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Prevention of Mother-to-Child Transmission of HIV (PMTCT)
I. Definition of the Prevention Area
Prevention of mother-to-child transmission (PMTCT; also known as prevention of vertical transmission) refers to interventions to prevent transmission of HIV from a mother living with HIV to her infant during pregnancy, labor and delivery, or during breastfeeding.
II. Epidemiological Justification for the Prevention Area
Approximately one-third of children born to mothers living with HIV will acquire HIV infection in the absence of preventive measures. Although only 14 percent of children who breastfeed up to 2 years will acquire the infection during breastfeeding, they account for 40 to 64 percent of children infected with the virus. The risk of transmission is particularly high if the mother herself acquires her HIV infection during pregnancy or breastfeeding because viral load tends to be highest during the early stages of infection. Mixed infant feeding in the first six months is also associated with an increased rate of mother-to-child transmission (MTCT).
Under ideal conditions, comprehensive prevention programs can reduce MTCT rates to about 1 to 2 percent. Antiretroviral therapy (ART) given to medically eligible women living with HIV during pregnancy reduces transmission by at least 75 percent. Ensuring that treatment eligible women receive treatment is critical not only to prevent MTCT but to protect women's own health and survival.
UNAIDS estimates that in 2008, 2.1 million children under 15 years of age were living with HIV; 430,000 were newly infected; and 280,000 died from AIDS-related causes. MTCT still accounts for a substantial, although decreasing, portion of new HIV infections in many African countries. Optimal PMTCT coverage has not yet been achieved. United Nations agencies report that in 2008, in low- and middle-income countries:
• Twenty-one percent of pregnant women were tested for HIV
• Forty-five percent of pregnant women living with HIV received antiretroviral drug (ARV) regimens or ART
• Thirty-two percent of infants born to mothers living with HIV received ARV prophylaxis at birth.
III. Core Programmatic Components
The World Health Organization (WHO) recommends a four-pronged approach to a comprehensive PMTCT strategy:
1. Primary prevention of HIV infection among women of childbearing age
2. Preventing unintended pregnancies among women living with HIV
3. Preventing HIV transmission from women living with HIV to their infants
4. Providing appropriate treatment, care, and support to mothers living with HIV and their children and families.
This resource describes the third strategy: PMTCT. Preventive interventions consist of a cascade of services, including HIV testing and counseling; ARV prophylaxis or ART; safe delivery; safer infant feeding and postpartum interventions such as cotrimoxazole prophylaxis; early infant diagnosis for HIV-exposed infants; and links to treatment and care, as well as standard postpartum child survival interventions. To achieve maximum impact of PMTCT, acceptable levels of coverage, access, utilization, and in some cases, adherence must be attained across the entire continuum of care.
The 2010 WHO recommendations for PMTCT are based on recent program experience and scientific findings. Highlights include lowering the eligibility threshold for ART for pregnant women to 350; immediate initiation of ART (regardless of gestational age) for treatment eligible women; and provision of ARVs to non-treatment eligible women and/or their infants in the postnatal period to prevent breastfeeding transmission. It is now recommended that mothers known to be HIV-infected (and whose infants are not infected or whose status is unknown) exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding until the infant is at least a year old.
IV. Current Status of Implementation Experience
Eastern and Southern Africa, the most affected regions, have made progress in PMTCT. In 2008, 21 percent of pregnant women in low- and middle-income countries were tested for HIV. However, in South Africa 78 percent of pregnant women were tested and in Namibia, 90 percent of pregnant women were tested. Among pregnant women living with HIV, 45 percent received ARV or ART and 40 percent of HIV-exposed infants received ARV prophylaxis.
National guidelines and policies warrant revision in order to effectively implement the 2010 WHO PMTCT recommendations. This would include the scale-up of CD4 testing for pregnant women infected with HIV; the revision of training curricula; the retraining of health workers; the improvement of follow-up of mother/baby pairs; and the enhancement of access to ARVs.
Eliminating pediatric HIV/AIDS is now regarded as achievable, and PMTCT is considered an essential part of maternal, newborn, and child health care. PMTCT programs not only reduce transmission of HIV, but if well implemented as part of a full continuum of care, they can result in HIV-free survival, meaning that infants are protected from other causes of death as well.
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The WHO guidelines Antiretroviral therapy for HIV infection in infants and children are based on a public health approach to HIV care. The update of these guidelines is harmonized with the treatment guidelines adopted for adults, pregnant women, and prevention of mother-to-child transmission (PMTCT). The present guidelines are part of WHO's commitment to achieve universal access to the prevention, care and treatment of HIV infection in infants and children.
This systematic review of clinical trials examined approaches to PMTCT during breastfeeding, when up to 42 percent of mother-to-child transmission occurs. Mothers who had a high viral load, were young, did not breastfeed exclusively, or who had breast lesions were more likely to transmit HIV to their infants. In low-resource areas with poor sanitation, infants who were not exclusively breastfed were more likely to die of diarrheal diseases and pneumonia, causing overall death rates among 2-year-old children to be the same whether they were breastfed or not. The authors suggest that for mothers who initiate breastfeeding, a) breastfeeding should be exclusive, and b) extended prophylaxis should be given to the infant (nevirapine alone or nevirapine with zidovudine).
The World Health Organization now recommends that treatment-eligible pregnant women receive antiretroviral therapy (ART) during pregnancy. This study, conducted in Côte d'Ivoire, evaluated the impact of providing treatment-eligible pregnant women with highly active antiretroviral treatment (HAART) and treatment-ineligible women with short-course antiretroviral therapy (scARV). All infants were treated with seven days of zidovudine and single-dose nevirapine on day three. Seventy-five percent of infants were breastfed for a median of five months. Overall HIV transmission just after birth was 2.2 percent and increased to 5.7 percent at one year. The natural transmission without intervention could exceed 30 percent. The authors say that treating all pregnant women living with HIV with three highly active antiretroviral drugs, regardless of their immune status, could avoid the HIV resistance associated with scARV.
This clinical trial conducted in Malawi evaluated HIV-free survival rates of children whose mothers were categorized into one of three groups: group A, highly active antiretroviral therapy (HAART)-ineligible (defined as a CD4 count of 250 or greater); group B, HAART-eligible but untreated women; and group C, HAART-eligible and treated women. At 24 months, HIV-free survival of infants was 82 percent in Group A, 68 percent in group B, and 81 percent in group C. When survival rates were adjusted for various infant prophylaxis regimens, the risk of death among the children of treated mothers and treatment-ineligible mothers were each approximately half that of the children of treatment-eligible but untreated women.
This study, conducted in Burkina Faso and Kenya, randomized 824 pregnant women living with HIV and with CD4 counts of 200 to 500 to receive either triple antiretroviral (ARV) prophylaxis or short-ARV prophylaxis. Over three-quarters of infants in both groups were breastfed. Infants in both groups were treated with single-dose nevirapine. At 12 months, the cumulative HIV infection rates among infants born to women receiving triple-ARV and short-ARV were 5.6 percent and 9.3 percent, respectively; however, there was no statistically significant difference in overall mortality.
Five hundred and sixty women living with HIV with CD4 counts of 200 or higher were randomized to receive one of two triple drug regimens (referred to by the authors as highly active antiretroviral therapy): Arm A received abacavir/zidovudine/lamivudine and Arm B received lopinavir/ritonavir/Combivir, which were prescribed at 26 to 34 weeks of pregnancy through 6 months following birth. A control group of 170 women with CD4 counts less than 200 were treated with nevirapine/Combivir. Seven of 10 mothers breastfed for five months or longer. Neither infant mortality nor HIV transmission differed significantly among the groups. Infant mortality at six months did not differ by groups and was very low in all arms.
This study randomized 2,637 mother-infant pairs, in which the mothers had CD4 counts higher than 250, to receive either maternal triple drug prophylaxis (referred to by the authors as highly active antiretroviral therapy), infant nevirapine, or no additional prophylaxis (all pairs were treated with single-dose nevirapine and one week of two-drug prophylaxis immediately after birth). Treatment extended up to 28 weeks of breastfeeding, and mothers breastfed exclusively for 24 weeks, followed by rapid weaning. Preliminary data show that at one week, 4.9 percent of infants in the two treatment groups were infected, reflecting transmission during pregnancy. At 28 weeks, 6.4 percent of infants in the control arm (those with no additional treatment) developed HIV; 3.0 percent of infants born to mothers treated with triple drug prophylaxis became HIV-positive; and 1.8 percent of infants treated with nevirapine became infected. Revised results will be published in an upcoming issue of the New England Journal of Medicine.
This cohort study of infants born to mothers living with HIV in Mozambique assesses HIV-free survival at one year among infants of mothers given three highly active antiretroviral drugs (referred to by the authors as highly active antiretroviral therapy, although it was used only as prophylaxis in some women and as therapy plus prophylaxis in others). Mothers were advised to breastfeed exclusively for six months. Treatment and/or prophylaxis was initiated as early as the 15th week of pregnancy and was continued for six months following birth (indefinitely if CD4 count was less than 350). Infant HIV-free survival at 12 months was 94 percent. Deaths among mothers and infants were reduced by 41 percent and 67 percent, respectively, based national death rate data.
This report provides an update on global progress in 2008 toward scaling up priority health sector interventions for HIV prevention, treatment, and care toward the internationally endorsed goal of universal access. Section 5, "Scaling up HIV Services for Women and Children," reports on PMTCT indicators. A key indicator, the percentage of pregnant women living with HIV who receive antiretroviral drugs for PMTCT in low- and middle-income countries, is low but increased from 35 percent of women in 2007 to 45 percent in 2008. Access to testing and counseling was also low but increased from 15 percent in 2007 to 21 percent in 2008. The report indicates that national political commitments to expand HIV prevention, treatment, and care services for women and children have intensified. An executive summary and the full report are available through the link below.
This report includes a section devoted to PMTCT. Overall, only 21 percent of pregnant women in low- and middle-income countries receive HIV testing and counseling. Those rates are higher in South Africa (78 percent), Botswana (87 percent), and Namibia (90 percent). However, of pregnant women living with HIV, only 45 percent received antiretroviral (ARV) prophylaxis in 2008 while 32 percent of HIV-exposed infants received ARV prophylaxis. These data are a subset of the overall body of data reported in the Towards Universal Access report (above). The report summarizes current challenges and identifies innovations necessary to improve scale-up and coverage of PMTCT.
This report by activists and researchers describes the perceived failure of PMTCT programs in six developing countries: Argentina, Cambodia, Moldova, Morocco, Uganda, and Zimbabwe. The authors call into question the United Nations' claims of success in PMTCT coverage and cite the poor quality of PMTCT programs in resource-poor countries. Reasons given for these failures include an overly-narrow focus on antiretroviral prophylaxis; lack of consistency and coordination among donors, United Nations agencies, and governments (especially with regard to infant feeding issues); inadequate integration among health services; and stigma, discrimination, and violence against women living with HIV. The authors use case studies from the six focus countries to support their findings.
The PMTCT field has been constrained by a lack of clarity and consensus around the optimal way to measure program effectiveness. The authors discuss benefits and pitfalls of population-based surveys versus facility-based surveys, and the biases that can be introduced. They urge adoption of a validated consensus model for effectiveness monitoring PMTCT. They also propose using HIV-free child survival as a gold standard measure of program effectiveness, and they suggest adapting the existing Demographic and Health Surveys (DHS) to routinely measure HIV-free child survival. The World Health Organization authors recommended adding questions to the DHS survey about infant feeding practices and child deaths, and they propose adding a heel-stick to obtain blood samples for HIV testing of children younger than two years old.
This study examines whether the 2001 United Nations goals for PMTCT were feasible and affordable, using a model based on data from actual costs, resource needs, and PMTCT and pediatric treatment budgets in Burkina Faso, Cameroon, Côte d'Ivoire, Malawi, Rwanda, Tanzania, and Zambia. The model included family planning promotion for people living with HIV; HIV testing and counseling; pediatric treatment; and cotrimoxazole prophylaxis. The authors concluded that more funds than are currently available in many countries will be needed to successfully scale-up PMTCT, and that human resource constraints are even more challenging than funding constraints. Based on this, the authors recommend that human resource capacity be assessed together with requests for increased funds for PMTCT programs.
