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An in-depth report on how asthma is diagnosed, treated, and managed in adults.
Asthma Guidelines
The U.S. National Asthma Education and Prevention Program (NAEPP) guidelines for the diagnosis and management of asthma recommend:
Asthma Symptoms
Symptoms of asthma include:
The word asthma comes from an ancient Greek word meaning panting. Essentially, asthma is an inflammatory lung condition that makes it difficult to breathe properly.
When people inhale, the air travels through the following body structures:
Asthma is a chronic condition in which the airways undergo changes that are usually triggered by by allergens, other environmental factors, or by infection. Asthma is characterized by two specific responses:
These actions in the airway cause coughing, wheezing, and shortness of breath (dyspnea), the classic symptoms of asthma.
In the hyperreactive response, smooth muscles in the airways of the lungs constrict and narrow excessively in response to inhaled allergens or other irritants. This sudden contraction in the muscle walls of the bronchioles is called a bronchospasm. Bronchospasms can result from many different health conditions (allergies, bronchitis, chronic obstructive pulmonary disorder) but asthma is the most common cause.
Everyone's airways constrict when exposed to allergens or irritants, but there are major differences in the hyperreactive response that occurs in people with asthma:
The hyperreactive stage is followed by the inflammatory response, which generally contributes to asthma in the following way:
Inflammation appears to be present in the lungs of all patients with asthma, even those with mild cases, and plays a key role in all forms of the disease.
Doctors don't fully understand the causes of asthma. They believe the disorder is most likely caused by a combination of genetic (inherited) factors and environmental triggers (such as allergens and infections). Asthma tends to run in families. Children whose parents have asthma are more likely to develop it themselves.
Nearly half of adults with asthma have an allergy-related condition, which, in most cases developed first in childhood. (In patients who first develop asthma during adulthood, the allergic response usually does not play a strong causal role.)
In people with allergies, the immune system overreacts to exposure to allergens. Allergic asthma is triggered by inhaling certain substances (allergens) such as:
An asthma attack can also be triggered or aggravated by direct irritants to the lungs. Important irritants involved in asthma include cigarette smoke, indoor chemicals, and air pollution.
Respiratory viral and bacterial infections play a role in some cases of adult-onset asthma. In both children and adults with existing allergic asthma, an upper respiratory tract infection often worsens an attack.
About 19 million American adults have asthma.
Before puberty, asthma occurs more often in males, but after adolescence, it is more common in females. In adults, women are more likely to report severe symptoms than men.
Hormonal fluctuations or changes in hormone levels may affect the severity of asthma in women. Many women with asthma experience fluctuations in severity that are associated with their menstrual cycle. Some women first develop asthma during or shortly after pregnancy, while others first develop it around the time of menopause (perimenopause).
African-Americans have higher rates of asthma than Caucasians or other ethnic groups. They are also more likely to die of the disease. Ethnicity and genetics are, however, less likely to play a role in these differences than socioeconomic factors, such as having less access to optimal health care, and greater likelihood of living in an urban area (another asthma risk factor).
Studies report a strong association between obesity and asthma. Evidence also suggests that people who are overweight (body mass index greater than 25) have more difficulty getting their asthma under control. Weight loss in anyone who is obese and has asthma or shortness of breath helps reduce airway obstruction and improve lung function.
Patients with asthma often also have gastroesophageal reflux disease (GERD), which is associated with acid reflux. It is not entirely clear which condition causes the other or whether they are both due to common factors. Acid reflux can worsen asthma symptoms. Treating GERD may help improve asthma control in some patients.
Aspirin-induced asthma (AIA) is a condition in which asthma gets worse after taking aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). AIA often develops after a viral infection. It is a particularly severe asthmatic condition, associated with many asthma-related hospitalizations. In about 5% of cases, aspirin is responsible for a syndrome that involves multiple attacks of asthma, sinusitis, and nasal congestion. Such patients also often have polyps (small benign growths) in the nasal passages. Patients with aspirin-induced asthma (AIA) should avoid aspirin and other NSAIDs, including ibuprofen (Advil and other brands, generic) and naproxen (Aleve, generic).
Doctors classify the severity of asthma into four groups (Intermittent, Mild Persistent, Moderate Persistent, and Severe Persistent) based on:
Persistent asthma is usually chronic, although it occasionally goes into long periods of remission. Long-term outlook generally depends on severity:
Death from asthma is a relatively uncommon event, and most asthma deaths are preventable. It is very rare for a person who is receiving proper treatment to die of asthma. However, even when it is not life threatening, asthma can be debilitating and frightening. Asthma that is not properly controlled can interfere with school and work, as well as with daily activities.
Asthma symptoms vary in severity from occasional mild bouts of breathlessness to daily wheezing that lasts even when a patient takes large doses of medication. After exposure to asthma triggers, symptoms rarely develop abruptly but progress over a period of hours or days.
The classic symptoms of an asthma attack are:
Not all patients experience the same signs or symptoms of asthma or experience them the same way.
The end of an attack is often marked by a cough that produces thick, stringy mucus. After an initial acute attack, inflammation lasts for days to weeks, even if it does not produce symptoms.
The following signs and symptoms may indicate a life-threatening situation:
Asthma often progresses very slowly, but it may sometimes develop to a fatal or near-fatal attack within a few minutes. It is very difficult to predict when an attack will become very serious. Any symptoms that suggest a serious attack should be immediately treated with a rescue bronchodilator. If symptoms persist, call for emergency help.
Exercise-induced asthma (EIA) is a limited form of asthma in which exercise triggers coughing, wheezing, or shortness of breath. This condition generally occurs in children and young adults, most often during intense exercise in cold dry air. Symptoms are generally most intense about 10 minutes after exercising and then gradually resolve.
EIA is triggered only by exercise and is distinct from ordinary allergic asthma in that it does not produce a long period of airway hyperactivity, as allergic asthma does. (However, some people have both forms of asthma.) People who have only EIA do not need long-term maintenance therapy.
Many patients experience a worsening of their asthma symptoms during the nighttime, especially during sleep. Attacks often occur between 2 - 4 a.m. Factors that increase the risk for nocturnal asthma include allergen exposure, sinus problems, GERD, chronic obstructive lung diseases, and the sleep-disordered breathing associated with obstructive sleep apnea.
Your doctor will want to know any patterns or triggers associated with your asthma symptoms. Be sure to let your doctor know:
If symptoms and a patient's history suggest asthma, the doctor will usually perform lung (pulmonary) function tests to confirm the diagnosis and determine the severity of the disease.
A standard test uses a spirometer, an instrument that measures the amount of air taken into and exhaled out from the lungs. The patient breathes into a tube that is connected into a machine. The spirometer can give several measures of airflow:
If the airways are obstructed, these measurements will fall. Depending on the results, the doctor will take the following steps:
Your doctor may recommend skin or blood allergy tests, particularly if a specific allergen is suspected. Allergy skin tests may help diagnose allergic asthma, although they are not recommended for people with year-round asthma.
Many other health conditions have symptoms similar to asthma:
Asthma is often a chronic condition but you can effectively manage it by:
Based on your age, symptoms, and asthma severity, your doctor will determine an individualized treatment plan. In general, doctors recommend a stepwise approach for treating asthma. Medications and dosages are increased when needed, and decreased when possible. Your record of peak flow meter readings can help your doctor manage your medications and make necessary adjustments.
These are the signs of well-controlled asthma:
It is important to understand the difference between coping with asthma attacks and controlling the disease over time.
Medications for asthma fall into two categories:
Unfortunately, many patients do not understand the difference between medications that provide rapid short-term relief and those that are used for long-term symptom control. Make sure your doctor explains how to avoid overusing your short-term bronchodilator medications and underusing your long-term corticosteroid medications. The overuse of bronchodilators can have serious consequences, while not properly using steroids can lead to permanent lung damage.
Most asthma drugs are taken through inhalers. The two basic inhaler devices are the metered-dose inhaler (MDI) and dry powder inhalers (DPIs). In a hospital setting, or when a patient cannot use an inhaler, a nebulizer may be used. A nebulizer is a device that administers the drug in a fine spray that the patient breathes in
Metered-Dose Inhaler. The metered-dose inhaler (MDI) is the standard device. It allows precise doses to be delivered directly to the lungs. The medicine is contained in a pressurized canister that is placed inside the plastic inhaler. MDIs are often used with a spacer, which is a tube that is attached to the inhaler. The spacer serves as a holding chamber for the medication sprayed by the inhaler. The spacer helps improve the ease and efficiency of medication delivery. .
Dry Powder Inhalers. Dry powder inhalers (DPIs) deliver a powdered form of beta2-agonists or corticosteroids directly into the lungs. Unlike an MDI, dry powder inhalers do not contain a propellant and do not require a spacer. Some patients find that they are more difficult to manage than MDIs.
Guidelines from the National Asthma Education and Prevention Program (NAEPP) emphasize that most asthma medications are safe for pregnant women. The guidelines recommend that pregnant women with asthma have albuterol available at all times. Inhaled corticosteroids should be used for persistent asthma. Patients whose persistent asthma does not respond to standard dosages of inhaled corticosteroids may need a higher dosage or the addition of a long-acting beta-agonist to their drug regimen.
For severe asthma, oral corticosteroids may be necessary. The NAEPP notes that while it is not clear if oral corticosteroids are safe for pregnant women, uncontrolled asthma poses an even greater risk for a woman and her fetus. Pregnant women with asthma face increased risks for complications including pre-eclampsia (a condition associated with high blood pressure) and preterm delivery.
Quick-relief (rescue) medications work immediately to relax airways and quickly control acute asthma attacks. They are not useful for preventing attacks or controlling inflammation in the airways.
The standard quick-relief medication is a beta2-agonist inhaler. Beta2-agonists are bronchodilators. They relax and open constricted airways during an acute asthma attack..
Specific short-acting beta2-agonists include:
Short-acting beta2-agonists are usually administered through inhalation and are effective for 3 - 6 hours. They relieve the symptoms of acute attacks, but they do not control the underlying inflammation. They are used alone only for patients with mild and intermittent asthma. Most patients with asthma use a beta2-agonist only for rapid symptom relief during an asthma attack, and use a long-term control medication to prevent attacks and reduce airway inflammation. .
Side Effects of Beta2-Agonists. Side effects of all beta2-agonists may include:
Beta2-agonists have serious interactions with certain other drugs, such as beta-blockers. People with diabetes, heart disease, high blood pressure, hyperthyroidism, an enlarged prostate, or a history of seizures should use these drugs with caution.
Short-acting beta2-agonists become less effective when taken regularly over time, which increases the risk for overuse. Overdose can be serious and in rare cases even life threatening, particularly for patients with heart disease.
Oral corticosteroids are generally used for asthma flareups that do not respond to inhaler medications. Common oral corticosteroids include prednisone, prednisolone, methylprednisolone, and hydrocortisone.
For asthma treatment, oral corticosteroids are typically used for short "bursts" of treatment lasting 5 – 10 days. In some severe cases, they may be used as maintenance therapy.
Short-term side effects of oral corticosteroids include mood changes and irritability, fluid retention and weight gain, and high blood pressure. Oral corticosteroids can cause severe side effects if taken for long periods of time. These side effects include cataracts, glaucoma, osteoporosis, diabetes, osteoporosis, susceptibility to infections, and other serious conditions.
If you need to take oral corticosteroids for more than 5 days, your doctor will gradually taper off the dose. Abruptly stopping steroids can cause withdrawal symptoms.
Two inhaled drugs, ipratropium bromide (Atrovent) and tiotropium (Spiriva), are bronchodilators that are not approved for asthma treatment but are sometimes used for this purpose. Ipratropium is used as a rescue medication. Tiotropium is being studied for use as a long-term control medication.
Possible benefits of anticholinergics include:
Asthmanefrin is an over-the-counter (non-prescription) rescue bronchodilator that contains a form of epinephrine called racepinephrine. The medication is inhaled through an atomizer. Asthmanefrin came on the market in 2012 as a replacement for Primatene Mist. Primatene Mist was discontinued because its inhaler used chlorofurocarbon (CFC) propellant. (CFCs are banned because of environmental concerns.) Asthmanefrin does not use CFC. However, many doctors do not recommend the use of epinephrine products for asthma because the drug can raise heart rate and blood pressure, and may increase the risk for heart attack and stroke. In general, patients are much better off seeing a healthcare provider and using inhalers that are prescribed.
