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Bone Density and Metabolism in Children and Adolescents With Moderate to Severe Cerebral Palsy
Objectives. Diminished bone density and a propensity to fracture with minimal trauma are common in children and adolescents with moderate to severe cerebral palsy (CP). The purpose of this study was to provide a detailed evaluation of bone mineral density (BMD) and metabolism in this population and to assess the relationship of these measures to multiple other clinical, growth, and nutrition variables.
Methods. The study group consisted of 117 subjects ages 2 to 19 years (mean: 9.7 years) with moderate to severe CP as defined by the Gross Motor Functional Classification scale. Population-based sampling was used to recruit 62 of the participants, which allows for estimations of prevalence. The remaining 55 subjects were a convenience sampling from both hospital- and school-based sources. The evaluation included measures of BMD, a detailed anthropometric assessment of growth and nutritional status, medical and surgical history, the Child Health Status Questionnaire, and multiple serum analyses. BMD was measured in the distal femur, a site specifically developed for use in this contracted population, and the lumbar spine. BMD measures were converted to age and gender normalized z scores based on our own previously published control series (n > 250).
Results. Osteopenia (BMD z score <−2.0) was found in the femur of 77% of the population-based cohort and in 97% of all study participants who were unable to stand and were older than 9 years. BMD was not as low in the lumbar spine (population-based cohort mean ± standard error z score: −1.8 ± 0.1) as in the distal femur (mean z score: −3.1 ± 0.2). Fractures had occurred in 26% of the children who were older than 10 years. Multiple clinical and nutritional variables correlated with BMD z scores, but interpretation of these findings is complicated by covariance among variables. In stepwise regression analyses, it was found that severity of neurologic impairment as graded by Gross Motor Functional Classification level, increasing difficulty feeding the child, use of anticonvulsants, and lower triceps skinfold z scores (in decreasing order of importance) all independently contribute to lower BMD z scores in the femur.
Conclusions. Low BMD is prevalent in children with moderate to severe CP and is associated with significant fracture risk. The underlying pathophysiology is complex, with multiple factors contributing to the problem and significant variation between different regions of the skeleton.
Fractures are common in individuals with moderate to severe cerebral palsy (CP), and many of those who sustain a fracture will sustain repeated fractures.1–3 Low bone density, stiff joints, poor balance leading to falls, and violent seizures are factors that can contribute to fractures in this population. The most common site of fracture is the femur. In reported series of nonambulatory children and young adults, nearly 20% had sustained a femur fracture at some time in their life.4,5 Usually these fractures are treated nonoperatively, but hospitalization may be required6 and malunion of the fracture is common.7 Repeated fractures diminish the quality of life for these children and add to their care requirements. It has been reported that the single most costly medical problem in a residential school for severely involved children is treatment of fractures.8
Multiple factors may adversely affect bone density and metabolism in individuals with CP. Clearly, limited weight-bearing ambulation during skeletal growth is 1 such factor. Another mechanical factor is the temporary immobilization that follows the orthopedic surgical procedures often performed on a child with CP. Hip spica casting of children with CP has been associated with increased risk of subsequent fracture,1,4,9 and even normal children who had an uncomplicated fracture of the lower limb that was treated with >4 weeks of casting have a small, persistent deficit in bone density.10
Oral-motor dysfunction increases feeding difficulty for many individuals with CP.11,12 Poor nutrition and low calcium intake are common in this population13,14 and may contribute to poor mineralization. Many children with CP take or have taken anticonvulsant medications, which some authors suggest may adversely affect bone mineralization.15,16 CP is often associated with premature birth, which in turn may be associated with metabolic bone disease, the "rickets of prematurity."17 It has been found that low birth weight premature infants have lower than normal bone mineral content when evaluated as older children.18 Outdoor activities may be significantly diminished in physically impaired individuals, which could be of consequence to bone metabolism given that seasonal sunlight exposure is an important determinate of serum 25-hydroxy vitamin D (25-OHD) levels in children with CP.19 Understanding the pathophysiology of skeletal mineralization in CP is difficult given the heterogeneity of the condition and the multitude of potentially important factors.
The purpose of this study was to further our understanding of bone density and metabolism in children and adolescents with CP. The most "at risk" subset of the population has been previously identified as children with little or no ability to ambulate.14 This study focuses on this group, including a population-based cohort necessary to determine true prevalences. Bone density is assessed in the clinically relevant distal femurs, and bone metabolism is evaluated with various serum markers. The multiple factors such as malnutrition, inadequate vitamin D levels, and use of anticonvulsants that may potentially have an impact on bone density and metabolism in these children closely covary. This study provides greater statistical power than previous studies to discern the relative importance of these factors.
The North American Growth in Cerebral Palsy Project (NAGCePP) is a multicenter (6 sites), cross-sectional, observational study of growth and nutrition in population-based samples of children and adolescents with CP. The project is described in detail elsewhere.20 Briefly, an intense effort was made to identify and evaluate all children with moderate to severe CP within defined geographic regions. Hospital records, newspaper notices, pediatric physical therapists, handicap equipment vendors, special education teachers in the local school systems, and regional United Cerebral Palsy newsletters are examples of the means by which potentially eligible children were identified.
Inclusion criteria were age 2.0 to 18.9 years and moderate to severe CP as defined by functional levels 3, 4, or 5 on the Gross Motor Functional Classification (GMFC) scale.21 Simply summarized, GMFC level 3 children achieve independent sitting and by 4 years of age are ambulatory with assistive mobility devices and/or aid from an adult. GMFC level 4 children are minimally ambulatory, even with assistance, and have some difficulty with sitting trunk control. GMFC level 5 children lack independent motor function even for basic antigravity postural control.
Excluded were children with recognized chromosomal abnormalities and children who were normal until a specific event or injury that occurred after 12 months of age resulted in their impairment. The core data collected at all NAGCePP study sites included a detailed anthropometric assessment, developmental assessment, GMFC assessment, complete medical and surgical history, and the Children's Health Status Questionnaire.22 The Children's Health Status Questionnaire is an established tool for the assessment of health-related quality of life, including the child's physical health, parental perception of the child's overall health, and the impact of the child's health on the family.
Given the close proximity, investigators at the University of North Carolina (UNC; Chapel Hill) and Duke University (Durham) collaborated as a single site in the NAGCePP, with all of the evaluations completed at UNC. At the UNC/Duke site and the Children's Hospital of Philadelphia (CHOP) site, the NAGCePP evaluation was expanded to include an assessment of bone density and metabolism. The results of this additional evaluation are the focus of this article.
Population-Based Study Participants
Sixty-five eligible children and adolescents were identified and contacted by telephone in the 3-county area of the UNC/Duke site, from a total population of 219 000 who were younger than 18 years. Forty-three (66%) of these 65 children and adolescents consented to the core evaluation of the NAGCePP. Thirty-nine of the 43 NAGCePP participants agreed to the additional dual-energy x-ray absorptiometry (DXA) evaluation described below and had at least 1 reliable measure of bone density. Similarly, 47 eligible children and adolescents were identified from a population of 688 000 who were younger than 18 years within the defined geographic region used by the CHOP site. Thirty-seven (79%) of these 47 potential subjects participated in the NAGCePP, including 23 who agreed to the additional DXA evaluation and had a reliable assessment of bone density.
Convenience Sampling Participants
At the UNC/Duke site, an additional 55 children and adolescents underwent the entire NAGCePP evaluation, including the additional DXA evaluation. This was a convenience sampling of otherwise eligible children who lived outside the defined geographic region. These children were located and recruited from multiple sources, including the pediatric orthopaedic clinics (n = 27), nonorthopedic tertiary care clinics (n = 12), and special education centers (n = 16). Therefore, the study group reported herein consists of 117 children and adolescents with moderate to severe CP, including 62 population-based participants (39 at the UNC/Duke site, 23 at the CHOP site) plus 55 additional subjects from a convenience sampling. The median age was 9.4 years (range: 2.0–19.0 years). There were 71 boys, 76 whites, 37 blacks, and 4 of mixed or other ethnic backgrounds. Informed consent approved by the institutional review board at each site was obtained for all study participants.
Bone Density Measurements
Bone mineral density (BMD) in the lumbar spine, proximal femurs, and distal femurs was measured with DXA. Standard scanning procedures were used for the lumbar spine and proximal femurs. Motion artifact, previous hip or scoliosis surgery, or contractures usually precluded reliable assessment of BMD in the proximal femurs and occasionally in the lumbar spine. BMD was reliably measured in 1 or both proximal femurs of just 16 (14%) of the 117 study participants and in the lumbar spine of 98 participants (84%).
The technique for assessing BMD of the distal femur projected in the lateral plane has been previously described in detail.23,24 This technique was developed specifically to deal with the significant hip and knee contractures that are common in this population and interfere with measurements in the standard proximal femur site. Three separate regions within the distal femur are examined independently. Region 1 is located within the metaphysis just proximal to the growth plate. Region 3 is the distal portion of the femoral diaphysis, and region 2 is the region of transition between the broad metaphysis (region 1) and narrow femoral shaft (region 3). These regions were defined such that region 1 is predominately cancellous bone and region 3 is predominately cortical bone. As with scans of the lumbar spine and proximal femurs and despite repeated attempts, motion artifact secondary to limited cooperation or involuntary muscle spasms made it impossible to obtain acceptable quality scans of the distal femur on all subjects. BMD was successfully measured in at least 1 distal femur for 78 (67%) of the 117 study participants.
A Hologic (Waltham, MA) model 1000W scanner was used at the UNC/Duke site, and model 2000 was used in the pencil-beam mode at the CHOP site. Exchange of each site's calibration spine phantom confirmed the reliability of pooling results from the 2 scanners. BMD measurements (g/cm2) were converted to age- and gender-normalized standard deviation scores (z scores) using our own series of normal pediatric controls (n = 365 for lumbar spine and proximal femur, n = 256 for distal femur23,25). BMD measures in the lumbar spine were also normalized for race, but it is important to note that the distal femur normal series did not include sufficient numbers of black children to control for race. The mean BMD of paired right- and left-sided measurements was used when converting to z scores.
Anthropometric Assessment
