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Newegg.com - A great place to buy computers, computer parts, electronics, software, accessories, and DVDs online. With great prices, fast shipping, and top-rated customer service - once you know, you Newegg.
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The easy-to-read Luminox Mens Black Ops watch glows 100 times brighter than other luminous watches, making it the perfect timepiece for low-light or non-light situations. This timepiece is constructed with a stainless steel, 45-millimeter case, a durable stainless steel band with fold-over clasp and safety mechanism, and an antireflective-sapphire dial window, perfect for late-night escapades. White Arabic numerals adorn the classic black dial face, while the black stainless steel bezel is unidirectional, textured, and adorned with white minute indexes for easy readability. Smaller white numbers inside the dial mark the standard 24-hour clock and a date calendar rests at the three o'clock position. Powered by analog-quartz movement, this watch is preferred by US Navy SEALs and US Air Force Pilots, and is water resistant to a depth of 660 feet.
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Mix three or four drops of almond oil with lavender and chamomile oil and massage the area affected from this mixture. It will probably lower scars as well rejuvenate sensitive skin.
Try to think of your epidermis as an official rubber band; when pulled that includes a lot or force or stretched to any extended period, very easy regain its original form nevertheless had comments appearing. The same thing happens whilst skin, you are able to being drastically stretched by e.g. an escalating baby rrnside the belly, it acquires tears. The sudden release from stretching at childbirth only will make the tears more pronounced as is also now unsupported and probably sagging.
One of the most useful what to experience your skin type to improve blemishes down to pregnancy: Castor oil between the best what kids experience the skin take moisture and aid it in redeveloping new skin tissue to heal the scars and blemishes. Contact the region at least a day, preferably after showering and before sleeping.

subset: commoncrawl


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Retail Remedy: Christmas in Paris by way of Galeries Lafayette, Printemps, Le Bon Marche Paris Holiday windows.. You know how I believe that Paris is where you find it is and that special chic lies inside of us all. Richard Nahem is an expat New Yorker who has been making Paris his home for the past nine years as a Paris insider blogger and personal concierge tour guide. Richard brings his take on Parisian Chic Anywhere! as one of the featured Bonus Experts in my C'est…
Tag Archives | Galeries Lafayette
Galeries Lafayette Paris Holiday Windows Loves Louis Vuitton
Retail Remedy: Our tour of Paris holiday windows continues with Galeries Lafayette, which kinda sorta reminds us of a not quite as elaborate version of Bergdorf Goodman's New York windows from a few season's back. Or, a tad of Le Musée de la Chasse et de la Nature in Paris gone fashionista. Let's see Richard Nahem's report. Galeries Lafayette Paris Christmas windows have also been hijacked by a mega-brand fashion label, Louis Vuitton, but at least they are more kid friendly than Printemps this year….
Tres French Chic Store Windows Approved by La Parisienne Ines de la Fressange
Retail Remedy: A homage to the stylish women of Paris Who better than French style icon Inès de la Fressange to be the ambassador for La Parisienne? That's the event at Galeries Lafayette department store to promote the stylish, urban women of Paris. Inès de la Fressange is a former top model, a muse to Karl Lagerfeld, and once the visage of Marianne, the national emblem of France. More recently she is also had a successful career as a designer,…
Christmas Windows Paris- Galeries Lafayette & Printemps
Christmas Windows Paris- Galeries Lafayette & Printemps


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realmagick.com The shrine of knowledge.
Chinook Salmon Appearance
A selection of articles related to chinook salmon appearance.
Original articles from our library related to the Chinook Salmon Appearance. See Table of Contents for further available material (downloadable resources) on Chinook Salmon Appearance.
- Survivalists' Guide for the New Millennium: Chapter 4
- THE TRANSFORMATION OF CATERPILLAR TO BUTTERFLY It is not difficult to see that the whole Agenda behind owning a bigger home, a newer car and more land is one of ego. This is an orientation toward the building of an empire of material wealth, in a vain...
Philosophy >> Survivalists Guide for the New Millennium
- Astral Beings and Wildlife
- The astral dimension contains a wide variety of what could be called non-physical subtle energy life-forms; or as Carlos Castenada so aptly calls them: inorganic beings. Some of these have a positive nature (nice) and some seem have a negative nature (not so...
Parapsychology >> Astral Projection
- What is hypnotic trance? Does it provide unusual physical or mental capacities?
- 2.1 'Trance;' descriptive or misleading? Most of the classical notions of hypnosis have long held that hypnosis was special in some way from other types of interpersonal communication and that an induction (preparatory process considered by some to be...
Parapsychology >> Hypnosis
- Bringing it Down to Earth: A Fractal Approach
- 'Clouds are not spheres, mountains are not cones, coastlines are not circles, and bark is not smooth, nor does lightning travel in a straight line.' B. Mandelbrot W e want to think about the future - it's our nature. Unlike other creatures, humans possess an...
Mystic Sciences >> Astrology
- Persephone - An Intutitive View
- Persephone is a Goddess whose history has been mainly inferred from ancient mythological placement of her as Demeter's daughter and Hades wife. She has rarely been addressed outside of the context of her connection to these two more infamous individuals....
Deities & Heros >> Greek
- Question the Premises of Society and Science
- Question the ultimate validity of the basic premises of society, in particular, scientific theory. Do not accept concepts or statements as truthful simply due to weight of tradition or learned opinion. The synthesis of these statements is a healthy skepticism...
Religion & Philosophy >> Philosophy
Chinook Salmon Appearance is described in multiple online sources, as addition to our editors' articles, see section below for printable documents, Chinook Salmon Appearance books and related discussion.
Suggested News Resources
- The art of migration: Whitehorse artist focuses on shifting species
- Leon said the Arctic tern's appearance always reminds her of Salvador Dali's work, especially because he often painted birds with long wings and tails. "I always thought they looked like a ...
- Monterey: A deep dive into epicenter of seafood sustainability
- Its ever-evolving and sustainability-touting Cooking for Solutions events are a festive way to soak up what's best about "smart sourcing," via tastings, special dinners, cooking demos and celebrity chef appearances.
- Unusual fish found near shores of Shuswap Lake startles residents, government
- Concerns were alleviated when the fish was identified as a Bichir, an African species similar in appearance to a Snakehead, but unlikely to survive in the local climate for very long. Bichirs are aquarium fish and can be bought online ...
- Mohawks streak comes at right time
- On Friday they beat Chinook 105-61, led by 21 points from Gerad Wagenaar and 17 from Darin Parker. Nick Myndio had 26 for the winless Coyotes. At home Saturday Hat High beat LCI's Rams 100-87, getting at least eight points from eight different sources.
- 'Beautiful' chinook salmon at Whitehorse fish ladder
- The Whitehorse fish ladder is now closed for another season, which has officials assessing the kind of salmon run it's been this year. They say it was average in terms of numbers, but the physical condition of the fish is what was noteworthy.
Great care has been taken to prepare the information on this page. Elements of the content come from factual and lexical knowledge databases, realmagick.com library and third-party sources. We appreciate your suggestions and comments on further improvements of the site.
Chinook Salmon Appearance Topics
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Bottle opener custom keychains are made of aluminum and is laser engraved to last as lifetime!
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CRANFORD — Centennial Avenue between Lincoln and South avenues is closed today, Oct. 2, for road work. Drivers should expect delays, Cranford Police said.
The Garden State Parkway ramp at Exit 136 will be accessible to all traffic (northbound and southbound) during construction with the use of the pre-planned detour routes.
The section of Centennial Avenue from Lincoln Avenue to Wall Street will remain open during this roadwork. Access to Hillside Avenue School, Lincoln Avenue School, and all businesses will be maintained throughout this project.
Up-to-date information on the roadwork is available at of the Union County government website.
More Cranford News: NJ.com/Cranford • Twitter


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Nightingale LXO Mid Back Mesh Office Chair With Adjustable Arms
Free Shipping!
This product typically ships within 10-15 business days more details
Shipping Instructions
This item includes free shipping in the contiguous United States. Most orders will ship via UPS or FedEx Ground. Orders for large items or multiple item orders will ship via freight carriers such as Roadway, Road Runner, and FedEx Freight.
Freight Delivery Instructions
When the items are delivered it is the customer's responsibility to inspect all cartons and items to make sure that there is no visible damage or missing packages. If there is damage or missing packages, make sure to note it on the delivery receipt or bill of lading. If this is not noted on the bill of lading the cost to replace damaged items will be the customers responsiblity. Make sure to retain a copy for your records as well. Please contact us immediately at 866-733-0698 so that we can arrange for replacements to be sent out.
Shipping Glossary
- Loading dock - This service is available to companies that have a loading dock at their facility. This service is free!
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- Lift gate - The driver will unload the items from the back of the truck for you but you will be responsible for bringing them into the location.
- Residential freight - This service is available to residential (home) deliveries. The items will be delivered by a freight truck. The items will be brought down from the back of the truck for you but you will be responsible for bringing the items into the residence.
- Inside delivery - Will only be dropped off inside the threshold of the front door.
- Description
- Colors
- Reviews
6000 Specifications
Overall Dimensions: 26"W x 24"D x 36 1/2" - 41"H
Seat Size: 19"W x 18.5-19.5"D x 17"-22.5"H
Weight: 50 lbs.
Ships Ready to Assemble
Nightingale LXO Mid Back Office Chair Features
- Color options change the seat color only! The back is only available in black
- Translucent ABLEX™ patterned weave mesh back provides generous lumbar support while allowing dynamic back movement. Allows air to pass freely, making it comfortable in all climates.
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- Energy absorbing ENERSORB™ seat foam reduces sitting fatigue by minimizing pressure points and increasing blood circulation perforated 4-way stretch mystic fabric provides maximum durability and exceptional airflow
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- Waterfall seat design that gently slopes away from the legs minimizing pressure on the thighs, promoting good posture
- Easy to use, height adjustable arms with intuitive finger-tip trigger for individual comfort and support. The arms can be manually adjusted for horizontal width
- Back depth adjustment allowing for greater seating depth for those requiring more leg support
- 5 prong heavy duty nylon base
- 2" Mag wheel carpets casters
- California Fire Code #117
- Meets or exceeds ANSI/BIFMA standards
Nightingale Lifetime Limited Warranty:
- Lifetime Limited: All non-moving metal parts
- 10 years: Control mechanisms, casters, pneumatic cylinders, self-skinned urethane parts, and plastic shells
- 5 years: Upholstery
*Please note that all Nightingale items are made to order and cannot be returned.
