text:
Pregnancy Outcomes in Women With Dilated Cardiomyopathy
Author + information
- Received May 15, 2009
- Revision received August 7, 2009
- Accepted August 10, 2009
- Published online December 29, 2009.
Author Information
- Jasmine Grewal, MD⁎,
- Samuel C. Siu, MD, SM⁎,†,
- Heather J. Ross, MD‡,
- Jennifer Mason, RN⁎,
- Olga H. Balint, MD⁎,
- Mathew Sermer, MD⁎,
- Jack M. Colman, MD⁎ and
- Candice K. Silversides, MD, SM⁎,⁎ (candice.silversides{at}uhn.on.ca)
- ↵⁎Reprint requests and correspondence:
Dr. Candice K. Silversides, University of Toronto, Toronto General Hospital, 585 University Avenue, 5N-521, Toronto, Ontario M5G 2N2, Canada
Objectives The objectives of this study were to determine adverse outcomes during pregnancy in women with dilated cardiomyopathy (DCM) and to compare their cardiac outcomes with those of nonpregnant women with DCM.
Background Women with DCM are at risk for complications during pregnancy, but few studies have examined outcomes in this specific population.
Methods This was a substudy of a larger prospective cohort study of outcomes in women with heart disease. Maternal cardiac, obstetric, and fetal outcomes in pregnancy in women with DCM were examined. For comparison, cardiac outcomes in nonpregnant women with DCM (n = 18) matched by age and left ventricular (LV) systolic function were examined. A matched-pair survival analysis was used to compare groups.
Results Thirty-six pregnancies in 32 women with DCM were included. Thirty-nine percent (14 of 36) of the pregnancies were complicated by at least 1 maternal cardiac event. In the multivariate analysis, moderate or severe LV dysfunction and/or New York Heart Association functional class III or IV (p = 0.003) were the main determinants of adverse maternal cardiac outcomes during pregnancy. In the subset of women with moderate/severe LV dysfunction, 16-month event-free survival was worse in pregnant women compared with nonpregnant women (28 ± 11% vs. 83 ± 10%, p = 0.02). The adverse neonatal event rate was highest among women with obstetric and cardiac risk factors (43%).
Conclusions In pregnant women with DCM the risk of adverse cardiac events is considerable, and pre-pregnancy characteristics can identify women at the highest risk. Pregnancy seems to have a short-term negative impact on the clinical course in women with DCM.
Women with dilated cardiomyopathy (DCM) are at risk for complications during pregnancy if they are unable to adapt to the hemodynamic changes of pregnancy. In the Confidential Enquiries into Maternal Death in the United Kingdom, maternal cardiac deaths during pregnancy, although rare, were frequently related to ventricular dysfunction (1). However, little is known about cardiac morbidity or risk stratification in this population. Although the literature generally advises against pregnancy in women with significant left ventricular (LV) systolic dysfunction (left ventricular ejection fraction [LVEF] <30%), there are minimal data to support this recommendation (2). Counseling about the safety of pregnancy can have a major impact on prospective mothers, and it is therefore important that more data be available to help provide appropriate advice about pregnancy risks to women with a DCM. Therefore, the purposes of this study were: 1) to examine adverse maternal cardiac, obstetric, and fetal and/or neonatal events in a contemporary group of women with DCM undergoing pregnancy; and 2) to determine the impact of the pregnancy on the clinical course of the disease by comparing adverse cardiac events in pregnant versus nonpregnant women with DCM and significant LV systolic dysfunction.
Study population
Women with previously documented idiopathic or doxorubicin-induced DCM were enrolled in our ongoing prospective pregnancy outcomes study between December 1994 and July 2008 (3,4). A DCM was defined as a dilated ventricle with reduced LVEF in the absence of coronary, valvular, congenital, or any systemic diseases known to cause myocardial dysfunction (5). Women with cardiomyopathies from other causes, including peripartum cardiomyopathy, were excluded. Peripartum cardiomyopathy was defined by: 1) the development of heart failure in the last month of pregnancy or within 5 months of delivery; 2) an LVEF <45% by echocardiography; 3) absence of an identifiable cause for the cardiac failure; and 4) absence of recognizable heart disease before the last month of pregnancy. Nonpregnant women were matched with pregnant women by age, diagnosis, degree of LV systolic dysfunction, and year of pregnancy (year of initial clinic visit) and followed up over 16 months to ascertain event rates. For the purpose of this comparison, only women with moderate or severe LV dysfunction (LVEF <45%) were included. This study received institutional ethics approval.
Baseline data and follow-up
Details pertaining to data collection in women with heart disease followed up in our Pregnancy and Heart Disease Research Program at University Health Network and Mount Sinai Hospitals have been described elsewhere (3). All pregnant women were followed up prospectively from the start of pregnancy until 6 months post-partum. Clinical, electrocardiographic, and echocardiographic data were collected at the time of clinic visits. These baseline data were recorded: age, comorbid medical conditions (pulmonary disease, thyroid dysfunction, hypertension, diabetes mellitus), smoking history, New York Heart Association (NYHA) functional class, prior cardiac events (heart failure, transient ischemic attack, arrhythmias, or stroke), prior cardiac interventions, use of cardiac medications, and anticoagulation. In the group of pregnant women, these additional baseline data were recorded: gestational age and parity status. Medication use was recorded at the time of the first antenatal visit among pregnant women. In many instances, cardiac medications recorded at the first antenatal visit were not representative of the medications used before pregnancy because medications such as angiotensin-converting enzyme inhibitors had already been discontinued by an alternate care provider or were stopped before conception. Obstetric risk factors associated with adverse fetal and/or neonatal events were also recorded for the pregnant group of women and included history of premature delivery or rupture of membranes, incompetent cervix, and cesarean section, and during the present pregnancy included intrauterine growth retardation, antepartum bleeding >12 weeks gestation, febrile illness, or uterine/placental abnormalities (3,6–9).
Echocardiographic assessment included left and right ventricular systolic function, valvular function, and systolic pulmonary artery pressure (4,10). Left ventricular systolic function was given a functional grade assessment: normal (LVEF >55%), mild (45% to 54%), moderate (30% to 44%), or severe (<30%) (11). The modified Quinones method was used to calculate LVEF (12), with subsequent visual estimation if endocardial definition was suboptimal. An experienced echocardiographer interpreted all echocardiograms.
Nonpregnant and pregnant women were followed up for an equal length of time (16 months). The beginning of follow-up in the nonpregnant group was at the time of their first visit to the heart failure clinic at our institution. Baseline clinical, electrocardiographic, and echocardiographic data as described earlier were recorded. Medication use at the time of first heart failure clinic visit was recorded.
Adverse events during the antepartum, peripartum, and post-partum periods were classified as cardiac, fetal and/or neonatal, and obstetric. Two physicians blinded to the women's baseline characteristics independently verified adverse events. Adverse cardiac events for both pregnant women and nonpregnant control subjects were defined as pulmonary edema (documented by chest radiograph or by crackles heard over at least one-third of posterior lung fields); sustained symptomatic tachyarrhythmia or bradyarrhythmia requiring treatment; stroke, angina, or myocardial infarction; cardiac arrest; or cardiac death. Fetal and neonatal complications were defined as premature birth (<37 weeks gestation), small-for-gestational-age birth weight (<10th percentile for gestational age), respiratory distress syndrome, intraventricular hemorrhage, fetal death (20 weeks gestation and before birth), or neonatal death (from birth to age 28 days). Obstetric complications were maternal death from noncardiac causes, pregnancy-induced hypertension (increase of 30 mm Hg in systolic blood pressure and 15 mm Hg in diastolic blood pressure compared with baseline values), or post-partum hemorrhage (blood loss >500 ml after vaginal delivery or >1,000 ml after cesarean section, requiring transfusion or accompanied by a decrease in hemoglobin level ≥20 g/l).
All data were analyzed using SPSS version 16.0 (SPSS Inc., Chicago, Illinois). Data are presented as median value with interquartile range, and in some instances ranges are also provided. Univariate predictors of maternal cardiac complications during pregnancy in women with DCM were determined using univariate logistic regression analysis. A multivariate logistic regression model was then created to identify predictors of adverse maternal cardiac events during pregnancy based on the univariate analysis. Variables identified in the univariate analysis with a value of p < 0.1 were included in the multivariate model. Because of the correlation between NYHA functional class and LV systolic function, a single variable was created for the multivariate model combining NYHA functional class III or IV and moderate or severe LV dysfunction.
The second analysis consisted of a comparison of outcomes in pregnant versus nonpregnant women with DCM and moderate or severe LV systolic dysfunction. Baseline characteristics between groups were determined using McNemar or Mann-Whitney Utests as appropriate. Adverse cardiac events in pregnant women were compared with those in nonpregnant women. Survival in both groups was depicted using Kaplan-Meier curves, and comparison between groups was performed using a matched-pair survival analysis. A value of p < 0.05 (2-sided) was considered statistically significant.
Between December 1994 and July 2008, 906 women with heart disease undergoing pregnancy were prospectively followed up and enrolled in our larger cohort study. Of these, 36 pregnancies occurred in women with DCM (32 women); 84% (n = 27) with idiopathic DCM and 16% (n = 5) with doxorubicin-induced cardiomyopathy. Baseline characteristics of pregnant women and control subjects are summarized in Table 1.Of the 4 women who had an episode of heart failure before pregnancy, 2 had mild, 1 had moderate, and 1 had severe LV systolic dysfunction at the time of enrollment. One woman with severe LV dysfunction had an implantable cardioverter-defibrillator implantation. Her ventricular function had improved before pregnancy, and the lead was subsequently explanted because of a manufacturer's recall. At the time of post-partum discharge, 3 (9%) women were in NYHA functional class II, 1 (3%) was in class IV, and the remainder were in class I.
Maternal cardiac outcomes
Fourteen of 36 (39%) pregnancies (up to 6 months post-partum) in women with a DCM were complicated by at least 1 adverse maternal cardiac event (Table 2).One woman experienced heart failure at 13 weeks gestation followed by nonsustained ventricular tachycardia at 15 weeks gestation, necessitating a therapeutic abortion. Twenty-four weeks after the procedure she presented again with ventricular tachycardia. Atrial fibrillation or flutter occurred in 4 women during the antepartum period (17, 23, 28, and 36 weeks gestation), and in 1 woman during labor and delivery. Heart failure occurred in 3 pregnancies during the antepartum period (20, 28, and 38 weeks gestation), 1 during labor and delivery, and 4 during the post-partum period (2 days, 5 days, 12 weeks, and 16 weeks after delivery). A transient ischemic attack occurred in 1 woman at 19 weeks gestation. All adverse maternal cardiac events were successfully managed with medical therapy.
Characteristics predictive of an adverse cardiac event during pregnancy in univariate analysis are shown in Table 3.In multivariate analysis, moderate or severe LV systolic dysfunction and/or NYHA functional class III or IV were the main determinants of adverse maternal cardiac events during pregnancy (Table 3). A history of cardiac events before pregnancy showed a trend toward significance for predicting pregnancy-related maternal cardiac outcomes. After excluding multiple pregnancies in the same individual, the univariate and multivariate analyses were repeated (n = 4), and the results remained unchanged.
The frequency of adverse maternal cardiac events over the 16-month follow-up varied according to the severity of LV systolic dysfunction. Only 1 woman with mild LV systolic dysfunction and in baseline NYHA functional class II had an adverse cardiac event; however, she also had a history of cardiac events before pregnancy. The frequency of adverse cardiac events was similar between women with moderate or severe LV systolic dysfunction (75% [6 of 8] moderate and 70% [7 of 10] severe, p = 0.81). All women with moderate LV systolic dysfunction also had 1 other high-risk characteristic; 50% (4 of 8) had a prior cardiac event, 25% (2 of 8) were NYHA functional class III or IV, and 25% (2 of 8) had moderate or severe mitral regurgitation.
All women with adverse cardiac events during pregnancy (n = 14) had either moderate or severe LV dysfunction, NYHA functional class III or IV, and/or a previous cardiac event. There were no adverse events in women with none of these 3 clinical parameters (moderate or severe LV dysfunction, NYHA functional class III or IV, and/or a previous cardiac event). If any 1 of these 3 risk factors was present, the risk of an adverse cardiac event was 64% (14 of 22) (Fig. 1).
Obstetric and fetal/neonatal outcomes
