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Mexico: A Better Choice than China?Harold L. Sirkin
The question doesn't really matter, but the answer for U.S. manufacturers always seems to be the same: China.
With good reason. China has a huge, low-cost, underutilized, and eager workforce unencumbered by outdated unions, labor laws, and expensive government mandates and regulations. China has a strong supply network that is getting better all the time. China understands the value of infrastructure and is investing heavily in it. National and provincial governments want to help business succeed, not tie its hands.
All this points to China as the wave of the future. But that doesn't mean China is the only option for manufacturers—nor is it always the best one.
There are many other low-cost manufacturing alternatives: Brazil, India, Thailand, and Vietnam, to name some. Closer to home lies America's third-largest trading partner, Mexico. If distant China is the Big Kahuna of low-cost manufacturing and sourcing, Mexico should be seen as El Pequeno Kahuna.
Mexico is growing more competitive
As noted in a 2008 Boston Consulting Group report, Mexico's Evolving Sweet Spot in the Globalization Landscape, the cost difference between low-wage Mexico and lower-wage China has been narrowing. In 1996, Chinese labor cost about one-third of Mexican labor. Today, Chinese labor costs are about half of Mexico's—$1.69 per hour, on average, in 2007, compared to $3.46 per hour, according to the International Labor Organization (ILO). In another year or two, according to estimates, hiring a Chinese worker will cost about 85% of what it costs to hire a Mexican worker.
A big reason for the narrowing gap is the fact that Mexico has already absorbed the rapid increase in manufacturing wages that are just starting to hit China and other developing economies. The shrinking labor-cost advantage, coupled with the devaluation of the Mexican peso in the past year, is making Mexico even more competitive.
Moreover, wage and exchange rates are not the only factors managers need to weigh. There's also the cost of transoceanic shipping and the inherent risks of a long-distance supply chain. When these and other factors are taken into account, Mexico often looks better.
The fact that Mexico is our neighbor means a company often can place an order one or two weeks before delivery is needed, rather than four to six weeks in advance, as is typically necessary when sourcing from China. In times like these, when demand can fluctuate wildly, the ability to respond quickly to changing market conditions can be critical.
shipping savings exceed labor edge
Mexico's proximity to the U.S. also means less dependence on America's crowded ports. It's also faster and cheaper to move heavy products relatively short distances by truck than to do it over thousands of miles by ship, and then further by rail, truck, or both. As Mexico's Evolving Sweet Spot noted, "…in the case of a refrigerator—a very bulky product—manufactured in a low-cost Asian country and sold in the U.S. for $500, the cost of shipping represents up to $100 of the price tag, or 20%. Shipping it from Mexico would cost less than half that amount."
If assembling each refrigerator takes four man-hours, a manufacturer would save just over $7 in labor costs per unit by manufacturing in China. If the company can save over $50 in transportation costs by manufacturing in Mexico, while paying seven or eight dollars more in labor, the advantage goes to Mexico, with net savings in excess of $40 per unit.
Without a supply base, manufacturing can't be shifted to Mexico any more than it can be to China or elsewhere, but Mexico is taking care of that. For example, many of the world's top manufacturers of industrial, commercial, and home refrigeration, heating, and air-conditioning equipment have formed an industry "cluster" to attract a supply base in and around Monterrey, in northern Mexico. The cluster grew by 9% in 2007. South Korea's LG has had a manufacturing presence in Mexico since 1988; in addition to refrigerators, the company produces digital TVs, PDP modules, monitors, and mobile phones there.
Aerospace is clustering in Mexico
The Monterrey industrial cluster has drawn leading suppliers of parts and components as well. For instance, China's Golden Dragon Precise Copper Tube Group—the largest producer of precision copper tube in the world—made an initial investment of $50 million in the area and eventually will employ 900 people there.
A second industrial cluster in Mexico also is attracting global attention, this time from the aerospace industry. Before the downturn, more than 160 companies were involved, employing nearly 17,000 workers.
Proximity offers other advantages as well. Being in the same general time zone means it's easier for U.S. companies to conduct real-time business in Mexico. The majority of Mexican cities, for example, lie in the same zone as Chicago, just one hour behind New York. When you need to be on-site, there are frequent and direct flights from some 20 U.S. cities. Language also is less of a barrier, with native Mexican managers typically speaking English and increasing millions of Americans conversant in Spanish.
Just as China has disadvantages, so too does Mexico. According to the January 2009 Wall Street Journal-Heritage Foundation Index of Economic Freedom, corruption remains "pervasive" there and "Mexico's rigid labor regulations continue to hamper…productivity," making it difficult to lay off workers when necessary. Mexico's infrastructure remains woefully inadequate, slowing the flow of needed raw materials and intermediate goods. And battles with drug traffickers make some areas unsafe.
What to look for overseas
So what should U.S. executives considering global manufacturing or sourcing do?
1) Think globally. Competing successfully probably will require more, not fewer, locations. To succeed in the future, most companies will need a global network of manufacturing, assembly, design, and research and development facilities.
2) Pinpoint production. Facilities should be built where they'll do the most good. The question managers need to ask is: What can be done best where? That's where the work should be done.
3) Develop a portfolio. Your objective in choosing manufacturing locations is to maximize returns while minimizing risk. Ask yourself where markets can be developed or expanded. This will help you determine what the future portfolio should look like.
In addition to its appeal as a manufacturing hub, Mexico is the world's eleventh-largest country and—prior to the recession—was experiencing a boom in domestic consumption (as were China and India). This might make Mexico a better choice than a country with a smaller domestic market.
4) Act strategically. The decision to acquire or build a plant in China, or Mexico—or Missouri, for that matter—should be part of a long-term strategy, not an isolated decision. As with all long-term capital decisions, you need to consider both your next potential moves and long-term changes in your customer base and competitive environment.
Managing isn't getting easier. It takes more knowledge of more things—and perhaps more chutzpah—than ever before. Competing with everyone from everywhere for everything is a different challenge than that faced by America's captains of industry in the 19th and 20th centuries.
To maintain America's leadership, business executives will have to be engaged far beyond our shores. Dozens of countries will play a role in our continued success. If we're wise, Mexico's role will be larger than most.


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good choice!
This is a discussion on my self defense carbine within the Defensive Rifles & Shotgun Discussion forums, part of the Related Topics category; I have a M1 carbine that my dad used in WW2.it still shoots great and with soft point or hollow point I trust it completely. ...
I have a M1 carbine that my dad used in WW2.it still shoots great and with soft point or hollow point I trust it completely.
I have several 15 round mags and 1 30 rounder all loaded and ready to go.
Its small,lightweight and easy to carry.
I think its a perfect defense gun. What do you guys think?
good choice!
"Deine Papieren bitte?" or "ΜΟΛΩΝ ΛΑΒΕ !"
(Choose only one)
NRA Endowment Member
"I bark at no man's bid. I will never come and go, and fetch and carry, at the whistle of the great man in the White House no matter who he is." -- David Crockett
That will work.
Liberty Over Tyranny Μολὼν λαβέ
Would work for me! My dad also carried one in the Seabees during WWII.
Retired USAF E-8. Curmudgeon at large.
Lighten up and enjoy life because:
Paranoia strikes deep, into your life it will creep. It starts when you're always afraid... Buffalo Springfield - For What It's Worth
Very close to perfect in my view as well.
An M1 Carbine is kept out of the safe around here for such purposes.
Charter Member of the DC .41 LC Society "Get heeled! No really"
No possible rapidity of fire can atone for habitual carelessness of aim with the first shot.
Theodore Roosevelt, The Wilderness Hunter, 1893
An utterly-reliable M1 Carbine's hard to beat. It's short, agile, lightweight, dead-nuts accurate, and easy to use. With the right ammo, it can be a devastating little defensive carbine (ie, Winchester X30M1 JSP 110gr, or Remington R30CAR JSP 110gr).
Enjoy it, and the memories/history.
Your best weapon is your brain. Don't leave home without it.
Thoughts: Justifiable self defense (A.O.J.).
Explain: How does disarming victims reduce the number of victims?
Reason over Force: Why the Gun is Civilization (Marko Kloos).
I want pictures.
I have a very strict gun control policy: if there's a gun around, I want to be in control of it.
Clint Eastwood
That's exactly what the DOD had in mind! The M1 Carbine was to be a short range SD weapon for truck drivers, cooks, building guards etc. When I was younger, almost every PD and Sheriffs office had a rack full of them. And they would still make an excellent gun for law enforcement. DR
You wanted a pic,I hope this works:
Yep, love it. Jealous.
I have a very strict gun control policy: if there's a gun around, I want to be in control of it.
Clint Eastwood
I would not hesitate to grab an M1 carbine in a SD situation,at night the only drawback might be the sights,but if your capable of point shooting it wouldn't be a drawback
"Outside of the killings, Washington has one of the lowest crime rates in the country,"
--Mayor Marion Barry, Washington , DC .
When I spent 2 years in Iraq as a contractor an M-1 carbine is I told the wife to keep by the bed at night, 2 jungle clipped 30 round mags of hollow points were in the gun ready to go and we did a fair amount of training in the backyard before I left. That along with her carry piece, a S&W 642 with Crimson Trace grips.
I use to have 2 carbines but upon returning home I was informed "Betsy" is now hers

subset: commoncrawl


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Monday – the most productive day of the week! Here are some links to go along with your second cup of coffee:
- The guidelines on what to have on your resume are always changing but here are some Do's and Don'ts that will always be relevant.
- Nowadays internships are being used as evaluation periods for future hires so here are a few tips to improving your standing in the internship market.
- What to make your internship count? Here a some tips that will help you achieve your expectations.