Color Swatches
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realmagick.com The shrine of knowledge.
Remington 700
A selection of articles related to remington 700.
Original articles from our library related to the Remington 700. See Table of Contents for further available material (downloadable resources) on Remington 700.
- Path/Peteh
- Ptah, Peteh, 'South of His Wall', 'The Ancient One', worshipped in Mennefer (Gr: Memphis) already in the early dynastic period, probably at first as the local patron of craftsmanship, his High Priest in Mennefer was titled 'Greatest of the controllers of...
Deities & Heros >> Egyptian
- The Truth Behind the History of the Necronomicon
- I don't think there are many people out there who haven't heard of the Necronomicon and the dreadful things connected with it. We've all heard the theories about how it is a Satanist tool; actual copies of the book are bound in human skin and how you risk...
Deities & Heros >> Chthulu
- Story of the Celts: The Ancient Celts
- The Ancient Celts [ 8 ] What is surprising to most modern readers is just how widespread across Europe the Celts once were. The Celts have been called the "Fathers of Europe," that is north of the Greco-Roman Mediterranean. Long before the Germanic...
History & Anthropology >> Celtic & Irish
- Story of the Celts: The Celts Today
- The Celts Today [ 40 ] The Celts, and Celtic peoples, are alive and well today. Celtic culture is well documented and preserved, and there are millions of people on different continents who make it a point to identify with that culture. In Ireland Irish...
History & Anthropology >> Celtic & Irish
- The Necronomicon
- There are those who believe in this grimoire, in its existence and in its potency, and there are those who do not. Those who believe say that this grimoire, originally named Al Azif, and written by Abdul Alhazred around 700 AD, contains the rituals that, if...
Deities & Heros >> Chthulu
- An Overview of Greek Gods and Goddesses
- The Twelve Olympians were the main gods and goddesses in Greek mythology. They resided in Mount Olympus and actually totals to fourteen Olympians but never more than twelve in a time.
Religion & Philosophy >> Deities & Heros
Remington 700 is described in multiple online sources, as addition to our editors' articles, see section below for printable documents, Remington 700 books and related discussion.
Suggested News Resources
- Timney's Remington 700 Trigger – This Week on Guns & Gear
- Guns & Gear is back for a seventh season to showcase the newest and most interesting firearms and products in the industry.
- Montana Man Sees Remington Recall Agreement as Worth Years of Fighting
- About 16 years ago, Montana man Richard Barber lost his 9-year-old son, Gus, after his Remington 700 accidentally fired without the trigger being pulled. Barber later settled a lawsuit against Remington, but went on to speak in public about a defective ...
- Remington rifle settlement delayed again
- Under a proposed nationwide settlement reached more than a year ago, Remington agreed to replace the triggers on its popular Model 700 rifle and a dozen other firearms with similar designs.
- Texas man blames Remington defect for loss of leg
- While getting into a vehicle, Arnold grabbed the Remington 700 rifle, which belonged to his buddy, that had the bolt up and muzzle pointed down, the lawsuit says.
- Remington continues recovery at Kootenai Health
- More than 200 people gathered at the scene the day after Pastor Tim was shot, that number swelling to more than 700 who attended a vigil in support of him Monday night.
Great care has been taken to prepare the information on this page. Elements of the content come from factual and lexical knowledge databases, realmagick.com library and third-party sources. We appreciate your suggestions and comments on further improvements of the site.
Remington 700 Topics
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Fit Life Articles
Eating healthfully doesn't have to break the bank. The Nutrition Twins offer up six easy ways to purchase wholesome foods while also drastically cutting your grocery budget.
If you have tried lots of diets and have lost and regained the same 5, 10, or even 50 pounds, you know that diets don't work! The key to successfully losing weight and keeping it off for good begins with making changes to your mental game.
An estimated 27 million Americans suffer from thyroid disease and 13 million people are currently undiagnosed. Learn about the risks of developing thyroid problems and how you can help keep your thyroid functioning optimally by adopting healthy lifestyle habits.


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Media Businesses For Sale in Rotterdam NY
Searched the MergerNetwork database for Media Businesses For Sale in Rotterdam NY and found no matches. Expanded the search to nearby areas and found the following matches.
Profitable IT Management & Software Development Co #454542 posted Sep 23, 2016
- West Hartford, Connecticut, United States
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The business builds and delivers commercial or "internal" software products that are "difference makers" for its customers. The company has earned the reputation for radically enhancing its client's technical capabilities by deploying world-class technologists throughout the software development life...
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Patrice Evra has worn the captain's armband for Manchester United since Nemanja Vidic suffered a season-ending injury against FC Basel in December, but who will be the club's captain after they are gone?
It is widely assumed Vidic will reclaim his armband when he returns from injury. Likewise, it seems obvious Evra will continue to deputize when Vidic is unavailable.
However, with both players now in their 30s, it is worth considering who will be the future captain of United.
That is not to say they should be replaced now.
Rather, this is simply speculation about who in the current squad can step up and receive the armband when the veterans call it quits.
Ideally, you want every player in the squad to be a leader, but only one can wear the armband.
These six players all have the characteristics necessary to be captain of Manchester United.


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正在考虑去法政大学留学的各位: Japan Study Support 是财团法人亚洲学生文化协会和倍楽生(倍乐生)股份有限公司共同主办的面向外国留学生的日本留学信息网。 法政大学的法 学部、文 学部、经济 学部、社会 学部、经营 学部、国际文化 学部、人文环境 学部、现代福利 学部、潜力开发人生设计 学部、设计工 学部、生命科 学部、理工 学部、国际教养学部(GIS) 学部、体育健康 学部、信息科 学部、Hosei University Japanese Language Program 学部等,不同系的详细信息都分别登载在此信息网上。正在寻找法政大学的留学信息的各位同学,请利用此网查询。另外,在此网上登载着约1300条大学、大学院、短大、专门学校正在招收留学生的信息。
Define yourself and your own future.
Global society is constantly in motion, driven by the various people of the world, who all hold their own cultures and ideas. In order to take one's place in this evolving global society, it is essential to develop new modes of free thinking. Since its founding in 1880 under the principles of "Freedom and Progress", Hosei University has graduated talented individuals who have gone on to promote societal reform in a wide range of fields, as well as contribute achievements in culture and sports. We nurture the talents and skills of our students so that they can excel on the global stage with our numerous fields of study in 15 faculties and over 200 clubs and unique extracurricular activities, all in 3 distinctive campuses located in Tokyo.
Diverse individuals gather here from throughout Japan and around the world.
Everyone has their own opinions and ideas to share.
Perspectives are broadened greatly through new challenges that encourage students to redefine their personal abilities and limits.
In our current fast-paced, complex society, just as vast amounts of information can be collected from the Internet, knowledge can be learned rather easily through classes. However, with just such knowledge alone, it is difficult to create new value when making products or forming concepts. What is demanded of us today is "thinking", that is to say, the ability to think for oneself and ask questions, and the capacity to "acquire", that is to say, to develop thoughts and creations freely by applying one's own experiences and wisdom.
In the Faculty of Science and Engineering, sciences are studied under the concept of understanding the "essence of things", and this is combined with studying engineering under the concept of "technology useful for humanity" to develop a new kind of science and engineering program aiming to train individuals who can "think to acquire". To these ends, the curriculum of the Faculty of Science and Engineering combines a solid foundation of study in the fundamentals of science and engineering together with a variety of interdisciplinary studies in these fields. An overseas study program is also available to provide hands-on experience for becoming an active global citizen.
Mechanical engineering, which supports Japan's manufacturing technologies, is the study of mechanical design and manufacture based on the principles of thermodynamics, machinery, fluid dynamics, and material sciences. The Course of Mechanical Engineering is notable in that it includes comprehensive aerospace research in addition to these other fields of study. Other fields not traditionally considered part of mechanical engineering are also covered, such as information engineering, electronics, electrical engineering, and business management to broaden the possibilities of technological developments. Hosei University's Graduate School of Science and Engineering has a joint research agreement with JAXA (Japan Aerospace Exploration Agency), which provides opportunities to participate in related research activities.
Practical courses are also held where students can come into contact with materials and experience firsthand how they behave and change. These exercises cultivate students' adaptability, visualization skills, and sensibilities as engineers, and bring deeper meaning to their classroom lectures.
The study of electronics and electrical engineering is the process of understanding the mechanisms of electricity and electronics, and then using them to research technologies for industrial applications. This covers fields from energy delivery to home appliances. The cutting-edge technologies of electronics and electrical engineering, such as integrated systems, contribute greatly to fields such as avionics, automobiles, and robotics, and supports areas where Japan is a world leader such as digital cameras, digital appliances, and wireless and fiber optic communications. In the Department of Electronics and Electrical Engineering, we aim to train technicians and researchers who possess a broad vision, creativity, and business sense that can contribute to this broad range of fields. In addition, from the third year of study onwards, students can participate in seminars where they can build working relationships with faculty and engage in high-quality research. As a result of these programs, many students quickly find themselves involved in academic conferences. A notable aspect of our program is that we send more undergraduates than other universities to present at conferences, such as those for the Institute of Electrical Engineers of Japan, the Institute of Electronics, Information and Communication Engineers, the Society of Instrument and Control Engineers, and the Japan Society of Applied Physics.
Applied informatics is the gaining of understanding of information technology (IT) to research and develop new and better usage methods. Global information services, which are accessible 24 hours a day, are influenced by both businesses and individuals, continuously giving rise to new technological innovations. Talented information and communications engineers play an essential role in quickly responding to the various issues that face our continuously diversifying information society. In response to this need for skilled technicians, in the Department of Applied Informatics we aim to train engineers who can build information environments that are safe and accessible for users.
We have also introduced "pre-seminars" that students can join soon after they begin their studies. Small-group classes allow faculty to give close, one-on-one guidance to students beyond their studies, providing consultation and guidance for student life as well.
Industrial and systems engineering is the study of understanding the complex systems of our modern society from a mathematical standpoint, and the formulation of solutions to various related issues. Notable examples of such solutions include Toyota's "Kanban" just-in-time scheduling system, and the distribution systems implemented by Coca-Cola Bottlers.
