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To describe the evaluation of optical coherence tomography (OCT) scans in the Muliticenter Uveitis Steroid Treatment (MUST) trial and report baseline OCT features of enrolled participants.
Time domain OCTs acquired by certified photographers using a standardized scan protocol were evaluated at a Reading Center. Accuracy of retinal thickness data was confirmed with quality evaluation and caliper measurement of centerpoint thickness (CPT) was performed when unreliable. Morphological evaluation included cysts, subretinal fluid,epiretinal membranes (ERMs),and vitreomacular traction.
Of the 453 OCTs evaluated, automated retinal thickness was accurate in 69.5% of scans, caliper measurement was performed in 26%,and 4% were ungradable. Intraclass correlation was 0.98 for reproducibility of caliper measurement. Macular edema (centerpoint thickness ≥ 240um) was present in 36%. Cysts were present in 36.6% of scans and ERMs in 27.8%, predominantly central. Intergrader agreement ranged from 78 − 82% for morphological features.
Retinal thickness data can be retrieved in a majority of OCT scans in clinical trial submissions for uveitis studies. Small cysts and ERMs involving the center are common in intermediate and posterior/panuveitis requiring systemic corticosteroid therapy.
Optical coherence tomography (OCT) provides cross-sectional images of the retina with differential reflectivity characterizing the retinal layers and various morphological features. OCT scans have been widely used to objectively assess retinal thickening in clinical trials in various diseases.1-4 Macular edema traditionally has been assessed using stereoscopic color photographs with graders assessing the percentage of elevation within the subfields of the ETDRS grid. 5 OCT scans have changed macular edema assessment options by providing an objective measure of the retinal thickening using a similar grid with subfields.6 In addition,OCT allows identification of intraretinal fluid in the form of cysts and subretinal fluid. The cross-sectional imaging also is advantageous for assessment of vitreoretinal interface abnormalities. Retinal distortion due to epiretinal membrane (ERM),and adherence of the posterior vitreous surface can be well characterized. 7
The Multicenter Uveitis Steroid Treatment (MUST) Trial is an ongoing study to compare standardized systemic therapy versus fluocinolone acetonide implant therapy for the treatment of active or recently active (within 60 days) cases of non-infectious intermediate uveitis, posterior uveitis or panuveitis.8 One of the goals of the study is to evaluate the incidence and outcomes of major ocular complications of uveitis. In the MUST Trial, imaging modalities including color photographs, fluorescein angiography, lens photographs and time-domain OCTs are used in a standardized fashion to assess the ocular complications. Here,we report the reproducibility of the evaluation method and baseline OCT features in the MUST Trial.
OCT images are obtained using the Stratus OCT-3 (Carl Zeiss Meditec, Dublin, California). All OCT operators and OCT machines are certified by the University of Wisconsin Reading Center. OCT scans are acquired using the fast macular scan protocol (128 A scans/B scans; 6.0 mm line length; 6 radial scans) and processed through the 'retinal map (single eye)' and 'retinal thickness (single eye)' analysis programs in the Stratus software (Carl Zeiss Meditec, Dublin, California). Additional high resolution scans are captured using the cross hair scan protocol ( 512 A scans/B scan) and processed to generate a vertical and horizontal B scan using the 'align process' algorithm in the Stratus software. The operators performed a preliminary quality check on the OCT scans before submitting to the Reading Center. Due to the lack of commercially available standalone review software at the time of this study, paper prints of the fast macular retinal map thickness report—the six retinal thickness reports showing the six radial B scans and two align process reports with the vertical and horizontal cross hair B scans—were submitted to the Reading Center. To ensure consistent, standardized data capture throughout the life of the study, the study leadership decided not to shift to digital or to spectral domain OCT evaluation during the course of the study. Subject identifiers other than a study number were removed from all images in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
At the Reading Center, OCT evaluation is performed by trained and certified non-physician ocular disease evaluators (graders). All OCT scans are evaluated independently with no reference to any other visit or the results of any other imaging modality from the same visit. Each OCT scan is evaluated by a single evaluator. The evaluation procedures consisted of 3 parts; the check-in process, quality scoring and morphological assessment. The check-in process consists of a careful verification that the images had been taken in accordance with the scan protocol and that all required paper prints had been submitted. If verification indicates a problem, queries are sent to the clinical sites either for a repeat scan or a repeat submission, if possible.
Quality scoring of the OCT scan involves a detailed assessment of the map report and the B scans for evidence of image artifacts that could affect the retinal thickness data.9 B scans are reviewed to look for artifacts that could affect central subfield thickness; e.g.,errors in the segmentation algorithm (boundary line errors) and inaccurate centering of the macula within the B scan (decentration). A score of Good, Fair, Borderline or Ungradable is given based on this assessment. A score of Good indicates that no artifacts are present and all the automatically generated retinal thickness data can be used. In order for an OCT scan to be considered of Good quality,the additional features required are: signal strength of 5 or greater and a standard deviation of less than 10% for the center point thickness. Fair indicates that one or more of the non-central subfields contains inaccurate data. In these cases, the central subfield thickness and centerpoint thickness are utilized and the unreliable non central subfields are discarded. Borderline indicates that the central subfield and automated centerpoint thickness are unreliable and a manual measurement for the centerpoint is required (Figure 1). Ungradable score is given when the central subfield and automated centerpoint are unreliable and a manual measurement of centerpoint thickness cannot be performed. The reason for the borderline or ungradable quality, such as poor signal strength or presence of a confounding abnormality, is noted. Manual measurement of centerpoint thickness is performed on the paper prints of the retinal thickness reports using a handheld digital caliper (Product 9900; Precision Graphic Instruments Inc, Spokane, Washington) after computing a scale factor. 9
Morphological assessment includes assessment of presence and lateral extent of cysts, and subretinal fluid. Cysts are defined as rounded, non-reflective or minimally reflective spaces withinin the intraretinal layers and include the following features: at least 2mm in size on the B scan, rounded in shape,well defined walls with at least 75% of the wall discernable, with reflectivity comparable to the vitreous. Subretinal fluid is a well defined, non –reflective,bell shaped space between the posterior boundary of the neurosensory retina and the RPE. Lateral extent is categorized into involvement of central 1mm (central subfield) alone, involvement of central 2 mm or extension of cysts beyond central 2mm. In addition, the axial diameter of the cyst at the centerpoint is categorized as small (≤ 200 μ),medium(201 – 400μ) or large (> 400μ). The height of subretinal fluid at the centerpoint is measured with calipers similar to centerpoint thickness. The type of vitreoretinal interface abnormality is identified; epiretinal membrane (ERM) with and without vitreomacular traction and macular hole. If present,their location within and outside the central subfield is categorized.
Intergrader agreement is assessed on a quarterly basis to ensure good quality control. Approximately 5% of images are randomly selected and re-graded every quarter by all four graders participating in the MUST Trial. Intergrader agreement is assessed as the percentage of agreement using kappa statistics for categorical variables and intraclass correlation coefficients for continuous variables.
Of the 479 baseline eyes,OCT images were not available for 26(5.4%) eyes. OCT scanning was not performed in eyes with poor dilation secondary to synechiae, dense cataracts or vitreous opacities. Of the 453 OCT images, 315 (69%) were of good or fair quality (see Table 1). Caliper measurement of centerpoint could be performed in 119 (26%). Boundary line errors and decentration were the primary contributors to automated centerpoint thickness errors. Although this study of severe uveitis cases included many patients with media opacities, which interfered with photographic grading more frequently,8 center point thickness data were measureable in all but 19 (4%) of the 453 scans performed. Poor signal strength was the most common cause for ungradable quality. Confounding abnormalities such as macular hole (2 eyes) and vitreomacular traction (2 eyes) were the reason for missing data in 4 scans.
The mean centerpoint thickness was 268 (SD 185) um with 36 % of eyes qualifying for the definition of macular edema (centerpoint thickness ≥ 240 um). 8
Morphological features are tabulated in Table 2. Cystoid spaces were present in 166 (37%), absent in 264 (58%), and ungradable in 23 (5%). Almost 86% of cysts involved the central subfield and most eyes had small cysts (<200 microns in diameter). Subretinal fluid was seen in <1% of scans. ERMs were seen in 126 (28%) of eyes, mostly involving the central subfield.
