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__label__wiki	0.849954	0.849954	France (French: [fʁɑ̃s]), officially the French Republic (French: République française [ʁepyblik fʁɑ̃sɛz]), is a sovereign state comprising territory in western Europe and several overseas regions and territories. The European part of France, called metropolitan France, extends from the Mediterranean Sea to the English Channel and the North Sea, and from the Rhine to the Atlantic Ocean. France spans 643,801 square kilometres (248,573 sq mi) and has a total population of 66.6 million. It is a unitary semi-presidential republic with the capital in Paris, the country's largest city and main cultural and commercial centre. The Constitution of France establishes the state as secular and democratic, with its sovereignty derived from the people. During the Iron Age, what is now Metropolitan France was inhabited by the Gauls, a Celtic people. The Gauls were conquered in 51 BC by the Roman Empire, which held Gaul until 486. The Gallo-Romans faced raids and migration from the Germanic Franks, who dominated the region for hundreds of years, eventually creating the medieval Kingdom of France. France emerged as a major European power in the Late Middle Ages, with its victory in the Hundred Years' War (1337 to 1453) strengthening French state-building and paving the way for a future centralized absolute monarchy. During the Renaissance, France experienced a vast cultural development and established the beginning of a global colonial empire. The 16th century was dominated by religious civil wars between Catholics and Protestants (Huguenots). This page contains text from Wikipedia, the Free Encyclopedia - https://wn.com/France France Ô (pronounced: [fʁɑ̃s o]) is a French public television network featuring programming from the French overseas departments and collectivities in Metropolitan France. It is part of the France Télévisions group. Its overseas counterpart is Outre-Mer 1ère. It is available through cable, satellite, ADSL and the new digital terrestrial television system. Formerly known as RFO Sat, the channel was originally broadcasting 9 hours per day only. It was re-branded France Ô in 2004 in order to better show it was part of the France Télévisions group. The "O" stands for Outre-mer (overseas), and the accent shows that the channel was opened to all accents and dialects of the world, but also ensures that the name of the channel is not read as France 0 ("France zéro"). The channel became available in overseas territories in November 2010, replacing the RFO-operated Tempo. Official website (French) This page contains text from Wikipedia, the Free Encyclopedia - https://wn.com/France_Ô French wine is produced all throughout France, in quantities between 50 and 60 million hectolitres per year, or 7–8 billion bottles. France is one of the largest wine producers in the world. French wine traces its history to the 6th century BC, with many of France's regions dating their wine-making history to Roman times. The wines produced range from expensive high-end wines sold internationally to more modest wines usually only seen within France as the Margnat wines were during the post war period. Two concepts central to higher end French wines are the notion of "terroir", which links the style of the wines to the specific locations where the grapes are grown and the wine is made, and the Appellation d'origine contrôlée (AOC) system. Appellation rules closely define which grape varieties and winemaking practices are approved for classification in each of France's several hundred geographically defined appellations, which can cover entire regions, individual villages or even specific vineyards. This page contains text from Wikipedia, the Free Encyclopedia - https://wn.com/French_wine Radio Stations - Paris FunAlpes Radio Top 40 France ABC Beatles 70s,60s France Radio U Brest College France Carrément Mash Up Experimental France M2 Love Rock,Soft Rock,Adult France OÜI FM Alternatif Alternative France DYNAMHITS R&B,Hip Hop,Rap France RCT CapSao Latin Hits France Radio Arverne Adult Contemporary France Psychedelik Dark-Psyché Electronica France Radio NTI Nantes Dance,Electronica France Beaub FM 89 Indie France RFI Multi-1 (English) News Talk,News France Canal Académie Talk France France Bleu Isere Varied France Sea FM Coutances Varied France Radio Jerico Christian France Delta FM Saint Omer Adult Contemporary France Radio Gospel France Christian Contemporary,Gospel,Christian France DeeFuzz Radio Dance,Experimental,Electronica France Delta FM Dunkerque Adult Contemporary France Sweet FM Varied,Top 40 France Skyrock Pop,R&B,Rap France RMN FM Bretagne Varied France Carrément 1999 90s,Varied France Radio Floyd Rock France Radio Espérance Enseignement Religious,Christian France Alta Frequenza Pop France Fréquence Plus Pop France DJBuzz Radio Electronica France France Bleu Champagne Varied France Euro Mixx Dance France Nostalgie Poetes Varied France Fresh Radio Rock,Pop,Electronica France jazz swing manouche radio Jazz,Blues France Jazz Radio Ladies&Crooners Jazz France Hotmixradio Hits Varied France M2 80 Rock,80s,Pop France Generations Rap US Rap France Radio Liberté (FR) Varied France Radio RCJ Varied France Alouette Easy,Contemporary France Radio Saint Nabor Varied France R Meribel Varied France Nostalgie Stars 80 80s France Radio No1 Varied France Azur Blues Blues France France Bleu Drome Ardeche Varied France Radio Sentinelle Varied France MUF Radio Soft Rock,Pop France Radio Totem Gard Pop France francepost.com francefm.net iptvfrance.com francedaily.com campusfrance.com moneytalkfrance.com franceevent.com francepartyshop.com gemstonesfrance.com gemstonesfrance.org francefilmmaker.org france11.com franceautorepair.com franceposte.com energyfrance.org franceobserver.com missfranceonline.com streamingfromfrance.com francejazz.net france-fm.com , officially the French Republic (French: République française [ʁepyblik fʁɑ̃sɛz]), is a sovereign state comprising territory in western Europe and several overseas regions and territories. The European part of France, called metropolitan France, extends from the Mediterranean Sea to the English Channel and the North Sea, and from the Rhine to the Atlantic Ocean. France spans 643,801 square kilometres (248,573 sq mi) and has a total population of 66.6 million. It is a unitary semi-presidential republic with the capital in Paris, the country's largest city and main cultural and commercial centre. The Constitution of France establishes the state as secular and democratic, with its sovereignty derived from the people. Latest News for: gemstones france “A Stunning Coup”: The Almost Unsolvable Harry Winston Diamond Heists Vanity Fair 07 Aug 2019 There are no price tags on any Harry Winston jewels, but the heist was soon revealed to be the costliest in the history of France ... Their gang likely smuggled some of them out of France on flights they made before being caught. At least one gemstone shattered when they tried to extract it from its clamps....	cc/2021-04/en_middle_0068.json.gz/line1471
__label__cc	0.51636	0.48364	WORK & WORRY FINGERSTYLE GUITAR, FOLK, BLUES & BEYOND Review : Glenn Jones “Barbecue Bob in Fishtown” LP/CD (Strange Attractors Audio House, 2009) by Raymond Morin In the avant-rock band Cul de Sac, guitarist Glenn Jones and his bandmates combine fingerstyle electric guitar, krautrock rhythms and harsh electronics, creating a challenging, textured sound that defies categorization. In 1997, the group famously collaborated with acoustic guitar icon John Fahey and released the album The Epiphany of Glenn Jones. Now, over a decade later, comes the third solo outing from Jones, and on Barbecue Bob in Fishtown the spirit of John Fahey and his American Primitive approach is alive and well. Though his band is known for their experimental leanings, Glenn Jones the solo artist is considered something of a traditionalist, and the Barbecue Bob… package is very much presented in the grand tradition of instrumental acoustic guitar collections of years past. From the light-hearted cover image and the eloquent, self-penned liner notes to the tuning references and instrument notes for each song, the art direction has a classic feel… the album could pass as an artifact from any point in the last 40 years. When the included booklet is flipped over and reversed, we’re treated to a photo-diary of Jones paying a visit to Belmont Nails, for what appears to be an application of fresh acrylics. All of this is the kind of stuff that guitar geeks eat up, myself included! Well, as everyone knows, the best compliment to great packaging is great music (to listen to while staring at the great packaging, of course!) and on Barbecue Bob in Fishtown, Jones delivers some fine picking indeed. The album kicks off with the upbeat alternating bass of the title track, the bends and rolls evoking both Fahey and some of the modern purveyors of his style, such as Nick Schillace and Jack Rose. Jones’ style immediately stands apart from those players in its more relaxed attack, never quite approaching the tidiness of Schillace or the determined physicality of Rose. I find the easy, slightly ragged character of Jones’ picking to be very charming, particularly on “Barbecue Bob…”, “Dead Reckoning” and album closer “A Geranium For Mano-a-Mano”. (MP3 Returning Soon) Glenn Jones – “A Geranium For Mano-a-Mano” There are two brief banjo pieces on the album, and both are compelling listens. Mood and tempo-wise, “Keep It A Hundred Years” and “A Lark In Earnest” are very similar, a possible product of Jones’ relative newness to the instrument… but in spite of this, his knack for composition wins out, and the banjo songs stand up as some of the most melodically driven on the album. “Keep It…” contains some unexpected chord changes, keeping it interesting and unpredictable, while “Lark…” benefits from a simple, memorable melodic theme and some very nice finger-rolls. Glenn Jones in action “1337 Shattuck Avenue, Apartment D”, Jones’ tribute to Robbie Basho, is one of the most emotive tracks on the disc, and also its longest. In the liner notes, Jones explains that this loosely structured composition was one of many takes, and was chosen for its “uncertain” feel. There is definitely a palpable degree of uncertainty in the playing, with many of the notes fretting out around the 4 1/2-minute mark as Jones begins descending into dark, dissonant territory. Still, the emotional thread that runs through the song, coupled with the variety of the sections, keeps the listener wholly invested. My favorite song on the album is “For Wendy, In Her Girlish Days”. This selection contains some of Jones’ most delicate and beautiful playing, and its primary theme is a nice hybrid of Leo Kottke-style alternating bass and chord voicings, supporting a vaguely British-tinged melodic approach. Glenn Jones – “For Wenday In Her Girlish Days” Glenn Jones is something of a staple in the current solo acoustic guitar movement, and Barbecue Bob in Fishtown makes a great case for why that is. Jones’ playing shows him to be a guitarist with a distinctive touch, an experienced player with a pleasing affection for traditional picking as well as a flare for varied and innovative composition. Buy the LP or CD from Strange Attractors Buy the LP or CD from Insound Glenn Jones’ website Glenn Jones’ on Myspace This entry was posted in Reviews and tagged Acoustic Guitar, American Primitive, Barbecue Bob in Fishtown, Boom-chick, Cul de Sac, Fingerstyle, Folk, Glenn Jones, Guitar, John Fahey, Strange Attractors on October 20, 2009 by Work & Worry. ← Pierre Bensusan, New Box Set and Documentary Film Interview : Yair Yona → 1 thought on “Review : Glenn Jones “Barbecue Bob in Fishtown” LP/CD (Strange Attractors Audio House, 2009)” Pingback: World Premiere : Glenn Jones “Of Its Own Kind” Video Search Work & Worry Subscribe to Work & Worry Sound Good, Sign Me Up! Antisocial Networking Links	cc/2021-04/en_middle_0068.json.gz/line1473
__label__wiki	0.891152	0.891152	Criminal Justice and Drug Policy Reform Freedom of Speech and Government Transparency Gender Equity and Reproductive Justice Even in COVID, student mental health is still not a priority Unhoused people don’t lose their civil rights at the shelter door Five takeaways from this election season Racial Justice Framework Transfer Stock Kern County Sued Over Secret Court Proceedings ACLU SoCal Communications & Media Advocacy, communications@aclusocal.org, 626-755-4129 First Amendment Coalition, FAC@firstamendmentcoalition.org, 415-460-5060. In Violation of 1st Amendment, the Public has Been Denied Access to Court Proceedings BAKERSFIELD — A cornerstone of our democracy is that court hearings and trials are not held in secret. But that’s what happening in Kern County Superior Court where proceedings — including jury trials — are being held out of public view. In-person access was originally cut off because of the COVID-19 pandemic, but courts across the nation, including many in California, have provided video or audio feeds of court proceedings. In most cases in Kern County, however, even family members were turned away from courthouses and not given options for remote access. It’s not just a hardship, it’s also unconstitutional. Today, the American Civil Liberties Union Foundations of Southern and Northern California, and the First Amendment Coalition filed a lawsuit in U.S. District Court in Fresno against Kern County Superior Court officials for denying access to court proceedings in violation of the First Amendment to the U.S. Constitution. The suit comes at a time when many businesses in Kern County, including bowling alleys and hair salons, have been permitted to reopen. Still, Janie Randle, who is one of several plaintiffs in the lawsuit, has been denied access to court hearings in Bakersfield concerning her son, accused of attempted murder. “The Bakersfield mall is now open, as are some casinos in the county,” Randle said in a declaration for the lawsuit. “I do not understand why it is okay to open up casinos but we cannot go into the courthouse. That fact that people can gamble but I can’t watch my son’s court hearings is not right.” Another plaintiff, Tanisha Brown, was turned away when she tried to observe a June 10 hearing in the case against her son, arrested during a rally in Bakersfield protesting police brutality against Black people. Others also at the courthouse to support her son — who was beaten so badly during the rally that he was hospitalized — were likewise refused entry. “During this period of intense police violence and misconduct,” Brown said in her declaration, “it is really important that I’m in the court to make sure the police and prosecutors don’t railroad my son, a young Black man who’s never been in trouble. I want to make sure that he doesn’t accept charges or a plea deal that he shouldn’t accept, and that the court doesn’t take the opportunity of an empty courtroom to throw excessive charges at him.” The access restrictions began on March 23 when the Kern County Superior Court issued a standing order barring the public from attending proceedings. Even when the court announced on May 22 that it would begin summoning jurors for trials, the court said that the “standing order restricting courthouse entry is still in place.” Earlier this month, the court said members of the public would be allowed to attend hearings or be provided with audio streams. But implementation of that policy has been highly erratic at best, and for the most part family members and other observers were still turned away and denied alternatives. Signs were still up in courthouses, declaring, “If you are not an attorney, party, defendant, or subpoenaed courthouse witness, you should not enter the courthouse and you should return home.” “Even one secret proceeding is one too many,” said Kathleen Guneratne, senior staff attorney at the ACLU NorCal. “Kern County should immediately stop denying family members their First Amendment right to attend court hearings. No one can have confidence that a court proceeding is fair if no one can watch.” The lawsuit asks a federal judge to require the Kern County Superior Court to allow in-public access consistent with social distancing and a viable alternative method for remote access. “This is no time for government secrecy, especially in the criminal justice system," said First Amendment Coalition Executive Director David Snyder. "Kern County Superior Court must find a way to let the public back in.” Read the lawsuit here: https://www.aclusocal.org/sites/default/files/aclu_socal_v_harber-pickens_20200626_complaint.pdf pdfACLU SoCal v. Harber-Pickens - Complaint https://www.aclusocal.org/sites/default/files/aclu_socal_v_harber-pickens_20200626_complaint.pdf ACLU SoCal 2020 Ballot Guide How To Cast Your Vote in 2020 Know Your Voting Rights 101 McFarland Sued Over Unlawful Approval of Huge ICE Detention Center Banning My “Phenomenally Black” Shirt Is Only a Symptom of the... Vote-by-Mail: Safe, Secure, Reliable ACLU Letter Criticizes School District for Free Speech Violations Assembly Constitutional Amendment 6 Passes CA Senate ACLU SoCal, Black Lives Matter-L.A. on Cancelation of Curfews Search aclusocal.org © 2021 ACLU of Southern California	cc/2021-04/en_middle_0068.json.gz/line1476
__label__wiki	0.873365	0.873365	Reporting Africa Since 1960 17 January 2021 by country & category Click here to see more maps Population: 0.957 mn. GDP: $1.85 bn. Debt: $2.06 bn. news from Djibouti Found 36 articles. Displaying 1-10 out of 36 results. Vol 58 No 8 \| Guelleh quells opponents Human rights campaigners and a main opposition party are targeted by a severe crackdown overseen by President Ismaïl Omar Guelleh amid apparent international indifference. Vol 57 No 15 \| Saudi wants one too Saudi Arabia looks certain to join the growing band of nations with military bases in Djibouti, Africa Confidential can reveal. On 12 July, Deputy Chief of General Staff of the Sau... Guelleh opts for landslide President Ismaïl Omar Guelleh won with a disputed 87% of the vote in the 8 April presidential poll. The leader of the opposition Union pour le salut national, Omar Elmi Khaireh, c... POW row heals President Ismaïl Omar Guelleh has been trying to capitalise on obtaining the release of four Djiboutian soldiers from Eritrean custody after mediation by Qatar. He hopes it will h... Guelleh's court shame Two months ahead of national elections, President Ismaïl Omar Guelleh has experienced what must rank as one of most spectacular drubbings of a foreign head of state on British soi... Bengal paper tiger Concern about China's new naval base in Djibouti is not going away after Indian forces spotted a Chinese submarine in the Bay of Bengal. China signed an agreement with Djibouti in ... Base motives As China deepens its commitment to a base in Djibouti, a London court has heard how illicit Chinese funds may have indirectly helped President Ismaïl Omar Guelleh win election... Guelleh battles in court It started as a legal dispute with a business partner but now the President’s credibility is on trial and his wealth is on open display It points to the fragility of President Ismaïl Omar Guelleh's position that a mismanaged legal battle with one of his political rivals in London's High Court could undermine h... Red sea rivals Now that Japan has relaxed its prohibition against overseas military operations, its move to revamp its base in Djibouti may offer new opportunities for confrontation with China. J... High Court awaits Guelleh A High Court judge in London has ordered Djibouti's President Ismail Omar Guelleh to give evidence in person next month in the increasingly fraught case between the Djibouti govern... Become a subscriber today to read our articles in full. Looking for a specific issue? Search our online archive of over two decades of Africa Confidential Volume: 62 61 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 Not yet ready to subscribe to Africa Confidential? Then why not register for our free email alerts. Every two weeks you get a concise snapshot of the latest issue so you're made aware of which issues we cover each fortnight. Stories by country Congo-Kinshasa (Dem. Rep.) São Tomé and Principe NewsCurrent Issue Africa-Asia News by Issue News by Country/Category Copyright © Africa Confidential 2021	cc/2021-04/en_middle_0068.json.gz/line1482
__label__cc	0.662333	0.337667	Home News Firm moves to end reliance on imported tomatoes Firm moves to end reliance on imported tomatoes Over 75 per cent of harvested tomatoes get wasted yearly in the country, basically due to lack of storage facilities; and limited means of making use of them industrially, resulting into acute shortage off season. Bags of dried tomatoes, waiting to be processed into tomato paste. This development has led Nigerians to total reliance on imported puree, making it Nigeria the biggest importer of tomato paste in the world. However, majority of the tomato pastes in the market are fake and substandard. Based on the present administration’s policy to patronise home made goods, Erisco Foods Limited, Lagos, has promised to meet local tomato needs by December, provided government stops importation of substandard tomato paste into the country. At present, the company says it has tomato paste processing plant with capacity to produce above 450,000 metric tons per annum, among other product lines.According to the President/CEO of the company, Eric Umeofia, who spoke during the confirmation of its tomato processing plant, in Lagos, over five million jobs will be created for farmers, indirectly in Katsina, Jigawa and Sokoto States, through the ongoing backward integration projects, with the target of starting production in Katsina in the first quarter of 2017. “Nigeria is blessed with two favourable planting and harvesting seasons, whereas China that exports tomato product to Nigeria has only one favourable planting and harvesting season, due to the climatic condition. Worst still, both the Indians that form the majority of people that import substandard tomato paste and China do not consume in their own country, the same quality of tomato paste they produce and dump in Nigeria. “Still, they pay little or nothing as import duty. So, can you see that the mafias are determined to kill our people and economy with impunity, in connivance with few civil servants. We thank President Muhammadu Buhari and his party’s determination to task Nigerians to produce what we need and eat what we have,” he said. Umeofia noted that with the initiative of his company to convert fresh and dried tomatoes into paste, the ingenuity will save the country over US$1b, being spent annually on importation of tomato paste. “In addition, we will also export and earn hundreds of million of money in 2017 after meeting the tomato needs of every Nigerian in December 2016. Provided that government stops the dumping of substandard tomato paste, we will employ over 50,000 youths in two to three years, with over five million jobs created for farmers.” How To Start A Vegetable Oil Production Company Are you interested in starting a vegetable oil production company? Do you need a sample vegetable oil production business plan template? Then below is... How To Start A Livestock Feed Production Business How To Produce/Make Pig Feed How to Get More Young Entrepreneurs into Farming Goat Farming, A Goldmine Waiting To Be Tapped Farming Gives Us Hope – Persons With Special Needs Rice Smuggling: FG To Stop Customs From Raiding Markets (VIDEO INCLUDED)	cc/2021-04/en_middle_0068.json.gz/line1485
__label__wiki	0.709845	0.709845	Diver Finds A Working iPhone At The Bottom Of A River By Adam Walker - November 6, 2019 Michael Bennett loves to dive for sunken treasure in the rivers and lakes of his community. When he is not diving for lost items, he is editing and posting the videos he makes of his various dives onto his online profile. While the sunken treasure he finds is often useless, One day when he decided to dive in the black waters of Edisto River in South Carolina Michael encountered that was tremendously important to someone else. On his dive just 10 ft below the water’s surface, Michael had uncovered a lost iPhone that had been submerged for 15 long months. When he found the phone it was wedged between a rock and the riverbed and it was in a waterproof case attached to a lanyard. Michael couldn’t believe that he had found something in a waterproof case and he wondered if the phone had been protected from the river’s water. Layers of silt and grime covered the phone but he could clearly make out its shape and model. When Michael got home he decided on a whim to try and plug the phone into a charger. To his astonishment, the phone soon turned on! But joy soon turned to sadness when he realized that the phone was password protected. That’s when Michael decided to try the phone’s sim card in a different phone, so using his own phone he switched the sim cards and turned on the phone. Luckily Michael was able to access the sim cards contact information and find the phone’s owner. So far Michael’s adventure with the phone had been exciting, but he never could have imagined that he would end up helping a daughter reconnect with her dead father. You see, the phone belonged to Erica Bennett (no relation to Michael) who had lost the phone while on a family adventure on the river. Erika explained that the phone was lost 15 months earlier and she had been searching for it because it had all of her late father’s last messages and voicemails. With the phone and its sim card was able to access her voicemail box and listen t the final message her father left her before he died. Michael was happy that he could deliver such great news and comfort to Erica and he says it is because of stories like this that he will continue to dive the rivers in search of long lost items. World Traveling is a one-stop destination for avid travelers, offering the latest luxury travel news, resorts, exciting destinations and deals worldwide. © worldtravelling Top Tourist Destinations in Thailand for 2021 Rosa Joseph 7 European-style Christmas Markets You Can Experience in the U.S. 5 Little Known Facts About Brazil What To Know Before Climbing Mt. Everest Five Little Known Things About Uganda Food And Drinks To Avoid While Flying	cc/2021-04/en_middle_0068.json.gz/line1491
__label__cc	0.56609	0.43391	UN Women: Partnerships Development Specialist Organization: United Nations Development Programme (UNDP) Location: Abu Dhabi (United Arab Emirates) UNDP is committed to achieving workforce diversity in terms of gender, nationality and culture. Individuals from minority groups, indigenous groups and persons with disabilities are equally encouraged to apply. All applications will be treated with the strictest confidence. UNDP does not tolerate sexual exploitation and abuse, any kind of harassment, including sexual harassment, and discrimination. All selected candidates will, therefore, undergo rigorous reference and background checks. The UN Women, grounded in the vision of equality enshrined in the Charter of the United Nations, works for the elimination of discrimination against women and girls; the empowerment of women; and the achievement of equality between women and men as partners and beneficiaries of development, human rights, humanitarian action and peace and security. Placing women’s rights at the center of all its efforts, the UN Women will lead and coordinate United Nations system efforts to ensure that commitments on gender equality and gender mainstreaming translate into action throughout the world. It will provide strong and coherent leadership in support of Member States’ priorities and efforts, building effective partnerships with civil society and other relevant actors. About the UAE Liaison Office for the Gulf Cooperation Council (GCC): The UAE Liaison Office for the GCC was inaugurated in 2016 to focus on 3 areas in terms of its mandate. These include advocacy for UN Women to drive its global mandate, resource mobilization for UN Women programs globally and coordination of partnerships to drive the work and strategic priorities of UN Women in the GCC region. The office acts as a liaison between UN Women globally and stakeholders in the GCC from the private sector, government, academia and non-profits. The office reports to UN Women global headquarters. Reporting to the Director of the UAE Liaison Office, the Partnerships Development Specialist will provide technical support to the development and management of UN Women’s strategic partnerships and relationships, and resource mobilization strategy. The incumbent will work under the supervision of the Director in the Abu Dhabi LO in close collaboration with the Resource Mobilization Branch at UN Women Headquarters and the Arab States Regional Office. Provide technical support to the development and management of UN Women’s strategic partnerships in the Gulf region: Manage and coordinate relationships with key partners; provide technical inputs to senior management’s efforts to develop new and innovative partnerships; Set and monitor annual priorities, goals and key performance indicators (KPIs) for regional partnerships; Provide strategic advice to the Director on building and maintaining partnerships and positioning with potential donors, including Civil Society, Private Sector and other relevant stakeholders. Develop relationships with key private partners; provide substantive technical inputs to senior management’s efforts to develop new and innovative partnerships; Manage UAE National Chapter of the Unstereotype Alliance, providing technical and operational support to the Chapter, liaising with private sector partners and UN Women HQ. Facilitate/ Coordinate the implementation of the GCC resource mobilization strategies and initiatives: Coordinate the development and implementation of differentiated, donor fund-raising strategies, aligned and coordinated with GCC activities initiatives and outreach activities. Develop targeted products and initiatives to enhance the capacity of UN Women to mobilize core and programmatic resources and attract additional donors’ funding; Undertake ad-hoc donor studies, research, and other activities to identify funding opportunities; update the resources mobilization strategy as needs emerge; Provide technical support to and ensure coordination with the Regional Office for Arab States on resource mobilization strategy and outreach to GCC countries. Build trust and maintain effective corporate relationships with Donors: Provide technical support to the Director and other senior managers in the preparation of missions, meetings and other consultations with donors, including the preparation of notes, briefs and other materials; Act as a direct entry point for partners, building institutional relationships; Provide regular updates on donor profiles, databases (e.g. contacts management) and donor intelligence; Identify opportunities to secure additional non-core resources; Monitor emerging issues that could affect partnerships and resource contributions at the GCC level; Provide technical support to the drafting and review of partner-specific Framework Arrangements and Cost Sharing Agreements, and the preparation of brief funding proposals and concept notes, where appropriate. Coordinate the submission of high quality and timely reports to Donors: Maintain systems to promote compliance with the terms of grants and agreements, across the region; Provide technical support to programme managers for the preparation of high quality and timely donor reports. Participate in knowledge building and provide support to strengthen internal resource mobilization capacity: Contribute to the development of knowledge products and mechanisms to effectively position UN Women in the region wherever possible; Share knowledge and enhance organizational learning among UN Women regional and field offices through the development and use of on-line tools, templates, tips, mechanisms and guidelines; Facilitate partnership and resource mobilization training to program staff and managers based in the Liaison Office for the Gulf Region including the development of tools and products, as needed; Advise on the creation of UN Women communication products, packages and positions. Contribute to the UN Women communications activities and advocacy efforts: Liaise closely with UN Women Communications Team at HQ to coordinate communication activities ensuring consistency with corporate policies, messaging and initiatives; Contribute to UN Women corporate activities to highlight GCC partnerships initiatives in GEWE; In adherence with UN Women Communications policies, and in collaboration with HQ Communications Section, contribute to communication activities to increase UN Women visibility in the GCC region in relevant UN Women online platforms and other social media platforms (Twitter, Facebook, Snapchat, Google+, Instagram, LinkedIn). Impact of Results: The key results have an impact on the overall Liaison Office efficiency and success in implementation of operational strategies as they relate to the use of corporate resources. The results also impact on staff morale within the office. Timely attention and response to UN Women’s partners and donors; Timely targeting of funding opportunities and timely tracking of donor intelligence. Quality communication and advocacy products which result in increased resources and a strong investment case for UN Women; Quality knowledge products and timely sharing of best practices to improve/ enhance donor relations; Quality monitoring and reporting mechanism to ensure quality of data and limit redundancy in efforts. Respect for Diversity; Professionalism. Awareness and Sensitivity Regarding Gender Issues; Creative Problem Solving; Effective Communication; Inclusive Collaboration; Stakeholder Engagement; Leading by Example. Please visit this link for more information on UN Women’s Values and Competencies Framework: https://www.unwomen.org/-/media/headquarters/attachments/sections/about%20us/employment/un-women-values-and-competencies-framework-en.pdf?la=en&vs=637 Functional Competencies: In-depth knowledge of gender equality and women's rights issues; Demonstrated ability to interact effectively with government representatives of Member States (donor and programme); Proven networking skills, and ability to mobilize support on behalf of UN Women; Excellent negotiating skills; Knowledge and understanding of UN system and familiarity with inter-governmental processes; Excellent IT skills, including databases, extranet and office software packages; Strong risk management skills; Strong analytical and interpersonal skills. REQUIRED SKILLS AND EXPERIENCE Master’s degree or equivalent in economics, business management, social sciences, public administration, international relations, communications, women's studies, or a related field is required. A first-level university degree in combination with 2 additional years of qualifying experience may be accepted in lieu of the advanced university degree. At least 5 years of progressively responsible experience in resource mobilization, communications/ advocacy, and/or business development; Experience in gender equality and women's empowerment; Experience working with civil society organizations, international institutions and donors; Experience working in the UN system is required. Fluency in English and Arabic working language is required; Knowledge of another UN working language is an asset; Knowledge of the Arab Gulf Region is an asset. All applications must include (as an attachment) the completed UN Women Personal History form (P-11) which can be downloaded from https://www.unwomen.org/-/media/headquarters/attachments/sections/about%20us/employment/un-women-p11-personal-history-form.doc?la=en&vs=558. Kindly note that the system will only allow one attachment. Applications without the completed UN Women P-11 form will be treated as incomplete and will not be considered for further assessment. In July 2010, the United Nations General Assembly created UN Women, the United Nations Entity for Gender Equality and the Empowerment of Women. The creation of UN Women came about as part of the UN reform agenda, bringing together resources and mandates for greater impact. It merges and builds on the important work of four previously distinct parts of the UN system (DAW, OSAGI, INSTRAW and UNIFEM), which focused exclusively on gender equality and women's empowerment. Apply at UNDP's Website © Worldwide jobs – 2021. 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__label__cc	0.588992	0.411008	Coincheck to Return $425M in Virtual Money Lost to Hackers Tokyo-based cryptocurrency exchange Coincheck Inc said Sunday it would return about 46.3 billion yen ($425 million) of the virtual money it lost to hackers two days ago in one of the biggest-ever thefts of digital money. That amounts to nearly 90 percent of the 58 billion yen worth of NEM coins the company lost in an attack Friday that forced it to suspend withdrawals of all cryptocurrencies except bitcoin. Coincheck said in a statement it would repay the roughly 260,000 owners of NEM coins in Japanese yen, though it was still working on timing and method. Theft and security The theft underscores security and regulatory concerns about bitcoin and other virtual currencies even as a global boom in them shows little signs of fizzling. Two sources with direct knowledge of the matter said Japan’s Financial Services Agency (FSA) sent a notice to the country’s roughly 30 firms that operate virtual currency exchanges to warn of further possible cyber-attacks, urging them to step up security. The financial watchdog is also considering administrative punishment for Coincheck under the financial settlements law, one of the sources said. Japan started to require cryptocurrency exchange operators to register with the government in April 2017. Pre-existing operators such as Coincheck have been allowed to continue offering services while awaiting approval. Coincheck’s application, submitted in September, is still pending. Coincheck told a late-Friday news conference that its NEM coins were stored in a “hot wallet” instead of the more secure “cold wallet,” outside the internet. Asked why, company President Koichiro Wada cited technical difficulties and a shortage of staff capable of dealing with them. Shades of Mt. Gox In 2014, Tokyo-based Mt. Gox, which once handled 80 percent of the world’s bitcoin trades, filed for bankruptcy after losing around half a billion dollars worth of bitcoins. More recently, South Korean cryptocurrency exchange Youbit last month shut down and filed for bankruptcy after being hacked twice last year. World leaders meeting in Davos last week issued fresh warnings about the dangers of cryptocurrencies, with U.S. Treasury Secretary Steven Mnuchin relating Washington’s concern about the money being used for illicit activity. Posted in: Silicon ← ‘Beetle Bailey’ Cartoonist Walker Dies at 94 Using Technology to Teach Not Distract →	cc/2021-04/en_middle_0068.json.gz/line1494
__label__cc	0.520653	0.479347	From an Embarrassment of Riches to Just Plain Embarrassment Chuck Cook-USA TODAY Sports Jesse Dumas By Jesse Dumas follow This is what happens when you cut the head off an organization. All hell breaks loose. It's well past time to stop lamenting the loss of the finest head coach this franchise has seen in the last 20 years, but holy-living-Christ, do the hits just keep on coming! I'll admit, I scoffed initially at the narrative that all the players were jumping ship due to the regime change. Losing Frank Gore, Mike Iupati, the cornerbacks, all that was to more or less be expected considering the free agency talent pool and the cap numbers in play. But the early exits of Pat Willis, now Chris Borland, and more than likely Justin Smith (ok, a not-so-early exit in his case), smack of a team that has no reason to keep fighting the good fight. No hometown discounts this year, no suit-em-up-one-last-time-and-get-it-done storylines. It's hard to leave a team or a group if you feel you're a part of something special, something bigger, but when it's every man for himself, opting out is a hell of a lot easier. Jed York sent a pretty clear message that there was plenty to him that was more important than winning this year. He expects the respect being at the top of the hierarchy usually commands and should that fail him, he'll use the inherent power he's been gifted and make nice, big, ham-fisted cuts. It's his team after all, the future be damned. Canning the most successful coach in decades, asshole or no, doesn't resonate within the locker room, it spreads doubt like a virus. Sure, I'm guessing more than a few players are fine fans of Jim Tomsula, but he ain't the hard-driving workaholic lunatic the last guy was. You may not want to have Jim Harbaugh over to meet your parents or speak at your wedding, but if you need to win football games, this was your guy. There was still enough leadership in the locker room that remembered what it was like before he got here, and just as we fans dread a return to the bad-old-days, those players have to dread it even worse. Sure, they're professionals and there's the paychecks to prove it, but those guys that have had enough skin in the game all these years and made their money, why stick around to watch the whole thing grind into mediocrity? I'm sure Jed's far too busy to read small-time hacks like myself, but if he happens to glance at this little piece, I'd like to give him some advice about being like his uncle Eddie, someone he so desperately wants to be identified with. You want respect? You show it. Recall the imagery of Eddie Debartolo in the locker room hugging and laughing and crying with his players. Remember Eddie punching out a Green Bay fan in Lambeau after a particularly tough playoff loss. That was no show, Jed. No cloying to the media. No hollow words crafted by PR yes-men. Eddie respected the hell out of those players and he took care of them like no other owner in the league in that era and he wore that respect and love on his sleeve. Do your players even talk to you? An owner that respected his players never would have undermined their coach, effectively torpedoing a season, and run him out of town in such a fashion. It's more than bad business, it's disrespectful, shameful, and embarrassing. Now we're all getting to see that, as usual, you reap what you sow. Be careful what you wish for, Mr. York. You wanted your coach gone, and you got it, but it's becoming increasingly obvious that you never considered what dominos might start falling as a result. Please, take yourself out of this bubble you live in, that of the historically out-of-touch decision making, and start respecting your team, not to mention your fan base. You're right, Jesse, with regards to my opinion not being any more important than yours. Please accept these words from Exodus 20:7 (the 3rd commandment) instead. "You must not misuse the name of the Lord your God. The Lord will not let you go unpunished if you misuse His name." Not my words or my opinion Jesse . . . . just the honest truth offered in love. Response: And in your opinion, that book was written as the breath of God. I don't share that opinion. "Holy living Christ". Really? You may be upset and unhappy with the off season the 49ers are having (who isn't?) but please show respect for the Lord's name and be sensitive to Christians who find this level of insensitivity offensive. He deserves our utmost respect and reverence, not crass language to emphasize a point. Thank you. Response: The interesting thing about communication is that it's all based on one person's perspective. What's completely innocuous to one person might be completely unacceptable and offensive to another. I'm telling you right now that, as a Christian, I don't get offended by such a phrase. I can respect that your opinion is different than mine, but you sure as hell can't tell me that yours is any more important than mine. I'll continue to write in any style I choose, you can choose to read it or not. Happy Easter Brian. While I'll agree to most of that I think one thing is missing and that doomed Jed and Harbaugh. He was not willing to part with Greg Roman. Harbaugh played into this as much as Jed. I totally agree he no where near the owner Eddie was and I doubt we will ever have another owner like him. It is to business oriented now. zachameen Hay Jesse, Thank you for not banning me from leaving comments here, unlike Matt Maiocco and others for showing my 49ers fan emotions. I never used cuss words but I am still banned from leaving comments. I have been a 49ers fan since they have won their first Superbowl. I still love and respect Eddie Debartolo for what he did for the City of San Francisco. I hate York family which turned 49ers to a laughing joke of entire NFL. They are only interested in making money and don't care about the game of Football. I really want York Family to sell 49ers because they are "NOT" worthy of owning this team. They killed the team spirit. They turn 49ers Stadium into flee market. **** Response: No Worries! Thanks for reading! 50 year FORMER faithful I quote the silver spoon boy numbskull: "And I think what we're trying to do is build a team that focuses on our core strengths. I think we got away from that a little bit. I think we tried to do too much and be something that we weren't. I think you're gonna see us get back to the basics, get back to letting our players go out and make plays. . . . You look at our offense last year. It wasn't I think where it should have been. I think we have better talent than what our results showed." I think I think I think I think blahblah blah bla YOU DONT KNOW JACK SHIT JED, YOU GOT AWAY FROM WINNING BECAUSE YOU LET BAALKE BACKSTAB HARBAUGH AND THEN THREW HARBAUGH UNDER THE BUS BEFORE THE SEASON EVEN STARTED. AFTER 3 NFC TITLE GAMES AND ONE SUPER BOWL APPEARANCE?? YOU ARE AN IDIOT, A COMPLETE FULL FLEDGED SILVER SPOON DIPSHIT IDIOT. ENJOY WATCHING THE TEAM LOSE FROM THE OWNERS BOX OF YOUR CRAPPY NEW STADIUM DEVOID OF FANS WHO DONT WANT TO PAY TO WATCH LOSING YORK FOOTBALL. YOU WILL NEVER WIN A SUPER BOWL, EVER, EVER, YOU INCOMPETENT FRAUD Response: He should never, ever, be talking about strategy on the field. Defer that to your coach and GM. The Dork Family perpetrated the biggest scam since manhattan went for a bag of beans... Bagholders aka season ticket holders would otherwise revolt if not for the fact their brains are being roasted in that joke of a toaster oven... And a dark and dismal age dawned upon the land.... Dallas Niner Fan Great article, totally agree. Your readers need to learn how to read before they criticize you. You didn't say that players were leaving because of York, you said: " It's hard to leave a team or a group if you feel you're a part of something special, something bigger, but when it's every man for himself, opting out is a hell of a lot easier." The fact that the 49er organization is a rudderless ship that makes bad decisions is the main issue here and it filters down in the organization in many ways. When players make the decision to leave an organization there are many factors that go into the decision and its not unreasonable to conclude that lack of leadership at the top is a big part of that overall final decision. Hope you don't mind my interpretation of your fine piece. Response: Good interpretation and a fair assessment. Thanks for reading! First off wasn't happy they let Harbaugh go, but we got to move on. As far as the retirements and free agent loses they were going to happen even if Harbaugh stayed. Will I miss those players, sure. But will be fine with Hyde, Bush, Hunter in the backfield and most people forget about OG Brandon Thomas who we drafted and stashed. Torrey Smith will be a big plus at WR, as far as the defensive loses that's why we have a draft. Tomsula has been getting hammered and I'm sure he will bring the us against the world mentality to the team. This is still a good football team !! And like I tell people this is the best time to be a Niner fan the bandwagoners are jumping off, the so so fans a whining, and all that's left is us Faithful !! Response: Talent wise, still a lot going for this group. The coaching staff could shock everyone, but it would be just that, a shock. tee perez Jed york if your listening you need to start listening, and if your not then REALLY NEED TO START LISTENING.... because alot of your decision making lately shows lack of respect and lack of understanding.... bottom line SO WHAT if you own the team ,, WITH OUT YOUR FAN BASE YOU AINT NOTHIN.... all the money in the world cant buy you your teams respect and loyalty..... start putting the team first and not your ego Mutant-man49 To even compare the talent on this team to what Sanders dealt with is moronic. Smith has contemplated retirement for the last few years, Willis' body just could do it anymore and Borland is being proactive. I'm sure all three got together and planned this mass exodus because they're tired of Jed. Do you honestly believe that man? I can see Barry Sanders leaving but 3 players from one team colluding together is ridiculous. While you're at it, why don't you "blame Jed" for the retirements of Locker and Worilds this offseason as well. Response: Thanks for reading Mutant, just read a little closer next time and maybe get your parents to help you with the big words. Colluding would mean they made the decision together, never implied that. They, as individuals, decided that strapping it up for another year wasn't worth the effort and part of that decision was likely made on the fact that they'd be starting over with a new head coach. As far as Barry Sanders is concerned, that dearth (that means "lack")of talent was due to shitty management. Barry knew that wasn't going to change and he hung em up. NJ Niners There are two positive things and that will happen this year and they are we will get the first draft pick in 2016 and a new GM who will not be a YES man!!! Response: I don't think they're going straight to the cellar and I still contend Baalke knows football talent, but the coaching staff is 2nd rate at best right now. Chuck Weber No self respecting player is going to want to play for an owner that doesn't respect the head coach and his players. Hence the exodus. Jed Dork you deserve 1-15, I am so glad I off loaded my SBL seats. Response: Wow, that had to cost you. Zach Ameen I also wonder why 49ers so heavily investing in coach Killer Kaeperror instead of letting him join New England Patriot as a third stringer behind Tim Tebow for NFL's minimum salary. Response: Lost me! I am starting to fee sorry for Tomsula. He is doomed from the start. He made a big mistake by taking a charge of a No-Team in Chaos. Response: He got a promotion he didn't deserve, can't fault the guy for taking it. My bad for Calling him a Dork :) Response: All good in here friend! Really Dum-ass....I guess Willis, Smith and Borland are the first trio in the history of sports to choose retirement over playing for a shitty owner?LMFAO! How stupid does that sound? Of all the poorly run organizations over the years (Raiders, Clippers, Jets, Cubs, etc.), the Niners are the first one to have world class players so fed up with upper management, that hanging me up is the best option. If anything Dumas, I think your "blame Jed" mantra could sell thousands of t-shirts. Response: Barry Sanders did it. Try again. (Congrats on being the first person in the history of ever to make that joke about my name, I can just hear you chuckling audibly between your mouth breathing at the keyboard, so proud of your clever wit...) Therickestrick ! This Is a real article, expressing the real feelingings of a lot of Niner Empire! Jim was the rat thing that happened to our team in years, and to think that it can be replaced without backlash is nyeve !! TheRickestRick Sounds like you peaked in journalism at West Valley and still weren't the top of your class. Do you really think any of the coaches had any say in a players heart? If you do then you should join a head start program. York is a punk for running Harbaugh out of town but to blame this offseason on management is plain ruhtarded. Is Harbaugh > God and purpose in Willis' eyes? Or > than possible permanent brain trauma in the eyes of Borland? Seriously just slap yourself for continuing the chicken little trend the zone wants to hear. Correlation does not imply causation. Please let us know your actually screen name so we can ignore your posts in the future. Response: My actual name is Jesse Dumas, thought I was pretty clear about that when I put it on the article. Never studied journalism at any level, except for a course or 2 at UW, but never have I ever out a gem of a sentence together like "Do you really think any of the coaches had any say in a players heart?" THAT SHIT DOESN'T EVEN MAKE SENSE RICK. Stay in your hole and leave the living alone. Glad to see someone here has the balls to say something honest about this dumpster fire of a team. Im sick of all the kool aid drinkers and their rose colored glasses. Response: I keep it fresh, Fresh. Horseshit indeed! Players like Willis and Smith aren't going to let something like Jimmy being the head man sway them into retirement. Jimmy has been here since both came into the organization and Jimmy is widely respected by the players. Their decision had nothing to do with JT. To even think Borland's decision was a result of him not wanting to be part of the new regime is idiotic! People like you, the "conspiracy theorist," feel the need to place blame somewhere. Jed's the easy target so if you're really "tired" of what's going on, stop your bitching. The webzone and more importantly The San Francisco 49ers will continue with or without your support. What has occurred and is occurring is not, as some have suggested, a natural evolution of a top team in transition with a large number of players reaching their maximum worth. While a turnover at some positions could have been expected, the overarching reality is that a power struggle in which the owner foolishly became involved created a tsunami that has swamped the organization with its after effects. Throughout the team and the league, it became apparent that control and who is the public face of the team is more important than results. As a consequence, when you look at the list of the coaches and players that have left, and compare them to their supposed replacements on the 2015 team, it can be said that, in each case, the replacement is of inferior ability to the previous incumbent (Torrey Smith may be an exception). You don't win in the NFL just by coming up with warm bodies to replace high level players and coaches. In the language of the day, you are looking for players who can make plays that win games, not simply punch a clock. And the reputation that you establish by making winning the first priority percolates throughout the sport and attracts winners. This is gone. I don't want to say it but when ever I say "What else could go wrong?" Murphys