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Conceived and designed the experiments: EA. Performed the experiments: EA MCK SC ET AHW RAK LHB. Analyzed the data: EA MCK SC ET EJG LHB. Contributed reagents/materials/analysis tools: EA. Wrote the paper: EA MCK SC ET AHW RAK LHB.
Predictors of adverse events (AE) associated with nevirapine use are needed to better understand reports of severe rash or liver enzyme elevation (LEE) in HIV+ women.
AE rates following ART initiation were retrospectively assessed in a multi-site cohort of 612 women. Predictors of onset of rash or LEE were determined using univariate and multivariate analyses.
Of 612 subjects, 152 (24.8%) initiated NVP-based regimens with 86 (56.6%) pregnant; 460 (75.2%) initiated non-NVP regimens with 67 (14.6%) pregnant.
No significant difference was found between regimens in the development of new grade ≥2 LEE (p=0.885). Multivariate logistic regression demonstrated an increased likelihood of LEE with HCV co-infection (OR 2.502, 95% CI: 1.04 to 6, p=0.040); pregnancy, NVP-based regimen, and baseline CD4 >250 cells/mm3 were not associated with this toxicity.
NVP initiation was associated with rash after controlling for CD4 and pregnancy (OR 2.78; 95%CI: 1.14–6.76), as was baseline CD4 >250 cells/mm3 when controlling for pregnancy and type of regimen (OR 2.68; 95% CI: 1.19–6.02 p=0.017).
CD4 at initiation of therapy was a predictor of rash but not LEE with NVP use in HIV+ women. Pregnancy was not an independent risk factor for the development of AEs assessed. The findings from this study have significant implications for women of child-bearing age initiating NVP-based ART particularly in resource limited settings. This study sheds more confidence on the lack of LEE risk and the need to monitor rash with the use of this medication.
The introduction of antiretroviral therapy (ART) has changed HIV management from that of a uniformly fatal disease to that of a chronic disease. Despite significant advances in HIV therapy, ART-associated toxicities remain an important factor in the treatment of HIV-infected persons. ART options, including for pregnant women, are limited particularly in resource-limited settings (RLS) and many countries rely on the use of nevirapine (NVP). Adverse events characterized by liver and skin toxicities, usually occurring within the first 18 weeks of treatment, have been associated with the use of NVP [1]–[4]. Investigators have reported these toxicities more frequently in women with higher baseline CD4 counts (>250 cells/mm3) [5]; in pregnancy [6]; and in the presence of pre-existing liver disease (i.e. hepatitis C) [7]. However, it has not been confirmed that pregnancy increases the risk of liver enzyme elevations (LEE) or rash in women receiving NVP or other ART [8]–[10].
Due to the inability to systematically identify severe but non-fatal toxicities associated with ART in pregnant patients outside of clinical trials, the true incidence of adverse events associated with NVP use in pregnancy is unknown [11]. This knowledge is critical for facilitating the decision-making process of the clinician in selecting optimal ART agents for use in pregnant patients.
Utilizing standardized data collected from three large HIV clinics serving HIV-infected women, we sought to assess the prevalence and the predictors of developing LEE and rash associated with NVP as compared to non-NVP regimen use in pregnant and non-pregnant women.
Three university-based clinics with large prenatal patient populations participated in a multi-center retrospective cohort study: Drexel University College of Medicine, Philadelphia, PA; Temple University, Philadelphia, PA; and the University of Alabama at Birmingham, Birmingham, AL. This study was approved by the institutional review board at each institution. A database search identified all female patients on ART between January 1999 and August 2005. Women 18–55 years old who initiated a new ART regimen during that time period and had at least one follow-up medical visit within 12 weeks of initiation, or within 12 weeks of their first prenatal care visit, were eligible for study entry. Eligible subjects could not be on ART at the start of the study period. Women who became pregnant while on an ART regimen were excluded. Thus both ART-naïve and ART-experienced women were eligible, but only those women who were not on ART at the entry into the study were included. Women must have been followed for at least 12 weeks and up to 18 weeks after the initiation of a new ART regimen. Women who initiated ART during the prenatal period and thus had any exposure to ART during pregnancy were included in the pregnancy group. Women who delivered during the 12–18 week period were followed throughout the study time frame into the postpartum period. Only the initial regimen that was started in this time frame was included for analysis. Only the first pregnancy was included in the analysis for women with more than one pregnancy during the study period.
Data were checked for inter-rater reliability and entered into a central database. Only charts that had clear documentation of client visits and assessment of side effect profile during the study period were included.
Demographic and medical information included: age, race/ethnicity, HIV transmission risk, HIV disease stage, ART regimens used during the study period, history of drug/alcohol use, liver function tests (LFT), nadir (lowest CD4 count recorded) and baseline CD4 count (result obtained at therapy initiation) as well as CD4%, HIV RNA measures within 4 weeks prior to the initiation of ART and throughout the study period, hepatitis C virus (HCV) status, presence of AE symptomatology, medication allergy, or intolerance.
Baseline lab values were defined as measurements taken up to 28 days before regimen initiation. Abnormal alanine aminotransferase (ALT) and aspartate aminotransferase (AST) values and rash were graded for severity according to the Toxicity Tables of the Division of Acquired Immunodeficiency Syndrome (DAIDS) [12]. Subjects were defined as having LEE if they had 1) at least one episode of new grade ≥2 elevation in ALT/AST after one week (considered baseline) and within 18 weeks of ART initiation, or 2) for patients who entered with baseline grade ≥2 elevation, at least one episode of elevation that was greater than their baseline value after one week and within 18 weeks of ART initiation. Patients who had a grade 4 LEE at baseline or had a rash at the time of regimen initiation were excluded. Due to the paucity of hepatitis C virus (HCV) viral load results available in the medical record, a positive HCV serology was considered synonymous with active hepatitis C infection for the purposes of this study. Patients whose rash was caused by other reasons, such as pruritic urticarial papules and plaques of pregnancy, herpes zoster, allergic dermatitis, etc., were excluded from entry into the study.
The sample size had ≥80% power to detect a difference in adverse events, of 10% vs. 3%, for NVP vs. non-NVP. Statistical analyses were performed using SPSS Version 15. Chi-square tests for dichotomous outcomes were used for regimen comparisons. Analyses were stratified by baseline CD4 cell count (≤250 cells/mm3 vs. >250 cells/mm3) and pregnancy status. Unpaired t-tests or Mann Whitney U tests were used for continuous variables. Results were considered statistically significant at p≤0.05. Univariate analyses were performed to test the difference in adverse event rates between NVP and non-NVP regimens. The results are expressed as relative risks. Multivariate logistic regression analysis was used to assess possible confounding factors such as pregnancy, baseline CD4 count (≤250 cells/mm3 vs. >250 cells/mm3), and presence of HCV. Odds ratios (OR) and 95% confidence intervals (CI) are provided. Because of the small number of events and specific research questions, no correction for multiple comparisons was employed.
Of the 612 subjects included in the analyses, 152 (24.8%) initiated NVP-containing ART, 86 (56.6%) of whom were pregnant. Among the remaining 460 (75.2%) patients who initiated non-NVP-containing regimens, 67 (14.6%) patients were pregnant. Thirty-nine women became pregnant after initiating ART and were excluded. Among the pregnant women included 66 started ART at the initiation of the study with baseline CD4 counts below 350 cells/mm3 (37 [56.1%] on a NVP-based regimen) and received ART based on their current stage of HIV disease. The remaining 87 women started ART at baseline CD4 counts above 350 cells/mm3 (49 [56.3%] on a NVP-based regimen) and initiated ART for the prevention of mother to child transmission (PMTCT). Based on the exclusion criteria [see Study Definitions], 599 women were included in the liver analysis and 526 in the rash analysis. [Figures 1 and and22].
The baseline demographic and clinical characteristics are shown in Table 1: 72.4% (n=443) patients were of black race/ethnicity, 18.1% (n=111) were of white non-Hispanic race/ethnicity, 8.7% (n=53) were of Hispanic race/ethnicity and 0.3% (n=2) were multiracial. Three subjects were missing race/ethnic information. The racial/ethnic distribution did not differ between the treatment groups (p=0.191). Of those with known transmission risk, heterosexual mode of transmission was the primary risk factor in both groups (83.6% for NVP and 85.4% for non-NVP, p=0.538). NVP recipients had higher baseline CD4 counts, and lower HIV-1 RNA viral loads (both p values <0.001). There was no significant difference in co-infection with HCV (22.0% NVP vs. 17.9% non-NVP, p=0.328) when stratified by type of regimen use [Table 1].
Patients on NVP-based regimens were significantly younger (mean: 32.8; SD: ±8.9 years) than those on non-NVP-based regimens (mean: 37.3; SD: ±7.9 years, p<0.001). [Table 1] However, when controlling for pregnancy there were minimal differences between groups. Specifically, in the non-pregnant group the mean (SD) ages for those receiving NVP-based regimens and non-NVP-based regimens were 38.8 (8.5) years and 38.6 (7.3) years, respectively. In the pregnant group, the mean (SD) age for NVP and non-NVP were 28.0 (5.5) and 29.4 (6.3), respectively. Pregnant women were more likely to be on NVP (86 [56.2%] vs non-pregnant 66 [14.4%] p<0.001), had higher CD4 counts (113 [74.3%] vs non-pregnant 210 [45.9.4%] p<0.001), and were of younger age (28.62 vs non-pregnant 38.68 p<0.001). Pregnant women were also less likely to have Hepatitis C (10 [9.2%] vs non-pregnant 83 [21.5%] p=0.004). [Table 2] LFTs were assessed with equal frequency in the pregnant cohort and the non-pregnant cohorts (p=0.388) as well as amongst those pregnant and not pregnant receiving NVP (p=0.301) and non-NVP-based regimens (p=0.712).
Among those receiving NVP, 20.8% were ART experienced and 70.0% were ART naïve and there were no significant differences in the demographics of ART experienced versus ART naïve women receiving NVP. Of those who were on NVP and pregnant, 43.0% were experienced and 53.0% were naïve and of those who were not pregnant, 57.0% were experienced and 47.0% were naive (p=0.33). Amongst ART experienced women, 40.0% had CD4 ≤250 compared to 34.0% of those who were ART naive (p=0.35).
