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Breast Augmentation with Fat Grafting
As an alternative method of breast augmentation, fat grafting has helped our patients at Richmond Aesthetic Surgery achieve natural-looking results without using an implant. This innovative breast augmentation technique uses your body's own fat cells to increase the volume and fullness of the breasts. Dr. Neil J. Zemmel has also used this procedure to successfully improve the results of our breast reconstruction patients. To harvest the fat used for this procedure, Dr. Zemmel will first perform liposuction on an area of your body with spare fatty tissue, such as the abdomen, thighs, or love handles.
The Procedure
After the fat is harvested from your body, it is purified and then re-injected into the breast tissue to gradually build up the volume and shape. Since this form of breast augmentation requires fat to be injected in small amounts, the final size can be tightly controlled. Many small injections of fat at a time allows Dr. Zemmel to control precisely the ultimate volume and shape of the breasts. In addition, because there is no incision required for an implant, this fat grafting method can minimize many of the risks and scarring typically associated with breast augmentation.
In addition to enlarging the breasts, augmentation with fat grafting can provide the added benefit of a contoured figure for a more comprehensive transformation.
Your Results
Sometimes referred to as "natural" breast augmentation, this fat grafting method does not need a breast implant and, therefore, any issues with downstream replacement of the implants are eliminated. We know that approximately 70% of the transferred fat will take. This means that approximately 30% of the transferred fat will not survive permanently. Multiple procedures may be needed to obtain your desired cosmetic outcome. Because breast augmentation with fat grafting can only increase the volume of the breasts by approximately one cup size, it can be ideal for patients who desire more subtle results. Patients wishing for a more dramatic enhancement may consider breast augmentation with implants.
Contact Us
If you would like to learn more about breast augmentation with fat grafting, or to schedule a consultation with Dr. Zemmel, please contact our office today.


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Shelby DeWitt's story begins in high school. A herniated disk in her back pulled her out of sports, something that had been very important in her life. She got into a slump, and began to fall into depression and started self-medicating: hanging out with the wrong people, partying, drinking.
Her senior year she attended a party with some friends where she struck up a conversation with a boy she had a crush on for some time. He asked her to go to another party with him, and she agreed to go, but it was there that things went awry. It was there when this boy took advantage of her.
"It was the longest five minutes of my life," she says. "It was like I knew what was happening, but I didn't know what was happening."
She remembers feeling sick, in shock, her heart pounding. She was able to find someone to take her home that evening but wasn't able to process through what had happened. "I couldn't say much, I just knew something had happened at that party."
A couple months later, Shelby fell into what she describes as the worst point in her depression. "I couldn't really figure out why, but I didn't really need a reason why," she recalls. Her mom began to notice that something was off and encouraged her to seek some help.
One day while Shelby was sitting in class, a teacher asked what was wrong. "You don't have to tell me, but you have to tell someone," this teacher encouraged. Shelby then went to her volleyball coach; she told her how she had been feeling empty, not hanging out with the right people, and going to parties. She remembers her coach telling her to be careful, and that eventually someone could take advantage of her. It was then, in that moment, Shelby realized what had happened to her just a few months before.
The week that followed was extremely difficult; summoning up the courage to tell her mom, whom she says is one of the most important people in her life. A few days later she recalls waking up one morning feeling an overwhelming peace; peace knowing what step she was going to take next.
"I grabbed a bottle of pills from our medicine cabinet and began to take them one at a time. With every one I took, I thought of a person who was going to be affected by what I was doing," she says.
Close to an hour later, Brook, Shelby's sister, knocked on the door to check on her. "She looked like she knew," Shelby recalls. Brook picked the empty bottle of pills up off of the floor and yelled. "Shelby, What did you do?" Brook then called an ambulance and ten minutes later they arrived and took Shelby to the ER.
"I wasn't really worried about anyone else at that moment. In fact, I was kind of mad at people for not just letting me die." After the emergency room visit, Shelby was transported to another facility to be monitored for a short time period. They put her in a tiny, sterile room; with a motivational poster hanging on the wall. She wasn't sure of what to expect during that time and when they told her that her parents couldn't stay with her that night, she began to cry.
"I couldn't sleep that night," she remembers. "I spent the entire night crying. It was probably the first time I had ever cried out to God… literally. I spent the evening just talking to Him out loud."
The hardest part of being in that hospital was when they began to ask her what her plan was. What was she going to do after? What did she want to say to her parents? She knew that she wanted to tell her dad about the assault she had suffered. She had already spoken to her mom, but not yet her father.
"It was the hardest thing to say. I didn't know what my dad would do, but as soon as I spoke, my dad got up and he didn't say anything, he came over and just knelt at my feet and wept. I realized then for the first time God weeps with us when we weep and rejoices with us when we rejoice. He doesn't just stand and watch things happen. He's broken when we're broken."
From that moment on, Shelby began the process of healing. She had the opportunity to attend camp the following summer where the High School Pastor asked her if she would be willing to share her story, not knowing the full extent of everything at that time. She told him no, at first; then after some prayer decided to do so. When it came to the night to share her story, she couldn't stop crying. After getting up on stage she locked eyes with her brother and sister the entire time; she held them as her constant.
The entire camp was silent as Shelby shared her story. Not a dry eye in the room. Immediately following a few girls approached her, opening up about the abuse they too had experienced in their lives. "It was really hard to hear, it was really sad. But at the same time it was encouraging, I guess, to know there are others who have experienced what I have and they were still living; because I didn't think I'd ever want to live after that happened." Camp was a big turning point in her life last year, being able to connect with people through her story.
"I think my story is really about discovering who God is. He is with us through absolutely everything. When we are in the lowest valley to the top of the highest mountain, He is constant."

subset: commoncrawl


text: This was really nothing more than experimentation with a new masking technique I was trying out. Although I'm reasonably pleased with the image, I feel it still needs a little work in some areas – or rather, I need a little more practice with the technique. That said, not bad for a first attempt.


text: 2nd Quarter Patient Satisfaction Goals Met August 28, 2015 Congratulations to Radiology, Cardiopulmonary, Emergency Department, Admitting, and Medical Records for meeting their 2nd quarter Patient Satisfaction goals! Team Yellow (Medical Records) deserves a special congratulations for meeting their division goal! Medical Records Team TagsAntibiotic resistance apm arizona public media Bisbee High School bob barnes canyon vista ceo chamber of commerce Cochise Regional Hospital copper queen community hospital Copper Queen Hospital CQCH CQMA CQMA Douglas dickson Douglas Douglas Clinic Douglas Dispatch Douglas Medical Complex emergency department grand opening James Dickson Jim Dickson kvoa Medical Records MGMA MRI Palominas Patient Satisfaction Physician Press Ganey Quickcare radio Rural health Rural Health Day Rural Hospitals SAHA Sierra Vista Herald Souglas Southern Arizona Hospital Alliance state license SV Herald Tejero turquoise valley golf University of Arizona Archives 2017January2016DecemberNovemberJuneMayAprilMarchFebruaryJanuary2015DecemberNovemberOctoberSeptemberAugustJulyJuneMayAprilMarch2014MayAprilMarchFebruaryJanuary2013DecemberNovemberOctoberSeptemberAugustJulyJuneMayAprilMarchFebruaryJanuary2012DecemberNovemberOctober


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Zantrex-3 slimming pill review
What is Zantrex-3?
Marketed as "5 times stronger than Ephedra", Zantrex-3 is non-prescription diet pill that claims it can help you shed unwanted pounds as well as gain lean muscles, speed up your metabolism, achieve high energy levels, fight depression and improve your mood.
Despite the fact that it is nearly impossible for a pill to give you all these benefits, let's see if Zantrex-3 can actually stand up to its claims.
Ingredients of Zantrex-3
Yerba mate, caffeine, Damiana, Guarana , Schizonepeta, Green tea, piper nigum, maca root , Tibetan ginseng, panax ginseng, cocoa nut, kola nut, thea sinensis complex.
As you can see, Zantrex-3 pill is packed with lots of Caffeine and stimulant content. It is said that one pill of Zantrex 3 contains the same amount of caffeine as in 3 or 4 cups of coffee.
Zantrex 3 side effects
A number of side effects related to stimulants can be expected by consumers: anxiety, irritability, fast heart rate, insomnia, restlessness, hyperactivity, confusion etc. Any diet pill that can give you these kinds of side effects is not a safe diet pill at all.
Zantrex 3 how much does it cost?
On the official website it is sold for $39.99 and they give you 30-days money back guarantee, which is hardly good for anything. One month is just not enough time to try a diet pill and make a conclusion about its effectiveness.
Is Zantrex-3 recommended?
Definitively not recommended and we advise you to avoid this one. List of ingredients speaks for itself; there are so much caffeine and stimulants in this pill that it becomes ridiculous. Consumers are advised to look for some other weight loss product.
Best alternative
When talking about effective fat burners we need to mention Phen375, fat burner that is slowly becoming one of the best rated fat burners on the weight loss market. With synthetic ingredients made in an FDA regulated lab and with high number of re-orders since its launch in 2009, Phen375 is definitely a pill that you should take a closer look at.
- success stories of rapid cuts femme
- Zantrex 3 Success Stories
- zantrex 3 weight loss stories


