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Arquivos de Neuro-Psiquiatria
Print version ISSN 0004-282X
On-line version ISSN 1678-4227
Arq. Neuro-Psiquiatr. vol.67 no.1 São Paulo Mar. 2009
Botulinum toxin type A in the treatment of lower-limb spasticity in children with cerebral palsy
Toxina botulínica tipo A como tratamento para espasticidade de membros inferiores em crianças com paralisia cerebral
Carlos Henrique F. CamargoI; Hélio A.G. TeiveII; Marise ZontaIII; Gilmar C. SilvaIII; Marcelo R. OliveiraI; Maurício M. RorizI; Ivar V. BrandiI; Nilson BeckerI; Rosana Hermínia ScolaII; Lineu César WerneckIV
INeurologist, Movement Disorders Unit, Neurology Service, Department of Clinical Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba PR, Brazil
IIAssociate Professor,Movement Disorders Unit, Neurology Service, Department of Clinical Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba PR, Brazil
IIIPhysiotherapist, Movement Disorders Unit, Neurology Service, Department of Clinical Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba PR, Brazil
IVFull Professor, Movement Disorders Unit, Neurology Service, Department of Clinical Medicine, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba PR, Brazil
We evaluated the safety and effectiveness of botulinum toxin A (BoNT/A) in the treatment of spasticity in 20 children with spastic diplegic cerebral palsy (CP). All the patients received injections in the gastrocnemius and soleus, and 15 received injections in the adductors. The total dose varied from 70 to 140 U (99.75±16.26 U), or 7.45±2.06 U/kg per patient. The treatment improved the patients' walking and gait pattern significantly. There was also a significant alteration in the heel-ground distance and increased motion of the ankle joint. These structural changes in the feet were sustained until the end of the follow-up, although the same was not observed for the functional parameters. Three patients complained of weakness in the lower limbs. In conclusion, BoNT/A is safe and effective when used in a single session of injections and produces a sustained structural modification of the lower limbs. However, functional changes are temporary and are only observed during the peak effect of the drug.
Key words: cerebral palsy, botulinum toxin, spasticity.
Para avaliação da segurança e eficácia do tratamento com toxina botulínica A (TB-A) na espasticidade na paralisia cerebral (PC), foram selecionadas 20 crianças com a forma diplegia espástica. Todos os pacientes receberam injeções nos gastrocnêmios e sóleos, 15 receberam doses nos adutores da coxa. A dose total variou de 70 a 140 Us (99,75±16,26 U), 7,45±2,06 U/Kg por paciente. O tratamento com a TB-A melhorou significativamente a deambulação e o padrão de marcha. Houve também significativa alteração da distância tornozelo-solo e aumento da amplitude de movimento da articulação do tornozelo. Essas mudanças estruturais dos pés se mantiveram até o final do acompanhamento. O mesmo não foi observado com parâmetros funcionais. Três pacientes apresentaram fraqueza em membros inferiores. Conclui-se que a TB-A, em uma única aplicação, é segura e eficaz. Há modificação sustentada da estrutura motora dos membros inferiores, porém mudanças funcionais são temporárias, durante o pico de ação do medicamento.
Palavras-chave: paralisia cerebral, espasticidade, toxina botulínica.
Cerebral palsy (CP) can be defined as a movement and posture disorder that appears at an early age, is secondary to a lesion or dysfunction of the central nervous system and is not caused by any known progressive or degenerative brain disease. The medical history, together with a neurological exam, allow the cause of the motor deficit to be identified as a brain abnormality and a diagnosis of CP to be made1. CP is a widespread problem and has a worldwide incidence of approximately 2 to 2.5 cases per 1,000 live-born infants. The condition is most common in premature children, who represent approximately 65% of all cases. The different types of CP have been well established and classified according to the degree of motor impairment in spastic, dyskinetic, ataxic, hypotonic and mixed CP2. The most common form of CP is spastic diplegia, which manifests mainly in the lower limbs and has a well-established association with prematurity3,4.
Spasticity in children with CP is a serious problem that affects daily life activities and places obstacles in the path to achieving the rehabilitation goals. Stiffness, restricted movement, the development of contractures and a serious potential for joint complications are associated with muscles affected by spasticity5. Botulinum toxin A (BoNT/A), a practical neuromuscular blocking agent that causes a clinical reduction in spasticity in working muscles, appears to have a beneficial effect on the natural history of CP patients with equinus deformity6.
The objective of the present study was to evaluate the safety and effectiveness of BoNT/A in the treatment of children with spastic diplegic cerebral palsy.
Patient selection
Twenty patients with spastic diplegic CP who had been referred to the Botulinum Toxin Outpatient Unit in the Neurology Service, Hospital de Clínicas, Federal University of Paraná (HC-UFPR), between May and November 2000 were selected.
The inclusion criteria were: (1) children from 2 to 16 years of age; (2) patients with dynamic deformities of the lower limbs due to static cerebral lesion with poor response to physiotherapy (dynamic deformities were considered to be those in which the limb could return to the neutral position with maximal or submaximal passive manipulation); (3) patients who were able to walk with or without assistance; and (4) patients taking part in rehabilitation programs.
The exclusion criteria were: (1) fixed deformity of a joint; (2) prior orthopedic surgery or the need for surgical treatment; (3) prior use of botulinum toxin; (4) myasthenia gravis or a disease of the neuromuscular junction; (5) use of aminoglycoside antibiotics; (6) physiotherapy discontinued; and (7) consent not given by those responsible for the patient.
Assessment and clinical follow-up
All the patients had the diagnosis of spastic diplegic CP confirmed by at least two neurologists following clinical examination and neuroimaging and laboratory tests. Each patient was then assessed by at least one physiotherapist before being included in the study.
The patients were assessed on admission and approximately 30, 90 and 180 days after treatment had started. This assessment consisted of:
1 Clinical neurological and physiotherapy assessment.
2 Measurement of the degree of hip abduction, knee extension and ankle dorsiflexion. The ankle dorsiflexion angle with the knee at maximum extension and 90º of flexion was measured using the goniometer. With the foot placed in the supine position, the ankle was kept in the neutral position to avoid calcaneus valgus or varus and dorsiflexed to the limit of movement. The fixed arm of the goniometer was kept parallel to the long axis of the fibula, and the mobile arm parallel to the long axis of the calcaneus.
3 Ashworth Spasticity Scale. Assessment of the tonus of the triceps surae during passive dorsiflexion of the ankle with the knee and thigh flexed7.
4 Physician Rating Scale (PRS). This scale allows six functional elements of gait to be assessed while the patient is walking barefoot for a distance of at least 15 steps. This scale grades the following functional elements: (1) gait pattern (02); (2) position of the ankle while walking (02); (3) elevation and curvature of the foot while walking (03); (4) position of the knee while walking (03); (5) degree of flexion and shortening of the lower limbs (03); and (6) gait speed (01). The total PRS score was the sum of the six components for each patient (014, 0=worst score and 14=best score)8.
5 Ambulation speed. A measurement of the time needed to cover a distance of 25 steps with or without assistance.
6 Heel-ground distance. Measured with the patient in the orthostatic position with the knee at maximum extension.
7 Spasticity scale for thigh adductors: 0normal muscle tonus; (1) increased tonus, thighs easily abducted up to 45º by only one examiner; (2) thighs abducted up to 45º by only one examiner with minor effort; (3) thighs abducted up to 45º by only one examiner with moderate effort; (4) two examiners needed to abduct thighs up to 45º.
8 Analysis of gait using video recordings.
All participants were required to continue physiotherapy throughout the study in the same institutions they had been having treatment in prior to the application of botulinum toxin. The staff at these centers were advised by the physiotherapists from the HC-UFPR to continue a program of at least three 1-hour sessions a week containing, as a minimum: (1) muscle stretching, especially for the Achilles tendon; (2) exercises to assist ankle dorsiflexion; (3) gait training going up and down steps; (4) training of those responsible for the child to ensure that certain exercises were repeated as part of the child's daily routine.
The clinical treatment patients had been receiving prior to inclusion in the study was continued, and none of the patients were submitted to surgery during the study. All the patients received BoNT/A therapy (Botox®, Allergan, Irvine, CA, USA).
The lyophilized preparation of the toxin (1 flask=100 U=5 ng) was stored at 20ºC and reconstituted with 1 mL of 0.9% saline solution at the time of injection . The 10 U per 0.1 mL solution was administered in a 1cc (1 mL) tuberculin syringe.
The number of points where the toxin was injected and the dose were adjusted for each muscle (Table 1). The maximum doses used for BoNT/A injections were: (a) 12 U/kg or 400 U per session; (b) 36 U/kg per large muscle; (c) 12 U/kg per small muscle; and (d) 50 U per injection point.7
The choice of muscle, site and amount of BoNT/A for each muscle were determined based on clinical evaluation with the aid of electromyography (Table 1). BoNT/A was applied using a Nihon-Kohden Neuropack II electromyograph. Monopolar, teflon-coated needle electrodes were used (37 mm ' 27 G), and the tuberculin syringe was coupled to a needle electrode. The appliance was calibrated with filters from 10 Hz to 5 kHz. A sensitivity of 100 microvolts (µV)/division was used and the analysis time was 10 milliseconds/cm. After the muscle where the BoNT/A was to be injected had been chosen, the needle electrode was inserted at the site nearest to the motor point, and when the presence of motor unit action potentials (MUAPs) suggested that the needle was inserted in the muscle, the BoNT/A was injected.
Adverse effects, latency to start, peak and duration of action of the BoNT/A and interference in daily life were measured with a questionnaire.
Statistical analysis
The distribution pattern for all the data was tested (normal or non-normal). The statistical differences between the means of the groups were determined using two-tailed and single-tailed paired Student t tests where indicated and the Wilcoxon test. The results are given as mean ± SD (standard deviation). All the statistical analysis was performed with version 99 of the Statistica for Windows program. Differences were considered significant if p<0.05.
All 20 children selected [13 males and 7 females aged between 2 and 11 years (4.73±2.18 years) and weighing between 8 and 34 kg (12.72±5.87 kg)] received BoNT/A injections at the beginning of the study. All had equinus in both feet and were given BoNT/A injections in the gastrocnemius and soleus muscles. There was no statistically significant difference between the severity of the deficit in the lower right limbs and that in the lower left limbs (p=0.827). Fifteen patients had difficulty abducting their thighs and therefore had BoNT/A injected in the thigh adductors.
The BoNT/A dose varied from 70 to 140 Us (99.75±16.26 U) and was 7.45±2.06 U/kg per patient. The parents or those responsible for the children reported that the medication started having an effect between the second and twentieth day after application (7.1±4.57 days). All the patients attended for follow-up assessment at 30 days post-application, 85% attended for assessment at 90 days and 75% at 180 days.
Treatment with BoNT/A improved ambulation and equinus gait pattern significantly in children with spastic diplegia when these parameters were assessed using the PRS (p<0.001). The treatment continued to have beneficial effects at the follow-up assessment 90 days post-treatment (p<0.001). At the follow-up assessment 180 days post-treatment, however, parameters similar to those prior to treatment were observed (Fig 1). Only two children (10%), who had severe functional impairment at the beginning of the study, failed to show any improvement on the PRS scale at the +30 day follow-up assessment and did not attend for reassessment at +180 days.
Gait speed also changed significantly as a result of the use of BoNT/A (p<0.05). Nevertheless, this improvement was not sustained, as can be seen in the +90 and +180 day follow-up assessments (Fig 2). Three patients (15%) were able to ambulate without any support in all the follow-up assessments. One patient who required support when walking at the first, second and third follow-up assessments, managed to ambulate without support at the +180 day follow-up assessment. The remaining 16 patients (80%) were unable to ambulate without assistance at any of the assessments.
Assessment of triceps surae spasticity with the Ashworth scale showed that there was a significant response to BoNT/A (p<0.05), which was still in evidence at day 90 (p<0.05), but that the muscles had returned to their baseline values at day 180. The response of these muscles was also tested by measuring ankle dorsiflexion. When this method of assessment was used, both with the knee flexed or at maximum extension, there was a significant response to BoNT/A in both limbs, and this was sustained until the end of the study. The heel-ground distance, which is increased in equinus because of the spasticity of the triceps surae, also changed significantly following the application of BoNT/A, and the results were sustained until day 180 (Table 2).
