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Cervical cancer in pregnancy: one case report and a review of current treatment recommendations
Cervical cancer is the most commonly diagnosed gynecological malignancy during pregnancy mainly, and the majority is in stage I. Choosing between delaying treatment until their pregnancy reaches full term or opting for immediate treatment is often a difficult decision for both the patient and the doctor. Patients who choose to delay the therapy until the fetus becomes mature enough for birth should undergo a cesarean section, during which a radical hysterectomy plus pelvic lymphadenectomy can also be performed. If the patient does not continue the pregnancy, there are several treatment choices. For example, radiotherapy alone, surgery after radiotherapy, surgery alone, and others, could be made depending on the stage and the gestational week. For patients who choose radiotherapy, traditional radiotherapy with or without chemotherapy will need to be adjusted appropriately. Transvaginal radical hysterectomy has been reported in some patients with early cervical cancer.
Our current case was a pregnant woman with stage IB1 poorly differentiated squamous cell carcinoma of the cervix. After detailed discussions with multiple departments and adequate communication with the patient and her families, neoadjuvant chemotherapy was first applied, followed by radical hysterectomy plus pelvic lymphadenectomy during the cesarean section when the fetus becomes mature enough for birth.
Case presentation
A 37-year-old G8P3+4 pregnant woman was admitted to our hospital at 21+3 weeks of gestational age because of abnormal vaginal bleeding for one month, and a cervical lesion identified ten days ago." She had received regular antenatal check-ups in another hospital. At 15 weeks of gestational age, she had a small amount of bright red vaginal bleeding without an apparent cause, which lasted for about ten or more days. No abdominal pain, fever, or other discomfort was noted. She received an antenatal examination in a local hospital, during which, the physical examination revealed a 2 cm neoplasm at the posterior lip of the cervix. HPV testing showed that HPV types 16 and 51 were positive. And a colposcopically directed cervical biopsy showed a cervical intraepithelial neoplasia grade 3 (CIN 3), and microinvasive squamous cell carcinoma was discovered in the local hospital. For more treatment, the patient visited the outpatient department in our hospital, and a revised pathological diagnosis of "CIN 3 involving glands" without microinvasive squamous cell carcinoma was made after consultation in the pathology department of our hospital.
For further treatment, she visited the gynecological outpatient clinic in our hospital in the 20th gestational week. After a gynecological examination, the doctor believed the CIN3 diagnosis was not consistent with her clinical manifestation, so a second biopsy under the colposcopy was undertaken. On September 12, 2016, the diagnosis of poorly differentiated squamous cell carcinoma was confirmed by the cervical samples from the second biopsy in our hospital. Then, the patient was admitted to the Gynecological Department. Gynecological examination showed the uterine height was 25 cm, and the abdominal circumference was 98 cm. The development of vulva was normal. Her vagina was unobstructed, without any deformity or abnormal mucosal color. The cervix was hypertrophic, with a 2-cm cauliflower-like neoplasm visible at its lower lip and the parametrium was soft. The lesion demonstrated contact bleeding; however, no bleeding was seen inside the cervical canal. Color Doppler ultrasonography revealed a single live fetus. The diagnoses were as follows: stage IB1 poorly differentiated squamous cell carcinoma of the cervix; G8P3+4 21+3 weeks of a single live fetus.
After discussions with multiple departments and adequate communication with the patient and her families about the benefits and risks of relevant treatment protocols, a treatment plan was established. The patient would first undergo neoadjuvant chemotherapy, followed by the termination of the pregnancy when the fetus becomes mature enough for birth. From September 18, 2016, to November 18, 2016, the patient received three cycles of TP (paclitaxel + cisplatin) intravenous chemotherapy in our hospital. Then she was regularly followed up in the gynecological and obstetrical departments, during which the disease did not aggravate obviously. On December 27, 2016, she received transabdominal cesarean section, radical hysterectomy, bilateral salpingectomy, bilateral ovarian transposition and pelvic lymphadenectomy under general anesthesia. The surgery was successful, and a live male baby was successfully delivered. The patient was discharged after seven days, and the abdominal incision healed well. The urinary catheter was kept for 49 days after the operation until the bladder function was recovered.
Postoperative pathological examination showed positive HPV16 and poorly differentiated squamous cell carcinoma of the uterus. Lymphovascular space invasion was determined, and the lesion had invaded 1/3 of cervical stroma, without involving the cervical junction, vaginal dome, surgical stump, left and right parauterine, resection margin of left and right pelvic wall, or left and right fallopian tubes. Metastasis was identified in one of four right pelvic lymph nodes, and reactive hyperplasia was found in 8 left pelvic lymph nodes (no carcinoma metastasis was found). Endometrial changes were typical during pregnancy, and chronic inflammation was noted in left and right fallopian tubes. Immunohistochemistry (IHC) showed that P16, +++; P63, ++; CK5/6, ++; Ck18, −; Ck8, −; CK7, −, and the fractions of Ki-67-positive tumor cells was about 80%. The patient received an additional 35 sessions of radiotherapy in another hospital. No recurrence was found in the follow-up period (the last follow-up visit was on January 14, 2019). The neonate had a good prognosis; his development was normal, and there was no special condition.
iMDT discussion
Discussion among physicians from the West China Second University Hospital of Sichuan University
Cervical cancer is the most commonly diagnosed gynecological malignancy during pregnancy, and the majority is in stage I. The frequency of cervical cancer is about 1 to 2 cases in 2,000 to 10,000 pregnancies (1,2). About 0.5% to 3% of cases of cervical cancer are diagnosed during pregnancy. In 2018, the Chinese Society of Obstetrics and Gynecology suggested that cervical cytology should be listed as a necessary pre-conceptional and prenatal examination (3). It had been proposed that the survival rate of pregnant women with cervical cancer is relatively lower as compared to the non-pregnant females; however, most studies have found that the prognosis has not been affected (4).
At present, there is no consensus on the treatment protocol of cervical cancer during pregnancy, the timing of delivery, and the mode of delivery. Delay of treatment until the pregnancy reaches full term or receiving an immediate remedy is often a difficult decision for both patients and doctors. According to the International Gynecologic Cancer Society (IGCS) and the European Society of Gynecological Oncology (ESGO), for patients who do not want to continue with their pregnancy, the treatment is the same as for non-pregnant women. For women deciding to continue with the pregnancy, individualized treatment should be applied, the timing of termination of pregnancy and the treatment protocol of cervical cancer can be determined according to disease stage and gestational age (5,6). Multiple factors including gestational age, tumor stage, metastasis, the wishes of the pregnant woman and her families, and the expectation of the pregnancy outcome should be taken into account when choosing the treatment option.
In 2018, the Chinese Anti-Cancer Association (CACA) released recommendations on the treatment of cervical cancer in pregnancy (7). As for the patients who want to continue the pregnancy, the following recommendations should be considered.
- Patients with stage IA1 cervical cancer should be closely monitored. Colposcopy should be performed every eight weeks, and cervical biopsy may be performed if necessary. The treatment could be initiated postpartum if the disease is not progressive, but the possible risk about the progression of disease should be informed to the patient (7).
- For patients with stage IA2–IV cervical cancer within the first 20 weeks of gestation, continuing the pregnancy is not recommended. In the early trimester, the fetus is often resected together with the uterus (2).
- For patients with stage IA2–IB1, cervical cancer sized <2 cm with negative lymph node involvement, simple trachelectomy or extended cervical conization can be performed if the diagnosis is confirmed within 25 weeks of gestation. But the radical trachelectomy was not advised because of the high possibility of abortion after surgery (8). For patients with stage IA2–IB1, cervical cancer sized <2 cm after 25th gestational week, metastasis status of the lymph node is difficult to confirm because of the enlarged uterus, neoadjuvant chemotherapy or close monitoring antepartum and delayed standard treatment postpartum is a choice of treatment (9).
- The management of patients with cervical cancer in the second trimester remains controversial. The CACA's suggestion is as follows: for patients with stage IA–IIA cervical cancer diagnosed during the second trimester (20–28 weeks) and have strong desires to continue the pregnancy, pregnancy may be continued with close monitoring. For patients with cervical cancer later than stage IIB, keeping the pregnancy is not recommended, but the desire of the patient about pregnancy should be respected, and the risk should be analyzed (7). If the patients have strong ambitions, neoadjuvant chemotherapy may be applied to retain the fetus until fetal maturity, as proposed by a European consensus (6). Compared to fetal exposure to chemotherapy, extremely preterm birth is associated with a far higher risk of poor fetal survival and outcome (10). According to IGCS and ESGO (5,6), if the diagnosis for patients with stage IA1–IB1 cervical cancer is confirmed after the 25th gestational week, neoadjuvant chemotherapy (NACT) can be used to continue the pregnancy until the fetal lung matures.
- For pregnant patients with locally advanced and metastatic cervical cancer (stages IIB–IV), it is typically recommended that the pregnancy should be immediately terminated to initiate the treatment of cervical cancer. The standard treatment for locally advanced cervical cancer is radiotherapy and chemotherapy. Usually, therapeutic doses of pelvic EBRT cause fetal demise (5). The management of patients with cervical cancer later than stage IIB in the second trimester remains controversial. Risks should be fully assessed, and the patients' choices should be respected. If the patients have strong desires, neoadjuvant chemotherapy may be applied to retain the fetus until fetal maturity, as proposed by a European consensus (6).
