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Actually this guide is for every new player and here i am going to add all details, of which i am sick and tired to repeat every time i want to train a new player enough to put him on his feet. First of all this is a guide only for those that want to get better and more competitive and not general game information. This includes getting cards, deck building, strategies, promotional in game events that improve your card variety and even guilds. It's for free players and spending players, should it fail for free players or low spenders (which currently i think it dosn't), then it means there is some free player bashing done by the alteil system, or there is some card imbalance (which is more often the case).
I am going to even skip stuff like the introduction, registering and account settings: http://alteil.com/rulebook/index.php?page=introduction. This means you have to find out the extras such as alteil story, out yourselves. If you want to be competitive right from the start even a bit, just follow my guide step by step the way i describe it and without questioning it. If you don't like my teachings, then just go back to your fun-playing, but this guide is something no new player should ignore!
Players must have patience to first learn game mechanics and all sorts of basics before they start to edit their decks or use up their gran or FM (fighting money).
Rule #1 When you first start, you should make 4 accounts (one for each sphere), right from the start. Nobody was born choosing the sphere that suits him best. There is FM lotto that allows you to gain the other starter cards, but if you don't take the journey from 0 with every starter you will gain far expierence in how you can progress and improve decks.
Rule #2 Then you go to mirrage master (a mini game inside of alteil; to get there click the purple button found on MY ICZER section inside the game). It's a "find the pairs"-type of memory game that gives gran once between one server mentainance time and the next. First click the beginner button and then select the 3 stars from the drop down menu, but if you have epierence with memory games click intermediate and then select 3 stars from the drop down menu. Find all pairs before the timer and your flip-tries run out and do this each day on all 4 accounts. There is currently no alternative to it of getting daily gran.
Rule #3 Learn the basics.
Mastering the basics of gameplay
Now you need to learn the game mechanics. You click MY ICZER and then the blue button (that got Alteil written on it). The tutorial that shows up after you select your sphere can be just skipped if you want. I did watch the tutorial when i first started but i only understood how sphere and SP works from it, the solo player training mode is probably much more useful than that.
Dueling with the bot in the solo arena (the dark green colored one) is the easiest way to learn the basics about dueling in alteil. Remember the bot dosn't lose its patience and will wait for ever for you to make a move, playing against the bot also has no negative effects on you, just make sure to play the level 1 first and adapt to it. The game mechanics are simpler than you can imagine so i won't go into detail about them, but the links below are those that really count and should be able to assist even the slowest learner:
- helps players understand basic terms and how attack, range and some skills work: http://alteil.com/rulebook/index.php?page=glossary
It dosn't explain counterskills but "Counterskills are triggered when the unit is hit, but does NOT go below 0 HP. (As opposed to Close skills, which are triggered when the unit is hit and does go below 0 HP)"
- helps players gain basic card types knowledge: http://alteil.com/rulebook/index.php?pa ... statistics
There is also a backlash effect that you need to consider when playing any cards. First of all if 2 players play the exact same card (has to have exact same name) then both cards are "backlashed", they are sent to the graveyard and the SP invested in them along with whatever big plans you had for them are gone.
Then there is character backlash they follow the "there can be only one" rule, so even if my dalos is closed on the field, don't even try to play yours since you have to wait until it gets completely removed from the field and only then you may play him.
- helps players understand how exactly soul cards and soul skills work: http://alteil.com/rulebook/index.php?pa ... soul_cards
There is something not true written about 3 LP soul skills there. They are not all bad, there are for example good soul skills such as Dance Macabre / Leilen, that in certain decks is a huge plus.
- This is the order of skill activation "Rank Up (only for Gowen), Openskill, Start Skill, Auto Skill, Action Skill, Counter Skill, Close Skill
All of these skills are AGI dependent. If a card has no AGI as in a grimoire, the order is randomly chosen, but grims always go first."
- This is the order units get removed "Cards die in a first in, first out style. That mean whichever card got closed (the card has lost all it's hit points and is flipped over) first, leaves the board first. This continues until all closed cards are removed from the battlefield. Cards that target a row or column of enemies work as such; if they kill more than one card, they die in number order. The battlefield position 1-9 determines which card leaves first.
As for Tempest, whoever casts Tempest, their cards die in order from 1 through 9 and then your opponents' cards die in the same order. Be careful with its usage!"
The Valuables - these are important to increase your card pool (following block of text is also for just knowing the basics)
To this category counts cards most of all, gran, experience, FM, point cards and award cards(the ones with a pink koala on them that are hardly ever found in the lottery, they give 150 gran). Avatar items are also very important even if they don't help you improve your decks, they improve your in-game avatar.
- FM is the easiest to get of all those and you get it by dueling in regus, crest or folrart arena (20 for losing a public game and 60 for winning a public game - i suggest you play only public games since private games offer half of that). You also get FM by playing mirage master after you completed your daily gran round, best level of getting FM from MM is the beginner 3 star.
With FM you can get point cards (currently 2500 FM = 1 point card ) and avatar items.
- Gran is obtained through special events, by playing at least once / week in regus, crest or folrart (You get 2 Gran for a win, 1 for a draw, and –1 for a loss. Also, there is a minimum of 10 Gran for every qualifying Iczer) or by simply purchasing it.
Gran is the easiest way that allows you to get cards.
- Expierence is gained only by dueling, loser gets always only 1 XP and winner gets [(diffrence in level if your level is lower)x2 +10 x1.5(if you play a public game)], those below level 20 gain extra 10 xp when they win.
It's important to level up since you get cards from leveling, here are the details: http://alteil.com/rulebook/index.php?pa ... l_up_cards
- Point cards are gained from special events or with FM.
Point cards get you any card of your choice, that means they are very important at getting exactly what you want, so keep them for the 4 and 5 star cards, which cost 50 and 60 point cards per piece.
- Cards are also obtained from treasure battles, GM battles and some special events. Sometimes in the arena you get to see a card at the start of a game and if you win you get that card. GMs all drop a 3 star rare. (chances are you get a higher rarity card vs a player).
- There are potions in the shop that give you FM or treasure card chances or XP, but smart players ignore those, because they know the potions suck and are quite useless most of the time.
Rule #4 Duel at least once each week to get at least the 10 weekly gran.
Special Events
I will update this part as often as i can. Try to participate in all of these, they add more fun to the game and some help you know the game better. It's also much easier to learn the game and the cards and find out strategies by participating in these. Currently there is:
Beginner's Quest - anyone who newly joins the game gets an mail in his ingame inbox with quests, each time you comeplete a quest you get a reward and the quest itself helps you gain knowledge about some basics about the game. It's a one time only quest and do try to take this before reaching level 3.
Arakis' Quest - details here: http://www.alteil.com/index.php/arakis-quest
latest challange: level 1 cards - http://alteil.com/index.php/articles/1- ... 2410-6710- (submission deadline 6/7/10)
Description: A very interesting contest that encourages a diffrent way of thinking from the ordinary. Sure you don't usualy struggle to find good level 1 combos or such, but for the sake of practice i suggest you should join this event since you never know when they gained knowledge might become useful. This contest seems to actually care how much of a "top dog" your submitted deck is, which is what makes it into a real challange. The submissions are judged by Arakis.
At the very least you could try to come up with some original and interesting idea for a quest, you never know how original your idea might be.
I have to say this a really great event, try to participate when you have time.
Community Managed Tournaments - details in the threads opened by those who felt like managing them (i managed some of those, give me five )
latest challange: Random Team 2v2! Details here:
http://www.alteil.com/forum/index.php/topic?f=27&t=5448 (tourney will be on 12th june)
Tends to have diverse and interesting types of challanges. Up till now it took place during the weekend.
Rule #5 Keep your gran and stick around for a while until you find out what cards you would like to get.
This rule applies to anyone and everyone who isn't rish or too damn good for his money, so he needs to get rid of them somehow.
Which cards should one get
Nobody knows that better than you! First of all you need to understand the strength of all or at least most cards so you do the right choice when deciding what set to buy from or if you should lotto. I suggest aiming for top decks or for cards that directly improve a bit or a bit more your deck. Note that in this game you can't always do gradual improvement since decks tend to be very different from eachother, even when it comes to top decks.
