 30,000 mg daily. However, some evidence suggests that there might not be any reason to take more than 200 mg of vitamin C daily (10 to 100 times less than the amount recommended by vitamin C proponents). 16 The reason is that if you consume more than 200 mg daily (researchers have tested up to 2,500 mg) your kidneys begin to excrete the excess at a steadily increasing rate, matching the increased dose. Your digestive tract also stops absorbing it well. The net effect is that no matter how much you take, your blood levels of vitamin C don't increase very much.
However, there are some flaws in this research. It is possible that vitamin C levels might rise in other tissues even if they remain constant in the blood. Furthermore, this study did not evaluate the possible effects of taking vitamin C several times daily rather than once daily.
Many nutritional experts recommend a total of 500 mg of vitamin C daily. This dose is almost undoubtedly safe. Others recommend that you take as much vitamin C as you can, up to 30,000 mg daily, cutting back only when you start to develop stomach cramps and diarrhea. This recommendation seems based more on a semi-religious enthusiasm for the vitamin C than on any evidence that such huge doses of the vitamin are good for you.
Intravenous vitamin C can easily raise vitamin C levels to a level 140 times higher than the maximum achievable with oral vitamin C. 152 However, there is no meaningful evidence that intravenous vitamin C provides any medical benefits.
Therapeutic Uses
According to numerous double-blind, placebo-controlled studies, regular use of vitamin C supplements can slightly reduce symptoms of colds and modestly shorten the length of the illness. 17,18,146,185 However, taking vitamin C at the onset of a cold probably does not work. 83,140, 185
Regular use of vitamin C does not seem to help prevent colds. 86,146,185 One exception is the "post-marathon sniffle"—colds that develop after heavy exercise. 19,20 Vitamin C may be helpful for preventing this condition, although not all studies agree. 153
A review of 3 randomized studies involving 2,335 people found that vitamin C may reduce the risk of pneumonia in adolescents and adults, . 187 The benefits of vitamin C appeared to be largely restricted to people at an increased risk of getting pneumonia and those with low dietary intake of the vitamin. The authors concluded that the widespread use of supplemental vitamin C to prevent pneumonia was not supported by their review.
Two double-blind studies suggest that the use of vitamin C combined with vitamin E might slightly reduce the risk of developing preeclampsia , a complication of pregnancy. 21,169 However, a much larger follow-up study failed to find benefits. 170
Two studies conducted by a single research group have found that vitamin C at a dose of 500 mg daily might help prevent reflex sympathetic dystrophy, a poorly understood condition that can follow injuries such as fractures. 110,180
Over time, the body develops tolerance to drugs in the nitrate family (such as nitroglycerin ). Some evidence suggests that use of vitamin C can help maintain the effectiveness of these medications. 142-145
Other small double-blind trials suggest that vitamin C might be helpful for anterior uveitis (when taken in combination with vitamin E ), 52autism , 40easy bruising , 29minor injuries , 41 protecting the liver in nonalcoholic steatohepatitis, 154 speeding recovery from bedsores, 37 treating female infertility (specifically, a condition called "luteal phase defect"), 155 and preventing early rupture of the chorioamniotic membranes ("the water breaking") in pregnancy . 156 Vitamin C might also improve the effectiveness of antibiotic treatment for Helicobacter pylori , the cause of most peptic ulcers . 179 Given the limited nature of this research, however, further studies are needed to conclude that vitamin C is beneficial for these conditions.
Preliminary evidence suggests that cream containing vitamin C may improve the appearance of aging or sun-damaged skin . 50,51,157 Inconsistent evidence suggests that oral or topical vitamin C, taken by itself or in combination with vitamin E , may also help protect the skin against sun damage. 42-49
Double-blind studies of vitamin C for the following conditions have yielded mixed results: asthma , 30, 178male infertility , 38,39 reducing the muscle soreness that typically develops after exercise, 36,176,177 and hypertension . 31-35,147,148Note : Unexpectedly, one study found that a combination of vitamin C (500 mg daily) and grape seed oligomeric proanthocyanidins (OPCs) (1,000 mg daily) slightly increased blood pressure. 158 Whether this was a fluke of statistics or a real combined effect remains unclear.
Limited and in some cases contradictory evidence suggests possible benefit in the prevention or treatment the following conditions:
- Allergies56-58
- Atrial fibrillation following coronary artery bypass grafting (CABG) 182
- Bladder infections during pregnancy181
- Gallbladder disease (in women) 53
- General anesthetics 171
- Glaucoma149
- Gout172
- Obesity173-175
- Vascular dementia54
Intravaginal use of vitamin C tablets might be helpful for non-specific vaginitis. 159
Observational studies indicate that people with a higher intake of vitamin C have a lower incidence of macular degeneration , heart disease , cancer , and osteoarthritis . 22-27,59-66 However, these findings do not indicate that vitamin C supplements will help prevent or treat these conditions. Observational studies are notoriously unreliable for showing the efficacy of treatments; only double-blind studies can do that. (For more information on why double-blind studies are so important, see Why Does This Database Rely on Double-blind Studies? ) Two large double-blind trials exploring the effectiveness of vitamin C for heart disease prevention—one in women at high risk 181 and the other in men at low risk— 183 failed to find any benefit at all.
Vitamin C has been proposed as a treatment for cancer, but this claim is very controversial, and there is as yet no scientifically meaningful evidence that it works. 67-70
Massive doses of vitamin C have at times been popular among people with HIV infection based on highly preliminary evidence. 71,72 An observational study linked high doses of vitamin C with slower progression to AIDS. 73 However, a double-blind study of 49 people with HIV who took combined vitamins C and E or placebo for 3 months did not show any significant effects on the amount of HIV detected or the number of opportunistic infections. 74 Furthermore, one study found that vitamin C at a dose of 1 g daily substantially reduced blood levels of the drug indinavir, a protease inhibitor used for the treatment of HIV infection. 160 This could potentially cause the drug to fail.
A large, 8-year trial involving 11,545 physicians aged 50 years and older concluded that vitamins C and E, alone or in combination, did not lower the risk of cataracts . 186
In a study of 80 women with Chlamydia trachomatis infection, adding vitamin C to doxycycline and triple sulfa vaginal cream reduced discharge and pain associated with intercourse. 184
One substantial study failed to find vitamin C useful for improving high cholesterol . 161
According to a double-blind, placebo-controlled study of 141 women with cervical dysplasia (early cervical cancer), vitamin C, taken at a dosage of 500 mg daily, does not help to reverse the dysplasia. 75
Vitamin C also does not appear to be helpful for treating Raynaud's phenomenon caused by scleroderma . 150
What Is the Scientific Evidence for Vitamin C?
As the most famous of all natural treatments for the common cold , vitamin C has been subjected to irresponsible hype from both proponents and opponents. Enthusiasts claim that if you take vitamin C daily, you will never get sick, while critics of the treatment insist that vitamin C has no benefit at all.