In the Department of Industrial and Systems Engineering, students will cultivate the ability to express problems in corporate organizations as mathematical models, and then use various analytical techniques to propose solutions to those problems. In order to create mathematical models, the basic methods and theories of the management science known as operations research (OR) are required. In this department, students will deepen their understanding of and gain specialized knowledge in fundamental probability and statistical methods, mathematical programming for maximizing efficiency, analysis for applications (differentiation and integration), and algebra. These studies are combined with one of three course plans: the study of economic trends (economic analysis), capital procurement mechanisms (financial engineering), or business planning for industries (production management). The curriculum also includes the study of implementation processes and computer simulations. Graduates will understand business management from a mathematical perspective and be able to contribute to innovations in business.
In the Department of Advanced Sciences, the fundamental aspects of physics and mathematics, which are the foundation of science itself, are studied. For example, students may have learned the laws of physics in high school, but in this department, the circumstances and contemporary issues caused by those laws are investigated. Once these ways of scientific thinking and problem-solving methods, which are referred to as the "paths of science", are learned, they can then be applied in various fields. Students will acquire general-purpose and holistic skills for addressing issues in a wide range of areas.


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In its full-year results for 2011, Aviva announced it would streamline the Aviva Investors business and concentrate on "core strengths" in fixed income, real estate and multi-asset products with sales and marketing focused on the institutional markets.
The asset manager arm of Aviva, revealed operating profits had fallen by 9% to £91m during 2011, while funds under management grew by 1% to £263 billion, from £260 billion in 2010. (article continues below)
Aviva Investors was forced to reassure the retail investment market in January that it had no plans on exiting, after earlier suggesting that it would be axing 160 staff as part of the streamlining process.


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1991 Mercedes-Benz 300-Class Wagon 300TE 4dr Wagon
I bought mine 1 year ago and have put 20k on the car with no worries. It had 152k at time of purchase. This is my fifth older mbz and is my favorite one of them all.Fun to drive, great reliability and the interior layout is practical.I have seen the 3.0 liter inline six go 400k plus with just a top end rebuild.Things to be aware of: head gasket and engine harness failure. A small price to pay in overall upkeep, for a car that is safe, has classic lines and can handle high mileage with proper care.
1991 Mercedes-Benz 300-Class Wagon 300TE 4MATIC 4dr Wagon AWD
We bought this car with 147K on it. We
had it checked out and were told it
was in great shape. It came to us with
a failed transfer case leaking a qt of
hydraulic oil every 100 miles. The
repair was nearly $2,000 and the part
very difficult to come by. Now the
front and rear engine seals are
leaking and the engine has to come
out. That will be another $2,000+. The
water pump and alternator failed
within days of each other. There have
been numerous hard start problems.
This is all within 4 months. The car
is fun to drive but I don't trust it
to go more than a month without
needing some hideously expensive
This car was purchased with 23K
miles in 97. I initially was shocked
with some of the repairs i.e., motor
mounts relaced again after 5K.
Electrical flaw in the hatch $600. The
radiator neck broke twice along with
the fan and polybelt. Then at 76K the
4matic went out which was the
biggest hit of $2300. Other than
those items the car is a workhorse. I
plan to keep it for another four years
then sell it and buy a 2000CL500.
I should be able to afford one by
I use a wheelchair and the cargo
space is great for carrying items.
When you are sitting in the drivers
seat it feels like any other sedan and
not a soccer mom.
It would be nice to have more power.
This car looks great, holds everything,
is extremely comfortable and sturdy,
and is totally reliable. I bought it
with 96,000 miles on it and expect
years of trouble-free driving. It's fun
to drive too -- peppy and with a sporty
feel. I LOVE it and recommend it to
The cargo space! Plus, Mercedes' paint
jobs are great. People always are
shocked that it's a '91 -- it looks new.
I couldn't put a combination CD
player/cassette tape deck in the dash,
so I had a CD player installed.
Otherwise, the car is perfect.
This is my 4th Mercedes-Benz product
and it has been troble free. Never
has it stayed over night in a shop.
Maintance is more expensive than
domestics but the quality of the job
is far superior because of the
dealerships' high levels of quality
control. If the car needs new breaks
the dealer does it right the first
time, every time.
Abiltiy to travel cost to cost without
ever feeling tired, excellent
ergonomics and orthopedically correct
seats, and safety that rivals most new
cars. You wont have that sea sick
undulating feeling other "luxury" cars
give you.
Bring this model back. The newer ('97
to present) E class wagons are built
for much less than these tried and
true cars were and it shows in
reliability stats.
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Located on Calle Claudio Coello, Barrio de Salamanca.
Surrounded by embassies, luxury shops, the best and most famous restaurants, just minutes from the historic city center and the main museums!
Exterior Studio of 28 square meters, on the second floor of a modern building with lift.
Outside, with lots of natural light. Large windows and electric shutters.
150 cm double bed with high quality mattress.
Maximum occupancy 2 people.
Located in the heart of Salamanca district, on Calle Claudio Coello.
Surrounded by luxury shops, famous restaurants and just a few minutes walk from Retiro Park.
Very safe, commercial, and the most glamorous of Madrid.
Well connected with the rest of the city by underground (Serrano), just 5 minutes walk away and Renfe (Recoletos), also by many bus lines.
The historic city center is just 10 minutes by subway or bus, you can also get walking down the wide avenues that will take you to Gran Via street Alcala and Paseo del Prado
At the time of confirming your reservation it is very important that you indicate your arrival time, to receive without this information does not guarantee entry into the housing.
Important ;: We need your arrival time at least 48 hours of their arrival time, without this information does not guarantee entry into our accommodation.
The day of your arrival you perdirà is identified presenting their passport or identity card as an essential safety measure. Must also deliver the security deposit worth 100 euros (refundable upon departure) may deliver cash or with your credit or debit card.
After starting your stay if canceled or decide to leave early accommodation booking date will not be entitled to a refund of the amount already paid.
From 14:00 h. until 21.00 h. (Only).
Always be done before 12.00 noon.
* Not have left-luggage storage, either the input or the output, keep this in mind.
- Kitchen
- Shower/bath
- Fridge/freezer
- Heating
- Lift
- Air conditioning
- Gay-friendly
- Internet
- Washing machine
- WiFi


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Are you looking for big agency style without the big agency price tag?
At Big Blue Pencil, we believe it's the size of the talent, not the size of the office, which matters. Big Blue Pencil develops creative marketing solutions that make people stop, think and take a course of action. There are times when you only have a fraction of a second to clearly communicate a message, concept or idea to an audience who may not know you, your product or your service.
When you hire Big Blue Pencil you deal directly with the people doing the work. In fact, many of our clients agree we're faster, easier to work with, and a lot more flexible than many of the bigger firms. As your communications partner, we'll help you create a unique design solution that gets the results you need.


text:
Lift your spirit.
World-class conference facilities and services, breath-taking beauty.
Cascades has great options for family fun all summer long! Take a look at the great programs and choose the best fit for your family!
With day camp options for 1st-6th grades, and overnight programs for kids in early elementary, upper elementary, middle school. Every child is sure to find that perfect camp experience at Cascades!
The teenage years are pivotal in developing faith. Check out Cascades' programs geared towards discipleship and growth for your high school student!
Who says camp is just for kids! Come to Cascades to play and relax in God's presence at one of our year-round events!
2016 Highlight Video Independence Day Family Camp 2016 was one to remember! Check out this fancy-schmancy recap video with highlights from throughout the weekend! Lots of great memories were made during this event – we hope you enjoy… Read More
Dear Friends, We have some bittersweet news to share with you. After 15 years of faithful service at Cascades, Claudia "Dirt" Fisher, our Program Director, is moving on. She has recently received her Master's degree in Counseling Psychology… Read More
This year we've been highlighting all of our year-round permanent staff members on our blog. Today we're introducing a man who wears many hats here at Cascades. Say hello to… Name: Rob "Trane" Mohrweis Job: Associate Director How long have you worked at Cascades? 16… Read More


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Sanskrit Literature The Ramayana
A selection of articles related to sanskrit literature the ramayana.
Original articles from our library related to the Sanskrit Literature The Ramayana. See Table of Contents for further available material (downloadable resources) on Sanskrit Literature The Ramayana.
- The Aeonic Perspective of the Enochian Temples
- The initiatory system of the Enochian Temples divides the path of initiation into four major stages, distinguished primarily by the types and sources of the influences they are sensitive to. Briefly, these stages are: 1. Lunar-planetary, focused in Yesod and...
Magick >> Enochian
- Bringing it Down to Earth: A Fractal Approach
- 'Clouds are not spheres, mountains are not cones, coastlines are not circles, and bark is not smooth, nor does lightning travel in a straight line.' B. Mandelbrot W e want to think about the future - it's our nature. Unlike other creatures, humans possess an...
Mystic Sciences >> Astrology
- Mother Of The Gods And The Father Of The Gael
- There is no surviving, or as yet translated, Creation story within Irish mythology. We learn from the Lebor Gabala Erenn, a text from the Christian Middle Ages, of the Tuatha De Danann, or "People of the Goddess Danu", who came to Ireland either...
Deities & Heros >> Celtic, Welsh, Irish & Brittish
- Select Cross-Cultural and Historical Personifications of Death
- This extensive introduction includes some of the more well known, along with some lesser known Death "incarnations", and I use that term loosely, as in many cultures, the Angel of Death can be quite an adept shapeshifter. We have tried to cull...
Mystic Sciences >> Necromantic Studies
- The Celtic Vedic Connection, Part I
- Of all the great ancient cultures perhaps no two share more parallels than those of the Celtic and Vedic peoples. A deep rooted affinity runs between them, what is present in one is mirrored in the other. Myths, Gods, Goddesses, even fairy tales bear a...
Religions >> Druidism
Sanskrit Literature The Ramayana is described in multiple online sources, as addition to our editors' articles, see section below for printable documents, Sanskrit Literature The Ramayana books and related discussion.
Suggested Pdf Resources
- Ramayana - Sanskrit Documents website
- duct of Sanskrit Literature has enjoyed a greater popularity in India down to the ... security than a palm leaf manuscript of the Ramayana too precious a Talisman.
- sanskritdocuments.org
- The Ramayana and the Mahabharata - Unesco
- Numerous episodes from the Indian epic, the Ramayana, are carved ¡n relief on ..... Sanskrit literature it is probably the most widely known out¬ side India, and ¡t ...
- unesdoc.unesco.org
- History of Sanskrit Literature Kerala Culture - University of Calicut
- History of Sanskrit Literautre Kerala Culture & Translation. HISTORY OF .... in Sanskrit literature based on the story of the Ramayana.
- universityofcalicut.info
- The Figure of Rama in India and Thailand: A Comparative - IOSR
- In his Ramayana, Valmiki delineates Rama as an ideal person, the epitome of the supreme human vir- ... In Sanskrit literature, the Rama saga was treated in the .