The 36 pregnancies resulted in 37 live births, including 1 twin and 1 triplet pregnancy (Table 4).There was 1 therapeutic abortion at 20 weeks and 1 fetal death. Among the live births, the median gestational age at delivery was 38 weeks (range 28 to 41 weeks), and the median birth weight was 3,060 g (range 1,230 to 4,045 g). The most frequently used method of anesthesia was an epidural in 86% of deliveries. Eighty-one percent (29 of 36) of the deliveries were vaginal, and were induced in 11% of cases. Cesarean deliveries occurred in the remaining 7 pregnancies for these indications: previous cesarean delivery (n = 3), failure to progress (n = 1), fetal distress (n = 1), breech presentation (n = 1), and coexistent medical condition (n = 1). Cesarean delivery was not performed for cardiac indications in any of the women. The length of hospital stay was a median of 3 days (interquartile range 3 to 6 days). Adverse obstetric outcomes are shown in Table 4.
Seven of 35 (20%) pregnancies (not including the pregnancy that ended in therapeutic abortion) were complicated by an adverse fetal and/or neonatal event (Table 4). Even when the 2 multiple-gestation pregnancies (1 twin and 1 triplet) were excluded from the analysis, the fetal and/or neonatal event rate remained high at 15% (5 of 33). Fifty-three percent (19 of 36) of women had at least 1 risk factor for adverse fetal and/or neonatal events. Obstetric risk factors associated with adverse fetal and/or neonatal events included any prior history of premature delivery or rupture of membranes (n = 1), incompetent cervix (n = 0), or cesarean deliveries (n = 2). During the current pregnancy, any of these variables was also considered an obstetric risk factor: intrauterine growth retardation (n = 1), antepartum bleeding >12 weeks gestation (n = 1), febrile illness (n = 0), or uterine/placental abnormalities during the present pregnancy (n = 3). Nonobstetric risk factors included smoking (n = 4), anticoagulation use (n = 3), multiple gestation (n = 2), and maternal age <20 or >35 years (n = 11). Neonatal complications were most common in women with more severe DCM (moderate or severe LV systolic dysfunction and/or NYHA functional class III or IV) if they had concomitant obstetric risk factors (Fig. 2).
Comparisons of cardiac outcomes in pregnant versus nonpregnant women with significant LV systolic dysfunction
Because the 16-month event rate was low among pregnant women with mild LV systolic dysfunction, these women were not included in this analysis. The baseline characteristics of the 18 nonpregnant women and 18 pregnant women with a DCM who had moderate or severe LV dysfunction are shown in Table 5.Significantly more nonpregnant women were taking cardiac medications during the 16-month follow-up period when compared with the pregnant women. Three nonpregnant women (17%) had events during the 16-month follow-up period: cardiac transplantation caused by refractory heart failure (n = 1), death secondary to ventricular tachycardia (n = 1), and syncope secondary to ventricular tachycardia (n = 1). In women with moderate or severe LV systolic dysfunction, adverse cardiac events were more common in pregnant women compared with nonpregnant women with a DCM (72% [13 of 18] vs. 17% [3 of 18]). The 16-month event-free survival was worse in pregnant women compared with nonpregnant women (28 ± 11% vs. 83 ± 10%, p = 0.02) (Fig. 3).
This is the first study to examine in detail the risks of pregnancy in women with DCM. In this cohort of pregnant women with DCM, we found that maternal cardiac complications were considerable in women with moderate or severe LV systolic dysfunction and/or NYHA functional class III or IV symptoms. In our study, women with no history of cardiac events, mild LV systolic dysfunction, and good functional class did well and did not have any cardiac complications during pregnancy. Adverse fetal and/or neonatal events were highest in women with moderate or severe LV systolic dysfunction and/or NYHA functional class III or IV if they had concomitant obstetric risk factors. Pregnancy seemed to have a negative impact on the clinical course of DCM because adverse cardiac events were more common over a 16-month period in pregnant women compared with nonpregnant women with DCM.
Cardiac complications during pregnancy in our series were high (39% of pregnancies). The most common complication was heart failure, and this typically occurred late in the pregnancy or post-partum. In 1 small prior retrospective series of women with DCM (8 women), 25% of pregnancies were complicated by adverse events; 1 woman with an LVEF of 16% required transplantation after termination of pregnancy, and in another, heart failure developed at 28 weeks of gestation (13). However, 50% of the women (4 of 8) had only mild LV systolic dysfunction. In another larger series of women with heart disease (43 women with cardiomyopathy, 18 with idiopathic DCM), adverse events occurred in 42% of pregnancies in the subset of patients with cardiomyopathy. However, the specific event rate in women with DCM was not reported (10). Furthermore, there were 3 maternal deaths in the cardiomyopathy group, but again it was not reported whether any of these deaths occurred in the setting of DCM. In our series, despite the high risk of complications in this group of women, all complications were successfully managed with medical therapy and there were no maternal deaths. This is a reassuring experience, but certainly maternal mortality is possible in high-risk women with DCM, and this possibility needs to be considered when counseling an individual. Furthermore, the late effects of pregnancy on the diseased heart are not well understood, and the effects on long-term ventricular function and prognosis require further study.
A number of prior studies have identified risk factors for adverse maternal outcomes during pregnancy, including NYHA functional class (4,14). Independent of functional status, LVEF <40% also has been shown to predict adverse events in pregnancy (4,14,15). Our findings in women with DCM are similar, although it is important to note that only a small number of women were in NYHA functional class III or IV in our study. The rate of adverse maternal cardiac events is high in this group of women, and approaches 65% if one or more of these risk factors were present: moderate or severe LV systolic dysfunction, NYHA functional class III or IV, and/or a history of an adverse cardiac event. Alternatively, if none of these factors were present, women did not experience adverse events. These disease-specific findings are incremental to previous work and will be important in the counseling and follow-up during pregnancy in women with DCM.
Results of this study also show that pregnancy in women with DCM directly impacts the natural course of the disease, at least over the short term. We showed that cardiac complications in pregnant women were significantly more common compared with those in nonpregnant women during a 16-month follow-up period. The increased incidence of adverse cardiac events among pregnant women seems to begin in the third trimester at the time of maximal hemodynamic change, supporting the idea that it is the hemodynamic load that leads to cardiac decompensation. Some studies have shown a transient decrease in LV contractility during pregnancy (16), and this may also play a role in cardiac decompensation in women with abnormal LV function. Although many of the baseline characteristics were similar between the 2 groups, the authors acknowledge that an important difference between groups was that nonpregnant women were more likely to receive angiotensin-converting enzyme inhibitors, beta-blockers, and diuretic agents over the 16-month follow-up when compared with their pregnant counterparts. Although many pregnant women were optimally managed on heart failure therapy before pregnancy, medications were discontinued early in pregnancy because of contraindications and/or patient preference. This factor may also explain some of the observed differences in event rates between the 2 groups. In addition to increased cardiac complications during pregnancy, discontinuing cardiac medications for the duration of pregnancy may also have late negative effects on ventricular function.
In the population of pregnant women with DCM described in this study, we observed a high rate (20%) of adverse fetal and/or neonatal events. Previous studies examining pregnant women with other forms of heart disease have also reported high rates of neonatal complications (14,15,17–21). Specifically, in a prospective study from our center of neonatal outcomes in pregnant women with all forms of heart disease, adverse neonatal outcomes occurred in 18% of pregnancies in the heart disease group, compared with 7% of healthy pregnant control subjects (2). Previous work and this study showed that these complications are more common in women with advanced LV dysfunction and poor functional class (3). In addition, we found there to be an important interaction between maternal cardiac and obstetric risk factors and fetal and/or neonatal outcomes (2). Fetal and/or neonatal event occurrences were high in women with moderate or severe LV systolic dysfunction and/or NYHA functional class III or IV if there were concomitant obstetric risk factors. The mechanism for this finding is not known and requires further study. Finally, although many risk factors cannot be modifiable, those that can, such as smoking, could certainly be addressed in an attempt to reduce the risk of fetal complications.
Study limitations
Because all women included in this prospective study were receiving care at a tertiary care cardiac center, a referral bias may exist. Women with less severe heart disease or those doing well during pregnancy may not have been referred to our center. However, a substantial proportion of women had only mild LV dysfunction, suggesting that milder forms of disease were indeed included in the cohort. Because of the small sample size, this study was not powered to identify multiple predictors of outcomes. Larger sample sizes would be needed to identify additional determinants of outcome. Newer echocardiographic measures of ventricular function and mechanics as well as serum markers such as brain natriuretic peptide were not obtained, but may serve as useful prognostic markers in the future. Longer-term follow-up was not the focus of this study, but would be valuable in understanding the long-term effects of pregnancy on the diseased heart.
In pregnant women with DCM, clinical parameters, including NYHA functional class and LV systolic function, can be used to identify women at highest risk for cardiac complications during pregnancy. When compared with nonpregnant women, pregnancy seems to have a negative impact on the clinical course for women with DCM, at least over the short term. Fetal and/or neonatal complications are also increased in mothers with DCM, and the risk is magnified by the presence of both cardiac and obstetric risk factors.
The authors thank Joan Ivanov for statistical assistance.
Supported by operating grants from Canadian Institutes of Health Research(53130 and 93722), Heart and Stroke Foundation of Canada(NA 5662 and 5927), the Ramsay Gunton Professorship in Cardiology from the Schulich School of Medicine and Dentistry (to Dr. Siu), and a generous donation from Mrs. Josephine Rogers. Dr. Grewal is the recipient of the Gordon B. and Shannon D. Allan Fellowship in Adult Congenital Heart Disease, Toronto, Canada.
- Abbreviations and Acronyms
- dilated cardiomyopathy
- left ventricle/ventricular
- left ventricular ejection fraction
- New York Heart Association
- Received May 15, 2009.
- Revision received August 7, 2009.
- Accepted August 10, 2009.
- American College of Cardiology Foundation
- ↵
- Roos-Hesselink J.W.,
- Duvekot J.J.,
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text:
Grady Ballenger
Professor of English
- Ph.D., English (American, modern), University of North Carolina at Chapel Hill
- M.A., English, Columbia University
- A.B., English and creative writing, University of North Carolina at Chapel Hill
Course Sampling
- First Year Writing
- American Indians in Fiction, Film, and Fact
- Reading Narrative
- A Junior Seminar on Literature and Medicine
- "Songs of Myself": An Exploration of American Life Writing in Autobiography, Fiction, and Film
- The Senior Project in English
- The Sophomore Workshop in the University Honors Program
- The Senior Colloquium, a "Best Books Club," in the Honors Program
Areas of Expertise
- American literature
A native of South Carolina, Grady Ballenger was drawn by a love of literature to the English and creative writing programs at University of North Carolina at Chapel Hill for undergraduate study. After a year of service as a VISTA volunteer in Pittsburgh, Pennsylvania, he earned a master's in English at Columbia University, his senior thesis concerning T.S. Eliot and the seventeenth-century. Ballenger returned to the University of North Carolina to teach literature and film and to complete a dissertation on James Thurber and the development of a distinctive style for humor in The New Yorker. Ballenger then worked in Louisiana, where he helped to develop the state's residential honors high school for 11th and 12th graders as well as a public liberals arts honors college, the Louisiana Scholars' College. Ballenger came to Stetson to serve as dean of the College of Arts and Sciences and now has happily returned to teaching literature and film. He currently serves as president of Stetson's chapter of Phi Beta Kappa and also as faculty advisor to the English department's chapter of Sigma Tau Delta, the international honor society in language and literature.
- American literature
- Liberal arts education for the twenty-first century
- Research relevant to courses, especially Native American studies and the intersections between literature and medicine
- "Perspectives on Kate Chopin," an edited collection of essays.
- Entries on Roy Blount and Peter de Vries for the "Encyclopedia of American Humorists."
- Funded grants from the National Endowment for Humanities and major foundations and many reviews and reports on liberal arts curricula

