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Many Western visitors to Kochi enjoy capping off a day on the beach with a night on the town. This port city on India's Malabar coast isn't known for its club scene, but as one of the country's hottest tourist destinations, it still keeps its foreign guests entertained after sundown. Most of Kochi's nightclubs and lounges are in big hotels and charge prices out of range for most locals, but a few attract a mixed crowd.
Kochi and Names
Kochi, on the Arabian Sea about 665 miles south of Mumbai, is in the state of Kerala. In colonial times, the city was called Cochin, and often still is. Even in Kochi/Cochin, you'll see it referred to both ways, but for all practical purposes, the two names are interchangeable. However, nomenclature gets a lot more confusing than that. The original city of Cochin is relatively small and one of many districts, towns and villages within the Greater Cochin metropolitan region. Original Cochin now part of the district of Ernakulam, where you'll find many of the hotels, shops and restaurants -- think of it as "downtown" Cochin. So when people refer to Ernakulam, they're usually using the name as a synonym for the original part of Kochi/Cochin, not the whole region.
Ava Lounge in Kochi's Commercial Hub
By day, the Ava Lounge, named in honor of the late movie star Ava Gardner, is an upscale restaurant in Ernakulum, Kochi's commercial district. After dark, though, it morphs into a lively disco and dance venue. You'll find the Ava Lounge in the Dream Hotel on Sahodaran Ayyappan, or S.A., Road.
Loungevity: Boogie to Bollywood Hits
Loungevity on Mahatma Gandhi, or M.G., Road is where visitors can meet and mingle with young locals out for a night on the town. Frommer's calls the club "a cool white minimalist lounge bar" in an "untouristy part of the city." Located in the Avenue Regent Hotel, Loungevity's DJs spin Bollywood as well as international pop hits.
Getting Your Glow On
Glow offers clubbers a 1,500-square-foot dance floor and an ambiance hearkening back to the 1970s heyday of disco, complete with psychedelic lighting effects. It's in the Hotel Harbour View on M.G. Road near the Cochin shipyard.
A Club for Sports Fans
Champs Sports Lounge sometimes hosts DJ-and-dance nights, but people mainly come to this informal tavern in Kaloor district to watch live telecasts of India's two favorite sports -- cricket and "football," meaning soccer. Decor consists of posters of great moments in sports, and prices are lower than many of Kochi's more glamorous venues.
For a Quieter Experience ...
Divine is an intimate wine lounge in the Malabar House, a boutique hotel in the historic Fort Cochin area. There, you can spend the evening sampling fine Indian vintages paired with recommended dishes food from an international menu.
One of Kochi's Best Views
On Marine Drive, the Harbour View lounge in the landmark Taj Residency Hotel, also known as the Taj Gateway, commands a striking view of Kochi Harbour.


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Bumping this Fabulous tape do u feel it?
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77 Year Old Woman Makes a Difference by Holding Garage Sales
Posted by Barb Filed under Blogs, Garage Sales
Rochester Hills, Mich: Neighborhood gives back for 19th year
Here's a tip: When visiting Joanne Marcil's home, watch your stuff. Just ask her husband, Ray, who left a jacket lying around. Joanne grabbed it and sold it at her community's Make A Difference Day flea market. When Ray later asked her about it, she just smiled.
The project began in 1992 as a garage sale, raising $150 to buy high chairs for a soup kitchen. Marcil, 77, had such a good time she enlisted family and friends to create bigger events every year. The two-day market is now tradition, requiring 150 volunteers and five families' garages to store donated items.
In 2010, the sale raised $13,000 for women in crisis, the homeless, people with chronic diseases and others. In 19 years, the project has raised $71,000. It's hard work but well worth it, Marcil says. "I'm doing something to help this world, not just wishing things were better."
$10,000 Make A Difference Day Award from Newman's Own goes to The Baldwin Center, Pontiac, Mich.
This year's judges:
Charles Gabrielson: President & Publisher, USA WEEKEND Magazine
Brian Gallagher: President and CEO, United Way Worldwide
Michael Havard: Vice President of Marketing, Newman's Own Inc.
Kim Martin: President and General Manager, WE tv and Wedding Central
Michelle Nunn: CEO, Points of Light, Institute & Co-founder, HandsOn Network


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(Reminder:This is a Cam blog, so if you do not ship and/or like Cam, please do not comment on this, I don't want to waste my time reading hate comments and such, thank you)
I was thinking, there should be a special day, just for Cam, but when? We all should deside when and what it should have,about Cam.
I'm thinking there should be a Cam song, fan made videos of Cam, and Cam pictures, made or edited by Cam fans. If you can think of anything Cam related we can do on this day, we can descuss it.
We would call this, Camiversary. It will be a special day about Cam. For instance I have a Cam paddle, and I have decorated a pink T shirt and sweatpants with Cam quotes and I would use and wear that for the Camiversary. I also have a bunch of pictures of Cam as well and I could make a collage of those pictures.
I wanted to make Camiversary because I just simply love Cam and would love to support it in the best possible way I can. Camiversary would be an funfilled Cam day, people making pictures, collages, videos all about Cam. It would be a really fun day. So if your a Cam fan, you really should take part in this day, but we have to discuss what day would be Camiversary. Leave comments and tell me what you think :) and if you want to take part in it, lets discuss of when we should have it. :)


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Popular movies week 12 March 1911
Here's the list of the most popular movies in the week 12/March - 18/March - 1911. Do you remember Dorian Grays Portræt by Axel Strm or Ansigttyven II starring Philip Bech, Aage Bjrnbak, Alfred Cohn ?
What else happened in that week of 1911?
Discover what the world looked like on:


text: #WikiaPageHeader {width: 750px;} #WikiaMainContent {width: 1200px; margin-left: 50px;} #WikiaRail {display: none;} div.tally {display: none;} — Lt. Col. John McCrae, MD, (1872-1918)Canadian Army Retrieved from "http://admintools.wikia.com/wiki/User_blog:SpikeToronto/Remembrance_Day_11:11_11/11/11?oldid=42620" Ad blocker interference detected! Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers Wikia is not accessible if you've made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected. Category: Blog posts


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Over the years Fox (the studio behind the X-Men movie franchise) has been very cautious with Wolverine's look. They've certainly made a believable and modern version of the character. But now it's time to give the fans something that resembles the original Wolverine costume. After all, they pulled off the yellow suits in X-Men: First Class.
Today we have our first full glimpse at the X-Men: Days of Future Past trailer. In the trailer, we see Wolverine wearing a futuristic blue and black suit, which is interesting. But what is even more interesting is the yellow right arm. (It's difficult to see because of the lighting in the trailer.) That's right, blue, yellow, and black; the classic colors for Wolverine.
A VERY similar design to the classic Wolverine suit was made for The Wolverine (2013). The suit did not make it into the film. This photo has curiously been removed from sites and videos by Fox.
UPDATE! (11/8/13): An alternate ending from The Wolverine DVD/Blu-Ray surfaced today. It shows Yukio giving Logan a case. When he opens the case, the iconic Wolverine suit is inside. He gives Yukio a mean glare after he opens the case. Yukio says,"Interesting" and it goes to the credits. Here is a picture of the suit in the film:
The best evidence of a similar suit to the classic design appearing in Days of Future Past is from one of Bryan Singer's early pictures of the film.
Even if the suit doesn't have some kind of mask similar to the classic design, it still pays homage to the original yellow suit.


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- Description
The Romano Collection is a study in refined contemporary design.
Block-front contemporary case pieces perfectly compliment the bi-cast vinyl channel-tufted headboard.
Absent of hardware, each drawer opens with the clever pull of the block drawer fronts.
Dimension: 23.75" W x 16.25" D x 26" H
Extensive assemble may be required.
More from this collection: Romano
- Additional Information
Additional Information
SKU 13400423 MPN 2114-4 GTIN UPC 782359159089 Brand Homelegance Collection Romano Assemble Length 23.75 Assemble Width 16.25 Assemble Height 26 Assembly Required Yes Material N/A Finish Espresso Styles Contemporary Shipping Time 1-2 Weeks Free Shipping No
- Reviews
Disclaimer: Pictures displayed may include optional products not included in the price. Computer monitors often display color variations. Color swatches are shown if alternative colors are available. Please call us or email us if you have any questions!


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TG Stays Nethaji Nagar
Call us 1800-300-2400-1 (Toll Free) and Get additional Discount upto 50% for this Hotel.
Per Room Per Night
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You are getting lowest possible rate for this hotel
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About TG Stays Nethaji Nagar
Emmanuvel Cottage is located in Thokkupara about 13 km from the Munnar Bus Stand. The accommodation in Munnar provides front desk assistance to its guests. Accommodation is provided in five well-furnished guestrooms. The cottage also has amenities that include a television, wardrobe and desk. Hot and cold running water is also available in the and an attached bathroom.
No of floors: 1 | No of rooms: 5
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Hotel Information and Amenities
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Hotel Amenities
- Front Desk
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- H/C Running Water
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Question: What is a collateralized debt obligation CDO
What is a collateralized debt obligation (CDO)?
View Solution:
View Solution:
Answer to relevant QuestionsWhat is a credit default swap (CDS)? Define and give an example of the following: a. Direct quote between the U.S. dollar and the Mexican peso, where the United States is designated as the home country. b. Indirect quote between the Japanese yen and the Chinese ...a. What is the geographical location? b. What are the two main types of trading systems for foreign exchange? c. How are foreign exchange markets connected for trading activities? Calculate the cross rate between the Costa Rican colón (₡) and the Canadian dollar (C$ ) from the following two spot rates: ₡500.29/$ and C$1.02/$. Andreas Broszio just started as an analyst for Credit Suisse in Zurich, Switzerland. He receives the following quotes for Swiss francs against the dollar for spot, one-month forward, 3-months forward, and 6-months ...
Post your question


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What is JotForm?
JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
At JotForm, we want to make sure that you're getting the online form builder help that you need. Our friendly customer support team is available 24/7.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you'd like help immediately, feel free to search for a similar question, or submit your question or concern.
Can I insert Excel spreadsheet into a form?Asked by guildforms on October 16, 2015 at 06:29 PM
While Excel file can not be uploaded and shown on the form, you could use the Spreadsheet widget to achieve similar effect, or alternatively use our Iframe Embed widget to show Google Spreadsheet right on your form.
If you can tell us what you would like to achieve we would be happy to assist you and recommend the best way to achieve the same.


