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CJD FARMERS WIFE 1989 http://www.bseinquiry.gov.uk/files/yb/1989/10/13007001.pdf http://www.bseinquiry.gov.uk/files/yb/1989/10/13003001.pdf 20 year old died from sCJD in USA in 1980 and a 16 year http://www.bseinquiry.gov.uk/files/yb/1995/10/04004001.pdf CJD in 3 farmer a cause for concern http://www.bseinquiry.gov.uk/files/yb/1995/01/00002001.pdf http://www.bseinquiry.gov.uk/files/yb/1995/10/23006001.pdf http://www.bseinquiry.gov.uk/files/yb/1995/10/20006001.pdf CONFIRMATION OF CJD IN FOURTH FARMER http://www.bseinquiry.gov.uk/files/yb/1995/11/03008001.pdf now story changes from; SEAC concluded that, if the fourth case were confirmed, it would be to; This is not unexpected... was another farmer expected? http://www.bseinquiry.gov.uk/files/yb/1995/11/13010001.pdf 4th farmer, and 1st teenager http://www.bseinquiry.gov.uk/files/yb/1996/02/27003001.pdf 2. snip... 3. You will recall that the advice provided by Professor Smith in http://www.bseinquiry.gov.uk/files/yb/1995/01/31004001.pdf http://www.bseinquiry.gov.uk/files/yb/1995/12/05018001.pdf The Committee has recently considered the cases of CJD in teenagers in the UK. They advised that it was not possible to draw any conclusions, as confirmed cases of CJD have been found in the same group in other countries... http://www.bseinquiry.gov.uk/files/yb/1995/12/07017001.pdf CONFINDENTIAL http://www.bseinquiry.gov.uk/files/yb/1995/12/22007001.pdf (check out clinical features etc...tss) http://www.bseinquiry.gov.uk/files/yb/1995/11/13011001.pdf SPORADIC CJD TABLE http://www.bseinquiry.gov.uk/files/yb/1996/03/04003001.pdf Dr J E Bell and Dr J W Ironside Pathology Reports from CJD Surveillance Unit http://www.bseinquiry.gov.uk/files/yb/1996/01/04011001.pdf cjd 28 year old 1981 http://www.bseinquiry.gov.uk/files/yb/1996/01/11010001.pdf unusual cjd http://www.bseinquiry.gov.uk/files/yb/1996/01/12009001.pdf FURTHER TWO INCIDENCE OF CJD AROUND DEVIZES http://www.bseinquiry.gov.uk/files/yb/1995/11/01023001.pdf PATHOLOGICAL REPORT http://www.bseinquiry.gov.uk/files/yb/1996/02/26005001.pdf http://www.bseinquiry.gov.uk/files/yb/1996/02/26006001.pdf http://www.bseinquiry.gov.uk/files/yb/1996/03/05004001.pdf http://www.bseinquiry.gov.uk/files/yb/1996/03/20051001.pdf 31 year old male cjd some parkinsonian features http://www.bseinquiry.gov.uk/files/yb/1996/03/22018001.pdf Professor John Collinge very concerned about BSE in sheep http://www.bseinquiry.gov.uk/files/yb/1996/03/26001001.pdf CJD INQUEST RESTRICTED http://www.bseinquiry.gov.uk/files/yb/1996/02/06009001.pdf http://www.bseinquiry.gov.uk/files/yb/1996/02/06016001.pdf CJD 27 YEAR OLD POLISH WOMAN http://www.bseinquiry.gov.uk/files/yb/1996/03/06003001.pdf NEW Information: Bob Wills and associateds at SEAC meeting on Friday reported indentifying a new (amyloid plaque-rich) type of CJD disease (clinically and pathologically) occuring in under fourty years olds over the last two (check accuracy of this time period - at one stage someone quoted six months on friday but I am not clear why according to the data) years. This could be called 'atypical CJD (A. CJD) ... http://www.bseinquiry.gov.uk/files/yb/1996/03/08007001.pdf SEAC and 10 cases of CJD under age 42 http://www.bseinquiry.gov.uk/files/yb/1996/03/20018001.pdf DOH still in denial http://www.bseinquiry.gov.uk/files/yb/1996/03/20020001.pdf unavoidable accumulation of cases http://www.bseinquiry.gov.uk/files/yb/1996/04/29001001.pdf http://www.bseinquiry.gov.uk/files/yb/1996/04/02001001.pdf http://www.bseinquiry.gov.uk/files/yb/1996/04/02001001.pdf http://www.bseinquiry.gov.uk/files/yb/1996/07/01001001.pdf http://www.bseinquiry.gov.uk/files/yb/1996/06/26005001.pdf cjd surveillance unit 4th annual report Q1 How do you explain a 50% increase in cases of sporadic CJD in one year (from 35 in 1993 to 53 in 1994) and a 100% increase since 1990 (26 cases)? (answer same old BSeee...tss) snip... A4 WE do not propose to make cjd reportable. snip... Q5 The report reveals a strong statistical association between a lifetime history of eating venison and the risk of developing CJD. There was a similar association with venison last year. IS venison safe to eat? A5 Venison is perfectly safe to eat. ... snip... Q7 The report draws attention to statistical associations with other meats lamb, beef, brain, and sweetbreads. Are you concerned about these? A 7: These associations, all of which were much less strong than venison, leave us with the same problems of interpretation. snip... CJD in teenagers A16: The recent case of CJD in a 19 year old is the first confirmed case of Q17: What about Vicky Rimmer? Doesn't she also have CJD? A17: There has been no confirmation that this patient is suffering from CJD. Q18: Given that you cannot explain why a 19-year old should die from CJD, isn't A18; There is absolutely no evidence to support a link between this case and BSE: - although the cause of most cases of CJD is unknown, there is no scientific - sporadic CJD in young people is extremely rare, but it is by no means - a further case in a 16 year old girl occurred in Canada, but the onset o1 96/10.05/1.9 ----- Original Message ----- Acta Neurobiol. Exp. 2002, 62: 175-182 Correspondence should be addressed to J.W. Ironside, Email: email@example.com Neuropathology of variant Creutzfeldt-Jakob disease James W. Ironside, Mark W. Head, Linda McCardle and Richard Knight National Creutzfeldt-Jakob Disease Surveillance Unit, University of Edinburgh, Western General Hospital, Edinburgh EH4 2XU, United Kingdom Abstract. The clinical, neuropathological genetic and biochemical features of variant Creutzfeldt-Jakob disease (vCJD) are compared to the 926 other cases of suspected CJD referred to the National CJD Surveillance Unit laboratory from 1990-2001. Histological studies of the central nervous system, lymphoid tissues and other organs were accompanied by immunocytochemistry for prion protein (PrP); Western blot analysis of PrP RES was performed on frozen brain tissue. The pathology of vCJD showed relatively uniform morphological and immunocytochemical characteristics, with PrP accumulation in lymphoid tissues, but not in other non-neural tissues. PrP RES accumulation in vCJD showed a uniform glycotype pattern distinct from sporadic CJD. All cases of vCJD were methionine homozygotes at codon 129 of the PrP gene. In view of the spread of bovine spongiform encephalopathy in Europe and Japan, continuing surveillance is required for all forms of CJD, with histological and biochemical analysis of suspected cases to allow an accurate laboratory diagnosis. Key words: variant CJD, prion, PrP, BSE, immunocytochemistry, Western blot, neuropathology INTRODUCTION Surveillance of Creutzfeldt-Jakob disease (CJD) was reinstated in the UK in 1990 in light of the epidemic of bovine spongiform encephalopathy in cattle and its possible consequences for humans. Identification of a new variant form of Creutzfeldt-Jakob disease (vCJD) in 1996 was based on neuropathological and clinical features in a series of 10 patients (Will et al. 1996) in the UK. At present, 116 cases of vCJD in the UK, six cases in France, one in Italy and one in Ireland have been identified. All patients who have undergone analysis of the prion protein gene (PRNP) were homozygous for methionine at the polymorphic codon 129. Since the identification of vCJD in 1996, the evidence for a causal relationship between vCJD and BSE has been considerably strengthened by the results of experimental strain typing and biochemical studies of the disease associated form of the prion protein (PrPRES) in wild-type and transgenic mice (Collinge et al. 1996, Bruce et al. 1997, Scott et al. 2000). Since it is likely that human exposure to BSE has occurred across Europe in all prion protein genotypes in the population, the development of criteria to detect a BSE-related disease is clearly important for surveillance purposes. Neuropathological examination is mandatory for the confirmation of a diagnosis of vCJD(WHO 1996). The original neuropathological criteria for vCJD are reviewed in relation to the widening age range of vCJD patients, with particular attention to the differentiation of vCJD from other forms of CJD (Will et al. 2000). These criteria have been applied to all suspected cases of CJD referred to the National CJD Surveillance Unit up to the end of 2001, in whom detailed clinical and genetic data are available. METHODS Since 1990, neuropathological review of all cases of CJD in the United Kingdom has been undertaken at the National CJD Surveillance Unit. Since the project began, 926 cases of suspected CJD have been examined. Brain biopsy is seldom performed as a primary investigation in cases of CJD, and the diagnosis is usually confirmed after autopsy. Brain tissue from autopsy cases were fixed in formalin for a minimum of three weeks prior to brain dissection. The brains were sampled extensively, including material from the frontal, parietal, temporal and occipital cortex, the hippocampus, hypothalamus, thalamus, basal ganglia, midbrain, pons, medulla and spinal cord (when available). Other organs were examined histologically if material was available. All tissue blocks were immersed in 96% formic acid for one hour prior to routine processing. Sections were cut at 5 m and stained by conventional histological techniques and by immunocytochemistry for PrP using monoclonal antibodies which recognise different PrP epitopes in a standardised validated technique (Bell et al. 1997) (see Table I). Biochemical Analysis Frozen brain tissue was stored at 80oC and investigated for the presence of protease-resistant PrP (PrPRES) by Western blotting as previously described (Ironside et al. 2000). Briefly, 10% brain homogenates were subjected to limited proteolysis by digestion with ProteinaseK(BDH). Electrophoresis was performed on a 12%T acrylamide SDS-PAGE mini-gel format (Bio-Rad Laboratories) and proteins transferred to Hybond ECL membranes (Amersham Parmacia Biotech). The anti-PrP monoclonal antibody 3F4 (Senetek) was used at a 1:10,000 dilution. Detection employed ECL+ reagents and Hyperfilm ECL (Amersham Pharmacia Biotech). PrPRES was visualised by the inclusion of streptavidin peroxidase at a dilution of 1:1,500 in the secondary incubation. The molecular weight was estimated by reference to biotinylated ECL 176 J.W. Ironside Table I Details of antibodies used for immunocytochemistry Antibody Source Dilution Incubation PrP (KG9) TSE Resource Centre Compton, UK 1:50 overnight at room temperature PrP (3F4) Senetek, USA 1:2000 overnight at room temperature PrP (6H4) Prionics, Switzerland 1:3000 overnight at room temperature molecular weight markers (Amersham Pharmacia Biotech.). RESULTS Pathology of vCJD cases The clinical and neuropathological features of vCJD cases in theUKare summarised in Tables II and III. The brain weight in most cases was within the normal ranges for age. However, in cases with a lengthy clinical history (>18 months) there was evidence of cerebellar atrophy (particularly involving the vermis), with a corresponding reduction in myelinated axons in the white matter. Cerebral cortical atrophy was identified in patients who had survived for 28 months and over. Incidental findings in vCJD include a small right temporal cavernous angioma and a small focus of chronic inflammation within the brainstem in the absence of a widespread encephalomyelitis. Spongiform change was focally distributed within the cerebral cortex in vCJD, particularly in the occipital and inferior frontal regions. Extensive confluent spongiform change was not a prominent feature in the cerebral cortex (in comparison to cases of sporadic CJD). The hippocampus was relatively spared. In cerebellar cortex, spongiform change was a prominent feature in the hemispheres and vermis with no particular anatomical predilection. Extensive spongiform change was always present in the caudate nucleus and putamen. In the thalamus, focal spongiform change involved many of the anterior and medial nuclei, often in the absence of plaques. In the hypothalamus, spongiform change was most evident in the paraventricular and supraoptic nuclei. Spongiform change was also detected in the periaqueductal grey matter of the midbrain and the pontine nuclei, but was not present in either the medulla or spinal cord. Table II Clinical diagnostic criteria for vCJD I A Progressive neuropsychiatric disorder B Duration of illness > 6 months C Routine investigations do not suggest an alternative diagnosis D No history of potential iatrogenic exposure E No evidence of a familial form of TSE II A Early psychiatric symptomsa B Persistent painful sensory symptomsb C Ataxia D Myoclonus or chorea or dystonia E Dementia III A EEG does not show the typical appearance of sporadic CJDc (or no EEG performed) B Bilateral pulvinar high signal on MRI scan IV A Positive tonsil biopsyd DEFINITE: I A and neuropathological confirmation of vCJDe PROBABLE: I and 4/5 of II and III A and III B OR I and IV Ad POSSIBLE I and 4/5 of II and III A a, depression, anxiety, apathy, withdrawal, delusions; b, this includes both frank pain and/or dysaesthesia; c, generalised triphasic periodic complexes at approximately one per second; d, tonsil biopsy is not recommended routinely, nor in cases withEEGappearances typical of sporadic CJD, but may be useful in suspect cases in which the clinical features are compatible with vCJD and MRI does not show bilateral pulvinar high signal. Table III Diagnostic neuropathological features of vCJD Cerebral and cerebellar cortex: Multiple florid plaques in H&E sections Numerous small cluster plaques in PrP stained sections Amorphous pericellular and perivascular PrP accumulation Caudate nucleus and putamen: Severe spongiform change Perineuronal and axonal PrP accumulation Posterior thalamic nuclei and midbrain: Marked astrocytosis and neuronal loss Brainstem and spinal cord: Reticular and perineuronal PrP accumulation in grey matter PrPRES accumulation in lymphoid tissues throughout the body Predominance of di-glycosylated PrPRES in central nervous system and lymphoid tissues vCJD neuropathology 177 f e Fig. 1. a, a typical florid plaque in the cerebral cortex (centre) comprises an eosinophilic core with a pale radial periphery, surrounded by spongiform change. Haematoxylin and eosin; b, low magnification view of PrP immunocytochemistry in the cerebral cortex in vCJD. In addition to the staining of plaques, multiple amorphous deposits are located around neurones and blood vessels.KG9antibody; c, immunocytochemistry for PrP in the cerebellar cortex shows large numbers of plaques, particularly in the granular layer (bottom) with numerous amorphous perineuronal deposits in the granular layer (top). 