subset: commoncrawl


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The trial date for a Maricopa double-murder case, which has been hanging in limbo for more than three years was set Monday.
The trial for Jose Ignacio Valenzuela, 40, the alleged killer of Michael and Tina Carreccia, is set to begin April 24, 2019.
Prosecutors are seeking the death penalty.
The case, which was initially filed in 2015, has seen numerous delays as a result of changes to both defense and prosecution teams.
Recently, lead defense attorney James Mannato, who had been working the case since its initial filing, decided to retire.
A new defense attorney, Bobbi Faldutto, was brought in to replace Mannato.
Falduto immediately requested more time to get familiar with the case, asking for a trial date no sooner than September 2019.
Special prosecutor Gary Husk, who himself was brought in the fold late, contested the defense's request, calling it "completely unreasonable."
Husk, a prosecutor from Navajo County, was assigned to the case after attorney Kent Volkmer was elected as the Pinal County attorney in 2016 and was forced to recuse himself due to previous ties to the case.
Presiding Judge Kevin White is also set to begin a new judicial assignment toward the end of the year. However, he said, given he had been involved in the case for so long it is likely he will see the case through trial.
At Monday's hearing, Falduto suggested the defense would need six to eight weeks to make arguments. Husk, on the other hand, believes the prosecution can make its case in as few as four weeks.
Valenzuela, who was not present for the hearing, stands accused of shooting and then burying the Carrecias next to his home in Thunderbird Farms the night of June 21, 2015, Father's Day.
A status hearing for the trial was set for Sept. 17 at 1:30 p.m. at the Pinal County Court House in Florence.
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If you are pregnant and are thinking about using
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Health Topics A to Z
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There are two kinds of people. Those who like to plan, and those who prefer to just go with the road and hop on their motorcycle and let their heart lead them. Regardless of which category you fall into, putting a little thought and planning in your next motorcycle trip can make it even more awesome.
Start at the End
Choose your destination and work backwards as you plan your trip. Once you determine where you want to go and outline your route, calculate the length of your ride in miles and approximate hours of travel. Be sure to consider your comfort level when you decide how long of a stretch you plan to ride before you need to stop for a break, or for the day. This will help narrow down the length of your trip for planning.
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- Emergency motorcycle tool kit—Don't forget to give your motorcycle a once over before you go
- Cash—Because some places still don't take plastic
- Rain gear and extra clothes for longer trips—Because Mother Nature can be fickle and change the forecast after you've left home
Embrace Unexpected Opportunities
If you're hardcore about planning your motorcycle trip, search Google for tons of resources and attractions along your route to make your trip as unique as you. If you're a go with the road kind of rider then just hit the road and plan to have an awesome time.