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headline reads 1200 gal water
Wholly irrigated corn can take up to 1200 gal of water to produce 1gal ethanol, according to a report on the MinPost today.
That's a lot of water and touches again on my obsession with aquifers.
1200 gals water make 1 gal ethanol
About Simon Robinson
9 Responses to 1200 gals water make 1 gal ethanol
1. The title reads 12000 instead of 1200 (this is only for soils without precipitation..)
2. The byproducts of corn ethanol production(distiller's grains) get some CO2 credits in life cycle calculations. Did those performing the study (I did not read the ES&T paper) do similar calculations for water use?
ken 28 April, 2009 at 6:32 pm #
That means it takes 3,172 gallons to grow one bushel of corn for food, plus another 8 gal or so to take it the next step to make ethanol. Sounds like a weak argument to me. Do you know how much water it akes to make the electricity you use in your house, or the gasoline you use in your car (assuming you have electricty in your house and drive a car of course)?
Simon Robinson 29 April, 2009 at 9:18 am #
Thanks for pointing that out. I've corrected the headline.
Simon Robinson 29 April, 2009 at 9:24 am #
Hi Ken, The argument gets a lot stronger if you live downstream from a corn producing belt and rely on a river for your drinking water.
It is also important if you are extracting that volume of water from an aquifer which is not being replenished at the same rate.
I don't have figures for the amount of water used in the other areas that you suggest. it would be interesting to look at the volume of water used per kW of energy produced from the different sectors. Do you have any numbers?
David B. Benson 30 April, 2009 at 2:19 am #
Depending upon the particular instillation, cooling water runs from 100 US gallons to 1000 US gallons per MWh generated.
Using the above values, one gets 360-3600 gal water/MJ of energy for electricity & 13.5 gal water/MJ of energy for ethanol, if my calculations are correct. [Ethanol HHV: 29.7 MJ/kg, density: 0.789 kg/L].
larry hagedon 5 June, 2009 at 3:20 am #
I believe around 4 percent of corn in the US is irrigated, and little if any of that is processed and used to best usages which involves making hundreds of products including ethanol out of it.
I believe most of the irrigated corn is used for people food.
larryhagedon 6 June, 2009 at 2:56 am #
more credible numbers are 8 gallons average per gallon of ethanol compared to 10 gallons average per gallon of gasoline.
The big difference is that every time we build a new ethanol distillery, the average water usage comes down. Current technology is 2 or 3 gallons of water per gallon of ethanol, thus each new distillery built is lowering the overall average.
Some are even claiming one gallon of water per gallon of ethanol.
(water recycled or fed to cattle as wet Distillers Dry Grains does not count against the ethanol produced nor does recycled cooling water and water pumped into oil wells to force the oil out count against the gasoline figures).
Doug Hoffman 12 June, 2009 at 10:02 pm #
The ineffectiveness of biofuels—ethanol and biodiesil—has been much in the news lately, with reports from the EPA, California's CARB and the EU's joint Research Council claiming that biofuels pollute more than the fossil fuels they are supposed to replace. Still, this has not prevented the biofuels industry from receiving big government subsidies. Now a new report discloses another reason to shun biofuels, one that has nothing to do with CO2 and everything to do with H2O. When the water use of biofuel feedstock crops is analyzed, the water footprint (WF) ranges from 1,400 to an astounding 20,000 gallons of water for each gallon of biofuel produced. See my blog article for the rest: http://theresilientearth.com/?q=content/watering-down-biofuels
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Quick Album Kits
12 x 12
Happy Land Quick Album - $12.00
Heidi Larsen
This kit is perfect for documenting your vacations and fun times! Simply drag and drop your own photos.
Related Products
Happy Land
Heidi Larsen
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Your Dog, Your Life
The Scoop
Dog News, Politics
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Wildebeest creates the perfect present for new dog parents.
Dog Breeds
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today is April 6th, 2006
i'm having puppies today ;)
so far i have two boys and two girls. the boys are both sable like me, one of the girls is too, the other girl is black and red like her daddy Mako.
i think i'm going to have some more....
be back later
Well, my temperature dropped, it's day 63....
My human is pacing... So is Mako....
I hope they're coming soon!!!!!!!!!!!!!
Look at my picture... I'm as big as a house!
My human made a web page for me and my puppies!
the address is:
if you click on 'puppies' there are pictures of my babies up there. My puppies are two weeks old today. My human is taking more pictures tonight and she says she'll put them up.
There are pictures of my boyfriend up there too :)
Copyright © I-5 Publishing, LLC. All rights reserved.
Visit Catster


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Posts Tagged 'frame house'
Kit Homes Benefits
To have a home as a shelter and the place to get the serenity and peace are the dream of everybody. However, to build a home from scratch will be really costly. You could choose the kit homes that McFarlane Joiners & Builders has to offer. Because the frames will be prefabricated in the factory, the time requires to get the assembly done is relatively much quicker than a conventional home.
It could be done in months, instead of waiting for more than a year. It will also more affordable than the conventional home because like the name kit, you just need to assembly the parts. Even when there is a modification need to be done, the company will finish it shortly on the assembly location. Now, having a home that will be the home of your dream is as simply as calling the McFarlane company. So, call them now and get the best kit homes for you and your family.


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Hair Type 3b - Severally Damaged
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Join Date: Mar 2011
Posts: 3,750
Monday, May 27, 2013 at 09:59AM
If your hair is severely damaged unfortunately nothing can bring that back to health, hair is dead so cannot permanently be repaired. Sometimes curl is temporarily lost due to dehydration but it can be permanently lost due to damage to the protein structure of the hair, so you may need to lose some length.
For hair closer to the roots that is less damaged try a combination of hydrolysed protein treatments, coconut oil and honey soaks (clean dry hair may absorb better), making sure every product in your routine is hydrating your hair, go 'strict' Curly Girl instead of shampooing, stop all heat styling.
What is your routine at present? Have you considered a hair analysis like Komaza Care to see how far up the hair the severe damage is? They can tell you exactly how much needs to be trimmed away.
Komaza Care HAIR ANALYSIS Service - Rave! - Long Hair Care Forum
2a-2c, medium texture, porous/ colour treated. Three years CG. Past bra strap length heading for waist.
CO-wash: Inecto coconut/ Elvive Volume Collagen
Treatments: Komaza Care Matani, coconut/ sweet almond/ fractionated coconut oils, Hairveda Sitrinillah
Leave in: Fructis Sleek & Shine (old), Gliss Ultimate Volume, various Elvive
Styler: Umberto Giannini jelly, Au Naturale styling gelee
Flour sack towel, pixie diffuse or air dry.
Experimenting with: benign neglect


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Honors Students Attend Afternoon Tea
The USC Upstate honors students donned their "Sunday best" to attend an authentic British afternoon tea on Monday, October 1. Students and faculty were treated to cucumber, watercress, and smoked salmon sandwiches, scones with butter, jelly, and clotted crème, and assorted British pastries such as Victorian cake, flapjacks, meringues and shortbread, while surrounded by fresh flowers, bone china, and British knick-knacks.
Dr. Charles Harrington, senior vice chancellor of Academic Affairs, welcomed the attendees and gave a brief background on the place of tea in the world. Dr. Harrington was followed by Karen Thomas, the administrative assistant to the dean of students and a native of Cornwall, England, who provided a running commentary on the history of the English tea, the correct procedure for brewing the perfect "cuppa" tea, and the proper protocol for enjoying the tea and its attendant goodies.
The students learned such historical tidbits as the fact that High Tea was not so named because it was consumed by the aristocrats of England. It was actually invented for the miners as a substantial meal to tide them over until their late dinner. It was called "high" tea because the miners sat on "high" stools to consume it. Conversely, "low teas" were served on low chairs.
Students also learned that "Afternoon Tea," the quintessential English ritual ("Every English home has a teapot," says Ms. Thomas) actually began with Anna, the 7th Duchess of Bedford in the early 19th century. The usual habit of serving dinner as late as 9 p.m. left the duchess hungry in the late afternoon. To stave off the hunger she would order tea, bread, butter and cakes to be served in her room. Because the duchess was associated with Queen Victoria, and because others in the court were equally hungry, the habit of tea and snacks in the afternoon quickly spread, and soon became a habit, and a beloved one, throughout the British Isles.
Ms. Thomas, by her own admission, is passionate on the subject of teas, and in addition to instructing the students, displayed her vast collections of teapots and cups, and even prepared two of the pastries – the Victorian cake and the flapjacks.
The British Afternoon Tea is the first of several "World Culture Experiences" that the USC Upstate Honor's Program will host throughout the year. The students and faculty who attended pronounced it a "great success," "very interesting," and "absolutely delicious!"
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Date of birth: 10 June 1959
Nationality: Italian
Playing career: Parma FC, AS Roma, AC Milan
Coaching career: AC Reggiana, Parma FC, Juventus, AC Milan, Chelsea FC, Paris Saint-Germain, Real Madrid CF, FC Bayern München
• One of only seven people to have lifted the European Champion Clubs' Cup as both a player and coach and the second manager, after Bob Paisley, to win the trophy three times. A combative midfielder, he helped Roma win the 1983 Serie A title and four Italian Cups before joining Milan in 1986 where he added two more league championships, as well as back-to-back European Cup triumphs in 1989 and 1990.
• Began coaching in 1995 with a year at Reggiana, earning them promotion from Serie B, before two seasons at Parma. Replaced Marcello Lippi at Juventus in February 1999 and returned to San Siro as coach of Milan in 2001.
• During eight seasons in charge, won the UEFA Champions League in 2003 and 2007, but lost the 2005 final on penalties to Liverpool FC after leading 3-0. Milan also won a Serie A title, a Coppa Italia and the 2007 FIFA Club World Cup.
• Resigned on 31 May 2009 and was named as Chelsea's new manager the following day. His first season in London ended with the club winning the league and cup double for the first time. Dismissed at the end of his second campaign, Ancelotti took charge of Paris in December 2011.
• In his one full season in the French capital, 2012/13, Ancelotti steered Paris to their first Ligue 1 title in 19 years. Left to take over at Madrid, winning the Copa del Rey and the club's tenth European Cup in his first season, becoming only the fifth coach to win the trophy with two clubs in the process. Madrid added the UEFA Super Cup at the start of the following campaign, the fifth time Ancelotti had won that trophy as player or coach, although he was dismissed at the end of the campaign. In December 2015, appointed Bayern coach on a three-year contract, taking the reins in summer 2016.
©UEFA.com 1998-2017. All rights reserved.


