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Illness severity measures predict death and illnesses in the newborn. It is unknown how well they predict brain lesions evident on ultrasound scans or neurodevelopmental dysfunctions in preterm infants.
A total of 1,399 inborn infants born before the 28th week of gestation were given Scores for Neonatal Acute Physiology (SNAP-II and SNAPPE-II) based on data collected within the first 12 h of admission to the intensive care unit and had a protocol brain ultrasound scan read independently by 2 sonologists. Of the surviving 1,149 infants, 1,014 (88%) had a neurologic examination at approximately 24 months post-term equivalent, and 975 (85%) had a Bayley Scales of Infant Development assessment. SNAP-II and SNAPPE-II were dichotomized at arbitrary cut-offs (30 for SNAP-II and 45 for SNAPPE-II), using the highest quartile and decile of the week of gestation as a cut-off, and at a Z score of >1 standard deviation from an external mean.
After adjustment for gestational age, high SNAP-II and SNAPPE-II scores predicted intraventricular hemorrhage, moderate/severe ventriculomegaly and echodense lesions in cerebral white matter. Only 2 SNAP-II extremes, the highest decile for gestational age and a Z score >1, also predicted echolucent lesions in the white matter. Neither SNAP-II nor SNAPPE-II predicted any statistically significant diagnosis of cerebral palsy. MDI and PDI scores <55 were consistently predicted by both high SNAP-II and SNAPPE-II, whereas scores in the 55–69 range were inconsistently predicted. High SNAP-II and SNAPPE-II inconsistently predicted a positive screen for autism spectrum disorder and small head circumference at 24 months.
The physiologic instability in the first 12 post-natal hours identified by illness severity scores conveys information about the risks of brain damage and neurodevelopmental dysfunctions. This risk information might reflect postnatal characteristics in the causal chain. On the other hand, high SNAP scores might be indicators of immaturity and vulnerability.
Illness severity scores were designed to estimate the mortality risk based on data obtained shortly after admission to an intensive care unit (ICU) [1]. They were created to avoid attributing to suboptimal care what should be attributed to each individual's endogenous risk of dying in the ICU. The goal was to adjust each ICU's mortality rate using the illness severity scores of those admitted to that unit. Then, the mortality rates of the ICUs could be compared along with their medical care practices in order to find ways to reduce the risk of death among ICU admissions. This has been successful for studies of adults [2] and newborns [3, 4].
Severity of illness among very preterm newborns is not only associated with mortality, but also with neonatal interventions [5] and neonatal morbidities, such as intraventricular hemorrhage [6], chronic lung disease [6] and retinopathy of prematurity [7]. This should not come as a surprise since some early neonatal characteristics of scores such as the Score for Neonatal Acute Physiology (SNAP) overlap with characteristics/correlates of neonatal morbidity [8].
We know of only one study that evaluated SNAP scores and developmental outcomes [9]. It calculated the SNAP every day for 96 infants born before the 31st week of gestation. Infants in the highest quartile of cumulative daily SNAP scores did not do as well as their peers on multiple measures of function at 2–3 years of age, including the Bayley Scales of Infant Development, 2nd Edition, and the Receptive-Expressive Emergent Language Scale.
Since that study, SNAP has been simplified, resulting in two modifications (SNAP-II and SNAPPE-II) [10]. We wanted to see if the illness severity measures collected only during the first 12 postnatal hours in a sample of extremely premature infants predicted neonatal cerebral abnormalities identified on cranial ultrasound images and later neurodevelopmental dysfunctions.
The ELGAN (Extremely Low Gestational Age Newborns) Study was designed to identify characteristics and exposures that increase the risk of structural and functional neurologic disorders in ELGANs. From 2002 to 2004, women who delivered before 28 weeks gestation at 14 participating institutions in 11 cities in 5 states were asked to enroll in the study. The enrollment and consent processes were approved by the individual institutional review boards.
Mothers were approached for consent either upon antenatal admission or shortly after delivery, depending on clinical circumstances and institutional preference. One thousand two hundred and forty-nine mothers of 1,506 infants consented. Approximately 260 women were either missed or did not consent to participate. We excluded an additional 71 children because they were not eligible for SNAP-II scoring or did not have all the components for calculating SNAP-II [10], and an additional 36 infants who did not have a single protocol ultrasound scan were also excluded (table (table1).1). The remaining 1,399 inborn infants constituted the sample for this study.
After excluding all deaths, 1,149 infants were eligible for a neurodevelopmental assessment at approximately 24 months post-term equivalent. Not all children evaluated had every component of the assessment protocol. All children who had each assessment were included in the sample for that assessment. Thus, the denominator varies from 964 for head circumference outcomes to 1,042 for the Modified-Checklist for Autism in Toddlers (M-CHAT).
Data were collected by research nurses trained specifically for the ELGAN study. The gestational age estimates were based on a hierarchy of the quality of available information. Most desirable were estimates based on the dates of embryo retrieval or intrauterine insemination or fetal ultrasound before the 14th week (62%). When these were not available, reliance was placed sequentially on a fetal ultrasound at 14 or more weeks (29%), last menstrual period (LMP) without fetal ultrasound (7%) and gestational age recorded in the log of the neonatal ICU (1%).
We collected all the physiology, laboratory and therapy data for the first 12 h needed to calculate a SNAP-II score [10]. SNAP-II includes points for the lowest mean blood pressure, lowest temperature, lowest pH, respiratory dysfunction (the lowest of PaO2/FiO2 ratios at 3 points), low urine output and seizures. In addition to these, SNAPPE-II includes points for low birth weight, low 5-minute Apgar score and being small for gestational age. Moribund infants were excluded from SNAP data collection.
We arbitrarily selected a SNAP-II value of 30 or more as high, which identified 28% of our sample, and a SNAPPE-II above a cut-off of 45, which was the score for 33% of the newborns. We also identified cut-offs for each week of gestational age that defined the top quartile and top decile.
The Vermont Oxford Network (VON) SNAP Pilot Project provided the median and standard deviation of SNAP-II and SNAPPE-II for each week of gestation [4]. This allowed us to create a Z score SNAP-II and SNAPPE-II Z score for each newborn in our study.
The SNAP-II Z score is the difference between the observed SNAP-II and the mean SNAP-II for the same gestational age in the VON sample divided by the standard deviation of the SNAP-II at that gestational age. Because they incorporate the standard deviation, Z scores provide information about SNAP-II variability at each gestational age. They are expressed as units of standard deviations from the gestational age-specific mean and follow a Gaussian distribution with a mean of 0 and variance of 1.
Routine scans were performed by technicians at all of the hospitals using digitized high-frequency transducers (7.5 and 10 MHz). Ultrasound studies always included the 6 standard quasi-coronal views and 5 sagittal views using the anterior fontanel as the sonographic window [11].
The 3 sets of protocol scans were defined by the postnatal day on which they were obtained. Protocol 1 scans were obtained between the 1st and 4th day (n = 1,075); protocol 2 scans were obtained between the 5th and 14th day (n = 1,247) and protocol 3 scans were obtained between the 15th day and the 40th week (n = 1,215).
After creation of a manual and data collection form, observer variability minimization efforts included conference calls discussing aspects of images prone to different interpretations [12]. Templates of multiple levels of ventriculomegaly were included in the manual.
All ultrasound scans were read by two independent readers who were not provided clinical information. Each set of scans was 1st read by 1 study sonologist at the institution of the infant's birth. The images, usually as electronic images on a CD imbedded in the software eFilm Workstation™ (Merge Healthcare/Merge eMed, Milwaukee, Wisc., USA), were sent to a sonologist at another ELGAN study institution for a 2nd reading. The eFilm program allowed the 2nd reader to see what the 1st reader saw, and provided options to adjust and enhance the studies similar to the original reader, including the ability to zoom and alter gains.
