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The newly appointed Minister of External Affairs, Subrahmanyam Jaishankar has crossed the barrier between politicians, who make policy and professionals who implement it. Those who broke the barrier earlier have done so by joining politics and working their way up through the characteristic methods of politicians. Since most professionals do not take that route, the chances of diplomats becoming ministers is unusual in the Indian system. In the Presidential system, however, ministers are often professionals and they do not need to go through the Parliamentary process.
By elevating Jaishankar, former foreign Secretary to Minister for External Affairs, Prime Minister Narendra Modi has created history by breaking the barrier. A personal chemistry between a politician and a professional of this kind may well be rare. Since there were murmurs among politicians and bureaucrats, this may remain an isolated experiment and may not become a trailblazer.
Reputations in the Foreign Service are not built on concrete accomplishments as successes and failures are difficult to measure. An initiative may be taken by a person or a group, which may materialise or fail many years later when another person or group deals with it. Foreign policy outcomes are nebulous and a success of today may be seen as a failure tomorrow. There are too many imponderables in the implementation of foreign policy.
Jaishankar has maintained a consistent record of working in important stations and making a success of each post. Changes of government did not change his fortunes and when the Chief Minister of Gujarat became the PM, he too happened to be a friend of Jaishankar. The bonanza continued and eventually he became the first former Foreign Secretary to become the Minister of External Affairs of India.
Jaishankar's pedigree was his best asset in the service from the very beginning. I remember receiving him with extra warmth as the son of K.Subrahmanyam, whom I had known as the Chanakya of India, when he came to meet me as a probationer in the East Europe Division, where I was a Deputy Secretary. I had just come back from Moscow and he was about to go there. I was impressed with his scholarship and maturity and our discussions were beneficial to me as well. We renewed our friendship later when we were neighbours in Vienna and Prague.
His educational qualifications were impeccable, as a graduate of St. Stephen's College at the University of Delhi, an MA in Political Science and an M.Phil and Ph.D. in International Relations from Jawaharlal Nehru University (JNU), where he specialised in nuclear diplomacy. His postings to Moscow, Colombo, Budapest, Prague, Singapore, Beijing and Washington, with intermittent postings to key positions at Headquarters gave him an excellent career graph.
As Head of the Americas Division in the Ministry of External Affairs, he was a key member of the Indian delegation to the nuclear deal negotiations, together with Shyam Saran and Shivshankar Menon. Today, many of the provisions of the 123 Agreement, appear irrelevant, but each word in them was fiercely fought over by the Indian and US teams. Modi's party rejected the Agreement, but subsequently hired Jaishankar to implement it. The Agreement was never fully implemented and the liability Issue was never resolved, but with all its blemishes the nuclear deal remains a symbol of India's diplomatic success.
It was when he was Ambassador in China that he got to know Modi and developed mutual admiration, which led to the appointment of Jaishankar as Foreign Secretary, by curtailing the term of his predecessor. Although Modi himself appeared to be the author and promoter of his diplomacy, which made waves around the world, as a backroom operator, he must have given it his realistic touch and made it logical and acceptable. Modi's triumphant journey around the world and the message of a strong India, ready to play its legitimate role on the world stage had the strong imprint of a thorough professional. The resetting of relations after the advent of Donald Trump was also a master stroke. No wonder Modi left him for a while so that he could become the President, Global Corporate Affairs of Tata Sons, but brought him back as a Cabinet Minister. It was the fulfilment of a special need and a vote of thanks to Jaishankar.
What awaits Modi and Jaishankar in the wide world cannot be anticipated. India has been largely reactive to the changes in the world. But as our economic and military strength increase, a much more proactive approach is needed. Modi and Jaishankar are poised to claim a place for India in a multipolar world.


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Re-engaging Disconnected Youth
Transformative Learning through Restorative and Social Justice Education – Revised Edition
Amy Vatne Bintliff
Series index
As schools struggle to redefine and restructure themselves, they need to be aware of the new realities of adolescents. This series is committed to depicting the wide variety of adolescent cultures that exist in today's troubled world. It is primarily a qualitative research, practice, and policy series devoted to contextual interpretation and analysis that encompasses a broad range of interdisciplinary critique. The series addresses such issues as curriculum theory and practice; multicultural education; adolescent literacy; aggression, bullying, and violence; media and the arts; school dropouts; homeless and runaway youth; gangs and other alienated youth; atrisk populations; peers, family structures, and parental involvement; identity formation; race, ethnicity, class, and gender/LGBTQ studies; and overall social, biological, psychological, and spiritual development.
Send proposals and manuscripts to the general editors at:
Joseph L. DeVitis & Linda Irwin-DeVitis
Darden College of Education
Old Dominion University
Norfolk, VA 23503
To order other books in this series, please contact our Customer Service Department at:
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subset: commoncrawl


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Menopause is a natural transition in a woman's lifetime when her menstruation cycle and ability to become pregnant has come to an end. A woman has reached menopause when she has not had a period over the course of one year.[1]
Common Symptoms: Menopausal women will normally report having irregular periods, spotting, period cessation, vaginal dryness, hot flashes, night sweats, insomnia, fatigue, and mood swings.[2] Other symptoms may include hair loss, migraines, a change in bone density or increase in bone fractures, and pain during sex. Menopause symptoms last an average of 4-5 years.
Causes: Menopause usually begins in her mid-to-late 40s when the ovaries begin to produce much less estrogen and progesterone. If spotting and irregular periods occur for some time, this is referred to as perimenopause, which is the early onset of menopause symptoms. However, menopause specifically refers to the absence of a period for one year. Menopause can also occur due to a hysterectomy and other uterine or ovarian surgeries.
Treatment: An OB/GYN can assess your symptoms or administer a blood test to check your follicle-stimulating hormone (FSH) and estradiol (E2) levels to ensure that your symptoms are menopausal and not related to some underlying cause.[3] Hormone replacement therapy such as low-dose birth control, prasterone, or other menopausal hormonal therapies that come in pill or patch forms are often recommended and prescribed by OB/GYNs to manage and mitigate menopausal symptoms.[4] Topical hormone therapies such as low-dose estrogen or progesterone creams, are also commonly used to mitigate symptoms. Keep in mind that any hormone replacement agents should be approved by yourOB/GYN as creating further hormone imbalance can increase your risk for polycystic ovary syndrome, ovarian cancer, breast cancer uterine fibroids and more.
Several natural hormone replacement supplements such as black cohosh, red clover, flaxseed oil, vitex, and others have been shown to have positive effects on menopause symptoms. Maintaining a healthy weight, exercising regularly, and ensuring you are getting your proper balance of vitamins and minerals (especially calcium) is vital to stabilizing your energy, mood, improving sleep, and releasing endorphins that make you feel better overall. This can also keep off excess weight gain that may lead to further estrogen/progesterone imbalances.
[1] https://medlineplus.gov/menopause.html
[2] https://www.womenshealth.gov/menopause/menopause-symptoms-and-relief
[3] https://www.nia.nih.gov/health/what-menopause
[4] https://www.womenshealth.gov/menopause/menopause-treatment


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"North Korea is a country with thermonuclear weapons sitting on ICBMs [intercontinental ballistic missiles] that can reach the United States. It is really important to understand them even if we don't like them. That starts by analyzing their propaganda. Even though it's tendentious, you can learn a lot about a country from the lies they tell."
In South Korea, the film was deemed as communist propaganda and a symbol of the enemy, and screening was banned; police were often mobilised when university students were found playing the film on campus, and the students were often accused of being sympathetic with the North.[11] In 1998, the Supreme Court of South Korea ruled that The Flower Girl and six other North Korean films were "not favouring anti-ROK sentiments" in regards to national security laws.[11]


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Finding peace in downtown park
Since the renovations at Mill River Park, several residents say they go there daily, to enjoy the scenery, birds and peaceful atmosphere in the midst of downtown Stamford.
Among them is Judy Selby, who was walking her two little dogs on a recent afternoon.
"We're here every day," Selby said. "We live right there in the Trump building. I was one of the first residents in the building, so I saw the change."
Selby, a corporate lawyer in Manhattan, said when she moved into her luxury apartment, the park was in shambles with an old house in the middle. She's pleased with the result of the renovations, calling them a "home run."
Looking around, Selby said the park totally improved the area, adding that it has a magnificent design and amazing wildlife. She said it's also good for residents of the nearby senior housing complex.
"So, we are loving the park," she said. "It's a gift."
Myriam Nybes, who was strolling around, said she doesn't live in Trump Parc, but that's her dream. She's staying at the Hampton Inn and loves visiting the park.
"If I was rich, I would move there," Nybes said, pointing to the 34-story high-rise. "It's so nice in the morning, it's beautiful because you smell the grass."
For the full story, subscribe now.