Regrades were performed on 78 baseline OCT scans. Intergrader agreement for the categories of quality and morphological evaluation was substantial (Table3). Agreement on quality score was 88% (k =0.78). Of the 78 images, 16 required caliper measurement. The intraclass correlation between the original grade and the regrade for caliper measured centerpoint thickness was 0.98.
Central retinal thickness is an important endpoint for various clinical trials with macular edema, and is an important parameter in the clinical management of macular edema. Image artifacts affecting automated retinal thickness measurements are not disease-specific, but the frequency of the artifacts varies with the disease.10,11,12 In a large series of 3,794 OCTs with diverse retinal pathology, automated central retinal thickness was erroneous in 16% of scans in diabetic retinopathy,24% in vein occlusion and 55% in wet macular degeneration. 10 Evaluation for structural changes showed that 10% of scans could not be interpreted in eyes with uveitis. 13 Detailed evaluation of OCT quality has not been reported previously for eyes with uveitis, which is known to potentially result in macular edema, ERM and tractional changes,14 and a propensity towards media opacity. OCT Evaluation in the MUST Trial using a standardized protocol with evaluation at a central Reading Center showed that automated retinal thickness measurements were inaccurate in more than 30% of scans, demonstrating that simple use of the automated measurements is not adequate for research or clinical practice. However, manual measurement of thickness in cases with decentration or boundary line errors resulted in measurable thickness in nearly all cases, despite a high prevalence of cataract and vitreous haze in this uveitic population. 8 Our estimate that approximately 5% of eyes could not be scanned and 96% of eyes can be graded is useful in calculating the expected sample size when OCT-measured central retinal thickness data will serve as a key endpoint in clinical studies.15
Understanding the extent and pattern of artifacts observed in the setting of uveitis also is important to improve future iterations of the OCT software. In the time-domain OCT dataset from the MUST Trial, artifacts affecting the central retinal thickness measurement algorithm were more frequent than in diabetic macular edema and retinal vein occlusions.10 Boundary line errors accounted for almost 50% of scans with inaccurate automated central subfield thickness. Errors in inner boundary lines might be attributable to the higher frequency of ERMs, retinal traction and poor signal strength resulting from media opacity in severe uveitis cases (Figure 1 top). Errors in the outer boundary lines were due to changes at the level of the retinal pigment epithelium (RPE) such as scars, hard exudates, and fibrosis (Figure 1 bottom). The frequency of decentration also was higher than in clinical trials of diabetic retinopathy or retinal vein occlusion10, perhaps because a number of participants had poor visual acuity, non dilating pupils, lens opacities, vitritis, and/or disruption in macular anatomy due to pigment changes, scarring and media opacities, all of which could hinder centration.
The quality scoring system represents the accuracy of the automated central retinal measurements. A B scan with poor quality can still be evaluated for morphological changes. Despite the media problems described above, the number of scans with ungradable morphological data was <5% in the MUST Trial. The mean retinal thickness for the baseline OCT scans in the MUST trial was 268(+/−185)μ for intermediate and posterior/panuveitis cases.8 36% of eyes had macular edema at baseline, defined as a center point thickness ≥ 240 um. Characterization of the edema showed predominantly small cysts in the center. This is contrary to the distribution of edema described by Castellano et al for cases of iridocyclitis, where the edema was located predominantly in a ring around the center, perhaps reflecting the different sites of inflammation studied. In contrast to the report of Markomichelakis et al, in which 20% of 84 uveitic eyes with macular edema had subretinal fluid,14 fewer than 1% of MUST Trial cases had subretinal fluid. The higher frequency of subretinal fluid compared to the MUST trial could be attributed to the more severe baseline macular edema with a mean retinal thickness of 333(+/−171) μ. ERMs were also slightly lower in the MUST dataset (28% vs.40%). A difference in the methodology, specifically inclusion of globally adherent ERMs could attribute to this.7 The Reading Center methodology defines ERM as a hyper-reflective layer with a bridging effect over the inner retinal layers. This definition potentially excludes globally adherent ERMs if their reflectivity merges with that of the nerve fiber layer. Corrugation of inner retinal layers is also considered insufficient to identify an ERM. These detailed definitions are essential to maintain good intergrader agreement in clinical trials where evaluation is masked to other imaging modalities; i.e. OCTs are graded without information from color photographs. The agreement was substantial (k=0.67) for the presence and location of ERMs in the MUST trial.
Although the MUST trial employed time domain OCT, the data derived from this technology is still useful in the era of spectral domain OCT (SDOCT). Standardized data from such a large number of uveitis cases with a two year follow-up period is not yet available with SDOCTs. Studies have shown a lower frequency of artifacts with SDOCT but the types of artifacts largely remain the same16, 17. Thus,our results indicating that macular thickening can be imaged in the large majority of severe uveitis cases suggest that SDOCT is likely to be highly effective in imaging macular thickening in the uveitis setting. The reduced sampling of the macular area with time domain OCT may limit the evaluation of ERMs, requiring input from other imaging modalities to accurately diagnose this condition, whereas the high scan density, three dimensional viewing and higher resolution of SDOCT provide improved ability to visualize vitreoretinal surface abnormalities. 18
In summary, the time-domain OCT evaluation method used in the MUST trial is reproducible. Quality determination, with manual measurement in cases with boundary line errors or defective centration, is an integral part of OCT evaluation when retinal thickness data are used as clinical trial endpoints. In the majority of cases, retinal thickness data can be accurately obtained, even when a large number of eyes with compromised media and inflammatory macular injury are included. Macular edema in recently active intermediate and posterior/panuveitis most commonly is characterized by small central cystoid spaces.
Financial support: Supported by cooperative agreements from the National Eye Institute to Mount Sinai School of Medicine (U10 EY 014655), The Johns Hopkins University Bloomberg School of Public Health (U10 EY 014660), and the University of Wisconsin, Madison, School of Medicine (U10 EY 014656).
Glenn J. Jaffe, MD (Director); Shelley Day, MD; Annie Lee, MD; Cindy Skalak. Former Members: Claxton Baer, MD; Sai Chavala, MD; Michael Cusick,MD; Pouya Dayani, MD; Justis Ehlers, MD; Muge Kesen,MD Alex Melamud,MD; Jawad A. Qureshi,MD; Adrienne Williams Scott; Robert F. See, MD; Robert K. Shuler,MD.
Steven Yeh, MD (Director); Alicides Fernandes, MD. Former Members: Deborah Gibbs, COMT; Daniel F. Martin, MD; Sunil Srivastava, MD.
James P. Dunn, MD (Director); Ellen Arnold, BS; Jeff Boring, COA; Diane M. Brown, MSN, RN; Alison G. Livingston, BSN, RN; Terry Reed,COA. Former Members: Marie-Lynn Belair, MD; Stephen G. Bolton, CRNP; Joseph B. Brodine; Lisa M. Brune, BSN, RN; Anat Galor, MD; Adam Jacobowitz, MD; Meera Kapoor; Sanjay Kedhar, MD; Stephen Kim, MD; Henry A. Leder, MD; Yavette Morton; Kisten Nolan, BSN, MPH, RN; George B. Peters, MD, MBA; Priscilla Soto; Ricardo Stevenson, MD; Michelle Tarver-Carr, MD, PhD; Yue Wang, MD.
C. Stephen Foster, MD (Director); Linda Bruner; David M. Hinkle, MD; Jyothir Johnson; Danielle Marvell; Sana S. Siddique. Former Members: Sarah Acevedo,MD; Fahd Anzaar, MD; Tom Cesca; Angelica Contero; Kayleigh Fitzpatrick; Karina Q. Lebron, MD; Chandra Morgan; Nita Patel, MSW; Jennifer Pinto; Janet Sprague; Taygan Yilmaz.
H. Nida Sen, MD, MHSc (Director); Michael Bono; Denise Cunningham, CRA; Darryl Hayes, COA; Dessie Koutsandreas, BS, COA; Nupura Krishnadev, MD; Theresa Larson, MD; Annal D. Meleth, MD; Robert B. Nussenblatt, MD; Patti R. Sherry, BSN; Gregory L. Short, COMT; Wendy Smith, MD; Alana Temple, BSN. Former Members: Allison Bamji, RN; Hanna Coleman, MD; Geetaniali Davuluri, MD; Lisa Faia, MD; Chloe Gottlieb, MD; Guy V. Jirawuthiworavong, MD; Julie C. Lew, MD; Richard Mercer, COT; Dominic Obiyor, BSN; Cheryl H. Perry, BSN; Natalia Potapova, MD; Eric Weichel, MD; Keith J. Wroblewski, MD; Steven Yeh, MD.
Paul A. Latkany, MD (Director); Jason Badamo; Jenny Gallardo; Monica Lorenzo-Latkany, MD; Robert Masini; Susan Morell; Ann Nour; Meredith Sanchez; Kate Steinberg. Former Members: Kenneth M. Boyd; Jacek Jarczynski; Mirjana McGrosky.
Richard J. Stawell, MD (Director); Lisa Breayley; Carly D'Sylva; Julie Ewing; Lauren Hodgson; Ignatios Koukouras; Lyndell Lim; Cecilia Ling; Rachel McIntosh; Andrew Newton; Richard Smallwood; Ehud Zamir. Former Members: Nicola Hunt; Lisa Jones; Suzanne Williams.
Pauline T. Merrill, MD (Director); Pam Hulvey; Elaine Kernbauer; Scott Toennessen; Denise L. Voskuil-Marre , BS. Former Members: Bruce Gaines; Christina Giannoulis; Heena S. Khan, BA; Sarah J. Levine.
Robert C. Wang, MD (Director); Hank Aguado; Sally Arceneaux; Kimberly Cummings; Gary E. Fish, MD; Keith Gray; Nick Hesse; Susie Howden; Diana Jaramillo; Michael Mackens; Karin Mutz; Brenda Sanchez. Former Members: Jean Arnwine; David Callanan, MD.
Susan Lightman, PhD (Director); Lavanish Joshi; Simon Taylor; Hamish Towler; Rebecca Tronnberg. Former Members: Kate Edwards; Timothy Stubbs.
Gary N. Holland, MD (Director); Robert D. Almanzor, COA; Jose Castellanos, COT; Jean Pierre Hubschman, MD; Ann K. Johiro, NP; Parthu Kalyani; Michael A. Kapamajian, MD; Ralph D. Levinson, MD; Susan S. Ransome, MD. Former Members: Christine R. Gonzales, MD; Anurag Gupta, MD; Peter J. Kappel, MD.