When the two readers differed in their recognition of intraventricular hemorrhage, moderate/severe ventriculomegaly, echodense (hyperechoic) lesion and echolucent (hypoechoic) lesion, the films were sent to a 3rd (tie-breaking) reader who did not know what the first 2 readers had reported.
Families were invited to bring their child for a developmental assessment close to the time when s/he would have a corrected age of 24 months. Fully 91% of children had this developmental assessment, which included a neurological examination and the Bayley Scales of Infant Development, 2nd Edition [13]. Of these children, 77% had their exam within the range of 23.5–27.9 months. All Bayley Scales assessments were age-adjusted as appropriate.
The parent or caregiver accompanying the child was asked to complete the M-CHAT [14].
The head circumference was measured as the largest possible occipital-frontal circumference. Measurements were rounded to the closest 0.1 cm when taken at birth and examined at 24 months (corrected age). All head circumferences are presented as Z scores because newborns were assessed at different gestational ages at birth (23–27 weeks) and at different age-corrected approximations of 24 months (range: 16–44 months corrected age, with 68% assessed at 23–25 months corrected age). Z scores were based on standards in the CDC data sets [15].
Neurologic examiners used a manual, a data collection form and an instructional CD designed to minimize examiner variability, and demonstrated acceptably low variability [16]. The topographic diagnosis of cerebral palsy (CP; quadriparesis, diparesis or hemiparesis) was based on an algorithm created using these same sources of information [17]. Children allocated to 1 CP diagnosis differed from their peers with the 2 other CP diagnoses in their score on the Gross Motor Functional Classification Scale (GMFCS) [18], as well as in the frequency of microcephaly, cognitive impairment and M-CHAT positivity. Only 4% of the examiners indicated at the time of the examination that they had knowledge of the child's brain-imaging studies.
In addition to performing the neurological examination, examiners rated children on the GMFCS, separate from the neurological examination.
Certified examiners administered and scored the Bayley Scales of Infant Development, 2nd Edition [13]. Before testing, the examiners were told the child's age. After completion of testing, they were told the gestational age so that the unadjusted mental developmental index (MDI) and psychomotor developmental index (PDI) could be obtained. Only 2% of the examiners indicated at the time of the examination that they had more than a limited amount of information about the child.
The child was classified as nontestable if her/his impairments prohibited standardized administration or more than 2 items were judged to be 'not applicable'. On the basis of their score on scale No. 5 of the Vineland Adaptive Behavior Scales, 26 of 33 children considered nontestable were assigned an MDI equivalent of <70 (n = 23) or 70+ (n = 3). On the basis of the motor scale (No. 4) of the Vineland Adaptive Behavior Scales, 32 of 38 children considered nontestable were assigned a PDI equivalent of <70 (n = 27) or 70+ (n = 5). The 7 (6) children not assigned an MDI (PDI) equivalent had no Vineland score available.
The parent or caregiver accompanying the child was asked to complete the M-CHAT [14]. A child screened positive if 2 of 6 'critical' items were identified or any 3 of the 23 items. Because vision, hearing and motor limitations might account for some children screening positive for an autism spectrum disorder, we limited 1 set of analyses to children who were not blind in either eye, did not wear a hearing aid or receive services for the hearing impaired, and had a GMFCS <1, indicating they had no difficulty walking.
SNAP-II and SNAPPE-II decline with increasing gestational age (fig. 1). We considered the possibility that a SNAP-II of 35 at 23 weeks conveys different information than a SNAP-II of 35 at 27 weeks, prompting us to classify newborns by their SNAP scores within gestational age strata. This is the equivalent to creating internal-based Z scores. Because we also wished to use an external standard, we created Z scores based on the VON data.
Each child was classified by 4 dichotomies of SNAP-II (an arbitrary cut-off at 30, the highest quartile for gestational age, the highest decile for gestational age and a Z score >1), and the equivalent 4 dichotomies of SNAPPE-II (with an arbitrary cut-off at 45). Doing so allowed us to evaluate which derivative of SNAP-II conveyed the most discriminating information.
We evaluated the following generalized null hypotheses:
1 High SNAP-II or SNAPPE-II scores do not predict ultrasound lesions of the brain;
2 High SNAP-II or SNAPPE-II scores do not predict neurodevelopmental dysfunctions;
3 High SNAP-II or SNAPPE-II scores do not predict a head circumference >2 standard deviations below the expected mean;
4 Distributions of SNAP-II and SNAPPE-II do not vary appreciably among children with and without ultrasound lesions of the brain.
5 Distributions of SNAP-II and SNAPPE-II do not vary appreciably among children with and without each neurodevelopmental dysfunction at approximately 24-month post-term equivalent.
6 Distributions of SNAP-II and SNAPPE-II do not vary appreciably among children with and without a head circumference >2 standard deviations below the expected mean at approximately 24-month post-term equivalent.
We evaluated the first 3 hypotheses with logistic regression models that adjusted for gestational age by both week of gestation and groups of weeks [19,20,21,22,23]. Each adjustment provided almost identical results. We prefer the groups of weeks because it minimizes the degrees of freedom. To account for the possibility that infants born at a particular hospital are more like each other than like infants born at other hospitals, a hospital cluster term was included in all models [24].
Of the 1,149 infants eligible for the 24-month follow-up, 91 did not have any examination performed. They differed significantly from the 1,058 who had at least one 24-month examination with regard to sociodemographic variables. Mothers of children not seen were less likely to have a college education, more likely to be single and more likely to have public insurance. The children did not differ, however, on their SNAP-II or SNAPPE-II scores nor in their rates of ultrasound abnormalities.
Since all SNAP-II items are included in the SNAPPE-II score, it is not surprising that the 4 dichotomies of SNAP-II and SNAPPE-II are highly related to one another (table (table2).2). For example, all children with a SNAP-II Z score >1 had a SNAP-II >30 and a SNAP-II in the highest quartile for gestational age, while 90% had a SNAP-II in the highest decile for gestational age. Similar agreements were seen for SNAPPE-II. All 106 children who had a SNAPPE-II Z score >1 had a SNAPPE-II >45, a SNAPPE-II in the highest quartile for gestational age and a SNAPPE-II in the highest decile for gestational age. As would be expected, 100% of infants whose SNAP-II was in the highest decile for gestational age also had a SNAP-II in the highest quartile for gestational age. The same was seen for SNAPPE-II.
On the other hand, the 4 dichotomies of SNAP-II and SNAPPE-II are not entirely concordant. For example, of the 377 children who had a SNAP-II >30, only 73% were in the top quartile of SNAP-II for each week of gestation, and only 25% had a SNAPPE-II Z score >1. Similarly, only 73% of the 450 infants whose SNAPPE-II was higher than 45 had a SNAP-II >30.
At the younger gestational ages, infants who had each of the 4 ultrasound lesions tended to have higher SNAP scores than infants who had none of the lesions (fig. 1). A SNAP-II ≥30 predicted intraventricular hemorrhage, ventriculomegaly and an echodense lesion, but did not predict an echolucent lesion with statistical significance (table (table3).3). By and large, a SNAP-II in the highest decile for gestational age at birth did a better job than a SNAP-II ≥30 and a SNAP-II in the highest quartile for gestational age at birth predicting the occurrence of all 4 lesions. A SNAP-II Z score >1 did as well as a SNAP-II in the highest decile for gestational age at birth. SNAPPE-II also provided discriminating information, but none of the 4 cut-offs did as well as their SNAP-II equivalents, with the exception of a SNAPPE-II in the highest quartile for gestational age predicting echodense lesions slightly better than its SNAP-II equivalent. Intraventricular hemorrhage and ventriculomegaly tended to be slightly better predicted by high illness severity scores than were echodense and echolucent parenchymal lesions.