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Nonagon Baptistry, BaptistryUK from Baptistryuk on Vimeo.
00 44 (0)345 230 1381
Note for your diaries…
Over the holiday period, there are no hires until w/b 3rd September. All offices will be staffed Mon-Wed for August.
Ex-hire Apostle baptistry – panels, step, liner and pads. £795+VAT. For new kit, see equipment page.
Leasing deals are now available. If you lease and use the pool 3 times a year, it will already have saved you money on what you'd have paid for 3 hires.
The pool and equipment would stay with you, which means less wear and tear, and time money saved on transport.
Monday – Friday 9-5.00
Ruth is not available Thursdays until 12.30
David is not in Wednesdays until 1.30pm.


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We have two Protégé M700 tablets and have encountered a problem. From time to time when they are in use the touch screen will stop working. I have looked through the Toshiba knowledge base and found no solution for the issue. I'm pretty sure that it is user error related but I though I would see if anyone else might have had this issue.
Thanks! ^_^
4 Replies
Sep 18, 2008 at 1:49 UTC
It's been forever since you posted this, however, we currently have a user that's exhibiting the same issue on the same model laptop. Did you find a resolution to this issue?
Sep 19, 2008 at 8:14 UTC
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Sep 19, 2008 at 8:30 UTC
I'm not sure what is going on with all that junk code.
After a bit of trial and error I found that it was a combination of user and tablet error. I found that the user wanted to use the touch screen feature without turning the screen around and down into the locked position. If the screen is not locked the touch feature will work for a little while, about an hour, but then stops working. When the screen was flipped and locked the error did not occur as often. The other problem was the fact that the end users where not shutting down/restarting the tablets. The drivers for the touch feature need to be reset pretty frequently it seems. So shutting down the tablet for a few minutes seems to take care of that. After all Windows can not run forever...it always errors if left running too long.
(And office is horrid for junk code)
Nov 11, 2008 at 7:52 UTC
I too had the same problem with the M700 tablets. I had 23 at one time.
I worked with their tech support and sent 2 units in for repair. As soon as the users had them for 2 hours, the problems resurfaced. I ended up working with 2 different USA engineers. I sent 2 laptops for them, to be replaced with new ones (from a different lot). Didn't matter, same problem.
The 2 I sent the last time went back to the engineers in Japan. They eventually found the problem was with the Wacom drivers (or so I was told), but there was no resolution. After 6 months, I finally obtained an RMA for all of the laptops and am currently replacing them with Lenovo X61's. I still have 6 to go, and the Lenovo's have been working great.
The sad thing is, I've been purchasing Toshiba's since the M200 line was introduced and they've been fantastic. I think the M700 went too far with the touch screen, which my users hated anyways.
This discussion has been inactive for over a year.
You may get a better answer to your question by starting a new discussion.


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Ask a QuestionHere are the questions asked by community members. Read on to see the answers provided by the ThriftyFun community or ask a new question.
This summer I will be vacationing in Nova Scotia and Prince Edward Island. I am looking for places that people have been to that are "must see" as well as any tips you may have.
az2010 from Easthampton, MA
We went to Nova Scotia and PEI last summer and I really liked PEI the best. They have a Ann of Green Gables show and we stayed the whole day there. They do parts of in the books and it was fabulous. The wax museum was a rip off, the people didnt look good.
I was raised in the Maritimes and head east any chance I get. In PEI- don't miss Green Gables if you have ever read the books. Charlottetown is full of Canadian history sites, there is a cool "touristy " mall right at the end of the bridge when you first hit the island that also had live entertainment when we were there a couple of years ago. Take time to walk along the wonderful ocean beaches, and try to find a lobster supper- usually put on by churches and oh so good! The scenery in both provinces is outstanding.
You can drive all over PEI in a day- NS is a bit bigger, so where to go depends on how long you've got. If you have time to travel the Cabot Trail- take lots of film. The views are incredible. The Alexander Graham Bell museum in Baddeck in cool to go to , at the NS/ NB border there were bagpipers at the tourist information center when we were there. Halifax is full of stuff to do, including the Bluenose, the Maritime Museum, great shopping, wonderful food and Citadel Hill. Peggys' Cove is world renowned and gets millions of visitors. Check out both provinces websites for good ideas and have a wonderful trip
Share on ThriftyFunCheck out these photos. Click at right to share your own photo in this guide.
This is a picture we took on vacation at my cousin's house in Nova Scotia. My young cousin describes them as cotton candy clouds!
By coville123 from Brockville, Ontario
Believe it or not, this is the ocean on a calm cold winter morning, not far from where I live in Nova Scotia, Canada. The island offshore protected this inlet from the winds.
By Linn
A fishing boat (Cape Island Boat) heading home with their catch. This photo was taken at the entrance of the Halifax Harbour, Nova Scotia, Canada.
By Linn
This was taken in Nova Scotia at my cousins house. It's beautiful there.
By Coville123 from Brockville, Ontario


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On this page you will find a comprehensive and impartial guide to the Druk Path Trek. We are not a tour operator, but we can put you in touch with our recommended partner, click here.
As this is a very long and detailed article on the Druk Path Trek, we recommend using the quicklinks below to navigate to the sections that interest you most. Alternatively, bookmark this page for future reference.
The Snowman Trek
Please use the quicklinks below to navigate the guide.
- Route Overview
- Regional Map
- Video Overview
- Detailed Itinerary
- Frequently Asked Questions
- Tour Operator Recommendations
Route Overview
The amazing kingdom of Bhutan boasts some of the worlds most beautiful and breath taking treks. They range from the arduous Snowman Trek (which fewer people have completed than have ascended Everest) to the Druk Path Trek, a trek that offers a great introduction to hiking in Bhutan.
Get a trek operator recommendation
Video Overview
Cool timelapse of shot at Jigmelang-tsho on the Druk Path trek! Video by Wanderers Travelust.
Detailed Itinerary
As with most Bhutan Treks, the starting point of the 6-day Druk Path Trek is the gateway to the Happy Kingdom – Paro. This is mostly due to the fact that it's home to one of the only airports in the country, unless you want to take a bus through India as there are no trains operating in Bhutan.
After what should be a spectacular flight (due to the views of the mountains you're seeing), you should be heading out towards one of the most prominent and awe-inspiring building structures in Bhutan, a Dzong. These ancient buildings had many uses to the Bhutnanese. Some were places of worship, some housed important members of state and others were used in the defence of the kingdom.
Paro Dzong sits at 2300m and just below it is Ta Dzong, the Bhutnaese National Mueseum. Depending on the time of your departure, a quick tour of the muesem is a necessity in taking in the vast amounts of history within Bhutan.
After taking in all your history notes, an easy day of trekking lies ahead. Apples Orchards (don't pick any!), outskirts of Damchena village and the wonderful serene pine forests of Bhutan are just some of the landmarks of the day. If you're lucky with the weather – you might just be able to see Mt. Jomolhari.
A ridgeline descent into rhododendrons and alpine forests is your start to the day. Yak herders roam these parts and a tip of the hat won't go amiss. Views of Kitchu Drake and Jomolhari dot the sky during the day and by night a pasture against the hillside shall be your home
Whereas your first two days were spent in alpine splendor, the third day of the trek ushers you out onto the open plains of the Bhutnases countryside. Wild Onions laden the fields around you and if you're lucky enough to have some Masterchefs on your group – most of these will turn up in your dinner. But first you'll have to reach Jangchu La (3800m) with it's panromaic views of the valleys below and the Himalayn Peaks and your desitnation for the day – Jimilangtsho Lake. There is a tale that farmers bring their cows to the lake in hopes to mate it with a mystical ox providing them with strong offspring.
Dawn greets you with more good trails, bypassing Lake Janetsho, and delivering epic views of the Himalaya's. At 4,110m – Lake Simkotatsho rests serine below you and camp is setup on a nearby yak pasture overlooking the deep valleys of the Himalayas.
A long last day of trekking – starting with a small saddle climp at 4,150m then onto Phumela Pass (4210m) with it's array of prayer flags and stone cairns set with a backdrop of Gangar Puensum, the world's highest unclimbed mountain. Down below is Thimpu and several sacred peaks which are used for sky burials, an ancient funreal practice in which a human corpse is placed upon a mountaintop to slowly decompose while exposed to nature. Although sounding macarb, it is considered an act of generosity on the part of the deceased, since the deceased and her/his realtives are providing food to sustain living beings.
After that. All downhill. Descending through Juniper Trees via a small community at Phajodhing, you'll finally reach the road at Sangaygang, where a car most likely will take you to Thimpu.
From Thimpu there are a variety of day trips (via vehciles) to other walks around the valley. But if you've had your fill of walking – you're mostly likely going to make your way back to Paro.
Regional Map
The Druk Path trek leads from Paro to Thimphu. The map below shows the trekking regions in Bhutan. The Druk Path follows well trodden trails in the west of the country.
For a detailed Bhutan guide we recommend the Bhutan Lonely Planet
Guides and Tours
Like most treks in Bhutan, routes can be very intricate and even when they are not it's still advised to join a guide or a tour in case of getting lost. Most amenities aren't readily available as soon as you set out of Paro and if you compound this with injuries on the route, there is no question you should have company whilst attempting the trek
Frequently Asked Questions
Below we have provided detailed answers to the most frequently asked questions on the Druk Path Trek.
The main airport in Bhutan is Paro International Airport, and most flights into the kingdom land there. (PBH/VQPR).
Being one of the shortest treks in Bhutan, prices for the Druk Path Trek are relatively low in comparison to some of the other more advanced and longer treks. Starting prices around $2500 to about $4000. The higher the price, the more luxuries en route.
Here are some suggested items for your packing list:
- High Quality Socks (4-6 pairs as the mud and water will certainly have you changing them often)
- Quick Dry Towel
- Sufficiently Shaded Hat
- Underwear
- Long and Short Sleeved Shirts
- Fleece
- Long trekking trousers
- Waterproof Jacket
- Warm winter jacket (down or synthetic)
- Light Shoes or Sandals for evening use
- Parka
Trekking Gear
- Daypack (35-45L)
- Duffle bag (90L) for your main gear
- Hiking Boots
- Four season sleeping bag
- Water Bottle or Hydration bladder
- Trekking Poles
Miscellaneous Items:
- Sunscreen
- Toiletries
- Sunglasses
- Headlamp
- Medical Kit
Tags: The Druk Path Trek, Druk Path trek Bhutan, Bhutan's druk path trek, Bhutan trek, Bhutan trekking
Get a Trek Operator Recommendation
Pop your details in the form and you will receive a price competitive quote from our trusted trekking operator.
Brilliant service guys! The operator you recommended is absoultely fantastic. Fast, responsive, amazing track-record and great prices! Thanks
Explore Other Routes
Snowman Trek
The Snowman Trek is one of the toughest treks on the planet! If you have 4 weeks to spare and are looking for a real challenge, then check out the Snowman Trek.
Druk Path Trek
The Druk Path Trek provides a wonderful introduction to trekking in Bhutan. The trek is ideal for those short of time or those in search of a relatively easy hike. Discover the Druk Path Trek.