Long-term control (maintenance) medications are taken on a regular basis to prevent asthma attacks, control inflammation in the airways, and manage chronic symptoms.
Corticosteroids, also called glucocorticoids or steroids, are powerful anti-inflammatory drugs. Steroids are not bronchodilators (they do not relax the airways) and have little short-term effect on symptoms. Instead, they work over time to reduce inflammation and prevent permanent injury in the lungs. They can also help prevent asthma attacks from occurring.
Taking a corticosteroid drug through an inhaler provides effective local anti-inflammatory activity in the lungs with very few side effects elsewhere in the body. (By contrast, steroids taken by mouth have considerable side effects throughout the body.) Inhaled corticosteroids are recommended as the primary therapy for any patient needing long-term control medications for persistent asthma.
The most recent generation of inhaled steroids include fluticasone (Flovent), budesonide (Pulmicort), triamcinolone (Azmacort and others), flunisolide (AeroBid), mometasone furoate (Asmanex), and ciclesonide (Alvesco). These steroids are sometimes combined with a long-acting beta2-agonist in a single inhaler, such as budesonide-formoterol (Symbicort), fluticasone-salmeterol (Advair), or mometasone-formoterol (Dulera). Optimal timing of the dose is important and may vary depending on the medication.
Inhaled steroids are generally considered safe and effective and only rarely cause any of the more serious side effects associated with prolonged use of oral steroids. The following are possible side effects of inhaled steroids:
Long-acting beta2-agonists (LABAs) are bronchodilator drugs that help to open and relax the airways. Unlike the short-acting Beta2-agonists used for rescue medication, LABAs are used for long-term asthma control. They are not used for treating attack symptoms.
LABAs should never be used alone in the treatment of asthma in adults or children. They can be dangerous when used alone, because they can mask asthma symptoms, and they can increase the risk of asthma death unless paired with an inhaled steroid. LABAs should only be used in combination with another control medication, such as an inhaled corticosteroid. LABAs should be used for the shortest time possible, and should only be used by patients whose asthma is not adequately controlled by other asthma maintenance medications.
Salmeterol-fluticasone (Advair), formoterol-budesonide (Symbicort), and formoterol-mometasone (Dulera) are long-acting beta2 agonists products combined with a steroid in a single inhaler that are used for treatment of moderate-to-severe asthma. The LABA-only versions of these drugs are salmeterol (Serevent Diskus) and formoterol (Foradil Aerolizer).
Doctors are still trying to determine when long-acting beta2-agonists should be added to, or removed from, an asthma treatment plan. If your symptoms do not improve or if symptoms worsen with this type of drug, your doctor will recommend discontinuing it. Do not, however, stop taking this drug or other asthma medications without first talking with your doctor.
Leukotriene antagonists (also called anti-leukotrienes or leukotriene modifiers) are pills that block leukotrienes. Leukotrienes are powerful immune system factors that, in excess, produce damaging chemicals that can cause inflammation and spasms in the airways of people with asthma. As with other anti-inflammatory drugs, leukotrienes are used for prevention, NOT for treating acute asthma attacks.
Leukotriene antagonists include montelukast (Singulair, generic), zafirlukast (Accolate, generic) and zileuton (Zyflo). These drugs may be used as second-line treatment for asthma control and are sometimes used for preventing exercise-induced asthma.
Side Effects and Complications. Upset stomach, headache, and sore throat are the most common side effects of leukotriene antagonists. Because these drugs can raise liver enzyme levels, patients may need periodic liver tests..
Leukotriene antagonists may cause mental health disturbances and behavioral changes. Mood problems include agitation, aggression, anxiousness, dream abnormalities, hallucinations, depression, insomnia, irritability, restlessness, tremor, and suicidal thinking. Patients who take a leukotriene antagonist drug should be monitored for signs of behavioral and mood changes. Doctors should consider discontinuing the drug if patients exhibit any of these symptoms.
Omalizumab (Xolair) is FDA-approved for patients age 12 and older who have moderate-to-severe persistent asthma related to allergies. Omalizumab is a biologic drug that targets and blocks the antibody immunoglobulin E (IgE), a chemical trigger of the inflammatory events associated with an allergic asthma attack.
Omalizumab is given by injection every 2 - 4 weeks. It is used only to treat patients who have moderate-to-severe persistent asthma related to allergies whose symptoms are not controlled by inhaled corticosteroids.
Side Effects and Complications. About 1 in 1,000 patients who take omalizumab develop anaphylaxis (a life-threatening allergic reaction). Patients can develop anaphylaxis after any dose of omalizumab, even if they had no reaction to a first dose. Anaphylaxis may occur up to 24 hours after the dose is given.
Omalizumab should always be injected in a doctor's office, and health care providers should observe patients for at least 2 hours after an injection. Patients should also carry emergency self-treatment for anaphylaxis (such as an Epi-Pen) and know how to use it. With an Epi-Pen, or similar auto-injector device, patients can quickly give themselves a life-saving dose of epinephrine.
Anaphylaxis symptoms include:
The FDA is currently reviewing whether omalizumab may be associated with increased risk for heart and vascular problems (ischemic heart disease, arrhythmias, cardiomyopathy, heart failure, pulmonary hypertension, and blood clots).
Theophylline is a broncholdilator drug. It relaxes the muscles around the bronchioles and also stimulates breathing. Since the introduction of inhaled corticosteroids and long-acting beta2-agonists, theophylline is not used as often for asthma treatment. It may still be used in some circumstances, such as for treating nocturnal asthma. Theophylline is available in tablet, liquid, and injectable forms. Theophylline should not be used by people with peptic ulcers or GERD, and should be used with caution by anyone with heart disease, liver disease, high blood pressure, or seizure disorders.
Patients with asthma should get an annual flu vaccine, and they should be vaccinated against pneumococcal pneumonia.
Patients with asthma and chronic allergic rhinitis may need to take medications daily. Patients with severe seasonal allergies may need to start medications a few weeks before the pollen season, and to continue medicine until the season is over. Treatment of
Immunotherapy ("allergy shots") may help reduce asthma symptoms, and the use of asthma medications, in patients with known allergies. They may also help prevent the development of asthma in children with allergies. Immunotherapy poses some risk for severe allergic reactions, however, especially for children with poorly controlled asthma.
Researchers are studying an oral form of immunotherapy that uses a sublingual (under-the-tongue) tablet. Recent reviews indicate that sublingual therapy may be helpful for asthma in particular, and may also be beneficial for allergic rhinitis. However, many questions remain including dosage and duration of treatment. At this time, sublingual immunotherapy is not considered standard practice in the United States.
Respiratory infections, including the common cold, can interact with allergies to worsen asthma. People with asthma should try to minimize their risk for respiratory tract infections. Using alcohol-based hand rubs and washing hands are simple but effective preventive measures. Vaccinations for viral respiratory infections are also important.
Asthma and GERD often co-exist. Some patients find that treatment of GERD helps improve their asthma symptoms. GERD treatment includes:
Women who suspect that menstrual-related changes may influence asthma severity should keep a diary of their menstrual dates and times of asthma attacks. Sometimes, adjusting medications in anticipation of menstruation may help prevent attacks.
Many people with asthma turn to alternative therapies including high-dose vitamins, homeopathic remedies, probiotics, and herbal supplements. There is no evidence that any of these treatments are helpful for asthma.
However, because stress can worsen asthma symptoms and make breathing more difficult, alternative therapies that focus on relaxation and stress reduction may be helpful. These modalities include:
Asthma action plans create a written document for patients to manage asthma during stable times and to more easily identify when asthma is worsening. Important components of a home program include:
A peak flow meter is a handheld plastic device for measuring peak expiratory flow rate (PEFR). PEFR measures how fast you can expel air out of your lungs and is an indication of lung functioning. Changes in the PEFR may indicate problems with asthma control even before symptoms appear.
It is a good idea to keep a written record of your peak flow meter readings. This data can help your doctor adjust medications and recognize problems before they become serious. Patients who self-manage their asthma with peak air flow measurements and appropriate medication use have fewer hospitalizations and unplanned doctors' visits, and generally have a better quality of life than those who rely only on the occasional doctor or emergency room visit to control symptoms.
To use a peak flow meter, stand or sit upright, set the meter to zero, take a deep breath and exhale hard and fast into the meter. Write down the number that appears on the meter.
Tips for regular peak flow monitoring include:
It is important to avoid and control triggers that lead to asthma attacks.
Controlling Pets. Patients who already have pets and are not allergic to them probably have a low risk for developing allergies. If pets trigger asthma, take the following precautions:
Controlling for Dust. Spray furniture polish is very effective for reducing both dust and allergens. Air cleaners, filters for air conditioners, and vacuum cleaners with High Efficiency Particle Arresting (HEPA) filters can help remove particles and small allergens found indoors. Neither vacuuming nor the use of anti-mite carpet shampoo is, however, effective for removing mites in house dust. In fact, vacuuming stirs up both mites and cat allergens. If possible, avoid carpets and rugs.
Bedding, Curtains, and Bedroom Environment.
Reducing Humidity in the House. Living in a damp house is counterproductive. Dust mites thrive in humidity and damp houses increase the risk for mold. Humidity levels should not exceed 30 - 50%:
Gas Stoves, Kerosene, and Cooking. Electric stoves and ovens are healthier than gas ones for people with asthma. Gas ovens release nitrogen dioxide, a substance that can aggravate asthma symptoms. Even smoky cooking can worsen asthma. Kerosene (used in space heaters and lamps) may also produce allergic reactions.
Exterminating Pests (Cockroaches and Mice).
Avoiding Cigarette Smoke. Cigarette smoke can accelerate the decline in lung function related to asthma. Even exposure to secondhand smoke can double the risk of an asthma-related emergency room visit. Everyone should quit smoking and encourage others around them to quit.
Avoiding Outdoor Allergens.
Asthma is no reason to avoid exercise. Historically, about 10% of Olympic athletes have asthma. Some studies indicate that long-term exercise even helps control asthma and reduce hospitalization. Exercise can help control weight, which can help with asthma symptoms. Patients should consult their doctors before starting any exercise program, however.
People who enjoy running should probably choose an indoor track to avoid pollutants. Swimming is excellent for people with asthma. Yoga, which uses stretching, breathing, and meditation techniques, may also have particular benefits.
Hints for Reducing Exercise Induced Asthma (EIA). EIA occurs only after exercise and is more likely to happen during regular paced activities in cold, dry air. The following are some suggestions for reducing its impact:
Brozek JL, Bousquet J, Baena-Cagnani CE, Bonini S, Canonica GW, Casale TB, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision. J Allergy Clin Immunol. 2010 Sep;126(3):466-76.
Brozek JL, Kraft M, Krishnan JA, Cloutier MM, Lazarus SC, Li JT, et al. Long-acting ß2-agonist step-off in patients with controlled asthma. Arch Intern Med. 2012 Oct 8;172(18):1365-75.
Chan WW, Chiou E, Obstein KL, Tignor AS, Whitlock TL. The efficacy of proton pump inhibitors for the treatment of asthma in adults: a meta-analysis. Arch Intern Med. 2011 Apr 11;171(7):620-9.
Cowl CT. Occupational asthma: review of assessment, treatment, and compensation. Chest. 2011 Mar;139(3):674-81.
Cox L, Nelson H, Lockey R, Calabria C, Chacko T, Finegold I, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol. 2011 Jan;127(1 Suppl):S1-55. Epub 2010 Dec 3.
Fanta CH. Asthma. N Engl J Med. 2009 Mar 5;360(10):1002-14.
Gibson PG, McDonald VM, Marks GB. Asthma in older adults. Lancet. 2010 Sep 4;376(9743):803-13.
Kerstjens HA, Engel M, Dahl R, Paggiaro P, Beck E, Vandewalker M, et al. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med. 2012 Sep 27;367(13):1198-207. Epub 2012 Sep 2.
Laumbach RJ. Outdoor air pollutants and patient health. Am Fam Physician. 2010 Jan 15;81(2):175-80.
Lazarus SC. Clinical practice. Emergency treatment of asthma. N Engl J Med. 2010 Aug 19;363(8):755-64.
Lin SY, Erekosima N, Kim JM, Ramanathan M, Suarez-Cuervo C, Chelladurai Y, et al. Sublingual immunotherapy for the treatment of allergic rhinoconjunctivitis and asthma: a systematic review. JAMA. 2013 Mar 27;309(12):1278-88.
Murphy VE, Namazy JA, Powell H, Schatz M, Chambers C, Attia J, et al. A meta-analysis of adverse perinatal outcomes in women with asthma. BJOG. 2011 Oct;118(11):1314-23. Epub 2011 Jul 13.
National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Rockville, MD. National Heart, Lung, and Blood Institute, US Dept of Health and Human Services; 2007. NIH publications 08-4051.
Schatz M, Dombrowski MP. Clinical practice. Asthma in pregnancy. N Engl J Med. 2009 Apr 30;360(18):1862-9.
Sindi A, Todd DC, Nair P. Antiinflammatory effects of long-acting beta2-agonists in patients with asthma: a systematic review and metaanalysis. Chest. 2009 Jul;136(1):145-54. Epub 2009 Mar 2.
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The Miseducation Of Lauryn Hill
One of my favorite albums to listen to when I travel. Especially on am track to up state New York. I hear she had displeasure with fame and the music industry but we know we can't stop a genius, even if she or we try.