To assess PMTCT coverage at a population level, researchers collected cord blood samples from 43 delivery centers in Cameroon, Côte d'Ivoire, South Africa, and Zambia, where all sites used nevirapine (NVP) for prophylaxis, either alone or in combination with other drugs. Cord blood was tested for the presence of antiretroviral drugs. Of nearly 30,000 cord blood samples collected, 12 percent were HIV positive. Among positive cases, complete charts were available for just over 3,000 cases; of those, roughly half of mother/baby pairs received both mother and infant nevirapine. Service-related failures occurred at every step of the PMTCT cascade and included HIV testing not being offered, mothers declining testing, HIV results not being given, NVP not being dispensed, mothers not taking NVP, and infants not being dosed. Better performance at each step of PMTCT is recommended.
Programs to prevent mother-to-child transmission (PMTCT) of HIV decrease the risk of vertical transmission and identify HIV-positive infants for treatment. To assess how well PMTCT programs reach women and infants and retain them in services, the authors conducted a meta-analysis of a decade of research (2002-12) on PMTCT involving more than 75,000 women in 15 African countries. The authors looked at 44 studies to examine four outcomes: percentage of pregnant women tested for HIV, initiating antiretroviral prophylaxis, being tested for CD4 cell count, and beginning combined antiretroviral therapy (ART). Two outcomes were examined for children: early infant diagnosis for HIV and combined ART initiation. The authors found that uptake of opt-out, or provider-initiated HIV testing is greater, with 94 percent of women getting tested, compared with 58 percent for opt-in, or patient-initiated, testing. The authors also found that 40 percent of ART-eligible women did not receive any form of ART. For infants, only about two-thirds returned after the birth for early infant diagnosis; even fewer returned for HIV testing between 12 and 18 months of age. Interventions that provide convenient access for mothers and their children, that involve male partners, or that integrate ART provision into standard antenatal care show promise for improving uptake, according to the authors. They recommend further research to understand the barriers to care that many of the region's pregnant women experience.
There is scarce data on antiretroviral therapy (ART) adherence during pregnancy, and no existing review has explored this subject. The authors performed a meta-analysis to determine the level of ART adherence among pregnant women and during the post-partum period in low-, middle-, and high-income countries. The meta-analysis included all studies that reported on adherence levels among women during pregnancy and/or postpartum--48 studies in all. The majority (74 percent) were observational; others (26 percent) were randomized controlled trials evaluating PMTCT regimens. Most studies (27 percent) were conducted in the United States; Kenya (12 percent), South Africa (10 percent), and Zambia (10 percent) were also represented. Across the studies, definitions on the meaning of "adherent" differed, with thresholds ranging from 80 to 100 percent. Also varying was how the studies measured adherence, whether based on self-reported data (51 percent), pill counting (18 percent), pharmacy refills (10 percent), or measuring blood levels (9 percent). Pooled adherence levels across all studies was found to be 73.5 percent. Adherence was higher among women in the antepartum period than postpartum (with pooled proportion 75.7 percent versus 53 percent respectively). Adherence was higher among participants in low- and middle-income countries than in higher-income countries (with pooled proportion 76.1 percent versus 62 percent). Factors inhibiting adherence included: advanced HIV disease; physical weakness caused by pregnancy; depression; economic stresses; and pill burden. Social support and disclosure to loved ones were found to motivate higher adherence. In conclusion, the review demonstrated that adherence among PMTCT clients is below that recommended for viral suppression. Therefore, to achieve optimal results, PMTCT programs must address adherence barriers and motivators.
Integrating programs for prevention of mother-to-child transmission (PMTCT) programs with other health care services within facilities has long been considered essential to successful PMTCT program scale-up. This meta-analysis of five studies in sub-Saharan Africa, built upon the systematic Cochrane Review methodology, finds limited, non-generalizable evidence of improved uptake of PMTCT interventions in such integrated programs. According to the authors, these findings are consistent with a recent Cochrane review that found evidence lacking for the effectiveness of strategies for integrating primary health services at the point of PMTCT service delivery in lower-income countries. The authors find little consensus on how to standardize integrated services as well as varying definitions of the concept. Regardless of the model, however, each program reviewed failed to achieve target coverage. The authors encourage programs and future research studies to evaluate additional outcomes of integration, including cost-effectiveness and impact on quality of care, human resources, stigma, and context. The authors agree with current guidance that PMTCT program integration must be assessed within the epidemiological context and the health system's readiness for integration. They also encourage additional research on integration of PMTCT to understand how it affects scale-up of effective PMTCT programs.
According to the study authors, children who acquire HIV postnatally are more likely to survive (with 36 percent mortality rate at 18 months) than those who acquire HIV during delivery (whose mortality rate is 60 percent). These results are from a pooled analysis of all available clinical trial data in sub-Saharan Africa on mother-to-child HIV transmission prevention over the past 15 years. The authors suggest that these findings can be attributed to the immunological immaturity of the fetus and newborn and consequent difficulty in controlling the virus, in contrast to the greater immunological maturity of infants who acquire HIV postnatally from infected breast milk. The authors also find that maternal health affects infant survival: the rate of infant mortality at two years was one-third higher among women with a CD4 count lower than 350 cells/ml than mothers with a higher CD4 count. Children of mothers who died during the first two years postpartum were also two times more likely to succumb to infant mortality. Based on these results, the authors stress the urgency of providing comprehensive care, including antiretroviral therapy, to all women with an antepartum CD4 count lower than 350 cells/ ml, to improve the survival not only of the mothers but also of their infected and uninfected children. The authors also recommend programming for prevention of mother-to-child HIV transmission due to breastfeeding as well as early assessment of HIV infection in HIV-exposed children.
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These recently-updated, evidence-based recommendations on PMTCT serve as a reference for countries to adopt and adapt according to conditions found at the national level (resource availability and limitations, etc.). They are intended to simplify and standardize previous recommendations by making guidelines for initiating antiretroviral therapy (ART) for pregnant women the same as for nonpregnant women and by taking into account programmatic considerations that affect implementation. They provide guidance for policymakers and program managers responsible for PMTCT programs and serve as a resource for health workers involved in prevention, care, and treatment of pregnant women and their infants.
The recommendations focus on two key areas: treatment and prophylaxis. The authors review drugs of choice for treatment-eligible women and when to start the drugs, and they discuss drugs of choice for prophylaxis in women who do not need ART for their own health and when to start those drugs for the mother and/or the child. Recommendations are given for both breastfeeding and non-breastfeeding infants.
New recommendations include: 1) earlier use of ART for a larger proportion of pregnant women living with HIV; 2) longer provision of antiretroviral (ARV) prophylaxis for pregnant women who do not need ART for their own health; and c) provision of ARVs. These recommendations form part of a larger guideline which is expected to be published and disseminated in 2010.
These World Health Organization guidelines were updated in 2010 in response to significant new programmatic experience and evidence regarding HIV and infant feeding. The 2010 recommendations recognize the important impact of ARVs during the breastfeeding period, and recommend that national authorities in each country decide which infant feeding practice, i.e. breastfeeding with an ARV intervention to reduce transmission or avoidance of all breastfeeding, should be promoted and supported by their Maternal and Child Health services. The document includes the principles, recommendations, and summary of the evidence. Nine key principles focus on overall HIV-free survival; integrated versus vertical infant feeding interventions; setting national strategies for infant feeding; information and counseling for mothers; and promoting breastfeeding among the general population. Seven recommendations are provided on breastfeeding and young child feeding practices.
Few women in low- and middle-income countries have been able to access antiretroviral therapy (ART) early in pregnancy. This study evaluated whether integrating ART provision into antenatal care (ANC) clinics in Lusaka, Zambia, would improve the proportion of treatment-eligible women initiating ART during pregnancy. The researchers compared a large control cohort of pregnant women with an intervention cohort of over 17,000 women who received care at an integrated ANC-ART center. Of the 1,566 treatment-eligible women, a larger proportion of those attending an integrated care center (33 percent) received ART during pregnancy compared to the control arm (14 percent).
This study evaluated the safety and efficacy of highly active antiretroviral therapy (HAART) given to 689 pregnant women treated in an integrated antenatal clinic of Johannesburg Hospital, South Africa. Only 302 mother-infant pairs completed follow-up, and of those, the transmission rate was 5 percent. Clinically significant adverse reactions to HAART included life-threatening skin reactions (Stevens-Johnson syndrome), non-fatal hepatitis, and mitochondrial toxicity. The authors caution that the retrospective, observational nature of this study, and the failure of many women to follow-up, is "likely to bias the data" as women who followed up could represent a distinctly different socioeconomic group. Nonetheless, the researchers concluded that initiating pregnant women on HAART was feasible, safe, and effective.
The researchers sought to determine the percentage of women who develop HIV during pregnancy (women who test HIV-negative in early pregnancy and test HIV-positive later in pregnancy). Of 5,233 pregnant women registered for antenatal care in the Eastern Cape and Free State of South Africa, 79 percent agreed to an HIV test. Of the 2,377 women who initially tested negative, only 1,278 accepted a repeat HIV test between 36-40 weeks of pregnancy; of those, 72 (3 percent) tested positive. This number represents an incidence rate of HIV of 10.7/100 pregnant-woman-years. The authors conclude that HIV retesting should be offered in pregnancy in order to promote PMTCT and to identify women living with HIV whose antibody levels were low at first testing.
The Elizabeth Glaser Pediatric AIDS Foundation has one of the world's largest PMTCT program datasets. The authors reviewed more than six years of program data from several countries, covering 2.6 million pregnant women through June 2006. They review the number of women who received counseling and testing services, and the number of women and infants receiving antiretroviral prophylaxis. The authors describe a dramatic increase in HIV testing after a policy change from "opt-in" testing to "opt-out" testing, in which the test is presented as a routine part of pregnancy testing that women can decline if they desire. They discuss their wide promotion of single-dose nevirapine for prophylaxis and some of the controversy surrounding this approach.
This article focuses on the weaknesses of the counseling and testing components of PMTCT. The authors state that overall global PMTCT coverage is just 8 percent. Because testing and counseling serves as an entry point for multiple downstream services, such as comprehensive family-centered HIV care, as well as for PMTCT, the authors suggest that improvements in this aspect of HIV prevention and treatment could lead to multiple benefits. The authors make 10 key recommendations, including provider-initiated testing and counseling; group pre-test counseling; use of rapid HIV tests; and the use of auxiliary health care workers. Each of the 10 recommendations is discussed in detail. Data from four African and two United Kingdom studies are presented and illustrate improved uptake of testing and counseling after the introduction of provider-initiated testing, which uses an opt-out technique for testing.
The authors review historical events and key research issues relevant to PMTCT. They describe interventions that have succeeded in the United States and Europe and how they have lagged in developing countries. The authors discuss program gaps or challenges to PMTCT in the United States, such as the practice of providers offering testing only to pregnant women felt to be at high-risk, rather than offering it to all pregnant women. Another pitfall is the failure to retest pregnant women who initially test HIV-negative. International gaps and challenges include limited ability to provide PMTCT services at the time of birth and shortly after because many women in resource-limited areas deliver at home. Some successful approaches to these problems are described.