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Abandoned Dog's Owners Choose Different Pup To Adopt
No one likes to hear a sad story but this one is just too much. This poor little pup was left at the shelter after her owners turn up, only to adopt another dog instead of taking her home.
It's fantastic news when we hear a successful adoption story, you know the kind of story that makes you smile and turns your day into a good one. Well, sadly it's not always that easy, and sometimes dogs even face the cruel reality of the world we live in.
This is 2 year old German Shepard Zuzu, a beautiful young girl, who is currently living at Downey Animal Shelter in California.
Zuzu is described as being "beautiful and loving" and "amazing". This is clear to see from the lovely profile she has set up by the volunteers at ShelterMe. ShelterMe specialise in re-homing pets with awesome and loving new owners.
However, Zuzu hasn't had the best of luck when it comes to finding a loving family. Her previous owners tell the story of a very upset and emotionally unstable young dog, and after her father passed away, Zuzu spent many hours crying. The poor pooch leaped over the fence into a neighbours garden, where animal control was called to deal with the situation.
Shelter volunteers noticed one day that Zuzu had become very excited and distracted by something. One of the volunteers at ShelterMe wrote "With her fast wagging tail seeing her owners Zuzu lite up like a Christmas Tree. She looked like the happiest dog. Yeah, she's going home."
Unfortunately for Zuzu she didn't end up returning to her home, even tough she was so excited. Her owners on the other hand weren't as excited and decided to adopt another dog instead.
Desi, a volunteer, stated Their reason was because she was crying and sad since her father passed away. She wasn't a happy dog anymore," She continued "Their solution for her unhappiness was just leaving her here. And [to] go get another dog."
Once the Facebook post had gone viral, understandably many people were frustrated and angry with Zuzu's owners.
People have made sure that Zuzu's story has been shared all over and helped to get her a new, loving family.
Desi has made a plea and commented: "Let's get her into the perfect home please".
Although Zuzu's story is unfortunate and heartbreaking we should all be thankful that she is in a place where people care and love her.
Desi also said "[I was] honestly sad but glad," Desi commented on Zuzu's situation. "I knew the rescues who come to [the shelter] would find her a good home where she would be a family member."
I just hope that Zuzu finds a home that she deserves and that she finds her forever home.