The mode of delivery for pregnant women with cervical cancer has been controversial. For young pregnant women with early invasive cervical cancer (stages IA2, IB, and IIA), the fetus is often removed together with the uterus in the first trimester; in the third trimester, a classical cesarean section can be performed firstly, followed by radical hysterectomy and lymph node dissection (3). For pregnant women with locally advanced cervical cancer, radiotherapy and chemotherapy are usually applied in the first trimester. Most patients will experience spontaneous abortion within 2 to 5 weeks from the beginning of radiation. In the late first trimester, the spontaneous abortion rate decreases. Some patients need to receive complete curettage of the uterine cavity at the end of external beam radiotherapy. For patients with cervical cancer in the second and third trimesters, a classical cesarean section can be performed firstly, followed by standard radiation and chemotherapy. A vaginal birth may be considered for patients with small stage IA1 lesions (11). For large and hard bulky-barrel lesions or large, vulnerable, bleeding exophytic lesions, the risk of vaginal delivery is exceptionally high. Studies have shown that compared with stage I cervical cancer, stage II A or above cervical cancer had higher recurrence rate and lower survival rate after vaginal delivery, and lateral episiotomy at vaginal delivery increased the implantation and metastasis of tumors (12). Therefore, for pregnant women with stage I A2 or later-staged cervical cancer above, the risk of complications such as obstructed labor, hemorrhage, sepsis, cervical laceration, dissemination of disease into lymphovascular channels, and tumor implantation at episiotomy site can be high, cesarean section is recommended for these patients (13). The 2018 Chinese Expert Consensus on the Management of Cervical Cancer in Pregnancy and the Guidelines on Diagnosis and Treatment of Cervical Cancer (7,8) propose that, when cesarean section for pregnancy with cervical cancer is performed, any possible placenta metastasis should be carefully examined during the operation.
Our current patient had stage IB1 cervical cancer during pregnancy, and the patient and her family members requested to continue the pregnancy. After consultations with multiple departments, three cycles of neoadjuvant chemotherapy using TP regimen was performed. After the fetal lung matured in the 34th gestational week, cesarean section was completed, along with radical hysterectomy and pelvic lymphadenectomy. No placental metastasis was found in postoperative pathology (Figures 1,2). The prognosis of the mother and the infant were perfect.
What's the optimal treatment protocol for stage IIB and above cervical cancer in the second, and third trimesters of pregnancy if the patient wanted to terminate the pregnancy?
Expert opinion 1: Junjie Wang, Michael D. Mueller, Andrea Papadia
The standard treatment for patients in this group is chemo-radiation therapy. In a systematic review and meta-analysis, Green et al. confirmed the superiority of chemo-radiation over radiation alone. Concurrent chemotherapy and radiotherapy improves overall and progression-free survival and reduces local and distant recurrence in selected patients with cervical cancer (14).
Uterine evacuation, in the form of suction evacuation or hysterotomy, is usually performed before starting treatment. The dose and regime of chemo-radiation are the same as the usual setting.
Expert opinion 2: Linda Mileshkin
The optimal treatment protocol should be the same as that recommended for a non-pregnant patient after the surgery has been terminated. For locally advanced cervix cancer, this would usually involve treatment with concurrent chemoradiation. The termination of pregnancy after the first trimester usually requires a cesarean section as vaginal delivery is not safe in this instance due to the potential risks of blood loss or scar recurrence at the site of episiotomy (15).
What's the optimal treatment protocol for stage IIB and above cervical cancer in the second, and third trimesters of pregnancy if the patient wanted to continue the pregnancy?
Expert opinion 1: Junjie Wang, Michael D. Mueller, Andrea Papadia
General comments
Treatment of cervical cancer in pregnancy is dependent on the stage of the disease, gestational age, histological subtype, and patient's wish to continue the pregnancy. These patients should be managed in a tertiary center under a multidisciplinary team, consisting of gynae-oncologists, obstetricians, neonatologists, and oncologists. Evaluation of the tumor is based on clinical examination and magnetic resonance imaging. The use of magnetic resonance imaging for the assessment of local extension and lymph nodal status is safe and effective. A chest X-ray can be performed after the first trimester with a lead shield. The experimental nature of cancer treatment in pregnancy and the risks involved should be informed to the patient. They should be reminded that chemo-radiation is the recommended treatment for locally advanced cervical cancer. In a single-center, phase III, randomized controlled trial, Gupta et al. showed that cisplatin-based concomitant chemo-radiation has superior disease-free survival compared with neoadjuvant chemotherapy (NACT) followed by radical surgery in locally advanced cervical cancer (16).
In patients with an aggressive histology
In patients with a more aggressive histological subtype like small cell carcinoma of the cervix, preservation of pregnancy is not recommended, and standard treatment should be commenced as soon as possible.
In patients who are near term or at term
For patients at term, a cesarean delivery is advised, followed by standard treatment.
In patients with pregnancy before viability
Interruption of pregnancy is recommended if the fetus is not viable.
In patients with viable fetus before the term
Use of NACT in locally advanced cervical cancer in pregnancy is reported in several case reports and series. However, the use of NACT in cervical cancer in pregnancy has not been adequately assessed because of its rarity, the difficulty for long-term follow up of exposed children and unrealistic to conduct a randomized controlled trial. The risk of progression of the disease, with worsening prognosis, while on NACT, should be explained to the patient.
NACT allows the pregnancy to reach a good gestation (34–35 weeks) before cesarean delivery and hence reduce the risks associated with prematurity. It can reduce the size of the tumor and prevent dissemination of the disease until fetal maturity. The choice of chemotherapy should be platinum-based, and addition of paclitaxel may increase response rates (17,18). The TIP (paclitaxel, ifosfamide, cisplatin) regimen is considered the most effective NACT treatment according to the SNAP01 trial (19). It is associated with a higher response rate than the IP (ifosfamide and cisplatin) regimen. However, as ifosfamide is toxic to fetal kidneys, it cannot be used during pregnancy.
The chemotherapy is administered every 3 weeks. Delivery is planned at least 3 weeks after the last cycle of chemotherapy to reduce the risk of bleeding, infection, and anemia in both mother and child. Chemotherapy is contraindicated in the first trimester and should not be given after 35 weeks of gestation. Standard treatment of chemo-radiation should be administered after delivery. Radical surgery can be considered at the time of the cesarean section if the tumor has responded well to the NACT.
Expert opinion 2: Taek-Sang Lee
The optimal management of cervical cancer in pregnancy has not been determined because we have no published randomized trials. Therefore, the strategy should depend upon gestational age at diagnosis, stage of the disease, lymph nodes involvement, patient's desire about her actual pregnancy. The definition of the second trimester varies slightly depending on literature, but usually starts in week 13 or 14 of pregnancy and lasts through the end of 26 or 27 weeks.
In stage IIB disease, if the patient who is in early second trimester wanted to terminate the pregnancy, primary chemoradiotherapy should be considered. Then, we may have two options—radiotherapy after uterine evacuation or radiotherapy with the fetus in utero. In the former option, however, the size of the tumor made dilatation and evacuation not feasible due to potential life-threatening procedure-related hemorrhage, but that does not mean that evacuation of the pregnancy by hysterotomy should be chosen because chemoradiation immediately after hysterotomy would interfere with wound healing and thus waiting for complete wound healing would result in delay of treatment. Even so, medical termination using misoprostol cannot be considered as an option due to the presence of bulky cervical lesions. Therefore, the latter option would be preferred in this situation. Spontaneous abortion occurs within 4–6 weeks after the initiation of radiotherapy but, in some case report, we may need to consider moral distress of radiation oncologists over the use of radiation treatment to the viable fetus. Therefore, fetocide by fetal intra-cardiac potassium chloride injection before initiation of radiation therapy can be discussed. After successful shrinkage of the primary lesion is achieved, elective labor induction may be considered in the middle of radiation treatment to avoid a risk of coagulopathy or infection.
If the patient strongly wanted to continue the pregnancy, the gestational age at diagnosis would be the most critical factors to the decision. If the patient is in the late second or third trimester, options of pregnancy continuation or termination were discussed with the patient thoroughly, including the risk of rapid tumor progression. Then, neoadjuvant chemotherapy can be cautiously considered.
If the patients were in the early second trimester, it would better to discourage the patient wishes to preserve pregnancy considering the risk of tumor progression and potential adverse fetal outcome related with a relatively long exposure of chemotherapeutic agent.
Expert opinion 3: Linda Mileshkin
Management of such patients needs to be multi-disciplinary and involve both the obstetric and oncology team. It should occur in centers with appropriate expertise and resources to manage pregnant patients with cancer. The patient requires both psychosocial support but also careful counseling so that she understands the potential risks to both herself and her child of continuing with the pregnancy.