subset: commoncrawl


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After going to war with Twitter, serial entrepreneur Bill Gross has come up with a new idea: take it on at its own game. His UberMedia is launching a Twitter/Tumblr hybrid, called ChimeIn, that draws on some of the best ideas of both.
The obvious question this begs: how many social platforms does the world need? Read more


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Thousands of party-goers vandalised a postal delivery office during an illegal rave in Croydon last night, which has seen part of the town shut down today.
Police put an end to the party this morning, June 15, next to East Croydon Station, but violence erupted last night when revellers threw furniture and fire extinguishers at cops.
A police car window was also smashed in the chaos.
Police noticed large numbers of people and large groups at the venue last night and called for backup.
The all-night rave, held in the disused delivery office in Cherry Orchard Road, carried on until the early hours and police shut down the party at about 8.30am and cordoned off the area.
Trams are currently not running through East Croydon.
Nine people have been arrested, but police said there is likely to be further arrests.
Croydon Central MP Gavin Barwell said those responsible should "feel the full force of the law".
He wrote on his blog that police found about 200 people inside, and a further 300 outside, when first called to the building at 9.40pm.
Two people were arrested for violent disorder and have been taken to a south London police station where they remain in custody.
Six people believed to be at the rave were taken to hospital.
Three people were ill, two were suffering from head injuries and the other had an injured hand.
Were you at the rave or did you see what happened? Call our newsdesk on 020 8722 6326.


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Sweet Cranberry-Glazed Carrotsby Amie Valpone in Healthy Holidays, December 23, 2012
A Christmas meal isn't complete without a "sweet" element — but who says the sweet stuff is just for dessert? This year, add some sweetness to your dinner table and have a not-so-traditional side dish: cranberry-glazed carrots. It's as simple as taking cranberries and carrots and combining them together for one delicious dish.
Including orange juice and zest is also a way to kick up the flavor – in a way even the kids will enjoy! To ensure this dish is not-too-sweet, add fresh mint to help bring balance.
So there you have it: cranberries, carrots and mint – oh my! Let this recipe knock your Christmas day socks off. This will mesmerize even people who aren't too fond of carrots. You can store leftovers in the refrigerator to bring for lunch or microwave as a side item a different night of the week.
Serves 4
1 1/2 pounds carrots, julienned
1 Tbsp extra-virgin olive oil
1 tsp. honey
3 Tbsp. freshly squeezed orange juice
1/2 tsp. fresh orange zest
1/3 cup dried cranberries
1/4 cup finely chopped fresh mint
1/4 tsp. sea salt
1/4 tsp. freshly ground pepper
In a large bowl, combine all ingredients; gently toss to combine.
Refrigerate until ready to serve.


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Product Information:
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The Smith Center for the Performing Arts Brings Country Music Icon Trace Adkins to Las Vegas, 4/28
The Smith Center for the Performing Arts continues to diversify its roster of world-class entertainment with a one-night-only concert with platinum-selling country music recording artist Trace Adkins inside Reynolds Hall on Sunday, April 28 at 7:30 p.m.
One of country music's most accomplished entertainers, Adkins' trademark baritone has powered countless chart topping hits and has sold more than 10 million albums. The Grammy nominee and Grand Ole Opry member has produced 10 solo albums, including the recently released Christmas album "We Three Kings." Adkins' eleventh studio album, "Tough People Do," will drop this spring.
His headlining date at The Smith Center is sure to be a crowd pleaser and will feature some of his most famed hits spanning his 17-year career including "(This Ain't) No Thinkin' Thing," "Ladies Love Country Boys" and "You're Gonna Miss This."
The oil-rigger-turned-country star is a famed television personality and screen actor with credits including NBC's "Celebrity Apprentice," where his integrity and wry humor made him a fan favorite and eventually a season finalist; three-time co-host of FOX's American County Awards; and a recent role in "The Lincoln Lawyer" playing a tougher-than-nails biker.
Adkins, known for his work with the Wounded Warrior Program and the American Red Cross, is not only a famed musician but a revered author, actor and philanthropist. The recording artist will soon embark on his eighth USO Tour performing for troops serving across the globe.
Tickets go on sale Friday, Feb. 15 at The Smith Center Box Office, located at 361 Symphony Park Avenue, by phone at 702-749-2000 or 808-326-6868 (TTY) and online at www.TheSmithCenter.com. For preferred seating and special rates for groups of 10 or more, contact 702-749-2348.