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Adolescent Health Care: A Practical Guide
Chapter 56
Ectopic Pregnancy
Melissa D. Mirosh
Mary AnneJamieson
Ectopic Pregnancy
Ectopic pregnancy in the adolescent population is fortunately uncommon. Teens usually have not had sufficient time to establish enough exposures to infection or other intraabdominal pathologies to acquire tubal damage and then conceive with resultant ectopic pregnancy. However, in managing ectopic pregnancies in teens, one must remember that access to care may be limited before or after the diagnosis, confidentiality must be respected, future fertility should be protected, and reliable and acceptable contraception should be offered and encouraged during and after treatment.
Ectopic pregnancy should be a consideration when any pregnant adolescent presents for an office visit with new onset of abnormal uterine vaginal bleeding or abdominal/pelvic pain.
Incidence and Prevalence
The risk of ectopic pregnancy in United States is approximately 19 per 1,000 pregnancies, which has remained stable for several years (MMWR, 1995). This is only an approximation because there are many miscarriages, abortions, and medically treated ectopic pregnancies that are not reported.
- Trends: From 1991 to 1999, ectopic pregnancies were responsible for 6% of all pregnancy-related deaths in the United States, of which 93% were due to hemorrhage (Chang et al., 2003). This represents an overall decrease of 13% since 1992, most likely due to increased detection of early pregnancy. The risk of death from ectopic pregnancy in the United Kingdom fell from 16 to 4 per 10,000 ectopic pregnancies during the nearly 30 years spanning 1973 to 2002 (Lewis, 2004), although mortality still remains high in developing countries (Igberase et al., 2005).
- Ectopic pregnancy occurs throughout the reproductive age spectrum. A review from California found a low rate of 12.5 per 1,000 reported pregnancies in women aged 15 to 19 to a high rate of 42.5 per 1,000 pregnancies in women aged 40 to 49 (Van Den Eeden et al., 2005).
- Ectopic pregnancies occur more frequently in black women (8%) than in white women (4%). This demographic trend is also seen with respect to overall maternal mortality. This discrepancy is unexplained at present, although it is consistent with the higher sexually transmitted disease (STD) rate and lower socioeconomic status seen in the black population in United States (Anderson et al., 2004; Centers for Disease Control and Prevention, CDC, 2006; MMWR, 1995).
- Location: Ectopic pregnancies occur almost exclusively in the oviduct (95.5%), while 1.3% are abdominal, and approximately 3% are cervical or ovarian. Within the tube itself, most ectopic pregnancies (70%) are located in the ampullary region, 12% are isthmic, 11% are fimbrial, and 2.4% are interstitial (Bouyer et al., 2002).
Etiology and Risk Factors
There are many factors associated with an increased risk of developing an ectopic pregnancy. (Table 56.1)
- Tubal abnormalities: The most common predisposing factor for adolescents is a previous episode of pelvic inflammatory disease (PID). This is more likely in females with a previous chlamydial infection because Chlamydia infections tend to be less symptomatic than gonorrhea and therefore may go untreated for longer, causing significant pelvic organ damage. The resulting salpingitis is responsible for approximately 45% of initial ectopic pregnancies (Westrom et al., 1981). Scarring of the tubes impairs the ability of the tube to permit normal motility within its lumen. Histopathological study of excised tubes previously involved with PID has shown multiple pockets and tortuous pathways that may also trap embryos (Green and Kott, 1989). Other tubal pathology associated with ectopic pregnancy includes damage or adhesions from previous pelvic surgery (previous tubal surgery for an ectopic pregnancy, ruptured appendix, trauma, inflammatory bowel disease, endometriosis, tubal ligation, or tubal reanastomosis). Adhesions outside the tube to nearby structures such as bowel or other pelvic organs may also cause distortion of the tube. Diethylstilbestrol (DES) exposure (extremely unlikely in this generation of adolescents) and other reproductive congenital anomalies may contribute to abnormal anatomy as well.
- Tubal pregnancy with the intrauterine contraceptive device Intrauterine Contraceptive Device (IUD): The IUD has long been erroneously associated with an increased risk of ectopic pregnancy. In fact, the absolute
risk of ectopic pregnancy is significantly reduced in women with an IUD compared with women who use no method of contraception. The current copper IUDs are no longer considered to increase the absolute risk of ectopic pregnancy (Xiong et al., 1995). However, if a patient becomes pregnant with an IUD in situ, the chance that the fetus will implant outside of the uterus is 15% to 20% (Weir, 2003). Progestin-releasing IUDs are associated with an even lower pregnancy rate than nonhormonal IUDs and thereby further reduce the chance of an ectopic pregnancy when compared with sexually active women who are not using contraception (French et al., 2004).
- Other factors: Other factors that increase the risk of ectopic pregnancy include smoking, infertility, in vitrofertilization, and prior ectopic pregnancy. In the adolescent population, smoking is the most common risk factor.
Differential Diagnosis
The differential diagnosis of ectopic pregnancy and those teens presenting with acute abdominal or pelvic pain is best divided into obstetrical, gynecological, and nongynecological categories.
- Obstetrical
- Normal intrauterine pregnancy
- Hemorrhagic corpus luteum
- Spontaneous or threatened abortion
- Gynecological
- Ovarian torsion
- Hemorrhagic ovarian cyst
- Symptomatic or ruptured ovarian cyst
- Pelvic inflammatory disease
- Nongynecological
- Appendicitis
- Renal colic
- Inflammatory bowel disease
- Gastroenteritis
- Severe constipation
Clinical Presentation
The range of symptoms depends on the integrity of the teen's fallopian tube and can range from mild cramping and vaginal spotting to frank hemorrhagic shock. However, the classic triad of vaginal bleeding, delayed menses, and severe lower abdominal pain is associated with tubal rupture and is now a fairly infrequent presentation, because early diagnosis is more routine. In general, there are two distinctly different constellations of signs and symptoms that are expressed by women with ectopic pregnancies, each of which dictates different action plans.
Acute Presentation: Classic, Ruptured Ectopic Pregnancy
- Symptoms: The patient who presents with an acutely ruptured ectopic pregnancy would typically exhibit the following symptoms:
- Sudden onset of extreme, sharp, or stabbing unilateral pelvic pain, as well as shoulder pain. The shoulder pain is referred pain resulting from subdiaphragmatic irritation caused by hemoperitoneum.
- Dizziness, lightheadedness, or loss of consciousness from acute intraperitoneal hemorrhage leading to hypotension.
- Abnormal menses: The patient may have missed her menses and/or experienced several days of abnormal vaginal spotting or bleeding, as well as vague pelvic pain before the onset of her acute symptoms. Teens often have irregular bleeding, and may not have noticed any difference from their "routine" menstrual pattern.
- Pregnancy symptoms: The patient may also have noticed nausea, vomiting, breast tenderness, or other symptoms of early pregnancy.
Statistically, the teen who presents with a ruptured ectopic pregnancy is more likely to have had a previous pregnancy and therefore usually does not suspect a problem (Saxon et al., 1997). Generally, gestational age at the time of active symptom development varies by the implantation site. For example, ampullary implantations are more likely to rupture at 6 to 8 weeks of gestation, but cornual implantations may not rupture until near the end of the first trimester.
- Classic signs of a ruptured ectopic pregnancy:
- Vital signs: the patient may be in shock with rapid thready pulse, hypotension, and change in mental status.
- Abdomen will be tender to palpation, possibly even rigid, with marked rebound tenderness.
- Bimanual examination: Cervical motion tenderness is apparent with a slightly enlarged and globular uterus. Often a pelvic mass is not palpable, either because of guarding or because the rupture has eliminated the bulging mass in the fallopian tube.
- Laboratory tests: Laboratory testing requirements are minimal and are necessary only to prepare for surgery and to rule out other pathologies.
- Pregnancy testing: Sensitive urine pregnancy test results should be positive. A baseline quantitative serum β-human chorionic gonadotropin (β-hCG) will allow monitoring of pregnancy resolution.
- The "Three C's of hemorrhage:"
- Complete blood cell (CBC) count—including hemoglobin and hematocrit.
- Cross-match—blood group and screen to prepare for possible transfusion as well as Rh typing to determine the need for Rh immunoglobulin.
- Coagulation factors—if the blood loss has been significant, patients may have evidence of disseminated intravascular coagulation (DIC) and consideration should be given to appropriate laboratory testing.
- Ultrasonography: If the patient is hemodynamically unstable, an ultrasonography is not indicated and should not delay a patient from getting into surgery. If an ultrasonography is performed, however, the most remarkable finding will be free fluid and clots in the pelvis; blood may fill the entire abdominal cavity. If there is a positive pregnancy test result, a corpus luteum cyst may be seen and the endometrium may be thickened with decidual material. In fact, a hemorrhagic corpus luteum cyst is the other main consideration in the differential diagnosis. The presence of an intrauterine pregnancy essentially rules out ectopic pregnancy in an adolescent because heterotopic pregnancy is extremely rare without assisted reproductive technologies. It is not necessary to visualize the pregnancy in the tube, although the absence of a uterine pregnancy seen on ultrasonography is not diagnostic of an ectopic pregnancy. In the context of an acute and unstable presentation, the final diagnosis will usually be confirmed at the time of surgery.
- Therapy:
- Fluids: The patient requires intravenous access in the form of at least one (preferably two) large-bore intravenous line(s). Fluid resuscitation should start immediately. Blood transfusion may be started if clinically indicated (and with informed consent whenever possible), but surgery should not be delayed by the need to give the patient a transfusion to some arbitrary hemoglobin level; the patient may be losing blood internally at a rate faster than can be replaced by transfusion.
- Emergency surgery is required: At surgery, every effort should be made in an adolescent to preserve the fallopian tube if possible, performing a salpingostomy as opposed to salpingectomy. If a hemorrhagic corpus luteum is determined to be the cause of the bleeding then every effort should be made to preserve the ovary. If an oophorectomy is required, progesterone supplementation should be instituted until 10- to 12-weeks gestation if the patient wishes to continue the pregnancy.
- The patient's Rh status must be confirmed and Rh immunoglobulin given if she is Rh negative.
Subacute Presentations: Probable Ectopic Pregnancy and Possible Ectopic Pregnancy
A woman with a positive pregnancy test result who presents with cramping, abnormal vaginal spotting or bleeding, and lower abdominal/adnexal pain should be suspected of having an ectopic pregnancy, particularly if the diagnosis is supported by physical findings of cervical motion tenderness, a closed cervix, adnexal tenderness, and (possibly) an adnexal mass. Women who present in early pregnancy with complaints of vaginal spotting or bleeding and cramping without those suspicious physical findings must also be evaluated to rule out an ectopic pregnancy, although their diagnosis is more likely to be threatened abortion. The work-up and treatment depend on the woman's risk factors and her pregnancy intentions.
The initial diagnosis of a clinically suspected ectopic pregnancy in the hemodynamically stable patient begins with a complete history and physical examination, lab work, and transvaginal ultrasound imaging. If the patient has a regular menstrual cycle, her last menstrual period may be helpful in establishing correct pregnancy dates. Other history that may assist in establishing gestational age includes the date of the first positive pregnancy test result and findings from any previous ultrasonography. The reason for established gestational age is that some authors have recommended using this as a starting point for the diagnostic work-up. In this approach, the first step in the evaluation is an ultrasonography if the gestational age is at least 6 weeks. However, the last menstrual period is often not a reliable or secure data point, particularly in adolescents who may have irregular cycles or imprecise recollections of their menstrual dates. Mol et al. (1998) reviewed 354 patients evaluated for ectopic pregnancy and found that gestational age did not discriminate between intrauterine and ectopic pregnancy. Quantitative β-hCG levels have more reproducibility and, therefore, are used as the basis of most management protocols. The lab work should include CBC count (for white blood cell [WBC], hemoglobin [Hgb], and hematocrit), blood typing, and screening to determine Rh status, and a serum quantitative β-hCG. The adolescent patient may need an explanation for the role of transvaginal ultrasonography as she may be hesitant to have a probe inserted vaginally.
Laboratory and Imaging Evaluation
The properties and limitations of each diagnostic test should be recognized to appropriately use each of them in the work-up.
- β-hCG: Typically, β-hCG levels will double every 2 days in a normal first trimester intrauterine gestation. Only 15% of normal pregnancies will fail to have this appropriate increase in β-hCG levels. The smallest increase over 48 hours that can still be associated with a continuing intrauterine pregnancy is 53% (Barnhart et al., 2004). If β-hCG measurements are unchanged or increasing abnormally, the pregnancy is nonviable; it may be an abnormal intrauterine pregnancy (destined to abort), or it may be an ectopic pregnancy. Pregnancies that have inappropriately low β-hCG levels are more likely to be ectopic. Serial β-hCG measurements can be extremely helpful in determining the fate of these pregnancies.
- Ultrasonography: Ultrasound studies at appropriate β-hCG levels are usually diagnostic, and often the definitive method of pregnancy dating in adolescents. Although ectopic pregnancies can have characteristic appearances on ultrasonography (Frates and Laing, 1995), ultrasound is not used to visualize the tubal pregnancy, but to identify a pregnancy within the uterine cavity. There is still debate over what β-hCG cutoff should be used as the discriminatory level (the lowest concentration of β-hCG that is associated with a visible normal intrauterine gestation), but this level is generally considered to be above 1,500 to 2,000 IU/L when using a transvaginal ultrasound probe. Above this level of serum β-hCG, a normal intrauterine gestational sac should be seen (Condous et al., 2005; Mehta et al., 1997). Although an intrauterine pregnancy may be detected at lower levels, the possibility that the pregnancy in question is intrauterine cannot be excluded until the β-hCG levels reach the discriminatory range. If no intrauterine gestation is seen, then an ectopic pregnancy should be strongly suspected. One must also keep in mind that multiple gestation pregnancies will not be visible until the β-hCG concentration is above 2,000 IU/L (Mol et al., 1998). If transabdominal scanning is the only method available, the β-hCG cutoff should be 6,500 IU/L (Kadar et al., 1994).
Outpatient Follow-up—Using Serial β-hCG Levels:
- Declining β-hCG levels: If the β-hCG levels are declining by 50% to 66% every 3 days, it is likely that the patient has experienced a complete resolution of the pregnancy. The β-hCG levels must be followed up until they are undetectable (based on local laboratory values).
- Increasing β-hCG levels: If the β-hCG levels are increasing by at least 66% every 2 to 3 days, they should be followed up in a mildly symptomatic patient until they reach the discriminatory zone and the diagnosis can be made ultrasonographically. If the patient becomes increasingly symptomatic before reaching the discriminatory zone, laparoscopic investigation may be considered. It is useful to discuss with the patient whether the pregnancy is wanted. A dilation and curettage (D&C) can be performed at the time of laparoscopy if the pregnancy is discovered to be intrauterine. If the pregnancy is wanted, consider delaying insertion of the uterine manipulator until an ectopic gestation is confirmed.
- Abnormally changing β-hCG levels: If the β-hCG levels are declining or rising at an inappropriate rate, the pregnancy (either intrauterine or ectopic) is likely nonviable.
- If her β-hCG levels are above the discriminatory level, an ultrasonography should be obtained to localize the pregnancy. If it is not within the endometrial cavity, the pregnancy is presumed to be ectopic.
- If her β-hCG levels are less than the discriminatory range, it is important to assess the patient's desire for pregnancy. If she does not wish to continue with the pregnancy, the presence of an abnormal uterine pregnancy can be ruled out by performing a D&C. A β-hCG level, obtained 12 to 24 hours after the procedure, should be compared with a preprocedure level (Lipscomb et al., 2000). If levels drop by 50% in that time, an ectopic pregnancy can be ruled out. If time allows, the histopathology from the D&C specimen will usually confirm trophoblastic tissue and villi. Otherwise, the asymptomatic patient who is well-informed and compliant can be followed up expectantly until the β-hCG levels either fall, plateau, or reach the discriminatory zone and the ultrasonography can be performed. At this point, decisions about laparoscopy, D&C, and conservative or medical therapy can be made.
- Methotrexate may be therapeutic for both abnormal intrauterine pregnancies and ectopic pregnancies. Therefore, some investigators have suggested forgoing the D&C and immediately using the methotrexate therapy (see later discussion) to treat the abnormal pregnancy (Tulandi and Saleh, 1999). Misoprostol can be used orally or intravaginally for treatment of an abnormal intrauterine pregnancy.
Other Diagnostic Modalities
- Serum progesterone levels: A meta-analysis done by Mol et al., in 1998 looked at the use of a single serum progesterone level for diagnosing ectopic pregnancy. A progesterone level <5 ng/mL is associated with a failing pregnancy (in any location) whereas levels >25 ng/mL are diagnostic of normal intrauterine pregnancies in 98% of cases. Most women presenting with a possible ectopic pregnancy had progesterone levels that fell within this range, therefore it did not appear to be helpful in determining either the potential for viability or the location of the pregnancy (Mol et al., 1998).
- Culdocentesis to determine if there is blood in the cul-de-sac is rarely used today. It has been replaced by ultrasonic imaging.
Issues Unique to Adolescents
- Access to care and follow-up: There are several factors in the evaluation and treatment of ectopic pregnancy that are unique to, or should be emphasized in, adolescents. These patients may present later in gestation because of denial of pregnancy or fear of consequences. They may have trouble accessing the medical system, or be unable to seek help due to lack of transportation or money. Once in your office, establishing an accurate history is often difficult as menstrual cycles can be irregular and teens may be poor historians.
- Confidentiality and consent for treatment: One must be aware of the local legislation with respect to informed consent for minors. Fortunately, in most states and provinces, health care providers can use clinical judgment and provide medical care to an adolescent who understands the nature of the diagnosis and/or treatment, without necessarily involving a parent or guardian. Teens may have a particular need for confidentiality and this must be respected. On the other hand, health care providers should make every effort to negotiate with the teen to involve a parent or a guardian in such an important issue as the diagnosis and treatment of an ectopic pregnancy.
Approaches to Management
In the adolescent with an ectopic pregnancy, treatment should generally be fertility-sparing and should take into account that adolescents may have difficulty complying with follow-up recommendations.
- Surgical approach: Most women diagnosed with an ectopic pregnancy will be treated surgically through laparoscopy or laparotomy. Open surgery is the method of choice for hemodynamically unstable patients, surgeons with little laparoscopic experience, or both. Some surgeons may consider laparoscopic treatment of their hemodynamically unstable patients, depending on their surgical experience and available equipment (Sagiv et al., 2001). A recent Cochrane review concluded that although the laparoscopic route was less successful than a laparotomy for complete resolution of trophoblastic tissue, it remains the cornerstone of treatment in hemodynamically stable patients owing to its decreased operative time, hospital stay, and recovery times (Hajenius et al., 2000). Finally, laparoscopy has also been shown to have equivalent success when compared with laparotomy in obese patients (Hsu et al., 2004).
Conservative or radical treatment? The most common surgical procedures are salpingostomy and salpingectomy. Unfortunately, there are no randomized controlled studies that directly compare the two. In theory, the benefit of removing the affected tube is an almost guaranteed resolution of the ectopic pregnancy, while treating conservatively preserves the potential for fertility with that tube (which is crucial in adolescents). Five nonrandomized studies have been published that observed the outcomes of conservative versus radical therapy (Bangsgaard et al., 2003; Bouyer et al., 2000; Job-Spira et al., 1996; Mol et al., 1998; Silva et al., 1993). Three of them showed a significant difference in future fertility, but the two more recent studies have implied that conservative surgery may be advantageous with respect to subsequent fertility (Bangsgaard et al., 2003; Bouyer et al., 2000). A randomized controlled trial will likely be needed to complete the debate. Two studies have confirmed that it is not necessary to close the tubal defect after salpingostomy (Fujishita et al., 2004; Tulandi and Saleh, 1999).
There are some patients in whom salpingectomy is the preferred method of treatment. These would include cases of intractable hemorrhage, three recurrent ectopic pregnancies in the same tube, or in women who have completed childbearing. The latter two scenarios seldom occur in the adolescent. One aspect to consider before removing the affected tube is the state of the contralateral tube. If the patient wishes to conserve her chances for spontaneous conception, the unaffected tube must appear normal. If it is abnormal or damaged, salpingostomy for the ectopic pregnancy would be recommended.
- Medical therapy: Early diagnosis of ectopic pregnancy using laboratory tests and sensitive imaging techniques has significantly reduced the mortality and morbidity of this condition. It has also enabled the use of outpatient medical therapy in lieu of surgical intervention, which in time has reduced hospitalization costs and surgical complications.
Methotrexate: Methotrexate has become an established method of treatment for patients diagnosed with an unruptured ectopic pregnancy. The main advantage of medical therapy over surgical therapy is that it is less invasive and less expensive.
- Modality of action: Methotrexate is a folic acid antagonist and therefore exerts its effect on rapidly dividing cells. The medication disrupts cytotrophoblast syncytialization and blunts β-hCG production, thereby decreasing support for progesterone secretion by the corpus luteum (Creinin et al., 1998).
- Success rate: Meta-analysis of outpatient methotrexate treatment for appropriate candidates demonstrated a cure rate of 92% (Slaughter and Grimes, 1995). At least 85% of those women successfully completed therapy, although 5% to 16% required a second dose of methotrexate (Henry and Gentry, 1994). Only 2.7% required three or more doses. Failure rates are higher with higher initial β-hCG levels. One study found that the failure rate was 32% when the presenting β-hCG levels were more than 15,000, but was 6% when the pretreatment β-hCG level was less than 10,000 (Lipscomb et al., 1999).
There are no randomized controlled trials comparing single dose to multi-dose treatment. However a meta-analysis found that although a multi-dose regimen is more successful (92.7% versus 88.1%), the overall success of medically treating an ectopic pregnancy with any method of methotrexate is 89% (Barnhart et al., 2003). Often one dose is sufficient (Lipscomb et al., 1998). One study reviewed a group of 55 adolescents who had successfully used the single-dose method and were able to follow the strict follow-up protocols. In this group of teens, the success rate of methotrexate for ectopic pregnancy resolution was 85% (McCord et al., 1996).
Efforts to determine factors that argue favorably for methotrexate therapy identified an initial β-hCG level of <4,000 and lack of fetal cardiac activity as strong predictors of success. Indicators predictive of failure included visible extrauterine yolk sac on ultrasonography and previous ectopic pregnancy (Lipscomb et al., 2004). Patients must be counseled about the possibility of treatment failure (and possible tubal rupture) and the signs and symptoms that may indicate complications and necessitate return to hospital. Because it is common for abdominal pain to occur as the ectopic pregnancy resolves 24 to 48 hours after administration of methotrexate, the differentiation of "normal" from "abnormal" pain can be challenging and may result in additional emergency room visits for reassessment and reassurance.
Gazvani et al., examined the addition of mifepristone to any outpatient regimen of methotrexate and found no benefit (Gazvani et al., 1998).
- Dose: The dose used for treating ectopic pregnancy, usually 50 mg/m2, is much lower than that used for cancer chemotherapy. Many different regimens of methotrexate delivery have been employed for treatment of ectopic pregnancy, including oral, intramuscular, and local injection (under laparoscopic or ultrasound guidance). Tables 56.2 and56.3 list exclusion criteria and logarithm for using methotrexate.
- Side effects: Because the doses are so much lower than chemotherapy, the common side effects of methotrexate at higher dosages including nausea, vomiting, stomatitis, and diarrhea are rarely seen with the doses used to treat ectopic pregnancies. Rarely, a reversible leukopenia or transient hair loss may be seen.
Other medical modalities: Other medical interventions have included injecting the embryo with methotrexate, hypertonic saline, or prostaglandins. Although successful, these methods are more cumbersome and invasive compared to oral or intramuscular methotrexate, and therefore are much less frequently used (Hajenius et al., 2000; Yao et al., 1996).
- Treatment of unusual ectopic pregnancy sites: As mentioned previously, ectopic pregnancies are rarely located outside the fallopian tubes. There are a number of individual case reports documenting surgical and medical management of pregnancies located on ovaries, surgical scars, omentum, and the cervix. The method of treatment for pregnancies in these sites is usually systemic or local methotrexate under ultrasound guidance (Doubilet et al., 2004), as treating them surgically would be technically difficult or dangerous due to uncontrollable bleeding or poor surgical access.
- Expectant management: Expectant management is reasonable for a certain subset of women presenting with ectopic pregnancy. These patients are asymptomatic and generally have a β-hCG level below 1,000 IU/L (Trio et al., 1995). They also need to be reliable, as losing a woman to follow-up could be disastrous. Under these circumstances, Pisarska showed that 68% of women had complete resolution of their ectopic pregnancy without intervention (Pisarska et al., 1998). Patients who have spontaneous resolution of their ectopic pregnancies also tend to have a good chance of return to normal fertility. Rantala et al., found that 93% of their study patients had patent tubes on a subsequent hysterosalpingogram and did not have an increased rate of second ectopic pregnancy when compared to the general population (Rantala and Makinen, 1997). Unfortunately, the need to carefully assess these patients over the course of several weeks, especially if they develop pain, may result in the need for repeated clinical visits. Adolescents should be considered on an individual basis as candidates for conservative management because for many teens the follow-up and surveillance requirements will be too compliance demanding.
Complete resolution of the ectopic pregnancy must be documented because residual trophoblastic tissue proliferation can cause clinical problems. Overall, with salpingostomy, almost 5% of women undergoing laparotomy and 8% to 15% of women who are treated laparoscopically will develop persistent trophoblastic tissue (Seifer et al., 1993). In this situation, it is prudent to ensure that the β-hCG levels return to normal, and another pregnancy should be prevented until that time. β-hCG levels should be measured 6 days postoperatively. If the sixth day value is greater than 15% of the baseline value obtained at the time of surgery, persistent disease is presumed. Some have suggested that postoperative day 1 determinations replace the more delayed follow-up measurements; if day 1 serum β-hCG levels are decreased by 50%, there is an 85% probability that persistent trophoblastic tissue will not occur, and that the patient has been adequately treated (Spandorfer et al., 1997). Expression of ectopic tissue from the end of the fallopian tube (i.e., milking the tube) has been associated with residual disease in up to 25% of cases. Careful postoperative monitoring in these cases is critical.
Obviously, women treated with methotrexate or expectant management will require weekly (or more frequent) quantitative β-hCG determinations until the levels of that hormone become undetectable. Table 56.4 outlines specific guidelines for following up a patient treated with methotrexate.
Persistent Disease
If persistent disease is diagnosed, further treatment is necessary. If surgical treatment was used initially, methotrexate should probably be used as second line as long as the patient is not continuing to bleed from the ectopic pregnancy. If methotrexate was used initially, options include surgical treatment or repeat methotrexate (Graczykowski and Mishell, 1997). Very occasionally, expectant management can be considered but would again require a well-informed, compliant patient.
It is important to provide your patient effective contraception during her recovery period, not only to prevent a second pregnancy from complicating the β-hCG results, but also to allow the tubal tissue time to heal, thereby presumably reducing the risk of a second ectopic pregnancy in rapid succession. Waiting until the β-hCG levels "zero out" before starting contraception puts a woman in jeopardy for pregnancy because ovulation often precedes complete β-hCG clearance. Assuming the
adolescent is not seeking to conceive, every effort should be made to offer and provide reliable and acceptable contraception to the teen who has had a failed pregnancy (intrauterine or ectopic) or any pregnancy for that matter.
Rh Considerations
Unsensitized Rh-negative women should be given an appropriate dose of Rh immunoglobulin (50–120 µg if gestational age <12 weeks; 300 µg if >12 weeks) promptly (ACOG, 1999; Fung Kee Fung et al., 2003). Although very occasionally the blood type of the "father" is used to determine whether an Rh-negative woman receives immunoglobulin, it is always prudent to treat the Rh-negative adolescent anyway, because of the uncertainty that may exist with respect to paternity.
Fertility after Treatment of Ectopic Pregnancy
Several studies have looked at ectopic pregnancy recurrence rates and the rates of subsequent intrauterine gestations. On an average, ectopic pregnancies recur in 10% of patients (Bouyer et al., 2002; Pouly et al., 1991). In women seeking pregnancy, reproductive success varies between 50% and 88% within 2 years of the initial ectopic pregnancy (Bangsgaard et al., 2003; Bouyer et al., 2002; Fernandez et al., 1998).
There is no consensus in the literature about the preferred method of surgical treatment with respect to subsequent fertility (Hajenius et al., 2000). Two recent studies suggest that conservative (tube sparing) surgery may lead to a higher intrauterine conception rate than radical (salpingectomy) surgery (Bangsgaard et al., 2003; Fernandez et al., 1998).
Studies looking at fertility after medical treatment of an ectopic pregnancy are also reassuring. Gervaise et al., showed that 64 of 81 women had spontaneous intrauterine pregnancies after local or systemic methotrexate (Gervaise et al., 2004). Fifty-two of these were intrauterine (with 12 spontaneous abortions), and 12 (18%) were recurrent ectopic pregnancies.
Regardless of the method of treatment, adolescent patients who have had only one ectopic pregnancy can be reassured that their chances of having an intrauterine pregnancy in the future are excellent. The method of treatment can therefore be tailored to the needs of the individual patient.
Web Sites
For Teenagers and Parents
http://www.rxmed.com/b.main/b1.illness/b1.illness.html. RxMed Web site providing basic information on ectopic pregnancy.
For Health Professionals
http://emedicine.com/emerg/topic478.htm. eMedicine Web site on ectopic pregnancy.
http://www.aafp.org/afp/20051101/1719ph.html. American Academy of Family Physicians article on ectopic pregnancy.
http://www2.mc.duke.edu/depts/obgyn/ivf/ectopic.htm. Information on ectopic pregnancy from Duke University.
http://www.cmaj.ca/cgi/content/full/173/8/905. Review article on diagnosis and management of ectopic pregnancy from the Canadian Medical Association Journal.
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Lipscomb GH, Stovall TG, Ling FW. Nonsurgical treatment of ectopic pregnancy. N Engl J Med 2000;343:1325.
Lipscomb GH, McCord ML, Stovall TG, et al. Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies. N Engl J Med. 1999;341:1974.
McCord ML, Muram D, Lipscomb GH, et al. Methotrexate therapy for ectopic pregnancy in adolescents. J Pediatr Adolesc Gynecol 1996;9:71.
Mehta TS, Levine D, Beckwith B. Treatment of ectopic pregnancy: is a human chorionic gonadotropin level of 2,000 mIU/mL a reasonable threshold? Radiology 1997;205:569.
MMWR. Ectopic pregnancy–United States, 1990–1992. MMWR Morb Mortal Wkly Rep 1995;44:46.
Mol BW, Hajenius PJ, Engelsbel S, et al. Serum human chorionic gonadotropin measurement in the diagnosis of ectopic pregnancy when transvaginal sonography is inconclusive.Fertil Steril 1998;70:972.
Mol BW, Lijmer JG, Ankum WM, et al. The accuracy of single serum progesterone measurement in the diagnosis of ectopic pregnancy: a meta-analysis. Hum Reprod 1998;13:3220.
Mol BW, Matthijsse HC, Tinga DJ, et al. Fertility after conservative and radical surgery for tubal pregnancy. Hum Reprod 1998;13:1804.
Murray H. Baakdah H. Bardell T, et al. Diagnosis and treatment of ectopic pregnancy. CMAJ Canadian Med Assoc J 2005;173(8):905.
Pisarska MD, Carson SA, Buster JE. Ectopic pregnancy. Lancet 1998;351:1115.
Pouly JL, Chapron C, Manhes H, et al. Multifactorial analysis of fertility after conservative laparoscopic treatment of ectopic pregnancy in a series of 223 patients. Fertil Steril1991;56: 453.
Ramakrishnan K, Scheid DC. Ectopic pregnancy: expectant management of immediate surgery? J Fam Pract 2006; 55(6):517.
Ramakrishnan K, Scheid DC. Ectopic pregnancy: forget the "classic presentation" if you want to catch it sooner. J Fam Pract 2006;55(5):388.
Rantala M, Makinen J. Tubal patency and fertility outcome after expectant management of ectopic pregnancy. Fertil Steril 1997;68:1043.
Sagiv R, Debby A, Sadan O, et al. Laparoscopic surgery for extrauterine pregnancy in hemodynamically unstable patients. J Am Assoc Gynecol Laparosc 2001;8:529.
Saxon D, Falcone T, Mascha EJ, et al. A study of ruptured tubal ectopic pregnancy. Obstet Gynecol 1997;90:46.
Seeber BE, Barnhart KT. Suspected ectopic pregnancy. Obstet Gynecol 2006;107(2 Pt 1):399.
Seifer DB, Gutmann JN, Grant WD, et al. Comparison of persistent ectopic pregnancy after laparoscopic salpingostomy versus salpingostomy at laparotomy for ectopic pregnancy.Obstet Gynecol 1993;81:378.
Silva PD, Schaper AM, Rooney B. Reproductive outcome after 143 laparoscopic procedures for ectopic pregnancy. Obstet Gynecol 1993;81:710.
Slaughter JL, and Grimes DA. Methotrexate therapy. Nonsurgical management of ectopic pregnancy. West J Med 1995;162:225.
Spandorfer SD, Sawin SW, Benjamin I, et al. Postoperative day 1 serum human chorionic gonadotropin level as a predictor of persistent ectopic pregnancy after conservative surgical management. Fertil Steril 1997;68:430.
Trio D, Strobelt N, Picciolo C, et al. Prognostic factors for successful expectant management of ectopic pregnancy. Fertil Steril 1995;63:469.
Tulandi T, Saleh A. Surgical management of ectopic pregnancy. Clin Obstet Gynecol 1999;42:31.
Van Den Eeden SK, Shan J, Bruce C, et al. Ectopic pregnancy rate and treatment utilization in a large managed care organization. Obstet Gynecol 2005;105:1052.
Weir E. Preventing pregnancy: a fresh look at the IUD. Can Med Assoc J 2003;169:585.
Westrom L, Bengtsson LP, Mardh PA. Incidence, trends, and risks of ectopic pregnancy in a population of women. Br Med J (Clin Res Ed) 1981;282:15.
Xiong X, Buekens P, Wollast E. IUD use and the risk of ectopic pregnancy: a meta-analysis of case-control studies. Contraception 1995;52:23.
Yao M, Tulandi T, Falcone T. Treatment of ectopic pregnancy by systemic methotrexate, transvaginal methotrexate, and operative laparoscopy. Int J Fertil Menopausal Stud1996; 41(5):470.
Zhang J, Meikle S, Trumble A. Severe maternal morbidity associated with hypertensive disorders in pregnancy in the United States. Hypertens Pregnancy 2003;22:203.