An anthropometrist who was trained and tested for reliability as part of the broader NAGCePP completed this portion of the evaluation, which focuses on growth and nutritional status of the children and is described in greater detail elsewhere.20 Weight in light clothing was measured on a digital scale. Contractures, scoliosis, and inability to stand erect make it impossible to obtain a reliable measure of standing height in these children. Alternative measures of linear growth were obtained, including upper arm length, tibial length, and sitting knee height. For the analyses, knee height was converted to an estimate of standing height,26,27 which in turn was expressed as an age- and gender-normalized height z score.28 Body fat was assessed with measures of calf, triceps, and subscapular skinfolds on the child's right side. For the analyses, nutritional status defined as adequacy of caloric intake was assessed based on age- and gender-normalized z scores for triceps skinfold measures.29 Upper arm, calf, and head circumferences were measured, and Tanner stage was determined.
Anticonvulsant Medication
Use of anticonvulsant medications was graded as never (n = 32), only in the past (n = 31), or ongoing (n = 54). Children who were categorized as having taken anticonvulsants only in the past received the medication for at least 6 months but none for at least 1 year before the evaluation. It is likely that the various anticonvulsant medications all do not have the same potential impact on bone metabolism.30 Nonetheless, statistical power was not sufficient to categorize this variable more elaborately.
Temporary Immobilization
Periods of immobilization, usually for orthopedic surgical procedures, were categorized as none (n = 58), brief (n = 17), or prolonged (n = 42). Children in the "none" group had not had on the lower limbs surgical procedures requiring postoperative casting but may have had brief periods of inhibitory casting to improve motion that did not diminish the child's usual weightbearing activities. Brief immobilization was considered as casting above or below the knee for a maximum of 6 weeks postoperatively. Prolonged immobilization was a cumulative total of >6 weeks of casting or any time in a hip-spica cast (a cast that includes the torso and lower limbs).
Feeding Difficulty
The care provider reported difficulty feeding the child as a result of oral-motor dysfunction on a categorical scale developed for this population31 as none (n = 48), mild (n = 17), moderate (n = 11), or severe (n = 41). The scale is based on whether the child has no problems with a regular diet (none category); has slight difficulty swallowing or feeding and requires some modification of foods (mild category); has moderate feeding difficulties, some difficulty swallowing liquids and requires moistened, mashed, or chopped foods (moderate category); or has a diet limited to well-moistened solid foods, thickened fluids, and/or tube feedings (severe category).
Calcium Intake
Dietary calcium intake was readily determined in children who received some (n = 10) or all (n = 23) of their caloric intake through feeding tubes, because the volumes and calcium content of prepared formulas and supplements are known. Calcium intake from normal foods was estimated using a calcium-focused food frequency questionnaire.32 Determination of dietary calcium intake also included specific calcium supplements if regularly given to the child (n = 9). Total calcium intake from all sources was categorized as <500 μg/d (n = 7), 500 to 1000 μg/d (n = 46), and >1000 μg/d (n = 64).
Serum Analyses
A peripheral nonfasting venous blood sample was obtained for analysis of multiple factors relating to nutrition or bone metabolism. The hospital laboratory at the respective institutions determined serum levels of calcium, phosphate, alkaline phosphatase, total protein, albumin, and transthyretin (prealbumin). Serum 25-OHD was measured in the Research Laboratories at the UNC Department of Orthopaedics using an equilibrium radioimmunoassay (DiaSorin, Stillwater, MN).
Even in skeletally mature individuals, bone is continuously in a state of flux, with both bone formation and bone resorption occurring simultaneously. Osteocalcin and bone-specific alkaline phosphatase, synthesized by osteoblasts during the process of bone formation, are released into the blood. Serum levels of these proteins can serve as useful markers of bone formation.33,34 Similarly, N-terminal telopeptides are breakdown products of collagen resulting from osteoclast-mediated resorption of the extracellular matrix of bone, and are a marker of bone resorption.35 These markers of bone formation and resorption were measured in the UNC Orthopaedic Research Laboratories. Bone-specific alkaline phosphatase was measured using the Alkphase B immunoassay (Metra Biosystems Inc, Mountain View, CA). Osteocalcin was measured with an immunoradiometric assay (Elsa-Osteo; CIS-US Inc, Bedford, MA). Serum N-telopeptides were measured with the Osteomark serum NTx immunoassay (Ostex Inc, Seattle, WA).
A blood sample was obtained from 80 (68%) of the 117 study participants, with the remainder declining or unattainable. The quantity of serum available in 13 of the 80 samples was inadequate for the full series of analyses.
Statistical Analyses
The population-based and convenience sampling cohorts significantly differ in several ways (Table 1). The convenience sample includes a higher proportion of more severely involved children as judged by multiple factors, including GMFC level, nutritional status (triceps skinfold z score), and feeding difficulty. Therefore, only the population-based cohort is used for determinations of prevalence.
For the assessment of the relationship between the analysis variables and BMD z scores, it is valid to include all children. In the first phase of these analyses, each of the key variables is independently examined for a relationship with BMD z scores at each of the 3 distal femur sites and the lumbar spine (Table 2). The proximal femur site was not included in the analyses because of the very limited number of children (n = 16) for whom data were obtainable.
It is expected that many of the key variables will closely covary, and this may have a significant impact on the apparent relationship between BMD z scores and the variable in question. For example, use of anticonvulsant medications is likely to be more prevalent in children with greater motor impairment (GMFC level 5) than in children with less severe CP (GMFC level 3). Covariance is important to consider when assessing the potential direct impact of these factors on BMD. Therefore, in the second phase of the analyses, multifactorial stepwise regression is used to assess the relationship between BMD z scores and the multiple clinical and nutritional factors that may adversely affect BMD.
BMD was severely diminished in the distal femur (mean ± standard error [SE] lowest of the 3 regions BMD z score: −3.5 ± 0.2) and to a lesser extent in the lumbar spine (mean BMD z score: −2.0 ± 0.1). Consistent with low BMD, fractures were common. Despite the young age of the study group (mean age: 9.7 years), 18 of the children (15%) had already sustained a fracture, and 7 of these children had had more than 1 fracture. In the subset of nonambulatory children (GMFC levels 4 and 5) who were older than 10 years, fractures were even more common (11 [28%] of 40). A total of 28 fractures were reported, with the femur (13 fractures) and tibia (4 fractures) being the most common sites of injury. There were no known spinal compression fractures.
Multiple factors were examined in univariate analyses for a relationship to BMD z scores at each of the measurement sites. The findings are summarized below and in Table 2. BMD z scores in the 3 regions of the distal femur correlated highly with each other (r = 0.84–0.94) and showed very similar relationships to the other analysis variables. (Table 2 reports the findings for region 2 of the distal femur.) Lumbar spine BMD z scores correlated only weakly with BMD z scores in the 3 regions of the distal femur (r = 0.51–0.55). As shown in Table 2, differences were also observed between distal femur and lumbar spine BMD z scores in their relationships with the other analysis variables.
General Demographics
There was a relationship between advancing age and declining BMD z scores at all 3 distal femur sites, but not the lumbar spine (Table 2, Fig 1). In the population-based cohort the prevalence of osteopenia (z score: <−2.0) in the distal femur was 86% in children older than 9 years (19 of 22 children). Two of the 3 exceptions were children who were capable of assisted ambulation (GMFC level 3).
Distal femur BMD z scores, which were normalized for age and gender but not for race were higher in the black children than in the white children (Table 2). With lumbar spine BMD measures, however, it was possible to normalize for race as well as age and gender, and no racial difference was observed (Table 2).
Neurologic Impairment and Other Clinical Factors
BMD z scores at all sites correlated strongly with the GMFC level (Table 2, Fig 2). Forty-five (96%) of 47 GMFC level 5 children had osteopenia (z score <−2.0) in the distal femur, as compared with 6 (43%) of 14 GMFC level 3 children. Other clinical variables, including use of anticonvulsants and whether the child had ever had a fracture, correlated with BMD z scores in the distal femur, but none of the other clinical variables besides GMFC level correlated with lumbar spine BMD z scores (Table 2).
Nutritional Status and Related Variables
Poor nutritional status defined as triceps skinfold z scores <−1.0 is prevalent in children with moderate to severe CP, involving 23 (37%) of 62 children in the population-based cohort and 58% of the children in the convenience sample. Both triceps skinfold z scores and serum transthyretin level correlated with BMD z scores in the lumbar spine but not with BMD z scores in the distal femur (Table 2, Fig 3). A particularly strong predictor of BMD z scores in both the distal femur and the lumbar spine was difficulty feeding the child as reported by the caregivers (Table 2, Fig 4). Use of a feeding tube was associated with lower BMD z scores in the distal femur but not in the lumbar spine. The remaining feeding- and nutrition-related variables, including previous use of a feeding tube and calcium intake, did not correlate with BMD z scores (Table 2).
Measures of growth including height, weight, and mid-arm circumference were significantly diminished relative to age- and gender-matched normal children, with mean (±SE) z scores of −2.9 ± 0.2, −2.6 ± 0.3, and −0.9 ± 0.1, respectively. These measures of growth correlated strongly with BMD z scores, with the exception of height and lumbar spine BMD z scores (Table 2).
Serum Vitamin D and Bone Metabolism Markers
In normal children, both dietary intake and sunlight exposure are important sources of 25-OHD, which is the precursor for the more tightly regulated, metabolically active 1,25-dihydroxy metabolite of vitamin D. Many of the children were found to have serum 25-OHD levels <17 ng/mL (25 [33%] of 75). The mean (±SE) 25-OHD level in samples obtained during the colder months of November to February (19.3 ± 1.1 ng/mL) was not lower than that found in children who were evaluated in June through September (20.3 ± 0.8 ng/mL). The finding of low levels of 25-OHD throughout the year suggests limited sunlight exposure in these physically impaired children. However, serum 25-OHD levels were not found to correlate with BMD z scores (Table 2).
Serum markers of bone formation (osteocalcin and bone-specific alkaline phosphatase) and bone resorption (N-telopeptides) ranged widely and correlated with each other (r = 0.3–0.6; Fig 5). This suggests considerable variation in rates of bone turnover. However, there was not a significant correlation between any of these markers and BMD z scores (Table 2).
Routine Serum Analyses
Routine hospital laboratory tests were not of value in identifying children with low BMD. Serum calcium level was low (<8.8 μg/dL) in only 4 (5%) of 75 children, and 3 of those had serum albumin levels <3.5 μg/dL. Alkaline phosphatase level was elevated in 4 children. Thirteen children (17%) had an abnormal serum calcium, phosphorus, or alkaline phosphatase; only 1 child had 2 of these outside the normal range. Mean BMD z scores were not significantly lower in these 13 children than in the children with normal values for these routine laboratory tests (Table 2).
Multifactorial Analyses
All of the clinical and nutritional variables listed in Table 2 were examined for their relationship to BMD z scores in age- and race-adjusted multifactorial stepwise regression analyses. This approach examines the relationship between each variable and BMD z scores while accounting for covariance with the other variables in the analyses. Severity of neurologic impairment (GMFC level), increasing difficulty feeding the child, use of anticonvulsant medications, and lower triceps skinfold z scores (in decreasing order of importance) all independently contribute to lower BMD z scores in the distal femur. Results were very similar in all 3 regions of the distal femur but differed somewhat with lumbar spine BMD z scores in which just GMFC level and triceps skinfold z scores were found to contribute independently to lower BMD z scores.
