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Patel, Sameer J. MD, MPH; Klinger, Ellen J. MPH; O'Toole, Dana BS; Schillinger, Julia A. MD, MSc
From the Department of Pediatrics, Columbia University, and the Bureau of Sexually Transmitted Diseases Control, New York City Department of Health and Mental Hygiene, New York, New York; and the Division of Sexually Transmitted Diseases Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.
The authors thank Susan Resnick, a computer programmer who provided demographic data for the analysis, and Annot Pierrot-Cox, who is the congenital syphilis surveillance coordinator who supervised data collection and completion of case investigations for the patients included in the study, both at the New York City Department of Health and Mental Hygiene.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Corresponding author: Sameer Patel, MD, 622 West 168th Street, PH 4W-475, New York, NY 10032; e-mail: firstname.lastname@example.com.
Financial Disclosure The authors did not report any potential conflicts of interest.
OBJECTIVE: To describe health care providers' missed opportunities for preventing and treating congenital syphilis in New York City.
METHODS: Review of congenital syphilis cases reported to the New York City Department of Health and Mental Hygiene from January 1, 2000 to December 31, 2009. Receipt and timing of prenatal care, serologic testing, and treatment of mothers and newborns were reviewed. Missed opportunities were defined as receipt of prenatal care plus one of the following: 1) lack of documented treatment for syphilis infection diagnosed before pregnancy; 2) absence of serologic testing during pregnancy; 3) late maternal treatment; 4) maternal treatment with a nonpenicillin regimen; or 5) lack of maternal treatment.
RESULTS: In total, 195 newborns with congenital syphilis were born to 190 mothers with 191 pregnancies. Overall, 80% (95% confidence interval [CI] 74–86%, 152 of 190) of all mothers received prenatal care; 63% (95% CI 56–71%, 96 of 152) of these had one or more missed opportunities for prevention. Twelve mothers received inadequate treatment or no treatment during the case pregnancy for documented syphilis infection before pregnancy, and 42 mothers without previous syphilis diagnosis did not have serologic testing during the case pregnancy. Of 103 mothers with syphilis diagnosed before 30 weeks of gestation, 12 received late penicillin therapy, 27 received no therapy, and 3 received inappropriate (nonpenicillin) therapy. Seventeen percent (95% CI 12–22%, 33 of 193) of liveborn newborns received no treatment during their hospitalization.
CONCLUSION: Providers missed well-defined opportunities to prevent congenital syphilis for the majority of cases. Combined efforts to prevent future cases include provider education and better integration of care between obstetricians and pediatricians.
In 2007, the World Health Organization (WHO) articulated a strategy for the global elimination of congenital syphilis,1 emphasizing that congenital syphilis is a preventable disease. The WHO strategy highlighted the importance of both the availability and quality of maternal and newborn health services to limit missed opportunities for prevention. The Centers for Disease Control and Prevention has identified elimination of congenital syphilis as a "winnable battle."2
The clinical manifestations of congenital syphilis range from asymptomatic infection to bone deformities, neurologic impairment, and stillbirth. Lack of prenatal screening and inadequate maternal therapy can lead to the diagnosis of congenital syphilis.3 Any stage of maternal syphilis infection during pregnancy may lead to intrauterine infection. Prompt penicillin therapy appropriate for maternal stage of infection is recommended on diagnosis and at least 30 days before delivery to prevent congenital syphilis.4 Serologic testing during pregnancy should be used to assess response to therapy, relapse, or reinfection. Previously described patient-level risk factors for congenital syphilis include poverty, crack cocaine drug use, lower educational status, lack of prenatal care, and black race.5–7 An increase in syphilis infections in women may presage an increase in congenital syphilis infections.
Nationally, and in New York City, rates of congenital syphilis cases were at a nadir in 2005.8 However, in the late 2000s, the national incidence of all manifestations of syphilis increased, with a congenital syphilis rate more than 10 per 100,000 live births per year from 2007 to 2009. New York City experienced a 24% increase in primary and secondary syphilis infections among women between 2008 (0.88 cases per 100,000) and 2009 (1.10 cases per 100,000).9
Because New York State laws mandate prenatal syphilis screening and treatment and follow-up of all women and newborns with syphilis, each case of congenital syphilis warrants examination to identify provider and structural factors that contributed to its occurrence. In this study, we examined newborn and maternal characteristics of congenital syphilis cases reported to the New York City Department of Health and Mental Hygiene from 2000 to 2009. We identified missed opportunities for prevention by evaluating provider compliance with the Centers for Disease Control and Prevention (CDC) and United States Preventive Task Force recommendations for management of pregnant women and newborns.4
New York State mandates prenatal syphilis screening of pregnant women at the first prenatal visit (Public Health Law Section 23O8) and, with limited exceptions, of neonates born alive and fetuses born dead after 22 weeks of gestation (New York Codes, Rules and Regulations, Title 10, Section 69–2.2), as well as treatment and follow-up of all women and newborns with syphilis (New York Codes, Rules and Regulations, Title 10, Section 69–2.5). In addition, laboratories and physicians in New York City are mandated to report positive syphilis test results and clinical diagnoses of syphilis, respectively (New York City Health Code, codified at Rules of the City of New York, Title 24, Sections 13.O3 and 11.O3). For New York City, pregnancy status, if available, must also be reported on laboratory case reports [Rules of the City of New York, Title 24, Section 13.O3(a)(1)] and on provider case reports [Rules of the City of New York, Title 24, Section 11.05(b)].
The New York City Department of Health and Mental Hygiene reviews each reactive serologic test for syphilis reported for women of childbearing age (age 15–45 years) residing in New York City and uses previously reported serologic test results and treatment to determine if further investigation and treatment are needed. If a reported titer suggests a new infection, then the Department of Health and Mental Hygiene contacts women and their providers to assure treatment is administered and that sex partners are tested and treated to prevent repeat infection. Women with a reactive syphilis serology who are known to be pregnant are the highest priority for investigation and are tracked by a single designated staff member. For each neonate born to a woman with a reactive syphilis serology, a field worker reviews the maternal and newborn records and completes a CDC case report form, which includes information on the following: demographics; receipt and timing of prenatal care; maternal and newborn serologic testing and treatment histories; and significant clinical, laboratory, and radiographic findings. A single staff member reviews the maternal and newborn medical records and makes a determination of congenital syphilis case status using CDC definitions for probable or confirmed congenital syphilis (Table 1).3 New York City Department of Health and Mental Hygiene field staff are trained to determine the appropriateness of treatment regimen for stage of syphilis infection, and the CDC case report form allows field staff to specify when a nonpenicillin regimen was used but does not collect information on specific penicillin formulations or doses. Data are entered into a surveillance and case management registry. The registry also includes other sexually transmitted infections reported to the New York City Department of Health and Mental Hygiene. We retrospectively reviewed this registry for cases of congenital syphilis from January 1, 2000 to December 31, 2009.
