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28 year old woman | Walnut, CA, USA | Seeking men 28-40 within 50 miles of West Covina, CA
Very ready for the OC fair. I want to listen every live band. It is the time to play harder
For my part: I love to laugh, even the old joke which I heard millions times before, I still could laugh out. Welcome to test. Lol. I have beautiful voice, like to talk to people, enjoy nice sweet small chat with random strangers and give each other the best wish for the day. I am passionate and extremely curious for new things. I want to try out everything. I love hanging out with friends after hard working. I care about my body, so i work out roughly 3 times per week. I care what I eat. If your mom is willing to teach, I am more than happy to lean. I am a huge believer and lover as well.I am never afraid to try new things, sometimes I need a little push but it's never because I was afraid, maybe just concern. I am in the international trade business/social media marketing and also working on my MBA right now. I am trying to build my life too. That's why I would be the biggest supporter of your career and life. For his Part: I am looking for a real gentlemen who is respectful, responsible, honest, and simple. He should love his job and work hard for that. He would be really lovely if he loves sports or exercise. He could be lazy sometimes, but he must have good attitude. It will be great if he likes animals. I wish he could have an open mind and don't mind me doing sth stupid. I wish he could appreciate what he gets: the job, the friends , everything. I wish he has humor and a care loving heart. I would like to know someone who is real who will late for the dating but show up with a bundle of flowers, who will make mistake and apologize immediate after he realized, who has a lot of friends and willing to involve me in his loop and who would stop and enjoy the sunshine in the afternoon with a cup of coffee in his hand.This person is not really need to have a belief of saving the world, but he cannot arrogant, he cannot lazy and judging, he can't be selfish. It will be better if he likes joking around and laughing out aloud. The best thing I could imagine: We could laying down on coach with him for a movie night or take a roll with him in weekends. Maybe cooking together. We could have nice morning run together. I would like enjoy a Blunch together in the morning of weekend. We could also read a book while the afternoon sunshine is pouring on us. The most important thing is we need to discover sth only belong to us.
Alumni connections , Camping , Coffee and conversation , Business networking , Cooking , Dining out , Fishing/Hunting , Hobbies and crafts , Movies/Videos , Museums and art , Music and concerts , Exploring new areas , Nightclubs/Dancing , Performing arts , Playing sports , Religion/Spiritual , Shopping/Antiques , Travel/Sightseeing , Volunteering , Watching sports , Wine tasting
Aerobics, Bowling, Dancing, Inline skating, Martial arts, Other types of exercise, Running, Skiing, Swimming, Tennis / Racquet sports, Walking / Hiking, Weights / Machines, Yoga
I exercise 3-4 times per week.
I like Cats, Dogs
Middle of the Road
Beach, Ocean, Mountain, Hill, Cloud, natural places
Sunshine, Big Smile, nice waves Everything that could make me happy is the best.
Believe or not, I love reading. I am a huge music-lover, crazily in love of live music concert. always leave space in heart for traveling and meet new people.
50 shades of grey. LOL~Always in
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What she is looking for
|5'5" (165cms)
|5'11" (180cms) to 8'11" (271cms)
|Body type:
|About average, Heavyset
|Blue, Brown, Green, Hazel
|Social Drinker
|Social Drinker
|I'll tell you later
|Artistic / Creative / Performance, Executive / Management, Financial / Accounting / Real Estate, Legal, Medical / Dental / Veterinary / Fitness, Political / Govt / Civil Service / Military, Self-Employed / Entrepreneur, Law enforcement / Security / Military, Fashion / Model / Beauty, Architecture / Interior design
|I'll tell you later
|No preference
|Never Married
|Never Married
|Have kids:
|Wants kids:
|Spiritual but not religious
|Christian / Catholic, Christian / LDS, Christian / Protestant, Spiritual but not religious
|Chinese, English
|English, French, Spanish
|Graduate degree
|Bachelors degree, Graduate degree, PhD / Post Doctoral


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Answers (1)
22 Jun 2012
Adults and children age 12 and older with seasonal allergies typically start with Allegra 60 mg or Allegra 180 mg tablets (either 60 mg twice a day or 180 mg once a day). The recommended dosage for children 2 to 11 years old is Allegra 30 mg twice a day.
For adults and children 12 years old and over with seasonal allergies, the recommended dosing is Allegra 12 Hour (60 mg) twice a day or Allegra 24 Hour (180 mg) once a day.
Maybe confirming the right dosage to be taken by your daughter you should talk to the doc/pharmacist, please.
take care, wish her the best!
Further Information
- Allegra Information for Consumers
- Allegra Information for Healthcare Professionals (includes dosage details)
- Side Effects of Allegra (detailed)
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Allegra may be giving me severe leg cramps at night, would halving my dosage help?
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Also got higher blood pressure is this normal for allegra. Of allegra d?
1 answer • 14 Apr 2013
I have swelling, itching and pain in my palm and toes. Is it an allergy?
Taking Allegra 180mg per day relieves me. It is happening from 6 months. My age is 38 (Female) and I am under obesity treatment.
1 answer • 18 Sep 2013

subset: commoncrawl


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Green Cards Lawyers in the USA
Green Cards Lawyers in the USA ► Other Countries
All Articles »Green Cards Lawyers USA - Recent Legal Articles
- What Happens When a Person is Charged with Illegal Reentry?
Returning to the United States after being deported or removed is a violation of federal law. Alleged offenders could be sentenced to prison before being returned to their home countries—where they could face additional consequences as well.
- What Factors Affect Prosecutorial Discretion in My Immigration Case?
Prosecutorial discretion may be exercised in certain immigration cases to permit individuals to remain in the country. On November 20, 2014, Jeh Charles Johnson released a memorandum entitled "Policies for the Apprehension, Detention and Removal of Undocumented Immigrants."
- What Are the Requirements for Adjustment of Status?
The Immigration and Nationality Act allows individuals to change their immigration status while they are in the United States. They may have begun as a nonimmigrant or a temporary alien but now wish to be classified as a permanent immigrant.
- Immigration Consequences of a DUI
While many individuals are aware of the serious consequences of receiving a DUI, these consequences are even graver for non-citizens. In addition to the same consequences of possible jail time, fines and a loss of driving privileges, a non-citizen's conviction of a DUI may result in a finding that he or she is inadmissible or is removable.
- EB-2 Visa Versus EB-3 Visa
The differences between EB-2 and EB-3 in an effort to alert aliens and employers, and help both seek EB-2.
- Transition from Optional Practical Training to H-1B Status
Here are some things to consider to make the road to obtaining H-1B status a bit less bumpy.
- Overview on New Immigration Policies through November 2014 Executive Actions
On November 20 and 21, 2014, President Barack Obama announced an overhaul of the immigration system through a series of executive actions. The actions established new immigration programs, changed guidelines for existing programs and created new proposals for visas.
- Special Immigrant Juveniles Status (SIJS) Eligibility & Process
Special Immigrant Juveniles Status, commonly known as SIJS, is a federal law that allows certain undocumented children to get legal permanent residency in the United States. Below, we discuss this complex immigration process and the requirements in detail.
- Can I Get a Green Card If I Have a Criminal Record?
Individuals who are pursuing permanent resident status may be deterred if they are convicted of a crime. While a misdemeanor conviction may not bar a person from still obtaining resident status, certain convictions may prevent a person from being approved for permanent residence status or possible cause the person to be subject to removal.
- Canadian Tourists Who Have Been "Flagged" By US CBP: Steps to Overcome Inadmissibility
Due to the close proximity of the US border to most Canadian cities and the extensive relationship between the two countries, it is not surprising that the US receives millions of Canadian tourists each year.


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By: EAS
Overall Score How is this Calculated?
Only 1 Review - Waiting for more trustworthy reviews
Ask a Question
L-Glutamine is a Glutamine Supplement manufactured by EAS. It contains glutamine which is the most abundant amino acid found in muscle tissue; It helps support lean muscle gain.
What should I take with L-Glutamine?
What should I take with L-Glutamine?
August 26, 2009
On my 2nd container, i found this to be the best bang for your buck when it comes to glutamine. 80 5g servings for about 15 bucks. I add 5g to my post-workout shake and another 5g to my bed time protien shake. Mixability is great you can't even tell its in there. Glutamine is essential for growth and recovery. Will continue to buy and use for a long time.