William R. Freeman, MD (Director); Igor Kozak, MD; Vivian Nguyen; Debbie Powell, BBA. Former Members: Tom Clark,BSc, CRA; Denine E. Cochran, COT, CCRC,Joshua Hedaya, MD; Tiara Kemper; Jacqueline M. LeMoine; Megan E. Loughran, BA; Luzandra Magana; Francesca Mojana,MD; Victoria Morrison, MD; Stephen F. Oster, MD.
Ira G. Wong, MD (Director); Nisha Acharya, MD; David Clay; Claire M. Khouri, BA; Mary Lew, BA; Todd P. Margolis, MD, Jay Stewart, MD. Former Members: Salena Lee, BA, OD.
Debra A. Goldstein, MD (Director); Marcia Niec; Anna Castro-Malek; Howard H. Tessler, MD. Former Members: Catherine E. Crooke; Dimitry Pyatetsky, MD; Misel Ramirez.
Janet L. Davis, MD (Director); Thomas Albini, MD; David A. Pinto. Former Members: Daniela Castaño; Marie Chin; Macy Ho; Jaclyn L. Kovach, MD; Richard C-S Lin, MD; Efrem Mandelcorn; Jackie K-DNguyen, MD; Aura Pacini; Susan Pineda; Jose Rebimbas; Kimberly E. Stepien, MD; Claudia Teran.
Susan G. Elner, MD (Director); Rebecca Brown, COA; Linda Fournier, COA; Julie R. Gothrup, COA; Richard Hackel; Moella Hesselgrave, COA; Robert Prusak; Stephen J. Saxe, MD. Former Members: Melissa Bergeron, COA; Reneé Blosser, COMT; Carrie Chrisman-McClure; Deanna Sizemore, COA.
John H. Kempen, MD, PhD (Director); James Berger; Sheri Drossner; Joan C. DuPont; Albert M. Maguire, MD; Dawn McCall; Janice Petner; Laurel Weeney. Former Members: Tim Hopkins, MD; Monique McRay; Daniel Will, MD; Wei Xu.
Peter Reed Pavan, MD (Director); JoAnn Leto; Lori Mayor; Kim McDonald; Scott E. Pautler, MD; Wyatt Saxon; Judy Soto. Former Members: Maria Ortiz; Dee Dee Szalay.
Amani Fawzi, MD; (Director); Lupe Cisneros, COA; Elizabeth Corona; Jackie Douglass; Dean Eliott, MD; Margaret Padilla; Narsing A. Rao, MD. Former Members: Alexia Aguirre; Lawrence Chong, MD; Rahul Khurana, MD; Jennifer Lim, MD; Rachel Mead; Sylvia Ramos; Julie H. Tsai, MD.
Albert Vitale, MD (Director); Paul S. Bernstein, MD, PhD; Bonnie Carlstrom, COA; James Gilman, CRA; Sandra Hanseen, COA; Paula Morris, CRA; Diana Ramirez; Kimberley Wegner, BS, CRC.
John D. Sheppard, MD, MMSc (Director); Brianne Anthony; Amber Casper; Lisa Felix-Kent, COA; Jeanette Fernandez, COMT; Stephen V. Scoper, MD. Former Members: R. Denise Cole; Nancy Crawford; Rebecca De La Garza; Lisa Franklin; Krista Hamelin; Jen Martin; Rebecca Marx; Gregory Schultz, DD; Joseph Webb, BS; Pamela Yeager.
Rosa Y. Kim, MD (Director); Matthew S. Benz, MD; David M. Brown, MD; Eric Chen, MD; Richard H. Fish, MD; Shayla Hay; Jame Major, MD, PhD; Laura Shawver; Tien P. Wong, MD.
P. Kumar Rao, MD (Director); Rhonda Weeks. Former Members: Rajendra S. Apte, MD; Kevin J. Blinder, MD; Ashley Hartz; Pam Light; Gaurav K. Shah, MD; Russell VanGelder, MD, PhD.
Douglas A. Jabs, MD, MBA (Chair); Michael M. Altaweel, MD; Janet T. Holbrook, PhD; John H. Kempen, MD, PhD; Natalie Kurinij, PhD.
Douglas A. Jabs, MD, MBA (Chair); Robert D. Almanzor, COA; Michael M. Altaweel MD; Diane Brown MD; James P. Dunn, MD; James Gilman MD; Janet T. Holbrook, PhD; Gary N. Holland, MD; John H. Kempen, MD, PhD; Rosa Y. Kim, MD; Natalie Kurinij, PhD; Nancy Prusakowski, MS; Jennifer E. Thorne, MD, PhD. Former Members: Stephen G. Bolton, RN, BSN; Lisa M. Brune, RN, BSN; Tom Clark, CRA; Larry Hubbard, MAT; Daniel F. Martin, MD; Robert B. Nussenblatt, MD.
Janet Wittes, PhD (Chair); Michael M. Altaweel, MD; William E. Barlow, PhD; Marc Hochberg, MD; Janet T. Holbrook, PhD; Douglas A. Jabs, MD, MBA; Natalie Kurinij, PhD; Alice T. Lyon, MD; Alan G. Palestine, MD; Lee S. Simon, MD; Harmon Smith, PhD. Former Members: James T. Rosenbaum, MD.
John H. Kempen, MD, PhD (Chair); James P. Dunn, MD; Glenn J. Jaffe, MD. Former Members: Daniel F. Martin, MD.
Jennifer E. Thorne, MD, PhD (Chair); Nisha Acharya, MD; Douglas A. Jabs, MD, MBA; John H. Kempen, MD, PhD; Paul A. Latkany, MD; Robert B. Nussenblatt, MD; Albert Vitale, MD. Former Members: Russell VanGelder, MD, PhD.
Robert D. Almanzor, COA (Chair); Judith Alexander, BA, CCRP; Jeffrey A. Boring, COA; Deborah Gibbs, COMT; Salena Lee, OD, FAAO; Jennifer E. Thorne, MD, PhD (Advisor). Former Members: Wai Ping Ng, BS.
David S. Friedman, MD (Chair); Anna Adler, MS; Judith Alexander, BA, CCRP; Alyce Burke, MPH; Janet T. Holbrook, PhD; Joanne Katz, ScD; John H. Kempen, MD, PhD; Nancy Prusakowski, MS; Susan Reed; Jennifer E. Thorne, MD, PhD. Former Members: Nicholas Cohen; Sanjukta Modak, MS; Wai Ping Ng, BS.
Elizabeth A. Sugar, PhD (Chair); Lea Drye, PhD; Kevin Frick, PhD; Janet T. Holbrook, PhD; JoAnn Katz, ScD; Thomas Louis, PhD; Mark L. Van Natta, MHS. Former Members: Sanjukta Modak, MS; David Shade, JD.
Douglas A. Jabs, MD, MBA (Study Chairman); Yasmin Hilal, MHS; Melissa A. Nieves, BA; Karen Pascual, MBA; Jill S. Slutsky, MPA. Former Members: Colby Glomp; Maria Stevens, CM.
John H. Kempen, MD, PhD (Study Vice-Chairman).
Janet T. Holbrook, PhD, MPH (Director); Anna L. Adler, MS; Judith Alexander, BA; Jeff A. Boring, COA; Alyce E. Burke, MPH; Karen Collins; John D. Dodge; Lea T. Drye, PhD; Cathleen S. Ewing; Kevin D. Frick, PhD; David S. Friedman, MD, PhD; Rosetta Jackson; Joanne Katz, ScD; Andrea T. Lears, BS; Hope Livingston; Thomas A. Louis, PhD; Curtis L. Meinert, PhD; Jill L. Meinert; Vinnette Morrison, BS; Deborah J. Nowakowski; Nancy Prusakowski, MS; Dave M. Shade, JD; Rochelle E. Smith, BS; Karen Steuernagle; Elizabeth A. Sugar, PhD; Jennifer E. Thorne, MD, PhD; James A. Tonascia, PhD; Mark L. Van Natta, MHS; Richard Zheng, BS. Former Members: Paul Chen; Nicholas Cohen, MS; Sanjukta Modak, MS; Wai Ping Ng, BS; Weijiang Shen, BS; Charles Shiflett, BS; Ada Tieman, MBA.
Michael M. Altaweel, MD (Director); Wendy K. Benz, PhD; Geoffrey Chambers, MS; Debra J. Christianson, BS; Amitha Domalpally, MD; Jacquelyn Freund, MS; Vonnie Gama; Sapna Gangaputra, MD, MPH; Kathleen E. Glander, BBA; Anne Goulding, BA; Jeffrey M. Joyce, MS; Christina N. Kruse, BA; Dawn J. Myers, BS; Susan Reed, BS; James L. Reimers, BA; Amy Remm, BS; Ruth A. Susman, BS; Dennis Thayer; Erika Treichel, DVM; Kelly J. Warren, RN, BS, MSES; Sheila M. Watson, BS, DVM; James K. White, BME; Tara Wilhelmson, BS. Former Members: Margaret A. Fleischli, AB, DVM; Dennis Hafford; Susan E. Harris, MS; Larry D. Hubbard, MAT; Kristine A. Johnson; Lauren Nagle; Gwyn E. Padden-Lechten, BS; Alyson Pohlman, BA; Peggy Sivesind; Mary K. Webster, BS; Grace Zhang, BA.
Natalie Kurinij, PhD.
Conflict of interest: Dr Kempen is a consultant/advisor for Alcon, Allergan, Lux Biosciences, Sanofi Pasteur, Xoma and Dr Srivastava has received research grants from Bausch and Lomb, Novartis and Allergan. Drs. Domalpally, Altaweel,Myers,Davis,Foster,Latkany and Stawell have no conflicts to declare.
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Defensive tackle Ryan Sims may have been the preferred selection of the Minnesota Vikings, but landing offensive tackle Bryant McKinnie is far from being a consolation prize.
While the time leading up to the NFL Draft, also known as the "Smoke and Mirrors Show" was in full gear churning out rumor after rumor, there was one certainty that was established. The Vikings wanted Ryan Sims.
What came as a surprise was the Kansas City Chiefs traded up with the Dallas Cowboys to acquire the standout defensive tackle.
The ball of events actually started rolling with the third selection in the draft when the Detroit Lions nabbed quarterback Joey Harrington. The selection made sense and was the preferred selection of many in league circles, come draft day numerous teams in the top of the draft expected Detroit to select cornerback Quentin Jammer.
In Buffalo, the Bills stayed the course and selected mammouth offensive tackle Mike Williams. So far, so good. The Vikings were in good shape as their guy, Sims was still on the board.
With San Diego on the clock, the unexpected occured. A not-so-shocked Marty Schottenheimer couldn't have received a better gift. Jammer was on the board and was the player that the Chargers wanted. Wasting little time, the Chargers selected Jammer.
Everybody in the league knew that Dallas coveted safety Roy Williams from Oklahoma. Since the departure of Jimmy Johnson from Dallas a few years back, the Cowboys have gained the reputation as being a poor drafting organization.
Out of the blue, the Cowboys appeared to drop the ball. The Chiefs had their sites set on Harrington or Sims, The Insiders has learned. When Harrington went off the board, they knew that San Diego was not going to draft a defensive tackle, so they got into the trading game with Dallas. A deal was made with time running out on the clock and the selection of Sims was announced.
Sitting with the seventh selection, the Vikings were still in the position to draft a highly touted defensive tackle, a very good safety, or the obvious, Bryant McKinnie.
After some brief discussion, the Vikings decided they couldn't pass on the dominant McKinnie. Projected as a fixture at offensive left tackle for years to come, the decision was easy and should have been the preferred selection according to one league player personnel director.
"If you look at the Vikings roster, there was a need at left tackle, much more so than any position," the director said. "Last season their pass protection was marginal, the running game suffered. Drafting McKinnie shores up that entire mess they had on the left side of the line."
"Sims and Williams are very good players and would have helped that team, but McKinnie has as much upside or more than any player in this draft."
Draft Baubles: When comparing the Vikings draft to that of the competition in the NFC North Division, the Vikings have done the most to improve their team, according to one highly respected draft expert.
"Drafting McKinnie was a great move for Minnesota. Backing up that solid selection in choosing linebacker Raonall Smith in the second round and safety Willie Offord in the third round, the Vikings have filled some glaring weaknesses," the draft expert said. "Smith and Offord are players that many teams had rated lower than Minnesota, but these are two players that really fit into the Vikings scheme."
"They bring size, speed and athletic ability to the table, all things that Minnesota has lacked on the defensive side of the ball."

