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Gregory Barker: To ask the Secretary of State for the Home Department whether the Metropolitan Polices Wildlife Crime Unit will close in 2007-08. [110869]
Mr. McNulty: This is a matter for the Commissioner of Police of the Metropolis.
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- Safe & Confidential - Call 24/7
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There are 6 Drug and Alcohol Addiction Recovery Centers and Resources in Goldsboro, North Carolina and 3 Nearby
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Cities Near Goldsboro, NC
How to Choose the Best Addiction Rehab Goldsboro, Offers
If you've determined what amenities you're looking for, you'll find Goldsboro inpatient addiction treatment facilities that fit just about any need. From professional treatment for businesspeople to luxury recovery centers for VIPs, your city offers many options, both low cost and high-end.
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Depending on the addiction kind and severity, you, a friend or a family member may be looking at anything from a 30 day in-patient alcohol or drug rehab facility all the way up to a 4-month one. Certain drug types may allow for short-term outpatient programs while severe cases may require long-term treatment center care. Fortunately, you can find a Goldsboro treatment program to fit just about any requirement.
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In determining the cost of rehab in Goldsboro, , you first have to consider the amenities the clinic offers and its locale in relation to your own needs. There's quite a wide range in price for rehab programs. Many accept private insurance, so either check with your provider to see if the costs can be partially covered through your PPO or HMO, or contact our toll-free helpline for a discreet insurance check.
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Introduction, The Introduction, Intro, or The Intro may refer to:
Intro (in Macedonian: Интро) is the debut album by the Macedonian male group Bravo Band. The album was released in October 2008 and it contains nine songs which are different by style.
The first single released from the album was "Lesno Ti E Tebe" ("It's easy for you") in 2006. With that song the band first promoted their self as a music group on the Macedonian festival Ohrid Fest. The song is work of Jovan Jovanov and Elvir Mekic which made their second single too called "Ne Bih Te Menjao" ("I wouldn't change you"). "Ne Bih Te Menjao" is a Serbian language song and it was the band's entry for Suncane Skale 2007. With this song they finished third in the first night with 63 points. The video for the song "Neka Patam" made by Dejan Milicevic was selected for best Macedonian video of 2008. In October all since then present songs they released on an album. The album is called Intro mainly for two reasons. The first one is the word intro which comes from the English word "introduction". It is just a metaphor for what they present in it, an introduction of their emotions which are in one way or another expressed in every song.
Never Back Down is the third full-length studio album and major label debut by post-hardcore band Close to Home, released on February 15, 2011, through Artery Recordings/Razor & Tie.
The album was produced and engineered by ex-A Day to Remember guitarist Tom Denney, and mixed by Andrew Wade.
On February 16, 2012, it was revealed that the opening track on Never Back Down entitled "Intro" was used in the Chinese multinational personal technology company Lenovo Group Limited's 0:33 second commercial entitled "The Jetpack: When Do Gets Done".
"Smoke" is a song by Australian-born pop rock singer-songwriter, Natalie Imbruglia. It was released on 11 October 1998 as the fourth and final single from her debut album Left of the Middle. The single reached No. 5 on the UK Singles Chart, but failed to enter the top 40 on the Australian Singles Chart, peaking at No. 42. The video for "Smoke" was directed by Matthew Rolston. There are two versions of the video; one of which contains additional visual effects including Imbruglia's face appearing and disappearing within animated smoke.
The first Sabre was a former knife thrower named Paul Richarde until he was selected by Modred to oppose Black Knight. Paul Richarde was given an armor, an animated gargoyle. and Mordred's Ebony Dagger (the weapon with which Mordred had killed the first Black Knight). He was defeated by Black Knight after his horse Aragorn kicked the dagger from Le Sabre's hand.
The second Sabre is a mutant super villain. His first appearance was in X-Men #106. Young and reckless, Sabre was chosen by Mystique to join her new Brotherhood of Mutants, though never actually participated in any missions. He had the mutant ability of super speed, and took the name of the deceased Super Sabre. It is unknown if he continues to serve Mystique behind the scenes, or if he even retains his powers after Decimation. Hyper-accelerated metabolism augments his natural speed, reflexes, coordination, endurance, and the healing properties of his body.
"Smoke" is a song by Australian rock band Eskimo Joe. It was the second single taken from their second studio album, A Song Is a City. It reached number 62 on Triple J's Hottest 100 for 2004.
All songs written and composed by Eskimo Joe.
Introduction, The Introduction, Intro, or The Intro may refer to:
The Independent | 27 Jan 2020
Time Magazine | 27 Jan 2020
WorldNews.com | 27 Jan 2020
Yahoo Daily News | 28 Jan 2020
Russia Today | 27 Jan 2020
Indian Express | 28 Jan 2020
News24 | 27 Jan 2020


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We've always said that Wega has a rockstar spirit. We proved it with the video we made to launch the IO. In it our friends Andrea, Gloria, Massimo and Nicola had a great time leaping in the air, playing the electric guitar and doing tricks on their skateboards while being covered from head to toe in buckets of green, orange and white paint.
Wega coffee machines enchant everyone in Iran!
Imagine a beautifully sunny piazza with immaculately-kept, leafy gardens surrounding a cascading fountain. We're talking about the main square in the city of Esfahan, in central Iran, which in the middle of July 2016 was the setting for the first ever Iranian Latte Art Competition.
Polaris takes centre stage at Shanghai for the Espresso Italiano Championship!
On 30 June Shanghai, one of the world's biggest cities, provided the backdrop for an exciting round of the world championship dedicated to true coffee lovers, the Espresso Italiano Championship, organised by the Italian Espresso National Institute (INEI).
Wega could not miss such an important date, and flew to China, taking with it a squadron of Polaris machines, coffee machines that guarantee a high level of reliability with a distinctive futuristic design.


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I am new to this forum and molecular biology generally. So I have been doing PCR, I now need to clean-up my product and am using a Min-Elute kit from Qiagen. I have to dilute the buffers included with ethanol of which we have lab stocks. My dumb question: Is it safe to use these lab stocks ? How susceptible to contamination is ethanol? I will soon be moving onto RNA work and am also wondering the same thing......can I trust lab stocks of ethanol or should I buy in my own........can I make ethanol nuclease free??
Oh am using the PCR product for sequencing after clean-up
Edited by phosphate girl, 04 March 2010 - 04:49 AM.


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In the past (here and here) we have discussed the machloket between the Shach and Bach (both in the Kelalei Psak of the Shach- Yoreh Deah 242) whether the rule acharei rabim lehatot applies only to cases of Beit Din or to all cases of pesak. The Shach argues that anything that has been ruled on by a majority of poskim throughout the generations becomes binding pesak and cannot even be invoked in a shaat hadechak. The Bach disagrees, arguing that only in Sanhedrin, where there was a formal vote, can we invoke rules of rov.
Both R. Yaakov Emden and R. Yonatan Eibshitz notes that practically the Shach is impossible to implement, as we have no way of knowing how many sefarim have been lost, how poskim have rules orally, etc, making it impossible to reach a rov. Continue reading Does Majority Rule Apply Outside of Halachic Issues?


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My home town, Aarhus.
City of Smiles as they call it.
During a long and cold winter I found myself back in town for a few days, with a head full of clouded thoughts and this view before my eyes.
It was a perfect match of mood in spirit and nature.