- iosrjournals.org
- ASHTANĀYIKAS IN RAMAYANA - Global Business Research Journals
- This study aims to explore the female characters of Ramayana in the ... The content of Ramayana was seen as a Sanskrit kāvya literature which was soon.
- globalbizresearch.org
Suggested News Resources
- The house of groaning shelves
- Madras Literary Society. "Books can be taken from there, but then most do not, because of the dust," shouts Uma Maheshwari from below, as I carefully climb the metal ladder leading up to a set of shelves.
- At crossroads of translation
- Various versions and translations of Ramayan underscore the point. Straying even a little from the ...
- The Vimanas Of Ancient India & The Tales Of Ancient Flying Machines
- The Ramayana is a Vedic epic that dates back to the fourth/fifth century, B.C.
- From Ceylon to Sri Lanka
- The earliest literary references to Lanka are found in the Mahabharata (compiled between 4th century BC and 4th century AD) and in a Sanskrit inscription dated to 4th century AD.
Suggested Web Resources
- Sanskrit literature - Wikipedia, the free encyclopedia
- [edit]. Main article: Ramayana. While not as long as the Mahabharata, the Ramayana is still twice as long as the Iliad and ...
- en.wikipedia.org
- Ramayana - Wikipedia, the free encyclopedia
- The Ramayana is a Sanskrit epic poem ascribed to the Hindu sage and Sanskrit poet Valmiki. It is regarded as one of the two great works of Indian literature, ...
- en.wikipedia.org
- Indian epic poetry - Wikipedia, the free encyclopedia
- The ancient Sanskrit epics, the Ramayana and Mahabharata, also termed Itihāsa ... Kannada epic poetry mainly consists of Jain religious literature and Lingayat ...
- en.wikipedia.org
- Sanskrit literature - New World Encyclopedia
- Main article: Ramayana. While not as long as the Mahabharata, the Ramayana is still twice as large as the Iliad and Odyssey ...
- www.newworldencyclopedia.org
- Manas: Religious texts of India, Ramayana
- Ramayana. The Ramayana belongs to a class of literature known in Sanskrit as kavya (poetry), though in the West it is considered to belong to the category of ...
- www.sscnet.ucla.edu
Great care has been taken to prepare the information on this page. Elements of the content come from factual and lexical knowledge databases, realmagick.com library and third-party sources. We appreciate your suggestions and comments on further improvements of the site.
Sanskrit Literature The Ramayana Topics
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Clean, quiet
Respects privacy, reliable to live with, easy to get along with, communicative, funny, love music, clean and tidy. I love my job as Sales Rep for a food product from Maleny. Mother of a grown up son & daughter who live independently. Last month thanks to my son & fiancé I became a Nonna to my beautiful granddaughter. They will visit occasionally of course. I have a cat that is my soulmate, Xena WP. 8 yrs old. I've had to live without her for 6 mths so hoping to find a home for the both of us.
I work full time, non-smoker, usually keep to myself, I get along well with pretty much anyone, I clean up after myself and I'm currently single. Between work and other engagements, I will probably spend a fair amount of time out of the property.
Love playing music Jamming Singing Painting Philosophising and getting real Energy vibes
Frenchie Sociable Clean and tidy barista so I can make good cup of coffee
Master bedroom furnished with a brand new Queen size bed, wardrobes, TV and DVD player, side table and lamps, +heater and air cooler, house is quite roomy and plenty of natural light, on a large block with only a short walk to the beautiful Mary Cairncross Park rainforest. 6kms to Maleny town centre and about 8 kms to Landsborough. Perfect for someone who loves nature and the peace and quiet! Birds and wildlife. Females only to share with one other female and cat Available late July 2016 Internet available
I'm a quiet person who is looking for a peaceful home to share where I can have my two children over on weekends and after school. I'm reliable and tidy and respectful of privacy. am easygoing and down to earth. Looking for a fresh start in a nice home that will be welcoming of two awesome kids and mum.
Hi ☺ I am a quiet, neat and tidy person looking for a granny flat/half a house OR someone likeminded who is willing to share a house. I have an 8yr old golden lab who is friendly and affectionate. I work part time and also run my own business from home. I am a spiritual person, love the outdoors and animals, and gardening and mowing, and I am a non drinker. I have all my own furniture and if you are interested in sharing a house all you will need is your own bedroom furniture.
- Stylish Queenslander - 2 large bedrooms + office - only one bedroom available; other rented - 2 undercover carports - Peaceful location on acreage - Quiet cul-de-sac - Spectacular ocean views - Preferably fully furnished - Large deck - Wood polished floors - Fireplace - Flyscreens - Inspections welcome - Electricity, gas and water bills included - Contact: Lucia or Clint
Hi, my name is Gemma and I am seeking some friendly, fun, reliable, tidy and trustworthy people to come and share my beautiful little home in the Sunshine Coast Hinterland. I am 25, a full time worker in the health industry and I live on a 1/2 acre- plenty of room for friendly pets as I have 2. I keep a neat home and would like motivated, positive people to come live with me. I am close to the highway, Beerwah has all the necessary shops, 20mins from the beautiful beaches and Maleny just up the range. I would like some form of bond on entry and to meet with you. Your board would include use of the whole house, wifi, and netflix, you would have to pay for your own food or your part of the bill, cooking will be negotiated. If I fill both my room you will only pay your third of the bill being water and electricity (maybe internet depending on your usage). I would like you to be a working or studying. I would expect you clean and look after yourself and respect my home. I sound strict but this is my expectation- but I am really relaxed and an open person. Pictures to come- can be partly furnished or you can bring your own for your room. I have little storage sorry. Smokers are ok- but must smoke outside. Up for negotiation on price for good housemates. Please contact me by phone if interested for quick response. Peaceful area and good neighbourhood.
Iam easy going and very good to share with have excellent references from past female flat mates Iam a diesel fitter by trade but been working as a mechanical fitter on the Sunshine Coast only been here about 6 months the house is four bedroom with two lounge areas and dineing area you get to share a full house not just a room if you have your furniture that's ok female will get the main bedroom with own Bathroom and toilet and walkin robe fully maintain yard and gardens good quiet area I've just taken a 6 month lease on the property with a 12 month option if you would like to know more about the place just contact me cheers rod
Brand new home in the pineview estate in beerwah. Room has a walk in robe and your own private bathroom. Possible opportunity to have a carpark in the garage if required. Foxtel. Ducted ac. Weber bbq. 2 separate tv rooms. Study nook.
Close to shops a d train station for easy access to brisbane only 15mins to sunny coast uni . Quiet street large block great housemates
Hi my names claudia Im 19 and work part time. I like to listen to music and an very easy to get along with. I dont mind mess and but im a great cleaner. Im trying to teach myself to cook and dont mind if you like to be social or keep to yourself
Hello :) I am Gemma a 25 year old Disability Support Worker at Mooloolah Valley. I enjoy riding my motorbike both on road and in the dirt, I love swimming, looking after my health and fitness, socialising with my friends and I love my job. I like to be very clean and tidy and I also don't drink or smoke. I am currently living at Caloundra in which I really get along with my housemate though I want to move somewhere cheaper and closer to work as I am going to study Mental Health or Nursing next year.
Truck driver work big hours .... Just like to relax on days off:)
Full time primary school teacher relocating to the sunshine coast area in 2017. Love the outdoors, hiking, beach, night at the pub with live music. Can cook and like to keep things clean and organised. Have a dog (staffyx) that I would like to live with me if possible but not necessary. I am looking to move in after Christmas or early January and rent for 1year.
I am a mature gent well respected a great sense of humour clean very domesticed and can cook a mean roast i might be a bit older im pretty smart for my age i enjoy the beach love fishing/crabbing i like the NRL my team is the Raiders i like the AFL/Cricketindoor/outdoor i follow the Sunshine Coast Falcons there coach Craig is my ex boss like going to the movies
Pretty quiet sort of fella! Good cook!
1 min to train bus shops etc. everything at your doorstep. Large lockable furnished room brand new bed.fully equipped kitchen. Quiet house suit full time workers/students.
Hi my names Lauren, I'm currently studying education at USC. I work part time as a teacher aid and am great with kids. Quiet but friendly :-) Looking for a room from late December on wards, as my current lease will end. Thanks so much!
Set on an acre the Landsborough side of Australia Zoo ..a peaceful sanctuary only 20 mins to the coast ..private air con studio room set a short distance from the house ..private bathroom in the house ....rent includes electricity & internet
Internet and Foxtel are including in rent. The property is also fitter with aircon and is close to beerwah and has its own creek and beautiful garden out the back.
Hi I am friendly and sociable yet also like to be by myself and be peaceful. I like to be tidy, clean and quiet. I don't watch tv and prefer reading. I am studying a graduate diploma of psychology online so I would like a place with internet included. I'll be a student for several years and looking to rent a room for that time, until I can afford a sail boat to live on. My daughter is 3.5 and lives with me 50% of the time (week on/week off). When we're together, we like to visit places, we're mostly pretty busy out and about in the mornings; then we come home in the afternoons for me to study and her to nap or watch barbie DVDs on my laptop in our room. We share a queen bed so we only require one room at this stage. I'd like a non-smoking household, with access to a bath, for my daughter's ducks and floating princesses! A pool would be amazing as she loves swimming. When my daughter is with her Dad I'll be mainly studying, although I also like to get out paddle boarding on the canals or sailing through one of the sailing clubs. A place on the water would be fantastic so that I don't have to take my paddle board far. I used to be a veterinarian so am comfortable around animals, plus my daughter loves them. Ive been a yoga teacher so get the mindfulness, meditation and spirituality thing. I like to sing and have a speaker and P.A system to practice that. My guitar also plugs into the P.A. but I don't really know how to play it yet. One day I'll get it I'm sure. Im more a book worm than a party animal and appreciate my peace and quiet. I am currently on the single parent pension and so paying rent on time is not a problem. Id be happy to set up a direct debit and forget about it. Thanks for reading Kat
Easy going, I enjoy the beach, cycling, and yoga. I'm very open minded, have lived abroad and very respectful of others. Currently working 2-3 days per week for an NGO and running my own consulting business the other days, like to socialise with my friends, so I'm pretty busy most of the time but like a catch up every now and then.