Of those women on non-NVP based therapy, 18.3% (n=83) were on nucleoside-based therapy only, though none received zidovudine monotherapy. Two hundred thirty four (50.9%) women were on protease inhibitors: 25.0% (n=58) on lopinavir/ritonavir, 3.0% (n=14) on amprenavir, 37.0% (n=87) on nelfinavir, 1.5% (n=7) on saquinavir, 5.0% (n=23) on indinavir, and 9.8% (n=45) on boosted or unboosted atazanavir. There were 143 (31.1%) women were on efavirenz, two of whom were pregnant.
Pregnant women on NVP started ART at a mean of 19.1 weeks gestation (median: 18 weeks, range 8–32 weeks). Women on non-NVP regimens started ART at a mean of 18.7 weeks gestation (median 16 weeks – range 3–38 weeks, p=0.693). If women were started on ART during the prenatal period and thus had any exposure to ART during pregnancy, they were included in the pregnancy group. If they delivered during the 12–18 week period, we continued to follow them throughout the study time frame into the postpartum period.
Adverse Events: The majority of liver and skin AE in both regimen groups occurred within 6 weeks of initiating ART: 7/9(77.8%) ≥2 LEE on NVP, 16/26 (61.5%) ≥2 LEE non-NVP (p=0.63 by continuity-corrected chi-square); 8/11 (72.7%) skin AE on NVP and 12/19 (63.2%) skin AE on non-NVP (p=0.893 by continuity-corrected chi-square).
Hepatic: In total 38 subjects experienced LEE of grade ≥2 at baseline or during the 12–18 week follow-up period; 11 were excluded per exclusion criteria. There were no significant differences in LEE by regimen group: NVP 6/140 (4.3%) vs. non-NVP 21/459 (4.6%) (p=0.885). [Table 3] Among women experiencing LEE, 7 developed grade ≥3 LEE, with no significant differences between NVP (n=2, 1.4%) and non-NVP (n=5, 1.1%; p=0.668). Those on NVP with grade 3 LEE were pregnant with baseline CD4 >250 cells/mm3 (n=2) and those on non-NVP were not pregnant with baseline CD4 ≤250 cells/mm3 (n=5). [Figure 1]
There were no cases with initial grade ≥2 LEE at baseline who subsequently had higher liver elevations during follow-up. There were two women who had baseline liver elevations of grade 3 who did not progress and thus were not counted as LEE due to ART. In the univariate analysis, a non-significant trend was noted for an increased relative risk for the development of LEE in NVP users with baseline CD4 counts >250 cells/mm3 (p=0.054 two-tailed). Patients on non-NVP regimes experienced a significant increase in LEE when the baseline HIV-1 RNA VL was greater than 100,000 copies/µl (p=0.04), an association that was not noted in subjects on NVP-regimens.
Women who were co-infected with HCV were more likely than those without HCV to develop grade ≥2 LEE regardless of regimen group: 9.9% (9/91) of HCV co-infected patients vs. 3.8% (15/394) of HCV negative patients (p=0.03). However, there was no difference in LEE between HCV patients on NVP (9.0%, 2/22) vs. HCV patients on non-NVP (10.1%, 7/69) (p=1.0). In Hepatitis C negative patients, the relative risk for NVP verses non-NVP use and the development of grade >2 LEE in those with baseline CD4 >250 cells/mm3 was 5.81 (95%, CI: 1.1 to 30.8, p=0.039 by Fisher's Exact Test). In contrast, no one in the NVP group with baseline CD4 ≤250 cells/mm3 developed LEE (p=0.61 by Fisher's Exact Test, data not shown).
Multivariate logistic regression performed to identify independent predictors of new grade ≥2 LEE demonstrated an increased likelihood of hepatic AE in those with HCV co-infection (OR 2.502; 95% CI: 1.04 to 6, p=0.040). Pregnancy status (OR 0.178; CI: 0.022–1.43, p=0.104), NVP use (OR 1.62; CI: 0.55–4.76, p=0.38) and baseline CD4 count >250 cells/mm3 (OR 0.62; CI: 0.25–1.50, p=0.29) were not independently associated with the development of LEE.
Adverse Events-Rash: In total, 114/526 (21.7%) women developed a new rash (Grades 1–4) after therapy initiation with 30 (5.7%) women developing a new grade ≥2 rash during the study period. One non-pregnant subject on NVP was diagnosed with Stevens-Johnson syndrome 22 days after initiation of treatment; CD4 count at therapy initiation was 420 cells/mm3. The patient was hospitalized and had complete resolution of rash within 12 days of discontinuing ART. [Figure 2]
No difference in the frequency of new rash was seen between regimen groups. However, there was a higher incidence of severe rashes in the NVP regimen group vs. non-NVP group (p=0.002): for grade 3 rash 2/127 (1.6%) on NVP-based regimens vs. 0/399 on non-NVP-based regimens; for grade 4 rash 2/127 (1.6%) on NVP vs. 0/399 on non-NVP. There was a non-significant trend towards a higher frequency of grade ≥2 rashes: 11/127 (8.7%) among those who initiated NVP-based regimens vs. 19/399 (4.8%) on non-NVP regimens (p=0.099). [Table 3]
Furthermore, NVP-based regimens were significantly associated with the diagnosis of grade ≥2 rash in subjects with baseline CD4 >250 cells/mm3 (p=0.001). A comparison of the relative risks for development of rash among women on NVP-based regimen was significantly different between the two CD4 sub-groups (p=0.005), indicating an interaction between treatment regimen and CD4 count. There was a trend of increased risk for the development of grade ≥2 rashes in the NVP treatment group among pregnant women (p=0.054) but not among non-pregnant women (p=0.476).
Stratifying women by CD4 count at baseline, NVP exposure was associated with the development of grade ≥2 rashes in pregnant patients with baseline CD4 count >250 cells/mm3 (p=0.042); a similar trend could be observed in non-pregnant patients (p=0.058). No association with regimen use was seen with baseline CD4 count ≤250 cells/mm3.
Using multivariate logistic regression modeling controlling for type of regimen, pregnancy status and baseline CD4 count, women were more likely to develop a grade ≥2 rash if they initiated an NVP-based regimen (OR 2.78; 95% CI: 1.14–6.76, p=0.024) or had baseline CD4 counts≥250 cells/mm3 (OR 2.68; 95% CI: 1.19–6.02 p=0.017). Pregnancy status was not an independent predictor for the development of a grade ≥2 rash (OR 0.46 95% CI: 0.15–1.4p=0.165). However, pregnant women were more likely to be on NVP and more likely to start therapy at higher CD4 counts. [Table 4]
A secondary analysis was performed to evaluate the AE patterns for CD4 percentage below and above 20%. During pregnancy there is a lowering of absolute CD4 count due to hemo-dilution and CD4 percentage measurements may be more reliable [13]. Our results demonstrated a non-significant trend in increased risk of LEE in women on NVP with a CD4 percentage above 20% (3/83, 3.6%) when compared to women on non-NVP-based regimens (1/188, 0.5%) (p=0.164 RR=6.8 (0.72–64.4). The risk of rash in those on NVP was increased five-fold among those with CD4 percent >20%, though this finding did not reach statistical significance (NVP - 4/79 (5.1%), non-NVP-2/178 (1.1%) p=0.138, RR=4.51 (0.84–24.1)). NVP use was also associated with an increased risk of rash in the low CD4 percentage group though to a lesser extent when compared to the group of individuals with higher CD4 percent values (NVP - 5/43 (11.6%), Non-NVP -17/211 (8.1%) p=0.645 RR=1.44 (0.56–3.7).
This large multi-center, retrospective cohort study of 612 pregnant and non-pregnant women on NVP and non-NVP ART regimens assessed the cumulative incidence of hepatic and rash-related adverse events over the first 18 weeks post-ART initiation. The strengths of this study include the multi-center nature of the study, the significant sample size and the use of a large non-pregnant comparison group, a group that has been missing from other studies evaluating the relationship of AEs and ART during pregnancy. The majority of liver and skin AEs in both regimen groups in the current study occurred within 6 weeks of initiating ART. There were no significant differences in the overall percentage of patients developing LEE between regimen groups. We did not find a statistically significant association between baseline CD4 cell count above 250 cells/mm3 and the risk of hepatotoxicity in patients taking NVP in univariate and multivariate analyses. Though a non-significant trend towards an increased risk of LEE in the higher CD4 count group was noted in the univariate analysis, no such association was noted in the multivariate analysis. NVP use in women with baseline CD4 counts ≤250 cells/mm3, including pregnant women, resulted in a hepatic safety profile similar to women treated with non-NVP regimens.
In comparison, both pregnant and non-pregnant women on NVP with a baseline CD4 count >250 cells/mm3 had a significantly increased rate of grade ≥2 rash compared to women on non-NVP regimens with CD4 count >250 cells/mm3. NVP use was predictive of rash when controlling for CD4 count at regimen initiation and pregnancy.
The lack of association of an effect of CD4 count on LEE is consistent with recent studies [9], [10], [14]. Ouyang reported on 1358 women with ART exposure during pregnancy and found no association between CD4 cell count above 250 cells/mm3 and risk of hepatotoxicity in patients taking NVP [9]. Our findings are also consistent with a large review on NVP and hepatotoxicity which also failed to demonstrate an association [14]. However, the results from this study are in contrast to prior published studies in which a greater proportion of women on NVP with CD4 counts >250 cells/mm3 had moderate to severe side effects as compared to those with CD4 counts ≤250 cells/mm3 [6]. Bersoff-Matcha found that both a higher CD4 at initiation of NVP therapy and a higher nadir CD4 count were strongly associated with the development of severe rash and discontinuation of therapy [15]. The risk of NVP–induced hepatitis was found to be increased 12-fold in women with greater than 250 CD4 cells/mm3 [16]. In a summary analysis of 17 clinical trials using NVP, the risk ratio was 9.8 in women with rash-associated hepatic events with CD4 count >250 cells/mm3 as compared to those with lower CD4 counts. [17].