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Flames NewsFlames Home > Men's Basketball Home > News
Construction Continues on Vines Center Court
Construction of the new basketball playing surface inside the Vines Center continues, this week. Workers have installed the wood flooring and are now painting the court. In the photo gallery below, you can also see stenciled outlines of the Liberty and Big South logos.
Be sure to check back with LibertyFlames.com later this summer for further updates as the project is completed.
Previous Construction Gallery: July 11


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GREEN SPRINGS, Ohio (AP) -- The owners of a former park in an area of northern Ohio where cancer has sickened dozens of children for more than a decade say more tests on the soil are being planned.
An attorney for the site's owners say tests will likely take place in February.
The U.S. EPA has said soil samples at the now-closed park showed high levels of a chemical believed to increase the risk of certain cancers.
The former park near the town of Clyde had been owned by the Whirlpool Corp., which has a washing machine factory in the town.
The News-Messenger in Fremont (http://ohne.ws/VUMud2 ) reports the U.S. EPA is overseeing the testing.
Nearly 40 young people have been diagnosed with cancer since the mid-1990s in a 12-mile-wide circle that's between Cleveland and Toledo.
Information from: The News-Messenger, http://www.thenews-messenger.com


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Elmer Eugene Reital (1899-1973)
WWI Vet and WWII Vet
Elmer E. Reital was born in St. Joseph, MO on 16 Jul 1899, the son of John A. Reital and Minnie Pugh. He attended law school at Washburn College in Topeka, KS in 1918-?. He was drafted into service in WWI on 1 Nov 1918 at Topeka, KS. He received an Honorable Discharge on 9 Dec 1918. He lived in the family home on 6th Avenue in St. Joseph with parents and several siblings for many years, until 1942 when he was drafted into military service.
After graduation, he became an attorney in St. Joseph, MO, working in the office of Price Shoemaker for many years before retiring. He served as president of the Bar Associatin in St. Joseph for some period of time. He also ran - unsucessfully - for Prosecuting Attorney.
Elmer was an avid outdoorsman, alway eager to go hunting or fishing. He like to listen to classical music, including especially opera from the Met that was broadcast on Saturdays. He was an individual of very high personal integrity and honesty. He seemed to be immune to any personal physical discomfort, whatever the environment, hot or cold.
Sometime during the period of 1942-1945, he married Nell E. Smith, after an extended courtship of several years. They had no children.
Elmer passed away at the Ft. Leavenworth Veterans Administration Center Hospital on 13 Jul 1973. The cause of death listed on his death cert was "Respiratory failure" due to "Pulmonary TBC with extensive involvement."
[Information added 31 Oct 2013 by nephew-by-marriage, James D. (Jack) Quinn.]


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Hi Nelly,
I share your compulsion for form and I have very much enjoyed reading through this thread.
The responses by Chris Campbell and OffCenter really resonate with me. Chris' sentiment that, "it takes as long as it takes," is the stance I've taken in my own work, as well as in my instruction of other potters. I find this particularly true when trimming and while babying handles and spouts. While I generally strive for forms that follow "the rules," the idea that there is a set-in-stone checklist of qualities for a form to embody in order to be considered proper is not something I subscribe to. OffCenter's comment about making dishes versus making anyhting else speaks to this.
For me what is most important in a piece of pottery, whether functional, decorative or sculptural, whether a traditional shape or not, is that the maker's intention is achieved. The majority of my work is in making dishes. I generally don't sit down at the wheel with an intention to make wonky, aesymetrical forms. If I make a bowl that is unbalanced, off-center, asymmetrical, etc it reads as a mistake. It is rare that I let these pots make it as far as the kiln, but the ones that do just seem "off." For anyone with a basic knowledge of the ceramic process, upon holding a piece like this, they can tell it's not exactly what I was going for.
In line with some of the comments made throughout the thread, I do think a lot of pots are unsuccessful. It's frustrating for me to check out other potters' work at shows, shops, galleries, wherever, and know as soon as I pick a piece up, that the pot does not truly reflect the intention of the maker. The heavy bottom, the wonky lip, the sloppy handle attachment are the usual giveaways, but the real issue is a disconnect between intended aesthetic and achieved results. Some of the pieces which speak most to me are unbalanced, asymmetrical, etc, but upon inspection of these pieces, it becomes clear that the "broken rules" were done so with clear intention.
In an artform where final results all begin simply as balls of mud, the only rule I really subscribe to is to strive for pots with which I feel I've acheived my vision and intention.
So Nelly, keep being compulsive; I will too.
Dear Chris,
What becomes interesting for me at these shows is how drawn people are to glaze. Color. It is that part of the vessel that they see the clearest. I am not sure but they could be asking themselves, will this fit into my decor. They do not recognize or really feel the energy of the piece. I am compulsive but so be it. There was a time where all I was concerned with was how many pots I could make in a short period of time. Now I can just putter. If I don't like the piece it goes into the scrap bin and I begin again. But this is my luxury as a hobbiest at this point. It is all about me learning as well.
Thank you for your response.


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Buy Bliss Spa Mini 6-Pack
Have the holidays left you broke not able to go to a spa? The Bliss spa kit is easy on the pocketbook and will transport you to the spa-like oasis in your own home. Included is shampoo, conditioner, soap, face wash and more. Zen-like atmosphere not included.


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When you put more than 80 of New York City's top restaurants in one room, they're going to show off a little. This year's Village Voice Choice Eats Annual Tasting was no exception. The 69th Regiment Armory was packed to the brim with bites from eateries showcasing the diverse and creative landscape of the city's cuisine.
All-American brisket sandwiches, ice cream and pulled pork shoulder all made appearances, but so did more ethnic flavors and dishes like Vietnamese style tofu, an arctic char crudo and even powdered olive oil (say what!?).
Brooklyn's Egg, for one, presented a beautiful plate of roasted root vegetables. Simple yet refreshing, beets and carrots were the star of this bright dish with puffed barley and buttermilk dressing.
The Blue Stove in Brooklyn has sweet and savory bites alike, but the bakery's Baby Bourbon Balls are off-the-charts good. With each bite, the bourbon flavor seeps into the extra moist chocolate cake without being overwhelming.
Other great dishes we saw:
Tenpenny's BBQ Bacon with "Slaw" Custard
Bowery Diner's Pancakes + Bacon with Maple Syrup
Porchetta's Porchetta Ragu on Toasted Crostini
Goat Town's Goat Face Killa Sangwich
ZuZu Ramen's Pork Belly and Kimchi Rice
Mexico Lindo's Oaxacan Style Chicken Tamales with Mole Poblano
Check out all our favorites of the night in our Best Bites Photo Gallery.
And, in case you're curious, see what we liked best from Choice Eats 2011.


