text:
Protection from malaria with insecticide-treated bednets (ITNs) during pregnancy is widely advocated, but evidence of benefit has been inconsistent. We undertook a systematic review of randomised trials.
Methods and Findings
Three cluster-randomised and two individually randomised trials met the inclusion criteria; four from Africa (n = 6,418) and one from Thailand (n = 223). In Africa, ITNs compared to no nets increased mean birth weight by 55 g (95% confidence interval [CI] 21–88), reduced low birth weight by 23% (relative risk [RR] 0.77, 95% CI 0.61–0.98), and reduced miscarriages/stillbirths by 33% (RR 0.67, 0.47–0.97) in the first few pregnancies. Placental parasitaemia was reduced by 23% in all gravidae (RR 0.77, 0.66–0.90). The effects were apparent in the cluster-randomised trials and the one individually randomised trial in Africa. The trial in Thailand, which randomised individuals to ITNs or untreated nets, showed reductions in anaemia and fetal loss in all gravidae, but not reductions in clinical malaria or low birth weight.
ITNs used throughout pregnancy or from mid-pregnancy onwards have a beneficial impact on pregnancy outcome in malaria-endemic Africa in the first few pregnancies. The potential impact of ITNs in pregnant women and their newborns in malaria regions outside Africa requires further research.
Citation: Gamble C, Ekwaru PJ, Garner P, ter Kuile FO (2007) Insecticide-Treated Nets for the Prevention of Malaria in Pregnancy: A Systematic Review of Randomised Controlled Trials. PLoS Med 4(3): e107. https://doi.org/10.1371/journal.pmed.0040107
Academic Editor: Stephen J. Rogerson, Royal Melbourne Hospital, Australia
Received: June 29, 2006; Accepted: February 1, 2007; Published: March 27, 2007
Copyright: © 2007 Gamble et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors received no specific funding for this study.
Competing interests: FOtK was co-author of two of the trials reviewed. No other conflicts of interest are declared.
Abbreviations: CI, confidence interval; EIR, entomological inoculation rate; G[number], gravidity [number]; Hb, haemoglobin; HR, hazard ratio; IPT, intermittent preventive treatment; IPTp, intermittent preventive treatment in pregnancy; IPTp-SP, intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine; ITN, insecticide-treated bednet; LBW, low birth weight; OR, odds ratio; RR, relative risk; SP, sulfadoxine-pyrimethamine; WHO, World Health Organization
Editors' Summary
Malaria is one of the world's most important killer diseases. It is responsible for around a million deaths every year, most of them in Africa and most of them in children. Pregnant women and their unborn babies are also at high risk. Women who have malaria become extremely weak because of anemia, they are more likely to miscarry, and their babies have low birth weights. (Birth weights under 2.5 kilograms are considered to be low; low-birth-weight babies face higher risks of sickness and death than other babies.) It has been estimated that, every year, malaria during pregnancy is responsible for the deaths of about 100,000 to 200,000 babies within their first year of life.
The parasite that causes malaria is carried by certain species of mosquito. In the areas where these mosquitoes are found, taking steps to reduce the chance of being bitten can reduce one's chances of getting infected with malaria. In Africa, these mosquitoes bite mainly in the hours of darkness, so sleeping under a mosquito net helps. During the last 20 years it has been established that mosquito nets impregnated with an insecticide provide much better protection than ordinary nets. Research has shown that children who sleep under these insecticide-treated nets (ITNs) are much less likely to get malaria than other children living in the same area. The correct use of ITNs is now being heavily promoted in many national and international programs.
Why Was This Study Done?
It seems logical that pregnant women should be encouraged to sleep under ITNs, and this is recommended by the World Health Organization and other authorities. However, we cannot be sure that there are benefits, as there is a lack of clear evidence to show whether women who sleep under ITNs actually suffer less from malaria and anemia, and what the implications are for their babies.
What Did the Researchers Do and Find?
They did no new work in the field or in the laboratory. Instead, they conducted what is known as a systematic review. Working to a set of criteria carefully formulated in advance, they searched the medical literature for well-conducted "randomized controlled trials" (RCTs) involving the use of ITNs by pregnant women. RCTs are studies where one group of people receives the "treatment" under investigation and another group does not. It is decided at random who goes into which group. The authors found five trials in Africa, four of which fulfilled the entry criteria for their analysis. In three of the four studies conducted in Africa, whole villages had been "randomized" to determine which pregnant women received ITNs. In another African trial, individual women had been randomized. In total, over 6,000 women were involved in the African trials. One trial had been done outside Africa, in Thailand, where just over 400 individual women had been randomized.
In the research done in Africa, it had been found that women who slept under ITNs had lower numbers of parasites in their blood. Miscarriages were much reduced—by a third in those women who were in their first few pregnancies. The overall proportion of babies who were low birth weight went down by nearly a quarter. In the research done in Thailand, the women using ITNs were less anemic and the miscarriage rate was again lower, although there was no change in the low-birth-weight figures.
What Do These Findings Mean?
The evidence from the three trials done in Africa strongly suggests that it is a good idea for pregnant women to sleep under ITNs. With evidence available from only one trial conducted outside Africa, it is hard to be sure at this stage whether ITNs have the same beneficial effects for pregnant women in other parts of the tropics. More research is needed there.
Additional Information.
The following organizations all have useful information about malaria on their Web sites, and we have provided links to the appropriate pages below. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040107.
- US Centers for Disease Control and Prevention has information specifically about malaria during pregnancy
- Roll Back Malaria has information specifically about malaria during pregnancy
- Wikipedia—a free online encyclopedia that anyone can edit
- The World Health Organization (WHO)
- The United Nations Children's Fund (UNICEF)
- MedlinePlus brings together authoritative information from the US National Library of Medicine, National Institutes of Health, and other government agencies and health-related organizations
- The Wellcome Trust
Approximately 50 million pregnant women are exposed to malaria each year. Pregnant women are more susceptible to malaria, placing both mother and fetus at risk of the adverse consequences [1–3]. In areas of low and unstable transmission, such as in many regions in Asia and the Americas, women do not acquire substantial antimalarial immunity, and are susceptible to episodes of acute and sometimes severe malaria, and fetal and maternal death [4]. In areas with stable malaria transmission, such as in most of sub-Saharan Africa, infection with Plasmodium falciparum in pregnancy is characterised by predominantly low-grade, sometimes sub-patent, persistent or recurrent parasitaemia. These infections frequently do not result in acute symptoms yet are a substantial cause of severe maternal anaemia [5] and of low birth weight (LBW) [3], and as such are a potential indirect cause of early infant mortality [6–8]. Because most of these infections remain asymptomatic, and therefore undetected and untreated, prevention of malaria in pregnancy is especially important in these settings.
The World Health Organization (WHO) advocates a three-pronged approach to malaria control in pregnancy that includes the use of insecticide-treated bednets (ITNs), intermittent preventive treatment (IPT), and case management (treatment) [9]. In areas of stable malaria transmission in sub-Saharan Africa, ITNs are highly effective in reducing childhood mortality and morbidity from malaria [10]. Although ITNs are promoted as a major tool in the fight against malaria in pregnancy, the available evidence about their efficacy in pregnancy has been inconsistent. In this review, we summarise the available data from randomised controlled trials that compared the effects of ITNs to no nets, or to untreated nets, on the health of pregnant women and birth outcome.
A protocol was developed for this review [11], and the standard search strategy of the Cochrane Infectious Diseases Group was used to identify potentially relevant trials [12]. The inclusion criteria were all trials that randomised individuals (pregnant women) or clusters (community or antenatal clinics) in areas where malaria transmission occurs. Where cluster-randomised trials were identified, the methods of analysis were checked to ensure that the precision of the data extracted from the reports was correctly estimated. The authors needed to have adjusted for clustering, as ignoring the clustering provides the correct point estimate of the magnitude of the trial effect but may overestimate the precision, resulting in potentially incorrect conclusions [13]. Primary outcomes selected were mean haemoglobin and anaemia, and mean birthweight and LBW; secondary outcomes included peripheral malaria in the mother assessed by finger prick during pregnancy or at birth, placental malaria assessed by microscopy, clinical malaria, pre-term birth, fetal loss (defined as miscarriage or stillbirth), and maternal death.
Trial quality was assessed as adequate, inadequate, or unclear based on the methods used to generate the allocation sequence and allocation concealment [14]. Minimisation of loss to follow-up was considered adequate (≥90% of the participants randomised included in the analysis), inadequate (< 90%), or unclear (not reported).
Outcomes were combined using the inverse variance method in RevMan [15,16]. We used the fixed-effects model throughout, and assessed heterogeneity by the I2 test (with values of >50% representing moderate heterogeneity) [17]. To minimise the anticipated heterogeneity, no attempt was made to combine trials that compared ITNs to no nets and those that compared ITNs to untreated nets [10]. Because all the included studies from Africa compared ITNs to no nets, and the one study comparing ITNs to untreated net was conducted in Thailand, this also resulted in stratification by the major malaria transmission regions (Africa versus non-Africa), which differ in transmission intensity, parasite species, predominant vector, and vector behaviour.
The effect of ITNs was expected to be greatest in the first few pregnancies because women develop pregnancy-specific immunity against placental parasites over successive pregnancies as a consequence of repeated exposure [18]. Because gravidity was considered the greatest potential modifier of the effect of ITNs, analyses were stratified a priori by gravidity groups whenever this was possible based on the details provided.
Other potential sources of effect modifications that were explored included concomitant use of IPT in pregnancy (IPTp), and differences between trials that used individual randomisation, in which women benefit primarily from personal protection by treated nets, and trials that used cluster randomisation. In the latter trials, ITNs were distributed to whole communities, which may result in a mass or community effect due to area-wide killing of the malaria-transmitting mosquitoes [19–21]. Women in the cluster-randomised trials were mostly provided with ITNs prior to becoming pregnant and were thus protected throughout pregnancy. In the individually randomised trials, nets were provided as part of antenatal care, i.e., typically from 20 to 24 wk onwards. We could not explore other potential sources of heterogeneity because the number of trials identified was too few.
Description of Trials
Six trials were identified; we excluded one trial as the analysis had not adjusted for clustering, and loss to follow-up was high (Text S1) [22]. Of the five included trials (Table 1), two were individually randomised [23,24], and three were cluster-randomised with analysis that took design effects into account [25–27].
