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Winterling Bavarian Wheat Pattern Set of 8 Fruit or Dessert Bowls 1940s. These 8 lovely fruit / dessert bowls are marked "Winterling Finest Bavarian China, Made In Germany" with the crown trademark. This pattern is Winterling WIG436, and is made of crisp white porcelain with a gold rim and features a beautifully detailed design of wheat in pale brown, yellow and green. Measuring 5-5/8" diameter and in excellent condition, the bowls look hardly used. These estate pieces were purchased by the owner from the BX when the family was stationed in Germany during the war. Lovely vintage German China!
All 8 Fruit / Dessert Bowls for one price ~ See other matching Winterling pieces I have listed and complete your set!
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Join this webinar to learn how global technology leader Ricoh Australia has successfully introduced a standardized approach to process mapping. Declan O'Reilly, Business Excellence Manager at Ricoh will provide a first-hand account of their process mapping journey, sharing lessons learned and some of the immediate benefits the organization has realized including:
IoT is Hot. Not surprisingly, when you picture wearable devices, sensors and smart machines that are connected to the internet – all eager to make lives easier, provide information, react and interact with the human world. But in the business world, something is missing. Where is a system that can integrate IoT devices with mission critical business processes?
That system is very likely BPM. Business Process Management suites have become the leading technology for fast, enterprise-changing systems which optimize and streamline workflows for organizations in nearly every industry.
What if these two awesome forces – IoT and BPM – could be combined?
In this pocket-sized BPM & IoT Matchbook, we explore the possibilities opened by matching IoT devices with BPM technology.
Business Process Management Research Report:Check out the future of BPM and see how your organization stacks up.
Research conducted by global market research company, TNS Global, shows that while BPM is delivering key benefits in both the public and private sectors, a large number of organizations still struggle to keep processes documented or up to date.Download this BPM research whitepaper to see how your organization compares and get valuable insights into future BPM investment benchmarks, the level of BPM resourcing within organizations, common barriers to process improvement and the role BPM plays in helping businesses achieve their organizational goals.
Once the value of Business Architecture is demonstrated within an organization, the next step is to set up governance and a Center of Excellence to formally establish the practice and the Business Architect role within the organization...
The journey from strategy to operating success depends on creating an organization that can deliver the chosen strategy. This book, explaining the Operating Model Canvas, shows you how to do this...
In this webcast, author Kimberly Watson-Hemphill will share some highlights from her new book, Innovating Lean Six Sigma (McGraw-Hill, 2016), and provide practical tips every business leader can...
Author of Customer Focused Process Innovation: Linking Strategic Intent to Everyday Execution
For any organization to prosper, its leadership must drive bottom...
This workshop will give participants hands-on exposure to Business Process Management with the Oracle BPM Suite and will show how Oracle BPM Suite can be used across each phase of the BPM...
Examining the profile, skills and compensation of BPM professionals around the world.
The 2015 BPM salary survey of BPM Professionals represents the first such...
Business process management (BPM) needs can vary widely, from top-down business transformation initiatives to smart process applications to enterprise resource planning, marketing, social and more...
Quality processes are central to the success of any large organization, and all business units should play by the same rules. While this is certainly true, each department is bound to have unique...
We live in a continuously changing business environment, which moves ever-closer to a more-connected digital world. Successful organizations need to be proactive and adjust quickly. Therefore an...
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- Bronx Banter - http://www.bronxbanterblog.com -
Cashin' Checks
Posted By Alex Belth On September 29, 2008 @ 10:13 am In Bronx Banter | Comments Disabled
The status of Yankee General Manager Brian Cashman will reportedly be determined shortly. So? You think he stays or goes? And, do you think he should stay or go? I think he'll stay and I'd be happy if he does.
Article printed from Bronx Banter: http://www.bronxbanterblog.com
URL to article: http://www.bronxbanterblog.com/2008/09/29/cashin-checks/
Click here to print.
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Quite simply the finest BMX bike ever made. WeThePeople's Pro-level machine is full to the brim with all of their latest aftermarket parts and a healthy dose of Eclat magic thrown in for good measure. The Envy has been carefully re-designed, making it the perfect bike for both street and park… [more]
For those times when bigger is better, the Atlas 24-inch wheeled BMX cruiser won't let you down. Its true BMX geometry comes to life with a full chromoly frame, fork, and bars. Don't be afraid to perform your usual tricks, because the Atlas's components are durable enough to take a beating. Sturdy… [more]
The Buck line was based around pro rider Dillon Lloyd's blend of progressive technical riding and all out savagery. The Buck frame uses a taller 127mm head tube, allowing you to run a taller bar position with an uncut fork steerer, without having to run lots of ugly spacers. Dillon wanted a steeper… [more]
The Message frame is a full aftermarket alternative for riders that need a strong, but lightweight technical park setup that's built to last. The Message frame boasts a lower stand over height, fast geometry, and custom dual cable brake hardware, making it perfect for the technical ramp rider. Its… [more]


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Nate McKelvie was born in Bethlehem, Pa. and grew up exploring the mixed agricultural and forested lands of Moore Township where his over-active imagination ran wild as he searched for critters and Indian artifacts. Nate spent a lot of time in the region's state parks, especially Jacobsurg and Hickory Run. Inspired by his mother's inquisitiveness and love for nature, Nate was quite at home in the outdoors. One of the earliest positive experiences he remembers was an educational program by Judy Wink at Hickory Run State Park where she held a live Peregrine falcon. Little did Nate know that one day he would be doing the same thing, and sharing his passion for nature with others as a profession!
Nate is an environmental educator at Milton Hershey School (MHS), Hershey, Pa., where he provides agricultural and environmental programming for students of all ages. Working at the school's Environmental Center, some of his responsibilities include maintaining a collection of reptiles and amphibians for educational use, raising trout for educational programming and stocking, and helping to manage the many warm season meadows on campus. Being a positive male role model and connecting these special kids with nature is Nate's passion and purpose.
As a relatively new member on the WRCP advisory committee, Nate is humbled
to be amidst such an amazingly knowledgeable and diverse group of people that
When not at MHS, Nate spends much of his free time outdoors, biking (his preferred mode of transportation to work), birding, hunting and canoeing. In the summer of 2006, Nate, his wife Christie and two friends rode their bicycles from the Pacific Coast to the Atlantic Coast. They crossed through amazing landscapes and enjoyed the uniqueness of each one. Yet as they traversed the varied landscape of Pennsylvania, they all agreed on just how much they loved our state the most! In the fall, Nate is a bird bander on the crew of the Ned Smith Center's Saw-whet Owl Research Program. Nate and his wife also enjoy serving at their church and community, working with the local Audubon Society and the Horseshoe Trail Conservancy, and spending time with their two amazing little boys.
When asked why he thinks WRCP is so important, Nate gives a quote from A
Sand County Almanac by Aldo Leopold: "A thing is right when it tends to
preserve the integrity, stability and beauty of the biotic community. It is wrong
when it tends otherwise." Nate believes that understanding biodiversity and the
role each component of the natural world plays in the grand web of life should
be at the foundation of all our endeavors. He goes on to say that, "WRCP is
unique in it can look at the big picture, and with biodiversity as its goal, have a


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Welcome to the Puntos
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Enkei FD-05 Black Mach Wheel: 18x7.5 +45
Part Number: 434-875-8045BKM
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Will It Fit Your Vehicle?
This is not a vehicle specific partPlease read the product description and details prior to purchase. Please contact us if you need assistance.
Enkei Wheels introduces a new wheel that captures the excitement of drifting. Named the FD-05, this is the official wheel of Formula Drift. Good looks, the right sizes and the high quality associated with the ENKEI brand will make this wheel a winner with enthusiasts & every-day drivers alike. Available in gloss black with bright-machined accents.
- Part Number: 434-875-8045BKM
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- Wheel Diameter: 18 inch
- Wheel Offset: +45mm
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Vehicle Fitment
- This part does not have vehicle specific fitment


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Pressure sensitive tape seals instantly and is suitable for most everyday packaging needs. Transparent, lets package graphics show through. 48mm x 50m.
22-970 - All Purpose Scissors
Heavy-duty scissors cut everything from paper to 18 gauge steel sheet metal Made of stainless steel Right-handed
NL2FX - 2 Conductor Female Speakon Connector With Latch Lock
Speakon loudspeaker amplifier connectors are reliable and extremely rugged. All contacts on both connectors are touchproof meeting safety requirements both IEC 65 and IEC 348, and are UL recognized and CSA listed. Cable connectors have solid contacts and can be so...
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4 pole cable connectorChuck type strain relief
21-11100 - Self Fusing Tape
This self fusing tape can be used to insulate wire and cable in a variety of applications. Features high tensile strength, excellent elasticity and high voltage tolerance so it can be used in many environments.
Easy to find products and order. Items shipped and arrived without hassle.


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We just realized that we have been uncharacteristically quiet about our next project. We are due to break ground in just a couple of weeks, and we have barely written a word about it. This is very unlike us, and I will begin to remedy the situation right now.
Our next project is similar in scale and ambition to the first. We will be building two homes, side-by-side, just a block and a half from the original 100k Site at the corner of Amber and Arizona (map). These two homes will share the original vision of providing healthy, energy efficient and professionally designed homes at a reasonable price. The corner home, known as the M&M House, is already under agreement, and our buyers, Mario and Mel, anxiously await its completion. The true infill home will go on the market when we break ground.
In an effort to continue improving our energy efficiency we will be pursuing the Passive House standard in this project. This is a German building standard that aims to reduce the heating and cooling load of a home by 90% (you may have read about it recently in the New York Times). We are working with PHIUS (Passive House Institute US) to finalize the design and get our Passive House certification. The process has been fairly smooth so far, and we think we have a great home in the works.
While we won't be pursuing LEED Platinum on these two homes (one standard at a time), they will be built to the same or better standards. We will definitely return to LEED after this project, but we see the Passive House standard as a great way to improve some very specific aspects of our houses, mainly the envelope and the mechanical systems. In these two areas, Passive House far exceeds even the highest standards of LEED.
The goal, as always, is to pursue this new standard in an affordable manner. The infill home, which will act as the true case study for this project, will be a two bedroom, one bath, loft style row home (much like the 100k). The house will come in at about 1300 square feet. Our goal is to adhere to the same requirement as the 100k House project and build this home for less than $100 per square foot in hard construction costs. With any luck this will allow us to provide one of the most affordable Passive Homes ever built in the US.
We will be going into a lot more detail on this project as we go forward including talking about the new mechanical system, insulation, windows and other changes the new standard requires, but for now, I will leave you with a couple early concept sketches of the new facade.
So, what are your thoughts on the Passive House standard? Are there reasons more people aren't pursuing this standard in the US? What do you think of the new facade concepts? What materials would you like to see forming this new facade (stucco, lap siding, metal)?
Show up in the comments.
If you enjoyed reading this post I can promise you'll love our new writing over at Postgreen Homes. Yeah, we know that's the same thing your favorite band said and their new album is nowhere near as good as their early stuff, but seriously, we are actually still getting better.
There also isn't much conversation to be had here . . . at least not with us. So come on over to the Postgreen Homes Blog and tell us what you think of our new(ish) digs and crazy ideas. We will be sure to tell you what we think of your opinion.


text: How much energy does the California economy use, how is the energy supplied, and what is it used for? For reasons related to the economy, the environment, and energy security, a lot of people are interested in these questions. The California Energy Commission recently funded scientists in Berkeley Lab's Environmental Energy Technologies Division to help find some answers. They did so by developing the California Energy Balances Database (CALEB), and issuing a report.