Several studies have examined bone density in CP.36–39 The largest reported series included 139 children and adolescents with CP of wide ranging severity and used DXA to measure bone density.14 It was found that the quadriplegic subset (n = 37), those with diminished mobility and often poor nutritional status, were at greatest risk of having low BMD. It is important to note that BMD assessment in this subset of subjects was usually limited to just the lumbar spine because hip flexion contractures and/or previous hip surgery prevented reliable measures of BMD in the proximal femurs. As discussed in the following paragraph, this proves to be an important limitation of that study.
Whether measures of BMD in the lumbar spine are predictive of fracture risk has been assessed prospectively in a cohort of 43 children with spastic quadriplegic CP.1 Nine fractures occurred over an observation period that averaged 4 years, and 60% of these injuries involved the femur. Ten (23%) of the 43 children had sustained a fracture at some time in their life. A history of hip spica casting or a previous fracture was found to be predictive of subsequent fracture risk, but BMD of the lumbar spine was not predictive. This seems counterintuitive but is likely explained by the finding in our current study that BMD is much lower in the distal femur (mean z score: −3.5 ± 0.2) than in the lumbar spine (mean z score: −2.0 ± 0.1), and the correlation between BMD in the 2 areas is weak.
In children with quadriplegic CP, a problem exists because BMD usually cannot be measured reliably in the proximal femurs, yet it is the femur that most commonly fractures, and measurement of BMD in the lumbar spine is an unreliable indicator of bone status in the femurs. For addressing this problem, a technique was developed using DXA to obtain measures of BMD in the distal femur projected in the lateral plane.23,24 This approach to the assessment of bone density is a critical feature of the current study. Unfortunately, it was not possible to obtain an acceptable quality DXA scan of the distal femur because of motion in one third of the study group. Subsequent to this study, however, we found that acceptable quality scans of the distal femur can be obtained without sedation in roughly 90% of these children using the newer model fan-beam DXA scanners that have shorter scan times.
It is important to note that BMD as measured with DXA is an areal density (gm/cm2) and not a true volumetric density (gm/cm3). Areal bone density may be diminished relative to age-matched normal subjects because of a true decrease in volumetric density or because of differences in the 3-dimensional structure of the bone.40,41 A diminished outer diameter and thinning of the cortex both will result in diminished areal BMD as measured with DXA, regardless of whether true volumetric density is diminished. The diameter of a cylindrical bone and the thickness of the cortex, however, are important mechanical parameters that have a significant impact on the ability of a bone to withstand loads without fracture. Radiographs of children with quadriplegic CP typically do show the bone to be smaller than normal and the cortex to be thin. Clearly, the diminished bone "density" measured in this study involves more than just a decrease in true volumetric density. However, these other factors that affect areal density also directly relate to mechanical strength and fracture risk, which is the clinically relevant reason for assessing bone " density."
An observational study such as this identifies only those factors associated with low BMD, not necessarily the causes of low BMD. It is clear that BMD in the femur, like other measures of various growth parameters such as height, weight, and arm circumference, falls further from normal standards as the child with CP ages.42,43 Diminished growth in CP is a complex issue, with both nutritional and nonnutritional factors likely contributing.44–46 Difficulty feeding the child, skinfold measures of body fat, and use of anticonvulsant medications were some of the factors identified in multifactorial regression analyses as likely to be directly related to low BMD.
Another important correlate of low BMD in children with CP is their GMFC level of motor impairment. It is widely thought that absence of weightbearing is an important direct cause of low BMD in physically impaired children. However, evidence is accumulating that the cause is much more complex. In this study, it was found that BMD z scores were significantly lower in GMFC level 5 children than in level 4 children, yet both groups are nonambulatory. Furthermore, it has been found in boys with Duchenne muscular dystrophy that BMD in the femurs is already very dramatically diminished years before the boys become nonambulatory.47 It seems that multiple factors intrinsic to the conditions of CP, muscular dystrophy, and perhaps other conditions contribute to low BMD at least as much as simple inability to bear weight.
It is interesting to note in both CP and muscular dystrophy that BMD is diminished much more in the femurs than in the spine. Consistent with this, fractures in children with these conditions usually involve the limbs, particularly the femur, and virtually never occur in the spine.2,3,47 In this study, it was found that BMD z scores in the lumbar spine and distal femur were not identically related to the other factors. For example, use of anticonvulsants did correlate with BMD z scores in the distal femur but not in the lumbar spine. Clearly, the pathophysiology of low BMD varies in different regions of the immature skeleton.
Identifying a clinical problem always raises the issue of treatment, and effective interventions may be available to address low BMD in this population. On the basis of small series of children with CP, it has been suggested that physical therapy38 and calcium/vitamin D supplementation36 may be beneficial for BMD. It has been shown that nutritional interventions can improve other aspects of growth in children with CP.48 Perhaps the most promising intervention is with the bisphosphonate medications, which are widely used to treat osteoporosis in the elderly. Lumbar spine BMD increased a mean of 42% per year in an uncontrolled study of 30 children with osteogenesis imperfecta treated with bisphosphonates.49 In a randomized, placebo-controlled trial, BMD in the distal femur increased a mean of 89% over 18 months in 6 children with quadriplegic CP treated with intravenous pamidronate, as compared with a 9% increase in the placebo group.50
Osteopenia defined as BMD z scores <−2.0 is found in the femur of most nonambulatory children with CP by 10 years of age. Fractures had occurred in more than one fourth of the severely involved children who were older than 10 years at the time of their evaluation. The clinical and nutritional factors that most directly correlated with low BMD were severity of impairment as graded by GMFC level, increasing difficulty feeding the child, use of anticonvulsants, and lower triceps skinfold z scores (in decreasing order of importance). The causes of and treatments for low BMD in children with disabilities certainly require additional investigation.
Support for the core NAGCePP was provided by the Genentech Foundation for Growth and Development and the National Center for Medical Rehabilitation Research, National Institutes of Health (R01 HD35739). The bone density and metabolism evaluations were obtained with additional support from the Genentech Foundation for Growth and Development; the General Clinical Research Centers program of the Division of Research Resources, National Institutes of Health (RR00046 at UNC, RR00240 at CHOP); a career award from the National Institute of Arthritis, Musculoskeletal, and Skin Diseases (K24 AR02132); and the Nutrition Center of the CHOP.
We thank D. Riggs and S. Slezak for the DXA scans; Gayle Lester, PhD, and D. Blackwood for the assays; and J. Beaumont for data management and analyses.
- Received December 17, 2001.
- Accepted March 8, 2002.
- Address correspondence to Richard C. Henderson, MD, PhD, Department of Orthopaedics, Campus Box 7055, University of North Carolina, Chapel Hill, NC 27599. E-mail: rchh{at}med.unc.edu
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- 25.↵Henderson RC, Madsen CD. Bone density in children and adolescents with cystic fibrosis. J Pediatr.1996;128 :28– 34
- 26.↵Stevenson RD. Use of segmental measures to estimate stature in children with cerebral palsy. Arch Pediatr Adolesc Med.1995;149 :658– 662
- 27.↵Chumlea WC, Guo SS, Steinbaugh ML. Prediction of stature from knee height for black and white adults and children with application to mobility-impaired or handicapped persons. J Am Diet Assoc.1994;94 :1385– 1388
- 28.↵National Center for Health Statistics, Centers for Disease Control and Prevention. The Third National Health and Nutrition Examination Survey 1988–1994. Hyattsville, MD: National Center for Health Statistics; 1996
- 29.↵Frisancho RA. Anthropometric Standards for the Assessment of Growth and Nutritional Status. Ann Arbor, MI: University of Michigan Press; 1990
- 30.↵Sheth RD, Wesolowski CA, Jacob JC, et al. Effect of carbamazepine and valproate on bone mineral density. J Pediatr.1995;127 :256– 262
- 31.↵Fung EB, Samson-Fang L, Stallings VA, et al. Feeding dysfunction is associated with poor growth and health status in children with cerebral palsy. J Am Diet Assoc.2002;102 :361– 373
- 32.↵Musgrave KO, Giambalvo L, Leclerc HL, Cook RA, Rosen CJ. Validation of a quantitative food frequency questionnaire for rapid assessment of dietary calcium intake. J Am Diet Assoc.1989;89 :1484– 1488
- 33.↵Pedrazzoni M, Alfano FS, Girasole G, et al. Clinical observations with a new specific assay for bone alkaline phosphatase: a cross-sectional study in osteoporotic and Pagetic subjects and a longitudinal evaluation of the response to ovariectomy, estrogens, and bisphosphonates. Calcif Tissue Int.1996;59 :334– 338
- 34.↵Johansen JS, Giwercman A, Hartwell D, et al. Serum bone gla-protein as a marker of bone growth in children and adolescents: correlation with age, height, serum insulin-like growth factor I, serum testosterone. J Clin Endrocrinol Metab.1988;67 :273– 278
- 35.↵Gertz BJ, Clemens JD, Holland SD, Yuan W, Greenspan S. Application of a new serum assay for type I collagen cross-linked N-telopeptides: assessment of diurnal changes in bone turnover with and without alendronate treatment. Calcif Tissue Int.1998;63 :102– 106
- 36.↵Jekovec-Vrhovsek M, Kocijancic A, Prezelj J. Effect of vitamin D and calcium on bone mineral density in children with CP and epilepsy in full-time care. Dev Med Child Neurol.2000;42 :403– 405
- 37.Wilmshurst S, Ward K, Adams JE, Langton CM, Mughal MZ. Mobility status and bone density in cerebral palsy. Arch Dis Child.1996;75 :164– 165
- 38.↵Chad KE, Bailey DA, McKay HA, Zello GA, Snyder RE. The effect of a weight-bearing physical activity program on bone mineral content and estimated volumetric density in children with spastic cerebral palsy. J Pediatr.1999;135 :115– 117
- 39.↵Shaw NJ, White CP, Fraser WD, Rosenbloom L. Osteopenia in cerebral palsy. Arch Dis Child.1994;71 :235– 238
- 40.↵Carter DR, Bouxsein ML, Marcus R. New approaches for interpreting projected bone densitometry data. J Bone Miner Res.1992;7 :137– 145
- 41.↵
- 42.↵Stevenson RD, Hayes RP, Blackman JA. Clinical correlates of linear growth in children with cerebral palsy. Dev Med Child Neurol.1994;36 :135– 142
- 43.↵Krick J, Murphy-Miller P, Zeger S, Wright E. Pattern of growth in children with cerebral palsy. J Am Diet Assoc.1996;96 :680– 685
- 44.↵Stevenson RD, Roberts CD, Vogtle L. The effects of non-nutritional factors on growth in cerebral palsy. Dev Med Child Neurol.1995;37 :124– 130
- 45.Shapiro BK, Green P, Krick J, Allen D, Capute AJ. Growth of severely impaired children: neurological versus nutritional factors. Dev Med Child Neurol.1986;28 :729– 733
- 46.↵Stallings VA, Charney EB, Davies JC, Cronk CE. Nutrition-related growth failure of children with quadriplegic cerebral palsy. Dev Med Child Neurol.1993;35 :126– 138
- 47.↵Larson CM, Henderson RC. Bone mineral density and fractures in boys with Duchenne muscular dystrophy. J Pediatr Orthop.2000;20 :71– 74
- 48.↵Sanders KD, Cox K, Cannon R, et al. Growth response to enteral feeding by children with cerebral palsy. JPEN J Parenter Enteral Nutr.1990;14 :23– 26
- 49.↵Glorieux FH, Bishop NJ, Plotkin H, Chabot G, Lanoue G, Travers R. Cyclic administration of pamidronate in children with severe osteogenesis imperfecta. N Engl J Med.1998;339 :947– 952
- 50.↵Henderson RC, Lark RK, Kecskemethy HH, Miller F, Harcke HT, Bachrach SJ. Bisphosphonates to treat osteopenia in children with quadriplegic cerebral palsy: a randomized, placebo-controlled clinical trial. J Pediatr. In press
- Copyright © 2002 by the American Academy of Pediatrics