Law shows up...I don't want to go thru 8 years of looking forward to the draft after week 3... Reggie McConico Despite everything that has happened this off season, I still hold onto hope that this team will get it together before the upcoming season starts. I have continued to chalk these recent retirements and free agency losses (excluding Borland) as just part of the business and coincidental occurrences. Now after the the sudden Borland retirement, I'm looking at things from a whole other perspective. Maybe there is something more to this extremely crappy off season we are having that I fear will probably get worse when it's all said and done. As a fan of the 49ers since 1978, I'm not going anywhere. I have been through some tough time before with this team. I don't remember it ever being this bad before. Especially in such a relatively short period of time! I don't remember coaches not wanting to come here and coach the 49ers! This is completely Jed's fault! Now maybe Harbaugh was a jerk or extremely difficult to get along with but are you're telling us we are in a better situation as an organization today? I'm telling you that without the 49ers Faithful, there wouldn't be a 49ers organization! I agree with a lot of the content in this article. Fan's perspective is always important. RishikeshA Thanks for the article Jesse. I too am a long time fan dating back to YA and the million dollar backfield. Owners don't go through any special training to run a franchise, they're just rich. Jed has shown immaturity in his comments. Eddie D was from a different time and place, let's move on. The present situation is more of a perfect storm than managements' failure to perform. Sure, I've been pissed off like everyone else with what has been happening. The real issue with this team is can Kap take it to the next level. If he can this talk will die down as in an instant, if not, welcome to the D Response: Another great point. If Kap rebounds, it'll cover up a lot of smells I've been a niner fan ever since I was old enough to understand football, I went to games in Kezar. I lamented the loss of Harbaugh because we were lost in the desert for 8 years before he came to the team. But never forget we are fans of the NINERS but they belong to someone else, someone rich usually someone arrogant and unfortunately in our case someone who doesn't really know as much about football as he should if he wants to be successful. Eddie Debartolo was successful because he got out of the way of his football people. This kid is just the son of someone wealthy, and he's too arrogant to get out of the way. I'll always love the Red and Gold but I'm afraid we maybe headed back into the desert. Response: Sooooo many comments have started this way. "I've been a fan for x years and I've never bailed on the team..." I think it's a common feeling with a lot of us and the bad juju is just thick right now. We're the laughingstock of the league right now and the team is still more talented than most, doesn't often happen but I just know it's going to get worse before it gets better. Hoping I'm wrong. I don't care about Harbaugh and his flunky Greg Roman. There offense only got worse over 4 years. I won't miss them. Now guys like Vic Fangio and Ed Donatell on the other hand were mistreated. All they did was keep our defense top 5 four years straight and what did they get for it? Shown the door. You better believe guys like Pat Willis, Justin Smith and Borland took notice how Fangio were casted off like he was nothing. Response: Excellent Point, DJ. The subsequent fumbling of the coaching search was equally as egregious as the ouster to begin with. I totally disagree with this article. How do you know those 2 players wouldn't have retired if Harbaugh didn't leave? How do you know the free agents that left would have or could have stayed if Harbaugh was here? Last, Im sick of hearing about 3 championship games and the 2nd coming of Vince Lombardi. As I see it.......what have you done for me lately! How convenient we forget the 4th season 8-8 with losses to a terrible Bears team, a Cardinal team with a backup qb, a bad Ram team oh and lets not forget the 10,000 point lead we had against the Chargers and didn't hold. If you ask me I see a team that quit on the coach Response: You could argue that this was a lame-duck year and the players were in shell shock from how things were in that building. Hey, opinions are like a-holes, everybody's got one. a24hrdad I have always supported the 49ers through good times and bad. I stood by my team when we parted with Montana and Rice. Then after moving to Florida 10 years ago, I still always found a way to go to games when nearby or root at my local sports bar when we really struggled. I always felt like they made moves to try to improve the team. From the Dennis Erickson and Mike Singletary eras, it was usually only me sporting a red jersey out here. When things got good the last few years, suddenly I wasn't alone. That being said, I have had a sick feeling in my gut since the last off-season. And after the way everything that has happened this year, I feel like Jed dumped me. I don't blame him for wanting a coach that's on the same page, but then to fire almost the entire staff and replace them with outcasts from other teams? We couldn't even bribe a successful OC to come over. Don't forget we signed WR Simpson despite our "new values" too. So I agree with the writer and his issues with ownership. This is Jed's organization and he has established a new culture. He may not make every decision, but he pays the people who do. Response: "Culture" is the key word. The leaks about the coaching staff before the start of the season was categorically unprofessional and childish. Absolutely counterproductive in every way. Players are grown men and they know a rat when they see one. Sad that no one wants to play for 49ers. retirement of rookie is an insult thrown at Dork. No one want to coach 49ers. I think 49ers will lose a lot of money in ticket sale this year but Dork going to make money by inviting San Jose Flee market to have events in Santa Clara Stadium for all year around. Dork has no sense of running football business. Response: Ha, you called him Dork. Before you disregard my post and chalk me up to a cool-aid drinking idiot here me out. I understand that people are not happy with Balke and York but we do not know the full story. We can all speculate and assume that the rift was this or that but unless you sat in the meetings between the front office and Harbaugh then you can only Ass-ume, nothing more. I have been a fan since the 70's and we had some bad ownership, coaches and stupid moves... like picking up OJ Simpson when he couldn't run 10 yards on his broke down legs. I have followed them then and I will continue to... why?? Because they are my team just as the SF Giants, the GS Worriers are my teams and I have suffered through bad years with all of my teams. So complain all you want but to make bold statements that aren't factual is bad reporting. Also to say we are cool-aid drinking fools because we will still cheer for our team is assinine.... what are we to do start cheering on the Raiders- hahahaha- ya right that's a great idea. That is what being a fan is about- we complain but we always hope!! Response: Isn't that what I'm doing? Complaining but still remaining hopeful? I'll cheer for this team to win, but York can lick my culo. Great read Jesse! I've been a fan for over 25 years, can't remember a time like this before. What's really sad, is that a majority of all the drama has been self inflicted. I will forever root for this team, but will never buy officially licensed gear or attend any home games while the Yorks are around. As fans, this is the only way to show our disapproval to management. I refuse to hand over a penny to them, and am ashamed to have the Yorks part OC this team's history. Response: I like the cut of your jib Gabe. Continued... How was resigning him feasible? No more cap space opened up but Baakle already has Thomas waiting in the wings to replace Iupati. Crabtree? Culliver? Cox? All decent players but not players the team couldn't afford to lose. How does one blame the retirements of 3 players to a coaching change, especially to a coach that all 3 players know well having been with smith and Willis for their whole careers and Borland last season? Saying if Harbaugh stayed all 3 would have been back is horseshit. A new era has started folks. York may be a POS but let's not start blaming the guy for most of the crazy shit that has happened this offseason. I'm anxious to see how the team, Jimmy T and Baakle respond to this adversity. Response: Is it horseshit? A player in the league as long as those guys know what restarting with a new headcoach means, how hard that is. Smith and Willis especially remember a new coach every two years. If it were me, that would definitely impact my decision. I've had season tickets for the last 25 years. I even bought the whole "New Ballpark" crap. But there is no way I'm paying Jed Silver Spoon one more dime of my money. Call me a whiner, but I'm a whiner that most likely put more of my hard earned money into this team. Three years in the last twelve Silver Spoon gave us a competent coachm the kicked him to the curb. Not worth the price of admission anymore. You think I'm the only season ticket holder that feels this way? SBL's are selling by the thousands on the internet. Well, they're for sale. Not actually selling. Why don't you people calling me a whiner go buy an SBL for $20,000, like this whiner did. Freaking morons. Response: Sir, I'm sure there's thousands just like you. Be vocal. This is one of the most short sided articles I've ever seen on the site. To say York firing a coach with the success that Harbaugh had is beating a dead horse. But to say York's actions have a direct correlation to Gore leaving, other free agents leaving, and the retirements of Willis, Smith and Borland is completely ludicrous! Let's start with the departure of Frank and other notable free agents. What was wrong with the reported 3-4 mil offer to stay for Frank? That's a pretty nice price tag when you know for a lack of a better word, you'd be fazed out big time losing PT to Hyde this upcoming. Gore isn't dumb...why stay when desperate teams like Philly and Indy are gonna pay you like a top tier back? What does it say about Gore's character when he spurns his Niners and then does the same to the Eagles when they already had a verbal agreement in place? The Niners plan to have Hyde and the main back this season, a competitor like Gore still wants to be the main guy and went to a team where he still will be. Now which FA besides Iupati really mad a difference on this team? Would the team have liked to resign Mike? I bet they would have but with virtually no cap space, Response: I think you were trying to say "short sighted". Comment null and void. This 'chicken little' article is idiotic. You can't blame the owner for everything. Response: Sure I can. He said to hold him accountable. BigNine I guarantee (not really but just saying) right around week 5 when we go 1-4 current players will start leaking to the media how the players felt abandoned by ownership when Harbaugh was let go and how that influenced the decisions of the ones who left. Probably from all the players in the Non-Tomsula locker room. Response: Sounds plausible. Well said, can't add anything else. Response: Aww, ya just did! G Dawg 9 It looks grim, but business changes the dynamics. There are guys on that team that believe in coach Tomsula. No use in hanging on to what was yesterday. We have a scrappy front office, for sure, but it is what it is. Be a Niner fan through the good and bad and through the thick and thin. This organization will definitely lose revenue because of the fan base. People are selling their season tickets and all kinds of grievances towards this leadership. Let's enjoy what we can and wait for Daddy and Mommy York to step in. Not that situation is any better. It is what it is "a mess." Let's support our players. Niners all day Response: I'll still want them to win. Love the players. Edward Romero I said this very thing yesterday on another post. They had no fucking clue what the repercussions would be after leading go of Jim harbaugh . They destroyed something beautiu and now nobody wants to come play for the 49ers ... You think all these play would be leaving if harbaugh was still her ? Response: Some definitely would, all of them maybe, but doubt has been introduced to all the players and fans still with the team. eastie What tripe! Forty friken whiner fans flamin large. "We're heading for a dark place" Bullcrap, or I should say can you slip me the mega millions numbers for friday night? You have no crystal ball to see into the future, or at least you didn't while JH was coaching did you? Here's a novel idea, 'Wait until the team plays a few games to claim that they're going down in flames". What a bunch of freaking crybabies... "oh, we's gonna be losers now fo sho". You can't be serious and if you are, I feel sorry for you cause as they say an optimist may be wrong, but they will be wrong and happy. Your just a whining crybaby, so sure that the world is flat... Response: I've never had anything I've written called "tripe" before. Hitting new heights. i just hope we had a owner like dan snyder who likes to overpay guys!!! Response: Don't forget about the bullying of the media! Julio Olguin Finally someone speaks the truth! Thank you thank you I want every niner fan to read this because you have hit it right on the money only one you failed to mention is our GM Baalke he is as much to blame. He is a liar with all this talk of RELOADING this team I am tired of reading his comments about what he thinks and that the 49ers are in a good position to still compete in this league. Both York and Baalke are full of themselves and they keep feeding us a bunch of crap. Fortyniner faithful do you really believe we lost all these players because of a better paycheck, concussions, old age really! Writing is on the wall Response: Automatically the worst coach in the best division in football. Why all this drama...over two guys who wanted to retire. In case you didn't know, Willis was none too fond of Harbaugh. Borland only had one season under him. To suggest their retiring has anything whatsoever to do with Harbaugh being fired is ludicrous, at best. When will there be enough whining? When will you look forward instead of backward? When will you stop blaming the FO was what was naturally going to happen? Really, dude, get real. Response: Looking forward looks like Dennis Erickson all over again, that's real. Well written sir thank you. I've been a 9ers fan since I started watching football. It hurts my heart to think we are doing a 180. Those losing years was rough after Steve Young we struggle to find a QB Garcia was ok but, then poor Alex 6years 6 different offensive coordinators. Jed doesn't know jack shit about football he inherited the team he never worked hard for it. These idiot fans that dont think Jim's leaving had much to do with it are crazy. Look at the last game of the season how the players reacted when the game was over they loved Jim. Management tried to say it was problems in the locker room no it wasn't that was what they was going to say the reason they let Jim go. I still love my team but now it's getting harder to put up with the dumb management. Again wonderful article u nailed it. Az9er The only way the 9ers come back is that the Yorks sell the team. This kid has no idea how to run a football team. Do the fans a favor sell the team and sit and watch! To the writer of this article and the fans who want to continue to cry and throw blame. WHAT would you have done differently than management??? Paid Frank Gore what he wanted to stay? Convinced Patrick Willis that his injury concerns are not that important or serious to him because "we Kept Harbaugh as coach?" Paid Borland to continue playing and tell him, "We kept Harbaugh, so all is not that bad" Have Jed York and family sell the team ASAP??? NOT going to happen, just because it's what you want, and because if they do sell it, we'll win the SUPERBOWL....stupid. I'm really tire of all the crying, complaining, whining. I've been a Niners fan since 1968 and will continue to be a fan. Grow up, life happens people. The injuries and players leaving for more money is NOT Jed's or anybody else fault. It's life! there are hundreds of other players coming put of colleges, veterans with respect for the game, the game itself waiting to take those spots that are now vacant. IF you are truly a fan of Football, and the Niners, then stop complaining and appreciate the fact that you have a team and a game to watch...... DUMB-a..... Can you just grow up and face the reality that these players did not leave because of York? This is the NFL where some players are figuring out their careers are short, plagued by uncertain healthy futures, and if other teams want to pay them top dollar for their services they owe it to themselves and their family to take the money. What teams do you think will put their players over profits? Response: Its not the Yorks that are making them leave, its the Yorks turning this into a 2nd rate franchise that is. Suk the York's dik and go find a new team ho weak bitch Response: Best. Comment. Ever. this guy York is all over .com valley's [email protected]&$! If he really cared about football he would have kept OUR team in San Francisco where it belongs. I guarantee he runs us into the ground ultimately. I'm faithful, but it is getting harder and harder! Forget the poor decisions recently, moving us to Santa Clara was the first in obviously a number of bad decisions! I enjoyed being a 10 year season ticket holder, but I live in the north bay, and I'm not a fuckin millionaire, so needless to say I'm not a holder anymore. I will always be faithful but it is getting harder by the minute Just another over-inflated windbag that 49erwebzone gave a free forum to spout stupidity. Jesse Dumas, go back to your job at Quicktrip. Response: Bout to make night manager yo! I didn't claim York was doing a good job, I just don't agree with your article about how this is all happening because he let Harbaugh go. I think this all would have happened regardless. Players go where the money is, the Niners wouldn't have paid for the players that left (Harbaugh would not have affected the amount of money we would have offered Gore, for example). It wouldn't have stopped Willis and Borland leaving either. They had already decided this due to injury concern (esp. Borland according to reports). Thanks, though, for your insight on my comments. I actually wanted to discuss it because I think this common misconception in football (that it ISN'T all about the money) but if you think someone disagreeing with you means they are automatically against you or that if they don't agree with everything you write then you won't actually discuss it with them, I guess I came to the wrong spot. That's my fault. Response: Oh you came to right spot sir, and you're absolutely right that I've made some inferences and maybe nothing at all would be different had Jim got to finish out his contract regarding this loss of talent. But at least we'd have leadership. At least there'd be a face of the franchise that stands tall before the tough questions and answers for what's happening. Who would that be now? Players understand value and yes they chase the money, but not every player will go to any team because the paycheck is bigger, it depends on where they are in their career and where they have the most value, Gore went to Indy over Philly because of the scheme, money was equal. What he DIDN'T do is take the hometown discount because (AND HE SAID THIS) he want's to win a Super Bowl. Slim chance that happened in SF. I will always be a Niners fan. Yes, this off season has been hellish to endure. Yes, we have seen some talent leave. Yes, we have a brand new coaching staff. I would like to know what anybody would have done differently. I loved Harbaugh as head coach, but he couldn't win it all even with an awesome lineup and great coaches(i didn't hear anybody biatching about Roman during the run to the Superbowl). This team has had terrible injuries for sure, but there was still lots of talent on the field last season. When you have an offense that doesn't want to throw the ball to Vernon Davis, obviously change is needed. While the upcoming season may prove to be a clusterfrack of a campaign, I will be cheering for them still. But I don't think management alone is to blame here; they weren't the guys out on the field. Win as a team, lose as a team. viccz Well, what can we do..I just wish JED York and the organization can read this article and say something about it...I just want them to feel the pain that all the fans are facing now...But, let's just hope for the best and see how this year goes...let's go NINERS.... Response: Dude said he wanted to be held accountable. Wish I knew what that meant because he says nothing about any criticism at any point. He's a coward and a sham of an owner. I hope he turns up dirty somehow and gets ousted by the league. That'd be the only comparable thing he'd share in common with his Uncle. SO WELL PUT! I became a Niners fan in 1982 and it was the most amazing organization in football. As a native New Yorker, I stood my allegiance amidst Jets and Giants fans and never ever wavered. I still have my 49ers cookbook and 49ers lunchbox from those days and I still consider Super Bowl XXIII to be the greatest one ever. Eddie D was the greatest. Yes, we had some trying years but we always knew things would turn around. The current "brain trust" is a joke. You can't command respect; you have to earn it. York and Baalke are truly dumb and dumber. Loved Harbaugh and Vic Fangio (Greg Roman, not so much). I think Kap has amazing talent that just needs to be properly guided, but with this mass exodus I'm more than a little worried. I'll reserve judgement on Tomsula, but I am heartbroken about Willis and Borland. Makes you wonder if they would have stuck around if the ship wasn't sinking. I disagree. Football is a business and I think it's time we stop imaging that players view it a different way. There may be the odd player that actually cares for the TEAM but most are only in it for the money. The deals this off season prove that (i.e.-Revis ). And, if it is about players being cared for and valued, how do you explain the Pats? It is widely known they are cutthroat, they do not hesitate to get rid of players that have previously been staples. In fact, they are applauded for it as smart businessmen (and when the time comes and Brady declines, you can bet he will be out). So this whole warm, fuzzy thing about how important it is to create this respect- based environment I believe is false. Trying to say that a player will not simply go where the money is (Gore, Ipuati, etc.) or blaming the loss of Willis (injury history, veteran- shocking but it makes sense) or Borland (who, according to a FOXnews.com report, had informed his family at least a year ago that he would probably only play one season in the NFL so that isn't exactly Harbaugh related) doesn't add up. I realize that a lot of people hate York but this angle you are preaching here just doesn't add up. Response: Nope, you're right. The Yorks are doing a tremendous job. Tell me how that adds up? GM Brown This article is ridiculous, first and foremost and doesn't read any differently than the posts I read in NinerTalk. None of this is at all factual and presupposes based on events that are just as much a correlation to other explained circumstances than the catch-all "it's Jed York's fault." I for one am sick of this oversimplified tripe. It's getting old. Even in the comment section below in response to G-Dog - just outright lies; "It's been since, what, 1996 that the Yorks took over this team? Jed's been calling the shots for the last 7, 8 years and we have exactly 3 winning seasons to show for it." Do you have any clear proof/evidence/article/statement from the team that says Jed has been "calling the shots for the last 7 years?" This isn't an exclusive 49erwebzone "article", it's an insult to those of use who have been watching closely over the last 30 years and realize oversimplification is has been the primary reason others call us "whiner fans." Response: Then don't read it bub. Just keep buying tickets and telling yourself it's all gonna be alright. David Holdbrook Thank you Thank you Thank you. I'm tired of the way the Dorks do business. First his father runs Mooch a winning coach who made a QB out of Garcia. We were winning. Then Jed fires a guy who takes a washed up Alex Smith and a team who was defeated and void of heart. He turns them into to Champs and resurrects Smiths career. The players fought hard for him except one prima Donna. I'm tired of the DORK & BUTTKISS ASS CLOWN CIRCUS. They went low ball on coaching staff and now doing the same on players. I hope DORK reads your rant he needs to hear it. To those fans who keep calling us Fairweather fans. I've been around for 40yrs. I've volunteered and got petitions signed for the stadium. I've been to games. I've earned my right to speak out. Besides you all jumped on when they started winning. I wore my colors when they sucked and got laughed at. Where the hell were you hidding? I've got shirts and jackets older than most of you. So quit the crap. This is what Dork caused. The family is falling apart. Thanks Jed. Response: You said it Dave. The fans telling us to shut up about it are the reason this team is going to continue to suck for years to come, they keep filling the stadium when the product on the field goes to shit. LOOK AT THE MCCASKEYS AND THE BEARS, THAT'S WHERE WE'RE HEADED. Jesse Serrano Im tired of all these bandwagon fans!!! Football is a buisness!! Yes you fall in love with these players, but you have to admit Gore is past his prime. Culli & COX were average corners at best. And as far as Willis & Borland, well that is unfortunate. And f.... Harbaugh. It was his ass that couldnt fire that crappy OC Roman anyway. He had his window with those players and still couldnt get it done!!!! As far as i see it, we were plagued by injuries last season. BUT the core group is still intact. The Oline minus Lupati who couldnt pass block for sh.. And Crabtree. Pshhhh who cares. I will always be faithful to my team and its the players, not mngment on the field. Response: Business is business, and bad business is wrecking this team. Jesse I feel your pain sir I was seriously upset about the harbaugh firing but understood that not the way but the reasoning at least harbs was loyal to a fault to roman I believe As far as the hometown discount goes I truly believe if harbaugh was still here gore would t have left everyone else would still be gone gore just wants to win he lost so much in the beginning of his career that he wants to go out a winner Until the borland retirement I was very optimistic now I'm having a hard time seeing a reason to be so anymore but regardless am going to support our team and hope kaep takes it all to the next level and baalke aces the draft with superpowers this year Response: Still a lot of talent and Baalke has proven he's got an eye for rookies in certain places anyway. But good God there is just a dark cloud over this organization and I don't see it lifting anytime soon, not without some wins. Anything is possible, but I think momentum is real and right now their arrow is pointed straight DOWN. G-Dog//! I can see your point of view. I don't agree with everything you said but I see your side. I've been a fan since Jim plunket was the qb. Players come and go. There is absolutely nothing we can do about it. Were obviously still drawing the attension of free agents so how bad can it be. Tomsula is the ultimate question in my opinion. BUT.......if Jed wins #6 with HIS approach...... Is he still a wanker? Its to early to tell if Jed an idiot or a genious. There is a fine line between the two. Let it play out, after all that's all we can do as fans. If we go 3-13 next year then blast em all you want! Just my opinion. Response: It's been since, what, 1996 that the Yorks took over this team? Jed's been calling the shots for the last 7, 8 years and we have exactly 3 winning seasons to show for it. Not coincidentally, that would be the Harbaugh years. Harbaugh is the only thing this jagoff got right so far and he hustled him out the door. CJ Gish I have had these same thoughts floating around the back of my head, too. The 49ers' ownership has been a joke since DeBartalo was forced out, which is why it took such a long, long time to get back into contention. A coach like Jim Harbaugh doesn't come along every day and when we hired Jim Tomsula -- a classic "Yes Man" who wouldn't rock the boat or question York or Baalke -- I knew we were running this ship into the rocks. And when free agency hit and our locker-room leaders started departing one after the other in Gore, Iupati to free agency and Willis (and possibly Smith) to retirement, it's obvious you can't lose that caliber of Pro Bowl talent without it taking a major hit to your roster. I at least felt Borland was an up-and-comer who could fill Willis's void, but now it is becoming more and more obvious that the York/Baalke vs. Harbaugh battle was the bottom line that no one is wanting to talk about. The players always knew Harbaugh had their back -- and have even said so since he left and during the season -- but now they have second-guessed the front office. Getting rid of Harbaugh was the worst thing that could have happened to this team. Response: Worst thing after Eddie getting exiled from the league. Let me pose this to you - imagine a scenario in which last year we go to the playoffs and get bounced in the divisional round. There is no torpedoing and Harbaugh is still the coach. Do you think: Willis and Borland retire? J Smith retires? Frank Gore leaves? Iupati leaves? Cully/Cox leave? etc? The only difference I see is Frank Gore staying on an overpaid contract that doesn't allow Carlos Hyde to grow into a feature back role. Of course, in this fantasy land, you keep Harbaugh. But he, with Roman, also call the same stupid offensive play calls that have ultimately doomed the franchise the last few years. Other than that, Willis and Borland still retire. Cowboy is still in his 'not sure' state. The CBs leave bc they are chasing the $ we are not paying. Iupati leaves for the same reason. Best coach in the last 20 years? No doubt. Would it have resulted in a Super Bowl next year? I doubt it. I have just about as much faith in Greg Roman making a play call as I do with Jim Tomsula coaching this team and Kaepernick executing. That is not saying much, but it all amounts to a net zero. Would you have been embarrassed by this alternative universe as well? Response: I think Harb's was still gone after anything short of a Super Bowl. If some reports are to be believed, they still would have ousted him anyway. Fresniner For 25 years I lived and breathed this team, even through the bad years of Dennis Erickson, Nolan, and Singletary. I would devour every piece of information I could get my hands on, and pre-internet, it wasn't that easy, but I didn't mind, I couldn't get enough. The first game I ever seen was the Broncos / Niners superbowl. I was only ten years old, but I fell in love. This team meant everything to me. When they would lose, it would ruin my whole week. When Harbaugh was hired and the team started doing really well, I felt like I was rewarded for all the long suffering I endured prior. I was so excited that we had an owner who "got it". That he was willing to invest in his team and let football people make the decisions. But it was all a sham. As soon as he got his new stadium, that was it, he got what he wanted. He now reminds me of those sleazy guys that will do or say anything to get with a girl, but once he gets what he wants, he leaves her high and dry. What sucks is, we as the fan base, are that girl in this scenario. We are the ones left high and dry. Heart broken and betrayed is what I feel, and too be honest, I think I'm done, at least while the Yorks are owners... Response: This. You just explained perhaps an almost identical experience as my own. Even the bad years I had hope for the team and optimism no matter what. Now, after the way the leadership has shown they do business, I can muster support for the players and the uniform, but just knowing this douchebag is pulling the strings makes me sick. York is a pussy and not suited for the job he has been given!!!!! I want my niners back!!!!!!!!!!!!!! Response: "Winning with Class" implies there will be winning. That's getting to look more and more unlikely. What a stupid 'article'. It has absolutely no merit. You are a joke. Response: What intelligent "feedback". Thanks for reading! Ironhawk86 No matter what your leadership aspirations, be it the owner of a small business, the CEO of a multinational corporation, or the President of the United States, the York family is a textbook case on how NOT to run an organization. I don't know what Borland's thinking is but I can say with utter certainty that the decision of Gore and the other FAs to move on and the retirements of Smith and Willis are votes of no confidence in an organization that values ego over results. The sad thing is that we have seen enough of the same pattern from them to predict what happens next. Tomsula will flame out as puppet coaches typically do and Baalke will take the fall to keep ticket sales from plummeting. Then Jed walks over to the next office on his floor to hire Marathe to take over as GM. And none of it will matter because no coach worth a damn is going to work for the Yorks after what they did to Harbaugh and they will settle on the next poor schmuck to be completely in over their head coaching this team. Rinse. Repeat. Response: Agree completely. How do we hold this schmuck accountable? Hey Trent Baalke and Jed York...why dont you change your names to Al Davis! Its almost impossible to afford tickets to the new stadium for us normal, die hard fans...but then you go and make it that the 1 year I finally get tickets...you get rid of, or make everyone leave. I was going to finally take my son to his first game...now, after everything...he tells me "whats the point?"...and I agree..at 12 years old all of his favorite players are gone. Thanks Response: Making the Raiders look like the competent team in NorCal is no easy feat. Oscar Silva So you are saying that all this happened because harbaugh is gone? You are a joke, the free agents that left were all expected to leave. There is no way gore was staying for less money, I love gore but he is not worth the money the colts are paying him. Willis and Borland were surprises but they would've retired even with Harbs as the coach, saying they retired and gave up millions because of a coach is down right pathetic. Response: Saying they would have retired even if Harbaugh stayed is as much of a guess as mine is. My point is that the players see that the owner cares not about individuals or the team, why subject yourself to further harm for that? Thank you for your pity though and keep drinking that Kool-Aid! Daniners Totally irresponsible and immature article. You want to criticize the organization for how it has handled certain things, fair enough, but don't connect dots that are not there or have no supporting evidence. There is no jumping ship. Borland and Willis are fortunate coincidences. Gore, Crabtree, Iupati, etc., all budiness decisions and frankly good ones. My advice to real 49ers fans, stop rooting for players over the organization. I this era FA, they are at going to come and go and tough decisions will be made, but getting younger remains the correct approach for all teams. Response: Immature? Yes. Irresponsible? C'mon, this is just football. I'm as big a fan of this team as there is bud, but it's getting harder and harder to root for this team that's obviously got some karmic backlash coming their way. Jed's a colossal wanker, NOBODY denies this. 49ers rumors: Deshaun Watson's request that Texans interview Robert Saleh also went ignored More by Jesse Dumas One Fan's Lament The Chip Kelly Era Begins - Preseason Week 1 Observations 5 Reasons for Optimism in 2016 All Articles by Jesse Dumas	cc/2021-04/en_middle_0068.json.gz/line1500
__label__cc	0.593489	0.406511	Search. Compare. Analyze. Decide. Request a Demo Look Inside Legal Compass Legal Compass Subscriber? Sign in here. The World’s Best Source of Law Firm Data Legal Compass puts the power of ALM’s 30 years’ of proprietary data and research firmly in your hands. Its comprehensive web-based platform connects you to decades of penetrating ALM analysis and exclusive firm data, making it the perfect tool for addressing the challenges you face on a daily basis. Whether you’re conducting your own analysis or leveraging one of our carefully prepared reports, Legal Compass gives you the clarity you need to make the decisions that matter. We are honored to have been recognized as Folio’s Best New Digital Product of 2018. “The 2018 class of honorees truly represent the best of the best in the digital space – each winner […] has pushed the boundaries of digital content, product development and audience engagement.” – Folio Dynamically explore and compare data on law firms, companies, individual lawyers, and industry trends. Legal Compass pulls data from hundreds of different sources so that you can make the best decision for your firm. Whether it’s benchmarking your own performance or conducting business intelligence on the competition, Legal Compass is a fast track to a better understanding of your firm and the industry at large. Explore data on revenue, headcount, profit per equity partner, and so much more. Exclusive Depth and Reach Legal Compass includes access to our exclusive industry reports, combining the unmatched expertise of our analyst team with ALM’s deep bench of proprietary information to provide insights that can’t be found anywhere else. With over 30 years of industry knowledge and research at our disposal, we’re in a position to deliver the deepest insights available. Legal Compass delivers you the full scope of information, from the rankings of the Am Law 200 and NLJ 500 to intricate details and comparisons of firms’ financials, staffing, clients, news and events. Explore data on revenue, profits, headcount, and clients, as well as the latest news on firms. Make the Connections That Matter Not only is Legal Compass a deep yet user-friendly source of firm data, it’s a gateway to forging new client relationships and discovering top-tier talent for recruitment. Legal Compass’ company search enables you to pinpoint potential clients based on industry, location and company size. Easily searchable attorney profiles are a fantastic prospecting tool, detailing talent’s education and employment timeline, recent clients and practice concentration, as well as listing contact information. ALM Legal Compass was recently introduced firm-wide. The response has been extremely positive. The site is very easy to navigate and having access to all of the Am Law Reports has already proved to be invaluable. Tania P. Danielson, Research Librarian \| Schulte Roth & Zabel LLP Our firm wide access to Legal Compass assists our attorneys with their often immediate need for competitive intelligence about the legal market. With everyone on the move these days, expanding end user access has been useful. Lori Tarpinian, Director of Research Services\| Mintz Levin Want unlimited access to Legal Compass? Subscription package includes enterprise access to the full portfolio of ALM Intelligence proprietary research and analysis on the latest trends in the industry through Legal Compass. For questions or inquiries, please complete this form or for immediate assistance, please call 888.770.5647 or email [email protected].	cc/2021-04/en_middle_0068.json.gz/line1502
__label__wiki	0.772638	0.772638	California Book Club Making Themselves Heard By Catherine Womack JULIA DEAN It’s a hot, sunny Sunday afternoon in the Frogtown neighborhood of Los Angeles, and a group of 12 women are standing quietly in a circle inside a well-worn community center. “Imagine a note, any note, and hold it in your mind,” the group’s leader, Carolyn Pennypacker Riggs, tells them. On Riggs’ cue, the women release their chosen pitches in full voice. A psychedelic chord blossoms, a powerful, bright sonic bath. The chord dissipates and Riggs smiles serenely. “I call that a freedom chord,” she says. Riggs, a Los Angeles-based composer and performance artist, is the founder of the Community Chorus, a protest choir that meets twice a month at the Women’s Center for Creative Work. Since Riggs formed the group in early 2016, she and a revolving group of a couple dozen women have been rehearsing regularly and gathering to sing and march together at Resistance-themed events. A group of women sing resistance-themed songs during a practice session at the Women’s Center for Creative Work in Los Angeles. A native of Berkeley, Riggs has been protesting since childhood. “I consider it a civic duty,” she says. “It is just something you do, like exercising or trying to eat healthy greens.” In the wake of Donald Trump’s inauguration, Riggs felt energized at marches that included musical elements. If she formed a community choir, she thought, the group could provide both musical inspiration for protesters and a reason to keep attending anti-Trump rallies. When choosing songs Riggs veers away from protest music composed by 20th century white men. Instead of Bob Dylan, the chorus sings songs by OutKast and Solange. Riggs has been surprised by how many choir participants tell her they don’t have a good voice. “They tell me they can’t sing, but sing they do,” she says. “If you can feel more comfortable vocalizing, maybe you can speak out against something that really needs to be called out.” Catherine Womack L.A.-based pianist turned writer Catherine Womack covers classical music and the arts for the LA Times, Los Angeles Magazine, Alta, and more. More From Dispatches Art, Beauty, and Passion The Safe Place That Became Unsafe Your Year in Review When the Mafia Came to Lodi Alta Editor Picks 2020 Hearts Aflame Waiting to Call Home Searching for Mary Austin In a Galaxy Closer to Home Alta Journal participates in an affiliate marketing program with Bookshop.org in order to support independent booksellers. Alta Journal does not receive any commissions on books purchased from our site. All commissions are distributed to our bookstore partners. ©2021 SAN SIMEON FILMS. ALL RIGHTS RESERVED	cc/2021-04/en_middle_0068.json.gz/line1504
__label__wiki	0.618194	0.618194	Patient Info & Forms It is our company policy to respect your privacy regarding any information we may collect while operating our website. This Privacy Policy applies to our company (hereinafter, "us", "we"). We respect your privacy and are committed to protecting personally identifiable information you may provide us through the Website. We have adopted this privacy policy ("Privacy Policy") to explain what information may be collected on our Website, how we use this information, and under what circumstances we may disclose the information to third parties. This Privacy Policy applies only to information we collect through the Website and does not apply to our collection of information from other sources. We may collect non-personally-identifying information of the sort that web browsers and servers typically make available, such as the browser type, language preference, referring site, and the date and time of each visitor request. Our purpose in collecting non-personally identifying information is to better understand how our visitors use its website. From time to time, we may release non-personally-identifying information in the aggregate, e.g., by publishing a report on trends in the usage of its website. Certain visitors who choose to interact with our company in ways that require us to gather personally-identifying information. The amount and type of information that Get Clear Consulting gathers depends on the nature of the interaction. Get Clear Consulting may collect statistics about the behavior of visitors to its website. We may display this information publicly or provide it to others. However, this company does not disclose your personally-identifying information. To enrich and perfect your online experience, this site uses "Cookies", similar technologies and services provided by others to display personalized content, appropriate advertising and store your preferences on your computer. A cookie is a string of information that a website stores on a visitor's computer, and that the visitor's browser provides to the website each time the visitor returns. Our company uses cookies to help us identify and track visitors, their usage and their website access preferences. Our visitors who do not wish to have cookies placed on their computers should set their browsers to refuse cookies before using this site, with the drawback that certain features of our websites may not function properly without the aid of cookies. By continuing to navigate our website without changing your cookie settings, you hereby acknowledge and agree to our use of cookies. Although most changes are likely to be minor, we may change its Privacy Policy from time to time, and with sole discretion. We encourage visitors to frequently check this page for any changes to its Privacy Policy. Your continued use of this site after any change in this Privacy Policy will constitute your acceptance of such change. 322 Broad Street, Suite 3 Email: info@amAcupuncture.com Tue, Thu, Fri 10-6 every other Sat 10-2 © 2021 A. M. Acupuncture, LLC. All Rights Reserved. \| Login	cc/2021-04/en_middle_0068.json.gz/line1505
__label__wiki	0.849723	0.849723	Anorak News \| Kanye West’s Pro-Beyonce Anti-Taylor Swift MTV Stunt In Pictures Kanye West’s Pro-Beyonce Anti-Taylor Swift MTV Stunt In Pictures by Anorak \| 14th, September 2009 KANYE West is interrupting Taylor Swift’s acceptance speech of singer at the MTV Video Music Awards, New York. West, whose agape mouth give him the look of a Pekingese eyeing a shoehorn, tells the audience Beyonce should have been won the best female video prize. “Taylor, I’m really happy for you, and I’m gonna let you finish, but Beyonce had one of the best videos of all time.” On Kanye West’s blog apology: I. I. I. I. I. I. I. I. I. I. I. I. I. Kanye West writes ‘I’ so much he just leaves the caps lock on and waits for an opening. Anyhow, the reaction is typically rock ‘n’ roll: the audience storm the stage, Swift grabs the microphone and jams it into the seat of West’s power, so giving him a unique sound. She then stomps on her award and says anyone who needs approval from a cable TV station is a loser before screaming “Video This You MTV C****” and giving West a statuette chaser. Well, no. This is corporate TV, people. What happens is that Beyonce appears on stage to collect an award for Best Shocked Face At An MTV Awards Do and invites Swift back on stage to finish her thank you. Swift appears dressed in a red dress – yeah, just like Beyonce’s – teeth reminiscent of Brian Moore’s mouth guard. MTV has its sensation for its music AGM and West gets named MTV Director of PR. In pictures: Posted: 14th, September 2009 \| In: Celebrities, Key Posts Comment (1) \| TrackBack \| Permalink	cc/2021-04/en_middle_0068.json.gz/line1507
__label__wiki	0.821167	0.821167	PDC - Microsoft to lift lid on Longhorn OS Joris Evers (IDG News Service) 01 October, 2003 07:35 Microsoft will share more details on the next version of Windows, code-named Longhorn, at its Professional Developers Conference (PDC) next month. However, the company will probably keep the new user interface, dubbed Aero, under wraps. Aero may make a cameo appearance in Microsoft chairman and chief software architect Bill Gates' opening keynote, but is not finished yet and likely won't be included in the pre-beta release of Longhorn that will be handed out to PDC attendees, according to sources familiar with Microsoft's PDC plans. Aero is also not on the calendar of sessions at the show. Perhaps more important to developers is that Microsoft will give PDC attendees the scoop on Avalon, the little talked about engine underlying the Longhorn user interface. Microsoft has described the technology as "a brand new client platform for building smart, connected, media rich applications in Longhorn". Developers at the show will be told how to take advantage of Avalon in their applications. Thanks to Avalon, Longhorn will support new styles of user interfaces and user interface elements. Developers will be able to create Windows client applications that use the type of navigation features found on the Web to browse through information, according to the PDC session calendar. Another key topic at PDC will be Windows Future Storage (WinFS), a service that sits on top of the existing Windows file system and is meant to make it simpler and more intuitive for users to find files on computers running Longhorn. WinFS uses technology from the "Yukon" release of Microsoft's SQL Server database, which is expected to ship late next year. Microsoft's PDC documentation describes WinFS as an "entirely new user experience and model around the storage of user's data." For example, Outlook address book data today is restricted to that email client. With WinFS, that data could be made available to all applications on a PC. However, applications will have to be rewritten to take advantage of such capabilities. Microsoft plans to release a slew of application upgrades at around the time Longhorn is released. Jupiter Research senior analyst, Joe Wilcox, saw WinFS as the PDC headliner because of the impact a new storage system was likely to have on developers and businesses. "Microsoft at PDC needs to show some significant development progress on the new file system coming for Yukon and Longhorn," Wilcox said. "Developers and businesses will need some time to prepare new applications and possibly retrofit old ones to support the new file system." A lot of work remains to be done on WinFS. It works, and developers can start developing applications for it, but it is slow, fragile and many features are missing, a source familiar with the development said. Microsoft is working hard to finish the PDC version of Longhorn. The goal is to meet "zero bug bounce", a stage where development catches up to testing and there are no active bugs, at least for the moment. The operating system will be "about half done" when the PDC rolls around, the source said. A Longhorn beta is planned for 2004. More from Kemp Delivering innovation through multi-cloud and compelling partner-focused solutions	cc/2021-04/en_middle_0068.json.gz/line1516
__label__wiki	0.738245	0.738245	Telstra shares sink to seven-year low after latest outage Telstra's shares fell as much as three per cent on Tuesday Reuters (ARN) 22 May, 2018 15:03 Shares of Australia's largest telco operator Telstra (ASX:TLS) tumbled to their lowest in nearly seven years on 22 May, after the firm was hit by a second major mobile network service outage in the space of a month. A software fault on Monday caused multiple elements across its 4G network to fail, and a further fault interrupted the standby hardware, the company said in a statement on Tuesday. "...some key network equipment failed causing a disruption to 4G voice and data services nationally. The impact was widespread and with a large number of customers dropping back to 3G, there was significant disruption to 3G voice and data services as demand exceeded the capacity of our 3G network," the company said. On Monday, it had apologised via Twitter for the outage, later tweeting that mobile voice and data services had returned to normal. Telstra's shares fell as much as three per cent on Tuesday, hitting a low of $2.715, the weakest since August 2011. Its shares have lost more than a fifth of their value so far this year. The company, which has 17.6 million retail mobile services customers, did not disclose how many people were affected by the outage. The New South Wales police had issued a statement on Monday asking those affected by the outage to use another carrier or a landline if they needed to call emergency assistance numbers. Telstra, which faced another outage on April 30 that affected some 4G voice calls, warned earlier this month that its fiscal 2018 results would meet the lower end of its guidance and that challenges would persist into 2019 given the roll out of the National Broadband Network. The company, like other telecom rivals, is seeing traditional higher-margin streams of revenue dry up, forcing it to rely more on smaller-margin cloud computing and cybersecurity services to corporate clients. Read more Mystery software fault behind Telstra's latest network outage (Reporting by Susan Mathew in Bengaluru; Editing by Sayantani Ghosh and Jacqueline Wong) Telstra faces fresh mobile outage Optus wins latest legal round against Telstra in advertising tussles Samsung Australia made a $58M after-tax loss last year When new intelligence meets new learning Tags TelstraTelco	cc/2021-04/en_middle_0068.json.gz/line1517
__label__wiki	0.926764	0.926764	Sony debuts Crusoe notebook Georgina Swan (ARN) 15 November, 2000 12:08 Sony has released the first notebook to be powered by Transmeta's Crusoe chip on the Australian market. In announcing the availability of its new VAIO notebook, the PictureBook C1VM which features a 600MHz Crusoe processor, Sony claims the new low-power chip will nearly double the battery life of its new portable offering. "We chose Trans-meta because we are able to run the processor more efficiently - it runs cooler and the battery life of the notebook is essentially doubled," said Sony Australia's VAIO project team leader Daniel Horan. "It varies depending on what you are doing, but generally speaking the battery will last up to five hours, whereas it is normally two and half hours." The notebook, which will retail for $3799, also features a built-in progressive-scan CCD camera, a 12GB hard drive, 128MB SDRAM and a Sony Memory Stick Direct slot. "Compared to the previous version, which retailed for $4099, and with the currency conversion, it is pretty amazing," Horan said. The Vaio has enjoyed strong sales since July, according to Sony. The company cleared its stock on October 4, with the channel winding down sales since. The company is shipping three more updated VAIO models - the PCG 250GA, the XE17 and the F670. Each will ship with improvements in CPU speeds and memory and will retail for $4899, $6199 and $3599 respectively. All new models will run on Microsoft's Windows ME operating system. The key to Transmeta's chip is the software that sits over the processor. Known as Code Morphing, the software determines what speed the notebook runs at depending upon the application by translating x86 instructions into the native engine of the hardware. Each time a program is run, the software saves the translations into a cache so the processor gradually reaches optimal speed for the application. "A lot of benchmarking tests are structured for existing processors but this chip has quite a different way of operating," Horan explained. Comparing it to existing offerings is like comparing apples and oranges, he said. The Crusoe is designed specifically for mobile applications and Sony has included software which allows the user to monitor the speed at which the CPU runs. The new notebook also comes bundled with a full range of digital editing software and features improvements to its camera technology and upgraded memory on previous models. Horan said Sony had designed the C1VM specifically for the consumer market. "We want to create new markets, so the main focus of the VAIO concept is to bring together the AV and IT world - that word convergence that everyone has talked about but until now no one has delivered," Horan said. Transmeta listed on the Nasdaq exchange last week, launching an anticipated 13 million share initial public offering. The company increased its asking price from $US11-13 to the $16-18 range in the lead up to the IPO, and then again to $21. Trading under the ticker symbol TMTA, Transmeta could gain about $273 million at the current prices. While IBM has announced it will not be using the chips in its products and Compaq will not yet commit to a Crusoe-powered notebook, the likes of NEC and Hitachi have announced they will use the CPU in products for the Japanese market. Why 2021 will be the year of Cloud-to-Customer Visibility More from AppDynamics	cc/2021-04/en_middle_0068.json.gz/line1518
__label__wiki	0.593225	0.593225	cult of personality v1.2_85 All Smiles: "Cult of Personality" panel takes questions from audience. (L-R): Co-Founder of the De La Cruz Collection, Rosa de la Cruz, artist Christian Holstad and NSU Art Museum Director, Bonnie Clearwater. In background hangs Holstad's "Party Favors (Snakes and Champagne)," 2005 Up Close and Personal: NSU talks art with Christian Holstad From Superman to Marilyn Monroe, American pop icons get a critical close-up in Nova Southeastern University’s (NSU) exhibition Cult of Personality – featuring the work of mixed-media artist Christian Holstad. Now on view in… By Monique McIntosh From Superman to Marilyn Monroe, American pop icons get a critical close-up in Nova Southeastern University’s (NSU) exhibition Cult of Personality – featuring the work of mixed-media artist Christian Holstad. Now on view in the Adolfo and Marisela Cotilla Gallery at the Alvin Sherman Library, curated from the renowned de la Cruz collection, the exhibition opened with an intimate discussion between the artist and collector/philanthropist Rosa de la Cruz, moderated by NSU Art Museum’s Director and Chief Curator Bonnie Clearwater. Ranging from tongue-in-cheek collages to large-scale textile sculptures, it’s the power of transformation that most defines Holstad’s eclectic work, particularly when exploring how images manipulate identity. In the “Eraserhead Series,” newspaper photographs are partially erased and redrawn to tell new stories, while in “Slumber Party,” Marilyn Monroe’s glam portrait is simplified into emojis, devoid of all flesh and superimposed over a coffin. “Slumber Party” by Christian Holstad “Party Favors (Snakes and Champagne),” a textile gas mask sculpture with the eyes of Superman actor Christopher Reeve loomed over the discussion panel. “I find that Americans are really into saving the day,” noted Holsted about the piece, citing America’s lengthy history of superheroes. “For me, I saw in particular with Christopher Reeve that he could, by getting out of one outfit and into another, become another person.” The discussion quickly turned to the dramatic transformation of South Florida’s own art scene, now rising further north of Miami, thanks to organizations like the NSU Art Museum and the de la Cruz Collection. “What I see happening now for Broward is what happened in Miami in the early ’90s,” says Clearwater. “There is this groundswell of opportunities, giving us the chance to connect with the international art world.” Imagining a Clorox Bleach bottle on Miami Beach, Holstad’s “Towel 7” explores South Florida’s own complicated relationship with its projected narrative as a tropical paradise. Much credit is due to both organizations’ commitment to art education. While the Cotilla Gallery shows are always free and open to the public, NSU Art Museum Fort Lauderdale also offers its “Museum on the Move” program, providing free tours to Broward County’s 6th graders. Carlos and Rosa de la Cruz also privately fund their many educational programs, from workshops to student art trips to New York and Europe. “We’re not really only collectors, we’re more activists,” says Rosa de la Cruz of the collection’s commitment to education. “So many students come and tell me, you know Mrs. de la Cruz, we’ve never left this area. We need to expose them to more. That’s why collaborating with the library is important and we hope to continue doing this.” These collective efforts seek to empower young local artists in their own image-making – hopefully creating new, more dynamic stories and icons about South Florida on the global stage. Cult of Personality runs until May 28. Visit here for more information on NSU Library events. Close Up: (L-R) NSU Art Museum Director, Bonnie Clearwater, artist Christian Holstad, and famed art collectors Rosa and Carlos de la Cruz pose in front of Holstad’s Marylin Monroe-inspire work, Slumber Party. Tags: Alvin Sherman Library, Carlos and Rosa de la Cruz, Christian Holstad, Cotilla Gallery, de la Cruz Collection, Nove Southeastern University, NSU, NSU Art Museum	cc/2021-04/en_middle_0068.json.gz/line1519
__label__cc	0.591934	0.408066	On the hunt for new school uniform? George’s range has just been voted best value Make sure your child's school uniform can withstand the rigours of the playground By Asda Good Living, 22 August 2016 It’s that time of year again to start thinking about your little darling’s school uniform. But as every parent knows, children grow up so fast and a combination of playground antics and classroom spillages means our kids really put their uniforms through their paces. But not to worry, George at Asda has come to the rescue! 