3F4 antibody; d, PrP deposition in the basal ganglia shows no plaque structures, but there is perineuronal staining and a linear decoration of axons.KG9 antibody; e, folicular dendritic cells and tingible body macrophages within the germinal centre of a tonsil from a patient with vCJD stain strongly for PrP. KG9 antibody; f, positive punctate staining for PrP in the spinal dorsal root ganglia in vCJD. As well as the punctate ganglion cell staining, some satellite cells also appear to be positive. KG9 antibody. b a d c 178 J.W. Ironside In the dorsomedial and posterior regions of the thalamus there was severe and extensive neuronal loss with marked astrocytosis (Zeidler et al. 2000). The distribution of astrocytosis did not relate to the presence of amyloid plaques or spongiform change. In the midbrain, severe neuronal loss and astrocytosis occurred in the colliculi and the periaqueductal grey matter. Neuronal loss in the cerebral cortex was most evident in the primary visual cortex, with accompanying astrocytosis. The neuronal populations in the hippocampus were relatively well-preserved. All layers of the cerebellar cortex suffered neuronal loss, particularly the granular cell layer. In cases with a lengthy clinical course, there was severe neuronal loss in the cerebral and cerebellar cortex with marked astrocytosis, consistent with the macroscopic finding of atrophy in these structures. Neuronal loss and astrocytosis were not prominent in the pontine nuclei, but were identified in the inferior olivary nuclei in the medulla. Florid plaques were identified on haematoxylin and eosin stains in all autopsy cases of variant CJD. As previously reported (Ironside et al. 1996, Ironside 1998), these structures comprise an eosinophilic central core with radiating fibrils which are surrounded by a rim or corona of spongiform change (Fig. 1a). Florid plaques were most numerous in the occipital cortex, particularly at the bases of sulci, but were present in all cerebral lobes in all cortical layers. In the cerebellum, florid plaques were most easily identified in the molecular layer, but were also present as aggregates in the granular layer.Noevidence of an amyloid angiopathy was identified. Immunocytochemistry Immunocytochemistry for PrP showed strong staining of the florid plaques in the grey matter in all areas of the cerebral and cerebellar cortex, and also revealed numerous smaller plaques arranged in irregular clusters (Figs. 1b, c). In addition, there was widespread deposition of PrP in a pericellular distribution, apparently around small neurones and astrocytes (Fig. 1d). These deposits were not visualised on routine stained preparations but some could be identified on Gallyas silver impregnation. In the basal ganglia and thalamus, there was a linear and perineuronal pattern of PrP accumulation (Fig. 1d), in marked contrast with the lower levels of PrP accumulation in cases of sporadic CJD which were methionine homozygotes at codon 129 in the PrP gene. In the hippocampus, the cornu ammonis showed little PrP deposition, but there was a dense accumulation in the dentate fascia and the subiculum. Synaptic and neuronal positivity was also present in the midbrain, pons and medulla, particularly in the pontine nuclei. In the spinal cord, PrP positivity was present in the grey matter regions at all levels, particularly in the substantia gelatinosa. No PrP immunoreactivity was detected in the dura mater. Spinal dorsal root ganglia stained positively for PrP (Fig. 1f). Non-CNS tissues The commonest immediate cause of death in the vCJD patients was bronchopneumonia. Occasional cases exhibited mild fatty change in the liver. Routine morphological analysis of the peripheral nerves revealed no evidence of a neuropathy. Positive staining for PrP was identified (as previously reported) in follicular dendritic cells within germinal centres of the tonsil (Fig. 1e), appendix, spleen and lymph nodes from the cervical, mediastinal, para-aortic and mesenteric regions (Hilton et al. 1999, Ironside et al. 2000). Positive staining for PrP was also identified in follicular dendritic cells in Peyers patches in the ileum, although marked autolysis prevented detailed analysis. PrP immunocytochemistry in other organs (the heart, lung, skeletal muscle, salivary gland, oesophagus, stomach, liver, gall bladder, pancreas, kidney, adrenal gland, thyroid gland, parathyroid gland, bladder, testes, and pelvic organs (vagina, cervix, uterus, Fallopian tubes and ovaries) and skin) was all negative in vCJD. In sporadic CJD, all lymphoid tissues, and other organs showed no immunoreactivity for PrP. Biochemistry In agreement with Parchi et al. (Parchi et al. 1997, Parchi et al. 1999a) we have only observed the presence of either one of two different mobility variants in case of sporadic CJD: the first having a non-glycosylated PrPRES of ~21 kDa and termed type 1, and the other of ~19 kDa termed type 2 (Fig. 2, lanes B and C). In our experience, the PrPRES isoform pattern from patients with vCJD is closely similar in terms of mobility to the type 2 isoform seen in sporadic CJD. However, as described previously (Collinge et al. 1996, Parchi et al. 1997, Ironside et al. 2000) vCJD samples do show a glycoform profile characterised by the predominance of vCJD neuropathology 179 di-glycosylated PrPRES, termed type 2B (Parchi et al 1997) (Fig. 2, lane D). The diagnostic use of this type 2B glycoform pattern is clear since we have found this characteristic hyperglycosylation in every case of vCJD and have not yet encountered it in any other case of CJD as defined by clinical and pathological criteria. Some atypical cases of sporadic CJD have exhibited clinical features which initially resembled those of vCJD. However, on Western blot analysis, none of these atypical cases show the characteristic type 2B glycosylation pattern of vCJD. Comparison of vCJD cases with other cases of CJD diagnosed in the UK since 1990 showed no major overlap in terms of neuropathological or biochemical features. Furthermore, only cases of vCJD have PrPRES detectable in lymphoid tissues, with a predominance of the di-glycosylated form of PrPRES in Western blots after proteaseKdigestion. The laboratory diagnostic features of vCJD are summarised in Table III. DISCUSSION Laboratory studies in vCJD have helped define neuropathological and biochemical features which are characteristic and allow a clear distinction from other forms of CJD. The uniformity of these features is in marked contrast to sporadic CJD (the main differential diagnosis), and is consistent with a single strain of causal agent, namely BSE. The significance of the florid plaque as a neuropathological hallmark of vCJD is also confirmed. Florid plaques are not unique to vCJD, and were first described in transmissions of Icelandic scrapie to mice (Fraser 1979). They also occur in chronic wasting disease (Williams et al. 1993), a disorder which appears unrelated to BSE. Since the initial description of florid plaques in vCJD, similar lesions were identified in the brains of macaques following experimental intracerebral transmission of BSE (Lasmezas et al. 1996). Florid plaques have been recently reported in small numbers in occasional cases of iatrogenic CJD in dura mater graft recipients in Japan; however, these iatrogenic cases do not exhibit any of the other distinguishing neuropathological features of vCJD (Schimizu et al. 1999). The small cluster plaques in the cerebral and cerebellar cortex visible on PrP immunocytochemistry may be a more specific pathological marker for vCJD, and have not been reported to occur in any other form of human prion disease. The amyloid plaques occurring in kuru can be distinguished easily from florid plaques by their restricted distribution in the cerebral cortex and cerebellum, their generally smaller size, and the absence of surrounding spongiform change (McLean et al. 1997). Ultrastructural studies of florid plaques in vCJD have revealed a close accumulation of amyloid fibrils in the central core. One recent study has also revealed neuritic dystrophy around florid plaques in the cerebellum (Liberski et al. 2000). This interesting observation requires further study, since neuritic dystrophy is not evident on light microscopy (and is not associated with positive staining for phosphorylated tau). The association between amyloid plaques and dystrophic neurites in vCJD is similar to that in Alzheimers disease, highlighting the potential similarities in mechanisms of degeneration in these disorders. The pattern of thalamic neuronal loss and gliosis in vCJD (Zeidler et al. 2000) is distinct from the thalamic lesions in both fatal familial insomnia (Gambetti et al. 1995) and sporadic fatal insomnia (Mastrianni et al. 1999), which focus on the anterior and medial thalamic nuclei. The clinical significance of this observation is of potential interest in relation to the sensory abnormalities experienced by patients with vCJD, which do not occur in neuroanatomical dermatomes and may therefore represent thalamic pain. Furthermore, this pathological Fig. 2. A, western blot analysis of protease resistant prion protein (PrPRES) in post-mortem cerebral cortex from patients without Creutzfeldt-Jakob disease; B, C, with sporadic Creutzfeldt-Jakob disease, or D, with variant Creutzfeldt-Jakob disease. PrPRES is absent from the control case (A) but is present in the cases of Creutzfeldt-Jakob disease (B, C, D). The PrPRES isotype found in sporadic Creutzfeldt-Jakob disease has either a 21 kDa non- -glycosylated PrPRES (B) or a 19 kDa non-glycosylated isoform with the predominance of the diglycosylated isoform (marked with an asterisk in D). 180 J.W. Ironside finding correlates with the anatomical distribution of the "pulvinar sign" on MRI in vCJD (Zeidler et al. 2000). The epidemiological features of vCJD indicate that a dietary route of exposure is the most likely route of exposure to the BSE agent in the cases identified so far (Will et al. 1996), particularly in a cluster of 5 cases identified in a 4 year period in a rural region of England. However, the identification of other routes of exposure to BSE in future cases cannot be excluded and is part of an ongoing case-control study. In the limited data available on kuru (another acquired human prion disease which was probably transmitted by the oral route), codon 129 genotype did not appear to exert a major influence on the clinical or neuropathological features of the disease in one series (McLean 1997), although in another larger series it was suggested that kuru plaques were more evident (but not exclusively present) in individuals who were valine homozygotes or heterozygotes at codon 129 (Cervenakova et al. 1999) Our experience suggests that a characteristic PrPRES glycoform ratio can usefully distinguish between vCJD and sporadic CJD as reported previously (Collinge et al. 1996, Parchi et al. 1997, Ironside et al. 2000); however, a glycoform pattern similar to that of vCJD is known to characterise fatal familial insomnia (Parchi et al. 1995, Telling et al. 1996) andGSS(Parchi et al. 1999b) and we have recently made a similar finding in an unusual Dutch case of sporadic CJD (Head et al. 2001). It is questionable whether this pattern will be conserved in patients with "human BSE" who are valine homozygotes or heterozygotes at codon 129, although transmission studies using transgenic "humanised" mice suggest that it might (Hill et al. 1997). The presence of PrPRES in the lymphoreticular system (Hilton et al. 1999, Hill et al. 1999) might similarly be a useful diagnostic criterion, although studies of scrapie in sheep have suggested that the distribution of PrPRES in lymphoid tissues is dependent on the host PRNP genotype. It should also be noted that the overall levels of both of PrPRES and infectivity in the lymphoreticular system are significantly lower than in the CNS in vCJD (Bruce et al. 2001, Wadsworth et al. 2001), requiring increased sensitivity in the Western blotting assay and careful assessment by PrP immunocytochemistry. An integrated approach to the post-mortem diagnosis of vCJD, relying on a combination of histology, immunohistochemistry, PrP gene sequencing and PrPRES analysis. As more cases of BSE and vCJD are identified in an increasing number of countries, detailed laboratory investigation of all suspected CJD cases is required in order to maintain vigilance concerning the effects of the BSE agent in man. ACKNOWLEDGEMENTS This study would not have been possible without the generous co-operation of all the neuropathologists and neurologists in the United Kingdom. We thank Ms BA Mackenzie for preparation of the manuscript. The National CJD Surveillance Unit is funded by the Department of Health and the Scottish Executive Department of Health. We are grateful to the TSE Resource Centre, Compton, for supplying the KG9 antibody and to Dr B Oesch, Prionics, Switzerland, for supplying the 6H4 antibody. 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Hilton D.A., Fathers E., Edwards P., Ironside J.W., Zajicek J. (1998) Prion immunoreactivity in appendix before clinical onset of variant Creutzfeldt-Jakob disease. Lancet 352: 703-704. Ironside J.W., Sutherland K., Bell J.E., McCardle L., Barrie C., Estibeiro K., Zeidler M., Will R.G. (1996) A new variant of Creutzfeldt-Jakob disease: neuropathological and clinical features. Cold Spring Harbour Symposia on Quantitative Biology; LXI: 523-530. Ironside J.W. (1998) New-variant Creutzfeldt-Jakob disease. Neuropathology 18: 131-138. Ironside J.W., Head M.W., Bell J.E., McCardle L., Will R.G. (2000) Laboratory diagnosis of variant Creutzfeldt-Jakob disease. Histopathology 37: 1-9. Lasmézas C.I., Ironside J.W., Chiach C., Demaimay R., Adjou K.T., Lamoury F., Dormont D., Robain O. (1996) BSE transmission to Macaques. Nature 381: 743-744. Liberski P.P., Ironside J., McCardle L., Sherring A. (2000) Ulstrastructural analysis of the florid plaque in variant Creutzfeldt-Jakob disease. Folia Neuropathol. 38: 167-170. Mastrianni J.A., Nixon R., Layzer R., Telling G.C., Han D., DeArmond S.J., Prusiner S.B. (1999) Prion protein conformation in a patient with sporadic fata insomnia. N. Engl. J. Med. 340: 1630-1638. McLean C.A., Ironside J.W., Alpers M.P., Brown P.W., Cervenakova L., Anderson R.M., Masters C.L. (1998) Comparative neuropathology of kuru with the new variant of Creutzfeldt-Jakob disease: evidence for strain of agent predominating over genotype of host. Brain Pathol. 8: 429-437. Parchi P., Castellani R., Cortelli P., Montagna P., Chen S.G., Petersen R.B., Manett V., Vnencak-Jones C.L., McLean M.J., Sheller J.R., Lugaresi E. Gambetti L., Gambetti P. (1995) Regional distribution of protease-resistant prion protein in fatal familial insomnia. Ann. Neurol. 38: 21-29. Parchi P. (a), Giese A., Capellari S., Brown P., Schulz-Schaeffer W., Windl O., Zerr I., Budka H., Kopp N., Piccardo P., Poser S., Rojiani A., Streichenberger N., Julien J., Vital C., Ghetti B., Gambetti P., Kretzschmer H.A. (1999) Classification of sporadic Creutzfeldt-Jakob disease based on molecular and phenotypic analysis of 300 subjects. Ann. Neurol. 46: 224-233. Parchi P. (b), Chen S.G., Brown P., Zou W., Capellari S., Budka H., Hainfellner J., Reyes P.F., Golden G.T., Hauw J.J., Gajdusek D.C., Gambetti P. (1998) Different patterns of truncated prion protein fragments correlate with distinct phenotypes in P102L Gerstmann-Straussler-Scheinker disease. Proc. Natl. Acad. Sci. USA. 95: 8322-8327. Scott M.R., Will R., Ironside J.W., Nguyen H.O.B, Tremblay P., DeArmond S.J., Prusiner S.B. (2000) Compelling transgenetic evidence of transmission of bovine spongiform encephalopathy prions to humans. Proc. Natl. Acad. Sci. USA. 96: 15137-15142. Shimizu S., Hoshi K., Muramoto T., Homma M., Ironside J.W., Kuzuhara S., Sato T., Yamamoto T., Kitamoto T. (1999) Creutzfeldt-Jakob disease with florid-type plaques after cadaveric dura mater grafting. Arch. Neurol. 56: 357-362. Telling G.C., Parchi P., DeArmond S.J., Cortelli P., Montagna P., Gabizon R., Mastrianni J., Lugaresi E., Gambetti P., Prusiner S.B. (1996) Evidence for the conformation of the pathologic isoform of the prion protein enciphering and propagating prion diversity. Science 274: 2079-2082. Wadsworth J.D.F., Joiner S., Hill A.F., Campbell T.A., Desbruslais M., Luthert P.J., Collinge J. (2001) Tissue distribution of protease resistant prion protein in variant Creutzfeldt-Jakob disease using a highly sensitive immunoblotting assay. Lancet 358: 171-180. Will R.G., Ironside J.W., Zeidler M., Cousens S.N., Estibeiro K., Alperovitch A., Poser S., Pocchiari M., Hofman A., Smith P.G. (1996) A new variant of Creutzfeldt-Jakob disease in the UK. Lancet 347: 921-925. Will R.G., Zeidler M., Stewart G.E., Macleod M.A., Ironside J.W., Cousens S.N., Mackenzie J., Esitbeiro K., Green A.J.E., Knight R.S.G. (2000) Diagnosis of new variant Creutzfeldt-Jakob disease. Ann. Neurol. 47: 575-582. World Health Organisation (1996) In: Report of aWHOconsultation on clinical and neuropathological characteristics of the new variant of CJD and other human and animal transmissible spongiform encephalopathies. Geneva: World Health Organisation.. Zeidler M., Sellar R.J., Colie D.A., Knight R., Stewart G., Macleod M.A., Ironside J.W., Cousens S., Colchester A.F.C., Hadley D.M., Will R.G. (2000) The pulvinar sign on magnetic resonance imaging in variant Creutzfeldt-Jakob disease. Lancet 355: 1412-1418. Received 8 July 2002, accepted 20 July 2002 182 J.W. Ironside http://www.nencki.gov.pl/pdf/an/vol62/iron.pdf 1 The BSE Inquiry / Statement No 210 CJD Surveillance Unit (not scheduled to give evidence) STATEMENT FROM THE CJDSU TO THE BSE INQUIRY 1. This Statement is presented in order to clarify some issues discussed at the time of our attendance at the Inquiry on 3rd June 1998. This Statement addresses the following issues : A. The difficulty of clinical diagnosis of new variant CJD prior to the announcement on the 20th of March 1996 and the effect this had on surveillance. B. The policy of the Unit in relation to obtaining consent for post-mortem. C. The difficulties of informing the families of victims of nvCJD of the imminent announcement relating to these cases made on March 20th 1996. D. The efforts made by the CJDSU to provide support and information to the families of cases of CJD since the inception of the CJD Surveillance Unit in 1990 and details of activities directly related to the relatives of nvCJD families after March 20th 1996. 2 A. The difficulty of clinical diagnosis of new variant CJD prior to the announcement on the 20th of March 1996 and the effect this had on surveillance 2. Since the start of the CJD Surveillance project in 1990 the methodology for case ascertainment of cases of suspect CJD has been to ask targetted professional groups and particularly neurologists, to refer any "suspect" case of CJD to the Surveillance Unit. This usually involves direct telephone contact with the Unit, but suspect cases have also been identified from other sources including death certificates and requests for advice or information. At the time of each referral a standard form is completed and a decision is made about whether to request permission to visit the hospital in order to obtain relevant information directly. An essential component of this process is to obtain permission to interview relatives of the suspect case. Since the start of the project it has been the policy of the Unit that it is essential to obtain permission from the consultant responsible for the case before a visit to the hospital can take place and that the relatives of any suspect case should know about the potential diagnosis of CJD prior to the visit from the CJDSU and that the relatives should be informed of the function of the CJDSU and the purpose of the visit. 