However, a cool-headed evaluation of the research indicates something in between. Numerous studies have found that vitamin C supplements taken at a dose of 1,000 mg daily or more throughout the cold season can modestly reduce symptoms of colds and help you get over a cold faster, but they do not generally help prevent colds. 81,83,146,162,185
Most studies on vitamin C have evaluated the potential benefits to be gained by taking vitamin C throughout the cold season. A review of 29 placebo-controlled trials involving over 11,000 people found that the use of vitamin C in this way can reduce symptoms and decrease the duration of colds. 185 Other studies have found similar results. 81,83
Many people use vitamin C for colds in a different way: they only begin taking it when cold symptoms start. Vitamin C is probably not effective when used in this way. 83,140,185 One double-blind trial enrolled 400 individuals with new-onset cold symptoms, and divided them into four different daily vitamin C dosage groups: 30 mg daily (a dose lower than the minimum daily requirement, and used by the researchers as a placebo), 1,000 mg, 3,000 mg, or 3,000 mg with bioflavonoids. 140 Participants were instructed to take the vitamin at the onset of symptoms and for the following 2 days. The results showed no difference in the duration or severity of cold symptoms among the groups. High-dose vitamin C taken at the onset of a cold, in other words, didn't help. A review of 7 randomized and non-randomized trials also found that taking vitamin C at the start of a cold did not offer any benefits. 185 The bottom line: If you want to use vitamin C to take the edge off your colds, take the supplement throughout the winter.
There are numerous other natural treatments for the common cold as well, some of which may be more helpful than vitamin C. For more information, see the full Colds and Flus article.
Although two relatively recent studies suggest that regular use of vitamin C throughout the cold season can help prevent colds, 167-168 they suffer from a variety of flaws, and most other studies have found little to no benefit along these lines. 146
However, people who are truly vitamin C-deficient, such as elderly people in nursing homes, may show increased resistance to infection if they take vitamin C (or other nutrients). 86
In addition, vitamin C might be helpful for preventing the respiratory infections that can follow heavy endurance exercise. Marathon running and similar forms of exertion can temporarily weaken the immune system, leading to infections. Vitamin C may be helpful. According to a double-blind, placebo-controlled study involving 92 runners, taking 600 mg of vitamin C for 21 days prior to a race, made a significant difference in the incidence of sickness afterwards. 87 Within 2 weeks of the race, 68% of the runners taking placebo developed cold symptoms versus only 33% of those taking the vitamin C supplement. As part of the same study, non-runners of similar age and gender to those running were also given vitamin C or placebo. Interestingly, the supplement had no apparent effect on the incidence of upper respiratory infections in this group. Vitamin C seemed to be effective in this capacity only for those who exercised intensively!
Two other studies found that vitamin C could reduce the number of colds experienced by groups of people involved in rigorous exercise in extremely cold environments. 88 One study involved 139 children attending a skiing camp in the Swiss Alps, while the other enrolled 56 military men engaged in a training exercise in northern Canada during the winter months. In both cases, the participants took either 1 g of vitamin C or placebo daily at the time their training program began. Cold symptoms were monitored for 1 to 2 weeks following training, and significant differences in favor of vitamin C were found.
However, one very large study of 674 US Marine recruits in basic training found no such benefit. 89 The results showed no difference in the number of colds between the treatment and placebo groups.
What's the explanation for this discrepancy? There are many possibilities. Perhaps basic training in the Marines is significantly different from the other forms of exercise studied. Another point to consider is that the Marines didn't start taking vitamin C right at the beginning of training, but waited 3 weeks. The study also lasted a bit longer than the positive studies mentioned above, continuing for 2 months; maybe vitamin C is more effective at preventing colds in the short term. Of course, another possibility is that it doesn't really work. More research is needed to know for sure.
Preeclampsia Prevention
Preeclampsia is a dangerous complication of pregnancy that involves high blood pressure, swelling of the whole body, and improper kidney function. A double-blind, placebo-controlled study of 283 women at increased risk for preeclampsia found that supplementation with vitamin C (1,000 mg daily) and vitamin E (400 IU daily) significantly reduced the chances of developing this disease. 96
While this research is promising, larger studies are necessary to confirm whether vitamins C and E will actually work. The authors of this study point out that similarly sized studies found benefits with other treatments, such as aspirin, that later proved to be ineffective when large-scale studies were performed. Furthermore, keep in mind that we don't know whether such high dosages of these vitamins are absolutely safe for pregnant women.
Cancer Treatment
Cancer treatment is one of the more controversial proposed uses of vitamin C. An early study tested vitamin C in 1,100 terminally ill cancer patients. One hundred patients received 10,000 mg daily of vitamin C, while 1,000 other patients (the control group) received no treatment. Those taking the vitamin survived more than four times longer on average (210 days) than those in the control group (50 days). 102 A large (1,826 subjects) follow-up study by the same researchers found a nearly doubled survival rate (343 days versus 180 days) in vitamin C-treated patients whose cancers were deemed "incurable," as compared to untreated controls. 103 However, these studies were poorly designed, and other generally better-constructed studies have found no benefit of vitamin C in cancer. 104,105 At the present time, vitamin C cannot be regarded as a proven treatment for cancer.
Reflex Sympathetic Dystrophy
Reflex sympathetic dystrophy (RSD) is a set of symptoms that can develop in the legs, arms, feet, and hands after fractures and other injuries. Also called complex regional pain syndrome (CRPS), symptoms include changes in skin temperature and color over the affected area, accompanied by burning pain, sensitivity to touch, sweating, and limitation of range of motion. The cause of RSD is unknown, and the condition is very difficult to treat.
Two studies performed by a single research group reported evidence that vitamin C can help prevent RSD after wrist fractures. 110,180
In one of these, a total of 123 adults with wrist fractures were enrolled and followed for one year. 110 All were given 500 mg of vitamin C or placebo daily for 50 days. The results showed significantly fewer cases of RSD in the treated group.
A subsequent study conducted by the same research group compared placebo against three dosages of vitamin C in 416 people suffering from wrist fracture. 180 Again, treatment continued for 50 days. The results indicated that approximately 10% of those given placebo developed RSD, while less than 2% of those given either 500 mg or 1,500 mg of vitamin C daily did so. According to the statistical analysis used by the authors, this relative benefit was statistically significant. The 200 mg dose of vitamin C did appear to offer some protection too, but not as much.
Easy Bruising
A 2-month, double-blind study of 94 elderly people with marginal vitamin C deficiency found that vitamin C supplements decreased their tendency to bruise . 111
Hypertension (High Blood Pressure)
According to a 30-day, double-blind study of 39 individuals taking medications for hypertension , treatment with 500 mg of vitamin C daily can reduce blood pressure by about 10%. 112 Smaller benefits were seen in studies of individuals with normal blood pressure or borderline hypertension. 113,114,148 However, other studies have failed to find any significant blood pressure-lowering effect. 115,116,147 This mixed evidence suggests, on balance, that if vitamin C does have any blood pressure-lowering effect, it is at most quite small.