The authors report on the results of the Maternity in Migori and AIDS Stigma Study (MAMAS), a prospective, mixed-methods study of how pregnant women's perceptions of HIV-related stigma affect their use of maternity services. In 2007, MAMAS surveyed 1,777 pregnant women of unknown HIV status at their first antenatal care visit in a high-prevalence region of rural Kenya. These baseline data revealed that more than two-thirds of the respondents anticipated experiencing stigma if they were to test HIV positive. Follow-up interviews were conducted postpartum with a subsample of 411 women--HIV positive, HIV negative, and untested--as were interviews with 48 community health workers, childbearing women, and family members. Qualitative data from the interviews showed that most women in the study believe that delivering in a health facility is preferable for pregnant women with HIV or other health complications. Quantitative data revealed that women with stronger negative attitudes about persons living with HIV are less likely to deliver in a health facility. The authors postulate that women who deliver at a health facility are more likely to be labeled as HIV positive by their communities. Because health outcomes are far better for clinic-based deliveries, the authors recommend community-based interventions to counter HIV-related stigma in order to reduce women's concerns about using health facilities for childbirth.
This article outlines five priorities for the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), as well as other donors, in programming for prevention of mother-to-child transmission (PMTCT). PEPFAR's comprehensive PMTCT strategy is based on its Global Plan Toward Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, co-published with the Joint United Nations Programme for HIV/AIDS (UNAIDS). The PMTCT strategy seeks to reduce new pediatric infections by 90 percent and to halve HIV-related maternal mortality by 2015. The authors endorse rapid implementation of the World Health Organization's PMTCT guidelines and of innovative approaches to retain women in care and to help them adhere to prophylaxis and lifelong treatment. According to the authors, in 51 studies of HIV-infected pregnant and postpartum women, adequate adherence (defined as greater than 80 percent) was significantly higher in the antepartum period than postpartum (70 percent versus 52 percent). The authors recommend partner-based support and community-based distribution of medications to increase adherence. They support partner-based HIV testing to more effectively include partners in PMTCT and to integrate HIV care and family planning efforts. Finally, the authors advise measurement of infant HIV prevalence and HIV-free survival at the population level, via household surveys or evaluations within infant immunization clinics, with long-term infant follow-up. At the International AIDS Conference in 2012, dozens of presentations discussed ongoing research and innovation in PMTCT programming, including Option B+, which provides lifelong triple antiretroviral therapy to all pregnant women regardless of their CD4 count.
Following an online and in-person consultation with more than 650 people living with HIV (PLHIV) in approximately 60 countries, the Global Network of People Living with HIV and the International Community of Women Living with HIV outlined challenges and potential areas for success within the Draft Strategic Framework (2010-1015) for Primary Prevention of HIV and the Prevention of Unintended Pregnancies in Women Living with HIV in the Context of PMTCT. According to the authors, health care workers' attitudes about PLHIV were identified as the single most important barrier to service access, with two-thirds of e-survey respondents reporting that they have experienced stigma in health care settings. More than half the respondents said that health care workers' negative attitudes threatened their ability to access safe contraception. One-fifth of e-survey participants reported that they had been pressured to make sexual and reproductive health decisions, decisions involving sexual abstinence, tubal ligation or hysterectomy, abortion, and/or condom use, without access to any other family planning option. Lack of confidentiality was also cited as a major issue, with more than 50 percent of e-survey respondents reporting that their right to have their health information kept confidential had been violated at least once. Potential solutions to such challenges include: capacity building and training; prevention of gender-based violence; use of peer counselors and support groups; sexual and reproductive health services designed for women and girls; counseling on family planning and safe conception, particularly for PLHIV; decentralization of services; male involvement; and support for disclosure in HIV-discordant relationships.
According to this research study, rapid initiation of antiretroviral therapy (ART) in infants is feasible, acceptable, and effective. The authors evaluated the safety and efficacy of three ART different regimens in infants born to late-presenting HIV-positive mothers who did not receive ART during pregnancy. Within 48 hours of birth, 1,684 formula-fed infants born to HIV-positive mothers were given one of three regimens: zidovudine for six weeks (the "zidovudine-alone group"); zidovudine for six weeks, plus three doses of nevirapine during the first eight days of life (the "two-drug group"); or zidovudine for six weeks along with nelfinavir and lamivudine for two weeks (the "three-drug group"). According to the authors, the overall transmission rate averaged 8.5 percent in all three groups, with a rate of 11 percent in the zidovudine-alone group. The two- and three-drug groups had similar rates and fared better than the zidovudine-alone group. Based on these results, the authors conclude that prophylaxis with a two- or three-drug ART regimen is more effective than zidovudine alone. They also found that the two-drug regimen, which uses liquid nevirapine, is easier to administer than the three-drug regimen, which requires reconstitution of nelfinavir powder before each dose is ingested.
This article reports on a study that examined the use of a Rapid Results Initiative (RRI)--which is designed to effect organizational change and improve performance in a limited period--to address challenges in delivery of services for prevention of mother-to-child transmission of HIV (PMTCT) implemented between April and June 2011 at 119 Kenyan health facilities. RRI includes two distinct phases: first, needs assessment; then, implementation and monitoring. According to the authors, this RRI was developed to increase service provision and uptake of antiretroviral therapy (ART) for HIV-positive mothers and infants. The authors found that following RRI initiation, ART uptake increased by more than 40 percent among all HIV-positive pregnant women, a rate that continued to improve post-RRI. The authors believe this increase will bring health facilities closer to the goal of providing ART to 30 percent of all eligible HIV-positive women. They also found a 13 percent increase in assessment for HAART eligibility as a result of improved CD4 testing as well as a 30 percent increase in polymerase chain reaction (PCR) testing leading to improved early infant diagnosis and increased male involvement. Attributing part of this success to community mobilization as well as to Ministry of Health leadership and involvement, the authors encourage further research to determine the RRI's longer-term impact on improving high-quality, cost-effective PMTCT services.
Large-scale elimination of pediatric HIV appears feasible in KwaZulu-Natal, South Africa, whose HIV prevalence is among the world's highest. This study was designed to determine the rates of mother-to-child transmission (MTCT) in KwaZulu-Natal, using all infants receiving their first immunizations as a population proxy. According to the authors, a major decrease in MTCT (66 percent) was achieved within a short period as a result of better programming for prevention of mother-to-child transmission; 90 percent of mothers reported that they had been tested for HIV during their most recent pregnancy, and 9 percent knew they were infected before their most recent pregnancy. The authors also cite the rapid transition of the province's health facilities to providing dual antiretroviral prophylaxis, which offers more protection than nevirapine alone, and to providing HIV-positive mothers with lifelong antiretroviral therapy. According to the authors, lifelong treatment will contribute significantly to reducing HIV infections in children as well as to lowering mortality in mothers and infants (currently, 14 percent of HIV-positive mothers in KwaZulu-Natal are enrolled in a lifelong treatment program). The authors detected challenges in the current MTCT programming, including ongoing high rates of maternal HIV prevalence and HIV diagnosis late in pregnancy. According to the authors, early HIV testing and ART regimens through the period of breastfeeding for at least 90 percent of HIV-positive women will be essential to reach the overall target of 5 percent or less for prevention of mother-to-child transmission by 2015.
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This generic training package, updated in 2008, provides all the tools needed for a five-and-a-half day PMTCT course, with an optional half-day field visit. The course is based on 75 resource documents, 17 of which are key World Health Organization guidelines. The course was updated in 2008 and serves as a comprehensive, evidence-based course that can be adapted and implemented in country or regional resource-constrained settings. Materials include a participant manual comprised of nine modules, a set of slides or overhead projections, and a trainer manual, which is aimed at nurses, midwives, physicians, social workers, outreach workers, counselors, and program managers working in PMTCT programs. Guidance is given for closing the course, offering an optional field visit, and answering frequently asked questions. A glossary is also made available. The document may be freely reproduced, in whole or in part.
The Health Policy Project conducted a systematic literature review to examine how stigma and discrimination affected women's uptake of and access to services for prevention of mother-to-child transmission of HIV (PMTCT). Findings were the basis for programmatic recommendations on how to reduce stigma and discrimination in PMTCT, antenatal care, and services for maternal, neonatal, and child health. The Health Policy Project defined the various steps to successfully complete the sequence of services offered through PMTCT and called it "the PMTCT cascade." Numerous barriers to PMTCT were identified at each step in the cascade. A couple of modeling exercises demonstrated that a large percentage of infections could be averted by reduction of stigma and discrimination. The report offers a number of strategies and recommendations based on field experience and this literature review.
This programmatic update provides the latest recommendations on antiretroviral treatment for HIV-positive pregnant women to prevent transmitting HIV to their infants and outlines important changes and considerations from the 2010 version. For example, this new version offers a third option for antiretroviral programs for preventing HIV transmission--Option B+. Following this protocol, an HIV-positive pregnant woman will begin antiretroviral therapy at the antenatal clinic and will continue treatment for the rest of her life. The report also provides details on the regimen's efficiency and its advantages and challenges, and answers questions relating to the new option. A more comprehensive guidelines revision is planned for early 2013.
The toolkit offers a selection of different materials including research papers, books, training materials, and behavior change communication materials across the spectrum of HIV prevention topics. Readers can access materials and resources on behavior change communication, condom use, family planning and HIV service integration, male circumcision, multiple and concurrent partners, prevention of mother-to-child transmission, and voluntary counseling and testing.
PMTCT: Expert Panel Report and Recommendations to the U.S. Congress and U.S. Global AIDS Coordinator
Independent Expert Panel. (2010).
This report was commissioned by the U.S. Congress to review PMTCT activities supported by the U.S. President's Plan for Emergency Aid Relief (PEPFAR) and others, and to make recommendations to appropriate congressional committees. The report makes numerous recommendations to achieve the goals of legislation enacted in 2008, which has as its central goal that PMTCT services will by 2013 "reach at least 80 percent of pregnant women in those countries most affected by HIV/AIDS in which the United States has HIV/AIDS programs." The report outlines PMTCT achievements in the 15 focus countries that receive PEPFAR support. Of these, three focus countries, Botswana, Guyana, and South Africa, have achieved 80 percent coverage of counseling and testing. Family planning services and efforts to prevent unintended pregnancies among women living with HIV are seen as integral to PMTCT. Challenges in achieving PMTCT goals are described and include the difficulty of offering the full continuum of care of PMTCT services within the short pregnancy and postpartum period; ambiguity around the definition of PEPFAR targets and goals; and funding constraints. Finally, the report contains a detailed section that describes the scientific evidence for PMTCT.
AIDS Epidemic Update
This report provides a detailed review globally and by region of HIV/AIDS epidemiologic data and trends including estimates of HIV/AIDS in women of reproductive age and in children. The authors caution that some increase in the prevalence of HIV is due to improved care as people with HIV are living longer. They conclude that it is possible to reduce new HIV infections among children through increased coverage of PMTCT. Under ideal conditions, PMTCT interventions can reduce mother-to-child transmission from an estimated 30-35 percent (with no interventions) to 1-2 percent with a full complement of interventions. Global and regional estimates are provided of the annual number of infant infections averted through the provision of antiretroviral prophylaxis globally from 1996 to 2008. A qualitative discussion is provided for PMTCT programming in each region and is based on data provided regarding specific patterns of HIV transmission and conditions in each region.


