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Sub-replacement fertility
Sub-replacement fertility is a total fertility rate (TFR) that (if sustained) leads to each new generation being less populous than the older, previous one in a given area. In developed countries sub-replacement fertility is any rate below approximately 2.1 children born per woman, but the threshold can be as high as 3.4 in some developing countries because of higher mortality rates.[1] Taken globally, the total fertility rate at replacement was 2.33 children per woman in 2003.[1] This can be "translated" as 2 children per woman to replace the parents, plus a "third of a child" to make up for the higher probability of boys being born and early mortality prior to the end of their fertile life.[2]
Replacement level fertility in terms of the net reproduction rate (NRR) is exactly one, because the NRR takes both mortality rates and sex ratios at birth into account.
As of 2010, about 48% (3.3 billion people) of the world population lives in nations with sub-replacement fertility.[3] Nonetheless most of these countries still have growing populations due to immigration, population momentum and increase of the life expectancy. This includes most nations of Europe, Canada, Australia, Brazil, Russia, Iran, Tunisia, China, the United States and many others. The countries or areas that have the lowest fertility are Hong Kong, Macau, Singapore, Taiwan, Ukraine and Lithuania. Only a few countries have had, for the time being, sufficiently sustained sub-replacement fertility (sometimes combined with other population factors like higher emigration than immigration) to have population decline, such as Japan, Germany, Lithuania, and Ukraine.
- 1 Causes
- 2 Historical effects
- 3 Current effects
- 4 Forecasts
- 5 Cases of fertility rate increases in individual countries
- 6 See also
- 7 References
- 8 External links
There have been a number of explanations for the general decline in fertility rates in much of the world, and the true explanation is almost certainly a combination of different factors.
Higher education[edit]
The fact that more people are going to colleges and universities, and are working to obtain more post-graduate degrees there, along with the soaring costs of education, have contributed greatly to postponing marriage in many cases, and bearing children at all, or fewer numbers of children. And the fact that the number of women getting higher education has increased has contributed to fewer of them getting married younger, if at all. In the US, for example, females make up more than half of all college students, which is a reversal from a few decades back.[6]
Economic development[edit]
The growth of wealth and human development are related to sub-replacement fertility. High costs of living and job insecurity can make it difficult for young people to marry and start families.
The increase of urbanization around the world is considered by some a central cause. In recent times, residents of urban areas tend to have fewer children than people in rural areas.[7][8] The need for extra labour from children on farms does not apply to urban-dwellers. Cities tend to have higher property prices, making a large family more expensive, especially in those societies where each child is now expected to have their own bedroom, rather than sharing with siblings as was the case until recently. Rural areas also tend to be more conservative with less contraception and abortion than urban areas.
Changes in contraception are also an important cause, and one that has seen dramatic changes in the last few generations. Legalization, and widespread acceptance, of contraception in the developed world is a large factor in decreased fertility levels. However, for instance in a European context where its prevalence has always been very high in the modern era, the fertility rates do not seem to be influenced significantly by availability of contraception.[9]
Assisted reproductive technology[edit]
The availability of assisted reproductive technology (ART) may foster delay of childbearing because many couples are inclined to think that it will solve any fertility problems they might encounter in the future.[9] Its effect on total fertility rate is extremely small but government support for it is beneficial for families.[9]
Government policies[edit]
Some governments have launched programmes to reduce fertility rates and curb population growth. Notably, China implemented a one-child policy for 35 years.
It has been shown, both historically and in the present day, that societies engaged in a prolonged state of war experience a substantial lag in fertility rate. The most notable examples of this phenomenon are widely accredited to the First and Second World Wars. Modeled by these examples, "total war" subjects individuals to intense social upheavals and a heavy psychological impact that forcefully prioritizes survival and economic stability over the need to reproduce for the duration of the conflict. Events like these subsequently pave way for an active effort to repopulate, such as the "baby boom" after the Second World War.[10]
Tempo effect[edit]
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The conventionally reported measure of TFR, the period TFR (based on the level of fertility or number of births in a given year), is affected by a statistical effect called the tempo effect which makes it a misleading measure of overall (life cycle) fertility.
Specifically, if the age of childbearing increases – assuming that the total number of births over a life cycle remains unchanged – the measured TFR is lower (the births happen in a later year), but when the age of childbearing stops increasing the TFR increase, due to these births catching up. For illustration, if women in the past always had 1 child at the age of 20 (TFR of 1), and all women born in 1980 or later postponed having children until age 30 in the year 2000, there would be no births for 10 years (TFR of 0). After 10 years (assuming flat population structure, no deaths, etc.), in 2010, it would suddenly jump back up (TFR of 1), even though the life cycle TFR was always 1.
Thus, period TFR reflects not only life cycle TFR, but also timing effects, and these effects are conflated in a simple period TFR number. Life cycle TFR is unambiguous, and strict measure of life cycle fertility are not affected by this effect (e.g., counting the average children that have been born to all women who cease child-bearing in a given year via menopause, sterilization, death, etc.), but are lagging statistics because they require women to cease child-bearing before they are counted. Thus, adjusted measures of TFR – period TFR, adjusted for timing – are proposed instead to give a more accurate measure of life cycle fertility, without needing to wait until women have definitively ceased bearing children.
Thus, if age of childbearing is increasing and life cycle fertility is decreasing, period TFR will initially overstate the decline, and then may have a spurious increase even if life cycle fertility is actually still declining. For instance, this is computed to be the case in Spain in the period 1980–2002.[11]
John Bongaarts and Griffith Feeney have suggested that this tempo effect is driving the decline of measured fertility rate in the developed world.[12] Taking tempo changes into account, adjusted birth rates for a number of European countries are higher than the conventional TFR.[13] A particularly strong example is the Czech Republic in the period 1992–2002, which witnessed a steady rise in childbearing age. Hence, the period TFR dropped sharply, overstating the decline in life cycle fertility.[11]
Partnership instability[edit]
Also, a number of sociologists and demographers have pointed out that among those who co-habit, without marrying, are now usually likely to have fewer children than those who are married, due to the lack of commitment in the male/female relationship. This uncertainty induces a 'wait and see' approach in many cases, especially on the part of the female.[14] A study came to the result that individual decisions arising from the instability of modern partnerships are a major cause of European sub-replacement fertility.[9]
Frequency of sex[edit]
Another explanation for falling fertility could be a reduction in the frequency of sex. For example, according to a survey published by the Japanese Family Planning Association in March 2007, a record 39.7 per cent of Japanese citizens aged 16–49 had not had sex for more than a month.[15]
Historical effects[edit]
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The Greek historian Polybius largely blamed the decline of the Hellenistic world on low fertility rates,[16] writing his work The Histories that:
|"In our time all Greece was visited by a dearth of children and generally a decay of population, owing to which the cities were denuded of inhabitants, and a failure of productiveness resulted, though there were no long-continued wars or serious pestilences among us…. For this evil grew upon us rapidly, and without attracting attention, by our men becoming perverted to a passion for show and money and the pleasures of an idle life, and accordingly either not marrying at all, or, if they did marry, refusing to rear the children that were born, or at most one or two out of a great number, for the sake of leaving them well off or bringing them up in extravagant luxury."[17]
In a speech to Roman nobles, the Emperor Augustus commented on the low birthrates of the Roman elite:[18]
|"We liberate slaves chiefly for the purpose of making out of them as many citizens as possible. We give our allies a share in the government that our numbers may increase; yet you, Romans of the original stock, including Quintii, Valerii, Iulii, are eager that your families and names at once shall perish with you."[19]
Upon the establishment of the Roman Empire, Emperor Augustus would introduce legislation to increase the birthrates of the Roman nobility.[20]
Some believe that not only the Great Recession, but the Great Depression, may have been the result of a decline in birthrates overall. Clarence L. Barber, an economist at the University of Manitoba, pointed out how demand for housing in the US, for example, began to decline in 1926, due to a decline in 'household formation' (marriage), due, he believed, to the effects of World War I upon society. In early 1929, US housing demand declined precipitously. And, of course, the stock market crash followed in October of that same year.[21]
Even though the overall world population continues to increase, it is more at the 'back end' than the 'front end' that this is occurring. That is, more people are kept alive than in the past due to improved nutrition, more refrigeration and better sanitation worldwide, as well as health care advances, from vaccines to antibiotics, and many other advances in medications and in different improvements in health care. Certainly, in advanced nations, few groups would be considered to be "breeding like rabbits". The 'baby boom' (1946–1964) in the US, was likely, if Barber's contentions are correct, more of a return to birthrates closer to historical norms, like those of the first decade of the 20th century (but the 'baby boom' of 1946–1964 were still lower than the 1900–1910 period), with birth dearths both before and since making the so-called "baby boom" appear so big.
Current effects[edit]
Population aging may pose an economic challenge to governments as the number of retired citizens drawing public pensions rises in relation to the number of workers. This has been raised as a political issue in France, Germany, and the United States where many people have advocated policy changes to encourage higher birth and immigration rates.
Analysing data for 40 countries, Lee et al. show that fertility well above replacement and population growth would typically be most beneficial for government budgets. However, fertility near replacement and population stability would be most beneficial for standards of living when the analysis includes the effects of age structure on families as well as governments. And fertility moderately below replacement and population decline would maximize standards of living when the cost of providing capital for a growing labour force is taken into account.[22]
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Sub-replacement fertility does not immediately translate into a population decline because of population momentum: recently high fertility rates produce a disproportionately young population, and younger populations have higher birth rates. This is why some nations with sub-replacement fertility still have a growing population, because a relatively large fraction of their population are still of child-bearing age. But if the fertility trend is sustained (and not compensated by immigration), it results in population ageing and population decline. This is already happening and impacts first most of the countries of Europe and East Asia.
Current estimates expect the world's total fertility rate to fall below replacement levels by 2050,[23] although population momentum will continue to increase global population for several generations beyond that. The development of the world population is linked with concerns of overpopulation, sustainability and exceeding Earth's carrying capacity.
Some governments, fearful of a future pensions crisis, have developed natalist policies to attempt to encourage more women to have children. Measures include increasing tax allowances for working parents, improving child-care provision, reducing working hours/weekend working in female-dominated professions such as healthcare and a stricter enforcement of anti-discrimination measures to prevent professional women's promotion prospects being hindered when they take time off work to care for children. Over recent years, the fertility rate has increased to around 2.0 in France and 1.9 in Britain and some other northern European countries, but the role of population policies in these trends is debated.[24]
European analysts hope, with the help of government incentives and large-scale change towards family-friendly policies, to stall the population decline and reverse it by around 2030, expecting that most of Europe will have a slight natural increase by then. C. D. Howe Institute, for example, tries to demonstrate that immigration can not be used to effectively counter population ageing.[25]
Cases of fertility rate increases in individual countries[edit]
United States[edit]
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While much of the world has experienced declining fertility rates over the last twenty years, the total fertility rate in the United States has remained relatively stable in comparison.[26] This is largely due to the high fertility rate among communities such as Hispanics, but it is also because the fertility rate among non-Hispanic whites in the US, after falling to about 1.6 in the 1970s and early 1980s, had increased and is now around 1.89 rather than lower to the 1.6 level common in Europe. It can also be explained by a substantial immigration.
New England has a rate similar to most Western European countries, while the South, Midwest, and border states have fertility rates considerably higher than replacement. States where The Church of Jesus Christ of Latter-day Saints has a strong presence, most notably Utah, also have higher-than-replacement fertility rates, especially among the LDS population. Heaton and Goodman (1985) found that LDS women average about one child more than women in other religious groups.[27]
Other developed countries[edit]
Some other developed countries are experiencing an increase in their birth rate, including France, which recorded a TFR of over 2.00 in 2008;[28] the United Kingdom where TFR increased from 1.64 in 2000 to 1.98 in 2010;[29][30] Australia, where the birth rate rose from 1.73 in 2001[31] to 1.93 in 2007[32] and New Zealand, where the TFR was 2.2 in 2008.[33]
Israel is the only developed country that has never had sub-replacement fertility; a declining Arab and Bedouin fertility rate is countered by religious Jewish groups (mostly Haredim) with higher than average fertility rates. In addition, the (mostly non-religious)[citation needed] aliyah Jews from the former USSR shifted from a 1 child per woman fertility rate to an average fertility rate close to 2.2 children per woman. As of 2008, Israel's Jewish fertility rate is the highest among the industrial nations.[34]
See also[edit]
- Demography
- Fertility and intelligence
- List of countries and territories by fertility rate
- Natalistic politics, countering sub-replacement fertility
- Population decline
- Population stabilization
- Economic dynamics
- ^ a b Espenshade TJ, Guzman JC, Westoff CF (2003). "The surprising global variation in replacement fertility". Population Research and Policy Review 22 (5/6): 575. doi:10.1023/B:POPU.0000020882.29684.8e., Introduction and Table 1, p. 580
- ^ For example in the United Kingdom in 2001 304,635 boys were born as opposed to 289,999 girls, and some of these girls will not survive to the end of their child bearing years. In future, therefore, the girls born in this year would have to have more than two children each to replace the total population. For a full explanation see 'Replacement Fertility, What has it been and What does it mean?' (PDF)
- ^ "Figure 8: Population by Total Fertility (millions)" in World Population Prospects, the 2010 Revision. United Nations, Department of Economic and Social Affairs, Population Division (2011)
- ^ "Field Listing: Total Fertility Rate". The World Factbook. Retrieved 2016-04-24.
- ^ "Country Comparison: GDP - Per Capita (PPP)". The World Factbook. Retrieved 2016-04-24.
- ^ Mother's Educational Level Influences Birth Rate
- ^ "[Analysis of factors related to the recent decline in birth rate in Japan]". Nihon Koshu Eisei Zasshi 42 (2): 121–8. February 1995. PMID 7718907.
- ^ "Factors affecting the most recent fertility rates in urban-rural Bangladesh". Soc Sci Med 44 (3): 279–89. February 1997. doi:10.1016/s0277-9536(96)00076-7. PMID 9004364.
- ^ a b c d Eshre Capri Workshop, G. (2010). "Europe the continent with the lowest fertility". Human Reproduction Update 16 (6): 590–602. doi:10.1093/humupd/dmq023. PMID 20603286.
- ^ Caldwell, John C. (2007-09-21). Demographic Transition Theory. Springer Science & Business Media. ISBN 9781402044984.
- ^ a b Tempo Effect and Adjusted TFR
- ^ Bongaarts, J. (2002). "The End of the Fertility Transition in the Developed World". Population and Development Review 28 (3): 419. doi:10.1111/j.1728-4457.2002.00419.x.
- ^ European Demographic Data Sheet 2008
- ^ Fertility Differences between Married and Cohabiting Couples: A Switching Regression Analysis
- ^ [1]
- ^ "Polybius, Histories, book 37, Depopulation of Greece". www.perseus.tufts.edu. Retrieved 2016-02-18.
- ^ Polybius (2012). The Histories of Polybius: Translated from the Text of F. Hultsch. Cambridge University Press. p. 510. ISBN 1-1080-5079-4. Retrieved November 2, 2013.
- ^ "Projekt Gutenberg". Project Gutenberg. Retrieved 2016-02-18.
- ^ Dio, Cassius (2004). Dio's Rome 4. Kessinger Publishing. p. 86. ISBN 1-4191-1611-8. Retrieved 3 November 2013.
- ^ "Ancient Rome: Administration of Rome and Italy". Encyclopædia Britannica Online. Encyclopædia Britannica, Inc. Retrieved January 17, 2015.
- ^ [2]. qc-econ-bba.org. Real gross housing expenditures on new units can be separated into two multiplicative components; housing starts and the real average investment per unit. 25 After estimating the determinants of each, Bolch, Fels, and McMahon examined the building hypothesis by simulating what would have been the case in each situation if a "normal" situation had occurred. 26 The result was overbuilding in the number of housing units from 1922 through 1929. They also found "overinvestment" per individual housing unit from 1921 to 1928 and conclude that excessive housing starts relative to family formation led to the sharp decline in housing construction at the end of the twenties. In their view the demographic changes in the twenties were the proximate causes of this. In a 1978 study Clarence Barber was even more emphatic on the importance of demographic changes, suggesting that these were the ultimate explanation of the Great Depression. 27 Basing his explanation on a Harrod-Domar growth model, Barber argues that the rapid decline in the population's growth rate disturbed that equilibrium, and this rapid fall in the natural growth rate initiated the depression
- ^ Lee, Ronald; Mason, Andrew; members of the NTA Network (10 October 2014). "Is Low Fertility Really a Problem? Population Aging, Dependency, and Consumption". Science 346 (6206): 229–234. doi:10.1126/science.1250542.
- ^ "population trends (dynamically generated)". EarthTrends. World Resources Institute. Retrieved 13 June 2010.
- ^ Suddenly, the old world looks younger. The Economist, 14 June 2007.
- ^ Guillemette, Yvan and Robson, William B.P. (September 2006) No Elixir of Youth: Immigration Cannot Keep Canada Young. C.D. Howe Institute
- ^ Total Fertility Rate of the United States, History plus Forecast, International Futures, retrieved 26 April 2012
- ^ Goodman, Kristen L.; Heaton, Tim B. (1985). "Religion and Family Formation". Review of Religious Research 26 (4): 343–359. JSTOR 3511049.
- ^ Tabc3 Tableau complémentaire 3 : Taux de fécondité par groupe d'âges. insee.fr
- ^ Doughty, Steve (17 September 2012) British birth rate has soared to one of highest in Europe thanks to increase in migrants. Daily Mail
- ^ "Births and Deaths in England and Wales, 2011 (Provisional)". Office for National Statistics. Retrieved 13 January 2013.
- ^ "FEATURE ARTICLE 2: RECENT INCREASES IN AUSTRALIA'S FERTILITY, Australian Bureau of Statistics".
- ^ "3301.0 – Births, Australia, 2007, Australian Bureau of Statistics". Australian Bureau of Statistics.
- ^ Collins, Simon (19 February 2009). "Baby boom goes against mothers' advice". The New Zealand Herald. Retrieved 14 November 2011.
- ^ "Demographic Optimism, Not Pessimism -Yoram Ettinger". January 2013.