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Loonie outlook turns slightly positive
FX Consultant / IFXA Ltd
· US Retail Sales rise, rate hike expectations don't
· Profit-taking forces USDCAD decline to pause
· The week ahead may lack drama
By Michael O'Neill
This morning's US Retail Sales data surpassed expectations and bode well for stronger US growth for the balance of the year. Still, the uncertainty surrounding Brexit and the possibility of increased market volatility will keep the doves on the Federal Open Market Committee firmly in control and US rates anchored.
Bank of Canada bullish on economy
The outlook for the Canadian dollar was rather bleak at the end of last week. "Buy USDCAD" strategies were everywhere and the technicals were pointing to a break of resistance at 1.3050, putting 1.3400 in play. Once again, however, the 1.3145-80 area proved to be formidable resistance. FX sentiment switched to risk-seeking on Tuesday and USDCAD pulled back from the brink.
The retreat was viewed as merely a correction which appeared to be accurate ahead of what was expected to be a dovish Bank of Canada interest rate statement and Monetary Policy Report.
Surprise! The Bank of Canada painted a very rosy Q3 outlook, forecasting a whopping 3.6% gain in real GDP, a far cry from its April forecast of 2.2%.
The surprise outbreak of good news gave the CAD a bid, too. Photo: iStock
The economic impact from the Alberta wildfires is expected to be completely reversed in Q3 while the boost from the federal fiscal stimulus has yet to be felt.
The BoC expects solid US domestic demand to increase exports and be a major contributor to Canada's growth. The solid US demand were not evident this morning. Canadian manufacturing shipments declined 1.0% which was not totally unexpected with some of the decline blamed on supply disruptions. At the same time, the decline in inventories is a positive.
Canada real exports:
Create your own charts with SaxoTraderGO click hereto learn more
Source: Bank of Canada MPR
USDCAD technicals getting bearish
The intraday USDCAD technicals are bearish while trading below 1.2920 and looking for a test of major support in the 1.2820-60 zone. That support is derived from the uptrend line from the May 1.2462 low, a double bottom at 1.2830 in July, and the 50% Fibonacci retracement level of the May range at 1.2822.
A daily close below 1.2820 would negate the uptrend and suggest that a revisit to the 1.2462 low is likely. A move back above 1.2980 would negate the downtrend and keep the focus on the 1.3080 resistance level.
USDCAD daily:
Source: Saxo Bank
The week ahead
The European Central Bank meeting on Thursday headlines what looks to be a fairly innocuous economic calendar, which should make for a dull week. The Bank of England didn't adjust policy at its July 14 meeting and it is likely that the ECB will follow suit.
There aren't any top-tier data available from the US which keeps the trading focus on sterling and UK issues. Tuesday's UK data may have limited impact due to expectations of August policy action by the Bank of England.
A holiday in Japan on Monday will put a damper on the Asia session although New Zealand CPI data may be extra important ahead of the reserve Bank of New Zealand economic outlook on Thursday. The week will start out slow and likely end the same way.
The week that was
Blow-out nonfarm payrolls numbers would normally be the main focus in Asia markets on the following Monday. But these aren't normal times and NFP took a back seat to politics and central banks.
Monday, Asia traders forgot about US data and focused on Japanese politics. Prime minister Shinzo Abe secured a "supermajority" and his comments about accelerating Abenomics propelled USDJPY from 100.50 to 102.90 by the end of the New York session.
Not to be outdone, sterling took centre stage when Tory leadership candidate Andrea Leadsom bowed out of the contest leaving Theresa May to run unopposed. GBPUSD took off from 1.2854 and ended the day at 1.3010, and just to keep things interesting, the health of some Italian banks was keeping EURUSD traders on their toes.
The risk-on sentiment helped drive the S&P 500 to a record close despite oil prices hitting a two-month low.
Tuesday's positive vibe from the rallying S&P 500 continued in Asia. AUDUSD headed higher on decent business confidence data. USDJPY added to Monday's gains but the rally stalled in New York, at 104.97. Pokémon Go took the Nikkei by storm and raised Nintendo's market cap by $7.9 billion in just two days.
Sterling continued to rally as markets warmed to the idea that there was no longer a risk of a prolonged and nasty Tory leadership race with rumours that Theresa May would be sworn in as Prime Minister on Wednesday. The rally continued throughout the New York session.
China's claim on the South China Sea was ruled invalid; Beijing was irked but FX markets didn't care.
Wednesday, the risk-on rally ran out of steam. USDJPY traded between 104.00-80 but could not crack 105.00. The GBPUSD rally petered out at 1.3335 and the currency pair traded sideways with a negative tone until the bottom fell out in NY trading, finishing the day at 1.3125.
The other story was a surprisingly optimistic Bank of Canada Monetary Policy report which led to a big selloff in USDCAD. WTI prices sank on an International Energy Agency report that said inventory levels were still extremely high. Later on, the EIA announced a 2.5 million-barrel drawdown in crude stocks but a build in other distillates sank WTI.
Thursday, the Asia session was very chaotic. A strong employment report boosted AUDUSD. NZDUSD got spanked on news of a RBNZ announcement of an economic update on July 21. It was a surprise and raised concerns of a looming interest rate cut. USDJPY finally cracked 105.00, came close to 106.00 and then settled at 105.20 by the end of the New York day.
European traders were waiting for the BoE interest rate decision with about 60% of the market expecting a rate cut. They didn't get it. GBPUSD soared from 1.3208 to a spike high of 1.3475 before retreating back to the 1.3300 area where it spent most of the day.
EURUSD continued to chop around in a 1.1030-1.1130 band which contained moves for the week except for a brief spike to 1.1160 in European trading. The Fed's Dennis Lockhart talked out of both sides of his mouth, saying that the Fed should remain cautious and patient regarding future interest rate hikes and then going on to say that it is still possible for the Fed to raise rates two times this year. FX traders ignored him.
Friday ended in Asia with USDJPY posting a three week high. Risk sentiment was upbeat on positive China economic data. News of another terror attack in France dominated the European session. Strong US data sparked a bout of pre-weekend profit-taking.
Another direct strike at Europe's heart, this time in Nice, saw the risk-on trend
set against security fears in today's session. Photo: iStock
— Edited by Michael McKenna


text: About Us Staff Values Who We Are The Social Issues What We Believe What to Expect Saturday 5pm Sunday 9:30am About the Kids Plan Your Visit Little Lambs Little Lambs Staff Our Program Before/After School Care Distance Learning Center About the Program Our Sponsors Distance Learning Staff Contact Giving Our Program OverviewLittle Lambs Preschool is an educational toddler and preschool center linked with Christ Lutheran Church. Our activities are Christ-centered and teach about God's love for all people. The program uses a variety of creative activities to help children develop cognitively, spiritually, socially and emotionally. HistoryLittle Lambs was established in the fall of 1994 to aide parents in the community with the educational and spiritual development of their children. Morning and afternoon sessions were offered 3 days a week for 2.5 hours for ages 3 to 5. To meet the need in the community for children wearing diapers Little Lambs expanded to full time child care and Preschool serving 1 year through 10 years in 2017. Mission StatementLittle Lambs is dedicated to helping parents with enrichment activities for early childhood development. We are committed to providing a safe learning environment that enables children to grow spiritually, socially and emotionally as well as cognitively and physically. Our goals are accomplished by using a variety of teaching methods and varied activities; including, but not limited to chapel lessons, music, art, independent and whole group activities, etc.Faith StatementWith the universal Christian Church, Little Lambs teaches the love of the Triune God: Father, Jesus Christ (the Son), and the Holy Spirit. The three persons of the Trinity are coequal and coeternal, one God.LicensingLittle Lambs is licensed by the State of Nevada, Southern Nevada Health District, State Fire Marshall and the City of Boulder City. We follow the established rules and regulations for maintaining a safe learning environment.HoursMonday through Friday 7am-6pm with early drop off upon request.Schedule a TourTo schedule a tour email email@example.com or call 702-293-4332.