subset: commoncrawl


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On April 5, 2012 Club Penguin released a Dubstep Puffle video on YouTube. Today on July 5, 2012 the dubstep black puffle appeared at the Dock, the Ski Hill and other rooms for about 15 seconds and it will probably appear every 10 minutes. The dubstep songs starts playing when the black puffle appears. This is a picture of him:
This is the puffle at the Ski Hill:
And this is the Dubstep Puffle video posted by Club Penguin on YouTube:
Maybe the puffle celebrates the victory of the Superheros at the party that just ended. I don't think it's appropriate that Club Penguin promotes dubstep music to kids, especially when they make hidden items easier and easier to find. Doesn't really make sense.


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Running Time: 114 minutes
Released: 12/2015
Studio Name: Club Innocence
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Responses to the President
Posted on Sep 14, 2007
Find out what Joe Biden, John Edwards and Rudy Giuliani thought about President Bush's speech. (Hint: One of them really liked it.)
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By don knutsen, September 15, 2007 at 10:58 am Link to this comment
FOX + Guilianni, boy theres a recipe for some straight talk. Notice the footage from Iraq being played of soldiers shaking hands in the market place….all is rosy, should be seeing the roses being tossed to the occupiers any time now. Despite what FOX News, Gulinani, or this White House would have us believe. This is not the atmosphere in Iraq except when there is an orchestrated presence of massive military hardware and soldiers to temporarily insulate a photo op for the camera. Similar to when McCain walked thru the market exclaiming all was rosy there, only to have a suicide bomber strike a day or two after in the same market after our cameras and military support for the photo op had left. Guilianni has no more respect or love for our democracy then the current chimp-in-chief, as slimy a political oppurtunist as there ever was, I'd imagine he'll be hiring Rove atleast on retainer soon. Because it isn't about the substance of the man, its only about the perception. Since this administration is still, after all that has come out, in power, we as a country seem to have rendered the truth as quaint and obsolete a concept as say the Geneva Conventions or Habeus Corpus.
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Puerto Rico Utility Ready To Refund
Related Articles
- HTA bond deal likely pushed back to 2013. Marino, John // Caribbean Business;10/4/2012, Vol. 40 Issue 39, p2
The article reports on the possibility for the Puerto Rico Highway & Transportation Authority (HTA) bond deal of $2 billion to rollback in 2013. HTA intends to use the bond to pay off Government Development Bank (GDB) loans and raise capital for public works amounting to $400. It clarifies that...
- GDB to issue $2 billion in bonds by year's end. Ruiz-Calderon, Maricelle // Caribbean Business;8/26/1999, Vol. 27 Issue 33, p4
Reports on the Government Development Bank's expected issuance of bonds before the end of 1999. Raising of funds to finance municipal, educational, tourism and road improvement projects; Specific projects earmarked for funding.
- GCB preparing $500 million bond issue. Prieto, Wilfredo // Caribbean Business;3/5/1998, Vol. 26 Issue 9, p6
Reports that a bond issue of approximately $500 million is being prepared for May 1998 by the Government Development Bank. Objectives of the bond issue; Benefits of the bond issue to Puerto Rico; Detailed information on the bond issue.
- Juan Agosto Alicea, Government Development Bank for Puerto Rico. // Bond Buyer;03/05/2001, Vol. 335 Issue 31089, p19
Focuses on the operation of the Government Development Bank for Puerto Rico. Attempt of competing in the global economy; Operational strategy; Names of associated companies; Cost and recipients of bond issuance; List of subsidiaries.
- GDB busy financing road and water projects. Ruiz-Calderon, Maricelle // Caribbean Business;5/20/1999, Vol. 27 Issue 19, p6
Reports on the plans of Puerto Rico's Government Development Bank (GDB) to issue about $1.75 billion in bonds before the end of 1999. Amount of bonds to be issued for roads, municipalities, government and education.
- GDB to sell two bond issues; Fiscal '98 total $2.22 billion. Casellas, Carmen T. // Caribbean Business;11/20/1997, Vol. 25 Issue 46, p2
States that the Government Development Bank (GDB) has announced two bond issues totalling $825 million. Dates the bonds will be made; Details on the bonds; Comments from GDB Executive Vice President Lourdes Rovira.
- Highways' $1.16 billion bond sale a hit. Cintron, Hiram // Caribbean Business;7/29/1993, Vol. 21 Issue 30, p12
Reports on Puerto Rico's Government Development Bank's success in the placement of bonds in Wall Street. Oversubscription to the Highways & Transportation Authority $1.16 billion issue; Average coupon rate; Use breakdown for the issue; `Baa-1' classification from Moody's Investors; `A' rating...
- Puerto Rico GDB Denies Port Authority Plans Bond. Slavin, Robert // Bond Buyer;4/3/2014, Vol. 123 Issue 34087, p1
The article reports that Government Development Bank of Puerto Rico spokesman has denied a report that the Puerto Rico Ports Authority has planned to sell a bond by the end of June 2014.
- GDB completes $1.257 billion bonds sale. Carmona, Jose L. // Caribbean Business;5/31/2001, Vol. 29 Issue 22, p8
Reports on the completion of a bond sale at Government Development Bank for the Commonwealth of Puerto Rico. Provision of a budget for construction projects; Refinancing of the government's debt.