For our study, race and ethnicity data were combined. Mothers were categorized as Hispanic or as the following non-Hispanic groups: black, white, Asian or Pacific Islander, Native American, and other (which included multiracial mothers). Academic hospitals were defined as hospitals primarily affiliated with medical schools. Receipt of prenatal care was defined as having at least one prenatal visit or serologic test before 30 weeks of gestation. Thirty weeks was selected to allow ample time for the clinician to have evaluated, screened, and treated mothers with reactive syphilis serology testing 30 days before a term delivery. Maternal syphilis relapse or treatment failure was defined as an increase in maternal nontreponemal titers after treatment or as a symptomatic newborn despite maternal therapy.
Missed opportunities for preventing congenital syphilis during pregnancy were defined as receipt of prenatal care plus at least one of the following: 1) lack of documented maternal treatment for syphilis infection diagnosed before the case pregnancy; 2) lack of serologic testing during the case pregnancy; 3) late maternal treatment (eg, less than 30 days before delivery); 4) maternal treatment with a nonpenicillin regimen; or 5) lack of maternal treatment for syphilis infection diagnosed during the case pregnancy. We analyzed women who received prenatal care but did not receive appropriate serologic testing or treatment to focus on provider deficits in preventing congenital syphilis. Women who did not receive prenatal care were not considered to have had a missed opportunity. Similarly, a positive serologic test after 30 weeks of gestation, after an initial negative test result earlier in pregnancy, was not considered a missed opportunity. When there were multiple missed opportunities to prevent congenital syphilis infection, we classified the cases by the earliest missed opportunity. Women who delivered twins with congenital syphilis were considered to have a single opportunity for prevention and were included in the prevention analysis only once. For women who delivered newborns with congenital syphilis over separate pregnancies, we only included the first pregnancy. When calculating case rates and describing the medical management of the newborns, we counted each unique newborn, including each newborn of a twin pair.
To evaluate the medical management of newborns with congenital syphilis, we used the CDC case report form and recommendations from the American Academy of Pediatrics to determine if diagnostic tests were performed (long bone radiographs, cerebrospinal venereal disease research laboratory testing, and cerebrospinal fluid [CSF] cell count) and if recommended penicillin therapy was administered to the newborns.10
Case rates (probable plus confirmed cases per 100,000 live births) were calculated for each year of the study period. Frequencies and percentages were calculated for categorical variables and medians and ranges were calculated for continuous variables. Although we calculated percentages that represented population parameters for New York City, we have calculated 95% confidence intervals (CIs) for generalizability outside of New York City. Odds ratios were calculated to evaluate potential associations between missed opportunities and maternal race or ethnicity, marital status, age, and delivery at an academic hospital, compared with nonacademic hospital, using multiple logistic regression. The a priori level of significance was set at P<.05. All models were run in SAS statistical software 9.5.2. The project was classified as nonresearch according to New York City Department of Health and Mental Hygiene guidelines on the use of public health surveillance data. One of the investigators was affiliated with Columbia University and the project was approved by the Institutional Review Board of the medical center.
From January 1, 2000 to December 31, 2009, 195 newborns reported to the New York City Department of Health and Mental Hygiene met the CDC surveillance case definition of probable or confirmed congenital syphilis. One hundred eighty-five women delivered one newborn with congenital syphilis, four mothers delivered twins, and one mother delivered two newborns over successive pregnancies. The congenital syphilis case rate over the course of the decade was 16.3 per 100,000 live births. As shown in Figure 1, rates decreased in the early 2000s but have shown an upward trend in the past 3 years. Fifty-four percent (95% CI 47–61%, 105 of 195) of cases were born at seven hospitals. Only 18% (95% CI 13–23%, 35 of 195) were born at academic hospitals associated with medical schools.
The median gestational age at birth was 39 weeks (range 23–42 weeks). The median birthweight was 3,145 g (range 942–4,670 g). Of the 195 newborns, two were stillborn and 193 were liveborn. Of the latter, 192 survived and 1 died in the neonatal period. Only the two stillborn fetuses met the CDC criteria for a confirmed case. The remaining 193 cases met the CDC case definition for probable cases. Only 5.6% (95% CI 2.4–8.9%, 11 of 195) of liveborn newborns had signs of congenital syphilis on physical examination, radiographs, or CSF venereal disease research laboratory testing. Of newborns who had CSF testing performed, 64% (95% CI 52–75%, 42 of 66) had an abnormal protein or cell count.
Among the 190 mothers, the median maternal age was 31.9 years (range 17.7–45.2 years). Seventy-seven percent (95% CI 71–83%, 146 of 190) were unmarried at the time of diagnosis in their newborns. Of mothers with available race and ethnicity data, 53% (95% CI 45–61%, 85 of 160) were non-Hispanic black and 36% (95% CI 28–43%, 56 of 159) were Hispanic.
Of the 190 mothers, few had primary (1%, 95% CI 0–1.6%, n=2) or secondary syphilis (2.6%, 95% CI 0.4–4.9%, n=5) infection. Twenty-six percent (95% CI 20–32%, 49 of 190) had early latent infection, 35% (95% CI 28–42%, 66 of 190) had late latent infection, and 36% (95% CI 29–43%, 68 of 190) had latent syphilis of unknown duration or syphilis of unknown stage. One hundred seventy-three mothers had syphilis first diagnosed during the case pregnancy. Of these, 21% (95% CI 15–27%, 36 of 173) were screened in the first trimester, 15% (95% CI 10–21%, 27 of 173) were screened in the second trimester, 24% (95% CI 18–31%, 42 of 173) were screened in the third trimester, and 38% (95% CI 32–47%, 68 of 173) were tested initially at the time of delivery, including 35 who received prenatal care.
After a negative test in the first or second trimester, 32 mothers had a subsequent positive serologic test result, indicating seroconversion during pregnancy. These 32 women included 16 instances of late therapy and 13 instances in which no therapy was provided within 30 days of or after delivery. Fourteen mothers or their newborns had evidence of relapse or treatment failure despite receipt of timely and appropriate therapy.
Figure 2 displays the continuum of care along which we considered missed opportunities for the 190 mothers, displayed in the chronologic order in which care might be expected to proceed: treatment of known infection before pregnancy; receipt of prenatal care during the case pregnancy; prenatal screening during case pregnancy; maternal treatment; and serologic follow-up during case pregnancy. Missed opportunities for prevention are highlighted along this continuum.
The majority (152 of 190, 80%, 95% CI 74–86%) of mothers attended at least one prenatal visit. This included 140 mothers without documented syphilis infection before pregnancy and 13 of the 17 mothers with documented syphilis infection before pregnancy. Of the 20% (95% CI 14–25%, 37 of 190) of women who did not receive prenatal care, 32 had syphilis first diagnosed during labor or immediately after delivery.