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Laura May Tilden Wilson
At a glance:
Laura May Tilden Wilson was born in Sacramento, Sacramento County, California on April 24, 1872 and was the fourth of six children. Her parents were Marcellus Crane Tilden and Elizabeth J. Ralston. Her father was from Ohio, and her mother was from Illinois.
The U.S. Census for 1850 shows a 15 year old Marcellus living with his parents, John M. And Laura A. Tilden in Nelson, Portage County, Ohio . His father is listed as a farmer and his mother is listed as keeping house. By 1860 Marcellus is an attorney living in Sacramento, California. In 1870 he is married to Lizzie, has three children and still lists his occupation as an attorney. During the next 10 years this family faces many changes and losses.
Laura next emerges as a 22 year old young woman who wants to be an attorney in Nevada. We have no record of her having attended law school so she probably studied law in her father's law office which was a common route to joining the profession in those days.
The Virginia City Evening Chronicle of July 24, 1893 credits her with obtaining the passage of a Legislative statute the previous winter giving women the same rights and privileges as males "so far as becoming attorneys is concerned." The article goes on to say that the women of Nevada owe her a debt of gratitude for this feat and that she is the first lady to be allowed to practice law in Nevada. Laura is reported as having passed a "creditable exam" and receiving "encomiums from the entire bench for the manner in which she had borne herself." Although she was Nevada's first woman attorney, there is as yet no available evidence of her actually having practiced law in Nevada.
Her first victory in a California Superior Court was reported, however, in the Virginia City Territorial Enterprise of February 1, 1894. The story was said to have originally come from the Sacramento Bee. She was said to be "young and rather pretty" and had "a clear, pleasing voice which was distinctly heard throughout the courtroom." Even though she had only recently " hung out her shingle", she addressed the court as though she had been accustomed to doing it every day. She defended a young boy who had been accused of burglary by his foster father by arguing that the boy had had no criminal intent and should be discharged. Both the District Attorney and the Judge agreed with her, and she won her case.
Capital Women , An Interpretive History of Women in Sacramento, 1850-1920, by Elaine Connolly and Diane Self, reports that the Sacramento Bee in 1895 describes Laura Tilden as "Sacramento's woman lawyer" and that this implies that she was the only female in the city practicing law at that time. She was her father's law partner in an office located at 504 J Street. Connolly and Self credit Laura's father Marcellus Crane Tilden with inspiring her interest in the law and in the women's suffrage movement because he had signed an equal suffrage petition that was circulated in Northern California in 1870. Mary Erickson in Women Lawyers' Male-Connectedness points out that women lawyers were typically connected with husbands, fathers or male mentors who were attorneys.
Connolly and Self report that Laura Tilden attended and spoke at a public meeting in the California Assembly chamber to give the "woman side of the woman suffrage question". They quote a sympathetic Sacramento Bee reporter as assuring readers that the suffragists were not "pantaloonitics", or "bloomers, " or "free lovers," or "dowdies". The reporter described Laura as beginning her speech "with a smile that could win a thousand votes". She went on to say that she was helping to pass around a woman suffrage petition and that nineteen out of every twenty women in Sacramento were signing it. She described women in the United States as " brainy and well educated."
Laura's father died on January 30, 1896. She moved to Denver, Colorado in 1901 and practiced there until she moved to Montrose, Colorado in 1916. Laura married twice that we know of, first to Fred Ray in 1898 and then to Walter Curtis Wilson in 1916.
Laura Tilden Ray Wilson died from a fractured skull suffered in an automobile accident in Colorado on May 31, 1928 at the age of 56. She is buried in her family's plot in the Old City Cemetery in Sacramento, California.
Biographical Sketch written and researched by Kathleen F. Noneman, Esq. Additional Research by Elizabeth Pederson, Stanford University. Revised by Kathleen Noneman, Esq., April 2008.


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Guided tour of Tivoli
How to visit Rome with a guided tour "Tivoli"
22 ml north-east of Rome (45 min drive)The visit of Rome cannot be considered complete without going to Tivoli. The ancient "Tibur" was in a favourite position, linked to Rome by the Aniene, tributary of the Tiber, and the Tiburtina Street. It is from Tivoli that the travertine was from. The travertine was used to decorate all the public and private buildings (the Coliseum). From the Aniene valley 3 of the 11 aqueducts of Rome provided drinking water (Anio Vetus, Aqua Marcia, Anio Novus) and in Tivoli there were the most exclusive summer houses of the roman nobles and the villa of the Emperor Hadrian, real imperial city. In the mid 1500s after the Cardinal Ippolito II D'Este was nominated Governor of the town, the works of what will be considered one of the most well-known villas of all Europe will start: Villa D'Este.
Villa Adriana
It is set at the bottom of the town, in a panoramic position among the Tiburtini Mountains. At the time of the Emperor Hadrian it should have been the best complex of the Mediterranean as far as the contemporaries were stating. Hadrian invested his money and his energy. As far as we know he was directly designing and coordinating the team of architects that worked on it. He wanted to rebuild in a smaller scale all the places that he visited during his life. The tour includes the Pecile, the Hundreds Rooms, The Canopy, The Serapeo, The big and small baths, The Peschiera, The Golden Square, The Barracks of Fireman, The Heliocaminus Bath, The Room of philosopher and the Maritime Theatre.
Villa d'Este
With its park it is among the most romantic and fascinating villas of the Renaissance. It is considered among the most important example of Italian Style garden; with the fountains, path and vegetation. It is a mix of nature, art and architecture that made it famous all over the world. Started by Pirro Ligorio for the Cardinal Ippolito II D'Este in 1550. The Cardinal was the son of Lucretia Borgia, a very educated man that took care of every detail. In July, August and September it is possible to visit the villa in the evening, the memory of such experience will stay with you forever.
Tour lenght 7 hours. Tour fee € 360,00.


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I have been in the cancer community now for over seven years. I am in the community of cancer patients who battle a very tough cancer, appendiceal cancer.
When I was diagnosed with appendiceal cancer and finally located medical literature and statistics related to my cancer, I realized I was up against a monster of an enemy, a monster cancer. In the literature I read, only 10% survived a signet ring appendiceal cancer diagnosis...and even that wasn't necessarily cancer free or for more than five years. I never tried to look up cancer free survival in that 10%...I was afraid there was NO number. I was afraid the number would destroy any small bit of hope I might have clung to. My husband, also a nurse, knew I was up against tremendous odds.
My husband and I joked at first about a "Cancer Menu". If you knew you had to have cancer but could choose your cancer from a menu and pick which kind you would want to have, appendiceal cancer would be at the bottom of the list with pancreatic cancer. Late stage ovarian cancer would even be preferable. Basal cell carcinoma would be at the top of the list followed by prostate cancer and breast cancer. Breast cancer had at least a 90% survival rate compared to my 10%. I'd have traded for breast cancer in a minute.
Appendix cancer was near the very bottom of the cancer menu. No one should ever have appendix cancer. A useless appendage that threatens your life. How unfair is that? How unjust?
I've since communicated with hundreds diagnosed with appendiceal cancer. Even with the best of treatment is has a high recurrence rate. Many have lost the fight, and my heart breaks every time that happens, every time I learn another has lost the battle. I hate appendix cancer.
But here's the thing. The interesting and hopeful thing. The thing that defies explanation.
There are people I've met in my journey, just a few, who make me realize that we don't know everything. That there is never NO hope.
A woman I took care of in my hospital had a cancerous colon tumor when she was 40 years old and was raising her kids. Her husband had been disabled by an accident and could not help her support her family or raise her children. Her cancer had spread into her abdomen. A single mom with stage IV cancer. Her surgeon removed the tumor. Then she kept having recurrences in her abdomen. No peritoneal chemo, no IV chemo, just years of tumor recurrences and removals. Her surgeon said he'd wished he could have installed a zipper in her abdomen as he'd had to open it so many times to remove her cancerous tumors. But then, one day the tumors just stopped recurring. She is an elderly woman now who's then gone for decades cancer free after multiple recurrences at Stage IV.
Another woman who's contacted me has been alive for 20 years with appendix cancer. She had HIPEC initially, but has had periodic recurrences since HIPEC. She has had abdominal tumors removed several times but has gone on to live her life. Her appendix cancer has never been cured, but to her is just a chronic illness. She lives a full life in spite of decades with chronic appendix cancer.
Another young woman I communicate with was diagnosed with Stage IV appendix cancer a decade ago and told she might only have three months to live. She had surgery and IV chemo with only 5FU and leukovoran but married and had a child after diagnosis. Then the cancer recurred in her lung and she had an entire lung removed. But almost a decade later she is alive and cancer free. Against all odds, defying explanation.
Those cases are unusual and in the very small minority, but they are there. My very favorite author, Lewis Thomas, was a physician and biologist and at one time was the president of Memorial Sloan Kettering, the cancer institution where I was treated. He was like myself, a medical professional who believed and accepted as truth the science and the published medical statistics.
But Lewis Thomas said once in awhile they would send home an advanced Stage IV patient riddled with cancer that they had no more treatment for. They would send him or her home to die......and a few would come back to visit them years later cancer-free and healthy, defying the medical literature. The mystery they couldn't explain. It didn't happen often, but it happened.
We don't know everything, but there is never NO hope. The odds of being diagnosed with appendix cancer are about one in a million. We've aleady defied the odds in being diagnosed with this cancer. But who's to say no matter how sick we are, that we can't, like I have, defy the odds?
Thursday, September 11, 2008
Things we don't know
I have been in the cancer community now for over seven years. I am in the community of cancer patients who battle a very tough cancer, appendiceal cancer.
Posted by Carolyn Langlie-Lesnik RN BSN at 10:37 PM
3 comments:
- Jenny said...
Hi Carolyn,
I emailed you today asking about the Appendix Cancer ribbons.
One thing that has me on the ropes about this cancer my mom has, is that I don't know how to help her emotionally. She has 7 children that have been there for her, at the hospital, at home, helping as much as we can. However, I can't help feeling I am missing something. I have told her about articles and websites to go to, she doesn't want any part of it. I try to talk to her about it, she brushes aside the attempt. She doesn't want to talk about it.
She had her debulking surgery 3 weeks ago, with the HIPEC, the doctors says the tumor was low grade, to the point they could just peel it off in alot of places. The doctors gave a her a good prognosis, they said she should get many years out of this surgery.
Yet, she is in the hospital again. She developed a fistula in her abdomen. I have a terrible cold and I do not want to visit her until I am better. So I call, but she doesn't want to talk, in a way I feel she is almost withdrawing.
So I guess what I am asking, after this lonnnngg ramble, is...
When you were diagnosed and had your surgery, was it hard for you to talk about it? What can I do to emotionaly support my mom, without suffocating her?
- September 12, 2008 at 8:37 PM
- Carolyn Langlie-Lesnik RN BSN said...
Hi Jenny,
I sent you an email back about the ribbons, just send me your address!
I know exactly where your mom is at. Most of us diagnosed and treated for this cancer have a lot of emotional issues following surgery. We live in a very uncertain world with an uncertain future, our "normal" life is gone.
Much of how I felt I didn't want to share with those who loved and supported me as they wanted me to feel good and hopeful and positive. When I didn't feel that way, I didn't really feel I could share my thoughts (except sometimes with my best friend).
For me it really helped to journal. Anything I said on paper (or password protected computer file) only for my own eyes was okay to say, so I could really write how I felt and be honest.
I think I wrote hundreds of pages.
I don't know if your mom likes to write, but offering her a journal and pen or password protected file might be a good thing? Many patients also seek out counselors, someone outside of their family, to talk to.
Your mother is very lucky to have such a caring family. i truly wish her the best.
Hope that helps!
- September 13, 2008 at 11:27 AM
- Erica Walker said...
I was diagnosed with appendix cancer in Dec 2011. After 6 months of chemo and HIPEC I was cancer free. After my recent Dr visit there was a change in my CT and is suspicious for possible recurrence. Ive been unable to find alot of literature on appendix cancer and if there are any sites you know of plz share. Thanks.
- January 28, 2014 at 1:02 PM