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PWP Studio, and other event sponsors, helped the AFR Event Furnishings 1st Annual Showcase and Networking Event hit on all the sixes last September 8. The AFR Furniture Rental was absolutely putting on the Ritz, at the 1920's inspired grand opening kick-off party, with its first-rate furniture and snazzy decor. Furniture rental experts and special events top dogs flocked the swanky speakeasy – The Venetian Room.
Some food and a little chitchat…
…plus barrels of giggle water later and everyone was having a lot of fun.
The other sponsors, besides PWP Studio, who contributed to the event's success:
Rainforest Foliage Décor & Rentals
Extraordinaire Affairs & Events

subset: commoncrawl


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Every year, law school applicants spend an inordinate amount of time obsessing about US News & World Report's law school rankings. The Pre-Law website discusses generally why you shouldn't care about the rankings. This summer, the New York Times published an article giving a new set of reasons: the rankings, even on their own merits, are unreliable, because law schools game the system as much as possible. From creative accounting techniques that inflate the amount of money they allegedly spend per student, to admissions processes that artificially eleveate their median LSAT and GPA rankings, law schools are engaged in any number of practices that—intentionally or not—affect their rankings in US News & World Report.
The full article is here.


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Another year, another 365 days of new chances, new decisions, new actions.. Sounds great doesn't it? But before you go charging into the new year, there's one question you need to answer:
How do you get from where you are to where you want to be?
A good place to start is to look at your goal, planner or to-do list (or if you're anything like me; planners and to do lists – plural) from last year, and critically analyse what you had written.
- What were your goals?
- Did you achieve them?
- What is still left to do?
From the goals that you achieved:
What did you learn from the experience? What worked well? What would you do differently if you had to do it again?
One of my main lessons from last year is to not wait to feel motivated.
Some days I do wake up full of motivation, raring to go and on those days I do accomplish a lot. But those days don't happen ever day and the lesson that I am carrying over to this year is that I can't wait to "feel" motivated before I do something. Even when I don't feel like it, I'm still going to work, progress my action plan and motivate myself!
From the goals you didn't achieve:
What are your outstanding goals? Why didn't you accomplish them?
It may be that these are big goals and its going to take some time to achieve them. If this is the case then they need to be broken down into smaller goals. Write down all the actions that will lead up to achieving the overall goal.
Doing this will have 2 positive effects:
- you will be able to see that you're actually progressing towards your large goal, and
- you will have ticked off more as completed, from your list.
What about the other goals that are still outstanding? Do they need to be carried over to your new list or…
should they be deleted or delegated???
There's always that one item on your to-do list that you keep putting off. That one thing that you know you should do but strangely enough, "never get round to." Do you really want it hanging over you again for another year? Either decide its never going to happen, OR just get it done and get it out of the way before the end of this week OR delegate it to someone else.
It's well worth considering delegation. Think of is this way… you don't actually want to do the task yourself or perhaps you don't feel that you have the necessary skills or time that is needed? Either way isn't it worth hiring someone to do the job for you? Someone with the skills, knowledge and experience to do the job well?
From the oven that needs a good clean, to the room that needs repainting, or that dripping tap that has never been fixed…
the database that needs updating, the website that could do with a refresh or the marketing plan that needs developing…
Whatever it is, there's an expert out there that can take that item off your to-do list for good!
It has taken me while to realise that I don't need to do everything myself. I will certainly be delegating more over the course of this year.
Looking back over the last year can really help with planning for the year ahead and there's no better place to start than deciding which of your goals are still relevant before adding new ones to your list.


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It is upon an inspired, Living Word in which I take this promise from – Jesus was fully God, and fully man* – and this is what my life is based on, sustained by and the only thing that brings hope to living further.
If you begin to doubt the 100% Divinity of Christ, your foundation is shaken. The moment you think Jesus couldn't have been fully man, your foundation is cracked. Soon enough, if continuing to believe these heresies, all that which you stand on will crumble beneath you, causing a great fall. A complete disillusionment.
God breathed the Truth throughout the pages of Scripture. He would become flesh to reconcile to Himself mankind. This is the only way for salvation. If Jesus had indeed been less than God, His sacrifice couldn't have been enough, couldn't have been sufficient.
But thanks be to God! That the fully Divine, fully human came to be that firm foundation on which we can stand. Knowing that because of who He was, and why He came, we can believe without a doubt. Period.
"The Word became flesh and dwelt among us…" John 1:14
**Col 1:16 ; John 1:10


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Make space on your bookshelf for July's most anticipated releases
Looking for a good book to squeeze into your suitcase? Here's our pick of the best summer reads…
The Trouble with Henry and Zoe by Andy Jones
Life is never quite what you expect it to be, no matter how hard you try. A cracking love story about – yes – Henry and Zoe, who are similar in more ways than they realise, mostly with how desperate they are to forget their pasts – something easier said than done.
Out 28 July, Simon & Schuster
The Invitation
The Invitation by Lucy Foley
Everyone seems to be hiding a post-war secret in 1950s Rome, but New York society girl Stella has the deepest secret of all. Journalist Hal Jacobs is infatuated by her beauty and when they are reunited on the Contessa's boat, Hal is determined to bring her back to life and remove her from her confinement.
Out 14th July, Harper Collins
Falling by Jane Green
As Emma Montague moves from England, to New York and settles in Connecticut, she slowly finds out what it is that truly makes her happy. Her seemingly perfect relationship with boyfriend Dominic and his son is put in jeopardy when a horrible fate invades their world, and Emma's determination is put to the test.
Out 14 July, Berkley Books
The Muse
The Muse by Jessie Burton
The highly anticipated second novel from Jessie Burton is about two women, separated by 30 years, but connected by a long-lost painting and the secrets behind it. Set in 1930s Spain and 1960s London, The Muse shows how two worlds become passionately intertwined.
Out now, Picador
All Is Not Forgotten
All is Not Forgotten by Wendy Walker
A violent attack on Jenny Kramer in the wealthy town of Fairview, Connecticut shakes it to its very core. With her memory medically erased, she struggles to come to terms with her emotional turmoil, spurning her father's obsession with finding her attacker, and her mother to shut herself away in a bid to protect her seemingly perfect world.
Out 14th July, St. Martin's Press
How To Find Love in a Bookshop
How To Find Love In A Bookshop by Veronica Henry
Bookshop owner Emilia Nightingale is struggling to remain open but is kept going by remembering the promise she made to her father and her everlasting loyalty to her customers. The bookshop proves to be a place where lives come together and are changed forever.
Out now, Orion
Lily and the Octopus
Lily and the Octopus by Steven Rowley
Dogs are man's best friend for a reason - and Ted Flask knows all about that. The bond between one man and his dog is fiercely strong throughout this novel and portrays the love and heartbreak of having someone we can't live without, and how hard we will fight for those we love most.
Out Now, Simon & Schuster
The Girls
The Girls by Emma Cline
Lonely, bored and desperate to fit in, Evie Boyd encompasses a small-town 1960s American teenager. When she meets a wild girl group on a run-down ranch and Russell, the man they're all mesmerized by, she is engulfed by a dangerous world of carelessness and violence.
Out Now, Chatto & Windus