3. With some referrals, particularly those not made directly by neurologists, the suspicion of the diagnosis of CJD may be insubstantial and in some cases, including those directly referred by neurologists, it may be necessary to wait for the results of investigation or the evolution of the clinical illness before the diagnosis of CJD can be considered as a real possibility. In these circumstances the decision may be made to defer a visit from the CJDSU, often because it is not felt justifiable by the responsible clinician to raise the possibility of the diagnosis of CJD with the relatives of the patient (or in some cases the patient themselves). It is not good medical practice to discuss hypothetical diagnoses with patients or relatives if there are no substantial grounds for a particular diagnosis. With CJD of all forms, even the suspicion of this diagnosis can cause major distress, at least in part because of the extensive public concerns about this condition. In many suspect cases referred to the Unit the decision not to visit at the time of the first referral has been vindicated by the subsequent diagnosis of an alternative condition or because the patient recovered. 4. The clinical features of new variant CJD are relatively distinct from classical CJD. The duration of illness is longer, the early clinical features are atypical for CJD, the electroencephalogram does not show the "typical" appearance so often seen in classical CJD and the mean age of death is about 40 years less than classical CJD. It is quite understandable that (prior to March 1996) neurologists might not suspect the diagnosis of CJD in a patient aged less than 50 years with predominantly psychiatric features and with a normal or "atypical" EEG. The diagnosis of CJD was raised as a possibility in some of the early cases of new variant CJD, but the decision to notify the CJD Surveillance Unit must have been difficult, because the clinical features of these cases were different from previous experience in CJD. Some clinicians took the understandable view that CJD was not a likely diagnosis and the involvement of the CJDSU was not appropriate, particularly if this might cause distress and potentially unnecessary distress to the relatives of patients who were having to cope with a terminal illness of a child or spouse. It is of note that the first three cases of new variant CJD underwent brain biopsy prior to referral to this Unit and two of these cases were promptly referred to the CJDSU when the diagnosis of CJD was confirmed. 5. On the 21st of March 1996 all neurologists in the United Kingdom were circulated with a letter from the Unit describing the clinical and pathological features of new variant CJD. The neurological community was thereby informed of the novel clinical pathological phenotype. Since the 21st of March 1996, all cases of new variant CJD have been referred to the CJDSU and the referring hospital visited with the permission of the responsible clinician and the patients relatives. 3 B. The policy of the Unit in relation to obtaining consent for post-mortem 6. The CJDSU was funded as a research unit to study the epidemiology of CJD. The methodology of the study involved a visit by a research registrar to referring hospitals to obtain relevant information in order that any change in the characteristics of CJD that might be attributable to BSE could be identified. This methodology involved the clinical examination of suspect cases and an interview with the relatives of these cases. As was stated in the original grant application, an important consideration from the start of the study was that the opportunity to discuss CJD in detail with someone knowledgeable in the subject might be of benefit to the relatives of patients with CJD. It has also been a primary imperative of the CJDSU not to interfere with the relationship between the relatives of patients and the responsible clinicians. This is an issue which was (and is) discussed in detail with all the research registrars who have worked on the CJD project. 7. The boundary between provision of information and perception of interference in clinical care is delicate and it is to the credit of all the research registrars who have worked in the Unit and to the neurological community that problems have only very rarely arisen. 8. Since the start of the project the view of the CJDSU has been that the research registrars should not raise the issue of post-mortem with the relatives of patients unless specifically asked. It may for example be particularly inappropriate to discuss post-mortem if patients are seen early in the clinical course. It has been our view that the issue of permission for post-mortem is a matter that should be discussed between the responsible clinician and the relatives. Although, if asked, the registrars have discussed the importance of post-mortem in the confirmation of diagnosis, consent for the post-mortem has not been a matter for the research registrars. We have encouraged clinicians to request post-mortem but we have always firmly believed that the final decision about post-mortem was a matter for the families to decide after discussion with the responsible clinicians. 9. The CJDSU has acted as a reference centre for the examination of neuropathological and other tissue and staff at the Unit have carried out post-mortems in suspect cases. These post-mortems have been carried out at the request of a Coroner or Procurator Fiscal or with a Consent Form for Post-Mortem signed by a relative. Some centres carry out their own examination of post-mortem tissue and may supply tissue blocks or slides for examination at the CJDSU. 10. The results of histological examination of brain tissue are supplied to the referring pathologist and/or clinician or to the Coroner/Procurator Fiscal. Since the start of the project it has been the view of the CJDSU that the provision of post-mortem results to relatives should primarily be the responsibility of the referring clinician. We have sometimes been asked directly by relatives for the results of post-mortem findings and have provided these results, usually in the form of an explanatory letter and with the post-mortem report itself, if requested. 11. The system for reviewing neuropathology of CJD which was established in the UK has been of great importance to the scientific study of this disease and was of critical importance to the identification of new variant CJD. However the CJDSU was set up as a research project and we have tried to avoid interference with the relationships between clinicians and the relatives of patients. Consent for post-mortem and the provision of the results of post-mortem have not been the direct responsibility of the CJDSU. 4 announcement relating to these cases made on March 20th 1996 12. The CJDSU has viewed the provision of information and support to relatives of patients with CJD as a matter of great importance since the start of the project. Details of the activities of the CJDSU in relation to this issue are described in Part D of this Statement. 13. The details of the process of the identification of new variant CJD have already been provided to the Inquiry. On March the 8th 1996 evidence was presented at the SEAC committee by Dr Ironside and Dr Will which raised the possibility that a new form of CJD had been discovered which might be causally linked to BSE. Further information was requested by the SEAC committee. Dr Ironside and Dr Will discussed the research findings with senior figures in neuropathology and neurology and further information was provided as requested to SEAC at a meeting on March the 16th 1996. At this meeting it was indicated that an announcement of these findings would be made, but there was no indication as to when this was to happen. My recollection of the meeting was that the announcement was not imminent. 14. On March the 17th and 18th Dr Will and Dr Ironside were attending a scientific meeting in Paris. If they had known there was going to be an imminent announcement of the research findings they would not have attended this meeting. In the late morning of March the 18th a telephone call was received from the Department of Health suggesting that Dr Will should return to London for a further SEAC meeting. On the afternoon of the 18th of March Dr Will and Dr Ironside returned to the United Kingdom. 15. On the morning of March the 19th, Dr Will discussed the research findings with a senior neurologist in London. The issue of informing the relatives was the first matter discussed at this meeting and it was agreed as a first priority that the families of the cases of the new form of CJD should be informed of the research findings prior to any public announcement. In the afternoon of March the 19th Dr Will attended a SEAC meeting but had to leave before the end of the meeting in order to catch the last flight back to Edinburgh. No date for any announcement was suggested during the time Dr Will was at the SEAC meeting. Dr Will arrived in Edinburgh about 10 p.m. and shortly afterwards received a telephone call from a media representative requesting involvement in a radio programme the following morning to discuss the details of the new cases of CJD as these were to be announced the following afternoon. This development was completely unexpected. 16. First thing the following morning, Dr Will requested Dr Zeidler, the Research Registrar, to contact all the neurologists who had been responsible for the care of the individual cases of new variant CJD to inform them of the situation and to ask whether they would prefer to inform the relatives directly or whether they would prefer Dr Zeidler to inform the relatives. As stated above, an important policy of the CJDSU has been not to interfere with the relationship between the relatives and responsible clinicians and it was felt essential the decision about the means of informing the relatives should be taken in collaboration with the responsible clinicians. Dr Zeidler contacted all but one of the responsible clinicians and most of the patients families were able to be contacted and informed prior to the announcement that afternoon. It is a matter of great regret to the CJDSU if some of the relatives of these cases were not informed about the research findings prior to the public announcement. The CJDSU has always regarded the provision of information and support to the relatives of people with CJD as a primary objective (see point 4). The CJDSU were not able to inform all the relatives prior to the announcement because the fact of the imminent announcement was only known to the Unit the night before the announcement and there was insufficient available time on the morning of March the 29th 1996 to ensure that all the relatives of cases of new variant CJD had been informed. 5 D. The efforts made by the CJDSU to provide support and information to the families of cases of CJD since the inception of the CJD Surveillance Unit in 1990 and details of activities directly related to the relatives of nvCJD families after March 20th 1996 17. Although primarily a Research Unit the CJDSU has regarded the provision and support of the relatives of patients with CJD as an important priority. This is referred to in Dr Wills original Statement paragraphs 28 to 33. 18. There has always been something of a dilemma between the need to provide a source of information for relatives of patients who have died of Creutzfeldt-Jakob disease and the importance of not interfering in the relationship between the relatives and clinicians. There has also been an imperative not to intrude on relatives who may not wish to be involved with further information and support. This issue was discussed by the CJD Support Network and it was decided in 1996 to forward a letter to the general practitioners of past patients with CJD in order to give the GP the opportunity to judge whether it were appropriate to forward a letter regarding the Support Network on to individual families. Copies of the documents that were drawn up in February 1996 are enclosed and these letters were sent to a number of past patients with CJD including cases that subsequently turned out to be new variant CJD (Annex 1). 19. On March the 20th 1996 the CJD Support Network were contacted in order to inform them of the facts of the recent research on the young patients with CJD. A draft statement was corrected by the CJDSU and returned immediately to the Alzheimers Disease Society. Enclosed are copies of the documents which were published by the Alzheimers Disease Society on behalf of the CJD Support Network on March the 21st 1996 (Annex 2). On the 26th of April 1996 there was a meeting of the committee of the CJD Support Network which included two relatives of a patient who had died of new variant CJD. Concern was expressed about the way the news broke about the discovery of the new strain of CJD and Dr Will who was a committee member explained the situation and the decision that had been made by the Support Group on the 10th of June 1994 that, after the initial hospital contact, the CJD Surveillance Unit would not contact individual relatives directly, but would do so through their clinicians or through the Support Network. Since 1992 the CJD Surveillance Unit has provided each suspect case with an information booklet with the name and address of the CJD Unit in order that any questions or concerns may be discussed with staff at the Unit after the original hospital visit. The CJD Surveillance Unit was in contact with some relatives of the new variant cases after the initial visit and as a policy had tried to provide as much information to these relatives as requested. It was not however the policy of the Unit to contact individuals without permission following the initial contact during the hospital visit. 20. In April 1996 following a visit by relatives of a patient with new variant CJD to the Unit in Edinburgh, a request was made that all the new variant CJD cases identified up until that time should be circularised in order to inform them that a group of relatives had been set up and that a meeting was to be arranged later in the year for a representative of the CJDSU to address the assembled relatives. In the light of previous policy, a draft letter was drawn up, a copy of which I enclose (Annex 3) which was sent to responsible clinicians who had been caring for the individual cases of new variant CJD. The decision about whether to forward this on to the individual families, as before was one that had to be made by clinicians who were directly involved with the care of these families. The difficulty of the situation is referred to in the draft letter that was to be sent to clinicians. In the second last paragraph this stated "We have of course been in contact with the families of the recent CJD cases and it is clear that in at least two cases currently there is no wish 6 for contact with any outside agency." 21. At the request of the new variant families, a meeting was arranged in Birmingham, funded by the CJDSU to allow the families to discuss directly various issues regarding the research findings of the CJDSU. This meeting was held on the 6th of July 1996. 22. Subsequently there has been extensive communication between the new variant CJD families and the CJDSU. We have made every attempt to keep the families informed of research developments and have sent them pre-publication copies of a number of papers including: · "Cerebrospinal-fluid test for new-variant Creutzfeldt-Jakob disease" published in the Lancet · "Transmissions to mice indicate that new variant CJD is caused by the BSE agent" published in Nature · "Predicting the CJD epidemic in humans" published in Nature · "New variant Creutzfeldt-Jakob disease: neurological features and diagnostic tests" published in the Lancet · "New variant Creutzfeldt-Jakob disease: psychiatric features" published in the Lancet · "Molecular analysis of prion stain variation and the aetiology of "new variant" CJD" published in Nature 23. Members of the CJDSU have attended the inaugural meeting of the Human BSE Foundation and a subsequent meeting in December 1997 and have also provided information at the Annual General Meetings of the CJD Support Network, during which the opportunity has been taken to have conversations with new variant families to explain any questions about this condition. There is extensive correspondence held at the CJDSU relating to these contacts. We believe we have done everything possible to try and provide information and support to the families of the victims of human BSE within the limits of available resources at the Unit and with the ethical constraint of not interfering in patient care. Professor R G Will Dr J W Ironside October 1998 7 Issued on behalf of the witness by: The BSE Inquiry Press Office 6th Floor Hercules House Hercules Road London SE1 7DU Tel: 0171 261 8377 / 8383 Fax: 0171 803 0893 Website: http://www.bse.org.uk email: firstname.lastname@example.com http://www.bseinquiry.gov.uk/files/ws/s210.pdf PDF] The BSE Inquiry / Statement No 60 Dr James Ironside (scheduled to ... http://www.bseinquiry.gov.uk/files/ws/s060.pdf [PDF] The BSE Inquiry / Statement No 60A Dr James Ironside Issued 15/12/1999 http://www.bseinquiry.gov.uk/files/ws/s060a.pdf TSS TSS