Maintaining the Effectiveness of Nitrate Drugs
Nitroglycerin and related nitrate medications are used for the treatment of angina. However, the effectiveness of these medications tends to diminish over time. According to a double-blind study of 48 individuals, use of vitamin C at a dose of 2,000 mg 3 times daily helped maintain the effectiveness of nitroglycerin. 142 These findings are supported by other studies as well. 143-145
Note : Angina is too serious a disease for self-treatment. If you have angina, do not take vitamin C (or any other supplement) except on a physician's advice.
Safety Issues
The US government has issued recommendations regarding tolerable upper intake levels (ULs) for vitamin C. The UL can be thought of as the highest daily intake over a prolonged time known to pose no risks to most members of a healthy population. The ULs for vitamin C are as follows:
- 1-3 years: 400 mg
- 4-8 years: 650 mg
- 9-13 years: 1,200 mg
Males and Females
- 14-18 years: 1,800 mg
- 19 years and older: 2,000 mg
Pregnant Women
- 18 years old or younger: 1,800 mg
- 19 years and older: 2,000 mg
Nursing Women
- 18 years old or younger: 1,800 mg
- 19 years and older: 2,000 mg
However, even within the safe intake range for vitamin C, some individuals may develop diarrhea. This side effect will likely go away with continued use of vitamin C, but you might have to cut down your dosage for a while and then gradually build up again.
Concerns have been raised that long-term vitamin C treatment can cause kidney stones . 129,130,163 However, in large-scale observational studies, individuals who consume large amounts of vitamin C have shown either no change or a decreased risk of kidney stone formation. 131-133 Still, there may be certain individuals who are particularly at risk for vitamin C-induced kidney stones. 134 People with a history of kidney stones and those with kidney failure who have a defect in vitamin C or oxalate metabolism should probably restrict vitamin C intake to approximately 100 mg daily. You should also avoid high-dose vitamin C if you have glucose-6-phosphate dehydrogenase deficiency, iron overload, or a history of intestinal surgery.
Vitamin C supplements increase absorption of iron . 121-128,164 Since it isn't good to get more iron than you need, individuals using iron supplements shouldn't take vitamin C at the same time except under a physician's supervision.
One study from the 1970s suggests that very high doses of vitamin C (3 g daily) might increase the levels of acetaminophen (such as Tylenol) in the body. 135 This could potentially put you at higher risk for acetaminophen toxicity. This interaction is probably relatively unimportant when acetaminophen is taken in single doses for pain and fever, or for a few days during a cold. However, if you use acetaminophen daily or have kidney or liver problems, simultaneous use of high-dose vitamin C is probably not advisable.
Weak evidence suggests that vitamin C, when taken in high doses, might reduce the blood-thinning effects of warfarin (Coumadin) and heparin . 136-139
As noted above, one study found that vitamin C at a dose of 1 g daily substantially reduced blood levels of the drug indinavir, a protease inhibitor used for the treatment of HIV infection. 165
Heated disagreement exists regarding whether it is safe or appropriate to combine antioxidants such as vitamin C with standard chemotherapy drugs. The reasoning behind the concern is that some chemotherapy drugs may work in part by creating free radicals that destroy cancer cells, and antioxidants might interfere with this beneficial effect. 76,166 However, there is no good evidence that antioxidants actually interfere with chemotherapy drugs, but there is growing evidence that they do not. 77,79,151
The maximum safe dosages of vitamin C for people with severe liver or kidney disease have not been determined.
Interactions You Should Know About
If you are taking:
- Aspirin , other anti-inflammatory drugs, or oral contraceptives : You may need more vitamin C.
- Acetaminophen (eg, Tylenol) : The risk of liver damage from high doses of acetaminophen may be increased if you also take large doses of vitamin C.
- Warfarin (Coumadin) or heparin : High-dose vitamin C might reduce their effectiveness.
- Iron supplements: High-dose vitamin C can cause you to absorb too much iron. This is especially a problem for people with diseases that cause them to store too much iron.
Medications in the
family: Vitamin C may help maintain their effectiveness.
Note : Angina is too serious a disease for self-treatment. If you have angina, do not take vitamin C (or any other supplement) except on a physician's advice.
- Protease inhibitors for HIV: High-dose vitamin C may reduce their effectiveness.
- Cancer chemotherapy : Do not use vitamin C except on physician's advice.
Revision Information
- Reviewer: EBSCO CAM Review Board
- Review Date: 12/2015 -
- Update Date: 12/15/2015 -


text: Wednesday, August 15, 2012 HHS Releases Final Guidance for Exchanges Yesterday, the Department of Health and Human Services' (HHS) Center for Consumer Information and Insurance Oversight released the final Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges. Most qualified health plans offered in these exchanges must offer plans that included the 10 mandatory categories of essential health benefits as mandated by the Affordable Care Act, which include rehabilitative and habilitative services. The guidance sets out timelines and requirements for state exchange documents (ie, "blueprints") each state must file with HHS. The document explains what type of exchange the state will run and how it will comply with the requirements. A complete blueprint and declaration letter (specifying the chosen exchange model) must be submitted no later than November 16 for states seeking to operate a state-based or state partnership exchange for plan year 2016. Those states that submit letters more than 20 business days before the submission of their blueprints may request additional consultation and support from the Centers for Medicare and Medicaid Services to assist in blueprint preparation. States that intend to operate in a federally-facilitated exchange but retain control of their own reinsurance programs also must submit a declaration letter by November 16. HHS will begin plans to implement a fully federally-facilitated exchange in states that do not submit a blueprint and declaration letter before or by November 16. The final guidance was released in conjunction with the first of 4 regional implementation forums that HHS is holding this month in the District of Columbia, Atlanta, Chicago, and Denver.


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The Digital Library is a database of articles about successful VoiceThread projects. Our hope is to create a resource that offers guidance and inspiration for people undertaking new projects. Please contribute a VoiceThread to help the Digital Library grow.
All About Polar Bears - Kindergarten ESL by Monica Schnee
Monica Schnee taught a nonfiction social studies/science unit about polar bears. We spent a lot of time reading books, looking at websites, particularly National Geographic and Nature on PBS. They collected facts, a word that children learned in nonfiction. Then, each student chose a fact, wrote it and had to illustrate it like a true nonfiction illustrator.
Higher Ed Grammar Practice - Infinitive or Gerund?
Students practice grammar by forming sentences from a word cloud.
Language learners use VoiceThread to practice speaking - Bophany Huot, City College of San Francisco
This is a great example of how an ESL student can practice her computer skills and her language skills to talk about everyday activities. Students can practice speaking as many times as they like before they can show it to their teachers/classmates.
Using VoiceThread in an online course from Professor Russ Meade
VoiceThread "humanizes" the on-line classroom experience. As a college Professor, I teach all over the US exclusively asynchronously. One of the drawbacks of online learning has always been that the student feels isolated and unconnected with either his or her classmates...
Higher Ed from Della Curtis
An engaging discussion between graduate students looking to earn a master's degree in education. This example showcases the collaboration that can be captured in a VoiceThread between colleagues...