I'm a clean, tidy person. I like my personal space but also like to socialise and have company. I love to cook and I'm pretty good at it also if I say so myself! I have a great, bubbly personality and like to relax when I have time off. I'm from Hervey Bay and just recently moved for more work opportunities as I am currently studying real estate so I can get into the industry. I have family and friends all around the Sunshine Coast but I would like to stay within a share accomodation for the experience. I love the beach and doing adventurous sports/activities. I study part time completing two diplomas and a real estate sales course. I have my own car and my P2 license.
We have a detached Granny Flat available for rent. Clean and modern with big ensuite and good size kitchen. Situated on a leafy 4 acre block it is nice quiet with a leafy outlook and only minutes from Mooloolah train station and local shops. We have a preference for couples or females. No fencing on the property so pets are not an option. Timeframe is short term to see if we get along and then long term. Close to trainCouch Fridge Microwave TV
Hi I'm an easy going, wholistically minded, non smoking 50 yr (young), semi retired, student. (Studying animal nutrition). I'm looking to share with easy going, stress free, respectful people, preferably animal lovers. Semi furnished accomodation and off street parking are also on my "wish list". I have a 7yo Golden Retriever & 2 (10yo) cats. I work casually, my dog goes into care whilst I work & my cats just "chill out", as cats do! All my animals are "trained", have great personalities and get on well with other animals and children.
I'm tidy and reliable, I love having a bit of fun but adore a good balance of sleep too. I love animals and get along with everyone. Looking to move soon and would rather teamup with someone for somewhere new Not sure if my saved number on here is right so best to message.
Friendly, single person seeking living SPACE. Reliable and honest semi-retired professional. Can team up to create new house-share. Needing to arrange a move in the next month or so. Must be very close to transport! I am making the move from a family home to living by myself (all the children has grown and left home). I currently have furniture, and household things that are in storage. This could be handy for unfurnished place or for use in share situation where you might not have everything yet. I am a mature aged single person and am self supporting - work part time at home (requires space for computer desk). Have had own businesses for last 25 years, currently an Internet business consultant, clients do not attend property. Tidy and clean without being fanatical. Looking for accommodation no further than about 20 minutes or so of the Maroochydore Airport to be close to family & grandchildren :) Interested in share houses or self contained studio/unit/flat/part house etc. Also interested in establishing new share house. --------------------------- I like a quiet, relaxed environment and don't mind occasional shared meals and company. Self-reliant, capable person who has had enough dramas in life, don't need any more. But also a good listener, caring and love a laugh. -------------------------- Absolutely do not want to be around - drugs or party house. Enjoys a wine or beer on a relaxing evening. -------------------------- I like nature, trees, whole/organic food (as a preference - not religiously). Love to cook, love open spaces and quiet places. Like to travel and experience new things, people & places. I am child-friendly and would make a nice live-in grandma so you could have time out occasionally :) I like animals, and get along with most. --------------------------- My wish list (I can dream) - these are not requirements, I am open to consider all situations, would rather ensure the people I might live with and I are compatible first. Swimming pool Great kitchen (love a big gas stovetop) Aircon or other cooling/heating Ensuite or private bathroom Extra room Storage space Close to transport (I do not currently have a car) Access to the outdoors from room / private entrance Light bright airy space Please contact me if interested in chatting about possibilities, especially if you are interested in looking at starting up a new household (hopefully with dual living). Thanks for reading!
My name is Jennifer, I am 53 years young, I am a mum of 3, they all live out of home. I am a kind, friendly, down to earth, easy going person. I enjoy outdoor activities, such as walking on the beach, walking my dog and going to great coffee shops. I am a relaxed person who enjoys a casual drink every now and again. I am a clean and respectful person and I love a good laugh. I do not work due to injuries, however I am on a steady income from Centrelink, so paying rent and other utilities is no issue. I have a little, very kind and friendly dog, she's a Moodle. I have a fluffy very kind and gentle cat, she's a rag doll. I also have a bird who is small as friendly, he's a 'love bird'. The cat is scared of the bird, so they are safe in a room together. I'm looking for a house mate, preferably female, or mixed genders-any age, who is kind, friendly, and likes animals.
Recently renovated house nestled in the beautiful Palmwoods hinterland suburb. Brand new kitchen and bathroom, freshly painted and new wooden floor boards throughout the house and bedrooms. Small outdoor deck to watch the clouds roll in across the hinterland horizon. 2 rooms available for rent and also the ability to furnish the rest of the house if you have the furnishings to make the rest of the place your home. One room is bigger than the other however single beds would suit the 2 bedrooms for a comfortable living. Lots of parking onsite on a big block. Suitable for parking your boat or camper also. Fenced front yard for the exisitng tenants happy staff dog who is already living there. Rest of the house is lonely without anyone occupying the rooms so if you are looking for your own house to call home please feel free to contact me for a walk through of the availed space to call your own.
Come enjoy a piece of Paddington in Palmwoods. This stunning cottage is separate to our house. The 1920's cottage has just been completely renovated with new kitchen, appliances, a gorgeous new bathroom and beautifully landscaped with 4 separate verandahs. We have 2 bedrooms with a shared bathroom available. Each bedroom has huge built in wardrobes with mirrored doors. Washing machine, fridge and TV provided. At the bottom of the block there is some stunning rainforest and the property is within walking distance of the Palmwoods train station and town centre with all the lovely cafes, including famous Ricks garage cafe and some great quirky little shops. All gardening and mowing will be taken care of. We have a brand new NBN box right on the footpath. :)


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Print Materials for Healthcare Professionals
On this Page
These print materials focus on when it is and is not appropriate to prescribe antibiotics and explain why antibiotic resistance is one of the world's most pressing public health problems.
Permission is not needed to print, copy, or distribute any materials from the Get Smart: Know When Antibiotics Work program. All materials are provided in low-resolution for office printers. If you want high-resolution formats for commercial printing or are interested in customizing the materials, please e-mail the Get Smart program at email@example.com. You can also order small quantities of select materials for free or purchase large quantities.
Fact Sheets
Checklist for Antibiotic Prescribing in Dentistry
This 1-page, full color 8.5"x 11" fact sheet describes how dentists can improve antibiotic use in their practices.
Is it Really a Penicillin Allergy?
Approximately 10% of U.S. patients report having an allergic reaction to a penicillin class antibiotic in their past; however, when evaluated, fewer than 1% are truly allergic to penicillins. This 2-page, full color 8.5"x11" fact sheet for healthcare professionals describes the evaluation and diagnosis of a penicillin allergy. It includes recommendations that healthcare professionals evaluate patients for true penicillin allergy by conducting a history, physical, and (where appropriate) a skin test and challenge dose. Doing so ensures the patient receives the best care and reduces the risk of antibiotic resistance from unnecessary use of broad-spectrum antibiotics.
- Printer friendly version in color [2 pages]
- Information to share with patients and families: Penicillin Skin Testing: Are You Still Allergic? (Rochester Regional Health) [PDF - 900 KB]
Save Money with Antibiotic Stewardship
This 2-page, full color 8.5"x11" fact sheet describes how antibiotic stewardship programs and interventions can be a "win-win" for all involved—patients get the right antibiotics at the right time for the right duration and heathcare facilities save lives and significant healthcare dollars.
Preserve the Power of Antibiotics – For Providers
This 2-page, full color 8.5"x11" fact sheet describes the health impact being seen in healthcare and community settings from overusing antibiotics and outlines steps health care professionals can take to help fight antibiotic resistance.
Antibiotics Arent Always the Answer - For Parents
This 2-page, full color 8.5"x11" fact sheet describes antibiotic resistance and questions parents should ask their child's healthcare provider to make sure they are getting the best care possible, which might not include an antibiotic.
Antibiotic Resistance - The Global Threat
This 1-page, full color 8.5"x11" fact sheet describes how antibiotic resistance is happening across the world and global actions to slow resistance.
Resistance Anywhere is Resistance Everywhere
This 2-page, full color 8.5"x11" fact sheet explains how antibiotics are a shared global resource that need to be prescribed and used wisely.
Prescription Pads
Prescription Adherence Tool
This tool is intended for use in pharmacies, clinics, and other healthcare facilities where antibiotic prescriptions are filled. It is intended to promote adherence to antibiotic therapy by citing ways that consumers can use antibiotics appropriately. It also raises awareness about why appropriate antibiotic use is important.
- Printer friendly version in color [1 page]
- Printer friendly version in black & white [1 page]
- View brochure in HTML
- Order free small quantities
(CDC-INFO product #999487)
This brochure is also available in Spanish.
Symptomatic Relief for Viral Illnesses Prescription Pad
This tool is designed for healthcare professionals to use with patients. This 4-color 4"x6" prescription pad is actually a checklist for healthcare professionals to describe symptomatic relief for a viral illness diagnosis.
- Printer friendly version in color [1 page]
- Printer friendly version in black & white [1 page]
- View brochure in HTML
- Order free small quantities
(CDC-INFO product #999486)
- Order bulk quantities
(PHF product #GS-007)
This letter is also available in Spanish.
Sample Letter
Return to Day Care Letter
When a child has been ill, many day cares will not allow a child to return without an antibiotic treatment. However, not all infections can or should be treated with an antibiotic. This letter explains that the child has a viral illness and will not be receiving antibiotics and should be allowed to return to day care once his or her fever is gone. Healthcare professionals should fill out and sign this letter for parents to give to their child's day care provider.
- Printer friendly version in color [1 page]
- Printer friendly version in black & white [1 page]
- View brochure in HTML
- Order free small quantities
(CDC-INFO product #999485)
This letter is also available in Spanish.
- Page last reviewed: July 25, 2016
- Page last updated: July 25, 2016
- Content source:


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Final submission for the JDM family crest I was commissioned to put together. Went down really well with the client, saying "It's simple enough for us rednecks to get it, but elegant enough to give us credibility we otherwise wouldn't have". Looking forward to getting some shots of the wood branding iron in use...
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Sorority History
Delta Sigma Theta Sorority, Inc. is a non-profit organization whose purpose is to provide assistance and support through established programs in local communities and throughout the world. Founded on January 13, 1913 by 22 collegiate women at Howard University, the sorority is currently a sisterhood of more than 200,000 predominantly Black college educated women. This includes more than 1,000 chapters in the United States and worldwide.