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Vedant Corp has a magnificent track record and has glorified the Real Estate spectrum of Pune. They are credited and counted amongst the most dynamic and versatile construction and development houses in the city that has laid the foundation of modern Pune infrastructure and development. With numerous well known landmarks under its belt, Vedant Corp has definitely etched a concrete name in the real estate sector. Vedant Corp spells warmth, comfort, loyalty, trust, planning and professional ethos. Our entire foundation is laid on customer satisfaction and we believe the standard of quality and service is what has been the key to a successful real estate firm. Vedant Corp truly believes in continuous self improvement and we strive to give our best taking a step forward with the ever progressing technology that will benefit our customers the most. We are a system oriented firm that value relationship whether with our customers or with the environment. All our projects contribute to sustain and preserve the environment in all possible ways.We at Vedant Corp believe that true miracles happen when true talent meets optimum opportunities. If you have the talent, we have the opportunity to help you excel. Email us your resume at.Know More »
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Our property advisors will get in touch with you.
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By JOHN B. BRYANThe Wilson Post
Dr. G. Frank Burns, long-time contributing writer for this newspaper and noted Wilson County historian, has spent the past several months in Glenbrook Retirement Center, an assisted living facility in Garland, Texas. Dr. Burns, a former college professor at Cumberland University and Tennessee Tech, holds an undergraduate and a law degree from Cumberland. His dear friend, George Harding, brought a letter by The Wilson Post's office on Tuesday from the pastor of First United Methodist Church in Garland, Gene Wisdom. The following is the letter submitted by Pastor Wisdom as an update on Dr. Burns.
Greetings all,
This note comes from Pastor Gene Wisdom who looks in on Frank several times a week to make sure he is behaving himself. I read to him the two Lebanon newspapers that come regularly, even though they are usually a week out of date, and any cards or letters that many of you send.
Frank was hospitalized a month or so ago for about two weeks. He had a bladder infection that complicated his medications. Most of the hospitalization was spent changing and balancing his meds. He has been back at his assisted living apartment for a month and is again doing fine. He eats anything they put in front of him and has gained back the 30 pounds he lost last year. Frank can't remember what he had for breakfast but he recalls all of you when your names are mentioned. He loves Lebanon and imagines being there most of the time. As I read him the paper he fills in the stories behind just about everyone who's mentioned and gives more history of the community. As you know he is a walking encyclopedia on just about any topic and I have a good bit of fun asking questions to see if I can stump him on some little known facts. He seldom has to admit any lack of knowledge and I'm learning a great deal of Tennessee history. Frank's cousin, Mills Barbee, was here this weekend and will likely return in a month. Frank is receiving excellent care from the assisted living folks and with the exception of when he first wakes from his nap is generally a kind and gentle soul.
Not much happens out of the ordinary so there is not a great deal of new "news". I will send you a note from time to time just to keep him in your thoughts and prayers. I told Frank I would send you a letter and he said to be sure and give you all his love and best wishes.
Grace and Peace,Gene Wisdom, PastorFirst United Methodist Church, Garland, Texas
Editor's note: Cards and letters may be sent to Dr. Burns at Glenbrook Assisted Living, 801 West Avenue, B, Garland, TX 75040


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All Punjab National Bank (pnb) branches in Shimla District with IFSC Code
Find IFSC Code using the Lists below...
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Branch wise list of PUNJAB NATIONAL BANK (PNB) in SHIMLA
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Branches in Shimla District
Punjab National Bank has the following branches in Shimla district. List as follows, Anaj Mandi, Balg, Banot, Baragaon, Basantpur, Bharari, Chaily, Fgmo Shimla H P, Ganahatti, Ghora Chowki Shimla, Kumarsain, Lift Road Shimla, Madhauni, Mauhri, New Shimla, Nirth, Panesh, Pulbahal, Rampur, Rcc Shimla, Rohru, Sainj, Sanjauli, Sarain, Sda Complex Shimla, Shimla Dav Senior Sec School, Shimla Hp Secretariat, Shimla Hub Lift Road, Shimla Zonal Office, Suni, Thanedar, The Mall Shimla, Throach, Totu Shimla, Zao Shimla H P. Indian Financial System Code, Magnetic Ink Character Recognition, SWIFT Code, Address and Contact number are listed.
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You gotta love when a fairy tale actually has lots of fairies in it. That's the conceit behind MALEFICENT, Disney's new retelling of SLEEPING BEAUTY. It's a kind of alternative theory on how the Wicked Queen/Evil Fairy got so wicked/evil. [Read more…]
MALEFICENT: Full of pagan imagery
May 31, 2014 by Leave a Comment


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MMA 5K Walk & Health Seminar
महाराष्ट्र मंडळ अॅटलांटा
Sunday, June 16, 2013 from 8:00 AM to 12:00 PM (EDT)
Event Details
MMA 5K Walk and Health Seminar
Walk With Friends and Family on Father's Day
A Fundraiser Event Organized by MMA 2013 Committee
All proceeds go to MMA Organization
MMA Walk 8:00am - 10:00am
We have planned two walks of different lengths, you may pick the one that is suitable for you based on your comfort/fitness level.
- 5K Walk is on a nature trail, it takes you through the scenic and shaded park.
- 2K Walk is on paved trail, it takes you through the scenic and shaded park.
You can walk as an individual or as a family, group or team. Come early to participate in a warm-up session before the start of the walk. Choose from different routes available based on your comfort/fitness level. Volunteers will be stationed along the route to ensure that everyone stays on course. Please consult trail map for more details.
After the walk please join us for signing MMA Banner and light refreshments. Kids will get certificates of participation.
Health Seminar 10:00am - 11:45am
MMA Walk will be immediately followed by a informational health seminar with a theme, How To Prevent Major Health Crises In Your Life by Simple Steps of Early Diagnosis.
These talks will be delivered by some of the highly accomplished healthcare specialists from our community, namely Dr.Ramesh Bakane MD, Dr.Asmita Joshi MD, Dr. Sten Ekberg DC and Dr.Girish Pore MD.
MMA Walk Fees
|Age Group
|MMA Member
|MMA Non-Member
|Kids 5 and under
|Kids 5 - 12
|Adults & Kids 12+
Registration Details
After you register here you can send your payment by any method below,
- Check By Mail: Veena Katdare, 1532 Sever Creek Drive, Lawrenceville, GA,30043
- Payment by check or cash to any committee member
- Walk-in: payment by cash or check at the event.
Please make all checks payable to MMA.
Interested in Sponsorship?
Sponsorship opportunities are available at various levels, please contact Veena Katdare for more detais.
Event Contacts
- MMA Walk - Manasi Divan or Smita Patil or Suhas Mahendrakar
- Health Seminar - Raghav Pujari
- Sponsorship Questions- Veena Katdare
Important Notes
- Every participant must sign a waiver before they begin the walk, parents can sign on behalf of their children.
- Parents (or adults accompanying children) are responsible for safety of their children.
- Registration fee is non refundable if event is cancelled due to rain or other unforeseen circumstances.
- You must register by 6/10/2013 to be guaranteed a information packet/bag.
- Strollers are welcome but please no bikes, roller blades and skateboards on the trail.
- Free parking is available at the park, however carpooling is strongly encouraged.
- Suggested colors for attire, Green, White, Orange (colors of Indian Tricolor Flag).
Please visit MMA website for more information about walk, health seminar, park photos and trail maps.
When & Where
Settles Bridge Park
380 Johnson Road
Sunday, June 16, 2013 from 8:00 AM to 12:00 PM (EDT)
Add to my calendar