English/Lang Arts
Lubo's Dream - First Grade English by Katie Stover
First graders used VoiceThread to publish their writing to advocate for social justice with a wide audience beyond the four walls of the classroom.
The C.U.B. Process by Ellen Phillips
C.U.B. is a great strategy to use on any type of question and in any content area. It teaches students to analyze the question by breaking it down into smaller parts to make it easier to comprehend and answer.
"Chicago" Literary Analysis - by Vicki Phillips
6th grade - Connotations from Julie Combs
Students learn what "connotation" means and then come up with descriptive words for various images.
Book Review: A Single Shard by Linda Sue Park from C Vidor
This VoiceThread aims to make these elements a bit more familiar to students with brief explanations and interesting images. The VoiceThread also suggests ways in which some themes of the book are evident in the story's imagery.
2nd graders play I-Spy
The project incorporates many tech skills as well as many literacy skills into a fun project they children loved. The parents and teachers also loved sharing their students work.
Higher Ed analysis of Tim O'Brien's "The Things They Carried"
This VoiceThread encouraged my students to critically examine the story and post their insights for the entire world to see. I saw them go from being reluctant and nervous students to enthusiastic and totally engaged teachers of one another.
8th grade Historical Fiction from Shirley Scamardella
This picture book was written, illustrated and told by students. It was entered into the Scholastic Books, Kids are Authors Contest and it won Honorable Mention. I feel this is a good VoiceThread because this is the finished product of a two month project.
Poetry and Illustration from Constance Vidor
The Poetry and Illustration VoiceThread shows how illustration can be used to interpret and illuminate poetry written for young readers. It begins by showing illustrations by two different illustrators of Edward Lear's The Owl and the Pussycat.
Comparing J.S. Bach and Paul McCartney, Constance Vidor
The J.S. Bach and Paul McCartney VoiceThread introduces young learners to the great baroque composer by way of a comparison/contrast with a musician with whom they are more familiar.
1st grade - Reading Analysis from Leanne Windsor
This VoiceThread was a culmination of a project we did in library to get the children thinking about the books they were choosing to read and why they liked them. They were also learning about story structure...
Kindergarten Storybook from Leanne Windsor
This VoiceThread displays the illustrations that the children drew with author Alison Lester when she visited our school. We followed the pattern of her picture book series about children and what they are doing day to day.
4th Grade - Where I'm From Poems from Tara McCartney
Students shared personally significant poetry against a backdrop of their own self portrait. This VoiceThread gave students a chance to share their work orally, as well as to explore the cultural differences between our students in a safe environment.
12th Grade - A Day in the Life from Joanie Batts
These High-School seniors used VoiceThread to create the final segment to a school wide literacy project, "A Day in the Life of Dunnellon High School."
4th Grade - I Am Poems from Jackie Gerstein
The "I am" feedback project demonstrates a method for providing qualitative feedback to students' poetry: students began with a hands-on activity: the magnetic poetry, and later put it into a VoiceThread.
4th Grade English from Ms. Naugle
VoiceThread enabled my students to put their poems out in an audio format to be shared with others. They eagerly practiced their speaking fluency to get it "just right" because they wanted to impress their "audience".
4th Grade book-reading discussion from Krystina Kelly
This VoiceThread shows how a wide number of students from different classes and grades can use VoiceThread to have an asynchronous conversation about books.
Kindergarten reading from Heather Taylor
I think that this is a good project because the children are able to share some of their experiences with reading and talking about books at home.
7th Grade from Amy Cobb
This is a great example of what a VoiceThread can do when embedded in a blog: foster global conversation.
It's Hiding Up My Sleeve - 7th Grade English by Amy Cobb
This is a powerful reflection of a young girl's seventh grade experience. It tells a story using six photos that defined her middle school year.
3rd Grade from Alice Mercer
This VoiceThread demonstrates the use of features that are unique to the application. The creator has used both voice and text to "teach" the lesson.
Foreign Language
Les Cantines du Monde by Rachel Sabre
In this activity, students research photos of typical school lunches from around the world. They select five photos and upload them to VoiceThread, name the country and describe each photo. Finally, students upload a photo of their own typical lunch and describe it. They discuss what foreign lunch they like best and why, along with what changes they could make to their own lunch to make it more healthy. This is an end of unit assessment.
The Use of Works of Art in a 2nd Semester German Course by Dagmar Jaeger
This VoiceThread shows how students can engage with a work of art in an active, personal and innovative way while practicing new vocabulary and grammar structures in the target language.
Getting to Know Berlin in a 1st Semester German Course by Dagmar Jaeger
Compare Them: Chinese Grammar Practice for 9-12
Chinese language students practice comparative grammar.
Using a Bilingual Spanish-English Dictionary by David Thompson
VoiceThread is a tool that allows instructors to create on-line learning tutorials that are both content-rich and interactive. Not only can tutorials made with VoiceThread help students see concepts and processes better, they let students actively engage the concepts / processes. Interactive tutorials made with VoiceThread ask students to practice what they learn outside of class, so the instructor can observe their practice, respond with feedback, or modify classroom teaching to address students' needs.
Les sons des animaux (Animal Sounds) by Audrey Misiano
This multi-age global VoiceThread is an example of how you can create a project that can keep on growing with more and more participants from around the world. There are voices of children from pre-school all the way up to about 10 years of age involved in this project. It was very fun for the children to hear the voices of other children as they were added.
Grades 3-6 - Hindi
This VoiceThread was created as a homework assignment for STARTALK summer Hindi immersion camp for kids in grades 3rd thru 6th. Kids loved this homework, as no writing was involved, they could use the technology and it gave them good reading, listening and speaking practice.
10th grade Chinese language practice from Lilia Hurteau
VoiceThread can be used to teach Chinese in a high school setting. Students have to repeat the words and then make sentences with the new vocabulary. They record themselves and they have to be creative.
9th grade Chinese language lesson from James Rolle
VoiceThread provides a medium for this character-by-character explanation of a commonly used phrase in Chinese that students can listen to and learn on their own time.
11th grade - French fluency and history from Hassina Taylor
Students found that responding to my questions orally via the Internet was a great way to improve on their fluency, and they found it very challenging to use the visual cues to find answers. They concentrated much better and retained information because it is a "hands-on"...
3rd grade language "Les Trois Petits Cochons" from Mme Smith
Using VoiceThread, students realized the power of voice as a tool of expression. All students in the class were able to contribute to this VoiceThread presentation of a play they had learned.
Higher-Ed, Studying Abroad in Ecuador, David Thompson
This VoiceThread is a good example of digital storytelling for the purpose of reflecting on a study abroad experience.
7th Grade Spanish from Eve Millard
Learning a second or foreign language, these students are introduced to vocabulary via images or text, and engage in oral practice of the language.
Information Technology
Game Design by George Haines' 4th Grade Class
A group of 4th grade students were asked to design and create a level for a video game with clear objectives, challenges, and strategies, then had game designers review their submissions.
Higher Ed blogs in teaching from Kristen Kozloski, Ph.D.