Characteristics of Included Studies
Four trials were conducted in stable malaria-endemic areas in Africa (three in Kenya [24,26,27] and one in northern Ghana [25]), all with entomological inoculation rate (EIR) > 1/y, and one in Karen refugee camps along the Thailand–Myanmar border in an area with low and markedly seasonal malaria where P. falciparum and P. vivax coexist (EIR 0.5/y) [23].
The African trials compared ITNs to no nets; 6,418 women were enrolled [24–27]. The remaining trial from Thailand randomised individual women to receive either ITNs, untreated nets, or no nets [23]. In the "no nets" arm, a large proportion of women received nets from another donor independent of the study, and the researchers split the results in this control arm into women using donor nets and women not using donor nets. Because this compromised the validity of the control arm, we included only the comparison of ITNs with untreated nets (n = 223).
All African trials gave double- or family-sized nets to each household. The nets used in Thailand were smaller single-sized nets (70 × 180 × 150 cm). All trials used the widely available insecticide permethrin (500 g/m2), except one trial that used cyfluthrin [24].
One trial included IPTp-SP in a factorial design [24]. Women were allocated to receive (1) ITNs plus IPTp-SP, (2) IPTp-SP alone, (3) ITNs plus IPTp-SP placebo, or (4) IPTp-SP placebo alone ("control"). None of the other trials included IPT.
In the four trials from Africa, only women having their first baby were included in one trial [26], women having their first or second baby in another [24], and women of all gravidity in the remaining two trials (Table 1) [25,27]. In the trials including pregnant women of all gravidity, the authors analysed them differently: ter Kuile et al. grouped by gravidity 1 to 4 (G1–G4) and gravidity 5 and above (G5+) [27]. Browne et al. grouped by first pregnancy (G1), second pregnancy (G2), and third pregnancy and above (G3+) for continuous endpoints [25]. To allow for sub-group analysis by gravidity group, we grouped the G3+ group from Browne et al. and the G5+ group from ter Kuile et al. into one sub-group, referred to as "high gravidity", and the G1 from Shulman et al., the G1 and G2 groups from Browne et al. and the G1–G4 group from ter Kuile et al. into another sub-group, referred to as "low gravidity" [25–27]. The study by Browne et al. also provided sub-group analyses for dichotomous endpoints, but unlike in the analysis for continuous endpoints they were not adjusted for cluster randomisation [25].The study by Dolan et al. in Asia did not provide estimates by gravidity group, with the exception of the effect on birth weight [23].
Treated Nets versus No Nets (Four Trials in Africa)
Primary outcomes.
All four trials reported the effect of ITNs on haemoglobin (Hb) levels and anaemia. Because of the variations in trial design and reporting, it was not possible to combine the results from all four trials for anaemia (Hb < 100 or 110 g/l) and severe anaemia (Hb < 70 or 80 g/l) [28]. The results for mean haemoglobin are provided by the time of assessment (third trimester or delivery) and by gravidity group (Figure 1).
The red squares represent the effect estimates of ITNs; the black lines represent the 95% confidence intervals associated with the effect estimates (a line with an arrow indicates that the confidence interval was greater than could be illustrated in the graph). The black diamonds represent the summary effect estimates for the different subgroups ("subtotal") and for the overall effect ("total"). "Dry" and "wet" refer to the dry and wet seasons. SP+, women randomized to IPTp-SP; SP-, women randomized to receive placebo ITPp (factorial design).
There was no evidence for improved haemoglobin levels in women having their first or second babies in the two trials that assessed haemoglobin levels in the third trimester [25,26]. The overall (i.e., all gravidae) summary odds ratio (OR) for any anaemia in the third trimester was 0.88 (95% confidence interval [CI] 0.71–1.10, p = 0.26, one trial) and for severe anaemia was 0.77 (0.56–1.08, p = 0.13, two trials). Insufficient details were reported to provide sub-group analysis by gravidity group.
There was significant heterogeneity of treatment effect between the two other trials and sub-groups that assessed haemoglobin levels at delivery, with no evidence for a consistent effect overall (Figure 1) [24,27]. Mean haemoglobin levels were significantly higher in G1–G4 in the trial by ter Kuile et al., who also reported a significant delay in the time to the first episode of any anaemia (Hb < 110 g/l) in G1–G4 (hazard ratio [HR] 0.79, 95% CI 0.65–0.96, p = 0.02), but not in G5+ (HR 1.00, 0.86–1.18, p = 0.97) [27]. Njagi et al. did not find a significant increase in the mean haemoglobin levels of primi- and secundigravidae (Figure 1) or a significant overall reduction in any anaemia, although sub-group analysis by gravidity showed that a significant reduction in any anaemia was found in primigravidae and not secundigravidae (not shown) [29].
All four trials comparing nets to no nets reported on mean birth weight (Table 2; Figure 2). The average birth weight was 55 g higher in the ITN group in women of low gravidity, but no difference was detected in women of higher gravidity groups. For LBW, two trials contributed (Table 2), indicating women of low gravidity had a 23% reduction in LBW, but there was no apparent effect in women of high gravidity in the one trial measuring this [27]. There was also no evidence for an effect in women receiving IPTp with sulfadoxine-pyrimethamine (IPTp-SP) (one trial) (Figure 2). Browne reported the overall OR adjusted for clustering for all gravidity as 0.87 (95% CI 0.63–1.19); as no information was provided by gravidity group, and because LBW was a common event in this trial, the OR could not be pooled with the relative risk (RR) estimates from the other trials.
Summary Effect Measures of Four Trials Comparing ITNs versus No Nets in Africa
The red squares represent the effect estimates of ITNs; the black lines represent the 95% confidence intervals associated with the effect estimates. The black diamonds represent the summary effect estimates for the different subgroups ("subtotal") and for the overall effect ("total"). "Dry" and "wet" refer to the dry and wet seasons. SP+, women randomized to IPTp-SP; SP-, women randomized to receive placebo ITPp (factorial design).
Secondary outcomes.
All four RCTs reported on malaria parasitaemia. One trial tested women every month and showed time to first infection in the ITN group was reduced (HR 0.67, 95% CI 0.52–0.86, p = 0.002) [27]. The prevalence of parasitaemia was less common in the ITN groups when assessed in the third trimester (OR 0.88, 073–1.06, p = 0.19, two trials) [25,26] or at the time of delivery (RR 0.76, 0.67–0.86, p < 0.001, two trials) [24,27]. Placental malaria parasitaemia was lower with ITNs by 23% (95% CI 10–34, three trials; Table 2). There was no evidence for an effect on the prevalence of peripheral or placental malaria in women who were provided IPTp-SP (one trial, Figure 3) [24].
The red squares represent the effect estimates of ITNs; the black lines represent the 95% confidence intervals associated with the effect estimates (a line with an arrow indicates that the confidence interval was greater than could be illustrated in the graph). The black diamonds represent the summary effect estimates for the different subgroups ("subtotal") and for the overall effect ("total").
Placental malaria was defined as the presence of asexual parasitaemia detectable by microscopy. Data from Shulman et al. [26] are based on 25.8% of all enrolled women, and includes only women who delivered in the hospital. The degree of heterogeneity approached moderate levels (I2 = 49.9%) in the low gravidity group. Similar analysis using random instead of fixed-effect models gave a summary effect of 0.82 (0.61–1.11), 0.72 (0.48–1.08), and 0.79 (0.63–0.98) for low, high, and all gravidae, respectively. SP+, women randomized to IPTp-SP; SP-, women randomized to receive placebo ITPp (factorial design).
Geometric mean parasite densities in peripheral blood tended to be lower in the ITN groups in women having their first or second baby, although the result was not statistically significant (geometric mean ratio 0.82, 95% CI 0.66–1.02, p = 0.07, two trials) [24,25]. There was no evidence for a beneficial effect in G3+ in the trial by Browne et al. (geometric mean ratio 1.28, 0.90–1.82, p = 0.17). Ter Kuile reported that maternal and placental parasite densities were identical in parasitaemic women from ITN and control villages, but insufficient details were provided for inclusion in this analysis [27].
Clinical malaria was reported in two trials, and episodes were less frequent in the ITN than in the control groups in both trials, but this was not significant. Shulman et al. reported on self-reported illness with parasitaemia (OR 0.85, 95% CI 0.47–1.54) [26], and ter Kuile et al. reported on any documented parasitaemia with documented fever based on monthly assessments in G1–G4 (HR 0.72, 95% CI 0.19–2.78) [27].
No effect was demonstrated in the one trial measuring pre-term delivery (<37 wk of gestation) [27] (Table 2).
The three trials reporting on fetal loss (miscarriage or stillbirth) showed a consistent reduction in fetal loss associated with ITNs in low gravidity women (33%, 95% CI 3–53, p = 0.03; Figure 4; Table 2). Browne et al. [25] did not provide a breakdown by intervention group.
The red squares represent the effect estimates of ITNs; the black lines represent the 95% confidence intervals associated with the effect estimates (a line with an arrow indicates that the confidence interval was greater than could be illustrated in the graph). The black diamonds represent the summary effect estimates for the different subgroups ("subtotal") and for the overall effect ("total").
Data from Shulman et al. [26] refer to stillbirths only. As the event is rare (<10%), the OR reported by Shulman et al. approximates an RR and has been combined with the RRs of Njagi [24] and ter Kuile et al. [27]. SP+, women randomized to IPTp-SP; SP-, women randomized to receive placebo ITPp (factorial design).
Maternal death was reported by Njagi [24] (five deaths), with no trends evident by group; Shulman et al. [26] reported four deaths but did not specify the groups.
ITNs versus Untreated Nets (One Trial from Thailand)
This trial was conducted on the Thailand–Myanmar border, with individual randomisation [23]. Fewer women experienced peripheral malaria parasitaemia in the ITN group, but this was not significant (RR 0.73, 95% CI 0.47–1.04); however, in women infected with malaria, the geometric mean parasite density was lower in the ITN group (507 versus 1,096, p = 0.049), and anaemia (hematocrit < 30%) was less frequent with ITNs (RR 0.63, 95% CI 0.42–0.93). Mean birth weight was similar between the two groups (ITN group, 2,858 g, standard deviation 486, n = 94, versus untreated net group, 2,891 g, standard deviation 481, n = 85), as was LBW (RR 1.04, 95% CI 0.52–2.07) and pre-term delivery (RR 0.92, 95% CI 0.45–1.88). Fetal loss was significantly lower in the ITN group (2/102, 2%) than the untreated net group (10/97, 10%) (RR 0.21, 95% CI 0.05–0.92). The number of maternal deaths was similar (ITN group, 0/103, versus untreated net group, 2/100).
This systematic review shows that ITNs were associated with some important health benefits for pregnant women and their babies. Women of low gravidity randomised to ITNs delivered fewer LBW babies and were less likely to experience fetal loss (miscarriage or stillbirth). Although the latter was not a primary endpoint in the trials, it is an important outcome. No significant decrease was observed in pre-term deliveries in the single trial that assessed this outcome. The consistent reduction observed in the miscarriage and stillbirth rates suggests that the attributable effect of malaria on fetal loss may be underestimated in malaria-endemic Africa, where most women remain asymptomatic when infected with P. falciparum. Despite the reduction in malaria infections, no overall effect on mean haemoglobin was demonstrated, and data on maternal anaemia were inconsistent.
