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Journal of Toxicology
Volume 2011 (2011), Article ID 862153, 8 pages
Cardiorenal Effects of Newer NSAIDs (Celecoxib) versus Classic NSAIDs (Ibuprofen) in Patients with Arthritis
1Department of Forensic Medicine and Clinical Toxicology, Benha Faculty of Medicine, Benha University, Benha, Egypt
2Department of Pharamacology and Toxicology, Faculty of Pharmacy, Umm Al-Qura University (UQU), Mecca, Saudi Arabia
3Department of Orthopedics, Benha Faculty of Medicine, Benha University, Benha, Egypt
4Department of Pharmacognocy, Alexandria Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
5Department of Pharmacognocy, Faculty of Pharmacy, Umm Al-Qura University (UQU), Mecca, Saudi Arabia
Received 22 November 2010; Revised 10 March 2011; Accepted 16 March 2011
Academic Editor: P. J. O'Brien
Copyright © 2011 Ragia Hegazy et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. Arthritis is a common condition that co-exists in the elderly population. This condition leads to frequent administration of comorbid analgesics especially non steroidal anti-inflammatory drugs (NSAIDs). Aim. To study cardiorenal toxicity of celecoxib versus ibuprofen in arthritic patients. Subjects and Methods. Seven hundred ninety-wo arthritic patients were enrolled in the study for 6 months. Three hundred ninety-six patients administered celecoxib 400 mg twice a day; 396 patients administered ibuprofen 300 mg three times a day. Effects measured included investigator-reported hypertension, edema, or congestive heart failure, increases in serum creatinine or reduction in serum creatinine clearance, and changes in serum electrolytes. Results. Celecoxib was associated with significant () lower incidence of hypertension and edema in comparison with ibuprofen. Systolic hypertension occurred significantly less () with celecoxib compared with ibuprofen. Serum creatinine was significantly increased () in patients treated with ibuprofen in comparison with celecoxib. Creatinine clearance was significantly lower () in cases treated with ibuprofen in comparison to celecoxib. Nonsignificant changes in serum body electrolytes occurred. Conclusion. The most important finding of this study was the lowering incidence of cardiorenal toxicity of celecoxib in comparison with ibuprofen.
1. Introduction
Nonsteroidal anti-inflammatory drugs, NSAIDs are widely used drugs valued for their anti-inflammatory, analgesic and antipyretic properties. However, Classic (nonselective,) NSAIDs work by inhibiting two isoforms of the enzyme Cyclo-oxygenase (COX): COX-1 and COX-2. COX-1 is expressed continuously in most body tissues and in the stomach catalyses the production of prostaglandins which safeguard the gastric mucosa. Inhibition of COX-1 is responsible for NSAID-induced gastrointestinal damage [1]. COX-2 is much less widely expressed but is induced by proinflammatory stimuli and catalyses prostaglandins mediating the inflammatory response. Anti-inflammatory action is derived from inhibition of COX-2 [2].
It is believed that selective COX-2 inhibitors (COXIBs) have reduced side effects especially gastrointestinal and platelet-related adverse events in comparison to classic NSAIDs. Celecoxib was the first COX-2 selective inhibitors to be developed. At full therapeutic doses, celecoxib possesses comparable analgesic and inflammatory efficacy to nonselective NSAIDs in the treatment of rheumatoid arthritis (RA) and osteoarthritis (OA) [3–5].
Non-selective inhibition of prostaglandins synthesis is associated with antinatriuretic and vasoconstrictor effects and frequently reduces glomerular filtration rate (GFR). The sensing mechanisms of sodium are largely through the COX-2 enzymatic pathway located in the macula densa of the kidney. The inhibition of this enzyme will lead to antinatriuretic effect that is manifested clinically by edema, and frequently linked with, destabilization of blood pressure (BP) control in treated hypertensive individuals. In addition, it may subsequently induce congestive heart failure in susceptible individual, so the use of nonselective NSAIDs may result in acute hemodynamically mediated deterioration of renal functions in one of five patients within several days of NSAIDs use. This is fully reversible following discontinuation of the offending drug. Other syndromes are extremely rare; they include other electrolyte complications such as hyperkalemia, and hyponatremia, nephritic syndrome with interstitial nephritis [6, 7].
On the other hand, the use of selective COX-2 in healthy individuals is associated with mild oedema and hypertension due to modest sodium retention in the first one to two days of therapy. It is followed by a return to baseline excretion levels and elimination of retained salt and water after another one to two days without drug discontinuation. It may be hypothesized that a selective COX-2 inhibitors (celecoxib) may have decreased renal adverse effects relative to non-selective inhibitors [8, 9].
The celecoxib long-term arthritis safety study (CLASS) was undertaken to compare the long term upper gastrointestinal tract of celecoxib 400 mg twice daily (b.i.d.) two to four times the full therapeutic doses for RA and OA, respectively, with normal full therapeutic doses of one of classic NSAIDs, for example, ibuprofen 800 mg three times a day (t.d.s.). The CLASS trial proved that celecoxib is safer to gastrointestinal tract in comparison to non-selective COX inhibitors [10].
Cardiorenal safety of celecoxib compared to ibuprofen according to the doses used in the CLASS trial is used in this study.
1.1. Aim of the Work
The purpose of this study was to examine the Cardiorenal effects of a representative agent from different classes of NSAIDs; celecoxib represent the selective COX inhibitors, and ibuprofen represents the non-selective COX inhibitors.
2. Subjects and Methods
2.1. Subjects
This study was conducted on 792 patients from the orthopedic outpatient clinics Al-Salam hospital, Jeddah, Saudia Arabia.
2.2. Inclusion Criteria
Patients with a history of RA or OA with average of 40–70 years, were divided into 2 groups.
Group I
This group included 396 patient's administered celecoxib (selective COX2 inhibitor) at supratherapeutic dose, that is, 400 mg b.i.d. The supratherapeutic dose equals two- to four-fold greater than the maximum effective doses for RA and OA.
Group II
This group included 396 patients administered ibuprofen (non-selective COX inhibitor) at therapeutic dose, that is, 800 mg t.d.s.
The used doses were commonly prescribed and indicated for use by FDA and CLASS trial.
An institutional review board (IRB) approval was obtained for the study. Informed consent was given to all participants before enrollment to read and being discussed with the investigator and staff. All participants signs on informed consent on entering the study.
After baseline visit and administration of the initial dose of study medication, followup took place every two weeks for two months, and then every 4 weeks thereafter, until study termination. All patients took study medication for 6 months from October 1st 2006 to April 1st 2007.
2.3. Exclusion Criteria(i)underlying peptic ulcer(ii)history of myocardial infarction(iii)stroke(iv)cerebrovascular accident(v)transient ischemic attack (TIA)(vi)renal insufficiency in 6 months before the study, that is, serum creatinine above 1.5 mg/dL(vii)any medications that could directly or indirectly affect renal functions.
2.4. Methods
In each visit, each patient in the two groups was subjected to the follwing:(1)questionnaires to collect relevant data for, example, any experienced symptoms that were not associated with patients' arthritis since the last visit(2)careful physical examination with special concern to the following:(a)body weight at least ≥3% increase was considered positive finding,(b)vital signs especially blood pressure with record of the positive cases, that is, increase in systolic >20 mm/Hg, increase in base line or absolute level above 140 mm/Hg, and for diastolic blood pressure >15 mm/Hg, increase in baseline or absolute level above 90 mm/Hg,(c)edema whether peripheral or generalized by inspection and palpation through pressing the skin over the lateral melleolus of the tibia in the leg,(d)manifestations of congestive heart failure (CHF): generalized edema, congested neck veins, and enlarged tender liver.(3)laboratory investigations.
Blood samples: in each visit, 25 μL of blood were drawn up from each patient and used to measure the levels of the following.
2.4.1. Blood Urea Nitrogen (BUN)
Each case had the BUN ≥20 mg/dL defined as mild prerenal azotemia and completes the other kidney function tests.
Blood urea nitrogen (BUN) was assayed by colorimetric method described by Patton and Crouch [11] using a commercial kit of Bio-Merieux (France). Normal value: 18–33 mg/dL.
2.4.2. Serum Creatinine Level
The aim was to detect any increase in creatinine level by 0.5 mg/dL over baseline or any value above 1.5 mg/dL during the study.
Serum creatinine was assayed by colorimetric method described by Henry [12] using a commercial kit of Diamond Diagnostics (Egypt). Normal value: 0.8–2.0 mg/dL.
2.4.3. Creatinine Clearance
(as calculated by Cockcroft Gaunt formula) .
If ≥30% from the baseline during treatment, it should be analyzed as well [12].
2.4.4. Serum Electrolytes
They included sodium, potassium, chloride, and bicarbonate [12].
3. Statistical Method [13]
The methods used for statistical analysis of the collected data were the following:(1)t-test for comparison between the means of two means ± standard deviations, and P values less than .05 was considered significant,(2)one-way ANOVA test (F test) for comparison between more than two means ± standard deviations.
4. Results
As Figure 1 shows, a total number of 792 patients were randomized, of whom received at least one dose of the study drug, and were, therefore, included in the intent-to-treat (ITT) population (RA: N = 290; OA: N = 502). In the ITT population, 396 patients received celecoxib, and 396 were treated with ibuprofen.
Mean patient's age was about 55 years in each treatment group; most (69%–71%) patients were female, and mean BP was 133/80 mm/Hg. As determined by medical history, slightly less than 40% of patients of each treatment group had preexisting hypertension. Overall BP levels and renal function were normal at baseline and comparable between treatment groups; see (Table 1).
Blood Presuure (Table 2)
Celecoxib was associated with an incidence of hypertension (both new-onset and aggravated) that was significantly lower than standard doses of ibuprofen . Withdrawals from study treatment owing to hypertension-related adverse events were uncommon and occurred with similar frequency among the two treatment groups. In patients taking ibuprofen, the increased incidence of hypertension versus celecoxib was accompanied by a corresponding trend towards a mean increase in systolic BP . Ibuprofen treatment was associated with a significantly greater proportion of patients with systolic elevation >20 mm/Hg and above 140 mm/Hg as compared with celecoxib. No treatment differences were observed for diastolic BP.
Fluid Retention (Table 3)
Ceceloxib was associated with significantly lower incidence of investigator-reported edema (including either peripheral or generalized edema) compared with ibuprofen (see Figure 2).
Adverse events of CHF were uncommon as reported by investigators (approximately one-tenth the rate of overall edema, and no significant differences were detected between treatments). Withdrawals from study treatment owing to either edema or CHF were uncommon overall, and no significant treatment-related differences were detected. In addition, no significant treatment differences were observed with respect to body weight gain ≥3%.
Renal Functions
Renal functions of enrolled patients were normal, as reflected by baseline serum creatinine levels or estimated creatinine clearance; see (Table 1). Nearly all patients (>99%) had a serum creatinine ≤1.5 mg/dL, which reflect normal function required for protocol.
Renal functions, as reflected by serum creatinine levels and estimated creatinine clearance, decreased significantly in patients assigned to ibuprofen compared with those receiving celecoxib (Table 4).
Clinically important renal dysfunction, defined as (1) increases in serum creatinine > 0.5 mg/dL relative to baseline assessment or serum creatinine >1.5 mg/dL at any post-baseline assessment or (2) a decrease in estimated creatinine clearance ≥30% relative to baseline are provided in.
For the entire treatment cohort, one significant treatment difference was detected: the incidence of ≥30% reductions in estimated creatinine clearance from baseline was significantly lower in treatment with celecoxib as compared with ibuprofen (Table 5).
An evaluation of the time course of these changes revealed that the highest frequency occurred early after initiation of treatment (week 4 and 8 clinic visits) and declined thereafter, rather than progressively increasing risk as a function of duration of treatment of the two treatment groups. It should be noted, however, that a substantial proportion of patients exhibited these changes 3 months or longer after treatment was initiated, suggesting that the hazard, although perhaps diminishing with time, does continue through the therapy period. Increases in serum creatinine of >0.1 mg/dL were uncommon, occurring in seven celecoxib-treated patients and nine patients taking ibuprofen. These differences were not significantly different. For those patients characterized by mild prerenal azotemia at baseline (serum blood urea nitrogen >20 mg/dL) but relatively normal renal functions; see (Table 5), the incidence of clinically important changes in renal function was at least two-fold lower in patients receiving ceclecoxib compared with ibuprofen-treated patients.
Treatment differences in mean serum creatinine and estimated creatinine clearance were also observed in this cohort; see (Table 5). No differences were observed between treatment groups for patients without baseline azotemia (i.e., with BUN ≤20 mg/dL).
Patients with normal serum creatinine/prerenal azotemia at baseline were significantly more likely to withdraw from the study owing to an adverse event if their creatinine level increased to >1.5 mg/dL on treatment versus the overall cohort (relative risk, 2.0; ). When expressed as percentage of the patients with normal serum creatinine/prerenal azotemia at baseline, the withdrawal rate in patients treated with celecoxib (1.5%) was significantly lower compared with those receiving ibuprofen (4.2%; ) as shown in Figure 3.
Electrolyte and Acid Base
Changes in serum levels of sodium, potassium, chloride, and bicarbonate were minimal between treatment groups and were not of clinical significance.
Serious Cardiorenal-Related Adverse Events
The incidence of serious cardiorenal-related adverse events during treatment with celecoxib or ibuprofen was low. The study investigator reported one case of uremia in an ibuprofen-treated patient. Two cases of hyponatremia were reported in patients treated with celecoxib, and one case was reported in a patient taking ibuprofen. No cases of serious adverse events related to nephrotic syndrome, interstitial nephritis, or papillary necrosis were observed.
5. Discussion
The large cardiorenal database from the CLASS trial provided the opportunity to observe and compare the natural history of the onset and clinical management of cardiorenal related adverse events that evolve when exposing a typical adult arthritic population to chronic treatment with non-selective NSAIDs (ibuprofen) or supratherapeutic doses of COXIB (celecoxib) [14]. Thus, this study provides a new and important clinical resource of therapeutic cardiorenal safety information. The data have permitted the description of a clinical paradigm, where in certain key patient characteristics, it may provide additional predictive clinical information with respect to future drug-specific susceptibility to impairment of cardiorenal function.
The present analysis support the hypothesis that rheumatoid arthritis (RA) and osteoarthritis (OA) patients receiving celecoxib 400 mg b.i.d. have an overall reduced risk of cardiorenal-related adverse events compared with standard therapeutic doses of the nonselective NSAIDs, ibuprofen 800 mg t.d.s. In particular, celecoxib treatment was superior to the nonselective NSAIDs with respect to renal function in patients with prerenal compromise. Some important differences were observed in the cardiorenal safety profiles of celecoxib versus nonselective NSAIDs. Compared with celecoxib, the incidence of adverse events related to hypertension and edema was significantly higher with ibuprofen, and the decline in renal functions was also more apparent with ibuprofen. These data provide a greater understanding of the relative effects of these agents on cardiorenal function and homeostasis.
The increased incidence of hypertension in patients taking ibuprofen versus celecoxib appeared to be largely a function of effects on systolic, rather than diastolic, BP. Ibuprofen was associated with significantly higher incidences of clinically meaningful elevations in systolic BP versus celecoxib. The importance of systolic BP has been highlighted in ALLAHT [15], Kostis et al. [16], and Steassen et al. [17]. These studies showed that elevated systolic BP is associated with heart failure, stroke, myocardial infarction, and death.
Whelton et al. [18] evidenced now that destabilization of BP in treated hypertensive patients, by rofecoxib, is a significant risk marker for the development of acute myocardial infarction and stroke events. Much additional information with respect to the latter issues and the emergence that some NSAIDs may also cause cardiotoxicity is needed [19].
In the present study, longterm treatment with supratherapeutic doses of celecoxib in the CLASS trial had a little effect on BP levels in these arthritis patients. This finding is supported by previous studies demonstrating that celecoxib does not affect mean systolic BP changes in hypertensive patients [20, 21].
In contrast, many NSAIDs and COXIBs, such as rofecoxib, antagonize the BP-lowering effects of certain antihypertensive agents, in particular, angiotensin-converting enzyme inhibitors and -blockers [22].
In the present analysis, celecoxib was superior to the ibuprofen studied with respect to renal dysfunction. Ibuprofen appeared to cause a significantly higher rate of decline in renal functions than celecoxib. This may suggest a disproportionate effect of ibuprofen on renal perfusion. Importantly, in patients with prerenal azotemia (but normal serum creatinine) at baseline, celecoxib was associated with a lower-rate deterioration of renal functions compared with ibuprofen. However, as some renal dysfunction was evident in the celecoxib treatment group, caution should still be used when treating patients at risk of adverse renal events. Changes in electrolytes levels were small and were not of clinical relevance.
In healthy human subjects on normal diets, COX-2 inhibitors have minimal effects on renal hemodynamics [23, 24] that COX-2 inhibitors decrease GFR in salt-depleted subjects [25–27]. Since nitric oxide (NO) regulates renal cortical COX-2 expression [28], Lopez et al. [29] proposed that in addition to the salt depletion and prolonged duration of COX-2 inhibition, reduced NO may be another factor underlying these effects of COX-2-specific inhibitors on renal hemodynamic.
It is evident from this study that there are differential cadiorenal effects associated with celecoxib versus nonselective NSAIDs, ibuprofen. Previous studies have also shown that cadiorenal safety profiles are not consistent across the class of COXIBs. For example, rofecoxib treatment is associated with dose-dependent increases in hypertension and edema [30–32].
In two recent, randomized double-blind trials for 6 weeks of OA patients taking antihypertensive agents, the study participants taking celecoxib 200 mg daily were less likely to experience renal adverse events than the group receiving rofecoxib 25 mg daily [33].
The differing renal safety profiles across the classes of nonselective NSAIDs and COXIBs suggest that some of the renal effects of the latter may be "molecule-specific" rather than as a result of a "class effect" of COX-2 inhibition [34].
This study suggested that the clinical management of arthritis patients may be impacted by the agent selected to treat their pain and by the patient's underlying health status with regard to cadiorenal side effects. Our results indicate that cadiorenal side effects are relatively common with NSAID treatment and require careful medical monitoring of patients together with other safety-related parameters (e.g., hepatotoxicity associated with some NSAIDs such as diclofenac).
Anti-inflammatory drug-induced effects on BP or renal function should be cautiously monitored clinically during the use of such drugs. These adverse renal events may be selectively reduced or minimized by the selection of an anti-inflammatory drug, such as celecoxib, that appears to have the least detrimental effects upon renal function, such as demonstrated in this study.
The present analysis had some potential limitations. Many OA and RA patients were elderly and had significant comorbidity, including cardiovascular disease, hypertension, and abnormal renal functions. However, our study did not include patients with abnormal renal functions at baseline, and results could not apply to these patients. Another limitation in the present analysis was that patients in this study were not stratified by baseline body weight, which may impact significantly on baseline creatinine levels.
6. Conclusion
Supratherapeutic dose of celecoxib was associated with a cardiorenal safety profile compared with standard doses of ibuprofen.
7. Recommendations(1)Further work is needed to study the renal safety profile of nonspecific NSAIDs and COXIBs in patients with abnormal renal function.(2)Physicians need to be alerted to effects of NSAIDs on BP and kidney functions.(3)Celecoxib should be given to arthritic patients with prerenal azotemia and classic NSAIDs should be avoided.
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In most respects, 2014 was a mighty good year in the Manhattan area for those who like the performing arts. Consider the live shows produced within an easy drive of Twelfth and Moro. I saw memorable and amusing performances in K-State'.
Just weeks after being named The Mercury's All-Flint Hills Coach of the Year for 2014, Wamego's Dale Burkholder has announced he is stepping down as head football coach after four years at the helm. Burkholder helped turn around a .
At Riley, the Mustangs held on to win, 63-57, Tuesday night, using a strong third quarter to take the lead for good despite the best efforts of a hot-shooting Riley County squad. The Falcons led 32-31 at halftime, but were .
Subscribers can access a list of local public employees' 2014 pay records.
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subset: commoncrawl