The thigh adductor muscle group also responded significantly to the therapy, and the longer the time elapsed since the BoNT/A injection, the greater was the response (Fig 3).
Three patients were found to have weakness in the lower limbs after BoNT/A had been applied, and one reported having falls. These symptoms were mild and resolved in a few weeks without the need for medical intervention.
In this study we have shown that the use of intramuscular BoNT/A injections to treat children with CP (spastic diplegia) who have spastic thigh adductor muscles and equinus is both safe and effective.
Treatment with BoNT/A was very effective in correcting the position of the feet, as shown by the reduction in the heel-ground distance and by the increased range of motion of the ankle joint, confirming the findings of previous studies10-15. The increased dorsiflexion of the foot caused by the greater range of motion of the ankle joint was similar both with the knee extended and with the knee flexed. This occurred because of the role of all the muscles in the triceps surae complex gastrocnemius and soleus in producing equinus in our patients16. There was thus an effective response to BoNT/A in all these target muscles. The improved positioning of the feet was also confirmed by the reduction in spasticity in the triceps surae muscles measured on the Ashworth scale. Physiological explanations for this adjustment in the feet include not only weakening of the gastrocnemii and soleus but also the increase in length of the gastrocnemii muscle-tendon unit, the shortening of the antagonist muscles or a combination of these events. Any of these effects could be the direct result of chemical denervation caused by BoNT/A, and it is unlikely that they would occur spontaneously11.
A clear improvement in the spasticity of the thigh adductor muscles was also observed after treatment with BoNT/A, corroborating the findings of other studies5. The positive effect on the thigh adductor muscles was progressive and was sustained throughout the follow-up period. We observed that the beneficial effects of BoNT/A in terms of spasticity of the triceps surae were still present six months after the application of the toxin. The effects of a single dose of BoNT/A lasted on average three to six months in other studies of children with CP. Although the duration and effect of BoNT/A reported in the literature varies, it is generally considered to be effective for at least three months11.
All our patients took part in rehabilitation programs before and after the application of BoNT/A, preferably based on a neurophysiological method, using splints when necessary. The use of electrical stimulation and immobilization was not recommended14,16. We believe that the prolonged positive effect of BoNT/A until the end of the study in some cases is also related to the results of physiotherapy11,17. Thus, BoNT/A should not be considered a substitute for physiotherapy or orthoses, but rather an additional therapeutic strategy10,18. Better biomechanical alignment through muscular relaxation, such as improved range of motion of the ankle, allows the patient to adapt better to orthoses10,11. Furthermore, the muscular relaxation achieved following application of BoNT/A allows muscle-stretching exercises to be performed more easily and the child to learn to use and strengthen opposing muscles. For most children BoNT/A does not lead to a sustained increase in the length of the gastrocnemii but helps delay shortening of the muscles. Specific physiotherapeutic treatment and orthoses can help the small percentage of children in whom there is evidence of prolonged muscle stretching19. These are clear arguments for intensifying physiotherapy after the application of BoNT/A to achieve better results in the long term6,10,11,20.
The impact of BoNT/A in children is different from that in adults. Unlike adults, whose organisms are relatively static, children have two processes that are exclusive to childhood growth and development superimposed on the underlying spastic condition. Although the effects of BoNT/A are seen primarily in a reduction of hypertonia, the change in tonus can improve the child's balance, strength, motor control and fixed contractures21. As the child develops, the spastic muscles fail to grow as quickly as the neighboring structures, and dynamic structures are transformed into fixed contractures. Relaxation of spastic muscles allows these to stretch, encourages their growth and prevents contractures. These improvements lead to functional gain10.
It has been stressed recently that assessment of functional improvement is more important than assessment of the reduction in muscle tonus or the increase in the range of motion of the joint10,18. The physiological and mechanical effects of BoNT/A treatment are genuine and measurable in patients with spastic diplegia. However, these effects may not trigger a major change in function or change in the patient's or his/her parents' perception of function and thus not be recorded as a significant improvement in the patient's family and social life22.
Hesse et al.12 reported a noticeable improvement in equinus followed by a more erect gait posture after injection of BoNT/A in the gastrocnemius and ischiotibial muscles. However, there was no functional improvement according to the assessment tools used. Reddihough et al.23 observed discrete gait improvements after three months of follow-up, but failed to observe functional improvements after 3 or 6 months. Fazzi et al.13 , on the other hand, observed a reduction in spasticity in muscles that had been treated and an increase in passive joint mobility. There was increase in the scores on scales and tests intended to assess function. These increases are reflected in the gait pattern (PRS), selective motor control in foot dorsiflexion, and the acquisition of new motor abilities.
We observed an improvement on the PRS scale after treatment; nevertheless, the beneficial effect was not sustained until the end of the study. The scale subitems gait pattern and ankle position, which are the two elements that are most closely related to spasticity of the gastrocnemii and soleus, improved significantly with BoNT/A. Gait speed, the item with the greatest functional value on the scale, also improved significantly, but this improvement was not sustained until the sixth month of follow-up. We also found that only one patient was able to ambulate without support, while the other 16 still needed support during the gait tests. These data, which show that functional gains were not sustained, support other authors' concern to lay greater emphasis on instruments to measure function when analyzing the applicability of BoNT/A10,18,22.
However, the objective of this study was to assess the efficacy of BoNT/A applied in a single session. Serial injections of BoNT/A may lead to a greater reduction in focal spasticity and allow children with CP to learn movement patterns that more closely resemble normal ones and to improve their balance and gait speed as well as increase step size when ambulating11. Hawamdeh et al.10 showed that there was an overall improvement for 18 months after three applications of BoNT/A in children with spastic diplegia. The improvement was greater than that observed when physiotherapy and orthoses were used in isolation and was sustained until the last follow-up session at 18 months. This suggests that BoNT/A may influence physiotherapy, prolonging and amplifying its effects and increasing the functional capacity of children with spastic diplegia.
In addition to increased functional capacity, another important benefit of long-term treatment with BoNT/A is that surgical interventions can be postponed6. Without treatment, muscles that have been spastic for a long time can develop fixed contractures that often require surgical procedures. Equinus recurs after corrective procedures are performed in early childhood. Reduced spasticity following BoNT/A applications can delay the need for surgery, thus reducing the possibility of deformities recurring11,17.
With regard to the effectiveness of BoNT/A, quantitative variables have been found to be predictive factors for a favorable treatment outcome. In terms of age, children under 48 months can show better results13. We assessed children from 2 to 11 years of age (4.73±2.18 years), and our initial results were significant. With younger children we might have been able to maintain the functional gains because the motor pattern of very young children provides greater scope for better development and recovery (a younger child has greater potential than an older child for increasing the plasticity of the central nervous system)13. Papadonikolakis et al.24 , however, support the view that carefully selected patients can show an improvement following treatment with BoNT/A despite being older (average age 11 years). These authors used selection criteria that were similar to those we used, i.e., only patients who were undergoing physiotherapy, did not have fixed contractures and were able to ambulate were included in the study.
Fattal-Valevski et al.25 found that greater spasticity, an inability to ambulate and lower motor function levels are predictive factors for a good response to BoNT/A. In contrast with these authors' findings, in our study we observed that patients with a high degree of motor limitation were precisely those who had the worst response to BoNT/A treatment. Kay et al.26 followed up 23 children over the age of four years with more severe CP (including patients with quadriplegia) who had dystonic movements and fixed contractures in the ankle. The authors did not observe any differences between lower-limb spasticity in the group that received BoNT/A and that in the group that had been treated with physical therapy alone. Two possible explanations for Fattal-Valevski et al.25 findings are that BoNT/A was injected in a larger number of motor points in patients with more severe CP or that small changes in function, tonus and the range of motion of joints can be detected more easily in these children.
Another interesting point, which we did not address in our study, is the influence of cognitive level and visual function. The role of cognitive and sensory development in the acquisition of motor abilities is well understood. Fazzi et al.13 showed that the best results in terms of gait improvement were produced by children with normal or borderline cognitive levels. Similarly, a significant improvement in gait was observed in patients with normal or borderline visual acuity.
As the predictive factors are well understood, BoNT/A treatment should be tailored to suit each patient. In addition, the effect and duration of treatment depends on the ability to deliver toxin to the target muscle(s); preinjection muscle physiology, including power, endurance and spasticity; connective tissue extensibility; and the range of motion of the joint11.
A critical assessment of the predictive factors for a good therapeutic result, the physiopathology of spasticity, the mechanism of action of BoNT/A and an understanding that a child's organism is undergoing constant change are directly related to the key elements for effective therapy using BoNT/A, namely, suitably chosen patients; clearly defined treatment objectives as a result of discussion with the patient and his/her family; and an effective long-term strategy for managing the changes that take place in a child with CP who is in a growth and development phase21,22.
Family members must have realistic expectations about the BoNT/A treatment before the procedure starts. Bjornson et al.22 showed that the family members' expectations for the therapy were far removed from the actual effects of the treatment and that they had difficulty appreciating the benefits of the treatment.
On the other hand, patients and family members understand and rarely complain about the adverse effects of the treatment. BoNT/A is generally well tolerated and safe when used to treat spastic CP and rarely produces severe side effects. In agreement with the literature, no important side effects were observed in our patients. However, we did observe weakness in the lower limbs and falls probably related to a reduction in muscle tonus after the treatment in individuals used to ambulating with spastic muscles11,15,17,24.
Although we did not use sedatives or local anesthetics, there were no complaints of pain at the injection site or local adverse effects because of traumatism as a result of sudden movements by the children. Koman et al.6 also failed to find adverse effects and reported that all their patients agreed to second injection sessions. Topical anesthetics are not effective in reducing pain produced by the injections because they do not affect the muscle underneath the skin at the injection site6. The argument for using general anesthesia when injecting BoNT/A is that it helps avoid emotional stress and anxiety in the child, especially when the procedure needs to be repeated in the future27. The use of sedatives such as oral midazolam, which causes amnesia, can be a safer, less expensive alternative to general anesthesia when the aim is to sedate the patient before the procedure15,27.
In the group of patients with spastic diplegia in the present study, a single session of injections of BoNT/A was safe and effective. There was an important, sustained change in the motor structure in the lower limbs of the children tested; however, functional changes were only observed when the effect of the medication was at its peak. These findings indicate that serial injections of the medication are required if all the positive effects obtained are to be maintained.
ACKNOWLEDGMENTS The authors would like to thank Allergan, Inc.; which provided the botulinum toxin (Botox®) for this study. Disclosure: The authors have nothing to disclose
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Received 11 April 2008, received in final form 3 October 2008. Accepted 17 November 2008.
Dr. Hélio A.G. Teive Rua General Carneiro 181 / 12º andar - 80060-900 Curitiba PR - Brasil. E-mail: firstname.lastname@example.com