There are card reviews to help you decide what cards are better and what cards are lacking:
http://alteil.com/forum/index.php?f=15& ... =viewtopic
You won't find reviews for all cards there, but at least some of you might get enough help from those review threads. They are not 100% accurate since there are always small things left out when they are reviewed, but they are generally right about the cards.
- Keep in mind there are cards that counter specific combos or cards, those counter-cards are also important to get as long as you know you can actually include them in one or two of your decks once you get them.
- There are EX cards that are available to get exact copy of only for a limited time once they get released for the first time in the US version. After that there is only the chance to get them in the lottery and getting them with point cards is currently impossible, maybe one day they will fix that issue.
Rule #6 Try to know the players, it might help in many ways.
Enter the chat room and talk with the others. It's not like those guys discuss alteil most of the time, actually there is more talk about other stuff than about alteil (at least that's what i noticed). Nobody is discouraging you to start a topic you would like to talk about, also you don't have to join the currently most active chat, you could just create your own chat room with a different room title.
Currently there is that "scroll down" chat BUG, yes it's a bug and not a feature, it's a damn bug since it's bugging people and it would be nice if someone finally removes that.
Just ignore it for now until they finally decide to fix it and have a talk to other iczers. It's one of the ways to help out the game and there is room for everyone, or at least you can make a room for everyone's taste. Also when you duel spectate enter the duel's chat and see what others comment on the game or you might even ask questions to understand the decisions one made better.
To the chat rooms and generaly in games your avatar counts too, i really think that dropping a bit of FM at the start to buy some avatars that are a bit hilarious is important. Fancy or funny avatars sometimes start conversations between iczers (if they are amusing enough at least). It dosn't have to be extremly charming, but you got to admit that in most games decorating the character the right way means a lot, same goes for alteil, even if it's not very visible at first. Personally i first take care of spending my FM on avatars, not say that you have to do the same, but look there are even players that sometimes feel like getting back their FM spent on the point cards.
To "socializing" in alteil belongs creating or joining guilds. This is partially supported by the chat, with the help of the chat you might find easier players that you want to form a guild with. Having a guild means you could also request a guild forum for your guild only which will also have its own password. In your personal guild forum you could discuss strategies, in-game progress or other stuff with your fellow guildies.
If you are just looking to join one then check the weekly guild rankings (http://alteil.com/index.php/rankings) and see which ones were there somewhere in the top, the higher the points, the more activity (usually) that guild has and mostly players from those guilds join the chat. So i say join at least to spy on them, it helps for sure. Look there are 1 player guilds that are there in the top, those guys don't communicate so much, otherwise they might join up with eachother and form a 4th or a 5th ... or an n-th top guild. Communication is very important, that's how Royal Flush appeared and i am trying to say that if people try hard enough they might create the next #1 guild that tops any other guild. There are also guild events, which encourages creating guilds.
Besides what kind of badazs can you be without in-game friends?
Rule #7 Practice makes the master. Outsmarting your opponent and good intuition can sometimes beat a stronger deck than yours!
Strategies & Finding Your Flow
- One must start first with trying out the all 4 spheres. Finding the sphere that fits you best is most important thing to do first, any sort of improvement is done better after that. I said to make 4 accounts one for each sphere to see for yourself which one suits your best, but beware since there is a best choice there is also a second best choice ... make sure to test long enough the spheres so you don't pick the 2nd or 3rd most fitting one for you. Otherwise it will take extra time to adapt to the playstyle of that other sphere instead of actually starting with the sphere that is easiest to learn for you. Also the refess and lawtia starters take time to become a bit better, that means it would be wise to play on them until level 10 or 15. Around that time you have an ok beginner card pool and can see for yourself if you can make anything better out of it than from the cards you have on your falkow or gowen account.
- Playing the other spheres also helps understanding the weaknesses and strengths and how most players might use them. You might also understand how the other spheres or decks work, by just playing a lot against them or seeing often how they are generally played. What you are learning is the flow of those spheres / decks. By knowing the flow you might be able to disturb it by outsmarting the opponent and also by adding 1-2 counters that you will use then when it hurts the most.
- You don't need to go through the strategy article section. There won't be anything there that this guide won't help more with.
"Card Spotlight" just reminds you of a card that probably has been ignored and dosn't matter anyway or of a card you get to see in use anyway and learn how others use it without wasting time to read that.
"Modifying Card Files" this is just a general idea section and the one current example listed there is not something i would recommend.
"Articles" section has general ideas of how the game works, but those just display facts and statistics. Something many people don't need to rely on when they play the game or build a deck. If you want go check it out, but know that it's something you must overcome and be able to not depend on, since once you know the flow of the game those will be completely useless. (http://alteil.com/index.php/strategy/articles , seriously ignore the "combo spotlight" article)
What cards or card combos are good, is usually obvious or will be noted fast anyways, no article needs to tell you that and what the articles don't tell is decks in which they are good and exactly how those work, which is usually discussed between "alteil-friends" so that's another reason i recommend joining a guild.
This is all just theory and what you really need is practice and to observe and see for yourself how things work. So i suggest you check out the video section instead: http://alteil.com/forum/index.php?f=33& ... =viewtopic
- Mastering the points above helps with understanding how decks work, so you have a basic idea of what they are made of. Because of this you might be able to easier understand what counters to add to your deck in order to win against a certain deck. For example you might be afraid as a new player of high levels, but if you understand how counters work (for example using fierte soul skill against big decks is a counter since it cripples their strategy) you know how to counter their decks and those "elite players" won't be anymore "a loss", they will be "xp bags" in case they are high level or they will be just another win in case you are about same level.
- Note that some people might add cards to their decks to overcome counters. For example stardragon deck can counter EM(eternal morning), but some add an assassin (a counter to big units such as dragons) in their soul cards to kill your dragon. That's a counter to the counter, but then you can also add a counter to that counter, which is shear winds played at the right moment (in case you have enough SP).
Rule #8 Whatever works, works. There is no room for second thoughts and don't let others decide for you what's good and what's wrong.
They are just hateful ignorants that care about their winning and their own fun (not about yours), so they come up with excuses that might sometimes sound "reasonable" enough for you to fall for it.
Deck building & Deck editing
- A deck first of all must have a specific strength that makes it stick out and by abusing that strength you are able to make a powerful deck. There are strong decks that have no real strength in any category, but they are able to hold their own and have decent or mediocre ways of countering the rival decks. Modified starters fit best into this description. Starter decks have average to low strength and overall only mediocre options to outplay the rival iczer, no direct counters, except for falkow since it has return and sylphs right from the start.
- At first it's good to just obtain few cards, try to slightly improve your starter deck and see how well the changes made have improved it. You don't need to rush anything, it's ok if you just keep the gran and study the cards available with gran purchase. At the same time note that even the regus and crest arena have observer options and viewing games there help you as a beginner with few cards more than spectating in folrart might help. At least if you aren't a hardcore spender it's good to first master what you got.
- The next step in learning how to build decks might be trying to imitate or even copy some stronger decks. You do need to have at least half the cards from the deck you try to imitate otherwise it will be an ugly useless mutant deck. Copy catting dosn't imply skill in deck building at all, but it helps you understand how decks work and look like, and by playing those decks you understand their flow.
- If you completed the above tasks or are at least half way done, you have a general idea of what cards you need and what to get and also you can still go back to cards reviews and check the forums and recent decks to see what of the new cards are used. So when there is an EX pack you can decide if you should keep the gran or not, you will be able at this point (in my guide) to know which of those cards or other cards directly improve your deck or allow you building up a new decks with a new type of flow that can hold its own.