WHO currently recommends that women in malaria-endemic areas of Africa use both IPTp-SP and ITNs in pregnancy to prevent malaria. One of the two trials from western Kenya assessed the effect of ITNs and IPTp-SP simultaneously, using a factorial design. This trial showed that ITNs provided benefits in primigravidae when used alone, but it did not demonstrate additional benefits of the combined interventions over either of the single interventions [24,29]. The main benefit of ITNs in women protected by IPTp-SP may thus occur after birth through protection of infants from malaria, since infants typically share sleeping space with the mother for the first several months to years [30]. Similar considerations apply to the benefit of ITNs in grand-multigravidae (G5+), as no direct beneficial effect on the developing fetus in terms of birth weight or fetal loss was apparent in this group.
The only trial included in this analysis that compared ITNs to untreated nets was also the only trial conducted outside of Africa, in an area with highly seasonal P. falciparum and P. vivax malaria on the Thailand–Myanmar border. It showed a statistically significant reduction in anaemia and fetal loss in all gravidae, but no evidence for a beneficial effect on birth weight or gestational age [23].
Extrapolation of results from the three cluster-randomised trials to predict the potential impact of programmes that distribute ITNs to individual pregnant women as part of antenatal care should be done with caution. Firstly, nets distributed as part of antenatal care will leave most women exposed to malaria in the first third or half of pregnancy, when the risk of peripheral malaria parasitaemia is greatest [3]. By contrast, most women in the cluster-randomised trials became pregnant after ITNs were distributed and were as such protected throughout pregnancy. Secondly, the effect of ITNs in the cluster-randomised trials reflects the combined effects of personal protection (individual barrier protection) and area-wide reductions in malaria transmission (community or mass effect) [19–21]. It is possible that the mass killing effect on mosquito populations in areas with a high ITN coverage will result in stronger treatment effects of ITNs than can be achieved with individual nets. It is also likely that the community effect in the cluster-randomised trials resulted in a slight underestimation of the magnitude of the effect of ITNs because women living in control households from adjacent villages not using ITNs will have benefited from the area-wide reductions in vector populations, as has been shown for effect estimates in young children [19]. Similar considerations apply to the trial comparing ITNs with untreated nets from the Thailand–Myanmar border [23]. Although, this trial randomised individual women, all trial participants lived in the same densely populated refugee camps and some mass effect by the treated nets cannot be excluded.
The most recent trial from western Kenya by Njagi et al. is informative in this respect, as it is the only trial that compared the effects of ITNs versus no nets using simple randomisation by individual in an area with low ITN coverage (little or no mass effect) [24,29]. This trial and the community-randomised trial by ter Kuile et al. [27] were conducted simultaneously in contiguous areas with similar malaria transmission at baseline, and similar socioeconomic and educational status and ethnicity of the trial population. The effect estimates were similar between the two trials (in women not randomised to IPTp-SP), suggesting that ITNs may work equally well when provided to individuals as part of antenatal care in the second trimester or when provided to entire communities.
The systematic review was informative, but there were some limitations stemming from the variety in trial designs and the number of trials. Outcome data were often expressed in different ways, and inclusion or analysis of gravidity groups was different. How anaemia and peripheral parasitaemia were detected and treated varied, with different periods of follow-up and different cut-offs, limiting our ability to provide summary estimates for some of the endpoints, or to provide sub-group analysis by gravidity group where desired. Shulman et al. and Njagi et al. tested and treated women only if they were suspected of being anaemic or of having malaria, but Dolan et al. performed weekly blood tests, and ter Kuile et al. tested monthly. The number of studies included in the analysis was limited. All four African studies were conducted in areas with stable malaria transmission with EIRs ranging from 10/y to 300/y. Three of the four were conducted in Kenya, and two of these in adjacent areas with similarly intense perennial transmission. These two studies had the greatest influence (expressed as the weight in the figures) on the overall results of the systematic review, particularly for the effect on placental malaria because in the trial by Shulman et al. [26] data were available for only 25.8% of women (those that delivered in the hospital). It is plausible that the 25.8% were different to those delivering at home and may not be representative of all those randomised. This may also explain some of the observed heterogeneity of the effect of ITNs on placental malaria.
Although relatively few trials have been conducted and some questions on the efficacy of ITNs in pregnant women in Africa remain, the four trials comparing ITNs with no nets suggest significant beneficial effects of ITNs on birth weight and fetal loss in the first few pregnancies in areas with moderate to intense malaria transmission in sub-Saharan Africa. These findings are consistent with a non-randomised trial of the effect of socially marketed ITNs conducted in an area with intense perennial malaria transmission in southern Tanzania [31], and with an excluded randomised controlled trial from The Gambia, which has lower and highly seasonal transmission [22]. These observed beneficial effects of ITNs during the first few pregnancies, together with the absence of apparent harm to the developing fetus, the potential beneficial effect on the infant when the net continues to be used after birth [10], and the potential for ITNs to reduce malaria transmission through a mass killing effect on mosquito populations, support the current recommendations from WHO to provide ITNs for pregnant women in all regions with stable malaria transmission throughout sub-Saharan Africa, regardless of the degree of malaria transmission intensity.
Further evaluation of the potential effect of ITNs on pregnant women and their infants is warranted in malaria regions including the Americas, Asia, and the southwest Pacific, which represent approximately half of all pregnant women exposed annually to malaria. The more complex vector populations with exophagic, exophilic, and early biting behaviour in some of these areas may result in lower efficacy of ITNs than in Africa, where Anopheles gambiae s.s. is the most important vector. These studies should include women of all gravidae, and ideally address the interaction between ITNs and drug-based prevention such as IPTp, which is also largely untested outside of Africa. In Africa, it took over a decade for the evidence of ITN or IPTp efficacy in pregnant women to accumulate. It would be more efficient if trials had a common design, and if systematic reviews used individual patient data to allow appropriate collection of design effects, more accurate and standardised handling of the data, and more robust sub-group analysis. In order to enhance the rate at which evidence becomes available and is translated into policy, future trials would clearly benefit from better co-ordination between research groups.
Supporting Information
Text S1. QUOROM Flowchart
Screened, excluded, and included number of randomised controlled trials.
We thank Dr. Kiambo Njagi from the Ministry of Health, Nairobi, Kenya, and Prof. Pascal Magnussen from the Danish Bilharzia Laboratory, Copenhagen, Denmark, for provision of a copy of Dr. Njagi's Ph.D. dissertation. PJE was supported by a Fellowship Programme grant from the Cochrane Infectious Diseases Group through the Effective Health Care Research Programme Consortium at the Liverpool School of Tropical Medicine, supported by the Department for International Development. FOtK was supported by a grant from WHO and the US Centers for Disease Control and Prevention.
This is an edited version of a Cochrane review available on the Cochrane Library 2006 disk issue 2[28]. Cochrane reviews are updated as new evidence emerges. The Cochrane Library should be consulted for the most recent version of the review.
Author Contributions
PG conceived the idea for the study. CG and PJE designed the study. PG coordinated the analysis. CG, PJE, and FOtK analyzed the data. FOtK and CG wrote the first draft, and all authors contributed to subsequent versions of the paper.
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Clarke M, Oxman A, editors (2003) Cochrane reviewers' handbook, version 4.2.0. Oxford: Cochrane Collaboration.
- 13. Bland JM, Kerry SM (1997) Statistics notes. Trials randomised in clusters. BMJ 315: 600.
- 14. Juni P, Altman DG, Egger M (2001) Systematic reviews in health care: Assessing the quality of controlled clinical trials. BMJ 323: 42–46.
- 15. Woolf B (1955) On estimating the relation between blood group and disease. Ann Hum Genet 19: 251–253.
- 16.
Cochrane Collaboration (2003) Review Manager (RevMan), version 4.2 for Windows [computer program]. Oxford: Cochrane Collaboration.
- 17. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327: 557–560.
- 18. Fried M, Nosten F, Brockman A, Brabin BJ, Duffy PE (1998) Maternal antibodies block malaria. Nature 395: 851–852.
- 19. Hawley WA, Phillips-Howard PA, ter Kuile FO, Terlouw DJ, Vulule JM, et al. (2003) Community-wide effects of permethrin-treated bed nets on child mortality and malaria morbidity in western Kenya. Am J Trop Med Hyg 68: 121–127.
- 20. Howard SC, Omumbo J, Nevill C, Some ES, Donnelly CA, et al. (2000) Evidence for a mass community effect of insecticide-treated bednets on the incidence of malaria on the Kenyan coast. Trans R Soc Trop Med Hyg 94: 357–360.
- 21. Binka FN, Indome F, Smith T (1998) Impact of spatial distribution of permethrin-impregnated bed nets on child mortality in rural northern Ghana. Am J Trop Med Hyg 59: 80–85.
- 22. D'Alessandro U, Langerock P, Bennett S, Francis N, Cham K, et al. (1996) The impact of a national impregnated bed net programme on the outcome of pregnancy in primigravidae in The Gambia. Trans R Soc Trop Med Hyg 90: 487–492.
- 23. Dolan G, ter Kuile FO, Jacoutot V, White NJ, Luxemburger C, et al. (1993) Bed nets for the prevention of malaria and anaemia in pregnancy. Trans R Soc Trop Med Hyg 87: 620–626.
- 24.
Njagi JK (2002) The effects of sulfadoxine-pyrimethamine intermittent treatment and pyrethroid impregnated bed nets on malaria morbidity and birth weight in Bondo district, Kenya. Nairobi: University of Nairobi. Copenhagen: Danish Bilharziasis Laboratory. 129 p. [dissertation].
- 25. Browne EN, Maude GH, Binka FN (2001) The impact of insecticide-treated bednets on malaria and anaemia in pregnancy in Kassena-Nankana district, Ghana: A randomized controlled trial. Trop Med Int Health 6: 667–676.
- 26. Shulman CE, Dorman EK, Talisuna AO, Lowe BS, Nevill C, et al. (1998) A community randomized controlled trial of insecticide-treated bednets for the prevention of malaria and anaemia among primigravid women on the Kenyan coast. Trop Med Int Health 3: 197–204.
- 27. ter Kuile FO, Terlouw DJ, Phillips-Howard PA, Hawley WA, Friedman JF, et al. (2003) Reduction of malaria during pregnancy by permethrin-treated bed nets in an area of intense perennial malaria transmission in western Kenya. Am J Trop Med Hyg 68: 50–60.
- 28. Gamble C, Ekwaru JP, ter Kuile FO (2006) Insecticide-treated nets for preventing malaria in pregnancy. Cochrane Database Syst Rev 2006: CD003755.
- 29. Njagi JK, Magnussen P, Estambale B, Ouma J, Mugo B (2003) Prevention of anaemia in pregnancy using insecticide-treated bednets and sulfadoxine-pyrimethamine in a highly malarious area of Kenya: A randomized controlled trial. Trans R Soc Trop Med Hyg 97: 277–282.
- 30. ter Kuile FO, Terlouw DJ, Kariuki SK, Phillips-Howard PA, Mirel LB, et al. (2003) Impact of permethrin-treated bed nets on malaria, anemia, and growth in infants in an area of intense perennial malaria transmission in western Kenya. Am J Trop Med Hyg 68: 68–77.
- 31. Marchant T, Schellenberg JA, Edgar T, Nathan R, Abdulla S, et al. (2002) Socially marketed insecticide-treated nets improve malaria and anaemia in pregnancy in southern Tanzania. Trop Med Int Health 7: 149–158.