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subset: commoncrawl


text:
basic constructions:
strong axioms
The axiom of multiple choice (AMC) is a weak version of the axiom of choice which can hold in constructive mathematics.
A set-indexed family of sets is said to be a collection family if for any and any surjection , there exists a and a surjection which factors through .
The axiom of multiple choice states one of two things:
The second formulation seems to be the one originally given by M&P, below, while the first is that given by Michael Rathjen and attributed to Peter Aczel and Simpson.
Mike Shulman: Are these the same? If not, why are they given the same name?
Note that is a projective set if and only if the singleton family is a collection family. Therefore, since AC is equivalent to "all sets are projective," it implies AMC.
An extension of this argument shows that COSHEP is sufficient to imply AMC.
The Reflection Principle? (RP) is equivalent to AMC (called stong AMC by van den Berg). RP is motivated by the regular extension principle (REA) from constructive set theory. RP states that every map belongs to a representable class of small maps.
However, AMC does not imply countable choice or any of the other usual consequences of AC.
Rathjen proves that SVC also implies AMC. It follows that AMC holds in "most" models of set theory.
AMC implies WISC, and therefore also implies that the category of anafunctors between two small categories is essentially small.
A ΠW-pretopos satisfying the axiom of multiple choice is a predicative topos.
Ieke Moerdijk, Erik Palmgren, Type theories, toposes and constructive set theory: predicative aspects of AST (2000) (web)
Rathjen, "Choice principles in constructive and classical set theories"
WISC is called the "axiom of multiple choice".


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When it comes to public schools, there is no doubt that community expectations and support affect quality and performance in a big way.
If a community expects to have excellent public schools, and provides the resources to achieve it, the biggest part of the battle is won. A community that tolerates mediocrity or worse will continue to get subpar performance in its schools.
Tupelo always has been a community that both demands much of its public schools and consistently backs up those expectations with support – financial and otherwise. That community connection with the schools has been a critical component of Tupelo's extraordinary economic success for many decades.
Whenever the schools have not met community expectations, Tupelo citizens have made it known that they expect better. That was the case four years ago when the district earned an "Academic Watch" designation under the old state ranking system, the fourth of seventh tiers. The next couple of years brought public expressions of dissatisfaction and changes in leadership, and much disagreement on causes and solutions, but the message resonated that the community expected improvement.
Today the results are clear: A school system long considered one of the state's best, and which drew national attention at times, has made significant progress in reclaiming that status. A decided turnaround during the last two school years, including two "A" schools this year and a second straight "B" rating as a district – the "Academic Watch" rating would have translated to a "D" – have given not only the schools but the community a new injection of confidence, pride and optimism about the future.
That rejuvenated spirit about Tupelo's schools was on full display Saturday when hundreds of parents, community members, teachers, school administrators and city leaders gathered in Fairpark for a festive celebration of the progress represented by last week's state rankings. Tupelo's school system isn't all the way to where it needs to be yet, but it has made remarkable progress in a very short time, and celebrating that progress and renewed pride was fully warranted.
Just two or three years ago, there were those who thought the Tupelo schools – and by extension, the wider community – had seen their best days. So tied together have the fortunes of the schools and the community been in Tupelo that it's fair to say that as go the schools, so goes the community.
But Tupelo citizens and educators have proven that a mobilized community, working in tandem with its schools, can right the ship. It's happening in Tupelo, and it all began – as it always has – with high community expectations and strong community support.