- Whatever set we are in or whatever the card balance might be, it dosn't matter, same goes for the top decks, because what you want is to be able to beat even those eventually. Try to overcome with one deck all your obstacles, slightly modify and keep testing your new or older tweaked decks to be able to beat some of the nasty popular ones. You can end up copying, there is no issue in that, why should other play it and you not? Also you want to win, since that's the only way you justify you are good and nobody can deny it. And if a deck is overused by many players there will be the high chance of it getting a nice nerf bomb up its precious. For example, if you feel like it, then start also playing shrine knights, who cares about what others think, they are just mad they get beaten up and besides why not help at getting something outstandingly strong , that also makes the game boring, get a nerf?
Best weekly activity
Remember to duel in a ranked arena (regus, crest and folrart) only after you mastered a bit the basics, there is a week time to get that 1 duel (win or loss) for the 10 gran. After you win or lose that 1 duel take care of the other things that help you gain something:
- play on the other 3 accounts you made to understand how the other spheres work
- check out the special events that are currently up and try to participate in all or at least most of them
- then after completing the 2 tasks above and in case you won that last duel and feel like dueling again in a ranked arena, go for it.
Otherwise (in case you lost) go to training arena or to the solo arena, to fight against other players there. Also in those 2 arenas you can test decks that you built yourself. In case you don't want to play just go spectate some games or do something else. Just remember that first you need to improve and be able to grab the game complexity well enough to duel in a ranked arena.
- avoid losing! In order to do that switch decks, build new decks if necessary and test them, have some counter decks ready for when people overplay a certain deck (for example people overplay shrine knights so your move should be to play something that can counter them, star dragon or lycan rush might help sometimes ...) Fact is nobody will give you wins or gran or treasure battles for free unless they are very careless, so you need to fight for it.
- try visiting the chat room or at least open your own room with whoever knows you more or likes to talk to you
Below you can see a guide for each sphere. I will even list there top meta decks for each sphere, probably not all, but it will help you counter them with what you have and also those guides are meant to help you out with the sphere or starter deck of your choice.
This is the end of my general guide about how to play alteil and those that wish to follow my lead can be my in-game friends.
Good Luck!


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Rasgullas...!!!Author: Siddhi Shirsat // Category: Desserts, Sweets
- 1 litre whole milk
- 2 table spoons of lemon juice/vinegar
- 2 cups sugar
- 5 cups water
- 3-4 tea spoons maida(optional)
- 1 tea spoon cardamom powder
- 1 tea spoon rose essence
I love rasgullas and I miss Kolkata's rasgullas... Yours have come out really well and am sure would taste yummmm too:)
Hi Siddhi
your rasagullas look so Yummy. I can almost grab a few of them. Thanks for sharing such a great sweet preparation with all of us.
Hey Sidhi
I am basically from Orissa and as every one know that Rasgulla is one of famous sweet in Orissa and Bengal, it is my first preference in sweeet.Few days back i made rasmalai and was thinking to make Rasgulla in coming days.Any way it is looking perfect.
woow!!!what a lovely rasagulla..looks so so yummy......
Rasgullas looks absolutely marvellous and tempting. Being Bengali I love rasgulla very much and feel like having it now. Looks soft and perfect.
Hey Siddhi,
tempting rasgullas.. i tried once and it turned out hard.. will try your version..
one more question for you.. how do make paneer cubes?
Hey Sidhhi
can u parcel those rasgulla to me please...Love love love them...looks so tempting and yummy...you are a great cook!!
Looks mouthwatering dear...yum yummm
Rasgulla looks amazing. i haven't made yet.
Soft, tempting and juicy rasgullas...yumm!
Reminds me of school days in Calcutta...yummm-ooo!!
Me toio :-) love love Bengali sweets ..You are making me crave for these rasgullas right now
my favorites are the bengali sweets..., its high time i make rasgullas..my favorites !!
Dear Siddhi
This is not the right way to turture ghosh uncle who is sitting at a place, where no Rasgulla is available..
Jokea apart , very well presented, I have failed to make Rasgulla so far even after expert instruction from Sangeeta on her blog..
Bengali Rasgulla is devoid of all maida and suji...
best wishes
Ghosh uncle
Wow Siddhi...
You prepare Rasgulla yourself ! Amazing... I haven't ever till now, or to put it better way haven't even thought to prepare them at home.... :)
Your post is inspiring me now to try it :)
Hey Siddhi, I am a big fan of Rasgulla's too..I mean give me any bengali mithai..and i would never say no to it....loved your step by step method with tips I guess..want to try soon..
Rasagullas look so tasty and inviting Siddhi...thanks for the step by step method :)
Looks great with step by step method, thanks for sharing.....
My favourite sweet. Nice procedures.
Its come out really perfect and one of my fav sweet dish as well...looks so tempting...
Hey Siddhi,Wow you really made a big attempt and succeeded too, Congrats!!! Liked ur small tips during the procedure.
gulab jamun & rasgulas are my favorites.
Wow... you sure can cook delicious rasgullas. these look perfect... I still have to muster up some courage before I attempt to make them...
yummy and delicious....
hey..they look awesome.. long back i had tried once and failed.. am tempted to try again..
juicy rasgullas!!
Hi Siddhi, tks for visiting me ya! ;) U've got an awesome space here with lots of foodies!!! Want some rasgullas pls!!! :)
Following U :D
Mouthwatering!!! Such a cute and yummy rasagulas..
I need help for making homemade paneer cubes/chunks.. for paneer curries
Siddhi, you are tempting me sooo much to make ras-gullas at home!! Picture looks so delicious.. I am just staring at my screen looking at these awesome treats..
I am foodie .. excellent they look wish i can make as good tooo.. loved the chicken preparations tooo
I am drooling! Fantastic Job dear!
Thanks for the help Siddhi.
Lovely rasgullas sidshi. I love milk sweets. Rasmalai is my fav.
aree yaar sidhhi, your blog makes me hungry everytime I come here....love those rasgullas....
Bengali sweets tops first in my list...love all the variety..
Ur rasgullas are very tempting perfectly done..I am sure it taste as sweet as it looks....
I love Rasgullas but never tried them at home !
You've inspired me to try this one .
Hey Siddhi,
May I have your email id
I love bengali sweets..they are so rich in taste..these look so mouth watering..yummy..
soft 'n yummy rasgollas... my all time fav...
Rasagullas are my all time favourites!!!your is looking really yummy and have come out really well....
Hullo Siddhi ...had to reply to u here too though did on my blog too....love ur blog too and yeah ur rite in my reader too but where my blog is concerned my new feeds aint updating and thats so sad....
thanx a ton ....am so glad to have u over...and ofcourse i'll be there over....again at ur next post...
And if u have any tips for me -my new posts dont update for the last 3 weeks and have tried it all including leaving loads of messages at the google forums...sigh ...sigh and any help is welcome dear....
I followed ur recipe. But after putting rasgullas in sugar syrup,affter 10 min they started cracking.I mean they are not soft as u had shown, Why so?
Did u follow d same procedure exactly?...u must keep the gas flame very high n sprinkle little cold water after evry 5 mins as i hv told. You must also kned the chenna well so that it binds well with maida. evn milk used should be fresh or else it leaves fat while cooking and this leads the rasgullas to break.If u hv followed all this steps thn m sure rasgullas wont ever crack while cooking.
Hi Siddhi,
When you say 2cups sugar and 5 cups water for 1litre whole milk, how many grams of sugar should we consider or how much should the cup size be?
Please clarify on this...
Hi Siddhi,
When you say 2cups sugar and 5 cups water for 1litre whole milk, how many grams of sugar should we consider or how much should the cup size be?
Please clarify on this...
Hi Siddhi,
When you say 2cups sugar and 5 cups water for 1litre whole milk, how many grams of sugar should we consider or how much should the cup size be?
Please clarify on this...