Numerous opportunities to prevent syphilis infection were missed among women who received prenatal care. Twenty-nine percent (95% CI 22–36%, 42 of 145) of mothers with no known history of syphilis infection or with previous adequately treated infection had no testing at all during the case pregnancy. Of note, eight of these mothers had gonococcal or chlamydial infection detected during pregnancy, yet they were not tested for syphilis infection. Of mothers who had timely serologic testing performed and had a positive serologic test result before 30 weeks of gestation, 13% (95% CI 5.5–18%, 12 of 103) received late penicillin therapy, 26% (95% CI 18–35%, 27 of 103) received no therapy, and 3% (95% CI 0–6.2%, 3 of 103) received inappropriate (nonpenicillin) therapy. Another 16 women received late therapy and 13 women received no therapy; however, these were not considered missed opportunities, because they were women who initially had a negative test result and seroconversion after 30 weeks of gestation. The nonpenicillin antibiotics used were erythromycin and doxycycline. Seven of the women who were inappropriately treated or untreated for known syphilis infection before their pregnancies were not tested and treated in a timely fashion during their subsequent pregnancies, despite receipt of prenatal care.
Overall, 63% (95% CI 56–71%, 96 of 152) of women who gave birth to newborns with confirmed or probable congenital syphilis had a missed opportunity for preventing congenital syphilis infection during prenatal care. Characteristics of the mothers with and without missed opportunities are listed in Table 2. Results of multiple logistic regression analysis are shown in Table 3. Age, race or ethnicity, marital status, and delivery at a nonacademic hospital were not associated with having a missed opportunity for congenital syphilis prevention.
Evaluation of case newborns was frequently incomplete. Long-bone radiographs were not performed for 46% (95% CI 39–53%, 89 of 193) of liveborn newborns. The CSF venereal disease research laboratory testing was not performed for 32% (95% CI 26–39%, 62 of 193) of newborns and CSF cell count was not performed for 47% (95% CI 40–54%, 91 of 193) of newborns. More than half (56%, 95% CI 33–79%, 10 of 18) of the newborns who had an rapid plasma reagin four-times or more their mother's titer did not have a complete diagnostic evaluation performed.
Seventeen percent (95% CI 12–22%, 33 of 193) of newborns received no treatment at all during their newborn hospitalization. Five percent (95% CI 2.1–8.3%, 10 of 193) received a nonpenicillin regimen and 5% (95% CI 1.7–7.6%, 9 of 193) received a penicillin course that was too short in duration (less than 10 days, despite clinical indication). Three percent (95% CI 0.7–5.6%, 6 of 193) of newborns had treatment initiated more than 2 weeks after birth. There was no association between the academic status of the hospital and failure to treat congenital syphilis after birth.
In our study of congenital syphilis cases in New York City over the past decade, several salient points emerge regarding patterns of infection and management of mothers and newborns. Although rare, cases of congenital syphilis in New York City have increased in recent years, similar to national trends.8 In New York City, the proportion of case mothers who received prenatal care was higher than the proportion of women nationally. However, missed opportunities were common among those who did have prenatal care, particularly with regard to antenatal screening and late and absent treatment. Newborns were rarely overtly symptomatic but commonly received inadequate evaluation and treatment. Importantly, our study described missed opportunities along a continuum of prenatal care, which should include treatment of known syphilis before conception.
The majority of the cases of congenital syphilis reported in New York City appear to be attributable to lack of provider adherence to screening laws and treatment guidelines or to some combination of provider-level and structural factors. Diagnosis of syphilis during pregnancy is dependent on interpretation of reactive serologic test results in the context of previous testing and treatment history—data that may not be fully reviewed or available at the time of a prenatal visit. Even with eventual appropriate treatment (more than 30 days before delivery), delays can result in treatment failure.11 Obstetricians may be able to obtain expert consultation from their local or state health department or to obtain a patient's serologic and treatment history from a registry, as is available in New York City, although many may not be aware of or use this resource.
Opportunities to prevent congenital syphilis existed across multiple clinical encounters, and some women were subject to multiple missed opportunities. Some women were known to have syphilis infection before conception and were inadequately treated at the time of that diagnosis. There were cases among women who had seroconversion during pregnancy that that could have been prevented if routine repeat third trimester screening had been performed. However, this is not currently mandated in New York City and may not be as cost-effective at current rates of disease, in contrast to previous decades when it was integral to congenital syphilis prevention efforts.12 At the least, our findings argue the need for careful history-taking at each prenatal visit, including asking about interim sexual partners and sexually transmitted infections, because this may identify women who may acquire infection during pregnancy.
Incomplete diagnostic evaluations of asymptomatic newborns can lead to missed diagnoses and have been associated with increased newborn mortality.13 We found that long-bone radiographs and CSF evaluations were frequently not performed on newborns born to mothers with undocumented treatment of syphilis. Even more surprisingly, a significant proportion of newborns with congenital syphilis received no treatment at all during their hospitalization. One possible explanation is that pediatricians may not be aware of the mother's syphilis status. Whereas this could be considered a provider-level factor contributing to congenital syphilis, this also may be the result of structural problems, such as poor communication between obstetrics and pediatrics staff, lack of laboratory alert values specific to obstetric patients, or lack of policies requiring documentation of maternal syphilis titers before discharging a newborn from the hospital.
There are limitations to surveillance data and, therefore, to the generalizability of our findings. Although we have records of whether women received prenatal care, we have no measure of patient adherence, and it is possible that some instances we classify as physicians' missed opportunities were not, in fact, under physicians' control. For example, women may not follow-up after their first prenatal visit, even if it occurs in the first trimester. In addition, we could not determine the duration or quality of prenatal care when present. We relied on retrospective data from a public health registry with predefined parameters and relatively few cases of congenital syphilis. Our findings are restricted to missed opportunities for prevention in newborns with probable or confirmed congenital syphilis infection, and we cannot use these data to make conclusions on the overall management of pregnant women in New York City with suspected or confirmed syphilis infection (ie, the number of congenital syphilis cases that were successfully prevented). All liveborn newborns had "probable infection" diagnosed rather than confirmed infection;" therefore, we may have included newborns who were not infected. The accessibility and quality of prenatal care may differ in other regions of the country, and the proportion of missed opportunities may differ in other parts of the United States. Finally, our methodology classified the congenital syphilis cases by the earliest missed opportunity, whereas in reality multiple opportunities may be missed for a given patient.