text:
The information stolen from Google in cyberattacks late last year included a password system that gives users access to multiple services after just one login, according to a news report.
Google in January said it had been hit by cyberattacks believed to be launched from China that caused the theft of Google intellectual property. The stolen information included the password system, code-named Gaia after the Greek goddess of earth, The New York Times said late Monday, citing an unnamed source.
The software, still used by Google but now known as Single Sign-On, has been discussed publicly only once, four years ago at a conference, the report said.
Gmail users' passwords do not appear to have been lost, but there is a small possibility that attackers with access to the stolen software could find vulnerabilities in it that Google itself does not know about, the report said.
Google spokesman Jay Nancarrow declined to comment beyond Google's original blog post revealing the attacks. In that post, Google cited the attacks and concerns over censorship as it also announced plans to stop filtering search results on its China-based search engine, which it had done for years to comply with government demands. Chinese users are now redirected from the old search engine to Google's Hong Kong site, where political content is uncensored.
Google has said over 20 other companies were also targeted in the attacks.
The theft from Google started when an employee in China clicked on a link to an infected site, which was sent to the employee via instant message, the Times said. The attacker was then able to access the employee's computer and, eventually, a software base used by developers at Google's California headquarters, the report said.
The attackers also had access to an internal Google directory called Moma that stores information about each employee's work tasks, it said.