text:
|Susanoo Bow
|Volume #51, Naruto Chapter #478
|Naruto Shippūden Episode #210
|Naruto Shippūden: Ultimate Ninja Impact
|Naruto Shippūden: UNSG anime cutscenes
|Appears in
|Anime, Manga, Game
Sasuke's completed Susanoo displays an unusually shaped bow on its left arm. The arrows it uses are produced in an orb in its third hand. The arrows fly very fast and have great piercing power, going through a tree created by Wood Release with ease. Kakashi, a ninja with impressive speed, resorted to using Kamui to warp the arrows away due to the impossibility of evading them. The bow also doubles as a shield which is strong enough to withstand powerful Wind Release attacks. The thickness of the arrows can seemingly vary according to the users choice to suit the situation.[1][2]
- After acquiring his Eternal Mangekyō Sharingan, Sasuke's Susanoo was able to wield a blade composed from the black flames of Amaterasu, which ignited anything that it pierced.[3] However, it is unknown as to whether it can too be used as an arrow.


text:
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Chris Rahi Kassab
DATE: Will be calculated from "Release
Start Date" field.
That work led to the redevelopment of the Ford Production System (FPS) – a standardized, structured system that would engage plant employees and provide a consistent foundation upon which to make continuous improvements.
Once the foundation for the FPS was laid, Ford began the process of implementation – learning and building capability – and by the end of last year all of Ford's manufacturing facilities were implementing to a level of 74 percent globally.
Now is the time to begin reaping the benefits, according to John Fleming, executive vice president, Global Manufacturing and Labor Affairs, who has dubbed 2014 the "Year of Traction."
"Traction is about the system taking root and us achieving the benefit of everyone in Global Manufacturing engaged working together within the standardized framework that our production system provides," he said. "This will enable us to realize the benefits in safety, quality and flow that comes from each of our teams around the world working to improve the business in a consistent way."
One important factor that will be watched very carefully in the coming year is a measure of success called "the velocity of improvement," according to Adrian Price, director, Global Manufacturing Business Office.
"What we will be looking to see is how fast we are improving. Obviously our goal is to get to best-in-world results and that doesn't happen by magic. It happens by hard work and engagement from everybody in the organization," he said. "We have put tools in place through the FPS, and now we have to make sure that they're delivering the results that we expect. And those results will help improve our performance and therefore help us lower cost, increase quality and throughput and give us a safer place to work."
Price said he ultimately hopes to see a shift in the mindset at Ford's manufacturing facilities throughout the world.
"The big thing for us is moving from being reactive to proactive. Instead of waiting for the customer to tell us they didn't like something, we need to proactively find that issue in the system and stop it from ever impacting the customer," he said. "We need to perform preventive maintenance on equipment so it doesn't break down. We need to put robust elements in place around error-proofing for quality and around training people – proactively working with them with deep knowledge to make sure they have the information they need to understand what an issue is and how to react to it. That's really where the traction is for us."
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Solitaire Pendants are classic jewelry pieces, perfect for all occasions. Diamond solitaire pendants are subtle yet shine enough to make a statement. They are timeless keepsakes to add to you jewelry collection and make for sentimental anniversary, Valentine's Day and birthday gifts.
James Allen offers a comprehensive collection of diamond solitaire pendants. Pendants are sold in both white gold and yellow gold and vary in price. Some of our most popular solitaire pendant styles include: Pave Set Frame Diamond Pendants, Pave Bail Diamond Pendants, and the traditional Diamond Pendant. All pendants come with diamonds of different carat weight, cut and clarity.


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Paula Wolfson, wtop.com
WASHINGTON – Doctors are noticing a disturbing trend this flu season – an unusually large number of people who received flu vaccinations are still getting sick.
"That seems to be a trend that we are seeing in our practice, and it fits with what people are seeing nationwide," says Dr. John Dooley, a physician at Foxhall Internists in D.C.
The process of making a vaccine takes time and guesswork. Scientists look at viruses emerging in the Southern Hemisphere and predict which ones will travel north when our flu season arrives.
For the 2012-2013 season, scientists created a vaccine that protects against three strains. The Centers for Disease Control and Prevention says 91 percent of the viruses circulating today are covered under this vaccine.
"The fact the vaccine is not completely protective is not a surprise," Dooley says. "No vaccine is."
According to Dooley, some of the people who receive a flu shot and then get sick weeks or months later, simply were not able to create an adequate immune response.
However, most of the time, people who come down with the flu even after the vaccine are the unlucky ones who picked up one of the rare strains not covered by the vaccine.
That is exactly what happened to Dave Byrd of Manassas, Va.
"I got sick all at once. I was fine when the 'Skins beat Dallas, but between the end of the game and the next morning, I was in bad shape," he says.
For a moment, despite the sudden aches and chills, he thought it couldn't be the flu.
"I had a flu shot and I thought it was supposed to prevent this, but I guess it didn't," Byrd says.
While the vaccine did not protect him from the flu, it did cut the duration of the illness, significantly. Byrd says the severe symptoms only lasted a day.
Dooley says when patients question the need to get a flu shot, he tells them the vaccine is not 100 percent perfect, but it is still very good.
"For the very large majority of people who get the vaccine, they are well protected such that they won't get the flu if exposed," Dooley says.
"If they do get the flu, they will get a much milder case or shorter duration."
Dooley says it is always a challenge to get people immunized against the flu, a challenge that may be tougher during the next go around, especially if others cite the experience of vaccinated persons still getting the flu.
However, despite catching the flu this year, Byrd says he'll still get a flu shot next year.
"Flu is nothing to mess with," Byrd says. "I will definitely get a flu shot."
Byrd's statement may be the lasting message of the 2012-2013 flu season. Dooley says a relatively severe strain is hitting a lot of people hard this year, and is sending patients a blunt reminder.
"It reminds them that the flu is not a trivial illness," Dooley says. "And that even an imperfect vaccine is much better than no vaccine at all."
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Recipes that will make your mouth water.


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August 23, 2007
Sean Callahan
For junior college transfer defensive backs Armando Murillo and Larry Asante, learning the Nebraska defense has been a process. However, if there's been one distinct advantage both of these players have had, it's been the fact they were able to take part in spring practice this past March and April.As the Huskers wrap up their final week of fall camp, both Murillo and Asante said their overall comfort level of the defense is night and day compared to where it was in the spring. "Since the spring I've come a long ways," Murillo said. "I had a lot of mental errors and everybody just seemed fast to me and way quicker and fast to me. Now, my speed and quickness makes me feel faster than guys I used to think were faster than me in the spring. I feel good out there now, I feel comfortable."Asante was hampered for most of spring practice with a hamstring injury, so his overall development was held back even more. But like Murillo, he also has taken some major steps this August. ...More... To continue reading this article you must be a member. Sign Up Now!
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Salt Lake City, UT (Sports Network) - Randy Foye had 26 points in the Utah
Jazz's 116-107 win over the Brooklyn Nets.
Al Jefferson and Mo Williams added 20 points apiece for the Jazz, who have won
four in a row on the heels of a 2-9 stretch.
Utah is a half-game ahead of the Los Angeles Lakers, who are currently playing
the Sacramento Kings, for the West's eighth and final playoff spot.
Brook Lopez tallied 27 points and seven rebounds, while Deron Williams totaled
21 points and 11 assists for Brooklyn, which has dropped three of its last
five contests.
The Sports Network


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What is RM Cash
"Customer service is priority #1 at Rocky Mountain ATV/MC. We value our customers and strive to be the best shopping experience- when you buy from us, you are buying lifetime service."
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We take pride in offering no hassle returns. In the event of a return, please call, email or chat with us to receive a solution to the problem. For apparel that doesn't fit quite right, Click here to see our Fit Guaranteed Program.
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Comments On Apr 26, 2015:This is a great oil if you like low smoke and no spooge. Running it at 32:1 in my KX250 for slower trail riding with some short blasts up a gravel road between trails. All other oils used in the last 9 years resulted in spooge and more visible smoke while riding similar terrain. The price is right too!
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Comments On May 17, 2010:Can't go wrong with factory chemicals! I run this at 20:1 in my Honda Pilot FL400 and it runs awesome. Excellent lubrication and corrosion protection. Good price too.
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Comments On Apr 25, 2010:It's decent oil but runs rich in my blaster with the same size jets. That makes me think that it is thinner than other oils. I have to run at high rpms to clean out the excess oil. I'm going to switch to HP2 because it's supposed to be better and burn cleaner. Still though, not bad if you run at high rpms and need cheap oil. Pay the extra for synthetic.