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Mosquitoes are pestering. And if you are in the Midwest (or different extraordinarily sticky region) you can't go for a stroll on a season dark short being bitten by a mosquito. They kind in the vicinity hose and they worship humidity, and when dark falls, they high regard the cool air so they go try to discovery a meal, YOU. Luckily, you may have a answer if you push garlic.
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login with
love doing mommmy duties..
love doinq mommy duties...
Comment deleted
i have alot of mommy duties? i love them but i get very irritated off of them but it be days i love them. cause i have to go right behind him he makes a mess every 2 minutes.
Comment deleted
lol. i only have one and he is 1/2 about to b two in april and i have a stepdaughter she 5 but i had her since she was 3
it is both so much fun and can be frustrating at times but always rewarding
About kelly white
Current: Greensboro, North Carolina
Birth: June 02
On Moms.com since: Feb 7, 2014
...hi my name is kelly im a mother of 1 and he is 2years old... And a Stepdaughter that is 6years old im a proud mother full time enjoyin the mother duties..
All Recent kelly's Posts
hi moms good afternoon sorry i havent been online.... i will hit u with the updates real soon. love kelz
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hi moms coming throuqh to hit u with the update ok so me & the father of my son is currently on a break but im still planning for my 2nd child and still kind of confused on how to plan this out.


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- 2 pounds green beans
- 1/2 cup extra-virgin olive oil
- 3 large garlic cloves, minced
- 3/4 teaspoon crushed red pepper
- 2 pounds cherry tomatoes, halved
- Salt
Bring a large pot of salted water to a boil. Add the green beans and cook over high heat until crisp-tender, about 8 minutes. Drain well.
Meanwhile, in a large, deep skillet, heat the olive oil until shimmering. Add the garlic and crushed red pepper and cook over moderate heat until fragrant, about 20 seconds. Add the tomatoes, cover and cook until softened, about 5 minutes. Add the green beans, season with salt and simmer over moderate heat until tender, 4 to 5 minutes. Serve the beans warm or at room temperature.


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Question: Describe the five step approach to combining nominal and real forecasts
Describe the five-step approach to combining nominal and real forecasts.
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View Solution:
Answer to relevant QuestionsAssume that inflation unexpectedly increases by 10 percent. Explain why a company's ROIC then needs to increase by more than 10 percent to preserve its shareholder value. Are there conditions under which you should consider using a local market risk premium and a local beta estimate for a valuation rather than a global risk premium and beta? Under what circumstances should a manager apply a standard NPV approach, a DTA approach, or an ROV approach to valuation? What is the importance of purchasing power parity when you are trying to establish value for a company located in an emerging market? Why do most young, high-growth companies have negative earnings?
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We all know that the week of Halloween begins with many haunts and scares. However, once we are done devouring candy, you should prepare yourself for a big gaming release schedule this week. There are many hot videogames coming out on November 1.
First off, we will begin with one of the most anticipated games of the year, Uncharted 3. Uncharted 3 once again has us controlling the character Nathan Drake as his adventures take him throughout the world. What really stands to set this Uncharted game apart from the other games in the series is the far improved multiplayer. Many people have already got the opportunity to go ahead and try out the multiplayer either in the beta mode or by using one of the Subway codes. As someone who has played it already, I'll testify that the multiplayer is pretty amazing. Also coming out this week is the re-make of a gaming classic, Goldeneye. GoldenEye 007: Reloaded features many graphical updates to the classical game. However, most intriguing is the addition of a new mode known as 007 Classic. In this mode, players are given the original HUD and read-outs, but with the updated graphics and AI.
Finally, the week wraps up with two more classic franchises – The Lord of the Rings and Sonic. The Lord of the Rings: War in the North is a role-playing game. Players have the ability to control three different characters - Eradan, the Human Ranger, Farin the Warrior Dwarf, and Andriel, the Elven Loremaster. The blue hedgehog returns in the game Sonic Generations. This game involves many fun aspects including time travel as Sonic travels back into the past and meets himself. Where the adventure goes from here is difficult to say? But also where the fun of the game comes in. Which of these games are you looking forward to playing the most?


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Fruity Loops Tutorial. Part 1
Ever wanted to write electronic music? Make a beat for your rap? Or just make some drums and bass to play your guitar too? The series will explain everything. This first part covers the basics of Fruity Loops.
PreambleI know this is ultimate-guitar.com, not ultimate-techno, ultimate-synth, ect. But, there is something to learn from every style of music. Not so mention, with the right soundfonts and samples, you can write a professional sounding backing tracks for your song. (Will probably include something in a later lesson.) This program isnt the best sequencer out there, but it is easier than most, and it can produce results just about as amazing as Reason or Cubase. I used FL Studio 6 XXL. Obtain it somehow.
Using Fruity Loops
|These are some of the basics of Fruity Loops, the next chapters will cover more techniques I use, how to program a Sytrus synth, how to make a complete song, and how to mix and master it! Download the Fruity Loops project file here.


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|Message view
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|"Jeff Kilbride" <j...@kilbride.com>
|Re: LinkageError running 4.0.1 on IBM 1.3.0 VM
|Mon, 19 Nov 2001 21:20:45 GMT
Hi Robin, I'm using the IBM JDK on Linux (RH7.1 w/2.4.14 kernel) with TC 4.0.1 without any problems. The only difference I can see from your setup is that my JAVA_HOME variable points to the toplevel of the IBM directory structure: /usr/local/java/IBMJava2-13 not /usr/local/java/IBMJava2-13/jre I get this output when I run startup.sh: ----------- Using CLASSPATH: /usr/local/java/jakarta-tomcat-4.0.1/bin/bootstrap.jar:/usr/local/java/IBMJa va2-13/lib/tools.jar Using CATALINA_BASE: /usr/local/java/jakarta-tomcat-4.0.1 Using CATALINA_HOME: /usr/local/java/jakarta-tomcat-4.0.1 Using JAVA_HOME: /usr/local/java/IBMJava2-13 ----------- Notice that the CLASSPATH contains the "tools.jar" file. On yours it doesn't. Don't know if this will make a difference or not, but I don't see anything else that's obvious. Thanks, --jeff ----- Original Message ----- From: "robin" <email@example.com> To: <email@example.com> Sent: Monday, November 19, 2001 10:09 AM Subject: LinkageError running 4.0.1 on IBM 1.3.0 VM Hi, I'm trying to run Tomcat 4.0.1 under the IBM JVM 1.3.0. If I start by unpacking the archive, and then use the startup.sh script, after setting my path and unsetting my classpath I get the following output from the scripts: Starting... Using CLASSPATH: /usr/local/jakarta-tomcat//bin/bootstrap.jar Using CATALINA_BASE: /usr/local/jakarta-tomcat/ Using CATALINA_HOME: /usr/local/jakarta-tomcat/ Using JAVA_HOME: /usr/local/IBMJava2-13/jre/ This seems healthy enough, but logs/catalina.out contains: Catalina.start: LifecycleException: start: : java.lang.LinkageError: Class java/net/URL violates loader constraints LifecycleException: start: : java.lang.LinkageError: Class java/net/URL violates loader constraints at java.lang.Throwable.<init>(Throwable.java:84) at java.lang.Exception.<init>(Exception.java:35) at org.apache.catalina.LifecycleException.<init>(LifecycleException.java:126) at org.apache.catalina.loader.WebappLoader.start(WebappLoader.java:641) [ etc. etc. ] Which is decidedly less healthy, and the server won't respond to any requests. I tried the same thing using sun's jdk 1.2.2, and got: Starting... Using CLASSPATH: /usr/local/jakarta-tomcat//bin/bootstrap.jar:/usr/local/jdk1.2.2//lib/tools. jar Using CATALINA_BASE: /usr/local/jakarta-tomcat/ Using CATALINA_HOME: /usr/local/jakarta-tomcat/ Using JAVA_HOME: /usr/local/jdk1.2.2/ from the script, and a working server. The platform is linux 2.2.12-20 on a PIII. After I hit this problem, I tried building from source under the IBM jvm, mainly to see whether it would throw up anything useful. I hit on a 'sealing violation' right at the beginning of the build, in ANT, and this reproduced on the sun jvm . I am aware that this means that there are more than one jar containing members of a package and at least one of them is sealed. I tried clearing the classpath altogether, but got the same problem. In any case - all I want is a binary version which works with the IBM vm. Am I doing something obviously wrong? Thanks. -Robin Barooah -- To unsubscribe: <mailto:firstname.lastname@example.com> For additional commands: <mailto:firstname.lastname@example.com> Troubles with the list: <mailto:firstname.lastname@example.com>
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By: Dalraj Bains Basketball Timeline Dr. James Naismith
(November 6, 1861 – November 28, 1939) Three Point Line (1933) NBA (National Basketball Association) (1946) The 24 Second Shot Clock (1954) Kevin Garnett (1995-Present) Larry Bird (1979-1992) Yao Ming (1997-2011) Magic Johnson (1979-1996) Toronto Raptors (1995) Phil Jackson (NBA -1967-1980) (Coach -1989-2011) Air Jordan (1985) Toronto Huskies (1946-1947) Wilt Chamberlain (October 24, 1959) WNBA (April 24, 1996) Michael Jordan (1984-2003)
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Melbourne has been pumping out some great indie-dance acts of late – Back Back Forward Punch and DEJA are testament to this.
Joining the ranks of brilliant up-and-comers are Philosophy Of Sound. The disco duo have just released the music video for their latest single. 'Freedom, What For?' sports a deep, dirty groove that is begging for a good ass shaking.
Dig it? Check out the video for Philosophy Of Sound's debut single of 2011, called 'It Is Like That':