Our courageous Founders:
Osceola Macarthy Adams Marguerite Young Alexander
Winona Cargile Alexander Ethel Cuff Black
Bertha Pitts Campbell Zephyr Chisom Carter
Edna Brown Coleman Frederica Chase Dodd
Jessie McGuire Dent Myra Davis Hemmings
Olive C. Jones Jimmie Bugg Middleton
Pauline Oberdorfer Minor Vashti Turley Murphy
Naomi Sewell Richardson Mamie Reddy Rose
Eliza Pearl Shippen Florence Letcher Toms
Ethel Carr Watson Wertie Blackwell Weaver
Madree Penn White Edith Motte Young
These 22 students demonstrated a vital concern for de-emphasizing the social aspect of sorority life. Their ideals have withstood the test of time. Surviving on the strength of its sisterhood, today Delta Sigma Theta is a non-profit organization providing programs and services to improve society.
Our Founders had the wisdom and the foresight to know that there was, and would always be, a need for Black women to be politically aware and involved. The first public act performed by Delta's Founders was the Women's Suffrage March in Washington, D.C. which was held on the eve of Woodrow Wilson's inauguration on March 13, 1913. They were the only group of black women to participate in the woman's suffrage march only two months after the sorority's inception.
Today, Delta Sigma Theta Sorority, Inc. remains a service sorority dedicated to public service, and remains at the forefront of accomplishments for blacks and women. Delta Sigma Theta Sorority, Inc. is unparalleled in terms of accomplishments as a whole, as well as those of individual members.
With a growing membership of over 250,000 women, Delta Sigma Theta Sorority continues to attract the brightest college educated women. Delta Sigma Theta Sorority has been shaped by its members who have committed to a lifetime of public service. The Sorority's initiatives are based on its Five Point Programmatic Thrust: Economic Development, Physical and Mental Health, Educational Development, Political Awareness and Involvement, and International Awareness and Involvement. Delta continues to serve the community in numerous capacities providing services and programs to promote human welfare. The Sorority's new initiatives are carried out under the leadership of 25th National President, Dr. Paulette C. Walker and the National Executive Board.


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The changing course of aortic valve disease in Scotland: temporal trends in hospitalizations and mortality and prognostic importance of aortic stenosis
Aims To investigate the contemporary clinical course of aortic valve disease types.
Methods and results We performed a retrospective population-level epidemiological study of hospitalized care in Scotland from 1 January 1997 to 31 December 2005 using electronic case identification of hospital admissions and deaths. Time-to-event analyses were performed using Cox Proportional-Hazards models. A total of 19 733 adults with an index hospitalization and a final diagnosis of non-congenital aortic valve disease were identified. Aortic stenosis, aortic insufficiency, mixed aortic valve disease, or unspecified aortic valve disease occurred in 13 220 (67.0%), 2807 (14.2%), 699 (3.5%), and 3007 (15.2%), individuals, respectively. The majority of hospitalizations occurred in elderly persons aged 80 and older. In total, 9981 (50.6%) patients had died by 31 December 2006. When compared with aortic stenosis, the risk of death was less with aortic insufficiency [hazard ratio (95% confidence interval) 0.79 (0.74, 0.84)] and mixed aortic valve disease [0.83 (0.74, 0.93)]. Female gender, admission year, and hypertension were associated with lower mortality in patients with aortic stenosis. Patients with aortic stenosis had increased risk of death or heart failure (adjusted P < 0.001). Of all, 3673 (19.4%) patients had a first aortic valve replacement of whom 73.2% had aortic stenosis, 11.9% aortic valve disease (unspecified),10.0% aortic insufficiency, and 4.9% aortic stenosis with insufficiency. Patients with aortic stenosis with insufficiency had increased likelihood of aortic valve replacement [1.19 (1.02, 1.38)]. Age, female gender, and co-morbidity reduced the likelihood of aortic valve replacement.
Conclusion The incidence of aortic valve stenosis has substantially increased in Scotland in recent years. Aortic stenosis predicts morbidity and mortality when compared with other types of aortic valve disease.
- Aortic valve
- Aortic stenosis
- Epidemiology
- Prognosis
Aortic valve disease includes, aortic stenosis, aortic insufficiency, and mixed aortic valve disease, which are distinct pathologies leading to reduced survival.1–3 A stenosis of the aortic valve obstructs left-ventricular outflow leading to pressure-overload hypertrophy, exercise intolerance, and heart failure. Aortic insufficiency is a different condition. The haemodynamic problem is volume overload and unlike aortic stenosis, aortic insufficiency may develop either acutely or progressively over several years.
Despite its importance, little is known about the contemporary clinical course and comparative prognostic significance of different types of aortic valve disease.4 The public health burden of heart valve disease increases with age,5,6 and until recently, valve replacement was the only treatment which could improve prognosis.7,8 However, new treatment options are emerging. Transcatheter aortic valve implantation (TAVI) improves prognosis in inoperable patients when compared with standard medical care,9 and in high-risk patients, outcomes after TAVI are similar to outcomes after surgical valve replacement.10 For these reasons, information on the burden of aortic valve disease and its prognosis are urgently required.
Accordingly, we studied the changing course of each type of aortic valve disease in Scotland and addressed the following questions: first, what are the temporal trends in hospitalizations for aortic stenosis, aortic insufficiency, and mixed aortic valve disease at a population level? Secondly, what is the clinical course of each type of aortic valve disease and what is the comparative prognostic significance of one type of aortic valve disease vs. another. Thirdly, what are the demographic factors and co-morbidities which might influence prognosis for each type of aortic valve disease? Finally, what are the temporal trends and predictors of aortic valve replacement?
In order to answer these questions, we studied contemporary information extracted from national databases for hospital admissions and deaths in Scotland with follow-up over a 10-year period.
Record linkage
We obtained data from the Information Services Division (ISD) of National Health Service (NHS) Scotland, an extract of linked data containing all hospitalization and mortality records of all patients in Scotland who have a hospitalization code for heart valve disease since 1981. The national record linkage scheme for discharges from Scottish hospitals and deaths11,12 has been used in other studies of cardiovascular epidemiology.13,14
In brief, the ISD of the NHS in Scotland collates data on all hospital discharges using the Scottish Morbidity Record Scheme (SMR01). These are then linked to the death records held by the General Register Office for Scotland. Diagnoses in the records are coded using the International Classification of Diseases codes (ICD9 or ICD10) and operations are coded using Office of Population, Censuses, and Surveys Classification of Surgical Operations and Procedures Fourth Revision (OPCS-4) codes.
Definitions of disease
Acquired aortic valve disease was taken to represent all forms of non-congenital heart disease. We identified the first report of aortic valve disease in a principal (primary) or secondary discharge diagnostic position with the following codes: I35 ['I350' (aortic stenosis), 'I351' (aortic insufficiency), 'I352' (aortic stenosis with insufficiency), 'I358' and 'I359' (other and unspecified aortic valve disease)] from ICD10. The diagnostic categories of aortic valve disease are available from ICD10 (but not ICD9). Aortic valve replacement was identified using OPCS-4 codes 'K261-K264' and 'K268'. Aortic valve replacement included elective or non-elective operations. Aortic balloon valvuloplasty was identified using OPCS- codes 'K265' and 'K352'.
Patients with congenital aortic valve disease (n = 203, codes ICD-9 746, ICD10 Q22, Q23) and endocarditis (n = 485, codes I011, I33, I38–I39) were excluded. Pulmonary and tricuspid valve disease was not studied since disease of these valves is strongly associated with congenital heart disease and pulmonary hypertension, respectively.
Data were available in the Scottish national databases from 1 January 1981 and complete records up to 31 December 2006 were obtained. Our analyses are based on new incident cases of aortic valve disease from 1 January 1997, from which point all records are fully coded using ICD10. OPCS-4 included a code for aortic valve replacement. To ensure that all patients in our database had a minimum of 1 year of follow-up, we included all index cases up to 31 December 2005 and incorporated follow-up until 31 December 2006.
Co-morbidity and hospital admission history
We identified the baseline medical history from events prior to the index event, co-morbidities for the index event, and various individual and composite clinical outcomes and also outcomes for valve intervention by surgery or balloon valvuloplasty. Co-morbidity was defined as concomitant or prior diagnoses (within 5 years) of the index hospitalization with aortic valve disease for the following diseases: diabetes (ICD-10 codes E10–E14); respiratory disease (J10–J18, J40–J47); cancer (C00–C99); hypertension (I10); renal disease (N17–N19); and rheumatoid arthritis (M05–M06).
Cardiovascular hospitalization history was identified from cardiac diagnosis or procedures separately on whether they are concurrent or in a prior admission within 5 years of the index admission. Cardiovascular events during follow-up were also identified. The ICD-10 codes used to identify these events are listed in the Supplementary material online.
The following cardiac procedures were included: aortic valve replacement (OPCS-4 codes K261–K264, K268), coronary artery bypass grafting (CABG) (OPCS-4 codes K401–K404, K408–K414, K418–K419, K421–K424, K428–K429, K431–K434, K438–K439, K441–K442, K448–K449, K451–K456, K458–K459, K461–K465, and K468–K469; OPCS-3 codes 323 and 324), and percutaneous coronary intervention (PCI) (OPCS-4 codes K491–K493, K498–K499, K501–K503, K508–K509, K511, and K518–K519).
Socio-economic status
Socio-economic status was determined using the Deprivation Category score.11 This is an ordinal index of socio-economic status in Scotland based on the place of residence, as defined by postcode. The score includes contemporary census-based information on the percentage of the population within attributes related to poverty (e.g. % without a car, % subject to overcrowding, % male unemployment, and % low social class). The 5-point scale was recategorized for analysis as 1 (high socio-economic status/affluent, scores 1–2) to 3 (low socio-economic status/most deprived, scores 4–5).
Quality assurance
Quality assurance analyses of heart valve disease codes in our data set were performed using SMR01 data for 2004–2006. Aortic valve diagnoses [106 rheumatic aortic valve diseases, 135 non-rheumatic aortic valve diseases, but excluding 108 multiple valve diseases (whether rheumatic or not)] were recorded at 3-digit level with an accuracy of 87.9% (95% confidence interval 76.7%, 99.0%), and at the 4-digit level with an accuracy of 81.8% (95% confidence interval 68.7%, 95.0%), and had a sensitivity of 70.7% and completeness of 80.5%.
Continuous variables are summarized as mean (standard deviation) and categorical data as count (percentage). Time to event analyses were undertaken using Cox Proportional-Hazards models. Time was derived from the date of index admission to the date of the event; for those subjects not experiencing an event a censoring date of 31 December 2006 was used. Backwards selection was used to identify the independent predictors of events using the baseline characteristics available (age, gender, calendar year of index diagnosis, deprivation, co-morbidity, and hospitalization history). The events studied were all-cause mortality, aortic valve replacement, myocardial infarction plus all-cause mortality, heart failure plus all-cause mortality, and stroke/transient ischaemic attack plus all-cause mortality. Only subjects with the full set of baseline characteristics recorded were included in this analysis.