Aarhus Harbour, Denmark. 2017


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Barely have interest to write anything now than essays but heres interesting documentary/true crime horror story about 50s/60s mind control experiments. MK Ultra, cybernetics, brain manipulation, triggered violence, psycho-surgery, human lab rats, etc. After seeing this anyone can imagine what they can do with todays technology, mobile frequencies, audio frequencies, nanotech, aerosols, chemtrails, satellite weapons, directed energy weapons and social media manipulation. Targeted individuals might be the unwilling labrats of today, it seems the people who dare to think and write about their thoughts are targeted.
So maybe targeted individuals are the most sane people in the world now and the psychopaths doing the experiments are the real criminals who manipulate people to mass murders, school shootings and other kind of violence, just for fun.
In the closing texts they hint that when americans stopped MK Ultra soviets continued from that, so who knows, its so easy to always blame Russia? And maybe EU has their own mind control/torture program going on, microchipping the citizens who are tired of corrupted democracy.


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Vor Shishkan possibly arrested after billions went missing from common fund
Oleg Shishkanov kept the money of his trustors, which could include politicians and big businessmen.
There is a version as to the cause of vor Oleg Shishkanov's (who is better known as Shishkan and Oleg Ramensky) problems with the law. Shishkanov is known to have kept the common fund of high-ranking people, including politicians and large businessmen, Nasha Versiya reports.
Thieves of non-Slavic nationalities may have something to do with the loss of several billion euros stored in Spain. It is reported that Shishkan's opponents are trying to get rid of him with the help of a criminal case. It is also noted that he was elected Thief in Law No. 1 as a disguise.
One of the influential Slavic thieves was detained by MIA and FSB officers in the village of Popovka, Ramensky district, on July 14. It was initially reported that the detention took place as part of an investigation into the criminal case of kidnapping and murder of Deputy of the Legislative Assembly of the Ramensky District Tatyana Sidorova and three members of her family during the night of February 20-21, 2012. However, this charge is no longer mentioned in his criminal case. Shishkan was brought to responsibility as a criminal leader holding a higher position in the criminal hierarchy.
Shishkan is one of the best known and powerful thieves of the Slavic wing. In August last year, he was elected Thief in Law No. 1, replacing Zakhary Kalashov (Shakro Molodoy), who had been sentenced to more than 10 years.
Other materials
Guli's closest associate Arman Diky launches challenge on social network. Khabib Nurmagomedov backs him
Beheaded corpse of man in women's clothing found on railway tracks
The deceased 35-year-old resident was wearing women's boots, a coat, and had a purse. He also had a wig on his head.
Girl beaten by historian Sokolov 11 years ago gets involved in investigative actions
The girl arrived in Petersburg from another country to take part in investigative actions.
Name of another alleged participant in brutal execution in Syria revealed
Earlier, Novaya Gazeta published an investigation in which it claimed that fighters of the Wagner PMC were involved in the execution of a man.
Yeltsin's son-in-law says Putin wanted to leave the Kremlin
According to Yeltsin's son-in-law, Putin thought about leaving the Kremlin after being appointed the deputy head of the Russian Presidential Administration.
Postgraduate student of Moscow State University, who committed suicide in dormitory, was on drugs
The media announced what had allegedly caused the death of Dmitry Nikolaenko.
Toulouse man fined €100 for giving alms to beggar
Despite a warning from the railway police that begging was prohibited, the traveler gave 70 centimes to the poor family.
Two US Air Force pilots die in training flight in Oklahoma
The incident occurred at 9:10 local near the Vance Air Force base.
Dismembered body of school cleaner found in a dumpster, Kuzbass
A local man saw the body parts in the trash and spoke about his find to the police.


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Enjoy this new brand luxury 2 Bedroom 2 Bath ground floor condo just across from the beach. The private bedrooms each have their own bath and flat screen tv, the beautiful gourmet kitchen has a spacious dining area and the private patio has an overlooking the stunning mosaic pool and tropical gardens. Minutes away from the energy of Playa del Carmen 5th Avenue where the international world enjoy world class dining and entertainment.
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Does your school or organization provide a concession stand for events run by volunteers? The safety of everyone visiting the concession stand, as well as your organization's reputation, rests on these volunteers. Make sure that they know how to serve food safely.
Here are FREE downloadable posters in English and Spanish that can be used to remind volunteers and students to use good food safety practices. The posters can also be used as a handout if you are providing a food safety training.
Always check with your local regulatory authority for requirements that apply to your specific operation.
Additional Resources:
- Free handwashing posters, activity sheets and other materials
- Cold Pizza for Breakfast - Learn all the important do's and don'ts for tweens and teens food safety! Download the PowerPoint and/or view the online slide show.


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"A boutique running holiday" – that's how the Wildrun team describes the trail running event along the Wild Coast, and beforehand I thought that was probably over exaggerated a bit... It appears I was wrong! It's been an incredible experience, beyond my expectations. To learn about how to prepare for such an endurance event as much so as the actual run itself.
Lisa is OmniBlend's Sales & Marketing manager, and avid runner. In this series she's sharing what she learned about training for an endurance event, specifically in terms of nutrition.
The Wild Coast Wildrun is one of South Africa's most sought-after trail runs along the rugged coastline of the Eastern Cape, and appears on many trail runner's bucket list. As the Wildrun approached, I got a little bit more anxious about what to expect, and how my body would hold out. In preparation of the event, I explored how to optimally train to be able to comfortably run the distance, and remain injury-free. Would it be enough?
The 3-day trail run covers 112km, and as such being able to burn fat for fuel is beneficial. I trained my metabolic efficiency with guidance of Adrian Penzhorn, registered dietitian and sports nutrition coach. Based on Adrian's recommendations, I've been paying specific attention to my protein intake. Following the results of the Fat Max Test, to further improve my metabolic efficiency, I also incorporated both long slow runs, and intervals in my training programme. So at least theoretically I was well prepared!
Coastal paradise
We arrived in Kei Mouth on the 30thof August, and received a warm welcome from the WildRun crew. It appears to be an event that is so appealing to runners that they come back for it a 2nd, 3rd, and even a 6th time! The atmosphere was relaxed, with a great sense of comradery among the runners. It was very useful to hear about the experiences from previous years, and exchange the last tips & tricks regarding the river crossings and what (not) to pack.
The Wildrun is an experience, not a race. That's how we approached it too, having put the training effort in to make it an enjoyable experience rather than a gruesome one! Running on trail for 3 days in a row is no easy feat, and preparation makes a huge difference. It all came together during the event, and as we crossed the river with the ferry on the first day, there was nothing left than to just run, take in the scenery, and enjoy the experience!
Picture credit: Mark Sampson
And what an experience it was! The Wild Coast is breathtaking. Wide pristine clean beaches, Nguni cattle grazing on the hills and chilling on the beach, and the trail meandering on and off the hard beach sand onto the cattle trails. Traversing some rock formations, and climbing some increasingly steep hills that offered the most amazing views. Dolphins swam alongside us for kilometers on day 3, adding to the magic of the run.
Every day I ran comfortably, at what felt like a leisurely pace. For nutrition I used Tailwind dissolved in water, which worked great offering plenty of energy and electrolytes to keep me fueled and hydrated. My heartrate during the runs was quite low, meaning I was able to burn mostly fat for fuel and I consumed less than the recommended caloric intake for a run of so many hours, and felt fine. The control points half way the run each day offered some orange, biltong, salted peanuts and other nibbles too, which was a nice snack. For recovery, I took a Tailwind recovery protein shake within 30 minutes after finishing each day.