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Working from our base in Pune(India), our company is a well-established provider in the industry. We have with us a well-maintained and capacious storage unit that is facilitated by advanced and automated warehousing system, which is operated and supervised by experts only.
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We have stocked up an array of the best quality Indian Pulses such as grams, beans, etc. We are one of the reputed Indian Pulses' Exporters and Suppliers from Maharashtra, India. We conquer the orders for the healthiest Indian Pulses, from anywhere across the country and abroad, in a time-bound environment. Such is our efficiency! And we offer these Pulses packed in food-grade packages, along with long shelf-li
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Situated in Maharashtra, India, we are engaged in offering Indian Pulses to places such as US, Canada, China, Central and South American countries. We are a top-notch Exporter and Supplier of Indian Pulses. The Indian Pulses that we bring to you are tasty, healthy, nutritious, and have longer shelf life. In order to meet immediate and bulk requirements of the buyers, we maintain a huge stock in our spacious and hygie
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Deals in Flavoured Jaggery, Pulses, Toor Dal, Black Beans, Groundnut Chikki, Urad Dal, Liquid Jaggery, Organic Jaggery, Black Eye Beans, Indian Pulses
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C/o Todkar B P, Shradha Nivas, Kalas, Vishrantwadi, Maharashtra - 411015, India
Deals in Indian Pulses, cooking pulses, Pulses, Fruits, nutritional pulses
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Deals in Pulses
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Office At 403, 4th Floor, Yadav Vyapar Bhavan, Shukrawar Peth, Near Tahasildar Office, Maharashtra , India


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The Fine Arts Library is located in The Wexner Center for the Arts. Here, you'll find a range of book, journals, magazines and audiovisual materials to support the Departments of Design, Art, History of Art, and Arts Administration, Education and Policy. Our collections number 150.000 volumes and we support the research needs of our faculty and students.
Need a research appointment? Curious about what we have? Feel free to email Tina Franks, Head, Architecture Library & Interim Head, Fine Arts Library. firstname.lastname@example.com
The entrance to the library is separate from the entrance to the Wexner Center. The front door to the library is located off the north/south exterior walkway framed by the white steel scaffolding. Enter the door marked "Fine Arts Library," and take the stairs or lobby elevator to the lower level.


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At Town Hall Meeting October 28, Community Will Hear Gay Students Experience at Lubbock High School and Discuss the Need for a Gay Straight Student Group
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(Lubbock, Texas, October 20, 2003) - Lambda Legal and the Lubbock chapter of Parents, Families and Friends of Lesbians and Gays will host a community town hall meeting Tuesday, October 28 about the need for and importance of a Gay Straight Alliance student club at Lubbock High School.
"We know some people in Lubbock are uncertain and have questions about this student group - and the Oct 28 town hall meeting is a chance for everyone to share their opinions and learn more," said Brian Chase, the Dallas-based Lambda Legal attorney handling the case. "People will hear directly from students about what it is like to be gay at Lubbock High and how much a GSA helps them, and then people can make up their own minds."
The town hall meeting centers around a lawsuit filed this summer by students who want to form a GSA at Lubbock High but were barred by school officials. Both Lambda Legal, which represents the students in the federal lawsuit, and the school district have filed motions for summary judgement. Replies to those motions are due to the court on November 10.
Ricky Waite, 18, who graduated from Lubbock High School in May, began to organize the Gay Straight Alliance in the fall of 2002. The group's purpose is to provide support for gay and straight students and promote equality in the school system and community. Mirah Curzer, 16, a straight member of the group and plaintiff in the case, joined to support her friends and to show other straight students that fairness is important to everyone. After constructing a number of procedural roadblocks to try to prevent the Gay Straight Alliance from forming, school officials formally denied the group's application.
The event is co-sponsored by Lambda Law Students, a Texas Tech School of Law student group, and the Lesbian and Gay Rights Lobby of Texas.
The community town hall meeting on Tuesday, October 28 is from 7-9 p.m. at the Texas Tech School of Law, The Forum, 1802 Hartford Ave in Lubbock, Texas.
Lambda Legal is a national organization committed to achieving full recognition of the civil rights of lesbians, gay men, bisexuals, transgendered people, and people with HIV or AIDS through impact litigation, education and public policy work. ### Contact: Lisa Hardaway, 212/809-8585 ext. 266; pgr: 888-987-1971