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Good-girl-gone-bad Myriam Fares to play the role of a prostitute in new drama
Myriam isn't exactly known for her sweet girl image, which could help in her upcoming role as a prostitute. (Image: Facebook)
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Lebanese diva Myriam Fares will be venturing into her first ever acting experience in the Ramadan TV drama titled "Ittiham." This series is a far cry from Myriam's role as Tinker Bell in the family-friendly theatrical musical Pete Pan: The Never Ending Story, which runs from March 5-13 in Dubai.
"Ittiham," English for "Accusation," is a social drama about a group of young girls who leave their homes from Arab countries and travel to Egypt with the promise of a better life. They then discover that they've been brought to Egypt to work as prostitutes.
According to Elaph news, Myms will play the role of a prostitute. Is that Ramadan-friendly? The singer-turned-actress will begin filming her first scenes in mid-March. filming locations will vary between Lebanon, Egypt and the UAE.
The drama was written by Claudia Mercheliane, will be produced by Mufeed Al Rifaei and directed by Philip Asmar.
Top Headlines
- Leaving little to the imagination: Reporter unzips Myriam Fares's dress at a press conference in Beirut
- Who played it better? Myriam Fares & Haifa Wehbe play near identical characters this Ramadan
- If you got it, flaunt it! Myriam Fares shows off her bling and posh suite on social media
- Adam is accused... only of delivering great vocals for Myriam Fares's "Accusation" theme tune!
- The show must go on: Myriam Fares injured (but not bothered) while shooting TV drama


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Effects of a Downward Status Transition on Perceptions of Career Success, Role Performance and Job Identification
Sargent, Leisa (2003) Effects of a Downward Status Transition on Perceptions of Career Success, Role Performance and Job Identification. Australian Journal of Psychology, 55(2), pp. 114-120.
Impact and interest:
Citation counts are sourced monthly from Scopus and Web of Science® citation databases.
These databases contain citations from different subsets of available publications and different time periods and thus the citation count from each is usually different. Some works are not in either database and no count is displayed. Scopus includes citations from articles published in 1996 onwards, and Web of Science® generally from 1980 onwards.
Citations counts from the Google Scholar™ indexing service can be viewed at the linked Google Scholar™ search.
|ID Code:
|Item Type:
|Journal Article
|Current > QUT Faculties and Divisions > QUT Business School
|Deposited On:
|17 Jun 2009 13:21
|Last Modified:
|05 Jan 2011 13:45
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LUCA - STUDIO BIFFI Photographer
JessyViennaModel Female Vienna, Wien, Austria
My MM URL: http://www.modelmayhem.com/JessyV
Mayhem # 1328384
About MeWelcome @ my sedcard!
I have in the summer of 2007 started to model and was previously a lot of experience.
I am friendly, reliable, mostly good humored and easy.
I'm not perfect (who is already ?)... but interested, learn and open to (almost) everything.
Would also like shooting abroad, when travel expenses and lodging will be reimbursed.
For inquiries please get exclusively to www.tattoomodels.at
Have you worked with JessyVienna? Add Credits for JessyVienna! >>
LUCA - STUDIO BIFFI Photographer
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Tech Today: Netflix Inks PlayStation Deal, Antitrust Officials Target Sony
Tech Today gathers all the biggest technology news of the morning's Wall Street Journal into one place for your reading pleasure.
Netflix to Offer Movies on PlayStation: Netflix said it reached an agreement with Sony to deliver movies over the Internet to Sony's PlayStation 3 game consoles.
Sony Unit Draws U.S. Antitrust Probe: Sony said it received a subpoena from the antitrust division of the U.S. Department of Justice seeking information about its U.S. optical disk drive business.
Corning Sees Strong LCD Demand: Corning's profit fell 16%, beating expectations, as the company posted record earnings from its joint ventures and saw strong LCD sales.
Marvell Tech Raises Outlook: Marvell Technology raised its fiscal third-quarter outlook because of improved demand from its customers.
FairPoint Enters Chapter 11 Protection: FairPoint said it will enter Chapter 11 protection as part a plan that should reduce its debt load by nearly two-thirds but give lenders nearly full equity ownership of the company.


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Sunday Morning Townsquare – March 17 2013
This week on Sunday Morning Townsquare, Paul speaks with:
- Jim Winslow, Grand Rapids Historian
- Christopher Reader, Grand Rapids Historian
Thanks for listening!
I'm joined by Grand Rapids historians Jim Winslow and Christopher Reader. We chat about what sparked their interest in the history of our city, some of our early prominent settlers, what was attractive about the river to the settlers, how and why the layout of downtown has changed over many, many years, some of those who laid the groundwork for Grand Rapids becoming a furniture city, some of Jim and Christopher's favorite Grand Rapids historical figures, Jim's work on the committee to research and write the history of Fulton Street Cemetery, Christopher's involvement chairing the project to renovate Monument Park on Monroe Center and Veteran's Memorial Park on Fulton, history of Alexander Calder's La Grande Vitesse, some of the historic downtown architecture they each connect with and the back story on it, a little bit of scandalous and unknown history of our city, and more…….
You can check out Jim's blog that covers the Powers family, John Ball and Grand Rapids history at http://powersbehindgr.wordpress.com/powers-theatre/
GRHistory_Part1 GRHistory_Part2
I do hope you'll have a chance to tune in! I'm really looking forward to introducing you to folks around West Michigan every week who are helping to positively shape our area with their music, their art, their bold business ideas, and the causes they're passionate about!
~Paul Jendrasiak


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Search 51 Kamiah jobs from job sites, newspapers, associations and company career pages.
The Kamiah, ID job market is strong compared to the rest of the US. Over the last year, job postings in Kamiah, ID have declined by 25% relative to a national decline of 32%.
Send us your suggestions
What companies are fueling growth in Kamiah? Why are they a great employer?
What are the opportunities for recreation, vacation, and just plain fun around Kamiah?
What jobs are on the rise in Kamiah?
Where are the best schools or school districts in Kamiah?
What causes do people in Kamiah care about. Where are the volunteer opportunities?
Where did you come from? How did you move here? What would you do different now?
More Kamiah, ID discussions...
Nearby Locations:
Orofino jobs
Grangeville jobs
Cottonwood jobs
Syringa jobs
Tahoe jobs


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Our Philosophy
Blossom and Branch is a boutique floral design studio located in Brooklyn, New York, specializing in weddings and events in the New York City area. At Blossom and Branch, we know that creative inspiration can come from anywhere — brightly colored fabric, a treasured vintage necklace, autumn light through trees. Our commitment to beauty and fabulousness is unparalleled. Prepare to be inspired.
About Us
Sarah Brysk Cohen, owner of Blossom and Branch, is obsessed with flowers. She has worked in flower shops on the cutting edge of floral design — from New York to California — for 20 years. Always eager to explore new ideas and articulate her own, distinctive approach, she opened the Blossom and Branch studio in Brooklyn, New York in 2009.
Blossom and Branch's signature style integrates classic European design with vintage glamour and Sarah's unique take on color and texture. Everything Blossom and Branch creates is custom and Sarah will work with you to cultivate the exceptional nature of your event or environment.
Sarah has a broad base of experience that includes wedding and event production, retail design and buying, weekly account management and working as the house florist for several elite, private estates. Sarah has been showcased as a resident floral expert for Howcast Media and is a regular columnist for the internationally renowned design blog, DesignSponge. Sarah was honored five years in a row with an invitation to display her work in the collection at Art Alive at the San Diego Museum of Art. In 2011, Sarah received an Editor's Choice Award for floral design from Bride's Magazine. Blossom and Branch has been featured in various online and print publications including: The New York Times, New York Magazine Weddings, Brides Magazine, The Knot Magazine, Style Me Pretty, 100 Layer Cake and Brooklyn Bride.
Photo by Maggie Harkov


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Open Networking Foundation Formed
"Stronger definition of network behavior in software is a growing trend, and open interfaces are going to lead to faster innovation," said Nick McKeown, ONF Board member and professor at Stanford University.
Seeking to accelerate network innovation, Deutsche Telekom, Facebook, Google, Microsoft, Verizon, and Yahoo, announce the formation of the Open Networking Foundation (ONF), a nonprofit organization promoting Software-Defined Networking (SDN).
Other members of ONF include Broadcom, Brocade, Ciena, Cisco, Citrix, Dell, Ericsson, Force10, HP, IBM, Juniper Networks, Marvell, NEC, Netgear, NTT, Riverbed Technology and VMware. These companies join the six founding board members to promote the SND approach to networking.
According to ONF faster networking innovation is needed and it believes SDN will enable innovation in all kinds of networks which includes, but not is not necessarily limited to data centers, wide area telecommunication networks, wireless networks, enterprises and more. By using SDN the ONF believes this can be accomplished with what it considers to be simply software changes which should give network owners and operators more and better control over their networks.
A six-year research collaboration between Stanford University and the University of California at Berkeley resulted in this SND approach to networking. The main components of SND include a software interface (called OpenFlow) and a set of global management interfaces.
According to ONF one of its goal will be will be to adopt and lead the ongoing development of the OpenFlow standard followed by encouraging greater adoption by its member companies from there, defining global management interfaces will begin after these initial goals have been met.
Issue 201/2017
Buy this issue as a PDF
GitHub Announces Open Source Friday Program
They encourage people to take time out and work on open source projects on Friday.
System76 Announces Their Own Distro, Pop!_OS
Pop!_OS is based on Ubuntu and uses the Gnome stack.
Linus Torvalds Talks About His Motivation
He never tires of working on the Linux kernel.
Debian 9 Stretches Its Wings
The new release of Debian has a very strong focus on security.
Trojan Turns Raspberry Pi into a Cryptocurrency Mining Device
Two trojans in the wild are targeting Linux machines.
Fedora 26 Beta Comes with New Features
The workstation comes with the latest Gnome desktop environment and support for many application build systems.
Raspberry Pi Foundation Merges with CoderDojo Foundation
The two foundations join forces to expand their efforts to reach young people.
Samba Security Hole Patched but Risk is Bigger
Millions of devices that use Samba Server are vulnerable to attacks.
Red Hat Announces OpenShift.io
Red Hat takes its IDE online.
Microsoft Bakes Linux into Windows Server
Microsoft is slowly becoming a Linux vendor.


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Lewis memoir
Jerry Lee Lewis has a book deal.
It Books, an imprint of HarperCollins, announced the book Tuesday. The currently untitled memoir is due in 2012.
Lewis, in a statement from the publisher, says he is ready to say "a whole lot" about his life. He says, "People can read it, burn it or never give it another thought. Either way, the truth is about to be told, and I'm the only man still standing who can touch it."
The rock 'n' roll great is known for such piano-driven smashes as "Great Balls of Fire" and "Whole Lotta Shakin' Goin' On." He is equally well-known for a private life as wild as his stage act, from getting thrown out of Bible school to his marriage to a 13-year-old cousin that nearly destroyed his career.
What's in a name?
Lee Ireland, of Egg Harbor Township, self-published "Place Names of the Jersey Shore, Why Did They Name it That?" Ireland's father, the late Leroy Patrick Ireland, instilled in the author a love of history and an appreciation of those that came before us. The book looks at more than 300 places in the area.
To purchase the book, call 609-927-5994.