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top gear tony 666 wrote:Yuck. Doritos.
MQuinny1234 wrote:Doritos are awful.
top gear tony 666 wrote:Evil within looks good, but that demo where the dude was being chased by that chainsaw bloke really cut down the subtlety
Mr. Sefrol wrote:Saw some gifs about it on tumblr, but had no clue what it was until now. Seeing that Mikami worked on it though is a big selling point to me. And knowing he's fully aware of the disappointing route the horror genre has gone and wants to bring it back is a refreshing feeling.
Blood Lord wrote:I still have no idea what you are talking about.
Randori wrote:DORITOS ARE AWESOME, ESPECIALLY DORITOS NACHO CHEESE!
Blood Lord wrote:Ponies. I think my list of the Main 6 I don't like are shorter.
Mad-Mutt wrote:Its okay BL. We're talking about the sad state of survival horror and Shinji Mikami whose pretty much the godfather of survival horror. Resident Evil use to be good, then Mikami had to leave Capcom some time after RE4 and by doing so, Capcom apparently lost the only guy in their employment who could make a good RE game.
Mad-Mutt wrote:I've been on kind of a Pringles faze myself.
Mad-Mutt wrote:Hell, I even like characters that some people hate like Diamond Tiara. And yes I'm aware of how much of a bitch she is.
Mr. Sefrol wrote:I like Silver Spoon better. Have this nagging feeling she'd actually get along with the CMC if Diamond Tiara wasn't around. Or that if she wasn't around, she'd be kind of lost and need someone to kind of follow around.
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quote:They can all pass around CMU, WMU, EMU, Miami-Ohio, Ohio U, etc..
quote:So this is just another impediment they put in their own way so that they get on their high horse and bitch about the SEC for something else?
quote:because their traffic cones are tougher than another team's traffic cones.
quote:i bet all the major conferences follow suit...
quote:that's one way to keep them from losing to FCS teams.