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Hi: 6° Lo:0°
By IH Thursday 06 December 2012 Updated: 21/12 08:38
GENEROUS shoppers dug deep to help Stratford Foodbank at the weekend.
More than two tonnes of food was collected at Tesco's Maybird Centre store on Saturday and Sunday (December 1 and 2). It was part of the supermarket giant's 'Help Feed People in Need' appeal supporting projects around the country.
The Observer first revealed plans to set-up a foodbank in Stratford - spearheaded by Holy Trinity vicar Martin Gorick - after shock revelations that some one in six households in the outwardly affluent town were living in poverty as defined by the government - those living on 60 per cent or less of average national household income.
It hit a nerve with Observer readers and some 60 volunteers have come forward following our original story in August to help operate the foodbank which is set to launch next month.
Work is also progressing well on establishing links with other organisations in the town for referring people in need
to the foodbank, and also to provide long term help for those receiving food parcels.
Alex Holmes, Stratford Foodbank project manager, said: "The response was tremendous at the weekend. We had people donating not just single items, but also bags and baskets.
"Increasing numbers of people are struggling to make ends meet in the current economic climate. Times are tough for many local people so Stratford Foodbank is delighted to be part of Tesco's 'Help Feed People in Need' appeal."
Volunteers are now busy sorting the donated items into parcels ready for the first hand out.
The project has been advised it needs about three tonnes of food prior to launch. Further collections are planned although no dates have yet been set.
To find out more about the project or to get involved email Alex Holmes at firstname.lastname@example.com
1 Two women trapped in three vehicle smash near Alcester
2 Teenagers seriously as car overturns near Alcester
4 Disgraced former councillor fined
5 Voters urged to sign up to electoral register in Stratford
LESS than a year ago central England was
MAKING Stratford a million times better is the
GOLDEN boy James Roe has topped off a
THE DEVASTATED family of a teenager who died
EVESHAM'S first weekly parkrun has been hailed a great success ...
TWO women had to be cut free from their cars ...
POLICE are looking to speak to this man in connection ...
Visit the Worcester Observer website for the latest.


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WW questions from a newbie
I post over on the KT but have some questions I bet y'all might know the answers to. I went to a WW meeting this morning and I'm not sure I understand all this stuff. They wouldn't let me take the pamphlets home and unless I know I've "got" this, I won't join. How difficult is it to follow all these points? Do you have to write down everything you eat? Did y'all do the flex or core program? I just don't see how you keep up w/ that every day. The gal said she carried some kind of paper in her purse. Just how hard is it? Can you tell me how you handle it? I just feel like a confused child on this deal. I was the only person there that didn't join.
Hi, Vannie! I rejoined WW back during the winter, and I opted to do the Core plan this time around. I found the Flex-points plan exhausting to keep up with, to be honest. I've been much more successful this time by knowing exactly what foods I can eat and have really enjoyed the cooking that goes along with it. I keep a mental list of the "required" foods needed for a healthy diet: 2 tsp. healthy oil, healthy grains, lean meats, veggies, and dairy. So much easier!
They didn't want you walking out of there with their literature because you didn't pay for the privilege. It may seem mean to you, but the literature goes along very well with the training you receive after your first meeting and sign-up and subsequent literature you'll receive over the first 10 weeks of membership. Members pay for this knowledge, which is why you weren't given anything to take home to read. If they'll allow you to attend another meeting for free, by all means ask if you can stay for the info meeting for new members afterwards to learn if or which plan is for you.
I was on WW for 3 years. I lost 55 lbs in 11 months. I have not been following it lately or getting regular exercise so gained some back. I am going on a different diet to see if it works as well as WW but I still eat a lot of the WW choices.
WW is easy to do as long as you know how to count. For the flex plan you get a slider that shows you how many points are in each thing you eat that has the calorie/fat/fiber on them and the WW books list every thing else. I still carry my slider in my purse when I go grocery shopping. (There are a lot of the frozen meals that show WW points on the back of the package. Everything else I just used the slider.)
At first you do have to write everything down but after a while you know how many points are in the foods you eat regularly.
With the Flex plan there is a lot of choices of foods. The core plan is good if you cook at home and don't go out to eat a lot.


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Teaches the intricacies of creating, editing, and publishing professional layouts with InDesign CS3.
Covers all InDesign's tool in depth and offers layout principles for new and experienced users.
"You've got my back. When a customer expects me to know something, I know where I can find it fast and get a clear, simple explanation." —Richard R.
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I was wondering if anyone out there has a recipe for Sanbitter? It is an Italian bitter soda, that I cant get in my region and would like to use for non-alcoholic cocktails. Also following on from this could someone point me in the direction of studies done on the solubility of flavour and aroma compounds of different herbs and spices in alcohol and water depending on the ph, temp etc. Thanks guys.
If I remember right, sanbitter is Sanpellegrino's take on the flavor that goes by the generic name of "ginger" in Italy. It's been about 10 years since I lived there, but I think that's about right. If sanbitter gives you the faint reminiscence of vomit flavor, then it's a dead match for "ginger". Which I don't know if it has actual ginger in it or not. That probably doesn't help you, but it will at least give you some more search terms to try.
My mistake, just browsed through the Italian wikipedia and it turns out I'm horribly wrong. It's possible that I just associated them because they're the same color.
Find Recipes on my blog: The Homemade Soda Expert I'd love some feedback!
Now Available from Quarry Books -- Making Soda at Home: Mastering the Craft of Carbonation Like on Facebook!, Follow on Twitter, Add to Goodreads


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Registering at The Depot Leeds - Rock Gym Pro
The Depot Leeds has now switched to a new database system called Rock Gym Pro. This system will enable us to check everyone in more efficiently and ultimately increase your time on the wall.19/03/2015
Winter Bouldering League 2014-15 Leeds
Final results available now. Thank you to everyone who took part.11/03/2015
La Sportiva Est 1928 Long Sleeve T-shirt Men's
A long sleeve t-shirt telling the story of La Sportiva.28/03/2015


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PenséesHackett Publishing Company, Inc. 2005; US$ 7.95
This eloquent and philosophically astute translation is the first complete English translation based on the Sellier edition of Pascals manuscript, widely accepted as the manuscript that is closest to the version Pascal left behind on his death in 1662. A brief history of the text, a select bibliography of primary and secondary sources, a chronology... more...
A Temporary GovernessAwe-Struck Publishing 2007; US$ 4.99
Clarissa Manning secures a position as a temporary governess to a spoiled young girl after learning her friend's been terrorized by her employer's lustful friend. more...
Never Let Me GoAwe-Struck Publishing 2008; US$ 4.99
Who will win the battle between two stubborn, strong-willed and unlikely lovers In this spritely, fun-loving and beautifully written traditional Regency Romance? more...
Lord Devereaux's LadyAwe-Struck Publishing 2009; US$ 4.99
A bored nobleman, his friend, and a penniless orphan conspire to win a wager that turns a country bumpkin Into an elegant Regency lady. more...
Pensees (Thoughts)MobileReference.com 2010; US$ 3.99
The Pensees (literally, "thoughts") represented a defense of the Christian religion by Blaise Pascal, the renowned 17th century philosopher and mathematician. Pascal's religious conversion led him into a life of asceticism, and the Pensees was in many ways his life's work."Pascal's Wager" is found here. The Pensees is... more...
Provincial LettersMobileReference.com 2010; US$ 3.99
The Lettres provinciales (Provincial letters) are a series of eighteen letters written by French philosopher and theologian Blaise Pascal under the pseudonym Louis de Montalte. Written in the midst of the formulary controversy between the Jansenists and the Jesuits, they are a defense of the Jansenist Antoine Arnauld from Port-Royal-des-Champs, a friend... more...
Time LordKnopf Doubleday Publishing Group 2011; US$ 16.00
It is difficult today to imagine life before standard time was established in 1884. In the middle of the nineteenth century, for example, there were 144 official time zones in North America alone. The confusion that ensued, especially among the burgeoning railroad companies, was an hourly comedy of errors that ultimately threatened to impede progress.... more...
The Meagre TarmacBiblioasis 2011; US$ 16.95
An Indo-American Canterbury Tales , by a North American master of short fiction. more...
Kleine Schriften zur Religion und PhilosophieFelix Meiner Verlag 2009; US$ 71.39
Hauptbeschreibung Das literarische Werk Blaise Pascals (1623-1662) z�hlt zu den gro�en Klassikern der franz�sischen Literatur. Es umfa�t neben den Lettres provinciales und den Pens�es bedeutende kleinere Schriften zur Religion und Philosophie, die in dieser Ausgabe vollst�ndig und zum Teil erstmalig in deutscher �bersetzung vorgelegt werden. Dazu... more...
Human HappinessPenguin Books Ltd 2008; US$ 7.98
Created by the seventeenth-century philosopher and mathematician Pascal, the essays contained in Human Happiness are a curiously optimistic look at whether humans can ever find satisfaction and real joy in life ? or whether a belief in God is a wise gamble at best. Throughout history, some books have changed the world. They have transformed... more...


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I couldn't ask for a better watch! I was just looking around for a gold tone watch, and this was perfect for me...My style is casual and fancy, and this watch fits me well with my daily suits...Definitely well worth the price!!! Thank You Overstock.com!!! :)
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Let's Celebrate: We are turning 9 – years
Ready to celebrate 9 years of Power Flow Vinyasa Yoga? Come join us on Thursday April 2nd. In each class we will be celebrating with ... Read more »
Join Shannon Hatfield for a 2-hour flow and workshop aimed at taking your practice into your own hands. We will move, sweat, break down some ... Read more »
S.U.P. Yoga Teacher Training 3-Day Immersion April 23-26, 2015
There is nothing better in life than floating on the lake while taking a yoga class. Take the beauty of Lady Bird Lake, the power ... Read more »
Essencha Flow: A Chakra Systems Awakening
Essencha Flow: A Chakra System Awakening with Megan Sullivan May 9th Within our bodies live 7 energy banks through which our life energy, or Prana, flows. The openness ... Read more »


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I saw this woman at the terrier races one year at the High Hope Steeplechase at the
Kentucky Horse Park here in Lexington. I knew that I would just have to paint her
as the title came to me as soon as I saw her. This piece will be going to
Wichita, Kansas for the Art Show at the Dog Show the first week of February.
All images on this website are copyright of the artist.
No images may be reproduced without permission.