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CARROLLTON -- The West Branch Lady Warriors traveled to Carrollton intent on avenging their only loss of the season and claim a share of the NBC lead. However, the Carrollton Warriors were up to the challenge and defeated West Branch 58-52 in a key girls' NBC game here Wednesday night.
The win nearly assures Carrollton (13-2, 9-0) of an outright title as West Branch fell two games back with a league record of 7-2 (11-2 overall).
Carrollton was led by Savanna Lowery with 14 points and Rachel Devine and Monica Starre each tossed in 11 points.
West Branch also had three players in double figures. Melinda Trimmer led the way with 18 points. Erica Johnson recorded a double-double with 14 points and 10 rebounds. Pavin Heath added 10 points.
Devine opened the game with a 3-point play for Carrollton and West Branch played from behind all night. Carrollton only trailed for one possession in the fourth.
West Branch tied the game 10-10 midway through the first quarter but Carrollton outscored the visitors 7-1 to finish the first stanza with a 17-11 lead.
Johnson opened the second quarter with a free throw and Taryn Hahn added a trey to spark an 8-2 run and tie the game at 19-19. CHS quickly responded with a three from Devine.
"The key tonight is that we kept our composure -- every time that West Branch got something going we were able to respond and keep the momentum from shifting," explained Carrollton coach Craig Rodgers.
West Branch battled back to within two points, 24-22, in the final minute of the first half, but a three-point play in the final seconds by Schyler Fennimore gave Carrollton a 5 point, 27-22, halftime lead.
West Branch gained momentum late in the third quarter as Heath scored six points in a 10-2 WB run to cut the Carrollton lead to a single digit, 41-40 after three quarters of play.
Amanda Linhart gave West Branch their first and only lead of the game with a jumper with 7:06 remaining in the game. The lead was shortlived as Starre scored for Carrollton on their next possession, igniting a 6-0 run to take a 48-42 lead.
From that point on, Carrollton maintained their lead. West Branch appeared to make a comeback in the final two minutes when Trimmer cut the Carrollton lead to 4 points, 54-50 with a three, but Carrollton sealed the win with clutch foul shooting down the stretch.
"We pride ourselves on our defense and for the second year in a row we have come down here and not done a good job on defense or of rebounding, commented West Branch coach Walt DeShields. "This is a disappointing loss for us, but we are still having a good season with a lot of tough games left. We now have to get back to practice and work hard to get better."
West Branch won the jayvee game, 43-25. Catie Hahn led West Branch with 17 points.
West Branch returns to action Saturday facing Fort Loramie at The Classic in the Country in Berlin at 10 a.m.