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United States History I students in Ms Megan Knoth's Class at the Arthur L. Johnson High School in Clark are currently learning about the American Revolution and the creation of the United States of America. These students had the great opportunity to go on an educational field trip to Philadelphia. Teachers, Miss Knoth, Mrs. Case, Mr. Stebbins, Mr. Caelblien, Mr. Trumepy, Mr. Hopkins, and Mr. Corby walked students through multiple historic sites including; Independence Hall and the Constitution Center, in addition students had the opportunity to see the historic Lib-erty Bell. Overall, students were highly enthusiastic and thoroughly enjoyed the experience. Pic-tured below posing in the Liberty Bell Museum is Caroline Hoynowski, Kaitelyn Aspinwall, Lauren Leppler, and Breanna Morecract. In addition, a picture of the Liberty Bell is also shown.
Arthur L. Johnson High School, Clark, students travel to Philadelphia
Suburban News By
on November 22, 2012 at 9:55 AM, updated November 22, 2012 at 9:56 AM
on November 22, 2012 at 9:55 AM, updated November 22, 2012 at 9:56 AM


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"No glitz, no glamor, no pyro. Just let the music do the talking."
Such is the mantra of Brazin Bull, a Tiffin-based band playing Texas-style blues, classic and Southern rock. Formed about four years ago, the foursome has performed locally at Loud Fest, the Heritage Festival, Tiffin Eagles, the Viaduct, Saucy Squeaks, Bear's Den and private parties. Other venues have included Third Saturday in August (a bike rally), Fremont, Port Clinton, Lima, White's Landing, Cridersville, the Village Cafe and Jimmy Bucket's.
Guitarist Bud Mowery and drummer Gary Burns founded the group to break away from "the standard bar band songs." Their common goal was to play good popular music "not already being played to death by other bands."
Article Photos
Brazin Bull is composed of (from left) Tom Courtney, Gary Burns, Chip Rowland and Bud Mowery.
The blues being the basis of their musical style, they chose a playlist to reflect that preference. Tom Courtney recently was added on bass and Chip Rowland contributes vocals.
Burns said he came up with the band's name.
"I was watching the History Channel one time about the inventor of torture equipment. The guy made a bull out of brass, and they'd cook people in it. They said it was called a brazen bull. I thought that would be a really neat name for a band. ... It didn't have nothing to do with torture, even though sometimes when I'm with these guys, it is almost torture," Burns said.
The musicians can take the ribbing in stride and have fun together. Music is a change of pace from their regular jobs. Mowery sells concrete block for Cantelli Block in Huron; Burns is a machinist for Sarka Sheet Metal; Courtney works for Seneca Medical; and Rowland is a tool salesman.
They all took up music at young ages.
Rowland said he played saxophone in his middle school band and sang in school choirs.
"I broke my hand and took up guitar for therapy," he said.
"I started playing musical instruments in fourth grade. I played violin for awhile, then switched to cello. I played saxophone, played guitar, and finally ended up playing bass, which I like the best," Courtney said.
Burns learned partly by imitation. He was about 15 and needed something to do.
"My dad had a drum set upstairs and I just decided to start playing one day. I put on some headphones and taught myself," he said.
"I started playing when I was 14," Mowery said. "I took organ lessons for about a year and a half. Then I started watching bands on TV, and I got rid of that organ and got a guitar."
Brazin Bull performs covers of music by Stevie Ray Vaughn, ZZ Top, Eric Clapton, Johnny Winter, Robin Trower, Robert Cray, Jimi Hendrix, The Allman Brothers Band, Kenny Wayne Shepherd, Frank Marino and Mahogany Rush, Stevie Wonder, Robben Ford, Dire Straits, Lynyrd Skynyrd and a few others.
The band is to be in action at 9:30 a.m. Saturday at Bear's Den in Tiffin. At 10 p.m. Feb. 11, they are to play at Meadowbrook in Bascom. They will return to Meadowbrook March 24 to open for McGuffey Lane.
To book the band, call Mowery at (419) 618-1035.


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570-632. Born in Mecca, died in Medina. Founder of Islam. Regarded by Muslims as a prophet of God. Teachings make up the Qu'ran, the Muslim holy book.
the sacred writings of Islam revealed by God to the prophet Muhammad during his life at Mecca and Medina
sunni/shiite muslims
Two major branches of Islam; Sunnis, the largest branch, are known as the orthodox branch supporting only descendants of Muhammad whereas Shiites support descendants of Ali as religious leaders
gold-salt trade
Gold and salt made up trade and wealth in the African kingdoms because the Europeans wanted gold, and the Africans needed salt.
City on the Niger River in the modern country of Mali. It was founded by the Tuareg as a seasonal camp sometime after 1000. As part of the Mali empire, Timbuktu became a major major terminus of the trans-Saharan trade and a center of Islamic learning.


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Lightweight Rod Salka Jr. dropped previously unbeaten Alexei Collado with a third-round left hook on the way to a unanimous decision victory on Friday before his fans at the Convention Center in Monroeville, Pa. The fight was a ShoBox: The New Generation main event on Showtime.
The 31-year-old Salka (19-3, 3 knockouts), whose hometown of Bunola is nearby Monroeville, won by scores of 96-94 and 96-93 (twice) over Collado (18-1, 16 KOs), a 26-year-old former Cuban amateur standout, and then immediately stated his case for a title shot.
Salka wants the winner of an April 26 bout between WBC lightweight titleholder Omar Figueroa Jr. and Jerry Belmontes that is the opening bout of a Showtime-televised tripleheader at the StubHub Center in Carson, Calif.
"I'm heading to Carson next week to call out the winner of Figueroa-Belmontes," Salka said in a prepared release. "I want to fight whoever wins that. Doesn't matter to me. I earned a shot at the title."
Salka had previously been in the ring in December, when he lost a junior welterweight bout against Ricardo "Dinamita" Alvarez, the 32-year-old older brother of Mexican star Saul "Canelo" Alvarez, by disputed majority decision at the Alamodome in San Antonio.
The bout represented the American debut for Alvarez in support of the main event featuring Marcos Maidana's unanimous decision that dethroned Adrien Broner as WBA welterweight titleholder on Showtime. His younger brother was sitting at ringside.
At his hotel, later that night with cornermen Paul Spadafora, Buzzy Garnic, Ron Roule and Rod Salka Sr., Salka lamented the lost opportunity based on the judges' cards, one of which scored it even at 95-95.
Salka did not let that happen against Collado.
"I dictated the pace of the fight," said Salka. "I kept him where I wanted him and forced him to keep going for that overhand right, which he couldn't land cleanly. I was throwing first and throwing last, just like I wanted to do. I mixed up my offense well and kept my hands up."
A former Cuban amateur standout, Collado chalked up the loss as a learning experience.
"He was smart and that was the difference." said Collado. "He kept moving. His movement was the problem for me."
In the ShoBox co-feature, Felix Diaz, a 2008 Olympic gold medalist from the Dominican Republic, scored an eight-round split decision against Ghanaian-born Brooklynite Emmanuel Lartey.
Diaz (15-0, 8 KOs), a 30-year-old from Santo Domingo, turned in a performance as auspicious as his surroundings, as the southpaw waltzed his way to two scores of 77-75.
Lartey (15-2-1, 7 KOs), who pushed 2012 US Olympian Errol Spence to his toughest test in his previous bout, won by 77-75 on the thrid card. Neither fighter was satisfied with the split verdict.
"It's disappointing to know it was scored a split decision," said Diaz, who is trained by Robert Garcia. "I think I dominated most of the rounds, so I don't see how the judges scored it that way. I want to see my family – it's been three months – and then head back to Oxnard to get in the gym with Robert."
Lartey took issue with the scoring of the fight.
"I can't tell the judges what to do," said Lartey. "I think it should have been scored a draw. This is the only job I know. I need to go back to the gym and work on some things."
In the opening bout of the broadcast, Samuel Vasquez (14-0, 10 KOs), of Monessen, Pa., scored three quick knockdowns of Juan Rodriguez Jr. (11-1, 5 KOs), of Union City, N.J., forcing referee Gary Rosato to stop the fight at the 2:49 mark. Vasquez is a former All-Army and All-Armed Forces champion as an amateur, and has served two stints in Iraq.
"It's not that it was easy. It was that it was well-executed. We had a game plan, stuck to it and that's what happened," said Vasquez, 28. "All the fans, the soldiers watching overseas on AFN [American Forces Network, my family watching on Showtime, that was the biggest part of the night."
Also on the card, Yudel Jhonson, a 2004 Olympic silver medalist from Cuba, outboxed Lenwood Dozier (9-6-1, 4 KOs) en route to an eight round unanimous decision. Jhonson (15-1, 9 KOs) scored a knockdown in the opening round en route to scores of 80-71 on all three cards.
The event was promoted by Iron Mike Promotions.