Differences in time to event between aortic valve disease types were investigated using unadjusted and adjusted Cox-Proportional-Hazards models. The unadjusted models included a covariate for disease type only and the adjusted models included all independent predictors identified from the backwards selection for each endpoint.
Incidence of aortic valve disease was age–sex standardized based on the age and sex distribution of the population in 2005. Incidence was presented as the standardized number of events per 1 million of the population. We also investigated the incidence of the specific types aortic valve disease within four age groups (<60, 60–69, 70–79, and over 80 years). We plotted the standardized incidence over time to investigate any trends over time.
Patient characteristics and temporal trends in hospitalizations for each type of aortic valve disease in Scotland
A total of 19 733 patients aged ≥18 years had an index hospitalization with a final diagnosis of aortic valve disease in a primary [n = 5176 (26.2%)] or secondary diagnostic position [2nd–6th positions, n = 14 557 (73.8% cases), Table 1] of the SMR01 record.
|Aortic stenosis n = 13 220
|Aortic insufficiency n = 2807
|Aortic stenosis with insufficiency n = 699
|Other and unspecified aortic valve disorders n = 3007
|Baseline characteristics
|Age, years
|75.70 (10.96)
|68.30 (14.33)
|73.60 (11.50)
|71.80 (12.06)
|Sex, males (%)
|6160 (46.6)
|1311 (46.7)
|356 (50.9)
|1419 (47.2)
|Deprivation, %
|Least deprived
|5477 (42.0)
|1057 (38.3)
|301 (43.4)
|1135 (38.1)
|2714 (20.8)
|513 (18.6)
|146 (21.1)
|687 (23.1)
|Most deprived
|4843 (37.2)
|1193 (43.2)
|246 (35.5)
|1157 (38.8)
|Co-morbidities, %
|1497 (11.3)
|169 (6.0)
|52 (7.4)
|293 (9.7)
|Respiratory disease
|2225 (16.8)
|434 (15.5)
|107 (15.3)
|490 (16.3)
|1239 (9.4)
|185 (6.6)
|54 (7.7)
|254 (8.4)
|3688 (27.9)
|808 (28.8)
|183 (26.2)
|868 (28.9)
|Renal disease
|1080 (8.2)
|183 (6.5)
|44 (6.3)
|203 (6.8)
|Rheumatoid arthritis
|228 (1.7)
|71 (2.5)
|16 (2.3)
|73 (2.4)
|Cardiovascular event
|Concurrent procedures, %
|528 (4.0)
|94 (3.3)
|49 (7.0)
|109 (3.6)
|Aortic balloon valvuloplasty
|3 (0.0)
|0 (0.0)
|0 (0.0)
|0 (0.0)
|328 (2.5)
|47 (1.7)
|18 (2.6)
|70 (2.3)
|165 (1.2)
|35 (1.2)
|12 (1.7)
|48 (1.6)
|Concurrent complications of admission, %
|932 (7.0)
|146 (5.2)
|40 (5.7)
|168 (5.6)
|2040 (15.4)
|403 (14.4)
|99 (14.2)
|486 (16.2)
|Heart failure
|3318 (25.1)
|684 (24.4)
|164 (23.5)
|553 (18.4)
|NH stroke
|380 (2.9)
|90 (3.2)
|17 (2.4)
|79 (2.6)
|Atrial fibrillation or flutter
|2116 (16.0)
|571 (20.3)
|142 (20.3)
|501 (16.7)
|Prior procedures, %
|96 (0.7)
|22 (0.8)
|5 (0.7)
|26 (0.9)
|104 (0.8)
|27 (1.0)
|11 (1.6)
|32 (1.1)
|Prior events, %
|582 (4.4)
|130 (4.6)
|26 (3.7)
|153 (5.1)
|1864 (14.1)
|455 (16.2)
|81 (11.6)
|488 (16.2)
|Heart failure
|1392 (10.5)
|322 (11.5)
|59 (8.4)
|359 (11.9)
|NH stroke
|374 (2.8)
|70 (2.5)
|22 (3.1)
|85 (2.8)
|Atrial fibrillation or flutter
|1175 (8.9)
|338 (12.0)
|76 (10.9)
|326 (10.8)
The P-value signifies a difference between aortic valve disease types.
AVR, aortic valve replacement; CABG, coronary artery bypass graft; PCI, percutaneous coronary intervention; MI, myocardial infarction; UAP, unstable angina pectoris; NH, non-haemorrhagic.
The average age at the time of a first presentation with aortic valve disease was 71 and 76 years in men and women, respectively. Age at first presentation differed between types of aortic valve disease (Table 1) and patients with isolated aortic stenosis at first presentation were older than patients with other types of aortic valve disease. Although gender was not related to the type of aortic valve disease, deprivation and several co-morbidities were, including a history of diabetes, cancer, and renal disease which were more common in patients with aortic stenosis. History of rheumatoid arthritis was more common in patients with isolated aortic insufficiency (Table 1). The most common cardiovascular problem overall was heart failure which was a complicating factor in one quarter of all index admissions (Table 1). Atrial fibrillation or flutter occurred in nearly one-fifth of all index admissions and was most common in patients with aortic insufficiency.
The temporal trends in the incidences of different types of aortic valve disease are shown in Figure 1. The (age–sex standardized) incidence of isolated aortic stenosis increased from 246 cases per 1 million of the population in 1997 to 365 per 1 million population in 2005. The incidence of hospitalizations with mixed aortic valve disease increased from 13 cases per 1 million population in 1997 to 24 per 1 million population in 2005, whereas the incidences of other forms of aortic valve disease were relatively unchanged. The majority of hospitalizations occurred in elderly persons aged 80 and older (Figure 2).
Changing course of health outcomes following a first hospitalization with each type of aortic valve disease
All-cause mortality
Among 19 733 patients with a first admission of aortic valve disease between 1 January 1997 and 31 December 2005, 9981 (50.6%) patients had died (all causes) by 31 December 2006 (Figure 3) and the majority of these patients (71.6%) had aortic stenosis (Table 2). When compared with aortic stenosis, the likelihood of death was less with aortic insufficiency [hazard ratio (95% confidence interval) 0.79 (0.74, 0.84)] and mixed aortic valve disease [0.83 (0.74, 0.93)]. The independent predictors of subsequent all-cause mortality are described in Table 2. Female gender, year of admission, and hypertension reduced the likelihood of mortality in patients with aortic stenosis. Deprivation increased the likelihood of mortality following a diagnosis of aortic stenosis.
|Aortic stenosis n = 13 220
|Aortic insufficiency n = 2807
|Aortic stenosis with insufficiency n = 699
|Other and unspecified aortic valve disorders n = 3007
|Number of events, %
|7147 (54.1)
|1134 (40.4)
|304 (43.5)
|1396 (4)
|Age (5-year change)
|1.33 (1.31, 1.35)
|1.29 (1.26, 1.33)
|1.35 (1.27, 1.45)
|1.34 (1.30, 1.37)
|Year of admission (5-year change)
|0.88 (0.83, 0.92)
|0.85 (0.75, 0.98)
|0.86 (0.77, 0.98)
|Sex (female vs. male)
|0.88 (0.84, 0.93)
|0.67 (0.53, 0.86)
|Medium vs. least deprived
|1.06 (1.00, 1.13)
|Most deprived vs. least deprived
|1.09 (1.03, 1.15)
|1.33 (1.24, 1.43)
|1.44 (1.16, 1.79)
|1.40 (1.18, 1.66)
|Respiratory disease
|1.38 (1.30, 1.47)
|1.66 (1.43, 1.91)
|1.42 (1.24, 1.62)
|1.53 (1.43, 1.65)
|1.52 (1.25, 1.86)
|2.05 (1.46, 2.89)
|1.61 (1.36, 1.89)
|0.92 (0.87, 0.97)
|0.87 (0.77, 0.98)
|Renal disease
|1.65 (1.53, 1.78)
|1.93 (1.58, 2.36)
|2.09 (1.44, 3.04)
|2.15 (1.80, 2.56)
|Concurrent procedures
|0.45 (0.37, 0.54)
|0.55 (0.31, 0.98)
|0.56 (0.37, 0.85)
|0.61 (0.44, 0.84)
|Concurrent complications of admission
|1.36 (1.25, 1.48)
|0.88 (0.82, 0.94)
|0.76 (0.63, 0.92)
|0.77 (0.66, 0.90)
|Heart failure
|1.68 (1.60, 1.77)
|1.52 (1.33, 1.73)
|1.71 (1.33, 2.21)
|1.50 (1.32, 1.70)
|NH stroke
|1.47 (1.11, 1.95)
|Atrial fibrillation or flutter
|1.07 (1.01, 1.14)
|Prior procedures
|0.30 (0.09, 0.93)
|Prior events
|1.33 (1.04, 1.70)
|Heart failure
|1.43 (1.34, 1.54)
|1.38 (1.17, 1.62)
|1.43 (1.00, 2.03)
|1.23 (1.05, 1.45)
|NH stroke
|1.20 (1.06, 1.36)
|Atrial fibrillation or flutter
|1.20 (1.02, 1.41)
AVR, aortic valve replacement; CABG, coronary artery bypass graft; PCI, percutaneous coronary intervention; MI, myocardial infarction; UAP, unstable angina pectoris; NH, non-haemorrhagic.
Death or index rehospitalization for heart failure, myocardial infarction, or stroke according to aortic valve disease type
Death or rehospitalization for heart failure
A total of 10 604 (53.7%) deaths or index heart failure hospitalizations occurred (see Supplementary material online, Table S1 and Figure S1). Of these, 619 (5.8%) and 1961 (18.5%) subjects experienced a fatal or non-fatal hospital index admission with heart failure, respectively. When compared with other types of aortic valve disease, aortic stenosis increased the risk of death following a heart failure hospitalization (adjusted P < 0.001).
Death or rehospitalization for myocardial infarction or stroke
In total, 10 301 (52.2%) deaths or rehospitalization for myocardial infarction and 10 688 (54.2%) deaths or rehospitalization for stroke or transient ischaemic attack occurred (Supplementary material online, Figures S1 and S2, respectively). Overall, a hospital admission for myocardial infarction was fatal in 38% of patients with aortic stenosis with or without insufficiency, whereas the fatality rate was much lower for hospitalization with stroke (18.8 and 20.3%, respectively) and for heart failure (24.8 and 28.9%, respectively) (Supplementary material online, Table S1).