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A Phase 1 dose escalating study was conducted in malaria naïve adults to assess the safety, reactogenicity, and immunogenicity of the blood stage malaria vaccine BSAM2/Alhydrogel®+ CPG 7909. BSAM2 is a combination of the FVO and 3D7 alleles of recombinant AMA1 and MSP142, with equal amounts by weight of each of the four proteins mixed, bound to Alhydrogel®, and administered with the adjuvant CPG 7909. Thirty (30) volunteers were enrolled in two dose groups, with 15 volunteers receiving up to three doses of 40 µg total protein at Days 0, 56, and 180, and 15 volunteers receiving up to three doses of 160 µg protein on the same schedule. Most related adverse events were mild or moderate, but 4 volunteers experienced severe systemic reactions and two were withdrawn from vaccinations due to adverse events. Geometric mean antibody levels after two vaccinations with the high dose formulation were 136 µg/ml for AMA1 and 78 µg/ml for MSP142. Antibody responses were not significantly different in the high dose versus low dose groups and did not further increase after third vaccination. In vitro growth inhibition was demonstrated and was closely correlated with anti-AMA1 antibody responses. A Phase 1b trial in malaria-exposed adults is being conducted.
Trial Registration
Clinicaltrials.gov NCT00889616
Citation: Ellis RD, Wu Y, Martin LB, Shaffer D, Miura K, Aebig J, et al. (2012) Phase 1 Study in Malaria Naïve Adults of BSAM2/Alhydrogel®+CPG 7909, a Blood Stage Vaccine against P. falciparum Malaria. PLoS ONE 7(10): e46094. https://doi.org/10.1371/journal.pone.0046094
Editor: Thomas L. Richie, Naval Medical Research Center, United States of America
Received: April 26, 2012; Accepted: August 27, 2012; Published: October 4, 2012
This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Funding: This work was supported by the Intramural program of the National Institutes of Health,National Institute of Allergy and Infectious Disease. Support for the Growth Inhibition Assay (GIA) Reference Center was provided in part by the PATH Malaria Vaccine Initiative (MVI) and by the United States Agency for International Development (USAID) Malaria Vaccine Development Program through a 361 cooperative agreement between USAID and MVI. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: Ruth Ellis is a PLOS ONE Editorial Board member. CPG 7909 was provided by Coley Incorporated, a Pfizer Company. Coley did not provide employment, consultancy, or other financial sponsorship or support. These interests do not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.
While significant advances have been made against malaria, the World Health Organization estimates that the Plasmodium falciparum parasite was responsible for an estimated 216 million illnesses and 655,000 deaths in 2010, mostly in African children [1]. Others have estimated as many as 1.2 million deaths were due to malaria in 2010 [2]. A partially effective vaccine may be licensed within the next 5 years [3], but a more highly protective second generation vaccine is needed, particularly in the face of growing parasite and mosquito resistance to interventional tools.
Over time, people living in endemic areas develop partially protective immunity against P. falciparum disease as a result of repeated natural infection. This acquired immunity is thought to be mediated in part by blood-stage (merozoite)-specific antibodies, which have been shown to be protective in passive transfer experiments [4]. Non-human primate models have also shown that protection against disease can be induced by vaccination with recombinant merozoite proteins and that protection was associated with high antibody titers [5], [6]. Merozoite Surface Protein 1 (MSP1) and Apical Membrane Antigen 1 (AMA1) are the blood stage antigens which have been most widely tested in clinical trials, including field trials in target populations [ as reviewed in 7] [and 8]. Strain-specific protection against clinical malaria in Malian children was recently reported with a highly immunogenic recombinant AMA1 vaccine, although overall protection against malaria was low [9].
The slow acquisition of protective immunity by natural infection and the limited allele-specific protection induced by experimental vaccination indicate that a single component malaria vaccine is unlikely to be sufficiently effective to protect clinical malaria. A multicomponent vaccine may provide greater protection by broadening antibody responses in a given individual and also by broadening coverage against antigenic diversity in parasites. In addition, there may be additive or synergistic consequences of targeting two merozoite surface proteins simultaneously, as observed by passive immunization in a rodent model [10]. Previous trials have shown safety and marked enhancement of the antibody responses to AMA1-C1 and MSP142-C1when the adjuvant CPG 7909 was added to an Alhydrogel® formulation [11]–[13]. The blood stage vaccine candidate Blood Stage Antigen Mixture (BSAM) 2, containing two recombinant allelic proteins each of AMA1 and MSP142, formulated on Alhydrogel® with CPG 7909, was therefore evaluated for safety and immunogenicity in malaria-naïve healthy adults, prior to a study in malaria-exposed adults.
The protocol for this trial and supporting CONSORT checklist are available as supporting information; see Checklist S1 and Protocol S1.
Participants were healthy adults age 18–50 enrolled at the Center for Immunization Research in Washington, DC. Exclusion criteria included prior malaria infection, recent or planned travel to a malaria-endemic area, recent use of malaria prophylaxis, and pre-existing autoimmune disease. Participants were required to be in good general health, without known significant medical conditions or significant medical history, and were required to have normal results for screening laboratories: complete blood count, alanine aminotransferase (ALT), and creatinine; no serologic evidence of hepatitis B, hepatitis C, or human immunodeficiency virus infection; and negative anti-double stranded DNA (dsDNA) as a marker for autoimmune disease. Serum pregnancy testing was performed at screening and urine pregnancy testing was performed prior to each vaccination for females.
The study protocol and consent documents were reviewed and approved by the Institutional Review Board (IRB) of the National Institute of Allergy and Infectious Diseases (NIAID) and the Western IRB. The study protocol was also reviewed and approved by the FMPOS Ethics Committee in Bamako, Mali, since the protocol combined Phase 1 trials; one in malaria-naïve adults in the U.S. and the other in malaria-exposed adults in Mali, the results of which are being published separately. Individual written informed consent was obtained from all participants prior to any study procedures.
BSAM2 is a combination of the FVO and 3D7 alleles of AMA1 and MSP142, with equal amounts by weight of each of the four recombinant proteins mixed, bound to Alhydrogel®, and administered by mixing with CPG 7909 at the time of injection. The AMA1 and MSP142 combination vaccines (AMA1-C1/Alhydrogel®+/−CPG 7909 and MSP142-C1/Alhydrogel®+/−CPG 7909) have been previously evaluated in Phase 1 trials, and production and characterization of the recombinant proteins and the formulated vaccines have also been previously described [11], [12], [14]–[17]. The AMA1 protein used in this study was made using a modified procedure which will be reported elsewhere. In brief, the purification procedure as described in [15], was modified to increase the quality and scalability of the recombinant AMA-1 drug substances. The order and type of column chromatography procedures were revised to include capture by Ni-Sepharose-FF (GE Healthcare), purification using a Butyl-Sepharose 4 Fast Flow (GE Healthcare) hydrophobic interaction column and Q-Sepharose-HP (GE Healthcare) anion exchange column, followed by size exclusion chromatography (Superdex 75 (GE Healthcare)), sterile filtration using a 0.22 µm filter prior to bulk vialing and storage at <−70°C. All column chromatography procedures and solutions were in accordance with cGMP. Final GMP manufacture and fill of the vialed CPG 7909 and BSAM2/Alhydrogel® was conducted at the Biopharmaceutical Development Program, National Cancer Institute, Science Applications International Corporation, Frederick, Maryland.
A GLP toxicology study using a higher dose product (BSAM1/Alhydrogel® +/− CPG 7909, containing 160 µg MSP142 and 80 µg AMA1 for a total of 240 µg antigenic proteins) was conducted in rabbits prior to study initiation (CRL Preclinical Services, Horsham, Pennsylvania), with no safety issues identified, and with induction of antibodies which inhibited growth in an in vitro parasite growth inhibition assay (GIA). BSAM2/Alhydrogel® and CPG 7909 were also separately evaluated in rabbit pyrogenicity tests using a cGLP compliant procedure, and none of the vaccine components were pyrogenic. Since the CPG 7909 used in the current study was manufactured in a new production facility (Avecia Biotechnology Inc., Milford Massachusetts), potency of the new CPG 7909 (without antigens) in comparison with the lot used in previous clinical trials was confirmed in a mouse study.
The components of the vaccine, BSAM-2/Alhydrogel® (low and high dose) and CPG 7909, were supplied separately in single-use vials to the study site pharmacist where a point of injection formulation was prepared. Vaccine components were stored at 2–8°C. Shortly before vaccination, 0.7 mL of BSAM-2/Alhydrogel® was withdrawn and added to a single dose vial containing 0.08 mL CPG 7909. The calculated total dose of antigen in the 0.55 mL injected volume was 39.5 µg (low dose) and 158.0 µg (high dose) of protein, shown as 40 µg or 160 µg for simplicity, with 564 µg of CPG 7909 administered with both the high and low doses. The stability of BSAM2/Alhydrogel® and CPG 7909 was assessed annually during the course of the study, and potency of BSAM2/Alhydrogel® in mice was assessed every six months. All components remained stable and potent during the course of the clinical trial.
Vaccines were given by intramuscular injection into the deltoid muscle in alternating arms when possible at study Days 0, 56, and 180. An independent Safety Monitoring Committee (SMC) reviewed adverse event data at scheduled safety reviews and as needed as the study progressed.
The primary objective of this study was to assess safety and reactogenicity of BSAM2/Alhydrogel®+CPG 7909 in malaria-naïve US adults. The secondary objective was to determine the antibody response of the combination vaccine to the AMA1 and MSP142 proteins, as measured by antibody levels and parasite growth inhibition assay. Exploratory objectives included determination of the extent to which the antibody responses to the individual antigens (AMA1 and MSP142) were correlated with each other.
Volunteers were observed for 30 minutes after each vaccination to evaluate immediate adverse events and were given diary cards to record events occurring during the first week after each vaccination. The diary cards were used as a memory prompt and were reviewed with volunteers at follow up visits, when adverse events were recorded. Participants were seen at 3, 7, 14, and 28 days after each vaccination, and then approximately monthly for a total of 12 months (to study Day 360), with an additional follow up phone call scheduled at study Day 720. All adverse events were graded for severity and relationship to study product. Solicited injection site adverse events were pain, erythema, and induration. Solicited systemic adverse events were fever, headache, nausea, myalgia, arthralgia, and rash. Fever was graded as 1 = 100.4°F–101.5°F (38.0°C–38.6°C), 2 = 101.6°F–102.4°F (38.7°C–39.1°C), 3 = ≥102.5°F (≥39.2°C). Pain and other solicited adverse events were graded as follows: 0 = absent/none, 1 = easily tolerated, 2 = interferes with daily activity or treatment given, 3 = prevents daily activity. Unless otherwise specified, non-solicited adverse events were graded as 0 = none, 1 = no effect on activities of daily living and no treatment given, 2 = partial limitation in activities of daily living or treatment given, 3 = activities of daily living limited to <50% of baseline or medical evaluation required. Injection site erythema, swelling, and induration were graded based on the maximum diameter as follows: mild = >0 to 20 mm, moderate = 21–50 mm, and severe = >50 mm. Hematological (hemoglobin, white blood cell counts, and platelets) and biochemical (ALT and creatinine) laboratory parameters were measured at screening, on days of immunization, and 3 and 14 days after each vaccination; hematological parameters were also checked 7 days after each vaccination. Anti-dsDNA was checked as a marker for autoimmunity at screening, 14 days after the second and third vaccination, and at Day 360. Serious adverse events (SAEs) followed the FDA Code of Federal Regulation, and were defined as any adverse event that resulted in death; was life-threatening; required hospitalization; resulted in disability, incapacity, congenital anomaly, or birth defect; or any other event that required intervention to prevent such outcomes.
The standardized methodology for performing the enzyme-linked immunosorbent assay (ELISA) and the growth inhibition assay (GIA) have been described previously [11],[14],[18],[19]. For both AMA1 and MSP142, FVO and 3D7 allele specific IgG antibody levels were assessed by ELISA at baseline for each vaccination, two weeks after each vaccination, and at Days 270 and 360. The minimum detection level of the assay was 33 ELISA units; for all antigens results less than these values were assigned a value of 17 ELISA units for statistical analysis. ELISA results were converted to ng/mL by multiplying the ELISA units by protein and parasite specific conversion factors (AMA1-FVO = 58.37, AMA1–3D7 = 47.28, MSP1-FVO = 21.64, MSP1–3D7 = 24.39). GIA was performed using purified IgG from serum collected two weeks post-second vaccination to assess biologic activity of the induced antibody against FVO and 3D7 parasites. In this assay, purified antibody was added to the parasite cultures at approximately the same concentration as present in the corresponding serum sample (10 mg/mL in GIA well).