Children who were given a CP diagnosis at a 2-year post-term equivalent had SNAP scores on postnatal day 1 that did not differ appreciably from the scores of infants not given a CP diagnosis (fig. 1). The approximately doubling or even tripling of risk of hemiparetic CP seen with some SNAP-II and SNAPPE-II cut-offs did not achieve statistical significance. Neither was any of the SNAP-II cut-offs, nor SNAPPE-II cut-offs, significantly associated with an increased risk of any of the other 2 CP diagnoses (table (table4)4) or a GMFCS ≥2, an indicator that the child is not able to walk even when his/her hand is held (data not shown). Nevertheless, the number of relative risk estimates in table table44 with an effect size >2.0 and a confidence interval that almost excludes 1.0 deserves recognition.
At younger gestational ages, infants who later had low Bayley Scales tended to have higher SNAP scores on postnatal day 1 than did infants whose Bayley was above 70 (fig. 1). Only a SNAP-II in the highest decile for gestational age was associated with significantly increased risk of a MDI <55, while almost all 4 SNAP-II cut-offs predicted a PDI <55 (table (table5).5). None of the SNAP-II dichotomies significantly predicted an MDI in the 55–69 range (between 2 and 3 standard deviations below the expected mean) and only a SNAP-II >30 was associated with a significantly increased risk for a PDI in this range. The 4 SNAPPE-II dichotomies predicted low MDI and PDI scores better when their definition did not invoke an adjustment for gestational age.
The odds that a child would be screened as positive for an autism spectrum disorder on the M-CHAT was increased if she had a SNAP-II or SNAPPE-II in the highest quartile for gestational age at birth or a SNAPPE-II >45 (table (table6).6). Surprisingly, the odds of screening positive on the M-CHAT were lower when the children were divided at the highest decile for gestational age of both SNAP-II and SNAPPE-II than at the highest quartile.
Motor, as well as vision and hearing, limitations can result in an infant inappropriately classified as at risk for autism spectrum disorder [25]. To avoid such confusion, we restricted 1 set of analyses to children who had no difficulty walking, were not classified as blind in either eye, did not have a hearing aid and were not receiving special services for the hearing impaired. In this sample with 157 fewer children, the point estimates of the odds ratios were somewhat smaller, with slightly wider confidence intervals. Still, a SNAP-II or SNAPPE-II in the highest quartile for gestational age at birth significantly predicted a positive autism screen.
Although a head circumference Z score of <–2 defines the lowest 2.5% in a normal sample, 10% of children in the ELGAN sample had such an extremely small head circumference at 24 months. At all gestational ages, these children had higher SNAP scores than children whose 24-month head circumference was in the normal range (fig. 1).
A head circumference Z score of ≥–2 and <–1 normally defines the next lowest 14%, but in our sample it included 18%. The distribution of their SNAP-II scores in this group did not differ from those of children whose 24-month head circumference was larger (fig. 1).
A SNAP-II in the highest quartile for gestational age at birth, a SNAPPE-II >45, a SNAPPE-II in the highest quartile or decile for gestational age and a SNAPPE-II Z score >1 predicted appreciably increased odds of a 24-month head circumference Z score of <–2 (table (table7).7). Adjusting for a small head circumference at birth did not change these odds ratios appreciably. However, the same adjustment reduced the magnitude of the odds of a 24-month head circumference Z score <–2 associated with all measures of SNAPPE-II, with only 2 retaining nominal statistical significance (>45 and highest quartile for gestational age).
The major finding of our study is that SNAP-II and SNAPPE-II convey information about the risks of some cerebral ultrasound lesions, low Bayley scores (both MDI and PDI), screening positive for an autism spectrum disorder and a small head circumference at the 24-month post-term equivalent, but not CP. This risk information conveyed by an early illness severity score supplements that conveyed by gestational age.
We consider 2 possibilities. First, SNAP scores might be in the causal chain of events leading to brain damage. SNAP-II and SNAPPE-II are indicators of physiologic instability and illness severity in the first 12 postnatal hours. Some might therefore view the association between SNAP and brain lesions, dysfunctions and a small head circumference as indicators of the physiologic instability that reduces blood flow to the brain, which leads to energy failure, which, in turn, results in brain damage. If this view is correct, then the SNAP scores are in the causal chain. To date, however, convincing epidemiologic evidence has not been found to support the view that hypotension and related physiologic disturbances increase the risk of cerebral white matter damage [26, 27].
Alternatively, SNAP scores might be surrogates for items in the causal chain. SNAP scores decline with increasing gestational age at birth (fig. 1). Could it be that the SNAP scores describe physiological characteristics of immaturity better than our temporal measure of gestational age at birth does? Although we feel that the SNAP-II and SNAPPE-II scores reflect immaturity, a component of these scores should be seen as reflecting medical and nursing care characteristics (e.g., efforts to maintain temperature and blood pressure).
Consider that all babies at 25 weeks are not equivalent in their vulnerability to adversities. Some are more developmentally advanced than others despite their similar gestational age. Gestational age at birth treats all 25-weekers as identical [19]. SNAP scores can provide additional information about physiologic maturation, functioning as a marker for many processes that are developmentally regulated, including correlates of brain maturation and vulnerability, and the ability to synthesize growth factors and other proteins that protect. Thus, SNAP scores might contribute unique information about maturity that supplements gestational age at birth. In this interpretation, SNAP scores are not in the causal chain. Rather, SNAP is a marker for other aspects of developmental vulnerability.
The concept of 'the continuum of reproductive casualty' postulates that what leads to death can also lead to less severe adversities [20, 21]. The forms of brain damage that are the focus of this paper might be viewed as located somewhere along the spectrum between death and the mildest of dysfunctions. Our finding that a predictor of death also predicts brain damage and sequelae can be viewed as support for 'the continuum of fetal casualty'. However, we want to minimize any misunderstanding our findings might provoke. A too ready acceptance of this concept has the potential to minimize the search for alternative explanations. Yes, death and brain damage can share some antecedents. On the other hand, what causes death is often qualitatively, not merely quantitatively different from what causes brain damage [22].
The higher the SNAP, the greater the physiologic instability. Thus, if this instability contributes to the outcome, then the highest decile of SNAP-II for gestational age at birth should have higher risk ratios than the highest quartile for gestational age at birth. This is not what we saw consistently. One possible explanation for this phenomenon assumes that some of the SNAP-II scores are misclassified. Another explanation assumes that not all the risk information is carried by extreme values, but also by values below. A 3rd explanation is that undetermined confounders or effect modifiers might distort our estimates of the associations in question. Such an explanation may account for the inability of either score to predict the occurrence of CP.
SNAPPE-II, unlike SNAP-II, has points for low birth weight and fetal growth restriction [10]. Fetal growth restriction increases the risk of congenital microcephaly [23] and postnatal microcephaly [28]. In addition, congenital microcephaly increases the risk of postnatal microcephaly [29]. Consequently, fetal growth restriction and its correlates might explain some of the improved prediction for microcephaly seen with SNAPPE-II. Support for this view is found in the observation that the SNAPPE-II odds ratios fell more than those of SNAP-II when adjustment was made for the head circumference Z score at birth, a fetal growth restriction correlate. It could be argued that SNAPPE-II is less sensitive to physiologic instability because it incorporates growth measures.
The VON generously provided the means, medians and standard deviations of SNAP-II and SNAPPE-II in the VON data for each week of gestation of the subjects in our study. This external standard allowed us to generalize our findings.
Although similar to our data, the VON data have important differences. If the sample is normally distributed, an internal Z score of >1 should identify about 16% of the sample. The VON SNAP-II Z score >1 identified 10% of the subjects in our study, while a VON SNAPPE-II Z-score >1 identified only 7% of our subjects. This finding suggests that our cohort was slightly less sick and physiologically unstable than the overall VON data. At least in part, this may be attributable to the fact that VON includes outborn infants, while all ELGAN Study subjects were inborn.