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Wastewater Aeration Systems
Arkea® Wastewater Aeration Systems by ArchaeaSolutions, Inc. combine the use of fixed film or suspended media with aeration for the treatment of wastewater. Our systems provide for enhanced or additional treatment of cBOD and nBOD in lagoon processes, especially for those processes that have difficulty satisfying their federal and state discharge requirements.
The unit or series of units are designed to float near the surface of a wastewater pond or lagoon and provide a surface for biofilm growth to occur. Air is supplied from an electric blower motor mounted on the shoreline which forces air through a single air header assembly and multiple diffuser hoses attached to the bottom of each device, creating fine bubble aeration.
Air bubbles pass through the media to the surface of the water. The rising wastewater passes by the biofilm growth and is absorbed into the growth, resulting in reduction and removal of cBOD and ammonium from the wastewater. Additionally, the distributed air continually replenishes the oxygen utilized by the microbes to break down waste particles.
The unique design of the Arkea® Wastewater Aeration System is self-supporting due to its buoyancy which allows each unit to maintain non-contact with lagoon or tank bottom at all times and requires no modifications to plant infrastructure. The air provides a continual addition of oxygen to the wastewater in the lagoon, increases the dissolved oxygen level, reduces the likelihood of septicity, and improves overall process wastewater conditions that ultimately lead to enhanced reduction and removal of cBOD and ammonium.
Arkea® Wastewater Aeration Fixed Film/Suspended Media
Using Fixed Film and/or Suspended Media in wastewater systems is becoming the technique of the future for wastewater treatment.
Fixed Film and Suspended Media provide surface area. Why is surface area so important? It provides a place for microbes to grow. The microbes grow on the surface area of the Fixed Film or Suspended Media and form slime. This slime removes tremendous amounts of CBOD and nutrients.
Wastewater lagoons are basically devoid of places for bacteria to grow. ArchaeaSolutions,Inc. add media to our aerators to give the lagoon a place to grow microbes. The results include reduced cBOD and, in many cases, a significant improvement in nitrification.


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Sample of name and number that can be printed on back of shirt...
Adult Style tee perfect for showing your school spirit!
These are regular style men's baseball tee that are light weight and oh so soft! Design on this shirt has a vintage look to it.
There are no reviews for this item. Be the first to review it!


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I've made the mistake of saying "socially liberal, fiscally conservative" in the past…before I understood what libertarian really means.
I clearly remember the first time I ever met a self-described "libertarian." I was a sophomore in high school (don't ask me how long ago, or not, it was). I was discussing politics with someone before sports practice and one of them said he was a libertarian. I asked what that was.
He said: We're essentially fiscally conservative Democrats.
That was my impression of libertarianism for almost a decade.
It was also totally false. The person who said that had no idea what libertarianism was or wasn't.
One of the most frustrating things about being a libertarian isn't that people don't like what we believe; it's that they don't even know, or correctly understand, what we actually believe. Their perception is based on fakes, charlatans, imposters, and shysters, or the plain ignorant who think using drugs makes you a libertarian.
One of the worst ways to describe…
View original post 618 more words


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WINNIPEG, Manitoba (Reuters) - A strike at Canadian Pacific Railway Ltd (CP.TO), the country's No. 2 railroad, will delay at least 162,000 metric tons (178,574 tons) of grain sold to Canadian Wheat Board buyers, a senior CWB official said on Wednesday.
The CWB, which is Western Canada's monopoly marketer of wheat and barley until August 1, roughly splits its grain-shipping business between Canadian Pacific and the larger Canadian National Railway Co (CNR.TO).
The CWB will now try to divert as much grain as possible to CN during the CP Rail strike, said Ward Weisensel, the Wheat Board's chief operating officer. But it expects to incur penalties for failing to deliver grain on time to vessels waiting in ports.
Canadian Labor Minister Lisa Raitt said on Wednesday that the government would introduce back-to-work legislation as early as Monday if the strike persists.
"It's going to put half your whole program basically a week behind, perhaps more, depending on how quickly the railway can begin to catch up on the backlog that will be there," Weisensel said in an interview with Reuters.
"We're one of many shippers facing the same issues here. We need to resolve the issue immediately and get the railway back and moving again."
The strike by 4,800 engineers, conductors and traffic controllers at CP Rail started early on Wednesday, shutting down all CP freight traffic.
Canadian shippers are highly dependent on the country's two dominant railways to move grain because there is no river freight system in Western Canada, unlike in the United States.
Canada is the biggest exporter of spring wheat, durum, canola and oats, as well as a top producer of the crop nutrient potash, all of which move to export position mainly by rail.
The CWB will give up its grain monopoly at the end of the current crop marketing year and compete in an open market.
Reporting by Rod Nickel in Winnipeg; Editing by Frank McGurty


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Ashley Zapf, M.D.
Non-Surgical Sports Medicine
Baptist Medical Park - Navarre
8880 Navarre Pkwy.
Suite 201
Navarre, FL
Andrews Institute
1040 Gulf Breeze Pkwy.
Suite 204
Gulf Breeze, FL
Clinical Interests
- Sports and Exercise-Related Injuries, Team Physician and On-Site Sports Coverage, Return to Play Rehabilitation, Concussions, Musculoskeletal Injuries, Neurological Injuries, Nerve Impingement, Ultrasound Guided Injections, Peripheral Joint Injections, Electrodiagnostic Studies
- Medical School: Eastern Virginia Medical School, Norfolk, VA
- Internship: Internal Medicine - Portsmouth Naval Hospital, Portsmouth, VA
- Residency: Physical Medicine & Rehabilitation - Schwab Rehabilitation Hospital - University of Chicago, Chicago, IL
- Primary Care Sports Medicine - University of Florida, Gainesville, FL
Board Certifications
- Physical Medicine and Rehabilitation
Major Publications
- Zapf A, Morgan C, Herman D. CSMR Clinical Pearls: Recognizing Cuboid Syndrome. Submitted for publication in Current Sports Medicine Reports, 2016.
- Herman DC, Zapf AD, Vincent HK, Vincent KR. Knee Osteoarthritis. Published in PM&R Knowledge Now through the American Academy of Physical Medicine and Rehabilitation, October 2015.
- Zapf AD, Joyce JP. Ice Sled Hockey. In: Adaptive Sports Medicine. Springer, In Press.


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Create a Drow Down Menu New Feature - repost
Budget $30-250 USD
Our CMS adds new pages using Horizontal Top Nav Menu system that it does not escale. We need to allow users to add more pages as a Drop down menu options so that the site number of pages can grow if needed.
1-) Add a Drop down menu options..
2-) Create a warming message stating that reads (below) if they try to add more than 6 pages.
"you have exceeded the number of pages that can be added.
Use the create drop down option instead to add more pages.
3-) Test it make sure that it works.
4-) resolve any bugs found.
See screenshots attached. By the Way our CMS is written in PHP and uses msql.
NOTE: You will be given higher priority if you can make this into a a plugin that can be easily added to any other mock ups we have.
Please see attachments
Awarded to:
14 freelancers are bidding on average $182 for this job
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text:
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Why study Italian today?
Apart from helping you acquire a useful skill and an understanding of another culture, study of a foreign language can be a transformative experience, changing the way you think about the world. Italian is the romance language closest to Latin. It is also the language closest to English, since English contains many roots from Italian and Latin.
Italian is the language having the "best phonetic fit". It is the easiest foreign language to read, write and pronounce because there is only one sound per letter of the alphabet and four consonant blends.
There are over 70 million speakers in the world Knowing Italian is greatly beneficial in several career fields: ie. interior design, fashion, graphic design, furniture design, machine tool manufacturing, construction machinery and transportation equipment. Italy has long been a magnet for the tourism industry.
Year 7 course outline
The Year 7 course covers introductions, simple dialogues, greetings, numbers to 100, dates, time, adjectives and nouns. Simple linguistic structures are introduced – singular/plural, masculine/feminine, essere and avere (singular), negative forms.
The course also enables the students to study the culture where the target language is spoken. Cultural units include background information on Italy, famous Italian people (past and present), Carnevale, Easter and Christmas.
Each chapter starts with a cartoon story plus audio as a way to introduce new grammar and vocabulary.
Language taught is reinforced with the use of DVDs and multimedia programs. Students are encouraged to read and write simple sentences in Italian and to take part in role-plays, songs and educational games.
ICT and Multimedia presentations are a part of the course whereby students incorporate cross-curricular knowledge and skills.
Students who study Italian through to Year 10 are eligible to apply for a four week school - organised study tour to Italy which occurs every two years.