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Defeat on Tyneside.
Youngsters set for Walsall match.
Latest from players away from B6.
Early Bird window now available.
Midfielder explains what drives him as he chats to presenter Rachel Stringer around Bodymoor Heath.
Steve Bruce talks to the press ahead of Villa's trip to Newcastle this Monday.
Full highlights of Villa's 3-1 defeat at home to Barnsley.
Come down to Villa Stores
Shop online
By Paul Brown in Portland
Stephen Ireland says confidence in camp is "sky high".
Ireland says Paul Lambert is the catalyst for this feel-good factor with the new boss desperate to help his players develop.
The marauding midfielder says, despite the short timeframe of Lambert's reign so far, that the boss has overseen a progression in performance, with players coming on "leaps and bounds".
He said: "It's a nice feeling at the moment. It's really encouraging to play football.
"The manager has pretty much been saying 'we have to score, keep the ball and get the ball through good running'.
"The confidence in all the players is sky high at the moment and it's nice to see because I think the club deserve better and the fans deserve better than what's been happening.
"I think it's going to be a really positive season for us at this club.
"It's brilliant. The gaffer is developing the players. I know he's only been here for a few weeks but you can already tell that the players are developing and learning. You can really see that.
"You can see the boys are willing to have the ball under pressure. There is no hiding place anymore really, you can't hide behind certain players or rely on certain players to win the ball anymore, we all have to do it for the team.
"I can already see players coming on leaps and bounds which is brilliant.
"I'm excited about it and I can't wait for the season to start to be honest."
Click here to buy season tickets for the new term as Villa embark on a vibrant new era.
Vale Park record attendance 49,768