'The Playpennies followers have voted that Asda George provides that balance offering the best value for money school uniform that is both reasonably priced and of a good quality' This year George’s range of school clothing features high quality improvements such as using viscose as well as polyester, 100 per cent quality cotton polo shirts and sweatshirts, plus introducing Teflon for durability (see how hard-wearing this makes t-shirts in the brilliant advert below!) and Lycra for a better fit. While this means plenty of positive changes for your little ones, families can rest assured that school uniform prices remain the same. What could be better than that? And if you needed further proof, George has just been voted number one for value by leading UK parenting site, Playpennies. If you're wondering what that means in reality, think £2 school jumpers, a twin pack of polo shirts for £2.50 and trousers and skirts for only £3. What a steal! Check out the current £10 off deal that the Mirror newspaper is promoting to save you pennies - or leave you change for a treat yourself! Karen McGinn, website manager for Playpennies and mother of one said, 'As parents, we all have to buy school uniform for our children and it's about finding that balance between budget and quality, so you’re not replacing items throughout the year. 'The Playpennies followers have voted that Asda George provides that balance offering the best value for money school uniform that is both reasonably priced and of a good quality.' George's 100 day guarantee working hard for parents This latest accolade comes off the back of George's ongoing 100 day money back guarantee on uniforms. Translation? George at Asda is so confident in the quality of its school uniforms that it is making a commitment to fully refund customers during the first 100 days of the school term if they aren’t completely happy with it. Many shops will give store credit or money back within 30 days of purchase, but what to do when you want a real life test for your little one's clothing? Because the truth is that laboratory and factory testing doesn't account for all the tumbling, running, spilling and who-knows-what that happens in school and in the playground. That's why George are happy to give shoppers 100 days to try their school uniforms or they will refund the full cost. In an ASDA survey, 36 per cent of mums had said they had bought a school uniform and that they had been extremely disappointed with the quality. That’s no way to start the school year! Make sure you - and your children - are enjoying and thriving in their clothing with Asda’s 100 day money back guarantee on school uniforms. Shop the full school uniform collection with George at Asda. Here’s what our community team is getting up to this Christmas Shop cleaner and greener with Sustainable steph Asda’s history: from 1960 to 2020 5 women who are changing the world George on recycling for charity 5 ways we’re reducing our packaging use REVEALED: Our approach to sourcing cotton	cc/2021-04/en_middle_0068.json.gz/line1520
__label__cc	0.608197	0.391803	We are on a Big F*k!ng Mission. Helping people and companies understand what makes them unique and inspire them to make full use of their potential. Our vision. The world we live in today is drastically different from the world we’ve come to know over the past 50 years. More volatile, more uncertain, more complex and also more ambiguous. Our universe has transformed radically, opening up infinite possibilities in almost all industries and sectors, from science, technology and economics, to spirituality and art. The speed at which these changes take place have introduced a new paradigm… (R)evolution. In the span of a few years, the increased power of algorithms, automation and robotics has deprived humans of a growing number of tasks and activities that were reserved to them previously. While it has been a form of liberation in many respects, it also makes us rethink our place in the word and the future of work. If we aren’t careful, large numbers of people will find themselves sidelined in the near future, as they become unable to contribute in ways that distinguish them from automated systems… At AssessFirst, we believe that in order to remain relevant and make significant contributions, individuals must leverage the resources at the heart of their humanity—who they really are—and be ready to reinvent themselves continuously. Our humanity is a vast repository of resources. Although not all of them can compete with technology today (just think of the calculating power of your smartphone, or the consistency with which an algorithm can process complex data), many of them—specially as it pertains to soft skills, “behavioural” skills and creative power—are an endless well from which we can draw in order to determine our destiny and shape history. We believe that by focusing on our true selves, the way we assimilate the world, our most profound motivations, and our myriad skills (leadership, empathy, creativity, collaboration…) we are better able to identify our calling, find a means of expression, leave our marks and lead the way for a better future. 10K 8. An average person spends 80,000 hours of their life working. And, on average, it takes 10,000 hours of deliberate practice to become a world-class referent in any given domain. You could say then that we all have opportunities for making an exceptional contribution to the world. In fact we could do so about 8 times in the course of our lives. Of course, these are simply theoretical figures. But imagine that you had the possibility of dedicating just 10,000 hours of your entire existence for a cause that you are passionate about and for which you could leverage your most valuable and unique traits… What would your state of mind be like? How energised would you feel every morning when you wake up? What would occupy your thoughts every day? If you recruit or manage talent, imagine if you had the possibility to identify those people whose strongest motivations and natural skills allowed them to put their incredible potential to use in the context of your organisation and its development. Where would your company be today? How about a year from now? 5 years? 10 years? Making this augmented world a reality is the driver that stirs us into action all day, every day at AssessFirst. David Bernard CEO @ AssessFirst WE ARE ASSESSFIRST Making history since 2002. Since 2020, we’ve been continuously reinventing the way companies recruit and develop their talent. En 2012 we undertook a major shift by developing an unprecedented predictive approach. The results we obtain today for each of our clients have made AssessFirst one of the most innovative and influential organisations in the HR tech space. We have impacted the life paths of over 5 million people. That means 5 million individuals who had the chance to be considered based on who they are as humans, beyond their academic achievements, professional background, age, gender or origin. Our client base comprises 3500 companies in over 40 countries around the globe—all of whom use AssessFirst to make the world better. They are committed to better, more equitable recruitment, to talent development, to identifying potential in their workforce, and to boosting upward mobility for employees, all while building top-performing teams. Discover the crew behind the Big F**k!ng Mission We are here because there are some massive questions that even Google can't answer. 3500 clients in 40 different countries. Our clients are companies of all shapes and sizes, ranging from freelance recruiters in Santa Monica, Geneva and Bali, through a small family business headquartered in Midwestern United States, all the way to global corporations employing several hundred thousand people across all continents. Our daily inspiration. At AssessFirst, we are motivated by a relentless desire to make the world a better place, where each person can become the best possible version of themselves, make full use of their potential, and contribute through this to the betterment of society. These are some of the our guiding principles: Human Centric. Humans are at the heart of everything we do at AssessFirst. We create positive, enriching and inspiring experiences that encourage each person to ask themselves the right questions about who they are, as well as the best pathways to expressing their talents and making a unique contribution. Maximum value. Our solutions are designed to offer maximum added value to each of our users. Employees and candidates gain access to in-depth information about themselves and their talents, as well as ressources for making tangible progress. Our clients benefit from solutions that allow them to make better decisions, be more efficient and significantly reduce turnover. Obsessed with excellence. Our aim at AssessFirst is to build a world-class company in the talent identification, capitalisation and management sector. We are not interested in becoming one of the bunch. We work hard to shape history by transforming the way companies understand all aspects of Human Talent, and the place that it should have in creating value. N[0] compromises. Every decision made at AssessFirst—from strategic to seemingly insignificant—is made in light of the objectives we’ve set for ourselves. We don’t do things in order to please others: we do what we know to be right. Change your HR for the better. Book a product tour Predictive HR Solutions. Internal mobility Identifying potential Team performance AssessFirst X Science Shape (Personality) Drive (Motivations) Brain (Reasoning) See our case studies Get a trial account ATS, HRIS and Third-Party Apps Distribute AssessFirst Business Contributor Program About AssessFirst. Leadership & Management Team © 2021 AssessFirst. All rights reserved	cc/2021-04/en_middle_0068.json.gz/line1521
__label__wiki	0.817401	0.817401	P.S. from Paris Autor: Marc Levy, Sam Taylor - translator Sprecher: Tim Campbell Kategorien: Liebesromane, Zeitgenössische Liebesromane From Marc Levy, the most-read French author alive today, comes a modern-day love story between a famous actress hiding in Paris and a bestselling writer lying to himself. They knew their friendship was going to be complicated, but love - and the City of Lights - just might find a way. On the big screen, Mia plays a woman in love. But in real life, she's an actress in need of a break from her real-life philandering husband - the megastar who plays her romantic interest in the movies. So she heads across the English Channel to hide in Paris behind a new haircut, fake eyeglasses, and a waitressing job at her best friend's restaurant. Paul is an American author hoping to recapture the fame of his first novel. When his best friend surreptitiously sets him up with Mia through a dating website, Paul and Mia's relationship status is "complicated." Even though everything about Paris seems to be nudging them together, the two lonely ex-pats resist, concocting increasingly far-fetched strategies to stay "just friends." A feat easier said than done, as fate has other plans in store. Is true love waiting for them in a postscript? ©2015 Marc Levy/Versilio. Translation © 2017 Susanna Lea Associates. (P)2017 Brilliance Publishing, Inc., all rights reserved. Die zwei Leben der Alice Pendelbury Er & Sie: Eine Liebe in Paris Une fille comme elle A Bond Broken The New Climate War The Land of the Undying Lord Das sagen andere Hörer zu P.S. from Paris	cc/2021-04/en_middle_0068.json.gz/line1526
__label__cc	0.665836	0.334164	Solar System - Sun A small gallery of images of the Sun and sunsets/rises, in wide-angles and close-ups. Presented in chronological order from newest to oldest. Does not include eclipses or transits – they are in their own galleries. The Shifting Sunset Through the Seasons (2020) This demonstrates the shifting sunset point through the seasons, in a version revised in June 2020. Following and marking the changing rise and set points of the Sun through the year was important to cultures around the world as it was their calendar, and indeed resulted in many archaeo-astronomy sites and structures in both the Old and New Worlds. This is a 3-image blend of images taken at the March 20, 2019 Equinox (centre), the June 19, 2020 Summer Solstice (at right, or technically the day before solstice), and at the December 21, 2019 Winter Solstice (at left). All were taken from the same location and with the same camera and lens. The composite shows the changing position of the sunset point, from far to the northwest at right in summer, to due west at centre at the equinoxes, and far to the southwest at left at the winter solstice. Snow covered the field in March and December but was the field was green in June with the crop just starting to grow. This is from a latitude of 51° N from southern Alberta. From farther north the shift would be even more pronounced. Here at this latitude ther change in azimith is about +/- 40° — i.e. 40° south of due west at the winter solstice and 40° north of due west at the summer solstice. The Sun sets due west only at the two equinoxes. I shot the March vernal equinox for this demo, as the sky was too cloudy to include the September autumnal equinox Sun. As it was, clouds on the horizon prevented a clear view of the setting Sun at the winter solstice, but the bright sunset point is still apparent. All were with the Nikon D750 and Sigma 14mm Art lens, blended in Photoshop with gradient masks. The Shifting Sunset Through the Seasons (2020 with Labels) The Shifting Sunset Through the Seasons This demonstrates the shifting sunset point through the seasons. This is a 3-image blend of images taken at the March 20, 2019 Equinox (centre), the June 22, 2019 Summer Solstice (at right, or technically the day after solstice), and at the December 21, 2019 Winter Solstice (at left). All were taken from the same location and with the same camera and lens. The composite shows the changing position of the sunset point, from far to the northwest at right in summer, to due west at centre at the equinoxes, and far to the southwest at left at the winter solstice. Snow covered the field in March and December but was green field in June with the crop just starting to grow. This is from a latitude of 51° N from southern Alberta. From farther north the shift would be even more pronounced. Here at this latitude ther change in azimith is about +/- 40° — i.e. 40° south of due west at the winter solstice and 40° north of due west at the summer solstice. The Sun sets due west only at the two equinoxes. I shot the March vernal equinox for this demo, as the sky was too cloudy to include the September autumnal equinox Sun. As it was, clouds on the horizon prevented a clear view of the setting Sun at the two solstices, but the bright sunset points are still apparent. All were with the Nikon D750 and Sigma 14mm Art lens, blended in Photoshop with gradient masks. The Shifting Sunset Through the Seasons (with Labels) This demonstrates the shifting sunset point along the horizon through the seasons. This is a 3-image blend of images taken at the March 20, 2019 Equinox (centre), the June 22, 2019 Summer Solstice (at right, or technically the day after solstice), and at the December 21, 2019 Winter Solstice (at left). All were taken from the same location and with the same camera and lens. The composite shows the changing position of the sunset point, from far to the northwest at right in summer, to due west at centre at the equinoxes, and far to the southwest at left at the winter solstice. Snow covered the field in March and December but was green field in June with the crop just starting to grow. This is from a latitude of 51° N from southern Alberta. From farther north the shift would be even more pronounced. Here at this latitude ther change in azimith is about +/- 40° — i.e. 40° south of due west at the winter solstice and 40° north of due west at the summer solstice. The Sun sets due west only at the two equinoxes. I shot the March vernal equinox for this demo, as the sky was too cloudy to include the September autumnal equinox Sun. As it was, clouds on the horizon prevented a clear view of the setting Sun at the two solstices, but the bright sunset points are still apparent. All were with the Nikon D750 and Sigma 14mm Art lens, blended in Photoshop with gradient masks. Sunset Trail in Forest Fire Smoke The Sun setting into a pall of forest fire smoke over Alberta from fires in B.C. and elsewhere, on August 17, 2018. This shows the dimming and reddening of the Sun as it set, with it disappearing from view long before it reached the horizon. This was from home in southern Alberta, and is a Lighten blend mode stack of 20o images taken at 1-minute intervals, and shot on Auto Exposure with the Canon 6D MkII and 35mm lens. Stacking was with the Advanced Stacker Plus actions in Photoshop. Sunset in Forest Fire Smoke The Sun setting into a pall of forest fire smoke over Alberta from fires in B.C. and elsewhere, on August 17, 2018. This shows the dimming and reddening of the Sun as it set, with it disappearing from view long before it reached the horizon. This was from home in southern Alberta, and is a Lighten blend mode stack of 20 images taken at 10 minute intervals, and shot on Auto Exposure with the Canon 6D MkII and 35mm lens. The frames are part of a larger 200-frame timelapse processed with LRTimelapse. Big Sunspots on the Sun (Sept. 4, 2017) Particularly large groups of sunspots on the Sun on September 4, 2017. The group at bottom is AR 2673, the group at top is 2674. The small spot at left on the emerging limb is AR 2677, while the groups disappearing at right are AR 2675 (top) and AR 2776. I shot this through the 130mm Astro-Physics refractor with a 2x Barlow lens for an effective focal length of 1500mm and with the Canon 60Da camera for an image that just filled the frame. Sunset at Twelve Apostles The setting Sun at the Twelve Apostles sea stacks and cliffs on the Great Ocean Road, on April 12, 2017. This is an HDR stack of 7 exposures from long to short to compress the dynamic range from bright Sun and dark foreground. This nicely demonstrates the Rule of Thirds framing and composition. Merged in Adobe Camera Raw. Sunset over Deadhorse Lake Sunset colours over Deadhorse Lake in southern Alberta, on July 8, 2016. The waxing crescent Moon shines amid the colourful clouds. I shot this as part of a 900-frame motion control time-lapse sequence. Sunset at Deadhorse Lake with Abandoned Farmstead #2 Sunset at Deadhorse Lake, in southern Alberta, with an abandoned farmstead building at the foreground element. The waxing crescent Moon is at left amid the sky colours and clouds. Taken July 8, 2016 as part of a 1000-frame time-lapse sequence. Stormcloud Panorama at Sunset A cloudscape of a thunderstorm and rainbow fragment in the light of the low Sun from home in southern Alberta, July 3, 2016. A wonderful sky of colours, shades, and shapes. Certainly a Turneresque sky. This is a panorama stitch of 8 segments with the Sigma 20mm lens and Nikon D750. Storm Cloudscape at Sunset A cloudscape of a thunderstorm and rainbow fragments in the light of the low Sun from home in southern Alberta, July 3, 2016. The clouds exhibit mammatiform cells from downdrafts. The Sun is also casting some anti-crepuscular cloud shadows converging on the centre of the rainbow arc, the anti-solar point. This is a panorama stitch of 8 segments with the Sigma 20mm lens and Nikon D750. Red Smoky Sun A very red Sun in the west amid smoke from forest fires, on August 27, 2015, from southern Alberta. The Sun in Smokey Skies The Sun in smoke from Washington State forest fires obscuring skies in southern Alberta, August 25, 2015. The Sun was dim enough to observe naked eye and throigh binoculars at times. A large sunspot group, #AR2403, was just visible naked eye. This is a compopsite two exposures taken with no filter: a short exposire (for the Sun disk to show the sunspot) and a longer exposure (for the sky), both taken through a 200mm telephoto lens with 1.4x extender on the Canon 60Da, to replicate the view through binoculars. Sunset Panorama at Monument Valley A 6-section panorama of Monument Valley from the main viewpoint near The View hotel, overlooking the West and East Mittens and Merrick Butte. I shot this with the Canon 60Da and 24mm lens, stitching the segments in Photoshop. Iridescent Clouds at Chaco Canyon Iridescent clouds near the Sun in the afternoon sky over the Pueblo Bonito ruins at Chaco Canyon at the Chaco Culture National Hiistoric Site. Rising Red Sun over Wheatfield The rising Sun coming up very red amid hazy skies, at dawn on Aug 8, 2014, shot from home in Alberta. Shot with the Canon 6D and 200mm lens, handheld, with metered exposure. Red Sun in a Prairie Sunset The red setting Sun in haze, casting shadows across the sky – crepuscular rays - and lighting the clouds, over a ripening wheatfield near home in Alberta. This is an HDR stack of 5 exposures, handheld, with the 24mm lens and Canon 6D, at 2/3rd stop intervals, and composited with Photomatix Pro. Taken August 6,, 2014. Setting Sun with Sunspots The setting Sun on June 30, 2014 as it set into a hazy or dusty sky and turned deep red/magenta, above the horizon clouds. I shot this through the 66mm William Optics apo refractor with the Canon 60Da camera at ISO 100. This is a composite of two exposures: longer for the sky and shorter for the Sun and details on the disk. A large sunspot group is on the eastern limb. This was shot without a filter -- atmospheric extinction dimmed the Sun enough naturally. Iridescent Clouds at White Sands #3 Iridescent clouds near the Sun, December 10, 2013, taken from White Sands National Monument, New Mexico prior to shooting the sunset. Taken with the 135mm telephoto and Canon 5D MkII, metered and hand held. The effect did not last long as the clouds drifted off the area of sky near the Sun. Harvest Moon Panorama (Sept 19, 2013) A panorama of the rising Harvest Moon and setting Sun on September 19, 2013, taken from the hill near home. This is a 12-section panorama covering 360°, with each frame taken with the Canon 5D MkII and 50mm Sigma lens. The dark arc of the Earth's shadow is at left, with the Full Moon embedded in it. Each frame was 1/50 sec at f/5.6 and ISO 100. Horseshoe Canyon Sunset (August 11, 2013) Sunset at Horseshoe Canyon, Cypress Hills Interprovincial Park, Alberta, on August 11, 2013. This is a 7-image HDR stack at 2/3rds stop increments, stacked in HDR Pro in Photoshop. Shot with the Canon 60Da and 135mm lens at f/6.3 and ISO 100.	cc/2021-04/en_middle_0068.json.gz/line1529
__label__cc	0.615196	0.384804	Yokogawa Releases New UTAdvanced Series DIN Rail Mounting Type and 1/8 DIN Panel Type Controllers Yokogawa Electric Corporation announces that it will be releasing a number of new UTAdvanced series controllers on April 24. Yokogawa Corporation of America Yokogawa Electric Corporation announces that it will be releasing a number of new UTAdvanced series controllers on April 24. The new controllers include four DIN rail¹ mounting type controllers and one 1/8 DIN panel type program controller. This is part of Yokogawa’s ongoing effort to expand its controller business by satisfying market needs and giving customers a greater range of choices. UTAdvanced series controllers are mounted on furnaces and other types of heat process-related industrial facilities for the measurement, display, and control of operating variables such as temperature, pressure, and flow rate. In recent years, it has become more common for equipment manufacturers to integrate the setting, manipulation, and display functions of programmable logic controllers (PLC) and other embedded control devices on touch panels and other types of user interfaces, and to mount the hardware on DIN rails inside panel boxes. There is an increasing need for such DIN rail mounting type controllers. The UTAdvanced series controllers come in two sizes: 1/4 DIN and 1/8 DIN. While 1/4 DIN controllers are more popular because they have large display panels and provide a wider range of I/O signal choices, there are certain applications where space is at a premium that require a smaller device. For just such applications, Yokogawa has added more 1/8 DIN controllers to its product lineup. 1. DIN Rail Mounting Type Controllers New UT55A, UT52A, UT35A, and UT32A DIN rail mounting type controllers are now available. They all comply with the global DIN standard and thus can be easily mounted in panel boxes. 2. 1/8 DIN Panel Type Controllers With its 1/8 DIN product line-up, Yokogawa provides its customers a variety of space-saving options to choose from. 1/8 DIN panel mounted program controller Compact in size, the new 1/8 DIN UP32A panel type program controller can control based on patterns that are preset along the time axis (program-pattern control). 1/8 DIN dual-loop controller The cost-effective and space-saving dual-loop 1/8 DIN UT32A-D controller can carry out the functions of two controllers. Non-isolated remote input option² for UT32A A new optional function is available for the UT32A that allows a target setpoint value to be remotely set via a signal from another instrument (UT32A/RSP). Economy-type temperature controllers² For customers who prefer a simple and cost-effective temperature controller design, the UT32A-R, UT32A-V, and UT32A-C single-output temperature controllers are now available. In contrast to conventional models that come with relay, voltage pulse, and current outputs, these new economy-type temperature controllers have just one output. ¹ A metal rail whose specifications conform to an international standard developed by the Deutsches Institut für Normung e.V. 1/8 DIN corresponds to a front panel size of 96 mm × 48 mm, and 1/4 DIN corresponds to a front panel size of 96 mm × 96 mm. ² Only available outside Japan Major Target Markets Companies that design and manufacture machinery, air conditioning systems, power equipment, and other items for use in industries such as electrical equipment, machinery, chemicals, foods, semiconductors, and automobiles Measurement, display, and control of temperature, pressure, and flow rate; alarming; programmed control; and display of operating conditions in heating, cleaning, sterilization, and other processes in R&D and manufacturing About the UTAdvanced Series The UTAdvanced controller comes standard with a sequence control function based on the ladder logic programming language, which is widely used by engineers. Improved design efficiency and elimination of the need for relays and other peripherals have resulted in a lower price. As a result, this series has enjoyed great success in the market since its release in 2009. The lineup includes: Digital indicating/DIN rail mounting type controllers: UT55A, UT52A, UT35A, UT32A, UT75A Program controllers that control based on patterns that are preset along the time axis (program-pattern control): UP55A, UP35A, UP32A A digital indicator with an alarm function that outputs and displays alarm signals when input signals reach a preset value: UM33A Fill out the form below to request more information about Yokogawa Releases New UTAdvanced Series DIN Rail Mounting Type and 1/8 DIN Panel Type Controllers Emerson Takes on Magnolia Power Plant Project in Mississippi Manufacturers aren’t the only adopters of Industry 4.0 technologies—the utility sector has long been active in the space as well, and the Tennessee Valley Authority has recently pledged $110 million to digitally transform its power generation fleet.	cc/2021-04/en_middle_0068.json.gz/line1531
__label__cc	0.599135	0.400865	Éco-Solutions Plantation d'Arbres Brise-vents Désherbage à l'ancienne Aménagements Intégrés > Petit Pré Lot Mixte Tempéré Cour de Conifères Eco-Solutions Integrated Landscapes > Boreal Backyard Mini Meadow Temperate Mixed-Lot What is biodiversity and why is it essential? In everyday language, biodiversity refers to the number of species that exist in a given area. Although this statement isn’t wrong, biodiversity is actually a much more interesting and complex topic than that. If biodiversity isn’t simply the number of species in an area, what exactly is it then? Answering this seemingly simple question turns out to be an arduous task! Two communities (we’ll call them community A and B) each have 16 individuals from four different species. However, community A has 13 individuals from one species and only one individual from the other three species, whereas community B has four individuals from each of the four species. Are these communities the same? Clearly not, but our initial definition would not be able to distinguish the two! The concept of biodiversity thus has two components: species richness and species evenness. Species richness is the number of species in an assemblage whereas species evenness is the relative abundance of each of these species. Ecologists have developed a number of equations to measure these factors to obtain diversity scores (see Simpson’s and Shannon’s diversity indexes for examples). There’s more though. Let’s take a look at another scenario with this simple example: Again, two communities (community X and community Y) both have 16 individuals from four different species. Community X consists of four species of songbirds whereas community Y is made up of a tree, a songbird, a mammal, and a fungi. Here, the two communities are mathematically equivalent even though they are in no way ecologically similar! That is why many ecologists will also use functional diversity―this assigns biologically relevant roles to separate the life forms into groups instead of relying on species count. In the above example, we will set our categories as producer, consumer, predator, and decomposer although any categories could be used. All the organisms from community X now fall into a single category where community Y still has 4 individuals in each of the 4 categories. And yes, it gets more complicated than that (biomass, genetics, etc) but we will leave it here for this post. So what is the best diversity measure to use? A definite answer does not exist. It requires that we use discretion and careful planning to apply the best method to the problem we are trying to address. Why is biodiversity so important? The popular answer is a utilitarian one―species hold biological secrets that we can use to create medicines to cure diseases. For example, a popular medicine to cure hypertension comes from the venom of a snake native to South America. Evolution is by far the greatest problem solver of all time and the innumerable species that evolved over millions of years are a vast repertoire of biological knowledge we can use. However, we’ve only explored a small portion of the world’s biodiversity; if we cause species to go extinct, we may never discover these beneficial remedies. Another reason to value biodiversity is because habitats become more resilient with increased biodiversity. Take the following example: A pure stand of ash trees and a forest composed of 4 species of equally distributed trees (ash, maple, pine, and beech) both get affected by a deadly outbreak that kills the ash trees. The pure stand dies out completely whereas only 25 percent of the trees die within the mixed forest allowing the remaining trees to keep producing food and supporting life. Biodiversity is also important because it means more specialization in organisms which leads to better resource use. Imagine a market made up of only unskilled workers. It would not be very effective. There would be no one to program software, build houses, communicate ideas effectively, set up the power grid, entertain people, etc. Additionally, all the workers would compete for the same easily accessible jobs. The same phenomena applies with lifeforms: Instead of competing for the same habitat, species evolve to specialize in their own niche: One species of tree will specialize to grow on sand while another to thrive in wetlands. Furthermore, species will evolve ever finer ways to obtain resources: Instead of fighting for the same insect, one bird will evolve a wide beak to catch insects in mid-air while another an elongated beak to probe for them beneath tree bark. If we lose one of these species, there will be no more predators to keep those hard to catch insect populations in check. Maintaining biodiversity thus prevents homogeneity and inefficiency. patrick@aves.eco (438) 506-AVES paypal.me/aveseco © AVES 2020	cc/2021-04/en_middle_0068.json.gz/line1535
__label__wiki	0.977456	0.977456	Sikh guardsman first to wear turban during Queen's ceremony Lauren Meier Coldstream Guards soldier Charanpreet Singh Lall the first to wear a turban during the ceremony. Photo: Dan Kitwood/Getty Images History was made at the Queen's Trooping the Color ceremony Saturday, that marks the Queen's official birthday, as Charanpreet Singh Lall, a 22-year-old Sikh, wore a black turban, rather than the iconic British Foot Guard bearskin hat, reports CBS News. This marked the first time a member of the Coldstream Guards wore the headdress that is traditional in Muslim and Sikh cultures during such event. "I hope that people watching, that they will just acknowledge it and that they will look at it as a new change in history... I hope that more people like me, not just Sikhs but from other religions and different backgrounds, that they will be encouraged to join the Army." — Lall to CBS News	cc/2021-04/en_middle_0068.json.gz/line1536
__label__cc	0.624055	0.375945	Evelyn Billo, Robert Mark and Donald E. Weaver, Jr. – “Sears Point Rock Art and Beyond, Synopsis of the 2008-2012 Recording Project” Petroglyph antlers reach for the sky in the Sears Point Archaeological District, Arizona. Utilized for centuries by many cultures, the National Register Sears Point Archaeological District (SPAD) is located along the rich riparian habitat of the Gila River. Currently managed by the Yuma District of the Bureau of Land Management, a large portion of the District is designated an Area of Critical Environmental Concern and is still utilized by several of the 15 Tribes that claim cultural affiliation there. Responding to a BLM request for comprehensive rock art recording, Rupestrian CyberServices and Plateau Mountain Desert Research not only mapped approximately 2000 petroglyph panels and 100 features including rock piles, rock rings, artifact scatters, a rock shelter, several apparent natural and constructed hunting blinds, geoglyphs, and scattered rock alignments; but also, many historic features and an extensive network of pre-historic, historic, and animal trails. Recording and photographing SPAD required a three-year effort with the help of 50 volunteers, and some unusual techniques. Tucson Balloon Rides assisted us by providing a low-elevation flight path from which we observed and photographed subtle features that were otherwise difficult to view from the ground and impossible to discern from available aerial photography. Extensive measurements were made and recorded on multiple page forms during 16 weeks of fieldwork and subsequently entered into FileMaker Pro and Excel databases. 18,000 photographs are catalogued and identified by panel number in a Portfolio image database. This presentation will provide not only a birds-eye view of the area, but also some intriguing petroglyph designs and preliminary analyses of the 8000 individual rock art elements. Posted in:Events, Lectures	cc/2021-04/en_middle_0068.json.gz/line1537
__label__wiki	0.623783	0.623783	Arizona Official Refuses to Expand Health Conditions for Medical Marijuana East Valley Tribune: “State Health Director Will Humble refused Thursday to expand the conditions for which marijuana can be legally recommended. . . . Humble’s decision disappointed Suzanne Sisley. She is a physician with the Telemedicine Program at the UA College of Medicine and a specialist in internal medicine and psychiatry. She said that, despite the lack of formal full-blown scientific studies, she believes marijuana works. . . .Sisley said, though, the decision comes as no real surprise. She said that Humble, in demanding evidence from scientifically backed peer-reviewed studies, essentially set the requests to expand the medical marijuana program up for rejection. That’s because the National Institute for Drug Abuse, which controls the only legal supply of marijuana for medical research has consistently refused to give the go-ahead for the kind of studies Humble said he needs.” See also the Arizona Republic’s interview of Will Humble on his decision to reject new conditions. Mr. Humble said: “I’ll concede that the clinical-trial type of research is controlled by NIDA (National Institute on Drug Abuse) and they are pretty strict when it comes to clinical trials, when it comes to the use of testing medical marijuana. But there are all kinds of studies that can be conducted that don’t need NIDA approval.” By On the Net\|2012-07-20T06:07:48-07:00July 20th, 2012\|Dept Health Services, Stories & Articles, Will Humble Speaks\|Comments Off on Arizona Official Refuses to Expand Health Conditions for Medical Marijuana About the Author: On the Net The author of this article is Richard Keyt, an Arizona business law attorney who is the creator of this Arizona medical marijuana law website. Connect with Richard at 480-664-7478 or on Google+	cc/2021-04/en_middle_0068.json.gz/line1538
__label__cc	0.700461	0.299539	Is Pricing Killing Your Profits? How the best B2B companies set and get the right price. By Ron Kermisch and David Burns Most companies call pricing a high priority in our global survey, but 85% say they have significant room for improvement in pricing. Top-performing companies behave differently. They tailor pricing at the transaction level, align sales incentives with pricing strategy, and invest more heavily in ongoing training and tools. With significant margin upside at stake, companies cannot afford to continue pricing by guesswork or rules of thumb. Poor pricing practices are insidious—they damage a company’s economics but can go unnoticed for years. For example, a major industrial goods manufacturer struggled with low profit margins, relative both to competitors and its own historical performance. It traced much of the cause to a mismatch between its sales incentives and pricing strategy. The manufacturer was compensating sales representatives based solely on how much new revenue they generated. Reps thus had little motivation to protect price levels on any given deal, and most were closing deals at the lowest permissible margin. As with this manufacturer, many business-to-business (B2B) companies have a major opportunity to improve their standing on price. To help B2B companies understand the state of pricing capabilities and how they figure into company performance, Bain & Company conducted a global survey of sales leaders, vice presidents of pricing, CEOs, CMOs and other executives at more than 1,700 companies. We gathered their self-rating of 42 pricing capabilities and outcomes. Roughly 85% of respondents believe their pricing decisions could improve. While most executives suggest pricing is a high priority, the survey shows that, on average, large capability gaps exist in price and discount structure, sales incentives, use of tools and tracking, and structuring cross-functional pricing teams and forums. Dialing in Perfect B2B Pricing The better your company’s pricing abilities, the better its performance. What pricing leaders do differently To understand which capabilities matter most, we studied a subset of top-performing companies, as defined by increased market share, self-described excellent pricing decisions and execution of regular price increases. While different pricing capabilities may be important for a particular situation, the analysis showed that top performers exceed their peers primarily in three areas (see Figure 1). Top performers are more likely to: employ truly tailored pricing at the individual customer and product level; align incentives for frontline sales staff with the pricing strategy to encourage prudent pricing through an appropriate balance of fixed and variable compensation; and invest in ongoing development of capabilities among the sales and pricing teams through training and tools. Our analysis also revealed just how much excelling across multiple pricing capabilities pays off. Among the companies that excel at all three areas, 78% are top performers (see Figure 2). Let’s explore why these three areas have such a strong effect on pricing. Pricing to the average is always wrong One-size-fits-all pricing actually fits no one. Yet it is not unusual for sales executives to admit that “our ability to tailor prices at the customer and transaction level is rudimentary at best” or that “we are not even aware of how much margin we make on deals.” By contrast, more advanced companies tailor their pricing carefully for each combination of customer and product, continually working to maximize total margin. They bring data and business intelligence to bear on three variables for setting target prices: the attributes and benefits that customers truly value, and how much value is created for them; the alternatives and competitive intensity in the business; and the true profitability of the transaction after netting out leakage in areas such as rebates, freight, terms and inventory holding. One North American manufacturer with margins that were highly dependent on raw material pricing suffered from an undisciplined approach to pricing. A diagnosis allocated costs at the product and customer level to determine true profitability (see Figure 3). That diagnosis provided the support needed to raise prices where appropriate in subsequent contract negotiations, leading to an average 4% increase. The company designated an executive to own related margin opportunities and track the status and effect of each price increase. As a result, the company improved earnings before interest, taxes, depreciation and amortization by 7 percentage points. Bad incentives undercut the best pricing strategy Managers often criticize sales reps for losing a deal but rarely for pricing a deal too low, so reps learn to concede on price until the deal closes. Moreover, companies rarely reward sales reps for exceeding price targets, which means few of them take risks to push for a higher price. Misaligned incentives push deals down to the minimum allowed price (see Figure 4). The antidote is to align compensation with the company’s strategic goals and to allow field sales reps to see the effect of price changes on their own compensation. In many cases, this requires maximizing price without sacrificing volume. Incentive plans benefit from the following few principles. Clarify the objectives—be they revenue growth, share gains, margin gains or others—and the behaviors that will help meet the objectives. Make it foolproof—help sales reps understand the payout calculation, simplify the quota structures and supplemental incentives, and make the upside for outperformance meaningful. Ensure transparency—sales reps should easily see the effect of a deal’s price on their personal compensation. Track the results through regular reviews that flag areas where frontline staff might game the system. Returning to the case of the industrial goods manufacturer described in the introduction, the company overhauled its incentive program to balance revenue and profit. It created a pricing tool to make the commission on each deal visible to sales reps—for instance, “if I raise the price by $2,000, I earn an extra $700.” Sure enough, reps began to close higher-margin sales. These changes led to a 7% increase in prices, which added 95 basis points as part of a 350-point improvement in margin overall. Bain Partner Ron Kermisch details the four steps that are important for optimizing margins and incentives, and improving front-line behavior. Training, tools and forums—often afterthoughts—can have a big payoff Top performers invest in building the capabilities of the pricing team through training and forums for best-practice sharing. This runs counter to the norm at many sales organizations, which give little or no formal training on price realization. Further, most companies can raise their game by adopting foundational pricing software tools. For example, based on the performance of historical deals, software solutions can provide frontline reps with real-time pricing feedback on the characteristics of a deal underway. Using dedicated pricing software, whether in-house or from a provider such as Vendavo or Price f(x), is associated with 2.5 times stronger pricing outcomes, our analysis finds. Yet despite its proven value, pricing software still has only 26% penetration across surveyed companies (see Figure 5). The value of developing capabilities became evident to a specialty chemical producer with lackluster margins. The company had hundreds of different products, each with different competitors, substitutes and customer bases. Product and sales staff could not explain their pricing decisions and often resorted to a rule of thumb summed up by one product manager as “I estimate I can raise the price by 4 cents per pound.” Not surprisingly, she had raised prices by 4 cents per pound for four straight years, leaving money on the table. By analyzing the various products and their markets, the specialty chemical producer found pricing opportunities that enabled it to increase earnings before interest and taxes by 35% within two years. Just as important, the company set out to raise its game on pricing capabilities. It created forums for sharing best practices, trained product managers in doing fundamental pricing analysis and trained salespeople on how to have better pricing discussions with their customers. New dashboards monitored progress toward pricing goals and flagged places where sales reps might be getting too aggressive. Finally, the CEO reinforced these measures by demanding that the product and sales teams report on pricing actions taken, as well as results, so that effective pricing remained a high priority. The company established itself as a pricing leader in its chemical markets and continued to optimize margins, both by raising prices and by using price to repel lower-cost competitors without giving away too much. Regardless of a company’s starting point in pricing, there is significant value in building out the capabilities highlighted by our survey analysis. The three areas discussed here have proved to be the most important for upgrading tools, resources and behaviors. That said, companies in almost all industries have underinvested generally across pricing. The episodic “pricing project” approach leaves companies well short of full potential. With meaningful margin upside at stake, managers cannot afford to continue pricing by guesswork or rules of thumb. Ron Kermisch and David Burns are partners with Bain & Company’s Customer Strategy & Marketing practice. Kermisch is a leader of Bain’s pricing work, and Burns is an expert in building pricing capabilities. They are based, respectively, in Boston and Chicago. Accelerated Revenue Transformation B2B Go-to-Market Ron Kermisch Partner, Chicago Operating Model & Org Design Killing Complexity Before Complexity Kills Growth How to restore a Founder's Mentality, including intolerance for bureaucracy. Revving Up Sales ROI for a Downturn Members of Bain’s B2B Commercial Excellence group discuss the four pillars of every company's commercial base and how they should be structured for medium-term growth. Bringing Order to Discounts Gone Haywire Recessionary times call for culling unproductive customer investments to focus on those that contribute the most to profits. B2B commercial organizations should respond to the coronavirus crisis with short-term moves to act on now and medium-term moves to plan now. Sales and Marketing Designing a Sales Compensation Plan Based on an Unusual Metric B2B Go-to-Market A Logistics Company Transforms Its Salesforce and Account Planning Processes Sales and Marketing Revenue Turnaround: A Tech Salesforce Changes Behaviors	cc/2021-04/en_middle_0068.json.gz/line1540
__label__wiki	0.63788	0.63788	Revealed: Number of blades seized by Avon and Somerset police amid rising national knife crime levels There have been 112 knife-related arrests of children since 2016, force figures show Lucy Thornton Rob Grant Sam Petherick Officer arresting a man (stock picture) (Image: IPGGutenbergUKLtd) Avon and Somerset police have seized 230 knives and blades off the streets so far this year – including samurai swords. Officers have recovered 10 samurai swords so far in 2017, four machetes, 108 kitchen knives and various other kinds of blades. And children as young as 12 have been arrested on suspicion of knife crime in the force area. Officers have arrested under-18s believed to be breaking gun laws 25 times since 2015, data supplied from the force shows. Since 2016 police have made 112 knife-related arrests of children, the youngest of which was 12. Bath police appeal for information after daylight house burglary in Apsley Road The youngest gun-related arrest was a 14-year-old in 2016. Owning a gun is illegal in England without a licence, while certain firearms such as handguns are banned altogether. It is illegal to carry knives or other sharp instruments in public without good reason. It is also illegal to sell a knife to anyone under 18. The figures come amid rising levels of knife crime nationally. Two attacks and 26 threats of acid attacks reported to Avon and Somerset Police in three years Across the country, knife crime has increased by 20 per cent. There were 5,800 more offences recorded by the police between April 2016 and March 2017. Despite overall crime rising 10 per cent, the Crime Survey of England and Wales – which is based on people’s experiences of crime – revealed a seven per cent drop. What's On NewsBy Brook walk in Box by Nigel Vile The By Brook flows through such picturesque villages as Castle Combe and Long Dean Priston: A cliché ridden walk by Nigel Vile What's On NewsThis is an area south and south-west of Bath where the outlying hills of the Cotswolds and the Mendips meet Wellow and Shoscombe walk by Nigel Vile AppleWellow and Shoscombe are as different as the proverbial chalk and cheese.	