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reddit is a platform for internet communities
Farming with nothing but human powered tools. (self.urbanfarming)
submitted by TimOK56
[Video] I wish all cities had urban farms like this one (youtube.com)
submitted by albertayoungfarmer
The Urbanite's Guide to Living—and Cooking—Like You're off the Grid (takepart.com)
submitted by wheeler1432
SF Urban Farming Startup will give you cash to train with them this week (workjunto.com)
submitted by Conaws
Putting a greenhouse into your window to grow vegetables. (cloud-farms.com)
submitted by cloudfarms
Village Farming (thecontraryfarmer.wordpress.com)
submitted by Vailhem
AKER : print your urban farm (indiegogo.com)
submitted by buovjaga
Hey gardeners! Consider planting an extra row for the hungry this year (inhabitat.com)
submitted by winterycate
HUGE Family Day Surprise for Urban Farm @GrowCalgary (youtube.com)
submitted by paulin8
Assistance with High School Research Project (self.urbanfarming)
submitted by FarmingResearch
A morning at Urban Adamah, a 1.5 acre Urban farm in Berkely, CA (youtube.com)
submitted by TheGoodDick
Underground and on rooftops, farms set roots in big cities (trust.org)
submitted by burtzev
Cityblooms Smart Modular Greenhouses Turn Urban Rooftops Into Gardens (springwise.com)
submitted by sustainablogjeff
Ron Finley: A guerilla gardener in South Central LA (youtube.com)
submitted by Tim_Finnigan
Urban agricultural farming in NYC question! (self.urbanfarming)
submitted by throwawayistoocool
Brand new and could use some guidance (self.urbanfarming)
submitted by AlsoNotBrian
Kale farming in central Stockholm 1917 because of the war shortages (filmarkivet.se)
submitted by Vazev
Anyone in NYC area interested in collaborating on a Roof project? (self.urbanfarming)
submitted by lmm489


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what sdk version are you using? also have you gone to task manager and tried ending adb.exe?
i was having the same problem, i took ADB.exe and adbwinapi.dll from 1.5r2 SDK and put it in the new SDK Tools folder, problem was fixed
XDA Developers was founded by developers, for developers. It is now a valuable resource for people who want to make the most of their mobile devices, from customizing the look and feel to adding new functionality.
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I want to learn Telugu. I'm a native English speaker from the U.S. and I would like to do a 50/50 language exchange. Skype me at: craig.hall150
We are glad to know that you are interested in learnng Telugu. We are willing to support you at our level best.
thats good
my skype name is r.sureshjai
we will have fun...............
Hello Craig!! Glad to see a person from U.S who passionate in learning Telugu.I hope that I can help you to learn telugu,I'm a native speaker from Andhra(INDIA).I am also on Facebook @ fb.com/dprajachowdary.
Hi I will teach you telugu if you want i would be help full may i know your availablity..so that we would be in touch.
Show More


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agriculture Subscribe to Feed
Victory! The New Farm Bill is a Major Win for Wildlife
Today, the farm bill passed the Senate by a vote of 68-32, its final major hurdle to becoming law for next five years. The White House reports that President Obama will sign the bill, so after a long, long wait, and […] Read more >
5 Ways the New Farm Bill is Good for Wildlife
The 2014 Farm Bill is closer than ever to becoming law; yesterday, House and Senate Agriculture committee leaders agreed on a final version of the farm bill that is a good compromise between the different versions of the farm bill […] Read more >
Will Congress be Naughty or Nice to Grassland Wildlife?
After two long years of trying to pass a new Farm Bill—a giant, 5 year piece of legislation that funds everything from food stamps to agriculture subsidies to conservation programs—members of the Farm Bill Conference Committee have assured us that […] Read more >
COP 19 Update: Delivering the Message
This weekend marked the official end of the 19th Conference of the Parties to the United Nations Framework Convention on Climate Change. Governments have agreed on a text after working through Friday night and into midday Saturday. Civil society spread its […] Read more >
Having Lost Thousands of Cattle to the Blizzard, Northern Plains Ranchers Need a Farm Bill
The recent blizzard in western South Dakota didn't just dump up to four feet of snow in the Black Hills, northwestern Nebraska and northeastern Wyoming. In killing thousands of cattle, it piled another hardship on ranchers, who in recent years […] Read more >
Thinking of the Future at America's Grasslands Conference
Like a herd of cattle heading to a stock tank, leaders in grassland conservation from all over the country are convening today in Manhattan, KS for two days of reflecting and sharing on how America's remaining grasslands can be conserved […] Read more >
Are Your Taxpayer Dollars Helping to Destroy Wetlands?
The Senate passed a 2013 Farm Bill that would stop this unbridled wetland drainage, but the House just refused to follow suit. Call your representatives and insist on wetland conservation compliance in the final 2013 Farm Bill. The Prairie Pothole […] Read more >
Heavy Rains, Runoff, Toxic to Wildlife
Lake Erie is experiencing a one-two punch of heavy rains and excess farm runoff that influences the magnitude of algae toxic to wildlife and humans. In a recent report: Taken by Storm: How Heavy Rain is Worsening Algal Blooms in […] Read more >
Is One of Our Country's Greatest Conservation Achievements at Risk?
If I asked a group of people what this country's greatest conservation success in last 25 years was, I might expect to hear stories about the protection of national forests, the recovery of endangered species, or maybe even the Conservation […] Read more >
Drought, Fire and Freeze: Lawmakers Consider Impacts of Extreme Weather on Agriculture
The votes are in and the winner for Most Arresting Title for a Senate Committee Hearing goes to the Agriculture Committee for yesterday's hearing, "Drought, Fire and Freeze: The Economics of Disasters for America's Agricultural Producers." But seriously folks, I […] Read more >


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Could you fit your worldly possessions into 100 square feet?
NOMAD Micro Homes, a Vancouver company, is proposing to build living spaces that are just 10 feet by 10 feet in size - or 100 square feet in total.
Here's what such a home might look like.
VIEW MORE PHOTOS HERE, or if you're using a mobile app, tap the story image and swipe.
The biggest sale of the year, on now! Find almost $4 million worth of items such as cars, trips, furniture, gift cards and more at discounts of up to 50% off. Don't miss out as savvy shoppers will move fast to take advantage of these deep discounts. Sale ends Wednesday, April 1, at 9 p.m. Like it? Buy it before its gone. Brought to you by The Vancouver Sun and The Province.


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- Used Cars
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- Sell Car
The car is ready to drive,no mechanical work needed as recently installed twin cam engine,tires are perfect,original seats with head rest,sprayed from out side except the roof,from inside its unsprayed,suspension is very nice,excellent in fuel consumption both in petrol and cng,usb+cassette player with new speakers....only interested buyers can contact!
My car is ready to drive,need no mechanical work as recently changed the engine,original seats,neat and clean dash board,usb+ cassette player with new speakers,tires are perfect,whole car is sprayed from outside except da roof,from inside genuine in color,no major accident,suspension is very good,cng installed,very economical and used mainly locally....interested buyers can call anytime...
Well kept and comfortable Sunny Nissan in awesome condition. 16 Valve TWIN CAM Engine in perfect condition. Inner in genuine condition, outer showered for fresh look. Neat & clean Interior. Good mileage on both CNG & PETROL Alloy Special Rim Very smooth & soundless drive Karachi Registered with Complete File in Hand No WORK is required at all, Exchange possible especially with small car..
Nissan Sunny, neat and clean very smooth in drive,TWIN CAM NISSAN brand new engine, petrol and CNG, very good consumption, Lahore registered, Life Time Token Free, New Battery,alloy rim, Bridgestone New Tyre, power windows, scratch less condition. Family car used with care and maintained properly. Inside Original condition and outside below the roof showered.
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Make a big impact on your digital photographs in a short time.
Explore the interface, tools, and new features of Photoshop Elements 10.
"I don't know how many times I've come back to review a topic or to watch a video as supplementary training to a class I'm taking, but you guys have helped me stay ahead of the curve." —Derek M.
more from our members »