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Like all twenty-year-olds, Ryan Cusack is trying to get his head around who he is.
This is not a good time for his boss to exploit his dual heritage by opening a new black market route from Italy to Ireland. It is certainly not a good time for his adored girlfriend to decide he's irreparably corrupted. And he really wishes he hadn't accidentally caught the eye of an ornery grandmother who fancies herself his saviour.
There may be a way clear of the chaos in the business proposals of music promoter Colm and in the attention of the charming, impulsive Natalie. But now that his boss's ambitions have rattled the city, Ryan is about to find out what he's made of, and it might be that chaos is in his blood.
The second novel from the author of the hugely successful debut The Glorious Heresies . . . McInerney's many fans will be pleased to hear her follow up revolves around the further misadventures of Ryan in Cork city.
- Bookseller
The narration is brisk and slick, the dialogue fizzing with acerbic wisecracking.
- Literary Review
Lisa Mcinerney is a writer busily combining the traditions of hardcore Irish crime writing with the kind of fast-talking foul-mouthed wit and gentle good humour that readers will recall from the work of Roddy Doyle, and producing popular state-of-the-nation novels as a consequence.
- Times Literary Supplement
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05.12.16Cultural Competence Quick Tip
The most diverse group in the United States is our children, and by 2018, the racial/ethnic minority will become the majority. Given that, its imperative that those who teach our children posses and demonstrate a deep understanding of the cultural variables those students and families bring. These cultural variables affect how we communicate, learn, solve problems and experience life.
So how do we help those who interface with children develop the skills to deal with the diversity in our nation? Here are a few quick tips to get the conversation and thought process going:
- Understand and articulate your own identities and beliefs– Be aware of your own beliefs and how they influence your view of other cultures
- Get to know your students families- Go beyond the typical conversation with your students and families. Ask them what they do in their personal time, what books they are reading. Find out what their support networks are as they pursue their education. Ask parents how they want to be involved in providing support to their children? What are they most proud of and what do they fear?
- Gather others and develop a learning community- Get comfortable with being uncomfortable. Share articles and books on cultural competence and develop a support group for engaging in a dialoge in diversity.
- Get to know your students- Get to know your students learning styles, backgrounds, interests, dreams and challenges.
- Embrace diversity in a way that is purposeful. For example, let your celebration of diversity be reflected in your selection of materials, assessments, and communication style.
Have other useful tips? Share them in the comments section!
Carmen Perkins is co-founder, managing partner and contributing author at PROJECT EDQUITY.
Latest Blog
New Restorative Justice Report
PE's own Carmen Perkins recently co-authored a rep
Check Out Carmen's Recent Interview About Re-Envisioning Education
Carmen recently sat down with RE-ENVISIONED, t
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What often sets ap
The past few weeks
Age Matters: Age as workplace asset
Age matters. It ma


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AVAILABLE SEPT- DEC 2019 $2,800. AVAILABLE JAN-APRIL 2020 $4,500/MONTH. Highland Woods is a wonderful "bundled golf" country club community very conveniently located to shopping, restaurants, beach, churches, airport and everything else you will want. Community swimming pools are located to the right and left of the condo. Mirrored dry bar in living room, eat-in dinette, walk-in closets, lovely bay window in master suite overlooking golf course. Wonderful amenities with golf and country club with fine dining (additional association), 4 tennis courts, and 7 swimming pools. Updated clubhouse, pro shop, grill room, exercise room. Fully turnkey furnished condo. TV in both rooms and living room. Master has king bed & guest room has a queen. Kitchen is very well stocked for cooking and entertaining. Get out of the cold and enjoy what SWFL has to offer! Call to book this unit today! Call or email us for seasonal rates. MINIMUM 3 MONTHS for 2019
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I'm no big fan of twelve of anything.
What's the big holdup at two more than ten, in the 12 step program? To recovery, and beyond! If a needful person repeats those four words, 12 times a day, for the rest of his or her life, I'll speculate that an equal number of needfuls get identical results as with a 12 step program. I especially like the "beyond" concept, though – there's no reason to stop at 12… Twenty-five's my lucky number – if I had addiction issues, I'd be looking for 25 steps, or be forced to wash my brain 25 times a day, instead of 12. Equal opportunity numbers. Feeling better already?
How about the 12 stages to getting rich? Listen, the truth is, you need money to make money and if you have money, you don't need any more of it. It would be great if you just let it fly out of your limo window, while heading to wherever you rich folks go to smoke, eat and sleep on your money. The bright side is that if you DO make MORE money with your money, you can get a receipt by giving away some of your money and support 12 worthy causes, thus avoiding the tax implications of HAVING the money which leaves you with still more money! 😀 The days of starting a business with twelve dollars are long gone, unless you rich folk move over for 25 seconds.
Don't forget about those dozen doughnuts, designed to put a dozen pounds on you, in twelve days or less. Keep eating them and you'll be having three quadruple by-pass surgeries in a heartbeat. The sight of these things makes me want to get out my coloring book…
Twelve steps to hiring a mover? When we moved north, we used these. It took us awhile though, well over 12 steps, especially with the horses…
Twelve steps to natural gardening? That's it? I can't figure the magic in the 12 step natural gardening thing – I suppose it's just cutting out the twelve toxic chemicals commonly use on veggies or ornamental plants to control the 12 THOUSAND insects that come around for lunch.
Twelve steps to eating a raw diet? Oh, oh, this spells trouble… If I took even a half-dozen steps to a raw diet, I'd be making twelve steps to the toilet every twelve minutes. I don't think this is a good idea for me.
I've only heard of 12 steps to intimacy. Twelve steps to intimacy? Hmmm… Seems simple enough, maybe it goes like this –
- Eye contact
- Brushing up against my target
- Striking up a conversation
- Having lunch or dinner together, with perfunctory conversation
- Going back to my place for wine and cheese
- Getting loaded
- Losing control of my wits
- Getting into something more comfortable
- Winding and twisting all over each other on the sofa
- Getting out of something more comfortable
- Making a run for the bedroom
- Your turn – you get to imagine the grand finale
Somehow, we just get there, without counting the steps. The voyage up the stairway to heaven – great – the trip down, a little thought-provoking…
I've read that blog posts are a dime a dozen, but a dozen declarations doesn't a diligent doer make. 😀


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Watching the video of Mark Wellman (para) accomplish what few ab people can is inspiring and motivating. (You can do it!)
Some of the things accomplished:
Sea kayaking, Alpine skiing, whitewater kayaking,
Cross country ski (arm power), climbing Yosemite's El Capitan half dome and more.
If interested go to www.AccessTR.com Click on videos (left hand margin)to order.
Onward and upward.


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Available from the internet site, apparently.
is definitely the last set of pics from the show!
Unless we...
here they are, Brant's pictures from the NEC event.
came, we saw, and we went home with the opinion that there's not...
packing our sandwiches, laptops and digicams and getting ready to ship off to Britains
best trade show at the beginning of next week.
The Cycle and...
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Wednesday, March 11, 2015
Harsh? Maybe, but Hand-Holding Doesn't Work
I know the last post is kinda harsh, but you have to understand that if you hold an addict's hand, as soon as you let go they will just fall back down again.
Nothing sticks unless we do it ourselves.
See Hand-Holding.
3 comments:
I for one do not find it harsh at all. You know why? You are right. I've been stuck in this cycle of addiction/relapse for over 8 years now and hand holding DOES NOT WORK! All hand holding does is make me feel better for a bit...until it doesn't any longer. There are no guarantees that us detaching from our loved ones will work but I sure as hell know that enabling doesn't either. It takes a great deal of prayer and commitment to stay detached but with God's help I'm doing it. I know his plan has to be better than what I've tried to do for almost a decade now. I have said it before but I'll say it again, thank you for your honesty. We parents/spouses need it so much. There is a commercial running on TV right now called Sober College. They are telling parents that their addicted children can enter their recovery program and earn college credits while being there. I know that they are probably making a fortune off these poor parents. Anyway Charlie, thanks for the truth because it will set us all free. xo janetReplyDeleteReplies
I changed 'yes' to 'maybe' in the title ;-) Bless you, Janet. xoDelete
- AnonymousMarch 17, 2015 at 3:11 PM
As a recovering alcoholic and addict with a little over 5 1/2 years, I think it is absolutely true that there needs to be some type of buy in from the young person in order for any type of rehab or support to be successful or beneficial. BUT, in my opinion, that buy in can be simply willingness to admit that my life is unmanageable and not going in the right direction. That being said, when I first went to treatment at 17 i basically HAD to go. My parents sent me to the "best program" there was but I didn't learn the tools i needed to stay sober long term with just 28 days and some groups. I knew i had a problem but i couldn't imagine life in college sober.Delete
Two years later, i was guided by professionals at my second (and hopefully last *knock on wood*) treatment center Sober College, which Janet mentioned above, i was taught the tools and skills i needed to get and stay sober.. here i am over 5 1/2 years later. Do i think that is is possible to get sober at 20 without a treatment center? OF COURSE I do. Do I think that enabling is beneficial to the addict or the parent? No. But i do believe, that giving over the reigns to professionals who can treat the disease of addiction, whether that be a treatment center, detox, therapist, life coach, whatever, can be beneficial also... Maybe not necessary, but for me, it made being sober at such a young age that much easier.
My mother let me know before sending me to Sober College that this was it, this was my last shot and that she would not be willing or able to support me getting help anymore. I had to do more research out there after my first treatment center at 17 but luckily i made it back and with the support of my mother, my treatment staff and the 12-steps i was able to learn the tools i needed to live life sober.
I don't know if i would have gotten sober without the help of my mom or treatment. I do know that they gave me the stepping stones i needed to walk on this new sober path and i am eternally grateful for it.
I think that changing the title to "maybe" was perfect because I do not think there is one right way to get sober. HOWEVER, i do agree that you cannot drag someone along the path to a sober life, they need to crawl, then walk then hopefully trudge along it on their own.
Anybody Can Take Steps - Chapter Three
* STEP 3 Made a decision to turn our will and our lives over to the care of God as we understood Him. Soun...
Sadly, people who find this blog often type in the search phrase, ' why do alcoholics hurt us? ', which results in an olde...
"Frothy emotional appeal seldom suffices." Translation: People can't keep us sober or fix us. That is, no...
So everybody's wrong, right? Uh, no, I don't think so. Regardless of what changes may occur to the brain from abusi...