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05 Oct 2012
Yorkshire Artspace with Museums Sheffield, Chaucer School & Park Academy
Yorkshire Artspace worked with pupils from Chaucer School and Park Academy on an education project inspired by the exhibition 'Auctorum' – a solo exhibition by the Sheffield based artist Paul Morrison – on show at Museums Sheffield's Millennium Galleries until 4th November.
In July and September this year, Year 10 pupils from both schools visited the exhibition at Millennium Galleries and were given an introduction to Paul's work. He is best known for his large monochromatic botanical landscapes and this became the theme for the education workshops.
Yorkshire Artspace artists Charlie Hill and Emilie Taylor ran two workshops each with the schools. Charlie brought the pupils to LEAF community allotments in Parson Cross where they had a closer look at the vegetables, plants and flowers that grow there. Charlie then asked the kids to make drawings, using only black and white and different types of drawing materials and paper. These drawings are now laser etched onto mirror polished stainless steel, a service provided by the Sheffield Assay Office.
Teachers who accompanied the pupils said that some of their Year 10s had never been to a gallery or visited an allotment before. "I enjoyed the visit to LEAF community allotments because it made me look at plants and flowers in a different way" Chaucer School pupil Park Academy pupils with their drawings from LEAF community allotments Emilie accompanied the pupils to Yorkshire Artspace's Manor Oaks Studios where they met some of the artists who work there and were then taken to the Discovery Centre and Turret House at Manor Lodge to learn about life during Tudor times from education officer Peter Machan.
They visited the Turret House where they were able to admire the wonderfully crafted decorative ceiling in the banqueting room, dating from 16thC and depicting a wealth of botanical imagery. Emilie followed the visit by running a clay tile making workshop at Millennium Galleries. The Park Academy pupils were also very lucky to meet with Paul Morrison and ask him all sorts of questions about his work and life as an artist. "I enjoyed meeting Paul Morrison and learning about what inspired him to be an artist" said one Park Academy pupil.
Paul studied and lives in Sheffield and has a studio at Yorkshire Artspace's Persistence Works Studios. Last year, for the 10th anniversary of Persistence Works Studios, Paul created a limited edition artwork, laser etched on mirror polished stainless steel, that Yorkshire Artspace was able to sell in order to raise the funds to enable this education project to take place.
Other in-kind support was given by the Sheffield Assay Office who provided the laser-etching service, Aalco (steel) Nottingham who provided the mirror polished stainless steel and Museums Sheffield who offered the activity room and exhibition space for the artworks the pupils created. The clay tiles and stainless steel etchings will go on display in the Avenue of Millennium Galleries from 8th October for a period of two weeks.


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NetBSD Security Advisory 2018-008: Several vulnerabilities in NPF
25 May, 2018 by email@example.com | netbsd
-----BEGIN PGP SIGNED MESSAGE----- Hash: SHA1 NetBSD Security Advisory 2018-008 ================================= Topic: Several vulnerabilities in NPF Version: NetBSD-current: source prior to Thu, Mar 22nd 2018 NetBSD 7.1 - 7.1.2: affected NetBSD 7.0 - 7.0.2: affected NetBSD 6.1 - 6.1.5: affected NetBSD 6.0 - 6.0.6: affected Severity: Remote Rule Bypass, Remote Memory Corruption Fixed: NetBSD-current: Thu, Mar 22nd 2018 NetBSD-7-1 branch: Mon, May 14th 2018 NetBSD-7-0 branch: Mon, May 14th 2018 NetBSD-7 branch: Mon, May 14th 2018 NetBSD-6-1 branch: Thu, May 17th 2018 NetBSD-6-0 branch: n/a NetBSD-6 branch: Thu, May 17th 2018 Teeny versions released later than the fix date will contain the fix. Please note that NetBSD releases prior to 6.0 are no longer supported. It is recommended that all users upgrade to a supported release. Abstract ======== Several vulnerabilities were discovered in NPF: 1) Integer overflow when parsing IPv6 headers. 2) Use-after-free when handling ICMP packets. Issue 2 will not be fixed in the netbsd-6-0 branch. Technical Details ================= 1) An integer overflow could be triggered when NPF was parsing IPv6 options of a packet. This overflow could result in a header length that was smaller than expected, which could allow an incoming packet to bypass L4 rules. 2) A use-after-free could occur when NPF was parsing an ICMP packet. This could result in a rule bypass, a panic, or unexpected behavior. Solutions and Workarounds ========================= For all NetBSD versions, you need to obtain fixed kernel sources, rebuild and install the new kernel, and reboot the system. The fixed source may be obtained from the NetBSD CVS repository. The following instructions briefly summarize how to upgrade your kernel. In these instructions, replace: ARCH with your architecture (from uname -m), KERNCONF with the name of your kernel configuration file and VERSION with the file version below File versions containing the fixes: FILE HEAD netbsd-7 netbsd-7-0 netbsd-7-1 ---- ---- -------- ---------- ---------- src/sys/net/npf/npf.h 1.55 184.108.40.206 188.8.131.52 22.214.171.124 src/sys/net/npf/npf_inet.c 1.45 220.127.116.11 126.96.36.199 22.214.171.124 src/sys/net/npf/npf_alg_icmp.c 1.29 22.214.171.124 126.96.36.199 220.127.116.11 FILE netbsd-6 netbsd-6-0 netbsd-6-1 ---- -------- ---------- ---------- src/sys/net/npf/npf.h 188.8.131.52 126.96.36.199.4.2 18.104.22.168.2.1 src/sys/net/npf/npf_inet.c 126.96.36.199 n/a 220.127.116.11.2.2 src/sys/net/npf/npf_alg_icmp.c 188.8.131.52 n/a 220.127.116.11.2.1 To update from CVS, re-build, and re-install the kernel: # cd src # cvs update -d -P -r VERSION sys/net/npf/npf.h # cvs update -d -P -r VERSION sys/net/npf/npf_inet.c # cvs update -d -P -r VERSION sys/net/npf/npf_alg_icmp.c # ./build.sh kernel=KERNCONF # mv /netbsd /netbsd.old # cp sys/arch/ARCH/compile/obj/KERNCONF/netbsd /netbsd # shutdown -r now For more information on how to do this, see: http://www.NetBSD.org/guide/en/chap-kernel.html Thanks To ========= Maxime Villard for finding and fixing these issues. Revision History ================ 2018-05-24 Initial release More Information ================ Advisories may be updated as new information becomes available. The most recent version of this advisory (PGP signed) can be found at http://ftp.NetBSD.org/pub/NetBSD/security/advisories/NetBSD-SA2018-008.txt.asc Information about NetBSD and NetBSD security can be found at http://www.NetBSD.org/ and http://www.NetBSD.org/Security/ . Copyright 2018, The NetBSD Foundation, Inc. All Rights Reserved. Redistribution permitted only in full, unmodified form. -----BEGIN PGP SIGNATURE----- iQIcBAEBAgAGBQJbBxHeAAoJEAZJc6xMSnBuCE4QAITWmvcJpv8dANlmBQWElzs7 XRah2CrpujfXeSVuocay80QpTwQTn6Hm4ZAlkYZBlwBVqepPjpwcdb5LmWHzwFgK 33oN/YO7tu/9HFgR9qHHyAnEPT3v7QHxomHgPGPDkAksMOJEj7Mjs0oZQaSiCeoU DF2VG+CNesIajJIz5WJDk+EE0G2YFOvkXYKWT26Ei1qUqeEYgfkK5E+ZGxE0rnE6 IVqubBIoNTmKvnsrv8uGKiQaau5iC2cztsZuCYsDwydYSNxXh5f/c9bfjpghaBw6 G8+3I9P2XGiNnP9wiyffpryktV1aUqtXFOeFjXKdPqmPscXnTWVtGYhPzyluG5Cv 4Led6qGvAzeB+TVHgjFc6pQVPkIyHF3lU4fQmfc3HZ1rsK7kEcGKVYwqCCnH7+jR NABVdzFmEqp4BDm+6JhPQvmi4iB8tTXXjIUWPQSGjkBBo0dQTC+Fom4m8zVF+/fe OqjslnTCw1fDO7byk19gsFXqR1fVOQ0qiVP55e3HKTyq1Y5gNpANJn8im5GOaBto AbGbTfwq/w6nb6nVi2c9J14HOf36FC+ynFltF7IH/F5lFowwQORs3RSLmXgSTGjk cFBpKt4IwfoYdPFBgBxkgoH+WNBmn7FoZWCa8b8mIEONyQNPH7+DiKzkcioj3Ttr aEG7z/h7Wbhd1/UxDTwm =40SA -----END PGP SIGNATURE-----


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For Monday January 21, 2019 - Please be advised that, due to extremely cold temperatures and high wind chills, and out of concern for the safety of students waiting for buses, all school transportation services Visit https://t.co/IUqpOGOD9c for further information— stsco.ca (@stsco_ca) January 21, 2019
Heads up: due to extreme cold and high windchills, all buses in the City of Kawartha Lakes, Haliburton and Muskoka for Trillium Lakelands District School Board are cancelled for Monday, January 21. Schools remain open. Stay warm everyone!!— TLDSB (@TLDSB) January 20, 2019
Email us with info to add your event!
PTBOCANADA is a website about Peterborough, Ontario, Canada. Copyright ©2010-2019, PTBOCANADA. All rights reserved.