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Guest Reviews
Each review and rating that we receive is verified to ensure that we only display information provided by guests who have actually stayed in the hotel.
Recommend This Property
Overall Experience
Recommend This Property
spacious and clean rooms
March 31, 2015
Rooms were spacious and clean. i enjoyed the full size frig with ice maker, dishwasher, full size microwave.
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Great value
BySan Antonio PoPs
March 29, 2015
The only improvements I would make to the room would be to add another bedside stand/table, and to include a sultcase stand in the room.
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Workout Room Needs More Care
March 25, 2015
Weight equipment was broken. The associated laundry area was frequently dirty.
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Poor Armchair maintenance
March 15, 2015
The two chairs in the room that I stayed in were so worn that I did not sat in them.
Posted byHotelStaff
March 19, 2015
We are sorry that we did not hit the mark for you during your stay. You are correct that we have a few rooms with worn recliners and task chairs. We are in the process of upgrading our rooms and I do apologize that you got one that has not yet been upgraded. I do hope that you will give us another try! If you would like to email me upon your return I will be happy to hand pick a room for you. Sincerely, Gabrielle T. Front Office Manager
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Trans North Bus & Coach
Trans North Bus & Coach Service is a family owned business operating in Far North Queensland. Trans North has eight fully established depots in Cairns, Atherton, Ravenshoe, Innisfail, Ingham, Mission Beach, Ayr and Mackay, providing school, charter and urban bus services.
Express Coach Services also operate between:
- Cairns and Karumba
- Cairns and Cooktown (inland)
- Cairns and Cooktown (coastal)
The business utilises more than 110 fully operational vehicles to meet the service requirements of 8 districts.
Trans North's goal is to meet the transportation needs of our clients with the highest levels of service. We aim to operate in a timely and efficient manner by listening to our customers' needs and ensuring that their transport and customer service requirements are met.
Please note: For express services between Cairns and Mackay, please contact Greyhound Australia or Premier Motor Service.
Alert Message - Service Updates
|Wednesday 1/4/15
|Cairns to Karumba (TN140)
|Service operating as normal
|Thursday 2/4/15
|Karumba to Cairns (TN141)
|Service operating as normal
|Cairns Kuranda Shuttle
|This service will operate to it's regular schedule during the Easter period including Good Friday.
|Atherton - Mareeba - Cairns Service
|A reminder that this service will not operate on Good Friday 3rd April. Only the 9.00am service departing Atherton and the 3.20pm service departing Cairns will operate on Easter Saturday, Sunday & Monday 4th, 5th & 6th April.
TRANS NORTH BUS & COACH is part of the donric group of companies.


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So i just came across an old schwinn collegiate sport 5 (i know this is MTBR not road bike review, sorry). i think its a '73 by the serial # and color. Its in pretty rough shape but nothings bent and i love a challenge. I have no use for it, i really just wanted to fix it up for a project. Is there a market out there for old collegiates, do people collect them? or am i just wasting my time and money on an old junker? any insight would be great.
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Exegesis of Surah al-Lahab
The name of this Sura is al-Lahab. It has one rukoo, five verses, twenty words and seventy seven letters.
This was revealed in Makkah Mukarramah. For the full information on the reason of revelation refer to point one. All that is being mentioned here is why Abu Lahab's name was taken when he was highlighted by the Quran, despite the fact that that in Makkah, Madinah and amongst other tribes of Arabia there were ample enemies of the blessed Prophet peace be upon him and Islam. Their attempts to cause pain, heartbreak and failure to Islam were no less than those of Abu Lahab. Therefore what is his significance that he is named and rebuked?


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A Special Thank You to our Corporate Sponsors:
A bill aimed at increasing penalties for day care providers convicted of negligent operations passed the house last week. HB 645 raises the criminal penalty levied against the operator of a child care center – licensed or otherwise – where a child suffers a permanent disability, debilitating injury, or death due to negligent operation. The bill upgrades this offense from a misdemeanor to a Class B felony, punishable by up to seven years' jail time. The bill was crafted as a response to the death of Willa Shine Clark, a four year old who choked to death outside an unlicensed day care center in Enfield. Day care providers may operate without a license in NH only if no more than three of the children attending are unrelated to the caregiver. Supporters argue that the bill make certain that unlicensed day care centers are subject to the same punishment provisions as licensed facilities. Current NH law only holds licensed daycare providers liable in cases of child endangerment. Currently, reckless conduct is only considered a Class B felony if it involves the use of a deadly weapon or results in a death.CLICK HERE to post your thoughts on our site.CLICK HERE to read coverage from WMUR.
The nonpartisan, nonprofit Live Free or Die Alliance (LFDA) serves New Hampshire citizens by providing objective information about issues and candidates; promoting the civil exchange of opinions in a variety of forums, online and in person; and connecting citizens with their elected officials.Show your support for our mission: join the LFDA community today! Membership is always free, and gives you posting privileges on our website.Want to learn more about us first? Visit our About Page to learn about our mission, our Issue pages to learn about hot topics in New Hampshire government, our Voter Resources section to learn about elected officials, or our Member Posts to see what fellow Granite Staters have to say. And don't forget to like us on Facebook!
On Tuesday, March 31 there is a primary election for the empty state Representative seat in Candia, Deerfield, Northwood, and Nottingham.Yvonne Dean-Bailey will challenge Brian Stone for the Republican nomination.Dean-Bailey is a college student and former Marilinda Garcia for Congress staffer. Stone is an Iraq War Veteran and studying for a Master's degree in public policy.Former state Representative Maureen Mann is the only Democratic candidate for the seat.Click on any of the candidates' names to see a full profile, including detailed issue positions.CLICK HERE to see all of the special election candidates in New Hampshire. There is a special election in Hampstead and Kingston April 28!
This week House budget writers drafted a new proposal for funding the Department of Transportation (DOT). The proposal uses money from the Renewable Energy Fund and decreases funding for UNH.Originally a group of four Republicans proposed raising the gas tax to fund a major shortfall in the DOT, but that idea fell flat in the House.Electricity providers pay into the Renewable Energy Fund when they do not buy enough electricity from renewable sources, according to New Hampshire's Renewable Portfolio Standard. The Renewable Energy Fund is intended to fund grants and rebates for individuals and businesses working on renewable energy projects."We made the policy decision that a temporary hiatus on that program was the price we had to pay so that the state's highways were maintained and properly funded for the next two years," said Rep. Neal Kurk (R-Weare), chairman of the Finance Committee.Supporters praise the new budget proposal for not raising taxes.Opponents argue that raiding the Renewable Energy Fund is dishonest budgeting. Because electricity providers pass some of the cost of the Renewable Portfolio Standard onto ratepayers, this budget proposal funds the Department of Transportation on the back of ratepayers' electricity bills.The proposed budget also decreases funding for local road maintenance, downshifting some costs to towns.Lastly, UNH says they will raise tuition if funding decreases.Budgeting in New Hampshire is never easy. How would fund the Department of Transportation next year? CLICK HERE to post your thoughts on our site.CLICK HERE to learn about Gov. Hassan's original budget proposal.CLICK HERE to read coverage from WMUR.
This week a Senate committee heard testimony on a bill that would prohibit schools from demanding access to students' social media accounts.Privacy advocates, including the American Civil Liberties Union, testified in support of the bill."We would never expect a school administrator to be allowed to enter a student's bedroom and look at their personal letters or look through their photo albums," said Devon Chaffee, director of the American Civil Liberties Union of New Hampshire. "We shouldn't allow them to do the electronic equivalent."Souhegan High School freshman Jonathan Petersen offered a different perspective. He took a year off of school after being bullied. In at least one incident, other students posted inappropriate pictures of him online."I've been bullied a lot and most of the time people get away with it," he said.Dean Michener, director of the New Hampshire School Boards Association, echoed Petersen's concerns."School districts have a unique parental role while students are in school," he said. "If you move forward with this legislation, we think it should include a provision that districts are not liable when they don't have access to evidentiary information."In 2010 the state expanded its bully law to hold schools responsible for policing cyberbullying.Do you think schools should have complete, limited, or no access whatsoever to student social media accounts? CLICK HERE to post your thoughts on our site.CLICK HERE to learn more about New Hampshire's bully law.CLICK HERE to read coverage from Seacoast Online.
This month school districts throughout New Hampshire premiered the Smart Balanced tests based on Common Core curriculum. Some schools told parents that their students have a right to opt-out of the tests, but the state Department of Education disagrees.According to the Department of Education, "Parents should be made aware that their public school children are
legally required
to take the
Further, the districts' legal obligations
parental demands that their child not
take the
assessment."That did not stop the Manchester and Nashua School Boards from sending a letter to parents asserting their right to remove children from the tests.Roughly 1% of Manchester students opted-out, according to NHPR. Federal law requires schools to administer standardized tests, but a school district only faces sanctions if 5% or more of students miss a test.Meanwhile there are no codified consequences at the state level for opting out of required testing.Do you believe parents have a right to pull their children out of standardized tests, for any reason? CLICK HERE to post your thoughts on our site.CLICK HERE to learn more about the debate over Common Core in New Hampshire.CLICK HERE to read coverage from NHPR.
LFDA Virtual Town Hall — 3/31/2015
When New Hampshire lawmakers this month shot down as frivolous a group of fourth-graders' effort to name the red-tailed hawk the official state raptor, the pols got pasted as insensitive bullies.
In The NH News
What's going on at the NH State House?850 New Bills are proposed for NH for 2015 - Are you aware of what these new bills are about? We've made it easy for you to quickly get up to speed. View our 2015 Bill Summaries.
Join our discussion on a NH issue each day with our 50,000+ Facebook fans! We summarize these discussions into Citizen Voices and forward them to the NH elected officials and media sources for publication, so your voice will be heard!
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my post
please if anyone here gets the chance can you see my post under the growing under lights forum. So far the people in this forum are very helpful. Thank you
FYi...going forward, it is best to post such things on the Conversation side of the forum here, as the Discussion side is for actual trading only. Sometimes GW will move non trade posts over to the Conversation Side here. The link to (off Topic) Conversations, is just above the list of all the threads.
If you don't find your threads, just check the Conversation side.
Glad you find the forum folks helpful.
Sue...resident busy body
Hi! Me again! I just had my first growing under lights experience this past winter. It was awesome! All I used was regular old shop lights,one warm and one cold. I bought those reflective blankets you can buy in sporting goods,lined my shelves,top and bottom and wrapped it around the whole unit. I left it so it could be opened in the front. Also,you will need a fan,I put mine in such a way that it could blow upward up one side of the unit.It made for great circulation. It was also suggested to use an osculating fan in the room. Another piece of advise I got was to sterilize your soilless seed starting mix,I used pro mix. I was also advised to use a peroxide solution to mist the flats/plants,1 tablespoon water to quart spray bottle. I dont know if it had anything to do with it or not,but I suffered no damp off or bug problems! Also,keep the lights within 2-4 inches of the plants,it prevents them from getting lanky. I did everything I was advised to do and I had great results. Good luck! :)