subset: commoncrawl


text:
Content-type: text/html
/usr/sbin/rpld [-fdDMblgz] interface
/usr/sbin/rpld -a [-fdDMblgz]
The RPL server provides network booting functionality to x86 clients by listening to boot requests from them according to the RPL protocol specifications. rpld runs on both x86 and SPARC systems. Boot requests can be generated by clients using the boot floppy supplied in the distribution. Once the request has been received, the server validates the client and adds it to its internal service list. Subsequent requests from the client to download bootfiles will result in the sending of data frames from the server to the client specifying where to load the boot program in memory. When all the bootfiles have been downloaded, the server specifies where to start execution to initiate the boot process.
In the first synopsis, the interface parameter names the network interface upon which rpld is to listen for requests. For example:
In the second synopsis, rpld locates all of the network interfaces present on the system and starts a daemon process for each one.
The server starts by reading the default configuration file, or an alternate configuration file if one is specified. If no configuration file can be found, internal default values will be used. Alternatively, command line options are available to override any of the values in the configuration file. After the configuration options are set, it then opens the network interface as specified in the command line and starts listening to RPL boot requests.
Network boot clients have to have information pre-configured on a server for the RPL server to validate and serve them. This involves putting configuration information in both the ethers(4) and the bootparams(4) databases. The ethers database contains a translation from the physical node address to the IP address of the clients and is normally used by the RARP server. The bootparams database stores all other information needed for booting off this client, such as the number of bootfiles and the file names of the various boot components. Both databases can be looked up by the RPL server through NIS. See the sub-section Client Configuration for information on how to set up these databases.
To assist in the administration and maintenance of the network boot activity, there are two run-time signals that the server will accept to change some run-time parameters and print out useful status information. See the sub-section Signals for details.
The RPL server is not limited to the ability to boot only clients. If properly configured, the server should be able to download any bootfiles to the clients.
The following configuration information is specific to booting x86 clients.
In order to allow clients to boot x86 from across the network, the client's information has to be pre-configured in two databases: ethers(4) and bootparams(4). Both databases can be accessed through NIS. Refer to Solaris 10 Installation Guide: Basic Installations for information on how to configure a diskless x86 client. The discussion contained in the rest of this section is provided for your information only and should not be performed manually.
The ethers database contains a translation table to convert the physical node address to the IP address of the client. Therefore, an IP address must be assigned to the client (if this has not been done already), the node address of the client must be obtained, and then this information needs to be entered in the ethers database.
The bulk of the configuration is done in the bootparams database. This is a free-format database that essentially contains a number of keyword-value string pairs. A number of keywords have been defined for specific purposes, like the bootparams RPC in bootparamd(1M). Three more keywords have been defined for the RPL server. They are numbootfiles, bootfile, and bootaddr. All three keywords must be in lowercase letters with no spaces before or after the equals symbol following the keyword.
numbootfiles Specifies the number of files to be downloaded to the network boot client. The format of this option is:
Always use numbootfiles=3 to boot x86 across the network.
bootfile Specifies the path name of the bootfile to be downloaded and where in memory to start loading the bootfile. A complete path name should be used. For example, assuming the client's IP address is 172.16.32.15:
bootfile=/rplboot/172.16.32.15.hw.com:45000 bootfile=/rplboot/172.16.32.15.glue.com:35000 bootfile=/rplboot/172.16.32.15.inetboot=8000
The path name following the equals symbol specifies the bootfile to be downloaded, and the hex address following the colon (:) is the absolute address of the memory location to start loading that bootfile. These addresses should be in the range of 7c00 to a0000 (i.e., the base 640K range excluding the interrupt vector and BIOS data areas). Address 45000 for this hw.com bootfile is also a suggested value and if possible should not be changed. The address of 35000 for glue.com is a suggested value that, if possible, should not be changed. The address of 8000 for inetboot is an absolute requirement and should never be changed.
These files, when created following the procedures in the Solaris 10 Installation Guide: Basic Installations are actually symbolic links to to the real file to be downloaded to the client. hw.com is linked to a special driver that corresponds to the network interface card of the client. glue.com and inetboot are generic to all network boot clients.
The order of these bootfile lines is not significant, but because problems have been found with certain boot PROMs, it is highly recommended that the bootfile lines be ordered in descending order of the load addresses.
bootaddr The absolute address in memory to start executing after all the bootfiles have been downloaded. This address should always correspond to the address where glue.com is being loaded. If possible, always use:
The following options are supported:
-b background_mode Specify 1 to run the server in the background and relinquish the controlling terminal, or 0 to run in the foreground without relinquishing the controlling terminal. This option corresponds to the BackGround setting in the configuration file. If you have specified that the error or warning messages be sent to standard output in the configuration file or by using the -D option above, the server cannot be run in background mode. Doing so will cause the server to exit after announcing the error.
-d debug_level Specify a level of 0 if you do not want any error or warning messages to be generated, or a level from 1 to 9 for increasing amounts of messages. This option corresponds to the DebugLevel setting in the configuration file. The default value is 0. Note that it is best to limit the level to 8 or below; use of level 9 may generate so many debug messages that the performance of the RPL server may be impacted.
-D debug_destination Specify 0 to send error or warning messages to standard output, 1 to syslogd, and 2 to the log file. This option corresponds to the DebugDest setting in the configuration file. The default value is 2.
-f config_filename Use this to specify a configuration file name other than the system default /etc/rpld.conf file.
-g delay_granularity This corresponds to the DelayGran setting in the configuration file. If retransmission requests from clients do occur, the delay granularity factor will be used to adjust the delay count for this client upwards or downwards. If the retransmission request is caused by data overrun, the delay count will be incremented by delay granularity units to increase the delay between data frames. If the retransmission request is caused by sending data too slowly, this will be used to adjust the delay count downwards to shorten the delay. Eventually the server will settle at the delay count value that works best with the speed of the client and no retransmission request will be needed. The default value is 2.
-l log_filename Specify an alternate log file name to hold the error or warning messages in connection with the -D 2 option or the configuration file DebugDest = 2 setting. This option corresponds to the LogFile setting in the configuration file. The default is /var/spool/rpld.log.
-M maximum_clients Specify the maximum number of simultaneous network boot clients to be served. This option corresponds to the MaxClients setting in the configuration file. A value of -1 means unlimited, and the actual number will depend on available system resources. The default value is -1.
-s start_delay_count This option corresponds to the StartDelay setting in the configuration file. Specify the number of delay units between outgoing data frames sent to clients to avoid retransmission requests from them. Using the LLC type 1 protocol, data transfer is a one-way, best-effort delivery mechanism. The server, without any type of delay mechanism, can overrun the client by sending data frames too quickly. Therefore, a variable delay is built into the server to limit the speed of sending data to the clients, thus avoiding the clients sending back retransmission requests. This value should be machine environment specific. If you have a fast server machine but slow client machines, you may want to set a large start delay count. If you have comparable server and client machines, the delay count may be set to 1. The delay is only approximate and should not be taken as an accurate measure of time. There is no specific correlation between the delay unit and the actual time of delay. The default value is 20.
-z frame_size This option corresponds to the FrameSize setting in the configuration file. This specifies the size of the data frames used to send data to the clients. This is limited by the underlying physical medium. For ethernet/802.3, the maximum physical frame size is 1500 octets. The default value is 1500. Note that the protocol overhead of LLC1 and RPL is 32 octets, resulting in a maximum data length of 1468 octets.
The RPL server accepts two signals to change run-time parameters and display status information, respectively:
HANGUP This will cause the RPL server to reread the default configuration file /etc/rpld.conf or an alternate configuration file if one is specified when the server is started. New values of certain parameters can be used immediately, such as DebugLevel, DebugDest, LogFile, DelayGran, and FrameSize. For MaxClients, if the server is already serving more than the new value, the server will not accept additional boot requests until the number has fallen below the MaxClients parameter. For StartDelay, this will only affect new boot requests. All the existing delay counts for the various clients in service will not be affected. Finally, the BackGround parameter will have no effect once the server has been running. You cannot change the mode of service without first killing the server and then restarting it.
USR1 This signal will cause the server to dump all the parameter values and the status of each individual boot client to the destination specified by DebugDest.
See attributes(5) for descriptions of the following attributes:
|x86, SPARC
bootparamd(1M), in.rarpd(1M), bootparams(4), ethers(4), nsswitch.conf(4), rpld.conf(4), attributes(5)
Solaris 10 Installation Guide: Basic Installations


text:
Based on an antecedent post, it seems people are excited about this one. I can only hope it lives up to expectations.
But first, this is a side jaunt to a series of posts I wrote about sample costs (pt.1, pt.2 & pt.3). By way of explaining the higher costs of cutting samples as compared to the design room or home workshop, I've made what I'm calling "fusing maps" for lack of a better description. It is the only way I can show you how much extra stuff we cut. I know fusible usage looks like more than you're used to so you wonder if you really need it. All I can say is that manufacturers are keen to shave costs wherever possible so if it were possible to eliminate it, they'd do it.
Without further ado, below are shown fusible placements on the typical sportcoat or suit coat. It also goes for coats too. For this to make sense, make note of the at top right. Shell or the self piece is grey. The fusible is pink. Other than that, this is self explanatory.
Feel free to post any questions you may have. The related entries listed below may also be of some utility.
On reviewing pattern books
Interfacing: 10 tips
How to apply interfacing


text:
Features & Benefits
- Eliminates excess pet hair and cuts down on shedding
- Great for both dogs and cats
- Extra-long hose allows noisy vacuum to be in another room, reducing stress on pets
- Uses your full-sized vacuum cleaner or central vacuum system
- Doubles as a "wet vac" to dry your pets after a bath, clean up pet accidents or other spills
PetVac™ Update text.
- Attach to your vacuum with the included adaptor
- Gently brush your pet's fur with the grooming tool
- Excess hair is drawn away to the collection canister
- Easily empty collected hair into the garbage
PetVac™ is ideal for after bath time to help dry your pet and collect excess shedding. You can also use it as a traditional "wet vac" and clean up pet accidents from your carpet!