text:
Quora, the crowdsourced question and answers community has been getting a lot of publicity lately. Purported to be more than just another questions and answers site, Quora is aimed at going beyond a simple forum for questions and answers (like Yahoo Answers) to being more of a brain trust where individuals' knowledge on a topic is collected and made available to members of the community.
Founded in 2008 by former Facebook executives, the latest social community for business seems destined for big things. Since its inception, Quora has grown steadily and in the last year, user counts have doubled – although according to this compete.com graph, the number of visits is still erratic. Quora doesn't make user counts available but there are an estimated 200,000 – 500,000 users – according to this Tech Crunch article.
On its website, Quora describes itself as:
" a continually improving collection of questions and answers created, edited, and organized by everyone who uses it. The most important thing is to have each question page become the best possible resource for someone who wants to know about the question."
It is easy and free to join Quora, simply sign up, enter a few details about yourself and you are off to the races.
Once there you can search questions (put the term you want to search for in the add question box but don't click enter or you will end up asking a question) and review all related answers, find and connect with others in your community and share your content in other networks.
I've always found LinkedIn answers a useful tool for researching blog posts so I thought I would test drive Quora and at the same time do little crowdsourced research for this blog post by asking the question:
How has using Quora benefited you?
It has been several days now and so far there are no answers. Now, this could be because I don't have many contacts yet, because its not a stimulating enough question or because people haven't yet decided on the benefits of using Quora. One neat feature of Quora is that it finds and suggests "related questions" that might be of interest. The one answer to the question "What are the benefits of using Quora?" has the short and sweet answer :
You get to read the answers to questions like the following: Quora: Frequently Asked Questions for New Users, Getting Started on Quora: How does the Quora search box work?
In browsing through Quora, I couldn't fail to notice that it has some very influential users. One question about social media startups had answers from industry pioneers like Robert Scoble: with answers that were both in depth and insightful (and a good read for anyone launching a web startup). Another Quora user, Marc Bodnick lists new and interesting Quora users they have discovered every week and whilst many of these users seem to be centred in the tech community, I was also able to to find questions about such diverse topics as the Vancouver Canucks Stanley Cup chances (go Canucks!), best Croatian Islands and Scotland's independence.
Some of the downsides to Quora seem to be question regulations, reviews and user administration. Personally, I came across a lot of comments about voting up a question but couldn't work out how to vote up a great answer far less vote down the crappy ones.
In the longterm, the value of Quora will depend on the quality of both the user base and the answers people provide as well the ease of use and ability to connect with your community. For now, Quora will stay on my radar (join me there!) but I won't need a daily fix for the foreseeable future.