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This is a metrics-driven world. Every business knows that it lives and dies by numbers, and those associated with both internal and external campaigns determine success.
Understanding which digital marketing metrics to track can go a long way toward impacting your bottom line. Here's what you should know about online marketing metrics.
Here's what you should know about online marketing metrics.
The Digital Marketing Metrics We're Tracking
When we send out monthly reports to our clients, we're doing our best to take a holistic approach to both marketing efforts and the numbers associated with them. We look at Google Analytics, checking on a number of things like:
- How are visitors finding the website? Are they searching for certain services or products online? Clicking through from another linked source, or typing in the exact web address?
- How many visitors are coming to the site?
- When are visitors visiting the site?
- What are visitors doing once they reach the site? How many pages are they visiting, what are the clicking on, and what is grabbing their attention?
- What are the results of the actions of the visitors? Are they purchasing, signing up for an email list, sharing the content with someone?
These questions tell us about two things: user behavior and the overall effectiveness of the client's website as a marketing tool. If a visitor is searching for a product or service, finds the client's website, spends a lot of time clicking around, and eventually joins a mailing list or makes a purchase—well, the website is doing its job. It's engaging the visitor, keeping him or her in the sales funnel, and eventually persuading him or her to take an action.
In contrast, if visitors are clicking on the site, spending a lot of time clicking around, but make no further action, something isn't working as effectively as it should. If visitors visit the site and immediately leave, that's an even bigger red flag. Understanding how the site is performing and how the visitors are interacting should shape digital marketing strategy. If things are working, your business should keep doing what it's doing and further promote those efforts. If things aren't working, and no conversions are happening, something on your website or in your digital marketing efforts needs to change.
Understanding how the site is performing and how the visitors are interacting should shape digital marketing strategy. If things are working, your business should keep doing what it's doing and further promote those efforts. If things aren't working, and no conversions are happening, something on your website or in your digital marketing efforts needs to change.
Digital Marketing Metrics to Track in Paid Advertising
Pay-per-click digital advertising (PPC) is a nuanced undertaking, but it's relatively easy to see if it's worth the investment. When we investigate the effectiveness of a PPC campaign, we take a look at these metrics:
- How much are you spending on the campaign?
- What is the return on investment (ROI) for that amount? (We calculate ROI based on the amount spent in both Google AdWords costs and the management/time spent on the campaign.)
- How many leads or transactions were generated by this campaign?
- How many sales have been generated by this campaign?
- How much product has sold because of this campaign?
At the end of the day, digital advertising is a marketing channel. If a channel isn't performing, you need to evaluate if it's a good fit for your business. Read this article for more information about whether digital advertising is a good match for your company or industry's needs.
Other Digital Marketing Data to Track
These are must-track items in digital marketing (and in business in general):
- Conversions of all types—purchases, email sign-ups, information requests, downloads, and other actions taken by visitors
- Calls coming in and where they originate
- Conversions per channel and how profitable they are
- Conversion ratios—at each stage of the sales funnel, especially the closing ratio to the next stage
All data should be tracked against your company's goals. This way, you can make adjustments the moment you realize something isn't working as well as you'd like it to be, saving you countless amounts of time and money.
The Online Marketing Metrics We're NOT Tracking
Traffic. What you track for your business is entirely dependent on your goals. If you're just looking for new readers, new visitors, or new clicks to your site, and you don't care what the users are doing once they get there, then traffic is a fine metric to track.
For most companies, though, the bottom line is about revenue and sales, and just getting a few extra people clicking on a website each month won't cut it. A million visits with no conversions is a waste of money—after all, you're paying for each of those clicks and no revenue is coming in. You could also be seeing millions of spam visitors if you're only looking at traffic, and that is equally as meaningless. Traffic by itself is not a worthwhile metric to track.
Our Recommendations for Digital Marketing Metrics
To keep abreast of what's happening in your company's digital world, pay attention to your metrics for Analytics and AdWords at least monthly. AdWords will need to be checked more often in the middle of a big campaign, probably weekly or biweekly to get the most bang for your buck.
If metrics aren't changing, you need to find out what's not working before you waste your whole marketing budget. Dive in. Understand the process and make sure that everything is tracking properly. Sometimes diagnostics reveal that an important piece of website code was not fully installed, or that something minor just needs to be tweaked. An expert can run diagnostics on your current status to make sure everything is running smoothly, and to give recommendations as to how to get more from your digital marketing efforts.
Not sure if your company's digital metrics are all they should be? We live and breathe digital marketing best practices, and we want you to get the most out of your marketing efforts. Contact us and we'll set up a free, 30-minute consultation to discuss your marketing strategy.


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Heat Treatment Furnaces
In the shuttle-loading type heat treating furnace, normalizing quenching & tempering, annealing and stress relieving are performed. The source of heat for this furnace is natural gas that is capable of increasing the product quality through a constant internal temperature. The internal temperature during the process is automatically controlled by an On/Off pulse control system. The heat treating furnace for simulated PWHT, which is separately installed, verifies any changes in the property occurring due to stress relieving.


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Military Watch Men's Sports Analog Quartz Watch Dual Display Waterproof Digital Watches Men's Digital Sports Watch Waterproof Casual Luminous Stopwatch Alarm Army Watch
Men's Military Watch Dual Display Dial Watch Sports Analog Quartz Watch Dual Display Waterproof Digital.
Main Features
Shape of the dial: Round
Water Resistance: 3ATM (30M)
Watches categories: Male Table
Watch Case Material: Stainless Steel
Clasp Type: Double Push Button Clasp Closure
Watch style: Sporty, Luxury Casual, Fashion, Classic, Military.
Gift Ideas
Sports fan watch with elegant box is a great gift choice to your loved ones for Christmas, birthday, anniversary, Father's Day, graduation and Valentine's Day, Or as a business and party present
Water Resistant
This wrist watch is very suitable for Daily Use(30m Living Waterproof). 3 ATM Water Resistant, NOT suitable for diving, snorkeling, swimming, water-related work.
Watch Mirror:Lucency Resin
Ultra quiet and low maintenance, and with modern, casual and fashion appearance. Casual enough for every day wear but also looks great with business attire. This wrist watch will go great with any outfit and any occasion. It enables you to easily spice up a normal outfit and add style to your life
DURABLE and COMFORTABL
Japan quartz movement and battery provide accurate time keeping and a service life of more than 3 years, certainly the battery is also easy to be replaced.
Main Feature:
1.Brand new and 100% high quality.
2.The case is made of 304 stainless steel.
3.Have founction of time,date & week.And it is very easy to read time by counting the blue led on the ring dial directly.
4.Band material: Stainless steel
5.Type: Pointer + LED
6.Watch Button: butterfly double snap
7.LED: Super bright LED lamp.
8.Waterproof: Depth waterproof
9: Clock: There are sould and light hint
Watch size:
case diametre: 45mm
thickness: 15mm
Band width:Approximate 22mm
Band length: 290mm
Band thickness:2 mm


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Without windscreens or fairings and with nothing between you and your engine, a naked bike gives you a taste of biking as it was intended. Whilst you may get buffeted by wind at high speeds, and may not receive as much protection from the rain than other bikes will provide, your naked bike's old-fashioned styling and authentic motorcycling nature will bring you a great deal of pleasure, however looking around for a naked bike insurance deal can be time consuming.
That's where we at Swinton can help, arranging policies for thousands of bikers each year, our dedicated bike team deal with all sorts of naked bike models and we always work hard to find great deals for our customers.
We'll compare quotes from a range of UK bike insurers to give you the lowest price we get back from them.
At Swinton, our dedicated Bike Insurance team will help you find the best deal, by comparing quotes from a panel of motorcycle insurers. We'll give you the lowest price we get back from them for a range of motorbike makes and models.


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Imagine this. One of the world's most powerful monopolies puts 10,000 people to work for five years to create one new product. And nobody is really sure if anyone wants it. How's that for a gamble?
That's what we have with Windows Vista, the new computer-operating system from Microsoft that debuted last week for businesses and, next month, for consumers. There has been so much buildup for this moment that you would expect Vista to cure cancer.
The article estimates that it 10,000 engineers and around $10 billion dollars to develop Vista. Can you believe that? Bill Gates is really big into his Philanthropic adventures. I wonder how much good he could have done with that $10 billion dollars instead of pouring it into Vista? I will have to wait and see but I don't think Vista is worth it. That's a fan of Linux talking though.
It is very expensive to achieve high unreliability. It is not uncommon to increase the cost of an item by a factor of ten for each factor of ten degradation accomplished. Norman Ralph Augustine


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Get your documents in order, homeowners in Connecticut's Quiet Corner. Money is coming to replace crumbling foundations. But get your expectations in order, too. There isn't nearly enough money to help everyone.
The state is heroically doing its best by making $133 million available over five years. But it will soon become clear that is not nearly enough. This is a billion-dollar problem.
Connecticut can't do this massive job alone. The average cost to replace a foundation — the only cure for the problem — is $185,000. The state's money might cover 700 homes. The number of affected homes, however, is believed to be at least 10 times that. The federal government and insurance companies have to step up.
In the meantime, get in line if you're among the multitude of homeowners in northeastern Connecticut who have confirmed that the dreaded mineral pyrrhotite is destroying your basement walls. Applications start at midnight Nov. 15. Go to crumblingfoundations.org to see what documents you'll need. They include proof of pyrrhotite in your foundation, proof that you own your home and a minimum of two estimates from approved contractors.
Homeowners who have already replaced their foundations are also eligible. The state has only enough money to reimburse eight of them this fiscal year.
This isn't the time to yell at those trying to help, or to despair and default on a mortgage, or to wait for more money to magically appear. This is the time to get your paperwork in order. When you apply, you help the state make its case about the magnitude of this problem.
So far, insurance companies have refused to help homeowners. The federal Housing and Urban Development agency has given Connecticut no new money for this problem, even though Secretary Ben Carson has been to Connecticut to see the damage firsthand. The Federal Emergency Management Agency has turned its back on Connecticut, although this is clearly a natural disaster.
An Underground Hurricane
This isn't the kind of disaster that flattens a house in a hurricane. This is more of a slow-moving underground hurricane. It's the "insidious kind, baked into the aggregate of your concrete," says Michael Maglaras, head of the program that will distribute the state money to homeowners.
Mr. Maglaras lives in the center of crumbling-foundation territory, in Ashford. He's superintendent of the Connecticut Foundation Solutions Indemnity Co., the company that is being funded by the state to help homeowners.
He spoke Saturday to a crowd of hundreds at Ellington High School. They hung on his every word and at times erupted in frustration. Unlike the Floridians and Texans who are regularly rescued by FEMA, these homeowners didn't choose to live in the path of nature's rage. They chose bucolic towns in a state that's considered among the safest in the nation. Now their homes are being ravaged by a mineral that few people besides geologists knew about before this crisis.
Congressmen Joe Courtney and John Larson have done yeomen's work getting Connecticut homeowners significant tax breaks for foundation replacements. Even so, "we don't have enough money" to help everyone pay for those replacements, Mr. Maglaras says.
Also, Mr. Maglaras is getting just five years to save as many homes as he can. The program runs out in 2022. "We won't be done in 2032," he says.
Latest Editorials
To repeat: Connecticut needs FEMA, HUD and the insurance industry to help the homeowners who thought they were paying taxes and insurance premiums to help them in just this kind of tragedy. The federal government can't leave these families behind. The insurance industry can't afford the ill will and the lawsuits that continue to be filed.
"I want to be overwhelmed by applications," Mr. Maglaras told Saturday's crowd. "I'll have a strong case that I need more money."
Go to crumblingfoundations.org to see if your home qualifies. Get your paperwork ready. And get in line starting at midnight on Nov. 15.
This editorial was revised Tuesday to remove the erroneous statement that state aid would average $71,000 per home. Mr. Maglaras says aid would be, in many cases, $130,000 to $150,000 or more per home, but will be capped at $175,000 per building.