In this study, pregnancy was not an independent risk factor for the development of LEE or rash. In contrast, a recent study of 2050 HIV-infected pregnant women concluded that NVP was not significantly associated with risk of LEE, and that pregnancy was a risk factor for LEE [10].
Hepatitis C co-infection was independently associated with the development of LEE in this cohort. This finding is consistent with previous studies that have examined the association of HCV with hepatoxicity in patients on ART. Co-infected patients in these studies were found to have a significantly greater risk of experiencing hepatic events [18]–[20]. Vogel and colleagues studied the impact of chronic viral hepatitis on the pharmacokinetics of NVP. They found that other factors such as accumulating NVP drug levels may be responsible for an increased risk of liver damage in HIV/HCV co- infected patients [21]. Rivero and colleagues found that HCV co-infection increased by two to seven fold the risk of developing LEE >2 in patients treated with non-nucleoside reverse transcriptase inhibitors [22]. Bonnett showed that patients with HCV and/or HBV co-infection who received NVP containing regimens had a 45% increase in hepatotoxicity at month 12 of follow-up when compared to patients without co-infection [23].
In our study, NVP use was predictive of rash even when controlling for CD4 and pregnancy. The 2NN Trial reported grade ≥3 rash occurrence in 3.4% of patients taking NVP twice daily [24]. Aggregate data from 1,752 patients who participated in 33 NVP clinical trials revealed a rash rate of 17.0%, the majority of which occurred within 6 weeks of NVP initiation: 6.0% discontinued NVP due to rash, and 0.5% developed Steven-Johnson syndrome [25]. Pollard reviewed prospective clinical trials with NVP and found an incidence of 0.3% SJS [26].
Recent studies have demonstrated that virologically suppressed patients switching to NVP do not show a higher risk of hepatotoxicity or rash dependent on CD4 counts [4]. The ATHENA cohort also suggested that the incidence of hypersensitivity reaction associated with NVP in patients with undetectable HIV RNA load at the start of NVP is lower in patients with prior treatment experience than those who are treatment naïve. While the importance of VL as a predictor for rash with NVP remains debatable, the current study has demonstrated that patients on non-NVP regimes had a significant increase in liver enzyme elevations at baseline HIV-1 RNA VL >100,000 copies/µl, a finding that was not seen in subjects on NVP-containing regimens (p=0.04).
During pregnancy there is a lowering of absolute CD4 count due to hemo-dilution. The stability of CD4 percentage measurements in comparison to absolute CD4 counts between prepartum and postpartum periods have been confirmed [13]. Similar to absolute CD4 count, CD4 >20% in this study demonstrated a non-significant trend in the increase of LEE and rash-related events associated with the use of NVP.
Our study has limitations that should be considered. There was an overrepresentation of pregnant women who were using NVP, had higher CD4 counts, and were of younger age. These women were also less likely to have Hepatitis C. It could be hypothesized that the reason why LEE and rash were seen more frequently in women with higher baseline CD4 counts on NVP-based regimens was due to these confounding factors. However, pregnancy was not an independent predictor of LEE or rash. Since women in the United States who are HIV-infected and pregnant are many times diagnosed earlier in their disease process during pregnancy through HIV screening programs, and are younger due to the childbearing years, this overrepresentation is hard to avoid [27].
The limitation of a retrospective study resulted in the reliance on chart documentation to distinguish drug induced hepatotoxicity from hepatotoxicity due to other causes. Women who are pregnant have an increased rate of LEE due to conditions that are unique to pregnancy [10]. In addition due to insufficient reporting in clinic records, alcohol use, drug use, and Hepatitis B were not evaluated as confounding factors. The fact that a positive hepatitis serologic result was used as a surrogate for chronic active HCV infection may have resulted in an attenuation of the association between HCV and LEE as several of the women who were HCV antibody positive may have cleared their infection. Finally, AST/ALT values may not be specific enough markers for liver injury. It is known that only a small proportion of those with LEE will eventually develop fulminant hepatitis or acute liver failure and that LEE often resolve without any intervention. Many instances of drug induced liver disease are unpredictable and asymptomatic.
The results from this study should be considered in assessing the recommendations for use of NVP in all women, but particularly for women of childbearing age in resource limited settings (RLS). The 2009 World Health Organization (WHO) now recommends starting lifelong ART for all pregnant women with a CD4 count at or below 350 cells/mm3 regardless of symptoms. ART is recommended to be continued in all pregnant women during the breastfeeding period to reduce the risk of HIV transmission. These guideline changes mean that more pregnant women will be initiating NVP-based regimens as part of first-line ART therapy in RLS [28]. In comparison to other studies in RLS where an association between high CD4 counts and LEE and rash have been reported, this study supports increased confidence on the use of NVP in similar populations as pregnancy status, NVP use, and baseline CD4 count ≥250 cells/mm3 were not independent predictors for the development of LEE [28], [29]. In addition, the DART study showed that routine laboratory monitoring for toxic effects in HIV patients receiving ART had no benefit in RLS [30]. Our study confirms that while clinical monitoring would detect the increased risk of rash seen with NVP use in women with higher CD4 cell counts, the risk of LEEs described may not result in significant hepatotoxicity to necessitate lab testing. As rash and hepatic events occurred more frequently in the first 6 weeks of NVP initiation in this analysis, more diligent clinical monitoring is recommended during this time frame.
Our study cohort is representative of the HIV epidemic in women in U.S. women in terms of age, race, HIV transmission risk and HCV status, and therefore contributes to the knowledge needed to better characterize adverse events specific to this population (7). This large cohort study provides additional information for clinicians in assessing the risk of NVP-induced liver and skin toxicity by taking into account the short latency period and potential risk factors such as baseline CD4 counts and HCV co-infection. All HCV co-infected women on NVP based regimens should undergo close monitoring for LEE. Empiric use of NVP in the absence of resources to determine baseline CD4 count and monitor liver enzyme levels continues to call for careful consideration of the risks and benefits of NVP therapy. However, with the significant increase in women of childbearing age initiating NVP-based ART in RLS, where there is limited laboratory capacity to monitor for LEE, this study provides supportive evidence for the use of NVP in this population.
Competing Interests: Boehringer Ingelheim Pharmaceuticals is a commercial funder of this study; however there are no other relevant declarations relating to employment, consultancy, patents, products in development or marketed products and this does not alter the authors' adherence to all the PLoS ONE policies on sharing data and materials.
Funding: This investigator-initiated research project was funded by Boehringer Ingelheim Pharmaceuticals, Inc. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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Integrative Medicine in Cincinnati - Steve Amoils, MD
As active contributors to the field of integrated medicine, Steve Amoils, MD, and his wife, Dr. Sandi Amoils, co-authored Get Well and Stay Well - Optimal Health Through Transformational Medicine, which was released in 2011. In addition, Steve Amoils, MD, has received a number of awards and commendations for his research and medical practice, including the America's Top Doctor in Family Medicine Award and two nominations for the Health Care Heroes award presented by Business Courier. Currently, Dr. Amoils and his wife work as co-medical directors for the Cincinnati-based Alliance Institute for Integrative Medicine.
In his spare time, Dr. Amoils gives back to his community by devoting resources, energy, and time to philanthropic and civic endeavors. He supports such organizations as H.O.P.E. (Help Other People Endure),where he serves as a board member, and the Integrative Medicine Foundation, where he serves as president. In addition, he enjoys a diverse variety of leisure activities, such as windsurfing, hiking, and martial arts.

subset: commoncrawl


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Posted by ESPN.com's Chris Low
The most underrated player in the SEC this season?
My pick would be Arkansas junior defensive tackle Malcolm Sheppard, who was undersized to be playing tackle in the SEC (277 pounds), but made out just fine.
Sheppard finished second in the league with 16 tackles for loss and led all SEC defensive tackles with 7.5 sacks.
In the Hogs' season-ending 31-30 win over LSU, Sheppard moved outside to end and had 3.5 tackles for loss against the Tigers. He could stay at end next season depending on what his offseason is like. If he can put on some more weight, which hasn't been easy for him over the years, he'll probably stay inside.
If not, he could see his snaps at end increase, particularly if Arkansas can build some depth at tackle.
Either way, look for Sheppard to be one of the SEC's best and most versatile defensive linemen in 2009.
Here's a look at some of the other guys in the league that were underrated this season. They're listed in alphabetical order:
Georgia sophomore offensive lineman Clint Boling: He started the season at right tackle, moved to right guard for a few games and finished the season at left tackle. Boling's versatility was a big reason the Bulldogs were able to weather so many injuries in the offensive line.
Auburn sophomore linebacker Josh Bynes: After playing sparingly as a freshman, Bynes stepped in at middle linebacker when Tray Blackmon was lost for the season and led the team with three interceptions and finished fifth with 53 total tackles.
Alabama senior offensive lineman Marlon Davis: Tackle Andre Smith and center Antoine Caldwell were both All-Americans and received most of the publicity, but Davis was a rock for the Crimson Tide at right guard.
LSU junior tight end Richard Dickson: The SEC was loaded with talented tight ends, but Dickson was Mr. Dependable for the Tigers. He was third on the team with 27 catches, including four for touchdowns.
Mississippi State senior linebacker Dominic Douglas: Quick, who led the SEC in tackles this season? That would be Douglas, who moved over to middle linebacker when Jamar Chaney was injured and finished with 116 total tackles.
Vanderbilt junior safety Ryan Hamilton: He led all SEC defensive backs with 98 total tackles and was second on Vanderbilt's team. Hamilton had three interceptions in the win over Ole Miss, including one he returned 79 yards for a touchdown.
Kentucky senior linebacker Braxton Kelley: After three years of starting in the middle, Kelley unselfishly moved over to weakside linebacker and ranked among the SEC leaders with 90 total tackles.