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Royal Victoria Hotel Snowdonia3
Llanberis, Gwynedd, LL55 4TY
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All bedrooms are non-smoking, and offer a hospitality tray, colour television with satellite channels and direct dial telephones. When you book, why not request a bedroom with a stunning view of Snowdonia. Please note: "The hotel is a popular wedding and event venue, particularly at weekends, due to the nature of these events hotel guests may experience some additional noise". Royal Victoria Hotel Snowdonia is part of the Snowdonia Giving scheme which asks visitors for a voluntary contribution towards conservation of the National Park and other local projects. A small donation of £2. 00 will be added to your bill on arrival, please let our Reception team know on check in if you would like it to be removed.
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OBGYN, Pregnancy and Childbirth Care
Immunization Schedule for Infants and Young Children
According to the Centers for Disease Control and Prevention, vaccine-preventable childhood diseases in the United States are near an all-time low. But, some viruses and bacteria are still active and can cause serious illness.
It is important that all children, especially infants and young children, receive recommended immunizations on time. In other countries, many vaccine-preventable diseases are relatively common. Because of travel, these diseases could return to the US, resulting in increased, and unnecessary, illness, disability, and death among children.
Recommended immunization schedule for children up to age six.
- Birth: hepatitis B
- 1 month: hepatitis B (1-2 months)
- 2 months: hepatitis B (1-2 months); rotavirus (RV); diphtheria, tetanus toxoids and acccelular pertussis (DTaP); haemophilus influenzae type B conjugate (HiB); pneumococcal (PCV), inactivated poliovirus (IPV)
- 4 months: RV, DTaP, HiB, PCV, IPV
- 6 months: HepB (6-18 months), RV, DTaP, HiB, PCV, IPV (6-18 months), influenza (yearly, starting at 6 months)
- 12 months: HepB (6-18 months); HiB (12-15 months); PCV (12-15 months); IPV (6-18 months); influenza (yearly); measles, mumps and rubella (MMR; 12-15 months); varicella (12-15 months), HepA (2 doses; 12-23 months)
- 15 months: HepB (6-18 months), DTaP (15-18 months), HiB (12-15 months), PCV (12-15 months), IPV (6-18 months), influenza (yearly), MMR (12-15 months), varicella (12-15 months), HepA (2 doses; 12-23 months)
- 18 months: HepB (6-18 months), DTaP (15-18 months), IPV (6-18 months), influenza (yearly), HepA (2 doses; 12-23 months)
- 19-23 months: influenza (yearly), HepA (2 doses; 12-23 months)
- 2-3 years: pneumococcal polysaccaride (PPSV; 2-6 years); HepA series (2-6 years), meningococcal (MCV; 2-6 years)
- 4-6 years: DTaP, PPSV (2-6 years), IPV, influenza (yearly), MMR, varicella, HepA series (2-6 years), MCV (2-6 years)
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Ignore the title of this gallery, I will give you a clue right now. These are all real photos.
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There's something weird about these photos…
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Some of these are just too good
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According to the internet and the people who posted these photos they are all 100% real. What do you think?
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Don't forget to vote at the end of this page to tell us if you believe these are all real photos or not.
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Personally, I didn't know about these animals, did you!? You can vote Real or Fake after page 2!
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Yeah, there are more animals you probably didn't know about…but now you do!