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Email to get in touch or to call me, I'm in our Tech City office.
Drew named #1 most respected in the 2011 Reputation Online survey in New Media Age
Drew named #4 digital big guy in the PR Week Powerbook 2011
Drew in the BR200 top 50 of "the Web's most influential bloggers"
Old school! Finalist:
Best PR Blog at the Business Blogging Awards 2005


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Congratulations to State Cup MVP Sean Halverson!
Rush Pikes Peak is proud to honor Sean Halverson for earning the MVP Award for last Spring's State Cup! Pictured here on the right, Sean is currently a member of our U13 Nike Team. He and his teammates are looking forward to representing the club at Regionals for a second straight year. Congratulations Sean, keep up all of your hard work!


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Directly Observed Therapy in High Risk Populations in Newark, NJ
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30 patients with poor antiretroviral therapy compliance will be identified from our pool of patients at Saint Michael's Medical Center and be given Directly observed therapy.
Condition | Intervention | Phase |
Directly Observed Therapy HIV Infections |
Drug: Invirase Drug: Norvir |
Phase 3 |
Study Type: | Interventional |
Official Title: | Directly Observed Therapy in High Risk Populations in Newark, NJ |
Estimated Enrollment: | 30 |
Study Start Date: | April 2004 |
Estimated Study Completion Date: | May 2006 |
30 patients with poor antiretroviral therapy compliance will be identified from our pool of patients at Saint Michael's Medical Center. Consent will be obtained, their regimens will be switched to QD based on previous therapies and resistance patterns if available. Patients will be placed on direct observed therapy.Each patient will be placed on Fortovase/Ritonavir (1600mg/100mg)QD plus two or three NRTIs based on a phenotypic baseline testing to a protease inhibitor. Patients will visit the office at baseline, weeks 1, 4, 8, 12, 16, 24, 32, 40, and 48. Patients will also be visited daily by the social worker (or designee) to observe patients taking their antiretroviral therapy for 6 months. After six months of direct observed therapy patients will be given a diary card to record administration of medications and the social worker ( or designee) will visit the home twice weekly. If the patient experiences a change in therapy secondary to virologic failure, the patient will return to baseline visit for the new once a day regimen. Virologic failure will be defined as < .5 log drop between each visit or > 400 copies/mL at week 24 on two separate occasions at least 14 days apart
Ages Eligible for Study: | 18 Years and older |
Genders Eligible for Study: | Male |
Accepts Healthy Volunteers: | No |
Inclusion Criteria:
1. Men and Women > 18 years of age with a confirmed HIV-1 diagnosis 2. CD4 count <350 and or history of opportunistic infection 3. HIV PCR >55000 and >55,000 on one occasion in last 12 months 4. Patients with poor compliance (Poor compliance will de defined as taking less than 80 percent of prescribed medication 5. Patients with mental illness, HIV dementia, substance abuse or social factor prohibiting compliance 6. Willingness to sign informed consent or legal guardian
Exclusion Criteria:
- CReatinine >2.0 -
Please refer to this study by its ClinicalTrials.gov identifier: NCT00285883
United States, New Jersey | |
Saint Michael's Medical Center | |
Newark, New Jersey, United States, 07102 |
Principal Investigator: | Jihad Slim, MD | Saint Michael's Medical Center |
No publications provided
ClinicalTrials.gov Identifier: | NCT00285883 History of Changes |
Other Study ID Numbers: | 36/03 |
Study First Received: | January 31, 2006 |
Last Updated: | February 27, 2006 |
Health Authority: | United States: Institutional Review Board |
Keywords provided by Saint Michael's Medical Center:
Invirase HIV DOT Treatment Experienced |
Additional relevant MeSH terms:
Acquired Immunodeficiency Syndrome HIV Infections Immune System Diseases Immunologic Deficiency Syndromes Lentivirus Infections RNA Virus Infections |
Retroviridae Infections Sexually Transmitted Diseases Sexually Transmitted Diseases, Viral Slow Virus Diseases Virus Diseases |
ClinicalTrials.gov processed this record on February 25, 2015


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Blood Lord wrote:I hope this comic doesn't take the turn for every girl gawking after Jr's boner.
I have a feeling there's going to be a lot of Chi/Mimi. I already ship it. No fucks given.
And I've said this before, I'll say it again: Chi is the daughter of Aku. There is 100% nothing Aku hates more than humans. I'm pretty sure Chi will have picked this up if nothing else, and Junior is half-human. This does not bode well for Junior possibly adding Chi to his potential love interests.
Mimi doesn't even seem to like Junior all that much, to be honest. The last time we saw them together she was attacking him...lol
stratus wrote:considering they potentially have the same mom or at least have 1/2 of blossoms DNA by whatever unnatural methods, they are basically siblings. Mimi is the closet thing Chi may have to a sister . it dont know if their aware of the fact that they may be blood relatives but maybe chi's love of Mimi could be just a strong sisterly love. Chi may have developed strong emotions for Mimi but may not know the reason. their ties/heritage with blossom could explain why thiers such a strong connection between them and why it was natural for them to become best friends. but knowing Grim Tales romance, a little Incest is not off the table neither is Yuri love.
Stratus knows what's up.


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Coverage: SUN
7:30 PM ET, March 6, 2013
AmericanAirlines Arena, Miami, FL
Top Performers
Orl: N. Vucevic 25 Pts, 21 Reb, 4 Ast, 1 Stl
Mia: D. Wade 24 Pts, 6 Reb, 3 Ast, 4 Stl, 1 Blk
MIAMI, FL - MARCH 6: LeBron James #6 of the Miami Heat faces defense during the game between the Orlando Magic and the Miami Heat on March 6, 2013 at American Airlines Arena in Miami, Florida. NOTE TO USER: User expressly acknowledges and agrees that, by downloading and/or using this photograph, user is consenting to the terms and conditions of the Getty Images License Agreement. Mandatory copyright notice: Copyright NBAE 2013 (Photo by Issac Baldizon/NBAE via Getty Images)