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Mr. Kevin Moon
Co-founder and General Manager
Kevin Moon is the Co-founder and General Manager of 45RICE, a social enterprise dedicated to ending hidden hunger, also known as micronutrient deficiency.
Kevin started his career working for a private education institution, providing collegiate opportunities for NYC students. He has also facilitated strategies for the establishment of Brown Charity Group, a non-profit organisation dedicated to building schools in Africa for children with HIV/AIDS. Following that, he jumped into the social enterprise sector working for Nisolo, a fair-trade leather goods company based out of the U.S. and Peru. Kevin then moved to Singapore in 2015 and joined BoP HUB, a social enterprise accelerator. At BoP HUB, he facilitates public-private partnerships (PPP) between corporates, governments, and social entrepreneurs to address challenging social issues through sustainable business models. His educational background is in International Development and Organisational Effectiveness from Vanderbilt University.Back to Speakers / Panellists »


text:
In Celebration of OSX Leopard…
Have any annoying Macazoid friends who picked up one of these shirts at the Leopard release party?
Doesn't that piss you off? Not only that you're friends with such a nerd, but that Apple would deface such a great movie by stealing the tagline and applying their own nauseating schtick to it?
Well, now you can fight back!
Introducing, the ACSMB.com Leopard release party t-shirts!
Check it freaks:
Click The Pic!
Awwww yea! Now that's some style right there. Click the shirt to go right to the ACSMB store!!
Which brings me to my next topic:
Ah yes, it had to come…Leopard gets released, we have a new T-shirt…it's time for a contest!! Yes!!
Get your pic taken with one of those shirts on, and send it to us via email:
Do something crazy! Trick or treating, standing on your head, whateva…let your hate for Apple guide you on your photographic quest. Best 5 will get reviewed by our panel and will get featured on the site!!
First person to send a pic of them with an ACSMB shirt on IN AN APPLE STORE gets $25.00. No foolin! (so you get the shirt for free + money for coffee:)) That would be so damn funny, it's worth way more…but hey it's not like I'm Apple and have a ton of money from charging people
$129 for what should be a free OS upgrade


text:
A. Installation and Registration
B. Create a Contact Form
C. Edit a Contact Form
D. Delete a Contact Form
E. Received Email
F. Requirements
A. Installation and Registration
A.1 Installation
For Dreamweaver CS6, CC
- open the "Contact_Forms _[version-no].zxp" file using Adobe Extension Manager;
- restart Dreamweaver.
For Dreamweaver CS5.5, CS5, CS4
- open the "Contact_Forms _[version-no].mxp" file using Adobe Extension Manager;
- restart Dreamweaver.
A.2 Where to find the extension in Dreamweaver
Extend Studio products are available in the "Insert" window in Dreamweaver. Click CTRL+F2 (Command+F2 for MAC) to display the Insert Window.
If the "Insert" window is displayed as Tabs, below the main Dreamweaver menu, the Extend products should appear on the right side of the Tabs.
If the "Insert" window is displayed as Floating Panel (usually displayed on the left or right of the working area, depending on the Workspace settings: developer, designer etc) you need to click on the "Common" drop-down - marked with a down arrow.
The Extend Studio products should appear in the pop-up list.
A.3 Registration
A.3.1 How to register the extension
When you'll first start the extension, a registration pop-up will appear. Paste the code from the email that you have received from Extend Studio after buying the extension or click on "Use as trial" to use it free for 10 days.
After you register the extension, all you have to do is to edit the form that was created in trial mode and update it in order to remove the Javascript alert.
A.3.2 Registration Errors
The error messages could be due to many different reasons - choose a solution from the list (below) which corresponds to the error code displayed on your screen.
301 : This message indicates that the license key which you have entered is already in use. If you are trying to install a single user license - you would have to reset the license from the Extend Studio website - "My orders" section.
License Invalid: this implies that the serial number entered by you is incorrect. Make sure you are entering the correct license key.
If it still doesn't work, go to Account "My orders" section and from there you can obtain the correct license key.
If you need more assistance regarding registration, you can email us to support [at] extendstudio.com
B. Create a Contact Form
In order to add an Flexi Contact Form to a site, you need to create a html page inside a site. If you don't know how to define a site in Dreamweaver, check this page for help: http://www.adobe.com/devnet/dreamweaver/articles/first_website_pt1.html
After clicking the "Insert Flexi ContactForms" button, the ContactForms editor will appear. From here you can add elements to the form, modify its settings and choose a skin.
B.1 Form Elements
The Form Elements represent the inputs that are included in your form. Whenever a form element is selected you can change its settings from the Flexi ContactForms Editor in right side.
Each element (except the "Submit button") has the option to choose if it is required or not. The "Is required" option allows you to choose if completing the element is mandatory. When the "Submit" button is clicked, a validation message will appear if the mandatory fields are not completed.
Also, you can change each label name by adding another text inside the input.
B.1.b Add, Remove, Edit Form Elements
The Flexi ContactForm extension has 3 default elements- "Name", "Message" and "Submit Button". There are 3 other elements availabe to add - "Email", "Website" and "Phone".
You can add form elements by clicking the "+" (add) icon.
To remove a form element, select the element that you want to be deleted and click the "-" (remove) icon. Any deleted element can be re-added by clicking the "+" (add) icon.
To change the order of the form elements, select the element that you want to move and click the "down" or "up" icon to move it lower or higher in the elements list.
B.1.c Name
Select the "Name" element to edit its settings.
You can choose to have a "Name" element by choosing the "Only name" option. If you choose the "First and Last name" option, a "First name" element and "Last name" separate elements will be created.
You can change the element title by typing another text inside the input. The default label is "Name".
You can set the number of characters allowed by adding another number to the "Number of characters allowed" input.
B.1.d Message
You can set the number of characters allowed by adding another number to the "Number of characters allowed" input.
B.1.e Email
You can set the number of characters allowed by adding another number to the "Number of characters allowed" input.
When the email address input is completed it should include the following characters: "@" and ".". Otherwise, a validation message will appear.
B.1.f Website
You can set the number of characters allowed by adding another number to the "Number of characters allowed" input.
The "Website" input has to include at lease one "." character.
B.1.g Phone
You can set the number of characters allowed by adding another number to the "Number of characters allowed" input.
Inside the "Phone" input, only numbers can be inserted.
B.1.h Submit Button
You can change the submit button text by adding your own text inside the input. The default element name is "Send form".
The "Submit" element is mandatory, so it does not have an "Is required" option.
B.2 Form Settings
B.2.a Email recipient
Insert the email address where you want the form data to be sent.
Inside the "Show the following text" input, you can type any text that will be shown after the form is sent succesfully.
You can choose what the form will do when email is sent successfully. The form can either show a message or redirect the user to a page.
The email will be sent to the recipient after you upload the page that includes the form and the correspondent "includes " folder on your web server. If you are testing the form send functionality locally, you will get the following message: "You are running this page locally. Because of this, the email sending functionality will not work. You must run the page on a web server for this functionality to work."
Inside the "Redirect to the following webpage" input you need to add the link to a page from your website where the user will be redirected after the form is sent successfully.
You can add the link to the page either as an absolute link - example: http://www.extendstudio.com//products/dreamweaver-extensions.html or a relative link (if it is redirected to a page from your website) - example: /products/dreamweaver-extensions.html
B.2.b Validation messages
You can change the validation messages by clicking the "Edit Error Messages" button.
By clicking this button, the xtdContactFormsMessages.js file open in Dreamweaver. This file contains the list with all form elements' validation messages. You can change any message by editing the comment for each element. After you finish editing the messages, save this file and close it.
B.2.c Form Width
The form width can be set to "auto" or in px value. You can choose the 2 options from the selection input.
B.2.d Form Align
The form can be aligned to left, centered or to the right side inside its parent container. In order to align the form, its dimension must be set in px.
B.2.e Label Position
You can choose to have the label potition at the top of the input, inside the input or in the left side of the input.
Top position
Left position
Inside position
B.2.f Label Width
The label width option activates when you set the label position to left. Make sure that the label width is not bigger than the form width.
B.2.g Label Font
You can choose the label font from the font family selection list. Also you can set the label font size in px.
When the label position is set to be inside the input, the "Label font" option is disabled.
B.2.g Space between controls
This option allows to to set the vertical space between the form labels. The value can be set in px.
B.2.h Text Font
This represents the text that the user types inside the form inputs. Choose the text font family from the selection list. Also you can set the text font size in px.
B.3 Form Design
Click on the "Form Design" tab to see the available skins. There are 11 form skins inside the Flexi Contact Form extension. Once you choose the desired skin, click the "Insert" button to add the form to your page.
B.4. Preview
The "Preview" option allows you to see how the form looks in the browser before inserting it into the page.
C. Edit a Contact Form
In order to edit the Flexi Contact Form you have to select it inside Dreamweaver. If your mouse cursor is placed somewhere else on the page, you will get the following Dreamweaver alert message: "Please place the cursor inside the Flexi ContactForm you want to edit." .
Click on the "Edit Contact Form" button to edit the form.
You can edit the contact form settings, change the recipient email, or choose another form design. After you finish changing the form settings, click the "Update" button.
D. Delete a Conact Form
Click on the "Delete Contact Form" button to delete the contact form.
E. Received Email
After the contact form is successfully sent, the email recipient will get an email with all the data that has been sent. Flexi Contact Form has a default email format that looks like in the following screenshot:
F. Requirements
1. The extensions works on PC or Mac on the following Dreamweaver versions: CS4, CS5, CS5.5, CS6, CC.
2. The Contact Forms web application requires PHP version 5.3 or higher.
3. Make sure to have the php function "sendForm" activated on your server.
4. The page where you use the form must have a HTML 5 Doctype. Click here for more information about the doctype and its importance.
1. Can I use the license to build forms for an unlimited number of websites?
Yes. This is an unlimited sites license, therefore you can use it for an unlimited number of websites.
2. Can I use the license to work on my both work and home computers?
We offer a secondary free license at the user's request. All you have to do is send an e-mail to support [at] extendstudio.com and ask for a secondary free license.
3. How can I move the extension to a new computer?
You will have to download the extension from your extend studio account and install it in on the new computer. Before registering, you will have have to reactivate the serial number by clicking the correspondent "Reset license" button from your account.
4. Does the Contact Forms extension have any anti spam mechanism?
Flexi ContactForms are secured by an anti-spam script that will successfully block any spam attempts on your form.


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Hello Springtime from Jennifer Causey
Jennifer Causey (Simply Photo) is one seriously talented lady. I can't gush enough about her work, and I know I always do, but I can't help it (partly because I don't want to!). I'm such a huge fan; I stalk her etsy store constantly for new photos. It's borderline sickness, I know. She just launched her latest series called "Hello Springtime" - full on gorgeousness for sure. These postcards below are available in sets of 5 or 10. Enjoy!
(image from jennifer causey)


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Tales with Teach: Stories in Reproductive Health
Featuring music by Kyle Jester
5PM – 6PM: Silent Auction and Cash Bar
6PM – 8PM: Storytelling
In celebration of TEACH's 15th Anniversary, join us for a night of storytelling to celebrate stories about reproductive health, sponsored by the Mary Wohlford Foundation. We will hear about abortion, contraception, puberty, and so much more. Before our storytellers take the stage, there will be a silent auction. Snacks, wine, beer, and seltzer will be available for cash purchase. Our annual storytelling event helps to fund TEACH's programs throughout the year. With your support, we train Family Medicine residents in comprehensive reproductive healthcare, and develop the leading abortion curriculum, used across the country and in over 60 countries. We hope to see you there!