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Thank you to all who attended the 2015 Amazing Taste: Global Festival!
The Amazing Taste is Ball State's annual vibrant celebration of global culture featuring cuisine from 20+ countries, live music and dancing, and an evening of family-friendly cultural activities.
Check back in fall 2016 for details about this year's event.
See the 2015 menu
2015 Activities & entertainment
Check back before Nov. 5 to see additions.
2015 Admission
Food fair wristbands are available at the door or by pre-sale.
Meal swipe or $8.20 (no tax), BSU students who hold a meal plan
$8.95 (no tax), BSU students who do not hold a meal plan
$8.95+tax, ages 13+
$5.95+tax, ages 3-12
Free, ages 2 and under
Access to cultural displays and activities is free! (no food purchase necessary)
2015 Pre-sale (Nov. 2-5)
Admission to the food fair portion will be capped at 1,500 guests. Guarantee your spot by pre-purchasing your admission wristband Nov. 2-5* at the Student Center Tally. Cash, credit card, Cardinal Cash, and Dining Plus are accepted. Meal plans may also be used; ask for Thursday's dinner meal to be removed.
The Amazing Taste is presented by BSU Dining, the Multicultural Center, the Rinker Center for International Programs, and University Program Board, with support from Housing & Residence Life.
Did you know?
The Amazing Taste is a silver award winner in the prestigious national L.E. Horton Dining Awards competition sponsored by the National Association of College and University Food Service.
The Amazing Taste 2012 earned BSU Student Life's Collaborative Program of the Year award.
Copyright © 2016 Ball State University 2000 W. University Ave. Muncie, IN 47306
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text:
Zoe Williams
|Zoe Williams
|United Kingdom
|Alma mater
|Oxford University
|The Guardian
Zoe Williams (born 1973) is an English columnist, journalist, and author.
Early life[edit]
Williams attended the independent Godolphin and Latymer School girls' school and read Modern History at Lincoln College, Oxford.[1] Her parents separated in 1976 and formally divorced 20 years later.[2]
Williams writes political commentary, interviews and reviews for The Guardian and the New Statesman. Her work has also appeared in other publications, including The Spectator, NOW Magazine,[3] the London Cycling Campaign's magazine London Cyclist, and the London Evening Standard where she contributed columns on a variety of subjects and a diary about being a single woman in London. She has also written restaurant reviews for The Sunday Telegraph.
Williams has also appeared as a guest on television. Clive James praised her appearance in documentary Teenage Kicks: the Search for Sophistication: "The brilliant journalist Zoe Williams did a short piece to camera that was almost an aria".[4] She has presented a radio documentary Inside the Academy School Revolution, which Miranda Sawyer found one-sided and "tame",[5] and hosted BBC Radio 4's What The Papers Say.
In May 2011 Williams admitted to fare dodging when in her 30s while travelling on London buses. She wrote "I actually had a lot of affection for bendy buses, mainly because evading your fare was so easy that to pay was almost missing the point. We used to call it freebussing."[6][7][8]
Williams describes her political views as left-wing and feminist.[citation needed] In 2014 she defended the social policy legacy of former Labour prime minister Tony Blair.[9] She sometimes covers feminist issues in her columns, and is a supporter of the British Humanist Association.[10]
She was longlisted for the Orwell Prize in 2012.[11][12] She was named Columnist of the Year 2010 at the WorkWorld Media Awards.[13]
She is the author of Bring It On, Baby: How to have a dudelike pregnancy (2010), a book of advice for mothers-to-be, which was republished in 2012 as What Not to Expect When You're Expecting.
Personal life[edit]
Williams lives in Camberwell, South London, with her husband.[14] Williams married the father of her son and daughter[15] in 2013 after ten years together and wrote about the wedding from a feminist perspective in her column for The Guardian.[16][17]
- ^ Marrin, Minette (17 May 2009). "When today's left speaks it is right-wing bigotry we hear". The Sunday Times. Archived from the original on 17 May 2009.
- ^ Williams, Zoe. "Talking heads". Marie Claire. Retrieved 10 December 2012.
- ^ "Now price cut and celeb boost follows rival launch". Press Gazette. 9 October 2002.
- ^ James, Clive (7 October 2011). "Clive James on... Grand Designs and Dragons' Den". The Telegraph (UK). London. Retrieved 10 December 2012.
- ^ Sawyer, Miranda (9 December 2012). "Rewind radio: The Kitchen Cabinet; The Budget; Inside the Academy School Revolution; Breakfast; The Atkinson People – review". The Observer (London). Retrieved 10 December 2012.
- ^ Maguire, Kevin, "Champagne or sham pain", New Statesman, 27 October 2011
- ^ Fawkes, Guido (27 October 2011). "Guardian Hack: "I'm a Dodger"". Order Order.
- ^ Zoe Williams "Boris Johnson and the Routemaster: soft edges and cheerful demeanour", The Guardian, 27 May 2011
- ^ Zoe Williams (8 April 2014). "Stop calling Tony Blair a war criminal. The left should be proud of his record". The Guardian. Retrieved 12 April 2014.
- ^ "Zoe Williams". British Humanist Association website. Retrieved 10 December 2012.
- ^ "Zoe Williams". Orwell Prize website. Retrieved 10 December 2012.
- ^ "Orwell prize: four Guardian journalists nominated". The Guardian (UK). London. 31 March 2012.
- ^ "David Cohen named reporter of the year at WorkWorld Media Awards". Press Gazette. 19 January 2011. Retrieved 10 December 2012.
- ^ "Zoe Williams: My neighbour, the Leopard Man of Peckham | Columnists". London: guardian.co.uk. Retrieved 10 December 2012.
- ^ "Live chat on parenting with Zoe Williams | Life and style". London: guardian.co.uk. 8 June 2010. Retrieved 10 December 2012.
- ^ Zoe Williams (24 August 2013). "Why I married late: a feminist's guide". The Guardian. Retrieved 17 October 2013.
- ^ Zoe Williams (11 April 2008). "Zoe Williams: My boyfriend is right | Life and style". London: The Guardian. Retrieved 10 December 2012.


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|We've played three all-ages shows in a row, and all three have been a gas. Andy's smoking has gotten so bad, it's the first thing he does each morning - roll over and light one of these trashy Canadian cigarettes. It's a little disgusting. I pray for it to end. He smokes all day and complains about it all day. Goodness! Let this be a lesson to you all!
Okay, today is a long drive so I'm gonna can it at that. We're under the gun. Apologies.
Back to the list


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About Us
Lumetra Healthcare Solutions solves healthcare business problems with an integrated clinical, analytical, and technological approach that reduces complexity and costs while improving patient outcomes. With over 30 years experience Lumetra has evolved to meet the changing needs of the healthcare industry; focusing on clinical quality improvement, independent peer review, clinical data analytics and health information technology.
Lumetra offers clients enhanced value through the integration of diverse skill sets. Our services target improving care delivered to patients, implementing clinical efficiencies and improving outcomes across the continuum of care.
With a longstanding record of performance and a reputation for integrity, Lumetra is a trusted partner, known for our commitment to improving the delivery of healthcare services and for our dedication to applying the highest standards of excellence to achieving the goals of our clients.
As a URAC-accredited Independent Review Organization (IRO) and a designated QIO-like entity, Lumetra maintains a diverse range of clients on the local, national, and international level. Our affiliation with IPRO, a New York based, national healthcare assessment and improvement organization, strengthens our service offerings to our clients.
Lumetra is recognized by the Internal Revenue Service as a tax-exempt, non-profit 501(c)(6) entity, organized as a mutual benefit corporation.