Florida sophomore center Maurkice Pouncey: He started 11 games at right guard as a true freshman, but moved to center this season and solidified the middle of the Gators' offensive line.
Ole Miss senior safety Jamarca Sanford: One of the strongest leaders on Ole Miss' team, Sanford led the Rebels with 80 total tackles and also forced two fumbles.
South Carolina junior linebacker Darian Stewart: Playing the "spur" linebacker position in the Gamecocks' 4-2-5 scheme, Stewart did a little bit of everything. He had eight tackles for loss and led the team with eight passes broken up.
Tennessee senior linebacker Ellix Wilson: In his first full season as a starter, Wilson led the Vols with 89 total tackles from his middle linebacker position and was sixth in the SEC.


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Etsy :: FromJapanWithLove :: Kawaii Japanese Anime Memo pad in Tofu Package-200 sheets-Cute Character-Hannari Tofu
This is soooo cute tofu character memo pad!! This is "hannari tofu (はんなり豆腐)" which is gorgeous tofu character made in to plushes, strap, stationery and etc. "Hannari" means gorgeous in kansai dialect. Her friends are also tofu like plum blossom tofu, yuzu tofu, green tea tofu, yaki tofu, yakko tofu and etc.
This is soooo cute!! It's called "usa and ham chan sewing room"(Rabbit And Hamster's Sewing Room). The cover is the puzzle to play and there are also quizes and mini origami sheets. Lots of cute rabbits and hamsters.Tags: japanese, stationery, paper, manga, supplies, Japan, cute, collages, scrapbookingAdded 9 Years Ago from Etsy
perfect choice for cute and kawaii origami lover :)
very cute origami star paper folding supplies :)Tags: japanese, paper, international, star, supplies, cute, origami, collages, scrapbookingAdded 9 Years Ago from Etsy
kawaii memo pad from Japan
elegant bag memo pad
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so cute puppy memo pad!!


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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.
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Visual Report : The report is not showing charts on Internet ExplorerAsked by moberempt on November 30, 2015 at 04:45 PMIn addition, I have a report that is viewed after a person clicks Submit - the report can also be viewed by a link I added at the top of the Form (click on the basketball). The report also doesn't display properly in Internet Explorer. The grid portion on the bottom shows up, but the bar graph on the top does not. However the report also works properly in Chrome. Both the form and the report were also tested in Safari, and worked properly.
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I was able to replicate your issue, now I will escalate it to our L2, our developers will take a look into this and will solve it.
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I have checked status of this thread and it is still opened. One of our developers is assigned to this thread and priority of this ticket is marked as important.
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Hi - just want to check on the status of this issue again, as i has been almost one month without any fix/update?
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Speak new languages using Romanian words you already know!
* Sample size (number in parentheses) may be too small and results inaccurate. ()
Romanian language | Romanian dictionary | Romanian vocabulary test | Romanian word games | Most similar languages to Romanian | Common words between Romanian and other languages | Etymologies of Romanian words | Top 3,000 words in Romanian | Top unique words in Romanian


text:
Home →
→ Health Advice & Tips
| Health Advice & Tips
If your family is among the many that will be traveling this summer, heed these food safety tips from the American Dietetic Association/ConAgra Foods Home Food Safety Program.- Remember to wash hands with soap and water during food preparation, especially between tasks.
- If you can't get to a restroom to wash your hands with soap and water, pack moist towelettes or a hand sanitizer to clean up before digging in.
- Don't let food sit out unrefrigerated for more than two hours; in hot weather (above 90°F), the time is reduced to one hour.
- Pack food with a frozen ice pack or ice in an insulated lunch bag or cooler -- and remember to drop in a refrigerator thermometer to ensure the temperature is kept below 40°F.
- In hot weather, transport food in a cooler (packed with ice or ice packs) in the back seat of an air-conditioned car instead of the trunk.
- If you don't have access to a cooler, try packing frozen juice boxes or bottles of water for a hydrating refresher that will also help keep other foods around them cool.
- If you plan to cook family favorites like hamburgers, hotdogs, or chicken breasts at home to take with on your trip, remember to cook to proper temperatures: hamburgers (at least 160°F), hot dogs (reheated to 160°F), and chicken (165°F).
- Consider packing easy-to-transport, shelf-stable foods: single-serve boxes of cereal, trail mix, popcorn, single-serve applesauce, cans of tuna peanut butter sandwiches, fresh fruit, carrots or celery.
- Don't forget that carry-out and fast-food are also susceptible to food poisoning.
Lyme Disease FAQ: Preventing, Symptoms, and Treatment
Head Lice FAQ
The Health Benefits of Me Time
Study: Handheld Screen Time Linked With Speech Delays
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Camp Guide
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Loyola University Maryland is delighted to host Democracy and the Humanities, a two-day Symposium commemorating the 50th anniversary of the founding of the National Endowment for the Humanities, Friday, Sept. 25 – Saturday, Sept. 26, 2015.
Join us as we celebrate fifty years of the promotion of excellence in the humanities.
All lectures and presentations during the Democracy and Humanities Symposium are free and open to the public. Seating, however, is limited; attendees must register for individual sessions in advance.
Featured speakers at this Symposium will include:
In addition to many members of Loyola's faculty, panelists in breakout sessions will include:
President Lyndon Johnson signed the National Foundation on the Arts and the Humanities Act into law on September 29, 1965, establishing both the National Endowment for the Arts and the National Endowment for the Humanities. This legislation came as a result of the work of three educational organizations: the American Council of Learned Societies, the Council of Graduate Schools in America, and the United Chapters of Phi Beta Kappa—all of which are co-sponsoring the Democracy and the Humanities Symposium, along with the Council of Independent Colleges, the Maryland Humanities Council, and the National Humanities Alliance.
On Saturday, Sept. 26, representatives of the three founding organizations will offer a panel presentation on "Founding and Supporting the Endowment," exploring why the NEH mattered fifty years ago and why it still does so now. Today the NEH is one of the largest supporters of humanities programs in the United States, providing funding to strengthen teaching and learning in schools and colleges, to preserve and provide access to cultural and educational resources; to facilitate scholarship and research; and to create and advance opportunities for lifelong learning.
We hope that you will join the ongoing national conversation on the importance of the humanities in education and in American society by coming to the Democracy and the Humanities Symposium. It will take place on Loyola University Maryland's North Charles Street campus in the northern part of Baltimore City, easily accessible from BWI airport, Amtrak's Penn Station, and major highways.
The Democracy and the Humanities Symposium is made possible by Loyola University Maryland's Center for the Humanities, Messina First-Year Program, and the Office of Academic Affairs.


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Just separated(7 Posts)
Hi, just need some support. I've been with my partner for 12 years, never married, however bought house together and have a three year old. We've always had ups and downs and as of late (ie last two years or so) things just seem to be more down than up. I love DP however think I have fallen out in love with him, and I don't feel like I am attracted to him anymore. He is very laid back, and I feel like I have to be constantly asking him to do things, I know this is common with guys but I don't think I can do it anymore, especially since our daughter came along. I don't feel like I get the support that I should as I feel raising our daughter should be a partnership but lately its more my doing things on my own with her. He's not abusive or anything like that but can be increasingly moody or down about things and I'm fed up of trying to lift him up and be positive about things. We split once before about 6 years ago for a couple of months but we decided to give it another go.
Things came to a head on Wednesday as we have been out of sync for a while, I'm not great at confrontation and as usual he did most of the talking. We decided to call things a day, he moved to his mums house on Thursday and to be honest I feel quite relieved, not having to worry about him or what he is doing, or what mood he is in. I know its only been a couple of days but I feel ok about things thus far.
I know things will be difficult at times and my daughter is the most important person in the world to me so I realise that I have to be happy to ensure she is happy.
I worry that I will 'give in' to him because the difficulty in separating everything etc will be too tough. Generally I'm a strong person but I've gave in before however I realise this time I can't. The texts have started with him wanting to give things a go, he'll change etc, but again I've heard this all before.
Thanks for reading this far, happy to hear from people who've been in similar situations and have been strong enough to get through it!
Hi Hun,
I could have wrote your post myself.
My ex and I survived ten years tooing and froing over splitting up- getting back together for kids- trying to repair damage done.
Things came to a head 2 years ago when he got a job- and a big promotion- and the male chauvinist (below the surface for years) really came out and I was expected to keep on with it. I was virtually left to be a single parent whilst he was off being important in job.
Anyway cut to the present- I am happier now- I get lonely in the evenings sometimes- but normally once my ds(6) hAs gone to bed my evenings gone.
It's been tough getting into my stride, working full time- shiftwork - it's hard to get a pattern. But eventually you do and you start to enjoy your own company again, an ds's properly. I don't feel the pressure to keep house/shopping/mum/wife pretences up to such a high standard- I can cut myself some slack some days.
I think it takes a good 6 months to even start to get on an even keel emotionally/financially etc but don't let this stop you.
We were so tied up financially it was hard and tight.
I guess in all this- only you will know when you are ready to throw in the towel.
It's no shame to also keep trying at it- either way, we ve all been there - trying to figure out what's best- but I am here trying to say- if you do throw in the towel, you ll be ok, and at least you ve given it a good good go
Hi Blakey, thanks for taking the time to reply.
We spoke again last night about things and he has again (like last time) realised in the few days that he has been staying at his mums, that he doesn't want to split up, how much he loves me (even so much to mention he's been thinking of marriage!) how he's realised how much he hasn't been spending time with our three year old daughter.
He admitted that he also felt we'd been drifting apart but felt that he needed to sort things out with himself. I explained to him that I felt we'd drifted apart months ago and that I felt like I was a single parent most of the time.
He wants us to try again but I explained that I felt it was too little too late and why it takes us to get to this point for him to realise all this? I explained that I believed I couldn't go on in this cycle of up and down. That I've tried so hard to keep optimistic about things but I was tired of trying so hard all the time.
He says his heart is breaking and he's losing me, his daughter, our house etc. (We are also financially tied up with stuff so it will not be a straightforward break up).