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Pollution : 75/100 of 465
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From latest gizmo to toxic waste: the dark side of the worldwide electronics obsession
Ian Williams, University of Southampton
11th February 2016Our thirst for the latest gadgets has created a vast empire of electronic waste, writes Ian Williams. The EU alone produces some 9 million tonnes of it a year, of which some 70% is still working when disposed of, and over a third is disposed of illegally. With increasingly affordable electronic devices available to ever more people, it's high time for effective global regulation. more...
Heavy metal poisoning in Scotland's beached whales
The Ecologist
15th February 2016High levels of toxins mercury and cadmium have been found in all organs of the whales recently beached on Scotland's North Sea coast, including the brain. The research shows that rising mercury levels in the oceans leads to toxic stress in the long-lived marine mammals. more...
Fund managers: campaign on climate, or face lawsuits
The Ecologist
12th February 2016Fund managers who neglect their 'duty of care' to clients by failing to put pressure on the companies they invest in to reduce their carbon emissions and prepare for a fossil-free future could be sued for their negligence, say respected experts in law, environment and finance. more...
As flooding in Gaza worsens, the most basic of human rights are under threat
Vanessa Amaral-Rogers
9th February 2016The humanitarian crisis in Gaza has worsened after floods and purposeful destruction has taken its toll in recent months, writes Vanessa Amaral-Rogers. The eight year blockade by Israel and conflict with Egypt has already hit Palestinian families hard but now Gaza is at even greater risk as Egypt diverts seawater into life-line tunnels. more...
A green Wales is taking off - in spite of UK government policies
David Clubb
16th February 2016Despite Cameron's promise to lead the 'greenest Government ever', the environment has taken a heavy bashing since the 2015 election, writes David Clubb - whether on oil, fracking, renewable energy or planning policy. But Wales is doing its best to follow a sustainable path, and demonstrating badly needed environmental leadership that the whole UK would do well to follow. more...
What's more corrosive than Flint's water? The cynicism of the powerful
Jesse Jackson
11th February 2016The Flint water crisis exposes like nothing else the toxic cynicism of America's ruling class, writes Jesse Jackson. In their privileged view, the victims of the lead poisoning are disposable 'unpersons' that matter less than General Motors' auto parts. But now they, and their peers in other poisoned communities, are fighting back. more...
Indian Point reactors contaminate New York groundwater
Sam Thielman & Alan Yuhas / Guardian Environment
8th February 2016Highly radioactive tritium has leaked into groundwater at the Indian Point nuclear site 40 miles north of Manhattan, New York, write Sam Thielman & Alan Yuhas. Governor Cuomo has ordered a review of safety at the site, where two reactors are operating with no NRC license. more...
MEPs vote for killer car pollution at double the legal limit
3rd February 2016Right wing MEPs in the European Parliament including UK conservatives today voted car makers a 'get out of jail free' card over air pollution that's killing tens of thousands of citizens a year, allowing their vehicles to emit double the legal limit for nitrogen oxides. more...
Time to crack down on car pollution - the silent killer with powerful friends
Jean Lambert, Molly Scott Cato & Keith Taylor
3rd February 2016Air pollution from vehicles is killing tens of thousands of people every year in the UK alone, write Jean Lambert, Molly Scott Cato & Keith Taylor, an outrage set into stark focus by VW's 'test cheating'. The EU's response? To relax tests and allow cars to be more polluting - with the full support of the UK government. more...
Ancient 'dead seas' offer a stark warning for our own future
Richard Pancost, University of Bristol
29th January 2016For long periods animals in ancient oceans could live only in shallow surface waters, above vast 'dead zones' inhabited only by anoxic bacteria, writes Richard Pancost. Human activity is now creating immense new dead zones, and global warming could be helping as it reduces vertical mixing of waters. Could this be the beginning of something big? more...
Humans will be remembered for leaving a 'plastic planet'
Oliver Tickell
28th January 2016Long after we go extinct the human presence on Earth will be marked by a geological stratum rich in plastic garbage, according to a new study. Long-lived plastics are already widespread over the ocean floor, and there's a lot more on its way. Forget the 'Anthropocene' - the human era should rightly be called the Plasticene. more...
Outside the EU, the UK could again be the 'dirty man of Europe'
Craig Bennett / Friends of the Earth
25th January 2016When the UK joined the EU in 1973, it was dubbed the 'dirty man of Europe' thanks to its out of control pollution, writes Craig Bennett. Since then EU laws have forced us to clean up our act. But if we leave, all that may go into the reverse, with terrible impacts on our air, water, health, and wildlife. more...
Pollution : 75/100 of 465
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Ditch coal now! The global destruction caused by the UK's coal power generation
Anne Harris
28th January 2016The UK's coal burn is not just having a huge impact on climate, writes Anne Harris. It's also devastating communities in the UK, Russia, Colombia and other nations that supply our coal power stations. Those impacted are doing their best to resist the mining companies that are destroying their land, stealing their homes and polluting their air and water. But they need our help! more...
Aliso Canyon methane catastrophe is telling us: go renewable, now!
Pete Dronkers
14th January 2016The massive methane leak at Aliso Canyon in California tell sus everything that's wrong with fossil fuels, writes Pete Dronkers: toxic, under-regulated, unsafe, and climate destroying. But the catastrophe also brings us a timely message: this is the time for the California, the US, and the world, to begin a rapid transition away from fossil fuels and into our clean, green, renewable future. more...
From Copenhagen to Delhi, 'smart cities' call for smart solutions - like cycling
Colin Todhunter
11th January 2016The world's big cities are choking with pollution and endless traffic jams, writes Colin Todhunter - except one. Copenhagen, faced with these problems half a century ago, decided to act. Now it is showing the world that cycling is not just the basis of a sustainable transport strategy, but is key to making our cities clean, green, human and livable. May the global revolution unfold ... more...
Bolivia's coming 'lithium boom': economic miracle or environmental nightmare?
Rafael Sagárnaga López
1st January 2016Lithium is a key global resource for the global energy transition thanks to its role in the lightweight, efficient batteries that will power cars and balance power grids, writes Rafael Sagárnaga López. But the booming demand threatens to contaminate one of the world's great wonders, the Salar de Uyuni, 12,000 feet high in the Bolivia's Andes, which holds 70% of the world's lithium reserves. more...
Nigerian farmers' win right to sue Shell in Netherlands courts
The Ecologist
18th December 2015In a landmark judgment today, four Niger Delta farmers have won the right to sue Dutch oil multinational Shell in the Netherlands courts after oil spills destroyed their farms and fish ponds. The case sets a precedent for other victims of corporate environmental and human rights harms around the world. more...
Zane: did Cameron order cover-up on landfill cyanide death of 7-year old?
Paul Mobbs
14th December 2015The apparent conspiracy by the UK government and its agencies to conceal the real cause of death of 7-year old Zane Gbangbola may go right up to Prime Minister David Cameron, writes Paul Mobbs. He was chair of the COBRA emergency committee at the time when it appears to have held back the truth that he was killed by cyanide from the toxic landfill site his home was built over. more...
UK Government attacks public right to environmental justice
Paul Mobbs
30th November 2015Little publicised government plans to 'reform' court costs are intended to foreclose access to environmental justice for all but the wealthiest individuals and communities, writes Paul Mobbs. Meanwhile cuts to agencies and regulators will make it ever harder for them to do their jobs - making public participation in environmental protection all the more important. more...
The march of the industrial mega-dairy - is this the future of milk?
Andrew Wasley
23rd November 2015As falling milk prices push dairy farm out of business, new mega-dairies and feedlot operations of 700 or more cows are filling the void, writes Andrew Wasley. Never mind the pollution, slurry lagoons, and heavy plant on country lanes - do we want the cows that produce our milk confined to sheds? And what's the future for traditional dairy farmers with small, well cared for herds? more...
Recycle industrial wastes to cut 1Gt from world's carbon emissions
Wilf Lytton / Sandbag
1st December 2015There's a quick climate win for COP21 negotiators to ponder, writes Wilf Lytton - one that could convert a billion tonnes a year of CO2 into mineral form while neutralising caustic wastes like coal ash and slag. But first, industries and regulators must adopt a 'recycling' mentality to these hazardous materials, rather than the 'dump and forget' model that prevails today. more...
Tailings dam breach - 'the assassination of Brazil's fifth largest river basin'
Ana Luisa Naghettini & Geraldo Lopes
19th November 2015Brazil has suffered its biggest ever industrial disaster, write Ana Luisa Naghettini & Geraldo Lopes. Breached and overflowing dams have released a massive slug of toxic muds and tailings from iron mining into the country's fifth largest river system that provides drinking water for downstream cities, destroying ecosystems in rivers and vast areas of biologically fragile ocean. more...
Voluntary schemes cannot replace environmental regulation
Donal McCarthy / RSPB
16th November 2015A new review of the performance of politically fashionable 'voluntary' approaches to environmental protection demonstrates limited effectiveness, writes Donal McCarthy. Laws and regulations play a vital role in protecting nature and the wider environment - for which voluntarism is no substitute. more...
Environmental racism in the US - black communities fight for justice
Heather Kathryn Ross / Earthjustice
11th November 2015Landfill sites, giant hog farms, incinerators and other 'bad neighbor' industries in the US tend to be situated in African American communities, writes Heather Kathryn Ross. The Environmental Protection Agency is legally obliged to prevent 'environmental racism', but from California to Michigan, low-income communities of color have been waiting years for it to take a stand. Now, backed by Earthjustice, they are forcing the issue - in the courts. more...
Chevron's star witness in $9.5 billion Ecuador oil pollution claim admits: 'I lied'
Paul Paz y Miño / Amazon Watch
28th October 2015It was all going so well for Chevron - a New York court had ruled that a $9.5 billion judgment against it set by Ecuador's supreme court for massive pollution deep in the Amazon was corrupt and fraudulent. But then its star witness broke ranks and admitted, in another court, that he had lied, and the only bribes were coming from Chevron. Will Ecuador's pollution victims finally get justice? more...
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Race Weekend
August 15-16
Don't break the law!
In 1891 the U.S. Board of Geographic Names recommended an end to possessive forms in place names. The Colorado legislature further established the correct spelling of Pikes Peak in 1978. Therefore, Pikes Peak is spelled without an apostrophe by law.
Pikes Peak Jackets and Apparel
Pikes Peak Book and DVDs
Order below for $10 or get both the 2010 and 2011 DVDs for $15!
50th Anniversary Book:
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DVDs and the book


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Shamwari upgrades some of its properties
Jock Safari Lodge at Kruger National Park, all bedrooms are in the process of a complete soft upgrade and a new adventure and accommodation option in the newly launched Jock Explorer. This Explorer offers an experiential insight of a bygone era into this remote Big 5 wilderness, as did the legendary Percy Fitzpatrick in the 18th century. Jock Explorer now complements the highly successful Sanbona Explorer and Shamwari Explorer. The camp and tents have been meticulously recreated with the similar style camp beds, canvas washing basins, lanterns etc in order to transport guests back in time.
Sanbona Wildlife Reserve, just outside Cape Town, has launched its new 'boat safari experience' adding to the many other unique experiences on offer in this Karoo wilderness reserve. The 'Peregrine', named after the Peregrine Falcon, takes guests on a 'water safari' on the impressive Bellair Dam situated in the middle of this vast reserve in order to reach what has been, up to now, unchartered territory and present guests with a new experience and perspective of the Big 5 wildlife, marine and birdlife.
Newly designed canvas has been installed at Dwyka Tented Camp and the Sanbona Explorer – a two day walking safari with accommodation in mobile tents – has proven to be a great Karoo experience offering guests the opportunity to learn more about this historical land with its unique flora and fauna.
Shamwari Game Reserve in the Eastern Cape will see a roll out of a 'soft refurbishment' for Eagles Crag, Riverdene Family Lodge and Long Lee Manor. The Shamwari Explorer has become a unique way to experience Shamwari, and many guests have opted to combine this with a stay at one of the lodges as part of their safari adventure.
A new kiddies tent has been erected in the Sarili Lodge courtyard giving younger guests even more fun options to explore at their leisure.
Shamwari Group General Manager Joe Cloete says, "We believe Shamwari Group offers not only new and unique experiences within the provinces the reserves and lodges are located but presents educational safari and conservational experiences year round."


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Your gift to help a hardworking entrepreneur will double in impact thanks to a generous World Vision partner.
Vestine is from Rwanda. She has 5 children. She needs a loan of $1,000 to purchase beans, rice, sugar to resell .
Vestine is from Rwanda. She has 5 children. She needs a loan of $1,000 to purchase beans, rice, sugar to resell .
Vestine is a grocery store owner. She has been selling beans, sugar, flower, rice, and other groceries to make a living. Vestine is a hard workingwoman. However, she has been having financial difficulties and it is been hard to grow her business without money.
Vestine would like to obtain a loan to invest in her business. Please help Vestine grow her grocery store business. A loan will improve Vestine's family's quality of life.
Vestine would like to invest the funds from the loan in selling beans, sugar, flower, rice, and other groceries to resell. She would like to save some of the profits for the future and to invest in her grocery store. Vestine would like to grow her business in a way that she can create more jobs in her community.
Vestine has five children; she is married, and she lives in Huye, Rwanda, Africa.
Retail is a quick and scalable way to begin earning a profit. Many entrepreneurs begin with stalls at markets or even at home and need a loan to expand or increase their inventory. Others may be ready to open a small store. Goods purchased from loan funds range from clothing, grocery or sundry items to jewelry, candy, perfume or health and beauty supplies. Loans in the commerce sector account for around 33% of our loans.
The community of Karaba is located on a lowland plateau in southern Rwanda, where the climate is temperate. Most of the region's approximately 39,000 residents depend on agriculture for income, but poor soil makes it difficult for crops to thrive. As a result, 70 percent of the population lives in poverty. Families eat mostly vegetables, but many struggle to find enough food for survival.
Most homes have wooden-pole walls and dirt floors and lack toilets and sinks. Diseases such as worms and diarrhea are constant threats, and more than 94 percent of families have been affected by malaria. Approximately 600 of Karaba's children have lost at least one parent, and the community is home to more than 350 child-headed households.
In Karaba, World Vision is assisting community members through nutrition classes, business and handicraft training, classroom construction, HIV and AIDS support, and the provision of shelter for orphans and vulnerable children.
Thank you for supporting a small business loan for Vestine so she could expand her grocery store business. After receiving the loan from World Vision, she invested the funds by purchasing beans, rice, sugar, flour, and other groceries to sell in her store.
Vestine is pleased to report that she has been repaying her loan on time with her new profits. In addition to repaying her loan, Vestine is using her additional income to purchase food for her family and provide them with the healthcare they need. Through this opportunity, Vestine is able to cover her five children's educational expenses so they can continue to study in school and have hope for a brighter future.
Thank you for supporting Vestine and World Vision Micro!
While Vestine Mukamuzima initially invested in her business loan by purchasing to purchase beans, rice, sugar to resell. Since that initial investment, she struggled to repay her loan.
While we continued to work with Vestine to help her reestablish her business, I regret to report that Vestine has now defaulted on her loan.
Vestine prays that she will someday be able to restart she business so that she can better provide for her family. She thanks the donors who were part of this investment into her business and her life.
Please pray for Vestine and her family during this difficult time.
Despite the fact that World Vision boasts a repayment rate greater than 98%, there will always be some loans that do not get fully repaid. While World Vision does everything it can to ensure that this does not happen, it is an unfortunate reality that must be recognized when providing loans to less fortunate populations.
Thank you for your understanding, and your support of World Vision Micro. If you have any questions or concerns, please feel free to call our Customer Care line at 1-888-511-6444.