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Bright Canvas Art
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Baby Chicks Canvas Reproduction - Blue by Dish and Spoon Productions
Transform your nursery into a whimsical and charming haven for baby with this heart-warming Baby Chicks custom canvas wall art! An original design by luxury children's artist and designer Patrice F. Fitzgerald, this delightfully detailed painting has been reproduced onto museum-archival-quality canvas using the giclee method of fine art printing. The canvas is then carefully hand-stretched over sturdy 2-inch-deep wood stretcher bars with the art image wrapping around each of the sides. The Baby Chicks wall art is offered in three sizes: 8in.x10in., 16in.x20in., and 20in.x24in. You can also order the artwork in a custom color of your choosing. Please specify your canvas size and color preferences when ordering. To preserve the integrity of the artwork for years to come, the surface of the canvas is glazed with a UV protective finish. Wall mounting hardware is included on the back of the stretcher bars to ensure level hanging. For a more refined look, order your canvas with Dupioni Silk ribbons! Hand-crafted and custom-made in the USA, the Baby Chicks wall art is the perfect gift for new or expecting parents looking to bring a little something special to their baby's room! Pair with additional canvas wall art from the ABC/123 Nursery Collection for a group display!
Known as a pioneer in children's lifestyle design, Patrice Flashner Fitzgerald is an accomplished interior designer with a Film and Visual Arts degree from Emerson College in Boston, Massachusetts. She also is founder and lead designer for Sweet Beginnings Inc., a manufacturer of hand-crafted and hand-painted luxury children's furniture and accessories, including cribs, changing tables, toy chests, beds, nightstands, dressers, armoires, desks, storage consoles, shelving units, bookcases, mirrors, and wall decor. Sweet Beginnings incorporates a combination of inspiring artistic designs, quality manufacturing, and exquisite hand-painted art, all made with pride in America. Describing Sweet Beginnings' design ethos, Patrice says, We take pride in the craftsmanship and attention to detail in all of our whimsical and unique designs. Patrice resides in Delray Beach, Florida, with her husband and two daughters. Her one-of-a-kind designs are offered exclusively in Dish and Spoon Productions' award-winning wall art!
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It must have been quite the gale that blustered through the forests near Elk Creek.
I wish I had seen it happen, as I am fascinated by all manner of meteorological spectacles.
Although probably it's better for me, and in particular for my skull, that both of us missed this particular show. A windstorm in the woods is an event best viewed from the summit of a rocky peak or the middle of a meadow, but these sorts of treeless safe zones aren't abundant around Elk Creek.
I first saw evidence of the prodigious gusts a few weeks ago. I was hiking the road that climbs from the Elk Creek ford to Old Auburn Reservoir (which these days rarely qualifies as much more than a snowmelt puddle).
At least half a dozen mature trees, ponderosa pines and Douglas-firs, had toppled within 100 feet or so of the road. All were in an area of maybe a couple of acres — I could see them all at the same time, anyway. Each tree had gone over intact rather than severed part way up the bole, and the root wads were up in the air, splayed in a way that has always reminded me of the tentacles of an octopus.
The thickest of the trees was maybe 24 inches through the trunk, the slenderest about half as much.
The trees all lay with their crowns pointing south, so it must have been a norther that felled them.
The sight of the downed trees surprised me because the road runs along the bottom of a draw oriented east-west. The place is as a result sheltered, by the higher ground to the north and south, from winds out of either of those directions. This was in fact why I had gone there to hike that day. The weather was typical for April — clear skies and a hard gusting wind from the north — yet only the gentlest zephyr dipped into the draw.
It scared me a little to imagine how powerful the wind must have been to push down 100-foot pines even there on the leeside.
Last Friday I went hiking about a mile north of the road, up toward the headwaters of Elk Creek.
I climbed a steep slope on the west side of the creek's canyon. On the spine of an east-west trending ridge I found nine big trees down, all pines and firs, all lying in the same direction as the others.
What I know of trees is scant but I figure, based on what I saw during the two hikes, that the damaging wind was potent but brief. Had the storm been of long duration it would have carved a wider swath through the woods.
I suspect too that the blowdown happened this spring, after most of the snow had gone but while the ground was still soggy from the meltwater.
I put the question to Bruce Countryman, who works for the Forest Service. He agreed that it's likely the trees fell recently rather than during the winter. When the ground is frozen and the snow deep, he said, wind more often cracks the trunks of trees than it levers their roots from the ground.
Probably it was one of those days we get half a dozen of every spring, when a storm has passed and in its wake the wind swings around to the north.
I wonder where I was and what I was doing when the gusts got strong enough to conquer all those tons of stubborn fiber. I wonder too if anybody was near enough to see the trees go, or to hear the thuds, which must have been considerable.
I doubt it. Almost everything that happens in the hinterlands happens without anyone being there to see it.
I think it is this essence of mystery which cloaks wild places, which makes them so dramatically different from the towns, that draws me to them.
When I'm home after a hike I often try to imagine, as I lie in bed and listen to the night wind whine past the eaves, what is going on right then at the places where I walked hours before.
This is a peaceful sort of pastime, though, and quite unlike the nagging feeling, which also sometimes intrudes on my bedroom after dark, that I have forgotten to latch the deadbolt on the front door.
The woods, fortunately, are in the main free of doors, and of locks.
Spring has finally taken hold on my property, following the series of false starts that is the season's custom at our northerly latitude and elevated geography.
My wife has sown seeds, trees are leafing out, the daffodils are on the wane.
The most exciting development, though — or at least the most interesting — has been the family of starlings that has appropriated the flower box just outside the kitchen window.
This is the sort of faunal trouble a man can get into even when he lives in the city.
It's a common thing for a town dweller to embark on a modest campaign to tame his land holdings, only to end up with a place that's wilder than it was before he started tinkering with it.
He builds a deck, for instance, and then he goes out to watch the sunset and gets stung by a yellow jacket that built its nest under the boards. Or he puts in a pond because he enjoys the serenade of frogs in the evening but what he breeds, mainly, are mosquitoes. Also then he's misplaced the bottle of DEET.
I've been complaining about the starlings but my wife reminds me that I had ample time to deny the birds their accommodations. I in turn accuse her of sticking up for starlings, an introduced species reviled for its tendency to steal nests from prettier, more musically inclined native songbirds.
The truth, though, is she's right.
(Although I stand by my indictment of starlings.)
I noticed more than a month ago that starlings were roosting on the flower box several times each day. I should have known then that the birds, as is typical with young families that are expecting offspring, were casting about for larger quarters.
At any rate the box is empty, so the birds weren't perching there to get a meal.
Then, before I got around to dismantling the nest (which is light work and would have been a satisfying trick to play on starlings), we found four pale blue eggs. A couple days later there was a fifth egg.
I was raised in a staunchly anti-starling home, and so was unaffected by the sight of the eggs. In fact I used their presence to bolster my argument that the nest ought to be destroyed.
My case, though, was as flimsy as the straw from which the starlings had constructed their nest, being based on vengeance but utterly lacking in persuasive evidence. I could hardly pretend that preventing the hatching of five starlings would curb in any meaningful way the local starling problem, nor could I argue that allowing those five birds to fledge would significantly add to the nuisance.
The starlings hatched last weekend. We took our daughter, Olivia, outside so she could peer into the nest at the almost hairless creatures. They were so tiny that all five would have fit on Olivia's palm, and she's not quite two. As with most baby birds these were capable of little more than uttering a feeble squeak and thrusting their gaping mouths toward anything that might be a regurgitating parent.
Which, fortunately, I am not.
Olivia suggested that what the birds wanted is soup.
Her mom and I laughed at this but to be frank I didn't think the idea was funny.
I've already supplied the freeloading starlings with shelter, after all. There's no way I'm chewing so much as a single nightcrawler for them.
Although there's an abundance of those right now, from all the rain.
Jayson Jacoby is editor of the Baker City Herald.