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Whether working as a volunteer or socialising as a guest, David Walker is often at SCS' Lane Cove Community Hub. After volunteering at SCS about four years ago, David has taken up so many SCS social activities that he might be more of a client of our services than a volunteer. Yet he's here every Thursday catering for social activities such as games afternoons – bridge, chess and solo afternoons – guided by SCS events coordinator, Julie.
He originally contacted SCS offering to do gardening and meal deliveries but, at the time, catering had a greater need so he's become a valued member of our volunteer kitchen team instead. Meantime, he joined the mobile men's group which goes out on Bus Outings for Older Men (BOOMers), comes to the Park View Room for the lunches SCS hosts fortnightly, regularly enjoys the monthly movie afternoon here, and comes on other monthly bus trips open to all over-55s (see SCS social activities here ).
"Socialising keeps me going – otherwise I'd just be sitting at home," says David, who is also very involved with St Aidan's Church and loves to play tennis.
Tambourine Bay has been home for almost 60 years so David has many local friends and is always making more through the handful of SCS activities he's taken up – and of course through volunteering.
"Volunteer work is just as social as the outings – the point is to be mixing with people," says David.


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Press Releases
News Release
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I am at a disadvantage to talk about "Changing Partners" because I've seen the stage play it is based on and I came into the movie wondering how they would pull off the play's unconventional narrative structure.
"Changing Partners" is the story of one couple with a fifteen-year age gap told in four variations played by two characters. It's the same couple throughout the film but at times they are a heterosexual couple and other times a gay couple with the genders switching.
Alex, the older person in the relationship, is played by Agot Isidro and Jojit Lorenzo, while the younger person, Chris, is played by Sandino Martin and Anna Luna. The story progresses continuously as the film starts with the couple in a good place and then as the narrative unfolds, the wear-and-tear of their age gap has begun to show as Chris starts to spend more time with Angel, who is always mentioned but never seen.
Dan Villegas and screenwriters Vince De Jesus and Lilit Reyes (from the original play written by De Jesus) are tasked to make this convention work on film, to sell the idea that this one story is being told in four variations and not confuse us.
Luckily, the film is also a musical, and the moment they start singing, it helps create the space to accept the shift in genders.
There is so much artistic and technical mastery at work in this film. As this single narrative is told in four iterations, each actor has to shift their persona from straight to gay or lesbian and portray all the nuances that come with that sort of relationship.
Even the design of each home shifts as well, each one looking lived-in for that couple. The editing is superb, switching at the most opportune moment as to maintain the drama and building intensity without confusing us as to which couple we are now following.
De Jesus' musical score and songs become the underlying thread that hold each version of this story together as the couple loses their ability to communicate with each other over time and it's only during the songs that they can speak their truth.
The acting in this film is incredibly precise, and Isidro, Lorenzo, Martin, and Luna are incredible at showing us the nuances between each version of Alex and Chris.
A lot of people would say that this is not a new story; that we have seen films about a couple breaking up before and that would be true. What makes"Changing Partners" special is by telling this same story in one straight narrative but with playing with the genders of the couple, it makes a statement about the nature of love and breaking up.
It says that there is no difference between how we experience it whether we are straight or gay or lesbian. The feelings are just as painful. The paranoia, the hurt, the bitterness, the regret are shared by anyone regardless of gender and preference.
It's a wonderful film that's masterfully done but I feel that the convention of the variations brings more attention to itself than it does to the story. I felt more involved with the editing and the acting and the production design and watching the magic of telling this story than I was with the emotions that were being portrayed in the film.
I hate to have to compare it with the play, but as fascinating as the switching of genders were on stage, I was still invested in the story. In the film version, I am more interested in the filmmaking because it's very good.
I do have an issue with the use of a handheld camera, which I feel only worked during the ending, but everything else was so good. But I was watching the filmmaking more than I was the story.
Regardless, I applauded at the end of the film because it was executed excellently and it was a daring move by Villegas and company, and they pulled it off. The people around me applauded too and they were moved. So maybe it was just me. Maybe having seen the play had affected my experience of it. It's still an amazing experience anyway.