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Good day,
Could you please recommend any free PHP library to create PDF files?I have a website for selling books made with HTML, PHP and CSS. After a customer selected some books (and have them in the cart), I'd like to generate a PDF quotation showing all selected books and the total.
Thanks a lot!!
Try this: Convert HTML to PDF with Dompdf
Thanks again!!
Hi Pullo,
I have read Dompdf information.
Could you please confirm what exactly I have to do here to download the library?
Navigate to wherever you want to put the library and execute:
git clone https://github.com/dompdf/dompdf.git
git submodule init
git submodule update
Thanks a lot!!!
Are you familiar with using GIT?If not, just navigate here and hit "Download ZIP" button
Hi try this http://www.mpdf1.com/mpdf/index.php,it's easy to use...:)
I downloaded it. I also discovered how to unpack the ZIP file in cPanel, so I have the library there.
Thanks a lot, I'll check it in case I cannot work with Dompdf.
Yay!It might also be worth having a look at jemz solution, too, especially if he can recommend it.
I started reviewing the documentation of this product.After making a test .php file with the first sample code and open it with a browser, I get a missing file warning message for dompdf-master/lib/php-font-lib/classes/Font.php, from dompdf-master/dompdf_config.inc.php on line 332.
Checking dompdf_config.inc.php, lines 330 - 333 are:
if (DOMPDF_ENABLE_AUTOLOAD) { require_once(DOMPDF_INC_DIR . "/autoload.inc.php"); require_once(DOMPDF_LIB_DIR . "/php-font-lib/classes/Font.php");}
But when checking dompdf inner directories, within php-font-lib there is nothing, so the error message is right, there is no classes directory nor font.php file there.Looking the whole dompdf directory, there is no classes directory nor font.pdf file at all.
Any idea of what am I doing wrong?Thanks a lot!!!
Sorry that you didn't get on with the tutorial I linked to.
Did you try mPDF as @jemz ; suggested?
Maybe it would be better if you tell us what you are trying to achieve in a little more detail, then we can consider what the best solution might be.
In the meantime I was able to find the missing files.I am now in testing process.
This is I'd like to do:We have an online bookstore. The idea is after the customer selected the books and put them in the cart, to be able to generate a simple PDF quotation showing a quotation number, customer name and e-mail (requested in a previous page), selected books and the total.
Good stuff.Let us know if you run into any problems
Thanks a lot. Based on my requirements, is DomPDF the right tool?
Also, do you know any basic tutorial?
Yes. It's a library for generating a PDF from HTML markup and CSS styles (
I thought the SitePoint one I linked to was pretty basic.I just followed it in 5 minutes and was able to get the basic example working with no problems.
Where are you getting stuck?
Also, check Google for more tutorials: https://www.google.de/search?q=dompdf+tutorial
Once again, thanks a lot for so much help.
I just followed it in 5 minutes and was able to get the basic example working with no problems.
I am feeling like a Neanderthal
I am still thinking like PHPMailer, where the idea is to build the final e-mail step by step with instructions.What is the basic strategy with this library? I guess I have to build a webpage of what I want as a PDF outcome. I do not see any instruction to build the PDF step by step.
I have this basic file:
$file= file_get_contents('http://www.libromania.cl/spanish/home_spanish.shtml');
$dompdf = new DOMPDF();
Please open http://www.libromania.cl/spanish/test_pdf.php to see the result.What am I going wrong?
Thanks again!!!
Your approach seems fine to me.
The first thing I would look at is whether your page is valid.If you run it through the W3C validator you get 7 errors. I would fix these first and see if it helps the situation.
Thanks a lot.
I am reviewing the errors.The first one is about "No Character Encoding Found".Researching, the suggested code for Latin America is ISO-8859-01. I have added it using two available instructions:
<meta charset="ISO-8859-01">
<meta http-equiv="content-type" content="text/html; charset=ISO-8859-01">
It looks well with Internet Explorer, but not with Firefox, please see the page. Characters with accents are not recognized: http://www.libromania.cl/spanish/home_spanish_test.shtml
Without any character encoding instruction, website is working well. Why should I use one?Also, can you see if the one I am trying to use is the right one and what am I doing wrong?
Please dismiss part of my last post. Website characters are ok with character encoding ISO-8859-1.
Running W3C validator for my test page (http://www.libromania.cl/spanish/home_spanish_test.shtml)), now I get 26 errors and 2 warning.
Without any character encoding instruction, website is working well. Why should I use one?Before start modifying my website trying to fix errors, could you please confirm if this is the right character encoding for me to use? (for Spanish Latin America).
I find UTF-8 works well for most languages
But things will get messy if you don't use it everywhere.
Try losing the "0" i.e.ISO-8859-1


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How to Sell Creative Cloud for Teams
About This Episode
This is a short video about how to sell Creative Cloud for teams using a new tool called the VIP Reseller Console. The Reseller Console allows you to enroll customers, add new seats, track what has been purchased, and more. This short video shows you how this is done.
Get the latest tutorials, information and more about any Adobe cloud solution on Adobe Learn.


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So we've got a number of new products headed to store shelves this week. First, Oblivion PS3 (above) finally comes to Japan this week. The Japanese 360 version was released several months ago and has done very well. Hopefully the PS3 version will meet with similar success.
Next, the Oblivion GotY edition for Xbox 360 is shipping this week throughout Europe. It was released last week in the UK and will be in stores towards the end of the week.
Finally, Oblivion GotY edition for PS3 is looking like it's on track to ship in N. America mid-October. I think we've cleared the few remaining hurdles we had left (although I've been doing this long enough to know there's an endless supply of hurdles and someone is apt to throw one out in front of you when you least expect it). We'll let you know when we do.


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Good day sitepoint, just want to ask for some advice in creating a logo. I'm designing the client's blog and will be coding it and would like to add a logo for his blog. In creating a logo where should i start. At the moment I'm just thinking a simple logo with only typography. By the way he brings a skateboard with him sometimes when goes to the office not sure if that will help me picture a good logo for my client hehe
Ask your client. After all, you aren't clairvoyant and the guessing game is really not business like. ( for all you know he carries a skateboard because he cant afford bus fare, and it could be shame not pride... not saying is the case, just saying dont make assumptions ASK CONFIDENTLY... and then let your once you have concrete info from the source ( your client) let your imagination run wild. OH yeah, since this will lead to MANY good ideas present only 3-5 or you might confuse your client.
For me, a good starting point would be the name of the blog. I can't imagine designing anything without a name, or at least a general idea of the purpose of the blog.. Then I would ask if there are any specific colors, fonts or images that your client doesn't like.
You need to know what niche does your client operates in. It is there you can get a basis or framework for your logo. You need to be constantly in touch with your client in the designing process. In this way, you will what he/she wants in or out of the logo.
Take a proper overview of the business from the client and understand the theme of the website. You can also take the help from the websites that creates logo for free. These site will provide you the complete overview about the look and feel that your client want.
Here is some EXCELLENT principles for creating a logo:
Logo design is not as simple as you may think. You might want to outsource this part of the task if you don't know what you're doing in that area.
Making a logo of a website is not much difficult as it seems. Ashmoresign.com is a leading company in the field of logo maker. You can take experience of logo making. Just visit our site below.
The words be of English and is very well spelled, but, of the grammar and meaning may found to be without many focus.
Hello dear, At first you have to think that what does the buyer's want...try to understand.what should you do...here is huge sample logo.just look by the this link below.http://psd.tutsplus.com/?s=logo
Try here : http://www.logoblog.org/
Logo is the important thing in website, so I suggest if you don't have experience creating logo before you can outsource, leave it to experts..
I agree, it depends on your client's niche and what 'vibe' they want to come across...also it would be nice to design the logo so that all or some element of it can be used as an icon as well (may come in handy for whatever future needs arise - favicon, avatar picture, etc).
Hi,Illustrator is good for designing logo .Because It will give vector output .
What I always do is have the client draw what they envision their logo to be on a sheet of paper. I will take that and work with a vector in Illustrator then finalize the finishing touches in Photoshop. The client should be the one you ask about all of the little details.
It would better if you can mention blog name in logo; not full name just put initial letter of each word and arrange them to create a professional meaningful look. For example lookout the logo of company Clipping Path Source (http://clippingpathsource.com). It is most popular and easy way to create logo.
if you have the resouces you can learn photoshop its quick and easy
First keep in mind what is the topic of your blog and then according to the topic just pick an image and then use your blog name in your logo.
Since the OP never bothered to return to this thread, I think it's met it's purpose.