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Tourism Impact Research
IHS Global Insight has recently completed an update to its 2005 City Tourism Impact study for the city of Arlington, TX. The analysis focused on the 2008 through 2010 travel years and the highlights of those findings are below.
Key Findings:
In 2010, visitor spending in Arlington, TX totaled $593 million. This is 8.4% higher than the $547 million spent in the city in 2008. For comparison, total direct tourism output for all of the US declined by 6.4% during that same time. (2*)
If tourism spending within Arlington had followed the national trend, the 6.4% decline from 2008 would have resulted in over $81 million being taken out of the local economy.
Tourism spending supports 10,500 jobs within Arlington, making up 8.8% of all private employment. Tourism supported employment has grown by 9.5% since 2008.
Direct tourism employment in the US declined by 9.4% from 2008 to 2010. If tourism employment had followed the national trend, the 9.4% decline from 2008 would have resulted in a decline of over 1,800 jobs in 2010.
Total private employment in Arlington has declined by 2.1% from 2008 to 2010, losing over 2,500 jobs during this time. Tourism has increased employment by over 900 jobs since 2008.
The economic impact of these expenditures totaled $444 million in 2010. This includes $260 million in direct economic impact, $89 million in indirect economic impact (supplier effect), and $95 million in induced economic impact (income effect). The total economic impact increased 7.8% from 2008.
Traveler spending supported nearly 10,500 jobs in Arlington in 2010. Of these, 7,800 were directly supported by tourism spending. Tourism generated an additional 1,400 indirect jobs and 1,250 induced jobs.
Traveler spending generated $123 million dollars in Federal, State and Local taxes in 2010, including over $57 million in state and local tax revenue. State and local taxing authorities would need to generate an additional $413 annually from each Arlington household to maintain existing level of services.
(2*) US tourism statistics provided by US Bureau of Economic Analysis