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Best of Boston
BEST Day Spa
Daryl Christopher Salon and Day Spa
Every once in a while, a spa comes along that hits an enviable note combining flawless service, a soothing environment, and extraordinary—and forward-thinking—treatments. That's the zone in which Daryl Christopher finds itself right now, thank to a perfectionist staff whose… read more »
Bella Santé
Let the soothing cup of honey-laced tea in the eucalyptus steam room be your first clue: Bella Santé is serious about relaxation. Cell phones are banished from the plush-but-minimalist space, set out in elegant neutrals. And unlike at most frenetic… read more »
Push through the glass and wood storefront, past the bright pots of Trish McEvoy cosmetics and rows of neatly packaged Molton Brown potions (you can hit all of the above on your way out), and head straight for the heart… read more »
Bella Santé
Some say visiting a good day spa is so therapeutic it's tantamount to regular trips to a shrink. If that's the case, the relaxed, blissful feeling you'll leave with after an afternoon at Bella Santé will seem like a breakthrough…. read more »
Bella Sante
This Newbury Street destination is everything a spa should be: luxurious, tranquil, soothing, and relaxing. Yes, you can get the usual spa fare like facials, massages, and various body treatments; but Bella Sante also offers a number of signature treatments… read more »
Bella Sante
A city spa should be an oasis—a lavender-scented curtain drawn between you and the press of daily life. With its vanilla-colored walls, soft classical music, and reception-area foot-massage units, Bella Sante transports you to a prettier place, where eveveryone glows…. read more »
One of Boston's newest and most talked-about spas, Grettacole boasts a staff that is petite, blonde, and warm—and an impressive services-to-square-foot ratio. Need a pedicure, facial massage, haircut, and makeup application? With such one-stop shopping, you'll be there long enough… read more »
Although we've officially gone into mourning with the recent closing of the Spa on Newbury, Guiliano makes us want to throw our black veils to the wind. Whether you're a stressed bride-to-be in need of that mandatory glow for the… read more »
Giuliano Hair Design and Day Spa
When the week has left you flagging, buck up your spirits and your body with a total rejuvenation—roots to toes—at Giuliano, where they're at your service seven days a week. Robert Nazzaro does great color, the waxing and manicure services… read more »
Le Pli
With an indoor lap pool, exercise and weight rooms, and a nutritionist on staff—as well as the customary beauty and spa services such as massage, facials, mud and herbal wraps, and bikini waxing—Le Pli offers the most complete spa services… read more »


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They're clearly in a hurry to get out of there. I was there. It was really, really loud.
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FIAT Repair in Raisin City
We found 20 FIAT service shops and mechanics in Raisin City.
4 are RepairPal Certified.
Zarate Auto Smog & Repair
4005 E Jensen(559) 702-1021
Fresno, CA 93725Map & directions
"They did a good job, they figured out what needed to be done and told me what I needed to do to g..." - Carlos, Fresno, CASee more real customer reviews
Sebring West Automotive Center
1744 N Blackstone Ave(559) 249-6613
Fresno, CA 93703Map & directions
Arams Auto Repair Center
6333 N Blackstone Ave(559) 777-6156
Fresno, CA 93704Map & directions
"I have been thoroughly satisfied with them and I trust them. I think they are very honest. I can..." - Sharron, Fresno, CASee more real customer reviews
Electric Lab Auto Service Center
133 E Sierra Avenue(559) 296-3057
Fresno, CA 93710Map & directions
"They are friendly and tell you everything that is going to happen." - ELIZABETH, Fresno, CASee more real customer reviews
RepairPal Certified Shops
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Pixie Casey lives in the mountains with her lovely husband, their enormous dog and an endless supply of Atomic Fireballs. She has a Twitter and a Tumblr, and someday she'll get around to using them.
Movies and TV make tidying up seem super fun.
Movies and TV shows about things that are—or seem—just beyond reach.
This is not where I imagined spending our last summer before college.
How to rediscover yourself after a breakup.
The gold-medal snowboarder on starting out, being homeschooled, and getting over fear.
Scenes from an ice cream stand.
A short story by five authors.
Share this story with 10 friends in the next 24 hours—or you will be very sorry!!!
This is going to be the party of the month.
There was no way to study for what was really testing me.
Hi, queen people! April's theme is BOTH SIDES NOW, which considers the many different answers to THE BIG QUESTIONS, whatever those are for you. If you've got a project or pitch about seeing things in a whole new light, please email it to firstname.lastname@example.com.
Rookie is a website for teenage girls. With monthly-themed content, we update three times every weekday, and once a day on weekends. Click here to find out where to send stuff you'd like us to see. Learn about the people who write this thing here.


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Seed pods?
I think my DS is growing seedpods for the first time. How long does it take for the pod to be fully grown?
LocoGuy, I don't know how long it takes, but when you see it with brown color, you need to cover it with something (stocking). to keep it in place. Without cover, when it opens, seeds fly everywhere. Fresh seeds germinate with high rate. Good luck.
This is one of my seed pods.. Here one day... then POOF!
The next night... Im glad i checked on it the next morning... I did manage to collect most of the seeds. I agree with Marie. Take a knee hi and place it over the pod when you think it is getting close..!
Good Luck!!!
Something special that i saw today!!!
Have a great night everyone!!!
Laura the pic with the dragonfly is fantastic! It looks like it came out of National Geographic.