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Assessment of Controversial Pediatric Asthma Management Options Using GRADE
OBJECTIVES: To develop explicit and transparent recommendations on controversial asthma management issues in children and to illustrate the usefulness of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach in rating the quality of evidence and strength of recommendations.
METHODS: Health care questions were formulated for 3 controversies in clinical practice: what is the most effective treatment in asthma not under control with standard-dose inhaled corticosteroids (ICS; step 3), the use of leukotriene receptor antagonist for viral wheeze, and the role of extra fine particle aerosols. GRADE was used to rate the quality of evidence and strength of recommendations after performing systematic literature searches. We provide evidence profiles and considerations about benefit and harm, preferences and values, and resource use, all of which played a role in formulating final recommendations.
RESULTS: By applying GRADE and focusing on outcomes that are important to patients and explicit other considerations, our recommendations differ from those in other international guidelines. We prefer to double the dose of ICS instead of adding a long-acting β-agonist in step 3; ICS instead of leukotriene receptor antagonist are the first choice in preschool wheeze, and extra fine particle ICS formulations are not first-line treatment in children with asthma. Recommendations are weak and based on low-quality evidence for critical outcomes.
CONCLUSIONS: We provide systematically and transparently developed recommendations about controversial asthma management options. Using GRADE for guideline development may change recommendations, enhance guideline implementation, and define remaining research gaps.
- guidelines
- asthma
- drug therapy
- child
- evidence-based medicine
- glucocorticoids
- leukotriene antagonists
- bronchodilator agents
- ciclesonide
- forced expiratory volume in 1 second
- Grading of Recommendations Assessment, Development and Evaluation
- hydrofluoroalkane
- inhaled corticosteroids
- long-acting β-agonist
- leukotriene receptor antagonist
- randomized controlled trial
Evidence-based guidelines for the management of pediatric asthma provide comprehensive and up-to-date overviews on asthma management in children. Although they may serve as a basis to develop local recommendations and to guide individual patient care, controversy remains because different guidelines contain different recommendations, using the same body of evidence.1–3 For example, if school-age children with asthma remain symptomatic despite treatment with inhaled corticosteroids (ICS), some guidelines specifically recommend adding a long-acting β-agonist (LABA),1,2 whereas others propose doubling the ICS dose or adding a leukotriene receptor antagonist (LTRA).3 The justification for these differing choices often remains unclear, although all guidelines provide levels of evidence to support each recommendation.
The systems usually applied to rate levels of evidence and strength of recommendations are limited by their lack of transparency about judgments, values and preferences, and lack of separation between quality of evidence and strength of recommendations.4–6 Grading of Recommendations Assessment, Development and Evaluation (GRADE) was launched as a highly structured and more transparent methodology to rate the quality of evidence and strength of recommendations in clinical practice guidelines.7 GRADE specifies how to frame structured clinical questions, choose outcomes of interest and rate their importance, evaluate the evidence, and incorporate other important values (such as safety and resources) and preferences to arrive at recommendations (Fig 1). Today, >50 influential professional organizations, including the Cochrane Collaboration and the American Thoracic Society (ATS), have adopted the GRADE system.8
In 2007, the Dutch Pediatric Respiratory Society, including all board-certified pediatric pulmonologists in the Netherlands, updated its national guideline on pediatric asthma management.9 Because a number of recommendations remained controversial, the group decided to examine these controversial issues using the GRADE methodology. In this article, we describe how the GRADE process helped us to summarize the evidence, weigh preferences and values, and arrive at final recommendations for these controversial asthma management issues that differ from other guidelines based on the same evidence.
Controversial Recommendations
There was controversy regarding 3 recommendations in the 2007 revision of the Dutch national asthma guideline (Table 1).
Framing Relevant Questions and Deciding on Important Outcomes
A working group consisting of 4 pediatric pulmonologists and a pediatrician epidemiologist experienced in evidence-based guideline development framed these controversial recommendations into structured clinical questions using the PICO acronym (Patient/Intervention/Comparison/Outcome; Table 2). Outcomes were categorized according to GRADE as "critical" (outcomes 1 and 2), "important" (3 and 4), or "of limited importance" (5–7) as a basis for making decisions regarding the overall quality of evidence supporting a recommendation (Table 3).
Identifying and Rating Evidence Quality
For each question, the Dutch Cochrane Centre performed systematic literature searches in Medline and the Cochrane Central Register of Controlled Trials Database until June 2010. Search filters aimed at retrieving systematic reviews and randomized controlled trials (RCTs) as described in the Cochrane Handbook were used.10 In the GRADE approach, RCTs start as high-quality evidence, but in contrast to other grading systems, 5 factors may lead to rating down the quality of evidence (Fig 1). Methodological quality of the studies (risk of bias) was assessed with criteria proposed by the Cochrane Collaboration: failure to conceal allocation, failure to blind, loss to follow-up, and failure to consider the intention-to-treat principle appropriately. For the critical outcomes, a quality rating was given (high, moderate, low, very low). If results per outcome could not be pooled because of heterogeneity, an overall quality assessment of the evidence was given.
Formulating and Grading Guideline Recommendations
GRADE recognizes other key factors besides quality of evidence determining the strength of a recommendation: (1) the balance between desirable and undesirable consequences of alternative management options, (2) values and preferences of patients and guideline panels, and (3) resource use. Final recommendations were circulated among all members and discussed at a plenary meeting of the Dutch Pediatric Respiratory Society. It was our aim to formulate specific recommendations, including when evidence is insufficient, and we specifically describe these other key factors underlying our choices. Recommendations can be either weak or strong.7,11
Question 1: In Preschool and School-age Children With Wheeze/Asthma, Are ICS With Extra-fine Particles More Effective (and/or Safer) Than ICS With Normal Particle Size?
ICS treatment with extra-fine particles aims to treat the entire bronchial tree including the small airways. Extra-fine particles penetrate better into small airways, leading to higher and more homogeneously distributed lung deposition.12 This might result in asthma control using lower daily doses with fewer side effects. Particle size may be of particular importance in young children because of their smaller airways and different breathing patterns, with higher breathing frequency and relatively small tidal volume. There are 2 ICSs with extra-fine particle size: extra-fine hydrofluoroalkane (HFA) beclomethasone dipropionate (licensed in Europe for children aged ≥5 years) and ciclesonide (licensed for children aged ≥12 years). Ciclesonide, a prodrug that is converted in the airways into the active metabolite desisobutyryl-ciclesonide (CIC), is thought to have a reduced potential for local and systemic side effects. Because of its binding to protein and slow release, it is licensed for once-daily use, which may improve adherence.
We did not find any systematic reviews in children specifically addressing this question. However, 7 RCTs were found: 2 using extra-fine HFA beclomethasone and 4 CIC.13–18 Because these agents have different pharmacokinetic and pharmacodynamic properties, they are discussed separately.
No clinical studies examined efficacy or safety of extra-fine beclomethasone in preschool children with asthma; both available studies were conducted in children >5 years of age.15,16 Pooling of data were not possible, but both studies showed no statistically significant or clinically relevant difference between HFA beclomethasone and fluticasone for symptom-free days, exacerbations, or adverse effects. Growth and quality of life were not reported.
All studies on ciclesonide were conducted in children ≥6 years and older and used a noninferiority design with a surrogate primary endpoint, forced expiratory volume in 1 second (FEV1).13,14,17,18 There were no significant differences between ciclesonide and other ICS (budesonide or fluticasone) in asthma symptom score and exacerbations, except for 1 study showing significantly more exacerbations in the CIC group (Table 4). Side effects (such as oropharyngeal candidiasis and hoarseness) occurred with similar frequency in both groups. One study showed a significant improvement in height in the CIC group compared with the BUD group (1.18 cm vs 0.70 cm respectively) after 12 weeks of intervention, but measurements were only performed in a subset of patients.18 Some studies showed significantly less suppression of 24-hour urinary cortisol levels adjusted for creatinine in the CIC group compared with other ICS, no suppression in the CIC group or even an increase in the CIC group. Adherence was not assessed in the studies.
The quality of evidence for our critical outcomes was rated down by 3 levels (Table 4). We concluded that there is no evidence that ICS with small particles are more effective or safer than ICS with normal particle size in preschool or school-age children (very low-quality evidence).
Other Key Factors
A relatively high value was placed on the consideration that new medications should either be more effective or safer before they can be recommended for clinical practice. The long-term safety of treatments for asthma has been identified as being of particular importance to patients and clinicians.19 Because older medications have been used for longer periods of time, more knowledge is available on their long-term safety, and they are usually cheaper than new drugs. Another argument against the use of "me too" preparations with only a slightly different pharmacokinetic or pharmacodynamic profile is that they increase the complexity of treatment; as for inhaled medication, additional and repeated instruction may then again be required to ensure correct inhalation.
The trade-off between benefits and harms of using CIC compared with other ICS is unclear. Ciclesonide has not been proven to be more effective or safer compared with fluticasone and budesonide for relevant outcomes but is noninferior on short-term lung function and asthma symptom score end points. Potentially more severe exacerbations in the CIC group cannot be excluded because of wide confidence intervals. For relevant adverse effects, such as growth and adrenal insufficiency, a follow-up period of 12 weeks is too short; and adequate duration should be at least 6 to 12 months. The clinical significance of lower 24-hour urinary cortisol levels is limited. The measurement is often unreliable and/or invalid and unable to detect partial hypothalamic-pituitary-adrenal axis suppression.20 Much more relevant is the ability of the adrenal cortex to be able to respond to stressful stimuli. The most appropriate test would then be the more invasive low-dose corticotropin (Synacthen) stimulation test, which is more sensitive in detecting adrenal impairment.21–23
One study was published assessing the long-term safety of ciclesonide.24 This RCT was not included in this review because it compared CIC only with placebo. Mean linear growth velocity and 24-hour urinary cortisol levels were comparable between the groups after 1 year. However, this study could not provide enough reassurance about safety, and considerable concern was expressed about compliance of the children because the study failed to show any benefit of CIC in terms of lung function or asthma control.25,26
Although once-daily dosing (CIC) may improve adherence, this did not lead to better asthma control and was therefore not considered a significant point.
We proposed that ICS with extra-fine particles were not to be recommended as first choice ICS in school-age children with wheezing/asthma (weak recommendation). Specific evidence for clinical superiority of ICS with extra-fine particles in preschool children is lacking. Hence we do not recommend these as first choice for this age group (weak recommendation).
Question 2: In Preschool Children With Viral Induced Wheeze/Asthma, Are LTRAs More Effective (and/or Safer) Than ICS?
There is no consensus on how to diagnose asthma in preschool children.27 Most preschool children with recurrent wheeze grow out of their symptoms and do not develop chronic persistent asthma.28 Although ICSs are universally recommended as the treatment of choice for older children with asthma because ICSs have been shown to be more effective than an LTRA in this age group, some guidelines propose LTRAs as the preferred treatment in preschool children with viral-induced wheezing.27
Two RCTs compared budesonide to montelukast in preschool children with recurrent wheezing.29,30 The number of symptom-free days and exacerbations defined as hospital admissions were not significantly different between the 2 groups, but in 1 study, the percentage of children requiring oral corticosteroids or additional asthma medication was significantly lower in the budesonide group than in the montelukast group (Table 5).30 There were no significant differences in quality of life, growth, and side effects.
The quality of evidence for our critical outcomes was rated down by 3 levels (Table 5). We concluded that LTRAs are not more effective (or safer) than ICS in preschool children with recurrent wheeze (very low-quality evidence).
Other Key Factors
Although the ERS Task Force recommended distinguishing episodic viral from multiple trigger wheeze in preschool children, it recognized that the evidence base for this recommendation was limited.27 Since the publication of the Task Force Report, it has been shown that the clinical phenotype in preschool children may vary over time.31 In addition, a systematic review of ICS studies in preschool wheezing showed that ICS were effective in these patients irrespective of their clinical phenotype.32 The distinction between episodic viral and multiple trigger wheeze does not take severity and frequency of episodes into account, although this is the main driver for starting maintenance therapy.33 Finally, it has been shown that 90% of wheezing episodes in preschool children are associated with viral infection.34 According to the working group, this invalidates the concept of viral versus multiple trigger wheeze to an important extent, and it was felt that making the difference on clinical grounds is probably not feasible.
A relatively high value was placed on the fact that ICSs have proven benefits and are more effective than LTRAs in older (>6 years) children with asthma.35 Several as have shown effectiveness of ICSs compared with placebo in preschool children when wheezing is severe, with a family history of asthma and/or atopy.36–38 A relatively low value was placed by the guideline panel on the potential short-term growth delay in children using an ICS, because this is unlikely to influence final height.39 However, this will depend on dose and duration of ICS use.
In preschool children with mild intermittent (viral) wheeze, we suggest not starting any medication. In preschool children with recurrent (severe) wheeze and/or a family history of asthma and/or atopy, we propose starting daily low-dose ICS (up to 250 μg of fluticasone equivalent per day) as the preferred first-line therapy. Daily LTRA therapy is second-line therapy that can be used when inhalation technique is poor or long-term higher dose ICS is necessary (weak recommendation).
Question 3: In Children With Asthma Symptoms Despite ICS, What Is the Most Effective and/or Safe Treatment Option: Doubling the ICS Dose, Adding an LABA, or Adding an LTRA?
Asthma management now focuses on clinical control rather than severity. In children whose asthma remains uncontrolled despite adequate ICS use, step-up treatment is advised. However, the most effective step-up strategy is still unclear.
We found 1 Cochrane review and 2 more recently published RCTs.40–43 The Cochrane review included 5 studies in children aged 2 to 18 years with persistent asthma and daily ICS use for at least 28 days. Because asthma symptoms despite ICS were not a prerequisite for inclusion, 3 of the studies in the Cochrane review could not answer our question.43–45 Four RCTs (2 from Cochrane review and 2 more recently published trials) were included.40,42,46,47 Children with ongoing symptoms during ICS use were randomized to either a double dose of ICS or adding an LABA. Only 1 study included a third arm: adding an LTRA to ICS.40 The primary outcome after 16 weeks of treatment was a composite endpoint comprising exacerbations, asthma-control days, and the surrogate end point FEV1 (change of 5%). Asthma control days were not separately reported. Pooling of results was impossible because of clinical heterogeneity. There were no significant differences between the double-dose ICS group and the adding an LABA group for asthma symptoms (except for 1 study) and exacerbations (Table 6). Two studies looked at a difference in treatment effect between subgroups based on FEV1 or FeNO; no difference was found.40,42
The quality of evidence for our critical outcomes was rated down by 3 levels (Table 6). We concluded that both adding an LABA and doubling ICS are effective in children with symptoms despite ICS, irrespective of airway reversibility of airway inflammation (very low-quality evidence). Only 1 study compared LTRA with ICS and LABA with ICS and provided insufficient evidence (compared with ICS and LABA) to position LTRA prominently in step 3 asthma management.
Other Key Factors
A relatively high value was placed on safety. The US Food and Drug Administration recently issued a black box warning and label changes for LABAs because of an excess of severe asthma exacerbations in adults treated with them.48 A systematic review and a recently published meta-analysis expressed the same concern in children.41,49 In children, long-term safety studies on LABA are lacking, and existing trials were underpowered to exclude relevant differences in (severe) exacerbations.
A low value was placed on short-term and surrogate growth outcome parameters, as described earlier.39 High-dose ICS (>400 μg per day fluticasone equivalent) is associated with adrenal insufficiency, and therefore 400 μg fluticasone equivalent is the maximum allowed dose.50–52
In addition, convenience and cost (resources) played a role in our final recommendation: we considered it easier to double the dose of ICS than to write a new prescription (with LABA/ICS), and ICSs are generally cheaper than LABA/ICS combinations.
In children with asthma and symptoms despite a low to moderate dose of ICS (up to 250 μg of fluticasone equivalent per day), we propose first doubling the ICS dose (weak recommendation). If improvement of symptoms is insufficient after 6 to 12 weeks or a maximum ICS dose (> 400 μg per day fluticasone equivalent) is achieved, we recommend adding a LABA (for children >4–6 years) and tapering down the ICS to a regular dose. The use of LABA should be stopped, if possible, once asthma control is achieved (for eg, after 6 months; weak recommendation). For children <4 to 6 years or children with side effects on LABAs, we recommend adding an LTRA instead of LABA (weak recommendation).
We have described the value of applying GRADE methodology to resolve 3 controversial issues in the Dutch childhood asthma management guideline. This has changed the recommendations previously made regarding the preference for the use of extra-fine particle aerosols in children aged <5, the use of LTRAs in viral-induced wheezing, and step 3 management in asthma.9 GRADE recognizes other important factors besides risk of bias that can reduce the quality of evidence. These other factors are inconsistency, indirectness of evidence, imprecision, and publication bias.9,53 As a consequence, the overall quality of evidence for important outcomes will generally be lower with GRADE than with other grading systems. Indeed, the quality of evidence for our 3 controversial pediatric asthma management issues was "very low," although they were all based on RCTs.
According to GRADE, guideline developers should start by specifying and ranking the most important outcomes.9,11,54 This helps guideline panels to focus attention on studies assessing the most important outcomes instead on those measuring surrogate end points. Instead of ranking the quality of each individual study, GRADE uses a rating of quality for each important outcome across studies. Symptom-free days and exacerbations were considered the most important ("critical") outcomes. Although lung function is commonly used as a primary outcome parameter in studies on pediatric asthma management, we considered this to be of limited importance because there is no evidence that measuring lung function improves asthma outcomes and it is of limited value to patients and parents. Our selected outcomes are in keeping with a recommended set of outcomes by an American Thoracic Society/European Respiratory Society task force relating to pediatric asthma control for clinical trials and clinical practice, except for lung function end points.55 A systematic review of RCTs in children with asthma concluded that short-term disease activity (eg, lung function) is the most frequently measured outcome and that those endpoints that may be more relevant to patients (quality of life, side effects, and long-term consequences of asthma) are rarely taken into account.56 Choosing relevant outcomes helped us to weigh the evidence in a more clinically relevant manner.
Going from evidence to recommendations, GRADE recognizes that, in addition to quality of evidence, other key factors determine the strength of a recommendation. Desirable and undesirable consequences (benefits vs harm and burden) of the treatment options should be balanced by guideline panels, and patient and clinician values and preferences should be taken into account. For these preferences and values, evidence is often lacking, and not all statements and choices made can be answered by evidence. However, they do play an important role in clinical decision-making and should therefore not be disregarded. Quality of evidence and strength of recommendations are thus separated in the GRADE approach; low-quality evidence can lead to a strong recommendation and vice versa.57 For the majority of pediatric illnesses, high-quality evidence for important outcomes is scarce. Treatment decisions in daily practice are therefore mainly based on other considerations, which are often not explicitly mentioned. We specifically describe the other key factors underlying our final recommendations. For example, we specifically considered the balance between benefits and harms, and this led to the recommendation to first double the dose of ICS in step 3 because safety was considered crucial. As a result, this recommendation differs from the recommendations in most other guidelines.1–3 We do recognize that for guideline panels in other countries, the preferences and values can be different, leading to different recommendations.
A weakness of our guideline development process was the fact that we did not include patient representatives in our guideline panel. Preferences and values that patients assign to the outcomes of interest can be different from those of clinicians.58 We did place a high value on long-term safety because we know this is of particular importance to patients.
Although clinical practice guidelines can facilitate translation of research into effective clinical care, they are commonly not followed in clinical practice. One of the main concerns hampering the implementation of guidelines in clinical practice is that there is no explicit link between the recommendations and the supporting evidence. The GRADE approach, by transparently defining each essential step in recommendation development, facilitates understanding of how recommendations are being derived. That this may indeed enhance implementation was recently illustrated by a randomized trial comparing 4 methods of presenting recommendations to clinicians based on the same evidence. The GRADE system was most effective in provoking change in the pediatrician's decision on a hypothetical clinical case.59 Therefore, future updates of guidelines on asthma management should preferably be developed according to GRADE methodology.
GRADE does not eliminate the need for judgments in interpreting the evidence, and there are no fixed criteria for downgrading the quality of evidence by 1 or 2 levels. However, GRADE does offer an explicit account of the judgments involved. It is likely that this facilitates the adaptation of guidelines for local use.
Despite a range of published studies, the lack of high-quality evidence supporting decisions about asthma treatment in children remains considerable. The GRADE approach can help to identify remaining research gaps and specify the design of studies to fill these gaps. By applying these additional factors influencing the quality of evidence, we identified a number of weaknesses in the studies on the controversial asthma management issues (Table 7).
We think that future randomized trials in pediatric asthma management should consider GRADE criteria from the design of the trial onwards, to ensure that the study results will generate high-quality evidence to guide clinical decision-making. Ideally, such trials should not be designed by pharmaceutical industry but by independent agencies. Studies should be powered to be able to detect differences in critical outcomes. Relevant patient characteristics, extending beyond the diagnosis of "asthma" and a lung function criterion should be defined in detail. Designing and running such high-quality clinical trials requires international collaboration. The large multinational clinical trial recently launched to resolve the uncertainty regarding the safety of LABAs, initiated by the Food and Drug Administration, is an example of such a high-quality study fulfilling all GRADE criteria and is therefore likely to provide the high-quality evidence needed to resolve this controversial issue.60
- Accepted May 11, 2012.
- Address correspondence to Nicole Boluyt, MD, PhD, Emma Children's Hospital/ Academic Medical Center, Room H7-214, PO Box 22660, 1100 DD Amsterdam, the Netherlands. E-mail: n.boluyt{at}amc.uva.nl
FINANCIAL DISCLOSURE: Dr Rottier has received a travel grant to attend the European Respiratory Society in Vienna (2009) from TEVA Pharmaceuticals and his institution has received a speakers fee for Motivational Interviewing for a Glaxo Smith Kline organized symposium (2010); in the past 5 years, Dr Brand has received funds for performing research, attending conferences, lectures, and consulting, from Astra Zeneca, Glaxo Smith Kline, Boehringer Ingelheim, Merck, and Nycomed; the other authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the Quality Funding Medical Specialists.
- ↵Global strategy for asthma management and prevention (revised 2008): Global Initiative for Asthma (GINA). Available at: www.ginasthma.com. Accessed August 2011
- ↵British guidelines on the management of asthma. 2011. Available at: www.brit-thoracic.org.uk. Accessed August 2011
- ↵Guidelines for the diagnosis and management of asthma. National Asthma Education and Prevention Program. 2007. Available at: www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf. Accessed August 2011
- ↵
- Atkins D,
- Best D,
- Briss PA,
- et al.,
- GRADE Working Group
- ↵
- Schünemann HJ,
- Best D,
- Vist G,
- Oxman AD,
- GRADE Working Group
- ↵
- Guyatt GH,
- Oxman AD,
- Vist GE,
- et al.,
- GRADE Working Group
- ↵
- Schünemann HJ,
- Jaeschke R,
- Cook DJ,
- et al.,
- ATS Documents Development and Implementation Committee
- ↵Asthma in children. Guidelines developed by the Dutch Respiratory Society Group. Utrecht, the Netherlands: Dutch Respiratory Society Group; 2007
- ↵Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions, Version 5.0.0 (updated September 2008). The Cochrane Collaboration, 2008. Available at: www.cochrane-handbook.org. Accessed August 2011
- ↵
- ↵
- Usmani OS,
- Biddiscombe MF,
- Barnes PJ
- ↵
- Pedersen S,
- Garcia Garcia ML,
- Manjra A,
- Theron I,
- Engelstätter R
- ↵
- Pedersen S,
- Engelstätter R,
- Weber HJ,
- et al
- ↵
- Robroeks CM,
- van de Kant KD,
- van Vliet D,
- et al
- ↵
- van Aalderen WM,
- Price D,
- De Baets FM,
- Price J
- ↵
- Vermeulen JH,
- Gyurkovits K,
- Rauer H,
- Engelstätter R
- ↵
- von Berg A,
- Engelstätter R,
- Minic P,
- et al.,
- von BA
- ↵James Lind Alliance. Research Priorities in Asthma (description of a workshop to set priorities for treatment uncertainty research in Asthma, March 2007). Available at: www.lindalliance.org/asthma_working_partnership.asp. Accessed August 2011
- ↵
- ↵
- Crowley S,
- Hindmarsh PC,
- Holownia P,
- Honour JW,
- Brook CG
- Lipworth BJ
- ↵
- ↵
- Skoner DP,
- Maspero J,
- Banerji D,
- Ciclesonide Pediatric Growth Study Group
- ↵
- Chapman KR
- ↵
- Malozowski S
- ↵
- Brand PL,
- Baraldi E,
- Bisgaard H,
- et al
- ↵
- Martinez FD,
- Wright AL,
- Taussig LM,
- Holberg CJ,
- Halonen M,
- Morgan WJ,
- The Group Health Medical Associates
- ↵
- Bacharier LB,
- Phillips BR,
- Zeiger RS,
- et al.,
- CARE Network
- ↵
- Szefler SJ,
- Baker JW,
- Uryniak T,
- Goldman M,
- Silkoff PE
- ↵
- Schultz A,
- Devadason SG,
- Savenije OE,
- Sly PD,
- Le Souëf PN,
- Brand PL
- ↵
- Castro-Rodriguez JA,
- Rodrigo GJ
- ↵
- ↵
- Jackson DJ,
- Gangnon RE,
- Evans MD,
- et al
- ↵
- Castro-Rodriguez JA,
- Rodrigo GJ
- ↵
- Chavasse RJ,
- Bastian-Lee Y,
- Richter H,
- Hilliard T,
- Seddon P
- Roorda RJ,
- Mezei G,
- Bisgaard H,
- Maden C
- ↵
- Teper AM,
- Kofman CD,
- Szulman GA,
- Vidaurreta SM,
- Maffey AF
- ↵
- Brand PL
- ↵
- Lemanske RF Jr,
- Mauger DT,
- Sorkness CA,
- et al.,
- Childhood Asthma Research and Education (CARE) Network of the National Heart, Lung, and Blood Institute
- ↵
- ↵
- Vaessen-Verberne AA,
- van den Berg NJ,
- van Nierop JC,
- et al.,
- COMBO Study Group
- ↵
- Bisgaard H,
- Le Roux P,
- Bjåmer D,
- Dymek A,
- Vermeulen JH,
- Hultquist C
- Heuck C,
- Heickendorff L,
- Wolthers OD
- ↵
- Verberne AA,
- Frost C,
- Duiverman EJ,
- Grol MH,
- Kerrebijn KF,
- The Dutch Asthma Study Group
- ↵
- de Blic J,
- Ogorodova L,
- Klink R,
- et al
- ↵
- Gappa M,
- Zachgo W,
- von Berg A,
- Kamin W,
- Stern-Sträter C,
- Steinkamp G,
- VIAPAED Study Group
- ↵
- Chowdhury BA,
- Dal Pan G
- ↵
- McMahon AW,
- Levenson MS,
- McEvoy BW,
- Mosholder AD,
- Murphy D
- ↵
- Adams N,
- Lasserson TJ,
- Cates CJ,
- et al
- ↵
- Todd GR,
- Acerini CL,
- Ross-Russell R,
- Zahra S,
- Warner JT,
- McCance D
- ↵
- Guyatt GH,
- Oxman AD,
- Vist G,
- et al
- ↵
- ↵
- Reddel HK,
- Taylor DR,
- Bateman ED,
- et al.,
- American Thoracic Society/European Respiratory Society Task Force on Asthma Control and Exacerbations
- ↵
- ↵
- ↵
- Tallon D,
- Chard J,
- Dieppe P
- ↵
- Cuello García CA,
- Pacheco Alvarado KP,
- Pérez Gaxiola G
- ↵
- Chowdhury BA,
- Seymour SM,
- Levenson MS
- Copyright © 2012 by the American Academy of Pediatrics