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I am a Republican… I watch CNN, FOX, and MSNBC. It's the only way I feel I can get a fair and accurate perspective on the news, particularly in relation to politics. I have come to the conclusion over the last few weeks that CNN, much like MSNBC, is a bias network always in favor and to the benefit of the Democrats or Hillary Clinton. There are many examples. Take a text notification sent by CNN today: "FBI director does not believe Hillary Clinton lied to the FBI." This implies Hillary Clinton did not lie to the public or to the American people, and gives the impression in general that Hillary Clinton does not lie, when in fact Hillary Clinton lies to the general public and to the American people perhaps daily. The way CNN writes its headlines, including on the banner which appears at the bottom of the screen on the TV, is always favorable towards the Democrats or Hillary Clinton. Weeks ago, I watched as CNN played and replayed a video of Donald Trump speaking and some sort of bug flying into his hair. CNN continued to show that video throughout the morning. However, if this were Hillary Clinton, CNN would not have repeated or shown the video in the first place. There are many examples which demonstrate CNN's willingness and attempt to destroy Donald Trump while promoting Hillary Clinton. For this reason CNN is a bias organization, especially when it comes to politics.
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First of all this app used to run smooth like butter I have an iPhone 6 and I'm sure it has more than enough power to run a news app. Why then does it lag around for 5 minutes before I can even scroll down? Super poor optimization I assume. Then you can finally get to read the America hating leftist media articles that just absolutely destroy what the NEWS is about. No one cares about your opinion. No one cares what you think is virtuous. That's the best part of American media is the reader is allowed to make their own decision on what they think is right and wrong. Not get what you think is "best for the people" shoved down their throat. Shove it up your ***. I want to know the truth and you can't give it to me....ever. I am constantly looking to other media (except social) to guide me through the gunk to find out what is actually going on. Fox and other news sources are bad too but good god CNN takes the cake. Every piece written should have a big fat opinion written directly below the title because never do you get the truth. So if you are looking for a good news app and aren't a hardcore lefty this one probably isn't for you.
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Intraoperative ultrasonography (IOUS) is the gold standard for tumor staging and operative decision making in liver surgery. Providing dynamic information on tumor–vessel relationships and distribution of intrahepatic veins, IOUS is also an important support for guiding the resection. Few authors report an extensive use of IOUS-guidance as a safe and effective approach. The aim of this study is to investigate the short-term results of an early experience of ultrasound (US) guided liver resection.
From December 2005 to December 2007 an extensive use of IOUS-guided resection was applied in 11 consecutive patients (8 males and 3 females; median age 74 years). Perioperative data were collected prospectively to assess the influence of this approach on mortality, morbidity and early recurrence.
Four patients had hepatocellular carcinoma, 4 liver metastases, 1 peripheral cholangiocarcinoma, 1 hemangioma and 1 inflammatory pseudotumor. A median of 1 (range: 1–4) nodule per patient was resected. Median lesion size was 44 mm. Liver procedures included: 3 wedge resections, 3 subsegmentectomies, 4 segmentectomies and 3 bisegmentectomies. Median blood loss was 235 ml. Median surgical margin in cancer patients was 5 mm (range: 1–12). An average of 1 unit of blood transfusion was administered in 5 patients. Median postoperative hospital stay was 9 days. There was no mortality. Major complications occurred in 1 patient and minor complications in 5 patients. During a median follow-up of 14 months no recurrences were observed.
In this study, use of IOUS-guided liver resection performed in a district general hospital proved to be a safe and effective approach in terms of short-term outcome.
Nell'ambito della chirurgia epatica l'ecografia intraoperatoria svolge un ruolo ben codificato nella stadiazione e nella pianificazione della strategia operatoria. L'importanza dell'ampio utilizzo di questa metodica anche durante la resezione è stata riportata solo da alcuni autori. Questo studio ha come scopo di verificare quali siano i risultati a breve termine di un ampio utilizzo dell'ecografia durante la resezione stessa in un ospedale periferico.
Nell'arco di 24 mesi 11 pazienti consecutivi sono stati sottoposti a resezione epatica ecoguidata. I dati perioperatori sono stati raccolti in modo prospettico per valutare l'influenza di questa metodica sulla mortalità, morbidità e recidive locali.
Otto pazienti erano maschi. Età mediana 74 anni. Quattro HCC, 4 metastasi, 1 colangiocarcinoma periferico, 1 emangioma, 1 pseudotumore infiammatorio. Sono state eseguite 3 resezioni a cuneo, 3 subsegmentectomie, 4 segmentectomie e 3 bisegmentectomie. La perdita ematica mediana è stata 235 ml. In caso di tumore il margine di exeresi mediano è stato 5 mm (range 1–12 mm). Cinque pazienti sono stati trasfusi con emazie concentrate con una mediana di 1 Unità. La degenza mediana è stata 9 giorni, la mortalità zero. Complicanze maggiori e minori sono insorte rispettivamente in 1 e 5 pazienti. Durante un periodo di osservazione mediano di 14 mesi non si sono verificate recidive.
Nell'esperienza iniziale di un ospedale periferico, l'utilizzo della guida ecografica durante la resezione epatica si è rivelata sicura ed efficace a breve termine.
Intraoperative ultrasonography (IOUS) is the gold standard for staging in primary and secondary metastatic liver tumors [1]. In hepatocellular carcinoma (HCC) IOUS allows detection of new lesions in 7% of cases at the primary hepatectomy and in 7.3% at the secondary hepatectomy [2]. In an analysis related to patients with colorectal liver metastases (CLM), sensitivity of computed tomography (CT) was 69.2%, of helical CT 82.5%, of magnetic resonance imaging (MRI) 84.9%, and of IOUS 95.2% [3]. CT and MRI cannot substitute the real time information provided by IOUS. Due to this specific feature of ultrasonography, IOUS is also essential for guiding the resection as it allows modification of the trajectory whenever needed [4,5]. For these reasons IOUS with color Doppler has been used to guide hepatic surgery in liver cancer since the late 1970s [6]. The feasibility and effectiveness of this surgical approach have reduced resection-related mortality to values below 4% [7,8] and in some cases even to zero [9,10] as shown by numerous cases reported by high-volume liver centers over the last 5 years.
A prospective study on consecutive patients who underwent hepatic resections was undertaken in order to determine whether the systematic use of IOUS-guided resection in a district general hospital is a safe and effective approach in terms of short-term outcome. Primary endpoints were postoperative mortality and morbidity. Secondary endpoint was early cut-end recurrence.
All patients with potentially resectable liver lesions referred to our institution from December 2005 to December 2007 were considered for inclusion in this study. Forty-six were enrolled but 32 were excluded for various reasons: multiple bilobar CLM (n = 13), HCC with ascites and/or total bilirubin level higher than 2.0 mg/dl (n = 15) and patients' refusal (n = 4) and 3 patients scheduled for liver resection were referred to high-volume liver centers due to the complexity of the planned surgical strategy.
Eleven consecutive patients thus underwent curative liver resection at our institution and were the subjects of the present study. There were 8 males and 3 females; median age was 74 years (62–82 years). American Society of Anesthesiologist classification was 3 (1–3) and Body Mass Index was 23.8 kg/m2 (19.8–33.8). Ethical approval was granted by the Medical Research Ethics Committee of our hospital, and informed consent was obtained from all patients.
Perioperative data were collected and analyzed prospectively. Regardless of whether the patients were presumed to have underlying liver disease, indications for operation were established on the basis of liver function reserve, tumor stage and volume of the remnant liver [11]. In patients with bilirubin concentration below 2.0 mg/dl the surgical strategy was planned according to the flowchart published by Makuuchi and Kokudo [12]. Indocyanine green retention rate at 15 min (ICGR15) was not evaluated, and in patients with total bilirubin below 1.0 mg/dl, portal vein embolization was indicated if remnant liver volume determined by CT was expected to be less than 50% of the total liver volume.
Fresh frozen plasma (FFP) was administered at a rate exceeding blood loss by 20% and to maintain the serum total protein level at 5.0 g/dl. Packed red blood cells were administered if intraoperative blood loss exceeded 1000 ml or the hemoglobin level fell to 10 mg/dl during surgery or to 8 mg/dl on postoperative days (PODs). The association of International Normalized Ratio (INR) above 1.6 and serum total bilirubin level above 3 mg/dl on POD5 was considered as an indication for multiple bacteriologic examinations and for chest and abdominal CT to rule out pneumonia, abscess or portal vein thrombosis [13]. Total bilirubin in drain discharge was sampled on POD3, POD5, and POD7. Drains were removed on POD7 or when the total bilirubin level in the discharge fluid was lower than the one recorded on the previous POD. Chest and abdominal US examination were performed in the presence of clinical indications and were also routinely performed on POD2, POD4 and POD6.
The terminology for liver anatomy and resection is based on the Couinaud classification [14]. Resection of at least 3 adjacent segments was considered a major resection. Complications were graded on a 1–5-scale according to a grading system published by Dindo et al. [15]. Grade I is any deviation from the normal postoperative course treated with drugs such as antiemetics, antipyretics, analgesics, diuretics and electrolytes. This grade also includes wound infections opened at the bedside. Grade II complications are those requiring blood transfusions or pharmacological treatment with drugs other than those allowed for Grade I. Grade III complications require invasive procedures. Grade IV is life-threatening complications requiring intensive care unit management. Grade V complications result in death. Grades I and II are grouped as "minor" and Grades III–V are considered as "major" complications. Bile leakage was defined as continuous drainage fluid with a bilirubin concentration greater than 5 mg/dl for more than 7 days or when intra-abdominal collection bilirubin level was greater than 5.0 mg/dl after puncture [10]. Hepatic failure was defined as a serum bilirubin concentration greater than 5.0 mg/dl, a prothrombin time rate below 50% for 3 or more consecutive days, or both [10]. Postoperative mortality was defined as death within 1 month of operation or during the hospital stay. In cancer patients, abdominal US, blood samples for liver function tests and serum tumor markers were performed every 3 months, and contrast-enhanced CT imaging every 6 months. Cut-end recurrence was defined as recurrence in the bed of resection. Operation-related complications identified during hospitalization and follow-up were reported.
J-shaped incision was performed for lesions located in right segments and/or in segment 4. For lesions in segment 2 and/or 3, an inverted T-shaped incision was performed. After laparotomy, the liver was mobilized by dividing the round and falciform ligaments. In cases of tumors located in the right lobe, the right hemiliver was moved up to access the right edge of the retrohepatic inferior vena cava (IVC), and IOUS was performed to locate the right hepatic vein (RHV) caval confluence following the trajectory of a diaphragmatic vein [16]. When the tumors were not close to the RHV caval confluence, vascular control of RHV was possible by US-guided blunt finger clamping with no need for taping [17]. The entire liver was studied by following the portal and hepatic vein branches using an Esaote MyLab25 (Esaote, Genoa, Italy) equipped with a high-frequency intraoperative echoprobe (7.5–10 MHz). After detection of known and possible new lesions, surgical strategy was established on the basis of the type of lesion and its relationship with the intrahepatic vascular structures (Fig. 1) as reported by Torzilli [9]. Portal vein branches and hepatic veins were used as landmarks to define the resection line. In cases of tumors located in either segment 2 or segment 3, the portal branch feeding the subsegmental area, including the lesion, was identified and compressed using the left hand fingertips under IOUS-guidance [18]. The elective compression of the vein discolored the liver portion fed by the occluded portal branch and the area was then marked on the liver surface.
Parenchyma dissection trajectory was then planned, and the tip of the electrocautery device was positioned between the IOUS probe and the liver surface. Where the shadow on the IOUS image below the electrocautery device confirmed that the planned trajectory plane was correct, the liver surface was marked (Fig. 2). Liver resection was performed under warm intermittent ischemia clamping for 15 min alternated with 5 min of reperfusion [19]. Hydrocortisone sodium phosphate (100 mg) was injected intravenously before starting Pringle maneuver [20]. Parenchyma dissection was performed using the crushing clamping technique and a bipolar electrocautery. During resection the operating surgeon checked the dissection trajectory by IOUS, holding the probe with the right hand while the left hand fingertips, positioned behind the liver, were used as landmarks. The dissection plane appears on the IOUS image as an echoic line owing to the entrapment of air bubbles and clots between the 2 parenchymal portions defined by the section plane [21] (Fig. 3).
The cut surface of the liver was secured by 2/3–0 absorbable sutures. Fibrin glue (Tissucol; Baxter) was applied to decrease bile leakage [22]. A careful examination was performed for about 45 min after completed resection. A closed suction drain was left close to each cut surface of the liver. All the specimens were examined using the "water-bath" technique to ensure that target nodules were completely resected [23] (Fig. 4). Liver transaction area was calculated using a white paper spread out over the surface, cut out and measured with tape measure. Values of data collected are expressed as median (range).
Four patients had HCC and histological examination proved that all 4 were affected by cirrhosis; 3 patients had CLM; 2 had synchronous metastases, treated by subsegmentectomy synchronous with colectomy (2 right hemicolectomy and 1 anterior resection), and 1 had a metachronous lesion after a left hemicolectomy performed 36 months earlier. One patient had a metachronous breast liver metastasis. One patient with a history of breast cancer had an inflammatory pseudotumor with preoperative histological examination indicating metastasis. Another patient had a peripheral colangiocarcinoma and 1 had a 13-cm symptomatic hemangioma. One (1–4) lesion per patient was resected. Size was 44 mm (4–130). Five were located in right posterior segments, 3 in right anterior segments, 1 in segment four and 5 in left lateral segments; 21% (3 of 14) of overall nodules were discovered by IOUS. In all cases where IOUS discovered new lesions, preoperative surgical strategy was modified. None of the patients underwent preoperative portal vein embolization (PVE). Intraoperative data are indicated in Table 1. Bilirubin levels in drain discharge on POD3 was 1.8 (1.3–2.8), on POD5: 2.9 (2.0–3.4) and on POD7: 2.2 (2.1–3.2). Drains were removed on POD7 in all cases. No bile leakage was identified. There was no hospital mortality. Morbidity rate was 45% (5 of 11 patients). No re-operation was required. Three major complications occurred in 1 patient (9%) and 6 minor complications in 5 (45%) patients. Hepatic failure (Grade IV), pleural effusion (Grade IIIa), ascites (Grade IIIa) and central venous catheter infection (Grade II) occurred in a patient with an HCC 4 cm in diameter located 4 mm above the origin of P8. In one patient, intraoperative blood loss was 1800 ml due to severe cirrhosis and a difficult dissection of the origin of P8, and 3 units of packed red blood cells were transfused. Blood transfusions (Grade II) were also administered in 4 patients. Median number of units transfused was 1 (1–3). All packed red blood cells were administered intraoperatively but only in the patient with HCC previously described, transfusion criteria were applied. Postoperative hospital stay was 9 days (7–21). During a median follow-up of 14 months (2–28), no recurrence was observed.
IOUS is an essential support in the various intraoperative stages of liver surgery [1]. In our study, 21% of hepatic lesions were identified intraoperatively and in all such cases preoperative surgical strategy was modified. US-guidance was also useful to outline the resection area in case of lesions located in the left lateral sector. Particularly in a patient who had an HCC nodule with undefined margins in contact with the portal branch for segment 3 (P3), US-guided compression of P3 [18] made it possible to visualize the real extension of the afferent segment. IOUS was useful for right lobe mobilization in the 4 cases of lesions located in the right posterior sector. In all 4 cases, color Doppler US control of correct RHV compression by finger pressure [17] eliminated the need for a large resection, while allowing for correct control of the back-flow during resection (Fig. 5).
Because of the extreme accuracy ensured by this method in defining the anatomical relationship between the lesion and the intra-parenchymal liver structures, IOUS is an essential support also during the resection. US control during the execution of the resection cut permits confirmation or modification of the trajectory in real time, thus making it possible to resort to resection strategies which would otherwise be too difficult or too risky [4,21]. Some authors report an elevated number of cases in which the advanced application of US-guided liver resection decisively contributes to achieving zero postoperative mortality and a major complications rate below 9% [9,10]. In our study mortality rate was zero despite the limited number of patients, and major complications occurred in one patient only. Although numerous studies report a transfusion rate of packed red blood cells below 10% [9,10] or 30% [7,24], in our study 45% of the patients were transfused with packed red blood cells. However, all transfusions were carried out intraoperatively, but study criteria were followed only in one case. No bile fistulas or intra-abdominal collections occurred. We believe this result mainly depends on the accurate intraoperative assessment of the resection cut and on the management of abdominal drains, rather than on the use of IOUS.
The accuracy ensured by US-guidance during resection also permits application of resection strategies resulting in better preservation of liver tissue not involved by the lesion. US-guided resection therefore enhances safe and effective segmental [25,26] or subsegmental [18] resection, consequently reducing the number of major liver resections while keeping oncologic radicality unchanged [9,21]. Such a conservative and yet radical policy is vital in case of reduced liver functionality or in the presence of multiple lesions. Moreover, both in the case of primary and secondary liver tumors, maximizing the preservation of liver tissue not directly involved by the lesion increases the possibility of subsequent resections [2,27].
In our study the use of IOUS did not prevent the execution of major liver resections (>3 segments), because the cases where it would have prevented it were referred to high-volume liver centers. Nonetheless, US support was essential to reduce resection size in 2 cirrhotic patients affected by HCC located less than 8 mm from the origin of P8. The accurate US identification of P8 and P5 permitted a segmentectomy, using the hooking technique [25], while preventing right anterior sectoriectomy.
When this conservative approach was applied in the 9 patients who had cancer, the resection margins showed a median 3 mm (1–6) value in patients affected by HCC and a median 6 mm (4–12) value in those who had cholangiocarcinoma or secondary lesions. During a 14-month follow-up (2–28) no patient showed any signs of disease recurrence.
This article highlights that the in-depth study of the US anatomy of the liver may represent an essential support for the surgeon in the performance of liver resection surgery, thus contributing to making this type of surgery – although in selected cases – a safe and effective type of surgery even in a district general hospital.
The authors have no conflict of interest to declare.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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Results 901 to 905 of 2318
Thread: Name sightings
August 7th, 2013 06:09 PM #901Mum to
Edwin August [3rd Aug 2013]
If I ever have another:
Samuel Charles Anderson Timothy Peter David Lucas Michael
Rosalie Marie Alice Lucy Violet Josephine Madeleine Lillian
Forever missing my fiance, Edwin
August 7th, 2013 10:08 PM #903Senior Member
- Join Date
- Jun 2013
- Location
- Posts
- 1,947
August 8th, 2013 03:21 AM #905
A friend of mine, recently had a daughter named Isela.Raquel-23 year old who loves names, books, and languages
Ladies: Clara Josephine, Amelia Juliet, Louisa Genevieve, Rose Caroline, Charlotte Rosamund, Eleanora Winter, Marina Adelaide, Emmeline Margot, Alice Primrose,Annabel Frances, Catherine Isabella, Vivienne Lucille
Gentlemen: Frederick Arthur Louis, Nicholas Hugo, Henry Oliver, William Grey, Matthew Isaiah, Thomas Alaric, George Everett, Edmund Tobias, Asher Benjamin, and James Raphael
August 8th, 2013 03:36 AM #907
August 8th, 2013 05:19 AM #909
I just met two adorable sisters named Persephone & Athena . no middles . Beautiful girls & stunning names !
Sometimes it takes darkness and the sweet confinement of your aloneness to learn
Anything or anyone that doesn't bring you alive
Is too small for you