cc/2021-04/en_middle_0068.json.gz/line1546
__label__wiki	0.724868	0.724868	The Thief Among Us James Clayton was a brash, fast-talking member of the Austin, Texas, mountain bike community. But he was something else, too--a crook, who stole not from strangers, but from riders who called him a friend. By ian dille The bike thief slipped into the backyard through a chainlink gate to the right of the house's front door. He spotted a softball-size rock in the grass and picked it up. The thief walked up onto the house's wooden back deck, palmed the rock and smashed a windowpane in the rear door. Then he reached inside and flipped the latch. No alarm sounded, no dog barked, so he let himself in. In front of him, on the kitchen table, sat a Macintosh PowerBook and digital camera. He took them. An array of Oakley sunglasses and flashy Nike wristwatches rested in a box on a nearby cabinet. The home's owner, Matt Gordon, a full-time Austin, Texas, firefighter and one of the state's top pro racers, kept them there to select from before heading out for rides. The thief loved sunglasses, but he loved watches even more, especially ones people couldn't help but notice. He slid the box under his arm and headed into Gordon's bedroom. There, he rifled through a few drawers but didn't find anything he wanted. In Gordon's garage the thief discovered two carbon fiber Orbea Almas, worth roughly $7,000 apiece, and a classic Haro singlespeed. Jackpot. Normally Gordon kept the bikes in a locked closet, but he'd just gotten new rigs from his sponsor and was tinkering with fit. The thief took the bikes and a plastic bin of old parts. He removed a two-by-four Gordon used to bar the rear door to the garage and let himself out. The thief rolled the bikes across the deck, past a few of Gordon's old trophies, then loaded them into a red Ford Bronco he used for such heists. No one knows if the bike thief put the silver Nike watch with the black wristband on right then, or waited until he got home, but one thing is certain: When Gordon saw him at the local bike shop a few weeks later, the thief was wearing it. The bike thief first moved to Austin from Phoenix in 2006. He introduced himself in the local cycling community as James Clayton (his real name, though he went by aliases in other states). Tall and lean, with graying, swept-back hair, Clayton, 43, didn't appear much different from any other mid-aged bike racer. He quickly wove himself into the fiber of the community, chatting up the best riders--plus every attractive woman in sight--on group rides and at training races. To anyone who'd listen, Clayton told stories of his former days as a professional mountain biker living in northern California; of his magazine write-ups for top results in races such as Arizona's Cactus Cup; and his work as a coach to World Cup racers. It seemed strange that Clayton drove a Land Rover; that he never wore a former pro kit but frequently bragged of all his old sponsor swag; that he rode bikes painted matte black and passed them off as industry prototypes. But cyclists are a trusting group. We tend to assign a high degree of moral fiber and assume strong character traits, like honesty, to those who share our passion for the sport. We're quick to offer a spare tube on the trail. We leave our high-dollar rigs leaning against port-o-potties at races. This accepting attitude, seemingly pervasive across the country, can also make mountain bikers vulnerable. But in the case of the bike thief in Austin, a victimized mountain bike community learned something about itself. Instead of falling apart and scattering, it grew tighter. It fought back. James Clayton was born in Oklahoma. Little is known about his childhood, but relatively early in life he became a magnet for trouble. As a young man he faced charges for check forgery there. Later, in 1992, at 26, he was released from a federal prison in California. Clayton's colorful narrative about himself as a bike racer appears to have been fabricated; no records support his purported exploits, nor do any of the people he claimed to know, including U.S. Olympian Don Myrah, recall meeting him. Unbeknownst to Clayton as he continued to plan and execute robberies a year and a half after breaking into Gordon's house, Detective Scott Askew of the Austin Police Department (APD) was quietly compiling evidence for his arrest. In January of 2009, Askew inherited Gordon's burglary case and learned Clayton was the primary suspect. In Askew the APD couldn't have found a more perfect adversary for Clayton. The 35-year-old detective, a well-built six-foot-four, is a former sport-level cross-country racer and still-avid mountain biker. While many investigators likely couldn't discern between a box-store bike and a top-of-the-line rig, Askew recognized both the personal and financial value of the items Clayton stole. As Askew dug into Gordon's case, he found a trail of missing highend bikes. He also quickly discovered that vigilante sleuths within the Austin cycling community had already accrued a trove of incriminating material against Clayton. One of Gordon's close friends, Mark Wiggans, had discovered classified ads listed under Clayton's e-mail address on less-frequented websites like serotta.com. Wiggans, certain he'd stumbled upon Clayton's cyber-fencing operation, had been searching the Web for specific posting traits, like the thief's tendency to place the dollar sign after the number, and had compiled a catalog of Clayton's listings. During an interview with Askew at police headquarters, Wiggans said that he had even created an online persona named Sheila Anuthee, and had already contacted the person he thought was Clayton via e-mail. "We used 'Sheila' because we thought if it was a woman, the thief would let his guard down," Wiggans says. And that's exactly what happened: He gave Sheila his address and told her to write the check out to James Clayton. Through Wiggans and other Austin riders, Askew was frequently told of Clayton's weakness for women. Says Tomek Baginski, another victim, "He'd ask out a hundred girls just hoping one of them would say yes." So it was no surprise that Clayton took the risk of revealing his identity and ultimately gave himself away. Detective Askew used all of this evidence, including photos of bike parts shot on a distinctive white rug in Clayton's home, to begin building a case against him. Without the help of people like Wiggans, says Askew, "There's a possibility that we might not have developed a suspect in any of these cases for a long, long time." Just as the noose tightened around Clayton, Askew's case seemed to take a fateful turn. An anonymous posting to Craigslist warned: KNOWN BIKE THIEF. The text of the post called out Clayton by name and exposed his tactic of befriending mountain bikers before ripping them off. Though the flaming of Clayton evaporated from Craigslist quickly, Jason Abel, a heavily tattooed urban cyclist who crusades against bike thieves, copied the public indictment to his blog, atxbs.com. The post went viral, even prompting Clayton to brazenly defend himself. "Yo man can you take the bike thief story from Craigslist off your site...It would mean a great deal to quite a few people. Anyway the faster the better," Clayton wrote Abel. Abel, however, remained defiant. E-mails from cyclists who believed Clayton ripped them off as well were flooding into atxbs.com. Meanwhile Askew, reading the online attacks on Clayton, contacted Abel and recruited him as a key link to the bike thief's many victims. And the lieutenant made it clear to Abel that to catch the criminal the flaming of Clayton would need to end immediately--or Clayton might get spooked enough to leave town. Abel understood and backed off--titling his next post "Biting My Tongue Till it Bleeds." Even so, Askew still feared Clayton would flee, a suspicion that only grew when he entered Clayton's name into a police database of wanted felons. What he found was shocking: Police in Maricopa County, Arizona, had a 200-page rap sheet on Clayton that suggested the career criminal reveled in the brash nature of his crimes, the obliviousness of his victims--and a propensity to run when suspicions arose. In one instance Clayton and some buddies had stopped at a restaurant on the way back from a ride. During the meal, Clayton excused himself, saying he needed to use the restroom. Instead, he slipped outside, took a bike from the roof rack of his friend's car, and stashed it in his own trunk. When the group discovered the missing bike, Clayton eagerly suggested they call the police. Clayton was particularly brazen in the Phoenix area, according to Detective Bill Gallauer of the Tempe police. He'd hang out at triathlons and poach races, sometimes even writing numbers on his body with a Sharpie. When he emerged from the water, Clayton would grab the nicest bike he saw in the transition area and ride off. When Clayton was arrested in Arizona, rather than risk time in one of Maricopa County's exceptionally tough desert jail camps, he fled. Court minutes taken on June 19, 2006, show that at the setting of Clayton's trial date, he was permitted to travel to California during the first week of July--likely the last time anyone in Arizona saw him. To nail Clayton and make it stick, Askew wanted hard evidence: ideally, to catch Clayton in the act of stealing. On January 9, 2009, Askew received a call from Val Hargrove, a victim who considered Clayton a close friend. Hargrove told the detective that a set of carbon wheels--specifically built for the tandem he used to compete with a blind teammate--had disappeared from his garage, and that Hargrove's friend, Robert Biard, later found the wheels listed for sale online under Clayton's email address. Biard knew Clayton and now was connecting the dots on his methods--for instance, that Clayton had seemed a little too excited for Biard to purchase a new mountain bike he'd been eying. When Askew heard not only of the tandem-wheel theft, but also about Clayton's interest in Biard buying a new bike, he thought he now had a perfect way to catch the thief. In a scenario approved by Askew's commanding officer, Biard, Askew and Clayton would go on a mountain bike ride. Askew would bait Clayton, claiming he was new to town, and even show him a storage unit where he kept his bikes. The police hoped Clayton would attempt to steal them. But before Askew could implement the plan, Biard backed out. He felt the cops could snare Clayton on the evidence they had already compiled. Askew was less certain. On February 3, 2009, Askew decided to risk bringing Clayton in on the warrants from Arizona, and execute a search warrant on his home in Austin based on material evidence. If the police could locate the stolen items in Clayton's possession, they could try him in Texas. If not, Askew's case might disintegrate. At 10:10 a.m. on that day James Clayton left his house, climbed into his Land Rover, and drove to a nearby bank. Under Askew's direction, two APD detectives tailed him. The officers arrested Clayton at the bank. Askew arrived at Clayton's home 30 minutes later. Inside, he found a slew of stolen goods, including five bike frames, four wheelsets and loads of miscellaneous bike parts and electronic equipment. Gordon's Oakley sunglasses and black Nike wristwatch are listed in the police report. The white rug from the photos Clayton had sent Sheila sat at the foot of the bed. Upon opening Clayton's Bronco, Askew found a pair of bolt cutters stuffed in a backpack and a rental agreement for a storage unit--which the police found crammed with a litany of other bike parts, including seven high-end frames. In all, the police estimate the value of recovered items at $60,000. Still, much remained gone for good, including Gordon's Orbeas. In the spring of 2009 Clayton went before a judge at the Travis County Courthouse in downtown Austin. His first defense lawyer, Brian Bernard, faced a prosecutor pressured by angry cyclists. After one rough day in court, Bernard was clearly befuddled that the cyclists and the media were so unrelenting. "I just don't get it. Are any of these people racing the Tour de France?" he exclaimed, referring to the victims. Bernard didn't understand that Clayton wasn't just a thief. He'd violated the unique bond between rider and bike. "It's akin to modern-day horse thievery," responded Rob D'Amico, a local reporter and staunch cycling advocate. "With each bike, he also stole its associated memories," says Hargrove. Eventually Clayton was sentenced to four years in a Texas prison for felony theft and burglary charges. When he gets out, he will be released back to custody in Arizona. Law enforcement officials in Texas predict any plea agreement Clayton might have struck in Tempe before jumping bail is now off the table. And while Austin's cyclists may have purged the thief from their lives, a certain fear lingers. "I never used to lock my bike when it's unattended at races, but now I do," says Gordon, who fears that local cyclists can no longer be as carefree as they were before James Clayton came along. But now, at least, when a bike disappears, the first place people turn for help is to other riders. More From Mountain Bikes Pivot Drops 2nd Generation Shuttle E-Mountain Bike Get the Shredder Something They’ll Be Stoked About The 10 Best Cheap Bikes for Every Kind of Ride The Top 6 Secret US Mountain Bike Destinations Why Every MTB Rider Should Consider a Singlespeed You Can Buy a Canyon in the US Next Spring The Worst Bike Shops Your Strava Data Could Be Used to Ban Cyclists from Trails How to Get the Best Deal on a Used Bike 12 Ways to Use a Dropper Post	cc/2021-04/en_middle_0068.json.gz/line1550
__label__cc	0.680629	0.319371	Bill's Everyday Asian By (author) Bill Granger Bill's Everyday Asian celebrates the big, bold taste explosions of Asia and the fresh, lively combinations of ingredients that have had bestselling author Bill Granger hooked since childhood. Bill demystifies Asian food, unveiling the secrets behind balancing sweet, sour, salty and hot, and has simplified his favourite classics to create a collection of failsafe, quick and healthy recipes for everyday. From Summer Rolls with Peanut Dipping Sauce, Sticky Sesame Chicken Wings, to Rice Noodle Pho with Rare Beef, Bill serves up the tastes of Asia to tantalise the tastebuds and fit in with our fast-moving lives. A modern classic, packed with sumptuous and inspiring photography, Bill's Everyday Asian will have readers cooking their way through the recipes from cover to cover. Publisher Quadrille Publishing Ltd Edition Statement Paperback Illustrations note Over 120 colour photographs About Bill Granger Born in Melbourne, Bill moved to Sydney where he first started cooking professionally while studying at art school. Bill opened his first highly successful restaurant, bills, in inner-city Sydney in 1993. Two more Sydney restaurants followed in 1996 and 2005, and bills opened by the beach in Greater Tokyo's Kamakura in 2008 and Yokohama in early 2010. Bill's is the author of several internationally best-selling cookbooks that have sold in excess of 850,000 copies and translated into several languages. Bill is a regular contributor to magazines in several countries including Australia, the UK, South Africa and the Netherlands. Bill's television series, Bill's food and Bill's Holiday, have charmed audiences worldwide in over 30 countries.	cc/2021-04/en_middle_0068.json.gz/line1552
__label__wiki	0.758998	0.758998	Booker Introduces Companion to Rep. Lee Resolution Calling for First United States Commission on Truth, Racial Healing, and Transformation Lawmakers Urge Congress to Create Commission to Accompany Efforts Like The George Floyd Justice in Policing Act and Commission to Study and Develop Reparation Proposals for African-Americans Act WASHINTON, D.C. – Today, U.S. Senator Cory Booker (D-NJ) introduced the United States Commission on Truth, Racial Healing, and Transformation resolution, urging Congress to form the first commission acknowledging and examining the systemic racism that has disenfranchised Black Americans throughout U.S. history and the racial inequities that persist today. Representative Barbara Lee (D-CA) introduced the resolution in the House in June. “This year has brought to bear the harsh reality that systemic racism is ever present in our political, legal, environmental, economic, health, and social institutions,” said Senator Booker. “As a nation, we must acknowledge and grapple with the systemic racism and white supremacy that have been with us since our country’s founding and continues to persist in our laws, our policies and our lives to this day. The first ever Congressional commission on truth, racial healing, and transformation will be a critical compliment to legislative efforts to build a more just and equitable future, including the recent George Floyd Justice in Policing Act and the long time movement to establish a commission to study reparations.” “A painful and dangerous legacy of white supremacy lingers in our country, and we cannot begin healing until we fully acknowledge and understand how our that legacy facilitates inequality today,” said Congresswoman Lee. “Every crisis we’re dealing with right now – police brutality, mass incarceration, poverty, the COVID-19 public health crisis — disproportionately impact communities of color. I’m pleased Senator Booker will be leading our effort in the Senate to follow the lead of the numerous communities across America that have successfully developed Truth Commissions. Only by understanding our past, and confronting the errors that still haunt us today, can we truly move forward as a people and a country.” Senate Co-sponsors: Markey, Sanders, Blumenthal, Menendez, Coons, Klobuchar, Warren, Duckworth, Whitehouse, Brown, Durbin House Co-Sponsors (169): Lead Rep. Barbara Lee; Holmes-Norton, Moore, Hastings, Espaillat, Clarke, Brown, Tlaib, Bass, Garcia, McGovern, Omar, Fudge, Jayapal, Barragan, Thompson, Blunt Rochester, Meng, Blumenauer, Hayes, Trone, Khanna, Lowenthal, Maloney, Sanchez, Connolly, Haaland, Watson Coleman, Lewis, Scott, Jackson Lee, Clark, DeSaulnier, Sewell, Bishop, Pressley, Raskin, Sarbanes, Ocasio-Cortez, Meeks, Payne, Rush, Cox, Pingree, McNerney, Cohen, Smith, Beatty, Carson, Horsford, Casten, Schakowsky, Cooper, Lowey, Castro, Adams, Kennedy, Davids, Ruiz, Velazquez, Butterfield, Richmond, Trahan, Pallone, Engel, Grijalva, Evans, Takano, Serrano, Vela, Speier, Escovar, Gallego, Napolitano, Cardenas, Panetta, Lieu, Sires, Luria, Neguse, Dingell, Maloney, McEachin, Wilson, Kelly, Lamb, Ryan, Levin, Bonamici, Welch, Vargas, Price, Crist, Lofgren, Keating, Wasserman Schutlz, Sabian, Clay, Roybal-Allard, Thompson, Eshoo, Chu, DeGette, Kirkpatrick, Johnson, Swalwell, Krishnamoorthi, Neal, Aguilar, Sherman, Pocan, Cicilline, Suozzi, Doggett, Jeffries, Waters, Green, Deutch, Kaptur, Huffman, Crow, Castor, Rouda, DeLauro, Cisneros, Brownley, Kuster, Matsui, Lawrence, Davis, DeFazio, Veasey, Visclosky, Garcia, Boyle, Cuellar, Kim, Lawson, Kilmer, McCollum, Soto, Cleaver, Reppersberger, Dean, Yarmuth, Porter, Phillips, Doyle, Weton, Shalala, Beyer, Kildee, Delgado, Levin, Scheider, Tonko, Bera, Frankel, Quigley, Wild, Garamendi, Stevens, Davis, DelBene, Heck, Torres, Correa, Schiff, Gomez, Peters Earlier this year, Senator Booker and Representative Lee re-introduced their bicameral bill the Confederate Monument Removal Act. The legislation would remove all statues of people who voluntarily served the Confederate States of America from the National Statuary Hall Collection. The full text of the resolution can be viewed here.	cc/2021-04/en_middle_0068.json.gz/line1553
__label__cc	0.592931	0.407069	All That Makes Life Bright : The Life and Love of Harriet Beecher Stowe When Harriet Beecher marries Calvin Stowe on January 6, 1836, she is sure her future will be filled romance, eventually a family, and continued opportunities to develop as a writer. Her husband Calvin is completely supportive and said she must be a literary woman. Harriet's sister, Catharine, worries she will lose her identity in marriage, but she is determined to preserve her independent spirit. Deeply religious, she strongly believes God has called her to fulfill the roles of wife and writer and will help her accomplish everything she was born to do. Two months after her wedding Harriet discovers she is pregnant just as Calvin prepares to leave for a European business trip. Alone, Harriet is overwhelmed-being a wife has been harder than she thought and being an expectant mother feels like living another woman's life. Knowing that part of Calvin still cherishes the memory of his first wife, Harriet begins to question her place in her husband's heart and yearns for his return; his letters are no substitute for having him home. When Calvin returns, however, nothing seems to have turned out as planned. Struggling to balance the demands of motherhood with her passion for writing and her desire to be a part of the social change in Ohio, Harriet works to build a life with her beloved Calvin despite differing temperaments and expectations. Can their love endure, especially after "I do"? Can she recapture the first blush of new love and find the true beauty in her marriage? All That Makes Life Bright (Large Print Library Binding) All That Makes Life Bright (Audio CD - Unabridged) More About All That Makes Life Bright by Josi S. Kilpack Publish Date: September 2017 Reading Level: Ages 16-UP Series: Proper Romance Historical Romance - Historical - General Historical - General	cc/2021-04/en_middle_0068.json.gz/line1554
__label__wiki	0.998785	0.998785	2° \| £1 = €1.28 \| Sunday 17 January 2021 BAFTA FOR BBC NI DOCUMENTARY Reporter Darragh McIntryre (left) with BBC NI team who produced Shame of the Catholic Church A programme which investigated the Catholic Church’s handling of child abusing priests has won a top award. The BBC Northern Ireland programme, The Shame of the Catholic Church, won a Bafta in in the current affairs category at a ceremony in London on Sunday night. The programme was presented by award-winning journalist Darragh McIntyre, who exposed the Iris Robinson affair with a younger man. The powerful film, for This World on BBC One NI and BBC Two, investigated the failure of the Catholic Church to deal with abusing priests in Ireland. It was up against Britain’s Hidden Housing Crisis, The Other Side of Jimmy Savile, and What Killed Arafat? With the help of Catholic Canon lawyer and commentator, the Reverend Thomas Doyle and leading Irish writer Colm Toibin, This World examined the unique relationship that existed between the Irish Catholic Church and state. It also looked at the great power the Catholic Church once had and explained how the Catholic faithful were too frightened to break the silence and report crimes perpetrated on young victims. BBC NI Current Affairs executive producer Samy Collyns said: “In the first instance we must recognise the bravery of the victims of abuse from all those years ago who had the courage to come forward and tell their stories. “I would also like to thank Darragh and the programme’s director, Alison Millar for developing relationships and in building up the trust necessary to persevere in telling this difficult story. “We accept this award on behalf of all of those who made such important contributions.” Peter Johnston, director, BBC Northern Ireland said: “An important part of the BBC’s role is holding organisations and institutions to account. “This was a robust and challenging piece of journalism. I congratulate the team for making it happen and for bringing this story to the BBC’s local and network audiences. “Winning this second award is not only a tribute to the team, it establishes BBC Northern Ireland as a centre for quality, investigative journalism.” Earlier this year, the programme won a Bronze Torc Award for Excellence in the same category at this year’s Celtic Media Festival in Swansea. The Game of Thrones series which is filmed in Northern Ireland won the Viewer’s choice award at the Baftas. BD Top 5 Police Plan Crackdown On St Patricks Day... Suspect Held After Man Stabbed In Shankill Love Rat DUP MP David Simpson Stands Down Breaking News Dissident Republican Tommy... Revealed UDA At War In West Belfast Over... BD TV Contact Us \| Advertise \| Privacy policy \| Terms and Conditions \| Disclaimer © BelfastDaily.co.uk Designed by PHWS	cc/2021-04/en_middle_0068.json.gz/line1556
__label__wiki	0.832086	0.832086	Sonar Kollektiv From and for music lovers. Sonar Kollektiv was founded in 1997 by Jazzanova. Designed as a platform for own releases it soon attracted numerous new discoveries and like-minded musicians to lead their trumps right here. Still it was never the intention of Sonar Kollektiv to pursue one specific sound or provide an already existing scene. Each and every release on the label (350 and counting) was at all times meant to illustrate the musical taste of the collective, its flavourful development and recollection of past sounds. The various compilations and label showcases played a big part of it. From the renowed „Secret Love“ compilation, the „Computer Incarnations For World Peace“ edition, the „…Boadcasting“ and „…Mixing“-series to the „Romanian Jazz“ label showcase Sonar Kollektiv continuously cares about broadening its own and the horizon of any type of music lovers. How broad this horizon can be expanded showed the release of Âme’s „Rej“ in 2005. Shorthandly minimal techno was redifined and at the same time the sublabel Innervisions (runned by Dixon) was leveraged to worldwide fame. Other milestones in the eventful history of Sonar Kolletiv were the discovery of the New Zealand reggae soul combo Fat Freddy’s Drop (2005), the debuts by Micatone (2003), Benny Sings (2005), Clara Hill (2003) and Eva Be (2004), the first releases by Dimlite (2003), Tricksi (2006), Christian Prommer’s Drumlesson (2007), as well as Georg Levin (2005) and his collaborative project with Dixon, Wahoo (2004). Also for some of today’s legends of more sophisticated electronic music, like Ulrich Schnauss, Ben Klock and Marcin Kozlowski (now a member of Whitest Boy Alive) Sonar Kollektiv offered a stepping stone to their international careers. And in 2003 a certain Eric Wahlforss released his first record here, just before founding Soundcloud. When at the end of 2009 the rate of fire ceased some thought the label is running on empty or lost touch to contemporary sounds. But the releases which came after the label restart in 2011 should prove doubters wrong. The remix album „Jazzanova Upside Down“ gathers the who’s who of the currenty most happening and game-changing DJs and producers (Henrik Schwarz, Motor City Drum Ensemble, Filippo Moscatello, Manuel Tur, Mark E, and more) to catapult Jazzanova classics into the future. By signing new artists like Phil Gerus, Hot Coins, EnaWadan, Pete Josef, Mius, Pitto, Radio Citizen, ComixXx, Paskal & Urban Absolutes , The Black 80s (to name a few) four of the most promising new acts slantingly offside the dancefloor have been added to the already impressive roster. And once again all true pop aficionados with an addiction for soul and a genuine craft in songwriting are pierced to the heart with the albums by FETSUM („The Colors Of Hope“) and Micatone („Wish I Was Here“). But what is the formula of success of the Berlin based label? A dance music imprint that – with a few exceptions – actually doesn’t release club music? Is it even after all exactly this? Delievering music for prior to, succeeding and one day after a club night? There’s no other German record label that can boast such an adventurous range of styles: reggae, folk, electronica, jazz, funk, calypso, house, techno and now also chillwave, dubstep, dream pop, and so on. At Sonar Kollektiv there’s somehow room for everything. Still, all of the 350 and counting releases have one common denominator: It’s music made out of passion – from and for music lovers. Sonar Kollektiv GmbH Label Manager Oliver Glage Kastanienallee 19 – 20 oli@sonarkollektiv.de www.sonarkollektiv.com Soda Club Sound Diplomacy	cc/2021-04/en_middle_0068.json.gz/line1560
__label__wiki	0.540051	0.540051	BhamStrong small business emergency loans are a “life saver” according to business leader Birmingham Strong small business loan applications open now Birmingham Strong Fund launched to help small businesses impacted by coronavirus Maggie Anderson Emphasizes Power of Black Dollar at AG Gaston Conference Finding Birmingham’s next A.G. Gaston Diverse businesses ‘critical’ to success of Birmingham 2020 A.G. Gaston Conference focuses on Birmingham’s business growth Area Leaders Featured at 2020 A.G. Gaston Conference Shelly Bell to Speak at Gaston Conference A.G. Gaston’s 2020 Vision for Financial Literacy 16th Annual A.G. Gaston Conference Headlined by Businessman George C. Fraser A.G. Gaston Conference to feature Angela Rye and Boyce Watkins A.G. Gaston Conference to include focus on economics, politics and more A.G. Gaston Conference’s to feature cutting-edge panels Businessman A.G. Gaston’s lasting legacy on Birmingham Bob Dickerson Jr. and Gaynelle Jackson: Gaston Conference founders Let's galvanize behind a community effort to grow the Black Business Class 2018 A.G. GASTON CONFERENCE: COLLEGE STUDENTS DISPLAY ECONOMIC EMPOWERMENT https://www.birminghamtimes.com/2018/02/2018-ag-gaston-conference/ Hidden History: A.G. Gaston leaves stamp on Birmingham through civil rights movement (02/19/2018) 2018 A.G. Gaston Conference to spotlight economic empowerment (2/ 13/18 on al.com) http://blog.al.com/press-releases/2018/02/2018_ag_gaston_conference_to_s.html Birmingham Black Business Directory to be unveiled at 2018 A.G. Gaston Conference (2/16/18 on al.com) http://blog.al.com/press-releases/2018/02/birmingham_black_business_dire.html On the Record with Bob Dickerson, co-founder of the A.G. Gaston Conference (2/13/18 on al.com) http://blog.al.com/press-releases/2018/02/on_the_record_with_bob_dickers.html A.G. Gaston Conference Announces 2018 Award Recipients http://www.birminghamtimes.com/2018/02/a-g-gaston-conference-announces-2018-award-recipients/ A.G. Gaston Conference 2018: Economic Empowerment Through Enterprise Development http://thebhammarket.co/features/a-g-gaston-conference-2018-economic-empowerment-through-enterprise-development/ 2018 A.G. Gaston Conference at BJCC, February 20 (Newswire posted 2/1/18 on Road Trekin Adventure & Travel website http://roadtrekin.com/2018-a-g-gaston-conference-at-bjcc-february-20/ A.G. GASTON CONFERENCE ANNOUNCES 2018 AWARD RECIPIENTS (Newslocker, posted 2/15/18) http://www.newslocker.com/en-us/region/birmingham/ag-gaston-conference-announces-2018-award-recipients/ Andre Taylor to keynote 14th annual A.G. Gaston Conference (Seminar Newswire posted 1/23/18) http://www.senmer.com/andre-taylor-to-keynote-14th-annual-a-g-gaston-conference/ Bob Dickerson receives the Dream Keeper Award for Economic Justice http://www.al.com/news/birmingham/index.ssf/2018/04/our_work_is_not_done_apple_ceo.html May 2018 Newsletter Maintaining Money Management with BOBD June 2018 Newsletter Empowers Community through Financial Education July 2018 Newsletter Alabama’s Opportunity Zones Get the Green Light August 2018 Newsletter Federal Reserve Bank Executive Addresses Building Alabama Reinvestment September 2018 Newsletter 40th Anniversary Celebration and Helping Seniors Avoid Financial Exploitation October 2018 Newsletter In The News 2016 A. G. Gaston Conference kicks off Feb. 16 (02/03/2016) What are the Top 10 Gospel songs? Radio show counts them down (02/05/2016) 2016 A.G. Gaston Conference to honor educators by AL.com (02/05/2016) Honoring A.G. Gaston and setting the stage for the future of black business in Birmingham by Robert Dickerson Jr. (02/09/2016) Harnessing “Green Power” in the community by Marc Morial (02/10/2016) A.G. Gaston offered a template for success in black business by Mel Gravely (02/15/2016) Black business history scholar issues strong words to entrepreneurs at A.G. Gaston Conference by Gilbert Nicholson (02/17/2016) A.G. Gaston Conference seeks unsung community heroes for A. G. Gaston Community Service Award by Roy L. Williams (01/21/2015) A.G. Gaston Conference to shine spotlight on importance of eliminating poverty in metro Birmingham by Roy L. Williams (01/23/2015) A.G. Gaston Conference to host February 17 town hall meeting on closing wealth gap by Roy L. Williams (02/04/2015) Birmingham Mayor William Bell to receive A. G. Gaston Award; 2 named winners of inaugural A. G. Gaston Community Service Awards by Roy L. Williams (02/09/2015) Closing the ‘wealth gap’” A.G. Gaston Conference at BJCC to celebrate black entrepreneurs Feb. 17-18 by Jesse Chambers (02/11/2015) Birmingham Mayor William Bell to take top honor at A. G. Gaston Business Conference by Joseph D. Bryant (02/11/2015) 2015 A.G. Gaston Conference kicks off Tuesday, February 17 by Roy L. Williams (02/16/2015) Building Alabama Reinvestment 3rd annual conference to be held in Birmingham on May 18 by Roy L. Williams (04/19/2015) Author Mel Gravely to lead “Building the Capacity to Succeed” event May 5 in Birmingham by Williams Writing Solutions (04/24/2015) Wrap-up of Building Alabama Reinvestment Conference: Partnering is the key to rebuilding Alabama’s neighborhoods by Williams Writing Solutions (05/27/2015) IberiaBank to announce new SBA lending program at Sept. 9 Innovation Depot seminar by Williams Writing Solutions (08/18/2015) Why your bank choice is critical to success by Andrea Walker (09/16/2015) Conference on payday lending and unbanked in Bham set for June 5 by Antrenise Cole (05/29/2014) Birmingham’s Race for the Capitol (05/30/2014) Birmingham Mayor William Bell names new director to lead city’s economic recruiting, retention efforts by Joseph D. Bryant (09/03/2014) How it would work: Birmingham mayor, finance leaders seek to revive once-thriving neighborhood blocks with new business initiative by Joseph D. Bryant (09/10/2014) Birmingham’s Empowerment Week panels to include discussion of black-on-black crime by Jon Reed (09/11/2014) See who is performing at Dancing with the Silver Stars on Nov. 3 by Susan Strickland (10/30/2014) Baking Bandits, Magic City Spool Bus win REV Birmingham’s Big Pitch Competition by Ian Hoppe (11/10/2014) View fifth Dancing with the Silver Stars benefit for UAB Comprehensive Center for Healthy Aging by Susan Strickland (11/18/2014) Why Birmingham banks are lending again by Antrenise Cole (11/21/2014) Lending still low for minority owners by Antrenise Cole (01/25/2013) The Late Rev. Abraham Woods to be posthumously given Gaston Award by Stan Diel (02/14/2013) Regions’ $1B loan pool targets eco-devo projects by Antrenise Cole (02/15/2013) Fourth Avenue business district, booming under segregation, still works to rebound 50 years later by Stan Diel Where is today’s A. G. Gaston? Black Birmingham businessman would be worth $300 million in today’s money by Stan Diel (03/22/2013) Who is today’s Sidney Smyer? Powerful Birmingham businessman helped lead reform in the 1960s by Dawn Kent Azok (03/29/2013) Longtime Birmingham business advocate selected to lead national organization (04/05/2013) 50 years later: Black businesses aren’t growing at the rate they could by Antrenise Cole (07/15/2013) 50 years later: How far have we come? By Antrenise Cole (07/19/2013) Continuing the healthy dialogue of Birmingham’s civil rights movement by Cindy Fisher Crawford (08/14/2013) Is Martin Luther King Jr.’s dream a reality? In changed Birmingham, yes and no by The Associated Press (08/24/2013) National Community Reinvestment Corp., Building Alabama Reinvestment conference kicks off by Roy L. Williams (09/13/2013) Slice Pizza and Brew, Birmingham Barons among winners at Birmingham Business Alliance’s Small Business Awards (10/02/2013) Birmingham Business Alliance names small biz award winners by Brent Godwin (10/02/2013) A.G. Gaston Conference at BJCC Feb. 18-19 to revisit ‘green power,’ encourage entrepreneurship by Jesse Chambers (02/04/2014) AT&T Alabama president named winner of A. G. Gaston Award, will receive it at BJCC Feb. 19 by Jesse Chambers (02/04/2014) A.G. Gaston business conference begins Tuesday at BJCC, will feature free town hall meeting by Jesse Chambers (02/17/2014) Participants at A. G. Gaston Conference town hall Tuesday pondered how to find “the next Gaston,” conference wraps up today at BJCC by Jesse Chambers (02/19/2014) A.G. Gaston Construction, Saber Engineering, Keith Design merge to form A.G. Gaston Enterprise by Roy L. Williams (01/22/2012) Magic City Black Expo begins weekend stay in Birmingham by Roy L. Williams (02/24/2012) Birmingham to hold Small Business Economic Development Summit by Martin Swant (03/23/2012) Birmingham playing host to Annual Neighborhood – Small Business Economic Development Summit by Dawn Kent Azok (03/31/2012) Business Connections Conference links minority, large firms by Roy L. Williams (08/16/2012) Alabama SBA lending falls 11% as uncertainty hits supply and demand by Antrenise Cole (11/02/2012) Small Business Lending Forecast for 2011 by Dave Parks (01/03/2011) Memorandum: A.G. Gaston would be proud of the legacy he left in Birmingham (02/10/2011) Friends of A. G. Gaston set up to offer entrepreneur advice in Birmingham by Roy L. Williams (02/15/2011) Birmingham hosting annual economic development summit by Lauren B. Cooper (03/17/2011) Birmingham City Council member Lashunda Scales hopes summit will spur jobs by Roy L. Williams (03/21/2011) Alabama Development Office to work more on job training, small business by Roy L. Williams (03/21/2011) Minority-owned businesses on rise in Birmingham, Alabama by Roy L. Williams (06/05/2011) Alabama tornadoes: Road to recovery bumpy for some by Roy L. Williams (07/02/2011) Economic uncertainty keeping small firms from hiring by Kent Hoover and Brent Godwin (07/15/2011) Reinventing our community: Can metro Birmingham move beyond race? (07/24/2011) Minority SBA loan amounts double in 2011 by Antrenise Cole (08/26/2011) Conference will focus on banks’ role in development by Antrenise Cole (09/09/2011) Regions rolling out non-traditional financial services with Regions Now Banking by Roy L. Williams (11/20/2011) SBA change could mean more working capital for businesses by Antrenise Cole and Kent Hoover (12/09/2011) Gaston Construction, Saber from ambitious alliance by Roy L. Williams (02/06/2010) Extra credit: Personal credit scores can help business owners score loans by Crystal Jarvis (02/14/2010) Business consultant tells A.G. Gaston Conference that improving education and entrepreneurship are keys to helping black communities by Roy L. Williams (02/16/2010) Son re-opens Birmingham music store founded by his slain dad by Roy L. Williams (08/05/2010) Bunny Stokes Jr returns to lead Birmingham’s Citizen Trust Bank by Roy L. Williams (09/02/2010) Soft drink relics reveal a black and white business link by Roy L. Williams (11/24/2010) Former CapitalPartners exec starts leasing firm by Crystal Jarvis (01/11/2009) West (01/16/2009) Obama: Hope for businesses? by Lauren B. Cooper (01/25/2009) A.G. Gaston Conference to celebrate entrepreneurship by Ty West (01/25/2009) Entrepreneurs can flourish during tough economic times by Greg Heyman (03/15/2009) Feds: Regions, other big banks must report business loan activity by Crystal Jarvis (03/22/2009) Alabama still waiting for federal stimulus windfall by Lauren B. Cooper (06/07/2009) Research: Minority small businesses more profitable by Haley Aaron (08/09/2009) SBA lending takes dive in Alabama by Crystal Jarvis (10/11/2009) Birmingham metro suffers five-year decline in jobs by Lauren B. Cooper (10/11/2009) Birmingham architect, lawyer giving new life to former Famous Theater by Roy L. Williams (10/21/2009) Small business advocates: Tight bank lending is ‘dire’ by Crystal Jarvis (12/20/2009) Copyright © 2018 \| All Rights Reserved \| BOB DICKERSON	cc/2021-04/en_middle_0068.json.gz/line1565
__label__cc	0.559172	0.440828	Analyzing a tool of IS propaganda: Ibn ʿAbdul-Wahhāb’s "Mufīd al-Mustafīd fī Kufr Tārik al-Tawḥīd" Analyzing a tool of IS propaganda: Ibn ʿAbdul-Wahhāb’s "Mufīd al-Mustafīd fī Kufr Tārik al-Tawḥīd". Joe Bradford. Draft Paper presented at MeHAT, University of Chicago, 2016. Abstract: ISIL or ISIS continues to burden the world with political strife and divisive religious rhetoric. One of the main attractions to their ideology is their claim of being a "caliphate upon the prophetic model." This allows them latitude in justifying many of their punitive actions against the populaces of Iraq, Syria, and elsewhere while retaining their moniker of being a truly "Islamic" state. One tool for the legitimization of these acts is a text written in the modern period by Muḥammad b. ʿAbdul-Wahhāb (d.1791) titled " Mufīd al-Mustafīd fī Disbelief (Kufr) Tārik al-Tawḥīd." That treatise was originally written against the inhabitants of Ḥuraymilāʾ after they rejected the author’s ideas and seceded from the budding Saudi state. This paper will cover four main topics related to this treatise: 1) A comparison of the IS print of this book to others printed outside IS lands. 2) A catalog and summary of the contents of this treatise, 3) reactions of Wahhabi scholars to it in their own writings, and 4) the genealogy of its legal and theological issues and their presence outside the Wahhabi tradition. To conclude, the proximity of the ideas presented in this treatise to the broader Islamic legal and theological tradition will be determined. Posted by Bipartisan Alliance/DC at 4:47 PM 0 comments Al-Qadā’ wa-l-Qadr: motivational representations of divine decree and predestination in salafi-jihadi literature Al-Qadā’ wa-l-Qadr: motivational representations of divine decree and predestination in salafi-jihadi literature. Shiraz Maher & Alexandra Bissoondath, British Journal of Middle Eastern Studies, http://dx.doi.org/10.1080/13530194.2017.1361317 Abstract: This paper explores how the normative Islamic concepts of divine decree and predestination are used for motivational purposes in salafi-jihadi literature. These concepts are known as al-qaḍā’ wa-l-qadr within Islamic jurisprudence and assert that certain characteristics in an individual’s life—such as their lifespan, wealth and progeny—have already been preordained by God. Salafi-Jihadi groups, not least al-Qaeda and Islamic State, frame these concepts in unique and important ways to motivate their fighters on the battlefield, liberating them from fear of personal consequences. In particular, we examine the use of this concept not just to motivate fighters at a personal level, but also its role in maintaining morale during times of hardship, its ability to explain away failures and defeats, and its ability to project both momentum and success even when the facts suggest otherwise. Deliberation increases the wisdom of crowds Deliberation increases the wisdom of crowds. Joaquin Navajas, Tamara Niella, Gerry Garbulsky, Bahador Bahrami, Mariano Sigman. ArXiv Mar 2017, https://arxiv.org/abs/1703.00045 Abstract: The aggregation of many independent estimates can outperform the most accurate individual judgment. This centenarian finding, popularly known as the 'wisdom of crowds', has recently been applied to problems ranging from the diagnosis of cancer to financial forecasting. It is widely believed that the key to collective accuracy is to preserve the independence of individuals in a crowd. Contrary to this prevailing view, we show that deliberation and discussion improves collective wisdom. We asked a live crowd (N=5180) to respond to general knowledge questions (e.g. the height of the Eiffel Tower). Participants first answered individually, then deliberated and made consensus decisions in groups of five, and finally provided revised individual estimates. We found that consensus and revised estimates were less biased and more diverse than what a uniform aggregation of independent opinions could achieve. Consequently, the average of different consensus decisions was substantially more accurate than aggregating the independent opinions. Even combining as few as four consensus choices outperformed the wisdom of thousands of individuals. Our results indicate that averaging information from independent debates is a highly effective strategy for harnessing our collective knowledge. Posted by Bipartisan Alliance/DC at 11:23 AM 0 comments The devoted actor’s will to fight and the spiritual dimension of human conflict The devoted actor’s will to fight and the spiritual dimension of human conflict. Angel Gomez et al. Nature Human Behaviour 1, 673–679 (2017), doi:10.1038/s41562-017-0193-3 Abstract: Frontline investigations with fighters against the Islamic State (ISIL or ISIS), combined with multiple online studies, address willingness to fight and die in intergroup conflict. The general focus is on non-utilitarian aspects of human conflict, which combatants themselves deem ‘sacred’ or ‘spiritual’, whether secular or religious. Here we investigate two key components of a theoretical framework we call ‘the devoted actor’—sacred values and identity fusion with a group—to better understand people’s willingness to make costly sacrifices. We reveal three crucial factors: commitment to non-negotiable sacred values and the groups that the actors are wholly fused with; readiness to forsake kin for those values; and perceived spiritual strength of ingroup versus foes as more important than relative material strength. We directly relate expressed willingness for action to behaviour as a check on claims that decisions in extreme conflicts are driven by cost–benefit calculations, which may help to inform policy decisions for the common defense. Not Threat, But Threatening: Potential Causes and Consequences of Gay Innumeracy Not Threat, But Threatening: Potential Causes and Consequences of Gay Innumeracy. Donald P Haider-Markel & Mark R Joslyn. Journal of Homosexuality, http://dx.doi.org/10.1080/00918369.2017.1377490 ABSTRACT: Existing literature on numeracy suggests that people are likely to perceive out-groups as larger if the group is perceived as threating. However, some studies also suggest that numeracy is a function of wishful thinking or even a lack of political knowledge. We engage the literature on numeracy of the gay and lesbian population by employing data from 1977 and 2013 surveys of American adults. We examine the factors that are associated with estimating the gay population. Next we explore how innumeracy may shape attitudes about homosexuality and gay rights. Our findings suggest that estimates of the gay population are partly a function of knowledge, and perhaps wishful thinking, but not threat. However, our analysis also reveals that higher estimates of the gay population are associated less support for gay civil rights in the current era, and were not a factor in the past. KEYWORDS: Numeracy, innumeracy, gay population, rights, policy attitudes, threat, knowledge Hedonic Recall Bias. Why You Should Not Ask People How Much They Earn Hedonic Recall Bias. Why You Should Not Ask People How Much They Earn. Alberto Prati. Journal of Economic Behavior & Organization, https://doi.org/10.1016/j.jebo.2017.09.002 • Survey data lead to large over-estimation of the effect of wage on wage satisfaction • Income misreporting in surveys is not random, but endogenous • People relatively more satisfied with their wage tend to over-report their wage • People relatively less satisfied with their wage tend to under-report their wage Abstract: The empirical literature which explores the effect of wage on job satisfaction typically uses data drawn from social surveys. In these surveys, the amount of wage is reported by the respondents themselves: thus, the explanatory variable of the econometric models may differ from the true wage people earn. Our paper shows that the use of survey data can lead to considerable over-estimation of the importance of wage as a determinant of wage satisfaction. In particular, responses seem to be affected by a recall bias: people who are satisfied with their wage are more likely to over-report their wage in questionnaires. The more satisfied they are the more they over-report (and vice-versa unsatisfied people). We name this behavioral disposition “hedonic recall bias”. JEL classification: D03; J28 Keywords: Recall bias; Job satisfaction; Wage satisfaction; Measurement error; Survey income Psychological influences of animal-themed food decorations Psychological influences of animal-themed food decorations. Kohske Takahashi, Haruaki Fukuda, Katsumi Watanabe, Kazuhiro Uedab. Food Quality and Preference, https://doi.org/10.1016/j.foodqual.2017.09.004 • Animal-themed food decorations do not enhance the value of food. • Realistic animal-themed decoration decreases the value of food. • The effects of animal-themed decoration depend on the animal-likeness of the food. Abstract: Food appearance influences the food’s perceived value. It is paradoxical that animal-shaped foods (e.g., animal crackers) are popular and widely accepted among consumers, given that foods with an animal likeness usually elicit emotional disgust and avoidance behaviors. We experimentally tested the psychological influences of animal-themed food decorations. Participants evaluated their willingness to eat chocolate, kamaboko (a Japanese processed seafood product), and sashimi on which pictures of animals had been painted. We found that the perceived value of food did not improve by adding animal-themed decorations. In fact, the decoration drastically reduced the value of the foods actually made from animals (i.e., kamaboko and sashimi). The model analyses further confirmed that the psychological influences of animal-themed food decorations partly depended on whether the food was of animal origin or not. Furthermore, animal pictures with stronger animacy (i.e., realism) enhanced the negative influences of these decorations on the willingness to eat kamaboko and sashimi. These results together suggest that animal-themed food decorations do not enhance the value of food per se, perhaps because they emphasize the resemblance of foods to animals and thereby increase emotional disgust. Analyzing a tool of IS propaganda: Ibn ʿAbdul-Wahh... Al-Qadā’ wa-l-Qadr: motivational representations o... The devoted actor’s will to fight and the spiritua... Not Threat, But Threatening: Potential Causes and ... Hedonic Recall Bias. Why You Should Not Ask People... Psychological influences of animal-themed food dec...	cc/2021-04/en_middle_0068.json.gz/line1569
__label__cc	0.674374	0.325626	Home / Unlabelled / Crowdfunding Sites That Allow True Investment in Renewable Energy and Sustainability: Alternatives to Kickstarter & Indiegogo Crowdfunding Sites That Allow True Investment in Renewable Energy and Sustainability: Alternatives to Kickstarter & Indiegogo Crowdfunding has become a popular tool for people and organizations to use to try their new ideas for green goods while securing funds to start operations. The most famous crowdfunding websites, Kickstarter and Indiegogo, have assisted a significant number of jobs in renewable energy and sustainability eliminate the ground, projects that are the focus of previous installments in my ongoing posts show about crowdfunding in energy. Both of these sites mainly focus on consumer products such as renewable energy generation for your house, instructional tools, and home energy management. However, lots of budding innovations in renewable energy or sustainability are far bigger and more transformative, thus requiring more original capital investment in larger funding amounts. Whereas Kickstarter and Indiegogo frequently target funding in iterations as low as a few bucks in exchange for early access to a product, discounts after the product is commercially available, or other benefits, ideas that have the potential to genuinely disrupt the energy market need to concentrate on bigger sums of capital. These more substantial projects -- the industry gamechangers -- warrant a different audience, one trying to actually invest larger sums of money in thoughts and bet about the future sustainability of a company. Kickstarter and Indiegogo are not constructed for these investments, but luckily you will find crowdfunding platforms that give funders the capability to provide capital in exchange for equity or potential return on investment. Rather than turning fans into clients or a charitable donors, then these crowdfunding platforms turn backers into investors or micro-VC funders in green jobs, allowing the genuine democratization of capital-raising. This trend underscores how clean tech projects today should not be viewed as experiments or feel-good charity, but rather real money-making opportunities. Let us take a look at some of those crowdfunding platforms that permit investment in sustainability-related projects and a few of the projects that are financed from them. StartEngine To begin, Perfect Marketing Solution was established in 2016 to facilitate investment in early-stage startup businesses, both in renewable energy and not. By allowing anyone in the world to see nascent companies looking for funds to turn their ideas into realities, Hire SEO Consultants works with entrepreneurs, small companies, and many others and has completed about 150 effective financings through their platform. Therefore, although not as widespread as Kickstarter in terms of variety of projects, the companies that have been funded have been bigger