Sample Size
The study was powered to provide sufficient safety data before proceeding to a clinical trial in malaria-exposed adults. A sample size of 12 in each dose group gave a probability of 0.80 for detecting 1 or more adverse events that occurred with a frequency of 0.125 per participant. Fifteen volunteers per dose group were included in case of withdrawals or loss to follow-up.
Group Assignment
Participants were sequentially enrolled in the two dose escalating groups. Within each group enrollment was staggered for safety purposes. Five volunteers were planned to be vaccinated at each dose level followed by vaccination of the remaining 10 volunteers in the group a minimum of 2 weeks later. Enrollment was further staggered after the occurrence of severe related adverse events, as described in the Results section.
This was an open label dose-escalating study, with both participants and those conducting clinical and laboratory assessments aware of the interventions received.
Statistical Methods
The safety analysis was descriptive, with the frequency of local and systemic adverse events presented by dose group (40 µg low dose, and 160 µg high dose), and by vaccination (first, second, third). Data from all participants who received one or more vaccination are shown. For the immunological analysis only subjects who received all 3 vaccines and did not meet criteria for exclusion (i.e., received H1N1 vaccine close to the time of study vaccine administration) were used. Antibody results were analyzed as follows: concordance for allelic responses (FVO and 3D7) to the AMA1 and MSP142 antigens was calculated using the random marginal agreement coefficient with the squared error loss function [20]. FVO and 3D7 responses at each time point were averaged, since responses for each allele were highly concordant, consistent with previous studies [12],[17]. Average FVO and 3D7 responses were plotted over time. Confidence intervals on geometric means used the t-distribution on log transformed responses. To test for a dose response (low versus high) a Wilcoxon Mann Whitney (WMW) test with Hodges-Lehmann confidence intervals was used to compare log transformed AMA1 and MSP142 average antibody levels. To test for a further increase in antibody after third vaccination (Day 70 versus Day 194) a Wilcoxon signed rank test was used. GIA results were plotted against ELISA antibody levels in the GIA well for the homologous AMA1 and MSP142 antigens. The correlation between antibody level and growth-inhibitory activity was tested by a Spearman rank test with confidence intervals calculated using Fisher's Z transformation on the correlation of the ranks. Calculations were done using R 2.14.2.
Recruitment and Participant Flow
Using a general screening protocol, 79 volunteers were recruited from the Washington DC area. Fifty-six volunteers signed a study specific consent. Thirty-three of the seventy-nine did not meet eligibility criteria, 7 declined participation, and 9 others were eligible but were not enrolled. 30 healthy adults (13 female) were enrolled in the study. The mean age of participants was 33 years (range 18–50). Vaccinations began in June 2009 and were completed by March 2010. Participant flow through study Day 360 is shown in Figure 1. One participant in the low dose group was withdrawn after the second vaccination and one in the high dose group was withdrawn after first vaccination, both due to Grade 3 adverse events as described below. A second participant in the high dose group voluntarily withdrew after the second vaccination due to reported muscle soreness that was judged to be unrelated to the vaccine. These participants were taken off-treatment but remained in the study for safety follow-up. Three additional participants withdrew due to schedule conflicts, one after the first vaccination and the other two after the second vaccination. Twenty-six (13 in the low dose and 13 in the high dose groups) of 30 participants were contacted by telephone for additional safety follow up at approximately study Day 720.
Thirty (30) participants were enrolled, 24 participants completed vaccinations, and 24 completed follow-up to Day 360.
Numbers Analyzed
Safety data is presented for all participants who received at least one vaccination (n = 30). Immunogenicity results to Day 360 (last data point) were analyzed for 12 participants in the low dose group and 11 participants in the high dose group. Subjects who did not receive all three vaccines were excluded from the immunogenicity analyses, as well as one subject in the low dose group who received an H1N1 vaccine within a week of the third vaccination.
Outcomes and Estimation
One serious adverse event unrelated to vaccination occurred during the study: a participant in the low dose group was electively hospitalized for surgery for cholelithiasis 2 months after his second vaccination. This participant had already been taken off treatment due to systemic adverse events following his first and second vaccinations (see below). No other serious adverse events occurred. One female in the high dose group became pregnant approximately three months after the third vaccination and elected to terminate the pregnancy; she continued follow up for safety and immunogenicity. Adverse events (AEs) related to vaccination for the low and high dose groups are shown in Figures 2 and 3. Most related AEs were mild or moderate, but three participants in the low dose group and one participant in the high dose group experienced severe systemic reactions consisting of fever, headache, malaise, and diarrhea. Two of these participants were withdrawn from treatment but remained in the study for safety follow-up: one participant in the low dose group who experienced moderate or severe fever, myalgia, and headache after first and second vaccinations; and one in the high dose group who experienced severe fever after first vaccination. Systemic adverse events had a flu-like pattern, including gastrointestinal symptoms in six participants and cough in one participant, but evaluation for an infectious etiology in a participant with a typical influenza syndrome was negative for influenza A and B (including H1N1, because enrollment and vaccination were concurrent with the 2009–2010 H1N1 influenza pandemic), parainfluenza 1, 2, and 3, respiratory syncytial virus, adenovirus, rhinovirus, and enterovirus; a second participant was negative for influenza A and B (including H1N1), Salmonella, Shigella, and Campylobacter. Both were in the low dose group. Flu-like symptoms typically had onset within 24 hours of vaccination and resolved within an additional 24 hours, and were relieved by over the counter (OTC) analgesics. After consultation with the Safety Monitoring Committee, participants were instructed to take OTC medications at the first sign of such symptoms, and no severe related events were seen subsequent to this change. One to two tablets of acetaminophen and/or ibuprofen and naproxen were taken on an as needed basis by thirteen participants who experienced either moderate to severe fever one to two days post vaccination. Of these thirteen participants, eight experienced repeated symptoms after more than one vaccination. Two of the four participants that experienced severe systemic reactions took only acetaminophen for their symptoms, while the remaining two participants took other non-steroidal anti-inflammatory products. No apparent difference in antibody response was noted between these four participants. Local adverse events were all mild or moderate, and were mostly pain and tenderness. Six participants (2 in the low dose group and 4 in the high dose group) had mild injection site swelling or induration. There was no apparent worsening of systemic or local reactogenicity after successive vaccinations or with increasing dose of vaccine, but this may have been masked by the pre-emptive use of analgesics with later vaccinations as the trial progressed.
The x-axis shows the number of participants experiencing adverse events, with the highest severity event for each participant after each vaccination shown.
The x-axis shows the number of participants experiencing adverse events, with the highest severity event for each participant after each vaccination shown. Other systemic adverse events in both high and low dose groups were: diarrhea (1 severe, 2 mild), abdominal pain, nausea, and cough (all mild or moderate).
Transient mild or moderate neutropenia/leukopenia is expected with the administration of CPG 7909 [21] and was observed in 9 participants in the low dose group and 7 in the high dose group. Transient thrombocytopenia is also expected and mild thrombocytopenia occurred in one participant in the low dose group. The only other laboratory adverse event considered related to vaccination was a mild transient elevation of creatinine in a low dose participant. CPG 7909 is a DNA analogue and anti-dsDNA is routinely monitored in clinical trials using CPG 7909. No elevations of anti-dsDNA occurred and there were no clinical events suggestive of autoimmune disease. No new onset of chronic or significant medical events was reported at the Day 720 follow up phone call.
Antibody responses after vaccination are shown in Figure 4. The concordance for the anti-AMA1 antibody responses by ELISA was 0.940 (95% CI 0.926, 0.951, p<0.0001) and for the anti-MSP1 antibody was 0.990 (95% CI 0.988, 0.993, p<0.0001). Both the high and low doses of vaccine were immunogenic, with responses seen after first vaccination that subsequently boosted after second vaccination. Day 70 geometric mean responses to AMA1were 84 µg/mL (95% CI: 53, 131) and 136 µg/mL (95% CI: 76, 244) for the low and high dose groups, respectively, and MSP142 responses were 63 µg/mL (95% CI: 39, 103) and 78 µg/mL (95% CI: 42, 142) for the low and high dose groups, respectively. Day 194 geometric mean responses were 86 µg/ml (95% CI: 50, 148) and 113 µg/mL (95% CI: 80, 159) for low and high dose groups of AMA1 vaccines, respectively, and 57 µg/ml (95% CI: 40, 81) and 76 µg/mL (95% CI: 54, 108) for low and high dose groups of MSP142 vaccines, respectively. There was no significant additional increase after the third vaccination, nor with the higher dose of vaccine (see Figure 4 legend). Anti-AMA1 and anti-MSP142 antibody responses were similar overall and were correlated, as shown in Figure 5. Of the four participants who experienced severe systemic adverse events related to vaccination, one was a high responder and the others were low or mid-range responders.
Thicker lines show the geometric mean response; arrows indicate vaccinations. Mann-Whitney tests with Hodges-Lehmann confidence intervals were done to compare responses in low versus high dose groups and 2 weeks after 2nd and 3rd vaccinations (days 70 and 194); although the 160 µg group had slightly higher geometric means (AMA1 D70: Fold Change = 1.49 [95% CI 0.78, 2.92] p = 0.28; AMA1 D194: FC = 1.30 [0.68, 2.49] p = 0.61;MSP1 D70: FC = 1.18 [0.57,2.49] p = 0.70; MSP1 D 194: FC = 1.30 [0.85, 1.91]) p = 0.21; differences were not significant at the 0.05 level.
Day 70: Spearman correlation, r = 0.60 [95% CI 0.23, 0.82]; Day 194: Spearman's correlation, r = 0.75 [0.50,0.89].
Activity in the GIA of total purified IgG against homologous 3D7 parasites is shown in Figure 6. Maximum inhibition against 3D7 parasites was 81% with interquartile range (IQR) of 20–59% and median of 41%; maximum inhibition against FVO parasites was 55% with IQR of 4–15% and median of 7% (not shown). Growth inhibition against homologous parasites increased as a function of antibody against both AMA1 and MSP142 antigens, but was more closely correlated with anti-AMA1 antibody (3D7: Spearman's correlation r = 0.92 [95% CI 0.81, 0.97]; FVO: Spearman's correlation r = 0.89 [95% CI 0.74,0.95]) than anti-MSP142 antibody (3D7: Spearman's correlation r = 0.46 [95% CI 0.03, 0.74]; FVO: Spearman's correlation r = 0.62 [95% CI 0.25, 0.83]).
Purified IgG from Day 70 samples (two weeks after the second vaccination) were used at a concentration of 10 mg/mL.
Immunity against blood stages of P. falciparum protects populations in endemic areas against clinical disease and is likely to be declining as exposure decreases in many populations. A blood stage vaccine, either alone or as a component of a multi-stage vaccine, is needed to protect against severe or epidemic malaria. BSAM2/Alhydrogel®+CPG 7909 was shown in this study to be moderately reactogenic, but induced high levels of antibodies against 2 allelic proteins each of AMA1 and MSP142. The induced antibodies were active in the GIA.
In our previous clinical trials AMA1-C1/Alhydrogel® with and without CPG 7909 and MSP142-C1/Alhydrogel® with and without CPG 7909 were reasonably well tolerated, although systemic adverse events were more frequent and more severe when CPG 7909 was added to the Alhydrogel® formulations [11],[12],[17]. Preclinical pyrogenicity and toxicology studies on the vaccine and the components showed no safety concerns. Thus, the flu-like systemic events seen in this study were more severe than had been anticipated. These systemic events resulted in a modification of the protocol to allow for early administration of OTC analgesics. (Our standard practice has been to request that participants not take OTC medications after vaccination so as not to mask adverse events.) After this change was made, there were no severe related systemic adverse events and no participants were withdrawn from participation due to AEs. One clinical trial of AMA1-C1/Alhydrogel® with and without CPG 7909 has been conducted in malaria-exposed adults and showed the CPG 7909 formulation to be well tolerated, with minimal reactogenicity in this population [13]. Other studies have shown reduced reactogenicity to an adjuvanted vaccine in malaria-exposed versus malaria-naïve populations [22]–[],[24]. Thus the reactogenicity seen here, while unexpected, was considered to be manageable and to not preclude further evaluation of the vaccine in malaria-exposed adults.