We used blogging as a reflective practice in my course on Designing Multimedia for Learning. This is an example of our final reflection, as a class, of that blogging process.
Higher Ed online technologies from Jen Hegna
The goal of this project was to have each team member reflect upon tools we utilized to collaborate and complete our online project entitled - Disrupting TCS 702.
Feed the Fish - 1st Grade Math from Heather Reinbrecht
This VoiceThread is a great example of using technology to get children interested in a math lesson.
7th graders practice Math in Action from Ms Redd
VoiceThread showcases this great example of Math in Action. My students love the idea that they can comment on a video featuring one of their teachers and it feels like they aren't even doing math!!
7th Grade - Exploring Probability from Britt Gow
Students from two countries were able to comment on the slides which show images of probability problems. My students enjoyed this exercise and another teacher has used it in her class to extend each of the problems.
7th Grade - Measurement from Britt Gow
Year 7 students from Hawkesdale P12 college were able to share their knowledge with Grade 5/6 students from a Ballarat Primary School about measurement and ratio. Students were required to articulate their thinking...
Higher Ed teaching with technology from Ellen Dobson
This VoiceThread, entitled "Surfometry," was created by a student-teacher as an assignment for a "Computers in Education" course. The creator incorporated images, video and graphics into an engaging geometry lesson.
Professional Development
Group Wikis and Inclusion/Exclusion in Higher Ed - by the Learning Technologies Team at University of Durham
We are using the functionality of VoiceThreads to address a real problem for us as staff developers - how to share good teaching practice. By uploading videos describing the approaches and experiences of teachers, we are providing an easy to access resource for our lecturers to find out about the approaches and projects of their peers. By using the features of VoiceThread, we have captured the perspectives of teaching colleagues and students.
Language from Carla Arena
This professional-development instructor used VoiceThread to introduce new technology for education to her groups of educators.
Higher Ed Radiology Case Study from Heather Schmuck
This VoiceThread gives users a chance to critically think and problem solve a real life scenario. This specific VoiceThread is geared toward radiology students currently enrolled within a program who possess some knowledge of pathology and protocols.
9th graders write Children's stories about astronomy, Mrs. Edenstrom
I had all of my 9th grade science students do a Children's story about astronomy. They had to have facts, but tell it in a creative way that could be read and understood by elementary aged students! I had great success with this.
4th graders study plants in collaboration with Pakistani students
Students from the US collaborate with Pakistani students to learn about a common interest! This project can be used by teachers of any grade level, can be shown to parents, can be a model for showing kids the possibilities of the medium.
7th Grade - The Water Cycle from Britt Gow
Year 7 Science students did a unit of work on water and the water cycle. They were asked to draw a picture containing mountains, clouds, the sea, a lake, a forest and an underground water reservoir (aquifer).
1st Grade Science from Michele Green
First grade students researched fish in the library, used Paint to draw pictures of them, and then recorded their voices.
Social Studies
Les Cantines du Monde by Rachel Sabre
In this activity, students research photos of typical school lunches from around the world. They select five photos and upload them to VoiceThread, name the country and describe each photo. Finally, students upload a photo of their own typical lunch and describe it. They discuss what foreign lunch they like best and why, along with what changes they could make to their own lunch to make it more healthy. This is an end of unit assessment.
Suicide Scenarios - 9th Grade Health by Mr. Carriere
This module serves as a lifelike simulation for Health students who need to make critical decisions in real life situations.
6th Grade - African Vocabulary by Julie Williams
Sixth grade students showcase their vocabulary learning through poetry as relates to Africa and African culture.
Our Community by Jasmane Frans
Second-grade students participated in a global project about communities with 10 other schools. Sao Paola, a school in Brazil led the project.
8th Grade - The Human Spirit - From Roberta
Students discuss what the "human spirit" means.
The Silk Road - from Constance Vidor
This VoiceThread provides a scaffolding for research and active engagement with an important topic of world history.
Digital storytelling - Abraham Lincoln's dog, Fido, from Clare Caddell
VoiceThread brought a little-known story about Lincoln to life, with images as well as voice. It was created in response to my second and third graders, who wanted to know more about Lincoln's dog, Fido.
History Podcast with secondary-ed students from Laurie Cohen
This project gives students an opportunity to be creative while demonstrating their content knowledge and technological skills. After developing the Lesson Plan and creating this sample, our US History teacher loved it for his class. He is using it in the 10th grade class.
5th Grade - Ellis Is. Narratives from Barbara De Santis
I wanted this project to enable the students to truly feel the immigrant experience. While primary documents are always in their textbook, there is seldom time to closely examine the images looking for clues to foster understanding.
3rd Grade - School Community from Trish Harrison
The objective was for students to learn to express values while looking at different communities. They practiced discussion; brainstorming; writing down ideas; using ideas in small-group talk as conversations.
11th Grade - Reconstruction from Molly Lynde
This is a great VoiceThread foremost because my students were actively engaged and finished with a clearer understanding of what the post Civil War era was really about... they no longer thought of a "universal freed slave" dancing in the street.
4th Grade - Letters from the Internment Camps
In this VoiceThread, students explore an historical event that is relevant to their physical community, the removal of Japanese-Americans to internment camps after the bombing of Pearl Harbor.
Visual/Perf Arts
The Use of Works of Art in a 2nd Semester German Course by Dagmar Jaeger
This VoiceThread shows how students can engage with a work of art in an active, personal and innovative way while practicing new vocabulary and grammar structures in the target language.
American Art: Searching for Values by Constance Vidor
American Art: Searching for Values asks students to observe and interpret works of art from several different eras of American history. An advance organizer at the beginning of the Voicethread shows the students how to describe what they see in the image and then draw conclusions about what these details might suggest about values and ideas that were important to the artist or to the patron.
Higher Ed Aztec Art by Janice Robertson
This VoiceThread shows what can happen when VoiceThreads are woven into a 500-level graduate/undergraduate seminar on Aztec Art, and everyone has the ability to see what everyone else is doing--a surprise ending turns out to be a game-changer.
Higher Ed Pre-Columbian Art History by Janice Robertson
This VoiceThread shows what can happen when students have the opportunity to expand on class teachings and assigned readings, incorporating material of their choice into an art history class: in this case, a 200-level undergraduate course on Pre-Columbian Art and Civilization.
8th Grade - Colors of the Night from Mrs. Brosnan
My goal was to further enhance their Art History knowledge that by using VoiceThread enabled me to extend my teaching "outside of the class room".
K-12 art, poetry, and music from Erin Berg
This VT is an example of the power of collaboration using technology. This encompasses art through words, visuals, and music.
Higher Ed Online Learning from Michelle Pacansky-Brock
An engaging and dynamic lecture delivered within an interactive environment engages in a way no 'downloadable' lecture can.
Higher Ed Online Learning from Michelle Pacansky-Brock 2
By engaging in discussions, students explore and engage in course material more deeply while practicing critical-thinking and discourse.