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"Trust is the breath of business, ethics its limbs, to uplift the spirit its goal"
- H.H. Sri Sri Ravi Shankar
The Federation of the Karnataka Chamber of Commerce and Industries (FKCCI) and The Art of Living in association with World Forum for Ethics in Business is hosting the "Corporate Culture and Spirituality (CCS) - India" Conference at The Art of Living International Centre, Bangalore, on the 8th & 9th of February 2013.
This will be the 10th edition of the CCS Conference series by The Art of Living, and marks a return to India as a venue following the earlier editions that were held in Singapore and the European Parliament in Brussels.
The Corporate Culture and Spirituality Conference is an annual event where leaders from the fields of business, governance, academia, civil society and faith-based organisations come together to engage in dialogue, network and explore business potentials and discover the benefits of emerging paradigms in leadership.
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His Holiness Sri Sri Ravi Shankar (Founder –The Art of Living)
K.V. Kamath (Chairman - ICICI Bank Ltd., Non-Executive Chairman - Infosys Ltd.)
To know more about the other speakers in the conference, Click Here.
You can watch the conference on LIVE Webcast.
Click Here to download the E-brochure
For Further updates on the Corporate Culture & Spirituality India Conference:
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Website: www.ccsconference.com
For any other Inquiry :
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Stingray Pant Women's
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On area GORE-TEX pant in a lower profile silhouette.
The classic Stingray pants have been upgraded to include side vents, colour matched instep patches and an improved, flattering fit. Comfortable and easy to wear, these GORE-TEX® with 3L softshell construction pants offer a supple, soft-to-the-touch face fabric and superb weather protection.
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Wow. That was fun! What a weekend, thanks to Sew Mama Sew. I will admit I didn't get to visit every giveaway I would have liked and I am still checking out posted links. So please be patient with me. I've never had my inbox so inundated! Thanks so much to those of you who shared. I found some really fun stuff through those links.
I will also try to answer some of the questions too. The main question I can answer here is that no, there is no pattern for that Arcadia quilt. It was my first real attempt at improve sewing. Working with the Moda pre-cuts made it really quick. Basically I can tell you this - it's a big strip quilt. I would sew sets of strips together and at random places, rotary-cut across those strip sets and insert a big layer cake square. All very random. It was a really fun, liberating excercise!
Okay, so now the moment you've all been waiting for. . . (and I'm sorry the wait was so long. First day of summer break here and both the computer and I have more people vying for our attention.)
Random Integer Generator
Here are your random numbers:
Timestamp: 2009-06-01 15:49:39 UTC
The winner is Candice! Congratulations Candice. I will contact your for mailing info.
MANY thanks to all of you for stopping by! I met so many fun, talented, hilarious, awesome, new bloggers. I wish I had Arcadia charm packs for all of you. And thanks again to Sew Mama for coordinating it all. :) Happy first day of June, folks.


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Emperor Maximian Herculeus
Also known as
- Marcus Aurelius Valerius Maximianus Herculius
Adopted son of Emperor Diocletian, and named his co-regent in 285, receiving the title of regent on 1 March 286. He resigned the regency at Milan, Italy after the election of his son Maxentius, but the new emperor proved incapable of governing and Maximianus was recalled to restore order as emperor. He failed. He again renounced the throne after the meeting of the Caesars in 307. The intensity of his persecution of Christians seems to have varied, but he conducted a vigorous persecution in the western provinces of which he was governor, and certainly had people murdered for their faith. He gave his youngest daughter Fausta in marriage to Constantine, and having again assumed the imperial crown was surrendered to Constantine by his own soldiers; he was eventually pardoned.
- c.250
- committed suicide in July 310
Profiled Saints Martyred by Maximian Herculeus
MLA Citation
- "Emperor Maximian Herculeus". Saints.SQPN.com. 17 August 2010. Web. 6 March 2015. <http://saints.sqpn.com/emperor-maximian-herculeus/>


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quote:im playing dcbjr this week and last night he left points on the bench. so im guessing he will be pretty inactive
quote:I have done my best to check my lineup, but I don't have the time to regularly check this thread every day right now.
quote:You rejected my trade so don't worry, your team will be locked shortly for the season
quote:gallo scored 15+ twice


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Drug Notes
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The haptoglobin blood test measures the level of haptoglobin in your blood.
Haptoglobin is a protein produced by the liver. It attaches to a certain type of hemoglobin in the blood.
A blood sample is needed.
Certain medicines may affect the results of this test. Your doctor will tell you if you need to stop taking any medicines. Do not stop any medicine before talking to your doctor.
Drugs that can raise haptoglobin levels include:
Drugs that can lower haptoglobin levels include:
When the needle is inserted to draw blood, some people feel moderate pain. Others feel only a prick or stinging. Afterward, there may be some throbbing or a slight bruise. This soon goes away.
This test is done to see how fast your red blood cells are destroyed. When red blood cells die, they release hemoglobin.
Haptoglobin attaches to this released hemoglobin, which is also called "free" hemoglobin. Free hemoglobin is not contained within red blood cells. The level of free hemoglobin is usually very low. But it rises when red blood cells are dying.
When the haptoglobin and hemoglobin attach, the new molecule goes to the liver. There, parts of it (such as iron and amino acids ) are recycled. The haptoglobin is destroyed.
When red blood cells are actively being destroyed, haptoglobin disappears faster than it is created. Thus, the levels of haptoglobin in the blood drop.
The normal range is 41 - 165 mg/dL (milligrams per deciliter).
Normal value ranges may vary slightly among different laboratories. Some labs use different measurements or test different samples. Talk to your doctor about the meaning of your specific test results.
Higher-than-normal levels may be due to:
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There is very little risk involved with having your blood taken. Veins and arteries vary in size from one patient to another and from one side of the body to the other. Taking blood from some people may be more difficult than from others.
Other risks associated with having blood drawn are slight but may include:
Schwartz RS. Autoimmune and intravascular hemolytic anemias In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine. 24th ed. Philadelphia, Pa: Elsevier Saunders; 2011:chap 163.
Sheehan AM, Yee DL. Resources for the hematologist: interpretive comments and selected reference values for neonatal, pediatric, and adult populations. In: Hoffman R, Benz EJ Jr, Silberstein LE, et al., eds. Hematology: Basic Principles and Practice. 6th ed. Philadelphia, Pa: Elsevier Saunders; 2012:chap 164.
Todd Gersten, MD, Hematology/Oncology, Florida Cancer Specialists & Research Institute, Wellington, FL. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.
For help in finding a doctor or health service that suits your needs, call the UPMC Referral Service at 412-647-UPMC (8762) or 1-800-533-UPMC (8762). Select option 1.
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quote:i'd rather a good smoke sausage in gumbo than andouille anyday
quote:You could use it as a pizza topping if you make your own pizzas.
quote:Look in the recipe book for my recipe for corn and crab bisque. In the recipe, I give instructions for making the same soup with corn and andouille. Great soup for this time of year.


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Mr. Sefrol wrote:Wait a flying freakin minute... I didn't get to say this on the last page, and looks other people noticed it too... but I'm reiterating that Nurse Jellybean looks like Endling's Lilith :I Some feedback on a yes or no to this would be wonderful.
As for the name drop, I'm also wondering if that was planned and will actually serve some purpose, or if it's just a joke they're wanting to drag on for a couple pages.
Return to Comic Updates and News!
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I've watched Gundam Seed and its sequel Gundam Seed Destiny.Keiran wrote:My friend named her dog after Lacus Clyne from Mobile Suit Gundam Seed. Has anyone else seen that? Great anime with mechs, war and guns... and a lot of really good characters dying.
It was good. It has more drama than any Gundam shows I've watched.
I like the Gundam franchise. I used to watch it whenever it's on TV.
Even own a few Gundam models stashed away somewhere.
What country are you from?Digimonadvent wrote:I seen it.
Sadly the version I have is in cantonese, so it's hard for me to understand.
No. I've never heard of it before.Digimonadvent wrote:Has anyone heard of an anime called "Transformers: Victory"?
But I did watched a somewhat similar one called Transformers: Armada.
I checked out the opening scene of that show you were talking about.
Looks like they turned it into some Super Robot show.


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Bow Neck Shell
Bow Neck Shell
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 A woven bow adds a splash of sweet to this soft jersey shell, with pleated details at the neckline and a banded hem for pretty structure. Jewel neck. Sleeveless. Solid trim at neckline and armholes. Keyhole back with button and loop closure.


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I was supprised at how watery the sauces were. Mine are usually a bit more paste like. The things that I was also amused by was the sausage that was put on the Chicago style was raw? anyone ever try this. I always cook mine prior to putting on the pie. Any comments???Pizzaholic
Yes, raw sausage is the best but alas I end up most of the time precooking the meat to at least reduce some of the fat.


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One day when she had just turned 4 I was bravely trying to bribe my way through a quilt fair with 3 small children. I let the girls each pick a fat quarter to keep them busy while I looked briefly. I was more than happy to buy this purple fairy fat quarter for the 4-yr-old because it guaranteed me a few minutes of browsing peace. We added it to the purple box and occasionally would get the fabrics out and look at them.
But somehow the purple quilt never materialized. In my defense, we moved to a new house almost 3 years ago which happened to coincide with the 4 month period of my daughter's life when she decided she was over purple and ready to move on to a new color scheme, and so we created this room and I made a fun new quilt for her bed, and felt like that was a great motherly effort accomplished.
But then the purple obsession returned and with it the guilt every time I looked at that box of purple fabric. The final straw came this spring when she was cast as the Purple Fairy in the school play, which seemed like some kind of divine intervention, and I knew that purple fairy fat quarter needed to come out of the box and get put to use.