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Hi guys. By the time my last shot passed, many things changed around the application, name and overall approach included. So without further a do this is some sneak preview of the landing page (logo is not official, the type currently serves mostly for presentation purpose)
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subset: commoncrawl


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Profanity Count
Fuck: 45
Shit: 13
Cow shit: 1
Dog shit: 1
Bullshit: 5
Dick: 2
Balls: 1
P—y: 2
Ass: 6
Asshole: 5
C–k: 3
Pot. P—y. Palin. Religion. These were just some of the topics HBO comedian and "Real Time" host Bill Maher addressed before a crowd in Rockville, Md.
"We get two parties and one can't be for pot?" Maher asked incredulously at the top of the show. Dressed in a watermelon-colored T-shirt and faded blue jeans, Maher's hair was styled in his familiar slicked back blond-gray do. "Pot is the one issue that unites hillbillies and hippies."
As the evening wore on he moved through the GOP candidates, President Obama and religion at a quick clip, moving on to sex, marriage, Cialis, ex-Rep. Anthony Weiner (D-N.Y.), ex-Sen. Larry Craig (R-Idaho) and House Speaker John Boehner. "Contraception? I thought we already accepted that," he said. "Presidential candidates talking about rubbers?"
On Obama: "Obama is half black and half white. I think the first term was the white term and now we're going to get the black term." The crowd roared with applause. Maher encouraged the President to change up his hairstyle. "Grow your hair out! That alone would accomplish a great deal. I would donate another million if you grow your hair out."
On GOP hopeful Rick Santorum: "He's more backed up than whatever highway is near here." … "And I love the sweater vest. Let's see, what should I be, the pedophile at a church picnic."
On GOP hopeful Mitt Romney: "Most people know that Mitt Romney is Richie Rich Prick."
On GOP hopeful Newt Gingrich: "There are actual newts that are less slimy than Newt." Maher pointed out that Gingrich left his first and second wives who had cancer and multiple sclerosis. He asked, "How is it that when Newt fucks you, you get very very sick?"
On ex-Rep. Weiner: "This is a guy who has a sex scandal and doesn't get any p—y. Really, not a blowjob from an intern or a tryst in a men's bathroom?"
On Palin: "Who has better qualifications than Sarah Palin? She's got a Facebook. She should be president."
At one point during the religion portion of his material, he remarked on the Catholic Church and joked about the Pope wearing a dunce cap. He said, "I was never molested. It's their loss, I was a cute kid." He also went off on Mother Theresa and said that even she had a crisis of faith during her life. "This is like finding out that the colonel doesn't eat the chicken!" Maher cracked.
On Fox News: "Outside the Fox News bubble are facts. You can actually measure shit."
On suicide: Maher said he's "pro-suicide" or "whatever clears the highway."
Maher recalled a USA Today story on weather casters who doubted global warming. He said his weather caster was a "woman with big tits who used to be on Telemundo."
At one point the audience moaned as Maher seemed to go too far. "Sorry," he said laughing as he looked out into the subdued suburban crowd. "I don't know where the edge is here."
Note to Readers: FBDC's Eddie Scarry was responsible for tracking the number of times Maher said "fuck."