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Whether you're visiting the spa to relax or refresh, as a routine therapy or a particular pleasure, anticipate a totally capturing experience that leaves you looking and feeling your very best.
Royal Day Spa is excited to offer a refreshing menu of spa treatments. There are more than 100 different treatments, all developed by our in house experts.
These customized treatments are drawn from and inspired by our serene natural setting and are based on the world's best ancient and modern therapeutic techniques. Let us help select the treatments that are right for you.
In the care of our experienced technicians and therapists, we welcome you to investigate the various pathways to health, both physical and mental. Try a genuine aromatic massage, a refreshing facial or one of our exceptional touch remedies.
Our list of premium day spa services:
- Full body massages
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Enjoy a relaxing day away by yourself or with a friend or perhaps plan a romantic day of indulgence for two. We make it easy with these special spa packages.
The possibilities for your ultimate spa experience are almost endless! To learn more about us, contact us at (905) 503-2513
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Research June 2017 | Volume 125 | Issue 6
Maternal and Cord Blood Manganese Concentrations and Early Childhood Neurodevelopment among Residents near a Mining-Impacted Superfund Site
1Department of Environmental Health, Boston University School of Public Health, Boston, Massachusetts, USA
2Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
3Department of Neurology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
4Department of Psychiatry, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
5Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
6Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
7Local Environmental Action Demanded (L.E.A.D.) Agency, Inc., Vinita, Oklahoma, USA
8Division of Environmental Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
PDF Version (655 KB)
- Background:
- Environmental manganese exposure has been associated with adverse neurodevelopmental outcomes among school-aged children; yet, few studies have evaluated prenatal exposure.
- Objectives:
- Our study examines associations between prenatal manganese concentrations and placental transfer of manganese with neurodevelopment in 224 2-y-old children residing near the Tar Creek Superfund Site.
- Methods:
- We collected maternal and cord blood at delivery, measured manganese using inductively coupled plasma mass spectrometry, and assessed neurodevelopment using the Bayley Scales of Infant Development-II. Associations between manganese and mental (MDI) and psychomotor (PDI) development indices were estimated in multivariable models. Placental transfer, approximated by cord/maternal manganese ratio, cord/total manganese ratio (total=maternal+cord), and by joint classification according to high or low (above or below median) maternal and cord manganese, was evaluated as a predictor of neurodevelopment.
- Results:
- Median levels [interquartile ranges (IQR)] of manganese in maternal and cord blood, respectively, were 24.0 (19.5–29.7) and 43.1 (33.5–52.1) μg/L. Adjusting for lead, arsenic, and other potential confounders, an IQR increase in maternal manganese was associated with −3.0 (95% CI: −5.3, −0.7) points on MDI and −2.3 (95% CI: −4.1, −0.4) points on PDI. Cord manganese concentrations were not associated with neurodevelopment scores. Cord/maternal and cord/total manganese ratios were positively associated with MDI [cord/maternal: β=2.6 (95% Cl: −0.04, 5.3); cord/total: β=22.0 (95% Cl: 3.2, 40.7)] and PDI (cord/maternal: β=1.7 (95% Cl: −0.5, 3.9); cord/total: β=15.6 (95% Cl: 0.3, 20.9)). Compared to mother–child pairs with low maternal and cord manganese, associations with neurodevelopment scores were negative for pairs with either high maternal, high cord, or high maternal and cord manganese.
- Conclusions:
- Maternal blood manganese concentrations were negatively associated with early childhood neurodevelopment scores in our study. Findings highlight the importance of understanding maternal exposures during pregnancy and factors influencing placental transfer. https://doi.org/10.1289/EHP925
Received: 04 December 2015
Revised: 20 November 2016
Accepted: 30 November 2016
Published: 28 June 2017
Address correspondence to B. Claus Henn, Boston University School of Public Health, Department of Environmental Health, 715 Albany St., Boston, MA 02118 USA. Telephone: (617) 638-4653. Email: firstname.lastname@example.com
Supplemental Material is available online (https://doi.org/10.1289/EHP925).
R.J. and E.H. were employed by the Local Environmental Action Demanded (L.E.A.D.) Agency, Inc., Vinita, OK, USA (http://www.leadagency.org/), at the time this study was conducted and are currently volunteers for the agency. The other authors declare they have no actual or potential competing financial interests.
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Supplemental Material PDF (166 KB)
Note to readers with disabilities: EHP has provided a 508-conformant table of contents summarizing the Supplemental Material for this article (see below) so readers with disabilities may determine whether they wish to access the full, nonconformant Supplemental Material. If you need assistance accessing journal content, please contact firstname.lastname@example.com. Our staff will work with you to assess and meet your accessibility needs within 3 working days.
Supplemental Table of Contents PDF (90 KB)
Manganese (Mn) is a trace essential element, necessary for physiologic processes such as neuronal function (Prohaska 1987; Sloot and Gramsbergen 1994), protein and energy metabolism, bone growth (Aschner and Aschner 2005; Hurley 1981), and enzyme activation (Erikson and Aschner 2003). During fetal and neonatal development, there is an increased need for manganese due to its critical role in brain function and skeletal development (Hurley 1981). Manganese crosses the placenta via active transport (Yoon et al. 2009), likely reflecting fetal nutrient demand. However, excess or accumulated manganese exposure can be neurotoxic and has been associated with deficits in cognition and motor function (Sanders et al. 2015; Zoni and Lucchini 2013). Little is known about how manganese transfer from the mother is regulated. The way in which manganese is partitioned in the maternal/fetal unit may be an important factor in fetal development (Kopp et al. 2012).
Concerns about heightened potential sensitivity to manganese neurotoxicity during fetal and early life compared to adulthood have recently been raised. Research is complicated by the increased fetal demand for manganese during development, as well as the unique physiology of the fetus and infant in which rapid growth makes it susceptible to nutrient deficiency. Increasing maternal blood manganese levels during pregnancy may by a physiologic response to this fetal demand, but the optimal range of manganese levels has not been determined and it remains unclear at what level maternal blood manganese may become harmful to the fetus. Manganese crosses the blood–brain barrier in the fetus at a higher rate than in adults, based on animal experimental data (Cahill et al. 1980; Kostial et al. 1978; Takeda et al. 1999). Because of the developing brain's high oxygen and energy consumption, it is sensitive to oxidative stress and damage from free radicals that can result from elevated manganese exposure (Blomgren and Hagberg 2006; Buonocore et al. 2001; Ikonomidou and Kaindl 2011). Given that neurodevelopment occurs as a cascade of well-timed, regulated events, exposure to toxic insults can cause damage at any stage, which may impair subsequent processes and result in developmental disability (Nowakowski and Hayes 1999).
Environmental manganese exposure has been associated with various neurodevelopmental outcomes among school-age children (Bouchard et al. 2011; Khan et al. 2012; Oulhote et al. 2014a; Wasserman et al. 2006; Wright et al. 2006). Relatively few studies, however, have evaluated neurotoxic effects of prenatal manganese exposure. An umbilical cord serum manganese concentration greater than 5.0 μg/L was associated with poorer performance on neurobehavioral tests in a population-based study of 933 3-d-old neonates in China (Yu et al. 2014). An inverted U-shaped association was reported between maternal blood manganese at delivery and mental and psychomotor development scores among 232 6-mo-old Korean infants with no known exposure source (Chung et al. 2015). Prenatal exposure estimated in deciduous teeth was not associated with mental and psychomotor development scores among 197 six- to 12-mo-old Mexican-American children living in an agricultural area of California where use of Mn-containing fungicides is common (Gunier et al. 2015). In the same cohort, prenatal tooth manganese was associated with poorer behavioral scores in 248 school-age children, but positively associated with scores on tests of memory and cognition (Mora et al. 2015). High (>75th percentile) cord blood manganese concentrations were associated with worse cognitive, language, and overall neurodevelopment scores among 230 2-y old Taiwanese children with no known exposure source (Lin et al. 2013). Cord blood manganese levels were inversely associated with performance on psychomotor tests among 126 3-y-olds in France, whereas no association was observed with maternal blood manganese (Takser et al. 2003). Most prior studies, except Takser et al. (2003), relied on a single biomarker of prenatal manganese exposure, typically cord blood or serum.
Our study examines associations between prenatal manganese exposure and neurodevelopment among young children living near a former mining area in rural Oklahoma. The objectives were a) to estimate associations of manganese, measured in paired maternal–infant blood samples, with neurodevelopment at 2 y of age while adjusting for exposures to other metals; and b) to explore the role of placental transfer of manganese as a predictor of neurodevelopment.
Study Participants
Subjects were participants in a prospective birth cohort study of biologic markers of fetal and early childhood exposure to metals, maternal psychosocial stress, and their impact on neurodevelopment. This research was conducted in the area of the Tar Creek Superfund site in Ottawa County, Oklahoma. This Superfund site, a former lead and zinc mining area, contains numerous piles of mine waste enriched in metals that are dispersed throughout the region (ATSDR 2004; Schaider et al. 2007). Study location and objectives have been described elsewhere (Ettinger et al. 2009; Zota et al. 2009). Briefly, pregnant women were recruited during prenatal visits or at delivery from the Integris Baptist Medical Center in Miami, Oklahoma. Mothers and offspring were followed until children were 7 y of age. Eligibility criteria included a) giving birth at Integris Hospital; b) intention to live within the study area for the next 2 y; c) not being currently enrolled in the study with another child; and d) having English-language proficiency sufficient to participate in the informed consent process. Eligible mothers received a detailed explanation of study procedures before consenting to participate. The research protocol was approved by the human subjects committees of Integris Baptist Medical Center and Harvard T.H. Chan School of Public Health (HSPH).
The original cohort included 713 mother–infant pairs, who were enrolled between 2002 and 2011. Biomarkers of prenatal manganese exposure data were available for 637 mother–infant pairs (5 pairs missing blood samples; 71 pairs excluded to avoid batch effects inherent in different instruments due to our laboratory's purchase of a new ICP-MS instrument near the end of the study). Neurodevelopment test scores at 2 y of age were available for 225 of these 637 pairs. One subject was excluded from this analysis due to scores that were more than 3 standard deviations below the expected means for both mental and psychomotor development, necessitating referral for intervention. A total of 224 mother–infant pairs were included in this analysis.
Prenatal Manganese Exposure Assessment
Prenatal exposure to manganese was estimated by measuring manganese concentrations in maternal blood and umbilical cord blood samples collected at the time of birth (±12 hr). Blood collection procedures have been detailed elsewhere (Ettinger et al. 2009). Briefly, venous whole blood from mothers and umbilical cord blood from the umbilical vein were collected in trace element–free tubes [BD Vacutainer royal blue top, with K2EDTA #368381 (Becton Dickinson)] following routine clinical procedures by delivery room staff and shipped frozen to the Trace Metals Laboratory at HSPH (Boston, MA). One milliliter of blood was digested with concentrated HNO3 acid, followed by the addition of hydrogen peroxide and dilution with deionized water. We measured total manganese concentrations in blood with a dynamic reaction cell–inductively coupled plasma mass spectrometer (DRC-ICP-MS; Elan 6,100; PerkinElmer, Norwalk, CT) using previously published methods and quality control measures (Chen et al. 1999; Ettinger et al. 2009). Average recovery of quality control standards for manganese (NIST 1643e, 1 ppb CV, human hair GBW 07601) was 96–104%. Lead and arsenic concentrations were also measured in blood samples and considered as covariates in all analyses given their co-occurrence in environmental media at this site (Zota et al. 2011). The limit of detection (LOD) was 0.02 μg/dL for manganese, lead, and arsenic. All manganese and arsenic measurements were above the LOD. Three (1.3%) lead measurements in cord blood were below the LOD and were assigned a value of one-half the LOD.
Child Neurodevelopment Assessment
Child neurodevelopment was assessed at 2 y of age using the Bayley Scales of Infant Development-II (Bayley 1993). Age-adjusted scores from the Mental Development Index (MDI) and the Psychomotor Development Index (PDI) were used as the primary outcomes. Two trained study personnel administered the test using a standardized protocol and were overseen by a licensed psychologist (D.C.B.) and a graduate student clinical developmental psychologist. All study testers were blinded to the participants' exposure information.
Covariate Assessment
We used interviewer-administered questionnaires at the time of enrollment to collect information on sociodemographic characteristics, including maternal education, race/ethnicity, and smoking and alcohol consumption during pregnancy, as well as potential sources of metals exposure. Information on child's birth weight, head circumference, and gestational age at birth was abstracted from medical records. Gestational age at birth was based on clinical assessment using data from the last menstrual period, the first accurate ultrasound examination during the first trimester, and clinical examination (ACOG 2014). Hemoglobin and hematocrit concentrations were measured in a maternal blood sample collected within 12 hr of admission to labor and delivery according to routine clinical procedures (as well as an extra tube collected at this time for measurement of blood manganese). Maternal IQ was assessed using the Kaufman Brief Intelligence Test (KBIT) at 6-mo postpartum (Kaufman and Kaufman 1990).