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A hacked email released by WikiLeaks exposes that Clinton's team was in a panic over a pending story the NY Times was about to break, revealing Clinton had attended meetings for the SuperPAC "Priorities USA."
According to FEC regulations, SuperPACS are supposed to be completely independent of a campaign. "These expenditures may not be made in concert or cooperation with, or at the request or suggestion of, a candidate, the candidate's campaign or a political party," states the regulations.
On Wednesday, May 6, 2015, campaign spokesman Jesse Ferguson sent out an SOS to Hillary Clinton and her team, including campaign finance chair Dennis Cheng, campaign manager Robby Mook, and communications director Jennifer Palmieri.
Ferguson wrote:
"FYI – the New York Times will soon report that HRC is doing meetings for Priorities USA. We have NOT confirmed the meeting and will not be confirming these types of meetings. We are, however, reflecting how will support Priorities USA work where needed and framed this up. If you get press questions as follow ups on this, please send them to me."
Palmieri wrote back that someone from Priorities USA must have been "yapping", and admitted that NYT had sources about the meetings.
"So afraid that NYT is going with this story on Priorities whether we like or not. They have sources about the meetings. Honestly, it sounds like Priorities staff was yapping. We are not confirming meetings on this trip but commenting on why we are participating with Priorities."
Cheng responded, asking, "Are they reporting any specific donor names?"
Clearly, they knew they were in hot water if this story came out.
The NY Times reported in September 2016 that Priorities USA raised $21.6 million in August, bringing their combined donations and pledged donations to $161 million for this election cycle.
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Actor Jon Voight's Plea To Save America


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The CL2 - HY-TEK Meet Results File is the plain text file format created and used by the HY-TEK Sports Software program. While the HY-TEK program is now saving files in a .HYV file format the CL2 format can still be used to open in HY-TEK but will save as HYV format for future use.
The HY-TEK Sports Software and the associated CL2 and HYV file formats are used to keep track of a number of things in sports meet. With these files you are able to maintain a meet schedule ensuring time and place of the meet. As the sporting event takes place any number of other data can be entered into the program and saved into these files. All participant information including participant names, events the person is participating in and participant scores.
This, of course, allows an easy way to keep track of the athletes, their events and performance outcomes in one file. With this information it becomes easier to track team or individual statistics through out a season or series of events. HY-TEK files, used in this way can be great way for a fan, coach or player to keep the necessary statistics handy.


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"Deterioration Of The Fight Or Flight Responce" is the twenty-sixth episode of the second season of Grey's Anatomy and the 35th produced episode of the series. It is also the 35th produced episode of the Grey's Anatomy franchise. It was broadcast on May 15, 2006.
After cutting Denny's LVAD wire in her bid to make sure he gets the heart, Izzie places her surgical career on the line while George, Cristina and Meredith all find themselves trying to help her save Denny's life while Bailey goes on the offensive when she discovers the truth about the situation. Derek wrestles with the life of one of his friends and colleagues being in his hands after Burke's shooting and Cristina struggles with standing by her man during his time of need while Richard's family life faces a challenge when Adele arrives at the hospital with his niece.
- "Human beings need a lot of things to feel alive. Family. Love. Sex. But we only need one thing to actually be alive. We need a beating heart. When our heart is threatened we respond in one of two ways. We either run or we attack. There's a scientific term for this: fight or flight. It's instinct, we can't control it. Or can we?"
- "Universe & U" - KT Tunstall
- "Look At Her Face" - The Coral Sea
- "Through The Backyards" - Au Reviour Simone
- "How We Operate" - Gomez
Title ReferenceEdit
This episodes' title references the album Deterioration Of The Fight Or Flight Responce, originally sung by The Flaming Lips


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Summer Camp Challenges and Tips
July 6, 2012
Summer sports camps are a terrific way to immerse youth players into sports for an extended period of time. There are a variety of summer camp offerings to select from and children respond differently to camps than seasonal programs.
Summer sport camps are so different than the seasonal sport activities our children engage in during the traditional sport seasons. Sport camps are offered in the hot and humid summer months which means children are not only dealing with meeting new coaches and friends, they are battling the discomfort of playing in the heat.
Parents can help! Be sure to pack two water bottles for camp. I am certain camps will allow for water breaks but sometimes players do not want to leave their station or team to fill up. So, let's give them some extra water with ice. Why water? Most sport drinks contain sugar and we need to hydrate our bodies with the purest sport drink out there – water.
Many camps are now on turf fields that radiate more heat off the surface and on to our bodies. Campers need to wear sunscreen throughout the day. Parents should diligently apply sunscreen before camp and send the player off to camp with the easiest type of sunscreen to apply – spray sunscreen!
It does not matter what type of sports camp your child is attending. If hats or helmets are not part of the equipment, make sure your camper is wearing one. The sun exposure is high during camp since these players are on the field all day (9am to 3pm for example) with the exception of a lunch break. Hats should be worn to protect their eyes and skin.
Camp is exhausting for youth players whether they are first timers or regulars. Most campers will fall asleep on the ride home or before dinner. These campers are tired from being active all day, engaging in conversations, and from the heat. A quick shower or dip in the pool once they get home may help get them re-energized.
Summer sports camp can be an exciting new time for youth players. As parents, we need to send them in with all the tools they need – from extra water bottles, to a rain jacket, and even an extra set of clothes in case they get wet. Big bags are the norm for summer camps – do not be afraid to over pack!


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Patriots QB Tom Brady continued the company line of "bumps and bruises" this morning and did not reveal whether his injured shoulder will be ready for Week 1.
Said Brady in remarks to a Boston radio station (via theBoston Globe):
"Well, there's a chance I won't make it down to the stadium in the next 30 minutes. There's a lot of time before that game. As I said, there's a lot of players on our team that have bumps and bruises. I have bumps and bruises. It's a physical game. I fell a little bit awkwardly, but I'm expecting to be out there and I'm expecting to play this week if coach lets me. We'll see how the week goes."
The Patriots said Friday that Brady had a "sore shoulder" after he was hit by Redskins DL Albert Haynesworth. Said Brady of the hit, "any time a 350-pound man lands on you, most people would be a little sore -- which I was."
The Patriots open on Sept. 14 -- two weeks from today -- against Buffalo. If Brady cannot play, their starter would be a question mark. They cut backup QB Kevin O'Connell on Sunday, leaving only rookie Brian Hoyer and Andrew Walter, picked up earlier this month, as the only backups. It's possible they could pursue a veteran such as A.J. Feeley (Eagles), Damon Huard (49ers) or Todd Collins (Redskins) by trade.
Brady said it's too early to predict whether he can make his first regular-season appearance since suffering a torn ACL in last year's opener.
Said the Patriots QB:
"What does it matter? We don't play for two weeks, so the reality is that no matter what I say – how confident I am – we're just going to have to wait until September 14, or hopefully this Thursday if coach lets us play. Traditionally, he doesn't let (me) play in this game. If he wants me to play, I'll play. For me to make a bunch of predictions on something that is two weeks away, I don't understand what the point is of that."
-- Sean Leahy
Nate Davis is a reporter, blogger and editor who's been at USA TODAY since 2000. He has covered the NFL since 2005. No, he did not play quarterback for Ball State. Davis' succession of our esteemed colleague Sean Leahy at The Huddle is considered a Brady-for-Bledsoe swap by most "insiders."More about Nate