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Frisco town council to talk development propsals, e-bikes at regular meeting
The Frisco Town Council will hold a regular meeting on Tuesday at 7 p.m. at town hall during which they will discuss clearing zoning hurdles for a seven-unit residential development at 90 S. Madison Ave. and a proposed four-unit project at 112 N. Fifth Ave.
The Madison Avenue project needs council to eliminate a condition of its permit that required it to include commercial space — a holdover from when the property was on unincorporated county land.
The Fifth Avenue proposal is requesting an historical overlay zoning designation, which would provide development incentives in exchange for the preservation of historic cabins located on the site. The Planning Commission has unanimously recommended that council grant the zoning overlay.
The council's work session will begin prior to the regular meeting at 4:30 p.m. with a discussion about recent state legislation modifying the definition of electronic bike (e-bikes). The new law prompted the county government to change its restrictions on e-bikes.
Next, at 5 p.m., the council will hear a progress report on a proposed child victim services center that local advocates and law enforcement hope to establish. The nearest such facility, which provides a nurturing environment for child victims of assault and abuse, is currently in Glenwood Springs.
The full council packet can be found here.
Start a dialogue, stay on topic and be civil.
If you don't follow the rules, your comment may be deleted.


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I am Vicki and I am the designer at Dea Kudibal. This Friday it is my turn to introduce my Friday favourite from the AW16 collection.
I am always on the run and when I don't have time to put together an outfit I find my self turning to our Daisy blazer. It is so easy to put over a simple t-shirt with jeans or leather pants and off you go. It is a classic blazer but the print gives the outfit that something extra so that my "easy" styling looks anything but boring.
Xoxo Vicki


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Hey all, I'm crowdsourcing a lesson for tomorrow from you guys. I want to put together a big list of things that are annoying to see in written text so I can give it to my students as a big "Hey, watch what yer doin' here" sign.
So the alot is an obvious inclusion. As is the fact that the word definitely has no a. Definitely is definitely not definately, and super definitely not defiantly - that's a completely different word.
Choose is present tense, chose is past tense.
Lose is a verb with the past tense of lost. Loose is often an adjective meaning not tight, and can be a verb (with the past tense of loosed) meaning to unleash or let go.
Lead is a metal. It rhymes with led, which is the past tense of the verb to lead (rhymes with feed).
Give me all the annoying things you've got - I'll be making a big lesson out of this tomorrow, so I need ammo.


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A Stone Mountain, Ga., health services facility is planning to launch a first-of-its-kind dementia care initiative in the U.S., according to an article on the DeKalb Neighbor website.
The facility is Georgia's first-ever, built-to-suit household model.
Isakson Living will open the Park Springs Health Services, located adjacent to its resort-style continuing care retirement community Park Springs.
The Butterfly Household Model of Care emphasizes emotion-based care and the importance of a nurturing and supportive staff
See the latest posts on our homepage


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EUR-JPY, in general, has entered a mature trend area, even for certain times it is already in an overbought condition. The short-term trend is bullish. It can be said that the conditions for holding back buy must be taken seriously.
But don't rush to sell. See also analysis for longer-term trends. For your information, the medium-term trend is neutral, according to our internal technical team. Even though it seems that the stochastic is over-bought, the MACI is over-bought, please remember that the area above level 80 means a strong bullish trend as well.
We see that consolidation conditions are taking place. This means that there may be a correction, but we see that the corrections that occur are limited. Short-term players may be interested in releasing some of their positions as profit-taking actions. You can also buy short to quote a few pips, but we tend to think that the trend will still rise again.
The conclusion we can take, we will still hold long positions for a few moments and see if there will be another resistance break-out. Since the breakout of 122.75, the EUR-JPY currency pair was evolving in a relatively neutral short-term trend, but the recent rise in the Euro currency pairs has allowed the currency pair to reach the target of the medium-term trend that has become bullish recently. In the case of a break-up, the trend and turnaround could be confirmed.
Our suggestion is to watch if the RSI line can break 70 level line trough from above. If it doesn't so, then buying stance is confirmed. Remember as well that Stoch-osc sometimes stays above 80 level for several days meaning that strong bullish condition is taking place.
Resistance: 127.54
Next resistance: 136.00


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What does the Christian life look like? Jesus continues preaching His Sermon on the Plain and provides a nice list but it is not a list we would make up. It starts with Love your enemies. Who would do that? Jesus, of course. Jesus takes love to a whole new level.
This week's readings:
Genesis 45:3-15
1 Corinthians 15:21-26, 30-42
Luke 6:27-38


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What type of quadrilateral has two parallel sides?
When I asked this question at the beginning of class I got a ton of different answers. Some students said a rhombus, others said a parallelogram, and some even said a trapezoid. We have to be very descriptive when talking about geometric figures. If we add the word only so that the question reads: What type of quadrilateral has only two parallel sides? Then we only have one answer, a trapezoid.
Check out the classwork below and the re-posted quadrilateral properties sheet for studying and practice:


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Converged Wi-Fi and VoIP phones are still a drop in the handset ocean this year — but don't rule them out as the next big thing yet, a new report has suggested.
Revenue from Wi-Fi/VoIP handsets totalled $54.7m (£31.1m) last year with 130,000 units sold, according to Infonetics Research.
Vertical markets are a particular hot spot for Wi-Fi/VoIP handsets, with logistics and healthcare likely to drive growth in the future as the spread of enterprise WLANs continues.
The consumer market may also help fuel uptake, as service providers start to bundle Wi-Fi routers and VoIP offerings along with traditional broadband packages. Infonetics' biannual report predicts strong growth for Wi-Fi/VoIP handsets until at least 2009.
Converged handsets remain small fry, netting just $6.7m in revenue in 2004. The future, however, looks bright for such devices. Infonetics predicts that in a few years' time, VoWLAN functionality will become as standard in mobiles as Wi-Fi capability is in laptops today.


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Find a Balanced Athlete Fitness Studio near you.
To be at our optimum, balance is key. Balance between flexibility and strength and a careful attention to the way we stand, sit, and walk are critical. By synchronizing your mind and your body, your awareness will expand and you will become more balanced.
Balanced Athlete is a company that is creating a movement toward a new paradigm of movement and exercise. Founded on the belief that our bodies are built to align with gravity, move fluidly, and age gracefully we have created a series of movement programs. These programs will help you understand how your body and mind work - and how to get the most out of your life.
Movement Principles. Evolved.
Seek a new outlook on exercise by developing a movement practice. Gain an intelligent understanding of how your body is designed to work. Focus on a technique that functionally improves strength, flexibility, and reduces injury. This is a program that builds you up instead of breaking you down.
Strength. Through Mindfulness.
Integrate mindfulness into your training. Where your attention goes energy flows. Mental focus combined with movement principles and techniques will create a more integrated mind and body. When you experience this state and train in this mindset, you begin developing the sixth sense.
Lifelong Wellness. Achieved.
Realize that maintaining balance is a moving target. We wax and wane with our balance. As we live our lives, challenge our limits, seek improved performance, and along the way, age; maintaining balance becomes a lifetime pursuit. Daily awareness of the preciousness of life becomes essential.
Johnny Gillespie's mission is to make us aware of our innate Movement Operating System. Practiced correctly, it can heal injuries and prevents us from becoming The Tin Man as we age.
In 1995,Gillespie began his career which has included the professions of personal training, strength and conditioning, yoga, and mindfulness based meditation. The movement operating system he calls Balanced Athlete® is the culmination of all his experience within these four industries. With humor and ease, he simplifies complex information into relatable terms and practices to empower a diverse population toward increased vibrancy and well-being.
Gillespie, earned a B.S. in Sports Management from West Virginia University in 1995. He is a Certified Strength and Conditioning Specialist (CSCS) and Personal Trainer (NSCA-CPT) with the National Strength and Conditioning Association (NSCA). Since 2005, he has presented annually at NSCA National Conferences under the Balanced Athlete vision. He has authored several training manuals which he uses as a continuing education provider for the American Council on Exercise (ACE), National Academy of Sports Medicine (NASM), the American Fitness and Aerobics Association (AFAA), and Yoga Alliance.
Johnny founded Empowered Yoga® in 2002, a practical approach to the healing art of yoga. It combines modern day exercise science and mindfulness based principles. Empowered Yoga operates three studio locations. Gillespie is a certified 500-Hour Experienced Registered Yoga Teacher (e-RYT 500) with Yoga Alliance. Since 2005 Empowered Yoga has served as a Teacher Training School certifying people to teach their approach to yoga. Johnny is trained as a mindfulness based meditation teacher by David Nichtern, a senior teacher in the lineage of renowned Tibetan Buddhist meditation master, Chogyam Trungpa Rinpoche. Since 2005, Johnny has maintained an authentic student-teacher relationship with David.
Find a Balanced Athlete Fitness Studio near you.