text:
Vijay Sai
A Desperate Cry - Poem by Vijay Sai
God's creation
Blessed to be born in this world
We all may feel that's the truth
Until I read this-
An abandoned baby
Malnourished, hardly an year old
Famine struck
Skin and bone
No food to feed
No water to have
Stranded alone in barren land
Helpless eyes staring straight
Standing legs more like a bamboo stick
Cerebral neurons popping out
Veins struggling to carry weak blood
Oh God! Nothing more I can add…
My heart is not strong enough
To read the rest-
A vampire vulture
Sitting beside and
Looking eager to end its hunger!
I pray! Save these innocents!
Let this never happen again!
Comments about A Desperate Cry by Vijay Sai
Benjamin Wiche (8/23/2016 8:51:00 AM)
Add no more,
God show mercy
for this sore
our soul need not see
God show mercy....
nice one (Report) Reply
Edward Kofi Louis (11/1/2015 8:28:00 AM)
The earth is full of the negative works of mankind. Nice work. (Report) Reply
Anish Debnath (10/14/2015 6:20:00 AM)
god's creation is a blessing.
But depending on where we are born,
somebody could continue with blessings
somebody with curse
It is really a hard truth of feelings reflecting in your verse.
Thanks for sharing. (Report) Reply
Sophy Chen (9/26/2015 7:23:00 AM)
An abandoned baby
Malnourished, hardly an year old
Famine struck
Skin and bone
No food to feed
No water to have
sad on this baby
where did you met this situation oh!
so sad, and i think the government should deal with this and his parents should not give birth him if they can not give him enough food!
Sophy Chen form China (Report) Reply
Stephen Pennell (9/16/2015 2:56:00 PM)
Very strong subject and conveys a lot of feelings, personally I wonder how gods can let these things happen but a good poem cheers (Report) Reply
Neela Nath Das (8/24/2014 9:51:00 AM)
Congrats.It shocks us very much.But this is the real picture. (Report) Reply
Chris Zachariou (7/10/2014 6:56:00 AM)
Another great poem from you that shocks the senses with its description of life for the very poor of this world. Living in a rich society I cannot help but have a feeling of guilt when I read such powerful words. (Report) Reply
Chris Zachariou (7/10/2014 6:54:00 AM)
Another great poem from you that shocks the senses with its description of life for the very poor of this world. Living in a rich society I cannot help but have a feeling of guilt when I read such powerful words. (Report) Reply
Susmit Panda (6/20/2014 10:56:00 PM)
Let there be a little optimism in your lyrics, like sweet stars in the night sky. (Report) Reply
Momodou Jarju (6/8/2014 8:22:00 AM)
This a wonderful piece Sai, i love it. It so emotional and touching. It's also picturesque, keep on pushing the pen you are good. (Report) Reply
Eugene Levich (5/31/2014 7:55:00 AM)
But it will happen again... and again... and again - probably forever. Why is life so brutal and unfair? An unanswerable question! But a very beautiful and thought-provoking poem! Thank you, Vijay! (Report) Reply
Paul Sebastian (4/22/2014 2:54:00 AM)
Thought provoking. You have a beautiful flair for writing poems. You are a blessing for many. Keep on writing! ! (Report) Reply
Gangadharan Nair Pulingat (4/22/2014 1:43:00 AM)
a poem pertaining the saddest thing that doesn't supposed to happen in a responsible world. The concern of the poet is expressed with anguish and sadness in perfect words and poem is good. (Report) Reply
Rich Persoff (4/22/2014 12:47:00 AM)
Not Cricket Safari - A Desperate Cry. This is not a comment about your heartfelt poem: I do understand your rage, pain, and grief. Sadly, we live in a world where there is not enough food, land, water, or work suited to people's abilities (e.g., though we need many teachers, not that many people have the qualities that would enable them to become good teachers) for everyone to lead a humane life. Even if everyone like you and me, with a little more, were to share to the point of impoverishing ourselves and our families, we would do no more than become another of the innocents. Even distributing the wealth of all the billionaires would only buy a few months' bread, and then the picture continues. As noted by others, poor societies which permit themselves the luxury of having children condemn themselves to destitution. (Report) Reply
Anubhav Gupta (4/22/2014 12:07:00 AM)
a good work, the explanation was deep. and if ever we see such situation we ought to help them. (Report) Reply
Jasbir Chatterjee (4/21/2014 11:16:00 PM)
Good poem...But crying helplessly while an abandoned baby is swallowed up by the vampires is of no use really to the society...We writers and poets ought to play a more active role... (Report) Reply
Cynthia Buhain-baello (4/21/2014 8:43:00 PM)
Simple minds look at situations and ask Who's to blame? Average minds assess them and ask Why did this happen? While great minds weigh the conditions and say How can we solve it? The poem speaks of an abandoned baby and clearly there were two people who made this human being and one mother who deserted him. Having a child is a responsibility and cultures must realize they cannot just breed and leave them to nature. Poverty is a culture's mindset and a nation can only release itself from Poverty by changing its mindset and make the people WORK. Making children and then asking others to feed them is not the way. As writers I think we need to weigh facts and present them logically using our skills to present a cause. We cannot just appeal to emotions and neglect what needs to be addressed, or else we bark at the wrong tree. A very emotional poem -(God is not to blame.) (Report) Reply
Geetha Jayakumar (4/21/2014 3:04:00 PM)
Very beautifully you have captured...A Desperate Cry... True picture you have portrayed in each lines.. Loved reading it.
Congrats.....for this lovely poem being selected as member poem. Thanks for sharing. (Report) Reply
Francis Lynch (4/21/2014 11:11:00 AM)
And who is to blame for this atrocity? We, the writers, speakers, voters. And it continues. Always. (Report) Reply
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On the evening of Tuesday, May 28 MeLCat will be down in order to perform several hours of routine maintenance.
– Patrons will not be able to search MeLCat or place new requests on MeLCat.
– MyMeLCat link will not be operational
– The ability to search multiple MeL Databases at the same time will be unavailable.
Thank you for your patience and we apologize for any inconvenience.


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APOLLO TOOLS 101 PIECE MECHANICS TOOL KIT - DT0006Item#: AEL-102371211 | Model#: DT0006
Currently Out Of Stock!
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101 PIECE MECHANICS TOOL KIT Product Details
Contains:Eight SAE Hex Keys, Twelve 3/8"
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text:
UK pulls the plug on saving energy
14 June 2012
WWF-UK today criticised the Government for 'cynically undermining' the European Union's Energy Efficiency Directive (EED), saying that the Government's position had 'effectively scuppered' the potential for energy savings across Europe.
Late last night the European Parliament, Council and Commission agreed the new EED, but failed to put in place the measures needed to reach the EU's 20% energy savings target by 2020 with the UK being instrumental in watering down the proposals.
In stark contrast to the UK's leadership on the need for 30% carbon reductions across Europe by 2020 the UK dug its heels in and insisted on changes to the EED that effectively provided the UK with get-out clauses.
Zoe Leader, energy efficiency policy officer at WWF-UK, said: "This unambitious deal shines a light on the UK's real attitude to energy efficiency. Despite plenty of rhetoric from the Government on the importance of energy efficiency their position throughout the negotiations has effectively scuppered the potential for real energy savings across Europe. It seems they are happy to talk the talk but not to walk the walk.
"If the UK Government is serious about building a low carbon economy then they need to stop cynically undermining measures, like the EED, that would bring real benefits in this area. Investing in energy efficiency would result in more jobs, lower bills and cuts in carbon, and it's essential we make this a cornerstone of UK energy policy. We can't afford not to."
The 20% energy savings target remains non-binding in the final text and thanks to the UK's efforts the 20% target amounts to much less with Member States being able to count action before and after the 6 year lifetime of the target. The only saving grace in the final text is that the energy savings obligations will be subject to a review in 2016 with the Commission able to make changes if Member States are failing to meet the target.
The building renovation provisions are especially weak when compared to the potential for energy savings in this sector with obligations limited to buildings owned and occupied by central governments only. The Parliament's suggestion to introduce roadmaps for reducing the energy consumption of the building sector by 80% has been turned into vague national strategies.
The new Energy Efficiency Directive will make some improvements to current EU policy, like a reference to deep renovations, but additional measures and efforts are still urgently needed to realize the full benefits of energy savings for citizens and businesses.
For more information:
George Smeeton, Senior Press Officer WWF-UK
Tel: 01483 412 388, Mob: 07917 052 948, email: email@example.com


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The purpose of the journal is to publish work that materializes theoretical renderings of, and practical approaches to culture. In particular, Kritikos seeks to publish work that is focused upon the currency of the postmodern period.
Kritikos publishes material continuously; please allow 1-3 months for review. Articles should be submitted in MSWord format and be between 3-5K words in length; book reviews should be between 500-1000 words.
Video and images should be submitted in commonly utilized formats. (e.g., MP3, AVI, Real Audio, MPEG,Windows Media, .JPG, .GIF, .WAV, etc.)
Send submissions via email or post to the address below.