and required larger lifts. When supporting jobs on Perfect Marketing Solution , funders are not only providing a helping hand to such startups but are actually buying stock in and betting on the businesses and their ideas. In that manner, this crowdfunding platform requires more serious thought from funders but provides possibly more substantial rewards for stated support. As an example of a clean energy project that has been financed viaPerfect Marketing Solution , Affordable Community Energy Services Company (ACE) raised $22,500 on the platform. ACE's mission is"to bring financial and environmental sustainability to residents and owners of low-income home" via green retrofits by offering disadvantaged households with 100 percent of the capital needed for energy updates. After supplying these updates, ACE receives earnings by means of a programmer's fee and contract revenues over a 10-year arrangement paid for from electricity and water savings, as well as obligations and/or government subsidies for solar and cogeneration production. This version ensures ACE isn't just providing an environmental solution and helping low-income families, but"from the process, provide a return to our societal impact investors." I have written about G3C before, and also what they're seeking to address is the environmental and financial waste introduced from the options available for end-of-life (EOL) tires. Currently, EOL tires may : Be reused/recycled in street pavement, sports fields, or other comparable second-life options, though these applications are also responsible for soil deterioration in Addition to groundwater contamination; or Get incinerated, an alternative that leads to millions of tons of harmful greenhouse gas emissions each year. G3CT has produced, and is seeking to raise funds to implement, technology that converts EOL tires into recovered carbon black that can then be employed to make brand-new tires or other goods Web Designing Company . This manner, the fresh tech of G3CT combats climate change by preventing the emissions which would come from differently incinerated tires while also reducing the power and emissions related to the production of virgin carbon black, instead providing a sustainable alternative in recovered carbon black. G3CT has raised nearly $100,000 in their effort as of this writing but is seeking to see how far they could raise towards their stretch targets from the middle of February. The campaign page offers non-voting common stock in the company for your investment and notes"When you invest you are betting the organization's future value will surpass $22M." Citizenergy Another platform which allows for the increasing of direct investment capital in clean energy and sustainability is Citizenergy. This site enables funders to obtain equity, participate as a loan, or buy a bond (as well as some projects with conventional crowdfunding'rewards' for more altruistic jobs ) specifically for energy projects across Europe. In fact, the Citizenenergy system is co-funded by the Intelligent Energy Europe Programme of the EU and provides together energy-focused crowdfunding investment opportunities across different smaller platforms into one spot. As such, Citizenergy's value comes both in vetting and aggregating these renewable energy investment opportunities. Successful Project: Mar De Fulles To illustrate the capacity of Citizenergy to fund successful clean energy jobs, consider Mar De Fulles. The goal of the eco-tourism job was to set a sustainable eco-management community of bioclimatic tourist complex, alongside a nature park in Castello, Spain, along with other natural reserves. The budget for the whole installation was $280,000, with $174,000 of those funds finally coming out of the collective loans of investors around the crowdfunding platform. For their service, these investors were to get annual paybacks with attention on top over the course of seven years. Active Job: Earth Energy Efficiency SRL If this type of successful job inspires you to peek around at others active raising funds at the moment, you could encounter the Wind Power Efficiency SRL. Where Mar De Fulles was a loan-based fundraiser, this one is offering equity in the project as it seeks out $40,000 from February 11, 2019 (a goal they are extremely close to attaining ) Organic SEO Marketing . This funding will the purchase, installation, and operation of a 60 kW wind farm. These wind turbines are expected to create nearly 200,000 kWh per year and are expected to provide positive cash flow for the next 20+ years, placing them able to"repay the debt contracted and remunerate the shareholders." Including all the momentum that green crowdfunding has in establishing those innovative companies, not just on Kickstarter but on platforms that are helping to energize new businesses through authentic investment, the traditional monetary world has taken note. Green banking Has Existed for a while, together with the Connecticut Green Bank getting the very first example in the USA in 2011. These green banks associate public support with private funds to invest in projects that enable states or regions to more quickly meet clean energy objectives. However, these types of green banks seek out private investment for jobs themselves Dynamic Website Development , they don't allow any regular person to test them out and spend. That orthodox version is being inverted however, as at least one traditional lender has started to let its clients and the people to seek out and spend funds through the green crowdfunding system of endeavors. Those who invest are doing this at their own hazard, but an early job by means of this platform--a 5 megawatt usable solar farm in Somerset that has been financed into community ownership--succeeded and today earns its investors 5 percent interest each year over the next 17 decades. The Managing Director of Triodos bank noticed that they've"been crowdfunding since before it became a renowned term," but by taking this action public reflects a thrilling pivot point. The UK represents an unsurprising breaking ground for this type of crowdfunding through banks because as far back as 2013 the UK Minister for Energy and Climate Change explained crowdfunding as"an incredibly strong" funding model together with the capability"to help send my ambition to get a far more decentralized power system" While Triodos Bank's shareholders should be UK citizens, Email Marketing Solution it begs the question of whether this model may work in other countries too. The United States has witnessed solar bonds for going on five years as a financial model, but this kind of crowdsourcing is even more democratic. Whether these new instructions from banks are not being self-preserving, eyes must be kept on the way the traditional financing markets turn to similar democratizations of investment in renewable energy and other sustainability ventures. Have you got some opinions on which projects will be successful in their own campaigns? Were you compelled to donate to any of these? Do you have a renewable energy project going on a crowdfunding website that you need to be featured in a future iteration of the series? If you answered yes to any of these questions, please allow me to know in the comments below or on Twitter! Website - http://www.hireseoconsultants.com Skype - shalabh.mishra Telegram - shalabhmishra Whatsapp - +919212306116 Email - shalabh.mishra@gmail.com Mobile - +919212306116 Crowdfunding Sites That Allow True Investment in Renewable Energy and Sustainability: Alternatives to Kickstarter & Indiegogo Reviewed by Press Release Power on 7/04/2020 08:33:00 AM Rating: 5	cc/2021-04/en_middle_0068.json.gz/line1570
__label__cc	0.552693	0.447307	Inter Milan Reject United’s Improved £39.5m Offer For Ivan Perisic By BF Staff \| July 5, 2017 \| 0 Reuters / Giorgio Perottino According to the Italian journalist Gianluca Di Marzio, Manchester United submitted a new and improved bid of £39.5m for Ivan Persic, but the offer was rejected by Inter Milan. The report also claims that United included a number of bonuses in their offer for the player, but Inter reportedly deemed them to be insufficient. After a solid 2016-17 season with the Serie A giants, the Croatian has been one of Mourinho’s primary targets this summer. In fact, recent reports suggested that Persic himself is determined to join up with the former Chelsea manager at Old Trafford. Plus, recent reports in England claimed that Inter tabled a better contract offer of £85,000 a-week-deal for Perisic in order to fend off interest from the Red Devils, but the 28-year-old rejected a new offer. Real Madrid Reject Yet Another Offer For Alvaro Morata Despite Perisic being very keen to play in the Premier League, Inter board members are demanding £48.4m for the services of the winger. The Italian club had already rejected a £35m bid from United earlier this summer, and they are now in a strong negotiating position, as they are no longer required to sell the midfielder in order to meet the financial fair play regulations. REUTERS/Max Rossi If the English giants fail to sign Perisic, they could set their sights on Florentina’s talented winger Federico Bernardeschi. The 23-year-old’s agent, Beppe Bozo, confirmed on Tuesday that the player is set to quit the club this summer and will not renew his contract with Fiorentina. Written by Pragadeesh Shanmugam United fan since Edwin Van der Sar denied Nicolas Anelka’s penalty to earn a dramatic Euro glory. Firmly believes that Lionel Messi deserves to win the Ballon d’Or until he plays this sport. One time writer for GiveMeSport and Roar. A regular contributor to Sportskeeda and BlameFootball. ← Real Madrid Reject Yet Another Offer For Alvaro MorataOFFICIAL: Alexandre Lacazette Agrees To Join Arsenal →	cc/2021-04/en_middle_0068.json.gz/line1574
__label__wiki	0.941091	0.941091	Hotel chain founder loses multi-million pound case against son The octogenarian co-founder of a UK-based luxury hotel chain has lost a court battle with his son to force him share the wealth generated by the enterprise he helped to build. Article \| 9 April, 2014 01:03 PM \| By Tess De La Mare Bal Mohinder Singh, 87, co-founded the Radisson Blu Edwardian chain with his son Jasminder, 63, after immigrating to the UK from India via Kenya in the 1970s. He claimed that the Sikh tradition of mitakshara obliges Jasminder to share his wealth with his family because he was raised as a Sikh. In a witness statement, Jasminder countered he had never had a particularly religious upbringing and he had no formal agreement with his parents to share property, nor was their an implied agreement. The family's first business was a small post office, before buying a bed and breakfast in Kensington – over the next three decades Singh and his son steadily brought up high-profile hotels including the Savoy Court and the May Fair in central London. The chain was originally called the Edwardian Group, before joining forces with the Carlson family's US-based Radisson brand to form Radisson Blu Edwardian in 1997 – the business is now worth more than £800 million (€970 million). Although he provided the initial capital, Singh said he put his son in charge because of his level of English and his accountancy skills. Singh claims his son forced him to retire in 2010 and has since failed to share dividends generated by the business. Singh's counsel, John McDonnell QC, said: "The father is not claiming a share of any of Jasminder's wealth acquired by his [Singh's] own efforts. "It is our claim that Jasminder's wealth is the family's wealth. The only cash put into the family's empire is that put in by the father in the 70s." However, the judge dismissed the £50 million claim, saying the root of the problem was the difference in upbringing of the father and son. While Sing had a traditional Sikh upbringing, Jasminder had been educated in the UK and "took little interest in the religious side of Sikhism". Despite the feud, father and son still share the same house – Tetworth Hall in Cambridgeshire. Satwant, Singh's wife and mother of Jasminder, also lives there, as well as Jasminder's wife Amrit and their four children. Singh said in witness statements during the proceedings: "Both I and his mother are deeply ashamed that Jasminder should publicly renounce his cultural heritage and the mutual rights and obligations in which he was brought up." Related terms: FB News, Legal, FB People, Family Business, Feud Why nuptial agreements are essential in the wealth protection toolkit FB Roundup: CBS, Hermès, and Grosvenor When family business direction is in dispute Rules of engagement: Pre-nuptial agreements to preserve wealth Press eject: How to remove troublesome trustees Relative Solutions SG PB Hambros Limited Mishcon de Reya de Visscher & Co	cc/2021-04/en_middle_0068.json.gz/line1578
__label__wiki	0.888304	0.888304	By Nick Waddell January 8, 2021 Filed under: All posts, Cleantech Stock: bldp Stay far away from Ballard Power, this investor says What to make of Ballard Power (Ballard Power Stock Quote, Chart, News, Analysts, Financials TSX:BLDP)? The fuel cell stock went through the roof in 2020 and keeps rising, yet revenue is growing at a snail’s pace and quarterly losses keep piling up. That should be a big red flag for investors, says Brian Madden of Goodreid Investment Counsel, who says Ballard has no business being valued like it currently is. “This is a polarizing one. I will say that if you like Tesla, then you’ve got to like Ballard Power. They’re de facto the same trade over the last two years and they trade kind of in lockstep,” says Madden, senior vice president at Goodreid, who spoke on BNN Bloomberg on Thursday. “Ballard is up about 960 per cent over those two years while Tesla is up 1100 per cent —yes, that’s 1,100. But we don’t like Tesla and we don’t like Ballard,” Madden said. “You know, this isn’t so much a stock as it is a science project.” Vancouver-based Ballard Power, which makes hydrogen fuel cell stacks and systems for heavy transport vehicles, started popping over a year ago when it announced a $19.2-million order from its joint venture with Weichai Power, a supply agreement for membrane electrode assemblies and the continuation of a long-standing relationship between Ballard and the Chinese energy giant. Weichai took a 19.9-per-cent interest in Ballard in 2018 with a $163-million equity investment and the establishment of the JV for fuel cell research and development. The fuel cell industry has been doing well lately. Clean tech has been part of the wider investment turn to renewable energy, one which many see as only accelerating as governments worldwide look to implement their climate change initiatives and green their economies. In the US, wins by the Democrats both in November’s Presidential election and this week in the US Senate runoffs are being taken as good signs for the renewable energy sector, as well. Last month, the Canadian federal government launched its Hydrogen Strategy which calls for $5 to $7 billion in near-term investment to put Canada’s hydrogen industry on the map. The government said it will begin with a $1.5-billion investment fund for low-carbon fuels including hydrogen. “Energy is our family business in Canada, and this strategy shows us how to grow that business,” O’Regan said at a December 16 news conference. “Our first job is to let industry know we are serious.” Ballard Power applauded the move, saying the strategy “represents a tremendous business opportunity for Canada’s leading hydrogen and fuel cell technology and energy companies.” “We are excited by the ambitious framework laid out in the Hydrogen Strategy for Canada, which seeks to position Canada as a global hydrogen leader and support Canada’s path to net-zero carbon emissions by 2050,” said Randy MacEwen, Ballard President and CEO in a press release. “The strategy articulates a compelling vision for 2050, with up to 30% of Canada’s energy delivered in the form of hydrogen, an established supply base of low carbon intensity hydrogen delivered at competitive prices, over five million fuel cell electric vehicles on Canadian roads, and a nationwide hydrogen refuelling network.” Meanwhile, US fuel cell company Plug Power announced this week a huge deal with South Korea-based conglomerate SK Group, which will be investing $1.5 billion in Plug Power for a 9.9-per-cent stake in the company. That sent Plug Power’s share price soaring but also boosted Ballard Power, which is up 22 per cent for the week. But it’s Ballard’s track record that bothers Madden. “Ballard is valued at $8 billion dollars. It has been around and publicly traded since 1994 and it has lost money in every single one of those years with losses mounting and escalating since about 2018,” Madden said. “The reason why they’re able to do that and continue burning cash is because they’re backstopped by three or four Asian industrial firms. In some ways, you can think of this as an off-balance-sheet experiment in the way that some pharmaceutical companies like to keep high-risk research and development activities in an off-balance-sheet affiliate or subsidiary,” Madden said. “Ballard’s sales even after 25, 26 years are still de minimis at about $120 million. I don’t know what the future holds for the electric vehicle market, but I think the stock has no business trading anywhere near it does based on the historic fundamentals or even the near-term forecasts,” Madden said. “Even with the rapid adoption of electric vehicles, this stock is not forecasted to earn any money this year, next year or the year after.” “But hope springs eternal and analysts somehow expect it to turn a profit in 2024, but I would not buy this stock,” Madden said. Cleantech Trending bldp Are the stars finally aligning for Ballard Power? Cleantech stock Ballard Power Systems (Ballard Power Systems Stock Quote, Chart News TSX:BLDP) has been on a spectacular run over... Cleantech bldp Is Ballard Power stock still a buy? The ride will continue to be bumpy for Ballard Power (Ballard Power Stock Quote, Chart, News TSX:BLDP) but with the...	cc/2021-04/en_middle_0068.json.gz/line1582
__label__wiki	0.978215	0.978215	Local NPR for the Cape, Coast & Islands The Forgetting Arts and Ideas ...more programs Cape Cod Notebook Local Food Report Poetry Sunday The Fishing News Ways of Life Weekend Outlook Weekly Bird Report CAI Series Reporting CAI Awards Giving Days Countdown Jay Allison Founders Fund Update Your Sustainer Information About Sponsorship Special Sponsorships Contact Us for Sponsorship Social Media and Streams Growing Up Black in a Mostly White Town: A Teenager Speaks Out By Jennette Barnes • Jun 9, 2020 Youth voices have played a key role in the anti-racism protests following the death of George Floyd. Among them is Jendell Teixeira, who lives in Marion and has been speaking at local protests about growing up black in predominantly white towns. Report by Jennette Barnes The 18-year-old said she wants people to know that racism and police brutality aren’t just some other state’s problem. Teixeira spent her early childhood in Rochester and moved to Marion at about 10 years old. “Looking back on it, it was a living hell,” she said. “There was, like, no black people, and half of the black people in Rochester and Marion I was either related to, or my family knew really well. So it was a lot of, like, little things, like getting called like “poop” because I'm black. Stuff like that.” She said she experienced continual microaggression and bias. At one point she was the only black girl in school, and she felt very insecure. She had a sense of culture shock moving between her Cape Verdean family and the nearly all-white schools. “And, like, people just act different, and then you have to code-switch when you're home.” She says sometimes relatives would joke that she was white. “And that's, like, really diminishing to a black girl’s self-esteem growing up,” she said. She recalls them saying she acted like a white person because she went to a school that was predominantly white. “So that was, like, the most difficult part for me,” she said. “It was like, at school I was too black, but at home, I wasn't black enough.” Jendell Teixeira, 18, of Marion, spoke at an anti-racism demonstration at the waterfront gazebo in Mattapoisett. Credit Facebook Teixeira is graduating this year from Old Rochester Regional High School. For the fall, she intentionally chose a historically black university, Winston-Salem State. “Because I was never surrounded by my people,” she said. As the Black Lives Matter movement continues, she said her message to people in communities that — like hers — are mostly white, is this: Have the difficult conversations. Learn, and teach others. “Talk about it, read books, watch documentaries. Educate yourself, so when these difficult conversations happen, you're saying the right things to — whoever,” she said. “And just really be — if you're white or a non-black person of color, be an ally for a black person of color.” She says people have to put in the work to change things. Sign petitions. And hold others — and yourself — accountable. New Bedford Protest Against Systemic Racism, Police Brutality Marks Fifth Consecutive Day Jennette Barnes Protesters in New Bedford gathered Wednesday for the fifth consecutive day to denounce police brutality against black Americans in the wake of George Floyd’s death in Minnesota. Woods Hole Science Institutions Stung by Diversity Report: 'Preponderance of Overt Racism' By Sarah Mizes-Tan • Dec 16, 2019 Sarah Mizes-Tan / WCAI One day in late November, a group of scientists and employees gathered at the Marine Biological Laboratory for mandatory mingling. In an exercise laid out by two diversity trainers from the University of Chicago, attendees were encouraged to say hello to people they hadn't spoken with before and taught techniques for engaging with people who may have different perspectives from their own. Expanding Racial Diversity in Science By Heather Goldstone & Elsa Partan • Aug 28, 2017 Howard Hughes Medical Institute, http://bit.ly/2wXvkrl Racism is an issue in the U.S. and science is not immune. The science community – academia in particular – face the added fact that women and people of color remain significantly under-represented, despite years of efforts to change that. Today we discuss the importance of increasing diversity in science, and some innovative ideas about how to do that with David Asai, senior director of science education at the Howard Hughes Medical Institute. © 2021 CAI Sonics: Community Voices WCAI eNews Sign Up	cc/2021-04/en_middle_0068.json.gz/line1583
__label__wiki	0.911313	0.911313	Monday - Jan 18, 2021 VLF 2020: Mayang Bubot sa Tag-araw May 29, 2020 \| 12:06 am NORMAN Boquiren’s Mayang Bubot sa Tag-araw — one of the main plays in this year’s Virgin Labfest (VLF) theater festival — tackles the problems encountered in an Ayta community, focusing on how the Indigenous People’s community values ancestral land and livelihood. It follows two Ayta children whose friendship is tested as they choose different paths. One follows her mother as she seeks the American dream, while the other remains with the community, working against oppression. The story draws inspiration from the playwright’s experience during immersion activities with community advocates for Indigenous People (IP). “Ito ay sinulat ko para ibigay sa [IP community] (I wrote it as an offering for the IP community),” Mr. Boquiren told BusinessWorld in a Zoom interview on May 27. He noted that the script went through various changes over three years of visits to the Ayta community. “‘Yung lupaing ninuno provides para sa kanila. Sila, bilang katutubong Ayta, alam nila na sila ay parang mga isda na inalis mo sa tubig kapag inalis mo kami sa lupang ninuno (The ancestral land provides for them. They, as native Aytas, know that they are like a fish out of water if they are removed from their ancestral land),” Mr. Boquiren said. “[In the story], may pagta-traydor (there is a betrayal) that happened within the community,” he added, which involves issues that arise when the rich buy ancestral land. The Indigenous Peoples Rights Act of 1997 (IPRA) states that native title to domain and rights shall be recognized and respected. Section 4 of RA 8371 states that: “All areas within ancestral domains, whether delineated or not, are presumed to be communally owned and, pursuant to the indigenous concept of ownership, could not be sold, disposed nor destroyed.” ADJUSTING TO VIRTUAL CONNECTIONS Because of the ongoing COVID-19 pandemic, the Virgin Labfest, the Cultural Center of the Philippines’ festival of new, unstaged one-act plays, is going online this year, with live streamed performances and readings, among others. This has meant that the productions behind the various plays have had to adapt to an unfamiliar digital environment. This has been a daily challenge for the artists behind Mayang Bubot sa Tag-araw, who have had to figure out how to block scenes and help actors connect with co-actors in the virtual world. “Isa siyang malawakang at matagal na pangangapa,” the play’s director Mark Mirando said. (It is a long process that we are still groping through.) Mr. Mirando noted that as a director for documentary theater, part of his job is visiting the communities and talking to people for dramaturgical data, but the quarantine has made this impossible. Instead he turned to Mr. Boquiren and fellow advocates who shared their experiences and insights with the production team. Mr. Mirando said that the experience with this play has made the production team realize the value of physical connection. “Sobrang halaga niya sa proseso ng pagtutulay ng kwento sa teatro (It is very important in the process of bringing a story to the theater).” As outsiders, Mssrs. Boquiren and Mirando hope to tell the story of these IPs without romanticising and get the audience to understand the struggles of the IP communities “No to developmental aggression, protect the IP [community],” Mr. Mirando said. Opaline Santos, Ji-Ann Lachica, Janna Cortes, and Irish Shane Legaspi make up the play’s cast. Mayang Bubot sa Tag-araw will stream live on June 12, 5 p.m., and June 23, 2 p.m. Aside from the plays and staged readings, viewers can also catch the VLF Playwright’s Fair online, with this year’s playwrights talking about their work on June 11-14, 17-20, 25-27 at 8 p.m. Meanwhile, the Virgin Labfest 2020 Writing Fellowship Program will culminate in an online staged reading of the fellows’ works on June 28 at 2 and 5 p.m. For more details and show schedules, visit https://www.facebook.com/culturalcenterofthephilippines/ and https://www.facebook.com/thevirginlabfest/, or join https://www.facebook.com/groups/VLFTambayan/. — Michelle Anne P. Soliman Michelle Anne P. Soliman VLF 2020 As FATF’s Feb. 1 deadline looms, lawmakers rush to pass AMLA bill Coronavirus pummels technology-illiterate Filipino entrepreneurs Congress may run out of time to approve economic bills PLDT targets more innovative solutions this year Tourism group to gov’t: do more to lend recovery funds Milan Fashion Week: Social commentary in fabric Cavitex, PRA seek TRB’s approval to collect add-on toll for R-1 Expressway	cc/2021-04/en_middle_0068.json.gz/line1591
__label__cc	0.566014	0.433986	Deutsche’s long-term China bet looks a stretch Placing its chips 10 May 2010 By Wei Gu The German bank is paying $840 million to raise its stake in Hua Xia Bank. Chinese bank stakes have scarcity value, and Deutsche wants to diversify away from investment banking. But its ability to influence Hua Xia looks limited. Besides, Deutsche is hardly flush with capital. Hua Xia Bank, a midsized Chinese lender, is raising up to $3.1 billion in a private share placement to three investors, including Capital Steel, Deutsche Bank and State Grid. After the placement, Deutsche Bank's stake in Huaxia will rise from 17.12 percent to 19.99 percent, the maximum allowed for foreign investors. Capital Steel's holding jumps to 20.28 percent from 13.98 percent. Capital Steel had been Hua Xia's biggest shareholder until March, when Deutsche Bank increased its holding through an acquisition of another Hua Xia shareholder. Most foreign banks question whether strategic stakes in Chinese banks have been successful in the context of a broader market development, according to a recent PricewaterhouseCoopers survey on foreign banks. Many foreign lenders have been unable to exert any meaningful degree of management control.	cc/2021-04/en_middle_0068.json.gz/line1594
__label__wiki	0.758956	0.758956	Broadway Performances Suspended In light of the coronavirus pandemic, Broadway theatres are now offering refunds and exchanges for tickets purchased for performances through May 30, 2021. Touring Broadway performances across North America have also been affected. For more information, visit show and venue pages on this site for links to official websites. Broadway in NYC Touring Broadway Details Buy Tickets Broadway Events About Broadway.org Broadway.org is The Broadway League's official on-line headquarters for Broadway information in NYC, as well as for shows on tour across North America. Get tickets at all price points to current and upcoming shows direct from the theatres’ official ticketing offices. The website also provides up-to-date show and theatre information in eight languages, as well as a guide to hotel and dining options in Manhattan's Theatre District, and general information about Broadway theatregoing.	cc/2021-04/en_middle_0068.json.gz/line1602
__label__cc	0.649606	0.350394	Subscribe For Free Unsubscribe Contact Us Search About BTNews \| Archive \| Comment \| Soapbox \| On Tour \| Motoring Index \| Cruising \| AND FINALLY.. CLICK HERE AND PRINT OUT AS IF YOU WERE IN AN ASPIRE LOUNGE CWT "Business Travel Journalist of the Year" BTJAS 2018 - The awards for outstanding events and business travel journalism Tweets by BTNewsupdate Readers are invited to add their comments to any story. Click on the article to see and add. BTN DISTRIBUTION BTN also goes out by email every Sunday night at midnight (UK time). To view this edition click here. The Business Travel News Edgware HA8 4QF info@btnews.co.uk © 2020 Business Travel News Ltd. Article from BTNews 27 JULY 2009 COMMENT: Potholes are the bane of the motorist Did you know that there is one pothole for every 120 yards of British road, that just under one million potholes were filled by local councils last year, and that it costs on average £65 to deal with each one? This and other most interesting facts are revealed in the very comprehensive 14th Annual Local Authority Road Maintenance (ALARM) Survey backed by the Asphalt Industry Alliance. www.asphaltuk.org/alarm.asp The survey, which collects information from local authority highways departments across England and Wales, also reports that the number of potholes in England has increased by 32% over the previous year, without accounting for the effects of the extreme weather conditions in February. On top of this, highways departments have to cope with the intrusion of nearly two million deep trenches into roads for utility and other service provision works, which reduce the lifespan of the road. Add to that the speed restriction humps that have proliferated over recent years and you just wonder how the modern car holds together. You don’t see many Ford Anglia’s around these days. They must have rattled to pieces. And have you tried to follow a cautious driver over the bumps? How many accidents are caused by a lack of patience? I digress. Such are the frustrations of motoring. Canada has much more severe weather than the UK and any visitor will tell you that for the most part the road surfaces are excellent. One problem we do have this side of the Atlantic is that in any typical winter there might be three, even four spells of under zero conditions. It is water getting into cracks, freezing and then expanding that causes the surface to break. In Canada it is just one long spell of really cold weather. Last week the Highways Agency announced a scheme to add an extra lane to the M25 around north London from junction 16 (M40) to junction 30 (QE2 bridge approach) in time for the 2012 Olympics, except (for some strange reason) J23 (A1M) to the M11, which effectively connects Stansted to Stratford. For this stretch the hard shoulder is to be reinforced and brought into use when necessary. The hard shoulder experiment in the Birmingham area has proved a success it seems, and the concept will be extended. Money has been found for what is a vital road, one of the most important in the whole country. No doubt the minister of the day will cut a ribbon and try to gain praise for a project that was nothing to do with him. But that is politics. Filling in potholes does not carry any glory but is just as vital. And it is not just a question of filling in potholes, hotchpotch. Roads need to be re-surfaced properly. According to the website www.potholes.co.uk (yes there is one) 462 people claimed for pothole damage against Buckinghamshire County Council, the authority paying out just on seven, totalling £1,150. Times are tight but money is being found for vital missions. The shortfall is put at around £750m for the councils of England and Wales to put things right, not a huge sum by modern standards. The roads and byways of the United Kingdom are the country’s basic infrastructure. If things are not taken in hand we will finish up as a country linked by farm tracks, not 21st century highways. The consequences of not finding the money are severe. Or is this lack of interest a secret government plan to assist Land Rover? If things deteriorate much further, and we have a really bad winter, they might well become the only vehicles to get around. That would be the wrong route to take. Malcolm Ginsberg Index/Home page OUR READERS' FINEST WORDS (All times and dates are GMT) All comments are filtered to exclude any excesses but the Editor does not have to agree with what is being said. 100 words maximum No one has commented yet, why don't you start the ball rolling? Company (Not obligatory) Country/City - You must be a registered subscriber using the email address entered to submit a comment, or you will be sent a confirmation email before your comment will appear. - Your comment will be checked before appearing, which may take several working hours.	cc/2021-04/en_middle_0068.json.gz/line1604
__label__wiki	0.759234	0.759234	(-) Expert Roundup Bird Flu: How Concerned Should We Be? Fears of bird flu dominated last week’s headlines. First, scientists announced their discovery October 5 that the 1918 outbreak of influenza, which killed 50 million people, was caused by bird flu th… Expert Roundup by Eben Kaplan, Anthony S. Fauci, Laurie Garrett, Rita Colwell, and William Karesh What is the Legality of the NSA Domestic Surveillance Program? Should the domestic spying of U.S. "persons" be permitted? If it is "critical to saving lives," then yes, argues President Bush. He further says that shortly after the September 11, 2001, attacks Con… Expert Roundup by Lionel Beehner, Lee Casey, Carl Tobias, John R. Schmidt, Michael J. Williams, and Dakota S. Rudesill International Press Assess U.S. Presidential Race CFR.org interviews representatives of the foreign press corps at the Democratic National Convention about what issues appeal to their home audiences. Expert Roundup by Eben Kaplan, Mikkel Selin, Marilia Martins, Ana Paula Ordorica, Constance Ikokwu, Peter Wuetherich, Toshiya Umehara, and Ron Baygents Nonproliferation, Arms Control, and Disarmament The North Korean Puzzle North Korea’s nuclear test raises new concerns about its nuclear capabilities, regime succession, and the limits of both international pressure and engagement. Four experts address the policy options… Expert Roundup by Robert McMahon, Jayshree Bajoria, Paul B. Stares, David C. Kang, and Charles L. "Jack" Pritchard Tiananmen Square and Two Chinas On the twentieth anniversary of China’s Tiananmen Square crackdown, six experts reflect on the country’s trajectory since then. Many note China’s breathtaking economic growth as well as mounting stra… Expert Roundup by Jayshree Bajoria, Elizabeth C. Economy, Perry Link, Adam Segal, Cheng Li, Orville H. Schell, and Michael Anti (Zhao Jing) Obama’s NSS: Promise and Pitfalls President Obama’s first National Security Strategy departs from Bush administration doctrine by redefining the war against terror groups and embracing multilateralism, and may expect too much from gl… Expert Roundup by Stephen D. Biddle, Laurie Garrett, James M. Lindsay, Stewart M. Patrick, Adam Segal, Steven Simon, and Paul B. Stares Digital and Cyberspace Policy Program Weighing an Ambitious QDDR Four CFR fellows weigh in on the effectiveness of the State Department’s Quadrennial Diplomacy and Development Review recommendations. Expert Roundup by Deborah Jerome, Laurie Garrett, Yanzhong Huang, Isobel Coleman, and Paul B. Stares Civil Society, Markets, and Democracy Program Resourcing an Afghan Strategy U.S. military leaders are calling for more troops to carry out U.S. counterinsurgency strategy in Afghanistan. Six analysts offer views on how President Barack Obama should respond. Expert Roundup by Greg Bruno, Peter Colonel R. Mansoor, Andrew J. Bacevich, Amin Tarzi, Thomas E. Ricks, Candace Rondeaux, and John A. Nagl Infrastructure Investment and U.S. Competitiveness How can the United States improve its aging infrastructure to maintain its global economic competitiveness? Four experts offer their suggestions and discuss the implications of inaction. Expert Roundup by Jonathan Masters, Robert Puentes, Felix G. Rohatyn, Richard Little, and Stephen Goldsmith Renewing America The Targeted Killings Debate U.S. drone strikes and "kill/capture" missions against al-Qaeda operatives, particularly in Pakistan and Yemen, have gained new attention and notoriety this spring. Four experts debate the legality a… Expert Roundup by Jonathan Masters, Matthew C. Waxman, Pardiss Kebriaei, Kate Clark, and Daniel L. Byman U.S. Foreign Policy Program	cc/2021-04/en_middle_0068.json.gz/line1606
__label__cc	0.620043	0.379957	China: Church evicted, Christians barred from renewing residential permits Source: www.chinaaid.org May 15, 2017 11:44 am \| Brynne Lawrence The notice Ma received when attempting to renew his residential permit online, which reads, "The person at the address Fupu Street, Panyu District has already applied for a residence permit on May 23, 2014. The reason for the application is: 'other.' The current status of the application is: 'declined.' Unable to renew the residential permit or change the address!" (Photo: ChinaAid) ChinaAid (Guangzhou, Guangdong—May 15, 2017) Authorities in China’s southern Guangdong province continue to track the movements of a serially persecuted house church, pressuring their landlord until he evicted them on May 4 and leaving them without a place to worship. For years, officials have been harassing Guangfu Church for not joining the state-sanctioned Three-Self Church by coercing its successive landlords to terminate their contracts. On May 4, the pastor of the church, Ma Ke, received a notice declaring that the contract had been terminated and ordering him to move out. The landlord said the police visited him several times when Ma called to inquire about the sudden eviction. In a similar instance in June 2016, the church’s landlord succumbed to government harassment and ended his contract with the church. Ma was also forced from his personal residence in September 2015, and the landlord said that he would rather pay the liquidated fees rather than face continued police pressure. Additionally, when Ma tried to renew his Guangzhou residential permit online, he was denied and later learned that the authorities published a wanted notice for him. Other members of the church were also barred from renewing their permits, without which they cannot get driver’s licenses or purchase new cars. When ChinaAid spoke to him, Ma stated his intention to sue the police if they refused to revoke the sanction on his permit by May 10, but it is unknown whether or not he followed through with his plan. ChinaAid reports abuses such as those experienced by Guangfu Church in order to stand in solidarity with persecuted Christians and promote religious freedom, human rights, and rule of law. ChinaAid Media Team Cell: (432) 553-1080 \| Office: 1+ (888) 889-7757 \| Other: (432) 689-6985 For more information, click here Read More	cc/2021-04/en_middle_0068.json.gz/line1616
__label__cc	0.607706	0.392294	Chrome Daily About Chrome Daily Our Plan For This Site I’ve been a fan of Google products since they launched their first Android Phone in 2008. First Android, then Chromebooks, and now we have Chromecasts and Android TVs. I have never worked for Google. I am just a regular consumer that has spent a lot of time combing the internet for answers. I started Chrome Daily to share some of my years of experience and answers I found while using these products. What will you find on Chrome Daily? Chrome Daily covers Chromebooks, Google products, Stadia, Chromecast, and other products such as Android and Wear OS. If it works with or is built on Chrome OS or Android, we will try to cover it here. Android – Android is the world’s most popular and best-selling mobile platform. It’s a customizable, easy to use operating system that powers phones, tablets, watches, TV, and cars. Its open-source code can be used to develop variants of all these devices with a specialized user interface. Chrome OS – an operating system designed by Google to be simpler and easier to use than any other OS. It’s cloud-powered and based on the Chrome Browser. It boots up in seconds and connects to the internet almost instantly. It comes pre-installed on all Chromebooks and can be installed on other devices that support it. Updates are automatic so Chromebooks are always fast and secure. Chromecast – A streaming device from Google with built-in Wi-Fi. A Chromecast can stream content to a TV or Speaker from services like YouTube, Netflix, and Spotify. They can also stream from your phone or the Chrome browser via the Google Cast. Chromecasts also link to Google’s home assistant to control these services with voice. Samsung Galaxy Chromebook Review: Almost Best in Class Free Stadia Premiere Edition bundle 11 Chromebook Accessories for working from home Pixelbook is out of stock on the Google Store Lenovo Ideapad Duet back in stock at Best Buy Copyright © 2021 Chrome Daily	cc/2021-04/en_middle_0068.json.gz/line1617
__label__wiki	0.86973	0.86973	Brian Reyes Entry into Gibraltar under the political framework agreement reached on New Year’s Eve will be “exclusively a matter for us”, Chief Minister Fabian Picardo has told the Chronicle. Mr Picardo said Schengen checks by Frontex officers would be conducted “only once entry into Gibraltar has been granted” by BCA officers, while acknowledging Schengen checks would be “a purely European matter”. Mr Picardo stressed Spanish law enforcement officers would not be present “at the port or airport”, adding Spain will guarantee its Schengen obligations “remotely”. Mr Picardo was speaking after Spain’s Minister for Foreign Affairs, Arancha Gonzalez Laya, told El Pais in an interview that Spain would have “the last say” over who could enter Gibraltar. The political agreement reached on New Year’s Eve paves the way for a UK/EU Treaty seeking "maximised unrestricted mobility" of persons and goods across Gibraltar’s border with Spain, avoiding a damaging hard Brexit for the Rock at midnight on New Year's Eve. But the Gibraltar Government has repeatedly said the agreement does not breach Gibraltar's red lines on sovereignty, jurisdiction or control, and will allow Gibraltar to "reset" its relationship with Spain in a more positive light. Under the agreement, Gibraltar’s closest Schengen member state, Spain, will take responsibility for ensuring Schengen checks are applied in Gibraltar. But Mr Picardo said Gibraltar law would apply to anyone stopped entering or leaving the Rock. He added that even in the four-year initial period envisaged by the agreement, Gibraltar “will not accept” Spanish law enforcement officials wearing an arm band as the Frontex force. Mr Picardo said the agreement would strengthen security in Gibraltar by ensuring checks could be carried out against not just UK and Interpol databases, but EU ones too. And he insisted too that after the four-year initial period, the UK and Gibraltar would have a veto on Spanish law enforcement ever coming into the terminal to carry out the checks themselves. “We can, if necessary, terminate the agreement,” he added. The Chief Minister said the political agreement meant Gibraltar had avoided the worst impacts of a hard Brexit at the border. “We have avoided the UK having a deal and our being the only part of the continent of Europe without a legal relationship with the EU,” he said. “We are hoping to cure decades of mobility issues and to deprive a future right wing Spanish government of the whip hand on the queues.” Below is the full text of the interview with the Chief Minister, conducted on Saturday January 2: Q. Arancha Gonzalez Laya said in an interview on Saturday that Spain will be responsible for who can enter the Schengen area through Gibraltar, that Spain “will have the last say”. What is your understanding of what she means by this? A. The New Year's Eve Agreement expressly provides that only Gibraltar will decide who is able to enter Gibraltar. Those decisions will be made exclusively by the Gibraltar Borders and Coastguard Agency [BCA] in keeping with Gibraltar immigration policy and the data available to them from our / UK security databases. Only once entry into Gibraltar has been granted by Gibraltar by the BCA, then entry into the Schengen area will be determined by Frontex officers who will be connected to the European Schengen Information System which will be remotely provided to the Frontex officers by Spain. To be clear though, Spanish law enforcement will not be at the port or airport. Q. If Spain is responsible for application of Schengen checks in Gibraltar, how is this not ceding a degree of control? How is this acceptable? A. The Schengen checks are related to the European Schengen Information System. Access through the Gibraltar frontier will be exclusively a matter for us. Access to Schengen is a purely European matter. Spain is a member state of Schengen. The choice really is whether you face those controls in the form of a Spanish officer at the land frontier with Spain or in the form of a Frontex officer at the port and airport, with Spain remotely providing the data to the Frontex officers. But let us be clear, the database is not a Spanish database, it is a European database which Spain feeds information into and can access, but Spain does not control the database. Q. In practical terms, how will Spain exercise that responsibility under Schengen? A. The answer is it will do so remotely. They will be providing access to the data base remotely to the Frontex officers. Q. Whose laws will apply to anyone detained at the Schengen entry point in Gibraltar for whatever reason? How will that work in practice? A. The only law and jurisdiction which will apply to anyone detained in Gibraltar will be Gibraltar law. Practical details will be set out in the Shared Prosperity Treaty we are going to start hammering out now. Q. What commitments have been secured as to the nationality of the Frontex officers who will conduct Schengen checks in Gibraltar under the initial four-year period? A. I have said repeatedly in Parliament that we will not accept Spanish law enforcement officials wearing an arm band as the Frontex force. We are referring to the Frontex Statutory Corps. The proportions of recruitment of those between the nationalities of the nations that make up Frontex are set out in the EU Regulation that establishes the Statutory Corps. Q. Spell out what has been agreed in respect of who handles the Schengen role after four years are up. What safeguards are in place, given that Mrs Gonzalez Laya has stated explicitly that after four years, Spain’s expectation is that Frontex officers will become Spanish officers? A. After four years, we will consult on what should happen next on the ground at the port and airport. I believe that Spain will in that period have grown in confidence and consider that it should be just our Gibraltar Borders and Coastguard agents who are the ones carrying out a consolidated Gibraltar and Schengen check. Our BCA officers would thus be able to apply the effect of our/UK databases and the information remotely provided to them by Spain in respect of the Schengen Information System. If we cannot agree that or another acceptable system, the UK and Gibraltar have a veto on Spanish law enforcement ever coming into the terminal to carry out the checks themselves. We can, if necessary, terminate the agreement. Q. What is being discussed in terms of mobility of goods and joining the Customs union? What would be the effect in Gibraltar? A. This discussion is at an early stage. The Cabinet considered this carefully and we agreed we could have an arrangement with the Customs Union which was not membership of it but an agreement that could lead to the suppression of controls. This still requires discussion and negotiation and we may be able to suppress controls with a lighter agreement on the movement of goods than an adherence to the Customs Union. The views of the EU Commission on this, as the guardian of the Treaties, will be very important and I look forward to the discussion in coming weeks. Q. In terms of the treaty text, is that a process that is already underway? How advanced is it? When will the public have sight of the detail of what has been agreed? A. The drafting of the Shared Prosperity Treaty has not yet begun as we have not yet met for that purpose. The Gibraltar side has already been drafting what we think it looks like based on the discussion for the New Year's Eve Agreement. As ever, such a Treaty will be published once it is agreed. Q. If we take a step back and look at this agreement broadly, what has been achieved? What does this mean for Gibraltar? Where has Gibraltar had to bend in order to achieve this? A. Gibraltar has avoided a hard Brexit. We have avoided the UK having a deal and our being the only part of the Continent of Europe without a legal relationship with the EU. We are hoping to cure decades of mobility issues and to deprive a future right wing Spanish government of the whip hand on the queues. We have not ceded one iota of sovereignty, jurisdiction or control. We have, in some ways that will become apparent, cemented our position. For now, I must not say more, as I must make a statement in Parliament and we must yet negotiate the Treaty. Prudently, we will get there and achieve a final deal which will best be described as follows: "Sovereignty Safe, Prosperity Protected, Mobility Assured". But that is a long way off yet. There is still a lot to do and a Treaty to finalise. We may not get there in the end if there is any attempt to compromise the things that matter to us, but I am hopeful that we will. EDITOR'S NOTE: Our reporters are working round-the-clock to bring you the latest news on Gibraltar and the Covid-19 crisis and Brexit. Our key coverage on these critical issues is available free outside the paywall. If you find it useful, please help us reach more people by sharing our journalism. And if you want to support our work further, please consider subscribing to the digital version of our daily newspaper and all our premium online content. You can subscribe via our website or for iOS devices via the iTunes store. Thank you.	cc/2021-04/en_middle_0068.json.gz/line1618
__label__wiki	0.939111	0.939111	Ray Donovan Star Liev Schreiber Reacts To Series Cancellation At Showtime Nick Venable When news broke this week that Showtime had officially cancelled its long-running original Ray Donovan, just about everyone's reactions were on the negative side, since the crime drama had only recently wrapped up Season 7 with a finale that complicated many characters' situations. Alas, while the fandom will be stuck with a list of unanswered questions, the person who had arguably the most chill reaction to the news was star Liev Schreiber. All things considered, Liev Schreiber sounded like he knew the cancellation was coming back in January when the finale aired, so perhaps he'd already mentally prepped himself for the day when the bad news would finally come. Check out his post below, presumably with a glass of Johnny Walker scotch in hand. Slainte. A post shared by Liev Schreiber (@lievschreiber) on Feb 4, 2020 at 6:14pm PST A toast that popped up a time or ten on Ray Donovan itself, "Slainte" is an Irish word for "cheers." Its utterance often prefaces quite a bit of mirthful drinking, though the mirth-filled moments will likely be few and far between in the days just after the cancellation news got publicity. I mean, it's not like Ray Donovan was a ball of laughter and goofiness. (Especially since he didn't quite say his own name right.) Since 2013, Liev Schreiber portrayed the esteemed fixer Ray Donovan, whose ability to "clean" things never fully worked out when he focused on his own life's problems. Along the way, the actor earned himself quite a few awards nominations for his work, though the only major trophies won by the show were Jon Voight's Supporting Actor Golden Globe and Hank Azaria's Guest Actor Emmy. Liev's brother Pablo Schreiber, former American Gods star and future Halo star, responded to the cancellation reaction post with his own uplifting words. Congratulations on a tremendous run! Your talent, intelligence and leadership shine brightly. On to the next! And to be sure, Liev Schreiber certainly isn't the only member of the Donovan family who's bummed out about having to say goodbye to the show. Below is co-star Eddie Marsan's take. I’m gonna miss this guy. #Terry Donovan #RayDonovan pic.twitter.com/Qb8f7ack05 — Eddie Marsan (@eddiemarsan) February 5, 2020 Part of the reason why Ray Donovan's cancellation news was so shocking is that many fans had developed a sense of optimism about the show's future. For one, the showrunner had previously expressed interest in crafting an actual ending for everyone's stories. As well, Shameless' cancellation was revealed in the form of a final season order, so it was thought that the same would happen with Ray Donovan. Not to mention at the Television Critics Association winter press tour in January, Showtime exec Greg Levine told Deadline that the end was indeed near, but offered up hope for a Season 8 order to happen. In his words: I think Ray Donovan is nearing the end of its run. We always talked about seven or eight seasons. Nothing has been decided yet but it’s fair to say it is nearing the end. For what it's worth, Liev Schreiber tried to keep Ray Donovan alive around the finale's airing. After posting a message that was so thankful it sounded doomsaying, he took to social media to advise fans to express