This is what I was afraid of and I feel awful of the thought that I am the one splitting up our family or that my daughter won't have her daddy around because I didn't want to continue in the cycle
I feel I just need to get me thoughts down on here as its impartial and whereas family and friends will understandably have their own opinions.
It's not you that's breaking it up though, it's him with his lassitude. He must have known this was coming and...yet...he..did..nothing!
I suspect it's partly being back home with his Mum that has made him think and it's making him miserble but you shouldn't be merely a stop gap for him. You've tried and given it a good go and he hasn't changed. Get on with your life OP and make it a good 'un.
The heart breaking statement he made is about himself and the situation he's put himself in.
From an outsiders view- you sound like you feel guilty, but are not the guilty one.
It takes one of you, to break the cycle and it's no point scoring if it's not you or is.
I feel for you as it was exactly how my years played out in my marriage.
In the end it's tiring, you spend all of your days an nights thinking on it etc.
If you truly think you will be better off and are tired of this- then call it a day- ur daughter when she's old enough will understand- and she won't have to know the ins and outs of it all.
Also she will have her daddy around- I used to think same and still do not like the single parent life- his dad is a twat and quite Disney dad- but he sees him- nearly every other day- he's 6- and also if his parents are a help they will ensure he maintains his relationship with her.
Don't get back together out of guilt- it won't work- it never does- take it from someone who's done it more than 4-5 times.
And also- don't keep speaking to each other going over and over it otherwise you may aswell be living together - set a day this week for him to take your daughter out for a few hours/day to give you a rest. Then set a day near weekend where u talk for 30 mins no more.
Give him set times/dates so that he knows he will get to talk to you and put his points across and doesn't feel shut out- but also gives you time to think on what you need/want to do.
If your going over and over it day in and out it muddys the water and both of you cannot see the wood for the trees.
If he earns more than you do then there is a huge advantage in patching things up and marrying quickly even if you divorce in 18 months' time. Also if you'd like more than one child in your life cynically the easiest way to get the second one is a reconcilation now to have the second child after the quick marriage.
Also if you do let him back on the basis he marries you do make sure it is with clear conditions eg he does half the house work , he has the child alone all day Saturday whilst you go out and he does bed time routine on his own at least 3 nights a week etc etc etc Very specific changes.
Thanks for your replies, I've been away on holiday and have a clearer head now, the holiday was good as it was just my daughter and me - we had a lovely time.
I've explained to him I do not want to continue in the relationship any longer, its hard as I still care for him but explained that I was not in love with him anymore. So far its been mostly amicable, apart from a few outbursts from him, though I know he would prefer for us to try again.
Blakey, I understand what you mean about getting back together because of the guilt feeling, I'm trying to put that to one side as I know if that happened again it wouldn't work.
I know there's going to be tough times ahead but generally I'm feeling positive about the whole thing which is the first step
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Start-up producers Kingman Films have come up with an enterprising way to identify new screenwriting talent: They'll give half a million dollars each to new screenwriting talent in the drama, comedy and action genres — and then they may even produce the winning screenplays. The King Arthur Screenwriters Awards were announced in October, and Kingman is currently trying to line up studio deals for the winners, while also working on more modestly budgeted pictures.Aspiring filmmakers can also make appointments via Kingman's Web site (kingmanfilms.com) for in-person pitch meetings with founder Arthur Chang every Thursday afternoon.
Kingman Films: Win a contest, sell your script
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Contact us with any questions you may have about qualifications, academics, the application process, the Johnson experience, or anything else related to our MBA programs.
November Round: 11/15/2017January Round: 1/10/2018April Round: 4/5/2018*
*After April 5th, applications will be received and reviewed on a space available basis.
Early Action: 9/5/2017 (Priority Review)October Round: 10/5/2017November Round: 11/15/2017January Round: 1/10/2018Rolling: 3/15/2018*
*After January 10th, applications will be received and reviewed on a space available basis with a final submission deadline of March 15, 2018.
Off-Campus - International
Thank you for your interest in the Cornell MBA program. We encourage you to review the enclosed information as you prepare your application for submission:
If luck is what happens when preparation meets opportunity, this is what happens when you add patience! I missed the #YayoiKasuma exhibit when it was in DC though I ended up seeing the first major survey of her work in Southeast Asia! #LifeistheHeartofaRainbow 🌈❤
Loving the look of our new immersion handouts, complete with our #CornellMBA students and alumni! #HappyFriday
Proud of you @quincys_ig and your #CornellMBA classmates. Thank you for bringing us together to support all of the #collaborative and #diverse communities that value mutual respect. ・・・
MLK taught me that an injustice anywhere is a threat to justice everywhere. Thank you @johnsoncornell for standing in solidarity against the intolerance and bigotry we've recently seen in our nation. We support our future colleagues at #Darden ✊🏾 #cornellstandsfordarden
Judi Byers
Join #CornellMBA Admissions Team members, Jade, Chris, and Heidi for #AskAdmissions on 8/22 at 11:00 am EST:… https://t.co/qHbisiqbby
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Meanwhile in #Ithaca, we are loving our new immersion handouts, complete w/ #CornellMBA students and #alumni!… https://t.co/7Q7MZT4pur
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Proud of you #CornellMBA - together in support of #collaborative and #diverse communities who value mutual #respect… https://t.co/PMITGu7mIz
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text:
The Goal: New Family Orientation Day for international schools
Grade Levels: Pre-K to Grade 12 (Reception to Year 13)
-->The following list is for search engine spiders (Please Leave): international curriculum, curriculum, international bacclaureate, IB, AP, A-level, GEMS, Core Values, values, standards, mapping, interdisciplinary, co-curricular, education, skills, events, world school, extra-curricular-->
Co-Curricular Activities for International Schools
Below are links to pages for co-curricular events/activities to inspire excellence in social, emotional, physical and academic development for students K-12. Co-curricular events involve parents, students and educators and are strategically placed on the school calendar to promote core values and academic success throughout the school year.
Core Values for International Schools
All international schools base their curriculum on core values and beliefs. Please add to values lists on maps below.
New Family Orientation Day Standards
The Curwikulum Wiki Project is designed to be a resource for international schools and teachers to develop an international school curriculum based upon universal values and principles. This is a trade-a-map website so please help us to grow by contributing. See the To Do page for ideas. It really is easy to help once you get started!
Big Idea and Key Concepts/Skills
- You can access maps by following the links above in the Co-Curricular Activities and Core Values columns. From either column, you are no more than six clicks away from any map. This is a good way to explore the site.
- You can use the extensive search capabilities of the site by entering a term into the search box in the left side bar.
- You can browse through various categories and subcategories.
Essential Questions
We aim to provide an up-to-date, authoritative statement of knowledge, theory, and practice in the whole field of education. The site is written to serve both staff and students of our academic community, to inform professional educators, both in training and in the classroom, and to provide information for students and their families.
By using the latest collaborative editing software we have built a new kind of knowledge structure for curriculum development that can be shaped and maintained, to the highest academic standards, by our profession as a whole.
We aim for factual accuracy and all curriculum maps should be properly referenced. We also aim to be a forum for ideas, so on each discussion page we encourage sharing of opinions using Essential Agreements for posting and editing Curwikulum maps and participating in discussions.
What will students/parents know and be able to do
For newcomers our orientation section and help section should ease you into the site. If you were looking for it, here is an introduction to curriculum mapping.
Additional introductory information is available now.
For an even fuller introductory experience go to the Curwikulum Wiki Community Portal.
Culminating Assessment Rubric and Assessment Other Assessment Tools
This was shared with the Curwikulum Wiki Project by Jeff Wornstaff: 21rst Century Schools
Please feel free to add internal or external links to curriculum maps, and/or improve maps if you can.
Resources and Funding
The Curwikulum Project Wiki and its founders make no money from this site. It is an entirely voluntary operation, deseminating copyright free international curriculum framework. Our goal is to share and build a world class internatioanl curriculum through a collaboration of academics and educators for use in improving student learning.


text:
08.20.2017 |
9.15 hrs
About Us
Our Vision & Mission
Our History
Our Board
Executive Management Team
Our Statutory Functions
Corporate Social Responsibilities
Port Operation
Our Ports
Eastern Ports
Western Ports
Lagos Port Complex
Tin Can Island Port Complex
Delta Port Complex
Calabar Port Complex
Rivers Port Complex
Onne Port Complex
Eastern Ports HQ
Western Ports HQ
Port Security
Port Statistics
Notices To Mariners
Marine Services
Aids To Navigation
Distances To African Ports
Information Services
Daily Shipping Position
NPA Tariff
Terminal Operators' Tariff
Authorized Agencies
Definitions of Terms
Managing Director's Speeches
Press Releases
Excursion to our Ports
Public Tender Notice
Lagos Pilotage District
Warri Pilotage District
PHC/Bonny Pilotage District
Calabar Pilotage District
PEC Pilotage Exemption Cert
ISPS Code Requirement
HSE Emergency Response
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Our Administrative Contacts
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Ms Usman (right) and Mr Onigbinde
The Nigerian Ports Authority ( NPA) has signed a Memorandum of Understanding ( MoU) with
Information Technology Network to open up its budget for the public and provide Nigerians with all the necessary information during its implementation.
The MoU, which was signed at the weekend, by the management of the NPA and BudgiT Information Technology Network will assist the NPA in promoting transparency and accountability in all its operations.
Speaking at the occasion, the NPA 's Managing Director,
Ms Hadiza Balla Usman
said that the partnership became necessary for the development of an open budget system platform and implementation of a public data dissemination programme that will help the agency in blocking revenue leakages.
she said, had achieved feats in the space of socio-technological advocacy towards opening up of public budgets for citizens' comprehension.
BudgiT, according to her, started operation in 2011. With the MoU, she said, NPA would be able ton deliver on its mandate and create more wealth for Nigerians. The MoU, Ms Usman added, would also assist the NPA as a critical organ in the economic artery of the nation to promote effective and efficient management of all its 24 terminals across the country.
The partnership, the Managing Director said, apart from promoting transparency in public expenditure, would also instill a framework for transparent budget provisions for the authority, allows stakeholders to add their inputs, encourages participatory governance by way of feedbacks and creates an enabling environment to encourage foreign investment.