Statistical Analysis
Distributional plots were examined and descriptive statistics were calculated for all variables. Bivariate associations were calculated between all exposures, outcomes, and covariates. The correlation between maternal and cord blood manganese was estimated using Spearman's r correlation coefficient. Characteristics of mother–infant pairs included in all analyses were compared to those excluded from analyses using t-tests for continuous variables and chi-square tests for categorical variables.
We estimated associations between prenatal manganese concentrations and neurodevelopment using multivariable regression. We examined potential nonlinear associations between manganese and neurodevelopment using generalized additive models with penalized splines (constrained to 4 knots). We used a likelihood ratio test comparing models with a smoothed manganese term to models with a linear manganese term to assess linearity of the manganese–neurodevelopment association. To address skewness, we used natural logarithmic-transformed metals concentrations in exposure–neurodevelopment models. We modeled manganese concentrations as continuous loge-transformed concentrations and compared the 25th to 75th percentile [interquartile range (IQR)]. Neurodevelopment test scores were normally distributed and analyzed as continuous variables.
Potential confounders were selected a priori based on previous literature and on established or plausible associations with neurodevelopment (Grandjean and Landrigan 2006; Lanphear et al. 2000; Tong et al. 2007). We included child sex, maternal education (≥12th grade vs.<12th grade), maternal IQ, maternal hemoglobin at time of delivery (g/dL), and concentrations of maternal or cord blood lead and arsenic, centered at the mean of the loge distribution and modeled as penalized splines (constrained to 4 knots). Maternal hemoglobin was used as a proxy for iron status, which is a potential confounder given that iron deficiency in the neonate can adversely impact neurodevelopment (Georgieff 2008) and that iron status may influence manganese levels (Gunshin et al. 1997). In sensitivity analyses, we considered the following additional potential confounders because they were associated with loge-transformed blood manganese levels or neurodevelopment scores in bivariate models (p<0.10): maternal smoking during pregnancy (yes/no), gestational age at birth (weeks), maternal age at time of delivery (years), first-born child (yes/no), annual household income ($20,000–40,000, >$40,000 vs.<$20,000), maternal marital status (married/living with partner vs. never married/separated/divorced), and use of prenatal vitamins. Given the recent emphasis on sex-specific metal effects (Llop et al. 2013) and possible sex-related metabolic differences in manganese regulation (Oulhote et al. 2014b), we explored sex differences in the association between manganese and neurodevelopment by including an interaction term (child sex*manganese) in regression models.
Some participants were missing data on one or more key potential confounders (i.e., maternal IQ, maternal hemoglobin, maternal and cord arsenic levels). We used multiple imputation to impute missing values using chained equations with the MI procedure in SAS (SAS Institute Inc., Cary, NC, USA) (van Buuren 2007; White et al. 2011). We assumed data were missing at random, that is, that the missingness did not depend on the unobserved data. We generated 40 imputed data sets. In the imputation process, we included all exposure and outcome variables and covariates thought to be related to the process causing the missing data (see Table S1, for a list of variables). We combined results from models fit with the multiply imputed data sets by applying Rubin's formula (Rubin 2004) in R (R Foundation for Statistical Computing).
We explored the hypothesis that the efficiency with which manganese is transferred from mother to fetus is an important determinant of neurodevelopment, as has been posited previously (Kopp et al. 2012). We evaluated cord/maternal blood manganese ratio as well as cord/total blood manganese ratio (total=maternal+cord manganese) as predictors of neurodevelopment. Ratios were calculated using untransformed manganese concentrations. We also clustered mother–infant pairs into four groups, based on blood manganese concentrations dichotomized at the medians of the two distributions: a) low maternal/low cord, representing concordant low exposures; b) low maternal/high cord; c) high maternal/low cord; and d) high maternal/high cord, representing concordant high exposures. Using multivariable regression models, we estimated the associations between this categorical variable, a crude representation of placental transfer, and neurodevelopment. Models with ratios and with clustered mother–infant pairs were adjusted for the same set of a priori covariates as manganese–neurodevelopment models (i.e., child sex, maternal education, maternal IQ, maternal hemoglobin at time of delivery, and concentrations of maternal or cord blood lead and arsenic).
We conducted sensitivity analyses to evaluate the robustness of our findings. a) We ran models using complete cases only and compared results with those using the imputed datasets. b) We examined the influence of extreme values of prenatal manganese concentrations by fitting models with and without outliers identified using the generalized extreme Studentized deviate (ESD) many-outlier procedure, set to identify up to 10 outliers (Rosner 1983). c) We examined the potential confounding effects of additional sociodemographic characteristics (listed above) by re-running models including these variables. For all statistical tests, the significance level was set at 5%. We conducted statistical analyses using SAS (version 9.4; SAS Institute Inc.) and R (version 3.1.2; R Foundation for Statistical Computing).
Table 1 shows characteristics of mother–infant pairs included in all analyses, as well as those excluded from analyses due to missing exposure and/or neurodevelopment data. Included pairs (n=224) differed from excluded pairs (n=489) on several characteristics: mothers included were older at time of delivery, had higher household incomes, were more likely to be married/living with partner and have at least a high school education, had higher blood arsenic levels, and were less likely to have smoked or have had smokers in the household during pregnancy. For study participants, the average age±SD at time of neurodevelopment assessment was 2.1±0.1 y. MDI scores ranged from 54 to 128 (mean±SD=98.8±15.9); PDI scores ranged from 57 to 133 (mean±SD=105.3±12.2). Among included pairs, characteristics of participants with complete data on all variables included in the imputation process (n=122) were similar to those of participants with incomplete data (n=102; see Table S2).
|Included (n=224)a
|Excluded (n=489)b
|n (%)
|Mean±SD or Median (IQR)
|n (%)
|Mean±SD or Median (IQR)
|Prenatal exposure measures, median, IQRc
|Maternal blood Mn (μg/L)
|24.0 (19.5–29.7)
|22.5 (18.6–29.0)
|Maternal blood Pb (μg/dL)
|0.6 (0.4–0.9)
|0.6 (0.4–0.9)
|Maternal blood As (μg/L)*
|1.8 (1.1–2.8)
|1.4 (0.9–2.2)
|Cord blood Mn (μg/L)
|43.1 (33.5–52.1)
|41.2 (32.1–51.9)
|Cord blood Pb (μg/dL)
|0.4 (0.3–0.6)
|0.4 (0.3–0.6)
|Cord blood As (μg/L)
|2.3 (1.7–3.3)
|2.4 (1.8–3.5)
|Child characteristics
|Female sex
|91 (40.6)
|234 (48.1)
|First-born child
|86 (38.6)
|189 (38.7)
|Birth weight (g), mean±SD
|Gestational age at birth (weeks), mean±SD
|Preterm birth (<37 wk)
|9 (4.0)
|24 (5.0)
|Head circumference at birth (cm), mean±SD
|Delivery type: cesarean sectiond
|64 (29.8)
|120 (25.4)
|Maternal characteristics
|Marital status: married or living with partner*
|174 (77.7)
|281 (59.4)
|Education: ≥12th grade*
|191 (85.3)
|335 (68.9)
|Smoked during pregnancy: yes*
|56 (25.0)
|190 (38.9)
|Any smokers in household: yes*
|50 (28.3)
|116 (45.5)
|154 (69.4)
|312 (66.2)
|Native American
|52 (23.4)
|115 (24.4)
|Other (including Hispanic)
|16 (7.2)
|44 (9.3)
|Annual household income*
|59 (37.3)
|174 (55.6)
|54 (34.2)
|99 (31.6)
|37 (23.4)
|31 (9.9)
|8 (5.1)
|9 (2.9)
|Hemoglobin at delivery, mean±SD
|Anemia at delivery: yese
|56 (25.4)
|119 (24.7)
|Use of prenatal vitamins: yes*
|147 (65.6)
|282 (57.7)
|Age at delivery (years), mean±SD*
|IQ, mean±SD
Note: Individuals included in analysis differed from excluded individuals, p<0.05. t-tests were conducted on loge-transformed blood metals concentrations.
aNumbers may not sum to total sample size (n=224) for some characteristics due to missing data: first-born child n=1, delivery type n=9, household smokers n=47, race/ethnicity n=2, income n=66, anemia n=4. Percentages are based on observations with known values only.
bNumbers may not sum to total sample size (n=489) for some characteristics due to missing data: sex n=2, first-born child n=1, marital status n=16, education n=3, prenatal smoking n=1, household smokers n=234, race/ethnicity n=18, income n=176, anemia n=8. Percentages are based on observations with known values only. Participants excluded from analyses due to missing blood samples (n=5), new ICP-MS instrument error (n=71), missing outcome data (n=412), and neurodevelopment scores more than 3 SD below expected mean (n=1).
cMedian and interquartile range (IQR, 25–75th percentile) reported for blood metals concentrations.
dCompared to vaginal or vaginal assisted delivery.
eAnemia at delivery defined as maternal hemoglobin <11.0 g/dL at delivery, which is based on the definition from the Centers for Disease Control and Prevention (during 3rd trimester), the World Health Organization (during pregnancy), and the American Congress of Obstetricians and Gynecologists (in 1st and 3rd trimesters; ACOG 2014).
Median (25–75th percentile) manganese concentrations in maternal and cord blood were, respectively, 24.0 (19.5–29.7) and 43.1 (33.5–52.1) μg/L. The median manganese concentration in cord blood was nearly twice the median concentration in maternal blood, and the median (25–75th percentile) cord/maternal manganese ratio was 1.8 (1.4–2.3). Manganese levels were in the range of levels reported in other studies of mother–infant pairs (Figure 1). Maternal and cord blood manganese levels were correlated (Spearman rho=0.39, p<0.0001, n=224), though in a nonlinear manner (Figure 2). At maternal manganese less than 40 μg/L, cord manganese level increased by an estimated 1.1 [95% confidence interval (CI): 0.8, 1.4] μg/L for each 1-μg/L increase in maternal manganese. At maternal manganese levels greater than 40 μg/L, however, a negative association was apparent, although the estimated curve is imprecise in this range because it is based on a limited number of observations (n=18).
There was a lack of evidence for a departure from linearity in the associations between loge-transformed maternal manganese levels and neurodevelopment scores, based on likelihood ratio tests and visual inspection (Figure 3A,B). Maternal manganese was significantly negatively associated with both mental and psychomotor development (Table 2): an interquartile range increase in maternal manganese (10.1 μg/L) was associated with decreases of 3.0 (95% CI: −5.3, −0.7) and 2.3 (95% CI: −4.1, −0.4) points in MDI and PDI scores, respectively.
|Outcome: MDI
|Outcome: PDI
|Models with loge
maternal blood manganesea
|Using imputed data
|−5.3, −0.7
|−4.1, −0.4
|Using complete case method
|−5.5, −0.3
|−3.7, 0.5
|Using imputed data, excluding outliersb
|−5.2, −0.2
|−4.4, −0.4
|Using imputed data, adjusting for additional potential confoundersc
|−5.3, −0.4
|−4.3, −0.3
|Models with loge
cord blood manganesea
|Using imputed data
|−1.8, 2.8
|−1.9, 1.8
|Using complete case method
|−1.8, 3.4
|−1.2, 3.0
|Using imputed data, excluding outliersb
|−2.3, 2.5
|−2.1, 1.7
|Using imputed data, adjusting for additional potential confoundersc
|−1.8, 3.6
|−1.7, 2.2
Note: Adjusted for child sex, maternal IQ, maternal education, maternal hemoglobin, and smoothed loge blood Pb and As (centered) in maternal or cord blood.
aScaled to difference between 25th and 75th percentile of blood Mn (maternal: 10.1 μg/L; cord: 18.5 μg/L).
bOutlying manganese levels in maternal blood: 73.2, 117.4 μg/L; cord blood: 139.1 μg/L.
cAdditionally adjusted for maternal smoking during pregnancy, gestational age at birth, maternal age at time of delivery, first-born child, annual household income, maternal marital status, and prenatal vitamin use.
Visual inspection of smoothed plots of loge-transformed cord blood manganese with neurodevelopment suggest an increase in MDI and PDI scores at lower concentrations and a leveling off at mid-range concentrations (Figure 3C,D). However, there was a lack of evidence for a departure from linearity based on likelihood ratio tests comparing models with penalized spline terms to models with linear terms (MDI: p=0.15; PDI: p=0.12). There were no significant associations between loge-transformed cord blood manganese and MDI or PDI scores (Table 2). Results from exploratory analyses of sex-specific manganese associations, in which we included an interaction term (child sex*manganese) in regression models, were inconclusive (see Table S3).
We modeled associations between neurodevelopment and three proxy measures of the efficiency of placental transfer. In multivariable adjusted models of cord/maternal blood manganese ratio and cord/total blood manganese ratio (total=maternal+cord manganese), MDI and PDI scores were positively associated with both ratios [cord/maternal-MDI: β=2.6 (95% CI: −0.04, 5.3); cord/maternal-PDI: β=1.7 (95% CI: −0.5, 3.9); cord/total-MDI: β=22.0 (95% CI: 3.2, 40.7); cord/total-PDI: β=15.6 (95% CI: 0.3, 20.9)]. Based on the analysis of clustered mother–infant pairs, pairs with high maternal manganese only (i.e., maternal manganese levels≥median), high cord manganese only, or high maternal and high cord manganese had lower neurodevelopment scores, compared to mother–child pairs with low maternal and low cord manganese levels (Table 3). PDI scores were significantly lower among pairs in all three groups, compared to the low concordant exposure group.
|Outcome: MDI
|Outcome: PDI
|Joint classification of maternal and cord Mn levels
|Using imputed data
|Low maternal, low corda
|Low maternal, high cord
|−9.5, 2.1
|−10.8, −1.5
|High maternal, low cord
|−11.0, 0.5
|−11.6, −2.3
|High maternal, high cord
|−12.3, −2.1
|−10.4, −2.3
|Using complete case method
|Low maternal, low corda
|Low maternal, high cord
|−9.0, 3.5
|−10.5, −0.4
|High maternal, low cord