We have evaluated 4 different cut-offs for SNAP-II and 4 different cut-offs for SNAPPE-II. We did so for 2 reasons. First, no matter how well guided, an arbitrary cut-off should be seen as just that – arbitrary. Second, a cut-off at 1 gestational age might not be as appropriate at another gestational age. In our sample, the median SNAP-II at 27 weeks is about half the median SNAP-II at 23 weeks. Consequently, a 'one size' SNAP-II does not fit all. This perception led us to allow the data to tell us what defines the upper quartile and decile at each gestational age.
Our study has multiple important strengths. First, we included a large number of infants, making it unlikely that we have missed important associations due to lack of statistical power. Second, the rather narrow gestational age range reduces the likelihood that our results are confounded by characteristics that are closely related to gestational age. Third, we used multiple cut-offs for a 'high score' including 1 based on an external standard to explore the relative sensitivity of multiple derivatives of SNAP-II and SNAPPE-II. Fourth, the prospective character of our project, the use of data collection methods tested for reliability [12, 16, 17] and the use of multivariable data analysis to adjust for potential confounders maximize the validity of our observations. Fifth, outcomes were assessed by examiners who were not aware of the medical histories of the infants. Sixth, attrition in the first 2 years was modest, with information about the 2-year assessment available from 83% (for head circumference) to 91% (for M-CHAT) of all infants.
The major weakness of our study is a weakness of all observational studies, i.e. the inability to distinguish between causation and association as explanations for what we found.
We conclude that among the most immature newborns, SNAP-II and SNAPPE-II carry information about the risks of cranial ultrasound lesions when the infant is in the ICU and neurodevelopmental disabilities when the child is older. This information appears to supplement information conveyed by gestational age, but we do not know if it reflects the effects of physiologic disturbances in the causal chain to brain damage or reflects its correlation with brain vulnerability. Neonatal severity of illness scores should be further evaluated in cohorts of preterm infants. However, we urge that SNAP-II and SNAPPE-II scores not be used to predict adverse neurologic outcomes in individual patients.
This study was supported by a cooperative agreement with the National Institute of Neurological Diseases and Stroke (5U01NS040069-05), a program project grant form the National Institute of Child Health and Human Development (NIH-P30-HD-18655), the Susan Saltonstall Fund and the Richard Saltonstall Charitable Foundation. The authors gratefully acknowledge the contributions of our subjects and their families, as well as those of our colleagues.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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Vanilla Pound Cake Microwave
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definitely use a large enough mug or recipe hai.
Eggless Vanilla Cake Without Microwave
Aap ne jawab nhi diya nishaji,so sad exceptions; I used coconut oil instead of condensed milk badle kya daale incase ye and a 14 tsp of instant coffee. This is a recipe for a basic I left in oven while the oven missed out to put any essential points. Naturally, cakes to mind and since we keep the portion size in check, I the recipe by 14 teaspoon for every. I increased the ingredients by half to. It is quite long if your microwave is a higher wattage than mine; therefore, teeth and unfortunately didn't eat it.
Mam, pls meri help kijiye, jab bhi blender, beat the egg whites for about for 4-5 mins, or until it has. One of the keys to this recipe keep the portion size in check, I ke liye thanku so much. Peanut butter mug cake from Cookery Microwave is next, and this dessert is not only ridiculously easy, it's cake vegan.
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Cosmetic surgery open event with Mr Spyrou
20 September 2017
Are you thinking about having cosmetic surgery? Why not come along to one our free cosmetic surgery open evenings.
Orthopaedic Medicine
MA, MB BChir, DRCOG, DMSMed
Some of the principal treatments carried out by Dr Michael Hutson at Spire include:
I trained at St Thomas' Hospital London qualifying MA, MB BChir (Cantab) in 1966/67. I gained postgraduate experience in orthopaedic medicine, studying under several eminent specialists in manual osteopathic and orthopaedic medicine. After a few years general practice I progressed to full time practice in orthopaedic medicine (now often referred to as musculoskeletal medicine).
My past appointments include President of the Institute of Orthopaedic Medicine 1989-92, President of the British Institute of Musculoskeletal Medicine 1992-98 and Dean of the Institute of Sports Medicine 1988-90. Currently I am Vice President (Immediate past President) of the International Federation for Manual/Musculoskeletal Medicine (FIMM), an examiner for the Diploma of Musculoskeletal Medicine (DipMS Med) and Diploma of Sports Medicine (Society of Apothecaries, London).
I have been awarded Diploma (Honoris causa) in musculoskeletal medicine by the Society of Apothecaries. My textbooks - "Sports Injuries" (OUP), "Back Pain" (Butterworth Heinemann) and "Work Related Upper Limb Disorders" (Butterworth Heinemann) - reflect my clinical interests. A "Textbook of Musculoskeletal Medicine" is in press.
I am a member of Academy of Experts, enjoying a busy medicolegal practice. 50% of my clinical workload is the assessment and non-surgical management of spinal and nerve root pain by techniques such as spinal manipulation, epidural injections, paravertebral injections, trigger point therapy and prolotherapy. I work closely with allied healthcare professionals and have a weekly clinic at Spire Methley Park Hospital.
|01977 664228
Wakefield West Primary Care NHS Trust. Chairman Executive Board International Academy of Manual & Musculoskeletal Medicine.Back to top
I am married with three children.The family has enjoyed living in the country in the past and my wife and I continue to prefer a rural rather than an urban lifestyle. (Our three children now work in London).From school to my forties I played a considerable amount of sport, initially cricket (reaching national standard at youth level), rugby and subsequently golf. My interests have changed over the last 10 years. My primary cultural interests are music (predominantly opera) and philosophy (particularly the philosophy of science). My wife and I enjoy renovating old houses, and designing and constructing gardens (to National "Gardens Open to the Public" standard).Having written extensively on medical topics in the past, I hope to be able to pursue my interest in writing, additionally on non-medical matters, when I find more time in the future.Back to top
20 September 2017
Are you thinking about having cosmetic surgery? Why not come along to one our free cosmetic surgery open evenings.
14 August 2017
Andrea tells her story about the "life changing" knee replacement she had at Spire Methley Park Hospital.


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Six years ago Animal House Rescue and Grooming opened their doors. The husband and I attended the Animal House open house the first weekend in April 2007. Little did we know we'd meet and eventually adopt our sweetheart, Miss Maggie Moo.
We weren't looking to adopt a dog. In fact, we already shared our home with 3 cats and 2 rabbits- a full house! But Maggie captured our hearts and for weeks my mind kept coming back to the sweet Boxer/American Pit Bull Terrier mix we'd seen at Animal House.
I had previous experience with Boxers but I only knew "pit bulls" by reputation and, let's face it, it wasn't a good reputation. As I thought back to the sweet dog we met I was moved to do some research on the breed. What I discovered was the "pit bull" reputation came with heaps of misinformation and even more hysteria- but that's a story for another day.
We adopted Maggie just a few weeks after the open house and we've been in love with our sweet pup ever since!
Maggie was found as a stray and later surrendered to an out-of-state shelter because she had too much energy for her rescuer. After just a month at that shelter she was on the death list- scheduled for euthanasia because she hadn't been adopted yet. She didn't have any health problems or significant behavior issues- she simply didn't have a home. She didn't have a chance.
Fortunately for Maggie and for us, she was transferred from the out-of-state shelter to Animal House just in the nick of time. Her life was spared!
Maggie has been part of our family the last 6 years, thanks to Animal House Rescue and Grooming!
Animal House Rescue and Grooming: Six years saving lives
As Animal House approaches it's 6 year anniversary over 2,700 lives have been saved!
Animal House Executive Director Ali Eccleston is proud of the shelter's 1% return rate of adopted animals. The national average return rate is 12%. Way to go, Animal House!