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Electromagnetic waves propagating in air are visually observed with phase evolution in real time by live electro-optic imaging technique. We show how geometrical and crystallographic arrangements of an electro-optic sensor plate enable the realization of the real-time visual observation of traveling 100-GHz electromagnetic waves. For this purpose, a… (More)
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text:
@Deskar Am so sorry to hear about your MC Luv & about your poor furbaby!!!😢 (((Hugs)))
Hopefully your FS can glean some info from your tracking Cycle & put a new plan of action in place for youxoxo
Have msg'd you back😊
@Deskar Am so sorry to hear about your MC Luv & about your poor furbaby!!!😢 (((Hugs)))
Hopefully your FS can glean some info from your tracking Cycle & put a new plan of action in place for youxoxo
Have msg'd you back😊
Last edited by BlondeinBrisvegas; 10-06-2016 at 13:28.
Blossom74 (10-06-2016),faithandhopellove (11-06-2016),Precious40 (10-06-2016),Rhino (10-06-2016),tuxcat (10-06-2016),winsor (10-06-2016)
so sorry to hear about your MC @Deskar. I hope your migraines/headaches go away soon too. sorry to hear about your dog too, I hope she's ok too
BlondeinBrisvegas (10-06-2016),Blossom74 (10-06-2016),faithandhopellove (11-06-2016),Precious40 (10-06-2016),Rhino (10-06-2016),tuxcat (10-06-2016)
Last edited by MissDa; 10-06-2016 at 16:16.
BlondeinBrisvegas (10-06-2016),Blossom74 (10-06-2016)
The waiver is for the higher chance of Down's syndrome I think, plus higher chance of m/c etc
BlondeinBrisvegas (10-06-2016),Blossom74 (10-06-2016),winsor (10-06-2016)
so sorry to hear your news @Deskar I hope you get some answers. I hope your poor pooch is on the mend, thats terrible!! I had to lol about the concept of doggy daycare..imagine a kitty daycare..there might be a few fights!!! Although there are the cat cafes, they seem to manage..
next to zero work done here today, and the house isn't even clean either
BlondeinBrisvegas (10-06-2016),Blossom74 (10-06-2016),faithandhopellove (11-06-2016),Precious40 (10-06-2016),Rhino (11-06-2016),winsor (10-06-2016)
Blossom74 (10-06-2016)
The Over 40's Warrior Woman Roll Call
- @skye76 - start stims 19/5 for June EPU/transfer
- @Green lady- 1xPGD Normal!!!...FET June
- @Lucky8 - 24/5 - start meds in preparation for DE in Greece in June
- @MissDa - DE cycle underway - 1xembryo for transfer
- @ECM1981 - CT DE ? EPU 9/10th June
- @Lastchance75 - USA FET 13th June
- @Twiglets - FET
- @ange1111 - Day 5 transfer 26/5
-@40NotOut -Day 5 transfer
- @tegs26 Zlin DE - BFP!
- @skeeter
- @Deskar
Awaiting DE
- @Blossom74 - EDA - PD found 8/5
- @winsor - EDA
- @tuxcat - Meeting Donor 6/6
- @Rhino - Deciding on o/seas options with DH
- @jo-anne.36
Babies due
- @JulieMalooley - B/G Twins Delivered C-Section 24/5
- @faithandhopellove - Baby Girl + Angel Baby "Little Bubba" 31/5
- @Corbes - EDD 17/7
- @Lolly99 - C section 30/ 7 (B/G twins)
- @Bongley- DD: 1st September
- @Felicity Fox - EDD 19th October
- @AnnaMM - EDD 19th December
- @MamaKes- EDD- 23 December
- @Gagingi - EDD- 25 December
- @Molros - EDD - 30 December
- @Gen72- EDD 6 Jan 2017
- @Precious40- EDD 13 Jan 2017
- @Tinachris - Start stims - TBA
- @Lucky8 - Depart for Greece
- @midnite01 - Cycling
- @Charlie74 - OE FET
- @Rhino - DE ? end of August
- @tuxcat - DE Cycle
- @Blossom74 - DE Cycle
- @Caesardust - DE Cycle
- @amie999 - DE
Last edited by BlondeinBrisvegas; 12-06-2016 at 11:49.
Blossom74 (11-06-2016),faithandhopellove (11-06-2016),MissDa (10-06-2016),Precious40 (10-06-2016),tuxcat (10-06-2016),winsor (10-06-2016)
@MissDa - as everyone says one is better than none, but we all know it's hard when you were expecting more eggs.
Happy birthday for this weekend! It's my birthday too. 43.
BlondeinBrisvegas (10-06-2016),Blossom74 (11-06-2016),faithandhopellove (11-06-2016),Precious40 (10-06-2016),Rhino (11-06-2016),tuxcat (10-06-2016),winsor (10-06-2016)
BlondeinBrisvegas (10-06-2016),Blossom74 (11-06-2016),Precious40 (10-06-2016),Rhino (11-06-2016),winsor (10-06-2016)
Saw my FS today. Discussed all the transfer options and on balance, for me, decided to go with a natural cycle with an HCG shot on day of transfer and progesterone support post. He's recommended acupuncture on day of transfer and prescribed serepax for day of transfer. If lining doesn't play ball I'll cancel the cycle and maybe go medicated the next one. Can't afford to waste the embie on less then optimal lining when I only have one ( assuming it thaws).
BlondeinBrisvegas (10-06-2016),Blossom74 (11-06-2016),Charlie74 (10-06-2016),faithandhopellove (11-06-2016),Precious40 (10-06-2016),Rhino (11-06-2016),tuxcat (10-06-2016),winsor (10-06-2016)
Pregnant for the first-time?
Not sure where to start? We can help!
Our Insider Programs for pregnancy first-timers will lead you step-by-step through the 14 Pregnancy Must Dos!


text:
Submit products to comparison shopping engines. Try our easy to use data feed management for only 99 cents in a 30-day trial.
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text:
The 6" Smooth Power Pack
Rotor Riot 6" Smooth Power Pack
(for frames that run 6" props)
New to the hobby? The wide range of miniquad parts available can easily become overwhelming, making it hard to choose "the best" combination of components for your build. We made it simple! Go with what the pro's would use, and save a few bucks in the process!
This bundle comes with our team pilots preferred combination of parts to give your 6" frame of choice the smoothest flight characteristics imaginable. It's the Rotor Riot recommended setup for the RR Alien Butter Quad Kit.
With the purchase of this bundle you'll save $30.00 compared to buying the same parts separately!
The bundle includes:
- 4x Lumenier RX2206 2000kv
- 4x KISS 24A ESC (v1.02)
- 1x KISS Flight Controller
- 1x Silicone Wire Kit
- 4x HQ 6045 Props (2x pairs)
NOTE: To complete a quadcopter build you will need a compatible receiver, as well as an FPV system. Depending on your choice of frame you might also need a Power Distribution Board (the Rotor Riot Alien Kits come with a built in PDB).


text:
Is Anne Kelly's Hair & Beauty Salon incorrect or missing key business information? Update your Hotfrog listing today.
Contact details
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Hotfrog Ireland provides information regarding Anne Kelly's Hair & Beauty Salon in Roscommon. Anne Kelly's Hair & Beauty Salon is located at 11 Goff st, Roscommon and provides Personal Care services. Contact them on (090) 662 5617.
Is Anne Kelly's Hair & Beauty Salon in 11 Goff st, Roscommon your business? Claim your listing and attract more leads by adding more content, photos and other business details.
We have more Personal Care services in Roscommon available on Hotfrog Ireland. You can update your search for Personal Care by location, keyword or service options.
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text: The Ministry of Defence has paid for a former RAF senior aircraftswoman to become a pole dancer. Stephanie Hulme, 23, was funded to take up the profession after completing five years' service. Her training was carried out through an RAF resettlement and training programme which reportedly cost over £2,000 over four weekends. The move has allowed her to pursue a career as a pole dancer at a club in London. Training bill Miss Hulme, who spent time as a senior aircraftswoman at RAF Aldergrave near Belfast, filled in an application form towards the end of her service stating that she wished to take up a course in pole dancing. She told the Mail on Sunday: "I got the idea after a bit of banter with one of my mates and when I decided to leave I started looking into what it involved. "Then one of my friends said I should ask the MoD to pay for the training. "I was very surprised when it was approved - I didn't think it would be." According to the paper, the bill for her training came to £2,100 and it was met under the RAF's resettlement programme. Under MoD regulations, servicemen and servicewomen are entitled to retraining through a grant programme after they have completed five years' service. A spokesman added: "The point of making this grant available is to improve their employment opportunities once they complete their service. "What they choose to do is a matter for them as long as it is legal." Miss Hulme now pole dances under the professional name Kitty at a club in Mayfair called For Your Eyes Only.