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Search Result
Search Tags: Environmental Protection Agency
Fort Detrick signs cleanup agreement with EPA
Fort Detrick signed an agreement Friday with the Department of Defense and the U.S. Environmental Protection Agency outlining how to go about cleaning up Area B's groundwater contamination.
Tags: Fort Detrick , Department of Defense , Ben Cardin , Federal Facilities Agreement
$100k offered for proof of impropriety in Detrick studies
An organization trying to connect activities at Fort Detrick to cancer cases in the immediate area of the Army post is offering a reward to anyone who can prove tests conducted were done improperly.
Tags: Fort Detrick , cancer , Kristen Renee Foundation , Frederick News-Post
Chesapeake Bay comments due Monday
Cleaning up the Chesapeake Bay is going to require its six watershed states to change the way things are done in waste-water treatment plants, on golf courses and on farms.
Tags: Chesapeake Bay , waster-water treatment
Former Chesapeake Bay scientist sees bleak future
Despite restoration efforts, government dollars, and a multi-state movement to save the Chesapeake Bay, one scientist doesn't think a rescue is possible.
Tags: Chesapeake Bay Program , Kent Mountford , Lusby


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Awesome Vacation Rental Marketing Idea: Competitive Advantage Through Local Partnerships
- By: Adam Norko
- On: 04/10/2014 10:29:33
- In: Sales/Marketing
- Comments: 5
Now that we've established the importance of vacation rental marketing (especially inbound marketing), and many vacation rental managers are hitting the busiest time of year, it's time to try to break off some VRM marketing ideas into smaller chunks.
I want to share a pretty awesome vacation rental marketing idea. And my guess is you may not of heard of it before.
Seaside has done an awesome job keeping the program rolling since my departure. I suggest you follow the Club Seaside link to take a look.
But here's a quick breakdown.
VRM "Club" Program:
- The idea of Club Seaside can be applied to each and every vacation rental market.
- Partner with local businesses that you know your guests will be interested in – hidden treasures, popular attractions, etc.
- Ask the local businesses to offer one free event to a limited amount of your guests on a weekly basis.
- In return, you promote your "Club" program to your guests and as a result, you promote the local business as well. This promotion can/should be year round. It's a great differentiator!
- Side Note: You'll notice in my One Year of VRM Marketing Content that the entire month of April is dedicated to announcing area partners. This is when we would announce all of our Club Seaside partnerships/events.
- Your guests love free – and you've carefully selected the best free there is!
- You expose your guests to businesses and activities that may otherwise go unnoticed. (Thought leader!)
- You get to differentiate from your competition by offering a pretty cool amenity.
- The local business gets great marketing to a large pool of visitors at a very low cost – i.e. the cost of a small weekly event.
Checkout the awesome list of free event Seaside is able to offer through this free program!
Related Links – Confessions of a VR Marketing Director:
- Part I: A bit of my experience and why I may have some secrets hidden up my marketing sleeves.
- Part II: Why "inbound marketing" is the bees knees & the PERFECT fit for vacation rental marketing.
- Part III: 12 tips & tricks for a vacation rental marketing ninja.
- Part IV: One Year of VRM Marketing Content
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Get the Facts on Ebola in 20 Minutes!
For questions regarding the Ebola Virus Disease, please call:
Toll-Free 1-(844) 49-EBOLA (32652)
Assisted Living Residence Regulatory (ALR) Act of 2000 became effective on June 24, 2000. The act was implemented August 17, 2007. The Community Residence Facilities Branch, Child and Residential Care Facilities Division, Health Regulation Administration (CRF/CRCFD/HRA) regulates the operation of the ALR. The overall philosophy of the ALR is to focus on the residents' quality of life and to enhance their ability to age in place in a home-like setting with the expectation that all areas of their needs will be met.
Individuals or businesses interested in operating an ALR must submit a completed application package to the CRF Branch for reviewing, processing, and scheduling of surveys for ultimate licensure.