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Community Programs
UCI Law is committed to encouraging and supporting students from disadvantaged backgrounds who may be interested in pursuing or learning more about a career as an attorney. Two programs are currently supported by UCI Law staff, faculty, and students: Saturday Academy of Law and the Pre-Law Outreach Program.
Saturday Academy of Law
This program is available to 9th grade students in the Santa Ana Unified School District who have demonstrated academic promise by maintaining a 2.5 GPA. Students are exposed to critical thinking and legal doctrine during Saturday morning sessions offered in both fall and spring.
Pre-Law Outreach Program
POP is a "pipeline" program to encourage undergraduate college students from disadvantaged backgrounds to enter the practice of law, and give them the tools to be successful in their pursuit. The program runs over six Saturdays each summer.


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Follow Us
Related Posts
Six trending tips
By Elizabeth Giles on Apr 30, 2012 in Insight
We already touched on the takeaways from this year's Apartment Internet Marketing conference but leaving such an event without forwarding on a few of the highlighted websites and resources presented would be remiss. Here's the list of trending don't-miss sites that may be useful for you and your business.
- Unroll.me: Unroll.me is a simple (very simple) way of managing your inbox. You can unsubscribe from pestering emails, discover new emails you didn't know you needed yet, and organize them all in one place.
- "Click-to-call" Call Extensions by Google: The idea that prospects who call your business are further along in the purchasing decision than those that just visit your site is the driving force behind Google's Click-to-Call service. Call Extensions allow businesses using ad-words to include a clickable phone number in their mobile ads rather than just a web address, ideally driving even more qualified leads.
- ToneCheck: Seemingly similar to the way your social media monitoring solution can provide insight to the online sentiment of your company using semantics and context, ToneCheck works with your existing email to do a quick pre-send check and make sure you're not saying something you'll regret. It's free and could save you from an accidental misunderstanding.
- Project MintChip: Consider this, with the growth of online payment options how will that translate into the offline world? The Royal Canadian Mint is working hard to answer that question and they hope that you'll join The Challenge.
- Responsive design: Recent statistics estimate that mobile devices account for 8.49 percent of global website hits. Responsive design is a concept that doesn't just allow for a mobile friendly website but allows you to deliver the best user experience by creating a site that reacts and shifts based on the visitors' available screen.
- ZMOT: Your prospects are all "digital explorers" according to Google and marketing has evolved to capture their constantly evolving attention span. Google has coined the online decision-making moment the "Zero Moment of Truth." Winning in that moment is the difference between being Google and being AOL. Download their free eBook and see if you can pick up tips to maximize your ZMOT moment.
Will you use any of these services or resources? If we left out one of your new favorites, please share by leaving a comment.


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Near MTNL, Rajouri Garden, Delhi, Delhi, 110027 Movie Theatres Cinemas
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Needle Exchange Program
Authorized by Title 29, Section 7993 of the Delaware Code, the goal of this program is to keep Injected Drug Users (IDUs) as healthy as possible while encouraging substance abuse treatment and enrolling HIV infected clients into medical and case management services. Keeping IDUs free of HIV, Hepatitis C and other blood borne pathogens also protects their wives, husbands, and families, who may not be aware of the drug use of their partners. Registered members of Wilmington's Needle Exchange Program (NEP) are exempt from Delaware's paraphernalia laws for possession of hypodermic needles.
Who is Eligible:
- An active injected drug user.
- At least 14 years of age.
- A resident of the city of Wilmington.
To Exchange Needles You Must:
- Turn in one used needle for each new needle. (5 used ones for 5 new ones, 10 used ones for 10 new ones, etc.)
- Bring old/used needles in a plastic container (an empty soda bottle, clear if possible, sharps container or coffee can will work)
- If you do not have a container, bundle 5 used needles together with a rubber band all facing the same way.
When & Where:
- The service is provided on a mobile van at sites throughout Wilmington.
- New sites will be added throughout the first 6 months of 2007.
- It is best to call or access the website for information and to find the service site closest to you.
Contact Information:
Phone: (302) 655-9880, extension 22
Website: Brandywine Counseling
Mail: Brandywine Counseling Inc
2713 Lancaster Avenue
Wilmington, Delaware 19805


text:
Fall Color Inspiration: Golden Yellow Interiors
- The dining room in this East Hampton residence designed by Rafael de Cardenas seems to radiate warmth on Seesaw.
- A Dutch wool blanket in golden hues adorns the wall above a bed made of honey colored wood, and seems to emanate warmth, via Martha Stewart.
- A bit of sunshine graces the walls of this living room featured in Elle Decor.
- Even just a bit of golden yellow brightens a room and makes everything a bit more lively. As seen on House to Home.
- A modern room is warmed up by a bit of golden warmth, in spite of it's cool minimalism. Featured on Room Decorating Ideas.
Images: As credited above.


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BIRMINGHAM, Alabama -- As of this afternoon, Birmingham's Phillips Academy is officially an International Baccalaureate school.
Principal Mark Sullivan said he received official word today that the school had been admitted into the IB Primary Years program for its kindergarten-through-fifth-grade students.
"We have a lot of negative press in the Birmingham school system but this really shows the school system is turning around and that the people of Birmingham city schools mean business," Sullivan said this afternoon. "Our teachers have been working overtime to make this happen, and our kids are really proud of being a part of all of this."
Phillips is the first public school in the Birmingham-metro area to have an IB program in the primary years. Cornerstone Schools of Alabama, a private school in Woodlawn, was named an IB Primary Years school this year as well.
In February, Birmingham's Ramsay High School was admitted into the IB Diploma Program for its 11th and 12th grades and began the program this fall.
Two years ago, Phillips Academy and Ramsay High schools applied to become IB schools. The Primary Years program runs through fifth grade; the Middle Years program is for grades six through 10; and the Diploma Program is for grades 11 and 12.
The Middle School program is still a year away from being authorized.
"We are certainly excited and proud of Phillips Academy in this accomplishment," said Birmingham Superintendent Craig Witherspoon. "This means a lot for students who have an opportunity to participate in this curriculum. In addition, it means a lot to Birmingham city schools as to what we offer in our school system."
The IB program is rigorous, requiring not only core courses such as language, social studies, math and science, but also technology, arts and personal, social and physical education. It also requires that students in the program learn a second language and perform community service once a month. It takes two full years to become an IB school.
Jefferson County offers an IB program at Shades Valley High School, and Hoover High School also has the IB program. If all three grade levels are accepted into the IB program, Birmingham would be the second district in the state and the first in the Birmingham-metro area to offer IB from kindergarten through the 12th grade.
Updated at 6:24 p.m. to include Superintendent Craig Witherspoon's comments.