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text:
Hotel Bethlehem, A Historic Hotel of America, Bethlehem
- Free WiFi
Main amenities
- 128 smoke-free guestrooms
- 2 restaurants
- Breakfast available
- Free airport shuttle
- Fitness center
- Self parking
- 24-hour business center
- 24-hour front desk
- Coffee/tea in a common area
- Air conditioning
- Daily housekeeping
- Computer station
For families
- Free cribs/infant beds
- Rollaway/extra beds (surcharge)
- Refrigerator
- Connecting/adjoining rooms available
- Private bathroom
- Premium TV channels
What's around
- Heart of Bethlehem
- Historic Bethlehem Visitor Center (0.1 mi / 0.2 km)
- Moravian Museum of Bethlehem (0.1 mi / 0.2 km)
- Colonial Industrial Quarter (0.1 mi / 0.2 km)
- Kemerer Museum of Decorative Arts (0.3 mi / 0.5 km)
- National Museum of Industrial History (1.1 mi / 1.7 km)
Hotel Bethlehem, A Historic Hotel of America, Bethlehemfrom $152
- Preferred 2 Doubles
- Traditional Room, 2 Double Beds
- Executive Room, 1 King Bed
- Traditional Queen
- Traditional Room, 1 King Bed
- Traditional Queen
- Preferred King
- Starview 2 Doubles
- Starview King
- Traditional King - ADA
- Traditional 2 Doubles
- Traditional King
- Traditional Room, 1 Queen Bed
- Premier Starview King Suite
More great choices
At a glance
Key facts
Hotel size
- This hotel has 128 rooms
- This hotel is arranged over 9 floors
- Check-in time starts at 4:00 PM
- Check-out time is noon
- Express check-in/out
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
- Minimum check-in age is 21
Travelling with others
- Children (17 years old and younger) stay free when occupying the parent or guardian's room, using existing bedding
- Pets not allowed
- Free WiFi and wired Internet access in public areas
- Free WiFi and wired Internet access in rooms
- Free airport shuttle (available on request) *
- Self parking *
- Free nearby parking
Other information
- Smoke-free property
Nearby Four Star Bethlehem hotels
In the hotel
- Full breakfast daily (surcharge)
- 2 restaurants
- Bar/lounge
- 24-hour room service
- Coffee/tea in a common area
- Fitness facilities
- 24-hour business center
- Conference space
- Meeting rooms 10
- Conference space size (feet) - 14000
- Conference space size (meters) - 1301
- Conference center
- Computer station
- 24-hour front desk
- Concierge services
- Tours/ticket assistance
- Dry cleaning/laundry service
- Luggage storage
- Wedding services
- Multilingual staff
- Porter/bellhop
- Number of buildings/towers - 1
- Year Built 1922
- Elevator/lift
- ATM/banking
- Television in common areas
In the room
- Air conditioning
- Coffee/tea maker
- Bathrobes
- Iron/ironing board
- Hypo-allergenic bedding available
- Down comforter
- Blackout drapes/curtains
- Turndown service
- Premium bedding
- Pillowtop mattress
- Private bathroom
- Designer toiletries
- Hair dryer
- 42-inch LCD TV
- Premium TV channels
- IPod docking station
- Desk
- Free weekday newspaper
- Free WiFi
- Free local calls
- Refrigerator
- Free bottled water
- Daily housekeeping
- Connecting/adjoining rooms available
Top Bethlehem hotels
Recently reviewed hotels in Bethlehem
- Wingate by Wyndham - Allentown PAFrom
"We had a very nice stay. The hotel is nice and clean and the staff is very nice. The kids loved the pool and hot tub. I loved the fitness center. The breakfast was excellent. No…"Jan 17, 2017
- Super 8 Allentown West KutztownFrom
"We stay here quite often...Its very comfortable and peacefull..Staff is helpful and friendly.."Jan 10, 2017
- Comfort Suites AllentownFrom
"It was located where I could have access to the town, It was comfortable and the food was nice. the air conditioner in my room was however a bit noisy."Jan 10, 2017
- Hawthorn Suites by Wyndham Allentown-FogelsvilleFrom
"Really liked this hotel, very friendly staff, clean n updated. Really like the simple things they did with the room like have a area where you could dry your hair and nothing in…"Jan 9, 2017
Nearby hotels
Also popular with travelers from the USA
Special features
DiningTap Room - This restaurant specializes in American cuisine and serves breakfast, brunch, lunch, and dinner. Guests can order drinks at the bar and enjoy alfresco dining (weather permitting). A children's menu is available. Happy hour is offered. Open daily.
1741 On The Terrace - This fine-dining restaurant specializes in American cuisine and serves brunch and dinner. Guests can enjoy drinks at the bar. A children's menu is available. Reservations are required. Open daily.
On Site
- Fitness facilities
- Golfing nearby
- Hiking/biking trails nearby
- Kayaking nearby
- Mountain biking nearby
- Rafting nearby
- Cross-country skiing nearby
- Downhill skiing nearby
- Snowboarding nearby
- Snowmobiling nearby
Awards and affiliations
- The property is a member of Preferred Hotels & Resorts.
Hotel Bethlehem, A Historic Hotel of America, Bethlehem's small print
Also known as
- Bethlehem Historic America
- Hotel Bethlehem Historic Hotel America
- Hotel Historic Hotel America
The property has connecting/adjoining rooms, which are subject to availability and can be requested by contacting the property using the number on the booking confirmation.
Parking height restrictions apply.
For transfers, guests must contact the property before arrival at the number on the booking confirmation.
Optional extras
Self parking costs USD 7 per night with in/out privileges
Rollaway beds are available for USD 20.00 per night
Breakfast costs between USD 8 and USD 16 per person (approximately)
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.
Recent reviews
Outstanding 4.6 /5 from 229 reviews
It's the perfect location for walking around the town. Lovely hotel
The atmosphere was elegant and historic. The staff from check-in to bell service to restaurant staff were all exceptional. The location is in the heart of downtown historic Bethlehem. Absolutely sensational location. And the bed was terrific! What a great night's sleep. We couldn't have had a better experience.
Small but nice, clean room.
Beautiful location and hotel, we will be back
Wonderful stay!
Is the description of this hotel not correct? Tell us


text:
If you have a carpeted staircase with a landing in the middle, you will experience a challenge in installing seamless hardwood between the steps and the landing if you decide to rip out the carpeting. There's an easy way to get around this challenge, though, and it only requires a few tools and materials available at hardware stores. One indispensable item is stair nosing, which will create a uniform flow between the steps and landing flooring.
- Skill level:
- Easy
Other People Are Reading
Things you need
- Measuring tape
- Hardwood tongue-and-groove slats
- Table saw
- Stair nosing
- Nail gun
- Mallet
- Wood putty
- Sandpaper
- Stain
- Paintbrush
Show MoreHide
- 1
Measure the length of the landing with a measuring tape.
- 2
Cut wooden tongue-and-groove slats to the length of the landing, using a table saw.
- 3
Cut the stair nosing to the same length as the slats, using the table saw.
- 4
Attach the hardwood at the front edge of the landing. Place the stair nosing in place at this edge with the groove facing in toward the wall.
- 5
Secure the nosing in place with a nail gun and insert the nails at an angle so they are offset.
- 6
Lay the panels along the landing after the nosing. Push each tongue into the preceding panel's groove. Use a mallet to bang the panels together tightly.
- 7
Nail the panels in place along the seams between the panels, using a nail gun.
- 8
Cut the width of the last panel so it fits in between the second-to-last panel and the wall.
- 9
Cover the nail depressions with wood putty and sand smooth.
- 10
Stain the landing to match the stairs around it, using a paintbrush.
Tips and warnings
- Try to stain the stairs at the same time you stain the landing for an even finish.
- Make sure the landing and stairs are level and safe before finishing them.
Don't Miss
- 20 of the funniest online reviews ever
- 14 Biggest lies people tell in online dating sites
- Hilarious things Google thinks you're trying to search for


text: Gumtree 59,841pages on this wiki Add New Page Edit History Talk0 Share Contents[show] thegumtree.com 2000–2003 gumtree.com 2003–2006 Gumtree 2006–2010 2010–2011 2011–2016 Still used on gumtree.sg, and gumtree.co.za. Logo used on the Australian site (gumtree.com.au)2016–present Retrieved from "http://logos.wikia.com/wiki/Gumtree?oldid=771563" Ad blocker interference detected! Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers Wikia is not accessible if you've made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected. Categories: EBay United Kingdom International Shopping websites 2000 Online retail companies of the United Kingdom


text:
Hydrated lime (calcium hydroxide) - inorganic compound.
In production it is obtained by mixing water with calcium oxide.
Widespread use of slaked lime obtained in the manufacture of construction materials such as plaster solution, plaster and whitewash.
Calcium hydroxide prepared in the laboratoryconditions by mixing sodium hydroxide and an aqueous solution of calcium chloride. The mineral form of hydrated lime is contained in some of the metamorphic, volcanic and plutonic rocks.
Besides it is possible to obtain calcium hydroxide during coal combustion. </ Blockquote>
Calcium hydroxide - White powder, odorless and colorless crystals which decompose when heated to 560 degrees to water and calcium oxide.
Refractive index 1.574 of calcium hydroxide, acidity (pKa) 12.4, solubility in water 0.189 g / 100 ml, density 2.211 g / cm3, the molar mass of 74.093 g / mol.
The alcohol hydrated lime is not dissolved.</ Blockquote>
Lime water - it is a saturated solution of white calcium hydroxide. Its antacid properties are used in the medical field in the treatment of acid burns.
Slaked lime is widely used in the following industries:
- For the production of calcium stearate - in the chemical industry-
- For the production of additives for oils - in the refining industry-
- In the production of metals. Gidoksid calcium is added in the treated gas stream to neutralize the acid-
- To improve the quality of ground soil - build-road
- To store vegetables in the hangars - the production of antimicrobial and antifungal preservatives.
To mitigate the greenhouse effect and reducing atmospheric CO2 calcium hydroxide is used as an additive in seawater.
Also, hydrated lime is used as a natural alternative to chemicals in the fight against bugs, fleas, mites and their larvae.
Often in the construction industry hydrated lime used for smearing whitewash rafters and wooden fences. Thus, materials to protect against fire and putrefaction.
Calcium hydroxide is also involved in the manufacture of brake pads, creams for hair removal, tank mixtures, bleach, ebony and others.
In dentistry, the special composition of slaked lime is used as a disinfectant for dental root canals.
In the food industry in the slaked limeexcess is used as a food additive E526. It is added at the production of baby food, fruit juices, energy, non-alcoholic and alcoholic beverages, sugar cane, pastries and baked goods, tortillas, sweets and confectionery products, edible salt, pickles.