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Skillful residue removal by NCS revealed a bright and lustrous coin.
This popular commemorative coin from 1983 issued in Poland features the then newly appointed Pope John Paul II. As popular as this commemorative issue is for many reasons, this particular example had developed a rather unattractive hazy residue.
Adept in removing offending residues from modern and classic coins alike, skillful residue removal resulted in a coin as bright and lustrous as it was first issued. This coin was able to grade very well with NGC following the residue removal; a residue that if not removed would have a negative impact on the final grade.
NCS is an independent member of the Certified Collectibles Group.
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Healthcare identities at the crossroads of service modernisation: the transfer of NHS clinicians to the independent sector?
Waring, Justin and Bishop, Simon. (2011) Healthcare identities at the crossroads of service modernisation: the transfer of NHS clinicians to the independent sector? Sociology of Health & Illness, Vol.33 (No.5). pp. 661-676. ISSN 0141-9889
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Official URL: http://dx.doi.org/10.1111/j.1467-9566.2010.01311.x
Health policies increasingly support private businesses to take an active role in the organisation and delivery of public healthcare services. For the English NHS, this is exemplified by the introduction of Independent Sector Treatment Centres. A number of these facilities involve the wholesale secondment of NHS clinicians to the private sector which, we suggest, raises important questions about the identities of healthcare professionals accustomed to working in the public sector. Our paper investigates this transition highlighting three prominent discontinuities in clinical work: the ethos of private sector ownership, new lines of authority and fragmented relationships. Drawing on Giddens, we examine how clinicians experience and interpret these changes and how they keep their biographical 'narrative going'. The 'pioneers' interpreted the independent sector as an opportunity to re-invigorate their practice through new roles, relationships and higher quality care; the 'guardians' as an opportunity to replicate and protect the customs and standards of the NHS in the private sector; whilst the 'marooned' longed to return to the NHS. Our study illustrates how the sectoral context can shape healthcare identities, and how contemporary reforms aimed at promoting partnerships across public and private sectors can have profound implications for clinicians.
Item Type: | Journal Article |
Subjects: | R Medicine > R Medicine (General) |
Divisions: | Faculty of Social Sciences > Warwick Business School > International Centre for Governance & Public Management Faculty of Social Sciences > Warwick Business School |
Journal or Publication Title: | Sociology of Health & Illness |
Publisher: | Blackwell |
Official Date: | 2011 |
Volume: | Vol.33 |
Number: | No.5 |
Number of Pages: | 16 |
Page Range: | pp. 661-676 |
Identification Number: | 10.1111/j.1467-9566.2010.01311.x |
Status: | Peer Reviewed |
Publication Status: | Published |
Access rights to Published version: | Restricted or Subscription Access |
URI: | http://wrap.warwick.ac.uk/id/eprint/45188 |
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NEVER miss Wishes or the Magic, the Memories and You! They are spectacular. Even for the grumpiest teens (I am a teen who loves Disney but my teen brother really dislikes it)
I love wishes too!!!! We didn't watch the memories during our trip. We kinda saw it going into the park on the boat thingy.
Oh a big tip is this: If given the chance . . . GO TO THE PARKS AT NIGHT!!! No one is there!!! Since all the little kiddies have early bedtimes NO ONE IS IN THE PARKS it's a ghost town for goodness sake!!!! It's the best decision of your trip.
Really?! Sounds great! We were up till 2am in august and there were barely any queues (except for Space Mountain which was 30 minutes). When did you go? You should see the Magic the Memories and You next time you go! It's great! And seeing it from inside the park is just so... Magical
We went from August 30-September 8 and everywhere was DEAD. It was great. Not just at night either. We were just hopping on rides like crazzzy. Except for the super popular rides like Space Mountain, Toy Story Mania, Soarin', every ride really was only 5-10 minutes. It was great!
go at night. It is best at Magic Kingdom because if there is no one in line you may be allowed to ride again without getting out and going through the entire line again. I rode splash mountain at least 5 times in a row because no one was in line.


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Event Name
- OR - Select an option belowJeff Sinelli, founder of Genghis Grill, is either ingenious or lazy by giving customers the choice to customize their own bowls of stir-fry. Whatever the case, he is clearly doing something right. The Mongolian-inspired fast-casual chain shows no sign of slowing its franchising expansion. People love playing with their food. Customers can either choose from one of the suggested Genghis Bowls, combos that comprise the menu, or they can get creative in the five-step ordering process. Choose a protein; season a protein; select veggies; choose a sauce; and then order a starch. Then cooks behind the counter go all hibachi on the stuff. An example of an available combo is the Firecracker Bowl. In it are scallops, calamari and shrimp seasoned with Dragon Salt that is mixed with its classic stir-fry mix, water chestnuts and green onions over steamed rice, the whole thing doused in Dragon sauce.


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The signs are posted at Little League, High School, College, Pro Fields about flying balls and bats. She should have been paying attention to the game.
They did the same thing when they voted on the pension reform for public employees. It is absolutely crazy. Would you make a major decision in your own household without knowing all the answers??????


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George the Salon
InStyle handpicked Michelle to be featured with the nation's top celebrity hairstylists on their expert hair panel for their annual Best Beauty Buys Awards. Michelle was then in charge of choosing the best products in hair with categories ranging from tools to styling, becoming one of the only stylists in Chicago chosen to be on this prestigious panel. Michelle picked InStyle's winners for Best Flat Iron and Best Shampoo & Conditioner for Color Treated Hair.
Prior, Michelle was Rosie O'Donnell's hairstylist when the The Rosie Show was in production.
About: As a hidden oasis on Hubbard in Chicago's River North neighborhood, George the salon is a luxurious and serene loft, home to 8 stations featuring the city's top stylists and colorists. Appearing on and completing makeovers for The Oprah Winfrey Show in addition to styling the series' celebrity guests, George the salon's top stylists continued their in demand star styling work with Harpo Productions when part of Rosie O'Donnell'


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Bayhealth is proud to be the first hospital in Delaware to introduce an online childbirth education class. This course is a great option for parents who want to learn all they can about what to expect when the new baby arrives, but aren't able to make it to a class at the hospital.
The online class is an interactive, web-based program that includes animated illustrations, activities, and videos. It can be viewed on a PC, Mac or mobile device. Participants will learn about childbirth, breastfeeding, and caring for a newborn—all key topics for new parents. The course is also a nice refresher for parents preparing for the birth of another child. "We believe if parents are prepared for the birth of their baby, they are more confident and have a very positive experience," said Wendy Lovette, MSN, RN, LCCE, Bayhealth clinical educator. One important part of the Bayhealth program focuses on communication. It helps parents understand how to ask questions and participate in the birth process along with doctors, nurses, midwives, and other care providers. The cost for this program is $70. Once users have registered and paid for the program, they are sent an access code and user's guide. Users will have 3 months to complete the program at their own pace, whenever it's most convenient. "Parents are much more comfortable using technology now," said Lovette. "This course is a way for us to reach our online moms with information that is reliable and safe. We also want to reach moms who are on bedrest or can't make it to the hospital." Parents-to-be can feel comfortable and confident, knowing they can complete childbirth education classes without having to leave home. When questions arise, Bayhealth educators are available as another layer of support. Bayhealth also provides education for parents after the baby is born. We continue to offer parent education classes and tours on-site in our hospitals, as well. To sign up for any of our childbirth classes, visit bayhealth.org/childbirth.