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At every conference and trade show I've attended this year, one major topic came up without fail: plastics recycling.
This isn't a new initiative and it's certainly not going away anytime soon. Not with the plastics recycling rate hovering around 8%, according to figures from the EPA.
But it's not as if people don't have the opportunity to recycle. After all, the American Chemistry Council (ACC) says more than 80% of Americans have easy access to plastics recycling opportunities, whether you participate in a municipal curbside program or live near a drop-off site.
Still, a national survey found that most Americans aren't feeling confident they're doing enough to help the environment and most say they don't know how, according to ACC's Plastics Make it Possible, which commissioned the survey by Kelton Research .
Only 37% of Americans in the survey say they're "doing enough for the environment," and less than half (46%) say they are "knowledgeable about what it takes to be eco-friendly in my daily life." Two-thirds of Americans say they would like to learn some simple steps that can help the planet.
Well, I guess you can say it's good to know that people do want to help and learn how to be "eco-friendly." People should be encouraged to recycle for many reasons, and the industry definitely has a business case for it.
Market demand for post-consumer recycled plastics
According to a new industry study from ReportLinker, U.S. demand for post-consumer recycled plastics is forecast to rise 5.9% per year to 3.4 billion lb in 2016.
This increase will be driven by a number of factors, including a growing emphasis on sustainability among packaging and consumer product manufacturers, advancements in processing and sorting technologies allowing a wider variety of plastic to be recycled, and an improved collection infrastructure that raises the plastic recycling rate, the study states.
Continued support by federal, state, and local governments for recycling efforts will also provide a significant boost to recycled plastic collection, processing, and demand. Packaging will continue to be the leading market for recycled plastic in 2016, with the strongest gains expected for food and beverage bottles and clamshell containers, fueled by rising production of recycled resins suitable for food contact uses.
However, the overall rate of plastic recycling in the U.S. will remain relatively low -- 6.5% of total plastic demand in 2016 -- as the study reports the industry faces a number of challenges.
Recycling is minimal in several major plastic markets, including construction products, motor vehicles (other than batteries), and packaging film, due to a lack of collection capability or economical processing. Export sales (particularly to China) siphon off a substantial portion of plastic scrap, and much of what is processed domestically has high levels of contamination. As a result, only 53% of the plastic collected for recycling makes its way to manufactured products in the U.S. market.
Still, the report says that bottles will remain the leading source of plastic for recycling, accounting for about half of all plastic collected in 2016. More rapid gains, however, are


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login with
5 1/2 weeks of third pregnancy and showing already
This is pretty common, especially with subsequent pregnancies. Your body remembers how to grow to accommodate your pregnancy and it is getting ready. Fluid retention and gas bloating are also very common at this stage of pregnancy. Your baby and uterus are still very tiny and hiding behind your pubic bone. It will still take some time for your actual baby to be showing. You might want to consider when and how you are going to announce your pregnancy because your body may give your secret away soon!
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About Katie
Birth: November 24
On Moms.com since: Jan 21, 2014
***Community Manager of Moms.com*** Mom to four amazing children. I am passionate about helping and supporting new moms as they enter into motherhood. I am a certified doula, certified childbirth educator and an accredited breastfeeding counselor.


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Remembering the 2015 Sapporo Snow Fest
- On:
- In: Sightseeing and Experiences
- Tags: contributor post,Events and Entertainment,festivals
- 9
by Odigo Contributor KIRSTY BOUWERS
First posted in February 2015. Updated January 12th, 2016
The time has come to start planning your visit to the 2016 Sapporo Snow Festival in Hokkaido, Japan. To get an idea of what is on offer, check out this post from last year, and stay tuned for more information in the coming weeks!
What do Star Wars, the Manila Cathedral and Doraemon have in common? They were all replicated in snow at the Sapporo Snow Festival in 2015. Over a million visitors descend upon Odori Park and surroundings each year to enjoy all the festival has to offer.
Star Wars at the 2015 Sapporo Snow Festival by Kirsty Bouwers
During the day, people meander along the main site, admiring the sculptures up close and sampling different local specialities offered at the various food stalls. The biggest statutes are near the Sapporo Television Tower, with smaller sculptures on display toward the far end of the park. The sculptures portray a range of subjects, although the smaller ones (often designed by local schools) are heavily anime-influenced.
Some sculptures carry a more nostalgic feel. This one of a mother bathing her child was a personal favourite:
Sapporo Snow Festival 2015 by Kristy Bowers
With 12 blocks chock-full of artwork and stalls, wandering around for a good few hours is easy. Most people start near the TV tower and work their way towards the smaller sculptures, but I recommend starting at the other end instead, going from small to big (and impressive).
Sapporo Snow Festival 2015 by Kristy Bowers
More entertainment is provided by the ski-jump close to the TV tower. Local teams show off their skills accompanied by loud music. A small seating area overlooking the jump is a great place to wind down and watch the spectacle.
Ski Jump by Kirsty Bouwers
From the main site at Odori Park, take a short walk to the smaller ice sculpture site in Susukino. Here, local businesses make displays, with artwork ranging from fish suspended in ice to human-sized glasses of beer.
The daily catch in ice! by Kirsty Bouwers
Sapporo Snow Festival 2015 by Kristy Bowers
Stop by the small ice bar to warm up with a coffee or something more alcoholic! With Suskino's bars and restaurants literally steps away, you can easily enjoy a few beers before heading back to the main site.
You'll want to catch the excitement during the evening when the sculptures are all illuminated. Two highlights from 2015 would have to be a Star Wars sculpture of Darth Vader and some Stormtroopers, accompanied by the Star Wars theme song, and a replica of the inner gate of the Kasuga Grand Shrine. The latter had a projection mapping show from 7 pm to 10 pm each night, during which a succession of prints, videos and lights made the sculpture come alive.
[wpvideo IRf76HdN]
Festival food stalls are open late luring visitors with everything from fresh seafood to roasted meats. Tents and small heated areas offer some respite from the cold. For a higher vantage point, be sure to either go up the TV Tower to look out over Odori Park, or take the cable car up to Mount Moiwa for some great views of Sapporo.
The festival attracts people from all over the world. Although quite busy with long queues, the general vibe in Sapporo is always relaxed. The food is good, the people are friendly and the surrounding nature is breathtaking. All in all, Sapporo is a great destination, and the festival will definitely add another dimension to your visit.
All lit up at the 2015 Sapporo Snow Festival by Kristy Bouwers
Event dates for 2016 | February 5th (Friday) to February 11th (Thursday / National Holiday), 2016
Venue | Main location- Odori Park
Illumination schedule | Snow and ice sculptures illuminated from sunset to 22:00 PM each evening.
Venue | Main location- Odori Park
Illumination schedule | Snow and ice sculptures illuminated from sunset to 22:00 PM each evening.
Discover other things to see and do in Sapporo!


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You are now registered to attend OCG's Identity-driven Security Summit 2016. Location and travel details are provided below. Note: an email has also been sent for your reference – please add our domain (oxfordcomputergroup.co.uk) to your email client's 'safe senders' recipient list in case we need to send you any future updates.
If you have chosen to attend a workshop(s) on day 2, a member of our friendly team will be in touch shortly with more details and to confirm your booking.
In the meantime, please check out our Advanced Threat Analytics (ATA) demo. This on-demand webinar reveals how Microsoft's latest addition to Enterprise Mobility Suite can help your organisation identify a data breach and prioritise security threats.
Useful information
Venue details
OCG's Identity Security Summit 2016 is being held at Microsoft UK Headquarters, Reading.
We will send out more details closer to the date, but advice for those travelling by road, rail, air or bus can be found on Microsoft's website here.
Microsoft UK Headquarters
Thames Valley Park
West Berkshire
United Kingdom
The map below can be used to help with travel directions to our summit.
Exclusive hotel rate
As a registrant for OCG's Identity Summit 2016, you qualify for a discounted rate at the Mercure George Hotel. The hotel is located on 10 – 12 King Street in the centre of Reading:
- £89 B&B: sole occupancy/per night
- £99 B&B: double occupancy/per night
Your booking needs to be made by telephone or via email using the reference code OCG Summit.
Tel: 0118 9573445
The agenda
The agenda for day 1 can be viewed here.
The agenda for day 2 can be viewed here.
The agenda is subject to change and future updates. Please add our domain (oxfordcomputergroup.co.uk) to your email client's 'safe senders' recipient list in case we need to contact you.