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Recent Helen Reviews
We woke up in Heaven
It would take me far more time than I have to tell you of every amazing detail of this cabin, so I will tell you my 5 year old granddaughters take on it: Our family joined us mid-way through our week. Their flight was delayed, so she arrived to the cabin sound asleep. Early the next morning she got to check out the vast cabin, and then we toured the grounds. Even at 5, the beauty is too much to be overlooked, and at every turn she was thrilled. The play area! The rock strewn creek! The watermill! The silhouette of mountains in the horizon! The bridge! The dam! The Pond! The grape arbor! The hummingbirds! At every turn she was more excited. And as we came around the foliage from the horseshoe pit and picnic area, she saw a large cross. She hurriedly grabbed my hands and exclaimed "Nana! That is Jesus' cross!! Is this Heaven?" So- my review of this amazing cabin is simply that quote- I surely couldnt sum it up any better. And this little slice of Heaven comes complete with Angel hosts that go out of their way to make sure your stay is perfect.
Perfect cabin!!
We loved staying at this cabin. It was a great girls trip and perfect set up for us. We didn't want or need for anything. Thanks again!!


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I was soooooo over being boring old brown and decided to do something exciting! So went blonde with pink! Some have absolutely loved others have absolutely hated it! So im going to post here and ask for you opinions, and being honest but please dont be brutal!
Im torn apart of me absolutely loves it and figures hell im a few years ill be too old to do this or be in a job where it would be frowned upon but then apart of em is like woaaaahhh man thats wayyyy too bright
so see pictures and give your opinions
1618452_204516956421934_1647367365_n.jpg 1555465_205010356372594_186036470_n.jpg


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Is National Historical Institute incorrect or missing key business information? Update your Hotfrog listing today.
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Hotfrog Philippines provides information regarding National Historical Institute in Manila Metro Manila. National Historical Institute is located at T. M Kalaw Street, Manila Metro Manila 1000 and provides arts services. Contact them on (02) 525 7695.
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Himalayan salt health benefits
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Pink Himalayan Salt Benefits that Make It Superior to Table Salt - Dr. Axe
10 Health Benefits of Himalayan Salt - http://www.seasalthealth.com
10 Things Can Happen When You Start Using Pink Himalayan Salt ~
Not all salt is created equal. Salt doesn't necessarily have a great reputation. These are the health benefits pink Himalayan salt can actually provide.
10 Reasons why you really need Himalayan Salt Lamps in your home...
Have you discovered Pink Himalayan Salt yet? Everyone's raving about the amazing uses and health benefits and you are going to love our hugely informative post. Ditch that salt table and replace with this. You are going to love how it makes you feel!
Amazing Health Benefits Of Cooking On A Himalayan Salt Block
If you've heard of Himalayan salt, you may be wondering why health enthusiasts recommend it, how it differs from other varieties of salt, and whether or not it's actually good for you. For the full article visit us here: http://paleo.co/tablevshimalayansalt
Himalayan Salt Lamp Infographic and Giveaway. I have these all over my house. Amazing. The glow is like a Christmas feeling. I love them.
TABLE SALT VS HIMALAYAN PINK SALT – Which is Better and Why


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We're here with a master fermentationist, avid outdoorswoman, and good friend, Summer Bock. You're going to learn how to upgrade your gut health with probiotics, how to properly complete a cleanse, and I'll even share a few tips to help you with your New Year's Resolutions.
Do you ever feel like there's a wild animal lurking somewhere inside you? If you've ever been derailed by your inner monkey, this show is for you. You'll learn how to quite bad habits and reprogram negative thought patterns, why we're always thinking about food, and tons more.


text: Feb 23, 10:31 AM EST Claims for US jobless benefits tick up, level still healthy By PAUL WISEMAN AP Economics Writer AP Photo/Mike Groll Multimedia A district summary of the Beige Book Measuring economic stress by county nationwide Mall malaise: shoppers browse, but don't buy Unemployment by the numbers Family struggles with father's unemployment Saying an affordable goodbye Hard times hit small car dealer Latest Economic News Puerto Rico governor meets with top US officials amid crisis Egyptians bear down under worst inflation in a decade China, France overtake US as top German trade partners Spirit Airlines CEO dismisses new, cheaper fares by rivals Tulsa's former Black Wall Street tries to remake itself UK economy grew less quickly than first estimated in 2016 German optimism up in positive sign for Europe's economy United, American begin selling cheaper economy-class fare American unveils prices, routes for new cheapest fare Irish employment WASHINGTON (AP) -- More Americans applied for unemployment benefits last week, but claims remained at a low level consistent with a healthy job market. THE NUMBERS: The Labor Department said Thursday that 244,000 Americans applied for jobless aid last week, up by 6,000 from the previous week. The four-week average, a less volatile measure, fell by 4,000 to 241,000, lowest since July 1973. Overall, 2.06 million people are collecting unemployment checks, down 7.7 percent from a year ago. THE TAKEAWAY: Unemployment claims are a proxy for layoffs. They have come in below 300,000 a week for 103 straight weeks, the longest such streak since 1970. The low levels of claims suggest that employers are confident enough in the economy to hang on to their workers and perhaps know it would be difficult to find replacements in a tight job market. KEY DRIVERS: Employers added a healthy 227,000 jobs in January after averaging 187,000 a month last year. The unemployment rate is 4.8 percent, which the Federal Reserve considers full employment. "The pattern (in jobless claims) is consistent with the trend in employment growth remaining strong - more than strong enough to keep the unemployment rate trending down," Jim O'Sullivan, chief U.S. economist at High Frequency Economics, wrote in a research report. Fed Chair Janet Yellen has said that the central bank is close to achieving its goals of maximum employment and modest 2 percent inflation. She noted in congressional testimony last week that at the December meeting Fed officials expected to raise rates three times this year. Many private economists believe the Fed won't start raising rates until June, giving the Fed more time to assess the potential impact President Donald Trump's stimulus program of tax cuts and infrastructure spending will have on the economy. © 2017 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed. Learn more about our Privacy Policy and Terms of Use. Health Weather Offbeat Today in History Podcasts Video Photos & Interactives En Español Generales Financieras Deportivas Espectáculos HamptonRoads.com Entertainment Calendar See what's going on around town » Post an event Restaurants Listings by cuisine and by city » Post Review Movies See what's playing in local theaters » Post Review Attractions Find listing of local attractions » Post Review Community Community Blogs Photo Sharing PilotOnline.com Latest local and national news Staff blogs Sports - local and national Business and stocks Military news Opinion and editorials Virginian-Pilot Subscribe Advertise Search archives ePilot digital edition Find. Do.Tag. Share. Find Local Businesses Popular Searches Restaurants Pizza Furniture Florists Car Repair Hotels Banks Tires Beauty Salons Apparel Appliances Auto Repair Car Rental Electrician Doctors General Contractors Realtors Dentists Insurance Surgeons Veterinarians Lawyers Plumbers Attorneys Landscaping Mortgage Banker


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Father (and Mother) Knows Best: Healthcare Providers' Responses to Parental Concerns Can Delay Diagnosis of Autism Spectrum Disorders
Children with autism spectrum disorder (ASD) can develop symptoms before 2 years of age and usually can be diagnosed by 3 years of age; early identification of ASD is associated with improved long-term developmental outcomes. In a new study scheduled for publication in The Journal of Pediatrics, researchers assessed how healthcare providers respond to parents' concerns about their child's early development, as well as how that response affected the timeliness of ASD diagnosis.
Katharine Zuckerman, MD, MPH, and colleagues from Doernbecher Children's Hospital Oregon Health & Science University and Oregon State University used data from the 2011 Survey of Pathways to Diagnosis and Services, a nationally-representative, parent-reported survey, to examine the experiences of 1,420 children with ASD and 2,098 comparison children with nonspecific intellectual disability/developmental delay (ID/DD). According to Dr. Zuckerman, "We know that early identification of ASD is beneficial to children and their families. Unfortunately, many families experience long delays between when they first have concerns and when their child gets diagnosed with ASD." So, the authors recorded the child's age when parents first had concerns about development, the child's age at first discussion with a healthcare provider about the concerns, the provider's response to the concerns, and, in children with ASD, age at diagnosis.
The researchers found that parents first had concerns about ASD at about 2 years of age, compared with ID/DD at about 3 years of age; they discussed these concerns with healthcare providers at an average age of 2.3 years (for ASD) and 3.2 years (for ID/DD). Children with ASD had 14% fewer proactive provider responses to parents' concerns than children with ID/DD, meaning that providers were less likely to take steps like conducting developmental tests or referring to a specialist. Children with ASD also were more likely to have their provider reassure parents or tell them that their child will "grow out of it." When the researchers compared children whose providers were more passive and reassuring with children whose providers were more proactive, they found that children whose providers were more passive waited longer, as much as 2 years more, to diagnose ASD. Overall, children were not diagnosed with ASD until approximately 5 years of age, almost 3 years after parents first voiced their concerns to healthcare providers.
Despite evidence suggesting that parental concerns strongly predict developmental issues, including ASD, there continues to be a long delay between initial conversations with a healthcare provider and diagnosis. "This study implies that the behavior of healthcare providers is likely a very important factor in delayed autism identification," notes Dr. Zuckerman. Providers may need more education and training to address and react to parental concerns, especially for ASD. Care coordination in the primary care setting may be helpful to ensure that children with ASD receive a timely diagnosis and early therapeutic services.
Notes for Editors
"Parental Concerns, Provider Response, and Timeliness of Autism Spectrum Disorder Diagnosis," by Katharine Elizabeth Zuckerman, MD, MPH, Olivia Jasmine Lindly, MPH, and Brianna Kathleen Sinche, MPH, appears in The Journal of Pediatrics (www.jpeds.com), DOI 10.1016/j.jpeds.2015.03.007, published by Elsevier.
About The Journal of Pediatrics
The Journal of Pediatrics is a primary reference for the science and practice of pediatrics and its subspecialties. This authoritative resource of original, peer-reviewed articles oriented toward clinical practice helps physicians stay abreast of the latest and ever-changing developments in pediatric medicine. The Journal of Pediatrics is ranked 6th out of 117 pediatric medical journals (2013 Journal Citation Reports®, published by Thomson Reuters). URL: www.jpeds.com
About Elsevier
Elsevier is a world-leading provider of information solutions that enhance the performance of science, health, and technology professionals, empowering them to make better decisions, deliver better care, and sometimes make groundbreaking discoveries that advance the boundaries of knowledge and human progress. Elsevier provides web-based, digital solutions — among them ScienceDirect, Scopus, Research Intelligence and ClinicalKey— and publishes over 2,500 journals, including The Lancet and Cell, and more than 35,000 book titles, including a number of iconic reference works. Elsevier is part of RELX Group, a world-leading provider of information and analytics for professional and business customers across industries. www.elsevier.com
Media contact
Eileen Leahy
+1 732 238 3628