"The collaboration will ensure key researches, industry policies and innovations are effectively communicated. It will also ensure that critical data are generated and made accessible for policy makers, private sector actors, stakeholders and the general public".
In his remark, the Lead Partner of
Oluseun Onigbinde said that the NPA was the first revenue generating government agency to make its budget public and assured that the management of the NPA would not regret for keying into the programme .
Onigbinde said, the collaboration, apart from promoting probity, transparency and accountability, would also restore government and public confidence in the management of NPA.
M. K. Ajayi
General Manager, Public Affairs
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26/28 Marina, Lagos. P.M.B 12588 Lagos Email:
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text: Detection of ALK-positive NSCLC using an FDA-approved test, indicated for this use, is necessary for selection of patients for treatment with XALKORI in the United States.XALKORI can cause fetal harm when administered to a pregnant woman based on its mechanism of action. Women of childbearing potential should be advised to avoid becoming pregnant while receiving XALKORI. If the patient or their partner becomes pregnant while taking this drug, apprise the patient of the potential hazard to the fetus. Among the 397 patients for whom information on deaths and serious adverse reactions is available, deaths within 28 days of the last dose of study drug occurred in 45 patients. Ten (2.5%) patients died within 28 days of their first dose of study drug. Causes of death included disease progression (32 patients), respiratory events (9), and other (4). Safety of XALKORI was evaluated in 255 patients with locally advanced or metastatic ALK-positive NSCLC in 2 single-arm clinical trials (Studies A and B). The most common adverse reactions (≥25%) across both studies were vision disorder, nausea, diarrhea, vomiting, edema, and constipation. Grade 3-4 adverse reactions in ≥4% of patients in both studies included ALT increased and neutropenia. Vision disorders including visual impairment, photopsia, vision blurred, vitreous floaters, photophobia, and diplopia were reported in 159 (62%) patients in clinical trials. Consider ophthalmological evaluation, particularly if patients experience photopsia or experience new or increased vitreous floaters. Severe or worsening vitreous floaters and/or photopsia could also be signs of a retinal hole or pending retinal detachment. Advise patients to exercise caution when driving or operating machinery due to the risk of developing a vision disorder. About INLYTA ® (axitinib) In January 2012, INLYTA ® was approved by the U.S. Food and Drug Administration (FDA) for the treatment of advanced renal cell carcinoma after failure of one prior systemic therapy. INLYTA was approved by the European Commission on September 3, 2012, for the treatment of adult patients with advanced RCC after failure of prior treatment with sunitinib or a cytokine. INLYTA has also been approved in a number of other countries and regions, including Switzerland, Japan, Canada, Australia, and South Korea. INLYTA, a kinase inhibitor, is an oral therapy that was designed to selectively inhibit vascular endothelial growth factor (VEGF) receptors 1, 2 and 3, which are proteins that can influence tumor growth, vascular angiogenesis and progression of cancer (tumor spread).


text:
SkippyJon Jones Lost in Spice 2015 MP3
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Official Oliver Lieb Youtube Channel. The album Lost In Spice by SPICELAB, written and produced by Oliver Lieb originally was released in 1993 on Harthouse.
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The New York Times bestselling kitty boy blasts off into another hilarious adventure. Buckle up, amigos— everyone's favorite kitty boy is about to lift off. You'll ...
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Cumberland County Schools retired Media Coordinator, David Aspinall, stops by the Tiger Cub Broadcast Club to read one of his favorites.
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Skippyjon Jones Lost In Spice read out loud for kids by Judy Schachner.
Lost In Spice MP3
Lost in spice is a platform game which transports you to four islands filled with danger and adventure. The paradisiacal islands of Matterhorn, Fiji, Denial and ...
Heather Lost in Spice - teaser MP3
Skippyjon Jones Lost in Spice read aloud MP3
Skippyjon Jones Lost in Spice by Judy Schachner is read aloud by Krystal Jones. No copyright infringement is intended. Enjoy!
Skippy Jon Jones Lost in Spice MP3
Walk to Read December 2013.
Lost in Spice MP3
Provided to YouTube by Believe SAS Lost in Spice · Spicelab Spicelab - Lost in Spice ℗ Solieb Digital Released on: 2013-03-21 Composer: Oliver Lieb Music ...
Neil Lost In Spice MP3
Stoneage Romeos - Lost in Spice MP3
Skippy Jon jones lost in spice MP3
"Lost in Time" by Devo Spice [Song for the Second Doctor Who: Patrick Troughton] MP3
From my Doctor Who concept album I Am The Doctor available on CD here: http://thefump.com/store_release.php?id=124 or on iTunes here: ...
SpiceWorld - Mel B's "lost" boots MP3
"I can't find my boots! I think I've lost 'hem"
Graystone Literacy Night MP3
Spice And Wolf Amv - Lost In Paradise MP3
Anime - Spice and Wolf Music - Lost in paradise by Evanescence.
"Lost Girl" Spice Girls Bo Tamsin and Kenzi WANABE MP3
Lost Girl Season 4 Sexy Moves. Funny Bo Kenzi and Tamsin Singing and Dancing. Made this video JUST FOR FUN. Petite video juste pour le fun avec Bo, ...
Britney Spears - Oops!...I Did It Again (Official Video) MP3
Britney Spears' official music video for 'Oops!...I Did It Again'. Click to listen to Britney Spears on Spotify: http://smarturl.it/BritneySpot?IQid=BritneyOo As featured ...
Oops!...I Did It Again
Britney Spears(Mmm, yeah) Yeah-yeah yeah-yeah yeah-yeah Yeah-yeah yeah-yeah yeah-yeah I think I did it again I made you believe, we're more than just friends (Friends) Oh baby, it might seem like a crush But it doesn't mean that I'm serious 'Cause t[...]
Let's go jungle! Lost in the island of spice game MP3
You can play this game at chuck e cheeses.. Thanks for watch and don't for get to subscribe.
Spice Boys GET LOST MP3
Follow the Spiceboys through the Rocky Mountains around Montana. Skateboarding from: Daniel Khamov Trevor Theriault Nick Kiery Grayson Certain Jared ...
Krista Siegfrids-Wannabe (Spice Girls cover) live at Lost in Music 2013 MP3
Lost in Music, Pakkahuone, Tampere 19.10.2013.


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I have setup rsync to backup a drive everyday using cron. This is the command:
0 1 * * * /usr/bin/rsync -av --stats --delete /media/sdc1/ /media/sdd1/
My understanding is that the "--delete" will delete any files on the backup drive that are not on the source drive....but it doesn't. The backup drive has accumulated all the files that were deleted on the source drive. If the rync command is correct then why are the files not being deleted or if the rsync command is incorrect please supply the correct command.


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"Ambulance not called for dementia patient"
About: City Health Care Partnership CIC / GP service (out-of-hours) City Health Care Partnership CIC GP service (out-of-hours)
Posted by englandsrose (as ),
An out of hours GP attended my mother at her HICA care home and diagnosed she had a stroke but an ambulance was not called. Neither did HICA care home. I arrived at the home and dialled 999. She died in hospital 10 days later. When I spoke to the GP and asked why they didn't ring for an ambulance, they replied to me because she had advanced dementia. I was then accused of harassing the, and they then put the phone down. I had seen the NHS advert on TV many times act fast if you suspect a stroke and dial 999.
I have contacted the NHS to ask if this is acceptable, but I do not believe I have had any comment from them. I think this is just typical.
I wonder where this leaves dementia patients who have a stroke. As I feel as if this out of hours GP and the care home did not care for my mother.
Response from Paul Wray, Out of hours GPs, City Health Care Partnership CIC 7 years ago
First of all I would like to offer my sincere condolences to you and your family on the loss of your Mother.
I am unable to comment on the processes of external agencies but as the Service Manager for the Out of Hours Service I would like to reassure you that any concerns regarding the Out of Hours Service that is brought to my attention would be taken very seriously and a full investigation would take place. However to ensure that we can deal with this or any other case which involves patient confidentiality I would need to ensure that the person highlighting concerns does have consent of the next of kin.
If you feel that you have not had an appropriate response please contact the Patient Advice and Liaison Service (PALS) tel: 01482 335409 at NHS Hull who will take details of your concerns and forward them on to myself.


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B.A., University of Michigan
Law Journals
Executive Technology Editor and Editorial Board, Michigan Telecommunications and Technology Review
Bar and Court Admissions
District of Columbia Bar
Supreme Court of the United States
U.S. Courts of Appeals for the First, Fourth, Sixth, Eighth, Ninth, and District of Columbia Circuits
U.S. District Court for the District of Columbia
Joshua S. Turner
Practice Areas
Josh represents clients in proceedings before the Federal Communications Commission (FCC), Federal Aviation Administration (FAA), and other federal agencies, as well as in federal and state court actions. In addition to regularly advocating in front of federal agencies, Josh argues in federal appellate court as well as in federal district court and state court.
Representative Experience
- Represents clients in matters involving FCC and state regulation of wireless and wireline telecommunications services, including commercial mobile radio service (both voice and data), TCPA, broadband services such as cable and fiber, competitive provision of video services, and satellite services.
- Provides counseling on compliance with evolving regulation of unmanned aircraft systems (UAS, or more commonly, drones); tracks and analyzes (a) Federal Aviation Administration (FAA) rulemakings and enforcement actions, and (b) state and local regulation of UAS, with a particular focus on potential conflicts between different regulatory authorities.
- Specializes in federal appellate review of FCC decisions and both prosecution and defense of federal district court actions involving communications law.
- Represents companies with communications law disputes in state and federal courts across the country.
- Particular experience in actions involving federal preemption of state regulation of wireless carriers, defense of radiofrequency emissions claims, wireless facility siting issues, and rights-of-way regulation.
- Provides large telecommunications carriers with national strategic legal advice on a variety of issues.
- Assists clients with federal and state regulation of investment and transfers of control in the telecommunications industry, including structuring the transactions and gaining the necessary regulatory approvals.