Our results inform provider and public health solutions that can help avert a future congenital syphilis case. Standardized forms can be used to obtain full sexual histories, including previous signs and symptoms of syphilis infection and new partners during pregnancy. Obstetricians should screen and treat for syphilis infection at the earliest possible opportunity. Public health agencies can play a critical role in preventing congenital syphilis through the timely investigation and follow-up of laboratory-reported reactive syphilis serologies and provider case reports of syphilis among women. Public health workers can help to find women who have reactive syphilis tests but who have not returned for care, and they also can help assure that providers adhere to treatment guidelines. To facilitate the role of public health agencies in preventing congenital syphilis, providers testing women for syphilis should record pregnancy status on laboratory requisition forms so that this information may be available to public health agencies receiving reports of reactive syphilis serologies, they should report cases of syphilis as required by law, and they should indicate pregnancy status. Pediatricians should discharge newborns only after the mother's syphilis status is determined and maternal and newborn therapy is provided, if needed. Because maternal treatment history affects the diagnostic evaluation of newborns, effective communication and integration of care between obstetricians and pediatricians must be maintained, including availability of medical records after hours. Providers should take advantage of access to serologic testing results contained in public health registry to facilitate timely and accurate staging of disease and appropriate therapy. It is critical that public health departments educate clinicians, particularly at hospitals where a significant proportion of congenital syphilis cases are diagnosed. Such education should address the diagnosis and treatment of syphilis, case definitions relevant to congenital syphilis, management guidelines including the importance of treating sex partners, and the changing epidemiology of syphilis, including, if available, local risk factors for infection in women of childbearing age. Access to initial prenatal care is only the first step. Access to quality care with adequate continuity is necessary to prevent congenital syphilis infections. Coordinated efforts between providers and public health departments will be necessary to prevent congenital syphilis infections.
© 2012 The American College of Obstetricians and Gynecologists
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MyPickupGirls - Josie - Anal Pickup Sex With A Virgin [HD 720p]
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Quarterback Donovan McNabb Released by Vikings After Losing Starting Role
Donovan McNabb was released today by the Minnesota Vikings, six weeks after the former Pro Bowl quarterback was demoted to a backup role.
McNabb, 35, was traded to the Vikings on July 30 from the Washington Redskins to be the National Football League team's starter. He was benched in October by Vikings coach Leslie Frazier in favor of rookie Christian Ponder.
The release of the six-time Pro Bowl pick and 2004 Super Bowl starter was announced as a one-line roster move from the Vikings, listing his name, position, years of NFL experience (13) and college (Syracuse).
McNabb may sign with another team. The Chicago Bears, Kansas City Chiefs and Houston Texans are among clubs that have lost starting quarterbacks to injuries in recent weeks.
The Vikings fell to 2-9 this season and into last place in the National Football Conference North division with a 24-14 loss to Atlanta on Nov. 28. In six games with the Vikings, McNabb completed 94 of 156 passes for 1,026 yards. He threw four touchdowns passes and two interceptions, and ran for another score.
McNabb was selected by the Philadelphia Eagles with the second pick in the 1999 draft. In 11 years with the Eagles, he was 92-49-1 as a starter, leading the team to the playoffs eight times and the Super Bowl after the 2004 season. Last season with the Redskins, he was 5-8 in 13 starts before being benched for the final three games.
To contact the reporter on this story: Michael Buteau in Atlanta at email@example.com
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A federal judge has ruled that despite drought conditions -- or perhaps because of them -- Stanford University must allow two environmental groups to inspect fragile endangered species habitat at the Jasper Ridge Biological Preserve. That inspection will place today, Feb. 28, starting at 8 a.m.
As part of an agreement for the "discovery" portion of the case, both sides agreed to three seasonal inspections of Searsville Dam and related areas by the plaintiffs' expert. The first inspection took place at the end of August 2013 during the dry season. The second inspection was to take place during the rainy season around the time of the first significant storm. The purpose was to observe wet season conditions in the San Francisquito Creek watershed. But this year's extreme drought sparked a controversy over the definition of seasonal inspection.
Our Children's Earth claimed it should be allowed to view the habitat during the fall, winter and spring seasons to observe all seasonal conditions, even if there is no rain. Stanford maintained the drought forestalls inspection, and it should not take place until there is a significant rain event.
Our Children's Earth expected the winter habitat inspection would coincide with changing creek flow and rainfall. But this winter has shaped up to be a historically dry one, perhaps the worst drought in the state's 163-year history.
The drought is precisely why Our Children's Earth should be allowed to inspect the habitat. Inspecting the areas under existing conditions would provide useful information concerning hoe the habitat is faring, and whether it can provide for the life cycles of endangered creatures despite the combined stresses of drought and Stanford's operations, the plaintiffs' attorneys said.
"We disagree that Stanford can unilaterally announce that plaintiffs will not be able to observe all ecologically relevant conditions -- which vary with seasons," lawyers for the ecological group wrote in an email to Stanford, according to court records.
Stanford maintained in its reply brief that it has never disputed about whether the inspections can take place. But the plaintiffs' request for a drought inspection rather than a wet-weather inspection violated the agreement, Stanford said. Sticking to the strict letter of the agreement, the university said Our Children's Earth agreed to one dry weather inspection and two wet-weather inspections.
Stanford told the court it would not object to the second inspection going forward soon, despite the less favorable conditions, provided the plaintiffs did not claim later that they did not see the migration conditions they needed to observe and demand another inspection.
U.S. District Court Judge Judith Laporte sided with Our Children's Earth in part, compelling Stanford to give up to four persons access to view inspection areas from the roads and trails. An expert, accompanied by the plaintiffs' attorney, may enter the San Francisquito Creek streambed at designated points to take samples and measurements. The permitted inspection areas include walking up to the confluence of Corte Madera and Bear creeks; up Corte Madera Creek to the base of Searsville Dam; and down the creek as far as is passable to a disputed area, the Jasper Ridge Road Crossing, a concrete road crossing that is downstream from Searsville Dam.
Our Children's Earth claims that Stanford's construction of the Jasper Ridge Road Crossing and some supports for the water pipeline violate the Clean Water Act by discharging sediment and pollutants from the booster pump into San Francisquito Creek. The university is also allegedly discharging sediment and pollutants from a pipeline valve at the base of the dam into Corte Madera Creek. But Stanford argued those allegations were not part of the original complaint, and therefore had nothing to do with the original discovery agreement.
Laporte ruled against a request by Our Children's Earth to extend its inspection to Bear Creek above Searsville Dam and Reservoir. But the order prohibits the university from introducing any evidence based on observations of those areas in order to show that they are not potential habitat for the Central California Coast steelhead trout.
Christopher Sproul, an attorney for the plaintiffs, said he disagreed that Bear Creek and the booster pump are not related to the lawsuit.
"We tried to explain that it is all about Searsville Reservoir and the water being drained from the watershed. We think it's related," he said.
Stanford spokeswoman Jean McCown said that Stanford's resistance stemmed from concerns over Jasper Ridge's ecologically sensitive areas. The university also wanted a clear picture of the type of equipment and testing that would take place to ensure sensitive areas were not disturbed. The plaintiffs did not initially make that information available to Stanford, she said. The scope and methods of testing were later laid out in court and mandated by the judge.