|−11.9, 0.5
|−11.4, −1.4
|High maternal, high cord
|−13.5, −1.3
|−8.9, 0.9
Note: Models adjusted for child sex, maternal IQ, maternal education, maternal hemoglobin, and smoothed loge cord blood Pb and As (centered); groups defined by maternal and cord blood Mn levels. Low indicates<median; high indicates≥median. Median maternal Mn=24.0 μg/L; median cord Mn=43.1 μg/L.
aReference category.
Sensitivity Analyses
Sensitivity analyses produced three main findings. a) Results from models of maternal and cord manganese with neurodevelopment using complete cases only were similar to results of analyses that included imputed data (Table 2). Adjusted associations between neurodevelopment and joint classification of maternal–infant groups according to high or low (above or below median) maternal and cord manganese were also similar when based only on complete cases (Table 3). b) Three subjects were identified with outlying blood manganese levels (two maternal: 73.2, 117.4 μg/L; one cord: 139.1 μg/L; Figure 2) using the generalized ESD many-outlier procedure. When these subjects were excluded, associations between manganese and neurodevelopment remained similar (Table 2), indicating that the few outlying manganese levels did not drive the associations we observed. Further, the correlation between maternal and cord manganese was unchanged (Spearman rho=0.40, p<0.0001, n=221 vs. for all observations: Spearman rho=0.39, p<0.0001, n=224) and a nonlinear pattern remained (Figure 2). c) With adjustment for additional sociodemographic variables, conclusions were unchanged (Table 2).
We estimated inverse linear associations between loge-transformed maternal blood manganese and early childhood mental and psychomotor development scores. Our findings are generally consistent with other studies that have estimated associations between biomarkers of prenatal manganese and neurodevelopmental outcomes (Lin et al. 2013; Takser et al. 2003; Yu et al. 2014). Our study is unique in that it is among the first to evaluate neurodevelopment outcomes in association with both maternal and infant biomarkers of manganese exposure, and with proxy measures of manganese placental transfer. To our knowledge, only one other study has estimated both maternal and cord blood effects: Takser et al. (Takser et al. 2003) observed inverse associations between cord, but not maternal, blood manganese and performance on psychomotor subscales of the McCarthy Scales of Children's Abilities among 126 3-y-olds with prenatal biomarker levels similar in magnitude to our study [geometric mean (range) 20.4 μg/L (6.3–151.2) and 38.5 μg/L (14.9–92.9) in maternal and cord blood samples, respectively]. In contrast, we found that maternal, but not cord, blood manganese was associated with neurodevelopment, as indicated by lower mean MDI and PDI scores, in our study population. Other studies have also reported evidence of adverse effects of cord blood manganese (Lin et al. 2013; Yu et al. 2014), although maternal biomarkers were not assessed.
Median blood manganese levels in our U.S.-based cohort were lower than median values reported for children in China (Chen et al. 2014), but higher than median or mean values reported for study cohorts in Germany, France, South Africa, and Canada (Abdelouahab et al. 2010; Chen et al. 2014; Kopp et al. 2012; Rudge et al. 2009; Takser et al. 2004). In this cohort, the routes of exposure likely include ingestion of manganese in dusts. We have previously reported positive associations between child hair manganese levels and house dust, but not indoor air, yard soil or tap water, in a subset of this cohort (Zota et al. 2015). Our observation that the median manganese level in cord blood was about twice as high as in maternal blood likely reflects active transport of manganese across the placenta (Krachler et al. 1999; Nandakumaran et al. 2016). Our finding is similar to previous reports in whole blood from 62 mother–infant pairs in South Africa (median 16.8 μg/L and 34.9 μg/L in maternal and cord blood samples, respectively) (Rudge et al. 2009) and in serum from 202 mother–infant pairs in China (median 2.8 μg/L and 4.0 μg/L in maternal and cord serum samples, respectively) (Yu et al. 2013). The Spearman correlation coefficient we observed between maternal and cord blood manganese was in the range of correlation coefficients reported by other studies (Abdelouahab et al. 2010; Chen et al. 2014; Gunier et al. 2014; Takser et al. 2004; Yu et al. 2013), though few studies appear to have allowed for possible nonlinearity (Chen et al. 2014; Gunier et al. 2014).
Our observation that the concentration of manganese in maternal blood, despite generally being lower than the concentration in cord blood, was a stronger predictor of neurodevelopment was unexpected, and the explanation is not apparent. We hypothesized that cord blood would more proximally represent fetal exposure, and therefore be more strongly associated with neurodevelopment. However, given that manganese is a nutrient, relationships are difficult to predict.
It is possible that high maternal manganese levels produce adverse effects on the placenta that are subsequently responsible for poorer neurodevelopment. This might explain differences in results compared to cord blood manganese. The fetus may be protected from direct adverse effects of excess maternal manganese by accumulating manganese in the placenta, but it may be indirectly affected by maternal manganese via placental factors that regulate neurodevelopment. An in vitro human placenta study has demonstrated that during normal steady-state exposure, the placenta efficiently transfers manganese to the fetus, but at high-dose maternal exposure the placenta limits transfer to the fetal circulation and accumulates manganese (Miller et al. 1987). This is consistent with the nonlinear relationship we observed between maternal and cord blood manganese levels, whereby levels were positively associated up to approximately 40 μg/L maternal blood, and cord blood levels subsequently leveled off or declined. There was, however, a relatively small number of observations in this higher exposure range. Alternative explanations may include mechanisms that do not involve a causal effect of maternal manganese, and findings should be confirmed in other studies.
Several biological mechanisms for the neurotoxic effects of prenatal manganese exposure have been proposed. Animal studies have reported that maternal developmental exposure in mice affects neurogenesis in the offspring, altering the number of immature granule cells in the hippocampal dentate gyrus and causing neuronal mismigration (Ohishi et al. 2012; Wang et al. 2012). In an experimental study, in utero exposure altered epigenetic gene regulation in offspring, which may affect programing of cells involved in neurogenesis (Wang et al. 2013). Manganese neurotoxicity appears to involve oxidative stress and dopaminergic dysfunction (Racette et al. 2012), and a link to adverse neurodevelopmental outcomes through disruption of thyroid homeostasis following alterations to dopamine activity has also been proposed (Soldin and Aschner 2007).
In our exploration of placental transfer, we found that MDI and PDI scores increased as the cord/maternal or cord/(maternal+cord) manganese ratios increased, suggesting that increasing cord manganese levels relative to maternal levels or relative to total (i.e., cord+maternal) levels might be beneficial. We also found that both MDI and PDI scores were lower among mother–infant pairs with either high maternal levels or high cord levels, compared to mother–infant pairs with both low maternal and low cord manganese. Overall, these results are consistent with our finding of a negative association between maternal manganese levels and scores for cognition and psychomotor function at 2 y of age. Further study is necessary, but these preliminary findings suggest that not only are concentrations of manganese in maternal blood predictors of neurodevelopment, but the relative amount of manganese transferred from maternal to fetal circulation may also be important. Factors that influence manganese transfer should be investigated more deeply.
Our study has several limitations. Prenatal maternal blood manganese may not best represent manganese total body burden given that it is a nutrient with a steady-state normal concentration range that is regulated in the body, rather than a xenobiotic that undergoes metabolism and excretion. Physiologic factors such as genetic variability or variability in metabolic function or liver function may contribute to differences in manganese levels (Claus Henn et al. 2011; Zerón et al. 2011). In addition, little is known about how maternal blood manganese levels vary during labor and delivery; therefore, timing of blood sample collection may influence blood manganese levels. However, blood manganese levels also increase in the setting of chronic exposure. For example, blood levels have been correlated with airborne manganese levels (Smith et al. 2007), with an indicator of take-home occupational pesticide exposure in a region where manganese-containing pesticides are commonly applied (Gunier et al. 2014), and with MRI intensity index in the globus pallidus among manganese-exposed children (Kafritsa et al. 1998). Our modest sample size limits the precision in our effect estimates. However, by multiply imputing missing covariate data, an approach that is valid if data are missing at random, we maximized the use of available exposure and outcome data. Finally, there is a possibility of selection bias from loss to follow up if factor(s) related to participation are associated with both manganese levels and neurodevelopment.
This is among the first studies to examine both maternal and infant biomarkers of prenatal manganese exposure in relation to neurodevelopment, which allows for a comparison of biomarkers as well as an exploration of placental transfer. The prospective design of our study strengthens the growing literature on manganese and neurodevelopment, which remains dominated by cross-sectional studies that cannot establish temporality. We collected data on a large number of potential confounders, including co-exposures to lead and arsenic, and results were robust to additional confounder adjustment.
In our U.S. study population, the concentration of manganese in maternal blood at or near the time of delivery was associated with lower neurodevelopment scores at 2 y of age. In addition, we found preliminary evidence suggesting that placental factors may influence associations between prenatal manganese exposure and neurodevelopmental outcomes. In studies of prenatal manganese exposure, careful consideration should be given to the selection of biomarkers and the role of placental transfer should be evaluated.
The research described in this paper was funded in part by National Institute of Environmental Health (NIEHS)/National Institutes of Health (NIH) grants P42-ES016454, R01-ES016283, P01-ES012874; R01-ES014930, R01-ES013744, P30-ES000002, P30-ES023515, and R00-ES022986. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
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Llop S, Lopez-Espinosa MJ, Rebagliato M, Ballester F. 2013. Gender differences in the neurotoxicity of metals in children. Toxicology 311:3–12, PMID: 23632092, 10.1016/j.tox.2013.04.015.
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Clarivate Analytics released the 2018 Journal Citation Reports, which tracks citations for articles published in 2015 and 2016. EHP's new Journal Impact Factor is 8.31, with a 5-Year Journal Impact Factor of 9.81. (more…)
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Getting In
Schools & Colleges
- College of Agriculture & Environmental Sciences
- College of Arts, Humanities, & Social Sciences
- College of Business & Economics
- College of Education
Employer Benefits
- Provides an excellent pool of well-prepared employees.
- Improves the personnel selection process by using actual on-the-job performance as a basis for permanent hiring decisions.
- Increases cost-effectiveness of recruitment and training.
- Increases retention rates among permanent employees recruited and hired through a co-op program.
- Both students and employers have the time to try out the position and ensure that the fit is the most productive and effective for both.
- Strengthens employer relations with the University.
Points of Pride
Largest HBCU
N.C. A&T is the largest public HBCU in the nation
N.C. A&T is the No. 1 producer of engineering degrees on the undergraduate level awarded to African Americans.
Admired CEO
Chancellor Harold Martin Sr. is named among the Triad's Most Admired CEOs by the Triad Business Journal.
Academic Excellence
The university's Center for Academic Studies in Identify Science is the first and only National Intelligence Science and Technology CASIS in the United States.
Higher Research Activity
N.C. A&T is classified as an R2: Doctoral University of Higher Research Activity by the prestigious Carnegie Classification of Institutions of Higher Education.
Teaching / Research
N.C. A&T is the highest-ranked public school for combining research and teaching by the Wall Street Journal.
Engineering Professor and Student
N.C. A&T is an inaugural and pioneering tenant of the innovative Union Square Partnership for healthcare training.
2016 MEAC Champs
N.C. A&T Women's Basketball team are the 2016 MEAC Champions
Bowl Champs
Aggies win 2015 Inaugural Air Force Reserve Celebration Bowl and Black National Championship.
Tarik Cohen
Running back Tarik Cohen broke the university and MEAC record becoming the MEAC all-time leading rusher.
Hall of Fame
The 1968 Aggies football team was inducted into the N.C. A&T Sports Hall of Fame as the first A&T team to win a black college national championship.
Aggie Track & Field
Three track & field athletes are named to the NCAA All-Academic team for excellence in their events and in the classroom; maintaining a minimum 3.25 GPA.
Kim Terrell-Kearney
Former professional bowler Kim Terrell-Kearney named N.C. A&T bowling coach
Track & Field Ranking
The United States Track & Field and Cross Country Coaches Association ranked A&T men's track and field team among the top-25 in program history.
Gail Wiggins
JOMC Professor Gail Wiggins selected as the NABJ Educator of the Year
PALO! Lyceum Series
The Band PALO! performed at N.C. A&T for the Lyceum Series
CD - Jazz Preeminence
A&T Theatre arts performs first production of "Radio Golf" by African American playwright August Wilson.
The Theatre Program at A&T was the first accredited Bachelor of Fine Arts (BFA) at an HBCU in North Carolina; second in the nation.
Black Nativity performances
The Theatre Arts Program is nationally ranked by Black Broadway as one of the top five Theatre Arts programs for African American students
Travis Alexander
Travis W. Alexander has been named National Conductor for the 105 Voices Of History National Concert Choir