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Brand JD, et al.Diabetes Care. 2013;doi:10.2337/dc12-1020.
Christianson MS, et al.Menopause. 2013;doi:10.1097/GME.0b013e31828ced7f.
Ryan J, et al.BJOG. 2014;doi:10.1111/1471-0528.12828.
Sarrel PM, et al.Am J Public Health. 2013;doi:10.2105/AJPH.2013.301295.
Stuenkel CA, et al.J Clin Endocrinol Metab. 2015;doi:10.1210/jc.2015-2236.
Svejme O, et al.BJOG. 2012;doi:10.1111/j.1471-0528.2012.03324.x.
Wellons M, et al.Menopause. 2012;doi:10.1097/gme.0b013e3182517bd0.
Experts dispel myths surrounding early menopause and risks of hormone therapy
Brand JD, et al.Diabetes Care. 2013;doi:10.2337/dc12-1020.
Christianson MS, et al.Menopause. 2013;doi:10.1097/GME.0b013e31828ced7f.
Ryan J, et al.BJOG. 2014;doi:10.1111/1471-0528.12828.
Sarrel PM, et al.Am J Public Health. 2013;doi:10.2105/AJPH.2013.301295.
Stuenkel CA, et al.J Clin Endocrinol Metab. 2015;doi:10.1210/jc.2015-2236.
Svejme O, et al.BJOG. 2012;doi:10.1111/j.1471-0528.2012.03324.x.
Wellons M, et al.Menopause. 2012;doi:10.1097/gme.0b013e3182517bd0.
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Menopause typically brings with it a host of symptoms that can be unpleasant, at best, and at worst, can increase the risks for heart disease and early death. For women who go through early menopause those symptoms and health risks can be compounded, whether the transition is natural or due to surgery.
Early menopause affects a minority of women. About 1% of women younger than 40 years experience what is known as either premature menopause or primary ovarian insufficiency (defined as the loss of normal ovary function), whereas 5% of women younger than 45 years experience what is defined as early menopause. But for women in this group, the stakes are raised when it comes to health risks. Research indicates that early menopause, which results in the loss of estrogen and other hormones, increases the risks for cardiovascular disease, osteoporosis, type 2 diabetes, sleep disturbances, dementia and all-cause mortality.
"There's a whole myriad of issues in earlier menopause or ovarian insufficiency," Holly L. Thacker, MD, a women's health specialist and director of the Cleveland Clinic Center for Specialized Women's Health, told Endocrine Today. "The reason it's more devastating to younger women, beside the whole fertility issue ... is because when you lose estrogen, you accelerate the aging process. So, if you start that process 10 or 20 years before the usual time, that's obviously going to have adverse effects."
Earlier menopause, more risks
In a 2012 study, Wellons and colleagues analyzed the association between a self-reported history of early menopause and future coronary heart disease and stroke, reviewing the history of 2,509 women (691 reporting natural or surgical early menopause before age 46 years) who participated in the Multi-Ethnic Study of Atherosclerosis, a longitudinal, cohort study of U.S. men and women followed between 2002 and 2008. In survival curves, the researchers found that women with early menopause had greater rates of CHD (P = .008) and lower rates of stroke-free survival (P = .0158). The risk remained after adjustment for age, race and traditional CVD risk factors, with an HR of 2.08 for CHD (95% CI, 1.17-3.7) and 2.19 for stroke (95% CI, 1.11-4.32).
The risk also increases for type 2 diabetes. In a prospective case-cohort study, Brand and colleagues analyzed data from 3,691 postmenopausal women with type 2 diabetes and 4,408 subcohort participants during a mean follow-up period of 11 years, examining the associations of menopausal age and reproductive life span with diabetes risk. Among women who had undergone menopause from ages 40 to 44 years, the HR for type 2 diabetes was 1.09 (95% CI, 0.9-1.31) relative to women going through menopause at ages 50 to 54 years. Women who underwent menopause before age 40 years had an HR of 1.32 (95% CI, 1.04-1.69) for type 2 diabetes, a 32% higher risk vs. women who went through menopause at ages 50 to 54 years. The risk persisted after multivariable adjustment, including BMI, waist circumference and smoking. The HR per standard deviation younger age at menopause was 1.08 (95% CI, 1.02-1.14).
The early onset of menopause also affects cognitive function, according to recent research. In a population-based cohort study, Ryan and colleagues analyzed data from 4,868 French women aged at least 65 years to determine the association between age at menopause, type of menopause (surgical or natural) and the use of menopausal hormone therapy and cognitive function. Researchers analyzed the participants' performance on a cognitive test battery at baseline and at 2, 4 and 7 years. Researchers calculated the change in test scores between each of the follow-ups and the baseline score to evaluate cognitive decline. Researchers found that women who entered menopause at ages 40 years or younger had worse verbal fluency (OR = 1.56; 95% CI, 1.12-1.87) and visual memory in later life (OR = 1.39; 95% CI, 1.09-1.77); the type of menopause was not significantly associated with cognitive function. In addition, premature menopause was associated with a 30% increased risk for decline in psychomotor speed and global cognitive function over 7 years, the researchers noted.
"Speculatively, our findings could be explained by a premature decline in estrogen exposure at a time when estrogen would have greatest neuroprotective effects," Ryan and colleagues wrote. "We could then expect that supplementing estrogen in the form of exogenous estrogen-based HT at the time of premature menopause would help counteract the negative effects of cognitive function, but we failed to find strong supporting evidence for this."
Several studies have linked a lower bone mineral density in women with early menopause and an increased risk for fracture later in life. In a 34-year population-based, prospective observational study evaluating the long-term effects of early menopause on the risk for osteoporosis, fracture and mortality, Svejme and colleagues analyzed data from 390 white European women aged 48 years at the start of the study. Women were divided into early menopause (occurring before age 47 years) and late menopause (occurring at age 47 years or later) groups. BMD was measured by single-photon absorptiometry in the distal forearm at baseline and again when women were aged 77 years; proximal femur and lumbar spine BMD were measured by DXA at age 77 years. Women who experienced early menopause had a 0.43 standard deviation lower BMD in the distal forearm at age 48 years and an RR at age 77 years of 1.83 (95% CI, 1.22-2.74) for osteoporosis, 1.68 (95% CI, 1.05-2.57) for fragility fracture and 1.59 (95% CI, 1.04-2.36) for mortality.
"The reason for the higher fracture risk among women with early menopause can only be speculated upon," Svejme and colleagues wrote. "One of the most recognized risk factors for fractures is low BMD ... however, the lower BMD level does not seem to be entirely able to explain the increased fracture risk. We must therefore speculate as to whether factors beyond bone mass, such as inferior muscle strength or inferior neuromuscular function, ought to be found in women with early menopause."
Estrogen is key
Most of the adverse health effects after early menopause can be traced to the loss of ovarian estrogen, said JoAnn Manson, MD, DrPH, an endocrinologist at Brigham and Women's Hospital, and professor of medicine at Harvard Medical School.
"An early decline in ovarian estrogen is associated with an increased risk for heart disease, osteoporosis and all-cause mortality, and this is because estrogen does have a role," Manson, one of the principal investigators for the landmark Women's Health Initiative, told Endocrine Today. "The premature loss of estrogen can increase the risk for those conditions as demonstrated in a number of observational studies."
Many women going through early menopause also experience a range of distressing symptoms, including vasomotor symptoms, more commonly known as hot flashes, difficulty sleeping, impaired concentration, mood swings and vaginal dryness. The severity of symptoms can vary depending on the type of menopause, Manson said.
"Symptoms will of course depend on whether it's an early natural menopause or a surgical one, in which case symptoms can be abrupt; this can also occur following chemotherapy or radiation therapy," Manson said. "For women who have early surgical menopause, there can be severe hot flashes, night sweats, difficulty sleeping, impaired concentration, an extreme state of what many of the women undergoing natural menopause go through. But the symptoms may be less dramatic if it's a more gradual or natural premature menopause."
Treatment and controversy
For many women going through premature or early menopause, there is relief to be found in HT, according to researchers. The Endocrine Society recently released a clinical practice guideline advocating HT as an effective treatment for most women 60 years or younger or less than 10 years past the onset of menopause who experience bothersome hot flashes and other symptoms and do not have contraindications.
Many women, however, remain reluctant to use HT. The guideline, in part, was designed to address a decrease in the use of HT following the results of the 2002 WHI, which demonstrated that, in women aged 50 to 79 years (mean age, 63 years), estrogen plus progestin increased the risk for CV complications, deep vein thrombosis and breast cancer. The results led to widespread uncertainty among patients, and the use of estrogen and progestin and even estrogen alone has declined sharply since the WHI results were published.
Studies have suggested that the confusion surrounding HT may have led to adverse health events and death. Sarrel and colleagues analyzed the effects of estrogen avoidance on mortality rates after the WHI study on women aged 50 to 59 years who had undergone a hysterectomy. The researchers related excess mortality among women assigned to placebo in the WHI to the population of comparable women in the United States, incorporating the decline of estrogen use between 2002 and 2011.
"Over a 10-year span, starting in 2002, a minimum of 18,601 and as many as 91,610 postmenopausal women died prematurely because of the avoidance of estrogen therapy," Sarrel and colleagues wrote. "[Estrogen therapy] in younger, postmenopausal women is associated with a decisive reduction in all-cause mortality, but estrogen use in this population is low and continuing to fall."
The results have left some clinicians frustrated.
"What I'm hoping you're going to be seeing, is a reanalysis [of the data]," Mary Jane Minkin, MD, FACOG, clinical professor in the department of obstetrics, gynecology and reproductive sciences at Yale University School of Medicine, told Endocrine Today. "Maybe we went a little overboard 13 years ago and scared the hell out of women for no good reason. If you don't give these women in early menopause — whether surgical or natural — estrogen, you are putting them at a huge risk. That benefit so far outweighs these other hazards."
"Young women's bodies expect to have estrogen," Erica T. Wang, MD, MAS, a reproductive endocrinologist and infertility specialist in the department of obstetrics and gynecology at Cedars-Sinai, told Endocrine Today. "There's a lot of debate over hormone replacement, but that does not apply to early or premature menopause. Estrogen is important for cardiovascular health, osteoporosis prevention and overall well-being.
"When I see my patients in premature menopause, whether its surgical or natural, I tell them that we are giving them back the estrogen their body would normally be exposed to," Wang said.
She said patients considering HT often express fears of increased breast cancer risk, citing the WHI study results on estrogen-progestin therapy. Estrogen therapy alone is not associated with a higher risk for breast cancer.
"Everyone is scared of breast cancer, and I completely understand that," Wang said. "But we also have to educate women on the benefits of estrogen on other aspects of their health, such as bone protection."
A timeframe for HT
Debate continues about how long women should be on HT. The North American Menopause Society (NAMS) recommends 5 years or less of estrogen-progestin treatment in women with a uterus, but the length of time can be individualized for each woman, and younger women in particular may need to be on treatment longer.
"I tell them I'd like to see them continue until at least their mid-40s, and then potentially tapering off," Wang said. "The tapering process will be dependent on their symptoms and quality of life."
Regardless of whether a woman going through early menopause is experiencing distressing symptoms, such as hot flashes, she should be treated with HT if it is the best option for her, Thacker said.
"[Women] have concerns because of misconceptions, the way the WHI was portrayed," Thacker said. "The average age of those women [in the WHI] were in their 60s. Even with Prempro [an estrogen plus progestin indicated for women with a uterus, Wyeth Pharmaceuticals], the women who started under age 60 [years] still had a reduced death rate."
"It's so ingrained," Thacker said of the fears surrounding HT. "I tell my patients, 'Any time you hear something negative about the word "estrogen," just plug in the word "women." That's actually what is meant.' And it kind of turns on a light bulb. Any hormone, too much or too little, is not good. Without estrogen, women would not be feminized, women wouldn't carry babies."
The clinician conversation
In a 2013 study, researchers sent a Web-based survey to all American obstetrics and gynecology residency directors to assess current menopause teaching. Among the 510 responders, 67% reported that they had limited knowledge of the pathophysiology of menopause symptoms, 67% reported a limited knowledge of HT and 68% reported a limited knowledge of nonhormonal therapies. Similar responses were reported for knowledge of menopause and risks related to bone health, CVD and metabolic syndrome.
"Doctors should be talking to women, and they should be saying, 'What symptoms are you having?'" Minkin said. "Even if a woman has no symptoms — 20% of women are blessed to have no hot flashes whatsoever — but, even with those women, you need to be talking about bones, you need to be talking hearts, you need to be talking brains."
Minkin recommends low-dose HT even in the absence of bothersome symptoms to reduce these risks.
Manson agrees that clinicians must stress the benefits vs. the risks in the setting of early menopause.
"Most importantly, women with premature menopause should understand that the findings of the WHI, in terms of the balance of benefits and risk of HT, do not apply to their situation," Manson said. "The WHI findings apply to a postmenopausal group of women with a mean age of 63 [years] at the time they were randomized to HT. So, for women who have early surgical menopause and do not have contraindications to estrogen therapy, the benefits are likely to outweigh the risks.
"In the premenopausal setting, estrogen is extremely important for maintenance of optimal health, and it's important to nearly every organ system," Manson said. "When we're talking about natural menopause at a more typical age, there may be controversy about HT for purposes beyond symptom management, because estrogen plus progestin therapy is associated with a complex pattern of benefits and risks. But in the premature or early menopausal state, it's more straightforward that the benefits of estrogen therapy would likely outweigh the risks in women without contraindications. The distinction is tremendously important, and hopefully, women will understand that, and their health care providers will help to clarify this distinction for them."
Minkin said she suggests that women going through early menopause look for a menopause clinician who can go over the risks and benefits of treatment options.
"For certain people, the metabolic benefits of estrogen are so important," Minkin said. "Even if they're not feeling [symptomatic], they should be thinking about it." – by Regina Schaffer
- References:
- Brand JD, et al. Diabetes Care. 2013;doi:10.2337/dc12-1020.
- Christianson MS, et al. Menopause. 2013;doi:10.1097/GME.0b013e31828ced7f.
- Ryan J, et al. BJOG. 2014;doi:10.1111/1471-0528.12828.
- Sarrel PM, et al. Am J Public Health. 2013;doi:10.2105/AJPH.2013.301295.
- Stuenkel CA, et al. J Clin Endocrinol Metab. 2015;doi:10.1210/jc.2015-2236.
- Svejme O, et al. BJOG. 2012;doi:10.1111/j.1471-0528.2012.03324.x.
- Wellons M, et al. Menopause. 2012;doi:10.1097/gme.0b013e3182517bd0.
- For more information:
- JoAnn Manson, MD, DrPH, can be reached at 25 Shattuck St., Boston, MA 02115; email: email@example.com.
- Mary Jane Minkin, MD, FACOG, can be reached at 40 Temple St., Ste. 7A, New Haven, CT 06510; email: email@example.com.
- Holly L. Thacker, MD, can be reached at 2049 E. 100th St., Cleveland, OH 44195; email: firstname.lastname@example.com.
- Erica T. Wang, MD, MAS, can be reached at 8700 Beverly Blvd., Los Angeles, CA 90048.
- Disclosures: Manson, Minkin, Thacker and Wang report no relevant financial disclosures.
Should clinicians offer nonhormonal therapies to manage menopausal vasomotor symptoms?
The decision-making process should be shared between a woman and her health care provider.
The key question is how women with early menopause and hot flashes should be advised about symptom relief.
The Endocrine Society recently published guidelines that recommended hormonal therapies for appropriate women but largely agreed with the NAMS position statement on nonhormonal methods for others. The Endocrine Society stated that women with mild or less bothersome vasomotor symptoms should consider a series of steps not involving medication, including turning down the thermostat, dressing in layers, avoiding alcohol and spicy foods and reducing obesity and stress. For those with moderate or severe vasomotor symptoms, hormonal therapies with estrogen alone (if no uterus) or estrogen plus a progestogen are most effective based on a large body of data and can be recommended unless the risks for cardiovascular disease, breast cancer or deep venous thrombosis are increased. An option available in the U.S. and Europe is the tissue selective estrogen complex (TSEC), which combines conjugated estrogen with bazedoxifene and eliminates the need for a progestogen.
For women with moderate or severe vasomotor symptoms [who are] unwilling to take hormone therapy or have contraindications, several options are effective. A key principle is that in randomized controlled trials, 30% of women with hot flashes respond to placebo. Notably, most experts consider the efficacy of the selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) agents to be the difference between placebo and drug. For example, a 30% reduction in the placebo group and a 70% reduction in treatment group equals only a minimal 40% drug-related reduction. However, a woman being treated does not care if the effect is due to placebo or due to the drug, but appreciates an improvement in symptoms.
In randomized controlled trials, the SSRIs and SNRIs reduce frequency and severity of symptoms overall by approximately 70%. Endocrine Society guidelines suggest that paroxetine, venlafaxine, desvenlafaxine citralopram, escitaloram, gabapentin and pregabalin are all equally effective. For those bothered mostly by nighttime vasomotor symptoms, gabapentin may be preferable as it also has welcome soporific properties. Recent studies suggest efficacy of cognitive behavior modification and hypnosis, but these therapies require trained practitioners and may not be practical to utilize. The Endocrine Society guideline classified genestein, S-equo, nonpurified isoflavones, red clover, high-dose or synthesized phytoestrogens, dietary soy and vitamin E as agents with inconsistent reports of benefit. Agents classified as having predominantly no benefit included black cohash, omega-3 fatty acids, acupuncture, exercise and a range of other complementary approaches, such as ginseng and wild yam. Modalities requiring further study included stellate ganglion block and guided relaxation.
To summarize, mild and less bothersome vasomotor symptoms are best treated with lifestyle modifications, and moderate to severe with hormonal therapy, depending on underlying risks and patient willingness. Nonhormonal therapies such as the SSRI/SNRI and gabapentinoids are not as effective as hormonal therapy, but provide significant relief.
Richard Santen, MD, is a professor of medicine in the division of endocrinology and metabolism at the University of Virginia Health Sciences System in Charlottesville, Virginia. Disclosure: Santen reports no relevant financial disclosures.
Hormone therapy remains the gold standard.
Up to 80% of women have hot flashes with 25% bothersome enough to seek therapy. Hot flashes on average last 7.2 years, varying by ethnic group and lasting longer among African American women in the SWAN trial. Hormone therapy remains the gold standard for relief of hot flashes and may have health benefits when started near menopause, particularly for women with early menopause. However, for those women who either cannot or choose not to take available hormonal therapies, nonhormonal options are needed. The NAMS panel reviewed the literature and provides evidence-based recommendations on these nonhormonal options, including herbal products in their 2015 position statement on nonhormonal management of menopause-associated vasomotor symptoms.
For nonprescription therapies, the NAMS panel recommended two behavioral approaches: a cognitive-behavioral therapy approach combining relaxation techniques, sleep hygiene and learning; and clinical hypnosis, which was better than a "structured attention" therapy approach and significantly better than no treatment in breast cancer survivors. Weight loss, stress reduction, a soy derivative (S-equol), and stellate ganglion block (nerve block) showed potential, but caution is recommended.
For prescription therapies improvements are seen, although in general they do not offer as much relief as HT. The NAMS panel recommended the FDA-approved nonhormonal therapy low-dose paroxetine salt. Although not approved by the FDA, the serotonin-norepinephrine reuptake inhibitors (SNRIs, such as venlafaxine), the gabapentinoids (gabapentin and pregabalin) and clonidine have been found effective over placebo but less effective than HT. For safety, the panel recommended use of the lowest dose with adjustment in dose as tolerated. Benefits and risks for individual patients need to be balanced, including lack of long-term safety and efficacy data.
For most lifestyle approaches, herbs and supplements the evidence was lacking or negative. Techniques unlikely to work include exercise, yoga, paced respiration and acupuncture. Similar lack of efficacy was seen with black cohosh, dong quai, evening primrose, flaxseed, maca, omega-3s, pollen extract, vitamins, relaxation, calibration of neural oscillations (a brain-training technique), homeopathy and chiropractic interventions.
JoAnn V. Pinkerton, MD, is medical director of the Midlife Health Center, professor of obstetrics and gynecology and vice chair of academic affairs at the University of Virginia, Charlottesville. Disclosure: Pinkerton reports no relevant financial disclosures.
Stuenkel CA, et al. J Clin Endocrinol Metab. 2015;doi:10.1210/jc.2015-2236.
The North American Menopause Society. Menopause. 2015;doi:10.1097/GME.0000000000000546.