The rains this week, however, would make the dry-inspection issue moot, she said. She conceded that Mother Nature had thrown a curve into the situation.
"The idea was to look at summer/fall during the dry season and in winter and spring during the big flows. But that really hasn't happened, This is not a normal season," she said.
Staff Writer Sue Dremann can be emailed at firstname.lastname@example.com.
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Cure Brain Cancer Foundation is the largest dedicated fundraiser for brain cancer research in Australia.
Their mission is bold: to increase five-year survival to 50% within 10 years.
Brain cancer kills more children than any other cancer. It has an extremely high mortality rate. Yet it remains seriously underfunded. Cure Brain Cancer's goal is to raise $20 million by 2015 to change this.
For more information about Cure Brain Cancer visit www.curebraincancer.org.au
The Alliance is a not-for-profit organisation dedicated to delivering continual improvements for everyone involved in motorcycling including individual riders, their families, and the entire motorcycle industry.
For more information about the National Motorcycle Alliance visit www.motorcyclealliance.com.au
Redkite is the Australian cancer charity providing essential support to children and young people (0–24 years) with cancer, and their families and support networks.
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Moonfleet Manor Hotel Fleet (Dorset): Find photos, reviews, information, amenities and compare prices for 4 stars hotels in Fleet, United Kingdom.
Moonfleet Manor Hotel Fleet is located in Fleet and offers outdoor tennis courts. The various amenities this chic hotel features include a 24-hour reception, a playground and massage services.
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FASB Not-for-Profit Advisory Committee
Author: Richard Wittgren
Recently, the Financial Accounting Standards Board (FASB) Not-for-Profit Advisory Committee met to discuss goals for improving the financial reporting model for not-for-profit organizations. The committee is exploring changes that would enable exempt organizations to better report and explain their finances to donors and other interested parties. In particular, the committee is looking at four topics:
- Net asset classifications and how liquidity is portrayed within the financial statements
- Improving statement of activities and cash flow reporting to better communicate financial performance, including:
- Requiring organizations to report operating measures in the statement of activities
- Encouraging organizations to further separate the statement of activities into sections that emphasize current operating results versus other changes in net assets
- Encouraging or requiring more complex organizations to report on a business segment basis
- Improving the statement of cash flows to more closely link operating cash flows to the results of operations reported in the statement of activities
The committee also discussed potential educational efforts to help organizations improve their current reporting in accordance with accounting principles generally accepted in the U.S.
If you have any questions about committee activities, contact your BKD advisor.


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President Rivlin Receives New Ambassadors from India, Chile, Myanmar, Estonia, LesothoWednesday, August 3rd, 2016
President Rivlin this morning (Wednesday) at his residence received the diplomatic credentials of new ambassadors to Israel from the India, Chile, Myanmar, Estonia, and Lesotho. Each ceremony began with the raising of the flag and the playing of the national anthem of the visiting country, included an honor guard, and – after the presentation of the credentials – the signing of the guest book, before the playing of Israel's national anthem 'Hatikva'.
First to present his credentials was Ambassador of India, H.E Mr. Pavan Kapoor. President Rivlin welcomed the Ambassador, his wife, and delegation and said, "The relationship between our two nations and our two states is being spoken about all over, and the cooperation between us is not only about innovation where we are trying our best to tackle problems in agriculture and water, energy, but also cyber and the need for security. I know that we can expand this cooperation and your appointment is an opportunity to look at ways we can do so. I convey my best regards to the President and Prime Minister, and I hope that the Prime Minster will be able to visit Israel and that I will be able to visit India in the coming months."
Ambassador Kapoor thanked the President and said, "We are working to take our relationship further. We have received Israel's help in a number of areas including defense, agriculture and water where we suffer a lot – in our country we either have droughts or floods, and we have a lot we can learn from Israel." The Ambassador added, "We are looking forward to your visit and are working on dates for what I believe will be a landmark visit."
President Rivlin thanked him and concluded, "The Indian and Israeli people have a lot in common, we know how to respect tradition and to be ready to learn and bring innovation to our lives for the benefit of our people and the whole world."
Next the newly appointed Ambassador of Chile, H.E Mrs. Monica Jimenez De La Jara presented her credentials. The President welcomed her and showed her a picture of him as Speaker of the Knesset together with former President of the Chilean Senate and daughter of former Chilean president Isabel Allende taken at an international conference in Santiago. The President congratulated the Ambassador on her appointment and said, "I know that coming here from having served as Ambassador to the Vatican, you will feel at home in Jerusalem which is the center of the Holy Land. I welcome you also as a former education minister and we know that everything one can bring to our people begins with education. We are doing all we can in Israel; while 90 years ago we had only one university, now we have more than 6 universities and many colleges that are giving the opportunity to every citizen of Israel to study. We believe that the future of all people is together with education." The President spoke of the relationship between the two governments and added, "From time to time we have some differences of opinion but we know that the relationship between our two nations and governments is strong. We can accept criticism – we do not accept boycott – but we can accept criticism."
The Ambassador of Chile thanked the President for his warm welcome and said, "I am honored to have come from the Holy See to the Holy Land. I greatly appreciate being in a country with so much university activity. We have visited the Weizmann Institute, and the Hebrew University and we have plans to visit many more. We would like to have an academic delegation from Chile to reinforce the academic and research relations."
She added, "I have worked all my life for peace. I know the situation in the Middle East is very difficult but Chile is ready with an open hand to do all it can to advance peace."
Next, Ambassador of Myanmar, H.E Mr. Maung Maung Lynn arrived to present his credentials. The President welcomed him, his wife and delegation and said, "Mr. Ambassador, I remember as a student in High School when the Prime Minister of your country, U Nu, came to visit Israel, and then as a soldier in the IDF I remember Israel's first Prime Minister Ben Gurion visited your country and brought back a great appreciation for your people and your culture. We are very proud of our connection and our relationship with your people. The Foreign Ministry started the idea of MASHAV in your country, the idea of connecting with other nations through learning together and sharing our knowledge about water for example. We also know that many Jews found shelter in your country until the outbreak of war. I want to congratulate you on the recent democratic elections in your country, which make Myanmar stronger."
Ambassador Lynn thanked the President and noted, "It is a great pleasure to be here. I am here with my family and my daughter who will study here, and we have visited much of the country."
Next, Ambassador of Estonia, H.E Mr. Sulev Kannike presented his credentials. The President congratulated him on his appointment and said, "We appreciate the wonderful relationship between our states and governments, and we appreciate your support for Israel in the international arena on so many issues, as well as the participation of Estonia in peace keeping efforts in the region. We appreciate also the understanding of Estonia on Holocaust education in your schools and among your people. In the field of cyber we are working together, in order to keep safe people in the region, and across Europe and the world." The President added, "Please send my special wishes to your Foreign Minister who served as Ambassador of Estonia in Israel."