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High waist brief controls tummy, hips and buttocks. Feel confident while slimming, smoothing and shaping your curves on the beach or poolside. A must have essential for the swim season.
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Innovative, fabulous new take on the swim suit for 2013. Confidence-inspiring, this new blouson design with hidden underwire is super sexy without being skin tight. Halter neck tie, banded bottom for shape. High waist control bottom sold separately.


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NIKE Men's Pro Compression Baseball Socks - 2-Pack
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PyRo wrote:Shitson, Rhys man this is hitting it off better than our ideas thread funny.......
Suggesting lurkers for enemies Oooo we would be soo screwd... Rhys we coulda soo incorporated heaps of this shit into our RP... mebbe we still can Undead Necromancers as playable characters (just the thought of raising the dude you just killed has some kind of irony to it... you kill them, they serve you till you/they die ). Warhammer Space/Chaos Marines, Tau, Eldar, Catachans, Imperial Guard, TYRANIDS Ooo they are sooo cool.... you can just think of something too.
PS: You shouldn't use the same character more than four times at max
Why do you think I like being a Necromancer anyway? I like killing people then bringing them back to life, under my control, until they die.
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Saturday, October 15, 2011
Quilting tip: Scant 1/4 inch
Typically lining up the edge of your fabric with the right side of your presser foot is a good guide for keeping your seam allowance consistent. You can buy a specific quiter's foot with a 1/4" seam allowance for your machine (newer ones may come with it) but if you're like me, I didn't want to spend the extra money and it seemed close enough. Then I took a class from Leslie Ison where she explained how much more effective it is to use a scant 1/4" when pieceing - especially when you are piecing a more complex block.
Above is are two seams on either side of a drawn line. On the right I just used my regular presser foot with the needle centered. On the left I adjusted my needle one space to the right and still used my regular presser foot.
Here is the difference. On the right you can see that the seam allowance is actually slightly bigger than 1/4". On the left you can see that the seam lies just slightly inside the 1/4" line. This, my friends, is a scant 1/4".
So get out your ruler and measure your seam allowance. Making adjustments may be as simple as moving your needle one notch to the right, but sewing with a scant seam allowance will make a difference in your piecing. Especially if your piecing smaller, detailed blocks - like those cute Farmer's Wife blocks. Give it a whirl and let me know if it makes a difference for you.
38 comments:
- Lurline said...
Nice of you to draw the 'scant' to attention - I've just recently started using it and is much more successful - very accurate!
Hugs - Lurline♥ - October 15, 2011 at 10:42 PM
- Rie said...
This makes sense to me - amazing - I'm gunna give it a go! Thanks for the tip!
- October 15, 2011 at 11:03 PM
- Crafty Newbie said...
Thank you. I have always wondered what that meant. Being a new sewer, I've never really had to come across anything that required it, but I have heard/read it in passing. :)
You're so good to us! Thank you for sharing. - October 15, 2011 at 11:14 PM
- mascanlon said...
Yep...it took me many years to figure that out...one little move of the needle over and it's amazing what a difference it makes!
- October 15, 2011 at 11:21 PM
- pinksuedeshoe said...
Hrrrmmmppph. My needle doesn't move to the right. Just one giant step to the left for zippers and whatever else you sew all the way over there. I do have a 1/4" foot, but I don't think I am as consistent with my seam allowance with it. But my regular foot is a little over 3/8" seams... which ends up being really big! Hmmm... must find a new solution!
- October 16, 2011 at 12:39 AM
- Sew Create It - Jane said...
Excellent advice! Once I worked out the difference my piecing skilled improved 10 fold. Good piecing = a happy quilter :o)
- October 16, 2011 at 2:15 AM
- Ann Marie said...
This works out great because when you have to press, that scant part is the fold from the seam to the top over the seam allowance bulk. It works really really well when you have lots of points you don't want cut off as well.
- October 16, 2011 at 2:47 AM
- Annabella said...
I`ve just bought a new machine and the quilter`s kit came with a quarter inch foot - is this the same as a scant seam? Before, I used to use a line of masking tape on the machine as I wasn`t able to move the needle right or left.
- October 16, 2011 at 3:14 AM
- Elisa Black said...
Thank you for this tip-- I think its a great piece of advice that I'm going to try!
- October 16, 2011 at 4:13 AM
- Katy Cameron said...
I discovered this recently (and actually have it on a post-it stuck to the machine, I'm that much of a dork) and it works so well!
- October 16, 2011 at 4:44 AM
- Jill said...
Thanks for this tip, I'm just about to start working on a block for a block of the month and was reluctant because I didn't love home my Farmer's Wife blocks looked! Will definitely try this!
- October 16, 2011 at 5:13 AM
- jlamanna said...
I have been sewing for about 45 years- but only quilting for about 4 months. Talk about the "aha!" moment...it never occurred to me to move the needle to get the scant 1/4 inch!! Thanks for the tip!
- October 16, 2011 at 6:06 AM
- Michele said...
I have a 1/4" foot that came with my machine and I couldn't live without it. It gives me the perfect seam allowance every time. For those who don't have one, it is definitely worth the investment.
- October 16, 2011 at 6:23 AM
- Jenny said...
My 1/4" foot was only $5 -- and well worth it because I can't move my needle either (a Janome mechanical). BUT . . . you have to check your seam regardless, because the first 1/4" foot I bought was defective -- nowhere NEAR a scant 1/4". I had to exchange it for one that was right.
- October 16, 2011 at 8:35 AM
- Lynn Brown said...
I SO wish I had known this before I started the quilt I'm currently working on. I had no idea what it meant and was just eyeballing it, so now I've got wonkiness. Thank you for clearing that up for me!
- October 16, 2011 at 9:29 AM
- Missy said...
Thanks for this info! I used to use the right side of my foot, then I switched to the inside of the right side of my foot which was a 1/4 in. That'll be so much easier if I just move the needle. GENIUS!
- October 16, 2011 at 10:17 AM
- amy smart said...
@Annabella - I don't have a return email address to respond to your comment, so I'm hoping you'll see it here:
So nice that your machine came with a 1/4" inch foot. I would just sew a seam and measure it with a ruler to check and see if it's a scant 1/4". If not, the masking tape is definitely another good option. - October 16, 2011 at 11:11 AM
- Elena said...
Thanks Amy! I love the idea of just moving my needle over a bit, instead of putting my fabric along a different seam line. Great idea!
- October 16, 2011 at 12:45 PM
- Kristen said...
It's amazing how that smidge helps when you sew!! Good advice!!
- October 16, 2011 at 4:10 PM
- amylouwho said...
yes! this is genius!! I have a 1/4" foot but I don't think it's genuine bernina because it doesn't fit my machine well and it's super slippery. I think i'm going to ditch it and start doing this. you just changed my life!!
PS - do you have an Bliss laying around? - October 16, 2011 at 5:54 PM
- amanda said...
I think you just solved all my problems and made all of my wildest dreams come true. Move the needle! *smacks forehead* Now why didn't I think of that? ('cause I'm not you, that's why!) THANK YOU!
- October 16, 2011 at 6:52 PM
- Thimbleanna said...
My blocks are always much more accurate if I use a scant 1/4" -- I love it!
- October 16, 2011 at 7:20 PM
- L'amore del fare said...
Only yesterday the exhibition of the hobby of Rome, I discovered the basics of quilters. It 'nice to see how much passion and love are created these masterpieces. Congratulations you are very good! I follow you always with pleasure. Hello!
- October 17, 2011 at 1:28 AM
- Linda said...
You know, I have read so many blogs that talk about using a 1/4" seams and I really didn't get it until I saw your visual. I had been trying to figure out exactly where is the scant? lol Thanks for the visual!
- October 17, 2011 at 7:59 AM
- kendascrafts said...
Wow, I just had an 'aha' moment. I've heard people talk about scant 1/4" seams but never really got it. Thanks so much for the visual, that's exactly what I needed!
- October 18, 2011 at 8:40 AM
- sunny said...
Thanks for sharing this! I know that's it's better to use a scant 1/4", but it never occured to me how simple it would be to achieve it. duh.
- October 18, 2011 at 10:04 AM
- theygrowuptoofast said...
Thanks for the tip- I'm going to measure mine and see how accurate it is.
- October 18, 2011 at 10:29 AM
- Sarah Kay said...
THANK YOU!! I spent SO much time last quilt measuring twice over and STILL not having the seam allowances right. I can't wait to try this tip!
- October 18, 2011 at 3:16 PM
- Kim said...
OMG!!! I'm so glad I read this before I started my new project... it's my 3rd quilt and I did as best I could with the first two... just wanted to tell you that I'm 2 blocks in and I can tell the difference in how the pieces are going to fit together. Thanks for the explanation and hint... although my needle only moves to the left so I feel backwards. :o)
- October 18, 2011 at 8:11 PM
- AnneMarie said...
You know, I've been quilting for 6 years and it took going to the Summit for me to FINALLY measure it up and resign myself to adjusting my needle position every time I turn on my machine to get the scant 1/4". WHAT a Difference!! Funny you should post this like 3 days after I finally saw the light!
- October 19, 2011 at 1:51 PM
- Kell said...
Thank you for the visual! I have a new Janome that comes with a 1/4" foot. I checked it before I started a new quilt & still is bigger than a 1/4" if I go by the guide. I had to move my needle over to the right & I'm going by the 1/4" mark on by extension table for right now.
- October 19, 2011 at 7:34 PM
- Erica said...
Thanks for the tip! I've been using the edge of my foot and some of my blocks aren't turning out correctly. Maybe this will help me.
- October 22, 2011 at 8:25 PM
- kait. said...
It's good to hear you say this Amy! I recently realized that my Singer's 1/4" measurement is more than that! I'm working on the Swoon quilt right now and find my HST aren't quite large enough so I'll definitely be switching to the scant measurement. Thanks!
- October 25, 2011 at 10:01 AM
- Tanyia said...
I just found this and wanted to thank you so much for explaining it so perfectly ... I didn't even know I could move my needle! Now I know the exact number to program it to to get the perfect seam!
- January 19, 2013 at 11:06 AM
- Wanda said...
Measure out 1/4" from your needle. Then place a piece of tape on your machine bed, so that guiding fabric along the edge of the tap ewill allow you to achieve a seam that is just slightly less than the 1/4".
- October 2, 2013 at 7:28 AM
- Wanda said...
No, chances are it will give you a regular 1/4" seam or maybe even a bit more than that, just as the author of the blog found when she tried her's out. Just move your needle to the right a notch. That should do it. Move the needle over and test your 1/4" foot with it. If you end up with just slightly less than 1/4", you will have the 'scant' 1/4" seam.
- October 2, 2013 at 7:30 AM
- Wanda said...
Unless you move your needle position, it probably still will not be a 'scant' 1/4". I used to figure that as long as I was consistent, it was OK. But using the scant 1/4" seam really does make a difference.
- October 2, 2013 at 7:32 AM
- Marie Atkinson said...
Excellent advice! I have used a scant 1/4" for years and it does make a difference.
- October 16, 2014 at 10:18 AM