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By Staff
The league-leading Phoenix Mercury has home court advantage throughout the WNBA playoffs and begins a quest for a third championship at home Friday against Los Angeles during the Western Conference semifinals. However, East teams kick off postseason action on Thursday. No. 2 seed Indiana, hosts the No. 3 team, Washington.
The first round of the WNBA playoffs is a two-out-of-three series (meaning the first team to two wins moves on to the next round). The top two seeds in each conference have the home court advantage for the series. The games alternate home sites starting at the home of the top seed.
The winning team in each first round series advances to the conference finals. This round is also a two-out-of-three series and again alternates home sites starting at the home of the top seed.
The WNBA Finals champion is determined in a best three-out-of-five series. The first two games are played at the home of the top seed, followed by two games (game 4 if needed) at the home of the lower seed. If the teams are tied at the end of four games, the fifth and final game is played at the home of the top seed.
The Finals begin Saturday, September 6. The last possible date for a finals game is September 17 (if the series stretches to five contests).
Eastern Conference Semifinals
#2 Indiana (16-18) vs. #3 Washington (16-18)
#1 Atlanta (19-15) vs. #4 Chicago (15-19)
Western Conference Semifinals
#2 Minnesota Lynx (25-9) vs. #3 San Antonio Stars (16-18)
#1 Phoenix (29-5) vs. #4 Los Angeles (16-18)
All times Eastern