Some investigations to determine the extent of cancer can be safely performed during pregnancy, such as the use of chest X-ray with abdominal shielding, ultrasound and the use of MRI without Gadolinium (which is not safe to use in pregnancy). PET/MRI if available, can also be safely performed and would provide an optimal assessment of the nodal status. The use of neoadjuvant chemotherapy during the second and third trimesters can be considered to manage cancer up until the time that delivery is planned. This is usually at around 37 weeks to optimize the chances of excellent fetal outcomes. Chemotherapy would usually involve 3–4 cycles of carboplatin and paclitaxel chemotherapy. Carboplatin is preferred over cisplatin because of the risks of ototoxicity in the fetus if cisplatin is used. It will be noted that the calculated GFR will be very high during pregnancy, but carboplatin can be safely dosed to the calculated value. Had the patient been found to have metastatic disease, then the use of bevacizumab during pregnancy would not be recommended. The last cycle of chemotherapy should be planned to occur 3 weeks before the scheduled delivery date. Routine anti-emetics, such as metoclopramide and ondansetron, as well as steroid pre-medication with chemotherapy, can be used. However, some recommend that the use of hydrocortisone or prednisolone is preferred over prednisolone as they are extensively metabolized in the placenta, and hence will result in little fetal exposure. The delivery needs to be done by cesarean section as discussed earlier. Following delivery, standard treatment with chemoradiation can be given. It is recommended to wait 6 weeks for the uterus to involute before commencement. It will not be possible for the mother to breastfeed during chemotherapy treatment due to potential transmission to the child (15).
What's the operational difficulties and precautions for the surgery of cervical cancer in pregnancy?
Expert opinion 1: Junjie Wang, Michael D. Mueller, Andrea Papadia
In the presence of a tumor on the cervix, cesarean section is the preferred route of delivery. Vaginal delivery may result in the lymphovascular spread, bleeding, obstruction of the birth canal, laceration of vagina and cervix and implantation of malignant cells on episiotomy wound. Abdominal wall recurrences have also been described after surgery, and hence a wound protective system can be used during cesarean section. As the cervical tumor is vascular, it is best to avoid the tumor by performing a classical incision of the uterus for delivery of the fetus. The method for radical hysterectomy, parametrial dissection, and ureteral mobilization is similar to a non-pregnant uterus, despite a larger uterine size. Particular precaution should be made to control hemostasis, as blood vessels will remain engorged.
Cross-matched blood should be readily available. Experienced gynae-oncologists in a tertiary center should perform the surgery.
Expert opinion 2: Taek-Sang Lee
When confined to radical hysterectomy, the significant changes of the uterus in pregnancy such as the larger uterine volume and increased uterine blood flow do not significantly affect the performance in the dissection of the parametria, ureteral mobilization and do not differ considerably in blood loss from those observed among non-pregnant women (20). Also, pelvic lymphadenectomy in patients with early invasive cervical cancer during the first and second trimester is a safe and reproducible operation with good oncological outcomes with minimal surgery-related complications (21).
What's the potential impact of high-risk HPV to the male and female fetus antepartum and postpartum?
Expert opinion 1: Junjie Wang, Michael D Mueller, Andrea Papadia
Vertical transmission of HPV from mother to fetus is known to occur. Up to 80% of neonates born to women with genital HPV have HPV DNA detectable in their nasopharyngeal aspirate or oral mucosa (22), and this may persist for months or years. Despite a high prevalence of HPV DNA detection, the children are usually asymptomatic.
Perinatal transmission of HPV types 6 and 11 can lead to the development of juvenile-onset recurrent respiratory papillomatosis, but this is rare with an estimated annual incidence of two to four per 100,000 infants (23,24).
Expert opinion 2: Taek-Sang Lee
While the risk of vertical transmission has been reported to be relatively low, it is clear that High-risk HPV can be transmitted during the delivery process. A recent study reported that among 153 healthy mothers who have a positive HPV test in the antenatal period, 5.2% of neonates showed HPV DNA positive in their cord blood or nasopharyngeal aspirates (25). However, HPV persistence in infants is known to be a rare event, and the substantial HPV positivity can be observed in children born to HPV-negative mothers (26).
Expert opinion 3: Linda Mileshkin
Vertical transmission of HPV infection from the mother to the fetus has been described in multiple case series. Hence it has been recommended that the mother receives HPV vaccination during pregnancy to reduce the risk of fetal infection. Several series have now been published suggesting that HPV vaccination during pregnancy is safe (15).
What's the impact of chemotherapy on fetal prognosis?
Expert opinion 1: Junjie Wang, Michael D Mueller, Andrea Papadia
The timing of exposure, the dose of the drug, and the degree to which the drug crosses the placenta influence the impact of chemotherapy on the fetus. First-trimester use of chemotherapy should be avoided as it increases the risk of fetal malformation, miscarriages, and fetal death (27). The use of chemotherapy in the second and third trimesters is associated with intrauterine growth restriction and low birth weight.
Several studies have proved that the use of chemotherapy in pregnancy is not associated with learning disabilities, hematological, or immunological abnormalities in exposed children. In a prospective study, Amant et al. found that the general health, cognitive development, and cardiac function of children who were exposed to chemotherapy in utero were comparable to children who did not (28).
Platinum derivatives were shown to be a safe option during pregnancy (29). Marnitz et al. measured cisplatin concentration in maternal blood, amniotic fluid, and umbilical cord blood of patients with cervical cancer in pregnancy. They found that the levels of cisplatin in umbilical cord blood and amniotic fluid are significantly lower than the levels found in the maternal blood. These results were confirmed by the same group of authors in another study on platinum agents (30,31). As cisplatin is the most common drug used in neoadjuvant chemotherapy treatment of cervical cancer in pregnancy, these results assure us of the safety of the drug.
It takes about 3 weeks for the bone marrow to recover after chemotherapy. Hence, delivery must be planned at least 3 weeks from the last cycle of chemotherapy, and chemotherapy should be avoided after 35 weeks of gestation. This will reduce the risk of infection and hemorrhage to both mother and child.
Expert opinion 2: Taek-Sang Lee
According to the evidence so far, exposure to chemotherapy in the second or third trimester of pregnancy is not detrimental to fetal life, but the risks of small for gestational age and preterm birth still exist. Cytotoxic chemotherapy administered during the first trimester has been known to be associated with an increased risk of congenital malformations and is therefore contraindicated.
Agents for targeted therapy such as bevacizumab has become an important therapeutic option for in metastatic disease of cervical cancer, but the data on the safety of these agents in pregnancy is overall scarce. Because of the small size, structure, metabolism, and pharmacokinetics of these agents, they are potentially teratogenic and harmful for the fetus (32) and these agents should, therefore not be advised in pregnancy; hormonal treatment in pregnancy is contraindicated.
Expert opinion 3: Linda Mileshkin
The impact of chemotherapy on fetal prognosis depends on the drugs used as well as the timing of delivery. Several different review articles provide an excellent summary of this information such as that by Maggen et al. In general, chemotherapy use is contraindicated during the first trimester as use has been reported to be associated with spontaneous miscarriage, fetal death, and congenital malformations. In the second, and particularly the 3rd-trimester chemotherapy can be given, although there is a risk of the increased likelihood of complications such as intra-uterine growth restriction, stillbirth, preterm birth or need for neonatal intensive care. Data on pediatric outcomes are not extensive but generally, do not report a significant incidence of long-term complications in children exposed to chemotherapy when in-utero (15).
Treatment of cervical cancer in pregnancy is dependent on the stage of the disease, gestational age, histological subtype, and patient's wish to continue the pregnancy. These patients should be managed under a multidisciplinary team. For patients who do not want to continue with their pregnancy, the treatment is the same as for non-pregnant women. For women deciding to continue with the pregnancy, individualized treatment should be applied. For pregnant patients with locally advanced and metastatic cervical cancer (stages IIB–IV) or with a more aggressive histological subtype like small cell carcinoma of the cervix, it is recommended that the pregnancy should be immediately terminated to initiate the treatment. For IA–IIA stage, different treatment including interruption of pregnancy, expectant management, neoadjuvant chemotherapy should be applied according to the gestational week.
The termination of pregnancy after the first trimester usually requires a classical incision of cesarean section as vaginal delivery is not safe because of the potential risks of blood loss in the tumor lesion during vaginal delivery. Vertical transmission of HPV from mother to fetus is usually harmless to the children. First-trimester use of chemotherapy should be avoided. The use of chemotherapy in the second and third trimesters is not associated with learning disabilities in the exposed children. This case could help surgeons have a better understanding and choosing about the treatment protocol of cervical cancer during pregnancy, the timing of delivery, and the mode of delivery.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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- Köhler C, Oppelt P, Favero G, et al. How much platinum passes the placental barrier? Analysis of platinum applications in 21 patients with cervical cancer during pregnancy. Am J Obstet Gynecol 2015;213:206.e1-5. [Crossref] [PubMed]
- Lambertini M, Peccatori FA, Azim HA Jr. Targeted agents for cancer treatment during pregnancy. Cancer Treat Rev 2015;41:301-9. [Crossref] [PubMed]
Cite this article as: Han J, Hu X, He X, Wang J, Mueller MD, Papadia A, Lee TS, Mileshkin L, Wang P, Yao Q, Jiang W. Cervical cancer in pregnancy: one case report and a review of current treatment recommendations. Gynecol Pelvic Med 2019;2:10.


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This spring, the Morgan Library and Museum exhibitis some of its more treasured medieval manuscripts exploring the ways in which people told and experienced medieval time
What time is it? The question seems simple, and with a watch on your wrist or a cell phone in your hand, the answer is easy. In the Middle Ages, however, the concept of time could be approached in many different ways, with vastly different tools.
Drawing upon the rich holdings of the Morgan's collection of medieval and Renaissance illuminated manuscripts, Now and Forever explores how people told time in the Middle Ages and what they thought about it. The manuscripts range in date from the eleventh to the sixteenth centuries and come from all the major countries of Europe.