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AN offender struggling with the pressures of work and community service tried to hang himself from a tree in a secluded Burnley wood, a court was told.
Jack Brooks, 21, had called police just before he did it to tell them where he was, as he didn't want anybody else finding him.
His solicitor, Richard Taylor, told the town's crown court: "They reacted quickly. They believed he was dead when they got to him, but he was resuscitated and taken to hospital."
The hearing was told Brooks, who had flouted a suspended jail term, had since been seen by mental health workers who concluded there were no signs of depression and that he had had a 'crisis moment' – something that prompted one judge to say he was astonished and it didn't make any sense.
In March, Brooks had received 12 months in prison, suspended for a year, with 12 months' supervision, the Resolve programme and 180 hours unpaid work. He was given the sentence after admitting possessing an offensive weapon and arson.
The defendant had turned up drunk and with a knife at The Victoria pub on Colne Road, Burnley, in the early hours in January and had threatened to stab a terrified barmaid. He had also set fire to a wheelie bin.
He appeared in court on Tuesday where a breach hearing was told he had done 15-and- a-half hours of the work.
Mr Taylor said Brooks, of Walsden Grove, Burnley, tried to take his life on May 9 when things got too much for him, but was found in time. He added: "He was very fortunate."
The solicitor said Brooks had had alcohol abuse problems in the past, but had sorted them out. Mr Taylor added: "He had alcohol on the day he attempted suicide, but he says that's the only time he has drunk since."
Brooks, who was living at the family home, was now not allowed out at night on his own.
Probation officer Nicholas Powell said Brooks had no enduring mental illness. He had been seen by a crisis team after discharging himself from a mental health ward in Chorley. Mr Powell said: "He was struggling, trying to balance work and unpaid work."
Recorder Nicholas Clarke, QC, told Brooks he had not applied himself to the order and had to give it priority, otherwise he would end up behind bars.
Brooks was given a three-month curfew, between 8pm and 7am.


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Phase 2 Study of Maintenance OSI-906 Plus Erlotinib (Tarceva®), or Placebo Plus Erlotinib in Patients With Nonprogression Following 4 Cycles of Platinum-based Chemotherapy
This study has been completed.
Astellas Pharma Inc
Information provided by (Responsible Party):
Astellas Pharma Inc
ClinicalTrials.gov Identifier:
First received: August 19, 2010
Last updated: April 7, 2015
Last verified: April 2015
- Full Text View
- Tabular View
- No Study Results Posted
- Disclaimer
- How to Read a Study Record
Detailed Description:
A multicenter, randomized, double-blind, placebo-controlled, phase 2 study with a 1:1 randomization scheme.
|Non-Small Cell Lung Cancer (NSCLC) With Nonprogression Following 4 Cycles of Platinum-based Chemotherapy
|Drug: OSI-906 Drug: erlotinib Drug: placebo
|Phase 2
|Study Type:
|Study Design:
|Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary Purpose: Treatment
|Official Title:
|A Randomized, Double-Blind, Placebo-controlled Phase 2 Study of Maintenance OSI-906 Plus Erlotinib (Tarceva®), or Erlotinib Plus Placebo in Patients With Nonprogression Following Four Cycles of 1st-line Platinum-based Chemotherapy for Advanced NSCLC
Resource links provided by NLM:
Genetics Home Reference related topics: lung cancer
Drug Information available for: Erlotinib hydrochloride ErlotinibU.S. FDA Resources
Further study details as provided by Astellas Pharma Inc:
Primary Outcome Measures:
- The Progression Free Survival (PFS) of maintenance OSI-906 plus erlotinib, or placebo plus erlotinib in patients with nonprogression following four cycles of first-line platinum-based chemotherapy for advanced NSCLC in the overall population [ Time Frame: 22 months ]PFS is defined as the time from randomization to disease progression based on RECIST v1.1 or death due to any cause whichever comes first
Secondary Outcome Measures:
- Overall survival (OS) [ Time Frame: 27 months ]The time from the date of randomization until the documented date of death
- Disease control Rate (DCR) [ Time Frame: 27 months ]The proportion of patients with a best overall response of continued Complete Response (CR), CR, Partial Response (PR), OR Stable Disease (SD) based on RECIST criteria
- Best overall response rate (ORR) [ Time Frame: 27 months ]The proportion of patients with a best overall response of CR or PR based on RECIST criteria
- Response upgrade rate (RUR) [ Time Frame: 27 months ]The proportion of patients with a response upgrade
- Duration of response [ Time Frame: 27 months ]The time from the date of the first documented response (CR/PR) to documented progression or death due to underlying cancer
- Safety assessed through physical examination, vital signs, clinical laboratory tests, electrocardiograms (ECG) and Adverse Events [ Time Frame: 27 months ]
|Study Start Date:
|December 2010
|Study Completion Date:
|March 2015
|Primary Completion Date:
|July 2013 (Final data collection date for primary outcome measure)
|Assigned Interventions
Experimental: Arm A: OSI-906 plus erlotinib
OSI-906 150 mg twice daily (BID) starting on Day 1; erlotinib 150 mg once daily (QD) starting on Day 1
Drug: OSI-906
Tablet administered with food and with up to 200 mL of waterDrug: erlotinib
Tablet administered at least 2 hours after food with up to 200 mL of water
Other Names:
Placebo Comparator: Arm B: placebo plus erlotinib
placebo BID starting on Day 1: erlotinib 150 mg QD starting on Day 1
Drug: erlotinib
Tablet administered at least 2 hours after food with up to 200 mL of water
Other Names:Drug: placebo
Tablet administered at least 2 hours after food with up to 200 mL of water
Detailed Description:
Adult patients with advanced Non-small Cell Lung Cancer (NSCLC) and nonprogression after platinum-based chemotherapy will be randomized 1:1 to receive either OSI-906 plus erlotinib or placebo plus erlotinib.
|Ages Eligible for Study:
|18 Years and older (Adult, Senior)
|Sexes Eligible for Study:
|Accepts Healthy Volunteers:
Inclusion Criteria:
- Histologically confirmed locally advanced or metastatic stage IIIB or IV NSCLC
- Have experienced Complete Response (CR), Partial Response (PR) or Stable Disease (SD) following completion of 4 cycles of first-line platinum-based chemotherapy and are not progressing at time of entry into study (prior completed first-line combination bevacizumab therapy is permitted; however, current use of maintenance bevacizumab is not permitted. A maximum interval of 28 days between the last day of the treatment cycle and randomization
- Patient has recovered from prior chemotherapy-related toxicity to ≤ grade 2
- EGFR mutation status must be confirmed for participation in the study. EGFR analysis can be performed either by central or local laboratory. If analysis is done locally, verifiable documentation confirming the EGFR mutation status must be submitted for review and approval by APGD prior to randomization. If no local result is available, formalin-fixed, paraffin-embedded archival tissue representative of the tumor or in the absence of archival tissue, a fresh tumor tissue sample of sufficient size to perform EGFR mutation analysis must be submitted centrally. Results of the central analysis must be available prior to randomization. Additionally, subjects should provide tissue blocks centrally for biomarker analysis whenever possible. Ideal tissue requirement: block with ≥5 mm2 tumor area sufficient to provide four 4-micron, and five 10-micron sections)
- Measurable disease (for those patients with PR or SD after first-line platinum-based chemotherapy) according to Response Evaluation Criteria in Solid Tumors (RECIST) (version 1.1)
- Eastern Cooperative Oncology Group (ECOG) Performance Status(PS) 0 - 1
- Previous adjuvant or neo-adjuvant treatment is permitted
- Must be able to take oral medication
- Fasting glucose ≤ 150 mg/dL (8.3 mmol/L). Concurrent use of non-insulinotropic antihyperglycemic therapy is permitted if the dose has been stable for ≥ 4 weeks at the time of randomization
Adequate hematopoietic, hepatic, and renal function defined as follows:
- Neutrophil count ≥ 1.5 x 109/L
- Platelet count ≥ 100 x 109/L
- Bilirubin ≤ 1.5 x Upper Limit of Normal (ULN)
- AST and ALT ≤ 2.5 x ULN, or ≤ 5 x ULN if patient has documented liver metastases
- Serum creatinine ≤ 1.5 x ULN
- Potassium, magnesium and calcium within normal limits (supplementation and retesting is permitted)
Female patient must be either:
Of non child bearing potential:
- post-menopausal (defined as at least 1 year without any menses) prior to Screening, or
- documented surgically sterile or status post hysterectomy (at least 1 month prior to Screening)
Or, if of childbearing potential:
- must have a negative urine pregnancy test at Screening, and
- must use two forms of birth control (one of which must be a barrier method) starting at Screening and throughout the study period and for 30 days after final study drug administration
- Female patient must not be breastfeeding at Screening or during the study period and for 30 days after final study drug administration
- Female patient must not donate ova starting at Screening and throughout the study period and for 30 days after final study drug administration
- Male patient and their female spouse/partners who are of childbearing potential must be using highly effective contraception consisting of two forms of birth control (one of which must be a barrier method) starting at Screening and continue throughout the study period and for 30 days after final study drug administration
- Male patient must not donate sperm starting at Screening and throughout the study period and for at least 30 days after final study drug administration
- Prior radiation therapy is permitted provided patients have recovered from acute toxic effects of radiotherapy prior to randomization. A minimum of 28 days must have elapsed between the end of radiotherapy and randomization
- Prior surgery is permitted provided that the surgery was performed 21 days prior to randomization and adequate wound healing has occurred prior to randomization
- Patients must provide written (signed) informed consent to participate in the study and for use of tumor tissues
Exclusion Criteria:
- Prior exposure to agents directed at the Human Epidermal Receptor (HER) axis (eg, erlotinib, gefitinib, cetuximab, and trastuzumab)
- Malignancies other than NSCLC within past 3 years (exceptions if curatively treated: basal or squamous cell carcinoma of skin; locally advanced prostate cancer; ductal carcinoma in situ of breast; in situ cervical carcinoma; and superficial bladder cancer)
- Type 1 diabetes mellitus or Type 2 diabetes mellitus currently requiring insulinotropic or insulin therapy
- Prior insulin-like growth factor receptor (IGF-1R)
- Prior investigational agent within 21 days prior to randomization
- Concurrent use of maintenance bevacizumab
- History of poorly controlled gastrointestinal disorders that could affect the absorption of study drug (eg, Crohn's disease, ulcerative colitis, etc)
- History (within last 180 days) of significant cardiovascular disease unless the disease is well-controlled. Significant cardiac disease includes second/third degree heart block; clinically significant ischemic heart disease; superior vena cava (SVC) syndrome; poorly controlled hypertension; congestive heart failure of New York Heart Association (NYHA) Class II or worse (slight limitation of physical activity; comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea)
- History of arrhythmia (multifocal premature ventricular contractions [PVCs], bigeminy, trigeminy, ventricular tachycardia, or uncontrolled atrial fibrillation) that is symptomatic or requires treatment (≥ grade 3), left bundle branch block (LBBB), or asymptomatic sustained ventricular tachycardia are not allowed. Patients with atrial fibrillation controlled by medication are not excluded
- Mean QTcF interval > 450 msec based on independent central reviewer analysis of screening visit ECGs
- Use of drugs that have a known risk of causing Torsades de Pointes (TdP) are prohibited within 14 days prior to randomization
- Use of the potent CYP1A2 inhibitors ciprofloxacin and fluvoxamine. Other less potent CYP1A2 inhibitors/inducers are not excluded
- Use of potent CYP3A4 inhibitor such as ketoconazole, clarithromycin, atazanavir, indinavir, itraconazole, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, troleandomycin (TAO), or voriconazole
- Use of proton pump inhibitors such as omeprazole. Use of H2-receptor antagonists such as ranitidine are not excluded
- History of cerebrovascular accident (CVA) within 180 days prior to randomization or that resulted in ongoing neurologic instability
- Active infection, serious underlying medical condition (including any type of active seizure disorder within 12 months prior to randomization), or serious chronic illness that would impair the ability of the patient to receive study drug
- History of any psychiatric or neurologic condition that might impair the patient's ability to understand or to comply with the requirements of the study or to provide informed consent
- Pregnant or breast-feeding females
- Symptomatic brain metastases that are not stable, require steroids, or that have required radiation and/or other related treatment (e.g., anti-epileptic medication) within 21 days prior to randomization
- History of allergic reactions attributed to compounds of similar chemical or biologic composition to study drug
- Participated in any interventional clinical study or has been treated with any investigational drugs within 30 days or 5 half lives whichever is longer, prior to the initiation of Screening or during the course of the study
Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.
Please refer to this study by its ClinicalTrials.gov identifier: NCT01186861
Show 69 Study Locations
Please refer to this study by its ClinicalTrials.gov identifier: NCT01186861
Show 69 Study Locations
Sponsors and Collaborators
Astellas Pharma Inc
|Study Director:
|Medical Director
|Astellas Pharma Global Development
More Information
Keywords provided by Astellas Pharma Inc:
Additional relevant MeSH terms:
ClinicalTrials.gov processed this record on August 23, 2017
|Responsible Party:
|Astellas Pharma Inc
|ClinicalTrials.gov Identifier:
|NCT01186861 History of Changes
|Other Study ID Numbers:
2010-020916-12 ( EudraCT Number )
|Study First Received:
|August 19, 2010
|Last Updated:
|April 7, 2015
Keywords provided by Astellas Pharma Inc:
Platinum-based chemotherapy
Additional relevant MeSH terms:
Carcinoma, Non-Small-Cell Lung
Carcinoma, Bronchogenic
Bronchial Neoplasms
Lung Neoplasms
Respiratory Tract Neoplasms
Thoracic Neoplasms
Neoplasms by Site
Lung Diseases
Respiratory Tract Diseases
Erlotinib Hydrochloride
Antineoplastic Agents
Protein Kinase Inhibitors
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action
ClinicalTrials.gov processed this record on August 23, 2017