Non-Traditional Online Students
This was a project for Electronic Word English Class at Eastern Oregon University. It is a great example of what can be done with VoiceThread for distance learning students. Both students that worked on the project live in different states.
Upstanders, Not Bystanders - Gail Desler and Natalie Bernasconi
The Upstanders, Not Bystanders VoiceThread addresses an essential aspect of digital citizenship by asking the question, "What does it mean to be an upstander?" - as opposed to a bystander, bully or target/victim. In less than a year since its March 2013 posting, this dynamic VoiceThread has had over a 1000 visitors and is quickly becoming a tool for connected learning by inviting and honoring stories of what it means to cross the line from bystander to upstander.
5th and 6th-grade Digital literacy project from Julienne Hogarth
I gave the learners the images and they researched and posted information and comments about Dale Chihuly's life and art. The learners were thrilled to use Voicethread as a tool in their learning as well as becoming very excited about the art work.
5th Grade - Digital portfolios for student-led parent confs.
As we're an international school, I was looking for a seamless way that relatives in other countries (Grandparents, parents away working etc) could view, comment, give feedback on the digital portfolio.
8th Grade - Refugee stories from Creative Technology
VoiceThread has enabled refugee communities to share stories about what it means to come to a new country to live.
6th Grade Class trip from Jennifer Bamesberger
We used VoiceThread to document our class trip to the Maker Faire 2008 in the San Francisco Bay Area as part of our study of the Spirit of Creativity. For some of our sixth graders, this was the first long trip away from home without family.


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Panasonic and Pelco Enter Interoperability Effort.
Secaucus, NJ (February 24, 2009) – Panasonic System Solutions Company and Pelco have aligned under the Panasonic Solution Developer Network (PSDN) in an effort to expand the interoperability of both companies' video surveillance solutions to best serve the needs of customers. As a new PSDN member, Pelco plans to support Panasonic's i-Pro network camera lineup under its enterprise-class IP-based video security system and management platforms. The joint effort reflects both companies' commitment to interoperability and meeting the market demand for integrated security solutions at the enterprise level.
Pelco currently supports Panasonic i-Pro network cameras with its Digital Sentry Digital Video Management System (DVMS). Expanded interoperability efforts will focus on Pelco's Endura platform, supporting the i-Pro cameras. Panasonic and Pelco will work together to quickly accomplish the interoperability to meet existing customer demand.
"Everything we do at Panasonic System Solutions Company is about empowering customers and serving their needs,†said J.M. Allain, President, Panasonic System Solutions Company. "We are committed to an 'Open Infrastructure' and are pleased to work with Pelco and other industry suppliers to meet the demands of end users on a common platform – the IT network.â€
"Delivering open and integrated systems is a cornerstone of Pelco's product development focus,†said Dave deLisser, Director of Integration at Pelco. "We are excited about expanding our interoperability with Panasonic i-Pro cameras to our enterprise class video management systems.â€
Panasonic System Solutions created the PSDN program several years ago to develop partnerships that complement and extend its lineup of security and surveillance products to better meet both integrator and end user requirements. As part of its "Open Infrastructure†initiative, the PSDN program provides members, including Pelco, with development tools, technical information and assistance to integrate with Panasonic products. In September 2008, Panasonic announced the global expansion of its PSDN program, better enabling multinational integrators and end users with broader interoperability. Through PSDN, Panasonic is helping to provide resellers with expanded product solution offerings and end users with seamless security solutions.
ONVIF (Open Network Video Interface Forum) announces today that the forum has accepted 18 new members since the beginning of 2009. Cisco, Samsung and Siemens have joined the forum as full members and Anixter and Milestone as contributing members. ONVIF has now grown to a total of 40 member companies. A complete listing can be found at www.onvif.org .
In line with its growing member base, ONVIF has extended the number of seats in each forum committee to a total of five seats from the previous three. The new positions have been filled through an invitation and election process that was finalized in mid February. As a result, Cisco and Panasonic are now members of both the Steering Committee and the Technical Committee.
Samsung was voted into the Technical Services Committee and the Communication Committee, and the final seats in the Technical Services Committee and Communication Committee were taken by Anixter and Hikvision respectively.
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Otitis externa is an inflammation and/or infection of the ear canal. The ear canal is the tube leading from the outer ear to the eardrum. Because it is often found in swimmers, particularly in warm, humid climates, it is often referred to as swimmer's ear.
Otitis externa is caused by infection, chemical irritation, or trauma. Trauma causes damage to the ear canal, which may cause inflammation or allow infection to invade.
Risk Factors
Factors that may increase your chance of otitis externa include:
- Frequent swimming in chlorinated water, stagnant water, or increasingly warm water
- Not rinsing all of the soap from the ear canal while showering or bathing
- Younger age with narrow ear canals
- Insertion of any object into the ear canal causing damage to the lining
- Skin conditions, such as eczema , that cause breaks in the skin of the ear canal
- Eardrum rupture from a middle ear infection— otitis media
- Diabetes
- Medical conditions resulting in a compromised immune system
People with weak immune systems or who have a chronic illness, such as diabetes or HIV , may get an aggressive form called malignant otitis externa. Malignant otitis externa results in infection of the cartilage and bone around the ear, as well as between the ear and the brain (the skull base). The condition can be severe and difficult to treat, causing nerve paralysis.
Otitis externa may cause:
- Redness and/or itching inside the ear canal
- Pain in the ear, sometimes severe, that may worsen when chewing or talking, and with pulling on the ear
- Hearing loss or a plugged-up or pressure sensation of the ear
- Drainage from the ear
You will be asked about your symptoms and medical history, and perform a visual exam of the ear, including the ear canal and inner ear, using a lighted device called an otoscope. If malignant otitis externa is suspected, a CT scan may be necessary.
This condition can easily be treated, but can become serious and life-threatening in some people, if left untreated. This can be very serious particularly in people with diabetes, where the infection can spread and cause malignant otitis externa.
Options may include:
For those with an infection, medication will depend on the cause of the infection. Other medications will help reduce other symptoms, such as pain and inflammation. The doctor may advise:
- Oral nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation
- Antibiotic ear drops to treat any infection
- Oral antifungal medications to treat fungal infections
- Oral antibiotics to treat severe infections or cellulitis of the ear canal
- Corticosteroid ear drops to reduce inflammation (this may be combined with an antibiotic ear drop)
- Intravenous antibiotics for malignant otitis externa
If the ear canal is very swollen, it may not allow the ear drops to get in. A small sponge, called a wick, may be inserted in the ear canal to absorb the drops. It is usually removed after 24-48 hours.
If medications or ear wash do not work, your doctor may need to remove any drainage or pus from the ear canal. However, this is rarely needed.
Malignant otitis externa requires immediate treatment, hospitalization, intravenous antibiotics, and possibly surgery. Surgery may be indicated for:
- Infection that has spread to the base of the skull
- Bone abscess
- Failure of other treatment methods
Debridement, the removal of dead tissue, may also be necessary to help the healing process.