The exhibition begins with the quirks of the medieval calendar, exploring sacred feasts, the mysteries of Golden Numbers, the utility of Dominical Letters, and how the Middle Ages inherited the Roman Calendar of Julius Caesar. Visitors will engage with the complexities of time as defined by liturgical celebrations and their two overlapping systems of temporale (feasts of time) and sanctorale (feasts of saints), systems that still influence the way we tell time today. Now and Forever also explores how time beyond the grave preoccupied medieval people for whom life on earth was a mere dress rehearsal for the main event—the afterlife.
The exhibition is accompanied by a beautiful catalogue written by Roger S. Wieck, Curator at the Morgan, and published by The Morgan Library & Museum in association with Scala Arts Publishers.
Now and Forever: The Art of Medieval Time is made possible with generous support from Barbro and Bernard Osher, The Janine Luke and Melvin R. Seiden Fund for Exhibitions and Publications, and the Andrew W. Mellon Research and Publications Fund.
Now and Forever: The Art of Medieval Time
The Morgan Library and Museum
225 Madison Avenue at 36th Street, New York, NY 10016
26.01.2018 – 29.04.2018
The False Prophet Directs the Worship of the Beast, "Burckhardt-Wildt Apocalypse," France, Metz, 1290s, illuminated possibly for Eleanor Plantagenet, The Morgan Library & Museum, MS M.1071.2v, gift of Mr. and Mrs. H. P. Kraus, 1985.

subset: commoncrawl


text:
[N MINT]Mamiya 645 AFD Camera Body w/ AF80mm, ZD digital back from japan #580. Total TOP Mint Pre-owned, Like new Near Mint Pre-owned, almost no signs of use Excellent+++++ Pre-owned, minimal signs of use Excellent Pre-owned, heavy signs of use Very Good poor appearance Serial Number Body:BF3275 Lens:BJ1226 ZD back:GB1044.Appearance is beautiful, tiny scuffs from normal use. It shows signs of use. There is No balsam separation. There is a few very tiny tiny dusts. No problem in the shooting. There is no liquid leak of the liquid crystal panel. All you can see on the picture will be included in a set of a package. Please refer to the pictures for more details. Please check the pictures and don't hesitate to ask any questions about the item!
I send a product by EMS. Weekends are not available because post office is closed.
All return requests must be made within 30 days of the receipt of the item. The item "N MINT Mamiya 645 AFD Camera Body with AF80mm, ZD digital back from japan #580" is in sale since Saturday, March 31, 2018. This item is in the category "Cameras & Photo\Film Photography\Film Cameras". The seller is "asakusacamera2015" and is located in saitamashi,kitaku. This item can be shipped worldwide.


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In this honest review, we'll take a closer look at the top 25 programs in the U.S. to find the best auto mechanic school for you.
Let's start NOW!!
If you're already interested in cars, becoming an auto mechanic might seem like a no brainer of a career path. There is a high need right now for more mechanics across the United States, so the employability rates are high. With the right training and experience, you can make a great salary doing something you love.
The best first step for those serious about becoming mechanics is to enroll in an auto mechanic school. These training programs are typically 2 years long and end in you receiving your Associate Degree or Technical Certification in auto repair. This gives you the baseline knowledge and schooling you need to pass your ASE exams and become a certified mechanic.
There are a lot of different auto mechanic training programs to choose from. While some are regarded more highly than others, there's no one right answer when it comes to picking the right one for you. We've picked out our top 25 auto mechanic schools in the nation and ranked them on the list below.
Anyone of these schools can give you the training you need to become a successful auto repair technician. Read what each one is known for below to find the one that's perfect for your needs.
Table of Contents
- 1 Top 25 Auto Mechanic Schools In The US
- 1.1 Pittsburg State
- 1.2 Weber State University
- 1.3 Lake Area Technical Institute
- 1.4 ATU Ozark
- 1.5 Delhi State University of New York
- 1.6 Eastern New Mexico University – Roswell
- 1.7 Arkansas State University
- 1.8 Alfred State College of Technology
- 1.9 Ferris State University
- 1.10 Northern Michigan University
- 1.11 Eastern Arizona College
- 1.12 Wisconsin Indianhead Technical College
- 1.13 UA Cossatot
- 1.14 Alexandria Technical & Community College
- 1.15 Athens Technical College
- 1.16 Pickens Technical College
- 1.17 Salina Tech
- 1.18 Northwest Iowa Community College
- 1.19 South Seattle College
- 1.20 Central Louisiana Technical Community College
- 1.21 Washburn Tech University
- 1.22 Southwest Tech
- 1.23 Northeast Community College
- 1.24 The University of West Alabama
- 1.25 Polk Education Pathways (Ridge Technical College, Traviss Technical College)
- 2 Job & Salary Outlook for Auto Mechanics
- 3 Mechanic School Checklist
- 4 Mechanic Licenses & Certifications
- 5 Essential Skills & Experience for Auto Mechanics
Top 25 Auto Mechanic Schools In The US
Pittsburg State
Pittsburg, KS
Since it's built inside the Kansas Technology Center, the repair labs at Pittsburg State are equipped with the latest in diagnostic equipment. This exposure to the cutting edge better prepares students to work in the modern world. The faculty is equally renowned, giving students access to all the resources they need to succeed.
Included Programs
- Master of Science in Technology (2 years, 30-33 credits)
- Bachelor of Science in Automotive Technology (4 years, credits vary)
- Associate of Applied Science in Automotive Service Technology (2 years, 64 credits)
- Certificate in Automotive Service Technology (2 years, 55 credits)
- In-state: $8,164/year
- Out-of-state: $18,804/year
Why study here?
- Offers the full range of degree programs, up through Masters programs
- Option of taking some courses online
- 32,000-foot garage equipped with cutting-edge technology
- Knowledgeable faculty
- Small classes with lots of hands-on learning
- Also offers emphasis in Diesel and Heavy Machinery
- No programs shorter than 2 year
Weber State University
Ogden, UT
Those looking to get a full BS or AAT should seriously consider Weber State University in Ogden, Utah. When you get your degree from Weber State University The flip side of this is it's a longer program, designed to be taken as a full-time student. If you have the time and money, though, attending Weber State is an investment in your future.
Included Programs
- Bachelor of Science in Automotive Technology (125-126 credits)
- System and repair courses: 48 credits
- Management and business: 9 credits
- Standards and regulations: 3 credits
- Supporting/general education: 66 credits
- Associate of Applied Science in Automotive Service Technology (63-67 credits)
- Automotive services courses: 21-23 credits
- Supporting/general education: 24 credits
- Automotive Service Technology Certificate of Proficiency (16 credits)
- In-state: $4892/year
- Out-of-state: $14,679/year
Why study here?
- Offers full degree programs
- Consistently ranked in the top 10 Automotive Technology programs
- Passionate and knowledgeable faculty
- Higher cost
- Programs will require at least 2 years to complete
Lake Area Technical Institute
Watertown, SD
Studying at Lake Area Technical Institute gives you solid experience with all the latest diagnostic equipment. This makes you very desirable to employers. Most of your time will be spent working on cars in their 27,000-foot repair shop so you'll graduate with real hands-on experience.
Included Programs
- Associate of Applied Science in Automotive Technology (71 credits, 4 semesters)
- Repair and technical coursework: 56 credits
- General education: 6 credits
- Leadership and career courses: 9 credits
- AAS: Light Duty Diesel Option (71 credits, 4 semesters)
- Same credit breakdown as AAS in Automotive Technology
- Light Duty Diesel Certificate in Automotive Technology (18 credits, 1 semester)
Tuition: $3,975-$4,063/semester
Why study here?
- Spend more of your time in a garage than in classrooms
- Gain experience with the most recent diagnostic equipment
- Choice of automotive gas or light-duty diesel courses
- Option of taking just the diesel courses if you're already an automotive grad
- Program designed only for full-time students
- Higher per-credit cost
ATU Ozark
Ozark, AR
The program at ATU Ozark is practical in nature. It's focused on automotive diagnosis and repair. Students learn how to test and fix all of the major systems in today's modern cars. Taking the full 2-year AAS program will give you a start-to-finish background for working in or even owning your own garage.
Included Programs
- Associate Degree in Automotive Service Technology (60 credits)
- Auto repair specific: 51 credits
- General education: 9 credits
- Duration: 2 years of full-time
- Technical Certificate in Automotive Service Technology (36 credits)
- Auto repair specific: 27 credits
- General education: 9 credits
- Duration: 1 year full-time
- Certificate of Proficiency in Automotive Service Technology (16 credits)
- Electronics: 6 credits
- Engine theory: 4 credits
- Brake systems: 3 credits
- Chassis and steering: 3 credits
- In-state: $125/credit
- Out-of-state: $250/credit
Why study here?
- Practical preparation for work on modern cars
- Offers full degree program for prospective garage owners
- Shorter Certificate program gets you to work in less than 1 year
- Relatively high cost per credit
Delhi State University of New York
Delhi, NY
Everything at Delhi State University is at industry standard. Faculty are required to have 15 years' experience in the automotive field and all equipment used by students is what you'll find in today's garages. Graduates have a high success rate in both the workforce and continuing education.
Included Programs
- AAS – Automotive Technology (4 semesters)
- AOS – Automotive Technology (4 semesters)
Tuition: $7,070/year
Why study here?