text:
Protecting the puck
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Registered User
Join Date: Nov 2007
Posts: 4,637
vCash: 500
Kind of, yeah.
The direction/speed of the defender's momentum and his position relative to yours will affect how you choose to protect the puck.
If the defender is slightly in front of you or beside you, you'll want to use your shoulders and your legs to block the body contact and the stick respectively. If the defender is behind you, you can use your forearm to block hooks and your leg again to block whacks at the puck. If the defender is far in front of you, you'll have turn your back to him to shield him from the puck.
It's really just a matter of putting your body between the defender and the puck, while carrying it at a distance where he cannot reach it with his stick and establishing a stance that maintains good balance.
That's actually the one thing I've always been very good at... and to be honest, developed the basics by putting a chair in the middle of my garage and practicing going around it.
Remember that when you're trying to beat the defender one on one, you have options.
The puck can go to the left of him, to the right of him, or through his skates. Your body can go to the left of him or the right of him. When you want to go on the same side as the puck, you're using a puck-protect move. When you want to go in the opposite direction of the puck, you're doing more of a deke. Ideally what you want to learn how to do is fake one way and go the other. A drop of the shoulder, a quick little move with the puck, or even a headfake can throw a defender off... if even for a split second.
Last edited by noobman: 07-26-2010 at
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Ireland's heroes dominate Sunday World back page
The Republic of Ireland's magnificent triumph in Austria takes top billing on the back page of this weekend's Sunday World, as we salute our heroes in green after their 1-0 win in Vienna.
John Brennan was in Austria to capture the mood of the night, with Roy Curtis and Kevin Palmer adding to our comprehensive coverage of a win that edges Ireland a giant step closer to the 2018 World Cup finals.
Ireland legends Paul McGrath, John Aldridge and Kevin Moran are part of our packed sports pull-out, which also includes a world exclusive interview with Everton manager Ronald Koeman, conducted by Kevin Palmer.
Ken Lawrence asked the pressing questions surrounding Jose Mourinho's Manchester United reign, while we also pick out the best seven players in the Premier League so far this season.
Our GAA coverage is spearheaded by Pat Spillane and we also have comprehensive reports from a a thumping win for Ireland's rugby heroes against Canada in Dublin.
You will not want to miss this weekend's bumper Sunday World.