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Cancer in dogs is much ubiquitous that plentiful inhabitants would direction to agree to. Studies bespeak that that roughly 25% of dogs will contract malignant neoplasm at every incident in their enthusiasm and that about 50% of all dogs senior than the age of ten years will die of cancer
If your dog contracts cancer, the put on areas can involve but are not set to the skin, organs, prepare and organs. Cancer in your dog may progress unhurriedly or beside rate.
The respectable information is that treatments be present for cancer in dogs . While laniary malignant neoplasm can be fatal it is not needfully a departure chastisement. The most primitive thing you must do is find out if in fact your dog does have metastatic tumor.Post ads:
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o A loss of weight in your dog
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If you find any of these symptoms in your dog. Don't fright. Taken individually, theses laniary symptoms may be modality of thing that is not metastatic tumor and may not be momentous at all. Make an appointment beside your veterinary surgeon for an communication for your dog. If metastatic tumor is the problem, he will serve you hone a nursing conceive. If laniary malignant neoplasm is not the cause, your vet may dictate a remediation to alleviate and mend the status.
Cause of Cancer in Dogs
There are varied causes of malignant neoplastic disease in dogs. The National Canine Cancer Foundation says that metastatic tumor can be attributed to factors such as as very high display to malignant neoplastic disease agents which view chemicals.
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Khabibulin blanks RangersOct 23, 2011 - 6:40 AM
Rookie Ryan Nugent-Hopkins had a goal and an assist and Corey Potter also scored for the Oilers, who snapped a two-game slide.
Henrik Lundqvist allowed both goals on 24 shots, but left in the third period with cramping. Matrin Biron played his first hockey of the season and stopped three shots the rest of the way for the Rangers, who had a two-game winning streak snapped.
"We sucked from head to toe," a blunt John Tortorella said of his team's effort. "We need to move by it."
After a scoreless first period that saw Lundqvist stop 11 games and Khabibulin make just four, the Oilers got on the board midway through the second.
With the puck in the New York end, Taylor Hall left a drop pass from the right circle over to the slot and Nugent-Hopkins wristed the puck into the left corner for his fifth goal of the season.
Khabibulin made seven saves in the second and his team gave him some breathing rook early in the third.
On the power play, Nugent-Hopkins held the puck at the right circle and faked a shot before sending it back to the right point where Potter blasted a one- timer past Lundqvist.
"We work on getting shots and chances on the power play all the time," said Potter. "To get one on the advantage tonight was nice."
Khabibulin stopped eight shots in the final frame to cap the 44th shutout of his career.
Game Notes
The Rangers play in Winnipeg on Monday...Edmonton hosts the Canucks on Tuesday...New York had won the previous two games in the series...New York went 0-for-4 on the power play while Edmonton was 1-for-4...Nugent-Hopkins has five goals and two assists over his first seven NHL games.
Oct 23 12:30 AM
- Edmonton Power-Play Goal - Corey Potter, from Ryan Nugent-Hopkins and Jordan Eberle at 4:03.
Rangers 0, Oilers 2 3rd - 15:57Oct 23 12:03 AM
End of 2nd
Oct 22 11:39 PM
- Edmonton Goal - Ryan Nugent-Hopkins (5), at 10:09.
Rangers 0, Oilers 1 2nd - 9:51Oct 22 11:17 PM
End of 1st
Oct 22 10:40 PM
- 10
rootsRUWTbot Added 10 roots
Rangers 0, Oilers 0 1st - 1:33Oct 22 10:38 PM
1st Period - 19:25
Oct 22 10:13 PM
Related News
- Major League Baseball suspends Rangers' Odor for 8 games and Andrus for 1 game, and Blue Jays' Chavez and Gibbons for 3 each and Bautista, Leiper for 1 apiece for role in brawl May 17
- Cup final awaits either playoff-starved Blues or Sharks May 14
- Capitals assistant Reirden a 'future head coach' in the NHL May 13
- New York Rangers sign KHL forward Pavel Bucknevich May 13
- Blackhawks agree to 3-year deal with D Gustav Forsling May 11
- Capitals are loose and confident and on brink of elimination May 6
- New York Rangers rookie Oscar Lindberg has hip surgery May 6
- NHL, Oilers, Flames each donating $100,000 to Fort McMurray May 5
- World championship offers audition for World Cup, draft May 5
- McDavid among finalists for Calder Trophy as NHL top rookie May 2
- Rangers agree to deal with backup goalie Antti Raanta May 2
- Jagr, Dupuis, Zuccarello are Masterton finalists May 1


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Kim Fox's "absolutely disgusting" joke about diabetes on EastEnders has fallen flat with viewers.
Fans of the BBC soap took to social media to voice their anger when the character, who was preparing for her daughter Pearl's 1st birthday party, quipped: "If the kids don't give themselves diabetes, it's not a good party is it?"
Viewers began pointing out that the line was factually wrong as children do not get diabetes from eating too many sweets.
"Epic diabetes fail on EastEnders," one viewer wrote, with others left "infuriated" by the lack of research on display.
Diabetes charity Diabetes UK noticed the tweets and contacted EastEnders, who will be "speaking to their research team".
A spokesperson for EastEnders said: "As regular EastEnders viewers known, Kim (played by Tameka Empson) has long been established as a facetious character who usually gets more things wrong than right.
"EastEnders has a rich history of covering important issues such as diabetes and has addressed the realities of living with the condition through the character Paul Coker, whose condition will be featured more in the future."
Sugar plays no role in getting diabetes. Type 1 is caused by the pancreas not producing insulin, the hormone that controls the amount of glucose in the blood. It is the most common type of childhood diabetes.
Media regulator Ofcom has received 39 complaints about the episode and will assess them before deciding whether or not to investigate.
- More about:
- Eastenders
- Diabetes


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Financial Success - A Definition
What is your explanation of monetary success? For more of us it way polar holding. And for most people, it is a uncertain definition with out a set numeral or sought after corollary. Most populace say that they privation to be "rich" or have plenty exchange so that they don't have to slog.
Well, what is that number? What is flush to you? What stepladder have you defined to achieve this goal? Your definition of financial occurrence should be a of her own definition, not several taxon definition that someone created in standard. But, if you cannot deliberation of one on your own, a taxonomic group definition may be a not bad deposit to opening. That man said, here is my ain account that my partner and I distinct on:
Financial glory - the qualifications to be able to pay bills in need worry, be loose of debt, abet others with our occurrence and business enterprise resources, amass our children's institute tuition/trust cash in hand regenerate in the amounts of (amounts here), and are on track next to our savings devise to have redeemed the means we poorness to have by (our day present).
Pretty epic explanation huh? Well, one of the best eminent things for woman a occurrence in thing is pellucidity. If you are single, you essential be unhampered as to what it is you are annoying to effectuate for yourself. If you are married, you must some be absolve on what it is you privation together, as resourcefully as individually, and put a hobby mean together to begin, gauge, and effect your goals.
Step 1 - Establish Clearly Defined Financial Goals
In charge for you to make a destination, you must be able to see wherever you are going. Have you of all time proven tearful finished mud? It would be amazingly fractious to do. In addition, you wouldn't be able to see wherever you are going and the fury would in all likelihood demean your find and you would tender up. If you don't have pecuniary goals set, this is precisely what you are doing.
Why do this if you don't have to? Clearly Defined Financial Goals permit you to see where you are, where you are going, and gives you a way to course your development. Imagine watery in the comprehendible vocalist off the seashore of Bermuda - able to see the submersed life and go accurately wherever you poverty to go. You can see the dangers and escape them. If you get off course, you can see where on earth you came from and correct your itinerary. Goals in any element of your life bestow you this dominion.
How to Set Financial Goals - Short Term
So how do you go more or less setting fiscal goals? I'm cheerful you asked! Setting short goals is vital because they lend a hand you bring about your semipermanent goals. You can set short goals that air thing suchlike this:
I will let go $600 by June 2005, protrusive now, by golf shot distant $100 a calendar month. I will have it involuntarily drafted. I will party singular 1 salt a day starting today, alternatively of three, and prevention the inequality in a Money Market narrative with (Name of Company) from (today's mean solar day) to (1 time period from today's solar day). I will squirrel away $5000 this time period in my Mutual Fund relationship next to (Name of Company) by having $208.50 drafted bi-weekly from my pay.
These short-term goals answer the questions who, what, when, where, and how. Do your goals do this? It may be instance to renovate. I can't load decent the need of cogency. Without clarity, your goings-on will be more so inaction than progress.
How to Set Financial Goals - Long Term
For semipermanent goals, you poverty to be rightful as unlimited. As a issue of fact, your semipermanent goals will pursue the same format, but will have dates that are more in the planned. For example:
I will have found $500,000 by my 55th wedding anniversary by background detour ($ set figure of dollars) for (set cipher of age) by having it unconsciously drafted into a Roth IRA with (Name of Company). On September 5th, 2020 I will have found ($ set numeral) for my child's teaching / holding monetary fund by having ($ set amount of dollars) drafted from my payroll check bi-weekly.
The short goals that my mate and I have set put us in sync with our long-run goals and our account. The maximal cut astir all of this is - if our rational changes roughly our coming plans, we can clear adjustments and carry on the track.
I am overconfident that the firstborn part of a set of this round is facilitatory to you, or has at slightest put you rear on course to your financial purpose. Stay adjusted for 3 Steps to Personal Financial Success - Part II: Budgeting.


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DeMarcus Cousins has earned a reputation for being one of the most volatile players in the NBA. He racked up 17 technical fouls in 2015-16 and 14 the year before that. About a quarter of the way through this 2016-17 season, Cousins already has nine, after picking up another tech on Monday night by jawing with Lakers assistant coach Brian Shaw.
Despite the fines (and potential suspensions), Cousins said after the game that he's not changing the way he plays.
"I don't understand what he saw," Cousins said of the referee's call, according to CSN Bay Area's James Ham. "B-Shaw and me talk trash since I've came into this league. Friendly trash talk, he (McCutchen) didn't like the curse words me and B-Shaw said so he gave us techs.
"It is what it is. I'll talk to the league. We'll see what happens, but I can guarantee this, it won't be the last."
The NBA has a maximum limit of 16 technical fouls per player, per season. Once a player reached that number, he will get a one-game suspension, along with additional suspensions for every other tech afterwards. Cousins may want to keep that in mind the next time he goes after an official over a close call. His reputation certainly doesn't help the situation, something that the Sacramento Kings center acknowledges.
"I've gotten a tech for getting fouled and accidentally hitting … I don't know what to do anymore," he added. "It's been awhile since I've just went up to a ref and cursed him out. So I really don't know what to do.
"I see how some guys talk to the refs and it's okay, and then there's me. And then there's me. Like I said, it just depends on their mood."