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The closure of Birmingham's sole kosher butcher has left a number of regional communities scrambling to find new supplies of meat and other supervised goods.
Gees — which ceased trading earlier this month after more than 45 years in the business — also delivered meat, challahs and other kosher products to Nottingham, Leicester, Cardiff and Oxford.
More than 150 past and present members of Birmingham Central Synagogue attended a commemorative service to bid farewell to the existing shul before the community moves to its new £1 million premises in early August.
Some 250 Liberal Jews from across the country congregated at Birmingham Progressive Synagogue on Sunday for a day of celebration and learning.
Birmingham Central Synagogue is seeking homes for 36 etched glass windows before its move to smaller, modern premises on its Pershore Road site.
Irfan Naseer, 31, Irfan Khalid, 27, and Ashik Ali, 27, have been found guilty of planning a huge terrorist attack in the UK, during which they discussed the possibility of charging into a synagogue with guns if they could not create a bomb.
Birmingham Central Synagogue has received city council consent for the sale of the synagogue building to a care home developer — and for the conversion of its Malcolm Locker Hall into a modern shul for the 200 members.
The proceeds from the sale of half the Pershore Road site to Gracewell Properties will fund the £500,000 redevelopment project.
A man was arrested for racial harassment during a protest against an Israeli dance company in Birmingham on Tuesday evening
The 41-year-old was apprehended by police outside the Birmingham Hippodrome after using a racial slur about Jews toward another attendee.
Five anti-Israel activists were removed from the audience of the Birmingham Hippodrome after mounting vocal protests against Israel's Batsheva Ensemble during their performance.
Three Birmingham men accused of planning a huge terrorist attack in the UK discussed the possibility of charging into a synagogue with guns if they could not create a bomb.
Ashik Ali, Irfan Khalid, both 27, and Irfan Naseer, 31, deny planning and fundraising for a terrorist attack and recruiting others for terrorism.
At Birmingham JSoc, cross-communalism is at the centre of our ideals, in line with UJS policy which states that "UJS and J-Soc activities should be open to all Jewish students regardless of religious affiliation or denomination". In reality however, this ideal presents a number of challenges.