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Why Ference is a 'competative SOB'
As hard as everyone's tried, it's probably still impossible to overstate Andrew Ference's intangible impact on a hockey team. Few people know that more than one of his former bosses.
Ference continues to acclimate himself with the Edmonton Oilers after leaving Boston to sign with his boyhood team this offseason, and in a couple of weeks, he'll go to camp with the Oilers.
It will be the first time since 2006 that Ference starts a season with anyone other than the Bruins. That means there was plenty of time for Ference to leave his mark on the organization.
That mark was a lasting one, as evidenced by the glowing praise he received upon his exit, and B's general manager Peter Chiarelli added to that ever-growing mound of compliments recently.
"Andy's a competitive little S.O.B.," Chiarelli told the Edmonton Journal. "He plays harder than his size."
Ference has made a living out of getting more out of his 5-foot-11, 185-pound than most. The 34-year-old is a health-and-fitness fiend who is much stronger than that frame might suggest.
"He's aggressive, he's efficient, he closes on guys really well, defends well and for his size, he's very strong," Chiarelli said.
It also doesn't hurt that Ference brings a winning attitude to Edmonton, a team full of young players with a ton of talent. However, all the Oilers have know in recent years is losing, and they'll likely lean hard on Ference — who has been to three Stanley Cup Finals, winning in 2011 with the Bruins.
"I think [he can help the younger players]," Chiarelli said. "But I think he's also cognizant of the fact that you just can't take it from here and put it there. It's case by case. The Oilers are a lot younger and you can't force-feed some of that stuff on younger players."
Ference and the Oilers host the Bruins on Dec. 12, and the veteran blueliner will return to TD Garden on Feb. 1.
FOX Sports Go