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Stay the Night: Pasha!Place, Istanbul, Turkey
Reflecting its location, this 19th-century apartment marries Ottoman heritage with modern flourishes
Arifa Akbar
Arifa Akbar is literary editor of The Independent and i newspapers. She has worked at The Independent since 2001 as a news reporter and arts correspondent before joining the books desk in 2009. She was a judge for the Orwell Prize for books 2013, and the Fiction Uncovered Prize 2014.
Sunday 10 June 2012
It makes you want to stay in and look at it forever. The dramatic view, that is, which stretches across the skyline as you enter the living room of pasha!place, a renovated late 19th-century apartment building on the European side of Istanbul. It is quite a feat given that you're in the heart of a city whose sights and sounds do all they can to draw you out.
We clamber up the sweeping spiral staircase – my mother climbing breathlessly behind me – to reach the spine-tingling third-floor view, just as the mosques sound their call for sunset prayer. It's a heady concoction of East-meets-West: Ottoman architectural history bristles beside brick-and-cement modernity; fishing boats streak across the Bosphorus; illuminated bridges sparkle against gold-bellied domes and cloud-covered minarets. There's a bottle of complimentary wine waiting at a viewing table by the window to invite us to watch the sun switch off and the city-lights switch on. In our three days in the bohemian district of Beyoglu – the Soho of Istanbul – we see this majestic panorama from many vantage points, but to have it at such close quarters is quite something.
Happily, pasha!place is right in the heart of things and there's lots to tempt you outside. Beyoglu is an up-and-coming area which is earning its name in cutting-edge fashion and design. The building that houses pasha!place is set on a side street surrounded by steep, labyrinthine alleys filled with artsy, music and ceramics stores, and vintage and upmarket fashion boutiques. You're also minutes away from bustling Istiklal Street, a mile-long pedestrianised artery leading to the central throb of Taksim Square.
The Rooms
The period three-bedroom apartment was restored by husband-and-wife business partners, Tarkan Cetindamar and Julia Bayne, who have run the istanbul!place collection for over five years. They have seven 19th-century apartments, each of which has its own original features: a gilded, wooden, oil-painted ceiling in pera!place, and floral frescos in sahkulu!place. "We've tried hard to be sensitive to the building and the original architecture," says Julia. To that end, pasha!place has a boutique hotel's spare white minimalism with all the mod-cons, set against elegant smatterings of antique furniture, original wooden floorboards, high ceilings and original window frames.
Flick through the welcome folder and you'll find personal recommendation cards of restaurants and bars off the beaten track (with maps drawn on the back). Smaller domestic details have been thought out too – there are umbrellas, washing powder and anti-mosquito plugs. The kitchen is immaculate: well-lit, large and luxurious.
Out and About
The 14th-century Galata Tower (00 90 212 293 8180; galatatower.net) – a circular Genoese landmark with a spectacular 360-degree view – is a stone's throw from the apartment. You can sip Turkish coffee in its top-floor restaurant or boogie in its turret nightclub. Five minutes' walk from the apartment is the revamped Galata Mevlevihanesi, a whirling dervish hall (00 90 212 252 0773) while Turkish author Orhan Pamuk's recently-opened Museum of Innocence (masumiyetmuzesi.org) devoted to everyday objects, is 15 minutes' walk away.
Istiklal Street offers a barrage of patisseries, bookshops, cafés, bars, clubs and high-street fashion. A charmingly antiquated tram chugs back and forth along the street.
A visit to the Istanbul Modern (00 90 212 334 7300; istanbulmodern.org) in nearby Karakoy Port is an absorbing way to spend the afternoon. Browse through the Burhan Dogancay urban art retrospective (50 Years of Urban Walls), and an exhibition of Turkish photography from the Ottoman era to the present day (After Yesterday); from its outdoor café-restaurant you can see the Asian side of the city glittering across the water.
Sultanahmet, the historic centre of Istanbul – home to the Blue Mosque, Topkapi Palace and Hagia Sophia – is about 25 minutes' walk from pasha!place, on the south side of the Golden Horn estuary. This is also the location of the magnificently-domed Turkish baths, Cemberlitas Hamam (cemberlitashamami.com.tr) – prepare to be taken in hand by women brandishing a flannel and olive soap for a very memorable spa experience.
Food and Drink
Istiklal Street is a hotch-potch of high-class eateries and average kebab restaurants. Among the most impressive is a glass-encased sixth-floor restaurant, Leb-i-Derya (0090 212 243 4375; lebiderya.com), whose Michelin-star quality dishes include parmesan-encrusted sea bass, spiced steak and scallop ravioli. Opposite, Markiz Patisserie (0090 212 244 9039) serves anything from cheesecake to grilled meat and borek (sweet or savoury stuffed pastries), and is worth a visit for its exquisite, tiled interior. For baklava, head to the Galata Tower, where Galata Kiva (00 90 212 292 9898; galatakivahan.com) serves the sticky-sweet pastries in a cavernous, exposed brick interior.
If pasha!place's views really do keep you inside the apartment, there's a grocery van that comes tooting along the side-streets of Beyoglu most mornings, selling seasonal fruits and vegetables and a great fish market – Balik Pazari – off Istiklal Street.
The Essentials
pasha!place, Serdar-i Ekrem Caddesi 20, Galata–Beyoglu, Istanbul, Turkey (01905 570877; istanbulplace.com). One night's rental starts at €234 (£188) for up to four people. Children welcome.
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The majority of multiple sclerosis (MS) patients develop some form of lower urinary tract dysfunction, usually as a result of neurogenic detrusor overactivity (NDO). Patients identify urinary incontinence as one of the worst aspects of this disease. Despite the high prevalence of NDO, urological evaluation and treatment are significantly under-accessed in this population. The objectives of this study were: 1) to adapt the previously validated Actionable Bladder Symptom Screening Tool (ABSST) to a short form for ease and brevity of application in a clinical setting that is clinically meaningful; and 2) to develop a scoring algorithm that would be interpretable in terms of referring/considering precise diagnosis and treatment.
A US-based, non-randomized, multi-center, stand-alone observational study was conducted to assess the psychometric properties of the ABSST among patients who have MS with and without NDO. Mixed psychometric methods (e.g., classical statistics (Psychometric theory (3rd ed.). New York: McGraw-Hill; 1994) and item response methods (Applying the Rasch Model: Fundamental Measurement in the Human Sciences. New Jersey: Lawrence Earlbaum Associates; 2001)) were used to evaluate the predictive and clinical validity of the shortened form. The latter included clinicians flagging clinically meaningful items and associated response options which would indicate the need for further evaluation or treatment.
A total of 151 patients, all with MS and with and without NDO, were recruited by 28 clinicians in various US geographical locations. Approximately 41% of patients reported a history of or currently having urinary incontinence and/or urinary urgency. The prediction model across the entire range of classification thresholds was evaluated, plotting the true positive identification rate against the false positive rate (1-Specificity) for various cut scores. In this study, the cut-point or total score of greater than or equal to 6 had a sensitivity of approximately 85%, and specificity of approximately 93% (i.e., 85% patients would warrant being referred to a urologist and 93% of the patients whose symptoms would not warrant urologist referral).
Overall the short form ABSST demonstrated sensitivity and specificity as it maintained the integrity of the longer form tool. Concurrent validity for each subscale as well as predictive and concurrent validity of the total shortened instrument was demonstrated. This instrument provides a new method for assessing bladder problems among MS patients, and may facilitate earlier and more precise diagnosis, treatment, and/or referral to a specialist.
Keywords:Overactive bladder; Multiple sclerosis; Patient reported outcome; Quality of life; Validation
Multiple sclerosis (MS) is a progressive neurologic disorder that causes demyelination of affected nerves in the central nervous system [1-3]. MS can cause almost any neurological symptom, and it often progresses to cognitive and neurological disabilities in the patient, including a decline in mobility [1]. MS affects women three times as often as it affects men. It affects approximately 1 in 1000 people in the US and is the most common cause of neurological disability in individuals 20–45 years old [4,5]. A majority of MS patients develop some form of lower urinary tract dysfunction due to disconnection between the brainstem and the lower spinal cord [6-8]. In particular, up to 75% of MS patients have neurogenic detrusor overactivity (NDO), a bladder disorder characterized by spontaneous overactivity of the detrusor muscle [9]. Symptoms of this disorder include urinary urgency, urinary frequency, and/or urinary incontinence [2,10]. Incontinence has been identified as one of the worst aspects of the disease from the patient's perspective [8]. High intravesical pressures may also lead to serious complications, including kidney infection, and reflux, ultimately causing irreversible damage [7]. Additionally, given all of the issues with NDO in MS it is noted that research groups are establishing guidelines for the evaluation of urinary disorders in MS [7,8,11]. Therefore, despite the high prevalence of urinary incontinence, urological evaluation and treatment are significantly under-accessed in this population [10]. This study outlines the development and validation of a shortened form of a new screening tool, the Actionable Bladder Symptom Screening Tool (ABSST), that healthcare providers can use to identify MS patients with urinary incontinence who may be in need of a more precise diagnosis and/or treatment for their urologic symptoms, including referral to a urologist. The objectives of this study were twofold: 1) to adapt the previously validated 17-item ABSST to a short form for ease and brevity of application in a medical setting that is clinically meaningful; and 2) to develop a scoring algorithm that would be interpretable in terms of referring/considering diagnosis and treatment. Novel item response and classical test methods were used to identify optimally performing items for inclusion in the short form assessment.
In view of recent research suggesting that patients and clinicians are more likely to use shorter instruments [12-15], it was decided to develop a short form version of the ABSST that is clinically meaningful from the clinician's perspective. The development of this short form version of the instrument is described here. In addition, a scoring algorithm was developed for the ABSST, with a identification of a score that would recommend further diagnosis or referral to a urologist. The novel approach of developing the scoring algorithm presented here is based on pivot anchoring as a means of demonstrating clinical meaningfulness.
Multi-site observational study