text:
I wonder how bad the consequences will have to be before these problems that can't be ignored.
Friday, November 18, 2011
James Bach: "Transitioning to Context Driven Testing (from Other Schools)"
Birmingham Software Testing Club Meetup
Here's James Bach speaking at the Meetup about "Transitioning to Context Driven Testing (from Other Schools)".
... and a reference to the schools of testing: http://www.prismnet.com/~wazmo/papers/four_schools.pdf
Here's James Bach speaking at the Meetup about "Transitioning to Context Driven Testing (from Other Schools)".
... and a reference to the schools of testing: http://www.prismnet.com/~wazmo/papers/four_schools.pdf
Posted by Griffin Jones at 4:33 AM 0 comments
Tuesday, November 15, 2011
Guidance on the use of AGILE practices in the development of medical device software - AAMI Technical Information Report - Working Committee Draft
I had the opportunity to see an advanced copy of the document from the Association for the Advancement of Medical Instrumentation .
Watch for the public version of this document, review it, and comment on it.
Agile TIR SW Committee Draft 1.0 10/7/2011 working draft
AAMI Technical Information Report AAMI/TIR XX:201X
Guidance on the use of AGILE practices in the development of medical device software
Abstract: Over the past several years, agile software development has become an accepted method for developing software products. There have been questions from both manufacturers and regulators as to whether (or which) agile practices are appropriate for developing medical device software. Enough medical device manufacturers have implemented agile practices in their software development that answers to these questions can be documented. Having clear guidance of what practices have been found to be appropriate will be very useful for all developers of medical device software. This TIR will provide recommendations for complying with international standards and United States Food and Drug Administration (FDA) guidance documents when using practices to develop medical device software.The paper describes how AGILE can bring value to medical device software, when adapted to the unique needs of medical devices.
Watch for the public version of this document, review it, and comment on it.
Posted by Griffin Jones at 4:34 AM 3 comments
Sunday, November 13, 2011
Surviving an FDA Audit: Heuristics for Exploratory Testing
I am presenting at:
- KWSQA in Waterloo Canada on November 30th. http://www.kwsqa.org/meetings/default.asp
- Software Test Professionals Spring 2012, scheduled for March 26-29, 2012 in New Orleans, LA http://www.softwaretestpro.com/Item/5119/Save-the-Date!/
- STAREAST Software Testing Analysis & Review Conference April 15-20, 2012 Orlando, Florida http://www.sqe.com/stareast/
In FDA regulated industries, audits are high-stakes, fact-finding exercises required to verify compliance to regulations and an organization's internal procedures. Although exploratory testing has emerged as a powerful test approach within regulated industries, an audit is the impact point where exploratory testing and regulatory worlds collide. Griffin Jones describes a heuristic model—Congruence, Honesty, Competence, Appropriate Process Model, Willingness, Control, and Evidence—his team used to survive an audit. You can use this model to prepare for an audit or to baseline your current practices for an improvement program. Griffin highlights the common misconceptions and traps to avoid with exploratory testing in your regulated industry. Avoid mutual misunderstandings that can trigger episodes of incongruous behavior and an unsuccessful audit. Learn how to maintain your composure during a stressful audit and leave with valuable heuristics to help you organize and present your exploratory testing results with confidence.
Posted by Griffin Jones at 3:02 PM 1 comments
Software glitch causes prescription error across R.I.
Software glitch causes prescription error across R.I.
Many patients? Many patients are not overdosing?
Doesn't that mean that some patients are/were overdosing?
Software glitch causes prescription error across R.I.
The software issue led to some discharged patients, who should have received a prescription for timed-release form of their medication, possibly receiving a prescription or instructions for the regular form. Timed-release medications are generally taken once a day, whereas the regular formulation provides the same effective dose of the medication, but the medication is taken multiple times over the course of a day.
The issue does not affect emergency room patients or outpatients.
Lifespan contacted 2,000 patients affected by this issue to ensure they receive the correct form of their medications. Many of the patients were already taking the correct medication, according to the provider.
Many patients? Many patients are not overdosing?
Doesn't that mean that some patients are/were overdosing?
Posted by Griffin Jones at 2:52 PM 1 comments
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text:
WASHINGTON (WJLA) - The NFL is reportedly considering requiring its players to stand during the national anthem after weeks of protests from players around the league.
The report came Tuesday from ESPN's Adam Schefter.
ESPN says it recovered a letter allegedly sent by NFL Commissioner Roger Goodell to NFL teams on Tuesday.
"Like many of our fans, we believe that everyone should stand for the National Anthem," Goodell says in the letter. "It is an important moment in our game. We want to honor our flag and our country, and our fans expect that of us. We also care deeply about our players and respect their opinions and concerns about critical social issues. The controversy over the Anthem is a barrier to having honest conversations and making real progress on the underlying issues. We need to move past this controversy, and we want to do that together with our players."
The full letter can be read below.
The act of players demonstrating during the anthem started in the 2016 preseason when then San Francisco 49ers quarterback Colin Kaepernick sat during the anthem as a protest of police discrimination against people of color. Kaepernick then began kneeling during the anthem as the season progressed.
Other players followed his example, either kneeling, sitting or raising a fist during the song.
These actions drew criticism from those who deemed the players' actions unpatriotic or disrespectful.
The movement has grown even larger in 2017 after President Donald Trump proposed firing any players who kneeled during the anthem.
Some fans have said they will no longer watch NFL games if the protests continue and on Sunday, Vice President Mike Pence left a game between the Indianapolis Colts and 49ers after multiple 49ers players took a knee.
Dallas Cowboys owner Jerry Jones made headlines when he said that his players will not play if they disrespect the flag.
"There is no room here if it comes between looking non-supportive of our players and of each other or creating the impression that you're disrespecting the flag, we will be non-supportive of each other," Jones said, according to The Associated Press. "We will not disrespect the flag."


text:
It's an interesting question to consider, especially if you use consider just how many Google services you might use: Gmail, Reader, Maps, GTalk, YouTube, Latitude, Calendar, Contacts and oh yeah, Search. Dashboard shows you everything Google knows about you.
It shows your most recent searches, last conversations in Google Talk, most recent location—basically, it summarizes all of the info you have poured into every Google service you use, so you can see it at glance. It's kind of starting, actually. From the Dashboard, you can drill down into every app to look at the info more closely or adjust privacy settings, which you certainly might feel inclined to do. Or it might make you want to unplug from the internet entirely. [Google via Lifehacker]


text:
I read yesterday that VMware has updated the "Microsoft Clustering on VMware vSphere: Guidelines for Supported Configurations" KB article linked here to include SQL Server 2012 AlwaysOn Failover Clusters. That's fantastic news! I've known it works great for quite a while now, but it's always nice icing on the cake to have the company publicly update their support policies.
As per the latest VMware vSphere 5.1 document "Setup for Failover Clustering and Microsoft Cluster Service", up to five MFC nodes are now supported per cluster. Again, this is great news. The document talks about the various options of configuring MFC on vSphere and does a great job with specific configuration details usually missed (or ignored) by folks that I know that cluster on vSphere.
Thanks VMware!