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Saturday, January 31, 2015
Bob Brough- tenor sax
Tim Bedner – Guitar
Artie Roth – Bass
Ken Harper – Drums
Tickets available for cash at the door or you can purchase advance tickets through PayPal or if this option does not work for you just give us a call 6132-729-0693 or drop in during Alcorn Music Studios open hours.
PayPal $20 + $1 credit card fee. GigSpace automatically receives notification of your payment and your name and payment information will be recorded for the event. On the night of the concert you just need to check in at the front desk when you arrive. We do not provide physical tickets, you can print the PayPal receipt for your records.
"For this evening we're going to play the music that was written and played by the musicians who affected me the most. Duke Ellington, Thelonious Monk, Charles Mingus, Sonny Rollins and Bill Evans are certainly among those. The drummers who have had the greatest impact on me, among others continue to be Jerry Fuller, Barry Elmes, Jim Blackley, Frankie Dunlop, Art Blakey, Philly Joe Jones,Elvin Jones and Danny Richmond. "
Toronto-born jazz bassist Artie Roth has been an active composer, bandleader, performer and educator in the national and international jazz communities, since his graduation from York University in 1992 with the Oscar Peterson Scholarship. After two Canada Council sponsored study tenures in New York City (1993 and 1997), Artie returned to Toronto establishing himself as one of the busiest, full-time composer/performers in Toronto. As a leader of his own group, Artie released "Parallels" in 2005 and will be releasing his second CD "Currently Experiencing" in the fall 2013. As well as leading his own group, Artie is also an active member of The Rich Underhill Group, The Bob Brough Quartet and Kollage.
Saxophonist Bob Brough is best known as a tenorman who's appeared over the years with various rock, jazz, and classical artists and has recorded as a sideman on many recordings
including 2 Juno-nominated CDs with 'Time Warp' during the 1980's. More recently
recorded examples of particular note are his solo and ensemble performances on tenor
saxophone on Richard Underhill's 2003 Juno-award winning CD 'tales from the blue
Guitarist Tim Bedner, is a modern lyrical composer and improviser, and an award-winning teacher and performer on six- and seven-string guitar. Reviewers have called him "a talent and a force, playing with grace, style, passion, and inventiveness." His CD recording "Of Light and Shadow" debuted in the #1 spot of the CMJ jazz chart. Tim teaches jazz guitar performance at Carleton University, where he founded the Contemporary & Jazz Guitar Ensemble. In addition to composing, Tim creates arrangements and guitar instructional materials. He performs extensively throughout the Ottawa-Gatineau region. Tim graduated from Duquesne University and Berklee College of Music.