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Dinsmore Scores Two Goals to Lead Catholic to 2-0 Victory Over Field Hockey
FSU falls to 5-12 while Catholic improves to 11-6.
The Cardinals scored the first of their two goals at 27:10 in the opening half. CUA was awarded a penalty shot and Dinsmore hit the back of the net to give the visitors the 1-0 lead.
Junior goalkeeper Amanda Runion (Leonardtown, Md./Leonardtown) kept the Bobcats in the game in the first period stopping four shots and senior Jenni Brygider (Locust Grove, Va./Orange County) recorded a defensive save as the teams headed for the locker rooms with the Cards up 1-0.
FSU attempted its only shots of the game (two) in the second half but was unable to find the net and Dinsmore added an insurance goal in the 69th minute to seal the win for CUA.
At the end of the contest, Catholic led in shots (20-2) and penalty corners (9-4).
Runion had a fine effort in the loss, making 11 saves while Cardinal netminder Marian Cassilly needed just one save to earn her seventh win of the year.
The Bobcats are back in action, Saturday when they host Houghton at 11:00 am.
For further information on this release, contact:
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- The gorgeous Jane who shares my love of words, stationery, all things French and much more. This wonderful lady is truly my greatest gift since starting my blogging adventure, I could write a whole page about why you should visit but instead I suggest you pop on over and say "Hi".
- Naomi who is a source of great reassurance as I wend my way through the maze that is step-parenting by sharing her own tried & true tips gleaned from thoughtfully raising her own seven cherubs. Naomi has so many wonderful features on her blog but I love her current focus on happiness, you must stop by if you haven't already. Today's post is truly poignant reading.
- The amazing and inspirational Maxabella who serves up great conversation at her place whenever you visit and is hosting THE most amazing giveaway - click 'You Must Enter' on my sidebar...
- Jennie my indomitable, clever, and wholly creative friend who inspires me at every turn.
- Cate alias Mrs Busy, if you think your life is a whirlwind of activity, you'll find a soulmate here.
11 July 2011
Of Friends and Unexplained Absences...
29 comments:
Lovely to have you back uplifting and sharing thoughts from your heart Felicity but you also have to know we want you to take the time out for YOU that you need right now as you have had many happenings in your own world. We so appreciate that you have not forgotten us and we all love you dearly. Big hugs and love to you and thanks so much for the sweet mention. N x
ReplyDeleteYou are delightful Felicity, and you are a big part of the friendly and supportive culture of this blogland we all float around in. I agree with Carol - there's no better time to take a little reflective hibernation than winter. Sometimes the screen can be a drain on our energy, just another little pressure on top of all the others. Wishing you free-flowing energy and snag-less enthusiasm, and more of those blue skies. xx Sarah
ReplyDeleteDear Felicity
Recognising the time to rest and be easy on one's self is part of the healing. I nodded when Sarah wrote about the draining effect of the computer screen. It does nothing for good posture and deep breathing either.
We love and cherish this space. Felicity you bring so much joy.
xxxOh my pleasure Felicity, yahoo that you're back but you know you can take your breaks whenever you need them, we're all here ready when you are!! Loving your open, loving & honest posts, wishing your grandmother a grand farewell for an amazing life lived & all that she has left inside of you. Love Posie
ReplyDeleteHi Felicity,
Yes I totally agree that mental health issues need to be brought out in the open, good on you for being open enough to share your journey!
Just yesterday I was re reading a great passage from a book called 'The Feeling Good Handbook' by David D. Burns, MD. He mentioned that it's a common misconception we have that we should always be happy and feeling good, and that basically it is okay and totally normal to go through bouts of or bad days.
Take care, spend time with those that mean the most to you and hopefully you'll start to feel better soon!
xYou are so strong and such a graceful woman. I'm seriously in awe of you and the way you seem to deal with life's challenges. You're a role model and inspiration in so many ways. Thoughts are with you as you plough through time in your life and know that support is here, if it's what you feel you need. Lots of love xxxx
ReplyDeleteI didn't realsie your journey was so tough my friend - lovely to hear from you (made me smile outloud)
I think I'm right in saying all your blogging friends are fully supportive of you taking the time to get yourself back on track - and will all be here whenever you sign back in.
meanwhile - be good to yourself.
fee ♥
(you write SO beautifully)Hello dear friend. You put so much kindness out into the world, I hope during your rest ,it will come your way and lift your heart. I was watching a baby bunny outside my window this morning and took a photo to share with my husband. It is not very high quality like the one on your post today but I find it interesting you posted that photo. I always feel a connection to you.
ReplyDeleteHi Felicity, I don't get to visit much at the moment, but I have just read your last few posts and I am so sorry to hear that you are going through a tough time. I recently lost my beloved Aunty and like you with your Grandmother, am so grateful that I grew up with this wonderful, inspiring woman. We are truly better people for knowing these special ladies.
I hope you are finding the time to rest and recoup - I used to have anxiety issues - quite chronicly actually, and the 2 main things that helped me were accupuncture and meditation. I still have it weekly (accupuncture that is!) - I swear by it (better than a facial I think!!!). It just seems to ground and balance me. I applaud you for sharing about your anxiety, depression and chronic fatigue - I have no doubt that by sharing your journey, you will help many people feel less "alone". Hope you feel better soon and also love the picture of the gorgeous bunny. Take care dear girl.xxxFelicity, you are such a gorgeous soul. Take care of you and your health first and foremost. Don't worry about missed comms in the blogosphere. I have a whole heap of 'bold' inbox entries that remain unanswered for now and it's the way it has to be. People don't follow you because they expect replies, they follow you because yours is the place where they find something valuable or engaging to take away with them xo
ReplyDeleteMental Health and brain chemistry - it's a pain in the bottom. I agree, too much unnecessary stigma, which I refuse to take part in. Mental health or unhealth is a fine chemical balance- like any other health, and it doesn't take much to tip the scales for some people. Diet, lifestyle, stress, hereditory stuff, past chemical exposure, allergies, liver/kidney/thyroid/glandular function, all kinds of stuff can mess with it.
Take care of you, when your energy levels return, get some good beach walks in, and in the meantime, rug up and just sit on the beach...breathing fresh air is good.
Chronic fatigue is another bitch of an illness....diet can have a big impact on it too.
tried acupuncture??
hope you are feeling brighter slowly.I am so with you on acknowledging mental health issues. Another thing that can hit one like a ton of bricks is SAD - even in a lovely warm climate like mine - and, I'm sure, yours. I've not really been myself since Easter, but today there's a definite change in the quality of the air - a tiny little hint of spring. And suddenly everything's all right again! I hope your spring (whether literal or metaphorical) comes soon.
Thank you for stopping by and sharing your thoughts.
Each new comment is a gift - unexpected and lovely.
Although I'd love to reply to each and every one, this isn't always possible, but know that I read and appreciate them all.
Felicity x


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Results 1 to 7 of 7
#1 Elderly couple abandons their home after address is posted on Twitter
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03-28-2012, 10:29 AMlink
Star Member PoliticAverse (2,818 posts) Profile Journal Send DU Mail Ignore
Elderly couple abandons their home after address is posted on Twitter as that of George Zimmerman
Source: The Orlando Sentinel.
A school-cafeteria lunch lady and her husband have received hate mail, unwanted visits from reporters and fearful inquiries from neighbors all because their Sanford-area address is being disseminated on Twitter as belonging to Trayvon Martin shooter George Zimmerman, her son said late Tuesday.
The woman, 70, who has a heart condition, and her husband, 72, have temporarily moved to a hotel to avoid the spotlight and possible danger, said son Chip Humble of Longwood.
The woman has another son named William George Zimmerman who lived with her in 1995 and still lives in Central Florida. He is no relation to George Zimmerman, 28, who killed 17-year-old Trayvon Feb. 26, sparking national outrage and international interest.
Zimmerman traced the tweets which he said have been retweeted by actor-director Spike Lee to a man in California. Zimmerman has implored the man to stop and said he received this response, "Black power all day. No justice, no peace" and an obscenity.
Read more: http://articles.orlandosentinel.com/...dition-twitter
Star Member baldguy (27,343 posts) Profile Journal Send DU Mail Ignore
3. If Zimmerman really wanted to stop this shit he'd turn himself in & confess to murder.
View profile
But then, he just a coward who played at being a cop.Star Member leveymg (21,406 posts) Profile Journal Send DU Mail Ignore
9. This is what happens when there's a selective cover-up of the facts by the media, incl. the Orl Sent
The Sentinel has done a terrible job of covering the real facts in this case. Zimmerman, the son of a Judge, committed a violent felony assault on a police officer and two domestic violence charges but the state attorney dropped the charges. Why was this guy allowed to walk and obtain a gun and be given the opportunity to assault people again? What role did the improper influence on the prosecutor have on this? Why was Zimmerman allowed to walk again by the State's Attorney, after he killed someone? Those are the question that the corporate media should have unearthed many days ago, but haven't.
The cover-up is why amateurs have had to step in to dig out the facts, and some of them have gotten it wrong or passed on bad information, which is inevitable.loyalkydem (1,117 posts) Profile Journal Send DU Mail Ignore
22. Please do not add to this mess
This story is a ginned up attempt by the Daily Caller and Michelle Mulkin to muddy up the waters. I spent 20 minuets going over Spike's old tweets all the way back to the 16th and the ONLY address on his twitter feed is that asking Martin supporters to send the Chief of Police skittles. We're supposed to be democrats, We need to support Spike instead of attacking him. I just had to come back to defend him because it seems like all you want to do is condemn him.
03-28-2012, 11:48 AMloyalkydem (1,117 posts) Profile Journal Send DU Mail Ignore
22. Please do not add to this mess
This story is a ginned up attempt by the Daily Caller and Michelle Mulkin to muddy up the waters. I spent 20 minuets going over Spike's old tweets
03-28-2012, 03:42 PMStar Member baldguy (27,343 posts) Profile Journal Send DU Mail Ignore
3. If Zimmerman really wanted to stop this shit he'd turn himself in & confess to murder.
View profile
But then, he just a coward who played at being a cop.
"Black power all day. No justice, no peace"The Obama Administration: Deny. Deflect. Blame.
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03-28-2012, 04:55 PMIt's the Smoking Gun that says Lee sent out the address. They're usually pretty good.
The person who actually sent out the wrong address to begin with was Marcus Davonne Higgens:
...The original tweet was sent to Lee (and numerous other celebrities like Will Smith, 50 Cent, and LeBron James) last Friday afternoon by Marcus Davonne Higgins, a 33-year-old Los Angeles man who uses the online handle maccapone. Higgins included the direction, EVERYBODY REPOST THIS.
Higgins, pictured at right, first began disseminating the Sanford address to his Twitter followers last Wednesday, including the claim that Zimmerman Like the fat punk he is, he still lives at home with mommie & daddy. In a simultaneous post to his Facebook wall, Higgins told his 4000 friends, FEEL FREE TO REACH OUT & TOUCH HIM. He also claimed in another post that, REAL TALK MY PEOPLE OUT THERE IN FLORIDA JUST TOLD ME GEORGE ZIMMERMAN IS NOT AT HIS HOUSE THEY OUT THERE RIGHT NOW.
Higginss dissemination of Zimmermans purported Edgewater Circle address was not, however, limited to cyberspace. At a protest rally last Thursday in an L.A. park near his Crenshaw home, Higgins held a sign containing Zimmermans name, address, and phone number.
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03-28-2012, 05:16 PMThe OReilly Factor contacted Spike Lees production company 40 Acres and a Mule. Instead of issuing a statement or an apology, the executive office told Factor producer Jesse Watters that Spike Lee had no comment.
Read more: http://nation.foxnews.com/spike-lee/...#ixzz1qRbn4ptP
Your whole career has been about racism.
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text: No recent wiki edits to this page. After suspecting Al-Bara might be funding terrorist, Michael Thorton goes to a party, where Bara is suspected to attend. Once there, you have to scan all the guards and guest using a custom made sniper rifle, until Bara finally reveals himself. Then you must choose rather to kill him on let him live.*Spoiler*If you killed him, you'll realize you made a mistake and draw unwanted attention to yourself. If you let him live, you'll find out that Al-Bara is innocent and used as a patsy to lure you out in the open.