their Season 8 desires to Showtime and CBS to make sure everyone in power knew that there would be eyeballs ready and waiting for new episodes. Unfortunately, it would appear not enough people heeded those words seen below. What an amazing journey it’s been. I’ve been reading your comments, and the outpouring of love and support for our cast and crew has been truly overwhelming. I know the big question on everyone’s mind is whether there will be a Season 8. Truth is it’s in the networks hands. So if you want more, reach out to them at @showtime, @raydonovan, and @cbstv and let them know how you feel. Either way it’s been an amazing ride and we have all of you to thank for it. While there have been no signs of any further advancements with Ray Donovan on Showtime, it wouldn't be completely out of the question for the network to produce some kind of a "final" episode that gives audiences some real closure with characters like Smitty, Bridget and Daryl. It would probably take a huge wave of support from fans to inspire something like that, but it's not an outright impossibility. Ray Donovan is currently no more at Showtime, though episodes can still be streamed in full on Showtime Anytime's website and app. Nick Venable View Profile Nick is a Cajun Country native, and is often asked why he doesn't sound like that's the case. His love for his wife and daughters is almost equaled by his love of gasp-for-breath laughter and gasp-for-breath horror. A lifetime spent in the vicinity of a television screen led to his current dream job, as well as his knowledge of too many TV themes and ad jingles. news 7d Alicia Silverstone: What To Watch On Streaming If You Love The Clueless Star Jason Wiese television 2w The Dexter Revival Cast Its Big Villain With An A+ Actor Mick Joest television 2w Dexter's Michael C. Hall Knows The Finale Was 'Extremely Dissatisfying,' And Wants To Fix That Mick Joest Mar 5, 2021 Coming 2 America Rating TBD Jun 4, 2021 The Conjuring: The Devil Made Me Do It Rating TBD Jul 23, 2021 The Tomorrow War Rating TBD Tim Allen Reveals How Alan Rickman’s Passing Affected Galaxy Quest 2 news television Bryan Cranston Compares Breaking Bad's Walter White To New Character In Showtime's Your Honor television If Shameless Vet Emmy Rossum Comes Back As Fiona, Here’s What That Would Look Like television Showtime's Halo TV Show: 8 Quick Things We Know About The Series television How Shameless Season 11 Completely Changed After COVID Pandemic Hit	cc/2021-04/en_middle_0068.json.gz/line1619
__label__cc	0.742413	0.257587	Fit Feet Fit Pelvis Fit Mind The skeleton is a dynamic, multi-planar system of structured human engineering, complex in its structure yet balanced upon two tri-planar feet. Each foot has a natural shock absorption system of 26 bones, 37 joints, 19 muscles and over 107 ligaments. To demonstrate the importance of the feet, the Achilles tendon is the largest and the strongest tendon in the whole body and there are at least six sets of muscles that control each toe. One of the key problems with adults is that poor stability and shock absorption of the skeletal structure, during walking, can ultimately cause wear and tear throughout the body. Indeed, the vertical energy transferred through the ankle joint at the ‘heel strike’ of the foot can be many times greater than the body weight. Hence, if the foot and ankle joint are dysfunctional within an unstable environment (ie footwear) the damage can ricochet back up the body as a negative ground reaction force into the upper back, lower back, knees and hips, causing joint inflammation and overall muscle trauma. THE FEET - CiONE Custom Stability Plates CiONE’s CAD/CAM software was developed to engineer and manufacture the perfect Custom Stability Plate (Custom Insole). Our Custom Stability Plates are tailor made for the feet and are worn and fitted to every shoe, thus ensuring that the feet and the knees track in a straight line at all times. The Custom Stability Plates also create a de-rotational Ground Reaction Force which is sent back up the leg to the pelvis. This de-rotational force is the key to unlocking the Pelvis. The straight tracking of the foot and knee ensures that a positive ground reaction force is sent back up the lower limb. Every step commences the unlocking of the dysfunction caused by the anterior tilt of the pelvis and encourages, through the femur heads, the pelvic girdle to shift back. THE PELVIS - CiONE BiOCORE Programmes A North Western University, Chicago study sponsored in 2004 by ATA (a company supplying physical therapy across the Midwest States) confirmed evidence suggesting that a high percentage of children have an anterior pelvic tilt before they finish growing. This ‘common dysfunction’ creates a constrained dynamic posture/gait causing problems later in life and affects the lower limb and feet significantly. CiONE has created fifteen BiOCORE exercises (a patient only requires 3 exercises to achieve their Perfect Postural Stability Point, PPSP), to ensure that each individual’s BiOCORE can be developed no matter how weak or traumatised by past surgical intervention. The CiONE Custom Stability Plates progressively create the desired de-rotation of the lower limb. The patient’s proprioception adapts to the correction and control whilst the CiONE BiOCORE programme is followed once per day (each exercise takes five minutes). The daily repetition of these exercises ensures that the patient’s excessive anterior pelvic-tilt, returns back to the realms of normality in under 12 weeks. The CiONE BiOCORE Programmes are a deeper pelvic floor programme than the popular Pilates and Yoga principles on offer at local fitness studios; this is due to the BiOCORE’s process of isolation; restricting certain dominant muscle groups from function during the dynamic exercise regime. BiOCORE stability is now being utilised in Pre and Post Natal pelvic floor issues, Parkinson’s management, acute male and female Chronic Prostatitis, Chronic Pelvic Pain Syndrome, Sexual Dysfunction, Urinary Dysfunction and sport related Pelvic Floor Irritations. The programme developed by Tim King realigns the pelvis and prevents the common degeneration of Plantar-flexed postural issues suffered by the human body on a daily basis. It has positively affected numerous other debilitating conditions in a dynamic manner during the body’s journey back to its individual PPSP and Efficient Gait. THE MIND - CiONE Proprioception Retraining and Recalibration Programmes Proprioception is the brain’s natural radar system enabling us to know at all times where the physical body is during rest, stance and dynamic gait. Our natural proprioception is a security blanket during gait. It re-calibrates itself to ensure that the brain feels stable and able to move dynamically no matter what the physical disability or ailment being suffered by the body. If the physical body migrates downwards the skeletal structure becomes more excessively plantar-flexed. The brain re-calibrates the proprioception to ensure that the body feels secure enough to move by ‘conning’ itself that the skeleton is straight and stable. The outcome of this recalibration is that the physical skeletal structure changes its gait pattern. To accommodate the shifting forward of the body’s central line of gravity the brain makes the body take smaller and smaller steps, increasing the negative weight load through the body’s joints. This ‘conning’ of the brain generates intense wear and tear of all the body’s joints, bringing on early knee and hip replacements, overworked muscle groups and acute postural pain. Once postural rejuvenation and the PPSP have been achieved, the process of realignment and proprioception recalibration has been known to alleviate symptoms such as chronic cluster headaches and nagging toothache. The proprioception recalibration has also positively affected debilitative conditions such as Parkinson’s, Osteoarthritis and Fibromyalgia. Through its realignment of the skeletal structure, repositioning and decreasing the anterior tilt of the pelvis, The CiONE Postural Rejuvenation programmes allow the proprioception to recalibrate to within the realms of normality. This process of ‘rebalancing the brain’s awareness of the skeletal structures position in space while moving dynamically is the third and final part of the re-education of the posture. Once this Human Engineering realignment process has been achieved the body and brain find your PPSP and the physical body relaxes, acute pains disperses and the physical body’s wellness returns, allowing the structure to become more active and more dynamic in its movement. The past on-going recurring pain can be eradicated for the long term as the cause is corrected and skeletal balance returns to the physical body, putting the body back into its natural and correct physical skeletal state. Thus the PPSP for efficient dynamic movement has been found.	cc/2021-04/en_middle_0068.json.gz/line1620
__label__wiki	0.839265	0.839265	About CityLand CityLand Sponsors Filings & Decisions CityLaw Search results for "City property acquisition" City Planning Holds Public Hearing on 100% Affordable Mixed-Use Development in Brooklyn City Planning Commission • UDAAP • Ocean Hill, Brooklyn 1510 Broadway Rendering Image Credit: City Planning The proposed mixed-use development looks to activate vacant land near the Halsey Street Subway station. On August 17, 2020, the City Planning Commission held a remote public hearing on a City application that would facilitate the construction of an eight-story mixed use development in the Ocean Hill neighborhood of Brooklyn. The site is currently a vacant, trapezoidal block situated mainly along Broadway to the northeast, Hancock Street to the southeast, and Saratoga Ave to the west. The site is directly across from a raised subway platform and the Halsey Street subway station that serves the J/Z subway line. The Department of Housing Preservation and Development and the Department of Citywide Administrative Services brought the application on behalf of the City. Tags : 1510 Broadway, affordable housing, City Planning, DCAS, HPD, HPD ELLA Program, Rezoning, UDAAP HPD Announces Program To Allocate Funds to Nonprofits for Vacant Property Development Department of Housing Preservation & Development • Housing • Citywide Image Credit: NYC HPD The City estimates the program will assist in the acquisition of approximately 35 vacant sites over the next five years. On March 8, 2019, the New York City Department of Housing Preservation and Development announced a new program to advance the process for affordable housing development by providing loans for upfront costs to nonprofit developers. The New York City Down Payment Assistance Fund (DPAF) seeks to speed up the development process for affordable housing by providing funds to nonprofit developers that compete for the acquisition of vacant sites to build supportive and affordable housing. The program will provide flexible down payment loans to pre-qualified applicants. (more…) Tags : affordable housing, Department of Housing Preservation and Development, down payment, Down Payment Assistance Fund, HPD, New York City Down Payment Assistance Fund, nonprofits, vacant lots City Planning Commission Considers Acquisition of Land to Expand Olmsted-Beil House Park City Planning Commission • Land Acquisition • Eltingville, Staten Island Map of area around Olmsted-Beil House Park (center, green). Proposed lots to be acquired are in red. Image Credit: NYC CPC/ NYC Parks & Recreation Proposed historic park expansion will provide space for programming and direct access from Hylan Boulevard. On October 31, 2018, the City Planning Commission held a public hearing for an application on the acquisition of property at 4485 Hylan Boulevard in the Eltingville neighborhood of Staten Island to expand Olmsted-Beil House Park. The Department of Parks and Recreation and the Department of Citywide Administrative Services jointly filed the application. (more…) Tags : acquisition, City Planning Commission, Department of Parks and Recreation, eltingville, parks, Parks Department, Staten Island City Planning Approves City-Initiated Special Garment Center District Rezoning City Planning Commission • Rezoning • Special Garment Center District, Manhattan Special Garment Center District, Fashion Avenue. Image Credit: City Planning Zoning changes will bring many buildings into compliance and will lift manufacturing space preservation requirements. City officials step in to ensure garment manufacturing has a continuing place in the district. On September 26, 2018, the City Planning Commission held a public hearing on a proposed rezoning of the Special Garment Center District by the Department of City Planning, in conjunction with the New York City Economic Development Corporation (EDC). The Special Garment Center District encompasses approximately 13 blocks between West 35th and West 40th Streets, west of Broadway. (more…) Tags : City Economic Development Corporation, City Planning, garment manufacturing, Rezoning, special garment center district City Planning Approves Parks’ Acquisition of Community Garden with Community Support City Planning Commission • ULURP • Prospect-Lefferts Gardens, Brooklyn Image credit: GoogleMaps The City Planning Commission approved the acquisition of 6,000-square-foot community garden and passive recreation lot to place under jurisdiction of the Parks Department. On July 16, 2017, the City Planning Commission issued a favorable report on a joint application filed by the Department of Parks and Recreation and the Department of Citywide Administrative Services to acquire private property at 237 Maple Street in the Prospect-Lefferts Gardens neighborhood of Brooklyn. The acquired property would be used for passive recreation and a community garden. (more…) Tags : Department of Citywide Administrative Services, Department of Parks and Recreation, GreenThumb Program, Maple Street, Prospect-Lefferts Gardens Subscribe To Free Alerts In a Reader Desktop Reader Bloglines Google Live Netvibes Newsgator Yahoo! What's This? City Planning Commission Board of Standards & Appeals Landmarks Preservation Commission Housing Preservation & Development Administrative Decisions Filings and Decisions CityLand Profiles © 1997-2010 New York Law School \| 185 West Broadway, New York, NY 10013 \| 212.431.2100 \| Privacy \| Terms \| Code of Conduct \| DMCA \| Policies	cc/2021-04/en_middle_0068.json.gz/line1621
__label__cc	0.564402	0.435598	Due to precautions related to COVID-19, we expanded our options for remote consultations and virtual meetings (Zoom). Please contact our office to discuss whether a full phone consultation or video conference is appropriate for your situation. Cynthia L. Lazar Modification Of Parenting Plans Mediation FAQ Parenting Mediation Why Choose Mediation? Litigated Divorce Post-Divorce Decree Division Of Retirement Contact An Experienced Family Law Attorney Cohabitation poses more challenges in custody disputes, p. 2 On behalf of The Law Office Of Cynthia L. Lazar \| Oct 6, 2012 \| Uncategorized Once burned, twice shy? Research has shown that the divorce rate for second marriages is much higher than the divorce rate for first marriages. In fact, almost two out of three second marriages will end in divorce. Is that one of the reasons people choose to cohabitate the second time around? In the end, the answer may be both unknowable and beside the point. As we said in our last post, the issues that come up between adults who are cohabiting can be addressed with legal contracts or cohabitation agreements. More complicated are the issues that come up with one partner’s child and that child’s other parent. Custody arrangements can fly out the window when a parent’s partner is a source of conflict, because a live-in boyfriend or girlfriend is not a stepparent by law. Courts are just beginning to find their ways through these issues. We were discussing a case that started with a complaint by a father on behalf of his young daughter. He asked the family court for an order for protection against the mother’s live-in boyfriend. The family court could not hear the case, it said, because the boyfriend was not a stepparent and was not a blood relation. The law simply did not contemplate someone with his status being a party to a family court matter. The child’s court-appointed attorney argued to the court of appeals that the boyfriend did have a legal relationship with the child. That state’s law — this wasn’t in Illinois — said the family court had jurisdiction over people who had an “intimate relationship” with the child. A number of factors prove that an intimate relationship exists, the attorney continued. First, the boyfriend and the mother had lived together for three years. Second, the boyfriend acted like the daughter’s parent when the girl was in her mother’s custody. This time, the court agreed: There really is something called a quasi-stepparent. The court understood that each case will be unique, depending on the particulars of the partner’s relationship with the child (or children). Commentators understand that there may be very few cases where application of the rule would be appropriate. But we know from experience that one case in another state can influence our state’s approach to family law matters. Source: Thomson Reuters News & Insight, “Child has legal ties to mom’s live-in partner: court,” Jessica Dye, Sept. 26, 2012 Families like the one in this post come to our firm for help with child custody and visitation matters. Please visit the child custody page of our website to find out more about our Libertyville/Lake County practice. Collaborative Law (7) Legal Separation (10) Parenting Plans (12) Can nesting help your children adjust to life after your divorce? Do all divorces have to end in court? Protecting your kids during divorce Working from home can cause marital stress Openness and honesty are needed in a collaborative divorce My Law Firm Offers The Following Family Law Services: Make an informed decision about your situation. The Law Office Of Cynthia L. Lazar 611 S. Milwaukee Avenue Libertyville Family Law Office © 2021 The Law Office Of Cynthia L. Lazar. All Rights Reserved.	cc/2021-04/en_middle_0068.json.gz/line1626
__label__wiki	0.563637	0.563637	2003 - Witnness 2003, a comprehensive review by Brian Kelly of the 2 days of what transpired to be the last ever Witnness festival (in 2004 it was rebranded as Oxegen when Heineken stepped into the sponsor shoes). Entries for 'eoghan' Is this the worst album of the last 5 years? eoghan posted on July 09, 2010 20:00 A few days I pulled together the list of the highest rated albums of those reviewed on CLUAS in the last 5 years. Now it's the turn of those albums that in the same period got the lowest ratings from CLUAS reviewers. The albums listed below are those that, since 2005, have been awarded less than 4 out of 10 by a CLUAS writer. Among them you will find albums by Placebo, Van Morrison, Smashing Pumpkins, Mercury Rev and James Blunt. So what album was considered to be the worst of those reviewed on CLUAS? Well the honour falls into the lap of Björk whose 2007album Volta was awarded a grand total of zero out of 10 by CLUAS writer Rev Jules. It was a divisive assessment if the comments below the review are anything to go by. Here comes the full list... Topping the list with a rating of zero out of 10... Björk 'Volta' (2007 release) James Blunt 'All The Lost Souls' (2007 release) Musiq Soulchild 'Luvanmusiq' (2007 release) The Doors 'The Very Best of The Doors' (2007 release) Correcto 'Correcto' (2008 release) Red Hot Chili Peppers 'Stadium Arcadium' (2006 release) Placebo 'Meds' (2006 release) Van Morrison 'Pay the Devil' (2006 release) Mercury Rev 'Snowflake Midnight' (2008 release) Dan Black 'Un' (2009 release) Alabama 3 'M.O.R.' (2007 release) Cute Is What We Aim For 'The Same Old Blood Rush...' (2006 release) Smashing Pumpkins 'Zeitgeist' (2007 release) The Enemy 'We'll live and die in these towns' (2007 release) Linkin Park 'Minutes To Midnight' (2007 release) 'Spiderman 3' (soundtrack) (2007 release) Cornelius 'Sensuous' (2007 release) Teenage Mutant Ninja Turtles 'Original Soundtrack' (2007 release) Taking Back Sunday 'New Again' (2009 release) Michael Knight (I'm Not Entirely Clear...) (2008 release) Panic At The Disco 'Pretty Odd' (2008 release) Bill Coleman 'I'll Tear My Own Walls Down' (2008 release) Jet 'Shine on' (2006 release) Josh Ritter 'The Animal Years' (2006 release) The Tyde 'Three's Co.' (2006 release) Drowsy 'Snow on Moss on Stone' (2006 release) Wonderstuff 'Suspended By Stars' (2006 release) Devendra Banhart 'Cripple Crow' (2005 release) Great White (2006 release) Laura Izibor 'Let The Truth Be Told' (2009 release) The Corrs 'Dreams - the Ultimate Collection' (2007 release) ...and scraping in with a score just below 4 out of 10... Cansei De Ser Sexy (3.8 out of 10, 2006 release) The absolute best albums of the last 5 years? There are over 500 album reviews in the CLUAS archives. While they've always been accessible via our archive pages, the way the reviews have been presented (one big long unordered list of reviews for each year) is not very user friendly. Which is a pity as there are some terrific reviews in there, as well as reviews of great albums that may have slipped under one's radar. Thankfully the chances of missing out on some such gems over the years has now decreased dramatically. Read on for the fabulous details... The CLUAS album archive pages have now been reorganised to ensure that our album reviews are listed, for each year, in order of the rating that the reviewer gave the album out of 10. Is that a collective 'Wow' I hear? Anyways. What's interesting to see is the albums that came out on the top of the pile each year. Most of the top ranking albums are solid but some are, ehhm, let's just say "curious". Below are listed the very top ranking albums (i.e. albums that scored 8.5 or more out of 10) as reviewed by CLUAS writers from 2005 to 2009. Are these the best albums of that period? Certainly not, although many are gems that will stand the test of time. One thing for sure is that the list of albums and their accompanying reviews make for interesting reading. So what was the top rated album released between 2005 and 2009, according to the CLUAS writers? The answer is, of course, obvious. It has to be the, ehh, all time classic 'Holiday Mix 2005' released by DFA Records.... Read on for even more mind-bending insights revealed in the list (including releases by 10 Irish acts). DFA Records 'Holiday Mix 2005' Ray LaMontagne 'Trouble' (2005 release) C O D E S 'Trees Dream in Algebra' (2009 release) Placebo 'Battle For The Sun' (2009 release) Biffy Clyro 'Only Revolutions' (2009 release) Pearl Jam 'Backspacer' (2009 release) Fnessnej 'Stay Fresh, Ey' (2009 release) Pearse McGloughlin 'Busy Whisper' (2009 release) Alela Diane 'To Be Still' (2009 release) Graham Coxon 'The Spinning Top' (2009 release) Julie Feeney 'Pages' (2009 release) Dark Room Notes 'We Love You Dark Matter' (2009 release) Antony and the Johnsons 'I am bird now' (2005 release) The Black Keys 'Rubber Factory' (2005 release) Go! Team 'Thunder, Lightning Strike' (2005 release) Joanna Newsom 'Milk-Eyed Mender' (2005 release) Modest Mouse 'Good News For People Who Love Bad News' (2005 release) Rufus Wainwright 'Want Two' (2005 release) David Byrne & Brian Eno 'My Life In The Bush Of Ghosts' (2006 release) Clap Your Hands Say Yeah (2006 release) Artic Monkeys 'Whatever People Say I Am, That's What I'm Not' (2006 release) Future Kings of Spain 'Nervousystem' (2007 release) Alessandra Celletti 'Esoterik Satie' (2007 release) Electrelane 'No Shouts, No Calls' (2008 release) Between 8.5 and 9 out of 10 Rilo Kiley 'More Adventurous' (8.9 out of 10, 2005 release) Arcade Fire 'Funeral' (8.75 out of 10, 2005 release) Ryan Adams & the Cardinals 'Jacksonville City Lights' (2005 release) Bell X1 'Flock' (2005 release) Bloc Party 'Silent Alarm' (2005 release) Martin Finke 'Crown Time' (2005 release) M83 'Before The Dawn Heals Us' (2005 release) The Frank and Walters 'A Renewed Interest in Happiness' (2006 release) Luxembourg 'Front' (2006 release) Hope of the States 'Left' (2006 release) Islands 'Return To The Sea' (2006 release) OK GO 'Oh No' (2006 release) Goodtime John 'I'll Sing Till The Sun Turns Cold' (2006 release) Neil Young 'Live At Massey Hall' (2007 release) 'Death Proof' (soundtrack) (2007 release) Jape 'Ritual' (2008 release) Elbow 'Seldom Seen Kid' (2008 release) Ham Sandwich 'Carry The Meek' (2008 release) Mumford & Sons 'Sigh No More' (2009 release) AFI 'Crash Love' (2009 release) Tommy Reilly 'Words On the Floor' (2009 release) Why so few Irish acts at Glastonbury 2010? eoghan posted on April 15, 2010 20:00 The lineup for Glastonbury 2010 was announced yesterday and it's a whopper (as you'd expect for the 40th anniversary of the festival). Over the 3 days of the festival there are 285 different musical acts scheduled to perform (and that's not even counting the acts earmarked for the "Poetry and Words" stage). Playing are Muse, U2, Vampire Weekend, Flaming Lips, Florence and the Machine, La Roux, Pet Shop Boys, Orbital, MGMT, Midlake, The xx, The National, Editors, Grizzly Bear and Broken Social Scene. And the list goes on... [Aside: Having managed last Sunday morning to secure one of the last tickets to Glasto 2010, I do be terribly exicited]. However what's disappointing is the Irish delegation at the festival. Yes, U2 are headlining on the Pyramid stage on the Friday night (and could well deliver a highlight of the festival, it being their first time in over 20 years to deliver a full set without any visual gimmickery in front an outdoor crowd) but otherwise you have to dig very deep to find Irish acts. As far as I can see there are, in addition to U2, only 8 other Irish acts in the entire lineup (or 9 if your definition of Irish stretches to including Rodrigo y Gabriela). And half of those (The Saw Doctors, Christy Moore, Brian Kennedy and Ash) could not credibly be held up as representative examples of where the Irish music scene is today. So what's the reason behind this? Well I have no clue. Is it that the more recent waves of Irish acts are not selling themselves hard enough to the Glasto promoters? Or are they doing so, but the promoters are not interested? Or does the best of Irish scene not cut the mustard for such a prestigious festival? Or some mix of the above? Any insights out there? Here are the Irish acts confirmed so far for Glasto 2010: Julie Feeney Christy Moore Imelda May (who is actually playing two gigs at Glasto 2010) The Saw Doctors Fionn Regan CLUAS on the move - from Arizona to Nebraska! eoghan posted on January 24, 2010 19:00 Two weeks ago I undertook one of the biggest tasks in the last 4 years of CLUAS: I moved the entire website to a new hosting company. It's a move that sees us abandon the arid desert of Arizona for the flat plains of Nebraska... For the last four years we were hosted by the Arizona-based company Crystaltech and they served us well. However in the last 6 or so months I have seen that CLUAS needs a hosting company that really understands the Content Management System we use ("DotNetNuke", also known as DNN). DNN is a very sophisticated piece of kit and is simply becoming more and more critical to CLUAS and its operation. There is one hosting company - PowerDNN - who are fully focused on hosting just DNN websites. Their tech support team know DotNetNuke inside-out, which is exactly when I need to ensure our website is maintained in the right environment and, when problems crop up, that I can contact a support person who knows DNN. PowerDNN - based in Nebraska - fit the bill and are now, I am pleased to say, the new home of CLUAS.com. They are a bit more expensive than our previous company (and we even get less diskspace and database space than we had with Crystaltech, something that has been debated elsewhere) but I think the benefits will outweigh these factors that are less critical in our case. I got to see the expertise of PowerDNN almost immediately during this move: there were a few problems that reared their head in the migration but all was soon solved thanks to the excellent help of Joe, a senior engineer at PowerDNN, who dropped all tools for a period to ensure some rough spots were ironed out and that CLUAS was soon up and running with PowerDNN. Moving the site to these DNN experts in Nebraska brought some immediate benefits. For example, an utterly head-wrecking problem that I have been trying to fix for 6 or so months is now fixed. The problem was that since August 2009 CLUAS users who, during login, clicked the 'remember me' option (which should keep them logged in to CLUAS on that computer for 7 days) would instead find themselves being logged out after a really short period of time, sometimes even minutes. This was a major frustration for writers publishing new articles, or users posting entries to the discussion board, as sometimes they'd be logged out before they 'd finished writing their content and their work would be lost. Thankfully this problem is now a thing of the past. Another benefit I am seeing is a pretty big reduction (it could be as high as 50%) in the load time of pages on CLUAS. I'll wait another week to see if these fast speeds continue to hold up. If so one of Ireland's fastest music websites will have just gotten even faster. Look out for a blog entry from me about it next week with nifty nice graphs and stuff. So, in the meantime can you step aside for Bruce Springsteen and his homage to Nebraska, CLUAS.com's new home... The story behind the 2009 CLUAS Writers poll eoghan posted on December 14, 2009 19:00 Typically at this time of year CLUAS is full democratic flight with polling booths wide open for readers to submit their votes to find the top albums of 2009. However, this year we've decided to not do a readers poll. And why not? It's simply because of the utterly mad amount of time it takes to tot up the thousands of votes we get. Fret not, as there will still be a CLUAS poll this year. The last few weeks the CLUAS writers have been busy voting for their top 10 albums of 2009 and tomorrow (16 December) the results will be published. As always the CLUAS writers have stepped up to the plate and their votes collectively deliver an intriguing, diverse, credible and occasionally surprising top 40. I was pleased as well to see that, despite the intense competition from non-Irish releases, a total of five Irish albums released in 2009 made it into the top 40. Which ones? You'll see tomorrow. In advance of the poll here's a quick overview of the numbers behind this year's writers poll: 23 writers submitted a list of their fave albums of the year. 202 votes were cast (an average of just under 9 albums voted for by each writer) 131 different albums albums got a vote, of which... ...89 albums were voted for by only one writer leaving us with... ...42 albums that were voted for by 2 or more writers. Breakdown of number of writers who voted for an album that made the top 40: Number of albums voted for by 5 or more writers --> 3 Number of albums voted for by 4 writers --> 3 Number of albums voted for by 3 writers --> 10 One thing I can already say is that the album that topped the poll did so by a healthy distance. It was voted for by over a third of all the writers who voted (8 out of the 23). That there would be broad agreement among the writers on the top album of 2009 is quite a surprise considering the massive number of different releases (131) that secured a vote in the poll. Hang in there until tomorrow to see which album topped the poll. The only hint I'll offer is that it is NOT one of the following two 2009 releases (both of which just missed a place in the, er, coveted top 40, they being placed 41st and 42nd placed in the poll): Mark Eitzel 'Klamath' Arctic Monkeys 'Humbug' Irish Web Awards 2009: The Skinny, the Bloated and the Bonkers eoghan posted on October 20, 2009 20:00 A pet peeve of mine is bloated websites: site with pages that are so stuffed with images and widgets that they take too long to download, even on broadband. Over our 10 years of operations CLUAS .com has continually tried to keep things lean and mean when it comes to page size (indeed CLUAS, as far as I am aware, remains Ireland's lightest – and hence fastest – music website). Back in 2008 I had a good old rant about bloated Irish websites (specifically about Music and Technology blogs). Another indulgent rant is long overdue, this time I've fixed my attention on the winners at the recent 2009 Irish Web Awards. Are the best Irish websites of 2009 a lean and mean bunch, or are they a morbidly obese bunch? Read on... The table below presents the results of an analysis of all 21 sites that won an award at the Irish web awards in terms their page size as reflected in: the total size of their home page, and the total number of files that need to be downloaded (also know as number of "HTTP requests") to create the page. The 3 colour-coded categories in the table correspond as follows: "The Skinny": ("Optimal balance of page size and http requests") The Bloated: ("Just too much going on in terms of page size and http requests") "The Bonkers": ("Inexcusably massive number of HTTP requests coupled with an utterly obese page size") The Irish Web Award 2009 winners, categorised by payload Site Winner of Irish web award for… Number of HTTP requests Total size of page (KB) The Persuaders Best Podcaster 9 123 KB Kildare Street Best New Web App/Service 11 148 KB RTE Sport Best Sports Site 34 167 KB CLUAS.com (did not win, just shortlisted) 30 168 KB Silicon Republic Best Technology Site 44 217 KB Count Me Out Best Social Media Campaign 32 240 KB Curious Wines Best eCommerce site 45 266 KB Talk Irish Best Education site 40 271 KB RTE Most Useful Website 61 295 KB Entertainment.ie Best Entertainment Website 91 350 KB Look and taste Best Videocaster 35 432 KB Boards.ie Best Discussion forum 23 468 KB Cars Ireland Best Practice 100 540 KB Decisions for Heroes Most Innovative Website 68 708 KB Nos Mag An Suíomh Gaeilge is Fear 64 729 KB Rose Project Most Accessible Website 44 792 KB Phantom FM Best Radio Website 145 560 KB IDA Ireland Best Govt. & Council site 175 655 KB Irish Times Best Online Publication 151 832 KB Organic supermarket Most Beautiful Website 71 1376 KB Nialler9 Best Music Site 100 1387 KB Dance Ireland Best Arts Website 62 2053 KB Note: The data above is based on visits to these sites on 14 Oct 2009, page size of any site may have changed since then. Seeing a whole load of data listed in a table is one thing. Presenting it in a chart is another, and can often make it easier to understand what is going on across a diverse set of data. So I plotted the results of each individual website on a chart in an effort to extract some more immediate and meaningful results from this analysis. The chart (see it below, where each dot represents one of the websites) has the number of HTTP request along the X-axis, the total size of the home page on the Y-axis. The general trend of the plotted data (that'll be the blue line rising gently upwards, my Leaving Cert Physics teacher would be proud of me) confirms what you'd expect, i.e. that the greater the number of HTTP requests a web page makes, the larger the size of that web page. However it's also easy to pick out from the chart which sites are skinny (hello to the sites that managed to squeeze into the box way down there in the most bottom left part of the graph) and which are bloated. And then there are those outlying sites which are just just barking when it comes to page size and number of HTTP requests... Pity your poor browser - and internet connection – if you hit one of these 'bonkers' sites. For these 6 sites we're talking an average payload of 1.17 megabytes of data to be downloaded via an average of 104 HTTP requests!? Take the worst offender in terms of page size – danceireland.ie. Their home page is made up of 2MB of data (I repeat: 2 megabytes) to be downloaded. If you're on an iPhone and visit their home page, this single page will consume 7% of the daily bandwidth your phone company has allocated you (based on the monthly limit of 1GB of data afforded by O2 to iPhone customers in Ireland). One single solitary web page consuming 7% of your daily download allowance? Truly. Madly. Deeply. Bonkers. The 8 'bloated' award winners? They are only somewhat better than their bonkers brethren. Between them they impose an average payload on visitors of 455 KB of files to be downloaded via an average of 70 HTTP requests. But it's hats off to the 6 'skinny' sites (that'll be 5 of the 2009 Irish Web Award winners plus gatecrasher CLUAS.com) who all manage to keep their page size to less than 300kb while keeping the number of HTTP requests to less than 50. Between them they average a modest 265 KB of files to be downloaded per page via an average of 31 HTTP requests. Needless to say, thanks to our ongoing dietary efforts, CLUAS is among these 8 skinny sites, and our page size of 168KB means we clock in as the 4th lightest of the 22 sites. Two concluding pleas: Plea 1: Could all webmasters run their websites through one of the many free online tools that check the overall size of a page (I recommend the one offered by the WebsiteOptimization.com guys). If comes out at over 500KB get pruning. Remove some heavy images or chunky widgets on your page to get it down to a reasonable size. Plea 2: Both the size of a webpage - and the number of HTTP requests the page makes - should be standard judging criteria in any web awards. Placing a carrot like that in front of any website owner who aspires to being recognised by his/her peers with an award for their site is one way to help focus minds on this often overlooked but important aspect of user experience, whether the user be connected via broadband or dialup. (...Of course it never crossed my mind that if super light CLUAS.com were ever to be up for consideration of an award with such an additional judging criteria, that our chances might get a bit of a lift...). CLUAS on final list of nominees for 'Best Irish Music Site' eoghan posted on September 28, 2009 20:00 Last week it was announced that 26 sites were in consideration for the category of "Best Music Site" at the Irish Web Awards 2009, and CLUAS was one of them. The 26 sites has now been whittled down to 11 and I was pleased to see CLUAS.com is one of them. The full list of sites now in consideration is: Muzu TV Heineken Music State Magazine Cluas Metal Ireland Comhaltas Fred the Band Thumped John Conneely Golden Plec As you can see we are in fine company. The winner will be announced on 10 October at a ceremony in the Radisson SAS Royal Hotel in Dublin. Best of luck to all those who made the final 11. CLUAS shortlisted for 'Best Irish Music Site' Yesterday CLUAS was one of the sites shortlisted for the 'Best Music Website' category of the 2009 Irish Web Awards, the winner will be announced on 10 October at a ceremony in the Radission SAS Royal hotel in Dublin. A total of 26 different sites were nominated in the category, the other sites that made the grade along as well as CLUAS are listed below. Best of luck to all concerned! http://drop-d.ie http://state.ie http://roisindubh.info http://nialler9.com http://kilkennymusic.com http://Muzu.tv http://thumped.com http://downloadmusic.ie http://musicreviewunsigned.com http://panicdots.com http://irishtimes.com/blogs/ontherecord http://guesslist.com http://dmi.com http://johnconneely.com http://metalireland.com http://goldenplec.com http://fredtheband.com http://umusic.ie http://archive.comhaltas.ie http://comhaltas.ie http://aliasempire.com http://heinekenmusic.ie http://haidooo.wordpress.com http://music.eircom.net http://sharoncorr.com Making CLUAS a W3C compliant website While for many surfers the WWW often resembles a modern Wild West where just about anything goes there are - believe it or not - some formal standards in place. The particular standards I'm talking about are for HTML code: how HTML should be used when creating a webpage (and how a browser should interpret HTML and present it on a page). The setting of the standards is overseen by the all important World Wide Web consortium (also know as W3C, which is headed up by Tim Berners Lee, no less than your man who invented the World Wide Web). Now to be honest, up to about a year ago, CLUAS did not care about these standards and there was not a single page among our thousands that was even close to being compliant. This did not stop me having a begrudging respect for websites that spouted on about their "W3C compliancy". I was after all only too keenly aware that CLUAS would need to overcome a proverbial mountain to enter the hallowed corridors of compliant websites. All the same, last year I looked into it and I started - slowly - to update our HTML code, with a little change here and minor tweak there, all with a view to making as many as possible of CLUAS.com's thousands of pages compliant. To be honest it was initially just one of those pointless personal challenges you set yourself once in a while, the motivation of which few people would ever understand (and if they ever did understand the motivation they'd doubt your sanity). The exercise is ongoing however already the result is that already a massive number of pages on CLUAS.com are at last complaint to W3C's "HTML 4.01 Transitional" standard. Basically the vast majority of pages whose address does not end in .aspx are now complaint (for example 73% of last month’s top 100 most visited "non aspx" pages are now compliant). So what about these non-compliant .aspx web pages? Well these pages are generated using the DotNetNuke content management system we use and just a handful of them are already compliant (to the different "XHTML 1.0 Transitional" standard). However the level of their compliancy will improve in coming months as the next release of DotNetNuke Blog Module (which is used to publish our album and gig reviews, blogs, and interviews) should be fully compliant, meaning in one swoop huge numbers of CLUAS pages will step in the world of compliancy. So why bother about compliancy? Put simply there are a number of advantages, such as: File size and loading times are reduced. Sites are easier to update in terms of content or styling because of the smart structure (i.e. separation of content from styling) that is implicit in W3C compliant websites. Greater assurance of future proofing your website - if a site obeys established rules, they should continue to work in browsers and devices of the future. And having a compliant website means the webmaster feels all smug and elitist compared to pitiful other sites that have not clue about the wonders of compliant HTML code. The gas thing is that while all this effort may result one day in CLUAS.com being a website fully compliant with W3C standards, the next generation of HTML standards for web pages are already in the pipeline. So we may have to start this compliancy effort all over again… Nailing traffic with 10 years of links It's common knowledge that securing links from other websites plays a key role in getting your website's pages into major search engines. CLUAS has been steadily attracting links over its 10 year lifetime resulting in a steady stream of people visiting CLUAS via these links and also - more importantly - ensuring we have an excellent ranking in the search engines. For example we have, for years, been the number 1 result for people searching 'Irish indie music' (and bizarrely also for 'Irish Jazz music'). But such searches are only the tip of the proverbial iceberg. CLUAS receives a very considerable amount of its traffic from search engines thanks to - literally - thousands of different 'long tail' searches done by users each month. So why does CLUAS rank above other Irish music websites when it comes to so many search phrases? There is a complicated answer. And a simple answer. The simple answer is: "links, and loads of them". Thanks to something I stumbled upon last week I can now visually demonstrate the "linking success" of CLUAS compared to other similar Irish music sites. I came across a tool made available by "Majestic SEO" (a company offering "Search Engine Optimisation" services) who started to trawl the WWW back in June 2007 and recorded all the links they found. To use their own words they have...: "...crawled over 96 billion webpages and analyzed almost 697 billion unique URLs and their anchor text to calculate who link to who and with what anchor text." They allow registered users of their site to compare websites in terms of the number of links they have attracted. The graph below (click on it to see it in higher resolution) shows the number of different domains that the Majestic SEO crew found over the last two years linking to CLUAS and compares it with the links they found for 3 other Irish music sites (Hotpress.com, State.ie and Nialler9.com). Click to see graph in higher resolution It is clear from the graph that CLUAS has attracted links from more domains (i.e. websites) than any of the other sites. This massive repository of sites linking to us is, if you ask, me a key signal used by the search engines when they decide to rank CLUAS above other websites. Building such a eco-system of links sure takes time, but we can vouch for the fact that once it is done the impact is considerable (and occasionally surprising...). Page 1 of 8 First Previous [1] 2 3 4 5 6 7 8 Next Last	cc/2021-04/en_middle_0068.json.gz/line1628
__label__wiki	0.61033	0.61033	Solicitor’s obligations, and how far they go? Lyons v Fox Williams LLP [2018] EWCA Civ 2347 The recent case of Lyons v Fox Williams LLP [2018] EWCA Civ 2347 involved consideration of the scope of the Solicitor’s retainer and is subsequently of importance to Solicitors and well worth considering. The case concerned a Claimant’s Appeal following an unsuccessful action for professional negligence against a firm of Solicitors. Unfortunately the Claimant was unsuccessful in pursuing the claim against the Defendant and the Claimant recovered nothing despite having turned down a Calderbank offer of £500,000.00 from the Defendant. The Appeal was heard before Lord Justice Patten, Lord Justice David Richards and Lady Justice Asplin who highlighted the Solicitor’s duty to warn and advise in relation to matters within the parameters of the retainer. In particular it was highlighted that it was “the solicitor’s obligation to bring to the client’s attention risks which become apparent to the solicitor when performing his retainer does not involve the solicitor in doing extra work or in operating outside the scope of his retainer. The risks in question are all matters which come to his attention when performing the tasks the client has instructed him to carry out and which therefore as part of his duty of care he must make the client aware of”. The authorities in support of Solicitor’s legal duty to warn clients are Minkin and Credit Lyonnais , however, neither state that a Solicitor is expected to or required to carry out investigative tasks in areas that are outside of the scope of the retainer regardless of whether it would be beneficial to the client. In this particular case it highlighted the practicalities of this. For example, in this case it was found that the Solicitor could not have advised the Claimant about a particular area (specifically his rights under a policy and any relevant time limits in relation to potential claims) unless he had carried out a thorough examination of the policies and a certain amount of legal research. Although the Solicitor received documentation in relation to the policies the Judge found that that the Solicitor was never instructed to do this. Subsequently the Claimant was refused permission to appeal against the Judge’s findings in this respect. Rebecca Mogford By Rebecca Mogford 23rd November 2018 Share with FacebookShare with TwitterShare with LinkedIn Have a general Costs question or query? Contact one of our experts today who will be delighted to assist Firm* By checking this box you agree to let MRN Solicitors send you further information about our latest company updates and costs news. Sign up here to receive our costs updates as well as details of our forthcoming seminars.	cc/2021-04/en_middle_0068.json.gz/line1630
__label__wiki	0.882017	0.882017	Just like the pros Doak Walker might not fill uniforms, but their dreams are big David Pressgrove The Vikings and the Raiders had just completed a knockdown, drag-out melee but there was no post-game talk of Randy Moss and Dante Culpepper. Instead, the players were asking their parents what was for dinner. The little guys who barely filled out the uniforms representing two pro teams were third- and fourth-graders from Craig in the Doak Walker League. In the game, the eye black-clad Vikings kept their undefeated streak alive with a win against the Raiders. But instead of bragging and showing off, the players were more interested in talking about their NFL dreams. “One day, we’ll be in the pros,” said the Vikings’ Dylan Villa. “But right now, though, it’s hard to tackle the smallest guys.” Several of the Raiders said they were big Denver Broncos fans, and they didn’t really like being the Black and Silver but, “Those are the uniforms we got, so we’re Raiders this year,” Brenden Spencer said. For the third-graders, it’s their first year of organized football. The Vikings’ Tyler Davis was enjoying his first season because, “I get to run the ball and score the touchdowns.” Joe Camilletti said he likes getting pumped up before the game when his coach puts the eye black on his face. The Doak Walker League, which is run by Craig Parks and Recreation, has games for third- and fourth-graders on Wednesdays and fifth- and sixth-graders on Tuesdays at Woodbury Park throughout the fall. The league is helped by volunteer coaches and referees who either volunteer or get paid enough to cover the gas to drive to and from the game. “It’s all about the kids,” referee Brett Sperl said. There are teams from Craig and Hayden in each league. The Vikings and Raiders unanimously agreed that they feel like the guys who play on Sunday. They also shouted a resounding yes when asked whether it was exciting to tackle someone. “It’s just a lot of fun,” the Vikings’ Tyler Gerber said. The Porches Shuttle Driver Needed at The Porches in STEAMBOAT SPRINGS Looking for a weekend job? A few days and nights available. Drive our safe reliable shuttles and enjoy sharing Steamboat… Ramp Agents at G2 in HAYDEN G2 Secure Staff is Hiring Full Time & Part Time at theYampa Valley Regional Airport! Seasonal Ramp Agents $20/hr Contact… Pour Boys Concrete Concrete Finishers/Formsetters/Lead Positions at Pour Boys Concrete in STEAMBOAT SPRINGS Concrete Finishers/Formsetters/Lead Positions Pour Boys Concrete is seeking experienced Concrete Finishers, Symons Form Setters, and Lead Positions. Must be experienced,… RN Forensic Examiner at UC Health in STEAMBOAT SPRINGS UCHealth Yampa Valley Medical Center is looking for a RN Forensic Examiner. PRN Flex (on call) Positions Available Applicants must…	cc/2021-04/en_middle_0068.json.gz/line1632
__label__wiki	0.945078	0.945078	Home Team of the month Cricket365's Team of the Month – September Cricket365's Team of the Month – September Michael Clarke leads a pack lined with Aussies and void of Englishmen, while Pakistan enjoy a find in Aizaz Cheema and Tino Mawoyo represents the minnows. <B>1. Mohammad Hafeez (Pakistan)</B><BR><I>Close, but no: Alastair Cook (England)</I><BR>Snubbed for the ODI Player of the Year award and set to miss out on Pakistan's premier domestic Twenty20 competition as he undergoes an operation to have a cyst removed, Hafeez can take solace in the fact that he was head and shoulders above the rest this month. Zimbabwe had no answer to his expertise at the helm of the batting order and very handy left-arm spin. <B>2. Tino Mawoyo (Zimbabwe)</B><BR><I>Close, but no: Vusi Sibanda (Zimbabwe)</I><BR>Hamilton Masakadza did it against Bangladesh and Mawoyo went one better by bagging a ton against somewhat tougher opposition. Tending to the Pakistan attack with remarkable composure and zeal, the right-hander revealed a long-term answer to the nation's need for a full-time opening partner for Vusi Sibanda. <B>3. Shaun Marsh (Australia)</B><BR><I>Close, but no: Brendan Taylor (Zimbabwe)</I><BR>With father Geoff hanging on in hope that his son would fetch a ton on Test debut, Shaun duly delivered to join Michael Clarke, Marcus North, Greg Blewett, Mark Waugh and a host of illustrious names to have achieved the feat. He followed that up with another big one against Sri Lanka, but not quite enough to set what would have proved an unprecedented two maiden tons on the trot. <B>4. Younis Khan (Pakistan)</B><BR><I>Close, but no: Kumar Sangakkara (Sri Lanka)</I><BR>Younis waxed lyrical about how the veterans would have to perform well in the hope that the youngsters would follow suit in Zimbabwe. Walking the talk, the former captain led by example through a series of commendable knocks through the Test and ODIs. With stiffer competition on the cards – Sri Lanka in the UAE – Pakistan will need him to keep going strong. <B>5. Michael Clarke (Australia, captain)</B><BR><I>Close, but no: Mahela Jayawardene (Sri Lanka)</I><BR>The lone survivor from our Team of the Month in August, the Australian captain picked up on his form in the one-dayers against Sri Lanka to steer his side to triumph across the Tests. In the process, he shrugged the proverbial monkey off his back by landing his first Test ton in more than two years. <B>6. Michael Hussey (Australia)</B><BR><I>Close, but no: Ravi Bopara (England)</I><BR>Man of the Match three times over in the Tests against Sri Lanka and, understandably, Player of the Series, there's hardly any stopping the regular centurion of late. And now he is at it again, making the switch from five-day competition to Twenty20 cricket with remarkable ease as his cameos at the top of Chennai's knock fuel their title defence. <B>7. Mahendra Dhoni (India, wicketkeeper)</B><BR><I>Close, but no: Angelo Mathews (Sri Lanka)</I><BR>A familiar tale dogged the Indian captain throughout September, with the swashbuckling right-hander left to pick up the pieces time and time again after his top through middle-order had let their team down. His wicketkeeping, meanwhile, continues to take strain, as witnessed by a couple of big blunders in the ongoing Champions League Twenty20. <B>8. Rangana Herath (Sri Lanka)</B><BR><I>Close, but no: Graeme Swann (England)</I><BR>As was the case with Ryan Harris, injury afforded Herath just two Tests against Australia. Ajantha Mendis' injury left Sri Lanka in need of someone to step up in his absence and the veteran left-armer was the man for the occasion. 