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With proper installation and care you can expect to proudly display our quality line of lighting in your interior setting for many years to come. Be assured that Nulco provides you a limited warranty that its materials and component parts are free from defects in material or workmanship for a period of one year from date of sale with evidence of proof of purchase. Any liability of Nulco Lighting for its products is expressly limited to the repair or replacement of its parts after evaluation by the company to determine if, in its opinion, damage is a result of defect and not incorrect installation, improper cleaning products or misuse. Liability on the part of Nulco is limited to any repair or replacement being made at its factory location and the purchaser will pay freight charges to and from the facility. Nulco Lighting will not be responsible for claims for labor or other charges at the job-site, unless written authorization is received in advance from our factory. This warranty is automatically voided if any unauthorized repairs or alterations are made.
It should be noted that some areas with high concentrations of salt water may, over time, break down the high-luster lacquer finish and that some free hanging and wall-mount fixtures may not be suited for high wind areas. Many finishes darken naturally with age, but the process can be accelerated when the fixture is placed in extreme sun or moisture.
Nulco's commitment to quality is shared by its entire work force of employees, and we value and appreciate your business.
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Brings back lots o'memories from my early gaming days. Nicely done!
Greyhawk Grognard Joe Bloch is doing this really cool old school Castle Greyhawk-esque mega dungeon called The Castle of the Mad Archmage.
I decided to try mapping this out in classic retro old school module blue and white using the December 2007 Cartographer's Annual. Here are the first two maps (the northeast and southeast sections of level two). I hope to have the last two map sections (northwest and southwest) completed by Sunday. I intend to paste all four maps together for a single "giant poster" PNG when I'm done as well.
Last edited by jaerdaph; 02-18-2009 at 12:34 PM.
Brings back lots o'memories from my early gaming days. Nicely done!
My Finished Maps | My Challenge Maps | Ghoraja Juun, my largely stagnated campaign setting.
Unless otherwise stated by me in the post, all work is licensed under a Creative Commons Attribution-Noncommercial 3.0 United States License.
Nice, Jaerdaph! Good to see you posting again
-Rob A>
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My Maps: Finished Maps ~ Challenge Entries ~ My Portfolio: www.cartocopia.com
Thanks, guys. It's nice to be back.
Welcome Back Jaerdaph!
Have some REP for some cool Oldschool Maps!
Daniel the Neon Knight: Campaign Cartographer User
Never use a big word when a diminutive one will suffice!
Any questions on CC3? Post them with CC3 in the Subject Line!
MY 'FAMOUS' CC3 MAPS: Thunderspire; Pyramid of Shadows; King of the Trollhaunt Warrens; Demon Queen's Enclave
I always wondered why they chose that blue color for some of the maps in those old modules. Still brings back memories though. I like it, though it does seem rather random. That's ok if it's supposed to be random, but it lacks a sense of overall design. Not that I know anything about overall design.
Apparently it was almost impossible to photocopy.
Frank Mentzer over at the Dragonsfoot boards mentioned that that colour of blue was difficult to photocopy and TSR was worried about pirate copies. Nice maps, jaerdaph.
Things have been a bit crazy on my end of things so I haven't been around here much recently but it's funny because I got a dungeon map done and I went with the old school blue theme as well (without seeing yours). Great minds think alike.
Considered yourself repped!
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"Do infants have as much fun in infancy as adults do in adultery?" - Groucho Marx


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Thursday, November 17, 2011
Richard and Carol: A Lifetime of Style Together
17 comments:
- this is Belgium said...
amazingly colorful !
- November 17, 2011 at 12:56 PM
- melody-mae said...
I have just recently found/follow your blog. I adored this article today on Richard and Carol! I will be 53 in January and love that style is ageless!!!
- November 17, 2011 at 3:07 PM
- out of order said...
this couple is so amazing, it's lovely to see a happy, productive couple who are still best friends, and have fun with clothing!
this made my and my boyfriend's day :)
- November 17, 2011 at 4:41 PM
- ifigenia said...
they're so special!
I like how they look together
- November 17, 2011 at 5:07 PM
- SymbioticLife said...
They're so amazingly colorful and spirited. I envy their ability to maintain such a simplistic living space and how they incorporate their sense of art into their dressing. I hope my husband and I rub off on each other in such a positive way over the years.
- November 17, 2011 at 6:06 PM
- Heidi said...
What an inspiring couple!
- November 17, 2011 at 6:15 PM
- byKEONA said...
How FABULOUS are these two young kids? This post just made me smile from ear to ear :)
- November 17, 2011 at 7:55 PM
- Clara Turbay said...
i find this blog amazing full of great ideas i´d like you check out mine and leave me some comments.
- November 17, 2011 at 9:12 PM
- Motherkitty said...
What an absolutely awesome couple! Their style suits them beautifully. I wonder if I could convince my husband to dress as dashingly as Richard. One can always hope. ;-)
- November 17, 2011 at 10:00 PM
- Titaz said...
they're so lovely :)
Hello from Indonesia,
- November 18, 2011 at 12:29 AM
- Hummingbird5 said...
I so love Carol and Richard. Could look at them every day!
- November 18, 2011 at 2:32 AM
- That's Not My Age said...
Wow - all that colour. They look fabulous!
- November 18, 2011 at 4:36 AM
- The Style Crone said...
45 years! A true love story!
- November 18, 2011 at 9:39 AM
- Camilla said...
How cool! Everyone else on the street are so grey, and then they show up!Awesome!
- November 19, 2011 at 9:11 AM
- Jeanne said...
I just found your blog and I'm enchanted!
- November 19, 2011 at 12:41 PM
- NykkeyB said...
oh how fun to see a some Gentlemen on her now I'm loving it. I have to say this is one of my favorite blogs.
- November 28, 2011 at 7:16 PM
- Justin said...
Richard was my painting professor at Tyler School of Art in Philadelphia. Huge influence on my sense of color. I remember him saying with regard to one of my more awful first attempts at painting, "I'm going to cut you up and roll you in butter." Wise words. Cheers Richard!
- May 23, 2012 at 12:41 PM


text:
What is RM Cash
"Customer service is priority #1 at Rocky Mountain ATV/MC. We value our customers and strive to be the best shopping experience- when you buy from us, you are buying lifetime service."
-Dan Thomas, CEO and Founder
We take pride in offering no hassle returns. In the event of a return, please call, email or chat with us to receive a solution to the problem. For apparel that doesn't fit quite right, Click here to see our Fit Guaranteed Program.
We will stand behind all products we sell with regards to manufacturing defects in workmanship and material. Most products are limited to the manufacturer's warranty. However, we will do everything in our power to take care of the problem.
Each review submitted enters you into a $100 gift card monthly drawing, and a $500 gift card quarterly drawing!
Comments On Feb 04, 2015:Got it for my scooter
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Comments On Sep 29, 2014:Keeps the sun and rain off my bike. has lasted a while without ripping or deteriorating. I will buy again
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Comments On Apr 04, 2014:Bought this cover for my Harley Davidson FatBoy. I bought the XXL and it fits really well and covers the bike well. But, when it is windy outside the cover lifts. I have to go out and adjust the cover every time the wind blows. There is only one tie down point on the bottom of the cover. It holds up well but when the wind blows it comes right off. If it were me I would have made at least 3-5 points along the bottom to tie it down. Other than that, it is a good cover.
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Comments On Feb 25, 2014:This covers the bike well and seems to be durable, but doesn't reach far down enough. It only goes down to the middle of the engine case on my 2009 KLR650 and it doesn't cover the brake discs, which is what I really want to protect from the elements.
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Comments On Feb 16, 2014:This one is made from good material, durable one, dust and water resistant. I used several other brand covers previously, but their quality was not good and water came through. This one is very good.
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Comments On Jan 21, 2014:I purchased this motorcycle cover prior to a road trip I was taking my dirtbike on. I placed the cover over my dirtbike that was in the back of my Tacoma...after a couple hours of highway driving there was a LARGE hole ripped in the side of the cover. By the time the road trip was half over, the cover was dead and ripped up. This is a great, low cost, cover for storing a bike, but NOT made for travel.