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Imtra "Mini" Bayonet LED Replacement Bulb
Item #:
Imtra Marine Lighting
Model #:
Shipping Weight:
0.10 Lbs.
Our Price:
Imtra "Mini" Bayonet LED Replacement Bulb
- LED replacement for bulbs with back-mounted single-contact bayonet sockets
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- Compatible with DMS Series Dimmer (see dimmer compatibility chart)
- 2-year limited warranty
- Base / Socket: Single-contact bayonet non-indexed BA15S
- Brightness: 70 Lumens
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- Nominal Voltage: 12 / 24 Volt DC
- Operating Voltage: 10 - 30 Volt DC
- Power Consumption: 1.5 Watts
- Halogen Equivalent: 10 Watts
- Current Draw: 125 mA @ 12 Volt DC / 63 mA @ 24 Volt DC
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- Dimensions: 1.05" dia. x 1.43" including base
For further details see:
Product Sheet
Dimmer Compatibility Chart
WARNING: This product MAY expose you to chemicals, which are known to the State of California to cause cancer, birth defects and/or other reproductive harm. For more information go to www.p65warnings.ca.gov


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Hello February!
The new month is here. I love a new month because it's a new start, a clean slate. New goals and new intentions. At the same time I think that it is important to look back on what you have achieved over the past month rather than what you haven't. I think one of the biggest lessons I have learnt over the past month is that it doesn't matter how much you do or don't do but how consistently you show up, work hard but also find balance and EASE in your life - work, yoga, personal.
So let's have a little look at my January Intentions and what I did or didn't do over the past month.
- My personal yoga practice has been a little hit and miss this month but that's okay. I didn't practice 6 days a week like I intended, often it was 3-5 days a week. I think that sometimes all I need as a slow flow to stretch out the body and calm the mind. Not only is that okay, it's important!
- My January yoga workshop was on Saturday and I feel like it was a huge success! I have this knack as a teacher to have a 'box of tools' which I can utilise and thread together creative sequences. I don't have a detailed plan and I LOVE to go with the flow. I think it's more authentic that way. This is what happened in the workshop. We had a whole range of levels and it was so much fun!
- Wedding planning - oh. my. gosh. I honestly didn't realise how much places charge when the word 'wedding' is involved! If you have any suggestions for a laid back, boho style barn wedding in either Bristol/ Gloucestershire/ Devon/ Somerset or Cumbria that won't cost the earth then let me know.
- Gratitude - a huge part of my daily life is feeling gratitude for everything and I love that.
- Lastly my blogging goals - I started out well in the month and I do feel that over all January has been a good month for blogging. My audience seems to have grown which is always good. I didn't get a video up on Friday due to me losing some footage but I'm okay with that!
So let's get into February...
Yoga Intentions
- Daily practice - but no pressure. It doesn't have to be a 90 minute practice of vinyasa, it can be just 10-15 minutes before bed. It doesn't matter!
- Keep learning! Let's brush up on some anatomy this month.
Life Intentions
- Wedding planning - don't stress! Simple right? ;)
- I'm teaching more than usual this month covering classes AND I'm teaching at Lululemon Bath this coming Saturday morning. So if you are in the area I would love to see you there! As I am teaching more than usual I need to say no to any other offers of cover classes, otherwise I might burn out - self care and all that.
- Workout - Let's see if I can get back into a routine this month.
- Read! I love reading, it's the ultimate down time for me with a hot cup of tea. I need to make more time for this at weekends.
- Start saving again.
Blog Intentions
- Be more organised.
- Stick to the schedule of filming videos on a Tuesday. It really does make life easier!
There we go! I'm trying not to overload myself and I'll take every day as it comes. I think my best advice when setting intentions is not to be too hard on yourself if life gets in the way and to be authentic to yourself.
Have you set some intentions or goals for February? How do you keep yourself motivated? As always leave me a comment below or tweet me @jaynebecca