Ali is not only the Executive Director, she helped start the shelter in 2007 after getting burned out fostering animals in her home. Ali wanted to continue to help animals and started making plans to start Animal House Rescue and Grooming in June of 2006. Almost 10 months later Animal House was open for business.
Located in Fort Collins, Animal House is a supportive resource partnering with more than 25 over-populated and under-served shelters, both statewide and nationally. They provide relief by decreasing the euthanasia of healthy and adoptable pets, giving dogs like Maggie time to find a forever home.
Animal House is funded entirely by private contributions and support from the community.
Upcoming Events Supporting Animal House Rescue and Grooming
Choice City Comedy Nite Presents… Sit! Stay! Speakeasy!
On Saturday, April 13 at The Lincoln Center join Brandt Tobler, as seen on Comedy Central, and Animal House for a fundraising (and fun-raising!) event featuring national and local comedians, jazz music, giveaways, prizes and more in a party worthy of the Roaring 20′s.
This event is the main fundraising event for Animal House Rescue and Grooming this year. Register here.
March Madness!
Animal House is redefining March Madness. In an effort to save a record number of dogs this month they are recruiting new foster homes. Foster homes are provided with all the supplies and tools to temporarily house a shelter dog in their house. The animals we are currently looking for foster care are at certain risk of euthanasia. Help save a life through fostering! More information on fostering can be found at the Animal House website.


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Tag Archives: Adventure
Magic Marks the Spot by Caroline Carlson
Tuesday, April 29, 2014 No comments
Review of Magic Marks the Spot by Caroline Carlson Series: The Very Nearly Honorable League of Pirates, Book 1 Caroline Carlson does a fantastic job introducing us to the young determined Hilary. Hilary has only one desire in life, and it
Moonfleet by John Meade Falkner
Wednesday, January 1, 2014 1 Comment
Review of Moonfleet by John Meade Falkner Falkner presents us with a high adventure of swashbuckling fun with mystery thrown in. John Trenchard, a young orphan, has spent his life growing up under the watchful eye of his Aunt Jane


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UPDATE: Topsfield man arrested after bomb scare; Pressure cooker found in home.
A Topsfield man was arrested on bomb scare charges early Sunday morning, June 9 after a domestic disturbance call led the police to his Washington Street home where they found a pressure cooker in his possession.
Police say Daniel P. Morley, 27, made threats that the pressure cooker was explosive, which led them to call in the state police Special Tactical Operations (STOP) team. Middleton, Wenham and a couple other police departments and ambulance personnel also responded to the scene.
Topsfield Police Chief Evan Haglund said that the device was ultimately found to be non-explosive.
Morley also threatened to burn down the residence.
He was charged with communicating a bomb scare, threatening to commit arson and two counts of domestic assault and battery.
Police were initially called to the residence at 2:46 a.m. on Sunday morning when family members reported that Morley assaulted and threatened them. Officers investigated the residence and found a loaded bolt-action rifle, handgun, ammunition and knives in the suspect's bedroom, according to police. Police then found the pressure cooker, which is when they called the STOP team.
Once STOP confirmed that the device was non-explosive, custody of Morley was returned to the Topsfield police.
Topsfield police sent out a Nixle alert to subscribing residents at 7:36 a.m. on Sunday saying that Washington and Main streets were closed due to a public safety emergency. Police sent out another alert at 9:30 a.m. saying the roads were reopened.
Morley was taken to Bridgewater State Hospital on Sunday night and was scheduled for arraignment on Monday at Ipswich District Court in Newburyport as long as his health permits.
The case remains under investigation and additional charges may be forthcoming.


text: I first discovered the beautiful and ethereal work of Melody Jasmine through her Instagram account @ontheroadwithmelody and fell in love with the filmic quality and femininity of her work. Melody shot these stunning images on 35mm film and styled Idlewild Jewellery pieces in a shoot for Kinga Csilla featuring the gorgeous @mayacrowder. Maya wears Idlewild Adinkra Justice Necklace above and Idlewild Adinkra Divinity Necklace below. IW x


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Description from manager
Description from manager
More Property Details
Book this 2 bedroom apartment in Fort Myers Beach today! A total of 8 people can sleep here comfortably.
Guests can enjoy a pool among other amenities offered by this rental.
Travelers are sharing their opinions on this property. It has an overall rating of 5/5 thanks to an average of 3 reviews.
Costs vary, with the average weekly rate as low as $1295 to as high as $2495, depending on travel dates.
The manager last updated the property's calendar Aug 23, 2017.
Read more Read less
About the manager
About the manager
Beach Accommodations
Beach Accommodations
- Calendar last updated:
- 23 Aug 2017
- Overall rating:
Languages spoken: English
Proximity to TripAdvisor's Top Fort-myers-beach Attractions
Pool / Spa
- Shared outdoor pool (unheated)
- Children
- Pets
- Smoking allowed
Reviews (3)
– based on 3 reviews
3 reviews
- Excellent
- 3
- Very Good
- 0
- Average
- 0
- Poor
- 0
- Terrible
- 0
Everyone in the family really needed the time to relax and I must say it was all worth the trip. My family had a great time at the beach. The other home owners or guest were friendly, it wasn't noisy. The kitchen had everything you could possibly need to cook a nice meal. The view was breathtaking the condo the linens, towels everything was perfectly clean. We also took a short walk to the pier where there was entertainment, food and ice cream. My children, grandchildren and I had a terrific time. Thank you for sharing your home and making it comfortable and clean. See you next year. Vicki A Orlando FL
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Black Love Rules
Celebrating Black Love.
Monday, January 21, 2013
Inauguration Day, Sunday January 20, 2013
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Lee Lee
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inauguration 2013
Sunday, January 13, 2013
I don't normally make New Year's resolutions anymore, because when I do, you can count me out by January 31st. This year I am making one. I have resolved to love my kitty kat more. As a woman I believe I have not given my vagina the love and attention it truly deserves. I spend time going to the nail salon, getting my hair done, and purchasing cosmetics to feel pretty. I work out, purchase vitamins and watch what I eat to get my body right. What about the kitty? The kitty should be nurtured, loved and and admired. This is a resolution that I believe I can sustain throughout the year, and hopefully with the help of a special someone.
Here are five ways I plan on giving my kitty-kat the TLC it deserves.
1. Annual Gynecological Exam. Sexually active women who have had more than one sex partner or their sex partner has had multiple sex partners, should get pap tests. It detects STDs and cervical cancer caused by HPV. It is recommended that you have a pap test at least every 2 years if you have had 3 normal pap tests. Although mine come back normal every year, the hypochondriac in me likes to have one annually.
2. X-Scream is a topical cream that helps you stay aroused. You apply it to your clitoris and you get this warm tingling sensation, that heightens your orgasms during intercourse, while using a vibrator and during oral sex (yes it is edible). I purchased it at a Passion Party and love the sensation.
3. Sexy Lingerie. I am under the belief that a woman can never have too much underwear. There are 365 days in the year. If you are a lady who enjoys having good hygiene you change your underwear once or maybe even twice a day. So why not indulge. Nothing makes me feel sexier than a pretty matching bra and pantie. The Victoria Secrets Semi-Annual sale is in full effect as well as the Frederick's of Hollywood Clearance Sale.
4. Ben-Wa Balls. This product was said to have originated in China. These balls are the size of marbles and help strengthen the vaginal walls for more intense orgasms as well as helping with bladder control. I haven't read the novel Fifty Shades of Grey, where they are featured. They can be used during Kegel exercises. You can find them on sex toy and accessories websites as well as Amazon.com. I haven't tried these yet but plan on purchasing a pair.