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$35.56$2489 / each


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Kohl's.com: TRU 1.5 qt. Slow Cooker Only $7.99 (Regularly $29.99)
This Hip2Save.com Deal was hand-posted on Thursday, December 27th, 2012 at 10:03 am.
As I mentioned previously, Kohls.com is offering up 20% off your order when you enter code NEWYEAR20 at checkout! This TRU Party Pot 1.5 qt. Slow Cooker is currently reduced to just $9.99 (reg. $29.99), so just $7.99 after the code. And, if you are a Kohl's charge card holder, you can also enter code SHIPGIFT4KC to score Free Shipping! Or, get free shipping on orders over $50.
* As a price comparison, this same item is selling for $24.95 on Amazon.com.
(Thanks, Clip & Follow!)
Save a buck in these similar categories:
- Online Bargains
- Kohl's Deals
Spread the word on a great deal:
21 Hip Readers Commented
Keely says:
How big is 1.5 qt? That seems tiny. I have a 5-6 qt and that is a normal to large sized one.
Kim says:
@ Keely, that isn't very big but good for hot dips for parties. A good deal for yourself or as a gift.
Keely says:
Thanks ladies, that is what I thought!
Rebecca Whitlock says:
Those are toothpicks in the little container next to it to give you some perspective on size.
Katie says:
Its not very big…
Kim says:
1.5 qt is dip size.
Melissa says:
1.5 quart is 6 cups. So, not very big, but it may be just right for some things.
Karla says:
This size is probably great for keeping dips or appetizers (like smokies) warm!
megan e. says:
1.5 qt = 6 cups
Katie says:
That is not a very good deal considering the size. At walmart they have actual Crock Pot brand 7qt crock pots under $20 I got one for my mom for Christmas. No coupons needed.
graciela says:
i get the one at homedepot for 9.99 and is 5 qt.
Jennifer says:
those codes only work for Kohls charge cards
Collin (Mrs. Hip) says:
Hi Jennifer,
The NEWYEAR20 code should work for everyone – not just cardholders. The free shipping code is only for cardholders.
Melissa says:
This would be a good size for dipping if you have one of those cake ball makers.
Nancy Anthony says:
That's what I was thinking – great for dipping truffles.
Nancy says:
I got 2 for $17.26 delivered to my door. Great deal for $10 grab bag/auction gifts.
Nancy says:
This would be great to take as a Hostess gift, filled with a dip for the party. Hmmmm…may have to order more!
Jamie says:
I bought 2, used the coupon codes and $10 kohls cash, that I was prob just going to buy socks with anyway since I don'r really need anything. My total was $8.48, and I'm giving them both away as house warming gifts :) Thanks H2S!
julie says:
Check out the hooded towels for kids only santa or snowman for only $7.50 before the discounts:)
Julie says:
I entered the ship code and it does not work on that item!
Vi says:
you need to be a kohl's card holder in order to get the freeship code to work


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Need to Solidworks/AutoCAD Expert designer
Closed - This job posting has been filled and work has been completed.
Job Description
I am looking for an CAD/Modeling designer who has great skills and experiences for mechanical components. I have a 3D models of mechanical compoments in SketchUp. I want to make sure it is technically and financially feasible.
This will be the first project and will be ongoing.
1. CAD drawing for production in SketchUp or hand sketch.(AutoCAD or AutoDesk Inventor)
2. 3D of the drawing (Solidworks)
3. Engineering ideal advise/suggestions on the structure/mechanics
4. Convert the extention to STL for 3D print
5. AutoCAD test
6. At least 4 years experience in engineering design.
7. Portfolio matching this project, you think.
Please contact me if you think you have the needed qualifications to deliver on these.
If you work well, then I will give you more projects in the future and bonus.
Please insert 'CAD/SOLIDWORKS' at the top of cover letter. If no, you will immediately decline.
Skills: drawing, engineering, autodesk-autocad


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Percutaneous neuromuscular electrical stimulation (P-NMES) for treating shoulder pain in chronic hemiplegia. Effects on shoulder pain and quality of life
Renzenbrink, Gerbert J. and IJzerman, Maarten J. (2004) Percutaneous neuromuscular electrical stimulation (P-NMES) for treating shoulder pain in chronic hemiplegia. Effects on shoulder pain and quality of life. Clinical Rehabilitation, 18 (4). pp. 359-365. ISSN 0269-2155
Restricted to UT campus only : Request a copy 1MB |
Abstract: | Objective: To evaluate the effect of percutaneous neuromuscular electrical stimulation (P-NMES) of the shoulder muscles on shoulder pain intensity and health-related quality of life in chronic hemiplegia.
Design: Prospective, open label design. Setting: The outpatient services of a large teaching rehabilitation hospital in the Netherlands. Subjects: Fifteen stroke survivors with chronic (> six months) hemiplegia and a therapy-resistant painful shoulder with subluxation. All patients suffered from clinically relevant shoulder pain, as assessed by a score of at least 4 out of 10 on a numerical rating scale. Shoulder subluxation was indicated by at least 1/2 fingerbreadth of glenohumeral separation on palpation. Intervention: Six hours of P-NMES per day for a total of six weeks. Main outcome measures: Shoulder pain (Brief Pain Inventory), shoulder subluxation (clinical and radiographic), shoulder pain-free external rotation (hand-held goniometer), motor impairment (Fugl-Meyer Motor test) and quality of life (SF-36) were assessed before treatment, after six weeks of intramuscular stimulation, at three months and six months follow-up. Results: A significant reduction in pain was found on the Brief Pain Inventory. Pain reduction was still present at six months follow-up. All domains, in particular bodily pain, of the SF-36 showed improvement in the short term. After six months of follow-up, bodily pain was still strongly and significantly reduced, whereas social functioning and role physical demonstrated a nonsignificant improvement of more than 10% compared with baseline. Conclusion: This pilot suggests that P-NMES potentially reduces shoulder pain in chronic hemiplegia. To establish the clinical value of P-NMES in treating hemiplegic shoulder pain a randomized controlled trial is needed |
Item Type: | Article |
Copyright: | © SAGE Publicationstnw |
Faculty: | Management and Governance (SMG) |
Research Group: | |
Link to this item: | http://purl.utwente.nl/publications/77120 |
Official URL: | http://dx.doi.org/10.1191/0269215504cr759oa |
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Main Content
Customizing this Reebok Premier jersey is the perfect way to support your favorite team! It's made of polyester two-way stretch pique fabric and has solid mesh inserts for ventilation. The front crest is embroidered just like the authentic jersey, and your personalized name and number in single-layer printed twill are heat-pressed onto the back and sleeves. Due to the customized nature of this product, this item cannot be returned or refunded. Once an order is submitted, changes cannot be made and the order cannot be cancelled. Damaged items will be exchanged for the same item.
- *CUSTOMIZATION: Personalized name on jersey will be decorated with all capital letters and no special characters (.,')
- 2-Way stretch mesh body
- Back-neck taping - no irritating stitch on the back neck
- NHL ® Shield patch sewn to bottom of front-collar fabric insert
- Reebok wordmark embroidered applique heat-sealed onto jersey
- Rounded drop tail hem
- Tackle twill shoulder patches sewn directly to the jersey (where applicable)
- Twill applique team logo heat-sealed on the front
- Twill name and number heat-sealed onto the back and sleeves
- Woven jock tag above left hem
Reviewed by 2 customers
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Comments about Reebok Toronto Maple Leafs Men's Premier Home Custom Jersey - Royal Blue:
I'm recently retired and a hockey fan since 1961 !!!
Dave Keon was my favorite player during the 60's !
it took me 54 years to finally get his jersey and I absolutely love it !
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- No
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Comments about Reebok Toronto Maple Leafs Men's Premier Home Custom Jersey - Royal Blue:
we ordered a custom jersey came as ordered and it was flawless would definitely do business with this company again
- Was this a gift?:
- Yes
Displaying reviews 1-2
Special event items are produced by manufacturers only after the outcome of a game
or event. These are advanced sale items and will ship immediately after they are
received in our warehouse.
Manufacturer direct items are shipped directly from the manufacturer. These items
are not available for international or expedited shipping.
Customized items can be personalized with options such as your name, your favorite
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- September 09, 2010
There may be no single person with more love and passion for BMX than Monster's infectious and always-entertaining man behind the microphone, Zack "Catfish" Yankush. With over 28 years riding, Catfish speaks the truth that only a rider would know at nearly BMX event across the world. From Barcelona to Tobago to Austin, Catfish is the guy that you may recognize from Fuel TV's Strangers In Danger making all the noise over the loud speaker at X Games and Monster's own The Street Series events. And, if you're looking for a laugh, follow him on Instagram (@catfishvsthug), as he tortures and confuses random people on the street.
#passingoutinelevators https://t.co/1C9vpSPpPL
Friends let real friends live in the garage
I get mad bc America is more concerned with Bruce Jenner's problems becoming a woman than real american women with real women problems.
Fun little bike ride with @catfishcatfish yesterday turned deadly. Tag someone that flips over the… https://t.co/rPw9XeiYY0
RT @MikeEscamilla: ITS Monday! Switch it up this week! Doing my best tateroskelley impression 15 years ago. #betheadventure https://t.co/Mo…
Who's in LAX RIGHT NOW AND WANTS FREE FOOD? #unitedistight
RT @desusnice: Eventually NYC will have no choice but to rename a bridge after Cam'ron
Love Aaron's work! RT @thecomeup: Aaron Zwall "Eyeballs" Gallery http://t.co/vz2OTWg0Yz