- Nationally ranked by the NATEF
- All faculty are master-certified technicians
- Credits are fully-transferrable to a 4-year college
- Train on customer vehicles in the automotive lab
- Students can earn up to 8 ASE certifications on graduation
- Higher cost
Eastern New Mexico University – Roswell
Roswell, NM
Becoming a Master Technician takes serious training. The Automotive Technology Program at Eastern New Mexico University provides the knowledge you need to get there. Along with the degree program, certificates in employability and occupational training make graduates especially appealing when they enter the workforce.
Included Programs
- Associate of Applied Science – Automotive Technology (62 credits, 4 semesters)
- General education: 21 credits
- Certificate of Employability (40 credits)
- Certificate of Occupational Training (52 credits)
- Automotive courses: 41 credits
- Certificate in Automotive Brakes (6 credits)
- Level 1 Certificate (14 credits)
Tuition: $3,103/semester
Why study here?
- Nationally certified by ASE/NATEF
- Covers all 8 major areas of study
- Students preparing for certification as Master Technicians
- Offers a variety of certifications
- Not as flexible working with part-time students
Arkansas State University
Mountain Home, AR
You want to get out of school and into the workforce as quickly and affordably as possible. At Arkansas State University, you can earn your AAS in Automotive Technology in just 3 semesters, and at a total cost of just over $10,000. You'll learn just as much as at other schools, but you'll learn it faster, and leave with all the tools you need to find a job.
Included Programs
- AAS in Workforce Technology – Automotive (60 credits, 3 semesters plus lab)
- Technical coursework: 35 credits
- Career coursework: 5 credits
- Automotive lab: 8 credits
- General education: 12 credits
- Technical Certificate in Automotive Systems Repair (48 credits, 2 semesters plus lab)
- Technical coursework: 35 credits
- Career coursework: 5 credits
- Automotive lab: 8 credits
- Certificate of Proficiency in Automotive Systems Repair (12 credits, 1 semester)
- In-state: $267/credit
- Out-of-state: $552/credit
Why study here?
- The fast-paced program lets you earn an AAS in 18 months
- Full hands-on lab eases the transition into the workplace
- Students leave with their own repair toolkit
- Program is intensive
- Not as flexible for part-time students
Alfred State College of Technology
Alfred, NY
The staff at Alfred State College of Technology are serious about preparing students for the real world. This intensive two-year program covers every system and style of engine, giving graduates the solid background they need to succeed. The option to complete a second Associate degree in motor sports, power sports, or motorcycles can make you even more versatile and employable.
Included Programs
- AOS – Automotive Service Technician (52 credits, 2 years)
- In-state: $8,075/year
- Out-of-state: $14,635/year
Why study here?
- 100% of graduates go on to full-time employment or further education
- Includes 1,800 hours of practical training in automotive repair
- Covers every system and type of car, including diesel
- Certified by NAFTC, NATEF, and the NYS inspection station
- Option to complete a second AAS in 1 year
- Can directly enter a BA program following degree completion
- Not suitable for part-time students
- Not as much program variety
Ferris State University
Big Rapids, MI
Looking for a school that offers online learning? Ferris State University gives you the option of completing their Automotive Management course remotely. This is ideal for those already working in a garage who just need the degree to expand their knowledge. There is also an in-person course with hands-on experience.
Included Programs
- Bachelor of Science in Automotive Engineering Technology (4 years)
- Bachelor of Science in Automotive Management (4 years)
- Associate Degree in Automotive Management (2 years)
- In-state: $431/credit
- Out-of-state: $696/credit
Why study here?
- Can earn an Automotive Management certification online
- Programs include instruction in marketing, accounting, and other business skills
- Can transfer credits easily to and from nearby universities
- Over 80% of students receive financial assistance
- Multiple degrees tracks available
- Doesn't focus on as many technical aspects of auto repair
- Lengthy program with a higher overall cost
Northern Michigan University
Marquette, MI
The hands-on aspect of the automotive technology program at Northern Michigan University is the most helpful part of the program. Along with the technical aspects of car repair, you'll learn how to run a safe and efficient workplace. This makes it ideal for someone who wants to run a garage, not just work in one.
Included Programs
- AAS in Automotive Service Technology (65 credits)
- Automotive repair: 41 credits
- Industry and safety: 5 credits
- General courses: 19 credits
- Duration: 1-2 years
- Certificate in Automotive Service Technology (46 credits)
- Technical courses of the AAS without the liberal arts requirement.
- Duration: 1 year
Tuition: $5,364/semester
Why study here?
- Teaches everything you need to manage a garage
- Focus on full mechanical aptitude
- Certificate option lets you complete the coursework faster
- Higher cost per credit
Eastern Arizona College
Thatcher, AZ
The student experience at Eastern Arizona College is just like working in a real garage. You'll make actual repairs while you learn the methods behind them. This is true of all their programs, which range from a consultant certification to a full AAS.
Included Programs
- AAS – Automotive Service Technology (64 credits, 4 semesters)
- Technical courses: 37-39 credits
- Supporting/general education: 25-27 credits
- Automotive Service Consultant Certificate (30 credits, 2 semesters)
- Technical courses: 21 credits
- Supporting courses: 9 credits
- Automotive Technician Certificate (23 credits, 2 semesters)
- Auto Maintenance Certificate (16 credits, 2 semesters)
- In-state: $1,350/semester
- Out-of-state: $5,700/semester
Why study here?
- Tons of hands-on experience
- Also provides the experience you need to manage a repair shop
- Offers both AAS and technical certifications
- Fully prepares students to take all necessary tests
- Very expensive for out-of-state students
Wisconsin Indianhead Technical College
Shell Lake, WI
The vocational programs at Wisconsin Indianhead Technical College are nationally ranked. More importantly, their graduates are consistently hired in serious garages. By focusing just on car repair they condense the program down to 9-12 months, one of the fastest on this list.
Included Programs
- Automotive Technician (55 credits, 2 years)
- Technical Diploma – Automotive Service Technician (29 credits, 9-12 months)
- Automotive Maintenance and Light Repair Technician (11 credits, 1 semester)
Tuition: $4,992 for full program
Why study here?
- The full program takes only 9-12 months to complete
- Financial aid is easy to apply for
- Credits can be transferred to a 4-year school for further education
- Flexible programs and class times work with real life
- Diagnostic training isn't as in-depth
UA Cossatot
De Queen, AR
All of the courses in the technical sciences at UA Cossatot are designed to get graduates directly into the workforce. This focus on advancing your career makes it a practical choice. UA Cossatot also offers one-semester certificates in a wide range of skills, making it an appealing option for continuing education.
Included Programs
- Technical Certificate – Automotive Service Technology (45 credits, 1-2 years)
- Certificates of proficiency:
- Brakes, Suspension & Steering (8 credits)
- Drive Train Specialist (8 credits)
- Engine Performance (10 credits)
- Diesel Engines (8 credits)
- Engine Repair & Climate Control (10 credits)
- Diesel Brakes (8 credits)
- Electrical/Electronic Systems (9 credits)
- Diesel Electrical/Electronics (8 credits)
- Diesel Steering and Suspension (8 credits)
Tuition: $74-$102/credit
Why study here?
- Will be thoroughly trained up to NATEF standards
- Focus on preparing you to enter the workforce
- Technical certifications are ideal for continuing learners
- Easy to transfer credits to other institutions
- Can pair certifications with an AAS in Skilled and Technical Sciences
- No AAS in Automotive Technology
Alexandria Technical & Community College
Alexandria, MN
If your main interest is in diesel engine repair, including trucks and industrial equipment. You'll get all the classroom knowledge, of course, including the theory of mechanics and current industry standards. More important, though, are the labs, where you'll work directly on equipment.
Included Programs
- AAS in Diesel Mechanics (75 credits, 108 hours)
- Repair and technical courses: 58 credits
- General education: 12 credits
- Internship: 4 credits
- Job seeking: 1 credit
- Diploma in Diesel Mechanics (66 credits, 99 hours)
- Repair and technical courses: 53 credits
- General education: 8 credits
- Internship: 4 credits
- Job seeking: 1 credit
- Online: $199/credit
- On-campus: $165/credit
Why study here?
- Options for online or in-classroom work
- Full introduction to repair of diesel engines
- Intensive internship prepares you for the workplace
- Includes a course on finding and keeping a job
- Higher cost per credit than other schools
Athens Technical College
Athens, GA
In addition to full courses in automotive repair, Athens Technical College offers a variety of certifications in systems like Climate Control and Electrical/Electronic Systems. All are certified by NATEF. With a mix of full 2-year degree programs and individual certifications, it has a lot to offer for car technicians in all stages of their career.
Included Programs
- Associate's in Automotive Technology (44-46 credits)
- Diploma in Automotive Fundamentals (55 credits)
- Diploma in Automotive Technology (62-63 credits)
- Climate Control (14 credits)
- Chassis (17 credits)
- Electrical/Electronic Systems (9 credits)
- Engine Performance (16 credits)
- Engine Repair (15 credits)
- Transmission/Transaxle (18 credits)
- In-state: $2,794/year
- Out-of-state: $4,930/year
- Single credit: $363
Why study here?
- Multiple options for full degree programs
- System-specific certifications for those not interested in a full degree
- Flexible scheduling with both day and night classes
- Will need to invest 2+ years to obtain Diploma or Associate's
Pickens Technical College
Aurora, CO
Pickens Technical College doesn't just prepare you to work as an automotive technician, they also teach you how to go out and find a job. The program ends with a 3-week internship with the potential to lead straight into employment.