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A place to Connect, Grow, and Serve
It's almost midnight, and the church is all quiet. I sit at my mostly emptied-out workstation, and I reflect upon these past three years, and upon the farewell events of recent weeks. I am thoroughly overwhelmed by all the kindness from members and friends of the congregation -- the well-wishes, the cards, the gifts, the emails, the phone calls, the hugs, the acknowledgements ... I can't express the depth of all that I feel. The closest I can come is mahalo, which is a Hawaiian…Continue
Posted on June 30, 2013 at 11:59pm — 2 Comments
Today, I was part of an 18-member delegation from VOICE (Virginians Organized for Interfaith Community Engagement) speaking with Sen. Mark Warner on the Senate's immigration reform bill. Because we know he's an ally of reform, we specifically wanted to know how we can leverage the power of our congregations to the get the bill passed. From the 25 minutes we had with him, here are some of the highlights:
-- As I introduced myself as one of the ministers at UUCA, Sen. Warner noted that…Continue
Posted on April 18, 2013 at 6:04pm
The Unitarian Universalist Church of Arlington shares in the grief from the bombing of the Boston Marathon Monday afternoon. We pray for the healing of the scores of people wounded. We pray for comfort for the families and friends of the three who were killed,with hope that the other severely injured people recover. We pray for the tortured souls that chose to lash out violently in their pain and anxiety, rather than trust in the ways of peace.
We give thanks for the first responders,…Continue
Posted on April 17, 2013 at 12:20pm
Opportunities to show generosity and compassion abound at UUCA this season!
We found out this week about additional families in our community who could use some holiday cheer through our Secret Santa gift-giving efforts. Now you can be a part of ... Santa's Bonus Run.
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- This Sunday morning, take one or more gift request tags from the upstairs Secret Santa tree.
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Posted on December 22, 2012 at 1:24pm