- Negotiates institutional and enterprise contracts for telecommunications services.
- Successfully defended binding nature of arbitration clause contained in online customer contract, resulting in the stay of a large class-action lawsuit.
- Representative matters include:
- Montgomery County, MD v. US, No 15-1240 (4th Cir.): Represents Intervenor CTIA in defending the FCC's Infrastructure Order, which interprets and implements limitations on local authority to deny wireless facility siting requests.
- State of Tennessee v. FCC, No. 15-3291 (6th Cir.): Represents the State of Tennessee in a challenge to the FCC's rules prohibiting states from regulating broadband provision by their municipalities.
- Sprint Spectrum et al. v. Zoning Board of Adjustment of Paramus, No. 14-2954 (3d Cir.): Represented T-Mobile in an appeal of a denial of a wireless siting application; the Third Circuit affirmed the finding below that a Distributed Antenna System would not be a viable alternative to the proposed site.
- Lenfest v. Verizon Enterprises, No. 13-cv-11596 (D. MA): Successfully defended binding nature of arbitration clause contained in online customer contract, resulting in the stay of a large class-action lawsuit.
- CTIA v. City and County of San Francisco, No. 11-17707 (9th Cir.): Represented the wireless industry in a major First Amendment and preemption challenge to the City of San Francisco's requirement that retailers display health warnings at the point of sale for wireless phones. The team succeeded in securing an injunction against enforcement of San Francisco's law from the Ninth Circuit.
- New York SMSA L.P. d/b/a Verizon Wireless et al. v. Town of Clarkstown: In a major victory for wireless carriers, the Second Circuit affirmed a lower court decision finding that a local ordinance that legislated a preference for alternate technologies, including Distributed Antenna Systems, and regulated radio frequency (RF) interference was preempted by federal law under a field preemption theory.
- Farina v. Nokia et al.: The Third Circuit affirmed a lower court decision dismissing class action claims tied to the alleged health effects of RF emissions from wireless devices; representing Verizon Wireless, Josh was part of a national team of counsel representing a cross-section of the wireless industry.
- Murray v. Motorola: On behalf of a group of wireless carriers and manufacturers, including Verizon Wireless and Nokia, the D.C. Court of Appeals upheld the dismissal of a number of injury claims involving allegations of injury caused by RF emissions from wireless devices and systems.
- BellAtlantic Mobile of Rochester, d/b/a Verizon Wireless v. Town of Irondequoit, one of the first decisions applying the FCC's Shot Clock following the affirmance of that order by the Fifth Circuit, the court found that the town had unreasonably delayed in failing to grant the carrier's application and that the application of environmental review was a mere pretext.
- Globalstar, Inc. v. FCC: The D.C. Circuit affirmed an FCC decision to reassign certain spectrum used for mobile satellite services from Globalstar, Inc. to Iridium Satellite LLC. Argued on behalf of Iridium.
- National Cable & Telecommunications Association, et. al. v. FCC: The D.C. Circuit affirmed an FCC decision to ban exclusive access provisions in agreements between cable companies and the owners of apartment buildings and other multiple dwelling units.
- Hartleib et al. v. FCC: Represented Sirius XM Radio Inc. as intervenor in appeals challenging the FCC's approval of the merger of Sirius XM Radio Inc. In dismissing the appeals, the D.C. Circuit held that it lacked jurisdiction to review the FCC's decision because the petitioners lacked standing.
- PRT v. Municipality of Guayanilla: The First Circuit handed down a decision affirming a grant of summary judgment in favor of Puerto Rico Telephone Company. The case involved a federal court challenge to a municipality's 5% gross revenue fee under Section 253 of the Communications Act. The case constituted the first Circuit-level precedent defining the limits on municipal authority to condition access to public rights-of-way on the payment of "gross revenue fees" under a part of the Communications Act enacted by the Telecommunications Act of 1996.
- Balthazar, et al. v. Verizon Hawaii Inc.: In a large putative class action alleging that Verizon Hawaii violated the Hawaii consumer protection laws in marketing its Touch Calling service, the Supreme Court of the State of Hawaii affirmed a decision granting summary judgment for Verizon Hawaii, Inc.
- Jaeger v. Cellco Partnership: The Second Circuit affirmed a lower court decision rejecting an attempt by an abutting property owner to block construction of wireless facilities based on alleged health effects of RF emissions on humans and avian wildlife.
- Federal Communications Bar Association (FCBA)
- Named a "Legal Lion" by Law360's Weekly Verdict Column (2016)
- Named one of DC's "Super Lawyers" for Communications by Super Lawyers magazine (2013-2017)
- Named by The Legal 500 US as a "recommended lawyer" in Telecom and Broadcast Regulatory Law (2011-2013)
- Named to Legal Times' list of the DC-area's "40 under 40" (2009)
News & Insights
- August 1, 2017 | ArticleLaw360Joshua S. Turner, Anna M. Gomez
- July 12, 2017 | Speaking EngagementWho Flies There? Emerging Legal Issues in Drone Identification and Counter-Drone TechnologiesWiley Rein WebinarAnna M. Gomez, Joshua S. Turner, David E. Hilliard, Katy M. Ross
- July 1, 2017 | ArticleNatural Gas & ElectricityJoshua S. Turner, Katy M. Ross, John T. Lin
- June 2017 | Newsletter
- May 19, 2017 | AlertAnna M. Gomez, Joshua S. Turner, John T. Lin, Sara M. Baxenberg
- April 24, 2017 | AlertBennett L. Ross, Scott D. Delacourt, Joshua S. Turner, Katy M. Ross, Madi Lottenbach
- March 23, 2017 | ArticleAnna M. Gomez, Joshua S. Turner, Kathleen A. Kirby, Hap Rigby, David E. Hilliard, Katy M. Ross, Sara M. Baxenberg, John T. Lin
- February 23, 2017 | ArticleBusiness and Commercial Litigation in Federal Courts, Fourth EditionThomson Reuters and American Bar Association Section of LitigationMegan L. Brown, Bert W. Rein, Richard W. Smith, Joshua S. Turner, Richard E. Wiley, Gregory M. Williams, Chapter Authors
- February 14, 2017 | ArticleLaw360Joshua S. Turner, Anna M. Gomez, Sara M. Baxenberg
- January 27, 2017 | Press Release
- January 6, 2017 | Las Vegas, NV | Speaking EngagementConsumer Electronics Show 2017Joshua S. Turner, Speaker
- December 27, 2016 | AlertFCC Seeks Data and Comment About Ways to Streamline and Expedite Local Approval of Small Cell Wireless Infrastructure DeploymentChristopher S. Huther, Claire J. Evans, Joshua S. Turner, Megan L. Brown, Shawn H. Chang, John T. Lin
- December 22, 2016 | ArticleLaw360Sara M. Baxenberg, Anna M. Gomez, Joshua S. Turner
- December 16, 2016 | Press ReleaseWiley Rein Files Supreme Court Amicus Brief in Lee v. Tam on Behalf of Rutherford Institute and Consumers' Research
- December 2016 | ArticleBusiness and Commercial Litigation in Federal Courts: Communications Litigation, Fourth EditionThomson ReutersRichard E. Wiley, Joshua S. Turner, Megan L. Brown
- November 4, 2016 | AlertMegan L. Brown, Scott D. Delacourt, Bennett L. Ross, Joshua S. Turner, Daniel P. Brooks, John T. Lin, Madi Lottenbach, Ari Meltzer, Katy M. Ross
- October 21, 2016 | Alert
- September 21, 2016 | AlertScott D. Delacourt, Megan L. Brown, Joshua S. Turner
- September 7, 2016 | ArticleWileyConnectJoshua S. Turner
- September 2, 2016 | Alert
- August 11, 2016 | ArticleUAS VisionJoshua S. Turner, Anna M. Gomez, Katy M. Ross
- August 10, 2016 | Press Release
- August 5, 2016 | Hot Springs, VA | Speaking EngagementThe West Virginia Bar Association's 130th Annual MeetingJoshua S. Turner, Speaker
- August 2, 2016 | Press ReleaseWiley Rein Participates in First-Ever White House OSTP Workshop on Drones and the Future of Aviation
- June 22, 2016 | AlertAnna M. Gomez, Joshua S. Turner, Katy M. Ross, Sara M. Baxenberg, Madi Lottenbach
- May 11, 2016 | ArticleLaw360Joshua S. Turner, Anna M. Gomez, Katy M. Ross
- May 4, 2016 | Alert
- May 2, 2016 | New Orleans, LA | Speaking EngagementAUVSI's XPONENTIAL 2016Joshua S. Turner, Speaker
- April 26, 2016 | ArticlePOLICYBERJoshua S. Turner, Scott D. Delacourt
- April 15, 2016 | Press Release
- March 30, 2016 | Alert
- March 21, 2016 | Press ReleaseWiley Rein Argues on Behalf of Tennessee in High-Profile Sixth Circuit Case Involving FCC's Attempt to Preempt State Rules on Municipal Broadband
- February 5, 2016 | Media MentionBloomberg BNA's Daily Report for Executives
- December 22, 2015 | Press ReleaseWiley Rein Helps Secure First Amendment Win Striking Down Ban on Registering 'Disparaging' Trademarks
- December 18, 2015 | AlertAnna M. Gomez, Joshua S. Turner, Megan L. Brown, Katy M. Ross, Sara M. Baxenberg
- December 18, 2015 | AlertMegan L. Brown, Joshua S. Turner
- December 18, 2015 | Press Release
- November 6, 2015 | Press ReleaseWiley Rein Files Amicus Brief in First Amendment Trademark Case, Pro-Football, Inc. v. Amanda Blackhorse
- October 6, 2015 | Alert
- September 21, 2015 | Media MentionLaw360
- July 13, 2015 | AlertScott D. Delacourt, Joshua S. Turner, Megan L. Brown, Jennifer D. Hindin, Kathleen E. Scott
- June 22, 2015 | Press ReleaseWiley Rein Files Amicus Brief Testing the Constitutionality of the Lanham Act's Bar on "Disparaging" Trademarks
- June 19, 2015 | AlertScott D. Delacourt, Joshua S. Turner, Jennifer D. Hindin, Kathleen E. Scott
- April 23, 2015 | Press Release
- April 22, 2015 | Press Release
- March 29, 2015 | Press Release