Data to support the short form adaptation was collected in a US-based, non-randomized, multi-center, stand-alone observational study in male and female patients who have MS with and without NDO. MS patients were recruited through neurology practices to complete patient reported outcome assessments (PRO) (the ABSST and the Overactive Bladder Questionnaire – Short Form (OAB-q-SF)) as well as a demographic and health information form. Written informed consent was needed before the subject could participate in any part of the study. All research involving patient interviews and patient completion of questions were in compliance of the Helsinki Declaration and had full Institutional Review Board (IRB) approval from Copernicus Group (an independent institutional review board organized and operating in compliance with regulations governing institutional review boards set forth in 21 CFR and ICH guidelines, as well as 45 CFR when applicable.) (Protocol # MAP1-11-049). Completed ABSST questionnaires (with patient specific identifying information removed) were shared with the referring clinician and the clinician denoted whether or not referral to a urologist was recommended based on the specific patient's responses. The presence of NDO was not a requirement for inclusion into the observational study. Details of the design of the multi-site observational study will be reported in a separate publication summarizing the development and validation of the ABSST long form [16].
Psychometric criteria/methods for inclusion on the ABSST-short form
The psychometric evaluation and subsequent development of the ABSST-Short Form integrated responses on the longer version of the tool collected from both patients and clinicians. A set of predefined statistical criteria was developed and tested to ensure that the resulting shortened tool included clinically meaningful and reliable items. These were as follows:
•Classical statistical methods
Percentage of patient responses at the floor of measurement (lowest response option) less than 50% [17].
Item correlation with the overall scale (e.g., the extent to which the items are related to other items on the scale) greater than 80% [17].
•Item response theory methods
Degree to which patients response as expected (e.g. measurement error) as measured by Rasch Infit Statistics [18] (acceptable criteria between 0.60 and 1.40).
•Clinician perspective
Greater than 50% of clinicians indicated that the item was clinically relevant.
For clinician response, a pivot anchoring approach was used. In this analysis, the 23 recruiting clinicians were asked to review the ABSST, circle the items that were important to them, and indicate the threshold at which they thought the items would indicate a potential bladder problem or be a cause for concern [18,19].
Classical statistical methods
Individual items were evaluated using two key classical statistical methods: percentage of items at the floor (lowest response option) of measurement and degree to which individual items correlated with the overall scale score. Floor effect refers to a high percentage of patients scoring the lowest score on an individual item. If floor effects are too pronounced, it could interfere with the ability of the instrument to screen patients as experiencing problems. An item was considered to have floor effects if greater than 50% of patients endorsed the lowest category. The degree to which individual items correlated highly with the remaining items on the scale was measured as the magnitude of the correlations ≥ 0.80 [17].
Item response theory methods - rasch analysis
Individual items of the ABSST were evaluated using the Partial Credit model, an extension of the 1-parameter Rasch model for use with items using multiple response formats (dichotomous, polytomous). A Rasch analysis allows for the accumulation of evidence associated with each response to an item by a group of respondents rather than relying on group level statistics (i.e., classical test theory) [20]. More specifically, this particular model allows for the joint estimation of symptom severity (item difficulty) and person's level of severity (person ability). The underlying assumptions for this item analysis are: 1) local independence and 2) unidimensionality. Local independence is evidence that items are conditionally independent of each other (i.e., each item measures a unique symptom). Unidimensionality is evidence that items on a scale measure one underlying trait (e.g., overactive bladder (OAB) symptoms). In the case of symptom measures, we assume the underlying trait as a hierarchical symptom structure which may, in fact, be considered multidimensional. The term unidimensionality, therefore, indicates the underlying symptomology of the condition.
The ability of the ABSST items to reflect an underlying latent construct was assessed by performing item fit analysis. Infit and outfit statistics compare the actual responses on the survey with responses predicted along the range of OAB severity. Acceptable values range from 0.60 – 1.40 for questions with rating scale response options [18]. Items that do not fit the Rasch model may be measuring domains other than the domain of interest or may elicit atypical responses (e.g., endorsement of a high severity symptom by persons with few symptoms). Two item fit statistics were calculated: mean-square infit and mean-square outfit. High infit reflects the tendency of the item to elicit unexpected responses among respondents whose level on the measure approximates the difficulty of the item. High outfit reflects the tendency of the item to elicit unexpected responses among respondents whose level on the measure is above or below the difficulty of the item. Mean-square infit and outfit statistics ≥ 1.40 indicate significant item misfit.
As a further test of local independence of the ABSST domains, individual items were evaluated under the Rasch model using the person separation and reliability, analogous to the Kuder-Richardson Formula-20 (KR-20) [20-23]. The KR-20 is defined as a measure of reliability for dichotomous response choices. Values above 0.90 indicate homogeneity of responses. Under the Rasch model, KR-20 is used as each response category has a hypothesized probability of 0.50 of endorsement to the adjacent category. The item and person separation indices estimate the separation of persons and items on the underlying latent variable. Rasch measurement allows for the additional analysis of both items and persons distributed along the same linear continuum (trait). In order to evaluate whether each of the domain items covers the continuum, items must be sufficiently separated in terms of their item difficulty (which can represent the severity of the underlying trait). The threshold for separation is an index of 2.0 and an associated separation reliability of 0.80 [22]. Rasch person reliability estimates allow for evaluation of whether the items appropriately estimate a person's symptom severity on the underlying trait. When reliability falls below the customarily accepted threshold of 0.70, it indicates that patients may be experiencing symptoms that the measure does not cover (i.e., construct deficiency) [22]. Rasch item reliability estimates the item severity range (i.e., Does the severity scale associated with the items cover the distribution of severity?); which is considered acceptable if ≥ 0.70 as well [22].
Pivot anchoring
In order to create a clinically useful ABSST, a pivot anchoring analysis was conducted utilizing both novel and classical test theories to identify optimal items. All 28 recruiting clinicians were asked to review the ABSST and circle which items were important to them in their clinical decision making, and at what threshold they thought the items would indicate a potential bladder problem or would be a cause for concern. Twenty-three responses were received and used in the pivot anchoring analysis.
A scoring method was developed which included both the clinician and patient responses. First, the clinicians referring patients to the quantitative study were surveyed on attributes of the patient population relative to the instrument. Each clinician was then asked to specify the lowest rating on each of the 16 items which would indicate a clinically meaningful potential bladder problem. Based on the clinicians' ratings of the items, each patient's response was then denoted by either a 1 (indicating a potential bladder problem) or a 0 (indicating no potential bladder problem). This scoring algorithm was then tested using classical test theory and item response theory methods (described in Pivot Anchoring and Predictive Validity sections).
Predictive validity
Logistic regression was used to determine the predictive validity of the ABSST total score to identify patients that would receive a recommendation to see a urologist. The predictive value was based upon a clinician rating of 'Yes' or 'No' on whether they would recommend a patient to see a urologist based upon the patient's responses to the ABSST. Results from logistic regression models testing different cut-points predicting the recommendation were summarized with odds ratio, sensitivity and specificity, Positive predictive value (PPV), Negative predictive value (NPV), percent who warranted referral, and area under the receiver operating curve (ROC). The odds ratio was defined as those MS patients more likely to be referred to a urologist than not. The sensitivity refers to those results that are true results (e.g. would refer to a urologist) while specificity refers to those results that are truly negative results (e.g. would NOT refer to a urologist). PPV refers to proportion of positive test results that are true positives (e.g. proportion of patients who would be referred to a urologist are warranted to be referred) while the NPV refers to the proportion of negative results that are true negatives (e.g. the proportion of patients who would NOT be referred to a urologist are NOT warranted to be referred). The percent of those patients who warrant referral is the percentage of patients classified as either a referral being warranted to a urologist or not. The area under the ROC refers to the ability to classify those who would warrant or would not warrant being referred to a urologist [24].
Patient population
A total of 151 patients, all with MS and with and without NDO, were recruited by 28 clinicians in various US geographical locations to participate in the study. Patients had a mean age of 48.2 (SD 12.11) years, with age ranging from 22 to 80 years of age. Patients had been diagnosed with MS an average of 9.1 (SD 7.24) years. Approximately 70% of patients described the severity of their MS symptoms over the past 6 months as mild, 23.8% described their symptoms as moderate, 1.3% described their symptoms as severe , and 4.6% described them as none/not applicable (4.6%). Severities were captured using patient self-report in a demographic form. Patients were asked how severe their MS symptoms were in the past 6 months on a 0–3 rating scale (0=Not applicable / None, 1 = Mild, 2 =Moderate (uses aides to walk), 3 = Severe (uses wheel chair sometimes)). Approximately 41% of patients reported having a history of or currently having urinary incontinence and/or urinary urgency.
Short form development
Table 1 outlines the results of the predefined statistical criteria that were developed to ensure that clinically meaningful and reliable items were included (please refer to Section 2.2). Eight items (plus the final "Yes/No" item) were identified from the original 17-item ABSST. Boxes marked with an (X) represent those items that met the patient level criteria. The black boxes indicate those items that met the clinician level analysis or statistical criteria. The final row in the table indicates important items from the pivot anchoring analysis. For example, on Item 1 (Urinate right away), if a clinician saw that a patient responded with a "4" (All of the time) then it would be a cause for concern and possibly referral to a urologist. Item 17 is the "Yes/No" item asking patients if they would seek help for their bladder issues. Please see Additional file 1: Table S1 for the ABSST short form.
Table 1. Clinician and patient short form results
Additional file 1: Table S1. Actionable Bladder Symptom Screening Tool.
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Classical statistical results