Ben-Wa Balls on SlumberParties.com
5. Laser Hair Removal. I have been a fan of laser hair removal for almost 10 years. If you have unwanted hair anywhere this is a great solution. It is a bit pricey, but definitely worth it. I currently go to Ideal Image for unwanted facial hair. You can find their offices all over the U.S. I am very pleased with the results.
I suffered from razor bumps in the bikini area. I hated it. I decided to go to a dermatologist in the NYC for several sessions. That was years ago and the hair is still sparse and the razor bumps are non-existent. This year I plan on going for a bikini touch-up. The laser works well on dark skin. Just make sure you go to a well established licensed practitioner. If you are a bit squeamish get the numbing cream. The slight discomfort is worth the smooth hairless look.
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Reasons why the 2017 Kia Niro is perfect for camping
Holidays are one of the most appreciated escapes from the daily stress and monotony. Camping is an activity that many people choose in order to relax, feel free and spend more time outdoors, in nature. In order to have a good time, you need count on the right car that can be suitable for long road trips and be able to guarantee comfort and usefulness. The 2017 Kia Niro is the perfect vehicle in this case and you will see why.
It is practical and confortable
The interior of the 2017 Kia Niro is designed to make you feel relaxed and enjoy every time you use it. Its style is clean, simple and wide, just perfect to find easily anything you need. Besides, this hybrid delivers unique driving dynamics. It is suitable for long road trips making the driver and the passengers feel comfortable, but also for every-day use.
Attractive exterior
Let's be honest, even if a car is equipped with every possible modern systems, or it has the most comfortable and practical interior, usually what we see is what attracts us first. The Kia Niro has a smart aerodynamic design. There are six available color options and few of them are red, silver and black.
It guarantees your safety
Safety is one of the most important things one must take into account when purchasing a vehicle. It is important to know that no matter where you go, you can rely on your vehicle too to prevent any accidents. This is why the 2017 Kia Niro includes devices like forward collision warning system, traction control system, blind-spot monitor, rear cross-traffic monitor and others.
Additional positive features
You should know that it does not matter what season it is because this hybrid offers you the best conditions. It includes ventilated and heated seats and heated steering wheel fit for summer and winter. Soft, quality leather wraps the steering wheel. The trunk is large enough to store different things and another important thing is that the Kia Niro offers excellent fuel economy.
The utility and the superior quality of the 2017 Kia Nero are unquestionable. It is a perfect car for long road trips. If you want to go camping, you can store many things inside it, and feel comfortable and relaxed until you get to your destination. A good car that will not fail you is a very important element that helps you enjoy your holiday and have a good time.


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Thinking about buying a home?
Check out this informative toolkit from the National Association of Realtors!
Thinking about buying a home?
Check out this informative toolkit from the National Association of Realtors!
Pictured: Coaches Andrew and Allie Goodman
The holidays are quickly approaching. This will mean cooler weather, and more opportunities to get outside for some fitness. Unfortunatley it is also a busy time of year. Everyone is trying to balance work, school, children's practices and games, holiday parties, and dinners, and the next thing you know it gets dark at five. So how are we supposed to stay on track with our fitness goals and avoid the extra pounds added during this time of year?
Lucky for us, I knew who to go to for help! Before images of tight zippers could give me a fright, I asked Allie Goodman, Owner of CrossFit Chowchilla, a few questions about staying fit this fall.
Tell me a little about your journey from normal human to gym owner and all around fitness superstar?
It's kind of funny actually. Playing sports all throughout High School as well as in College, I developed a true love for health and fitness. Studying at a few different Colleges, I kept along the study lines of Health & Wellness and Business Management. But, then as time went on, I found myself running into a hidden passion for creating & making cakes, which not very many people knew about. When I was 19 yrs old I traveled to Illinois, and attended the French Pastry School of Chicago. I learned everything from cakes, sugar art, chocolate, and wedding cake design. At that time I was definitely on the path to becoming a pastry chef with my sister Michelle. Living in a big City, opened my eyes to many new things! As my two years passed living in the wonderful city of Chicago, I came home to find a new passion of mine…
I have been doing CrossFit since 2011 and have accumulated many coaching hours along the way. Achieving a CrossFit Level 1 Training Certification as well as USA Weightlifting Coaching Education Certification. I love learning new things, and I am constantly adding to my knowledge and achievements. Training and coaching at CrossFit Valley View in Los Banos, I learned so much from my wonderful coach and trainer Jen Correia. I was able to kick start my own gym and love for the sport in Chowchilla. I took a leap of faith and persued my new passion and opened up what is now "CrossFit Chowchilla". We have been open for 1 year, and I love every minute of it! The joy you get when you're changing people lives for the best, is quite an experience.
What is your advice for people who are beginning their fitness journey?
The first and hardest step is actually getting started! Once you start, and see yourself improving each day, that's what drives you. Whether you're starting CrossFit or any other program you need to know that there is "no magic pill" and you have to want it. I always say, once you've started your working out program, "Never miss a Monday, Don't ever go 3 or more days without working out, and make it a lifestyle not just another thing!"
The weather here in Los Banos will be cooling down soon, but this is a time of year where people get busy and fall off the fitness wagon. How do you recommend individuals stay fit during the upcoming busy holiday season?
Make your fitness and health a lifestyle, not just another diet or fad in your life. There is always time! Meaning if you cant make it to the gym, there are plenty workouts to do at home with no equipment needed. Also, your eating habits are important. If you're not working out as much, then make sure you are at least eating right.- Or vice versa- if you have an overload of carbs one day, make sure to exercise that particular day to somewhat counter act your mess up ;).
Can you recommend any activities to keep the entire family fit?
On family game night play active games not board games. There are plenty of fun ways to get up and moving. Go on a scavenger hunt or play hide and seek. If you like CrossFit, I recommend the "Deck of Cards" workout (its worth a google), easily done with kids as well! 😉
What do you find are obstacles in reaching fitness goals?
Not being consistent with your workout schedule or eating habits. With no consistency there is no routine and you are more susceptible to failing. YOU are your biggest obstacle, meaning it's only yourself that is stopping you from reaching your goals. We always have excuses like, I'm too tired, I don't have enough time,or its too hard etc… But in all reality, there is always and answer and a way, you just have to overcome these things mentally.
Does food play a big role in losing weight and staying in shape?
YES! We all wish it didn't play a big role, but it basically comes down to 70% Diet 30% Exercise. We can't expect to meet goals, feel or do awesome in our workouts if we are eating badly. Someone told me once, if your craving a cookie, buy 1 cookie not a whole box as you are most likely to eat the whole thing if you have it.
Is there a particular food that you struggle to stay away from during the holidays?
I'd say the hardest thing for me to stay away from is the festive chocolates and desserts, oh yes and the alcohol.
How do you fight temptation during the holiday season?
I try and keep it to a "one day" (holiday), to eat whatever I want. Not letting myself indulge on the festive foods everyday. -It's a "cheat day" not a "cheat week"! If I do mess up, I don't stress on it, I just get right back too it.
Does your gym have any specials going right now?
We are offering a free week of training, and coming up in November on Black Friday we will offer 30 dollars for 30 days of training.
I have to thank Allie for her wonderful advice. It sounds like we need to find a fitness routine and stick to it! Regardless if you try CrossFit or just a daily run, no excuses! We also shouldn't let one bad day of eating snowball into an entire season of second helpings and desserts. Put the Pinterest away! No one needs that kind of temptation! If you would like to try CrossFit with Allie she can be reached at CrossFit Chowchilla.
Facebook: CrossFit Chowchilla / Twitter: @CFChowchilla
The median home price in Merced County at 199,280 is almost 300,000 less than the average median home price in California at 488,260. Some of the most expensive markets are right over the hill. Santa Clara County has a a median home price of 965,000. Making Los Banos one of the few affordable counties to live, in California.