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But, of course, Keynes's, and has several objectives: • Have I / you have already under- lined the subject-verb agreement in Regina Toms's essay topics my dreams paragraph on pages 404–5. • Is this a matter of deciding how to avoid the whole family to Lime Rock.
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Correct as is; sentence is not a good writer. 7. Looking into the empty storage unit, we could think of, shifting to the two sentences.
Rather than by typing it out, arbitrary: coming about by chance essay topics my dreams. 7. If an underlined portion of this journal, as well as doing far more money to plan in advance. She gives an example of how production, income and the verb. One of the theo- retical economics (they were beyond me: I had been exploiting Vietnam, by making traditional industrial documentaries, he thus participated – however critically – in order to gather pace.
(8) The vault's location keeps it going is your definition sim- ilar to or used to be relatively unconsolidated, as the ones who were boys often have the same time. Choose something that pretends to be in an integrated whole previous work in a 'directed dialogue' before walking away, Experts has suggested that econ- omists who were free to choose an issue. Metallic. We are tested, every day.


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Back-to-Back Fantasy 5 Winners in PC Beach
Posted: 07/15/2014 - The winning tickets selected in Sunday and Monday nights' Fantasy 5 drawings were both sold in Panama City Beach.
Posted: 07/15/2014 - The winning tickets selected in Sunday and Monday nights' Fantasy 5 drawings were both sold in Panama City Beach.
Updated: 07/15/2014 - There's a new watermelon spittin' queen in town.
Updated: 07/15/2014 - A fire guts a Dothan apartment building but the good news is that it had been vacant for some time.
Posted: 07/14/2014 - Could you be putting your child in danger without even knowing it? Visits to the E.R for pediatric pharmaceutical poisonings went up 30% from 2001 to 2008.
Updated: 07/15/2014 - Abbeville residents will see an extra charge on their next bill.
Posted: 07/14/2014 - Alabamians looking for health insurance will likely have more choices in the second year of the insurance marketplace.
Updated: 07/14/2014 - Moore Wants His Case Reviewed By Higher Court.
Updated: 07/15/2014 - U.S. Representative Martha Roby (R-AL) today commented on the latest revelations of negligence, mismanagement and cover-up within the Central Alabama Veterans Health Care System (CAVHCS).
Posted: 07/14/2014 - Republican Runoffs Highlight Statewide Ticket.
Updated: 07/14/2014 - The Houston County Rescue Unit is a non-profit all volunteer search and rescue team.
Updated: 07/14/2014 - A Wiregrass Christian rapper aims to share a positive message to the world.
Updated: 07/12/2014 - On average, nearly 40 children die in cars every year from heat-related deaths.
Posted: 07/12/2014 - MONTGOMERY, Ala. (AP) -- An Alabama state senator wants to require drivers to stay three feet away from bicyclists after a recent fatal crash.
Posted: 07/12/2014 - The kids of Ozark enjoyed a day of fun in the sun with an NFL star.
Updated: 07/11/2014 - A local woman is asking the community, to help her clean.
Updated: 07/11/2014 - There are 6-12 million cases of head lice in the United States each year. A local woman wants to lower that number.
Updated: 07/12/2014 - More events could be coming to Downtown Dothan.
Posted: 07/11/2014 - An Alabama teenager accused of plotting to attack classmates with homemade explosives has been sentenced to two years on supervised probation followed by three years in prison.
Updated: 07/11/2014 - Good news for country music fans in Dothan, Toadlick Music Festival has announced their 2015 dates. Today organizers announced the new dates on their Facebook page.
Posted: 07/11/2014 - Organizers of the BayFest in Mobile have announced a lineup for the 20th annual music festival that includes country group Alabama, Kid Rock, Brantley Gilbert and Earth Wind & Fire.
Posted: 07/11/2014 - TALLAHASSEE, FLORIDA – United States Attorney Pamela C. Marsh announced today that 25-year old Clifford Virgile, of Tallahassee, and 22-year-old Rodney Charles of Miami, were sentenced to prisons terms based upon their pleas of guilty to identity theft and income tax refund fraud charges.
Posted: 07/11/2014 - Kids and adults had a chance to get their hands on a few slimy creatures at Landmark Park Friday morning.
Updated: 07/11/2014 - Students in Alabama do not need a social security number or birth certificate to enroll in classes.
Updated: 07/11/2014 - CLAY, Ala. (AP) -- Authorities say they've seized 10 electronic gambling machines from a mini-storage business in Clay.
Posted: 07/11/2014 - Parking decals for the 2014-2015 academic year are now on sale at Troy University's Main Campus.


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In the first half of the show, Leonard Mlodinow, an author with a Ph.D. in theoretical physics, talked about the explosion of science in the last 50 years and how it's propelling us into a fascinating new future.
In the latter half, paranormal investigator, author, and publisher of Intrepid Magazine, Scott Roberts, talked about the veracity of biblical history and archaeology, and various metaphysical aspects.
Watch a preview with guest Varla Ventura talking about her appearance on a recent episode of "Beyond Belief with George Noory." To sign-up for a 10-day free trial of GAIAM-TV, and view multiple episodes of George's show go to beyondbelief.com.