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All Eyez on Me, the biopic about the life and untimely death of Tupac Shakur, was finally finished last year and will release this June. However, it's not just any release date, as Variety is reporting that the film will hit theaters on June 16, 2017, which would have been the slain rapper's 46th birthday.
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BUZZARDS BAY, Mass – Friday night, the 2-3 Buccaneers hosted the winless Bay Path Wildcats at a windy Clean Harbors Stadium. At the end of the 60 minutes, the Bucs had improved to 3-3 on the season and earned the first shutout win in program history, 20-0.
The Buccaneers were led offensively by freshman attacker Alyssa Blumenthal (Braintree, Mass) and junior Cammi Balentine (Haverhill, Mass) who each scored five times in the game. Balentine also had two assists on the night. Freshman Nora Mclaughlin (Quincy, Mass) scored three times and assisted on another goal for the Bucs. Sophomores Hannah Mannai (Keene, N.H.) and Jennifer Leung (Quincy, Mass) each scored their first goals of the season. Sophomore Casey Sullivan (Sagamore Beach, Mass) scored twice in the game and assisted on four goals. The two goals put Sullivan at 65 career goals, third all-time in Buccaneer women's lacrosse program history. Sullivan also caused six turnovers in the contest which is tied for most in a game in program history, tying Stephanie Hunt who did it last season against Worcester State. Attacker Anna Deely (Marstons Mills, Mass) scored once and had two assists while also causing five turnovers for the second time, in consecutive games, this season. The teams 20 goals and 10 assists, is the most points by the Bucs in a game (30) since they had 29 against Bay Path last season. Defensively, as a team, the Bucs caused 21 turnovers, another program record as the previous record was 20, set last season against Fitchburg State. In goal, freshman goalie Laure Kleber (Westport, Mass) faced no shots in the 60 minutes of play.
Bay Path was stifled by the Buccaneer defense, unable to get off a single shot in the contest. The turned the ball over 38 total times in the game, though they did cause four turnovers of the Buccaneers 27 on the night. Goalie Caitlin Esposito (East Haven, Conn), normally an attacker, made eight saves in the game.
Blumenthal opened the scoring for Maritime a minute and a half in to the game. By the time 10 minutes had expired in the first half, the Bucs had scored eight times. One of which was a man-up goal after a yellow card was assessed to the Wildcats and Balentine took advantage to score her first of the night. At the halfway point of the first half the Buccaneers opened their lead to 11. With the clock running now, up 10 or more goals, the hosts scored three more times and went to the halftime locker room up, 14-0.
In the second half, Maritime scored six more times in the first 15 minutes of the half to take the eventual final score lead of 20-0. In that time, Leung and Mannai each scored their first goals of the season.
The Buccaneers are back in action on Monday evening when they travel to Anna Maria College to take on the AMCATS at 7pm.


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The basement in your home may be a great space, but if there is water seeping in through the walls, you need to seal it before you can use it. Converting a basement to usable space is common and a great way to expand the square footage of your home, but if you do not deal with the moisture first, you run the risk of creating a breeding ground for mold, losing furnishings to damage, and ending up with a space that you spent a lot of money on but can never really use.
Determining Where The Water Is Coming From
Before you can seal that water out, you have to determine where it is coming from. It is possible the something simple is causing the water to run into the home like a gutter down spout that is not working or some water that is being left on near the walls outside. Take the time to look at where the water is coming from so you can attack that area directly. If you do not have any gutters on your home, that can be enough to let water accumulate around the basement walls when it rains.
Sealing The Water Out From The Inside
Once you have determined where the water is coming in, you can work on sealing it out. Painting the walls inside your basement with a high-quality waterproofing paint is a good start. You will need to paint all the walls, not just the spot that is seeping water or the water will just work around it. Remember, water will follow the path of least resistance so if there is another way in, it will find it over time. If you do not address what is causing the water to come in, waterproofing may stop it, but you may still be getting damage outside so that is something to consider.
Waterproofing From The Outside
Waterproofing from the outside of the basement is a better solution, but it will be a lot more labor-intensive and time-consuming. In order to waterproof the walls from the outside, you will need to remove the dirt from the basement walls and foundation. Once you have exposed the walls, they can be painted with a high-quality waterproofing on the outside. This not only stops the water from coming in, but also it doesn't allow the damage to the concrete that could be happening if you waterproof inside only. Once the waterproofing is dry, you can fill in around the walls again. In most cases, this will be enough to solve the problem. If it doesn't, you may need to consider adding drainage around the foundation to move the water away from the home completely.
For more information on basement waterproofing, contact a local professional.Share
11 April 2017
Concrete doesn't have to be boring. In fact it can be absolutely beautiful. My name is Andrea Reese, and I am an artist as well as an avid gardener. I enjoy sculpting and decided to try to combine my two passions to create an incredible backyard oasis. The results are incredible. In this blog, I'll show you how I learned to make small sculptures and etchings in walkways to turn what used to be ordinary concrete into something amazing that adds tremendous artistic flair to the beauty of my garden. You can make visitors to your backyard think they've stepped into a fairy land. I can show you how.


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BOSTON (MarketWatch) -- Charles Schwab Corp. said Schwab Funds are now being made broadly available through other brokers and clearing houses outside of Schwab due to growing demand from both individuals and investment advisers. Investors can now purchase Schwab Funds and Laudus MarketMasters Funds through platforms at Ameritrade, Fidelity, TD Waterhouse and Union Bank of California, Schwab said late Wednesday. Other companies, such as Pershing and Fiserv Trust, are in the process of being added. In most cases, the investor share class of the funds will be offered on the fund companies' no-transaction-fee platforms, Schwab said. Shares of Charles Schwab SC.H, +50.00% fell 36 cents to $13.04 Wednesday.
Schwab Funds launched onto third-party fund platforms
Quote References
+0.01 +50.00%


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author = "Tiwari, Amy and Russpatrick, Scott and Hoehne, Alexandra and Matimelo, Selma M. and Mazimba, Sharon and Nkhata, Ilenga and Osbert, Nicolas and Soloka, Geoffrey and Winters, Anna and Winters, Benjamin and Larsen, David A.",
title = "Assessing the Impact of Leveraging Traditional Leadership on Access to Sanitation in Rural Zambia",
journal= "The American Journal of Tropical Medicine and Hygiene",
year = "2017",
volume = "97",
number = "5",
pages = "1355-1361",
doi = "https://doi.org/10.4269/ajtmh.16-0612",
url = "http://www.ajtmh.org/content/journals/10.4269/ajtmh.16-0612",
publisher = "The American Society of Tropical Medicine and Hygiene",
issn = "0002-9637",
type = "Journal Article",
abstract = "Abstract.
Open defecation is practiced by more than one billion people throughout the world and leads to significant public health issues including infectious disease transmission and stunted growth in children. Zambia implemented community-led total sanitation (CLTS) as an intervention to eliminate open defecation in rural areas. To support CLTS and the attainment of open defecation free communities, chiefs were considered key agents of change and were empowered to drive CLTS and improve sanitation for their chiefdom. Chiefs were provided with data on access to sanitation in the chiefdom during chiefdom orientations prior to the initiation of CLTS within each community and encouraged to make goals of universal sanitation access within the community. Using a survival regression, we found that where chiefs were orientated and mobilized in CLTS, the probability that a village would achieve 100% coverage of adequate sanitation increased by 23% (hazard ratio = 1.263, 95% confidence interval = 1.080–1.478, P = 0.003). Using an interrupted time series, we found a 30% increase in the number of individuals with access to adequate sanitation following chiefdom orientations (95% confidence interval = 28.8–32.0%). The mobilization and support of chiefs greatly improved the uptake of CLTS, and empowering them with increased CLTS knowledge and authority of the program in their chiefdom allowed chiefs to closely monitor village sanitation progress and follow-up with their headmen/headwomen. These key agents of change are important facilitators of public health goals such as the elimination of open defecation in Zambia by 2020.",


text:
Height: 24cm, Diameter: 14cm
Made of poly resin. Solar powered with internal LED lights. A solar panel is on the back of the roof.
The front door does not open. Suitable for indoor and sheltered outdoor fairy gardens.
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During a divorce or after parents have decided to separate a child's life may be thrown into chaos as custody is determined. Since Spokane children may not live on their own until they reach the age of 18, they generally will be placed under the care of one or both of their parents, when their household dissolves from one to two.
Domestic violence may affect child custody outcomes
Is joint custody best for your child?
It can be difficult to go through the divorce process at any time in your life. This is even more so the case if you have a child with your soon to be ex-spouse. In addition to details associated with your divorce, such as matters of property division, you also need to focus on those involving your child.
Credit card debt and divorce: Know the finer details
Are you going through the divorce process? Are you concerned about the impact this will have on your finances?
Fighting for a father's rights during the divorce process
As many readers of this Spokane divorce and family law blog know, ending a marriage can be a difficult process. Even when the couple does not share children there can be strong disagreements and arguments that arise in the legal process to dissolve a marriage. When kids are part of a divorce, those fights can become downright mean.