text:
Chicago, IL - 2014 American Society of Clinical Oncology Annual Meeting. Group Shot of Conquer Cancer Foundation of ASCO 2014 Young Investigator Award Recipients at Grants and Awards Ceremony and Reception, Sunday June 1, 2014. More than 30,000 physicians, researchers, health care professionals, cancer survivors and patient advocates are expected to attend the 50th Anniversary meeting at the McCormick Convention Center. The Annual Meeting highlights the latest findings in all major areas of oncology from basic through clinical and epidemiological studies. Photo by © ASCO/Brian Powers 2014 Technical Questions: email@example.com
2014ASCO02915tonedAM14_PressPlenary ASCO 2014


text:
- Browse
- Merchandise
Business, Industrial
Sorry, there are no listings currently in this category in your area. Would you like to Create a listing?
Vehicles 1 Housing Merchandise 1 Art, Collectibles Baby Items Books Business, Industrial Cameras, Camcorders CDs, DVDs, VHS Clothing Computer Accessories Computers Electronics Furniture Health, Special Needs Hobbies, Crafts Home & Garden Home Appliances Jewellery, Watches Musical Instruments Phones, PDAs, Ipods Sports, Bikes Tickets Tools, Equipment Toys, Games Video Games, Consoles Other 1 Pets 1


text: The only Bricklin I ever sat in caught on fire and burned to the axles. This is notably ironic, since the car's creator the smooth-talking Malcolm Bricklin didn't include an ashtray or lighter in the car, to discourage smoking. Despite its hand-removing, 100-lb. gullwing doors, the SV1 was supposed to exemplify the safer car of the future; the name stands for "Safety Vehicle 1." The bodies were made of brightly colored, dent-resistant plastic, like PlaySkool furniture. Another safety feature: incredible, crust-of-the-Earth-cooling slowness. All those resin panels and compressible bumpers added hundreds of pounds that the emissions-limited V8s couldn't handle. This thing couldn't outrun the Rose Bowl Parade. Less than 3,000 of the wedgy coupes were built, but Malcolm Bricklin was far from through, as we'll see.


text:
NORFOLK, Va. – Anthony Hubbard came off the bench to score 16 points and Morgan State pulled away in the second half to defeat South Carolina State 61-52 Monday night in the first round of the Mid-Eastern Athletic Conference tournament.
Hubbard scored 11 points in a span of just under 7 minutes midway through the first half to rally the fifth-seeded Bears (15-14), who will play Savannah State in a Thursday night quarterfinal.
South Carolina State (6-24) went cold after scoring the game's first 10 points and leading 32-29 at halftime. The 12th-seeded Bulldogs shot 25.7 percent (8 of 31) in the second half, including 1 of 13 from 3-point range after making 4 of 6 first-half 3-pointers.
DeWayne Jackson scored 12 points for Morgan State to move into fifth place on the Bears' career scoring list with 1,549 points.
Matthew Hezekiah paced South Carolina State with 17 points and 10 rebounds.


text:
- Cipta senarai lagu anda sendiri
- Selarikan senarai lagu dengan semua peranti
- Tiada gangguan iklan
If Ever I Would Leave YouIL Divo, Alberto Quintero, Bratislava Symphony Orchestra, David Hernando5 Nov 2013
Lirik If Ever I Would Leave You
If ever I would leave you - IL Divo
If ever I would leave you
It wouldn't be in summer.
Seeing you in summer I never would go.
Your hair streaked with sun-light,
Your lips red as flame,
Your face witha lustre
that puts gold to shame!
But if I'd ever leave you,
It couldn't be in autumn.
How I'd leave in autumn I never will know.
I've seen how you sparkle
When fall nips the air.
I know you in autumn
And I must be there.
And could I leave you
running merrily through the snow?
Or on a wintry evening
when you catch the fire's glow?
If ever I would leave you,
How could it be in spring-time?
Knowing how in spring I'm bewitched by you so?
Oh, no! not in spring-time!
Summer, winter or fall!
No, never could I leave you at all!
No, never could I leave you at all!


text: Research In Motion has accused unnamed competitors of trying to compound and profit from its problems in India by "suggesting or implying" that RIM's BlackBerry Enterprise Server (BES) will be singled out by Indian regulators, even as their own products that use encryption will escape scrutiny.RIM said in a customer update on Tuesday that it had been assured by senior Indian government officials that it would not be singled out, and that any policy relating to "lawful access" requirements for encrypted enterprise or VPN (virtual private network) communications would be applied to all products and services that use encryption in India.The company also debunked reports that it was under an obligation to provide access to communications on BES to Indian law enforcement agencies by a Jan. 31 deadline, the company said. The Jan. 31 deadline was a "mutually agreed target" date between RIM and the Indian government only for the delivery of a solution to Indian carriers for lawful access to RIM's consumer messaging services, which include BlackBerry Messenger and BlackBerry Internet Service email. The interception facility was delivered to carriers ahead of schedule, RIM said. Indian government officials were not immediately available to comment on RIM's update.RIM has maintained that it cannot technically provide access to BES, its corporate service.India now wants to demand access to communications on BES through mobile service providers, according to reports. Indian law allows the government to require operators to provide access when directed. But RIM has said in the past that the architecture of the BES does not allow either RIM or service providers the technical ability to access communications on that platform, as the encryption keys are held by customers.RIM is trying to expand the scope of the discussion on interception with the Indian government to ensure that other providers of products and services using end-to-end encryption, a feature of enterprise grade virtual private networks (VPNs), are also included in a "lawful access" policy by the government.It hinted on Tuesday at which other companies it would like included in this discussion, when it referred to Apple, Cisco, Good Technology, Google, Hewlett-Packard, HTC, Microsoft, Motorola, Nokia, Samsung and Sony Ericsson in a partial list of technology companies that utilize strong encryption in their products and services in India. The Indian government has previously said it would demand lawful access to communications on Google and Skype's services, but has not taken any action so far in this direction. John Ribeiro covers outsourcing and general technology breaking news from India for The IDG News Service. Follow John on Twitter at @Johnribeiro. John's e-mail address is firstname.lastname@example.com


text:
- Home
- Government
- Departments A-E
- Emergency Management
- Response
- Emergency Operations Plan (EOP)
Emergency Operations Plan (EOP)
Virginia is continuously threatened by emergency and disaster situations such as flash flooding, hurricanes, hazardous materials incidents and resource shortages. The Virginia Emergency Services and Disaster Laws of 2000 requires that the state, and each county and city within the state, develop and maintain a current Emergency Operations Plan (EOP) which addresses their planned response to such extraordinary emergency situations. It is imperative that this plan mirror the National Response Framework, the Virginia Emergency Operations Plan, and other localities to ensure interoperability during large-scale disasters. This plan meets and exceeds all Department of Homeland Security National Incident Management System (NIMS) compliance mandates. It is designed to meet this responsibility and to include the city in the mutually supportive statewide emergency management system.
Parts of the Plan
The City of Roanoke Emergency Operations Plan actually consists of several parts. The development and maintenance of these plans is the basis of the local emergency management program.
Parts of the Plan
The City of Roanoke Emergency Operations Plan actually consists of several parts. The development and maintenance of these plans is the basis of the local emergency management program.
- The Basic Plan describes the concept of emergency operations and assigns duties and responsibilities to agency heads or organizations which are either part of, or will serve in support of, local government in time of emergency. It becomes the organizational and legal basis for emergency operations. The emergency support functions (ESF), support annexes, and incident-specific annexes to the Basic Plan provide additional guidance and set forth detailed procedures as needed to assure an appropriate level of emergency preparedness.
- The separately published Roanoke Valley Hazardous Materials Emergency Response Plan (available) was developed by the Roanoke Valley Emergency Planning Committee according to the Superfund Amendment and Reauthorization Act of 1986. This plan provides for emergency planning, response, mitigation and recovery specifically for hazardous materials in fixed facilities and transportation incidents in the Roanoke Valley.
- The separately published Roanoke Regional Airport Emergency Operations Plan (available) provides guidance for response and recovery from an aircraft emergency.
- To ensure that telephone and resource listings are current, a separate EOP Telephone and Resource Directory has been developed as an adjunct to the EOP and will be updated every 6 months. Because it contains confidential home, cellular and pager numbers, the directory must be strictly controlled and its distribution limited.
- There are 2 Support Annexes that, at date of adoption, will not be completed. They are Evacuation and Animal Care and Support. The Evacuation Plan is a 2-part plan addressing general evacuation procedures and routes around Roanoke. The second part will address the specific evacuation of the Downtown Market District. Both parts are being written with the support of the Roanoke Valley-Allegheny Regional Commission. The Animal Care and Control Plan is in development and being supported by the Roanoke Chapter of the Virginia State Animal Response Team.