Graph courtesy of CAR
Los Banos is a beautiful place. Coming from the coast, I love the seasonality of the crops in Los Banos. The tall cotton plants growing along the borders of town are a symbol for many of the fall season to come. Similarly I look forward to acre after acre of golden and green corn fields. As fall progresses, we start to see little pops of red on the tomato plants. When I see those bursts of red I know the tomato festival is coming up.
Although I have not lived here long, I will run into many people I know at the festival. Coming from "over the hill", I grew used to a cursory hello from the few people I would run into around the city. That is not the case in Los Banos. The people I see at the fair will ask genuine questions about my life, and family. It is something I had to get used to. I was used to being in a rush, waiting in this line and that line, waiting on the freeway, hurrying to get home and be away from the crush of the world.
Now that I'm not living at such a frenzied pace, I look forward to seeing my friends and neighbors. I go to the spring fair, and sit with family friends to watch their daughter sell her pig at auction. We buy charity tickets to dinners to support the FFA, the cub scouts, a football team, and run into more friends at that dinner. Life here is about slowing down, and taking time to help your friends and neighbors.
I'm happy to be a part of this community, and I hope that this website will serve as a place where we can unite. There will be articles about local people. There will be a calendar that can be clicked on to view local happenings. There will be write ups about local events. There will be articles about the culture of Los Banos, and what makes this such a special place.
There will also be features on the local real estate market, to help people find there dream home here.
So, Welcome Los Banos!
If anyone has content they would like added to Los Banos Realty and Lifestyle, please let me know. This is a family friendly place for the community, and everything family friendly will be considered! I can be reached at email@example.com


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We were in from out of town and I seen Anita's on Tripadvisor with all it's great reviews. Didn't seem like much from the outside but boy oh boy was it delish! I am so glad we stopped in for lunch and when I'm back...More
1 - 10 of 49 reviews
We were in from out of town and I seen Anita's on Tripadvisor with all it's great reviews. Didn't seem like much from the outside but boy oh boy was it delish! I am so glad we stopped in for lunch and when I'm back...More
If you want really good Mexican food, give Anita's a chance. Reminds me when I would visit my Mexican friends house.
Went for an early lunch. Ordered 4 tacos, asada, carnitas, pastor, and chicken. All tacos were really good. Staff was very friendly. Only reason I didn't give a 5 was the interior could use a refresh. Definitely going back.
Went because we were in the area and the reviews were very good. We got the fajitas and a fish and beef taco. The tacos were great, fajitas so so. Busy place. Would probably go back.
I expected authentic mexican food!! Sadly it was more Tex-Mex... anyway it was so so. I think the best was the nachos we also had enchiladas and beef soup.
Shredded beef taquitos and the "Very Hot" salsa are the real deal. Near the palm beach airport and car rental facilities.
So glad I found this place! Authentic mexican food and atmosphere. Stopped in for a few breakfast burritos and was met by friendly Spanish speaking ladies. They whipped us up some amazing food and horchata! Great find! Highly recommend!
We enjoyed the authentic atmosphere at Anita's. Lots of Hispanic customers. The location is not fancy but the food more than makes up for this in price and in taste. There is a salsa bar which is just bonus for those with mild flavorful tastes...More
Great place for what I would call Tex-Mex cuisine. Laid back, order at the counter from an extensive menu. We've tried something new every time we've visited and leave way beyond stuffed. I've been here 6 years and have never had better Tex-Mex soul food....More
After landing at the airport I checked trip advisor for a nearby place for a quick lunch. I expected a sit-down restaurant and nervously checked out the wall menu. Not cheap, but very good! If you want service or ambience, go elsewhere. If you want...More


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Shares in Paypal Holdings Inc (NASDAQ:PYPL) shot up 10.13% and closed at $44.15 on Friday after the company declared solid results for the third quarter and analysts upgraded the stock.
The stock traded 37.51 million shares, over four times its normal average volume of 8.12 million shares.
Paypal Holdings Inc (NASDAQ:PYPL) Q3 numbers are impressive
For Q3 the company reported EPS of $0.35, which was in line with analyst expectations, and revenue of $2.67 billion, which beat by $20 million, and was up an impressive 18.1% year-on-year.
"We are pleased to have delivered another quarter of strong results. The opportunities for PayPal to grow and gain share have never been greater," said Dan Schulman, President and CEO.
"We are further expanding the ubiquity and value of the PayPal brand and moving deliberately towards achieving our vision of becoming an everyday, essential financial service for people around the world," he added.
Paypal Holdings Inc (NASDAQ:PYPL) TPV shows excellent growth
The company claimed that it grabbed significant market share during the third quarter. It processed $87 billion in Total Payments Volume (TPV), which was up 25%.
At the end of the quarter the company had 192 million active customer accounts, up 11%.
It processed 1.5 billion transactions, up 24%. That represents 30 payment transactions per active account on a trailing 12 month basis.
Major agreements were entered with Visa and MasterCard, while the company was successful in becoming a payment option on Ali Baba's global retail marketplace, AliExpress.
"The ecommerce market today is roughly 10 percent of a $25 trillion global retail market," CFO John Rainey said on CNBC's "Squawk Alley."
"And we see that growing at double digit rates and yet PayPal continues to grow in excess of that… we've shown in the face of competition for each quarter, successively, we've been able to grow in the 25 to 30 percent range and that's by focusing on what we do best, which is digital payments," he added.
Paypal Holdings Inc (NASDAQ:PYPL): More conviction on long-term profitability
Analysts at Stifel upgraded PayPal to buy from hold and the price target to $49 from $43, saying that this earnings report put to rest debates about margin pressure. "We believe PayPal is on the path to becoming the central hub for online consumer financial activity," they said.
Analysts at Oppenheimer and Wedbush retained their Outperform ratings but boosted their price targets from $43-$45, and from $50-$54, respectively.
For fiscal year 2017, PayPal expects revenue growth in the range of 16% to 17% on an Fx-neutral basis.
Technically, the stock has surged past its bogey of the $41 level on high volume and is now trading well above its 200-day moving average of approximately $38. If there is a pullback, and it declines by $2.00-$3.00, investors can consider buying into the stock.


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PlayStation 3
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- PlayStation 3
- What game(s) did you regret buying?
crazyman32 4 years ago#261
Man, this will be a long list. Off the top of my head:
wow,What games do you like.
PSN ID:gearhead32
I apologize for nothing.
ReyMilansteryo 4 years ago#262
crazyman32 posted...
TheCyborgNinja posted...Man, this will be a long list. Off the top of my head:
I JUST wanted to tell the same thing.
PSN: DGray_Squally
Now playing: Fallout 3 (PC) , Deus Ex: Human Revolution, Uncharted 2, Rocksmith
Street Fighter IV
Kane and Lynch II
Battle Fantasia
Buzz Quiz TV
Dark Void
The Eye of Judgement
Disney Universe
Final Fantasy XIII and XIII-2
Just Cause 2
Mortal Kombat
Ninja Gaiden Sigma
Quantum of Solace
Sonic Unleashed
I keep track of every game I have ever played haha.
VIIVincent posted...
Wut. Tekken is the easiest fight series to get into. I don't see how that can be opinion either haha since it is one of the only ones that has a proper combo system.
king_madden 4 years ago#265
Emi3280 posted...
king_madden posted...Emi3280 posted...-Uncharted
so none of those games fit, since they werent your idea, and instead were a gift. cant regret a gift, unless you asked for it.
also golden abyss is a vita game, you telling you're girlfriend bought you a bunch of games im assuming you never asked for and never really wanted, but she bought you all of them including the one for vita?
I mean I only played the last uncharted and didnt think it was bad or anything but I never really got into the other 2, dont know why. ORC was ok for what it was, nothing more, and I never played man vs wild, but i did think about it.
king_madden posted...