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- Neighborhood: Gibson
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Listing Agent: Leah Olivotti
Updated: 8th December, 2019 5:22 AM.
1200 Brick Church Pike Nashville, TN
Real Estate | Homes in Tennessee Powered by Placester


text:
It's safe to say that Demari Grant has been a perfect piece to Oswego East's puzzle.
After his mom changed jobs, the 6-foot senior transferred last summer from Bolingbrook, where he had started for a team that reached a sectional final.
Oswego East returned a solid core of three starters featuring shooting guard RayJ Dennis along with forwards Kamron Battle and Sam Schultz.
Grant has fit right in at point guard for the Wolves (13-2), feeding the team's scorers and averaging 4.4 assists.
Dennis, the Boise State recruit, leads the team in scoring with a 22.8 average. Battle and Schultz average 11.9 and 11.6 points, respectively. Grant averages 10 points, 2.6 rebounds and 2.3 steals.
"I was familiar with some of the guys, so it wasn't too big of an adjustment," Grant said. "It's been fun."
Grant and Dennis have played travel ball together since grade school, and Battle was on the same team in fifth and sixth grade.
"Everyone else was new to me, but we're getting out, getting wins," Grant said.
Oswego East added another win Tuesday at home with a 82-73 victory over Metea Valley.
Despite giving up 35 points to senior guard Ethan Helwig, the Wolves led by as many as 21 points in the first half. That got whittled down to seven, but they never lost the lead.
"We really stress coming out strong in the third quarter, but we definitely didn't do it," Grant said. "They got some momentum. Helwig is a good shooter. We were lazy on our switches, though, sagging off to the 3-point line when we needed to get out on him with a hand up.
"A good shooter like that can shoot it from deeper."
Oswego East hosts Southwest Prairie co-leader Romeoville at 6:30 p.m. Friday, and Wolves coach Ryan Velasquez said his team needs to get better at stringing together defensive stops.
He's not worried about his offense with Grant at the point.
"He's good with the ball and brings an energy we need," Velaszuez said. "We love it when he's driving the ball and getting into the paint. If he doesn't get a shot, they collapse on him, leaving somebody open."
A pile of wins: West Aurora is among a select few boys programs being honored this season by the Illinois Basketball Coaches Association for surpassing the 1,500-win milestone.
The Blackhawks are 1,607-969 dating to the program's start in the 1910-11 school year.
On hand Friday for the plaque presentation before the home varsity game against Glenbard South will be coach Gordie Kerkman (1976-2015), the program's career win leader, and members of the family of late coach John McDougal (1965-76), who's second on the list.
Kerkman, the fifth-winningest coach in Illinois history, had 806 wins and McDougal had 209.
"It's pretty cool and should be a fun night," West Aurora coach Brian Johnson said.
The game features the top two teams in the Upstate Eight with the Blackhawks (15-3, 8-0) and Raiders (11-6, 6-1).
It will also mark the second annual Rowdies Reunion for alumni of the school's vocal student section.
Neal Ormond, who played for West in 1958 and 1959 and is in his 55th season broadcasting, will be on the air. He has been behind the microphone for 1,090 of those wins.
Topping the list: With 35 points in the loss to Oswego East, the sharpshooting Ethan Helwig became the first player in program history at Metea to reach 1,000 for his career.
Helwig, a strong 3-point shooter who also attacks the basket, is a three-year varsity starter. He has 1,018 points heading into Friday's home game against Waubonsie Valley.
"He's a competitor and a special talent who has gotten this good by working at his game every year," Metea coach Matt Walpole said.


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Frack the San Andreas
With the continuing slump in oil prices, a lot of drilling and fracking equipment is idle. What better use to put it to than triggering earthquakes?
There have been reports of this happening: in Oklahoma, some fracking operations were discontinued after they seemed to be triggering earthquakes. And it stands to reason that they could: injecting liquid directly into a seismic fault lubricates it, encouraging the fault to slip.
Avoiding this seems to usually be easy enough: there aren't all that many major seismic faults in the world, and most oil and gas deposits that people want to frack aren't next to one. The wells that seemed to be causing the trouble in Oklahoma were wastewater disposal wells; for that, injecting into a fault probably makes things easier since the water doesn't have to crack rock to make its own paths away from the injection point; cracks already exist.
But though earthquakes are normally something to avoid, they also could be provoked on purpose. The way earthquakes work is that motion along a fault is interrupted by the rocks sticking. The stress builds up until the sticking points give way, which happens suddenly and with little or no warning, yielding an earthquake. In areas where the sticking is weak, earthquakes happen more often but are smaller. Lubricating the fault would push things in this direction: instead of decades of quiet followed by "The Big One", there'd be a lot of little ones, which in sum total would not be nearly as damaging. At least that'd be the long-term goal.
In the short term there is of course a hitch with this: if it's about time for the Big One, lubricating the fault for the first time will bring it on. This is not necessarily as bad as it sounds, because with deliberate lubrication the timing would be predictable. Injection wells would be drilled; injection pumps would be prepositioned at them; and at an appointed time the pumps would all be turned on. The public would have been warned ahead of time to bolt things down and to evacuate the area. If after a week or so of injection no earthquake resulted, the pumps would be stopped and people could return and relax. Or if The Big One happened they could return and rebuild. Either way they would know (at least this would be the hope) that they were no longer living on top of a hair trigger: if the fracking didn't provoke it, it probably wouldn't go off any time soon. After a couple of years, the exercise could be repeated; if it had not provoked anything, one might try increasing the amount of fluid injected.
Of course there are lots of things that could go wrong with this; the only real way to know whether it'd work would be to try it. And while the San Andreas Fault, the best known fault in the United States, would likely be the most valuable target, it'd be prudent to first try it on a fault that wasn't valuable, so as to establish parameters like how many injection wells were necessary without having to issue too many evacuation warnings to too many people.
And of course this is not just the sort of thing people call "politically impossible"; it's way beyond that. Even Mr. "Make America Great Again" would be most unlikely to advocate for it; it's not his sort of big construction project. In today's political environment, many things that work well and reliably are under attack, and this actually would be adventurous.


text:
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Production of high pure aluminum is one of Slavich Company activities.
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The Bank of Ghana on Friday November 29, 2019, introduced two new high denominations. They are the GH¢ 100 and GH¢ 200 Banknotes. The Central Bank also introduced a new GH¢ 2 coin. Why The New Notes? According to the Central Bank, high levels of inflation currency depreciation in the past have eroded some of the gains from redenomination. It ...Read More »
Public Announcement : Dr. Yaw Tsikate
Dear Family, Friends and Loved Ones, It it with deep sorrow and sadness that on behalf of Madam Faustina Ahiatroga (aka Fuastie) and the entire bereaved families (home and abroad), that we officially announce the sudden death of our beloved Dr. Prosper Yao Tsikata (aka PYT and popularly known in Anloga as "Zagabuta The Mortexorme") on Sunday March 17, 2018. ...Read More »
Annual Okuapemwn Fekuo New Year Party.
Chicago Illinois, January 1 2018 : The annual Okuapeman Fekuo New Year party came off today at 1060 East 41st street. , Chicago Illinois. One can eat and drink all he or she wants since there were diverse alcoholic beverages and food. The lenses of www.sankofaonline.com were there to ring these images to you.Read More »
Abena Asantewaa Agyeman-Bugyei celebrate 44 in style!
Chicago Illinois, January 1 2018: If you are from Obama Town and your age is 44, then you know you and USA President number 44 have got something in common! Seriously, if the day falls on January 1st, you know your friends and family will storm your house for your birthday party, ready or not! Well,Abena Agyeman-Bugyei 44 today ,falls ...Read More »
2017 Asanteman Association of Chicago & the Midwest Fundraising Dinner Dance!…A
Matteson IL September 23 2017: The Asanteman Association of Chicago and the Midwest organized a successful fundraising dinner dance at the luxurious Holiday Inn Banquet Hall, 500 Holiday Plaza Dr. Matteson IL 60443.The event is to raise funds towards the rehabilitation of the Okomfo Anokye Teaching Hospital's Maternity Ward A2! Attendance was estimated to be over ,400 majority dressed ...Read More »
A memorable 50th birthday bash in Chicago…A
August 26 2017 Chicago Illinois: The spotlight was beamed on one of Chicago's own beautiful daughters, Ms. Juliana Owoo-Battlet, at the South Central Community Cultural Center on 83rd and Ellis Avenue. The event was one of the most elegant and well attended 50th birthday celebrations in Chicago recently with over 300 attendees. The hall was transformed into a luxurious banquet ...Read More »
House passes bill for $1.6B down payment on U.S.-Mexico wall
Source:Fox32 News Facebook page. Visit foxnews.com for more updates.Read More »
Ghanaians in Chicago Ready To Set "Obama City Ablaze" On Saturday July 29 2017!
Source: sankofaonline.com Chicago, Illinois, July 25 2017: The Ghana National Council of Metropolitan Chicago, GNC, has informed all Ghanaian media that the most astounding African cultural festival in the Diaspora, Chicago's Ghanafest, is slated on July 29 2017 at the historic Washington Park from 10 A.M to 9 P.M. The original Ghanafest, Chicago, is upon us once again and this ...Read More »