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Singapore trainer Michael Freedman is confident Super One has made the required improvement to give a Group One race a shake at Flemington on Derby Day.
The Singapore champion two-year-old of last season is set to run in the Coolmore Stud Stakes on Saturday where he will line-up against some of the best sprinting three-year-olds in Australia including Exosphere.
Freedman said Super One had come on following his Australian debut when beaten into second place at Cranbourne on October 11 after arriving from Singapore with an unbeaten record from four starts.
While initially disappointed with Super One's defeat at Cranbourne, Freedman said there had been extenuating circumstances.
Freedman and jockey Hugh Bowman were both impressed with Super One's jump-out at Flemington last Friday in preparation for Saturday's race.
"I think he's going into the race in pretty good shape," Freedman said.
"I was disappointed with Cranbourne but with the benefit of hindsight he didn't have a great preparation going into it.
"He had very restricted work access in quarantine in Singapore and then working on his own he only had two opportunities to gallop at Werribee where he can be a lazy."
Freedman revealed six of the 16 days Super One spent in quarantine in Singapore was either a public holiday or a weekend and with the government vets not working it meant Super One couldn't be worked.
Super One has been stabled at Freedman's older brother Lee's yard at Flemington since Cranbourne with the younger Freedman keeping an eye on the colt in the past week.
He was taken with the work the three-year-old produced on the synthetic track at Flemington on Tuesday and Freedman is taking extra confidence into the race with Bowman sticking with Super One.
Bowman has been riding in stellar form and last week picked up the Cox Plate, Moonee Valley Cup double.
"He's been on a few of the opposition three-year-olds over the past couple of months and he's been pretty happy to stay with my bloke," Freedman said.
"That gives me some confidence that he'll run pretty well."


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ICICI Emerging Sectors Fund has sold 1.56 per cent stake in commodity bourse company Multi Commodity Exchange of India (MCX) for Rs 106.8 crore after MCX made its debut on Friday. The shares had been sold at 59 per cent gain for an investment made in November 2007.
However, the fund did not sell shares in the Rs 663 crore IPO of MCX, which included share sale by more than half-a-dozen shareholders, including its promoter Financial Technologies (India) Ltd.
According to an earlier report, ICICI Emerging Sectors Fund is managed by ICICI Venture Funds Management Company Ltd, although it is not currently listed on its website. An e-mail query sent to ICICI Venture did not get any immediate response.
The fund held 2.65 per cent stake or 1.35 million shares in MCX, the first Indian exchange to get listed. It picked up the stake in 2007 from MCX promoter Financial Technologies for Rs 130 crore. The shares were acquired at an average cost of Rs 840 a unit and some shares were sold in 2009 to Bennett, Coleman and Co. Ltd for Rs 16.7 crore at cost.
With the current transaction, ICICI Emerging Sectors Fund has nearly taken out its principal investment amount. As per Friday's closing price of MCX, the fund's remaining shares are valued at Rs 72 crore.
On Friday, the fund sold part of its stake on the National Stock Exchange for Rs 1334.88 a unit. The share price of MCX closed at Rs 1,297.05, up 25.68 per cent on the BSE on Friday, after rising to Rs 1,426 in the initial hours of trading.
On Monday, shares of MCX were trading at Rs 1,293 a unit on the BSE at 12:15 pm, down 0.31 per cent.
"MCX competes directly with four other national level commodity exchanges in India, namely, NCDEX, NMCE, ICEX and ACE. However, its product portfolio, reach and market share are much ahead of the competition. While , at present valuation, trades at 18x annualised earnings, its peers in the region (like Hong Kong Exchange and Singapore Exchange) trade at 24x-26x on CY12 earnings, with margins in the range of 55-60 per cent and have growth rate of 10-15 per cent," an IPO report by brokerage Ventura Securities stated.
Besides being the first bourse in India to get listed, the issue was also unique as it comprised only sale of shares and no money was being raised for the company. The issue involved sale of 12.6 per cent stake by promoter shareholder Financial Technologies. Others who sold their stake included the State Bank of India (Equity), GLG Financials Fund, Alexandra Mauritius Ltd, Corporation Bank, ICICI Lombard General Insurance Company and Bank of Baroda.
For FY11 and the nine months ended December 31, 2011, MCX's total consolidated income was Rs 447.56 crore and Rs 474.50 crore, respectively, with net profit Rs 176.27 crore and Rs 217.95 crore, respectively. The total value of the commodity futures contracts traded on the MCX exchange in the nine months ended December 31, 2011, stood at Rs 11,980,689 crore.


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Rebekah Anguiano, PharmD, BCPS, BCACP
Dr. Rebekah Anguiano, PharmD is the Clinical Coordinator for Specialty Pharmacy Services and the clinical pharmacist for the Pulmonary Hypertension Service with the Lung Health Program at the University of Illinois Hospital and Health Sciences System (UI Health). She is also a Clinical Assistant Professor at the University of Illinois at Chicago (UIC) College of Pharmacy. Her major responsibilities include oversight and management of specialty pharmacy services clinical operations and patient management program; clinic-based patient medication assessments, education, training, and ongoing management of pulmonary hypertension therapies; as well as teaching, research, publications, and other scholarship activities related to her specialty. Dr. Anguiano graduated from the University of Wisconsin at Milwaukee with a Bachelor of Science in Biology and then acquired her Doctor of Pharmacy at the UIC College of Pharmacy. She completed her residency training and practiced at the Jesse Brown VA Medical Center as a clinical pharmacist until January 2009 at which time she took a position with a major specialty pharmacy as the clinical supervisor of the pulmonary arterial hypertension program. Dr. Anguiano is a member of several professional societies including American Society of Health System Pharmacists (ASHP), American College of Clinical Pharmacy (ACCP), and Pulmonary Hypertension Association (PHA).


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Juvenile (CINA) Law Resources
Iowa Standards of Practice for Attorneys Representing Parents in Juvenile Law (See Rule 8.36)
Handbook on Juvenile Court for Parents
Mid-Iowa Family Therapy Clinic
Middleton Children's Rights Center
Parenting Classes/Workshops
Integrative Parenting Workshop
Medication Assisted Treatment ("MAT")
Substance Abuse and Mental Health Services Administration
Federal Guidelines for Opioid Treatment (downloadable .pdf—click on the link on the right)
Medication-Assisted Treatment for Opioid Use Disorders in Drug Court
The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use
Advancing Access to Addiction Medications
Financial Assistance (housing, utilities, food, etc.)
2-1-1 (United Way)
Mental Health
Treatment for Substance Use Disorders
Bethel Mission/Hope Ministries
For Foster/Adoptive Families
The following links (through "Four Oaks") are from DHS' website regarding foster care and adoption:
How to Adopt or Become a Foster Parent
Iowa Foster and Adoptive Parents Association
Certified Adoption Investigators
Former Foster Care Student Age 18 to 21:
- Click Transition Education Services for more information or
- Visit Iowa College Aid atiowacollegeaid.org to complete the ETV and All Iowa Opportunity Foster Care Grant.
Iowa Foster and Adoptive Parents Association ("IFAPA")
Licensing and Regulation of Family Foster Homes
Other Foster/Adoption Resources:
American Academy of Pediatrics: Parenting after Trauma
Dave Thomas Foundation for Adoption|Foster Care
Foster Child Information Form (DRAFT)
Family Law Resources
Collaborative Law Attorneys in the Des Moines Area (Family Law)
[1] Jean M. Baker, J.D. does not endorse any of the listed resources or attorneys or their work. This page is simply provided as a convenience to those seeking more information. If you have any questions, you are urged to contact the organization or the attorney of your choice.


text: Reckless Ruckus is a strategy card RPG game with intense PvE and PvP combat. Collect and upgrade your cards and use formations and abilities to lead your team to victory! Players can adventure with friends to defeat powerful enemies or compete with one another in intense battles! Reckless Ruckus contains adorable style, relaxing game atmosphere, plenty of dungeons, lots of cards and even more strategies. Massive scale boss events and cross server battles with glorious loot awaits your arrival!