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Chickenpox is a viral infection in which a person develops extremely itchy blisters all over the body. It used to be one of the classic childhood diseases. However, it has become much less common since the introduction of the chickenpox vaccine.
Varicella; Chicken pox
Chickenpox is caused by the varicella-zoster virus, a member of the herpesvirus family. The same virus also causes herpes zoster (shingles) in adults.
Chickenpox can be spread very easily to others. You may get chickenpox from touching the fluids from a chickenpox blister, or if someone with the disease coughs or sneezes near you. Even those with mild illness may be contagious.
A person with chickenpox becomes contagious 1 to 2 days before their blisters appear. They remain contagious until all the blisters have crusted over.
Most cases of chickenpox occur in children younger than 10. The disease is usually mild, although serious complications sometimes occur. Adults and older children usually get sicker than younger children.
Children whose mothers have had chickenpox or have received the chickenpox vaccine are not very likely to catch it before they are 1 year old. If they do catch chickenpox, they often have mild cases. This is because antibodies from their mothers' blood help protect them. Children under 1 year old whose mothers have not had chickenpox or the vaccine can get severe chickenpox.
Severe chickenpox symptoms are more common in children whose immune system does not work well because of an illness or medicines such as chemotherapy and steroids.
Most children with chickenpox have the following symptoms before the rash appears:
The chickenpox rash occurs about 10 to 21 days after coming into contact with someone who had the disease. The average child develops 250 to 500 small, itchy, fluid-filled blisters over red spots on the skin.
Most pox will not leave scars unless they become infected with bacteria from scratching.
Some children who have had the vaccine will still develop a mild case of chickenpox. They usually recover much more quickly and have only a few pox (fewer than 30). These cases are often harder to diagnose. However, these children can still spread chickenpox to others.
Your health care provider can usually diagnose chickenpox by looking at the rash and asking questions about the person's medical history. Small blisters on the scalp usually confirm the diagnosis.
Laboratory tests can help confirm the diagnosis, if needed.
Treatment involves keeping the person as comfortable as possible. Here are things to try:
Medications that fight the chickenpox virus are available but not given to everyone. To work well, the medicine usually must be started within the first 24 hours of the rash.
Do NOT give aspirin or ibuprofen to someone who may have chickenpox. Use of aspirin has been associated with a serious condition called Reyes syndrome . Ibuprofen has been associated with more severe secondary infections. Acetaminophen (Tylenol) may be used.
A child with chickenpox should not return to school or play with other children until all chickenpox sores have crusted over or dried out. Adults should follow this same rule when considering when to return to work or be around others.
Usually, a person recovers without complications.
Once you have had chickenpox, the virus usually remains dormant or asleep in your body for your lifetime. About 1 in 10 adults will have shingles when the virus reemerges during a period of stress.
Rarely, serious infections such as encephalitis have occurred. Other complications may include:
Cerebellar ataxia may appear during the recovery phase or later. This involves a very unsteady walk.
Women who get chickenpox during pregnancy can pass the infection to the developing baby. Newborns are at risk for severe infection.
Call your health care provider if you think that your child has chickenpox or if your child is over 12 months of age and has not been vaccinated against chickenpox.
Because chickenpox is airborne and very contagious before the rash even appears, it is difficult to avoid.
A vaccine to prevent chickenpox is part of a child's routine immunization schedule. For information, see: Chickenpox vaccine
The vaccine usually prevents the chickenpox disease completely or makes the illness very mild.
Talk to your doctor if you think your child might be at high risk for complications and might have been exposed. Immediate preventive measures may be important. Giving the vaccine early after exposure may still reduce the severity of the disease.
Myers MG, Seward JF, LaRussa PS. Varicella-zoster virus. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA: Saunders Elsevier; 2007:chap 250.
American Academy of Pediatrics Committee on Infectious Diseases. Recommended immunization schedules for children and adolescents--United States, 2008. Pediatrics. 2008;121:219-220.
This article uses information by permission from Alan Greene, M.D., © Greene Ink, Inc.
Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Bethanne Black, and the A.D.A.M. Editorial team.
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text:
quote:Trajan Langdon
quote:Williams needa minutes. He can still do.something
quote:these stats have decreased from last year to this year: FG% FT% TS% p/40 r/40 a/40 b/40 his PER has decreased by more than 3 points again, he's already 23. he's towards the end of his developmental curve
quote:he can't crack the lineup when even when the starter (Love) is out.
quote:So basically what you are saying is you haven't actually watched him play.
quote:Most of the plays Faried makes aren't measured by stats.
quote:Oh and FYI its normal for a player's rate stats to go down when they first start playing more minutes.
quote:Did anyone say J. Noah?
quote:Rashad McCants is a great one. How that guy fell off the face of the earth as fast as he did is unbelievable.


text:
quote:For Squirrels- Mighty KC
quote:Man no one listed "the freshmen" - verve pipe??
quote:mmmm mmmm mmmm - crash test dummies.
quote:Superman's Song got a lot of airplay before that one and was way better (as was nearly everything on their first album).
quote:soul asylum - runaway train
quote:They also had a song named Misery that was kind of hit. It sucked though.
quote: They also had a song named Misery that was kind of hit
quote:You crazy.
quote:The Verve's Bittersweet Symphony
quote:Counting Blue Cars - diswalla


text:
Objective: Uniform standards from Lisbon to Vladivostok Opublikowano w dniu : 15/12/2013, Ostatnia aktualizacja: 17/12/2013
While the European Union and Russia are already strong trading partners, differences in standards still prevent truly unfettered bilateral trade.
To remedy these differences and unleash the potential of this partnership, European standardisation authorities and Russia signed a landmark agreement that will promote cooperation and enable easier, more profitable trade.
Divergent standards are frustrating for consumers and businesses alike, but they can cause even greater headaches when they happen on a larger scale. Entire companies, or even entire industries, might be unable to sell their products abroad because of differences in domestic and international standards.