Other Suggestions
The doctor may also advise:
- Keeping the ear dry for 7-10 days
- Taking baths instead of showers
- Avoiding swimming
- Avoiding rubbing or scratching the ear or inside the ear canal
- Avoiding using hearing aids or earplugs until you are healed
To help reduce your chance of otitis externa, or from having the condition recur:
- Avoid swimming in unclean water.
- Thoroughly drain and dry the ear and ear canal after swimming or showering.
- When showering, gently place a cotton ball lightly coated with petroleum jelly into the outer ear to prevent water collection.
- Do not insert anything into the ear canal, including your finger or cotton swabs.
- Do not remove earwax. If you are having problems hearing, see a doctor first.
- Limit use of earplugs since they can irritate the lining of the ear canal and can trap water inside the ear.
- Consider using a tight-fitting swimming cap.
- Use a white vinegar/rubbing alcohol ear drop solution following swimming, or glycerin drops before and after swimming. This will help restore the natural healthy environment inside the ear canal.
Revision Information
- Reviewer: EBSCO Medical Review Board Michael Woods, MD FAAP
- Review Date: 09/2018 -
- Update Date: 09/30/2013 -


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DHS can help you meet basic needs, cope with illness, emergencies, or other challenges.
To find additional information and programs, click through our related links on the right hand side of the page.
Please use the DHS Office Locator


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ITT & Latitudes Travel | Call: 760-763-3183/3184 | Email: email@example.com
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Kensington Tours specializes in custom tours to over 90 countries worldwide. Our tailor-made journeys are carefully crafted to deliver a personalized adventure like no other. We build in extraordinary, enriching experiences and put the best private guides at your service. We do all this with award-winning attention to detail and unbeatable value for your travel dollar.
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What's the secret sauce behind every one of our tailor-made experiences? Seasoned destination experts intimately versed on the new, the old, the different, the must-sees, the off-the-beaten track and the out-of-this-world. Whether you are looking for a value adventure, a premium tour or the most exclusive activities, properties and amenities (or better yet, the flexibility to mix and match between these), our experts have the deep knowledge to transform a trip into an experience of a lifetime.
Experienced Local Guides and 24/7 On-the-ground support
Experienced local guides, finely attuned to your personal expectations and connected to the people and culture, deliver breathtaking moments. This is the simple truth that guides Kensington Tours. The best spot to find the black rhino, a secret café and a favorite local dish, a personal account from a defining cultural moment and a local tradition shared - these are the experiences that endure.
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Kensington Tours is the inspiration of intrepid explorer and Royal Geographic Society Fellow Jeff Willner. His thirst for travel stems from growing up in Africa where his parents worked for most of his childhood, and where he discovered the richness of global cultures. A veteran of global expeditions to over 70 countries, he has criss-crossed the continents to experience the extraordinary. During these years, Jeff realized the vast difference between a package tour and personal discovery - where deep knowledge and personal attention of a local guide can turn a trip into an experience.
It is from these roots that Jeff began building his vision for Kensington Tours, drawing on his years with McKinsey & Company and Wharton. Led by a team of destination experts with real in-country experience (not a call center) and a commitment to rethinking the way you travel - it has resulted in an award-winning travel company that spans the globe. What does this mean for you? It's simple: extraordinary travel experiences at unrivaled value.
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Sleep apnea occurs when breathing stops for brief periods of time while a person is sleeping. It can last for 10-30 seconds, and may occur up to 20-30 times per hour. During one night of sleep, this can cause up to 400 episodes of interrupted breathing.
Every time you stop breathing, you interfere with the normal patterns of deep sleep. The quality of sleep that you get is greatly impaired. Your level of alertness and your ability to pay attention may be seriously affected.
If you have sleep apnea, you are also more likely to have:
- Accidents, especially car accidents
- Coronary artery disease
- Stroke
- Lung disease
- High blood pressure
- Diabetes
- Kidney disease
There are several kinds of sleep apnea. These include:
Obstructive Sleep Apnea
This is caused by a temporary airway obstruction. This blockage may be partial or complete. Obstructive sleep apnea can occur when the tissues of your throat relax too much and cave in on each other. If you are overweight, then your excess tissue might be putting too much pressure on your airway, causing it to collapse. You may have a deviated septum , nasal polyps , large tonsils, or an elongated soft palate and uvula that obstruct your airway while you are sleeping.
For children, enlarged tonsils and adenoids are the most common reason for obstructive sleep apnea.
Central Sleep Apnea
This occurs when the lower brain stem fails to send signals to the muscles that control breathing. Conditions that cause problems with the lower brain stem include certain types of polio, encephalitis, stroke, brain tumors, and other diseases that affect the brain and central nervous system. For children, the most common reason for central sleep apnea is prematurity.
Mixed Sleep Apnea
Mixed sleep apnea includes aspects of both obstructive and central sleep apnea.What are the risk factors for sleep apnea?What are the symptoms of sleep apnea?How is sleep apnea diagnosed?What are the treatments for sleep apnea?Are there screening tests for sleep apnea?How can I reduce my risk of sleep apnea?What questions should I ask my doctor?What is it like to live with sleep apnea?Where can I get more information about sleep apnea?
Revision Information
- Reviewer: Marcie L. Sidman, MD
- Review Date: 12/2016 -
- Update Date: 08/11/2015 -


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Advanced Planning
As an Agent of New York Life, I have exclusive access to the Advanced Planning Group - a premier planning team with expertise in law, accounting, financial planning and insurance. My access to these resources allows me to bring experience, value and insight to assist you with your business and estate planning needs.
To learn more about the services I can offer you through my exclusive access to this resource, please visit the Advanced Planning Group web site.
Neither New York Life nor its Agents or employees provide legal or tax advice.


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Your secure purchase will appear on your credit card statement as "SAFECART.COM". Information submitted as required by this payment process is handled within the constraints of our industry-leading privacy policy and terms of service. Your name and email address may be provided to the original publisher of this product upon completion of the order registration purposes. SafeCart is a trademark of RevenueWire Inc. in Canada, the United States, and in other countries. 3962 Borden Street, Suite 102, Victoria, BC - Canada V8P 3H8 This order is processed by SafeCart as online reseller for Verispy. If you have any questions specific to the product(s) you purchased, please contact Verispy


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Symptoms of sinus infection are very similar to those of the common cold. However when due to a cold virus, such symptoms typically improve in 1-2 weeks. If you continue to have nasal symptoms that linger after having a cold , then you may have developed a sinus infection.
Symptoms of sinus infection may include:
- Nasal congestion
- Nasal discharge that may be thick, and greenish or yellowish in color
- Headache (in acute sinusitis)
- Ear pain
- Toothache (dental pain)
- Facial pain and pressure that increases when you lie down or lean over
- Facial fullness or congestion
- Nagging cough that may get worse when lying down
- Fever
- Decreased energy or fatigue
- Bad breath
- Unpleasant taste in your mouth
- Decreased sense of smell
- Fever, especially in children
Most experts believe that sinus infection does not cause chronic headaches. However, alteration in sinus pressure associated with weather changes might provoke headaches in susceptible people.