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BIM and CAFM - complementary worlds
CAFM is established, now BIM is about to follow. This is a good development, because now the entire life cycle of buildings can be recorded both structurally and by the operation. If the systems can be integrated then.
Who leads, who follows?
The question of which system should be the leading is, in my view, clear CAFM to answer. For most of its existence, a building is used, operated and managed. To accompany this is the original task of the CAFM.
In return, BIM provides a variety of relevant data to flank the operation, and it makes sense for CAFM to consider some aspects from the outset, including BIM data CAFM system can be transferred.
Immodest: 5D instead of 3D. Or equal to 6D?
For many, BIM means a three-dimensional model of the building, including its installations, from supply lines to technical installations to doors and windows. This is in principle sufficient for the construction process, but is often already supplemented by two additional dimensions today.
The construction process is planned in steps that follow a specific time dictate and is budgeted. These factors are incorporated in modern BIM planning and extend the 3D to a 5D model. This brings us close to the needs of a CAFM system that requires yet another dimension: the operational data.
So what's relevant to your business?
Operational data includes all those requirements that are essential in the context of maintenance and servicing. These include maintenance plans and documents as well as contracts that may be closed before the building is put into operation, for example with cleaning companies, in order to have the basic cleaning done under one roof.
It is also important to tag and document every technical installation that is later assigned to the Facility Manager's task area. This facilitates later maintenance measures because the operating site can already be localized and virtually inspected in advance on the 3D plan so that, for example, tools can be put together exactly or a ladder provided, if this is visibly necessary.
Integration or coupling?
A highly topical discussion is whether and how CAFM and BIM systems integrated or can be coupled. Whether integration makes sense, I would like to doubt. The tasks of the systems are ultimately too different and an integrative system would unnecessarily complex, so that recommends another method: so-called data drops.
Data drops are selective data transfer from the BIM to the CAFM systemAbbreviation for "Computer Aided Facility Management": CAFM is the support of facility management by information technology in the form of a computer program consisting of a database and a user interface. Here ... more. Some of the interfaces required for this are already available on the market, but they could also be programmed depending on requirements.
Currently, data drops are already used to define milestones for data deliveries in the BIM and to actively control the data completeness in the CAFM system. In principle, this procedure can also be extended to other areas and would automatically lead to the transfer of only those data from the BIM to the CAFM system, which are also needed here for daily work.
Incidentally, a more detailed discussion of the topic can be found in a specialist article in the current issue of the journal Der Facility Manager. If you like, check out March 2017 issue. Or just write me an email.
It greets you warmly
We are sorry that you did not like this post so much.
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No, sorry. Free Return Tickets do not include Adventure Theme Park rides.
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- Free Return Visits have changed! Please Read!
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- I've lost my paper Free Return Ticket, but have my receipt, can I use that to gain free entry?
- I have extra people coming with me next time, are they covered by my Free Return Code?
- I have fewer people coming with me next time, can I have a refund or another ticket issued for those?


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- published: 29 Jun 2018
- views: 2204376
The World Bank is an international financial institution that provides loans to developing countries for capital programs. It comprises two institutions: the International Bank for Reconstruction and Development (IBRD), and the International Development Association (IDA). The World Bank is a component of the World Bank Group, which is part of the United Nations system.
The World Bank's official goal is the reduction of poverty. However, according to its Articles of Agreement, all its decisions must be guided by a commitment to the promotion of foreign investment and international trade and to the facilitation of Capital investment.
The World Bank is not to be confused with the World Bank Group, an extended family of five international organizations:
Payday 2 PC Gameplay/ Playthrough I'm not good in speedruns and I don't like the RNG thing that makes it so hard. Even though I still like to do a speedrun from time to time. I'm not going for any world records (unless I get it by accident LOL) ...I'm just happy with a good and fast run and I hope you enjoy. This run is like 1:30 minutes slower than the world record and on speedrun.com it is rank 7 (June 2018 - no glitch used). The 4:05m run is WITH GLITCH! https://www.speedrun.com/pd2/First_World_Bank#DW_and_Above_Solo Maybe I could improve my time a little bit but I just don't have the time and patience at the moment. I think about uploading the fails of this run on my patreon page soon. ➤ Want to support me? Monthly support: https://www.patreon.com/M0rtifer One time donations: https:/...
Question Time: In this show, economist Omkar Goswami, speaks to Roberto Zagha, World Bank Country Director for India, on subjects ranging from Indias GDP, the banks India spending and global economic environment.
They happen twice a year in Washington – the World Bank –IMF Meetings. But what exactly are the two institutions, and why are they considered important?
you need the manager
Моё почтение грабители, в комментариях под прошлым видео вы выбрали для некст спидрана F.W.B., хороший выбор. Сейчас мы посетим не побоюсь этого слова народный хайст Первый Мировой Банк! Для кого то это был самый первый хайст ещё в первой части игры и у многих с ним только приятные воспоминания, но мы сегодня здесь по другому поводу , приятного просмотра! ▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬ Доп. материал из видео : Билд (Старая версия) : https://vk.com/topic-62190887_36562461 Трек : Axwell Λ Ingrosso Can't Hold Us Down (ft. Pusha T, Salvatore Ganacci, SILVANA IMAM) Simon Viklund - Gun Metal Grey 2015 Моды из видео : (\/ \/ \/ В описании ролика \/ \/\/) https://www.youtube.com/watch?v=Spw8h... ▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰▰ Материальная поддержка канала : http://www.donationalerts....
Why choose to work for an International Financial Institution such as the World Bank Group? Brought to you by Global Careers Jobs and Events. Follow Global Careers on: LinkedIn: https://www.linkedin.com/company/global-careers-fair/ Facebook: https://www.facebook.com/globalcareersfair/ Twitter: https://twitter.com/GCFjobs Visit our website to register for forthcoming campaigns, online career fairs or webinars from International Organisations: https://www.globalcareersfair.com Visit our Job Board, GCFjobs for the latest International Jobs https://www.GCFjobs.com The World Bank is a vital source of financial and technical assistance to developing countries around the world. Our mission is to fight poverty with passion and professionalism for lasting results and to help people help themse...
We ranked the 10 Biggest Bank Heists In History! (ReUploaded, story in the comments) • Read full article here; http://www.alux.com/most-successful-bank-robberies-in-history/8/ As promised, in the richest banks video, here we are with the top 10 biggest heists in history! Since the oldest on our list 'til today, bank heists sure have changed drastically and mostly due to technology! We hope you guys love our epic video as much as we loved puttin' it together for you. *** DISCLAIMER! *** Robbing banks is absolutely illegal and we do not encourage such behaviour!! If you find yourself thinking about such things just stop! Better to become a politician this are more legal that way. #alux #heist #robbery Say Hello on: https://www.instagram.com/aluxcom/ https://twitter.com/aluxcom https://...
The World Bank's mission is to alleviate poverty – but does it achieve its goals? Bigger Than Five visited Lebanon and is joined by Ferid Belhaj, the Bank's VP for the Middle East and North Africa. #BiggerThanFive #WorldBank #Lebanon
Both the World Bank and the IMF have stressed that the Eurozone needs to speed up plans to support weaker banks across the region and to create a banking union. CCTV's Shraysi Tandon has an exclusive interview with World Bank Managing Director Sri Mulyani to discuss the global economic outlook.
Coinciding with World Environment Day, the World Bank Group is announcing a new strategy to make sure development doesn't come at the expense of environment.
Here it is, the real deal and the reason why I didn't bother to improve the PB I posted a few days ago. First World Bank is cheese and filled with spots and holes from where you can go out of bounds then inside the vault. The thing is it never was useful as we never found a way to get past the first gate after looting the vault. Until now. This was recorded literally the day after I discovered the OoB, so don't be surprised if you happen to find better routing. There is also no multiplayer route at the moment, so start working on it! And as always with OoBs, I kindly ask you not to spread it nor use it casually, as it will only hurt both casual players (griefing) and speedrunners (dead category if patched). I plan to record a One Down version, hopefully soon enough (after next week at le...
Buy it: https://bank.bandcamp.com/album/bathroom-wall "As a totem to reflect onto with text, to rest ones eyes in blur, or to physically hold ones self up in the throes of intoxication, the bathroom wall takes and gives numerous gestures of use. Klein uses the symbology of the bathroom wall to construct five disparate wall scrawlings and hazed meditations into the compositional grounds for four meaner mid-tempo, rhythmic purges." Artist(s): Nick Klein Title: Bathroom Wall Record Label: BANK Records NYC Catalog Number: Date: 2018
The World Bank is an international financial institution that provides loans to developing countries for capital programs. It comprises two institutions: the International Bank for Reconstruction and Development (IBRD), and the International Development Association (IDA). The World Bank is a component of the World Bank Group, which is part of the United Nations system.
The World Bank's official goal is the reduction of poverty. However, according to its Articles of Agreement, all its decisions must be guided by a commitment to the promotion of foreign investment and international trade and to the facilitation of Capital investment.
The World Bank is not to be confused with the World Bank Group, an extended family of five international organizations:
Radio Free Europe | 24 Oct 2020
Dear Dad, I think about you every now and then,
I hope to God that I don't turn out like you as I grip this pen.
Every time you cross my mind, I cross my heart and hope to die,
That I wont ever let myself become a disappointment to my mum.
Father, you never bothered, about as close as north and south are to each other.
But my mother, I really love her, although sometimes I wish she would have chose another.
As I reminisce, I think of all the birthdays and Christmas' you missed
And no millionaire could afford what you cost me walking out the door.
I've cried a thousand times but now I realize that this is only biological,
You're a name on my birth certificate and that's all.
I'll tie a rope around the neck of your Fred Perry and hang you from my family tree.
Radio Free Europe | 24 Oct 2020
Sputnik | 25 Oct 2020
The Independent | 24 Oct 2020
Gulf News | 24 Oct 2020
South China Morning Post | 24 Oct 2020
The Independent | 24 Oct 2020
Yahoo Daily News | 24 Oct 2020