Included Programs
- Maintenance and Light Repair Certificate (27 credits, 2 semesters)
- Automotive Service Technician Certificate (16 credits, 1 semester)
- Master Automotive Service Technician Certificate (17 credits, 1 semester)
- NATEF Automotive Service Technician Certificate (60 credits, 4 semesters)
Tuition: $1,600-$2,300/semester
Why study here?
- Emphasis on getting a job after school
- Affordable alternative to full AAT programs
- 2-year NATEF certificate is a full comprehensive program
- No Associate degree programs
Salina Tech
Salina, KS
The instructors at Salina Tech have over 30 years of experience working with cars. This depth of knowledge is what makes their program so effective. They focus on real-world and hands-on experience in transmission, electrical systems, and all the other crucial components of today's vehicles.
Included Programs
- Associate of Applied Science in Automotive Technology (68 credits, 4 semesters)
- Technical courses: 53 credits
- General education: 15 credits
- Technical Certificate in Automotive Technology (53 credits, 4 semesters)
- Technical courses of the AAS without the general education requirement
Tuition: $2,500/semester
Why study here?
- Impressive faculty with extensive real-world knowledge
- Gives students hands-on experience
- Offers both Associate Degree and Technical Certificate options
- Also offers an AAS in Auto Collision Repair
- The program can take up to 2.5 years to complete
- Not as much focus on finding employment
Northwest Iowa Community College
Sheldon, IA
As the school's site says, this program studies cars from bumper to bumper. The inclusion of light duty diesel right in the automotive coursework is helpful, saving you time on additional certifications. Use of the latest technology and diagnostic tools also helps prepare students for real-world work.
Included Programs
- Associate of Applied Science – Automotive and Light Duty Diesel Technology (78 credits, 4 semesters)
- Automotive courses: 60 credits
- General education: 12 credits
- Internship: 6 credits
Tuition: $169-184/credit
Why study here?
- Makes use of the latest technology and tools
- Includes diesel engines in the main coursework
- Summer internships add to the hands-on experience
- Comprehensive system by system training
- Not as flexible for part-time students
- Relatively high per-credit cost
South Seattle College
Seattle, WA
The automotive repair program at South Seattle College is relatively small, offering only a single 1-year certification option. This focus lets it excel at what it does, though. If you want to quickly learn what you need to know for an entry-level repair position, you can do it here.
Included Programs
- Maintenance & Light Repair Certificate
- Steering/Suspension (4hrs)
- Tires/Wheel Alignment (4hrs)
- Brake Systems (7hrs)
- Engine Diagnosis (4hrs)
- Engine Rebuild (8hrs)
- Drivability (3hrs)
- Automotive Technology (9hrs)
- General Courses: 15hrs
- Total Credits: 54 (1 year)
- 1-10 credits: $285/credit
- 11-18 credits: $60/credit
Why study here?
- 1-year option for a full certification
- Relatively low cost per credit for full-time students
- No individual certifications
- No option for a full Associate's
Central Louisiana Technical Community College
Alexandria, LA
The automotive repair program at Central Louisiana Technical Community College is straightforward and effective. All instruction is NATEF certified and designed to prepare you for the institute's certification test. Since you can get a certificate after each semester, it's a great choice if you're not sure that you'll complete a full 2- or 4-year program.
Included Programs
- Technical Diploma in Automotive Technology (60 credits)
- Electrical Technician (12 credits)
- Engine Performance Technician (15 credits)
- Steering, Suspension & Brake Technician (12 credits)
- Heating & Air Conditioning Technician (7 credits)
- Automatic Transmission & Transaxle Technician (7 credits)
- Manual Drive Train Technician (5 credits)
- Engine Technician (20 credits)
Tuition: $2,250/semester
Why study here?
- Option to complete full program or earn competency certificates each semester
- Competencies offered in all the major systems
- Full preparation in all aspects of automotive repair
- Learn about motorcycles, aircraft, and marine vessels as well as cars
- Not a full Associate program
- No internship or lab for true hands-on learning
Washburn Tech University
Topeka, KS
Washburn Tech offers a range of transportation training programs, from truck driving to collision repair and even locomotive diesel technology. Their faculty has a depth of knowledge you won't find in other programs. You'll learn the ins and outs of how car engines work at both an intellectual and a practical level. Graduates leave well-prepared for a variety of repair careers.
Included Programs
- Auto Service Technician Certificate (1-2 years)
- Engine courses: 23 credits
- Transmission/transaxle: 10 credits
- Steering/suspension: 5 credits
- Brake systems: 6 credits
- Electricity/Electronics: 14 credits
- Heating and air-conditioning: 4 credits
- Auto OJT: 2 credits
Tuition: $2,100-$2,200/semester
Why study here?
- Nationally certified program
- Includes both classroom and hands-on learning
- Gain in-depth technical knowledge of engine operation and repair
- Can go on to complete a full AAS at Washburn University
- Includes certifications in a variety of systems
- The option of full-time or part-time coursework
- Doesn't offer a full AAS program
Southwest Tech
Fennimore, WI
Here's another program that will teach you all the basic servicing techniques you need to start a promising career as an auto technician. It's definitely aimed at traditional students, with little in the way of scheduling flexibility.
Included Programs
- AAS – Automotive Technician (60 credits, 2 years)
Tuition: $136-$204/credit
Why study here?
- Occupational internships included in the coursework
- Courses like Workplace Communication make you a better employee
- All courses in the degree are focused on work as a repair technician
- Some financial aid is available
- No night-time classes
- The full-time two-year program is the only option
- Out-of-state tuition is steep
Northeast Community College
Norfolk, NB
The goal of Northeast Community College is to prepare students for entry-level positions as technicians in repair shops. They combine classroom and garage education to do this, and the program includes an internship for real-world training.
Included Programs
- Associate of Applied Science – Automotive Technology (77 credits, 2 years)
- Automotive courses: 66 credits
- General education: 15-16 credits
- In-state: $99/credit
- Out-of-state: $139/credit
Why study here?
- The co-operative internship provides on the job experience
- Can transfer credits to a 4-year program
- Fully accredited to prepare you for certification tests
- The comparatively affordable program, especially for Nebraska residents
- Less scheduling flexibility
The University of West Alabama
Livingston, AL
You'll get a pretty standard two-year college experience at the University of West Alabama. The program is designed for traditional students and has a larger general education component. If you're especially interested in the engineering and technology behind car repair, you'll love this program.
Included Programs
- Associate of Applied Science in Automotive Technology (62 credits, 4 semesters)
- Engineering technology courses: 42 credits
- General education: 29 credits
- In-state: $8,450/year
- Out-of-space: $16,900/year
Why study here?
- A comprehensive education in automotive education
- The curriculum includes courses on industrial equipment
- The full degree program for a more well-rounded education
- Prepares you for a career in a dealership or repair shop
- More emphasis on classroom learning than hands-on work
- Will spend more of your time in general education courses
- Tuition cost is on the high side
Polk Education Pathways (Ridge Technical College, Traviss Technical College)
Winter Park, FL
This is a relatively small school, focused entirely on the automotive sector. The Automotive Service Technology program run by Polk Education Pathways is designed to prepare students for entry-level jobs in the automotive repair sector. Taking the course makes you eligible to take an Automotive Service Excellence test approved by NATEF.
Included Programs
- Automotive Service Technology 1:
- Automobile Services Assistor (300hrs)
- Brake System (150hrs)
- Suspension/Steering (150hrs)
- Electrical/Electronic (300hrs)
- Engine Repair (150hrs)
- Automotive Service Technology 2:
- Engine Performance (300hrs)
- AT/Transaxle (150hrs)
- Manual Drivetrain and Axle (150hrs)
- Heating/Air Conditioning (150hrs)
- Total class hours: 1,050 (AST 1), 750 (AST 2)
Tuition: $3,919/year
Why study here?
- Offers great hands-on experience
- Small school means more personal attention from faculty
- No full Associate's Degree option
Job & Salary Outlook for Auto Mechanics
Auto mechanics as a whole have a bright outlook right now in the United States. Everybody needs their car and needs it to work well. Much of today's workforce is older, though, and likely to retire in the next 10 years. This means a lot of openings for those coming out of auto mechanic school.
You can make good money as an auto mechanic. Salaries vary based on your education, experience, and whether you're employed in a garage or work independently, ranging from a low of $11.26/hour to a high of over $32/hour. The average hourly wage for a mechanic in 2018 was $19.78, which translates to around $40,000 a year.
Mechanic School Checklist
Having a degree from an auto mechanic training course is the best way to push yourself toward the upper end of that pay spectrum when you enter the workforce. But how do you choose the right school to get you there?
Online learning is one way to get around relocating for school. With something like repairing cars, though, you really need the hands-on experience. If you already work in a garage, an online course might work for you. For those new to auto repair, though, an in-person program is a must.
What else should you look for when choosing your school? Here's a brief checklist of the main factors to consider:
Are they accredited?
The most important thing is to find a school accredited by the NATEF (National Automotive Technicians Education Foundation). Only accredited programs can offer the ASE tests students need to take to become certified Master Technicians.
How large are the classes?
The teacher-to-student ratio at a school tells you how much personal instruction you'll get from the faculty. Auto mechanic training works best in small classes, where everyone can get their hands on the cars and really learn how to make them work. Large lectures can be fine for general education classes, but when it comes to the more technical stuff, look for smaller class sizes.
How advanced are the facilities?
Car manufacturers are constantly updating their vehicles, and mechanics need to keep up with these changes. Make sure the school uses the latest diagnostic and repair equipment so you're ready to work in real garages when you graduate.