Ambassador Kannike thanked the President and said, "I am happy to convey the greetings of my President who visited Israel in 2012. Bilateral relations between Israel and Estonia are almost without problems. We understand each other very well, and this is important for us. In July next year Estonia is taking over the Presidency of the European Union and I hope this will help us improve not only our bilateral relations but also our multilateral relations. I also express my appreciation for Israel's work in cyber security and startups – an area in which Estonia is also working hard."
Ambassador of Lesotho, H.E Mrs. Lineo Irene Molisa-Mabusela then presented her credentials as non-resident Ambassador to Israel. President Rivlin congratulated the Ambassador on her appointment and stressed, "The relationship between our two nations is very important to us and despite any crises, we have maintained uninterrupted relations." The President spoke of the important cooperation between the nations in the fields of agriculture and water innovation, he said, "We would like to see more of your students come to study through MASHAV especially here in Israel." The President added, "Israel would be pleased to return to its observer status at the African Union."
Ambassador thanked the President and said "Allow me to pass the warmest wishes of His Majesty and the people of Lesotho. We are appreciative of the wonderful relations between our two countries, and we would like to work to open new channels of communication including in the fields of healthcare, agriculture, water and many others."Jewish Press Staff


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Let us know when your receive great advice so we can thank our lawyers and point others with similar questions in the right direction.Got it!
So my wife is filing for adjustment of status i485 and I-765 and we got to the part with the fingerprints and everything seemed fine as far as our paperwork but now we received a letter stating we need to submit a complete income tax return submitted to the IRS from the petitioner/sponsor on form I-864 affidavit of support, for the most recent year......
Can anyone clarify exactly what they need because I sent a copy of my tax transcripts (petitioner) initially and I'm waiting on my tax return transcripts to come next to send it in...
Will that be enough or is their something im missing because when I call immigration they tell me to follow the instructions on the paper which isn't helpfully at all
Any help would be greatly appreciated
It sounds like they want a complete copy of the petitioner's 2011 1040 form with all schedules.
You will need to carefully read the instructions and the request for evidence letter. If you are missing some parts of the tax return documentation, then you may face a possible denial. Perhaps, you should seek an appointment with a competent and experienced immigration attorney, who can take the time to review the USCIS request before something more serious happens.
Perhaps, something very simple, like a W2 is missing, but this is unclear.
This is general information, not legal advice, and does not create an attorney client relationship.
Did you submit you affidavit of support at all? From what you describe, it appears to me that you only mailed your tax returns, but not the affidavit itself. I would suggest that you take a copy of your application to an immigration attorney for review. If you do not respond to the request properly, your application will be denied and your fees will not be refunded.
Nothing in this post shall be construed as a legal advice. If you need advice regarding your particular situation, please contact my office directly. This information is transferred without an intent to creat an attorney-client relationship.
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Dollars & Sense
About us
Dollars & Sense is a nonprofit publisher of magazines and books that explain the workings of the U.S. and international economies, and present progressive perspectives on current economic affairs. The magazine and books are produced by a collective of economists, journalists, and activists who are committed to social justice and economic democracy.
Contact information
Date Founded: 1974
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Phone: 617-447-2177
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2010 Saleen 435S Mustang - Click above for image gallery
Just days after a lawsuit was filed against it by Steve Saleen for the use of his name, MJ Acquisitions has launched its first Mustang model under the new company Saleen Performance Vehicles. The initial offering seems to be fairly light on visual changes, similar to the Racecraft-branded 420S Mustang that debuted last year, but Mike Shields, the new Saleen's CEO claims they wanted to "deliver a lot at an affordable price." Each 435S Mustang comes with a Saleen Series VI twin-screw supercharger that makes the 4.6-liter V8 good for 435 horsepower and 425 lb-ft of torque, driven through a 5-speed manual and 3.73:1 gears. Improved handling is provided by a sport-tuned suspension package and 14-inch brakes up front. Customers can also opt for the Aero Package, which includes a chin spoiler and rear wing to go with the Saleen graphics and 18-inch alloy wheels that look to be a take-off of the Dan Gurney Signature Edition Mustang introduced by Saleen last year. Pricing has yet to be announced, but we expect it to be somewhere in the low $40,000 range. Full details can be found in the press release after the jump.


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How to Photograph Dubrovnik, Croatia
Don Mammoser
Published by Don Mammoser at Smashwords
Copyright 2013 Don Mammoser
Discover other titles by Don Mammoser at Smashwords.com
How to Photograph Dubrovnik, Croatia
Don Mammoser
This is Croatia's premier coastal town, with lots of historical significance and tons of photo opportunities. Dubrovnik is a fairly large, modern city with a population of around 50,000 people. Dubrovnik is located on the Adriatic coast, across the sea from Italy. The city spreads over an area of more than eight square miles, however most of the photographic action is in and around the walkable, walled, medieval old town. Expect to point your camera at narrow cobblestone alleys, ancient churches, colorful street performers, a pretty boat harbor, and quaint cafes where life passes by in quiet, traffic-less bliss. Ready your camera!
Location History & Facts


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Quiet Moments Alone with God: A Devotional For Women
By: Emilie Barnes
Harvest House Publishers / 2009 / Hardcover
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Classy padded gift book will minister to the heart of women of all ages, offering a devotional entry by Emilie Barnes, with Scripture and closing prayer. Beginning with a loving explanation of God's salvation and new life in Christ, each brief reading focuses on one Scripture. It is easy to see that these verses have spoken first to the author's heart and as she shares her personal insights, you will feel as if you are having a personal conversation with her!
If you recognize the importance of reading God's word each day, you will be blessed by the truths in this book.
If you recognize the importance of reading God's word each day, you will be blessed by the truths in this book.
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Publisher's Description
Muchloved author and home management expert Emilie Barnes wrote Quiet Moments Alone with God to help women develop consistent devotional habits. This beautiful deluxe edition, with a padded cover and in a takeanywhere compact size, is filled with heartfelt meditations for busy women. From someone who has been there, Emilie writes about God's grace, family struggles, forgiveness, the challenges of everyday life, and other subjects close to heart and home.
Each quiet moment
- includes a Scripture verse, a brief devotion, and an inspiring message
- takes 15 minutes or less to complete
- ends with encouragement to put thought to action
Readers experience God's touch daily as they make their way through this book spending a few Quiet Moments Alone with God.
Emilie Barnes is the author of 70 books, including 101 Ways to Clean Out the Clutter; Heal My Heart, Lord; and 15 Minutes Alone with God. Emilie and her husband, Bob, are also the founders of More Hours in My Day time-management seminars.
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luvyorkees5 Stars Out Of 5devotional for women: Quiet moments alone with GodDecember 18, 2014luvyorkeesQuality: 5Value: 5Meets Expectations: 5Lovely Book for any young woman,as well as someone "up in years". Would recommend this book, very pretty as well.