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Comments On Oct 15, 2012:The XL fits my Honda CR125r perfectly. It keeps my bike nice and dry when I have to store it outdoors. The elastic on each end keeps it secure on the bike and prevents the wind from blowing it off. Also, for storage it comes in a little bag made of the same material.
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Purdue University was founded in 1869 as a land-grant university. The first college to offer an aeronautics program, Purdue has risen to such high stature in that field that it even out-ranks the United States Air Force Academy. Purdue was the first university to actually offer a four year degree in the field. This type of specialization in aeronautical studies has led to over twenty Purdue graduates becoming astronauts, including the first person to walk on the moon Neil Armstrong.
Located in West Lafayette, Indiana, it makes perfect sense the Boilermakers have a strong basketball tradition. The Purdue basketball team plays their home games at Mackey Arena. During college football season be sure to root on the Boilermakers at Ross-Ade Stadium. The university hosts many other types of events at the Mackey Arena as well. Join Purdue Pete and a legion of other Boilermaker fans at all events in support of Purdue University athletics!
Use the following links to purchase tickets for events at Purdue University:


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Clinician Summary – Mar. 19, 2012
Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults
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Table of Contents
- Focus of Research for Clinicians
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- Table 1: Descriptions of Nonpharmacologic Treatments Studied
- Table 2: General Adverse Effects Associated With Nonpharmacologic Therapies
- Gaps in Knowledge
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Focus of Research for Clinicians
In response to a request from the public, a systematic review of 63 clinical studies published between January 1980 and November 2010 examined the comparative effectiveness, benefits, and adverse effects of nonpharmacologic interventions for treatment-resistant depression (TRD) in adults. The full report, listing all studies, is available at www.effectivehealthcare.ahrq.gov/trd.cfm. This summary, based on the full report of research evidence, is provided to inform discussions of options with patients and to assist in decisionmaking along with consideration of a patient's values and preferences. However, reviews of evidence should not be construed to represent clinical recommendations or guidelines.
Among patients who receive appropriate treatment for major depressive disorder, about 50 percent will not adequately respond. Patients who do not respond to at least two adequate antidepressant trials are considered to have TRD for the purpose of this report.
Patients with TRD are significantly less likely to respond to subsequent medications and thus may require nonpharmacologic treatments, which have traditionally included electroconvulsive therapy (ECT) and psychotherapies such as cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Newer nonpharmacologic approaches for major depressive disorder have broadened potential options to include repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS). Descriptions of these treatments are available below in Table 1.
Current evidence indicates that ECT has a role in the treatment of people with depression and in certain subgroups. The current role for ECT in depression is for treatment resistance or intolerance and for suicidality. Recently, trials have focused on the newer treatments rTMS and VNS. The systematic review focused on the effectiveness of the various nonpharmacologic options compared with each other and with pharmacotherapy, and also evaluated the efficacy of rTMS and VNS.
Comparative clinical research on nonpharmacologic treatments for TRD is in its infancy. Few direct comparisons between nonpharmacologic options were available, and all available evidence involving direct comparisons was either insufficient or of low strength. Within this limited evidence base, comparative outcomes for both ECT and rTMS are similar, with no apparent synergistic effect from combining these therapies. Evidence suggests that rTMS is effective in reducing depressive severity and producing response and remission over sham treatment. The effectiveness of ECT was not addressed in the review. No benefit was seen for VNS over sham treatment. Evidence regarding adverse effects is limited.
Clinical Bottom Line
Comparative Effectiveness of ECT Versus Pharmacotherapy
ECT, when compared with paroxetine, produced a greater improvement in depressive severity (9 points on the HAM-D, p = 0.001) and treatment response rate (71.4% for ECT vs. 27.8% for paroxetine, p = 0.006).
- No other studies evaluating other pharmacotherapies were included in the systematic review, and the adverse event rates of ECT versus pharmacotherapy were not compared in studies.
Comparative Effectiveness of rTMS ± ECT Versus ECT Alone
rTMS does not clearly differ from ECT with respect to depressive severity, response rates, and remission rates. Available evidence showed that ECT and rTMS groups may not differ with respect to withdrawals due to adverse events, but overall withdrawal rates were lower with rTMS than with ECT.
- Evidence is insufficient to evaluate ECT versus rTMS with respect to adverse events and effects on cognitive or daily functioning.
Treatment interventions combining ECT with rTMS do not clearly differ from treatment with ECT alone with respect to depressive severity, remission rates, improvements to daily functioning, or specific adverse events.
Effectiveness and Adverse Effects of VNS*
VNS does not clearly differ from sham treatment with respect to improvements in depressive severity, response rates, or daily functioning. However, VNS may produce increased rates of some specific adverse effects (see Table 2) and may have greater withdrawals attributed to adverse events.
Effectiveness and Adverse Effects of rTMS*
Benefits (rTMS vs. sham treatment)
- Greater decrease in depressive severity (5+ points on the HAM-D).
- Three times as likely to produce a response (number needed to treat = 5).
- Six times as likely to achieve remission of depressive symptoms (number needed to treat = 4).
- Better outcome for depressive severity and response rates for young adults.
- Better outcome for depressive severity in older adults with poststroke depression than with sham treatment.
- Greater improvement in health status and daily functioning.
- Evidence is insufficient to evaluate the ability of rTMS to maintain response or remission.
Adverse Effects (rTMS vs. sham treatment)
- More scalp pain at the stimulation site.
- Evidence is insufficient to permit conclusions for withdrawals due to adverse events or patient nonadherence.
Other Comparisons
Evidence is insufficient to evaluate the comparative effectiveness or adverse effects between the following comparators:
- ECT versus sham treatment.
- rTMS + pharmacotherapy versus pharmacotherapy alone or sham treatment alone.
- Psychotherapy versus control treatment or pharmacotherapy.
These results do not suggest that ECT and psychotherapy are ineffective treatments for TRD but merely that data are lacking for these comparisons within the population requirements used for the systematic review.
*VNS and rTMS have been approved by the U.S. Food and Drug Administration (FDA) for treatment of major depressive disorder but are not yet approved for the treatment of TRD.
HAM-D = Hamilton Depression Rating Scale
Strength of Evidence Scale
Further research is very unlikely to change the confidence in the estimate of effect.
Further research may change the confidence in the estimate of effect and may change the estimate.
Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.
Research is either unavailable or does not permit estimation of a treatment effect.
Table 1: Descriptions of Nonpharmacologic Treatments Studied
|Electroconvulsive Therapy (ECT)
|Passing an electric current through the brain after administering anesthetic and muscle relaxants to produce a convulsion.
|Repetitive Transcranial Magnetic Stimulation (rTMS)
|Focal magnetic stimulation through the scalp without the use of anesthesia.
|Vagus Nerve Stimulation (VNS)
|Surgically implanted electrodes around the left vagus nerve to modulate mood and control seizures.
|Psychotherapies (CBT or IPT)
|Psychotherapy to identify negative depressogenic cognitions or interpersonal behaviors.
Table 2: General Adverse Effects Associated With Nonpharmacologic Therapies
The information below is generally reported and was not critically reviewed in the source report.
|Common adverse effects or contraindications
|Electroconvulsive Therapy (ECT)
|Repetitive Transcranial Magnetic Stimulation (rTMS)
|Vagus Nerve Stimulation (VNS)
|Cognitive Behavioral Therapy (CBT) or Interpersonal Therapy (IPT)
Gaps in Knowledge
- Information about health-related outcomes that concern quality of life or levels of functional impairment is substantially missing from current studies.
- Few studies compare nonpharmacologic interventions with each other or with pharmacologic interventions. Moreover, the comparative effectiveness of combined treatment interventions has not been evaluated.
- Almost no direct evidence exists on how the comparative effectiveness of nonpharmacologic treatments might differ as a function of symptom subtypes or for subgroups defined by sociodemographic characteristics (e.g., age) or by coexisting medical conditions (e.g., depression following a stroke or a myocardial infarction; perinatal depression).