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Can you believe it.......?
Another Shabby Apple giveaway HERE ......?
Because I can't.
No, seriously.
I can't.
But I am every bit as THRILLED to tell you about Shabby Apple this time around as I was a few months ago -- when one of you lucky gals scored that gorgeous black dress.
(Perhaps this time I will get my wish and the lucky winner will give ME the dress ....?)
My birthday IS only five months away, you know .....
Just sayin'.
I know we have lots of new readers here at Little Lucy Lu, so just in case they don't know about the fabulous company that is Shabby Apple, let me fill them in.
(And for you Shabby Apple junkies out there who already know all about it .... never hurts to get reacquainted, right? :)~
Shabby Apple is an online boutique, specializing in women's dresses and accessories. Their styles are vintage-inspired, which is why I LOVE them.
As you will see when you click HERE, Shabby Apple dresses are extremely versatile. Relaxed enough for the beach, fancy enough for a party, modest enough for church, and comfortable enough for work (especially for teachers like me!).
If you don't already .... you will soon LOVE these dresses.
And speaking of LOVE .... allow me to introduce you to one of the dresses I LOVE the MOST at Shabby Apple:
The AHOY!
(You must click HERE to see the dress in all its glory .... click through all of the thumbnails!)
First of all -- it's TURQUOISE.
Never met a turquoise I didn't like.
Second of all -- it is fun, flirty, classy, and chic .... all rolled into one sweet little dress!
And third -- it makes me want to get on a boat and set sail in the sunshine!
(Anyone else beyond ready for Summer ...?)
Heck, I might even bring along one of Shabby Apple's adorable swimsuits!
But back to the dress ....
the beautiful, turquoise dress.
It must be nice to be all of you! :)~
Entering to win is SO easy, gals.
***You MUST go HERE and {like} Shabby Apple's Facebook page. (And better yet, while you're there .... tell them Little Lucy Lu sent you!)
***Then, come back here and COMMENT, telling me you did.
THAT is your entry.
No comment? ....no chance to win.
You have to leave a comment!
Want some extra chances?
Leave a comment for any of the following things: (up to FOUR additional entries possible!)
1) Visit Shabby Apple and leave me a comment, telling me which dress is your favorite.
2) Visit Little Lucy Lu's Facebook page and click {like} -- then leave me a comment here, telling me you did (or that you already do).
3) Follow Little Lucy Lu on Twitter -- then leave me a comment here, telling me you did (or that you already do).
4) Tweet about this fantabulous giveaway -- then leave me a comment, telling me you did (include your twitter ID).
The winner will be announced on the Little Lucy Lu Facebook page in ONE WEEK.


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Please confirm your email before writing a review.
1 person thought this review was helpful
The couple that runs this store are good people. They sell the best weed in Columbia County. I live several miles away and it's worth the trip everytime. Ask for the Doggy treats.
great place and great staff. very helpful great products. I go nowhere else.
Ive said that you'd have to fart rainbows to get 5 stars in any review from me, well then plug your nose my peeps, cuz the Flowershop is a 5 star venue!! The staff is helpful and friendly, current on not just their product, but the legal and social issues pertaining to marijuana nationwide. They have a very comfy wait room, and scored an excellent location with great parking. Your first love is always the best, and this is sure true with my favorite green team in the northwest, The Flowershop!! FLOWER POWER!!!!!!!


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Accounting Operations Supervisor
We are looking for experienced candidates to supervise and coordinate a team delivering Finance and Accounting operational services for an European customer in Łódź. Person will be responsible for setting broad performance goals and objectives, coordinating projects and program teams, driving changes, and ensuring proper tools are in place to support team's timely and effective delivery of processes, programs, and systems.
Your responsibilities:
- Coordination and control of daily work
- Ensuring performance quality level in accordance with Standard Level Agreements
- Response to queries coming occurring during internal and external audits conducted in the department
- Building relationship with the Customer
- Improving Voice of the Customer result through planning of corrective actions
- Preparing department presentations during potential customers' visits
- Planning of process improvements and increasing efficiency in the relevant process areas
- Optimization of resource management
- Participation and providing feedback for preparing trainings for employees
- Conducting Business Controls as per agreement with direct Manager and Global Compliance & Controls Team
- Setting up goals for employees and conducting Focal Point Review sessions
- Cooperation with HR department and supporting functions
- Participation in project finance-related meetings and cost forecast on monthly basis
We require:
- Fluency in English
- Experience in BPO/BPS business
- Experience in team leadership / management
- Analytical skills
- Accurate and detail-oriented
- Good communication skills
- MS Office products proficiency
- Accounting background or/ and experience is an advantage
We offer:
- Medical package for Employees and their closest family
- Multisport card
- Life insurance package
- Employee Assistance program – help in a difficult life situation
- Free coffee, tea, sandwiches and fruit
- Modern offices in the city center
- Work-Life balance support including flex-time arrangements and work from home opportunities
- Trainings, opportunity for personal development and advancement within the company
- Wellness program
- HPE Culture – special offers from theatres and cinemas
- CSR (Corporate Social Responsibility)
- HPE Badge discount program
Meet Some of Hewlett Packard Enterprise's Employees
Jeremy H.
Business Compensation Manager
Jeremy ensures all HPE employees are properly compensated for their contributions to the company, helping to retain top talent and market leaders for the organization.
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Smith & Nephew Endoscopy's KINSA(R) RC Suture Anchor Designed for Secure Repair of Rotator Cuff Injuries
Surgeons can repair these injuries using arthroscopic -- or minimallyinvasive -- techniques with specialized instruments and devices such as theKINSA RC Suture Anchor, which re-attaches the torn tissue to restore mobility.
The KINSA RC Suture Anchor is the second in Smith & Nephew Endoscopy'sline of KINSA suture anchors. The original KINSA anchor, for treatment ofshoulder instability, was released in 2006. Both KINSA anchors encase asliding, self-locking knot that permits the surgeon to secure the repairwithout tying knots on top of the tissue. Surgical knots in arthroscopicrepairs can sometimes loosen or cause irritation of surrounding tissue. TheKINSA RC anchor instead delivers "low profile" repair, without knots orprotrusions to interfere with the joint motion.
Successful rotator cuff repair requires that a suture anchor sit securelyin the cortical, or dense outer layer of bone, and that the surgeon controlsthe tension of the sutures that hold repaired tissue in place.
The anchor is well suited for "double-row" fixation, a procedure thatclinical studies have shown delivers the superior rotator cuff repair andshoulder mobility. This technique calls for the surgeon to anchor the rotatorcuff tissue at several points, distributing the strength of fixation acrossthe shoulder.
A surgeon taps the anchor into the bone surface, and then seats it with afinal twist. The surgeon controls the amount of tension applied to the repairby manually tightening the KINSA suture. Surgeons who use competing anchorsdon't have total control over the tension.
"Its design allows me to properly sink the anchor first, and then applythe amount of tension for optimal tissue-to-bone contact to promote healing,"said Dr. Michael Terry, orthopedic surgeon based at the University of Chicago."This is important because too much tension can interfere with blood flow inthe tissue and compromise healing.
"Another benefit of this system is that it is so easy to use," Dr. Terrysaid. "There are no knots to tie and the instrumentation is simple andfamiliar."
The KINSA RC anchor is small -- about 1/2-inch in length -- and made froma unique, implantable PEEK-OPTIMA(R) polymer from Invibio(R), which closelymatches the density of cortical bone. The implants deliver strong repair butdo not show up on X-rays or distort MRIs, as metal anchors would.
"The KINSA RC Suture Anchor enhances our innovative line of shoulderfixation devices, which have been designed to provide the best possible repairfor patients, and the most efficient delivery for busy shoulder surgeons,"said Joe Darling, senior vice president and general manager of Smith & NephewEndoscopy's Arthroscopic Repair strategic business unit.
About Smith & Nephew
Smith & Nephew is a global medical technology business, specialising inOrthopaedic Reconstruction, Orthopaedic Trauma and Clinical Therapies,Endoscopy and Advanced Wound Management products. Smith & Nephew is a globalleader in arthroscopy and advanced wound management and is one of the leadingglobal orthopaedics companies.
Smith & Nephew is dedicated to helping improve people's lives. The Companyprides itself on the strength of its relationships with its surgeons andprofessional healthcare customers, with whom its name is synonymous with highstandards of performance, innovation and trust. The Company has 9,600employees and operates in 31 countries around the world. Annual sales in 2006were nearly $2.8 billion.
This press release contains certain "forward-looking statements" withinthe meaning o
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The peak of expectation and new adventure blend together in this invigorating and curious mixture of citrus lime, lemon peel, sliced celery root, and droplets of violet mist, muguet and passionate amber exploring the depths of emptiness and the philosophy of hope.
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There's an app for that! No matter the device, a host of apps are available to help you manage, promote and connect with customers. The Washington County Chamber and Virginia Highlands Small Business Incubator are hosting a unique workshop that will cover how to use built-in apps as well as add on apps to perform everyday and business functions with your smart phone or tablet. Discover apps that can turn your device into an indispensible workplace tool. The Workshop will be held May 22 at 9-11 AM. Details and registration info can be found at http://events.vastartup.org/events/1058
The workshop is designed for professionals who want to use their tablet or smart phone more effectively for business applications and in doing so, free up time spent on ow value, repetitive tasks.