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There's nothing like adding a surprising burst of color to your look with a pair of bright blue shoes. We're headed into fall, but these shoes will surely add a spring to your step. Take a look at some of our favorites.
Next Slideshow: The Return of Leggings
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iHerb Customer Reviews
Savings of: $0.79 (16% off)
Nice, humble gift for expectant mothers
Posted by YoungerNextYear on Mar 30, 2016
I always bring tea as a small gift when I go to someone's house for lunch or dinner. Decaf is nice for expectant mothers and it's a safe choice for anyone if you're not sure if they take caffeine or not. If you find this review helpful, please click "YES" to let me know.
Decaf Twining Tea in Japan
Posted by 5631393361588436910 on Feb 19, 2015
Decaf isn't very big in Japan. This is a great gift for expected mothers.
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recommended love the taste u should try some soy milk with it..
Posted by 5685610328029488998 on May 30, 2015
nice tea just like regular one
Items 1-4 of 4 total


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Skip to comments.Citing high number of rural black voters, Maine GOP chair suspects "improprieties" at the polls
Posted on 11/15/2012 3:36:32 PM PST by Oldeconomybuyer
Maine Republican Party chairman Charlie Webster is doubling down on his suggestion that there were "improprieties" at the Maine polls last week, insisting he received complaints from candidates in small towns across the state that "new people came to vote" and "I believe that that's questionable."
Webster has been the source of some controversy after suggesting in an interview with WCSH-TV this week that "In some parts of rural Maine, there were dozens, dozens of black people who came in and voted on Election Day."
"Everybody has a right to vote, but nobody in [these] towns knows anyone who's black," Webster told WCSH-TV's Don Carrigan. "How did that happen? I don't know. We're going to find out."
(Excerpt) Read more at cbsnews.com ...
And the poll watchers sat on their hands?
And the poll watchers sat on their hands?
White stupidity...er, uh, guilt.
What actions can a poll watcher legally take?
I think all they can do is take note and not interfere even if obvious fraud is being attempted (other than maybe point it out to the polling officials.)
The national republican STUPID PARTY sat on their hands and got it right up the old a$$. And the rest of America suffers while this whole election was stolen from under the establishment republican noses . . . and they'll do NOTHING about it.
Yup. or be called racist. My friend who works at the public library stated that blacks do not understand the concept of an ID, in order to get another ID. They're also the worst liars.
Irregularities in Cleveland and Philly as well. Don't expect anyone to look into these problems.
Same thing in Maryland...didn't both of these states have queer marriage on the ballot?
these are people who needed to be taught how to use door knobs and light switches when brought here by their oh so caring benefactors.
we lived on the NH/Maine border for three years and I don't ever recall seeing a black person, except for the evening news. I'm assuming they lived further north or in Portland?
So the precincts didn't check ID to confirm these people actually LIVED there?
Aaayup, don't see much of any of them black folk round here.
they had to ,their heads were some place else
But considering (for insttance) how many voters in Wisconsin were wearing Chicago Bears gear on election Day, and how easy it is for AFL-CIO, SEIU, etc. to organize bus caravans (e.g. the Walker recall), I cringe at the failure of the GOP to foresee this happening nationwide.
The only Republican with ANY b@lls, apparently, is Allan West - the guy who should be our next candidate for POTUS. He is the only one insisting on a recount and the fraud being exposed in his district.
That's the thing about early voting. Makes it much easier to be a frequent voter.
were there any poll watchers??? maybe they were cast by the machines ....
An Acorn-like organization presents a bunch of voter registration cards in a timely manner for the election. Time passes and it is election day. Many of these first-time voters show up at the polls and visually, one would wonder where all those African-Americans were hiding since the town demographics show a single-digit minority population.
The voters vote and then are long gone. Everyone who saw it play out on Election Day is talking but no one has it on video nor is there any indication on the voter roll of the registered person's race. Charlie has no proof, Charlie is screwed. Over time he may be able to prove that many of the registrations had little or no basis in fact but he will never be able to locate the voter and certainly not be able to substantiate his claim. Did it happen? Who knows?
We can thank George Herbert Walker Bush for the Somalians in this country. I remember when he got us involved with that s*$%hole country in December 1992. What is next? Libyan refugees? Syrian family chain immigration?
Just like Lydon Johnson and his busloads of Mexicans that got him elected.
Some things never change. See http://www.ejfi.org/Voting/Voting-10.htm
Obama won Maine by 100,000+ votes. That's a lot of black people in small rural towns...
>> " I cringe at the failure of the GOP to foresee this happening nationwide." <<
What makes you think they give a damn?
It is so ridiculous that even the U.N. says so.
If this cannot be audited and the IDs of the fraudulent voters determined, then the whole election system is a sham.
The House elections weren't close either. Maybe the concern was the Senate race, but liberal Independent candidate probably couldn't count on as much African-American support as Obama.
One Democrat did win a state house seat by four votes, though.
Do not forget indoor toilets! They squat on the bowl instead of sit.
What a joke the presidental election has become.
Portland Maine is full of Somalis. From what I understand the Somalis have a great network to send Somalis to the States with the best benefits. Before they come, they mutilate the little girls.
They were too busy trying to make their smartphone apps work to notice.
Another reason to eliminate early voting...can't be in 2 places at one time. There were reports of people being bused up from Chicago to vote in Wisconsin, wearing Bears garb no less in Packer country.
And the poll watchers sat on their hands?
If you do not, you have commiited a crime here.
Oh,and even if you cchallenge, the vote gets counted anyway.
One new law passed this past year makes all voter registration cards public record.
Once the state has all the info gathered, a group of us are gonna' be doin, some door knocking.
Film at eleven.
Agree with everything you said. Which is one of the reasons this claim makes no sense.
And the poll watchers were supposed to what exactly ?
Also look for the leadership of the GOP at the national level to spike this story & order the local party officials to shut up.