- The following shortcomings of evaluated studies may limit the applicability or generalizability of some findings:
- Inconsistent definitions of TRD
- Inconsistent reporting of measured outcomes
- Short followup periods
- Limited, short-term, variable, and inconsistent adverse event reporting
What To Discuss With Patients and Caregivers
- The definition of TRD and why it may need different forms of treatment.
- The potential benefits and adverse events associated with nonpharmacologic treatment options.
- The patient's values and preferences regarding the trade-offs between the benefits and harms of the various treatment options.
- The availability of nonpharmacologic treatment options.
Resource for Patients and Caregivers
Therapies for Treatment-Resistant Depression, A Review of the Research is a free companion to this clinician research summary for patients and caregivers. It covers:
- A description of TRD, its symptoms, and why treatment may feel frustrating.
- Descriptions of the types of treatments, how they work, and potential side effects.
- Questions to guide a discussion with you about treatment options.
Ordering Information
To order free print copies, call the AHRQ Publications Clearinghouse at 800-358-9295.
The information in this summary is based on Nonpharmacologic Interventions for Treatment-Resistant Depression in Adults, Comparative Effectiveness Review No. 33, prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. HHSA-290-02-0016-I for the Agency for Healthcare Research and Quality, September 2011.
This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX. It was written by Emily White, M.S., Thomas Workman, Ph.D., Mark Kunik, M.D., and Michael Fordis, M.D


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- See: Calendar of events
Recent News and Developments
- December 2011: EG-Solar reports that it is working on a carbon-credit solar cooking project in Zambia.
- August 2010: The Solar Health and Education Project (SHEP) began in 2007 to fund solar cooking workshops in rural areas of Zambia, and also with the urban poor in the Livingstone area. The main goal of the workshops was to introduce solar cooking methods to the community in a sustainable fashion. Most at the workshop have little education, but are completely sold on harvesting the sun for their daily needs of cooking fuel. The team, with direction from Alison Curtis, developed a system to appoint a local leader at the workshop to follow-up with a group of participants to help and encourage using the new cookers. Now, three years later, the solar team has ten excellent leaders who take turns spreading the solar news by setting up at shows, events, museum gatherings, school playgrounds, clinics and so on. These unschooled women leaders have learned to fill in a simple form, which SHEP developed with their input, so they have the knowledge to complete a request for funds themselves. The headmaster at the nursery school reads these requests and grants the money from SHEP to hold the demonstration or workshop. The women do the shopping, keep receipts, hold the event and then fill in a very basic report. They are paid for their workshop day @ $2.00 per event. The women are quite resourceful, as they have learned to make Cookits from cartons and reflective Crisp wrappers found in the trash.
- August 2009: The Workers Education Association of Zambia sent Victor Phiri to be trained as a trainer in solar cooking and expose him to other cooking energy technologies. This was in recognition that they needed to build the capacity of at least one trainer, and afford him a hands-on experience and a to visit on-going projects so that he could learn more, both in theory and in practice. This training was a lead up to a training of trainers, in Shapi village, Mansa. The weekend of November 20-21, 2009 was a busy one for the selected trainers. A training of trainers was facilitated by Solar Cookers International trainer, Faustine Odaba assisted by Victor Phiri, National coordinator of the Workers Education Association of Zambia. A total of 46 men and women were trained. The following foods were solar cooked; Isima (Ugali) groundnuts, cabbage, rice, meat stew and solar water pasteurization. They also learned how to use fireless cookers and how to recycle plastic waste materials into useful items.
- May 2009: The Solar Health and Education Project (SHEP) funded a very successful workshop run by Manda Chisanga and Crosby Menzies in Mfuwe, Zambia in June 2009. Read project report.
- November 2008: Manda Chisanga, a safari guide in South Luangwa National Park, first learned about solar cooking from U.S. travelers on safari. He immediately understood the environmental and health benefits that solar cookers could provide to the women of his community, many of whom walk several miles, through areas where elephants sometimes attack humans, to collect firewood for cooking. When Chisanga was named top travel guide by Wanderlust magazine and awarded £5,000 to be spent in his local community, he knew what to do with the money. Chisanga approached SunFire Solutions with a proposal to introduce solar cookers to the women of his community in Luangwa valley. SunFire, a solar cooker promotion and development agency based in Johannesburg, South Africa, distributes a variety of solar cookers and related technologies. According to SunFire representative Crosby Menzies, deforestation is a serious problem in and around wildlife areas like South Luangwa National Park. "Loss of habitat means loss of species, loss of species reduces tourism, lack of tourism brings in less income to the area," he said. Menzies also noted that women and children must walk increasing distances to collect firewood for cooking, stating, "In many parts of Africa people say that the trees are running away from them." In 2007, five SunFire14 parabolic solar cookers were assembled and distributed to families in the village of Mfuwe. Subsequently, an additional 10 cookers have been distributed. SunFire is currently looking for funding to bring several hundred solar cookers to the community of about 6,000 families. The cookers have proven useful for cooking local staples including rice, beans, and maize. The women who have access to the solar cookers have reportedly reduced their firewood collection trips from an average of three per week to only one. A documentary film about the Mfuwe solar cooker project, called "Manda's Prize," has been airing on the Al Jazeera documentary program Witness, and can been seen on-line here.
- September 2008: A documentary has been made on a project in Zambia called the Mfuwe Solar Cooker Project. Manda Chisanga, a guide in South Luangwa National, Park won a guiding award and decided to spend his prize money on Solar Cookers. SunFire Solutions was asked to go up to Zambia and launch a Solar Cooker Project at Mfuwe - the documentary covers the installation of five SunFire14 Parabolic Dishes - the project has been expanded to 15 and we are looking at ways to get 500 Parabolic Dishes into the community to cover 6000 families. Cookers are being shared by 2 families and at present we are short of financial support to expand the project and are examining options. For more info contact Crosby Menzies.
- July 2007: Solar Health and Education Project (SHEP) reports holding workshops in both Zambia and Kenya for newly trained teachers preparing to go to remote villages on assignment. The workshops were five days long. The first day was used for basic education about solar cooking and solar water pasteurization, while the other four days were used to practice and implement solar cooking skills. The 70 participants all built their own solar cookers. Based on the success of these workshops two more have already been scheduled. SHEP has developed a relationship with Tetra Pak International — manufacturer of aseptic drink containers — whereby SHEP uses Tetra Pak's excess foil-lined paper for solar cooker construction. (The foil-lined paper is printed in wide rolls, sometimes resulting in excess material begin generated.) According to SHEP, Tetra Pak is willing to accept proposals from other nongovernmental organizations that may want to use the reflective material as long as the material will be used for workshop participants to construct solar cookers.
The History of Solar Cooking in Zambia
A small solar cooking project has been started in Zambia with the assistance of the Rotary Club of Lusaka Central and the Girl Guides Association of Zambia. At the time of reporting, December 1999, 50 people had been trained to use the solar cookers. Rotarian Nic Money is carrying on the work, which was started by American Rotarian, Wilfred Pimentel, and Girl Scout trainer, Barby Pulliam, also an American.
[Information for this section was taken originally from State of the Art of Solar Cooking by Dr. Barbara Knudson]
Climate, Culture, and Special Considerations
Solar Cookers International has rated Zambia as the #25 country in the world in terms of solar cooking potential (See: The 25 countries with the most solar cooking potential). The estimated number of people in Zambia living in sunny areas but suffering from fuel scarcity in 2020 is 1,100,000.
See also
Audio and video
|September 2008: Manda's Prize (Part 1): Video showing Manda Chisanga's solar cooking work as a Safari guide in Zambias South Luangwa National Park
|September 2008: Manda's Prize (Part 2): Video showing Manda Chisanga's solar cooking work as a Safari guide in Zambias South Luangwa National Park
Articles in the media
- March 2010: Solar Cookers For Africa – The story so far -Wanderlust
External links
Manufacturers and vendors
Government agencies
Educational institutions
See also