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Dog-friendly Ulpha & 3 People
Formerly a chapel, this wonderful holiday cottage, adjoining the owner's home, enjoys uninterrupted views over the peaceful Duddon Valley. It is surrounded by beautiful mature gardens that back onto established woodland, with superb views of Caw and Stickle Fells. On the doorstep are some of the best fell walking…
- 1


text:
Hey there, time traveller!
This article was published 20/1/2012 (2039 days ago), so information in it may no longer be current.
In Western cultures, in most Eastern cultures -- in fact in almost all cultures -- family lineage is traced through the male line of descent. The father's ancestors, the father's descendants, form a continuous stream of DNA that proclaims the family's presence in the world today, in history and in the future.
It is also basically stuff and nonsense, as every woman knows. The only cultures that have any guarantee of a continuous stream of DNA up and down the generations are those that trace their lineage through the mother. Everyone knows, every time, who the mother of the baby actually is; the child's paternity, on the other hand, is pretty much an act of faith.
Even so, this instinct is so deeply rooted that one suspects it is genetic rather than cultural. "It's a boy!" are the words that almost every man wants to hear when his woman delivers her first child.
For most Canadians, "It's a girl!" works just as well -- "It's healthy!" works best of all -- but that's a particular cultural thing that is not shared by everyone. Neither has it been consistent through history. In Europe and Asia at one time and even still today, babies that didn't meet their parents' requirements or were simply inconvenient were left out in the elements to die.
We are more sophisticated than that now, although the results are the same, and we have the technology to tell us just about everything about the baby long before it is born. Most pertinently in this case, we can tell what sex the baby will be very early on in the pregnancy, and that is causing a moral problem, according to Rajendra Kale, interim editor of the Canadian Medical Association Journal.
(Or at least he was interim editor until this week, when he was informed that he would not get the editor's job. Whether or not this has anything to do with controversial editorials he has written -- another article outraged medical administrators when it argued for the abolition of parking fees at hospitals -- no one will say. Coincidence, perhaps.)
In the current issue of the journal, Dr. Kale argues that the ability to identify the sex of a fetus early in pregnancy can encourage abortions, particularly when the fetus is female.
His research suggests that Asian immigrants to Canada are more likely to abort a female fetus than the general population for cultural reasons -- for example, Indian immigrants with two daughters are 50 per cent more likely to have a boy as their third child than is the national norm, a statistical anomaly he thinks may result from gender-inspired termination of pregnancies, or feticide, as it is called.
With its one-child per family population-control policy, the ratio of boys to girls, of men to women is remarkably disproportionate in China, where abortion is almost as freely available as it is in Canada and where parents look to their children -- or, more exactly, their child -- to care for them in their old age.
Dr. Kale suggests that prospective parents not be told the sex of the fetus until the third trimester, when abortion becomes more problematic.
Some multiculturalism advocates see this as racism at worst and racial stereotyping at best, and it has also been denounced as an infringement of a woman's right to know so that she can exercise her right to choose.
Dr. Kale's initiative is unlikely to go anywhere in contemporary Canada -- it offends too many politically correct sensibilities and the problem it addresses isn't that big just yet. What that means is that "It's a girl!" might not be heard as often as it used to be in the corridors of Canadian hospitals.
Medical research today is truly the Garden of Good and Evil.
Thanks to it, infertile women can become pregnant. Because of it, unwanted babies can -- metaphorically -- be put out on the Prairie to die.
Thanks to it, we live twice as long as our ancestors did just a few generations ago, which means we have twice as much opportunity to live in pain.
Thanks to medical research, or because of it, depending on your point of view, you can almost order your baby from eBay now. Gender is just the beginning. Genetic research can tell prospective parents if their children are predisposed by their DNA to any number of diseases, illnesses and conditions that would produce a baby who is something less than Daddy dreams of. Genetic modification, which is just down the road, might mean every baby will be perfect in her parents' eyes.
Recent studies, for example, show that intelligence is largely determined by DNA, as are mental and emotional dispositions to conditions such as post-traumatic stress disorder and depression. Genetic testing can also be used to determine predispositions to diseases such as Huntington's (Lou Gehrig's disease), breast cancer, ovarian cancer, Alzheimer's disease and cystic fibrosis, to name a few. If we could identify all those conditions in the womb, or shortly afterwards -- what difference does a year or two make? -- we would have a country full of Canadians who, while fewer in number and predominantly male, would be mostly hale and hearty.
It can only happen in Canada, because Canada is the only nation in the world that has no law to protect the unborn from being killed and no law to protect those lucky enough to survive the pre-birth screening process from being tabbed as genetic misfits -- "Tom is predisposed to Alzheimer's" -- as they stumble through the garden of life.


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Fubsy is a tool for efficiently building software. In concrete terms, it lets you conditionally (re)build targets from sources based on which sources have changed since the last build. Typically, targets and sources are all files in a directory tree. In theory, they can be any resource on a computer. More abstractly, Fubsy is an engine for conditional execution of actions based on the dependencies between related resources.
Fluxfont is a specialized tool that attempts to tackle the privacy concerns raised by the possibility to collect information about the fonts installed on a system. Such information can be used to uniquely identify a system. With Fluxfonts, new fonts are randomly created and removed to prevent the same fingerprint from being recreated.
epers stands for "Erlang persistence". As the name suggests, it tries to make it easy to use databases in Erlang programs, to make the language a little more agile, and (humbly) offer a nice adapter for several databases, hiding their implementation details (and the API of the library/framework/driver used to communicate with them). To achieve this, it aims to offer a somewhat consistent API to define and work with your model, while at the same not coupling your code too tightly to it.
Weed-FS is a simple and highly scalable distributed file system. There are two objectives: to store billions of files, and to serve the files fast! Instead of supporting full POSIX file system semantics, it implements only a key-file mapping. Instead of managing all file metadata in a central master, it manages file volumes in the central master and lets volume servers manage files and the metadata. This relieves concurrency pressure from the central master and spreads file metadata into volume servers' memories, allowing faster file access with just one disk read operation. It is modelled on Facebook's Haystack design paper. Only 40 bytes of disk storage are required for each file's metadata, and disk reads are O(1).
UniMote server is a universal Android-to-Linux Bluetooth remote controller for multimedia applications. It is fast and stable. It supports easy-to-develop plugins. For now, plugins for controlling these applications are available: XBMC, Clementine, VLC, and file browser. More plugins will be added as soon as the core is stable.


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For moms who breastfeed, what's your favorite thing about nursing? (Circle of Moms Sweepstakes)
Circle of Moms, in partnership with My Brest Friend, is giving away one Deluxe Breastfeeding Pillows each day, for five days. To enter, simply answer the question above by...
Started by Community on 01/31/2011 in Welcome To Circle Of Moms!!
Last update on 02/06/2011 by Renata