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Before I left France, I mailed a box home to my family. Inside this box were a number of things: letters from friends, postcards and coins I'd collected during my travels, a Ramos kit I wanted my brothers to have, a carry on bag I was returning to my family because I'm thoughtful like that, that map of France I'd pinned places on and, finally, a scrapbook that I'd made of all the places I'd gone and things I'd done since I'd left Canada. I waited. And waited. AND WAITED. for them to get this box because I just wanted all the praise of a job well done. Unfortunately…. Continue reading
Tag Archives: family
Au Pair Lessons: Be the Good, Better, Best Organized
I pride myself on being a pretty organized person. Depending on how I'm feeling, I even throw in some colour coding for good measure. However, over the last six months, I have stepped it up a notch. Or five.
TV Therapy
I feel like I talk about the weather more than the farmers I used to serve coffee to at 8 a.m. on Saturday mornings. Which is saying something because a.) they're old men and b.) they're farmers, which means that their topics of conversation are basically reserved to talking about the weather or the crops or how the weather affects the crops. Continue reading
re: That Homesickness Issue
I've talked about homesickness a few times. It's not my favourite feeling in the world. It's up there with having to deal with needles or catching your hand in the door or that time you fell off the tire swing at school and was literally green with feeling sick. Except worse. Continue reading
Hello March
Can we talk about how excited I am that it's March? Because I'm really excited that it's March. Normally I don't mind February. I mean, it's my birthday month. Plus there's always a school holiday. And it's the only month with 28 days. Really: there's really nothing to NOT like about February.
Except this year. This year between issues with the train during my trip to Lyon, difficult e-mails, tearing off the back half of a car topper and then a random speeding ticket (90€ for three kms over the limit!), all topped off with a complete emotional melt down after a long day hiking, I was more than happy when I got to flip my calendar.
Part of it was just plain ol' bad luck (like sliding on ice and scraping my knee badly) and part of it was stress getting to me (forgetting the car topper). I've always been someone who tries to do it all. I've gotten quite good at juggling and balancing and making sure to remember things. Then, other times: I don't.
For some reason, I've never been good at, or liked, asking for help. I just don't. More because I've felt that I should be able to do everything, even though I know, better than anyone, that I can't.
So the last five days, as we've had grandparents visiting, have been wonderful. Because grandparents, especially grandmas, don't wait to be asked. They just do it. They help you out and lighten your load and tell you that you're doing a good job and hold you while you sob in the driver's seat while there are cars honking behind you and three children in the backseat asking you why you're crying.
I think grandparents, more than parents, oddly enough, remember what this age was like. They can look at it from a different angle and sympathize more. They also really know what to say.
We were watching Mary Poppins and everyone was joking about how I'll now have to learn how to snap my fingers to help all the toys march back to their places during clean up. And Bonne Maman (as she's called) said, "She doesn't need to learn. She already has the magic touch. With both the children and the cleaning."
Which was exactly what I needed to hear.
Things I'm Loving:
+ This interview/those photographs – (Because you're never too young to do amazing things.)
+ These travel tips – (I'm thinking about this summer. I miss the warmth. I miss shorts. I'm constantly wearing sunglasses, so there is that.)
+ These tips – (Because I'm always up for a refresher course.)
+ This video – (Was exactly what I needed.)


text: Kareem Abdul-Jabbar: Sports Taught America That 'Bigotry Is Not a Cool Thing' – Dave Zirin / The Nation Subscribe to Blog via Email Enter your email address to subscribe to this blog and receive notifications of new posts by email. Email Address Subscribe February 1, 2016 The sports legend sits down with the Nation's Dave Zirin. Watch the video, and listen to the conversation. Share this:LinkedInEmailFacebookPrintTwitter


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Work Station Layout and Injuries
This content was COPIED from BrainMass.com - View the original, and get the already-completed solution here!
You are the safety professional at a pipeline transmission facility. You have one operator in the control room on each of three eight-hour shifts. You have received complaints from one of the operators (a 5-foot tall, small-boned woman) who has stated she is experiencing back pain, leg pain, neck pain, and arm and hand pain due to the layout of the work station.
Explain how you will resolve her physical issues with this work station. Remember to address the biomechanical, physiological, and anthropometric aspects of this problem.© BrainMass Inc. brainmass.com October 10, 2019, 5:30 am ad1c9bdddf
Solution Preview
The symptoms exhibited by the worker can help to determine the type of issues that are causing the workstation problems for the woman. She is experiencing multiple symptoms, which is common in ergonomics. Several solutions will be suggested for the woman's multiple symptoms in this brief summary about how best address the biomechanical, physiological, and anthropometric aspects of this problem.
The back pain being experienced by the woman can emanate from non-adjustable lumbar support, no lumbar support, the chair being too high with her feet dangling as they pull away from lumbar support, and the chair ...
Solution Summary
The expert examines work station layout and injuries. Pipeline transmission facilities are examined.


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New partnership between AMD and the blockchain gaming platform Ultra
Blockchain and traceability: the implementation of new technologies in traditional sectors
Bitfinex: the privacy-safe solution of Chainalysis for anti-money laundering
Travala: the migration to Binance Chain has begun
How to buy Ethereum with the Revolut card
Revolut launches a fundraiser for Save the Children
Report Fintech100: Asia dominates the sector
Google to introduce bank accounts
Electroneum: "a crypto smartphone available on Amazon for £59"
Georgy Sokolov, Wirex: "working with regulators will achieve mass adoption"
Altcoin Season coming up: the prediction in disagreement with McAfee
Interview Revolut: "Cryptocurrencies are like the Internet in the 90s"
Le Fonti International: an episode dedicated to music on the blockchain
Le Fonti International: an episode dedicated to DeFi
Xriba, bookkeeping on the blockchain
Gip Cutrino, "Here's how blockchain changes gaming"
Switzerland publishes a manual on the regulation of tokens
Finma: "the blockchain poses new risks"
China: the central bank still against cryptocurrency trading
Thailand: the SEC more flexible with regard to digital assets in 2020
Ethereum 2.0 launched! But it is a scam
TezBox: the Tezos wallet under attack
Cybersecurity Report: Increasing number of online attacks
Enterprise Ethereum Alliance: a report on blockchain and telecommunications
The BitTorrent Speed program is now available
The Lightning Network based protocol for mobile phones
Radix: 10-year Bitcoin transactions replicated in 1 hour
Holland: banking giant ING is working on crypto custody services
Jared Tate, DigiByte: "The biggest scam in history is TRON"
A token sale to buy a football team
Ledger Nano arrives on ShapeShift
Stellar & Keybase: when an airdrop fails
6 candles for the anniversary of Dogecoin
Litecoin: a trust fund for Confidential Transactions
TRON wants to give away the new Tesla Cybertruck
New records for Bitcoin (BTC) addresses
Bakkt: new Bitcoin futures contracts launched
LocalBitcoins: new volume records in Venezuela and Argentina
Inside Bitcoin: Segregated Witness (SegWit). Part 8B
Ethereum: the Istanbul fork has been successfully executed
Binance announces support for the Ethereum Istanbul upgrade
China's Great Firewall blocks one of the most popular Ethereum blockchain websites
Canaan: IPO of the bitcoin mining company collects 90 million
The date of the Canaan IPO has been confirmed
Bitcoin Cash: 21 blocks mined in 1 hour. What's going on?
Bitcoin.com launches the HashRace promotion
Almost 1 billion USDT on TRON
Maker DAO might be vulnerable
Hybrid Euro (HEUR) arrives on Zilliqa
Coinbase Card adds support to DAI
New updates from MakerDAO as DAI overtakes SAI
DeFi news: new record for USDC loans
pToken: new logo and website announced
What is DeFi? And why is it having so much success?
Tezos: the price and the market cap on the rise
The weakness of the crypto market continues
Matic Network: crypto trading news
Ethereum: the price does not benefit from the fork
XRP: increases the price of Ripple
A meetup dedicated to DeFi in Lugano
Blockchain Week Rome 2020 coming soon
Blockchain Ladies: an event for the second birthday
Traders Fair&Gala Night will take place on November 9th
Blockchain Life 2019: a success event held in Moscow
The ranking of crypto exchanges by the amount of bitcoin
A short guide to the Eidoo wallet and exchange
Inside Bitcoin: transactions and scripts. Part 8
Monolith, the decentralised bank on Ethereum
dApps: the 5 most popular blockchain games
CryptoZombies: the game that teaches how to program dApps
Ethereum: what are blockchain-based smart contracts?
Kraken: futures trading on the mobile app
ShapeShift eliminates fees through its token
The Binance crypto exchange is coming to Australia
Changelly: a guide on how it works
Telegram chats dedicated to DeFi around the world
Electrum Cash: the wallet for Bitcoin Cash and SLP tokens
Sense.chat app: Everipedia, Karma and Lumeos open new channels
Review: BitBox02 hardware wallet from Shift Crypto Security
Guide to the main Lightning Network bitcoin wallets for mobile
User's guide to the IOTA Trinity Mobile Wallet
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