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The Soma AirBag is a $150 inflatable surfboard bag constructed with 600-denier ballistic polyester coated with polyester vinyl chloride (PVC) and 1000-denier PVC along the tail, nose and rail. Inside are individual columns of air intended to help disperse the force of some pretty intense-looking impacts.
Soma is currently sold out until the end of June, but I'm told the next iteration will boast "extra protection" including dual-density foam and side stabilizers to help maintain air pressure. Soma says the new bag will be able to withstand a 2-story drop.
As soon as they send me one, we'll find out.


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Example :: released August 09 2013
After recently finishing a sell-out UK arena tour and currently travelling the globe for festivals including a residency for Ibiza & Mallorca Rocks, this August will see the release of UK electro sing-star Example's greatest hits, '#hits', featuring all his biggest and best tunes to date.
The 16-track album features the multi-platinum ARIA single with Calvin Harris "We'll Be Coming Back", ARIA Platinum Selling smash Change The Way You Kissed Me and Stay Awake from his Top 15 album 'Playing In the Shadows' along with the massive hits Kickstarts and Say Nothing.
A firm favourite here in his adopted second home Australia (having recently married Australian beauty queen Erin McNaught) – this is a MUST HAVE album for all festival loving Example fans, not to mention the wider fanbase of electronic music.