- March 13, 2015 | Article
- January 14, 2015 | ArticleSupreme Court Holds that Denials of Cell Tower Siting Applications Must Be Accompanied by Written Reasons
- December 9, 2014 | ArticleUnmanned Aerial Online
- November 20, 2014 | Article
- November 18, 2014 | AlertNTSB Reverses ALJ Decision in Pirker; Finds that Unmanned Aircraft are "Aircraft" and Governed by FAA RulesJoshua S. Turner
- October 27, 2014 | ArticleBennett L. Ross, Joshua S. Turner, Megan L. Brown, Henry Gola
- October 1, 2014 | Press Release
- August 25, 2014 | Alert
- August 1, 2014 | Media MentionLaw360, Fortune
- July 23, 2014 | Media MentionForbes
- June 19, 2014 | Media MentionJoshua Turner Featured in Q&A with Bloomberg BNA on Cell Tower Siting CaseBloomberg BNA
- June 2014 | ArticleThe Metropolitan Corporate Counsel Vol. 22, No. 6Joshua S. Turner
- May 15, 2014 | ArticleLaw360
- May 13, 2014 | Press Release
- May 2014 | Newsletter
- April 25, 2014 | Press Release"Super Lawyers" Recognizes 66 Wiley Rein Attorneys in Washington, DC Area Across 18 Areas of the Law
- March 14, 2014 | Media MentionJoshua Turner Weighs in on Continued FAA Commercial Drone Ban; Path Needed to Allow Safe and Responsible UseLaw360
- March 11, 2014 | ArticleLaw360
- March 10, 2014 | Washington, DC | Speaking EngagementFederal Communications Bar Association CLE ProgramJoshua S. Turner, Moderator, Eve Klindera Reed, Speaker
- February 20, 2014 | ArticleLaw360
- February 14, 2014 | Press Release
- February 3, 2014 | ArticleBloomberg BNA's Telecommunications Law Resource CenterMark B. Sweet, Eve Klindera Reed, Joshua S. Turner
- November 21, 2013 | Alert
- September 6, 2013 | AlertFCC Receives Comments on Further Notice of Proposed Rulemaking and Notice of Inquiry Assessing Radiofrequency Exposure Standards and Policies
- June 20, 2013 | Press ReleaseSupreme Court Rejects Funding Condition Requiring Affirmation of Belief, as Urged by Wiley Rein Attorneys
- June 7, 2013 | Press ReleaseThe Legal 500 US Ranks Wiley Rein's Telecommunications Group in the Top Tier for the Seventh Consecutive Year
- June 4, 2013 | Press ReleaseLegal 500 US Recognizes 25 Wiley Rein Lawyers Across Five Practices Nationally; Wiley and Senkowski Are "Leading Lawyers"
- May 17, 2013 | Press Release
- April 19, 2013 | Press Release
- April 8, 2013 | AlertSummary of the First Report and Order, Further Notice of Proposed Rulemaking, and Notice of Inquiry In the Matter of Reassessment of Federal Communications Commission Radiofrequency Exposure Limits and Policies and Proposed Changes in the Commission's Rul
- April 4, 2013 | Press Release
- February 28, 2013 | Press Release
- September 11, 2012 | Press Release
- August 13, 2012 | Alert
- June 2012 | Newsletter
- June 6, 2012 | Press ReleaseThe Legal 500 US Ranks Wiley Rein's Telecommunications Group in the Top Tier for the Sixth Consecutive Year
- May 30, 2012 | Press ReleaseThe Legal 500 US Ranks Four Wiley Rein Practices Among Nation's Best; Wiley and Senkowski Named 'Leading Lawyers'
- March 19, 2012 | ArticleThe National Law Journal
- February 22, 2012 | Alert
- February 3, 2012 | Alert
- February 1, 2012 | Press Release
- December 15, 2011 | ArticleProduct Liability Law360
- November 28, 2011 | Press Release
- October 28, 2011 | Press Release
- October 20, 2011 | Press Release
- June 6, 2011 | Press Release
- June 1, 2011 | Press ReleaseThe Legal 500 US Names Wiley Rein's Bankruptcy, Copyright and Telecom Practices Among the Best in the Nation; Wiley and Senkowski Honored as "Leading Lawyers"
- July 1, 2010 | Press ReleaseWiley Rein Attorneys Obtain Second Circuit Affirmance of Major Victory for Wireless Carriers Preempting Local Government Preference for Particular Technologies
- July 13, 2009 | Press Release
- May 28, 2009 | Press ReleaseWiley Rein Attorneys Assist in Attaining Important Ruling Affirming Ban on Exclusive Cable Contracts
- March 30, 2009 | Press ReleaseWiley Rein Attorneys Secure Major Victory for Wireless Carriers Preempting Local Government Preference for Particular Technologies
- August 27, 2007 | Press ReleaseWiley Rein Secures Major Victory for Wireless Carriers and Equipment Manufacturers in Cases Alleging Cell Phone Emissions Cause Injury
- December 29, 2006 | Press Release
- June 9, 2006 | Press Release
- November 28, 2005 | Press ReleaseWRF Successfully Defends Grant of Summary Judgment in $300 Million Class Action; Litigation Establishes Important Filed-Rate Doctrine Precedent in Hawaii Supreme Court
- August 10, 2005 | Press ReleaseWRF Selected as Lead Counsel in Country's Most Important Wireless Telecom Case Before the U.S. Supreme Court
- January 28, 2005 | Press Release
- August 4, 2004 | Press Release
- August 29, 2003 | Press Release


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|Contact Us
If you have any questions about the site, please feel free to contact us. We are always looking for ways to better serve our members - YOU are important to us!
4/12/20172017 AIC Annual Conference
4/12/20172017 AIC Spring District Workshops
3/24/2017 » 10/9/2017
2017 Energy Conference Exhibitor/Sponsor
9/20/2017 » 9/22/2017
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Reissue with the latest 24bit remastering. Features original cover artwork. Comes with a descripton in Japanese. A sublime little set all the way through – an early 60s date from the west coast scene – and one that was almost as important to that side of the country as the Verve bossa records were to New York! Bud Shank's in the lead on alto sax – no flute at all this time around – blowing sharp and soulfully, in a way that's even more deft than most of his other albums! But the equal star here is the young Clare Fischer – who plays piano in the group, and also contributed a host of original tunes to the set – fresh numbers that are way different than the usual "bossa-ized" standards, or American remakes of Brazilian classics. Ralph Pena is a key member of the group on bass – and Larry Bunker plays some vibes as well. Titles include "Joao", "Pensativa", "Samba Guapo", "Samba Da Borboleta", and "Que Mais?".
Reissue with the latest 24bit remastering. Features original cover artwork. Comes with a descripton in Japanese. One of the greatest albums of Brazilian jazz that Bud Shank ever recorded — done with a style that's a lot more like some of the best bossa albums from Rio at the time! Bud's recorded in other bossa settings before — but there's something about this record that really gets the whole thing right — as Shank's alto and flute come into play with a killer combo that includes Clare Fischer on piano, Larry Bunker on vibes and drums, Joe Pass on guitar, and Milt Holland and Chuck Flores on percussion.


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Great response time!
Excellent products!
Check out their edibles-yummy!
Will definitely buy again!
This place hands down has the best customer service.. Always making sure the customer is happy and satisfied. Their GirlScout is the best I've had anywhere.. Definitely found my new everyday spot.
1 person thought this review was helpful
This is hands down the most proffesional and discreet delivery service out there. I mean they deliver your order dressed in slacks. A vendor that dose not look like vendor lol It makes the transaction more comfortable for new comers and buisness types. Prices are fair and the buds are always densly sticky and smell phenomenal. Even the cheaper strains are really good quality. Will be using this again!!


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Biodiversity Research
Patch history and spatial scale modulate local plant extinction and extinction debt in habitat patches
Version of Record online: 1 FEB 2013
DOI: 10.1111/ddi.12045
© 2013 John Wiley & Sons Ltd
Diversity and Distributions
Volume 19, Issue 7, pages 825–833, July 2013
Additional Information
How to Cite
Guardiola, M., Pino, J., Rodà, F. (2013), Patch history and spatial scale modulate local plant extinction and extinction debt in habitat patches. Diversity and Distributions, 19: 825–833. doi: 10.1111/ddi.12045
Publication History
- Issue online: 13 JUN 2013
- Version of Record online: 1 FEB 2013
Funded by
- European Commission. Grant Number: SSPI-CT-2006-044346
- Spanish Ministry of Science and Innovation
- LANDPOLNET. Grant Number: CGL2009-12646
- Spanish Consolider-Ingenio 2010 programme in the project MONTES. Grant Number: CSD2008-00040
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Getting to Cork
Cork Airport
Cork International Airport is the country's second busiest airport after Dublin and serves more than 50 destinations. The airport is located just 10 minutes from Cork City centre on the highest point of the Southside.
To/From Cork Airport by Bus
From Cork Airport, you can take the 226 to Parnell Place Bus Station, the main bus station for Cork city.
The 226 bus departs from Parnell Place Bus Station to Cork Airport and then on to the nearby village of Kinsale. Bus Éireann provides a frequent direct coach service between Cork Airport and Cork City Centre and Cork Bus Station.
To/From Cork Airport by Taxi
A taxi fare from Cork Airport to the City Centre is around €14. There is a taxi rank outside the main terminal building.
To/From Cork Airport by Car
Cork Airport is just 8 kilometres from Cork City Centre on the south end of the N27 when coming from the North, West, or East of Cork and off the R600 when coming from Kinsale.
Other Airports
Kerry Airport is 104 km from Cork city
Shannon Airport is 123 km from Cork city
Dublin Airport is 267 km from Cork city
Belfast Airport is 438 km from Cork city