Picture credit: Mark Sampson
Being able to finish in the top 25% every day, and feel comfortable to be able to enjoy the run and take in the scenery was first prize for me. I participated to celebrate good health, and to enjoy one of the most beautiful places of South Africa in a unique setting. Overcoming the fear of running long distance again, learning about training methods and nutrition, and finding so much joy in running the event made it a fantastic experience. On top of it I finished 3rdLady overall, which made it even more memorable.
Reflecting on the Wildrun, I realized however that participating in such an event is not a stand-alone activity. What entering this type of events brings is a journey of exploring, learning, discovering new places and meeting new people. Defining your own goals, learning about how to achieve these, and then working your way towards achieving it adds an extra dimension to the run. This 'work' comprised of many fantastic training runs exploring new routes, being more conscious about my nutrition, and reaching out to people to learn. This is what made the entire experience so incredibly valuable over and beyond the 3-day event, and continues to be so enriching.
For anyone still reading, and interested in which factors apart from nutrition & training may have played a role, I'm sharing a few other factors that I think were beneficial to me.
I haven't gone very technical on my gear, as this run isn't a technical trail run. In fact, I ran day 1 on my road running shoes, to go easy on my feet and not wearing the same pair of shoes over 3 days (the road running shoes being a bit softer). I stuck to the same brand for both my road running and trail running shoes, as the brand just fits my foot (go by what suits your feet and don't worry too much about the brand). I took the advise to not take my shoes off before or after a river crossing, and wear a double pair of socks to protect my feet against fine sand. Usually running on thin running socks, the double pair of these thin socks did the trick and prevented blisters.
Aside from the training runs, I've been walking a LOT. Outside the border collies loved the longer walks, excited to go out without fail, even on the rainiest of days! At home and at our office I was clocking about 3 hours a day on the treadmill desk, walking while working. Working on a treadmill desk helps to be more active during the day and spend time on your feet, to build stronger leg muscles, and even to develop your core.
Strength & flexibility
I've also done strength exercises: squads, lunges, various abs exercises, push-ups, etc. A friend introduced me to Hot Pod Yoga, which was the encouragement I needed to do more for my flexibility, and learn about movements to support flexibility. I was a bit nervous about the hot pod at first: what about the risk to overstretch in the warm environment and cause injuries? The classes were great though, with very good instructors, and small groups. It made a big difference to me in developing both strength, and flexibility.
Science of Ultra was my favourite podcast to listen to and learn more about ultra distance training (and by all means; listening to these stories makes running 112km over 3 days seem like child's play!). It was useful to hear about experiences, and techniques, and finding a new 'normal'. One of first shows that I listed to already shared an important lesson: when training for or running an event, remember why you do it in the first place. That reason should keep you on track during training, and during the event when it does get tough.
I'm grateful for the opportunity I've had to participate, and the enriching experience it turned out to be. Special thanks to Adrian Penzhorn of Food for Sport for the insights into the right nutrition, which really has been an eye opener.
And if you're now keen to participate in a trail run trough Africa's most beautiful places too, check the other events on the Wildrun calendar.
Previous posts:
What I didn't know about training for an endurance event
The role of nutrition in endurance sports
The Fat Max Test and relevance of keeping a food diary
5 best sources of protein and why they are important for everyone
OmniBlend supplies commercial blenders to the hospitality industry, and domestic market since 2012. Operating from Cape Town, we work as young dynamic team delivering a great customer experience and offering a reliable product and service. Our aim is to offer the best value for money, and do so by importing durable blenders, and backing this up with local warranty and after-sales service. Offering a smooth customer experience, we've been able to grow our business and establish ourselves as preferred suppliers to major franchises and top restaurants in South Africa. Superior customer service is key to the business success, and main driver in our operations. We value good health, and in our modern workspace you can walk & work on a treadmill desk, make your own nutritious smoothies, and brew a good quality cup of coffee with freshly ground beans.
Job Summary
Customer orders are placed via email or through our ecommerce store. In this role, you're an allrounder contributing to handling sales enquiries, managing the ordering and fulfillment process, and hands-on handling of after-sales requests and repairs. As the end-to-end office support you also keep stock in check, for efficient shipping.
In this role you need to have a thorough understanding of our products and services, being able to assist customers with queries. As our company is fully automated, computer literacy is key (incl spelling & typing skills). You need to be able to professionally handle email and calls, and have the ability to quickly adapt to new systems. The role requires you to be organized, and work neatly and accurately to handle tasks correctly and efficiently, with the right priority. You're also responsible for handling maintenance enquiries and performing electronic and mechanical repairs of blenders. Some experience with maintenance jobs is preferred. You work on weekdays, normal business hours, around 70% of the time is computer-based and 30% hands-on.
You'll also get involved in OmniBlend's sister companies, performing similar type activities.
Key Responsibilities
You are key in making sure customer enquiries and orders are handled professionally, and our 24hr return on repairs customer promise is met. You work directly with sales ops and management, and you're fully responsible over your domain. This requires you to review your tasks, plan your time, and work accurately. Professionalism and accuracy in English writing is essential, as is the ability to work with a MacBook and iPad.
In this role you are responsible for the following (but not limited to) tasks:
This role is for somebody who is passionate about working directly with customers, and enjoys dealing with a wide variety of tasks on a daily basis. We're looking for an independent person, who's able to review and prioritise his activities in the best interest of the customer. The role requires physical abilities to pick and pack large boxes, and handle repairs. The following skills are essential:
Candidate requirements
Market related, junior management level
How to apply?
Only applications with a motivation letter and CV are considered, explaining your experience with customer service and sales, as well as repairs of mechanical/electronical nature. Please also include a short description of yourself. Email your CV and motivation letter to email@example.com
Chimichurri is a green sauce that's delicious served with lamb, flame-grilled steak, or as a condiment in a chicken wrap. This recipe is so easy to prepare that you'll just want to use fresh ingredients, to serve with your grilled meat.
There's no need to discard the stalks of the herbs. They're full of flavour too, so don't let them go to waste. They'll blend smooth, so you won't see them in the sauce.
Ingredients (makes 200ml):
Remove skins of the shallots and garlic, and add to the OmniBlend jug. Remove seeds and membranes of the jalapenos, and wash, then add to the jug too. Wash the herbs, and pad dry with kitchen towel. Add the herbs to the jug, along with the vinegar and olive oil, and a grind of salt.
Place the lid on the jug, and insert the tamper. Blend on low for about 30 seconds.
This type of sauces is best made in either the 2 liter jug, which has a narrow base, or in the 1.5ltr narrow base jug. All OmniBlend models are compatible with the different jug models.
Step aside Nutella ... this Carob Almond Butter is the perfect substitute for those decadent chocolate cravings! Free from the notorious refined sugars that are the downside of the scrumptious hazelnut paste, this nutbutter is sweetened with just a little maple syrup.
If you have a sweet tooth, this refined sugar-free will still hit the spot (yes, we tested it!). This nut butter is delicious for on toast, drizzled over your smoothie bowl, or for even eating straight from the jar with a spoon - need we say more?
Carob adds sweetness, as well as essential vitamins and minerals. Both carob and cacao are high in antioxidants, and you could replace carob by cacao or cocoa in this recipe for a more intense chocolate flavour. Play around with the different ingredients to your liking, as you'll find this spread will become an essential on your breakfast table!
Cherries are juicy and sweet, making them delicious in a fruit smoothie. Buy frozen fruit to enjoy them in and out of season, with the additional benefit that the frozen cherries from FRÜT are pitted, so you can add them without any hassle, for a quick and easy summer smoothie.