text: MELBOURNE PRESS CLUB membership is open to everyone with an interest in the media. Members receive significant discounts on the cost of our regular lunches, as well as the annual Quills Awards dinner. The Club runs other social and professional events and occasionally offers special discounts on goods and services through arrangements with sponsors or related activities. MPC members pay no fee for their first entry in the Quill Awards each year. Annual membership is currently $75 for journalists, $95 for associate members and $30 for students. Please note that after holding down fees for several years, the Board has decided on a modest increase, which will apply from 1 August 2017. The new membership rates will be: Journalist $85, Associate $110 and Student $40. Journalist memberships are open to reporters, editors, photographers and camera crews, artists and designers and editorial production staff employed by recognised news outlets, and freelancers who derive the majority of their income from journalistic work. Journalist memberships are also available to retired journalists not engaged in other regular employment. The Club board approves all membership purchases, and retains the right to determine the appropriate membership category in each case. Please click here to apply for Melbourne Press Club membership. You will be prompted to fill out a contact details form and set a password. Once your login has been established you will be able to pay for your 365 day membership.


text:
The AntiPasta
This dish does away with pasta's bad reputation. It's light, loaded with flavor and powered by whole grains, protein, and vitamins. And it all comes together in 15 minutes, max! … buon appetito!
1 28-oz can of whole peeled tomatoes
8 oz whole grain pasta
2 garlic cloves, crushed
fresh basil leaves
salt + pepper
olive oil
Here's how:
1. Start a big pot of boiling water for the pasta.
2. Heat 1 tbsp of olive oil in a large saucepan to medium. Add the garlic and 1 tablespoon of the tomato sauce from the can. Cook for 2-3 minutes, then add the rest of the can of tomatoes. (I add the tomato sauce first so the garlic doesn't crisp up as it softens.)
3. Use a potato masher to gently mash the tomatoes. I like my sauce chunky. Season with salt and pepper to taste. Cook just long enough so that the tomatoes are warmed through, about 5 minutes. (I don't like to cook this sauce for too long in order to keep the bright red color of the tomatoes.)
4. Season the pasta water with a generous amount of salt. Cook the pasta according to package instructions or until al dente. You can use any whole grain pasta you like: shells, rigatoni, spaghetti – the possibilities are endless these days!
5. While the pasta cooks, cut the basil into ribbons. The easiest way is to stack the leaves, roll them up and cut across into strips.
6. Drain the pasta, and add it to the tomato sauce along with a handful of the basil. To serve, top with extra sauce, basil and fresh parmesan cheese.


text:
|By GretriXcape
|More from GretriXcape
|G (all ages)
|No update page
|The Forest of Thorns
|Chapter information
|Written by
|Release date
May 15, 2014
|Last chapter
|Next chapter
A new evil has risen; a darkbending nation. The world may be fighting, but only the Avatar can defeat the Dark Lord and bring peace to the world.
Book One: Dark
Chapter Four: The Forest of Thorns
Previously on Naton
The earth boy, Naton is revealed to be the Avatar, and has been trained in the four elements by the guardian spirit Alang. At the refugee camp, Naton realizes he must keep training if he wants to beat the Dark Lord. Naton and the Ben Hai travel to a person Master Onza believes can help Naton....
Chapter Four: The Forest of Thorns
"Gooooooood moooooorning, Avatar!" Beeno jumped up and landed on Naton.
"WHA-DUH- Beeno! Ow! Don't do that!"
"Naton! You're late! We're gonna meet the gardener!"
"Onza didn't tell you? The guy who's going to train you in awesome lightbending stuff!"
"I know! But I didn't think he'd be a gardener!"
"Doesn't matter! Let's go!"
Beeno dragged Naton out of the tent, and the Ben Hai were assembled in the center of the camp. The mayor of Guang and Naton's parents were there, too.
"Are you ready?" Aeron asked. Naton nodded.
"Good luck, Avatar. The world needs you," the mayor said.
Wushu and Linnie walked over to Naton. "Do you have to go? It's not safe out there," Wushu said.
"It's my duty as the Avatar. I'll be fine," Naton said.
"That's my son." Naton turned to the Ben Hai.
"Well?" Master Onza stepped forward. "We'll be leaving now. We will come back."
As the town waved good-bye, the Ben Hai traveled north, towards the dense forest.
"So, who is this gardener?" Kian asked. "You never told us about him."
"He is a good friend of mine. But he prefers to be alone," Onza replied. "But you will like him. He is young, kind and full of knowledge. He gets along with spirits."
"Sounds like my kind of guy, minus the alone part," Beeno said.
On the top of a rock face, they rested, and Tazen lit a small fire.
"I got some rabbit-snake stew ready!" Beeno cheered. "Don't worry guys, it's not my own recipe. Oh, I forgot the salt."
"Beeno! I need the salt!" Aeron protested.
"We'll have to do without it. The darkbenders are everywhere," Tazen said.
Naton sat next to Aeron and Karrie. "So, if you're an airbender, is Tenzin your grandpa?"
Aeron nodded. "Yup. Jinora's my mom. I have an older sister, but she's in Republic City."
"Aeron's my cousin. My mom is Ikki. My little brother joined the Flare Rebels," Karrie said.
Naton turned to Beeno. "What's your story?"
Beeno's face lit up. "I was a 3-time pro-bending champion! Have you heard of the Brown Battle Badgermoles?"
"Well you should! We were the best!"
"Are you still part of the team?"
"Nope. During a tour, we were attacked by darkbenders, and I stayed in Guang," Beeno explained.
Tazen stood up. "I was living with the Fire Governor, until a dragon attacked. Many people thought the spirits were mad at us. After the attack, I traveled to Guang, where I joined the Ben Hai."
All eyes then riveted to Kian, who was silently slurping his stew. "Oh, my story." He set the bowl down. "I was a soldier in the Northern Water Tribe, until an army of dark spirits attacked. My father owned a rebel army, and I traveled down to Guang as well." Then he resumed with the stew.
Onza cleared his throat. "Well, now that our Avatar has been introduced to everyone, let's hear what the Avatar has to say."
Naton blinked. "Me? No no no. My story's not very fun. You know, Wushu's Fruit Juice, market, sleep, regular stuff. Sorry, no fun stuff. Don't you guys have, a car or something? Something other than feet?" Naton asked.
"No, we don't. It would be too obvious," Tazen said.
"But it's so slow going by foot!" Naton complained.
"SHHH!! Everyone," Aeron hissed. "The forest. It's over there."
Onza pointed his staff to a large sea of tall trees. "The Forest of Thorns. The most sacred and spiritual place you'll see for miles."
Naton gasped in amazement. "It's so green."
"Where are the buildings and cars?!" Beeno shouted.
The Ben Hai trekked down the valley and entered the forest. The trees were straight and stood tall. The sunlight seeped through the branches, lighting the ground with spots. "Hello, Mr. Gardener?" Karrie cried out. Suddenly, a log shot past them, and collided with a nearby tree.
"Master Onza, are these nice or evil spirits?!" Naton cried.
Vines grew out of the ground and grabbed their ankles. Tazen firebended, and shot fire in the general direction. Several trees fell down, trapping them. The vines continued to wrap them up, and Naton spun around, creating a ring of flame. "Gardie! This is Onza!" the master yelled. At once, the rogue plants retreated, and out of the shadow, came a young man.
"I'm sorry, Onza, I get so many darkbender visitors these days."
"It's fine. But I think the log was a bit too much."
"Heh heh."
Gardie was around 35, with long dark hair and a small beard and mustache. He wore old dirty green clothes, and a blue necklace. His leather belt held leaves, herbs and vines. "So this is the Avatar," the gardener said to Naton.
Naton bowed in respect. "Hello, gardener."
The man laughed. "I prefer Gardie." The Ben Hai bowed to Gardie. "I look forward to training the Avatar. Did he master all four elements?" Gardie asked.
"Yes," Onza replied.
Gardie turned to Naton. "Have you been trained in plantbendng?"
"Oh, well then this will be fun. Let's begin your training."
Character or Plot Revelations
- Tazen was friends with the Fire Governor.
- Kian's father was the leader of a rebel group.
- Beeno was a 3-time pro-bending champion.
- Aeron is the son of Jinora.
- Naton's master, Gardie, is a talented plantbender.
Writer- GretriXcape
Illustrator- GretriXcape
See more
For the collective works of the author, go here.


text:
I stayed here for a romantic weekend and definitely enjoyed the hotel and its location within the city. It is situated near many shops and restaurants and tourist sites as well. The hotel was very clean, and the staff was very friendly. I would definitely recommend this hotel to anyone visiting Santa Fe.
- Official Description (provided by the hotel):
- Named for the patron saint of Santa Fe, New Mexico, the newly remodeled Hotel St. Francis pays respect to the origins of the city with its unique interior. With a palette of natural colors reflecting the days of Santa Fe and handcrafted wood furniture by local artisans, staying at the hotel is a cultural experience. Listed on the National Register of Historic Places, its recent restoration and renovation expanded the amenities to entertain travelers from across the world. The hotel is located just steps away from the historic Santa Fe plaza. Whether you're planning a weekend escape, a business retreat, or a lavish wedding, the Hotel St. Francis is the ideal destination. "Hotels supporting cultural causes." ... more less
- Reservation Options:
- TripAdvisor is proud to partner with Travelocity, Booking.com, Hotels.com, Expedia, Orbitz, Priceline, Hotwire, Cancelon, TripOnline SA, HotelsforEveryone, Agoda, getaroom.com and HotelQuickly so you can book your Hotel St. Francis reservations with confidence. We help millions of travelers each month to find the perfect hotel for both vacation and business trips, always with the best discounts and special offers.
- Also Known As:
- Hotel St Francis
- St Francis Hotel


text:
Hooray! The Sims 2 site is back!!! :D I'm not sure if it's permanent or for how long, so Sims 2 players--I suggest getting any custom content now before it goes down again!
For those of you who haven't been able to download items, check today because today I was able to download items! Let's be glad the site pulled through, for at least a bit!