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NEW YORK (MarketWatch) - Energy stocks fell Thursday in the face of sustained worries about a stalled economic recovery, adding to big losses in the previous session.
Setting a bearish tone, the Dow Jones Industrial Average DJIA, +1.20% fell 59 points. Shares of blue-chip energy components Exxon Mobil XOM, +1.56% and Chevron Corp. CVX, +0.04% dropped by 0.3% and 0.1%, respectively.
Crude-oil futures weighed, with the front-month contract retreating 1.5% to $76.88 a barrel. See Futures Movers.
Against this backdrop, the Philadelphia Oil Service Index OSX, +3.95% fell 0.5% to 178. Cameron International CAM, +10.60% rose 0.3% to $36.89 as a rare gainer in the group.
The NYSE Arca Natural Gas Index XNG, +2.78% sank 1% to 507 and the NYSE Arca Oil Index XOI, +0.96% dropped 0.6% to 979.
Among stocks in the spotlight, Chevron said it discovered natural gas off the coast of Western Australia, in an exploration well some 217 miles northwest of Onslow, in 4,550 feet of water. The well was drilled to a depth of 9,022 feet.


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Amazon Student members Enjoy 6-Month FREE Trial & 50% Off Prime Membership Fee
How to Use Voucher Code?
As we all know that Amazon Prime is a paid service that gives Amazon shoppers a few distinct advantages. Members of Amazon Prime are eligible for free two-day shipping on any item, without a minimum-order balance. (Otherwise, free shipping requires a $35 minimum purchase.) The service lets members use the streaming-video service Amazon Prime Instant Video, allows them to stream music via Amazon Prime Music and allow them upload unlimited photo via Amazon Cloud Drive.. Users in select areas can also access Prime Now, which allows same-day delivery of certain Amazon products.
If you are a student, you will get a discounted Amazon Prime rate (50% off) and 6 Month Free Trial when you join Amazon Student.
To qualify as a student, though, you'll need a .edu email adress.
Here is some benefits:
1. 6 Month Free Trial:
You can cancel Amazon Student here after free trial
2. FREE Two-Day Shipping:
Wait until the last minute and avoid the lines with FREE Two-Day Shipping on textbooks and tons of other stuff.
3. Get exclusive deals and promotions for Students
Get exclusive offers and discounts on items you love, need, and want. You'll also be eligible for sweepstakes, giveaways, and contests.
4. Earn a $10 Credit for each referral
Receive a $10 Credit for referring friends via email and social networks with no limit on the number of referrals made.
5. Store your photos securely and access them from anywhere
Get free unlimited photo storage with Prime Photos.
6. Get unlimited instant streaming of movies, TV shows, and music*
Watch more than 40,000 movies and TV episodes on your laptop, phone, tablet, or gaming console with Prime Instant Video, plus listen to more than a million songs and hundreds of playlists with Prime Music.


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Barney - Havanese Puppy for Sale in Hagerstown, IN
Seller Information
These wonderful Havanese pups are ready for a new loving home! Havanese are natural companion dogs, gentle and responsive. They become very attached to their human families and are excellent with children. Very affectionate and playful with a high degree of intelligence, these cheerful dogs are very sociable and will get along with everyone including people, dogs, cats and other pets. They are easy to obedience train. This curious dog loves to observe what is going on. The Havanese is a gentle and affectionate breed that thrives on human companionship. Your Havanese will often follow you from room to room throughout the day. He's intelligent as well, and will enjoy making you laugh with goofy antics, or simply sitting on your lap watching the world go by. they are curious and playful, willing to approach people and be held by them. These pups are family raised and well socialized! They are up to date on shots and wormers! They have also been Vet Checked! They will make you a wonderful pet and companion! You are sure to fall in love with them at first sight! They can't wait to meet you! 765-489-5949


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clone prepare [ id] [ provider]
Finishes cloning a specified node.
This completes the work done by SLONIK CLONE PREPARE(7), establishing confirmation data for
the new "clone" based on the status found for the
"provider" node.
clone finish (id = 33, provider = 22);
This command was introduced in Slony-I 2.0.


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The scheduled July date has now been postponed to Saturday 6th August and has been moved to my Somersby farm studio.
This workshop is for students who have experience in basic Italic capital letterforms. You will be shown how to explore free lettering, flowing lines of writing, varied interlinear spacing, change of letter weight & to pen modern layouts. By the end of the day you will have worked on finishing a small contemporary piece of calligraphy, including embellishment with colour & gilding.
Booking enquires: firstname.lastname@example.com, Ph: 0423 947 472
Fee: $100/pp - due Friday 29th July


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Dina Bacvic, University of Melbourne
Australian urban design has historically focused on providing and improving access to public green spaces. As cities increase in density, this is a crucial part of creating healthy, engaged communities. But Australian urban designers often fail to consider the "other half" of public space – the town square.


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Restorative Yoga
Hot Stones & Essential Oils
Sunday, December 11th | 1:30-3:30pm | $35
with Kimberly Paul
Melt away physical tension and energetic knots with deeply restorative yoga poses.
Restorative yoga is a very gentle inward form of yoga where the body is placed in highly therapeutic postures that are supported with props while the mind is invited to slow down and watch the breath.
The result is a state of relaxation much deeper than traditional sleep.
A restorative practice is perfect for almost anyone, from an athlete who needs time to repair his body after strenuous training to a mother who needs some quiet time for herself. Restorative yoga is a perfect complement to other styles of yoga and other forms of exercise.
Hot stones will be placed on you during poses to aid in the release of constrictions and provide a warm, relaxing sensation. Experience light pressure point techniques that are said to release body tension. Essential oils will be put on specific areas to aid in healing and opening. Please bring your own eye pillow & bolsters if you have them, as props may be limited.
Space is limited, please register in advance.


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Tyres are the most the important part of a vehicle. Tyres keep a vehicle running on any kind of road, but while running tyres come in contact with different rough surfaces, which damage the upper layers of the tyres, they need to be changed from time to time. Continuous wear and tear of tyres flattens the grips on the upper most layers and shortens their lifespan. Naturally, cars and other vehicles need a regular inspection to check the condition of tyres. After a certain period, tyres need to be changed with newer ones or with better ones. Tyres are costly products, and owners want to buy them at cheapest possible prices. This is why there are many vendors are selling cheap tyres Gold Coast has to offer for budget-conscious clients.
Types of Tyres Available
Car or vehicle tyres need to be changed at any moment. Due to continuous friction with the road, the uppermost layer of the tyres loses its grip. The grip is very important to keep vehicles in control. Once the tyres lose their grip, they need to be changed immediately. Car owners who are hesitant to change their damaged tires due to the high cost can contact vendors selling cheap tyres Gold Coast offers for them to cut on expenses. These vendors usually stock tyres for two-wheelers and four-wheelers in larger quantities so they can offer them at affordable rates. For customer convenience, used tyres that still have a longer lifespan are also stocked and sold. Old tyres don't imply damage tyres. There're many owners, who are more conscious and can afford to change tyres much before these are damaged. These tyre dealers collect such old tyres, which are in very good condition and can still last longer.
As far as the new tyres are concerned, these dealers directly buy them from manufacturers. All well-known brands in Australia are available from these companies as well.
Services Provided by These Companies:
The most positive aspect of these Gold Coast based tyre selling companies is that they have huge stocks of cheap tyres. Moreover, the availability of stocks is displayed and updated regularly online. Many other services are rendered by these companies, which include:
- Tyre inspection services are very vital and hence provided for every type of vehicle and for every type of tyre. The experienced technicians with the help of modern equipment can determine lifespan and problems with the tyres;
- Tyre repairing including puncture repair and tyre maintenance services;
- Tyre pressure maintenance;
- Wheel alignment and wheel balancing services are undertaken by the technicians of the company on demand; and
- Brake repair and maintenance of cars and all other vehicles.
Some Distinguishable Features:
Companies providing cheap tyres are extremely professional in their services. They're popular because of the quality of tyres they sell and all other repair and maintenance services they offer. Here are some distinguishable features of these companies:
- Their technical staff is very efficient in rendering services. Companies provide all modern equipment and relevant training to make these technicians more professional in their respective field;
- Customer help desk executives always remain active in taking calls and meeting customers to register orders and complaints. After sale service and support are also very well managed; and
- Online presence enables customers to get cheap tyres and book technicians more easily and quickly.
Hence, cheap tyres Gold Coast vendors sell today are a great option for those who are on a tight budget. They are very reliable and trusted by thousands of customers due to their years of good track record.


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MEGADETH Guitarist Interviewed In Milwaukee
TheRave.com conducted an interview with MEGADETH guitarist Chris Broderick on February 12 prior to the band's performance at The Rave Eagles Club in Milwaukee, Wisconsin as part of this year's Gigantour. You can now watch the chat below.
Gigantour — the critically acclaimed package festival founded in 2005 by MEGADETH — is making its highly anticipated return for the first time since 2008. The multi-artist bill — with metal heavyweights MOTÖRHEAD, VOLBEAT and LACUNA COIL all personally picked by MEGADETH frontman Dave Mustaine — kicked off on January 26 in Camden, New Jersey. Before wrapping February 28 in Denver, Colorado, the tour will make stops all across the U.S. and Canada, including a February 24 show in Los Angeles.
MEGADETH was among the nominees for the 54th annual Grammy Awards, which was held on Sunday, February 12 at Staples Center in Los Angeles. The band's tenth Grammy nomination was for its new single, "Public Enemy No. 1", off MEGADETH's latest album, "TH1RT3EN", which came out on November 1, 2011.
"Public Enemy No. 1" actually marked the second Grammy nomination for music from "TH1RT3EN", as the song "Sudden Death" was first unveiled in the 2010 video game "Guitar Hero: Warriors of Rock" and received a "Best Metal Performance" nod.


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Flamboyant West Indian cricketer Chris Gayle has shared several exclusive photos of his luxury mansion on social media.
Although his overseas Twenty20 commitments make him travel all year, he makes sure he has a gala time with his near and dear ones when he his home — a place that is truly the reflection of his lifestyle.
The Jamaican cricketer has all the requisite arrangements for an in-house party at his residence – a nine-bedroom mansion with a personal cinema and multiple swimming pools, a host of staff to care for him and his home and cash to splash on cars and bling, thanks to an estimated yearly income of $10.7 million.
There's also a pool table, a strip-club, a game zone, a bar, a restaurant, a mini-theatre to name a few among elaborate other arrangements at his mansion.
News in the streets is that the superstar cricketer is currently building another mansion on the island.
Check out these exclusive photos of Chris Gayle mansion!
Continue to the next pages for more photos!