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What's the NEXT step for removing the door panel to diagnose broken window regulators
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E39 touring
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More window stuff
Bluebee I found the vapour barrier not too hard to get off without ripping,by accident I found it restuck back on easily because the sun had warmed up the black adhesive.
Not sure about the front window assembly (i've just done a rear repair )but you have to be very careful when testing the unit out the door as the window guide can overun which causes the soft alloy guide to bend.
I had to carefully straighten my guide as this happened to me I think because it runs very fast without the load of the glass on the guide.
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Oct 4, 2013Game Freak has really outdone itself this time, and Pokemon X and Y will be remembered as great transition point for the series' transformation into an even more social, beautiful, and strategic game.
Oct 5, 2013Pokemon X and Y benefit greatly from their leap to a fully 3D world, and have plenty to offer both veterans and novices alike.
Oct 4, 2013It still feels like a Pokémon game, but the ease of player control, the updated art direction, 3D graphics, and the scaling of the world make everything more inviting, attractive, and fun. It's a great stepping-on point for new trainers, and a worthwhile continuing adventure for those who know what to expect.
Oct 14, 2013The extensive single player adventure is complemented by accessible multiplayer trading and battle.
Oct 16, 2013Pokemon X doesn't necessarily represent a massive leap forward for the Pokemon franchise. Instead, it is a major improvement of existing features.
Oct 4, 2013The finest expression of Satoshi Tajiri's obsessive vision yet. The transition to 3D is smooth and natural and the multitudinous additions to the proven formula will excite even the most jaded Pokémon fanatic.
Oct 7, 2013This is the true modern age Pokémon fans spent years waiting for: it's just bigger and better and will appeal new users too thanks to its delightful visuals and extremely polished and deep gameplay. It's a masterpiece very few nuisances and some ineffective 3D effect cannot even scratch.
Oct 21, 2013X & Y are two of the best 3DS games available and succeed in making Pokémon feel next-gen.
Oct 4, 2013Pokémon comes back with another adventure, as fun and addictive as always, with a great visual evolution that suits it really well. It's yet another must-have on 3DS.
Games Master UKNov 27, 2013The biggest change in Pokemon's history. [Christmas 2013, p.80]
Oct 23, 2013Fans of Pokémon will be in familiar territory while newcomers will have a great time learning the ropes. It never deviates from the norm too much, but what X and Y does and does brilliantly, is the improvements to connectivity and game progression.
Oct 4, 2013Though they don't reinvent the core concept of the franchise, they do a fantastic job of cleaning up the aging mechanics and creating a Pokémon world you'd be crazy not to explore.
Oct 11, 2013Nobody has demonstrated they can do Pokemon better than Pokemon can. X and Y does everything it needs to remain relevant, to prove why it's the top of its field, and if that's not good enough for you, there's nothing Ekans say to change your mind.
Oct 22, 2013Pokemon X & Y insert a lot of new concepts in the series, making this Pokemon game another very good RPG.
Oct 4, 2013Not revolution, but regeneration. The Pokémon series takes a step forward energizing the classic gameplay formula with new and interesting twists and tweaks, like megaevolutions. A must-have for Nintendo 3DS owners.
Oct 10, 2013Pokemon X / Y is, undoubtedly, the evolution of the species. The latest work by Game Freak fits into one of the most solid structures ever created on the handheld console, in a series that needed important innovations to dispose of the outdated mechanics. One of the best chapters since the very first adventures of the series.
Oct 9, 2013The core formula has had slow refinements enacted upon it for generations, but X/Y feel like a triumphant return to the central philosophy that made Red/Blue great – these are games about exploration, and getting in touch with that childish joy of the undiscovered. A game that prompts that in both adults and children can be considered nothing other than a success.
Oct 4, 2013In the games' improved communication features, too, X and Y are truer to their narrative's ethos: the joy of sharing moments of beauty and surprise with others. It's a delightful message to send to a new generation of players, many of whom are just starting out on their own gaming journey.
Oct 20, 2013Pokemon X & Y set a new standard for Pokemon games to come.
Nov 22, 2013Pokemon X and Y are definitely two of the best games in the series to date.
Oct 8, 2013X&Y are familiar on the surface, but nothing about each game is untouched in Game Freak's amazing Pokémon revolution.
Oct 4, 2013Pokémon X and Y are the best Pokémon versions ever made. The new 3D graphics are astounding and the nostalgia effect when playing many of the most famous first/second generation Pokémon is overwhelming. The ultimate evolution of the series, a new standard for every Pokémon game to come.
Oct 4, 2013Once again, Game Freak hits the nail squarely on the head, making Pokémon X and Y an excellent new addition to the series' expansive library.
Oct 5, 2013From the first moment you boot up this game you will know you are playing the future of Pokémon.
Nov 11, 2013Pokémon X and Y makes the classic series feel brand new.
Oct 4, 2013The best new Pokémon for a decade and a game of exquisite depth and longevity, with visuals and online options that finally do the series justice.
Oct 25, 2013There's a good game in Pokemon X, and fans looking for another game near-identical to the ones before it likely won't find issue with a lot of the dusty trimmings and transparent battle system. If you want to get into into the new stat rebuilding features and grind out tons of easy battles to prep for high-level online multiplayer, it's never been easier to do so. But for all else, the game's excellent visuals belie the frustratingly old-fashioned design. RPG folk can find better times on their 3DS.
Oct 9, 2013With Pokémon X and Y, GameFreak finally delivers on the big promise: a Pokémon game in which the pocket monsters actually come to life. That the game is also filled to the brim with content, makes X and Y the ultimate Pokémon generation.
Oct 4, 2013A new graphics engine takes the lead in a sixth generation that brings along tons of new Pokémons, new gameplay elements and the same old-school combat style that has earned a die hard fanbase for more than 20 years. It's Pokemon at his best, a must-have for both fans and 3DS owners.
Oct 4, 2013Pokémon X and Y is an odd pair of games to quantify because, on one hand, they are still solid entries in an incredible JRPG series and they offer some select new features that go above and beyond to make this feel like a brand new generation. On the other hand, inconsistent presentation, insubstantial core innovation, a low Pokémon count, and a minimal post-game keep them from achieving the total nirvana that this series has always been capable of.
Dec 11, 2013For the first time in a long time, Pokémon has taken a real step towards pushing the series forward.
Oct 21, 2013This is the well rounded Pokémon adventure I was longing for. An absolutely worthy gift for the 15th birthday of the series.
Oct 4, 2013Pokemon X / Y is the perfect version we were dreaming about 17 years ago.
Oct 23, 2013Thanks to it's new look, well atmosphere, loads of customizations and other changes and additions, Pokémon X and Pokémon Y are very accessible RPGs, you can easily become addicted to.
Oct 15, 2013Whether you're battling online or plowing through the single player mode, the huge range of things to do and places to go -- along with numerous revisions and additions -- more than compensate for the games few flaws and relatively low number of new Pokémon.
LEVEL (Czech Republic)Nov 25, 2013Pokémons once again stay true to their roots while bringing updated graphics, alongside with a few smaller evolutionary changes. They remain highly playable and this time, they're even more accessible to new players. [Issue#236]
Oct 4, 2013That aside, X and Y are great editions to the Pokemon franchise, ideal for gamers who walked away from the series and hardcore fans who have been there the whole way. On that note, generation six is a mega evolution of its own. With this in mind, we highly recommend X and Y for any Pokemon fan or 3DS owner looking to complete their game collections.
Nov 3, 2013Pokémon X/Y offers the same core experience, only better and sleeker than before. Loads of new features, quicker progression, and an emphasis on connectivity all help lift it above its predecessors.
Oct 18, 2013With just the right mix of nostalgia and new features, as well as beautiful, colourful graphics, and a very impressive online experience, Pokémon X and Y both offer a refreshing change to the much loved series that both newcomers and long time fans can appreciate, and these games are one of the best titles available for the 3DS system to date.
Oct 24, 2013Though Game Freak is sometimes criticized for recycling gameplay in the Pokémon franchise, they've really outdone themselves with these games. Highly recommended.
Oct 12, 2013Don't expect a revolution, but with dozens of thoughtful changes and the best Pokemon battles ever, X and Y cap an incredible year for 3DS.
Oct 8, 2013Nintendo brings a new generation of Pokémon on 3DS. With more depth and some new interesting take on the old formula, it succeeds in creating an engrossing and fascinating adventure.
Nov 7, 2013The game's campaign is quite simple to no avail, and some features should be refreshed. However, underneath its puerile skin there are hidden the best executed Pokémons with their traditionally catchy gameplay, pleasing both young and mature gamers. There's no reason for fans of the series to be hesitant, and the rest of you should know the meaning of our number nine - one of the best RPGs of the year.
Oct 25, 2013Pokemon X&Y set a new high point for the series with beautiful, new 3D graphics, evolved gameplay and amazing online features. Simply put, it's the perfect opportunity to fall in love with Pokemon all over again.
Oct 30, 2013The sixth Pokémon generation's leap into three dimensions is a godsend, maintaining a recognisable experience while giving the aesthetic experience much-needed depth and dynamism. Even with this new presentation, though, the seventeen-year-old core remains the same – a trusty old heart that doesn't really need to change.
Oct 8, 2013Pokémon X & Y do not change the formula of the series but has undoubtedly modified some bases already established. Never before has there been so many novelties to come at once and this is precisely why you will want to play it.
Oct 10, 2013The major change is the aesthetics, but Nintendo has worked on so many minor adjustments and tweaks that Pokémon feels.. changed. In a good way.
Dec 12, 2013Even if Pokémon X & Y has graphics in 3D and several other gameplay innovations it is still the same core experience as before. Focus is as always on catching them all and it is still an addictive experience. The difficulty bar is lower than before, the online functions more present and the gameplay mechanics better realised.
Oct 13, 2013At a glance Pokémon X and Pokémon Y did seem like a standard leap in numbers and a new look, but upon diving into the new world, it's more than just a pair of new Pokémon games.
Oct 4, 2013Like a faint Pikachu attempting to escape a rare Poke Ball, Pokemon X shouldn't fail to draw you in and hold on tight, even though it's not quite the mega evolution we were expecting.
Oct 30, 2013With Pokémon X and Y, Nintendo may have become their worst enemy; they've outdone themselves so much that it's difficult to see how the series could get any better.
Oct 22, 2013Pokémon X is easily the best game in the series since Ruby & Sapphire released nearly eleven years ago (not counting HeartGold and SoulSilver), and it's amazing how much a touch of 3D and some potent online features can add to the tried and true formula.
Oct 5, 2013In 1996 Game Freak created some kind of a ritual that still remains untouched today with Pokémon X and Y, which, besides being the most ambitious game in the series, is the cherry on top for a spectacular year for 3DS.
Oct 4, 2013Whether you've wrangled dozens of Charmanders or couldn't pick a Pikachu out of a Safari Zone lineup, Pokémon X/Y is hands-down the best in the series.
Oct 7, 2013The best main Pokémon series entry in years, X and Y sees several new features breathe life into a process that had grown stale and stagnant. Newcomers and longtime trainers alike should be able to find the joy in catching 'em all once again.
Oct 4, 2013Everything about Pokemon X and Y instills a feeling of adventure that extends far, far beyond its campaign. It lets you take ownership of so much — from your wardrobe to your meticulously groomed team — and then lets you take that identity onto a global stage.
Oct 21, 2013Even though Pokemon X is undoubtedly the strongest entry in the series yet, after 14 years of playing with a basically unchanged formula, I kind of expected something more.
Oct 23, 2013But here is X & Y, finally dragging me in with added accessibility and a visual flourish. If Pokemon's greatest pleasure is the joy of discovery, then I've finally discovered it. And hooray for that.
Oct 21, 2013Whether you're a new or old Pokemon fan, X and Y is one of the best offerings from Game Freak yet, if not the very best.
Oct 21, 2013It's the same old Pokemon that you know and love, but shinier than ever thanks to the graphics. X and Y doesn't shake the age-old formula up when you examine it closely, but it really doesn't need to as it shifts the franchise into a more modern age.
Oct 28, 2013Pokémon X/Y is a marvelous refinement of a tried and true concept, both larger and better than its predecessors. Despite this, it is unmistakenly a repetition of that old concept, one which may be past its prime in the presence of contemporary iterations on the concept, such as Skylanders or Ni No Kuni.
Oct 4, 2013Despite the nagging feeling that something's missing, Pokémon X and Y make some huge leaps forward for both the competitive and casual crowds. I just wish these games felt as complete as their predecessors.
Oct 4, 2013Pokémon X and Y might mark a big visual jump for the series, but the structure remains steadfast in its dedication to tradition.
Oct 26, 2013Pokemon X and Pokemon Y are the best, most refined versions of the games to date.
Oct 17, 2013Why there are so few new Pokémon and such an emphasis on the old ones is really up to speculation, but all I know is that there's a Chespin out there who needs a pet.
Oct 20, 2013This game will likely be remembered as the biggest leap forward for the franchise, an amazingly smooth and altogether necessary transformation in presentation that does well to preserve the nostalgia that comprises much of the series's lifeblood.
Oct 4, 2013These caveats aside, Pokemon X and Y is a very successful update for the venerable series, and actually, it compares rather favorably to Diamond and Pearl in terms of content out of the box (not as much Black and White, which had half a continent to explore after the Elite 4 was done).
Oct 29, 2013Bigger, better, stronger and prettier than anything we've ever seen with the label "Pokémon" on the cover.
Jan 30, 20143D Visuals transformed the classic Pokemon approach in a good way. Online capabilities are top notch, this new generation will really make Pokemon fans happy.
Oct 4, 2013The jump to 3D does wonders for a series that was starting to show its age, with a host of new monsters and revamped old ones pulling together to create a completionist's worst nightmare and a Pokémaniac's dream game.
Awards & Rankings
User Score
Generally favorable reviews- based on 867 Ratings
User score distribution:
Positive: 142 out of 181
Mixed: 31 out of 181
Negative: 8 out of 181
Oct 12, 2013I made an account just so I can express how brilliant this game is, everyone I know bought a 3ds for this game and they wee not disappointed.I made an account just so I can express how brilliant this game is, everyone I know bought a 3ds for this game and they wee not disappointed. This game tweaks every single nit-pick that the previous entries in the series had. Character customization? Check. Diagonal walking? Check. Ability to run from start? Check. Incredibly sped up gameplay? Check. Brilliant graphics? Check. Ability to challenge anyone anywhere? Check. this game is truly one of the greatest RPGs of all time, it introduces new elements while improving on past elements, and fulfills every wish I had for it. Get this game now.… Full Review »
Oct 16, 2013I'm writing this AFTER I beat the game so for those who have not beat it please vote after you finish E4 and see if you agree.
I will save myI'm writing this AFTER I beat the game so for those who have not beat it please vote after you finish E4 and see if you agree.
I will save my compliments as I know it's a great game but the major flaw is that it lacks replay value, after you beat E4, there's literally nothing to do that's sparks people as OOOO this is fun.
Let's take a look at Soul Silver and Heart Gold, after you beat the game, you get to explore Kanto, the game opens up a whole new world, all the gym now offers toughened up rematchs, all the variety of legendary you can catch from previous generations. X and Y has nothing
Another flaw is that the Kalos Pokemon doesn't stand out, the game throws in pokemon from previous generation from the beginning and natually people will capture ones the recognize, take a look at black and white, they give you pokemon from previous gen at a much later time this forces players to use and familiarize pokemon from this generation, I have found myself a party full of pokemon from previous generations because why risk it when I know what pokemon works?
and then there's the starters, if you count the Torchic giving to you by gift, they give you 4 starters, that's ABSURD, it completely devalues your starter pokemon.
There are flaws that keep me from spending more than 20 hours on it when each game previously would take me 100 hours each, great game, but needs work… Full Review »
Oct 12, 2013This game is pretty amazing. First off, it is in 3d. This means that the game looks wonderful. I,ve been a fan of pokemon for a long time nowThis game is pretty amazing. First off, it is in 3d. This means that the game looks wonderful. I,ve been a fan of pokemon for a long time now and this game is what i've always wanted.… Full Review »