Add all ingredients to your OmniBlend, blend starting at low, increasing to high for about 30 seconds until smoothie and creamy (or use the 35 second timer on the OmniBlend V).
In this video we used the OmniBlend I - 2ltr Pro, which is the recommended model for home use, smoothie bowls, and restaurant kitchens. For commercial use in smoothie bars the most popular model is the OmniBlend V - 1.5lt.
These vegan cheesecake bars are rich, creamy, delicious and so easy to prepare. They make the perfect dessert for a weekend treat! The trick is in soaking the cashews to get that creamy cheese cake texture. From there you can play around with different flavours, we topped our cheesecake with date syrup (which is easy to make yourself, following this recipe), walnuts and chocolate. Tastes like a cheese cakey snickers bar, yum!
Soak the cashews in hot water for 1 hour, then drain thoroughly.
For the crust, add dates, walnuts, oats and coconut flakes to the jug, pulse a few times until well combined and crumbly.
Line a loaf pan with parchment paper. Transfer crust layer to loaf pan and press down into an even layer, place in the freezer to set.
For the filling, add soaked cashews, maple syrup, coconut milk, coconut oil, vanilla essence, lemon juice and salt to the jug. Blend on high until creamy and smooth.
Pour the filling over the crust, drizzle with date syrup and sprinkle chopped walnuts on top. Freeze until completely set and firm.
To serve, thaw briefly and drizzle the dark chocolate over the cheesecake, slice into bars. Enjoy immediately. Store leftovers in the freezer.
These bars were made using the OmniBlend I - 2ltr Pro. The shape of the 2ltr jug make it well-suited to grind dry ingredients, and blend textures like the cashew 'cheese' batter.
Kickstart your day with this Coffee Smoothie Bowl! Not just deliciously creamy, but filling too. We used frozen cauliflower, which gives it that extra creamy texture and Wazoogles Superfood Kungfu Coffee protein blend with a cinnamon kick. Each scoop is equivalent to 1/2 cup of coffee and it's packed with nutrients that assist in providing sustained energy. Perfect breakfast option!
Add all the ingredients to your OmniBlend jug, blend until smooth, using the tamper. Scoop in a bowl and top with favourite toppings.🌈 We used banana slices, coconut flakes, Wazoogles trail mix & peanut butter drizzle.
This bowl was made using the OmniBlend I - 2ltr Pro. The narrow base jug is recommended for blending thick and creamy bowls.
These zesty pumpkin seed bites are about to become your favourite snack! They literally taste like little cake popsicles, soft melt in your mouth pumpkin goodness & just the right amount of sweetness. With a hint of zesty orange flavour and a slight kick from the matcha powder for a great energy boost!
For coating:
Desiccated coconut (you can grind coconut flakes for the same texture) and orange zest.
Add the cashews and pumpkin seeds to your OmniBlend jug & pulse into fine crumbs. Add the rest of the ingredients and blend until well combined.
Use a tablespoon to scoop the mixture and roll into balls.
Roll each ball in a mixture of coconut and orange zest and place the balls in the fridge for half an hour to set and enjoy!
For this recipe we used the OmniBlend I - 2ltr Pro. Both the OmniBlend I and V have a pulse function for a quick chop. This function is ideal for grinding nuts: simply pulse a few times until you've reached the desired consistency. For grinding nuts and seeds to a flour, blend on high speed. The 2ltr jug is recommended for this use as it has a narrow base, which is ideal for grinding dry ingredients.
Date syrup is the perfect sweetener for your oatmeal, overnight oats, puddings, smoothies, frosting or even savoury dishes like marinades or soups. Date syrup is a natural fruit sweetener which can be used in place of sugar for baking and cooking. This is an easy plant-based recipe, without any preservatives. When using a high powered-blender like the OmniBlend you could skip the soaking part, but we do recommend soaking the dates in bicarbonate of soda as it helps bring out the dates' caramel flavour. Yum!
Pour boiling water over the dates just to cover, add bicarbonate of soda, stir then soak for 15 minutes. Add the soaked dates with the water to your OmniBlend jug.
Blend for 1 minute until silky smooth. Scrap down the sides to ensure everything is well combined, blend again for about 20 seconds.
For this recipe we recommend using a narrow bases jug. We made this recipe using the OmniBlend I – 2ltr Pro, which has a turn-dial for variable speed control, and the 2ltr jug has a narrow base, perfect for this kind of pastes and syrups.
Baked cheesecake remains a firm favourite on any gathering, and this baked Spiced Butternut Cheesecake adds warm flavours that make this cake extra special for autumn and winter.
As one little girl who had a taste of our test cake put it: "I really liked it, and I don't even like cheese cake, and butternut!" She was keen to get her own slice, after first sharing a slice with her little brother. :) That tells you that the deep creamy texture doesn't lean to the overly cheesy flavour, or butternut rich taste.
The spice mix is what makes this cake so special, and is easy to put together. We'd recommend you make a batch, as it works well in carrot cake (instead of cinnamon), and gingerbread too!
Spice mix:
Cinnamon, cloves, nutmeg, and ginger are essential, and the others can be left out if you don't have, however obviously changes the flavour slightly.
Crust ingredients:
Filling ingredients:
Pre-heat oven at 200C
Roast the butternut without oil until tender, making sure it doesn't discolour. Remove from the oven, and reduce oven temperature to 190C.
While the butternut is roasting, prepare the cake crust. Soak the dates in hot water for about 10 minutes, and measure the nuts. You can use a mix of nuts. For this cake we used almonds, brazil nuts, and walnuts, but you can use cashew and/or pecan too.
Add the nuts to the OmniBlend jug, and grind on low to medium speed to create a nut meal.
Drain the dates, and pad dry with kitchen towel to remove excess water. Add the dates to the ground nuts, and add the vanilla.
Blend on high, using the tamper to create a dough. The trick is to push the tamper into the corners, pushing the ingredients into the blades. Once the dough has come together, remove it from the jug with a silicon spatula into a cake pan. Create an even layer in the pan, and cover the edges.
Remove the butternut from the oven once soft, and reduce the oven temperature to 190C. Bake the crust for about 10 minutes, until set, and remove from the oven to cool down.
Add the roasted butternut to the OmniBlend jug, and puree using the tamper through the lid.
With a hand mixer, beat the cream cheese for a few minutes. Add the sugar, and mix again. Remove ¼ cup of this mixture and keep aside for decoration later.
Add butternut purée and spices, and mix. Add eggs one at a time, making sure it's fully incorporated before adding the next.
Transfer the mixture into the cake crust, and spread evenly. Now take the cream cheese & sugar mix that you've kept aside, and divide teaspoons full over the batter. Take a skewer, and draw lines through the blobs to create a pattern. You'll feel like a barista, creating latte art!
Bake the cake for about 40 minutes, keeping a close eye on it toward the end of the baking time, making sure no cracks appear. If they do, reduce the oven temperature as this may vary for every oven.
Remove from the oven (the middle will still look a bit wobbly), and leave to cool to room temperature. Then place in the fridge to further set, for 6 hours (after 4 hours it'll be set, if you have less patience, just a little bit soft still like in the pictures, so 6 hours or more is better for a fully set result). This cake is also perfect to prep the day before, so that the cake sets properly and the spices fully develop the flavour.
For this recipe we used the OmniBlend I - 2ltr Pro. This model has a turn dial for variable speed control, and a pulse. The 2lt jug works best for grinding dry ingredients, and pureeing with a narrow base.


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The diaphragm relies on pressure differential, so taking both the signal and draw from the same side of the the reeds would not give the pumping action properly.