What is their student success rate?
The true measure of a school's quality is how well their students do after graduation. How many of the program's graduates found work in their field within the first 6 months? The higher this percentage, the better your chances to enter the workforce.
How experienced are the faculty?
You want the people instructing you to be experts in their field. The more experience they have, the more they'll be able to pass on to you. Check out the faculty bios and look for people with at least 10 years of experience as working mechanics.
What specialties do they offer?
Some schools also offer courses in collision repair, motorcycle repair, and other tangential services. Specialties like this can often make you more employable, especially if they're something you already have an interest in.
How much does it cost?
We all know college can be expensive. The good news is that most of these courses are offered by trade schools and community college, which are on average far cheaper than 4-year universities. Still, if budget is a factor in your decision, pay attention to the cost per credit. It varies widely from one school to the next.
How long is the program?
To be ASE certified, you need to enroll in at least a 2-year program. You can also take the test with two years of work experience, however. If you already have that, you might prefer a program that gives you the knowledge you need to pass the ASE exams in 1 year or less.
Mechanic Licenses & Certifications
In order to become a certified technician, you have to pass the ASE exam. ASE stands for the National Institute for Automotive Service Excellence, an independent organization that safeguards the quality of the auto repair.
Certification also requires either two years of on-the-job training or a two-year degree from an accredited repair program and one year of on-the-job training. This is the main reason most mechanics seeking certification attend an automotive training program.
The automotive school also gives you the knowledge you need to pass the ASE exams. The tests are difficult, and only about 2/3 of test-takers pass their first time.
Automotive technicians also need to re-take the ASE exams every 5 years to maintain their certification. Returning to school for a semester to prepare for the exam can help keep you current with the industry's standards.
Essential Skills & Experience for Auto Mechanics
Before you decide to enroll in an automotive technician training program, you should make sure it's the right career path for you. There are some common traits and skills that make someone a good auto mechanic. Ask yourself:
Are you physically able to be a mechanic?
Auto technicians don't sit at a desk. For most people, this is one of the most appealing things about the job. Just make sure you've prepared for the reality of being on your feet or under cars pretty much all day.
Are you good with people?
Whether you work for a dealership or own your own garage, there's an element of customer service in every mechanic's job. Explaining complicated problems to a layman can be tricky, especially a layman who's already mad about his broken car. A good mechanic needs customer service skills as much as technical knowledge.
Are you good at problem-solving?
Mechanics have a lot of diagnostic tools at their disposal, but they won't always give you the answer. An auto technician uses the clues from the vehicle to diagnose and solve the problem as quickly as possible. If you're good at identifying problems and finding solutions, you'll be a good mechanic.
Are you technically proficient?
More and more, there are two levels to a mechanic's technical proficiency. You still need the mechanical aptitude to get under the hood, but now you also need the technical knowledge to get inside the dashboard. Understanding electronic systems is a huge advantage for a modern mechanic.
Can you work well under pressure?
Nobody wants to wait around for their car to be fixed. Every time a car comes in, you want to get it back on the road as fast as possible. A good mechanic can keep his cool and maintain his focus even in a hectic environment.
Do you like to learn?
A car mechanic isn't done learning when he graduates. Staying up-to-date with the latest developments in-car technology—and how to repair them—means being a life-long learner. An auto repair technician is a great career for somebody who loves figuring out new and better ways of doing things.
Do you know a lot about cars?
This one might seem obvious, but it helps to have a starting background in car repair before entering into an auto mechanic training program. If you already know how to do simple repairs, you'll catch on faster with more advanced techniques.
Read more: Top 35 Auto Blogs for Car Enthusiasts 2020


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Think only of the past as its remembrance gives you pleasure — Jane Austen as Elizabeth, P&P
Dear friends and readers,
Last year, really 2012, the admiral, I and Yvette heard and after "Elvis had left the building," danced to this band in the Kennedy Center Great Hall:
The admiral could cook.
I found it on YouTube around 11 at night this year, 2013.
Earlier (between 5 and 6:30 pm) Yvette and I had driven to an Olive Garden not far from our house, and with her $25 gift certificate, our Italian meal, salad, breadsticks, spaghetti and meatballs for her and egglplant parmigian with wine & coffee for me cost us $11.34 (exclusive of tip). We talked.
Home again, I watched on my Macbook Pro PBS Newshour, Amy Goodman for 2 hours (catching up), a powerful (anti-war) episode of the 1972 War and Peace (finely, realistically done, no computers so they had to hire all those men to enact battles in a park), wrote friends, read friends' letters, was on the phone with a woman friend. Clarycat on my lap some of the time, looking at the screen too, sometimes on her grey pad behind said computer, Ian pussycat came in to try to get me to play with a string with him, but I wasn't having any of this just now, so he returned to stay with Yvette in her room, while she watched something on TV, browsed the Internet, or napped.
About a quarter to twelve Clarycat and I went into Yvette's room where she was watching CNN which was televising the mad vast public party that goes on in Times Square each New Year's Eve. Ian on Yvette's bed.
On her widescreen TV, two anchor people, Kathy Ann Gifford (comedian, most known for a part in a reality show, "My life on the D list") and a newsman from the station, Cooper Anderson. They were exemplarily handcuffed to one another — the crowd was very thick, and while they would not have been pulled apart as it was not thick and everyone well behaved, people sometimes advise couples to do this. In 1976 on July 4th, the Admiral and I went down to the Bowery for a final ceremony of the centennial. My parents (also then alive, also now both dead) fearful for us in such a huge crowd, gave us ropes and we promised to tie our waists to one another's. In fact, the crowd surged and was in thickness and numbers a mob, and when it broke up he and I could have been parted but for that rope.
Back to her TV: a huge stand with a electronic piano-looking instrument in the center of the square. I did not know they do shows nowadays and about 2 minutes from twelve there's Melissa Etheridge in winter coat, trousers, sweater, heavy boots, with microphone, belting out John Lennon's "Imagine" for all she's worth. I love the lyrics of that song.
Imagine there's no heaven
It's easy if you try
No hell below us
Above us only sky
Imagine all the people
Living for today…
Imagine there's no countries
It isn't hard to do
Nothing to kill or die for
And no religion too
Imagine all the people
Living life in peace…
You may say I'm a dreamer
But I'm not the only one
I hope someday you'll join us
And the world will be as one
Imagine no possessions
I wonder if you can
No need for greed or hunger
A brotherhood of man
Imagine all the people
Sharing all the world…
You may say I'm a dreamer
But I'm not the only one
I hope someday you'll join us
And the world will live as one
As she was on the last stanza, the superlit ball began to come down and the crowd roared; there was 2014 blinking in neon. I have been there at the Square standing twice, once with my first husband (I was 18 so gentle reader 49 years ago), and once with the Admiral (we were in our 30s). Then piped in Frank Sinatra doing "New York, New York," and then a male voice (why not Judy Garland I thought?) "Somewhere over the rainbow."
On stage were a row of people dancing in a row, armed intertwined, one of theme the hispanic supreme court justice, Sonia Sodamayor. She had released the ball because in his last year the ex-Mayor (about time) Bloomberg could't be bothered to stay in NYC but went to Paris where there is a more decorous street scene around the Eiffel Tower and fireworks. In the year 2000 the Admiral, I and Yvette spent 2 weeks of Christmas in Paris and we were there that New Year's Eve. It was raining and began to pour just around fireworks time so I remember best catching a cab which took us outside the central city to a highway and brought us back again to our flat as the streets were so crowded with cars and people. Sodamayor looked very happy as she danced away.
But it was 20 minutes after twelve and I must keep to my sleep schedule. So Clarycat and I went to bed, and with a pill, I was asleep inside 20 minutes.
Up now at 7:30 am — from bed, I actually woke around 6:15 but lay there resting until about half an hour ago.
New day, bills. I did tell myself, maybe I'll think about writing a book or go back to my A Place of Refuge, thus far 5 chapters on the Sense and Sensibility Movies.
Yvette and I are going to the US ice-skating championship do in Boston from Jan 5th to 13th, and she has just contributed this YouTube of Johnny Weir teaching Kathy Ann Gifford to ice-skate:
Yvette: "Keep in mind while watching this that when it was filmed and aired in 2006 society in general had already assume Johnny to be gay, even though he wouldn't actually come out until 2011. (Also, he was actually coming off a rough breakup, which his fans shortly became aware of, though society in general didn't)."


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Prometheus Ribbon
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Prometheus Ribbon
|(direct image file)
|service ribbon
The Prometheus Ribbon is a campaign service ribbon awarded to a person who helped in handling the Prometheus Incident and ensuing chaos during 2392.
Bronze Stars for Multi-Phase Campaigns
Beginning with the Prometheus Incident (2392) campaign, characters can earn multiple bronze stars when participating in a multi-phase campaign. Each bronze star corresponds to participating in a mission in one phase of a campaign.