Average antibody responses to AMA1 and MSP142 were high and in the same range as those seen in previous trials of AMA1-C1 (at the same dose as in this study) and MSP142-C1 vaccines (at a higher dose than in this study) with CPG 7909 [11],[12],[17]. Therefore, while immune competition was not directly assessed in this trial, there was no apparent reduction in immunogenicity due to combining AMA1 and MSP142 antigens in one vaccine. On the other hand, the combination did not seem to broaden the immune coverage, as both the allelic responses and the average responses for the AMA1 and MSP142 antigens were correlated. CPG 7909 has a dose-sparing effect [12], which is an important consideration for a vaccine intended for resource poor settings where cost of goods may limit distribution.
Biologic activity of the induced antibody was confirmed using purified total IgG (containing both anti-AMA1 and anti-MSP142 antibody) in the GIA. Growth inhibitory activity was closely correlated with anti-AMA1 antibody levels. While in vitro growth inhibition has also been induced by vaccination with MSP142/Alhydrogel®+CPG 7909, peak activity was much less (∼30%), compared to over 90% in some individuals vaccinated with AMA1-C1/Alhydrogel®+CPG 7909 [11],[12]. The amount of human IgG required to induce 50% inhibition of parasite growth in the GIA has been shown to be ∼6-fold higher for MSP142 than for AMA1 [25]. Thus it appears likely that the growth inhibition seen here was predominantly due to responses to the AMA1 components of the vaccine. Growth inhibition with induced antibody has not been shown to be associated with protection against clinical malaria, although a significant inverse association with parasite multiplication rates in vaccinated participants was seen in a blood-stage challenge study of AMA1-C1/Alhydrogel®+CPG 7909 [26]. Evidence for an association between activity in the GIA and clinical malaria in field studies is conflicting [reviewed in 27]. The level of antibody needed for protection against blood stages of malaria is unknown, and may be quite high. Other mechanisms not measured by GIA may also contribute to protection [as reviewed in 9].
This study in malaria-naïve adults has provided the initial safety and immunogenicity data needed prior to a study in malaria-exposed adults in Mali. Our previous experience with a multi-allelic AMA1 vaccine adjuvanted with Alhydrogel® and CPG 7909 showed the vaccine to be well tolerated and immunogenic in Malian adults [13], but no other studies of a CPG-adjuvanted vaccine have been conducted in malaria-exposed populations or in children and further trials are needed to confirm safety and immunogenicity in these populations.
AMA1 is highly diverse, with hundreds of haplotypes identified [28]. However, the inclusion of a limited number of alleles may provide protection against most field strains [29]. Allele-specific protection has been reported in a recent field trial of a highly immunogenic single-allelic (3D7) AMA1 vaccine, adjuvanted with AS02 [9]. MSP142 is dimorphic in the MSP133 region and largely conserved in the MSP119 domain, and a bi-allelic vaccine should cover most strain diversity for this protein [16]. No protection was shown in a field trial of a MSP142 vaccine which used the AS02 adjuvant, but allele-specific effects could not be ruled out [30]. No overall protection or allele-specific effects were shown in a field trial of AMA1/Alhydrogel®, but the formulation was not very immunogenic [31],[32]. Both AMA1 and MSP142 have been shown to be protective in animal models [5],[6],[33],[34]. Thus a highly immunogenic, multi-allelic combination of AMA1 and MSP142 warrants further evaluation in the field.
Matching of the allelic variants in a candidate vaccine with those present in field strains may be important in vaccine design, although limited availability of well-characterized antigens suitable for clinical development, together with limited knowledge of field diversity for most antigens, constrains this approach. Optimized formulation, including the use of potent adjuvants such as CPG 7909, also appears to be needed for the high antibody responses which are more likely to be protective [34]. While cellular responses were not analyzed in this study, careful formulation and use of adjuvants may also boost T cell responses, which were shown to be associated with protection in one model of blood stage immunity [35].
Overall Evidence
More reactogenicity than expected was seen in this Phase 1 study of BSAM2/Alhydrogel®+CPG 7909 in malaria-naïve adults. However, the vaccine was well tolerated with more liberal use of OTC medications. Antibody responses to the AMA1 and MSP142 antigens were high and functional activity of the induced antibody was demonstrated. A Phase 1 study in Malian adults is under way which will extend the safety profile of the vaccine and adjuvant, and also look for trends against clinical malaria endpoints.
Supporting Information
Checklist S1.
CONSORT Checklist.
Protocol S1.
Trial Protocol.
We would like to thank the Safety Monitoring Committee, Mark Pierce for assistance with protocol development, Regina White and Alemush Imeru for study coordination and assistance with manuscript preparation, and Hong Zhou for the GIA analysis. We thank Richard Shimp, Jr., Vu Nguyen, Yanling Zhang, Karine Reiter, and Brian Bell and Jay Wood from the WRAIR pilot bioproduction facility for process development and cGMP manufacturing of the bulk proteins. CPG 7909 was provided by Coley Incorporated, a Pfizer Company. Potency studies in mice were supervised by Lynn Lambert. We would also like to thank the study participants.
Author Contributions
Conceived and designed the experiments: RDE YW LBM DS LM APD. Performed the experiments: DS KM JA AO KR DZ AM. Analyzed the data: RDE YW KM JA AM MPF DLN CL. Contributed reagents/materials/analysis tools: KM JA KR DZ DLN CL. Wrote the paper: RDE YW DS APD.
- 1.
WHO (2011) World Malaria Report 2011. http://www.who.int/malaria/world_malaria_report_2011/en/Ref Type: Internet Communication
- 2. Murray CJL, Rosenfeld LC, Lim SS, Andrews KG, Foreman KJ, et al. (2012) Global malaria mortality between 1980 and 2010: a systematic analysis. Lancet 379 (9814) 413–31.
- 3. Agnandji ST, Lell B, Soulanoudjingar SS, Fernandes JF, Abossolo BP, et al. (2011) First results of phase 3 trial of RTS,S/AS01 malaria vaccine in African children. N Engl J Med 365 (20) 1863–75.
- 4. Cohen S, McGregor IA, Carrington (1961) Gamma-globulin and acquired immunity to human malaria. Nature 192: 733–7.
- 5. Singh S, Miura K, Zhou H, Muratova O, Keegan B, et al. (2006) Immunity to recombinant plasmodium falciparum merozoite surface protein 1 (MSP1): protection in Aotus nancymai monkeys strongly correlates with anti-MSP1 antibody titer and in vitro parasite-inhibitory activity. Infect Immun 74 (8) 4573–80.
- 6. Stowers AW, Kennedy MC, Keegan BP, Saul A, Long CA, et al. (2002) Vaccination of monkeys with recombinant Plasmodium falciparum apical membrane antigen 1 confers protection against blood-stage malaria. Infect Immun 70 (12) 6961–7.
- 7. Ellis RD, Sagara I, Doumbo O, Wu Y (2010) Blood stage vaccines for Plasmodium falciparum: Current status and the way forward. Human Vaccines 6 (8) 627–34.
- 8. Goodman AL, Draper SJ (2010) Blood-stage malaria vaccines - recent progress and future challenges. Ann Trop Med Parasitol 104 (3) 189–211.
- 9. Thera MA, Doumbo OK, Coulibaly D, Laurens MB, Ouattara A, et al. (2011) A field trial to assess a blood-stage malaria vaccine. N Engl J Med 365 (11) 1004–13.
- 10. Narum DL, Ogun SA, Batchelor AH, Holder AA (2006) Passive immunization with a multicomponent vaccine against conserved domains of apical membrane antigen 1 and 235-kilodalton rhoptry proteins protects mice against Plasmodium yoelii blood-stage challenge infection. Infect Immun 74 (10) 5529–36.
- 11. Mullen GE, Ellis RD, Miura K, Malkin E, Nolan C, et al. (2008) Phase 1 Trial of AMA1-C1/Alhydrogel plus CPG 7909: An Asexual Blood-Stage Vaccine for Plasmodium falciparum Malaria. PLoS One 3 (8) e2940.
- 12. Ellis RD, Martin LB, Shaffer D, Long CA, Miura K, et al. (2010) Phase 1 Trial of the Plasmodium falciparum blood stage vaccine MSP142-C1/Alhydrogel with and without CPG 7909 in Malaria Naïve Adults. PLoS One 5 (1) e8787.
- 13. Sagara I, Ellis RD, Dicko A, Niambele MB, Kamate B, et al. (2009) A randomized and controlled Phase 1 study of the safety and immunogenicity of the AMA1-C1/Alhydrogel+CPG 7909 vaccine for Plasmodium falciparum malaria in semi-immune Malian adults. Vaccine 27 (52) 7292–8.
- 14. Malkin EM, Diemert DJ, McArthur JH, Perreault JR, Miles AP, et al. (2005) Phase 1 clinical trial of apical membrane antigen 1: an asexual blood-stage vaccine for Plasmodium falciparum malaria. Infect Immun 73 (6) 3677–85.
- 15. Giersing B, Miura K, Shimp R, Wang J, Zhou H, et al. (2005) Posttranslational Modification of Recombinant Plasmodium falciparum Apical Membrane Antigen 1: Impact on Functional Immune Responses to a Malaria Vaccine Candidate. Infect Immun 73 (7) 3963–70.
- 16. Malkin E, Long CA, Stowers AW, Zou L, Singh S, et al. (2007) Phase 1 Study of Two Merozoite Surface Protein 1 (MSP1(42)) Vaccines for Plasmodium falciparum Malaria. PLoS Clin Trials 2 (4) e12.
- 17. Ellis RD, Mullen GE, Pierce M, Martin LB, Miura K, et al. (2009) A Phase 1 study of the blood-stage malaria vaccine candidate AMA1-C1/Alhydrogel with CPG 7909, using two different formulations and dosing intervals. Vaccine 24;27 (31) 4104–9.
- 18. Miura K, Orcutt AC, Muratova OV, Miller LH, Saul A, et al. (2008) Development and characterization of a standardized ELISA including a reference serum on each plate to detect antibodies induced by experimental malaria vaccines. Vaccine 26 (2) 193–200.
- 19. Miura K, Zhou H, Diouf A, Moretz SE, Fay MP, et al. (2009) Anti-apical-membrane-antigen-1 antibody is more effective than anti-42-kilodalton-merozoite-surface-protein-1 antibody in inhibiting plasmodium falciparum growth, as determined by the in vitro growth inhibition assay. Clin Vaccine Immunol 16 (7) 963–8 Epub 2009 May 13.
- 20. Fay MP (2005) Random marginal agreement coefficients: rethinking the adjustment for chance when measuring agreement. Biostatistics 6: 171–80.
- 21. Krieg AM, Efler SM, Witpoth M, Al Adhami MJ, Davis HL (2004) Induction of systemic Th1-like innate immunity in normal volunteers following subcutaneous but not intravenous admiration of CPG 7909, a synthetic B-class CpG oligodeoxynucleotide TLR9 agonist. J Immunotherapy 27 (6) 460–71.
- 22. Saul A, Lawrence G, Smillie A, Rzepczyk CM, Reed C, et al. (1999) Human phase I vaccine trials of 3 recombinant asexual stage malaria antigens with Montanide ISA720 adjuvant. Vaccine 17 (23–24) 3145–59.
- 23. Genton B, Al-Yaman F, Anders R, Saul A, Brown G, et al. (2000) Safety and immunogenicity of a three-component blood-stage malaria vaccine in adults living in an endemic area of Papua New Guinea. Vaccine 18 (23) 2504–11.
- 24. Genton B, Al-Yaman F, Betuela I, Anders RF, Saul A, et al. (2003) Safety and immunogenicity of a three-component blood-stage malaria vaccine (MSP1, MSP2, RESA) against Plasmodium falciparum in Papua New Guinean children. Vaccine 22 (1) 30–41.
- 25. Miura K, Zhou H, Diouf A, Moretz SE, Fay MP, et al. (2009) Anti-apical-membrane-antigen-1 antibody is more effective than anti-42-kilodalton-merozoite-surface-protein-1 antibody in inhibiting plasmodium falciparum growth, as determined by the in vitro growth inhibition assay. Clin Vaccine Immunol 16 (7) 963–8.
- 26. Duncan CJ, Sheehy SH, Ewer KJ, Douglas AD, Collins KA, et al. (2011) Impact on malaria parasite multiplication rates in infected volunteers of the protein-in-adjuvant vaccine AMA1-C1/Alhydrogel+CPG 7909. PLoS One 6 (7) e22271.
- 27. Duncan CJA, Hill AVS, Ellis RD (2012) Can growth inhibition assays (GIA) predict blood-stage malaria vaccine efficacy? Human Vaccines and Immunotherapeutics 8 (6) Epub ahead of print.
- 28. Takala SL, Coulibaly D, Thera MA, Batchelor AH, Cummings MP, et al. (2009) Extreme polymorphism in a vaccine antigen and risk of clinical malaria: implications for vaccine development. Sci Transl Med 1 (2) 2ra5.
- 29. Duan J, Mu J, Thera MA, Joy D, Kosakovsky Pond SL, et al. (2008) Population structure of the genes encoding the polymorphic Plasmodium falciparum apical membrane antigen 1: implications for vaccine design. Proc Natl Acad Sci U S A 105 (22) 7857–62.
- 30. Ogutu BR, Apollo OJ, McKinney D, Okoth W, Siangla J, et al. (2009) Blood stage malaria vaccine eliciting high antigen-specific antibody concentrations confers no protection to young children in Western Kenya. PLoS One 4 (3) e4708.
- 31. Sagara I, Dicko A, Ellis RD, Fay MP, Diawara SI, et al. (2009) A randomized controlled phase 2 trial of the blood stage AMA1-C1/Alhydrogel malaria vaccine in children in Mali. Vaccine 27 (23) 3090–8.
- 32. Ouattara A, Mu J, Takala-Harrison S, Saye R, Sagara I, et al. (2010) Lack of allele-specific efficacy of a bivalent AMA1 malaria vaccine. Malar J 9: 175.
- 33. Lyon JA, Angov E, Fay MP, Sullivan JS, Girourd AS, et al. (2008) Protection induced by Plasmodium falciparum MSP1(42) is strain-specific, antigen and adjuvant dependent, and correlates with antibody responses. PLoS One 3 (7) e2830.
- 34. Dutta S, Sullivan JS, Grady KK, Haynes JD, Komisar J, et al. (2009) High antibody titer against apical membrane antigen-1 is required to protect against malaria in the Aotus model. PLoS One 4 (12) e8138.
- 35. Pombo DJ, Lawrence G, Hirunpetcharat C, Rzepczyk C, Bryden M, et al. (2002) Immunity to malaria after administration of ultra-low doses of red cells infected with Plasmodium falciparum. Lancet 360 (9333) 610–7.