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San Diego International Airport
Getting to San Diego International Airport is easy from most major roadways. Be sure to monitor traffic conditions during certain times of the day. It is essential to allow yourself enough time for airline check-in and to pass through security. Arrive two (2) hours prior to domestic flight departures and three (3) hours prior to international flight departures.
The Airport is served by I-5 with connections to State Route 163, I-8 and I-15. The following directions will help you arrive at your designated terminal on time.Addresses Directions Using Public Transportation
The San Diego Trolley and the Coaster commuter train do not stop at the Airport. The only public transit available is the Flyer Route No. 992 , a Metropolitan Transit System bus that travels between the Airport and downtown San Diego, stopping between Terminals 1 & 2 and the Commuter Terminal. The 10-minute bus service to and from downtown connects with Trolley, Coaster and Amtrak stations and is wheelchair accessible.
San Diego International Airport offers travelers several long-term parking options. Each location offers quick and easy access and is conveniently located within close proximity of the airport terminals. All locations offer free shuttle service. For your safety and security, each parking facility is fenced, well lighted, paved, and open 24 hours. No reservations are required.SAN Park Harbor Drive
3015 North Harbor Dr
San Diego, CA 92101
290 Parking Stalls
2395 McCain Road
San Diego, CA 92101
1,300 Parking Stalls
Map/Directions (MapQuest estimate)
Terminal to Terminal
The Red Bus provides complementary wheelchair-accessible transportation between the Airport's terminals. Buses run at intervals not to exceed 10 minutes. Designated Red Bus stops are located curbside at all three terminals. For additional information call Lindbergh Parking, Inc. at 619.291.1508.
Here are the airlines that serve San Diego International Airport. You can visit their web sites or call to make reservations.
You can also access flight arrival and departure times (updated every 10 minutes) or plan a flight itinerary .
|Air Canada
|AirTran Airways
|Alaska Airlines
|Alaska Commuter (Los Angeles flights only)
|Allegiant Air
|American Airlines
|American Eagle
|Continental Airlines
|Continental Connection (Los Angeles flights only)
|Delta Air Lines
Delta Connection (Los Angeles flights only)
|Delta Connection (all other flights)
|ExpressJet Airlines
|Frontier Airlines
|Hawaiian Airlines
|JetBlue Airways
|Midwest Airlines
|Northwest Airlines
|Southwest Airlines
|Sun Country Airlines
|United Airlines
|United Express (Los Angeles flights only)
|US Airways
|US Airways Express
|Virgin America
|WestJet (Summer only)
|Zoom Airlines UK
History of the AirportFrom Lindbergh Field to San Diego International Airport In 1927, Charles A. Lindbergh electrified the world when he made San Diego the starting point for the first-ever solo, nonstop transatlantic flight. In his Spirit of San Diego , Lindbergh took off from Dutch Flat bound for St. Louis, New York and Paris, France. Lindbergh later agreed to lend his name to a proposed new airport: San Diego Municipal Airport - Lindbergh Field.
Early aviation supporters saw their efforts rise from the mud when construction began on the long anticipated municipal airport. A cast of public and private agencies, military officers, politicians, philanthropists, and engineers worked tirelessly to build upon the muddy ground that gave birth to San Diego International Airport on its Dedication Day, August 16, 1928.
On June 1, 1930, the San Diego-Los Angeles airmail route was initiated, becoming the airport's major selling point for local government. At 5 o'clock sharp, the first airmail plane left the only building at the airport and raced down the runway, marking the beginning of a new era for San Diego.
At the outbreak of World War II, and as San Diego's population boomed, the military transformed San Diego International Airport into a modern aviation transportation center. The U.S. Army Air Corps took over the airport in 1942, and Army engineers improved the existing runways to accommodate the heavy bombers churned out by San Diego's aircraft manufacturers during World War II.
The 8,750-foot "mega-runway" built to accommodate World War II-era long-range bombers made San Diego International Airport "jet-ready" long before United Airlines became the first airline to offer pure jet service in September 1960. American Airlines followed with their "Jet Ace" scheduled service to Dallas/Fort Worth a few weeks later. San Diego had entered the Jet Age.
Today, at the beginning of the 21st century, San Diego International Airport is the nation's busiest single runway commercial airport — serving over 17 million passengers in 2005, and servicing 18 airlines, seven airfreight companies, 16 airline support providers and 23 concessionaires. A far cry from the first, dusty runway and single terminal, San Diego International Airport now contributes nearly $5 billion annually to the regional economy.
Free WiFi
Free WiFi throughout Hotel.
Guest Laundry
Guest Laundry available for guests. Detergent available
Free Parking for our guests.
Pool and Spa
Seasonal Outdoor Pool and Spa along with Handicapped Chair.
September EVENTS Calendar
Free WiFi
Free WiFi throughout Hotel.
Guest Laundry
Guest Laundry available for guests. Detergent available
Free Parking for our guests.
Pool and Spa
Seasonal Outdoor Pool and Spa along with Handicapped Chair.


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Kaka is undoubtedly a wonderful player, a fact confirmed by his World Player of the Year award, his Champions League winners medal and the huge number of fans he has, not just at the San Siro but all over the world.
What makes a player truly iconic is the unique style they employ out on the pitch. Kaka is so tall and strong and sometimes a little awkward looking, but his control and vision for that defence splitting pass is second to none. Nobody plays football like Kaka and that makes him a truly great footballer.
Another signature of a great player is that they will always rise to the big occasion. In the big matches, when it really matters, truly top draw players will always perform at their best. AC Milan's Champions League victory in the 2006-07 competition was all about the Brazilian genius. In the semi final he bossed both legs of their tie with Manchester United, making other brilliant players look distinctly average.
The 2006 World Cup was another stage where Kaka truly reached the top of his game. In a Brazil side that so much was expected, they never really delivered but Kaka still came away with much credit. Critics recognised the fact that it was he who was at the centre of most of the good things Brazil did in the competition.
His unique style and big game performances mean that sales of Kaka football shirts have gone through the roof. A player that can sell shirts is always an important commodity to any top football club. AC Milan will want to tie him down to a lengthy contract to ensure other giants of world football don't start sniffing around.
With players like Ronaldo and Messi rising to the top of the game, Kaka still sits at the top of the tree and is still young enough to enjoy the finest football of his career and join other great Brazilians in football's hall of fame.


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Pretzel Cookies with Chocolate & Peanut Butter Chips
Category: Cookies & Candies
posted by: kfaulkn
1 1/2 cups of all purpose flour
1/2 tsp. of salt
1/4 tsp. of baking soda
1/2 cup of butter at room temperature
1/2 cup of tightly packed light brown sugar
1/3 cup of granulated sugar
1 egg (beaten)
1 tsp vanilla extract
1 cup milk chocolate chips
1/2 cup peanut butter chips
1/2 cup broken up pretzel pieces
Preztel Salt or Sea Salt
1. In a medium bowl, sift together the flour, baking soda, and salt. Set aside.
2. In a larger bowl, beat the butter and sugars together on medium speed until light and fluffy (about 2-3 minutes). On low speed, slowly add the beaten egg and vanilla extract. Beat to combine, scrape down the sides of the bowl.
3. Add the flour mixture and beat just until there are no more streaks of flour. Stir in the chocolate chips, peanut butter chips, and preztels. Cover and refrigerate for an hour.
4. Preheat the oven to 350F. Line baking sheets with parchment paper. Scoop out well rounded tablespoonfuls of the dough and sprinkle with pretzel salt. Leave about 2 inches between each ball. Bake for 10 minutes. If you prefer crispier cookies increase the baking time by 1-2 minutes. Allow the cookies to cool on the baking sheet for a few minutes before removing.
Source: http://sugarcooking.blogspot.com/2010/07/pretzel-cookies-with-chocolate-peanut.html


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Displaying 1 - 10 of 11 results
- The CRVS profiles consolidate knowledge shared by countries on the status of their CRVS systems in the recent past, including through government websites, published reports, media releases and presentations, and direct engagement between the authors of these profiles and in-country civil registration offices and health information offices.August 30, 2021News & Reports
- ESCAP just published a report titled "Getting every one in the picture - A snapshot of progress midway through the Asia and Pacific Civil Registration and Vital Statistics Decade". The report shows that the Asia-Pacific region is on the right path to reach goals of universal and responsive CRVS systems.June 28, 2021News & Reports
- The Curriculum on medical certification of cause of death for Pacific Island countries and territories report is now available.
A death certificate is a permanent record of the fact of and characteristics of death. It provides important personal information about the decedent, the circumstances and cause of death and serves as the main source of mortality statistics for a country.May 18, 2021News & Reports
- A well-functioning civil registration and vital statistics (CRVS) system is the cornerstone of good, sustainable governance and is key to social and economic development; The CRVS Systems Improvement Framework report is now available.May 10, 2021News & Reports
- Population registers are recognised for their dual role of providing critical information about the civil status of individuals within a population. In the Pacific, to the extent known bySPC, there is no evidence of a country that implements a functional population register.May 4, 2021News & Reports
- The report covers vital events (births and deaths) and causes of death for Tonga for the period 2013 to 2018.April 15, 2021News & Reports
- This paper draws on Vanuatu's experiences to discuss the importance of civil registration and vital statistics (CRVS) systems and the challenges faced when these systems are implemented during disasters and emergencies. The paper also discusses key strategies to mitigate the impact of disasters on CRVS systems.April 8, 2021News & Reports
- The COVID-19 pandemic has impacted on the ability of governments to maintain services and routine functions, including the operation of national civil registration and vital statistics (CRVS) systems.March 22, 2021News & Reports
- Technological advances have increased the potential uses of population registers for producing statistics.October 28, 2020News & Reports
- Theme: 2020+ the era of Administrative data; looking into the role of registers and administrative data in Census programmes of Pacific Island countries
July 27, 2020News & Reports