Re: is there a "downdraft" carb for mopeds?
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Running With The Wolves
When the science world decided that yes, perhaps the wolf and
the dog are essentially members of the same species, the news
was welcomed heartily by those who champion the cause of
wolf/dog hybrids, animals that, thanks to human-induced
practices, are part wolf and part dog. After years of
grappling with opposition to their right to breed and keep these
animals, hybrid enthusiasts hoped that with wolves and dogs
viewed scientifically as the same species, exoneration would
soon be theirs. Yet widespread-not to mention
legal-acceptance of wolf/dog hybrids has yet to occur, and the
problems associated with these animals remain. No matter
how closely related dog and wolf may be, we are talking about
the combination of wild and domestic blood. Combine
the two within a single animal and more often than not it
produces an animal that is eternally confused and possibly
It starts off innocently enough. The hybrid puppy
is as cute and cuddly as any
other young canid, wild or
domestic. But in time-often as early as 6 months of
age-the wild impulses kick in, as does the strength borne of the
animal's hybrid vigor. Stuck in the middle of two worlds,
this increasingly powerful animal does not under-stand
how to express its impulses properly within the context of a pet
household. The animal cannot be housetrained or confined.
Furniture is destroyed (as are small animals who cross the
hybrid's path) and there may be little consistency in the
hybrid's behavior, as both wild and domestic instincts struggle
for psychological control of the animal. In the worse case
scenario, the hybrid must be destroyed in the wake of an attack
on a child.
Although there are a few individuals who are prepared
to handle and live with wolf/dog hybrid, the majority of these
animals find themselves with people who view them only as status
symbols and who have no idea how to care for them.
Without the proper housing or management skills required for a
hybrid, these people quickly realize that the hybrid has no
place in their home and unfortunately must go-preferably before
they find themselves on the receiving end of a liability suit as
the result of an attack situation. And yet another
wolf/dog hybrid, an animal that I believe should never have been
bred in the first place, must suffer the consequences of an
ignorant and unsuitable owner.
---Betsy Sikora Siino
You are enjoying "Just Like Jesse James" by Cher


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Social justice News
Social equity the slumbering elephant behind legalizing marijuana
Karen Graham
Questions about marijuana and social justice have played a prominent role this year in several U.S. states' debates about pot legalization.
Op-Ed: The Green New Deal is our chance to really honor MLK's legacy
Karen Graham
As the U.S. honors the life and legacy of iconic civil rights leader Martin Luther King Jr. today, we are reminded that the social justice and the climate movements are deeply connected.
Op-Ed: Arizona again attacks Martin Luther King's legacy with new bill
Brett Wilkins
Phoenix - Just in time for Martin Luther King Jr. Day, in a state that refused to recognize the holiday until 1992, comes yet another attack on the civil rights icon's teachings and legacy as Arizona Republicans push a bill that would ban social justice education.
Op-Ed: How social justice warriors are ruining universities
Ben Morris
Toronto - While students educate themselves in majors that will not give them jobs, another worrisome issue has risen. The infestation of social justice warriors are turning our young people into whiny, gutless cowards.
Author explores a fascinating life of social justice
Paula Kirman
Edmonton - Alexis Kienlen is an Edmonton-based writer who is a journalist and published poet with two volumes of poetry to her credit. Her third book is a work of non-fiction about someone who is well known for being an advocate for social justice.
Irish Premier's apology for Magdalen Laundries a 'cop-out'
Robert Myles
Dublin - On Feb. 5, the Irish government released a long awaited report on Ireland's Magdalen Laundries. The Magdalen Laundries operated from 1765, and took in 'fallen women' but their existence was often ignored in Ireland and unknown to the outside world.
Video: Man sets himself on fire during social protest in Tel Aviv
Darren Weir
Tel Aviv - A man taking part in a social justice protest march Saturday night in Tel Aviv, shocked other demonstrators as he set him self on fire.
Unprecedented social justice riots in Tel Aviv
Jack Goldenberg
Tel Aviv-yafo - 22- 23 June 2012: Tel Aviv social justice protests (Friday night and Saturday Night) turned into violent riots as protesters and police kick it up three notches.
Massive Montreal rally supports students, not Bill 78
Richard Mccallum
Montreal - Polls and pundits thought that the recent Quebec student strike movement had lost it's momentum and sympathy in that city. On Tuesday what may have been over 250,000 protesters marched through the metropolis to make their position clear; "Our Streets!"
Op-Ed: The Libertarian Manifesto — Woe unto everyone else
Paul Wallis
Originally, libertarianism was a highly respected ideal, based on individual liberty. Far from its original high principles, modern libertarianism has turned a philosophical Disneyland into a downmarket trailer park and called it art.
UNICEF releases 1st report card on inequality in rich nations
Stephanie Dearing
Florence - UNICEF has released its first report card that answers the question, 'how far behind are children being allowed to fall?' The report focuses on the world's 24 richest nations, the OECD countries.
Canadian government & Ambassador guilty of defaming filmmaker
Stephanie Dearing
Ottawa - Sometimes the little guy can take on big government -- and walk away a winner. That was the case for former student, Steven Schnoor, who took on the Canadian Government and former Canadian Ambassador to Guatemala, Kenneth Cook.
Report: Strong income security measures means a stronger Ontario
Stephanie Dearing
Toronto - Ontario's Social Assistance Review report, released Monday morning, called for Ontario to create a plan to ensure income security for the province, saying such a plan would help the economic recovery.
Thousands of Foreigners Flee Bangkok
Leo Reyes
This is about the occupation of two Bangkok airports by militant protesters that stranded thousands of tourists and businessmen for about a week now. Police failed to retake the airport and disperse the protesters
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All signs point to this September 12 posting on Celeb. Later, she'll show me a Virgin Mary lawn ornament and a 7-foot cross that she stashed in the garage. To read more of Anne Hathaway's cover story, check out the August issue, on newsstands now.
Watch Next
Either that, or Follieri's got an axe to grind. You will acquiesce to it without complaint.
1 2 34 5 Read more →


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Post Content
It's not exactly stop-the-presses stuff, but it turns out that for the first two months of collections, the imposition of the sales tax on beer, wine and alcohol in Massachusetts has exceeded projections by about 33 percent.
The tax took effect August 1, but revenue from sales tax is not reported until the 20th of the month, following, so the first month's collection was recorded in September. Now, with October collections in hand, the combined two month collection of sales tax on beer, wine and alcohol totals $20.5 million, beating the estimate of $15.6 million for those two months by nearly $5 million.
September collection was $9.2 million (estimate was $7.9 million); October collection was $11.3 million (estimate was $7.7 million). The overall revenue collection estimate for this fiscal year from this new piece of the sales tax is $79 million.
There is also a way to measure alcohol, beer and wine sales on a baseline basis. The state levies an excise tax on beer and wine (wholesalers pay it and it is included in the retail price) that amounts to a penny for a bottle of beer or 11-cents for a 750 ml bottle of wine, for instance. That excise tax has not changed.
Bottom line: the excise tax collection for September and October is up 1.1 percent, so at this stage of the fiscal year demand for beer, wine and alcohol has slightly increased even with the imposition of the 6.25 percent sales tax.
If you'll pardon the pun, the liquor business may be recession-proof.
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At the Department of Revenue, we are committed to recruiting and retaining talented people throughout the New England region. We have many positions open for a seasonal workforce to join our team. What's a Seasonal position? Seasonal positions are essential jobs that help the Department …Continue Reading Are you ready to join the DOR Team?