text: PoliticsReligious controls lifted in Benghazi Once banned religious gatherings now free to operate in opposition-held Libyan city. 19 May 2011 12:17 GMT | Politics, Africa In Libya's eastern city of Benghazi, the opposition's version of governance is in full swing. Before Libya's uprising, large religious gatherings would have been unthinkable - but today in the opposition-held city, some Muslim clerics say times have changed.Al Jazeera's Tony Birtley reports from Benghazi, where reforms are already being put into action.Source: Al Jazeera


text:
Please turn off your AD BLOCKER to play this game!
Category: Parking Games
Played: 21,155
Category: Parking Games
Played: 21,155
Description: Park your vehicle in the parking lot.You need to collect all coins to activate parking area.Avoid hitting people on road and other obstacles.You have limited chance to clear the level. Click play again to restart the level.. Paid Parking is a Parking Games.
Instructions: Arrow keys to drive..


text:
MM Good chicken cutlets
Recipe by Maryann Crawford
Very easy delicious chicken dish. It goes great with mashed potatoes or noodles.
Top Review by shanti2
This was good.My husband loved it.No extreme seasonings etc.Great for kids. I like to look for recipes that are fast and easy and this was both. I also like recipes that I can add to or change to my taste and this was perfect for that.It is a great way to oven bake cutlets,they stayed very moist. I don't care that much for the Good Seasons sauce mixture,although good, it's just a personal thing.If you like Good Seasonings well enough, you'll like this.I am going to use this again as it is easy to adapt. I will be experimenting with some of my favorite dressings to add.
See Discussion:1 Review
Ingredients Nutrition
- 2 lbs boneless chicken cutlets
- breadcrumbs
- Good Seasonings Italian salad dressing mix
- 3 tablespoons lemon juice
- 3 tablespoons wine (red or white)
Directions See How It's Made
- Wet cutlets with water: dredge with bread crumbs and place in baking pan.
- Mix dressing as directed and add 3 tablespoons each of lemon juice and wine.
- Shake well and pour over cutlets.
- Bake at 350 for about 35 to 45 minutes.


text:
19 August 2017
Moscow: 12:07
London: 10:07
Consular queries:
+44 (0) 203 668 7474
5 Kensington Palace Gardens, London W8 4QS
(Entrance from Bayswater Road)
Consular Information Helpdesk: +44 (0) 203 668 7474 Fax: +44 (0) 20 7229 3215
E-mail (consular issues only): firstname.lastname@example.com
04.08.2017 - E-visa will be available to visit Primorye territory of the Russian Federation
Starting from August 8, 2017, nationals of Algeria, Bahrain, Brunei, India, Iran, Qatar, PRC, DPRK, Kuwait, Morocco, Mexico, UAE, Oman, Saudi Arabia, Singapore, Tunisia, Turkey and Japan may be granted an electronic visa (e-visa) to enter the Russian Federation through the border crossing checkpoints, located on the territory of the Free Port of Vladivostok.
07.06.2017 - On 12 June the Consular Section will be closed
The Consular Section of the Russian Embassy in the UK will be closed on 12 June.
30.05.2017 - Terror threat level in the UK lowered to severe
Based on the progress of the ongoing investigation, the British Government lowered the terrorism threat level from critical to severe.
29.05.2017 - List of 18 countries whose citizens can benefit from simplified entry to Russia through checkpoints at the Free Port of Vladivostok
The Government of the Russian Federation has approved a list of eighteen countries whose citizens can now obtain a regular single-entry business, tourist or humanitarian visa in an electronic form to enter Russia through checkpoints at the Free Port of Vladivostok.
25.04.2017 - Opening times of the Consular Section of the Embassy in May
The Consular Section of the Russian Embassy in London will be closed for the national holidays on 1, 8 and 9 May.
03.04.2017 - Helpline numbers after the explosion in St. Petersburg
Hotlines for information about friends and relatives after the explosion in St. Petersburg metro station
29.03.2017 - 2017 FIFA Confederations Cup and 2018 FIFA World Cup
Entry and exit from Russia for foreign nationals coming over to the sports events as spectators will require a personalized "Fan ID".
06.03.2017 - On 8 March the Consular Section will be closed
On 8 March the Consular Section will be closed.
06.03.2017 - Missing Russian citizen alert!
Russian citizen Mr Victor Ivanelo, student of the University of Surrey, has been reported missing in England. Investigation and search are being conducted by Surrey Police. Updated information about the incident and search activities, including CCTV images, has been released by the police at https://www.surrey.police.uk/news/have-you-seen-missing-man-viktor-ivanelo/
In this regard should you have any additional information which can help locate Victor Ivanelo please contact police at 101 and quote Operation Decibel reference 45170020251.
21.02.2017 - On 23 and 24 February the Consular Section will be closed
On 23 and 24 February the Consular Section will be closed


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- D Horenstein, B K Houston
- Journal of clinical psychology
- 1976
The confirmation or disconfirmation of initial client expectation with regard to the psychotherapy process was related to drop out from psychotherapy for clients of a university psychological clinic. Previous hypotheses and research findings emphasized the existence of a linear relationship between expectancy confirmation or disconfirmation and drop out… (More)
- D Horenstein
- Journal of clinical psychology
- 1977
Practitioners in the mental health professions presently are faced with the tasks of understanding the dynamics involved in the problem of child abuse and devising efficacious treatment and rehabilitation programs for both the abusive parent and the abused child. The present paper reviews research done by comparative psychologists more than a decade ago… (More)
- R P Cerniglia, D Horenstein, E W Christensen
- Journal of clinical psychology
- 1978
Examined the effects of a treatment program of patient decision making and self-management upon the self-concept, locus of control and behavioral adjustment of psychiatric patients. It was hypothesized that patients exposed to the experimental treatment would reveal significantly higher levels of self-concept, lower levels of external control and more… (More)
- D Horenstein, B K Houston
- The Journal of psychology
- 1975
Twenty men undergoing vasectomies completed the Tennessee Self Concept Scale shortly before the operation and again at 6- and 18-month postoperative follow-up periods. Twenty nonvasectomy comparison subjects completed the test at the same points in time. Results indicated that vasectomy adversely affects psychological adjustment, and this effect fluctuates… (More)
- D Horenstein
- Journal of clinical psychology
- 1975
Relationships were investigated between initial levels of client disturbance in each of 10 problem areas and client drop-out, lateness to, and absence from therapy, expectations with regard to therapy, and various demographic variables. Data were obtained from 154 outpatients at a university psychological clinic. Correlations computed between initial… (More)
- D Horenstein
- Journal of clinical psychology
- 1976
Previous research in college student mental health indicates that most psychological problems stem from the academic area of the student's life. However, many previous studies focused upon the general college population and did not consider the problems of students who are receiving mental health services. In the present study, college students who sought… (More)
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text:
The Los Angeles Lakers and Paul George rumors are flying, and they rose to another level after his interview on Jimmy Kimmel Live last night. It was a good interview, but things got interesting when Kimmel started questioning George about him potentially joining the Lakers shortly.
Kimmel started off by showing George the clip of Magic Johnson making it clear that he wanted the Indiana Pacers' franchise player in L.A. He then proceeded to ask George if that made any difference to George, which the Pacers' superstar seemed to shrug off. It then came out that George plans to work out with Kobe Bryant shortly and will pick his brain about George's future options.
Last season with the Pacers, George averaged 23.7 points per game to go along with 6.6 rebounds and 3.3 assists per game. George took those numbers to a new level during the NBA Playoffs against LeBron James and the Cleveland Cavaliers, averaging 28.0 points, 8.8 rebounds, and 7.3 assists per game. During the regular season, George shot 46.1 percent from the floor overall and knocked down 39.3 percent of his three-point attempts.
All of that being said, George has not shut down the rumors that he wants to play for the Lakers at some point. He has made it clear that he loves the city of Indiana and would love to stay long-term if the Pacers can put a championship contender around him.
Taking a look back at @Yg_Trece's 2016-17 season today on https://t.co/ETpri0sWm8: https://t.co/L8WmXg4bMq pic.twitter.com/UnO91WMXdY
— Indiana Pacers (@Pacers) May 16, 2017
Check out a video of George's response to Kimmel's Lakers' advances for yourself:
Los Angeles is trying to put a championship contender back in place and signing George would give them a big step in that direction. He would immediately become their franchise player and would help the Lakers become an attractive free agency destination once again.
George still has one more season left on his contract with the Pacers, but many think he will bolt next offseason in free agency. Indiana is hoping that he makes the All-NBA Third Team, which would allow them to offer him a massive extension that no other team could come close to matching. There has been no indication about whether George will make the All-NBA team, but many think he will end up missing.
Indiana's general manager, Kevin Pritchard, believes that George would like to stay in Indiana. He knows that he has to bring in more help for George if he wants to make that happen.
Paul George talked about his interest in the Lakers during an appearance on Jimmy Kimmel Live. ????
????: https://t.co/FvqWpS3msR pic.twitter.com/hq86HJ78EM
— SLAM Magazine (@SLAMonline) May 16, 2017
Pritchard mentioned that George talked about staying in every scenario during his exit interview following the season.
"We talked about a lot of different things. In every scenario he talked about being here. That's important. He wants to win. Picking up Lance late in the year made us a better team and got us into the playoffs. We want to win. We want successful teams year in and year out, and that has to do with Paul. He wants to win, the Pacers want to win, we're on the same page."
Needless to say, George's name will be in rumors all offseason long. If the Pacers can't convince him to sign a contract extension this offseason, there is a decent chance that Pritchard could consider trading his star player.
Paul George to Train with Kobe Bryant, 'Pick His Brain' https://t.co/XL4pAgKfol
— TMZ (@TMZ) May 16, 2017
Expect to see the Pacers be extremely active in free agency and on the trade market this offseason. If they want to keep one of the best players in franchise history, they will need to pick up another big name or two. Gordon Hayward is one name that has come up, although there are other players in free agency that could take the Pacers to the next level as well.
Do you think the Indiana Pacers will find a way to keep Paul George long-term? Will he leave Indiana to head back to Los Angeles? Let us know your thoughts in the comment box below!
[Featured Image by Michael Conroy/AP Images]