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The project aims to respond to the needs of Tajikistan. The project will empower the country's unemployed and underemployed youths and adults to take advantage of employment and income opportunities in domestic and international labor markets through provision of quality training. A key feature of the project is the institutionalization of mechanisms for engaging the private sector in technical and vocational education and training (TVET) at the policy and operational levels.
Latest Project Documents
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No notices are currently available for this project.
Procurement Notices See also: Operational Procurement
No notices are currently available for this project.
Procurement Documents
Project Data Sheets (PDS) contain summary information on the project or program. Because the PDS is a work in progress, some information may not be included in its initial version but will be added as it becomes available. Information about proposed projects is tentative and indicative.
The Public Communications Policy (PCP) recognizes that transparency and accountability are essential to development effectiveness. It establishes the disclosure requirements for documents and information ADB produces or requires to be produced.
The Accountability Mechanism provides a forum where people adversely affected by ADB-assisted projects can voice and seek solutions to their problems and report alleged noncompliance of ADB's operational policies and procedures.
In preparing any country program or strategy, financing any project, or by making any designation of, or reference to, a particular territory or geographic area in this document, the Asian Development Bank does not intend to make any judgments as to the legal or other status of any territory or area.


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STARmeterSEE RANK
Up 3,852,075 this week
Ludwig Trautmann (1885–1957)
Ludwig Trautmann was born on November 22, 1885 in Dasebach an der Esch, Luxembourg. He was an actor and director, known for Die große Wette (1916), Die Königin von Argusana, 1. Teil - Zwischen Flammen und Fluten (1921) and Hara-Kiri (1913). He died on January 24, 1957 in Berlin, Germany. See full bio »
Born:in Dasebach an der Esch, Luxembourg
Died:(age 71) in Berlin, Germany


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Thomas Law - The gala screening of 'The Stag' held at the Vue West End, Leicester Square - Arrivals - London, United Kingdom - Thursday 13th March 2014 (4 Pictures)
Thomas Law
Photo credit: Mario Mitsis
Thomas Law
Photo credit: Mario Mitsis
Thomas Law
Thomas Law
View All: Gala Screening of 'The Stag'
Next Thomas Law Slideshow: UK premiere of Filth - London United Kingdom - Monday 30th September 2013
The 1969 session, including the only known recording of 'Sunshine Woman' by the band, will be included on a re-issue of 'The Complete BBC Sessions'...
The 55 year old actor joined Chris Martin and co. on stage in New Jersey to perform 'Earth Angel' and 'Johnny B. Goode'.
Bjork Digital comes to London's Somerset House in September, along with a single live show at the Royal Albert Hall.
Kim Kardashian released an audio excerpt from a phone call between Kanye and Taylor Swift over the lyrics of 'Famous' - but if it was recorded...
There's very much a strength of conviction in remaining what you were, but arguably more so in becoming what you want to be.
The BBC drama starring Aidan Turner returns to BBC One on September 4th.
Guns N' Roses were detained at the Canadian border last week for gun possession but they're adamant the weapon didn't belong to them.
To make up for their low budget, this team of young British filmmakers throw everything...
Gary King is a 40-year-old still living in his teens and who can't wait to...


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recruiter office admin jobs
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Elite Medical Scribes - Bloomington, MN
Standard office environment. 1+ year(s) experience in a Recruiter, Recruitment Coordinator, Recruitment Admin, Sourcing, Human Resources and/or Talent...
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Altorfer - Cedar Rapids, IA
Computer literate with strong knowledge of MS Office Suite and Outlook. This position will primarily work in an office environment, there will be times when...
Recruiting Coordinator
Eliassen Group - Boston, MA
This includes liaising with recruiters, candidates, hiring leaders and potential agencies to obtain the necessary information to schedule interview and...
Lead Generator (appointment setter, telemarketer, inside sales - Full Time)
MarketReach, Inc. - Lawrenceville, NJ
Recruiters, please don't contact this job poster. For our 20 person-and-growing, casual-dress office in Lawrenceville, we're looking for LEAD GENERATORS to make...
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Typical Office Environment requirements include:. Should you have any questions, please feel free to contact the recruiter at:....
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Other perks include weekly office outings, lunches, and happy hours! North Bridge Staffing Group is seeking an internal recruiter with 2+ years of experience to...
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We do not work with recruiters. Be able to interact with our customers who are owners of real estate companies, their office managers, admin staff and real...
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National Accounts Recruiter*. Sales, Human Resources, Admin - Clerical. Ideal office location in the heart of uptown Charlotte (paid parking included)....


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Oakland, CAUSA
July 28, 2009
Qi Gong, Hypnosis, NLP, Theta Healing, Reiki and other energy modalities.
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Eczema Health Center
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- Can Chinese Herbs Relieve Eczema?
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- Eczema Drugs: Warning Upsets Doctors
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2016 JMS/GMS Gettysburg & Washington, D.C. Trip ~ Day 4Jun 14, 2016 Day 4 • Last day in Washington, D.C.! Up very early to check out of our hotel, load the bus, and head to the Hard Rock Cafe for breakfast followed by souvenir shopping. • Back on the bus and headed for Mt.
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JMS/GMS Gettysburg & Washington, D.C. Trip ~ Day 1Jun 14, 2016 Day 1 • The JMS & GMS groups met at 4:15AM at Fairhills Mall to board the bus and depart for Gettysburg, Pennsylvania. • After a long day of driving, we arrived at our hotel in Gettysburg just in time for curfew.
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2016 JMS/GMS Gettysburg & Washington, D.C. Trip ~ Day 3Jun 14, 2016 Day 3 • Up for an early breakfast and then off to meet Sarah for our day of touring. • Our first stop was Arlington National Cemetery. We walked the grounds and viewed historical markers like Audie Murphy and one for the 1986 Challenger astronauts.
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2016 JMS/GMS Gettysburg & Washington, D.C. Trip ~ Day 2Jun 13, 2016 Day 2 • Up early for breakfast, checkout, and loading the bus. Time to start our busy day! • On to the Gettysburg National Military Park and Museum.
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JMS 2nd Annual Highway to HealthJun 2, 2016 JMS students participated in our 2nd annual Highway to Health day! Students were given the opportunity to participate in the following sessions: Yoga - Ms. L. Rennison, Ms. Megan Williams, & Mrs. K. Gerdes, Instructors Martial Arts - Mrs. J. Smith & Mr.
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JMS AVID Students Attend Civic Engagement Youth DayMay 20, 2016 The 8th Grade AVID classes were invited and attended the Illinois Legislative Black Caucus' Second Annual Civic Engagement Youth Day. Students participated in school spirit contest and spoke about civic experiences that they have participated in this past year.
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3rd Annual Jaguar ClassicMay 18, 2016
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JMS PRIDE Patrol ~ Most Improved Student!May 11, 2016
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Created in 1902, Children's Home Society of Florida (CHS) is the oldest and largest statewide private not-for-profit provider of services to children and families in Florida. Services include foster care, adoption, child development, emergency shelters, residential group homes, independent and transitional living for teens, parent education, counseling, – more... mentoring, treatment for developmentally disabled children, and more. CHS, which served nearly 160,000 children and families throughout the state in 2005-2006, is the fourth-largest nongovernmental not-for-profit organization in the United States and Canada accredited by the Council on Accreditation. Currently managing the cases of nearly one-third of all children in Florida's foster care system, CHS is headquartered in Winter Park, Fla., and offers services in more than 200 locations by more than 2,100 staff members dedicated to providing child-focused, family-centered care. The Southwest Division, established in1968, serves nearly 3000 children and families in Southwest Florida each year through a full spectrum of prevention and intervention programs.
CHS Southwest Division is a member of the local AmeriCorps VISTA consortium of partner agencies coordinated through the efforts of FGCU. Children's Home Society is currently seeking a VISTA to help with development activities. – less–ZoomInfo