Tax Security 2.0 – A "Taxes-Security-Together" Checklist posted on Jul 16
DOR is sharing the following IRS "Taxes-Security-Together" checklist to increase awareness amongst taxpayers, and specifically tax professionals, about safeguarding private taxpayer information. The "Taxes-Security-Together" Checklist Some tax pros may routinely overlook these checklist items and others need to regularly revisit them. The steps are not …Continue Reading Tax Security 2.0 – A "Taxes-Security-Together" Checklist
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I created the Let's go for Hajj Activity Pack this week. It's a printable pack that is perfect to learn the steps of Hajj through play.
What to Pack for Hajj and Advice to make your Hajj Comfortable
In this post: What to pack for Hajj : Advice to make hajj more comfortable to avoid the frustration, minimize fatigue and not fall sick!
Hijri Calendar: The 12 Islamic Months and their Importance
The 12 Islamic months and their importance for Kids. Are you looking to teach the Hijri Calendar to children? I am sharing a few ways we teach in my home. These are fun ways that include scientific learning, fact finding and a road to discovery for them. We find it easier to remember the Arabic…
10 Simple Hajj Activities for Kids + Hajj and Eid al Adha Link Up
In this post: Hajj crafts, Simple Hajj activities for kids and Teaching Hajj to kids that require minimal to no prior preparation. At the end of the post, find more resources to plan kids activities, crafts as well as recipes, parenting tips and personal stories from other bloggers on Hajj and Eid al Adha. What is Hajj…
What to expect in Hajj : My Hajj Story
In this post: I am sharing my Hajj story today so you know what to expect in Hajj. Have you ever wondered why Hajj is once in a life time? There are many hardships a Hajji faces but definitely lessons that can turn a life around.
Muslim Doll Jenna the Quran Teacher – Review
In this post: Review of the Muslim Doll Jenna the Quran Teacher. It is a modest Barbie style doll that was launched 4 months ago. Perfect gift for little Muslimahs to look up to.
The Best Islamic Toys and Eid gifts for Muslim Children
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BRIEF UPDATE ON CONTRACEPTION, by John Guillebaud (JG)
WHO CLASSIFICATION OF CONTRAINDICATIONS (for any method) - with some amplifications by JG
WHO 1: A condition for which there is no restriction for the use of the contraceptive method
"A" is for ALWAYS USABLE [eg COC with history of Candidiasis; uncomplicated varicose veins]
WHO 2: A condition where the advantages of the method generally outweigh the theoretical or proven risks
"B" is for BROADLY USABLE [eg COC in smoker age 20; history of hypertension in pregnancy, only]
WHO 3: A condition where the theoretical or proven risks usually outweigh the advantages (suggest alternative). Yet respecting the patient/client's autonomy - if she accepts risks and relevant alternatives are contra-indicated or rejected, given the risks of pregnancy the method can be used with care/monitoring
"C" is for CAUTION/COUNSELLING, if used [eg COC in diabetes; any enzyme inducer treatment]
WHO 4: A condition which represents an unacceptable health risk
"D" is for DO NOT USE, at all [eg COC with personal history of VTE; or migraine with aura]
Note: Clinical judgement is required, always in consultation with the contraceptive user, especially:
[Reference: WHO/RHR/00.02. Medical Eligibility Criteria MEC) for contraceptive use (2nd Ed). Geneva: WHO, 2001.
This is now paired with: Selected Practice Recommendations (SPR) for contraceptive use. Geneva: WHO, 2002]
COMBINED ORAL CONTRACEPTIVES (COCs – full glossary at end)
Breast Cancer risk: Good news!A major US study [1] of 4575 women aged 35-64 with breast cancer and matched controls shows no increased risk – OR 1 or less - whether for current users, past users, long-term users, users starting at a young age or before full-term pregnancy (thus good reassurance about the so-called "time-bomb") or users with a family history! Reassuring, given volunteers' Pill exposure >75 %, though not the "last word". Study did not recruit COC-continuers right up to menopause, nor EARLY Ca's developing pre-age 35. For the latter we still use the 1996 model, equating to 1:1000 extra cases by age 45, if they used COC till 35 [2].
Cervical cancer: Once the HPV oncogen virus is acquired, a good 2002 study [3] supports the COC being a co-factor for CIN progressing to more advanced stages (the rel. risk of invasive Ca up 4-fold after 10 years' COC use). Yet invasive Ca cervix remains a minimal risk for COC-users (even if also smokers), so long as there is 3-yearly cervical cytology, plus colposcopy as indicated. Risk of VTE: Term "Generations" unhelpful, main thing is that LNG/NET progestogens may reduce VTE risk, for given EE dose. Using the absolute rates given by the CSM in 1999 (other estimates exist), with around 100 extra cases per million users per year, and assuming 2% mortality for VTE gives 2 per million difference in annual VTE mortality between 3rd gen DSG/GSD products and 2nd gen LNG/NET products. One hour of driving gives a 1 per million mortality risk. So if a pill-taker chooses to switch from Microgynontm to say Marvelontm/Femodenetm, as she sensibly may to control any minor side effect: if she avoids one 2-hour drive in a whole year, she will have the same overall VTE risk next year as she would otherwise have if she did not change brands! [2].
Risk of arterial disease: Thrombotic stroke risk of COCs should be reducible by improved prescribing in migraine - for tips on diagnosing aura and chart for COC eligibility with migraine, see pp 42-44 in ref [2] or pp 214, 216 in [8] Latest and probably better study [4] contradicts 'MICA' [5] and suggests that pills with 3rd gen progestogens may actually be better than LNG ones for risk of myocardial infarction. So, pending more data, I advise that we (continue to) use 20 m g DSG or GSD products for risk-factor and migraine-free COC-users above age 35 through as may be requested to age 51, with the NET option (Loestrin 20) an alternative. NB: the primary reason for using, or changing to, a DSG/GSD or other estrogen-dominant product at any age remains for the control of side effects [2,8]. Reassuringly, COCs have their main (small) effect on every known cause of mortality during current use and for some varying time thereafter: 10 years after use ceases, mortality in past users is indistinguishable from that in never users [6].
Prescribing: Current scientific evidence suggests only two pre-requisites for the safe provision of COCs: a careful personal and family history with particular attention to cardiovascular risk factors including migraine [2,8]- and a well-taken blood pressure [7]. Routine screening by any blood test, and breast/bimanual examinations are not relevant to the COC per se, do them only if clinically indicated.
Intercurrent diseases [8]: It is impossible to list every known disease which might have a bearing (ie WHO 4, 3 or 2) on COC prescription, and for many the relevant usage data do not exist. A working rule therefore is to ascertain whether or not the condition might lead to summation with known major adverse effects of COCs, particularly with the risk of any circulatory disease. This usually means WHO 4, sometimes 3. If not, COCs are WHO 2, though used with alertness for the onset of new risk factors. Reliable protection from pregnancy is often particularly important in these cases. NB: Beware the dis-ease of OBESITY: see page 2 below.
Counselling should be backed by the FPA leaflet "Your guide to the combined pill". NB: New edition (April 2005) has, as always, very good text, now based on WHO MEC and SPR (ref above). But its Flow Diagram re "missed pills" on pp 12-13 is disappointing. Most UK providers consider it should simply advise "more than 1 of any COC missed" as the action trigger for added condom use and, in last pill-week, for running on to the next pack; and that EC is only indicated if >2 pills are missed in first week + sexual exposure since last pack. JG's practice until much-needed revision of this Flow dia is to delete pp 12-13 of FPA leaflet and give a separate instruction card!