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Copper has been dubbed 'the metal of the moment' and one of the biggest trends throughout the past couple of years, not only in interior design but in fashion too. With its Scandinavian inspired roots uplifting an industrial interior movement, copper (or rose gold) has risen in popularity as the metallic-must-have for the modern home. Because of its rich bronze tone, copper brings warmth to your living space and its reflective surface allows light to bounce around the room making it brighter! Metallics add an affluent glamour to your home, which can be achieved through minimal accents of metallic paint or wallpaper, or through metallic accessories such as candles, lighting, brushed hardware like trays and bowls, planters, ornaments and even fixtures like rails. The great news is, you can totally work copper with your reclaimed wood furniture! It lifts those rustic hues and creates a juxtaposition between the raw naturalness of the wood and the industrial, modern look of the metal. It can be used to bring in sepia tones to vintage inspired interiors, or used to create an art deco look for the Gatsby lovers! Whatever your personal taste, metallics can be weaved in and out of your home as subtly or with as much grandeur as you please! Copper brings a radiant ambiance to any living environment, and when styled right, can look ambitiously edgy - sky rocketing your space as a trend-led and aspirational home. Commonly styled with marble for a modernist minimalist set up, or incorporated with eclectic prints and bohemian styles for an otherworldly look, copper can also enhance the rustic reclaimed furniture we adore so much! WAYS TO DRESS UP YOUR RECLAIMED WOOD FURNITURE WITH COPPER Bring in rose gold chairs, stools, table runners, place matts and coasters and table top ornaments to bring opulence to your rustic dining table. Keep accents minimal to avoid it becoming overbearing - think subtle with copper cutlery or a pretty vase to add some foliage! Build copper into your fixtures and rails by using piping for a really industrial look! The contrast is somewhat bewitching with its unrefined elegance. If you're a little more daring and can't wait to spruce up your home with regal rose gold - go all out with a copper stand alone bath or shower unit, panel your kitchen with a bronze splash back board or even cascade it across your walls to contrast your wooden flooring! Lighting is a great way to hone in those hues, look for simple geometrically shaped shades and wire cages to house exposed bulbs for the modern twist. These look particularly great hanging from an exposed wooden beam or as a lamp on a wooden table. The easiest way to bring in copper is to accessorise with it using interchangeable ornaments and decorative artefacts. Consider candles with rose gold accents or holders, crockery and utensils with copper handles or patterns, wall prints with quotes in copper foiled lettering and indoor planters for all your greenery!
Get The Look: Incorporate Copper with Reclaimed Furniture
Posted by Mark Godsell-Fletcher on


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Page 5 Archives for December 2008
Experiments with explosions are usually the best kind. I am not sure what they were trying to prove, but I consider this a huge success.
Everyone knows that mixing bored people with shopping carts equals pain and hilarity.
These guys hook up a 7000 volt generator to a light switch and the film their roommate coming home and flipping on the switch.
One of our classic Christmas clips. The kids listen closely to Santa walking on the roof and then watch him fall off and land on a truck.
This kid gets ahold of a quarter stick of dynamite that doesn't have a fuse and thinks he can blow it off and still have time to get out of the way.
Break Gallery 255 is stuffed with awesome pics from all over the web. It's the perfect holiday gift, so instead of buying presents for your loved ones, just send them this gallery URL. They'll love it! Enjoy!
Ham seems to be as big a hit with huge monitor lizards as it is at most Christmas dinners.
No matter what holiday you may celebrate, remember to take joy in the simple things, like horrible gymnastics faceplants.
This guy is embarrassed as a senator from Illinois: the public finally saw their dirty laundry.
This guy grabs his camera and takes it on what has got to be the 10 most terrifying hikes in the world. While some terrifying hikes are meant to exist this one is mostly terrifying because of it's dilapidated trail. Truly a most terrifying hike.
A hot trick like this can backfire so easily and so literally.
A hilarious cover of Metallica's 'Enter Sandman' played entirely on the kazoo. Don't try to upload it to Napster, though.
Break Gallery 256 is packed with awesome pics from all over the intertubes. Sick of hanging out with your family all holiday weekend, and playing with all your awesome new toys? Then spend some quality time with the gallery. Enjoy!
Were any of your presents broken on delivery this year? You probably had this expert as your delivery man.
Skiing is an entertaining sport, especially when two skiers collide.
Mascots have had the spotlight for too long; this little kid looks a lot better at center stage.
You probably have seen a lot of these clips over the past few years but this is a really cool compilation of chance makes or near misses.
This kid has his buddy film him jumping over a chair and table leading up to what is likely the most predictable face plant of all time.
This amateur thief gets locked into the bank he held up and is finally arrested. Should've listened to Hans Gruber: 'Shoot the glass!'
Here's a deleted scene from 'Fast and the Furious: Bozo Drift.'
In hard economic times, some people can't even afford to head to the slopes. They have to faceplant off their grandma's shed instead.
This dudes roommmate is returning from class and just as he steps off the elevator he gets nailed in the face with a garbage can lid.
These cool statistics from 2008 taught us at least one important thing: never underestimate the power of cute puppies.
Crazy tricks like this belong in video games, but they manage to flip and crash without getting hurt.
These two idiots manage too crash into each other while spinning out in a large empty parking lot.
While doing a live report from Lambeau field MSNBC Weatherman Mike Seidel slips busting his wrist on the ice.
We all have a buddy that is a big fan of The Office and uses this line too much. Always looking for an opportunity to slide one in. (that's what she said)
Who knows what bet this Russian guy lost, but he pays his debt with seared flesh on a glowing hot stove top.
Forklifts seem like very bad luck vehicles. Then again, this man is amazingly fortunate that these shelves didn't crush him completely.
A kid as fiery as his red hair gets shot by a goofy friend as he is mowing the lawn, then he throws a knife.


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The sweetest blush skirt featuring a high waist and pleated detailing. Zip/hook closure at back, unlined. By Nasty Gal.
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Daiane is a US size 2
Height: 5'10.5"
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Looking for a Used Grand Caravan in your area?
CarGurus has 34,503 nationwide Grand Caravan listings starting at $1,995.
1996 Dodge Grand Caravan Overview
I'm too sexy for my car, so sexy by far...Once again setting the bar high for minivans, Motor Trend's Car of the Year, the 1996 Grand Caravan, revealed a new sleeker, rounder design in place of the boxed-off previous minivan of yore. A larger windshield, sloping roof lines, and wrapound headlights gave owners something to show off as they transported screaming kids to various sporting events.
In 1996, the chassis was redesigned to provide better stability with less noise and shuddering, and it seems to have worked. Inside, the biggest innovation was the introduction of rear seat rollers, to make them easier to remove, a common complaint among previous Grand Caravan owners. As in previous years, the 1996 Grand Caravan offered a first for minivans, by offering the optional second sliding door on the driver's side. That, combined with the low step-in height, made for easier entry and exit. There were probably more cupholders added this year as well, but it's easy to lose count.
Owners responded well to the changes, praising the better interior functionality along with the smoother ride and the responsive driving experience. One thing Dodge didn't seem to address in its 1996 Grand Caravan was the repair record, most notably the transmission headaches that have plagued the number one minivan in America.
What's your take on the 1996 Dodge Grand Caravan?
Cars compared to 1996 Dodge Grand CaravanPeople researching a 1996 Dodge Grand Caravan contacted a dealer about
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Dodge Grand Caravan Questions
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Can I Trade My 1996 Dodge Caravan In On A Vehicle?
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I have a 96 dodge caravan my van drive forward good but when I back up it makes a rough lil shakey noise in my front end I don't if it my transmission or front end or my tires an I think I'm leaki...
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