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Mineral oil: don't knock it 'til you try it!!
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Join Date: Oct 2012
Posts: 323
Monday, February 11, 2013 at 04:00PM
So, do you just use Johnson's baby oil (pink lid just MO and fragrance?) Cuz I have some of that on hand (I have a 19 month old). Can I just use that?
also, how would you go about applying this? I have a few different products, but I'm thinking the smoothie, which I usually use, will be too much oil with the MO. Which is fine. I have KCCC, SM Smoothie,
Curls Creme Brûlée
, FSG, ag curl trigger, KC spiral spritz. What should I use together?
Rae ~ 2c/3a ~
Wife to a 3c Curly Guy
Mom to a straight and a curly.
"The Longer the Hair, the Bigger the Blob."
Porous, very dense but fine hair. Medium everything else.
CoWash: Tressemee naturals
RO: Generic biolage and generic joico k-pak
LI: Tresemee
Miss Jessie's Pillow soft curls, diffuse 50%, add KCCC and diffuse to 80%.
Always wash upside down.


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When Ironworks set up their own YouTube channel, the Interactive group started thinking about how we could contribute content. I mean, we're all really, really, ridiculously good-looking, so how could the camera deny us?
We've got a lot of great ideas lined up for the near future, but the first thing we decided to shoot was a simple conversation. Interactive is a pretty collaborative and opinionated group, so rarely a day goes by that we don't end up talking about current web events, theory or the like. It just made sense to document and share one of these conversations.
Larry King and I have been having this discussion on the future of mobile applications for a while now, and it's a fun thing to talk and ponder about because we're rapidly approaching a crossroads. What will the mobile application landscape look like in 5 years? Will the iTunes store be but a painful memory?
If you're interested in the mobile space and want to hear what we think, head on over to the Ironworks YouTube channel and watch our newest video, Mobile Web Apps vs. Native Apps


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Rooms & Rates
Rooms and Rates
Our Inn offers rooms with plush mattresses in either a king-size bed or two queen beds.
Each room is equipped with:
- Individual heating/air conditioning
- Private bath
- Hairdryer
- Iron/ironing board
- Remote control cable television
- Telephone
- Free High-speed Wireless Internet access
Our rates and other services are as follows:
- $99.99 for Single Occupancy (per night)
- $5.00 for each additional guest
- Rates slightly higher on event weekends such as Homecoming and Houghton College Graduation.
- Children 12 and under stay for free
- Government employee rate
- AAA, senior citizen and other discounts
- All major credit cards accepted
- Rollaway beds ($10.00 per stay)
- Crib ($5.00 per stay)
- DVD player available upon request
- Small refrigerator available ($5 per stay)
- Fax service includes a small fee per fax


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/// Facebook's Latest Talent Grab: Carsabi's Co-Founders
October 1, 2012 | All Things Digital
Another quick talent deal for your Monday morning: Facebook has picked up engineers Christopher Berner and Dwight Crow, the two young, YCombinator alumni co-founders of auto-indexing Web site Carsabi.com, the company announced in a blog post . No acquisition, meaning the two are still looking to offload the site to any potential buyers. The site, as Berner described it, is essentially a Kayak.com for cars. Terms of the talent deal, of course, were not disclosed.
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Facebook's Latest Talent Grab: Carsabi's Co-Founders
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VILLANOVA, Pennsylvania – The Marist water polo team split its opening weekend of Metro Atlantic Athletic Conference play on Saturday, falling to the #16 Wagner College Seahawks 10-6 before beating the Villanova University Wildcats 15-8.
With the results, Marist stands at 9-11 (1-1 MAAC) on the season.
Against the Seahawks, sophomore Susan Cantoni led the Red Foxes offensively, totaling three goals, while senior co-captain Amanda Amorosa finished with one goal and two assists. Her two assists moved Amorosa passed Shelby Rinker (10-13) for third all-time in program history. Sophomore Grace Doerfler and senior co-captain Jocelyn McQuade each chipped in one goal.
In net, junior Jessica Hermosillo played the opening two quarters and finished with five goals against, three saves and one steal and freshman Carsen Horvatich played the second half and totaled five goals against and five saves.
Versus the Wildcats, Amorosa led the team with four goals, two assists and two steals, while senior Nastassia McGlothlin finished with two goals, two assists and one steal. Cantoni and fellow sophomore Katie Tijerina each chipped in two goals, one assist and one steal, junior co-captain Diana Carballo finished with two goals and one steal and McQuade chipped in one goal, one assist and one steal. Doerfler finished with one goal and one steal and freshman Justine Castro chipped in one goal.
In goal, Horvatich played the first half and finished with three goals against, three saves and two steals. Hermosillo played the third quarter and totaled no goals against and one save and sophomore Hope Vickers played the fourth quarter and finished with five goals against and three saves.
Looking to start conference play off with a win, both teams came out ready to play. The Seahawks opened the scoring when Erica Hardy found the back of the net just 1:23 into the game. Defense was the name of the game for the remainder of the quarter, as neither team scored.
Cantoni evened the score with 4:27 left in the first half but Wagner answered 12 seconds later when Kimberly Watson scored to regain the lead. Watson scored again with 3:39 left to make it a two goal game before Hardy scored with 2:02 left and Elise Begg found the back of the net with 23 seconds remaining to extend the Seahawks lead to 5-1. McQuade made it a three goal game with three seconds left on an assist by Ariana Singer and the two teams went into the half with Wagner ahead 5-2.
Watson's third made it 6-2 just 1:05 into the second half. Doerfler made it 6-3 1:24 into the third quarter but Wagner answered with three consecutive goals by Franciska Milo-Sidlo (2) and Hardy to make it 9-3 with eight minutes remaining.
Milo-Sidlo made it 10-3 with a goal at the 7:30 mark, before Cantoni answered 1:06 later off an assist by Amorosa. With 2:33 left in the game, Amorosa made it 9-5 with a five meter at 2:23 and then Cantoni found the back of the net for her third at 0:13 to make it 10-6 but that was as close as it would get with Wagner emerging victorious 10-6.
Coming off the tough loss to the Seahawks, Marist was determined to get into the win column. Amorosa opened the scoring 3:39 into the game, before Carballo made it 2-0 with a goal at 3:44. The Wildcats answered with a goal 12 seconds later by Lizzie Louwers, however, Tijerina regained the two goal lead when she found the back of the net with 2:45 remaining. With 20 seconds remaining in the first quarter, Castro made it 4-1 with her first goal of the day.
McGlothin extended the lead to 5-1 34 seconds into the second quarter before Villanova answered with a goal at the 5:47 mark by Kate Stenmoen. Carballo scored just under three minutes later to push the score back to a four goal margin but again Stenmoen found the back of the net to trim the deficit to 6-3. Back-to-back goals by McGlothlin and Cantoni made it 8-3 and the two teams headed into the half.
The third quarter was all Red Foxes as McQuade, Amorosa, Cantoni and Tijerina found the back of the net while Villanova was held scoreless and with eight minutes remaining it was 12-3.
The Wildcats found their stride in the fourth with four consecutive goals in the opening 3:25 of the quarter and suddenly it was 12-7. Amorosa scored her third of the game with 3:57 remaining but Dominique Clark answered for Villanova to make it 13-8. With just minutes remaining, the Marist defense was up to the task and shut the door with Doerfler and Amorosa scoring and the final horn sounded with the Red Foxes victorious 15-8.
Up next, Marist returns home for its annual MAAC home day. The Red Foxes will play VMI (10:30 AM) and LaSalle (4 PM). Prior to the game vs LaSalle, the team's three seniors will be honored with a Senior Day Ceremony.


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4S Ranch
Now Open!
4s Ranch Village Center
Across from Starbucks
Open for Lunch & Dinner
Premium. Natural.
No microwaves.
No fryers.
If it's roasted, we roasted it.
If it's marinated, we marinated it.
We made the soups.
We made the dressings.
Freshest Ingredients
At the Greenspot we put the freshest ingredients possible on your table. We take advantage of the abundant Southern California agriculture and buy local whenever possible.
Premium. Natural.
The Greenspot Salad Company is committed to providing our customers with a delicious, convenient, and healthful dining experience.
Sorrento Valley
Located outside of the Sorrento Mesa food court at Mira Mesa Blvd & 805 Freeway.
M-F: 10:00am – 4:00pm
4s Ranch
Located off Camino Del Norte at 4S Ranch Village Center across from Starbucks.
M-Sa: 10:00am – 8:00pm