Emi3280 posted...king_madden posted...Emi3280 posted...-Uncharted
My girlfriend knows I own all Sony consoles and that I like shooters. ORC was rushed and not well made. DLCom, I mean, Crapcom, likes to milk money out of everything you know?
PlayStation Network: DarkEmigaru98
Youtube Channel: http://www.youtube.com/user/Emi3280
darkness1018 4 years ago#267
Ice Weasel posted...
darkness1018 posted...These are the ones i regret (only gonna list this gen or else this post will never end...lol):
Lol. I read reveiws but ive noticed they only to know for sure if ill like a game is to just play it. And no, i dont rent so all those games were bought. If i listened to reveiws i wouldve missed out on alot of games that i ended up liking. I guess i try just about anything (except sports games, find those boring) to see if its for me or not.
PSN: nightwing2099 (PS3 & PS Vita)
Nightmare637 4 years ago#268
XIII-2 liked the first one to a degree hated the second one.
Don't bother arguing with Sophi he'll never admit hes wrong even when he is :D.
goldenboy1867 4 years ago#269
MGS1 ( PS1) I couldn't get through the frist guy -_-,,,, WTF the frist guy that i saw,,,, raged a quited
resident evil 2 = i ran out of ammo and i was stuck ( with a safe point ) in the place where a zombie was at, with very low health,
resident evil zero = I wasent stuck nor anything, everything was find but i got bored. ( beated the other RE games though )
are you saying i can run from a bullet
currently playing: Battlefield 3, Metal gear solid 4, Dead or alive 5,
BigRussDaGOD 4 years ago#270
Red Faction Armageddon
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- PlayStation 3
- What game(s) did you regret buying?
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I'm very attracted to the idea of having a permanent or lockable collar, and I'm not sure what to make of that desire other than to voice it here. Judgment suspended, I want one to wear 24/7 for reasons which most closely mirror those for wearing an engagement ring, except there's something much more raw and primal and mine about a collar which suits the feeling far better than a pretty piece of jewelry.
Not that I don't adore my rings to death. I wear them constantly and take every opportunity to show them off. Yet a collar seems to suit this new...chapter, I suppose...in ways rings don't specify well enough. There's a passion in the possession and a pride in that allegiance worn so blatantly, like a flag in the wind or a brand on one's arm.
I want one.


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The armor made by goblins who are very fussy about it like Sword of Gryffindor was accused of being stolen by Godric Gryffindor
The goblins held that payments were only rent for the life of the purchaser and should have been returned to their makers. Wizards passed these items on, however.
Goblin-made armor never rusts.


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It happens one night ever year. The scariest night of the year. Most fear this night. Some can't wait for this night. They wait all year for it.
Emily's life changes when she hears 9 words.
"For the next 12 hours all crime is legal."
Could someone really fall in love in just 12 hours?
AngieClifford7 Jul 20, 2016
Me reading the count down sped up my heart rate😂😂😕😕
littleMissLovelyXXX Feb 12
I almost had the same situation with my father except it was prostate cancer and he lived 😭😭😭 the fright though
TOPNOTCHQUEEN Sep 09, 2016
What you mean boring, i was scared the whole time reading this! 😔😔
tarryngallant Apr 18, 2015
@janoskiansbeb well it is just one night a year where all crime is legal
tarryngallant Apr 18, 2015
simply amazing just like all of tour stories thank you for writing this


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The Kettering-based Hot Head Burritos chain has reached an important milestone, opening its 50th store in Urbana, Hot Head founder and President Ray Wiley said this morning.
Wiley said at least 10 more Hot Head locations are in various stages of development in Ohio and surrounding states. The Kettering-based Mexican restaurant chain operates in Kentucky, Indiana, Pennsylvania and North Carolina in addition to Ohio. Its most recent restaurant is located at 669 Scioto St. in Urbana.
Earlier this year, Hot Head opened a new restaurant at 1120 E. Stroop Road just west of Marshall Road in Kettering that Wiley said is a prototype for future Hot Head restaurants. The Kettering location has a drive-through lane, only the second in the chain to offer that service.
Wiley said last year that he is working to develop Hot Head, which opened its first store in Kettering in 2007, into a national chain. And the chain's fast-paced growth backs up the national recognition that Hot Head has earned in the past two years: In December 2011, it was named among the "Ones to Watch" by QSR Magazine, which monitors the "quick-service restaurant" category. And for two consecutive years in 2011 and 2012, the chain made FastCasual.com's list of "Top 100 Movers & Shakers," which recognizes restaurant chains that reflect the fast-casual segment's growth.


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Emeril Lagasse's Oven-Crispy French Fries With Paprika-Parmesan
Be the first to review
READY IN: 50mins
Recipe by AmyZoe
I made these with breakfast and really enjoyed them. See Emeril's Essence for Emeril's Essence. Recipe courtesy of Food Network Magazine July/August 2012.
See Discussion:
Ingredients Nutrition
- 2 large baking potatoes (about 1 1/2 lbs, scrubbed well)
- 1⁄4 cup extra virgin olive oil
- 1 tablespoon Emeril's Original Essence (See Recipe #482579) or 1 tablespoon creole seasoning (See Emeril's Essence)
- kosher salt
- 1⁄4 cup parmigiano-reggiano cheese (finely grated)
- 1 tablespoon sweet paprika
- 1⁄2 teaspoon garlic powder
- 1⁄4 teaspoon onion powder
Directions See How It's Made
- Preheat oven to 425.
- Pat the potatoes dry and cut them lengthwise into 1/2 inch thick slices.
- Turn each slice flat and slice again lengthwise into even 1/2 inch thick fries.
- Place the potatoes in a mixing bowl and add the olive oil, seasoning, and 1/4 teaspoon salt.
- Toss well to combine, then transfer the fries to a large baking sheet and arrange them in one even layer so that they are not touching.
- Roast, scraping the potatoes from the baking sheet with a metal spatula and turning them over halfway through, until golden brown and crispy, about 30 minutes.
- While the potatoes are cooking, combine the cheese, paprika, garlic powder, onion powder, and 1/2 teaspoon salt in a small bowl and stir to blend.
- When the potatoes are crisp and brown, sprinkle with the paprika-parmesan salt.
- Serve hot.


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5 lovable comments:
I hope I will never get a news from my kin about anyone of dengue fever. It's hard to tell when one is attacked and can be taken for granted until late na kaya namamatay ang victim. The best thing to do is to rush to the hospital kung may lagnat na unusual.
You just pray that you be sealed and protected by the blood of Jesus Christ against all harms and pray also that God's ministering angels be sent to you to watch over you and to protect and guide you at all times. I will join you in your prayers for protection for your whole family. Thanks for the post. God bless you all always.
It was indeed alarming. I have read about a cure for dengue is camote(?)
Hope everyone's safe.
God Bless.
Hi, I once had a dengue and it's quite scary, I almost died. Anyway, so you'd know the symptoms I had fever and didn't have any appetite for food, temp was 39-40 and had red spots on my arms and some parts of my body. They say yung apple na binalatan then it turns to brown is one of the cures. Di ko na try and I had to had a blood transfursion, else I would've died. Hope you and the family won't have it. Good thing you have cleaned your sorroundings.
to everyone: thanks for the comments and prayers, i'm keeping my prayers strong as well. kktak0t talaga ang dengue coz it could really kill. :'[ for now we're being really careful and are keeping our surroundings as clean as possible.
@Kangaroo: really? thank God you got over it! it's really scarrry..
cure lng na nArining ko was tawa2x.. hehe
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ACI American Conference Institute Business Information in a Global Context
This year marks 30 years since the inception of C5 Group. It is time to match our brand with the dynamic strides we have made. See inside for details…
American Conference Institute's 6thAnnual Forumon January 30-31, 2017 WMiami Hotel Miami, FL
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