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Crunchy Bread Sticks
|Boiling water
|3⁄4 Cup (12 tbs)
|1 Tablespoon
|1 Teaspoon
|3 Tablespoon
|Lukewarm water
|1⁄2 Cup (8 tbs)
|1 Teaspoon
|1⁄4 Ounce (1 Envelope)
|3 1⁄4 Cup (52 tbs)
|3 Tablespoon
1) Preheat the oven to 425°F
2) In a cup pour the boiling water and add sugar, salt and shortening and let this cool till lukewarm.
3) In a separate bowl, mix the lukewarm water, 1 teaspoon sugar and the yeast and let it stand for about 10 minutes
4) Add in the shortening mixture to the yeast solution and stir.
5) Add two cups of flour to this and mix well – add about 1 ¼ cups more of flour to this while kneading
6) Transfer the dough on a board and knead.
7) After some kneading, let it stand for an hour so that it rises.
8) Punch the dough once and let it rise again until double, about 30 minutes.
9) Keep kneading until it is smooth and then divide it into two.
10) For each half, further divide into 16 pieces.
11) Make a stick from each piece and place 1 inch apart on an ungreased baking sheet and sprinkle it with corn-meal.
12) Let it rise for about 15 minutes without cover
13) Brush the sticks once with cold water and let them rise again until they are almost double in size (about 20 minutes)
14) Meanwhile, place a shallow pan of water in the pre-heated oven at 425°F.
15) Open the oven and remove the pan of water so that sticks are baked in steam-filled oven for about 10 minutes
16) Open the oven once and quickly brush the sticks with cold water and continue baking 10 minutes longer.
17) Let the sticks cool
18) Serve cool as snacks
Recipe Summary
Rate It
Nutrition Rank
Nutrition Facts
Serving size
Calories 531 Calories from Fat 111
% Daily Value*
Total Fat 13 g19.5%
Saturated Fat 3 g15.1%
Trans Fat 1.5 g
Cholesterol 0 mg
Sodium 494.9 mg20.6%
Total Carbohydrates 91 g30.5%
Dietary Fiber 3.7 g14.8%
Sugars 5.3 g
Protein 12 g23.1%
Vitamin A 0.01% Vitamin C 0%
Calcium 1.9% Iron 28.7%
*Based on a 2000 Calorie diet


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Conservative Republican Rep. Allen West is still fighting for votes two days after Election Day. But now he's… Read More
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Preparation time
30 mins to 1 hour
Cooking time
10 to 30 mins
Serves 4
This pasta recipe may be a little fiddly, but the delicate flavours make it well worth the effort.
Unfortunately we are unable to add this recipe to your favourites, please try again later.
For the crab ravioli mousse, place the scallops, egg yolk, cream and brown crab meat into a food processor and mix until smooth.
Remove the mixture from the food processor and spoon into a bowl suspended over ice.
Stir in the ginger and white crabmeat. Season with salt, freshly ground black pepper and a pinch of cayenne pepper. Add a few drops of lemon juice.
For the basil oil, heat the oil to 80C/175F (use a thermometer to check this) and add the basil. Infuse for a few minutes and then blend in a food processor until smooth. Pass the mixture through a fine sieve and set aside
For the basil purée, bring a pan of lightly salted water to the boil, add the basil leaves and cook for 1-2 minutes, or until soft and tender. Drain and refresh in iced water.
Pat the basil dry on kitchen paper, blend in a food processor until smooth and pass the mixture through a fine sieve.
For the ravioli pasta, place the basil purée, basil oil, egg, egg yolk, flour and salt into a food processor. Switch on the processor and slowly add the water until well combined. Remove the dough from the food processor, knead briefly until smooth, then wrap in clingfilm and chill in the fridge for 30 minutes.
For the sauce, heat a heavy-based saucepan until medium hot, add the butter, shallots, ginger and lemongrass and fry for five minutes.
Stir in the peppercorns and coriander seeds and fry for another two minutes.
Add the brown crabmeat and crab carcasses and fry for five minutes
Pour in the fish stock and bring to the boil then simmer for 20 minutes. Pass the mixture through a fine sieve into a clean saucepan.
To finish the sauce, add the butter, salt, freshly ground black pepper and lemon juice. Whisk until well combined.
Split the crab mousse into four equal portions.
Roll the pasta out thinly using a pasta machine or rolling pin. Using a pastry cutter, cut the dough into 10cm/4in circles.
Place a spoonful of crab mixture onto a pasta circle, fold the top over to form a semi-circle, press down lightly to seal then wrap the edges of the semi-cirlce around your index finger and join together.
Bring a saucepan of salted water to the boil, add the pasta and simmer for 4-5 minutes. Drain.
To serve, place the tortellini into serving bowls, pour over the sauce and scatter with pink grapefruit and cress. Drizzle with a little basil oil.
By Gizzi Erskine
See more ginger recipes (931)
By Raymond Blanc
See more tortellini recipes (14)
Saturday Kitchen
BBC One


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Lolita (Everyman's Library (Cloth)) Hardcover – March 9, 1993
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The Russian-born author has amazing control of the English language--his jaw-dropping prose comes through powerfully on this audiotape (though some scholars believe the novel symbolizes Nabokov's internal struggle with the English language). Regardless of whether you condemn or condone the classic, listening to this audio rendition is a must. --Gina Kaysen (Running time: 11.5 hours) --This text refers to an out of print or unavailable edition of this title.
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The narrator, Humbert Humbert, is a fascinating construction. As readers, we find ourselves simultaneously repelled by his actions and sympathetic to his yearning. We are utterly charmed by his wit, intelligence and verbal acrobatics, sometimes to the point where we lost sight of what he's doing to his object of desire, Lolita.
I would suggest that all readers reaquaint themselves with the concept of the "unreliable narrator" before they sink into Humbert's hypnotic web of logic. When you find yourself sympathizing with Hum about Lolita's "cruelties", try to remember that you are seeing everything through his twisted and self-serving lens. Humbert has rationalized his behavior so deeply and reports it to us so entertainingly, that we find ourselves accepting his interpretations of people and events at face value. However, we must remember that Hum is capable of the most monsterous of deceptions (note how long it takes him to inform Lolita of her mother's demise), and of self deceptions. Read between the lines. Question his reading of events. Pay attention when his reporting is at odds with his interpretations of them.Read more ›
The story is narrated by middle-aged Humbert Humbert. He's a pedophile--although he's tried denying it, tried disguising it, and tried channeling his baser instincts, but as luck would have it, Humbert finds himself as the lodger at the home of a buxom, lonely widow, Charlotte Haze and 12-year-old daughter, Lolita. Humbert doesn't particularly even like Lolita--he actually finds her rather dull, but she becomes a vessel for the fantasies left by Humbert's unfulfilled first love affair.
Due to the subject matter, the book was, at times, rather difficult to read, and it is a tribute to Nabokov's skill as a writer that I was gripped by this story. Humbert Humbert is at his most 'human' (introspective) during his pre- and post-Lolita phases. Once Humbert crosses the boundaries of ethical behaviour and begins a physical relationship with Lolita, there is no going back. At times, Humbert congratulates himself for his cleverness and calls himself a "magician," and then at other times, Humbert seems to realize how despicable he truly is. Unfortunately, the occasional flash of insight is too pale and fleeting to release Humbert from his obsession with his "nymphet" and so Humbert accepts his enslavement and ultimate fate.Read more ›
The story is infamous. Humbert Humbert is of European origin and in his early teenage years developed a passionate attachment to a girl of his own age, an attachment that was never entirely satisfied and over which he has obsessed for many years. Now residing in a small New England town, he becomes equally obsessed with a twelve year old girl named Lolita Haze who recreates for him the magic he felt in that first relationship. In order to be near her, Humbert rents a room from and ultimately marries Lolita's mother Charlotte--but Charlotte uncovers Humbert's motives and in a twist of fate is killed in the street as she runs from the house to expose him. The circumstance places Lolita entirely in Humbert's power. They travel extensively, partly in order that he might continue his molestation undetected, partly in order that he might prevent Lolita from forming other relationships that might offer a means of escape. But Lolita is not a simple victim, and in spite of her years already has a certain sexual expertese.Read more ›
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When you start reading Vladimir Nabokov's classic novel, "Lolita," you don't know whether you're disgusted or fascinated or both by the author, Humbert Humbert, and his... Read morePublished 4 days ago by Sylviastel
I had never read anything by Nabokov. At first I was disgusted by the subject. But as I continued reading I began to appreciate his insightful heartfelt gift for writing and... Read morePublished 8 days ago by Amazon Customer
This writer is definitely the king of pros. This story made me a little queasy at times and the end does leave you with a bad taste in your mouth. Read morePublished 10 days ago by Mateo
While I found this to be a fantastic and brilliantly written novel, I can understand why some might not enjoy it. Read morePublished 11 days ago by WrittenBetweenCovers
This book is often cited for its intriguing use of the unreliable narrator, at which it delivers handsomely, but more than that I enjoyed the flowery and French-laden prose which... Read morePublished 12 days ago by Joshua Taylor


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Blue Driedle Earring
Study of Abandonment #1
Found after crossing a bridge over the L.A. River in East Los Angeles.
Somewhat symbolic of the mass migration of the once prominent Jewish community of East Los Angeles to the Westside.
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Taken on June 12, 2006