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The discovery of a new active plant extract is an important step in the development of a potential new drug or active ingredient. This development requires being able to go as fast as possible to the pure molecule responsible for the biological activity and to elucidate its chemical structure.
Greenpharma combines experimental techniques and original knowledge-based approaches such as databases exploitation and molecular modelling to accelerate the process and offers you the Greenpharma
Activity Guided Fractionation Service
In conjunction with biological activity tests, Greenpharma uses :
- Preparative HPLC, LC/MSn and NMR to purify and characterize the molecule responsible for the biological activity.
- Greenpharma proprietary database to search links between plants and molecules
- Molecular modelling to identify the most likely compound(s) for the desired activity
These steps are iteratively executed until the active molecule is found.
Greenpharma proposes you this complete solution established on a one year based program.


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The elderly woman had a somewhat shocked look on her face, her mouth slightly open underneath an oxygen mask, as she sat buckled in the front passenger seat.
The car, parked on a footpath, was partially covered in a thin layer of snow. Temperatures in the small city of Hudson, New York were in the single digits that Friday morning.
A citizen saw the woman and frantically called 911, according to news reports. The elderly woman had "frozen to death," she told authorities.
Hudson police rushed to the location of the Subaru, CBS New York reported. Officers were unable to find the owner of the car, so they smashed the back passenger-side window — only to find that the woman was actually a life-size mannequin.
The mannequin was "extremely realistic," CBS New York reported, citing a news release from the Hudson Police Department. It was wearing women's clothing and glasses, and its face was covered in liver spots.
Read More On MSN


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Fiscal years come and go, but FY14 has been different. As a country, India has never been as united as it was this year, giving Narendra Modi the mandate to form a coalition-free government, with a lot of expectations riding on it. From 45 ministers in May to 66 currently, a lot has changed in the Modi Government. But what has changed in governance? Is it still a wait-and-watch game for the construction industry?
After the new government was sworn in on May 26 this year, a gradual revival was visible in June 2014 with a marginal growth of 0.50 per cent in July. Core sector output growth accelerated to 5.8 per cent in August 2014 compared to 2.7 per cent in July 2014, as steel, coal, cement and power production expanded significantly. The April-August figures showed 4.4 per cent expansion compared to 4.2 per cent growth in the first five months of the last financial year.
The Oil and Gas Ministry has been an achiever with regulated fuel prices and aversion of major price hikes to an extent. With crude prices witnessing a decline, fuel prices have actually reduced.
The Budget
The new and progressive Budget presented within 45 days focused on long-term benefits and was devoid of major reforms or market-shaking policies. Apart from the green signal to the much-awaited bullet trains and 100-per-cent foreign direct investment (FDI) in Railways, excluding train operations and safety, the Railway Budget focused on greater efficiency.
Infrastructure projects will get easier long-term loans without regulatory pre-emptions such as CRR, SLR and priority-sector lending norms. The National Highways Authority of India (NHAI) was allotted Rs 37,880 crore for highway construction, and Rs 3,000 crore to boost road connectivity in the Northeast.
The development of 16 new ports was proposed at Rs 11,000 crore and Rs 11,600 crore were allocated for the development of outer harbour port projects. Other components of the Budget û development of new airports through PPP mode, money allocation for cleaner thermal power technology, development of villages along the border, rail connectivity in the Northeast, toilets in every school and household - further fuelled the positive sentiment. Every MP was instructed to adopt a village to develop it efficiently. And Rs 7,060 crore was allotted for the creation of 100 smart cities across India.
Housing bonanza
As for the housing sector, the Budget brought good news: Rs 4,000 crore for low-cost housing schemes and relaxation of FDI norms for the affordable housing sector. The Government´s vision of ´Housing for all by 2022´ requires an investment of over $2 trillion. And Modi´s ´Make in India´ has already received success with Japan´s $35-billion and China´s $100-billion investment plans. Facilitating clearance However, 467 projects worth Rs 23 lakh crore are still pending for clearance from the Project Monitoring Group (PMG). Of these, there are 57 projects where hardly any action can be taken. The good news is that 180 projects worth Rs 6.5 lakh crore have already been cleared and around 220-225 projects entailing Rs 11 lakh crore are under consideration.
Company play
Notably, when the domestic order book was drying up, some large companies focused on global markets. L&T followed this strategy to sustain growth. Although the margins in the global markets were a tad lower than domestic markets, the consistent inflow of orders kept the financial performance of the company on track. To sum it up, the dream of achhe din is very much alive in the market. And, as the industry looks forward to the new government delivering what it promised, India´s infrastructure kings share their experiences this year and recommendations for a smooth 2015, exclusively with CW.
RK Goyal Managing Director, Kalyani Steels Ltd
¨This has not been a great year from the customer side. The business did not grow in the automobile sector to which we are the largest supplier. Ditto for power, where we supply steel. We did not acquire any new projects as few orders were placed. Infrastructure projects have been announced but there is still time for orders to be placed for steel. That said, we see order inflow in the next six months to a year. At the policy level, there have been many reforms in labour laws to make for a more hassle-free environment. Also, bureaucrats and ministers in Delhi are much more accessible now. We are yet to see any result but things are moving positively. If we want rapid industrialisation, project clearances should become quicker. With this, investment will start coming into place, employment will be generated and the economy will be on the fast track.¨
Madhukar N Parikh CEO-VNR Rail & Business Development, VNR Infrastructures Ltd
¨As a company, we are focused on Railways, which is going pretty slow. The change will take place next year. Engineering, signalling and overhead are very different for Railways and the earlier government had clubbed them under a PSU called RVNL - Rail Vikas Nigam Ltd - formed in 2003. Railway employees are recruited into this and getting approval from them is challenging. If the new government looks into this area, it will certainly open up opportunities galore. Also, there have not been many changes as the Railway Budget was a mere carry-forward one. Changes will come in the next Budget. We definitely need a policy change. We are expecting the Railways to start the redevelopment of railway stations, metros and monorails and give ownership to private companies. Let´s hope the Budget will be realistic.¨
Vipin Sondhi Managing Director & CEO, JCB India Ltd
¨The industry is down by 20 per cent and JCB is down less than the industry. We have gained in market share. We sell a lot to small contractors and individuals, but the large contractors are now coming back. They have gone through a difficult time. Going forward, we see 2015 translating into large contracts with big contractors. A lot of opportunities have come in from roads and real estate. Changes in policy will impact the people who actually construct. Policy changes in the environment are making it easier for constructing linear projects. I would recommend only execution, execution and execution to the government. This means take the top 15 nationally important projects and execute them. And the wheels will start rolling. All small, medium and large projects will start moving. People want to see whether we can implement projects.¨
K Subrahmanian Vice Chairman & Managing Director, Afcons Infrastructure Ltd
¨We had taken certain insulators from the negative swing; otherwise, the year has been brilliant. We get one-third of our business from outside the country and even in India we go only for selected projects. We have a light rail project in Mauritius that will take off in 2015. Hence, it was a balanced year for Afcons. But for the industry, 2014 has been a testing year. The government has to bring in some people for leadership to key areas, people who walk that extra mile and are not run of the mill. The government should take their solutions and implement them. Many projects are on the run. While there have not been any changes at the ground level, it is a wait-and-watch situation for the private sector.¨
Rajas R Doshi Chairman & Managing Director, The Indian Hume Pipe Co Ltd
¨The year 2014 has been satisfactory and we are growing at 25 per cent so far. There have not been any changes. We are living on the past orders of the last government. There has not been any action after the new government came to office. I do not know what is going to happen. The government has to spend a lot of money on infrastructure and remove bottlenecks like land acquisition, higher interest cost and higher inventories that are a big problem for the industry.¨
Somnath Bhattacharjee President & CEO, Material Handling Solutions Equipment & Project Solutions Business, TIL Ltd
¨As domestic demand remained quite stagnant, we focused on taking our business to the international arena. We have expanded our reach stackers business, and our market value has risen to 60 per cent. In our coal business and mobile cranes, we have grown in volumes. Compared to expectation and capacity, the growth is not in line. But we have worked on operating efficiency and delivery cycle. Although basic infrastructure was weak, oil and gas remained strong. The mine sector was low, but overall we have seen a marginal growth in volume. Some things on the policy side could improve TIL´s business and the construction equipment business. The root cause for projects not taking off was that the basic policy framework did not work. We have great expectations from the winter session of Parliament with bills such as the Land Bill and Labour Reform being taken up for approval.¨
Rajeev M Pai CFO, JSW Steel Ltd
¨It was a challenging year for the steel industry but JSW Steel witnessed profitable growth by 8-9 per cent. It is on track to maintain its guidance on volumes for the year. We work in a dynamic business model, with 25 per cent exports and have strong retail sales in the rural sector. Also, the company has collaborated with Japan´s JFE Steel Corporation, which supplies to large OEMs. There has been a focus on manufacturing and mineral resources allocation like coal and iron ore. We are looking forward to the Land Acquisition Bill. The year 2015 will be an extremely positive one. There may be a cut in the interest rates; this could result in a revival in the investment pipeline and we are eagerly looking forward to it.¨
AVN Raju Director, NCC
¨We could still achieve, despite the unpleasant situation. We are already executing one of the big projects in the power industry, and have taken an EPC of 1,320 mw valued at Rs 5,000 crore. At the policy level, we are expecting changes with the new government and believe that things will improve in the infrastructure and construction world for a greater future. In the construction industry, there are several rules and regulations for tenders, and we sincerely advise the government to follow the FedEx system that is being used worldwide.¨
Sanjay Bahadur Group CEO, Construction Chemicals Business, Pidilite Industries Ltd
¨It was a tough year, but we managed to grow. As we work on many small orders, if there is a growth in the overall business and more construction activity, our products are naturally consumed. The present is promising, but results are yet to come. However, the general energy level looks good. But it has not transformed into figures. This will take more time. Everybody will manage. I do not want to recommend anything.¨