When compared with other forms of aortic valve disease, aortic stenosis had a higher hazard ratio for time to death following myocardial infarction or stroke, although this was not significant after adjustment for age, year of admission, and co-morbidity (Supplementary material online, Table S2).
Aortic valve replacement according to the type of aortic valve disease
The first aortic valve replacement took place in 3 367 (19.4%) patients of whom 73.2% had aortic stenosis, 11.9% had an unspecified type of aortic valve disease, and 10.0% had aortic insufficiency and 4.9% had aortic stenosis with insufficiency (Figure 4 and Table 3). Seven hundred and eighty patients had an aortic valve replacement during their index hospital admission. The likelihood of aortic valve replacement in patients with aortic stenosis (isolated or mixed) was reduced with female gender, co-morbidities (e.g. renal disease, respiratory disease), and concurrent myocardial infarction (Table 3). In patients with aortic stenosis, the likelihood of aortic valve replacement increased with the year of admission and decreased with concurrent coronary artery bypass surgery and PCI.
|Aortic stenosis n = 12 692
|Aortic insufficiency n = 2713
|Aortic stenosis with insufficiency n = 650
|Other and unspecified aortic valve disorders n = 2898
|Number of events, %
|2689 (21.2)
|367 (13.5)
|180 (27.7)
|437 (15.1)
|Age (5-year change)
|0.85 (0.84, 0.87)
|0.88 (0.85, 0.91)
|0.81 (0.77, 0.85)
|0.90 (0.87, 0.93)
|Year of admission (5-year change)
|1.15 (1.06, 1.24)
|Sex (female vs. male)
|0.70 (0.65, 0.76)
|0.53 (0.43, 0.66)
|0.63 (0.46, 0.86)
|0.67 (0.56, 0.82)
|Respiratory disease
|0.52 (0.45, 0.60)
|0.53 (0.36, 0.79)
|0.59 (0.36, 0.96)
|0.65 (0.47, 0.90)
|0.61 (0.51, 0.73)
|0.78 (0.71, 0.85)
|0.75 (0.58, 0.97)
|0.64 (0.50, 0.82)
|Renal disease
|0.45 (0.35, 0.59)
|0.47 (0.24, 0.91)
|0.21 (0.05, 0.84)
|0.27 (0.11, 0.66)
|Rheumatoid arthritis
|0.65 (0.44, 0.95)
|Concurrent procedures
|0.17 (0.08, 0.38)
|0.34 (0.21, 0.55)
|Concurrent complications of admission
|0.46 (0.37, 0.59)
|0.42 (0.21, 0.84)
|0.19 (0.05, 0.78)
|0.32 (0.15, 0.68)
|0.83 (0.74, 0.92)
|0.73 (0.54, 0.99)
|0.62 (0.47, 0.83)
|Heart failure
|0.72 (0.63, 0.81)
|0.61 (0.43, 0.87)
|NH stroke
|0.27 (0.18, 0.41)
|Atrial fibrillation or flutter
|0.67 (0.58, 0.77)
|0.42 (0.29, 0.61)
|0.60 (0.43, 0.84)
|Prior procedures
|0.39 (0.21, 0.74)
|Prior events
|0.49 (0.36, 0.67)
|0.20 (0.08, 0.54)
|0.69 (0.61, 0.80)
|Heart failure
|0.68 (0.55, 0.85)
|NH stroke
|0.52 (0.36, 0.76)
|0.30 (0.10, 0.93)
CABG, coronary artery bypass graft; PCI, percutaneous coronary intervention; MI, myocardial infarction; UAP, unstable angina pectoris; NH, non-haemorrhagic.
Our results provide insights into the distinct and changing course of different types of aortic valve disease in Scotland over a 10-year period.
Aortic stenosis was the commonest type of aortic valve disease and its incidence in Scotland has nearly doubled from 1997 to 2005. The rising incidence is mainly in elderly persons aged 80 and older. Our results identify the prognostic importance of aortic stenosis when compared with other types of aortic valve disease. Aortic stenosis conferred a higher risk of death, or death and heart failure when compared with other types of aortic valve disease. The fatality rate associated with a hospitalization for myocardial infarction was 38% which was approximately double the rate of death associated with a hospitalization for heart failure or for stroke. The cumulative incidence of aortic valve replacement has nearly doubled during the past 10 years and aortic stenosis with insufficiency was the commonest indication for surgery.
Our findings indicate a striking rising trend in hospitalizations for aortic valve disease in Scotland in recent years. This trend is most pronounced for aortic stenosis which appears to have a distinct clinical course. The possible reasons to explain this finding include a lower threshold for patients to seek medical care and improved diagnostic methods. One other important factor is increased longevity in the general population since degenerative aortic valve disease is much more common in the elderly.6
There were notable differences in the characteristics of patients according to the type of aortic valve disease. Patients with aortic stenosis were older than patients with mixed aortic valve disease or isolated aortic insufficiency. Deprivation status also differed according to type of aortic valve disease and a higher proportion of patients with aortic stenosis (with or without insufficiency) were deprived. Heart failure was a common complicating problem, affecting a quarter of patients with either aortic stenosis, aortic insufficiency, or mixed aortic valve disease. Cancer was more common in aortic stenosis, perhaps because patients with this type of aortic valve disease were older.
Natural history following a diagnosis of aortic valve disease
Our findings point to differences in the health outcomes following a diagnosis of aortic stenosis, aortic insufficiency, or mixed aortic valve disease. When compared with other types of aortic valve disease, aortic stenosis conferred an increased risk of mortality or of adverse cardiovascular events including myocardial infarction, heart failure, and stroke. Year of admission reduced the likelihood of mortality in patients with aortic stenosis. One explanation for this finding could be earlier detection of aortic stenosis and the presence of less advanced cardiovascular health problems at the time of first hospitalization. We also found that deprivation increased the likelihood of mortality and cardiovascular morbidity following a diagnosis of aortic stenosis.
Our observations draw attention to the prognostic implications of aortic stenosis. When compared with other types of aortic valve disease, aortic stenosis was an independent predictor of all-cause mortality and of all-cause mortality plus heart failure hospitalization. We also observed that the mortality rate associated with a subsequent hospitalization for myocardial infarction was very high. The fatality rate with myocardial infarction was highest (41%) in patients with aortic stenosis with or without aortic insufficiency. This finding suggests that patients with aortic valve disease, and aortic stenosis in particular, have a limited capacity to tolerate the negative inotropic effects of acute myocardial infarction.
Strengths and limitations of current epidemiology of heart valve disease
Nkomo et al.6 have provided information about the prevalence and age distribution of valvular heart disease from a randomly selected population of patients from Rochester, USA. They found that the prevalence of heart valve disease was strongly influenced by age, with the cumulative prevalence of aortic and mitral valve disease ranging from 0.7% in adults aged 18–44 to 13.2% in the elderly (age ≥ 75 years). Although mitral insufficiency was the commonest valve pathology, aortic stenosis was also common, particularly in the elderly.6 The only other contemporary epidemiological study is the EuroHeart Survey5 which was a prospective multicentre European study of planned and unplanned hospital visits by patients with a diagnosis of aortic and mitral valve disease (April–July 2001). Our study is different since we have provided a population-level analysis in a much larger cohort during a 10-year period.
Treatment of aortic valve disease
Increasingly, heart valve disease is being recognized as a public health concern with requirements for healthcare planning.15 The treatment of heart valve disease can be difficult. Drug therapies alleviate symptoms but do not modify prognosis.7,8,16 Aortic valve replacement improves prognosis17 and the proportion of patients >75 years undergoing valve replacement has steadily increased in the UK since 1999.18 Therefore, because of increasing longevity, the number of aortic valve replacements is projected to rise markedly in the coming years.4,14
Many elderly persons with heart valve disease are unsuitable for surgical valve replacement9,10,18,19 and this area of unmet need has stimulated new therapeutic approaches. Transcatheter aortic valve implantation is a promising emerging treatment for patients who are unsuitable for surgery.9,10,20,21 The PARTNER trial demonstrated that in patients with inoperable aortic stenosis, TAVI reduced all-cause mortality and hospitalizations compared with usual care9 confirming that TAVI represents an alternative to surgical aortic valve replacement in high-risk patients.
Limitations of the current study
We accept that the data on incidence of aortic valve disease may be affected by detection bias. However, we believe the distinct trends over time for each aortic valve entity are correct and cannot simply be explained by increased detection such as through improved access to echocardiography, since uniform increases in the incidences of different types of aortic valve disease did not occur. For example, the number of first hospitalizations with a diagnosis of aortic stenosis increased markedly over time, whereas the number of hospitalizations with a diagnosis of aortic insufficiency remained reasonably constant. We accept that a small minority of patients with undisclosed bicuspid aortic valve disease may have been included, although imaging typically detects this pathology. We also accept that coding of some clinical characteristics, such as hypertension, may be incomplete.
The management of heart valve disease in Scotland may differ in some ways (e.g. concomitant revascularization rates with valve surgery) compared with other countries. However, the prognostic models in our study will be relevant to populations elsewhere, since our data are derived from the full spectrum of socio-economic backgrounds.
In conclusion, we report the epidemiology and temporal trends of different types of acquired aortic valve disease at a population level. The incidence of aortic stenosis has increased in Scotland in recent years. Probably because of increased longevity in general, aortic stenosis will become an increasingly important public health problem.
Supplementary material
Supplementary material is available at European Heart Journal online.
Authors' contributions
C.B. conceived the idea for the study, interpreted the data, and wrote the first and final drafts of the manuscript. S.M.L. conducted the final statistical analyses and contributed to the writing of the manuscript. Y.W. conducted the initial statistical analyses and contributed to the writing of the manuscript. A.M. performed the data extraction and reviewed the manuscript. I.F. developed the design of the study, contributed to data analyses and interpretation, and helped write the manuscript.
C.B. was supported by a British Heart Foundation International Fellowship and a Senior Clinical Fellowship from the Scottish Funding Council. I.F. was supported by a grant from The Wellcome Trust for the Scottish Health Informatics Programme (SHIP). I.B., C.B., and S.M.L. were supported by a grant from the Chief Scientist Office, Scotland to study the epidemiology of heart valve disease in Scotland.
Conflict of interest: none declared.
We thank staff from the Information and Statistics Division, NHS Scotland National Services. C.B. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analyses.
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