YASMINtm containing DrospirenoneYasmintm contains 3.0 mg drospirenone and 30 m g of ethinylestradiol (EE). Drospirenone differs from other progestogens in COCs: it has diuretic properties due to anti-mineralocorticoid activity. This may help to oppose the salt and fluid-retaining effects of EE and so reduce fluid retention symptoms.
Drospirenone is also an anti-androgen, so Yasmin is an alternative to Dianettetm (or the cheaper Marvelon, which is often effective) for conditions like PCOS. The combination with EE is estrogen-dominant, and so cannot be expected a priori to have the lower risk of VTE associated with the functionally anti-estrogenic levonorgestrel in, for example Microgynon.
ELIGIBILITY. Yasmin adds some new WHO 4 conditions: this particular brand should not be used – if COCs usable at all – in anyone at risk of high potassium levels (i.e. severe renal insufficiency, hepatic dysfunction, and adrenal insufficiency).
Q: On what criteria will you consider Yasmin? A: The need for contraception, PLUS:
What about weight? Not usually an indication, given the lack of evidence of a true (ie non-fluid-related) weight benefit of the product and its extra cost. Moreover if a woman already is overweight, the usual BMI advice should apply ie BMI > 30 is WHO 3 (= a LNG/NET product is preferred) and BMI > 39 remains WHO 4 for all EE-containing products (COCs, EVRA, NuvaRing).
EVRAtm transdermal combined hormonal contraception
This is an innovative transdermal patch delivering ethinylestradiol (EE) with norelgestromin, the active metabolite of norgestimate. The daily skin dose of 150 µg norelgestromin and 20 µg EE produces blood levels in the range of those after a tablet of Cilest. All the absolute and relative contraindications plus most practical management advice about that relatively estrogen-dominant COC apply here. About 2 percent of women in the trials had local skin reactions which led to discontinuation. The patch has excellent adhesion: the incidence of detachment of was 1.8 % (complete) and 2.9 % (partial). The hormones are in the adhesive, so a dried-out fallen off patch should NOT be re-used! Failure rate for consistent users of EVRA was similar to the oral pills - and less than 1 per 100 woman-years.
PROGESTOGEN-ONLY PILLS (POPs)
Cerazettetm: the first POP to be primarily an anovulant. This contains desogestrel 75 m g, blocks ovulation in c 97% of cycles, plus still has the mucus effect: hence showed higher efficacy than in any previous POP study, Pearl Index 0.17 (CI 0-0.9). So this is a realistic alternative if the COC is WHO 4 in a young woman: though cheaper old-type POPs suffice in low fertility states like lactation or above age 40, where POP already is so effective. Useful for trial sometimes before inserting Implanon, though this only helps to predict hormonal side effects - and risks Cerazette's usual early bleeding problems. It is also an option with past history/ high risk of thrombosis and (unlike other POPs) a past ectopic. Often, but not very predictably, it benefits menstrual symptoms: eg dysmenorrhoea, menorrhagia, PMS, Mittelschmerz. There are no concerns about having to increase dose in women of high body mass. BUT should warn that unacceptable irregular bleeding may occur in early months, usually improving to offer 50% oligo-amenorrhoea at one year.
Missed Cerazette pills: 12 hour leeway in pill-taking is now approved, before extra precautions advised – but, for ALL POPs, Cerazette included: in the new WHO Practice Recommendations these need only be for 48 hours (+ EC if sex while the mucus block lost).
[NB Organon's own advice cannot deviate from their SPC, with the stricter requirement for 7 days' added contraception if a tablet is taken > 12 hours late].
ImplanONtmis a single 40mm x 2mm subdermal rod releasing etonogestrel (the biologically active metabolite of desogestrel) over 3 years[9]. To date its effectiveness when actually inserted - assuming insertion is not too late in a conception cycle, indeed best to avoid that by an anovulant method pre-insertion - is unmatched: aside from abstinence and vasectomy. In studies, mean insertion and removal times were well under 5 minutes. NB special insertion training is vital: if put in too deep removal can be complex, under u/sound control. Should contact Organon for advice re such cases, using u/sound guidance. Frequent or prolonged bleeds affect around a fifth of users at one year. But there are no current worries here re low estradiol levels (cf DMPA below), so the high amenorrhoea rate is a bonus! Irregular bleeding: With both DMPA and Implanon, if irregular bleeding is unacceptable – consider trial of a suitable 20-30 m g COC (if not contraindicated), for around 3 cycles. Mercilon contains the same progestogen as Implanon and usually controls the woman's bleeding while the tablets are being taken, with shedding of her spotting–prone endometrium between packs. Thereafter she may (or may not!) achieve what she finds an acceptable bleeding pattern - though she should be pre-warned that it is unlikely to be as good as on the short-term COC. If the combined pill is contraindicated, in selected cases it is acceptably safe (i.e. WHO 3) to use a similar cyclical course of a natural estrogen, preferably by transdermal patches since this route causes least alteration in clotting factors.
Implanon and body weight: The blood levels of etonogestrel were lower in obese women and it has been suggested that in those with the very greatest body mass (say over 100 kg) it may be appropriate to discuss replacing their Implanon early. However there were no failures at all in the pre-marketing trials. Hence there must be some 'margin'. If after discussion the >100 kg woman wishes to do so, and particularly if she is amenorrhoeic - which suggests continuing anovulation – she may certainly continue with her implant to the end of the third year. (And if she weighed less than 100 kg I would not even discuss the point, unless raised by herself).
Implanon and enzyme inducers: The SPC does point out that enzyme inducers lower the blood levels of etonogestrel. Organon therefore recommends that "an additional contraceptive" be used. They do not recommend inserting two Implanons, but otherwise leave the choice open. Patients in monogamous relationships may not wish to use additional condoms or even user-friendly options like the sponge or a spermicide. So the chosen "added contraceptive" might instead (JG's opinion) be a daily Cerazette, the obvious progestogen-only pill here, in addition: though on a "named-patient"* basis [2,8] as this use is unlicensed. There is more re what NP use means in EC section below. If the woman is to be on an enzyme inducer long term, she could continue that combination indefinitely. But as users of enzyme-inducers do so well with Mirenatm (see below), this might be a better as well as a cheaper choice!
DMPA 150 mg every 12 weeks – NB the same injection frequency is now advised even if the user is on an enzyme-inducer…
Late injections (JG's advice; WHO and the Faculty give more 'leeway'):
How long to use DMPA? given ongoing concern about anovulation with low estradiol levels. Much uncertainty persists, not all eliminated by latest CSM circular (18/11/2004) which mainly recommends "careful re-evaluation of risks and benefits in all those who wish to continue use for more than 2 years". IF strong risk factors for osteoporosis are present, DMPA is WHO 3 or even 4 for all, at any time. Under age 19, due to concern that it may prevent achievement of peak bone mass, WHO classifies DMPA as WHO 2; and the UK advice of Nov 2004 is to use it first-line "but only after other methods have been discussed" and are unsuitable or unacceptable. DMPA is also WHO 2 above age 45 (since ?early ovarian failure). In sum, DMPA is very useful for relatively short term use, after which switching to another long-term method is usual. If the woman wishes to use it for longer, even much longer, it is as always her right to decide to do so, after counselling about the uncertainty. This should be with formal 2-yearly reassessment of alternatives but without imaging or blood tests unless clinically indicated for that woman. Remember it is clearly safer, overall, than the COC!