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1 Perimeter Road,Manchester NH, 03103
50,000 sq. ft
Status: Active
Berkshire Hathaway HomeServices Verani Realty
(888) 723-0306
Listing Provided Courtesy Of: Jackman Commercial Realty, Inc. - John Jackman
Last Updated: 2/23/2017 2:21 PM
Description for 1 Perimeter Road Manchester, NH 03103
Two end Unit office/R&D spaces available. Large windows on several sides. Unit 100 is 3,053 +/- SF and has a large delivery door, freshly painted, carpeted offices, metal frame doors, large kitchenette, two bathrooms. Unit 1,100 is also an end unit with large windows, an open bullpen area, many perimeter offices and a large R&D type open area that could be converted into warehouse space. Unit 900 is 6,243 SF and is finished as office but could be converted to some warehouse distribution space. It has two loading docks. The property beautifully landscaped with ample free ample parking and professionally managed. Located near the Manchester-Boston Airport and easily accessible to South Willow Street, Brown Avenue and Route 93 and 293. Floor plans are attached for reference.
Listing Information
One Perimeter Road
Public Water Service
Public Sewer
Room Information
Interior Features
Central Air
Gas Heat, Electric Heating, Forced Air
Exterior / Lot Features
Industrial Area, Office Park, City Road, Paved Road
Inside AccessTM
Current market conditions for 1 Perimeter Road
Active Market Trends
Source:MLS DATA
Median list price$254,900
Days on market103
Properties for sale211
Sold Market Trends
Source:MLS DATA
Median sold price$199,250
Sales to list price9,877.0%
Properties sold286
Median sq ft price$135
Arrows indicate 90 day trend
Listing Price History for 1 Perimeter Road
Manchester Real Estate
Manchester is located in New Hampshire. Manchester, New Hampshire 03103 has a population of 109,786.
The median household income in Manchester, New Hampshire 03103 is $54,320. The median household income for the surrounding county is $70,472 compared to the national median of $53,046. The median age of people living in Manchester 03103 is 36.2 years.
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FSU Reads will begin Feb 20 and will run until April13th. It is offered on Mondays or Tuesdays from 4:15-5:15pm in Room 215 of the Turley Center. Please note the program will not be held:
- If Marion County Schools are closed due to inclement weather
- During the week of FSU Spring Break, March 13-17


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Is Worldwide Tours and Safaris incorrect or missing key business information? Update your Hotfrog listing today.
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No telemarketers, please
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We open 7 days a week , 365 days per year
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Safari Cape Town Worldwide Tours &Safaris is one of the leading safari travel operators in Southern Africa, East Africa. We Read more
Is Worldwide Tours and Safaris in 52 St Georges Mall P.O.Box 2917 60 Victoria Road , Clifton, Cape Town Western Cape 8000 your business? Claim your listing and attract more leads by adding more content, photos and other business details.
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Bulla Louw and Ou Kaapse Weg Sunnydale Cape Town Western Cape 7975
LOMPRE HSE 5 LOERIE KANTOORPARK Cape Town Western Cape 7550
18 BROADWALK SQUARE Cape Town Western Cape 7405
18 20 CHICHESTER RD Cape Town Western Cape 7708
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Professional lead sheet transcription from Woody Shaw's two time Grammy-nominated album Rosewood (1978). Digital Download - PDF.
- 38-page full score, album arrangement
- 12 separate instrumental parts: trumpet, soprano sax, alto sax; tenor sax, tenor trombone, bass trombone, flute, piccolo, piano, percussion, bass, and drums
- 76 pages total
- Includes concert lead sheet


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The 2015 UK Employment Tribunal case that determined that Uber drivers were employees means that Uber will have to give the UK government 16.67% of its drivers' earnings for Value-Added Tax, going back four or more years (that would be £20M for 2015 alone); and the ruling will likely apply to Uber's EU-wide rules (because VAT rules are harmonized across the EU) -- so not only does Uber owe hundreds of millions to EU governments for the past 4+ years' earnings, but it will face a 16.67% (or more) reduction to all future earnings. Read the rest
For the past week, Naked Capitalism has run a series of articles by transportation industry expert Hubert Horan on the economic shenanigans of Uber, which cooks the numbers it shows investors, drivers and the press to make it seem like something other than a black box that uses arrogance and lawlessness to make a bet on establishing a monopoly on transport in the world's major cities. Read the rest
People's Ride is a co-op ride-hailing company in Grand Rapids, Michigan: drivers own the service in common and collectively decide how to spend its profits (for example, on deploying an app to go with its website); for-profit competitors like Uber take 30% commissions from their drivers and deliver them to investors, while People's Ride spends all the revenue paying drivers and improving the service. Read the rest
The March 29 edition of Airbnb's terms of service requires that people who rent out their homes acknowledge that despite the company's widely advertised Host Protection Insurance program, "you understand and agree that Airbnb does not act as an insurer." Read the rest
Uber and Lyft are only economically viable because they offload their cost of capital -- the investment and depreciation on cars and the cost of keeping a driver fed and healthy -- onto the drivers, who are only willing to accept such a bad deal because the labor market sucks. Read the rest
Chariot for Women is a new woman-only rideshare service launched by a former Uber driver who had a bad run-in with a hulking drunk dude that made him realize how scary things must be for woman riders and drivers both. Read the rest
Indie sf movie kingpin Jim Munroe writes, "Ever wonder how the Hilton and the Marriott families feel about Airbnb? What would happen if the heir to a hotel chain empire gets fed up and decides to rebrand the sharing economy... as the scaring economy? A concept trailer for a new tech-horror webseries called THE INTERNET WANTS by Postopian Pictures, the guys behind HAPHEAD and GHOSTS WITH SHIT JOBS." Read the rest
Umbracity aims to solve the problem of unexpected urban showers with a shared-umbrella service. They've rolled it out in soggy Vancouver, and the deal is that you get to use an umbrella from any of their kiosks for free for 48h, but if you keep it longer, it's $2/day to a maximum of $20. Read the rest


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Exquisite Aluminum Dragon Dish by Benzara
- Product measures (inches): 21x9x14
- Colour: Yellowish Silver
- Made from 100% aluminum
Could a physical dish get any lovelier in terms of the antique effect it creates? Well, one couldn't guarantee that, but it will be a rare find that beats this Aluminum Dragon Dish in terms of its looks and appeal. Classic and timeless, this dish has been made with 100% aluminum and hence will last in pristine condition for years to come. It features a yellowish tint with a lovely design that gives it an antique and rustic charm. You could keep this Dragon dish in the living room on a side table, or you could keep it in the kitchen. It has the look of a trophy and so it would start a heap of conversations with those who see it for the first time. It can also make for a wonderful gift for someone who has interest in all things antique. So why wait? Get this Cool Dragon Dish today!