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Best route map between Albany, NY and Punta Gorda, FL. This route take about 1363 Miles.
The distance and estimated time is placed on the right depending on the status of the road.
, 21:49
* You can see Albany, NY and Punta Gorda, FL photos above. We provide this photos from Google Panoramio service.
* Albany, NY weather as celsius: °C
* Punta Gorda, FL weather as celsius: °C
* Weather information on route, provide by Open Weather Map.
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Is your resume in need of a little disruption?
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StartUpHire is the place to find Technical-Writer jobs in and near . Review the list below of Technical-Writer jobs. These Technical-Writer jobs represent some of the most rewarding careers available. You can refine your job search for Technical-Writer jobs in by adding a job title, company name, or keyword to the search box above … or click the "Advanced Search" link for more options. Don't see the employment opportunity you're looking for? Check back soon for more Technical-Writer jobs in , or sign up for an email alert (link in upper left) to receive periodic updates on new Technical-Writer jobs in , .
What does Aras Development do? Aras Development is responsible for developing, testing, supporting and maintaining a suite of applications based on Aras Innovator development framework. We are a process oriented team with a focus on core engineering principles. Our team is8/23/2016 Andover, MA Save This Job
Location: Portland, Oregon APPLY Technical Writer - CONTRACT POSITION ABOUT JIVE SOFTWARE Jive Software is the leading provider of modern communication and collaboration solutions for business. Our products empower people and organizations to work better together, using9/23/2016 Portland, OR Save This Job
Technical Writer - SP Scientific Location: Gardiner, NY Schedule: Monday - Friday, 8:00 AM to 5:00 PM FLSA Status: Salaried Exempt SP Industries is seeking an entry-level Technical Writer to create and manage the delivery of various technical documents (e.g. user manuals,8/17/2016 Gardiner, NY Save This Job
Documentation San Jose, CA, United States Apply Send Jobvite This position represents an opportunity to join a very fast-paced startup company that is developing both proprietary and open source Big Data products. MapR Technologies is looking for a talented, motivated9/27/2016 San Jose, CA Save This Job
Join the Subscription Revolution! Zuora is the hottest SaaS Company in the Silicon Valley. We were built to change the way people do business and fuel the Subscription Economy. In just 4 years, we have been on a high growth trajectory and one of the fastest growing SaaS companies8/27/2016 San Francisco, CA Save This Job
WebsiteFirstBest FirstBest Systems is looking for a software technical writer. In this role you will develop accurate, user-friendly product documentation including user guides, developer guides, help systems and release notes. To be successful, you must be self-motivated,8/9/2016 Bedford, MA Save This Job
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Location: Warminster, PA Schedule: Monday - Friday, 8:00 AM to 5:00 PM FLSA Status: Salaried Exempt SP Industries is seeking an entry-level Technical Writer to create and manage the delivery of various technical documents (e.g. user manuals, equipment specifications, testing8/17/2016 Warminster, PA Save This Job
Engineering Kent, WA, United States Apply Send Jobvite We are seeking motivated candidates in pursuit of career growth. At Novinium you?ll find that our culture is fueled by fun and teamwork. We are driven to succeed and our core values of safety, quality, integrity, innovation8/14/2016 Kent, WA Save This Job
Redwood City, CA Technical Writer (Contract) San Jose, CA IMVU is seeking an experienced technical writer with a background in adopting and working with Confluence. This individual will help champion the culture of creating and maintaining better documentation practices and9/23/2016 Redwood City, CA Save This Job
Technical Writer -Policy and Procedure Specialist If you are a Technical Writer who's itching to join a leading edge company, you should explore an exceptional opportunity with Webroot. As the Technical Writer, you will hold a very crucial position as you join a team that will8/30/2016 Broomfield, CO Save This Job
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New York City or Palo Alto MongoDB is looking for intelligent, curious, and articulate technical writers to join its Documentation team! The Documentation team exists to work with technical staff and customers alike to provide the best possible experience to users of MongoDB. We8/8/2016 New York, NY Save This Job
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Alameda, CA, US Job Class Corporate Mission Singulex is a commercial stage, privately held company pioneering Next Generation immunodiagnostics (NGI). Singulex?s provides unprecedented ultra-sensitivity in the precision measurement of biomarkers. Such reliable ultra-sensitive9/29/2016 Alameda, CA Save This Job


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711 Franklin St., Tampa, FL 33672
A series of films with lesbian, gay, bisexual and transgender interest or subject matters. Runs through Oct. 8 at several venues.Ticket packages range from $50-$5,000. See tiglff.com for lineup.
Price: $15; free for 25 and younger for age-appropriate films.
Phone: (813) 274-8982
More in this neighborhood: Downtown TampaMore dates for this event:


text:
As Immunotherapy Revolutionizes the Cancer Treatment...
Developers of DTC Genetic Testing Are...
Wall Street Decline Takes Its Toll...
LC-MS Gains Favor Due To the...
Quantitative PCR (qPCR) technologies have exploded in the last decade. Commonly used for both diagnostics and basic research, new and exciting advances are being made in such areas as biomarker discovery and treatment monitoring. This rapid growth has also come with some problems, including what to call it. The technology is variously known as real-time PCR, real-time qPCR (RT-qPCR), qRT-PCR, and several other incarnations.
A new movement is under way that provides qPCR guidelines, not only for more consistent terminology, but also for more reliable experimental practice. Additionally, researchers are developing new ways to overcome obstacles in experimental designs and data analysis. Presenters at Select Biosciences' "Advances in qPCR", held recently in Berlin, described innovations as well as new strategies for overcoming bottlenecks.
The remarkable success and popularity of qPCR has also come with an assortment of challenges, according to Ivan Delgado, Ph.D., application scientist at Helixis. Dr. Delgado discussed a recent initiative designed to help ensure data relevance, accuracy, correct interpretation, and repeatability.
"In 2008 over 18,000 publications referenced qPCR. While most scientists demonstrate appropriate practice, some have failed to use this technique appropriately. A consortium of well-known researchers developed and recently published guidelines designed to provide a comprehensive toolkit for more uniformly performing and reporting qPCR data. As is often the case, the trick is in the details."
The so-called MIQE (pronounced mykee) guidelines provide a recommended checklist for performing assays as well as documentation to accompany journal submissions (see August 2009 GEN, page 40).
"MIQE consists of 85 guidelines that can be quite daunting for scientists new to qPCR," Dr. Delgado reported. "There is no question that many of these guidelines are definitely critical to generating reliable data, yet some are desirable best-practice. The next step for our community is to establish how to integrate these guidelines practically and seamlessly into everyday science."
Two of the most critical guidelines address assay validation and template quality assessment. "It is important to assess the performance of the qPCR assay itself," Dr. Delgado said. "For example, what is the efficiency of the reaction, the linear dynamic range, limit of detection, and the precision? qPCR reactions should first be validated by running a standard curve to evaluate the efficiency of the assay. Another important consideration is the need for good quality control of the nucleic acid samples, in particular RNA. Accurate quantification and quality assessments are needed to be sure of the input and integrity of the RNA in the sample."
Judy Macemon, vp of marketing at Helixis, added that, although the guidelines are voluntary, many in the field believe that implementing the recommendations is good practice. "We are working closely with the guideline developers to make it easier for scientists to adopt them. Our new real-time PCR system software meets all of the MIQE guidelines. And the new Helixis instrument has been designated the first real-time PCR system to provide a MIQE-compliant solution."
"Junk in, junk out" goes the saying indicating the importance of good starting material. The same applies for data generated by qPCR, according to Ramon Goni, Ph.D., head of the qPCR division at Integromics.
"In our projects, we understood the critical need for checking datasets before they are analyzed," Dr. Goni said. "Data analysis is only as good as the input data. So, even a correct analysis can produce wrong results if the input data has errors. Our strategy is to provide a workflow that minimizes discretional criteria and human input and instead interfaces directly with instrumentation and provides multilevel analyses."
One of the company's flagship products, RealTime StatMiner®, was designed with quality control in mind. It not only integrates filtering criteria, it automatically selects the best endogenous control. "We have designed this solution to allow great confidence in the analysis of experimental data because of built-in quality control measures," Dr. Goni said.
"For example, the heatmap representation can immediately highlight sample outliers as well as find poor correlations with other samples under the same biological conditions. Also, the user can navigate gene by gene to assess the quality of replicates. It is compatible with all of Applied Biosystems' RT-qPCR platforms and works with TaqMan® and SYBR® Green studies."
Dr. Goni presented experimental data at the meeting that described the company's completed studies utilizing tissue from patients with chronic obstructive pulmonary disease. "It is important to characterize the intactness of patient samples. We utilized RealTimeStatMiner to identify samples with mRNA degradation and outliers in measurements. This allowed us not only to validate the conclusions of the qPCR project, but, more importantly, to help optimize results. We've just submitted our data for publication."
The company continues to expand and refine the software. "After every congress and meeting, we always come up with new ideas and new challenges. Methods continue to change, so it's important to continually update your product."
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text:
Rainout Again!
Aug. 27, 2005
Huntington, W.Va. - For the second day in a row, the weather has been uncooperative in southwestern West Virginia and the participants were again unable to get in the opening round of Marshall University'sThundering Herd Nike Classic Tournament.
The games, matches between Jacksonville and Pittsburgh and between the Dukes and host Marshall, originally scheduled for Friday night, had been postponed until today. However, continued poor weather conditions has cancelled these matches.
The forecast is that the heavy rain will end Saturday afternoon. Chances of showers will continue past sunset and end in the late evening. Sunday is expected to be much better, partly cloudy with highs in the upper 80s.
Sunday's games with follow the original schedule. Duquesne (9-10-1, 4-6-1 A-10) will face Jacksonville (5-9-5, 3-3-4 Atlantic Sun) at 11:30 a.m. followed by host Marshall (3-13-3, 0-11-1 MAC) versus Pittsburgh (6-10-1, 2-7-1 Big East) at 2:00 p.m.


text: BRIDE AND GROOM GOOD VOODOO DOLLS | Funny Wedding Wishes | UncommonGoods Flag this deal What's the matter? Choose a reason Dead deal Duplicate Bad link Spam Inaccurate No value Alive again Edit deal ArtemisDeals Jan 14, 2013 I would have to say that this is a very interesting item. Thanks for sharing :) Reply Load More Comments


text:
Joann Sheets was in the deli, halfway into her cheesesteak sandwich, when the bell on the door of the adjacent grocery store jingled, indicating that a customer had entered.
She noticed the manager was absent and the grocery store cashier was busy serving customers in the deli.
Sheets, a regular, put down her cheesesteak, headed up the two steps connecting the deli to the grocery, positioned herself behind the cash register, rang up the customer's items, bade her farewell and returned to finish her sandwich.