Revision Information
- Reviewer: David L. Horn, MD, FACP
- Review Date: 09/2018 -
- Update Date: 09/17/2014 -


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Find your favorite travel destinations from all around the world on jigsaw puzzles in every piece count and style. Each major city and country features is highlighted on the previous page, but you can also sort by Theme to the left to find specific locations.
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Tetralogy of Fallot (TOF) is a combination of 4 heart defects. It is present at birth. These defects make it difficult for your child to get oxygen to the entire body.
The defects are:
- Ventricular septal defect (VSD)—A hole in the heart. It is on a wall that separates the 2 lower chambers.
- Overriding aorta—The aorta, which is the body's largest artery coming out of the left ventricle, partially covers or comes out of the right ventricle.
- Pulmonary stenosis—The valve in the heart that allows blood to pass from the heart toward the lungs is too narrow.
- Right ventricular hypertrophy—The muscle on the right side of the heart is too thick.
VSD and overriding aorta can decrease the amount of oxygen in the blood. This makes it difficult for the body to get the oxygen it needs. Pulmonary stenosis and right ventricular hypertrophy can make it difficult for blood to pass to the lungs. This will also decrease the amount of oxygen in the blood.
A child's heart develops very early in pregnancy. TOF is caused by a problem during this development. It is not known exactly why these problems happen. Some have been associated with genetics, mother's nutrition, or infections. Most have no known cause.
|Ventricular Septal Defect
|Copyright © Nucleus Medical Media, Inc.
Risk Factors
Factors that may increase your child's chance of TOF include:
- Family history
- Mother's use of retinoic acid
- Mother's use of oral fluconazole
- Mother's alcohol use
- Mother has infection with rubella
- Pregnancy in mothers over 40
- Maternal diabetes
Some people who have TOF also have a chromosome disorder. This may include Down syndrome , CHARGE syndrome, and VACTERL association.
For most, symptoms will appear during the first few weeks of life. For children with mild TOF, symptoms may not appear until much later. They may not show until your child or young adult becomes more active. Physical activity places more demand on the heart. A heart with TOF cannot keep up with the extra demand, causing symptoms. Without treatment, symptoms will continue to occur.
Symptoms may include:
- Blue coloring of the skin and lips caused by a low oxygen level in the blood
- Shortness of breath and rapid breathing caused by a low oxygen level in the blood
- Older children may have shortness of breath and fainting spells when exercising
- Clubbing of the fingers
In severe cases, a tetralogy spell may occur. This happens when the oxygen level in the blood drops suddenly. Symptoms include:
- Lips and skin become very blue
- Baby will become breathless and irritable
- Baby may become sleepy or unconscious if low oxygen levels continue
- Older children may squat with their knees on their chest to help recover from the breathlessness
A diagnosis of TOF is often made soon after birth. You will be asked about your child's symptoms and the mother's medical history. A physical exam will be done.
The doctor may begin tests based on your child's symptoms. A newborn with blue skin will often be given extra oxygen. If the oxygen does not help, a heart defect may be suspected. If the skin color is normal, the first clue is a loud heart murmur.
Images may be taken of your child's heart. This can be done with:
Heart problems may also be detected using cardiac catheterization .
Medications may be given to relieve symptoms. They may also help to prevent complications like a tetralogy spell.
The defects of the heart are treated with surgery. Surgical options include:
Temporary Operation
Small infants with severe TOF may not be strong enough for a complete repair surgery. A temporary operation will help increase the amount of oxygen in the blood. This will give the baby time to grow, get stronger, and prepare for a complete repair.
During this operation, a temporary, new path is made for the blood. The blood will be sent past the problems in the heart and go directly to the lungs. This will increase the amount of blood getting to the lungs. The oxygen in the blood will increase as a result.
Complete Repair
Most children with TOF have open-heart surgery within the first few years of life. The operation includes:
- Closing the hole in the heart. A patch will be placed over the hole.
Improving the flow of blood from the heart to the lungs by one or more of the following:
- Removing some of the thickened heart muscle on the right side of the heart
- Repairing or replacing the valve that allows the blood to flow from the heart to the lungs
- Increasing the size of the blood vessels that carry blood to the lungs
For some, a path is created between the heart and the blood vessels to the lungs.
In many cases, the surgery is successful. For some, further surgery may be needed. Long-term follow-up is always needed to detect recurring or new problems.
American Heart Association http://www.heart.org
National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov
About Kids Health—The Hospital for Sick Children http://www.aboutkidshealth.ca
Canadian Adult Congenital Heart Network http://www.cachnet.org
Explore tetralogy of Fallot. National Heart, Lung, and Blood Institute website. Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/tof. Accessed February 14, 2018.
Ma M, Maiwaring RD, Hanley FL. Comprehensive management of major aortopulmonary collaterals in the repair of tetraology of Fallot. Semin Thorac Cardiovasc Surg Pediatr Card Surg Ann. 2018;21:75-82.
Seki M, Kuwata S, Kurishima C, et al. Report from the Japanese Society of Pediatric Cardiology and Cardiac Surgery Research Committee on Cardiovascular Function in Adult Patients with Congenital Heart Disease: Mechanism of aortic root dilation and cardiovascular function in patients with tetralogy of Fallot. Pediatr Int. 2016 Jan [Epub ahead of print].
Tetralogy of Fallot. American Heart Association website. Available at: http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/AboutCongenitalHeartDefects/Tetralogy-of-Fallot%5FUCM%5F307038%5FArticle.jsp#.Vr5Ayk2FMdU. Updated January 19, 2018. Accessed February 14, 2018.
Tetralogy of Fallot in infants and children. EBSCO DynaMed Plus website. Available at: https://www.dynamed.com/topics/dmp~AN~T115349/Tetralogy-of-Fallot-in-infants-and-children . Updated June 19, 2017. Accessed February 14, 2018.
Tetralogy of Fallot (TOF) in children. Cincinnati Children's Hospital website. Available at: http://www.cincinnatichildrens.org/health/t/tof. Updated July 2015. Accessed February 14, 2018.
10/1/2013 DynaMed Plus Systematic Literature Surveillance https://www.dynamed.com/topics/dmp~AN~T115349/Tetralogy-of-Fallot-in-infants-and-children : Molgaard-Nielsen D, Pasternak B, Hviid A. Use of oral fluconazole during pregnancy and the risk of birth defects. N Engl J Med. 2013;369(9):830-839.
Revision Information
- Reviewer: EBSCO Medical Review Board Rimas Lukas, MD
- Review Date: 03/2018
- Update Date: 05/07/2014


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Kari, Canada, 15-year-old Girl Guide: "I have started an environment committee at my high school, where we help in the awareness of our planet's health. The flag I have created represents Mother Nature reaching out a helping hand,the unity of people, animals and the environment and how we are all friends, here to support each other. The shimmering moonlight pours onto the picture to symbolize hope, peace and global community. Only together can we maintain the treasures of the Arctic."
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