Evaluation of the classical statistical methods, floor effect and item correlation statistics, indicated that items 1, 7, 8, 9, 10, and 13 met one or both criteria for inclusion into the short form. More specifically, items 1, 7, 8, and 9 met the criteria for inclusion into the short form based on floor effect less than 50%; and items 1, 7, 10 and 13 met the criteria for inclusion into the short form based on item correlation with scale greater than 80%.
Item response theory Rasch analysis results
Based on the criteria detailed in the methods section, each of the items on the ABSST demonstrated the evidenced person reliabilities ≥ 0.70. Fit statistics indicated that 9 item responses were within the expected criteria (Table 2). However, items 2, 4–6 and 14–16 scored outside of the acceptable ranges, demonstrating less than desirable infit or outfit statistics. For example, Item 16 was shown to not directly measure Impact of Symptom Intensity as it scored an infit statistic of 2.68 and an outfit of 2.57, both of which are outside of the threshold of 1.6 – 2.4. This result suggests poor fit to the Rasch model. Similarly, Items 2, 4, 5, 6, 14, and 15 fell outside of the acceptable range as previously described.
Table 2. Infit and outfit statistics by item
Predictive validity
Results from logistic regression models testing different cut-points predicting the recommendation to refer to a urologist are summarized in Table 3. The results of the odds ratio, sensitivity and specificity, PPV, NPV, and percent correctly classified suggest a raw score of 6 or more for further evaluation from a urologist. The overall ABSST Total Score c-statistic was equal to 0.928 and the logistic regression model was robust (Hosmer and Lemesow Goodness-of-Fit Test (p=0.5180)).
Table 3. Performance of the revised ABSST total score at various cut-points* predicting Clinician's Urologist Referral
The performance of the ABSST total score predicting clinician's referral to a urologist is presented in Figure 1 via the ROC curve. Figure 1 displays how different cut-points on the ABSST total score affect sensitivity and specificity of the prediction for referral to an urologist. The prediction model across the entire range of classification thresholds was evaluated; plotting the true positive identification rate against the false positive rate (1-Specificity) for various cut scores. In this study, the cut-point of greater than or equal to a raw score of 6 had a sensitivity of 85.7%, and specificity of 93.1% (i.e., 85.7% patients would warrant a referral to an urologist and 93.1% of the patients would not warrant a referral to an urologist).
Figure 1. ROC Curve of the ABSST Total Score at Cut-Points Predicting Referral to a Urologist.
The goal of this study was to validate the short form Actionable Bladder Symptom Screening Tool (ABSST) as a patient driven, clinically useful measure that is easy to administer and score. The goals were to develop a tool that is sensitive, MS-specific, easy to interpret, easy to use in a clinical setting, and multidimensional, all of which encourage patient-clinician interaction. The unique application of a mixed methods approach was used to select the best items from the long form, using both qualitative and quantitative techniques.
The original, long form ABSST was developed as a de novo measure after it was determined that existing measures did not appropriately assess the symptoms and impacts of NDO on MS patients. The long form of the ABSST is a 17-item instrument (16 items with an additional "Yes/No" item asking patients if they would like to receive help for their bladder problems) that covers three domains: Bladder Symptoms, Coping Strategies, and Impact of Bladder Symptoms. It was developed using established qualitative methods [25,26], including a literature review and clinician input to identify potential symptoms, open-ended concept elicitation interviews with MS patients who have OAB, and face and content validity testing through cognitive interviews (face-to-face debriefing interviews on the ABSST – details to be reported in another publication) with another group of MS patients with OAB. Once the qualitative phase was completed, a US-based, non-randomized, multi-center, stand-alone observational study was carried out to evaluate the measurement properties of the newly developed instrument. Analysis of item completion, item and scale distribution, and predictive validity of the long form ABSST demonstrated strong psychometric properties (details reported in another publication) [17,19,27-30]. The ABSST total score also demonstrated predictive validity, identifying patients who would receive a referral. In order to demonstrate that this screening tool was valid and reliable as a short form, classical test theory and item response theory approaches were taken to ensure that each item included provided the most information, was clinically meaningful, and demonstrated predictive attributes for patient referral to a urologist. Overall, concurrent validity for each subscale as well as predictive and concurrent validity of the total instrument were shown, demonstrating strong psychometric properties.
The simplified scoring method for bladder problem assessment developed here will make it easier for clinicians to identify patients with MS who may have potential problems. The approach used to develop the scoring algorithm adheres to the FDA guidance, is psychometrically valid, and appropriately utilizes pivot anchoring [31], which has been widely used in the interpretation of clinically meaningful points along a categorical continuum. This methodology allowed for synthesis of meaningful cut-points along the continuum where patients are likely to demonstrate urinary problems, as reported by clinicians. This mixed statistical methods approach to item reduction and scoring optimizes selection of items for making sound clinical decisions based on clinicians' assessment of the need for patient referral. These data, when subjected to predictive validity calculations, provided very strong results indicating that clinicians could use it to refer patients appropriately.
This study has several limitations. First, the ABSST is a screening tool and was not designed for diagnostic purposes. Second, although it was identified as being clinically meaningful, the relevance in overall clinical practice has not yet been tested. Lastly, because of the error range on the tool itself, it is possible that some patients' symptoms may go untreated (under-sensitive results) while other patients may incur unnecessary tests and costs (under-specified results). However, the specificity and sensitivity are strong which indicates that the ABSST Short Form is able to differentiate patients who would likely benefit from a referral from those who would not.
Other questionnaires have been developed such as an 8-item screening tool to aid in identifying patients who may have OAB in a busy primary care setting which has a sensitivity of 98% and specificity of approximately 83% [32]. Moreover, the 3-Item OAB awareness tool (which is a short version of the 8-item screening tool) has recently been validated with a sensitivity of 82% and specificity of 91%. In addition, the International Prostate Symptom Score IPSS has been used to identify the severity of bladder symptoms in an MS population (All patients had an Expanded Disability Status Scale score of <6.5, with a mean of 3.4). The 8-item IPSS was originally developed to measure symptom severity in benign prostate hyperplasia. It has also been utilized to measure the prevalence of bladder problems over 2–3 years [33]. Only the ABSST Short Form has been developed or psychometrically tested to the scientific rigor of the FDA Guidance for PRO development. Overall the short form ABSST demonstrated good sensitivity and specificity as it has a positive predictive value of approximately 86% and a negative predictive value of approximately 93%. This shows that the short form ABSST maintains the integrity of the longer form tool which had a positive predictive value of approximately 76% and a negative predictive value of approximately 95% [16]. The sensitivity and specificity of the short form ABSST are in-line with other validated tools in the field and demonstrate its strength and potential positive impact in a clinic and primary care setting [34]. Of particular importance is the ability of the tool to detect more true-positive cases which increase the cost-effectiveness of screening and early detection of OAB problems as opposed to the false-positive cases, which can be detrimental to the screening process.
The simplified scoring method of the ABSST allows for clinicians to easily identify patients with MS who may have potential urinary problems. The approach used to develop the scoring algorithm adheres to the FDA guidance, is psychometrically valid, and appropriately utilizes pivot anchoring [31], which has been widely used in the interpretation of clinically meaningful points along a categorical continuum. The methodology allowed for synthesis of meaningful cut-points where patients are likely to demonstrate urinary problems, as reported by clinicians. The reduction in items and scoring optimizes the most informational items for making sound clinical decisions. These data, when subjected to predictive validity calculations, indicate that clinicians can use the ABSST to refer patients appropriately. In conclusion, ABSST provides a new method for assessing bladder problems among MS patients, and may facilitate earlier diagnosis, treatment, and referral to a specialist.
ABSST: Actionable bladder symptom screening tool; FDA: Federal drug administration; IRB: Institutional review board; MS: Multiple sclerosis; NDO: Neurogenic detrusor overactivity; NPV: Negative predictive value; OAB: overactive bladder; OABqSF: Overactive bladder questionnaire – short form; PPV: Positive predictive value; PRO: Patient-reported outcomes; ROC: Receiver operating curve.
Competing interests
Bates, D.: 'The authors declare that they have no competing interests'.
Burks, J.: Consultant; Speaker's Bureau for Acorda, Allergan (financed manuscript), Avanir, Bayer, Novartis, Sanofi-Aventis, and Serono. Consultant for Genzyme.
Globe, D.: Employed by Allergan (financed manuscript).
Signori, M.: Employed by Allergan (financed manuscript).
Hudgens, S.: Senior Lead on Research Study, funded by Allergan (financed manuscript).
Denys, P.: Advisor and investigator for Allergan (financed manuscript) and Ipsen, advisor and lecturer for Medtronic, Astellas, Coloplast and Astratech.
MacDiarmid, S.: Consultant; Speaker's Bureau for Pfizer, Allergan (financed manuscript), Astellas, Uroplasty.
Nitti, V.: Astellas, Allergan (financed manuscript), Pfizer.
Odderson, I.: Speaker for Allergan (financed manuscript).
Perrin Ross, A: 'The authors declare that they have no competing interests'.
Chancellor, M: Consultant and investigator, Allergan (financed manuscript).
Authors' contributions
SH and DG were involved in conducting the analyses and drafting the manuscript. JB, MC, SH, DG and MS were involved in developing the draft measures, developing the analysis plan and interpreting the results. All authors were involved in the design of the studies, review of the analysis and review, editing and approval of the manuscripts.
The authors would like to acknowledge the following for their help in the development of this manuscript:
Vasudha Mukherjee Bal and Marcy Fitzrandolph for managing and overseeing the qualitative design and development of the ABSST.
Benjamin Banderas for managing the quantitative phase of the study.
Beth Anderson and Jeanne Cloppse of Lawrence and Company for their assistance in site-identification, publication strategy and manuscript development through-out study.
No medical writer was used in the development of this manuscript.
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Pre-publication history
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