Same problem with long term Implanon? No, the data are reassuring so far, re both estradiol and bone density: in comparative 2-yr. studies both remained similar to those in copper IUD-users. By analogy, no worries yet on this account with Cerazette either - or with the IUS (below) whose amenorrhoeic action is anyway primarily at the end-organ level, the endometrium.
INTRAUTERINE DEVICES (IUDs) [NB see reference 10, which is excellent, for all long-acting methods]
Any banded Cu IUD is in the 'gold standard' category, first choice unless an alternative is indicated - all are on the Drug Tariff. They are: T-Safe Cu 380Atm (a), OR a new variant (b) with the same name but with its copper bands sunk into the plastic frame (available June 2005 from FP Sales) OR a third clone (c) available from Durbin plc and called the TT 380 Slimline (itself essentially identical to (b) but has simpler loading system than the fiddly little plastic "hat" of (a) or (b) – however NOTE slightly wider introducer).
¨ It really is worth the effort to make this banded IUD one's first choice, since it is usable for 10 years (the newest clones of it are actually licensed for this long) and the data support its effectiveness till 12 years, even when fitted below age 40. The main reason is not its probable greater efficacy [10] – above all in its latest form, with the copper bands near each tip of the T – but rather, the fact that research in the past 50 years has so clearly shown that most IUD complications can be insertion-related and reduce in frequency with duration of use. It usually passes through the cervical canal surprisingly easily, in all parous women.
When to use the Nova T380tm? In my opinion, this one might be appropriate for a nulliparous woman using it for emergency contraception (EC) and planning to have the device removed once established on a new method, such as DMPA. But a randomised controlled trial [10] showed the Nova T380 (aren't the names confusing?!) which has copper wire but no bands, to be significantly less effective than the T-Safe Cu 380A (cumulative failure rate at 3 years 3.6 versus 1.7 for the T-Safe). Therefore, adding in the benefit of fewer routine re-insertions, in my view either Nova T 380 or the UT 380 Short (from Durbin plc = Nova T style but on a short stem)
should usually be reserved for when the T-Safe Cu 380A or equivalent cannot be fitted, for some reason (including the tight cervix of some nulliparae). Another good EC option for nulliparae is the Flexi-T 300tm which is tiny and has an exceptionally easy push-in fitting technique with no separate plunger - and at only £8.80 would be cheaper. But it has been shown to have a highish expulsion rate. There is now also available the Flexi-T 380tm, on a slightly larger frame and with bands on its side arms but otherwise identical in shape. We need more data on this, sought but not so far forthcoming! It might be very effective and usable for longer than its 5 year licensed life; be as easily inserted as the Flexi-T 300; and have an acceptable expulsion rate. IF all that were true, being Cu-banded it might come to rival the T-Safe Cu 380A and its clones, above. At present we lack the data to be sure.
When to use the banded GyneFixtm [11]? – NB not widely available, specific insertion training needed. Useful in some cases.
Special indications include a distorted cavity on ultrasound scan (if IUD useable at all), or a small uterine cavity sounding <6 cm. [A rival option for the latter, however, is that new UT 380 Short or one of the Flexi-Ts].
All users should be forewarned about unrecognised expulsion: being able to feel the threads is particularly important with GyneFix.
[Note: the Multiloadstm are without any established advantages. Schering no longer market the ineffective Nova-T 200.]
Mirenatm IUS [12,13]
This is a major advance in contraceptive technology, with the added value in relief of PAIN [12] as well as menorrhagia:facts still not widely enough appreciated! But there are two more differences between Mirena and copper IUDs:
Insertion: Attention to detail is important, esp to be VERY sure that the green slider stays initially fully in the starting (forward) position, not only when loading the Mirena into the to-be-inserted end and cleating the thread, but also when first passing the loaded inserter into the fundus: if the green slider is slightly back from max forward, friction at the internal os can make the outer tube slide back – ie the system tries to release the IUS in the cervix!
What about Mirena and enzyme-inducers? Walli Bounds of Margaret Pyke Centre collected data on about 50 IUS plus enzyme-inducer-users and good effectiveness was maintained (one definite pregnancy reported) [10]. This is biologically plausible, since the LNG would be released in high local concentration locally and should therefore still have its normal effects, on the utero-cervical fluid and also in impairing implantation. Therefore, pending more data, the use of Mirena by women on enzyme-inducers is a good choice, a WHO 2 situation. No added precautions need be taken, but with advice that there might be a minimal reduction in its amazing efficacy.
PID risk? Neither IUDs nor IUSs, intrinsically, increase PID risk. The essential thing is selection so far as possible for mutual monogamy; PLUS secondly the practice of inserting only through a "Chinese cervix" – as explained on pp 85-87 of ref [2] & pp 390-5 in ref [8], this means one established, by screening - verbally always, and where appropriate also for Chlamydia - to be pathogen-free….
Past ectopic? Although anovulant methods would be even better, in my view this is at most WHO 3 for the IUS or banded IUDs [14].
The Peterson et al study of 1996 [15] showed the failure rate of female sterilization as performed in the USA to be 18/1000 at 10 years! – very comparable to the T-Safe Cu 380A and the IUS (14/1000 and 11/1000 failures respectively by 7 years) [12]. In UK the RCOG estimates the 'lifetime' failure rate of the Filshie clip as better, 3-4/1000, whereas it is 0.5/1000 for vasectomy with azoospermia [16]
The LNG-only method is more effective than the previous combined hormonal method, now superseded [17-18]. Every 12 hours' delay increased the failure rate by 50 % [19]. Now a further WHO study shows that the whole 1500m g dose (now a single tablet) may and indeed should be given at once, working equally well with NO difference in side effects. WHO's 2002 protocol [20] allowed use up to 5 days and there were 8 failures among 314 women (2.5%), treated with 1500 m g LNG either stat or in divided doses, between 72 and 120 hours after a single coital exposure [20]. WHO concluded this is "prevention of a high proportion of pregnancies even up to 5 days after coitus". So use of Levonelletm up to 5 days is acceptable as an example of evidence-based but unlicensed use of a licensed product – what is usually termed *'Named patient'use [see p141 of [2] or p535 of [8]]. For medico-legal safety, there should be a record that the woman understands this and gave informed verbal consent, ideally backed by a written handout to explain the difference(s) from the PIL of Levonelle. In this example she should also understand that a copper IUD would definitely be a more effective method of EC [21], failure rate about 0.1%.
Aside from current pregnancy the only absolute contraindications (WHO 4) to hormonal LNG-only EC are:
Caution (WHO 3) also applies: {if used in women on Warfarin – enhanced anti-coagulation reported [22], so check INR post-treatment –
{OR if an enzyme-inducer is in use (eg St John's Wort), indicating a second 1500m g dose after 12 hours.
SELECTED REFERENCES, FURTHER READING and GLOSSARY
Brief Glossary:COC combined oral contraceptive / OR odds ratio = relative risk / Ca cancer / VTE venous thrombo-embolism / EE ethinylestradiol/ DSG desogestrel / GSD gestodene / LNG levonorgestrel/ NET norethisterone/ SPC Summary of Product Characteristics / PCOS the polycystic ovarian syndrome / BMI body mass index / POP progestogen-only pill / PMS premenstrual syndrome / DMPA depot medroxyprogesterone acetate /EC emergency contraception/ IUD (IUS) intrauterine device (system) / NSAID non-steroidal anti-inflammatory drug /LA local anaesthesia /PIL Patient Information Leaflet / INR International normalized ratio (test for anti-coagulation).
JOHN GUILLEBAUD, Professor Emeritus of Family Planning and Reproductive Health, UCLJanuary 2006


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