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"We love Tom Brady, right?" asks Trump. Maryland crowd, full of Ravens fans, boos loudly.
— Jonathan Lemire (@JonLemire) April 21, 2016
Donald Trump's barking up the wrong tree if he's trying to get votes by mentioning Tom Brady's name in this town. Maybe do a little research on where you are before dropping the name of this state's biggest enemy. But I LOVE how Trump thought he was gonna hit a home run when he mentioned Brady's name, like we all just kiss the ground that the guy walks on, only to be promptly met with a lot of boos. I don't care what your political views are, I would have been disappointed if Brady didn't get booed. I never want to hear Tom Brady's name if it isn't followed by boos. It just wouldn't even sound right.


text: The Graduate School offers PhD candidates a framework for training, guidance and support. But the Graduate School is more than that. Within the context of the Graduate School, seminars, master classes, courses and meetings take place that enable researchers from all corners of the faculty to engage in discussion about content, methods and ethics. Through these events the Graduate School aims to achieve the research mission of the Faculty and to contribute to an environment in which researchers show interest for each other's work, inspire each other and keep each other focused.


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Matthew Pavlich – True Superstar!!
May 25, 2010 by admin
Filed under Junior Football
The much anticipated visit of AFL Superstar and Fremantle Dockers Captain Matthew Pavlich came to fruition when he arrived at Dairy Farmers Park on Sunday. Extremely surprised by the Tigers Facilities and he was quoted saying "that we have by far the best set up in country football that he has seen". Matthew arrived at […]
Young Tiger wins Award!
May 25, 2010 by admin
Filed under Football Club
Award for Young Tiger 21 year Tigers player Daniel McGavin has won the prestigious 2009 Welding Technology Institute of Australia Annual Award for Young Trades-person of the Year. He defeated 800 nominees from throughout Australia to win the award. The young Tiger now has a multitude of opportunities to further his career either in Australia […]


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New Law Protects Patients On Medicaid From Eviction
WASHINGTON -- President Clinton signed into law new protections for nursing-home patients whose bills are paid by Medicaid.
Under the Nursing Home Resident Protection Act, current Medicaid patients can't be evicted or transferred from nursing homes, even if the institutions stopped participating in the federal health program for the poor and disabled. Previously, the patients could be evicted with 30 days' notice.


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Click here to book online!
We offer 12 en suite traditional rooms: 'Main Inn' rooms & our 'Master Suite'. We offer a b&b service, so all of our hotel rates include a Full English & continental breakfast with plenty of tea & coffee.
A stay with us is not for the faint-hearted – although charismatic, our low beams & busy bar may cause you a sore head in the morning!
If you are coming for a cosy night or wish to bring young children, please remember to mention to our lovely receptionists that you would like a room that is not above the bar.
Please also note that when booking a room with us you will be asked to give your card details. This is just to secure the booking, no charge is made before departure day.
Please call directly for room rates!
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Let us know what you think!
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Contact Us
14th August 1948 The first Summer Olympics to be held since 1936, were closed in London.
14th August 1941 Josef Jakobs, German spy, executed in Tower of London
14th August 1903 Born today: Ronald Stewart, CEO (London Brick Co)
14th August 1867 Forsyte Saga author John Galsworthy was born in Kingston Upon Thames.
14th August 1802 Poet and novelist Letitia Elizabeth Landon (LEL) was born in Chelsea, London.
A Fruity place to Dance
Where Louie Spence throws shapes and amuses the nation
Location: 7 Langley Street, London, WC2H 9JA
Description: 'Pineapple Dance Studios' is a dance studio complex based in the Covent Garden area and is widely recognised as being the foremost dance centre in the United Kingdom and one of the most famous in the world - being used for castings and rehearsals by leading international dance companies, record labels, television networks, film studios, West End shows, cruise lines, talent and model agencies.
The studios are primarily a venue for dance training, with a daily timetable of classes that are open to the public and which cater for all ability levels including beginners as well as professional dancers.
A docusoap following Pineapple Studios and its employees such as Louie Spence and Andrew Stone were first shown on 14 February 2010 on Sky1.
With narration by ex-BBC newsreader Michael Buerk, it was a documentary that included impromptu dancing and the promotional tag-line: 'Pineapple Dance Studios: Where careers are made, dreams are broken, bitching is an Olympic sport and everyone is fabulous!'.
Ranking This Month: 2103/2778
Pages Hit This Month: 22
Link to This Page: http://www.shadyoldlady.com/location/2015
Credits: http;//www.pineapple.uk.com
Where Louie Spence throws shapes and amuses the nation
The Shady Old Lady points out that you can drag this map using mouse. Or visit our full massive map.


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As the clock runs down on the 114th Congress, some Kentuckians are making a last-ditch effort on behalf of people and places hit hard by the coal industry's decline.
As best we can figure, the two pieces of legislation they are championing face at least two major roadblocks:
▪ Politicians from Wyoming who insist that their state should be able to keep building sports arenas, roads and other non-mine related projects with money paid by the coal industry into a fund for repairing public hazards and environmental damage left over from mining that was done before 1977.
▪ Our own Mitch McConnell, the Senate's powerful majority leader, who is a famous friend of coal but less a friend of coal miners, especially if they belong to the United Mine Workers of America, whose retirement benefits are at risk.
McConnnell on Tuesday did offer encouragement to the 16,000 UMWA retirees, including 3,000 Kentuckians, whose health benefits will expire at the end of this month unless Congress acts. McConnell said he has called on House Speaker Paul Ryan to include protection of the health benefits in the government funding resolution that must pass by Friday.
McConnell made no mention of the bipartisan plan to rescue the UMWA pensions, a rescue that would also save the federal agency that insures pensions from insolvency.
Sen. Joe Manchin, D-W.Va., was not impressed with McConnell's stopgap, threatening to hold up the spending bill unless McConnell lets the Senate vote on the Miners Protection Act, saving UMWA pensions which are tottering because of coal industry bankruptcies.
The UMWA pension and health funds pump more than $100 million a year into Kentucky, in places hurting the most from the industry's decline. McConnell's sympathies lie with coal operators who dislike the miners union and with fellow Republicans who dislike all unions. But he would be truly cold-hearted to let the pension fund collapse at such a high cost to the coal communities that have entrusted him and other Republicans with their votes.
As for the westerners who insist that if they can't have the abandoned mine lands money, no one can, we can only appeal to conscience. The money should go where the need is. Wyoming has documented needs of $68 million to repair such hazards as dangerous slides, polluted water and underground fires, according to the U.S. Office of Surface Mining. Kentucky has documented more than five times that much — $357 million in need — while Pennsylvania has almost $4 billion in need.
The RECLAIM Act, sponsored by Republican Rep. Hal Rogers of Kentucky, would accelerate $1 billion in payments that are already owed to Appalachia, where need is greatest and the money could put some miners back to work cleaning up the dangers left by the industry before Congress enacted reclamation requirements.
Members of Kentuckians for the Commonwealth have been delivering petitions supporting the two measures to McConnell's offices in Kentucky and Washington. Thousands of Americans have signed the petitions. They understand what is fair and just. Does Congress?