The Prometheus Incident campaign was comprised of three phases:
- Phase I
- Began on: 1 February 2392
- Ended on: 30 April 2392
- Phase II
- Began on: 1 May 2392
- Ended on: 31 July 2392
- Phase III
- Began on: 1 August 2392
- Ended on: 30 November 2392


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STARmeterSEE RANK
Up 111,121 this week
David Victor (I) (1910–1989)
David Victor was born on August 22, 1910 in Odessa, Kherson Governorate, Russian Empire as David Vikodetz. He was a producer and writer, known for Marcus Welby, M.D. (1969), Gunsmoke (1955) and The Man from U.N.C.L.E. (1964). He died on October 18, 1989 in Los Angeles, California, USA. See full bio »
Died:(age 79) in Los Angeles, California, USA


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Finding the Best, Affordable Roofer In Connecticut
When setting up a house construction of the roof, this is something that you have to concentrate on. Notwithstanding when you basically need somebody to fix your roof or replace an old one, there's always a trustworthy roofer in Connecticut that is the services that you need. Finding a decent roofer is a significant piece of this specific errand. With the end goal for you to find the best roofing worker, it may be a smart thought for you to go on the web and do some analysis. If you are more curious about roofing company ct then you can learn more about it on rooferinct.
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1. Your principle contemplations would be the expense.
Since you have to remain inside a particular spending plan for your roof fixes, founding or replacement, you should check costs that are now and again detailed on the websites of the roofing organizations. If the cost isn't recorded, you should get in touch with them. You need to utilize the contact data found on the websitesforquote.
2. Inquire as to whether they have insurance or not.
You would not have any desire to be obligated for mishaps that may happen when these roofers start dealing with your property. A few people have wound up in high temp water with temporary workers that are not protected, which is the reason it is perfect that you get some information about this off-the-bat. Ensure they have general liability insurance.
3. What you may need to tell the roofer in Connecticut you just hired.
Theproject you have for them and if they can provide you anitemized proposal that you can examine first and matchwith others roofing companies. You will most likely need to know the amount you have to compensate for the job with that proposition. This has to incorporate the sorts of materials they are planning to use on your roofing.


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Reviewed by Management Team: March 2020
This policy will be reviewed: March 2021
Universo Capoeira Ltd
The aim of the anti-bullying policy is to ensure that pupils learn in a supportive, caring and safe environment without fear of being bullied. Bullying is anti-social behaviour and affects everyone; it is unacceptable and will not be tolerated.
Bullying is defined as deliberately hurtful behaviour, repeated over a period of time, where it is difficult for those being bullied to defend themselves. The three main types of bullying are:
- Physical (hitting, kicking,theft)
- Verbal (name calling, racist remarks)
- Indirect (spreading rumours)
Students who are being bullies may show changes in behaviour, such as becoming shy and nervous, feigning illness, taking unusual absences or clinging to adults. There may be evidence of changes in work patterns or lacking concentration.
Universo Capoeira instructors and staff must be alert to the signs of bullying and act promptly and firmly against it in accordance with the group policy.
Statutory duty of Universo Capoeira
Universo Capoeira has drawn up procedures to prevent bullying among students and to bring these procedures to the attention of staff, parents and students.
Implementation of Policy
Universo Capoeira
The following steps may be taken when dealing with incidents:
- If bullying is suspected or reported, the incident will be dealt with immediately by the instructor or staff member who has been approached
- A clear account of the incident will be recorded and given to the management
- The instructor will interview all concerned and will record the incident
- Instructor will be kept informed and if it persists the instructor will advise the appropriate subject to the Director of Universo Capoeira
- Parents will be kept informed (if a child is involved)
- Punitive measures will be used as appropriate and in consultation will all parties concerned
Students who have been bullied will be supported by:
- Offering an immediate opportunity to discuss the experience with an instructor or member of Universo Capoeira of their choice
- Reassuring the student
- Offering continuous support
- Restoring self-esteem and confidence
Students who have bullied will be helped by:
- Discussing what happened
- Discovering why the students became involved
- Establishing the wrong doing and need to change
- Informing parents or guardians to help the attitude of the students (child)
The following disciplinary steps can be taken:
- Official warning to cease offending
- Minor fixed-term exclusion of the classes
- Major fixed-term exclusion of the classes
- Permanent exclusion of the Universo Capoeira activities
Monitoring, evaluation and review
Universo Capoeira will review this policy annually and assess its implementation and effectiveness. The policy will be promoted and implemented throughout the Universo Capoeira.


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The Cat in the Hat
June 21 – August 18, 2019
Based on the book by Dr. Seuss
Play Originally Produced by the National Theatre of Great Britain
Adapted and Originally Directed by Katie Mitchell
Directed by Adam Immerwhar
From the moment his tall, red-and-white-striped hat appears around the door, Sally and her brother know that the cat in the hat is the funniest, most mischievous cat they have ever met. With the trickiest of tricks and craziest of ideas, he is certainly fun to play with. And he turns a rainy afternoon into an amazing adventure. But what will mom find when she gets home...?


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Uphill, Rilla Mill Guide Price £575,000
* VIDEO TOUR AVAILABLE * A fantastic opportunity to purchase a recently renovated family home with a beautiful holiday home set in a private position set in approximately one and a half acres. The main property has been much improved by the current owners whilst retaining many character features, with landscaped gardens that have the potential to be further divided to offer a small paddock if desired. A recent addition is the spacious self-contained two-bedroom holiday home which has its own gardens and ample parking, set away from the main dwelling. This beautifully designed property has incorporated a horseshoe shaped barn, blending modern with contemporary with exposed beams and stone walling whilst boasting a large reception room with various windows to offer a great degree of light. The holiday home offers an income of approximately £15,000 per annum and could also be used a guest accommodation. The property is located within a close proximity of Rilla Mill. Rilla Mill is a pretty village set in East Cornwall and relatively equidistant to 3 surrounding towns in Launceston, Liskeard and Callington all of which boast a wide range of amenities, facilities and schools. Rilla Mill itself offers a popular local public house with a Primary School in the neighbouring village of Upton Cross.
Rilla Mill PL17 7PB
Entrance Porch
Entrance Hall
Living Room
14' 0'' x 11' 10'' (4.26m x 3.60m)
14' 11'' x 13' 10'' (4.54m x 4.21m)
27' 0'' x 6' 0'' (8.22m x 1.83m)
Dining Room
10' 7'' x 10' 9'' (3.22m x 3.27m) + 11' 2'' x 5' 7'' (3.40m x 1.70m) Study Area
Rear Porch
Utility Room/W/C
7' 6'' x 5' 4'' (2.28m x 1.62m)
First Floor Landing
Master Bedroom
14' 6'' x 11' 11'' (4.42m x 3.63m)
Bedroom 2
11' 2'' x 10' 10'' (3.40m x 3.30m)
6' 11'' x 6' 4'' (2.11m x 1.93m)
Bedroom 3
11' 1'' x 8' 8'' (3.38m x 2.64m)
9' 1'' x 5' 4'' (2.77m x 1.62m)
Holiday Home
Living Room
16' 11'' x 10' 8'' (5.15m x 3.25m)
Dining Area
16' 3'' x 15' 4'' (4.95m x 4.67m)
9' 8'' x 8' 8'' (2.94m x 2.64m)
Master Bedroom
13' 5'' x 10' 5'' (4.09m x 3.17m) at widest
Bedroom 2
10' 0'' x 7' 7'' (3.05m x 2.31m)
7' 10'' x 7' 7'' (2.39m x 2.31m)
Ample parking for numerous vehicles leading to a front garden surrounding by stone walling with a separate drive leading to the holiday home. The main garden is located to the side of the property with a large area laid to lawn with a further 'secluded garden' offering an variety of seasonal color via a range of plants and bushes. The holiday home currently has a further large area laid to lawn with a chicken coup and polytunnel to offer guests a taste of country living. This area has the potential to be incorporated with the main garden to create a small paddock area if required.
Mains electricity and water. Private drainage. Council Tax Band F. Oil fired central heating.
Rilla Mill PL17 7PB


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Infrastructure Resell
Moving to the cloud can be a critical component in cost effective implementation of business and technology strategies. However, without a comprehensive understanding and focus on the optimization of cost and performance, organizations and agencies can quickly overprovision and overspend.
As part of JHC Technology's value-added services, we maintain an Infrastructure Sales Team that is laser focused on the efficient use of cloud infrastructure from both a cost and performance perspective. This group of Cloud Cost Analysts, Cloud Engineers, Cloud Developers, and Solution Architects support the resale of Amazon Web Services (AWS), Microsoft Azure Infrastructure as a Service (IaaS) and Google Cloud.
Our Infrastructure Sales Team provides vital capabilities to support various facets of cloud deployments such as: cost optimization, reporting, cost analysis, customer onboarding/offboarding, management and maintenance of customer accounts, general Cloud Service Provider support, and the effective use of third-party tools to provide accurate monthly invoicing, billing, and utilization support.
JHC Technology's Infrastructure Sales team holds cloud certifications across the industry spectrum, allowing our team to be the valuable assets our customers and partners can rely upon.
JHC Technology protects customer data by requiring only authorized users to use AWS Multi-Factor Authentication (MFA) when accessing the account, implementing strong password policies and least privilege administration.


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Did you know there's a month dedicated to the art of scrapbooking, an ever-growing paper craft hobby? To celebrate, Stampin' Up! is offering three specials in May! The first is a buy-three-get-one-free promotion with Stampin' Up!'s fabulous designer series paper and textured 12x12 cardstock!
The second promotion is an opportunity to purchase a not-yet-released alphabet stamp set, Jumble Alphabet, at 20% off! This is a sneak peek and this stamp set will not be available again for purchase until the new Idea Book & Catalog is released on July 1st.
And if you've wanted to take the plunge and become a demonstrator, you can purchase a scrapbooking starter kit for only $75!
Visit my website for more information on these promotions!