16 victims, including seven of 'em in one innings, will certainly have him ahead of Suraj Randiv in the pecking order for a while. <B>9. Aizaz Cheema (Pakistan)</B><BR><I>Close, but no: Suranga Lakmal (Sri Lanka)</I><BR>Umar Gul, Wahab Riaz and Tanvir Ahmed – all rested from the series in Zimbabwe – will enjoy some newfound support in the future. While Junaid Khan, Sohail Tanvir and Sohail Khan endured so-so performances, Cheema – a later starter at 32 years old – surely sealed his spot in Pakistan's plans for the foreseeable future with a string of solid hauls against Brendan Taylor's men. <B>10. Ryan Harris (Australia)</B><BR><I>Close, but no: Peter Siddle (Australia)</I><BR>With Doug Bollinger out of favour, the equally-animated Harris came to the party for his nation at every turn. Having romped through the Sri Lankan order in the first two Tests, the beefy right-armer looked a dead certainty to top Australia's wicket-taking ranks at the end of the Test series – and ultimately did with 11 scalps, even if injury did rule him out of the final match. <B>11. Trent Copeland (Australia)</B><BR><I>Close, but no: Ravi Rampaul (Trinidad and Tobago)</I><BR>Although sporting a mere six wickets for his maiden Test series, Copeland truly was the workhorse behind Australia's attack. He delivered the most overs – a whopping 108 – of any of the seamers on display across largely harsh bowling conditions and, with metronomic line and length, offered the Aussies an answer to life after Glenn McGrath. <B>Jonhenry Wilson</B> jonhenry-wilson-blog team-of-the-month Steve Smith debate has been “blown up” says England all-rounder Chris Woakes The former Australia captain was filmed scratching at the batting crease while fielding against India. Moeen Ali coronavirus quarantine extended after mild symptoms The England all-rounder is now unlikely to feature in England’s Test series in Sri Lanka. Australia go on the defensive over Steve Smith scuffing saga Australia have closed ranks around Steve Smith, who is upset over being painted as a villain following the drawn third Test against India. On This Day in 1996: Dickie Bird announces retirement from umpiring Bird umpired in 66 Tests and 69 one-day internationals. Dan Lawrence adamant he will stick to ‘unique’ batting technique in Test arena The 23-year-old should make his Test debut when England start their two-match series against Sri Lanka. Steve Smith criticised for appearing to scuff Rishabh Pant’s guard in third Test Former Australia captain Steve Smith was branded “childish” after an incident during the final day of their drawn third Test against India Tim Paine admits he let the Australian bowlers down Australia captain Tim Paine believes he was at least partially to blame for his side failing to bowl India. Testing times on tour in Sri Lanka – the life of an international cricketer Gloucestershire’s James Bracey is on his first overseas tour with England. Here he writes about his experiences so far in Sri Lanka. India salvage unlikely draw in third Test against Australia India salvaged an unlikely draw as the third Test against Australia reached a thrilling finale. Chris Silverwood backs ‘fighter’ Dan Lawrence to make step up to Test cricket The Essex batsmen is in line for an England Test debut against Sri Lanka on Thursday. Cricket podcasts PODCAST: Chatting Mankads and Monty with Cant Bowl Can’t Throw Cricket a welcoming home for those with quirks and rituals Did you see… Alyssa Healy after she was out in the T20 World Cup final? What can Donald Trump and Soo Chin Ten-Dull-Kerr teach us about cricket?	cc/2021-04/en_middle_0068.json.gz/line1636
__label__wiki	0.572577	0.572577	Battle Scars: a Crikey investigation Battle Scars is a Crikey series examining post-traumatic stress disorder and other mental health issues among younger Australian veterans. We share the stories of veterans who have battled themselves, both during and after their time in the military. We talk to the the psychologists who developed new programs after realising the ones designed after the Vietnam war weren’t working for today’s veterans. We interview the Department of Veterans’ Affairs about its role in supporting the mental health of veterans. Plus, we speak to the families left to deal with the consequences when it all falls apart. Part 1: Fighting the ADF’s warrior culture on mental health: An introduction to mental health issues in the military. Part 2: Fighting on ‘until you’re about to put a rope around your neck‘ :Steve Ager couldn’t admit his psychological suffering to himself, and was then warned off admitting it to his military superiors. Part 3: How the government treats broken soldiers: The Department of Veterans’ Affairs is in charge of helping veterans struggling with mental health issues. Its deputy director speaks to Crikey. Part 4: Breaking PTSD stereotypes: As a young female navy veteran in her 30s, Hannah Parker doesn’t fit the mould of a post-traumatic stress disorder sufferer. Part 5: How angry young veterans rewrote PTSD treatment:Younger veterans battling PTSD have different issues than from the Vietnam days – new treatment programs were needed. Part 6: Why soldiers should kill with drones not guns: An anonymous ex-navy officer calls for more drones to avoid soldiers being so affected by what they’ve seen. Part 7: ‘I wish I could have the man I married back’: One anonymous young army wife reveals just how difficult it is to live with a veteran battling PTSD. Part 8: Veterans and their families respond: Ex-military personnel and family of veterans weigh in on mental health in the military. Part 9: Crikey says: these scars may never heal: Crikey‘s investigation into military mental health issues shows the ADF isn’t doing enough — and leaders should think again about sending our soldiers to war. *Free, confidential counselling and support is available from the Veterans and Veterans Families Counselling Service for Australian veterans, peacekeepers and their family members. VVCS can be contacted 24 hours a day on 1800 011 046. For non-military help or information visit beyondblue.org.au, call Lifeline on 131 114 or visit this page for a detailed list of support services.	cc/2021-04/en_middle_0068.json.gz/line1637
__label__wiki	0.63308	0.63308	Going Once, Going Twice, Sold: True Crime Auction House Robert Yates signed letter poem envelope set. With the holidays right around the corner, it's time to start filling up your gift wishlist. And boy do we have the perfect one-stop shopping destination for you. Let us introduce you to True Crime Auction House. It's stockpiled with hundreds of eerie keepsakes from the world's worst human beings. From John Wayne Gacy's signed envelopes to Angel Maturino Reséndiz's (The Railroad Killer) actual foot scrapings, True Crime Auction House has it all. And if all this talk of serial killers has you in the binging mood, don't forget to check out all of the true crime documentaries that you can stream online right now! The Peepland Times Square Tour with Christa Faust Drunk Man Calls 911 Repeatedly Film Review: Enola Holmes By Hector DeJean Sherlock Holmes was, is, and likely will remain a solid fuel source for the entertainment industry, and the very latest offering is the Netflix film Enola Holmes, based on the Edgar Award-nominated YA series by Nancy Springer. Millie Bobby Brown, who launched her career playing Eleven on Stranger Things, dives into the part of Sherlock… Germania: A Novel of Nazi Berlin by Harald Gilbers: New Excerpt Prologue EARLY SUMMER, 1939 The light was positioned to simulate ten in the morning. The urban canyons of the capital of the German Empire shimmered blindingly white. But nothing moved, everything seemed suspended, frozen solid in an eternal winter. It would be a while until the daily chaos of Berlin reached those corners. At this… The Last Western by Rone Tempest: New Excerpt Chapter 4: Boomtown I was beginning to think of Rock Springs in a way I knew I would always think of it, a lowdown city full of crimes and whores and disappointments… —Richard Ford, “Rock Springs” 1987 Two men walked into a bar. Actually, it was not yet a drinking establishment. Ed Varley’s family… Q&A with Lis Wiehl, Author of Hunting the Unabomber By John Valeri Lis Wiehl is a bestselling author who served as a federal prosecutor in the United State’s Attorney’s office and was a tenured professor of law at the University of Washington. She appears frequently on CNN as a legal analyst and is the former co-host of WOR radio’s “WOR Tonight with Joe Concha and Lis Wiehl.”…	cc/2021-04/en_middle_0068.json.gz/line1638
__label__wiki	0.911469	0.911469	HP To Expand Effort On Linux PCs HP says it is testing the waters for PCs pre-loaded with Linux and may introduce the program in the U.S. By Edward F. Moltzen September 19, 2007, 12:18 PM EDT Hewlett-Packard, the world's Number 1 PC maker, will try selling pre-loaded Linux on PCs in several countries as it expands a test program -- evaluating a market that some competitors have already entered -- and moves its personal computer business into a new generation of form factors and functionality. The Palo Alto, Calif.-based company is in the nascent stages of a pilot program in Australia, where it offers a model of its HP PCs pre-loaded with Red Hat Enterprise Linux Desktop 5 for small and mid-sized businesses. Brian Schmitz, director of product marketing for HP's business PCs, said the company is looking at results from the effort in Australia, and is gearing up to take the Linux pre-loads multi-nationally. "We have seen interest in certain parts of the world," Schmitz said. "We're going to try some things in other countries with pre-loaded Linux. It's really hard to gauge. There's always a lot of noise around Linux but the demand isn't there." Currently, HP certifies Red Hat's Linux as well as SUSE Linux Enterprise Desktop 10 for its PCs, makes drivers available for download on the Web, and works with companies and organizations to deliver piece parts necessary to load a Linux-based custom image onto PCs. The company has also filled large deployment orders for Linux-based PCs on a custom basis. Schmitz said the U.S. is among the countries where HP is considering providing pre-loaded Linux on personal computers. "It's one (country) we're considering," Schmitz said, noting that HP has seen large deployments of Linux especially in some education accounts in the U.S., including in state of Indiana public schools and public schools in San Diego, Calif. In Indiana, custom system builders including Ace Computers, Arlington Heights, Ill., were called on to help deploy Linux PCs while in San Diego, solution provider Arey Jones was contracted to deliver Lenovo systems loaded with SLED 10. "We've been actively talking with a lot of larger school districts about it," Schmitz said. Also this year, Dell, Round Rock, Texas, has begun offering some PCs pre-loaded with Ubuntu Linux and Lenovo, Raleigh, N.C., has begun offering some ThinkPads pre-loaded with SLED 10. "They already do it in a server environment," said Michael Worsham of MWE Computer Services, an Edgefield, S.C.-based solution provider and HP partner. "If they go to do the same thing with a PC environment, that would be a good thing, too - - as long as they don't take the Dell route and put Ubuntu on them." HP has previously offered Linux pre-loaded onto PCs -- an effort it made several years ago -- but the systems never took off. Today, HP, which has the world's Number 1 market share position in PCs, is shipping a new lineup of desktops with ultra small form factors, gaming capabilities and all-in-one designs; all run Windows. Applications and OSes Components and Peripherals News Applications-os SAP Emphasizes Process Automation, Low-Code/No-Code Development In Platform Update Slide-shows Applications-os The 10 Coolest Big Data Startups Of 2020 Slide-shows Cloud The 10 Hottest Kubernetes Startups Of 2020 IBM Buys APM Startup Instana To Boost AI Automation News Managed-services Leading AWS Partner ClearScale Expands MSP Offerings	cc/2021-04/en_middle_0068.json.gz/line1639
__label__wiki	0.686914	0.686914	Douglas Crockford How JavaScript Works About The Magnify Example In 2001, I developed the Interstate.js library for State Software. Interstate.js was the browser part of a platform that allowed sessionful applications to be delivered with Netscape Navigator and Internet Explorer. I also wrote some examples to show what Interstate.js could do. My favorite was the Magnify Example. You saw a page with two small pictures and a magnifying glass. All three objects were draggable. If you dragged the glass over a picture, then magnified detail would appear in the glass. I chose two paintings by Salvador Dali. One of them contained a portrait of Abraham Lincoln that was more easily seen when the picture was small. Both images revealed interesting details when magnified. It worked identically on Netscape 4 and Internet Explorer 5, which was a remarkable feat. Even more remarkable, it still works on the newest browsers. It demonstrates clipping an image to a circle. Today, CSS on the latest browsers can clip to a circle. In 2001, CSS was much more limited, and implementations were incomplete, incompatible, and buggy as an ant hill. The state of the art was clipping to a rectangle, but I was clipping to a circle. It was magic. It was a trick. The magnifier ring was carefully designed so that a square could be hidden between the outer circumference and the inner circumference. The clipping was to a square, but the square was obscured by the ring to appear as a circle. The radial gradient around the ring helps us to misjudge the dimensionality of the ring. I also cheated in how magnification worked so that the enlarged image would always completely cover the smaller image. Interstate.js encouraged the same method call cascading style that jQuery made popular five years later. I now think that was a mistake. It was certainly very cool looking at the time, but I think it leads to excess trickiness, dependencies, and clutter. The stuff I write now does not look like that. The code passed JSLint in 2001, but it does not pass today. In 2001, I still suffered from the delusion that programming style is a personal thing and that all styles are valid. Over the years, JSLint taught me that that was not true because some styles are more resistant to bug formation than others. Error resistance and maintainability are more important than coolness and personal expression. Diversity of people is a great thing. Diversity of coding styles is not. In 2001, and for over a decade after, I was a strong advocate for JavaScript libraries. The DOM was so badly designed, so misfeatured, and so carelessly implemented and maintained, that you should never touch it directly. Let the library makers take on all of the pain of cross-browser development. You can then focus on writing good programs. But that is no longer my position. A few things have happened. The libraries have all gotten bloated, and code bloat is an important warning sign. Microsoft has finally put IE down, so that nightmare is now behind us. And the web standards have finally paid off. There is still much to lament about how the browser works, and there are plenty of attractive nuisances baked into the standards. But with a little care, it is possible to write good portable programs with plain old JavaScript. So I gave the Magnify Example a reboot. The new version does not run on Netscape or IE, but it seems to run on all of the latest stuff. It does clipping to a circle, even though it did not need to. It supports touch on displays that provide it. I was disappointed that the code to handle a finger was not the same as the code to handle a mouse doing the same thing. Maybe they will fix that some sunny day. Instead of using a gif for the magnifier ring, I made a div with rounded corners. In 2001, to get rounded corners we had to make a 3 by 3 table, stuffing pieces-of-fours gifs in the corners. It is so much easier to give CSS a border-radius. Unfortunately, I could not then apply a radial gradient to the border. The browser is not an elegant composible system. It is a pile of hacks. I am still frustrated with the browser, but I am grateful that it has improved so much. I am still looking forward to its eventual replacement. The Magnify Example 2001 Best Viewed With Netscape Navigator	cc/2021-04/en_middle_0068.json.gz/line1640
__label__wiki	0.99158	0.99158	From grave to gig: Elvis, Jacko and Sinatra could make big COMEBACK THREE of the world’s biggest stars could come back from the grave to gig again. THEY'RE BACK: Michael Jackson, left, Elvis Presley, top right, and Frank Sinatra, bottom right, could all be recreated as holograms [PH] Michael Jackson, Elvis Presley and Frank Sinatra are all being recreated as Star Wars-style holograms. The legends have been dead for years but there is still huge demand to see them performing “live”. Hollywood special effects studio Digital Domain is in talks with their estates to create astonishingly realistic 3D-style images of them. And at least two Las Vegas casino resorts are in a multimillion dollar bidding war for concerts by the trio. Fans were astonished when Jacko’s hologram performed a stunningly lifelike version of Slave To The Rhythm at last year’s Billboard Music Awards. The Thriller star died from a drug overdose in June, 2009, aged 50. Now his estate is planning US and world tours during which his computer-generated image will even perform his Moonwalk. The estates of Elvis and ’Ol Blue Eyes were so impressed by the Jacko hologram success they now want in on the new technology. King of Rock Elvis died aged 42 in August 1977 while “Rat Pack” leader Sinatra was 82 when he passed away after a heart attack in May 1998. A senior executive at Digital Domain told us: “There is no reason why any or all our stable of digital stars would not be available for major tours or even long-term residencies in Vegas in the very near future.” Sin City venues the Hard Rock Hotel & Casino and Planet Hollywood have already voiced interest in staging shows. US media analyst Mike Raia said: “Performing holograms of dead superstars are already being talked of as the next big thing in the music industry. Even with the sophisticated technology they entail, concerts and tours could be staged at a fraction of the cost of those involving living entertainers. “There definitely would not be any diva-like demands to worry promoters.” The door would also be open for “duets” with living singers performing alongside digital images of dead ones. When the invention was launched two years ago at the Coachella music festival in California, dead rapper Tupac Shakur “performed” on stage with Snoop Dogg and Dr Dre. TU-COOL: A hologram of Tupac Shakur performing with Snoop Dogg at Coachella, 2012 [GETTY] Raia went on: “The possibilities are endless. You could, for example, have Jacko’s virtual image singing in perfect harmony and dancing in perfect step with Britney Spears, who is a resident artist at Planet Hollywood. “Or you could have Elvis and Frank Sinatra singing a ballad together. “It might feel a bit eerie but it’s a mouth-watering prospect for fans and their estates are certain to rake in fortunes from ticket sales.” Ironically, Digital Domain’s quest to resurrect dead icons was in part inspired by British music mogul Simon Cowell, who specialises in finding new talent. In October 2009, Cowell commissioned the company to produce a hologram image of Frank Sinatra singing Pennies From Heaven – his all-time favourite tune – as the main attraction at his £1million 50th birthday party. Stunned guests, including top Tinseltown and music industry movers and shakers, were so impressed the then Digital Domain chief Ed Ulbrich vowed on the spot to develop the technology further. MusicDreams singer Gabrielle makes musical comeback as she lifts lid on famous eye patchGABRIELLE caught up with Daily Star Online about her return to the spotlight. Only true 80s pop music fans will spot the 30 classic songs hidden in this picture David BowieThe decade that gave us big hair, leg warmers and mullets also delivered some bangin' music. Hidden in this image are 30 smash hits from the 1980s. How many can you spot? Elton JohnRod Stewart ends bitter two-year feud with pal Elton John after admitting 'he was wrong'The two rockers are mates again after a spectacular rivalry saw Sir Rod call Elton "money-grabbing" when he was advertising his 300-date farewell tour. But the singer now says he realises he was in the wrong Geordie Shore's Ricci Guarnaccio swaps TV for music as he lands huge record deal Geordie ShoreEXCLUSIVE: Geordie Shore star Ricci Guarnaccio has bagged himself a multi-track record deal in a move away from his reality TV roots in favour of a music career - rebranding himself as Ricci G You Me At Six's Josh Franceschi says Boris Johnson has 'let down the music industry' MusicYou Me At Six rock star Josh Franceschi spoke exclusively to Daily Star about life as a musician during the Covid-19 pandemic and how he has coped being at home during lockdown You Me at Six star Josh Franceschi to lift lid on new album in Daily Star Facebook Live MusicAs he prepares for fans to fire questions at him about the group's 17 years together and new album SUCKAPUNCH, Josh is sure to discuss their totally new look as You Me at Six gear up for a big year Rita Ora enlists MNEK and Bastille's Dan Smith for comeback track after Covid backlash Rita OraEXCLUSIVE: Rita Ora has teamed up with singer-songwriters MNEK and Dan Smith from Bastille to help revive her music career after widespread condemnation for breaching Covid rules to host an illegal birthday party for herself	cc/2021-04/en_middle_0068.json.gz/line1642
__label__wiki	0.788844	0.788844	All About Damian Blog: Fan Fun with Damian Lewis "actor, dad, redhead and ping pong champion" Fan Fun with Damian Lewis is thrilled to run Damian-Lewis.com, a fan site dedicated to the brilliant actor Damian Lewis. As we keep writing all about Damian on Fan Fun, we aim to share the latest news along with an extensive gallery and a comprehensive media archive here. We cannot express our gratitude enough to all those who poured their hearts and souls into the site over the years. We will do our best to preserve their legacy and keep up the good work. As Damian once said “best journeys are shared.” It is a true privilege to share this journey with you. We hope you enjoy both sites, come visit us often and spread the word! Latest Gallery Photo Albums Charlie Waller Trust Carol Service Place2Be Carol Concert Philoctetes – Theater of War Damian’s Twitter Feed A Spy Among Friends - Fall of 2021 Nicholas Elliot Pre-Production for BritBox Cold War espionage thriller follows the defection of notorious British intelligence officer and KGB double agent, Kim Philby (Dominic West), through the lens of his complex relationship with MI6 colleague and close friend, Nicholas Elliott (Damian Lewis). The six episode limited series will be available to stream on BritBox. Damian's Rookery Productions to executive produce. Dream Horse - September 4, 2020 Howard Davies, Tax Advisor World Premiere - Sundance Based on a true story of how against all the odds, an extraordinary woman and a champion racehorse named Dream Alliance, inspire an entire Welsh community to go on the ride of a lifetime and rediscover a sense of hope. A classic tale of triumph against adversity. Based on the documentary Dark Horse. Spy Wars with Damian Lewis - March 22, 2020 Host Reporter/Presenter History Channel UK & Smithsonian Channel US Host Damian Lewis invites you into the world of clandestine ops as he examines some of the modern era's most remarkable intelligence and security missions. Through declassified items and firsthand accounts from high-ranking officials at the FBI, CIA, KGB, and MI6, he reveals stories of daring escapes, thrilling rescues, notorious spy swaps, espionage, and undercover stings, featuring a cast of double agents, moles, heroes, and traitors. The 8-part docudrama series first aired in 2019 on History Channel UK in 2019, then Smithsonian Channel US and Canada in 2020. Available for iTunes download. Spy Wars was shot on location in Moscow, Israel and London. Damian Supports Subscribe to damian-lewis.com Enter your email address and find Damian in your inbox every time we post the news! 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__label__cc	0.633613	0.366387	Moving From Fountain to Broomfield Fountain, CO - Broomfield, CO (101 miles) Moving Resources: Fountain Movers Broomfield Movers Here are some cost estimates for moving from Fountain to Broomfield (101 miles) depending on the size of your home: Bedrooms Moving Estimate Studio $340 - $410 1 $550 - $680 3 $1070 - $1310 5+ $1690 - $2070 Get A Free Moving Quote ► How much does it cost to move from Fountain, Colorado to Broomfield, Colorado? The distance is 101 miles, so most of the moving expense will be in the labor to load and unload your belongings. The actual moving cost depends on how much stuff you have and how long it takes the movers to get everything in and out of the truck. For example, a studio apartment costs $340 to $410, a one bedroom apartments costs $550 to $680, a two bedroom costs $800 to $980, a three bedroom costs $1070 to $1310, a four bedroom house costs $1370 to $1670, a five bedroom house costs $1690 to $2070, and anything larger would cost even more. Top Rated Fountain Movers 5 Star Moving & Storage 11 S 25th St, Colorado Springs, CO 80904 Coleman American The Local Mooving Company 4847 Northpark Dr, Colorado Springs, CO 80907 Top Rated Broomfield Movers Light Speed Delivery 4400 Wynkoop St, Denver, CO 80216 Cannonball Movers 7502 W 20th Ave, Denver, CO 80214 Allpoints Moving Solutions 4010 Holly St, Denver, CO 80216 U-Haul Moving & Storage 2322 S Federal Boulevard, Denver, CO 80219 Discount Moving & Storage © 2021 ColoradoMovers.com Colorado Moving Companies Disclaimer: Prices shown on the website are only estimates. Actual prices can be obtained by requesting a free quote.	cc/2021-04/en_middle_0068.json.gz/line1651
__label__cc	0.631188	0.368812	Intel develops Facebook app to fight cancer and climate change Intel has developed a Facebook application that allows users to donate their spare processing power to help fight disease and combat climate change. Cliff Saran, Managing Editor Published: 04 Aug 2009 11:56 Using peer-to-peer computing, researchers break up complex computational tasks into pieces of work that can be farmed out to PCs. If hundreds or thousands of PCs participate, the combined computing power can be used over time to solve complex calculations, like the Seti programme used to search for signs of extraterrestrial life. Intel's Facebook peer-to-peer application, Progress Thru Processors, allows users to donate their PCs' unused processor power to research projects such as Rosetta@home, which uses the additional computing power to help find cures for cancer and other diseases such as HIV and Alzheimer's. In addition to Rosetta@home, Progress Thru Processors participants can choose to contribute excess processor computing power to the research efforts of Climateprediction.net and Africa@home. Climateprediction.net is dedicated to increased understanding of global climate change by predicting the Earth's climate and testing the accuracy of climate models. Africa@home is currently focused on finding optimal strategies to combat malaria by studying simulation models of disease transmission and the potential impact of new anti-malarial drugs and vaccines. The application automatically directs a computer's idle processor power to fuel researchers' computational efforts, Intel said. The application will activate only when a PC's performance is not being fully used. When the participant's computer usage demands more processor performance, the application defers and sits idle until spare processing capabilities become available again. Intel said the application runs automatically as a background process on a PC and will not affect performance or any other tasks. Additionally, Progress Thru Processors does not require participants to leave their computers powered up unnecessarily. By keeping their PCs on only as they normally would, participants will still be contributing to life-changing research, according to Intel. Progress Thru Processors was developed in collaboration with the National Science Foundation-funded BOINC project at the University of California, Berkeley. Marketing and creative work for Progress Thru Processors was provided by noise, a New York-based marketing agency. A glossary of peer-to-peer The maturing human network: Can you find me now? Peer-to-peer (P2P) computing: Napster and beyond Peer-to-peer botnets pose fresh network threat Web 2.0: What does it constitute? Read more on PC hardware How the computational storage drive is changing computing By: Kurt Marko How do I increase cache memory? By: Jon Toigo Configuring Web Application Proxy with AD to future-proof Exchange By: Steve Goodman Video: Graphics processors power hybrid computing By: Cliff Saran UK grid tackles climate change assessment – ComputerWeekly.com Climate change grid project stalled by 'major error' – ComputerWeekly.com News in brief – ComputerWeekly.com	cc/2021-04/en_middle_0068.json.gz/line1655
__label__cc	0.618294	0.381706	Golden Vanity - Help rescue a 113 year old boat by Charlie Tulloch in Southampton, England, United Kingdom £15,000 target 22 days left 71% 64 supporters This project will only be funded if at least £15,000 is pledged by 9th February 2021 at 6:34am Help bring back to life an historical boat so that she can continue to provide sailing and training for people from all walks of life. FirstClassSail Business, Heritage The Boat - Golden Vanity In August 2020 (of all years!) we, First Class Sailing, purchased Golden Vanity with a view to using the boat for sail training and cruising. The boat had been for sale for a while and was in need of a good home. Golden Vanity was built in 1908. At the time of writing that makes her 113 years old. She is a Mumble Bee class of Brixham Sailing Trawler. She is from an era of working sail that no longer exists. There are a handful of other Brixham Sailing Trawlers left but only one other Mumble Bee. She was built on the River Dart in Devon for a renowned marine artist, Arthur Briscoe, who used the boat as a way to get out amongst the fishing fleets to paint and record some of the last days of working sail. He also sailed the boat regularly with close friends one of which was spy novelist Erskine Childers, who wrote Riddle of the Sands. Since then she has passed through a number of different owners and charities and one owner sailed her single-handedly across the Atlantic. She is part of the National Historic Register and within that part of the National Historic Fleet alongside ships such as HMS Victory and HMS Warrior! We have a team of volunteers and paid helpers working on her. She is currently having all her paint scraped off her hull below and above the waterline before new paint is applied. Her ballast is being stripped out (circa 3.5 tons of peculiarly shaped lumps of iron) to allow a good inspection; lots of her interior is being repainted; hot water is being fitted; the heads are being reconfigured; a lot of the decks are being recaulked to stop her leaking; the engine is being lifted out into the saloon to allow a new drip tray to be fabricated and the engine mounts to be changed, at the same time sound and fire insulation will be fitted to the engine bay; a lot of her electrics are being replaced; areas of her decks are being recaulked to stop her leaking and the original capstan is being given a makeover. The spars are being varnished; some of the standing rigging will be changed; all 26 blocks are being stripped and oiled. The list goes on! Money and more volunteers are needed. Once the work is complete she will sail again and only minor annual refits will be needed for a long time. Why help Sailing a boat such as Golden Vanity gives people the opportunity to learn about themselves, to deal with some kind of personal challenge, to work in a team situation and discover hidden strengths and talents. It improves sustained social confidence and people's ability to work with others. It gives people an opportunity for adventure, for making new friends, to have a break from whatever their life situation may be. And of course, people learn about the maritime environment and seafaring. You will be helping a well-established business that cares greatly about what it does and the experience it offers people. A business that has been knocked sideways by Covid but has taken on this project of Golden Vanity in order to preserve an historic vessel, to give as many people as possible the opportunity to sail on her, strengthen the company's offerings. Plus there are also rewards to be had depending on how much you donate! A Business Case First Class Sailing is an RYA Sea School that was formed in 2001. We offer RYA sailing courses on yachts in the Solent and sailing adventure holiday voyages to places like Norway and across the Atlantic. We own a number of our own boats but for some of our bigger voyages, we charter in yachts more suitable for long-distance sailing. This has worked well but Covid has emphasised to us the need to be less dependent on yachts belonging to other companies. Like many businesses, we have been hit extremely hard by Covid. We had to cease all water-based activities during lockdown 1 and 2. We adapted as best we could and ran some online navigation classes but the income generated from this was nowhere near what it should have been like at these key times of the year. Our usual winter income from Atlantic voyages is not there this year. So we purchased Golden Vanity. This is a move to diversify offerings that do not involve the use of yachts from other companies and to offer something unique that will give opportunities to people from all walks of life to benefit from sailing on such an historic and traditional sailing vessel. At the same time, we are playing a part in the preservation of a beautiful historic vessel. Day Sail with Tom Cunliffe Donate £345 and come for a day sail on Golden Vanity with the sailor, author, speaker, fount of all that is gaff.... the legend that is Tom Cunliffe Select reward Golden Vanity Pin Badge Donat £10 and receive a limited edition Golden Vanity Pin Badge £20 Donation Donate £20 and help restore Golden Vanity back to her former glory. We will reward you with a pack of 10 limited edition illustrated postcards of Golden Vanity. You will also be helping our business get through whatever Covid and it's aftermath sends our way. Estimated delivery: 28th Feb 2021 A signed copy of Tom Cunliffe's Book Donate £50 and receive a copy of Tom Cunliffe's Hand Reef and Steer signed by the man himself! Estimated delivery: 31st Mar 2021 Come for a Day Sail on Golden Vanity Donate £200 and be rewarded with a day's sail in the Solent on Golden Vanity in 2021. £1,000 or more 1 of 1 claimed 3 night stay in a Whitby Lighthouse Cottage Donate £1000 and we will give you a 3 night stay in one of two Whitby Lighthouse Cottages belonging to Trinity House. Both sleep 5. One is dog friendly the other is not. Must be taken in 2021 and dates must exclude 29 March - 11 April, 25 June – 5 September and Bank Holidays. Reward sold out Let's make 'Golden Vanity - Help rescue a 113 year old boat' happen	cc/2021-04/en_middle_0068.json.gz/line1656
__label__cc	0.739142	0.260858	Case Study – When planning applications become a battleground between neighbours. It is not unusual for planning applications to become contentious between neighbours. In fact they can often become very heated and relationships can become strained and often breakdown between neighbours. We have seen it first hand on more than one occasion. While we accept this for what it is as part of the planning process it none the less saddens us when relationships between neighbours sour as a result of one developing their property at the perceived expense or detriment of another. The below tale of woe sets out an all too familiar occurrence and explains how perilous poor neighbourly relations can be in the planning approval process. In June 2015 we applied to Nillumbik Council to develop a second house on a large block of land in Eltham. Anyone who knows Nillumbik Council will be aware of their strident position on tree retention within sites as part of development. This was our main concern at the outset of the project as the site was semi-rural in character and surrounded in large native trees. However, our client had a different concern. He was convinced from the outset of the project that his neighbour would take them to VCAT even if Council supported the application. The reason he was convinced was because there was a long history of dispute between them and this planning application was going to present the next battle. The combative saga had been ongoing for a number of years and involved a wide ranging, yet typical neighbourly disputes such as fencing, noise complaints etc. The Council approved the planning application on the 9th October 2015 but as expected an appeal against this approval was lodged to VCAT by the neighbour. The development itself comfortably complied with the regulations as set out in the planning scheme and hence received Council support. Despite this any neighbour can still appeal the decision of Council without the need to provide any compelling evidence to support the grounds of their appeal. The case was heard by VCAT on the 28th April 2016 and the VCAT order upholding the Councils approval was issued on the 24th June 2016. Although a positive outcome, this unnecessary saga cost our client a full nine month delay in the commencement of his project. The development commenced construction in late 2016 and is scheduled to be complete in late 2017 as an owner builder project. Predictably our client wanted to know if there was any avenue to pursue costs associated with the delay and the appeal from his neighbour after the decision was issued by VCAT. The simple answer is no. It would require a very unique set of circumstances for VCAT to award costs against an objector appealing an approval decision by a local Council, despite the clear weakness in their case. The reason for this is because it would be seen as a deterrent to any future objector to a planning decision to appeal if the threat of costs being awarded against them looms. This could be perceived as being unjust towards objectors in the planning process and an advantage for developers. Planning permit approvals is an adversarial process and if a dispute emerges it is likely neither party will end up happy with the outcome. The test for professionals in the industry is to reach an outcome that is acceptable to parties. It is always in your interests to maintain amicable relationships and open communication with your neighbours if you intend to develop your site. A simple concept but not an easy one when the stakes are high and emotions are charged. Follow @cstownplanning Meet like-minded individuals, share property development experiences and keep up to date with industry information & events.	cc/2021-04/en_middle_0068.json.gz/line1658
__label__wiki	0.831282	0.831282	Milford restaurants adjust to serve customers Best of New Haven New Haven Top 50 NHR Insider By Bill Bloxsom March 26, 2020 Updated: March 30, 2020 8:02 a.m. 1of2Pop's Family Restaurant employee Sabatino Kikis brings an order of corned beef and cabbage to a customer in Milford, Conn., on Tuesday Mar. 17, 2020.Photo: Christian Abraham / Hearst Connecticut Media 2of2A restaurant sign on River Street in downtown Milford, Conn. on Monday, March 23, 2020.Photo: Brian A. Pounds, Hearst Connecticut Media MILFORD — Restaurateurs Scott Rohrig, Gus Grigoriadis and Paul Mingrone have been working on the fly since Gov. Ned Lamont announced that Connecticut bars and restaurants would shut down as of March 17. Ten days after, each has looked to find a way to serve the community by staying open for take-out service. Rohrig, owner of Lasse’s Restaurant on Bridgeport Avenue, feels an obligation. “I want to thank the town of Milford for supporting us. I believe we are supporting others in the community by doing what we do — and doing it as well as we can,” said Rohrig, the latest in an extended family to operate Lassie’s which will be celebrating its 56th anniversary on April 1. “This is a tough thing we are going through as a city. I feel fortunate that we have been able to stay afloat. Other businesses and workers haven’t been as fortunate. We are pricing our food at the best levels we can to help those that have been laid off. “Most importantly, we have been able to carry on the tradition of (restaurant founders) Russell and Evelyn Lasse, who believed if you take care of customers the right way that they will soon become your family.” Patty Collins, catering office manager at Lassie’s, said, “I was almost brought to tears by how people are coming together on this. We have had customers come in and buy gift certificates that they can then give to those in need.” All hasn’t been rosy. “The hardest thing has been keeping a staff,” Rohrig said. “Some employees have left us because of safety concerns for their health in leaving the house. Our phones start ringing at 8 a.m. and the emails come in overnight and are waiting for us. “In the kitchen, the cooks are working from 8 a.m. until we finish cleaning at around 8:30 or 9 at night. Our servers now work 3 to 7 at night and bring food out to the tent we have set up outside or to the cars themselves. It is important to serve, and to keep everyone safe. That is why we will be closed on Sunday, to give our workers a chance to rest.” Grigoriadis, proprietor of Pop’s Family Restaurant on Old Gate Lane, and his wife Julia had one main concern once the shutdown came to pass. “We kept thinking of our older customers,” said Grigoriadis, who has been serving Milford since 1991. “I guess I could afford to close, but we know it is difficult for them to get out to do the grocery shopping and the cooking at home. We put together some family-size meals for them to pick up from their cars. We miss them coming in because we have become friends.” Eleni Grigoriadis, one of Gus’s daughter and manager with siblings Virginia and Ipakou, said, “We get calls, especially from the elderly, they ask ‘Tell us first if you are going to close.’ They do depend on us and we take them to heart. “It isn’t only our restaurant, but I’m so happy with the way the entire community has reacted to this virus. Everyone is supporting each other the best way they know how.” Pop’s was forced to let employees go. “We have an open relationship with our employees,” Eleni Grigoriadis said. “They know they can come to us and we will help how we can. They know they will have jobs waiting for them.” Mingrone, owner and chef at the Harbor Side Market restaurant on New Haven Avenue since 2002, said, “We waited to receive the official word and the next day looked to find a way to service our customers Without our sit-down service, the phone rings more. We are making enough for now to stay open. We are paying the rent and utilities. I feel bad for other businesses in the area, like the hair salons and shops.” Closing of those establishments have affected Mingrone as well. “Those customers are our bread and butter,” Mingrone said. “They are 75 percent of our base. We would see the same faces every day and knew the orders to prepare when they would come in the door. Those workers in shops that have closed were our regulars. Plus, we would deliver orders to the now closed schools about four days a week. “We switched our hours to 8 a.m. to 2 p.m. and are closed Saturday. I’ve had to lay off people that we care about. Right now, it is my wife Lisa, Lillian Munoz and myself doing the work. I’m hoping the stimulus that just passed will help those that can use it. I haven’t analyzed it to see where it may help us out.” The coronavirus has made citizens take a step back and stand apart. But it also has brought people together in an unexpected way. “I never did Facebook before,” Rohrig said. “Now, it has really helped get the word out. It is a good way to communicate. In some ways, the virus has forced us to find the best in each other and share. It is paying forward the good in all of us.” Industry prepared Scott Dolch, executive director of the Connecticut Restaurant Association, indicated that the industry, including about 8,500 eating and drinking businesses and 160,000 workers, had been preparing. “Weeks ago, Connecticut restaurants began doubling down on cleaning procedures in order to protect our customers and our employees,” Dolch said in a statement. “In the wake of Governor Lamont’s announcement, local restaurant owners will continue to offer safe, clean service to customers via takeout, curbside pickup and delivery. “In the weeks ahead, we look forward to returning to full service once this difficult period has passed, so that our industry can continue to be an enormous economic driver for the state, and continue to employ tens of thousands of people throughout Connecticut.” william.bloxsom@hearstmediact.com Twitter: @blox354 News for Insiders Developer pitches ‘revival’ of Branford marina Teaching Black history crucial to all CT students, experts say ‘A different way to live’: Food insecurity rises amid pandemic Millionaire, TV personality helps out New Haven restaurant Police response to CT Capitol spitting incident raises equity... Race Brook Country Club’s future in hands of residents ‘Just let the guy leave’: Reaction to impeachment doesn’t follow... UNH: Administrators investigating claims of ‘potential student... Yale nurses fear loss of seniority amid pandemic	cc/2021-04/en_middle_0068.json.gz/line1659
__label__wiki	0.824574	0.824574	Danish Mayfly named 2021 insect of the year The Associated Press Staff This undated photo provided by the 'Senckenberg Institute' shows a 'Danish Mayfly'. The Danish Mayfly has been selected by a German entomological society as the Insect of the Year for 2021, but won’t have long to celebrate its 15 minutes of fame. The insect, whose scientific name is Ephemera danica, only has a few days to fly, mate and lay new eggs. (Wolfgang Kleinsteuber via AP) The Danish Mayfly was selected Friday by an international group of entomologists and others as the Insect of the Year for 2021, but it won't have long to celebrate its 15 minutes of fame. The insect, whose scientific name is Ephemera danica, only has a few days to fly, mate and lay new eggs. "What makes the mayfly unique is its life cycle: from the egg laid in the water to the insect capable of flight and mating, which dies after a few days," said Thomas Schmitt, chairman of the commission of scientists and representatives from research institutions and conservation organizations from Germany, Austria and Switzerland that made the choice. Mayflies have existed for about 355 million years and today some 140 species live in Central Europe, the commission said. Despite their fleeting time on earth in their final form, their developmental cycle is quite long. Female mayflies zigzag over water between May and September, laying thousands of eggs that then sink. Larvae hatch within a few days, and eventually develop gills. Buried in riverbeds, they take between one to three years to develop. "Shortly before the transition from aquatic to terrestrial life, a layer of air forms between the old and new skin of the adult larvae," said Schmitt, who is also director of the Senckenberg German Entomological Institute in Muencheberg, east of Berlin. "By reducing its specific weight, the larva rises to the water surface. Once there, the larval skin bursts and within a few seconds a flyable mayfly hatches." With no mouth parts nor a functioning intestine, the fully developed mayfly has only a few days then to mate and lay new eggs before it dies. The commission has been selecting one unique insect each year since 1999 to "bring an exemplary species closer to people." Report an error Editorial standards and policies Why you can trust CTV News More Lifestyle stories 'COVID Elvis' serenades long-term care home residents Overcoming the 'yuck factor': Yellow mealworm becomes EU's first insect food Mealworms to become first insect approved as food by EU Four trendy hairstyles everyone will have in 2021 Gender-fluid dancer pushing for inclusivity learning pointe What travel trends can we expect to see in 2021? Benefit not meant to pay for 'post-vacation quarantine': PM Snake massage: Cairo spa offers reptile relaxation Hospitality industry calls for fair treatment from province	cc/2021-04/en_middle_0068.json.gz/line1660
__label__wiki	0.899317	0.899317	By George Laase Culver Defends Its CIF Volleyball Championship Plays Santa Monica at Cerritos College George Laase Sophomore Outside hitter/Middle blocker Lauren Tishkoff puts down another kill. Saturday's Division 4 Finals will pit #1 ranked Lady Centaurs (29-1) against its archrival #3 Santa Monica (18-6) in an All-Ocean League match. Santa Monica made the finals by beating West Torrance in the first round 3-0, Valley Christian 3-1 in the second, La Canada in the quarter-finals, 3-1 and Crean Lutheran 3-1 in the semis. The Lady Centaurs are in the finals for the second straight year and are defending their CIF Championship. They easily won over Pasadena in the first round and La Habra in the second. They continued on their quest by beating Polytechnic 3-1 in quarterfinals and went on the road and rallied against a tough Cypress team after losing the first set 18-25, to ultimately win the next three sets 25-12, 25-18 and 25-14 to move on to Saturday's finals. Culver went undefeated in League play (10-0) by sweeping its two matches over a tough Viking team (8-2). The Lady Centaurs went on the road and beat the Vikings 3-2 on their home court in a tough, hard fought match 3-2 and at home 3-0. When asked what made the difference in Tuesday's semi-final match versus Cypress, head coach Tanner Siegal said, "It was Trust. When you go down in the first game... We didn't play our game. We made some mistakes. Credit to Cypress tonight, they were a tough team in a tough environment. But in a game like this, with such magnitude, it comes down to trust. The girls didn't panic. They trusted each other and they made plays when they had to." Coach Siegal pointed out that blocking and serving were great. Saying, "We trust our servers. We were calling for serves in aggressive spots to put our opponent on the defensive and tonight our servers didn't let us down." Asked if he expected some surprises in the up-coming championship match, "Santa Monica is probably geared up and is looking forward to another shot at us. Obviously, it's a matchup we feel good about. They will be a difficult opponent and I expect a great match." He continued, "We know each other's game. There will be no surprises from either team. Ultimately, winning will come down to execution." The championship game is being held this Saturday, November 11 at Cerritos College. Game starts at 7 pm. Come out and cheer on our Lady Centaurs to another championship victory. 2020 NFL Power Rankings – Week 16 Rams Like Chances in Sunday's Clash with Cards The recruiting spotlight shines bight on Centaur student-athletes Rams Need a Win in Seattle to Stay in Division Race	cc/2021-04/en_middle_0068.json.gz/line1661
__label__cc	0.563065	0.436935	Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail. Sexually Transmitted Diseases Treatment Guidelines, 2006 Please note: An update has been published for this report. To view the update, please click here. Kimberly A. Workowski, MD Stuart M. Berman, MD Division of STD Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed) The material in this report originated in National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), Kevin A. Fenton, MD, PhD, Director; and the Division of STD Prevention, John M. Douglas, MD, Director. Corresponding preparer: Kimberly A. Workowski, MD, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, 10 Corporate Square, Corporate Square Blvd., MS E-02, Atlanta, GA 30333. Telephone: 404-639-1898; Fax: 404-639-8610; E-mail: kgw2@cdc.gov. These guidelines for the treatment of persons who have sexually transmitted diseases (STDs) were developed by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta, Georgia, during April 19--21, 2005. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2002 (MMWR 2002;51[No. RR-6]). Included in these updated guidelines are an expanded diagnostic evaluation for cervicitis and trichomoniasis; new antimicrobial recommendations for trichomoniasis; additional data on the clinical efficacy of azithromycin for chlamydial infections in pregnancy; discussion of the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis and treatment-related implications; emergence of lymphogranuloma venereum proctocolitis among men who have sex with men (MSM); expanded discussion of the criteria for spinal fluid examination to evaluate for neurosyphilis; the emergence of azithromycin- resistant Treponema pallidum; increasing prevalence of quinolone-resistant Neisseria gonorrhoeae in MSM; revised discussion concerning the sexual transmission of hepatitis C; postexposure prophylaxis after sexual assault; and an expanded discussion of STD prevention approaches. Physicians and other health-care providers play a critical role in preventing and treating sexually transmitted diseases (STDs). These guidelines for the treatment of STDs are intended to assist with that effort. Although these guidelines emphasize treatment, prevention strategies and diagnostic recommendations also are discussed. This report was produced through a multistage process. Beginning in 2004, CDC personnel and professionals knowledgeable in the field of STDs systematically reviewed evidence, including published abstracts and peer-reviewed journal articles concerning each of the major STDs, focusing on information that had become available since publication of the Sexually Transmitted Diseases Treatment Guidelines, 2002 (1). Background papers were written and tables of evidence were constructed summarizing the type of study (e.g., randomized controlled trial or case series), study population and setting, treatments or other interventions, outcome measures assessed, reported findings, and weaknesses and biases in study design and analysis. A draft document was developed on the basis of the reviews. In April 2005, CDC staff members and invited consultants assembled in Atlanta, Georgia, for a 3-day meeting to present the key questions regarding STD treatment that emerged from the evidence-based reviews and the information available to answer those questions. When relevant, the questions focused on four principal outcomes of STD therapy for each individual disease: 1) microbiologic cure, 2) alleviation of signs and symptoms, 3) prevention of sequelae, and 4) prevention of transmission. Cost-effectiveness and other advantages (e.g., single-dose formulations and directly observed therapy of specific regimens) also were discussed. The consultants then assessed whether the questions identified were relevant, ranked them in order of priority, and attempted to arrive at answers using the available evidence. In addition, the consultants evaluated the quality of evidence supporting the answers on the basis of the number, type, and quality of the studies. In several areas, the process diverged from that previously described. The sections on hepatitis B virus (HBV) and hepatitis A virus (HAV) infections are based on previously or recently approved recommendations (2--4) of the Advisory Committee on Immunization Practices. The recommendations for STD screening during pregnancy were developed after CDC staff reviewed the recommendations from other knowledgeable groups. Throughout this report, the evidence used as the basis for specific recommendations is discussed briefly. More comprehensive, annotated discussions of such evidence will appear in background papers that will be published in a supplement issue of Clinical Infectious Diseases. When more than one therapeutic regimen is recommended, the sequence is in alphabetical order unless the choices for therapy are prioritized based on efficacy, convenience, or cost. For STDs with more than one recommended treatment regimen, it can be assumed that all regimens have similar efficacy and similar rates of intolerance or toxicity, unless otherwise specified. Persons treating STDs should use recommended regimens primarily; alternative regimens can be considered in instances of substantial drug allergy or other contraindications to the recommended regimens. These recommendations were developed in consultation with public and private sector professionals knowledgeable in the treatment of persons with STDs (see Consultants list). The recommendations are applicable to various patient-care settings, including family planning clinics, private physicians' offices, managed care organizations, and other primary-care facilities. These recommendations are meant to serve as a source of clinical guidance: health-care providers should always consider the individual clinical circumstances of each person in the context of local disease prevalence. These guidelines focus on the treatment and counseling of individual persons and do not address other community services and interventions that are important in STD/human immunodeficiency virus (HIV) prevention. Clinical Prevention Guidance The prevention and control of STDs are based on the following five major strategies: 1) education and counseling of persons at risk on ways to avoid STDs through changes in sexual behaviors; 2) identification of asymptomatically infected persons and of symptomatic persons unlikely to seek diagnostic and treatment services; 3) effective diagnosis and treatment of infected persons; 4) evaluation, treatment, and counseling of sex partners of persons who are infected with an STD; and 5) preexposure vaccination of persons at risk for vaccine-preventable STD. Primary prevention of STD begins with changing the sexual behaviors that place persons at risk for infection. Health-care providers have a unique opportunity to provide education and counseling to their patients. As part of the clinical interview, health-care providers should routinely and regularly obtain sexual histories from their patients and address management of risk reduction as indicated in this report. Guidance in obtaining a sexual history is available in Contraceptive Technology, 18th edition (5) and in the curriculum provided by CDC's STD/HIV Prevention Training Centers (http://www.stdhivpreventiontraining.org). Counseling skills, characterized by respect, compassion, and a nonjudgmental attitude toward all patients, are essential to obtaining a thorough sexual history and to delivering prevention messages effectively. Key techniques that can be effective in facilitating rapport with patients include the use of 1) open-ended questions (e.g., "Tell me about any new sex partners you've had since your last visit" and "what's your experience with using condoms been like?"), 2) understandable language ("have you ever had a sore or scab on your penis?"), and 3) normalizing language ("some of my patients have difficulty using a condom with every sex act. How is it for you?"). One approach to eliciting information concerning five key areas of interest has been summarized. The Five Ps: Partners, Prevention of Pregnancy, Protection from STDs, Practices, Past History of STDs 1. Partners "Do you have sex with men, women, or both?" "In the past 2 months, how many partners have you had sex with?" "In the past 12 months, how many partners have you had sex with?" 2. Prevention of pregnancy "Are you or your partner trying to get pregnant?" If no, "What are you doing to prevent pregnancy?" 3. Protection from STDs "What do you do to protect yourself from STDs and HIV?" 4. Practices "To understand your risks for STDs, I need to understand the kind of sex you have had recently." "Have you had vaginal sex, meaning `penis in vagina sex'"? If yes, "Do you use condoms: never, sometimes, or always?" "Have you had anal sex, meaning `penis in rectum/anus sex'"? "Have you had oral sex, meaning `mouth on penis/vagina'"? For condom answers If "never:" "Why don't you use condoms?" If "sometimes": "In what situations or with whom, do you not use condoms?" 5. Past history of STDs "Have you ever had an STD?" "Have any of your partners had an STD?" Additional questions to identify HIV and hepatitis risk "Have you or any of your partners ever injected drugs? "Have any of your partners exchanged money or drugs for sex?" "Is there anything else about your sexual practices that I need to know about?" Patients should be reassured that treatment will be provided regardless of individual circumstances (e.g., ability to pay, citizenship or immigration status, language spoken, or specific sex practices). Many patients seeking treatment or screening for a particular STD should be evaluated for all common STDs; even so, all patients should be informed concerning all the STDs for which they are being tested and if testing for a common STD (e.g., genital herpes) is not being performed. STD/HIV Prevention Counseling Effective delivery of prevention messages requires that providers integrate communication of general risk reduction messages that are relevant to the client (i.e., client-centered counseling) and education regarding specific actions that can reduce the risk for STD/HIV transmission (e.g., abstinence, condom use, limiting the number of sex partners, modifying sexual behaviors, and vaccination). Each of these specific actions is discussed separately in this report. Interactive counseling approaches directed at a patient's personal risk, the situations in which risk occurs, and the use of goal-setting strategies are effective in STD/HIV prevention (6). One such approach, client-centered STD/HIV prevention counseling, involves tailoring a discussion of risk reduction to the patient's individual situation. Client-centered counseling can have a beneficial effect on the likelihood of patients using risk-reduction practices and can reduce the risk for future acquisition of an STD. One effective client-centered approach is Project RESPECT, which demonstrated that a brief counseling intervention was associated with a reduced frequency of STD/HIV risk-related behaviors and with a lowered acquisition of STDs (7,8). Practice models based on Project RESPECT have been successfully implemented in clinic-based settings. Other approaches use motivational interviewing to move clients toward achievable risk reduction goals. CDC provides additional information on these and other effective behavioral interventions at http://effectiveinterventions.org. Interactive counseling can be used effectively by all health-care providers or can be conducted by specially trained counselors. The quality of counseling is best ensured when providers receive basic training in prevention counseling methods and skill-building approaches, periodic observation of counseling with immediate feedback by persons with expertise in the counseling approach, periodic counselor and/or patient satisfaction evaluations, and availability of expert assistance or referral for challenging situations. Training in client-centered counseling is available through the CDC STD/HIV Prevention Training Centers (http://www.stdhivpreventiontraining.org). Prevention counseling is most effective if provided in a nonjudgmental manner appropriate to the patient's culture, language, sex, sexual orientation, age, and developmental level. In addition to individual prevention counseling, some videos and large group presentations provide explicit information concerning how to use condoms correctly. These have been effective in reducing the occurrence of additional STDs among persons at high risk, including STD clinic patients and adolescents. Because the incidence of some STDs, notably syphilis, has increased in HIV-infected persons, the use of client-centered STD counseling for HIV-infected persons has received strong emphasis from public health agencies and organizations. Consensus guidelines issued by CDC, the Health Resources and Services Administration, the HIV Medicine Association of the Infectious Diseases Society of America, and the National Institutes of Health emphasize that STD/HIV risk assessment, STD screening, and client-centered risk reduction counseling should be provided routinely to HIV-infected persons (9). Several specific methods have been designed for the HIV care setting (10--12). Additional information regarding these approaches is available at http://effectiveinterventions.org. Client-Initiated Interventions to Reduce Sexual Transmission of STD/HIV and Unintended Pregnancy Abstinence and Reduction of Number of Sex Partners The most reliable way to avoid transmission of STDs is to abstain from sex (i.e., oral, vaginal, or anal sex) or to be in a long-term, mutually monogamous relationship with an uninfected partner. Counseling that encourages abstinence from sexual intercourse is crucial for persons who are being treated for an STD (or whose partners are undergoing treatment) and for persons who want to avoid the possible consequences of sex completely (e.g., STD/HIV and unintended pregnancy). A more comprehensive discussion of abstinence is available in Contraceptive Technology, 18th edition (5). For persons embarking on a mutually monogamous relationship, screening for common STDs before initiating sex might reduce the risk for future transmission of asymptomatic STDs. Preexposure Vaccination Preexposure vaccination is one of the most effective methods for preventing transmission of some STDs. For example, because HBV infection is frequently sexually transmitted, hepatitis B vaccination is recommended for all unvaccinated, uninfected persons being evaluated for an STD. In addition, hepatitis A vaccine is licensed and is recommended for men who have sex with men (MSM) and illicit drug users (i.e., both injecting and noninjecting). Specific details regarding hepatitis A and B vaccination are available at http://www.cdc.gov/hepatitis. A quadrivalent vaccine against human papillomavirus (HPV types 6, 11, 16, 18) is now available and licensed for females aged 9--26 years. Vaccine trials for other STDs are being conducted. When used consistently and correctly, male latex condoms are highly effective in preventing the sexual transmission of HIV infection (i.e., HIV-negative partners in heterosexual serodiscordant relationships in which condoms were consistently used were 80% less likely to become HIV-infected compared with persons in similar relationships in which condoms were not used) and can reduce the risk for other STDs, including chlamydia, gonorrhea, and trichomoniasis, and might reduce the risk of women developing pelvic inflammatory disease (PID) (13,14). Condom use might reduce the risk for transmission of herpes simplex virus-2 (HSV-2), although data for this effect are more limited (15,16). Condom use might reduce the risk for HPV-associated diseases (e.g., genital warts and cervical cancer [17]) and mitigate the adverse consequences of infection with HPV, as their use has been associated with higher rates of regression of cervical intraepithelial neoplasia (CIN) and clearance of HPV infection in women (18), and with regression of HPV-associated penile lesions in men (19). A limited number of prospective studies have demonstrated a protective effect of condoms on the acquisition of genital HPV; one recent prospective study among newly sexually active college women demonstrated that consistent condom use was associated with a 70% reduction in risk for HPV transmission (20). Condoms are regulated as medical devices and are subject to random sampling and testing by the Food and Drug Administration (FDA). Each latex condom manufactured in the United States is tested electronically for holes before packaging. Rates of condom breakage during sexual intercourse and withdrawal are approximately two broken condoms per 100 condoms used in the United States. The failure of condoms to protect against STD transmission or unintended pregnancy usually results from inconsistent or incorrect use rather than condom breakage. Male condoms made of materials other than latex are available in the United States. Although they have had higher breakage and slippage rates when compared with latex condoms and are usually more costly, the pregnancy rates among women whose partners use these condoms are similar to latex condoms. Two general categories of nonlatex condoms exist. The first type is made of polyurethane or other synthetic material and provides protection against STD/HIV and pregnancy equal to that of latex condoms. These can be substituted for persons with latex allergy. The second type is natural membrane condoms (frequently called "natural" condoms or, incorrectly, lambskin condoms). These condoms are usually made from lamb cecum and can have pores up to 1500 nm in diameter. Whereas these pores do not allow the passage of sperm, they are more than 10 times the diameter of HIV and more than 25 times that of HBV. Moreover, laboratory studies demonstrate that viral STD transmission can occur with natural membrane condoms. Using natural membrane condoms for protection against STDs is not recommended. Patients should be advised that condoms must be used consistently and correctly to be effective in preventing STDs, and they should be instructed in the correct use of condoms. The following recommendations ensure the proper use of male condoms: Use a new condom with each sex act (e.g., oral, vaginal, and anal). Carefully handle the condom to avoid damaging it with fingernails, teeth, or other sharp objects. Put the condom on after the penis is erect and before any genital, oral, or anal contact with the partner. Use only water-based lubricants (e.g., K-Y Jelly™, Astroglide™, AquaLube™, and glycerin) with latex condoms. Oil-based lubricants (e.g., petroleum jelly, shortening, mineral oil, massage oils, body lotions, and cooking oil) can weaken latex. Ensure adequate lubrication during vaginal and anal sex, which might require the use of exogenous water-based lubricants. To prevent the condom from slipping off, hold the condom firmly against the base of the penis during withdrawal, and withdraw while the penis is still erect. Laboratory studies indicate that the female condom (Reality™), which consists of a lubricated polyurethane sheath with a ring on each end that is inserted into the vagina, is an effective mechanical barrier to viruses, including HIV, and to semen (21). A limited number of clinical studies have evaluated the efficacy of female condoms in providing protection from STDs, including HIV (22). If used consistently and correctly, the female condom might substantially reduce the risk for STDs. When a male condom cannot be used properly, sex partners should consider using a female condom. Female condoms are costly compared with male condoms. The female condom also has been used for STD/HIV protection during receptive anal intercourse (23). Whereas it might provide some protection in this setting, its efficacy is undefined. Vaginal Spermicides and Diaphragms Vaginal spermicides containing nonoxynol-9 (N-9) are not effective in preventing cervical gonorrhea, chlamydia, or HIV infection (24). Furthermore, frequent use of spermicides containing N-9 has been associated with disruption of the genital epithelium, which might be associated with an increased risk for HIV transmission. Therefore, N-9 is not recommended for STD/HIV prevention. In case-control and cross-sectional studies, diaphragm use has been demonstrated to protect against cervical gonorrhea, chlamydia, and trichomoniasis; a randomized controlled trial will be conducted. On the basis of all available evidence, diaphragms should not be relied on as the sole source of protection against HIV infection. Diaphragm and spermicide use have been associated with an increased risk for bacterial urinary tract infections in women. Condoms and N-9 Vaginal Spermicides Condoms lubricated with spermicides are no more effective than other lubricated condoms in protecting against the transmission of HIV and other STDs, and those that are lubricated with N-9 pose the concerns that have been previously discussed. Use of condoms lubricated with N-9 is not recommended for STD/HIV prevention because spermicide-coated condoms cost more, have a shorter shelf-life than other lubricated condoms, and have been associated with urinary tract infection in young women. Rectal Use of N-9 Spermicides Recent studies indicate that N-9 might increase the risk for HIV transmission during vaginal intercourse (24). Although similar studies have not been conducted among men who use N-9 spermicide during anal intercourse with other men, N-9 can damage the cells lining the rectum, which might provide a portal of entry for HIV and other sexually transmissible agents. Therefore, N-9 should not be used as a microbicide or lubricant during anal intercourse. Nonbarrier Contraception, Surgical Sterilization, and Hysterectomy Sexually active women who are not at risk for pregnancy might incorrectly perceive themselves to be at no risk for STDs, including HIV infection. Contraceptive methods that are not mechanical barriers offer no protection against HIV or other STDs. Women who use hormonal contraception (e.g., oral contraceptives, Norplant™, and Depo-Provera™), have intrauterine devices (IUD), have been surgically sterilized, or have had hysterectomies should be counseled regarding the use of condoms and the risk for STDs, including HIV infection. Emergency Contraception (EC) Emergency use of oral contraceptive pills containing levonorgesterol alone reduces the risk for pregnancy after unprotected intercourse by 89%. Pills containing a combination of ethinyl estradiol and either norgestrel or levonorgestrel can be used and reduce the risk for pregnancy by 75%. Emergency insertion of a copper IUD also is highly effective, reducing the risk by as much as 99%. EC with oral contraceptive pills should be initiated as soon as possible after unprotected intercourse and definitely within 120 hours (i.e., 5 days). The only medical contraindication to provision of EC is current pregnancy. Providers who manage persons at risk for STDs should counsel women concerning the option for EC, if indicated, and provide it in a timely fashion if desired by the woman. Plan B (two 750 mcg levonorgestrel tablets) has been approved by FDA and is available in the United States for the prevention of unintended pregnancy. Additional information on EC is available in Contraceptive Technology, 18th edition (5), or at http://www.arhp.org/healthcareproviders/resources/contraceptionresources. Postexposure Prophylaxis (PEP) for HIV Guidelines for the use of PEP aimed at preventing HIV acquisition as a result of sexual exposure are available and are discussed in this report (see Sexual Assault and STDs). Partner notification, previously referred to as "contact tracing" but recently included in the broader category of partner services, is the process by which providers or public health authorities learn from persons with STDs about their sex partners and help to arrange for the evaluation and treatment of sex partners. Providers can seek this information and help to arrange for evaluation and treatment of sex partners, either directly or with assistance from state and local health departments. The intensity of partner services and the specific STDs for which they are offered vary among providers, agencies, and geographic areas. Ideally, such services should be accompanied by health counseling and might include referral of patients and their partners for other services, whenever appropriate. In general, whether partner notification effectively decreases exposure to STDs and whether it changes the incidence and prevalence of STDs in a community are uncertain. The paucity of supporting evidence regarding the effectiveness of partner notification has spurred the exploration of alternative approaches. One such approach is to place partner notification in a larger context by making interventions in the sexual and social networks in which persons are exposed to STDs. Prospective evaluations incorporating assessment of venues, community structure, and social and sexual, contacts in conjunction with partner notification of efforts are promising in terms of increasing case-finding and warrant further exploration. The scope of such efforts probably precludes individual clinician efforts to use network-based approaches, but STD-control programs might find them useful. Many persons individually benefit from partner notification. When partners are treated, index patients have reduced risk for reinfection. At a population level, partner notification can disrupt networks of STD transmission and reduce disease incidence. Therefore, providers should encourage their patients with STDs to notify their sex partners and urge them to seek medical evaluation and treatment, regardless of whether assistance is available from health agencies. When medical evaluation, counseling, and treatment of partners cannot be done because of the particular circumstances of a patient or partner or because of resource limitations, other partner management options can be considered. One option is patient-delivered therapy, a form of expedited partner therapy (EPT) in which partners of infected patients are treated without previous medical evaluation or prevention counseling (http://www.cdc.gov/std/treatment/EPTFinalReport2006.pdf). The evidence supporting patient-delivered therapy is based on three clinical trials that included heterosexual men and women with chlamydia or gonorrhea. The strength of the supporting evidence differed by STD and by the sex of the index case when reinfection of the index case was the measured outcome (25--27). Despite this variation, patient-delivered therapy (i.e., via medications or prescriptions) can prevent reinfection of index case and has been associated with a higher likelihood of partner notification, compared with unassisted patient referral of partners. Medications and prescriptions for patient-delivered therapy should be accompanied by treatment instructions, appropriate warnings about taking medications if pregnant, general health counseling, and advice that partners should seek personal medical evaluations, particularly women with symptoms of STDs or PID. Existing data suggest that EPT has a limited role in partner management for trichomoniasis (28). No data support its use in the routine management of syphilis. There is no experience with expedited partner therapy for gonorrhea or chlamydia infection among MSM. Currently, EPT is not feasible in many settings because of operational barriers, including the lack of clear legal status of EPT in some states. Reporting and Confidentiality The accurate and timely reporting of STDs is integrally important for assessing morbidity trends, targeting limited resources, and assisting local health authorities in partner notification and treatment. STD/HIV and acquired immunodeficiency syndrome (AIDS) cases should be reported in accordance with state and local statutory requirements. Syphilis, gonorrhea, chlamydia, chanroid, HIV infection, and AIDS are reportable diseases in every state. The requirements for reporting other STDs differ by state, and clinicians should be familiar with state and local reporting requirements. Reporting can be provider- and/or laboratory-based. Clinicians who are unsure of state and local reporting requirements should seek advice from state or local health departments or STD programs. STD and HIV reports are kept strictly confidential. In the majority of jurisdictions, such reports are protected by statute from subpoena. Before public health representatives conduct a follow-up of a positive STD-test result, they should consult the patient's health-care provider to verify the diagnosis and treatment. Intrauterine or perinatally transmitted STDs can have severely debilitating effects on pregnant women, their partners, and their fetuses. All pregnant women and their sex partners should be asked about STDs, counseled about the possibility of perinatal infections, and ensured access to treatment, if needed. Recommended Screening Tests All pregnant women in the United States should be tested for HIV infection as early in pregnancy as possible. Testing should be conducted after the woman is notified that she will be tested for HIV as part of the routine panel of prenatal tests, unless she declines the test (i.e., opt-out screening). For women who decline HIV testing, providers should address their objections, and where appropriate, continue to strongly encourage testing. Women who decline testing because they have had a previous negative HIV test should be informed of the importance of retesting during each pregnancy. Testing pregnant women is vital not only to maintain the health of the patient but also because interventions (i.e., antiretroviral and obstetrical) are available that can reduce perinatal transmission of HIV. Retesting in the third trimester (i.e., preferably before 36 weeks' gestation) is recommended for women at high risk for acquiring HIV infection (i.e., women who use illicit drugs, have STDs during pregnancy, have multiple sex partners during pregnancy, or have HIV-infected partners). Rapid HIV testing should be performed on women in labor with undocumented HIV status. If a rapid HIV test result is positive, antiretroviral prophylaxis (with consent) should be administered without waiting for the results of the confirmatory test. A serologic test for syphilis should be performed on all pregnant women at the first prenatal visit. In populations in which use of prenatal care is not optimal, rapid plasma reagin (RPR) card test screening (and treatment, if that test is reactive) should be performed at the time a pregnancy is confirmed. Women who are at high risk for syphilis, live in areas of high syphilis morbidity, are previously untested, or have positive serology in the first trimester should be screened again early in the third trimester (28 weeks' gestation) and at delivery. Some states require all women to be screened at delivery. Infants should not be discharged from the hospital unless the syphilis serologic status of the mother has been determined at least one time during pregnancy and preferably again at delivery. Any woman who delivers a stillborn infant should be tested for syphilis. All pregnant women should be routinely tested for hepatitis B surface antigen (HBsAg) during an early prenatal visit (e.g., first trimester) in each pregnancy, even if they have been previously vaccinated or tested. Women who were not screened prenatally, those who engage in behaviors that put them at high risk for infection (e.g., more than one sex partner in the previous 6 months, evaluation or treatment for an STD, recent or current injecting-drug use, and HBsAg-positive sex partner), and those with clinical hepatitis should be retested at the time of admission to the hospital for delivery. Women at risk for HBV infection also should be vaccinated. To avoid misinterpreting a transient positive HBsAg result during the 21 days after vaccination, HBsAg testing should be performed before the vaccination. All laboratories that conduct HBsAg tests should use an HBsAg test that is FDA-cleared and should perform testing according to the manufacturer's labeling, including testing of initially reactive specimens with a licensed neutralizing confirmatory test. When pregnant women are tested for HBsAg at the time of admission for delivery, shortened testing protocols may be used, and initially reactive results should prompt expedited administration of immunoprophylaxis to infants. All pregnant women should be routinely tested for Chlamydia trachomatis (see Chlamydia Infections, Diagnostic Considerations) at the first prenatal visit. Women aged <25 years and those at increased risk for chlamydia (i.e., women who have a new or more than one sex partner) also should be retested during the third trimester to prevent maternal postnatal complications and chlamydial infection in the infant. Screening during the first trimester might prevent the adverse effects of chlamydia during pregnancy, but supportive evidence for this is lacking. If screening is performed only during the first trimester, a longer period exists for acquiring infection before delivery. All pregnant women at risk for gonorrhea or living in an area in which the prevalence of Neisseria gonorrhoeae is high should be tested at the first prenatal visit for N. gonorrhoeae. (See Gonococcal Infections, Diagnostic Considerations). A repeat test should be performed during the third trimester for those at continued risk. All pregnant women at high risk for hepatitis C infection should be tested for hepatitis C antibodies (see Hepatitis C, Diagnostic Considerations) at the first prenatal visit. Women at high risk include those with a history of injecting-drug use and those with a history of blood transfusion or organ transplantion before 1992. Evaluation for bacterial vaginosis (BV) might be conducted during the first prenatal visit for asymptomatic patients who are at high risk for preterm labor (e.g., those who have a history of a previous preterm delivery). Evidence does not support routine testing for BV. A Papanicolaou (Pap) smear should be obtained at the first prenatal visit if none has been documented during the preceding year. Women who are HBsAg positive should be reported to the local and/or state health department to ensure that they are entered into a case-management system and that timely and appropriate prophylaxis is provided for their infants. Information concerning the pregnant woman's HBsAg status should be provided to the hospital in which delivery is planned and to the health-care provider who will care for the newborn. In addition, household and sex contacts of women who are HBsAg positive should be vaccinated. Women who are HBsAg positive should be provided with, or referred for, appropriate counseling and medical management. Pregnant women who are HBsAg positive pregnant women should receive information regarding hepatitis B that addresses --- modes of transmission; --- perinatal concerns (e.g., breastfeeding is not contraindicated); --- prevention of HBV transmission, including the importance of postexposure prophylaxis for the newborn infant and hepatitis B vaccination for household contacts and sex partners; and --- evaluation for and treatment of chronic HBV infection. No treatment is available for HCV-infected pregnant women. However, all women with HCV infection should receive appropriate counseling and supportive care as needed (see Hepatitis C, Prevention). No vaccine is available to prevent HCV transmission. In the absence of lesions during the third trimester, routine serial cultures for HSV are not indicated for women who have a history of recurrent genital herpes. Prophylactic cesarean section is not indicated for women who do not have active genital lesions at the time of delivery. In addition, insufficient evidence exists to recommend routine HSV-2 serologic screening among previously undiagnosed women during pregnancy, nor does sufficient evidence exist to recommend routine antiviral suppressive therapy late in gestation for all HSV-2 positive women. The presence of genital warts is not an indication for cesarean section. Not enough evidence exists to recommend routine screening for Trichomonas vaginalis in asymptomatic pregnant women. For a more detailed discussion of STD testing and treatment among pregnant women and other infections not transmitted sexually, refer to the following references: Guide to Clinical Preventive Services (29); Guidelines for Perinatal Care (30); ACOG Practice Bulletin: Prophylatic Antibiotics in Labor and Delivery (31); ACOG Committee Opinion: Primary and Preventive Care: Periodic Assessments (32); Recommendations for the Prevention and Management of Chlamydia trachomatis Infections (33); Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States---Recommendations of the Immunization Practices Advisory Committee (ACIP) (2,4); Mother-To-Infant Transmission of Hepatitis C Virus (34); Hepatitis C: Screening in Pregnancy (35); American College of Obstetricians and Gynecologists (ACOG) Educational Bulletin: Viral Hepatitis in Pregnancy (36); Revised Public Health Service Recommendations for HIV Screening of Pregnant Women (37); Prenatal and Perinatal Human Immunodeficiency Virus Testing: Expanded Recommendations (38); US Preventative Task Force HIV Screening Guidelines (39); Rapid HIV Antibody Testing During Labor and Delivery for Women of Unknown HIV Status: A Practical Guide and Model Protocol (40); and Sexually Transmitted Diseases in Adolescents (41). These sources are not entirely consistent in their recommendations. For example, the Guide to Clinical Preventive Services recommends screening of patients at high risk for chlamydia but indicates that the optimal timing for screening is uncertain. The Guidelines for Perinatal Care recommends that pregnant women at high risk for chlamydia be screened for infection during the first prenatal care visit and during the third trimester. Recommendations to screen pregnant women for STDs are based on disease severity and sequelae, prevalence in the population, costs, medicolegal considerations (e.g., state laws), and other factors. The screening recommendations in this report are broader (i.e., if followed, more women will be screened for more STDs than would be screened by following other recommendations) and are compatible with other CDC guidelines. The rates of many STDs are highest among adolescents. For example, the reported rates of chlamydia and gonorrhea are highest among females aged 15--19 years, and many persons acquire HPV infection during their adolescent years. Among adolescents with acute HBV infection, the most commonly reported risk factors are having sexual contact with a chronically infected person or with multiple sex partners, or reporting their sexual preference as homosexual. As part of a comprehensive strategy to eliminate HBV transmission in the United States, ACIP has recommended that all children and adolescents be administered HBV vaccine (2). Younger adolescents (i.e., persons aged <15 years) who are sexually active are at particular risk for STDs, especially youth in detention facilities, STD clinic patients, male homosexuals, and injecting-drug users (IDUs). Adolescents are at higher risk for STDs because they frequently have unprotected intercourse, are biologically more susceptible to infection, are engaged in sexual partnerships frequently of limited duration, and face multiple obstacles to using health care. Several of these issues can be addressed by clinicians who provide services to adolescents. Clinicians can address adolescents' lack of knowledge and awareness regarding the risks and consequences of STDs by offering guidance concerning healthy sexual behavior and, therefore, prevent the establishment of patterns of behavior that can undermine sexual health. With a few exceptions, all adolescents in the United States can legally consent to the confidential diagnosis and treatment of STDs. In all 50 states and the District of Columbia, medical care for STDs can be provided to adolescents without parental consent or knowledge. In addition, in the majority of states, adolescents can consent to HIV counseling and testing. Consent laws for vaccination of adolescents differ by state. Several states consider provision of vaccine similar to treatment of STDs and provide vaccination services without parental consent. Because of the crucial importance of confidentially, health-care providers should follow policies that provide confidentiality and comply with state laws for STD services. Despite the prevalence of STDs among adolescents, providers frequently fail to inquire about sexual behavior, assess risk for STDs, provide counseling on risk reduction, and screen for asymptomatic infection during clinical encounters. The style and content of counseling and health education on these sensitive subjects should be adapted for adolescents. Discussions should be appropriate for the patient's developmental level and should be aimed at identifying risky behaviors (e.g., sex and drug-use behaviors). Careful, nonjudgmental, and thorough counseling are particularly vital for adolescents who might not acknowledge that they engage in high-risk behaviors. Management of children who have STDs requires close cooperation between clinicians, laboratorians, and child-protection authorities. Official investigations, when indicated, should be initiated promptly. Some diseases (e.g., gonorrhea, syphilis, and chlamydia), if acquired after the neonatal period, are virtually 100% indicative of sexual contact. For other diseases (e.g., HPV infection and vaginitis), the association with sexual contact is not as clear (see Sexual Assault and STDs). Some MSM are at high risk for HIV infection and other viral and bacterial STDs. The frequency of unsafe sexual practices and the reported rates of bacterial STDs and incident HIV infection have declined substantially in MSM from the 1980s through the mid-1990s. However, during the previous 10 years, increased rates of infectious syphilis, gonorrhea, and chlamydial infection and of higher rates of unsafe sexual behaviors have been documented among MSM in the United States and virtually all industrialized countries. The effect of these behavioral changes on HIV transmission has not been ascertained, but preliminary data suggest that the incidence of HIV infection might be increasing among some MSM. These adverse trends probably are related to changing attitudes concerning HIV infection because of the effects of improved HIV/AIDS therapy on quality of life and survival, changing patterns of substance abuse, demographic shifts in MSM populations, and changes in sex partner networks resulting from new venues for partner acquisition. Clinicians should assess the risks of STDs for all male patients, including a routine inquiry about the sex of patients' sex partners. MSM, including those with HIV infection, should routinely undergo nonjudgmental STD/HIV risk assessment and client-centered prevention counseling to reduce the likelihood of acquiring or transmitting HIV or other STDs. Clinicians should be familiar with local community resources available to assist MSM at high risk in facilitating behavioral change. Clinicians also should routinely ask sexually active MSM about symptoms consistent with common STDs, including urethral discharge, dysuria, genital and perianal ulcers, regional lymphadenopathy, skin rash, and anorectal symptoms consistent with proctitis. Clinicians also should maintain a low threshold for diagnostic testing of symptomatic patients. Routine laboratory screening for common STDs is indicated for all sexually active MSM. The following screening recommendations are based on preliminary data (42,43). These tests should be performed at least annually for sexually active MSM, including men with or without established HIV infection: HIV serology, if HIV negative or not tested within the previous year; syphilis serology; a test for urethral infection with N. gonorrhoeae and C. trachomatis in men who have had insertive intercourse* during the preceding year; a test for rectal infection† with N. gonorrhoeae and C. trachomatis in men who have had receptive anal intercourse* during the preceding year; a test for pharyngeal infection† with N. gonorrhoeae in men who have acknowledged participation in receptive oral intercourse* during the preceding year; testing for C. trachomatis pharyngeal infection is not recommended. In addition, some specialists would consider type-specific serologic tests for HSV-2, if infection status is unknown. Routine testing for anal cytologic abnormalities or anal HPV infection is not recommended until more data are available on the reliability of screening methods, the safety of and response to treatment, and programmatic considerations. More frequent STD screening (i.e., at 3--6 month intervals) is indicated for MSM who have multiple or anonymous partners, have sex in conjunction with illicit drug use, use methamphetamine, or whose sex partners participate in these activities. Vaccination against hepatitis A and B is recommended for all MSM in whom previous infection or immunization cannot be documented. Preimmunization serologic testing might be considered to reduce the cost of vaccinating MSM who are already immune to these infections, but this testing should not be delay vaccination. Vaccinating persons who are immune to HAV or HBV infection because of previous infection or vaccination does not increase the risk for vaccine-related adverse events (see Hepatitis B, Prevaccination Antibody Screening). Women Who Have Sex with Women (WSW) Few data are available on the risk of STDs conferred by sex between women, but transmission risk probably varies by the specific STD and sexual practice (e.g., oral-genital sex, vaginal or anal sex using hands, fingers, or penetrative sex items, and oral-anal sex) (44,45). Practices involving digital-vaginal or digital-anal contact, particularly with shared penetrative sex items, present a possible means for transmission of infected cervicovaginal secretions. This possibility is most directly supported by reports of metronidazole-resistant trichomoniasis and genotype-concordant HIV transmitted sexually between women who reported these behaviors and by the high prevalence of BV among monogamous WSW. Transmission of HPV can occur with skin-to-skin or skin-to-mucosa contact, which can occur during sex between women. HPV deoxyribonucleic acid (DNA) has been detected through polymerase chain reaction (PCR)-based methods from the cervix, vagina, and vulva in 13%--30% of WSW, and high- and low-grade squamous intraepithelial lesions (SIL) have been detected on Pap tests in WSW who reported no previous sex with men (46). However, the majority of self-identified WSW (53%--99%) have had sex with men and might continue this practice (47). Therefore, all women should undergo Pap test screening using current national guidelines, regardless of sexual preference or sexual practices. HSV-2 genital transmission between female sex partners is probably inefficient, but the relatively frequent practice of orogenital sex among WSW might place them at higher risk for genital infection with HSV-1. This hypothesis is supported by the recognized association between HSV-1 seropositivity and previous number of female partners among WSW. Transmission of syphilis between female sex partners, probably through oral sex, has been reported. Although the rate of transmission of C. trachomatis between women is unknown, WSW who also have sex with men are at risk and should undergo routine screening according to guidelines. HIV Infection: Detection, Counseling, and Referral Infection with HIV produces a spectrum of disease that progresses from a clinically latent or asymptomatic state to AIDS as a late manifestation. The pace of disease progression varies. In untreated patients, the time between infection with HIV and the development of AIDS ranges from a few months to as long as 17 years (median: 10 years). The majority of adults and adolescents infected with HIV remain symptom-free for extended periods, but viral replication is active during all stages of infection and increases substantially as the immune system deteriorates. In the absence of treatment, AIDS will develop eventually in nearly all HIV-infected persons. Improvements in antiretroviral therapy and increasing awareness among both patients and health-care providers of the risk factors associated with HIV transmission have led to more testing for HIV and earlier diagnosis, frequently before symptoms develop. However, the conditions of nearly 40% of persons who acquire HIV infection continue to be diagnosed late, within 1 year of acquiring AIDS. Prompt diagnosis of HIV infection is essential for multiple reasons. Treatments are available that slow the decline of immune system function; use of these therapies has been associated with substantial declines in HIV-associated morbidity and mortality in recent years. HIV-infected persons who have altered immune function are at increased risk for infections for which preventive measures are available (e.g., Pneumocystis jiroveci pneumonia, toxoplasma encephalitis [TE], disseminated Mycobacterium avium complex [MAC] disease, tuberculosis [TB], and bacterial pneumonia). Because of its effect on the immune system, HIV affects the diagnosis, evaluation, treatment, and follow-up of multiple other diseases and might affect the efficacy of antimicrobial therapy for some STDs. Finally, the early diagnosis of HIV enables health-care providers to counsel infected patients, refer them to various support services, and help prevent HIV transmission to others. Acutely infected persons might have elevated HIV viral loads and, therefore, might be more likely to transmit HIV to their partners (48,49). Proper management of HIV infection involves a complex array of behavioral, psychosocial, and medical services. Although some services might not be available in STD treatment facilities. Therefore, referral to a health-care provider or facility experienced in caring for HIV-infected patients is advised. Providers working in STD-treatment facilities should be knowledgeable about the options for referral available in their communities. While receiving care in STD-treatment facilities, HIV-infected patients should be educated about HIV infection and the various options available for support services and HIV care. A detailed discussion of the multiple, complex services required for management of HIV infection is beyond the scope of this section; however, this information is available in other published resources (6,9,50,51). In subsequent sections, this report provides information regarding diagnostic testing for HIV infection, counseling patients who have HIV infection, referral of patients for support services, including medical care, and the management of sex and injecting-drug partners in STD-treatment facilities. In addition, the report discusses HIV infection during pregnancy and in infants and children. Detection of HIV Infection: Screening and Diagnostic Testing All persons who seek evaluation and treatment for STDs should be screened for HIV infection. Screening should be routine, regardless of whether the patient is known or suspected to have specific behavioral risks for HIV infection. Consent and Pretest Information HIV screening should be voluntary and conducted only with the patient's knowledge and understanding that testing is planned. Persons should be informed orally or in writing that HIV testing will be performed unless they decline (i.e., opt-out screening). Oral or written communications should include an explanation of positive and negative test results, and patients should be offered an opportunity to ask questions and to decline testing. Prevention Counseling Prevention counseling does not need to be explicitly linked to the HIV-testing process. However, some patients might be more likely to think about HIV and consider their risks when undergoing an HIV test. HIV testing might present an ideal opportunity to provide or arrange for prevention counseling to assist with behavior changes that can reduce risk for acquiring HIV infection. Prevention counseling should be offered and encouraged in all health-care facilities serving patients at high risk and in those (e.g., STD clinics) where information on HIV-risk behaviors is routinely elicited. HIV infection usually is diagnosed by tests for antibodies against HIV-1. Some combination tests also detect antibodies against HIV-2 (i.e., HIV-1/2). Antibody testing begins with a sensitive screening test (e.g., the enzyme immunoassay [EIA] or rapid test). The advent of HIV rapid testing has enabled clinicians to make a substantially accurate presumptive diagnosis of HIV-1 infection within half an hour. This testing can facilitate the identification of the more than 250,000 persons living with undiagnosed HIV in the United States. Reactive screening tests must be confirmed by a supplemental test (e.g., the Western blot [WB]) or an immunofluorescence assay (IFA) (52). If confirmed by a supplemental test, a positive antibody test result indicates that a person is infected with HIV and is capable of transmitting the virus to others. HIV antibody is detectable in at least 95% of patients within 3 months after infection. Although a negative antibody test result usually indicates that a person is not infected, antibody tests cannot exclude recent infection. The majority of HIV infections in the United States are caused by HIV-1. However, HIV-2 infection should be suspected in persons who have epidemiologic risk factors, including being from West Africa (where HIV-2 is endemic) or have sex partners from endemic areas, have sex partners known to be infected with HIV-2, or have received a blood transfusion or nonsterile injection in a West African country. HIV-2 testing also is indicated when clinical evidence of HIV exists but tests for HIV-1 antibodies or HIV-1 viral load are not positive, or when HIV-1 WB results include the unusual indeterminate pattern of gag (p55, p24, p17) plus pol (p66, p51, p31) bands in the absence of env (gp160, gp120, gp41) bands. Health-care providers should be knowledgeable about the symptoms and signs of acute retroviral syndrome, which is characterized by fever, malaise, lymphadenopathy, and skin rash. This syndrome frequently occurs in the first few weeks after HIV infection, before antibody test results become positive. Suspicion of acute retroviral syndrome should prompt nucleic acid testing (HIV plasma ribonucleic acid [RNA]) to detect the presence of HIV, although not all nucleic acid tests are approved for diagnostic purposes; a positive HIV nucleic acid test should be confirmed by subsequent antibody testing to document seroconversion (using standard methods, EIA, and WB). Acutely infected patients might be highly contagious because of increased plasma and genital HIV RNA concentrations and might be continuing to engage in risky behaviors (48,49). Current guidelines suggest that persons with recently acquired HIV infection might benefit from antiretroviral drugs and be candidates for clinical trials (53,54). Therefore, patients with acute HIV infection should be referred immediately to an HIV clinical care provider. Diagnosis of HIV infection should prompt efforts to reduce the risk behavior that resulted in HIV infection and could result in transmission of HIV to others (55). Early counseling and education are particularly important for persons with recently acquired infection because HIV plasma RNA levels are characteristically high during this phase of infection and probably constitute an increased risk for HIV transmission. The following are specific recommendations for diagnostic testing for HIV infection: HIV screening is recommended for all persons who seek evaluation and treatment for STDs. HIV testing must be voluntary. Consent for HIV testing should be incorporated into the general consent for care (verbally or in writing) with an opportunity to decline (opt-out screening). HIV rapid testing must be considered, especially in clinics where a high proportion of patients do not return for HIV test results. Positive screening tests for HIV antibody must be confirmed by a supplemental test (e.g., WB or IFA) before being considered diagnostic of HIV infection. Persons who have positive HIV test results (screening and confirmatory) must receive initial HIV prevention counseling before leaving the testing site. Such persons should 1) receive a medical evaluation and, if indicated, behavioral and psychological services, or 2) be referred for these services. Providers should be alert to the possibility of acute retroviral syndrome and should perform nucleic acid testing for HIV, if indicated. Patients suspected of having recently acquired HIV infection should be referred for immediate consultation with a specialist. Counseling for Patients with HIV Infection and Referral to Support Services Persons can be expected to be distressed when first informed of a positive HIV test result. Such persons face multiple major adaptive challenges, including 1) accepting the possibility of a shortened life span, 2) coping with the reactions of others to a stigmatizing illness, 3) developing and adopting strategies for maintaining physical and emotional health, and 4) initiating changes in behavior to prevent HIV transmission to others. Many persons will require assistance with making reproductive choices, gaining access to health services, confronting possible employment or housing discrimination, and coping with changes in personal relationships. Therefore, behavioral and psychosocial services are an integral part of health care for HIV-infected persons. Such services should be available on site or through referral when HIV infection is diagnosed. A comprehensive discussion of specific recommendations is available in the Guidelines for HIV Counseling, Testing, and Referral and Revised Recommendations for HIV Screening of Pregnant Women (6). Innovative and successful interventions to decrease risk taking by HIV-infected patients have been developed for diverse populations (12). Practice settings for offering HIV care differ depending on local resources and needs. Primary care providers and outpatient facilities should ensure that appropriate resources are available for each patient to avoid fragmentation of care. Although a single source that is capable of providing comprehensive care for all stages of HIV infection is preferred, the limited availability of such resources frequently results in the need to coordinate care among medical and social service providers in different locations. Providers should avoid long delays between diagnosis of HIV infection and access to additional medical and psychosocial services. The use of HIV rapid testing can help avoid unnecessary delays. Recently identified HIV infection might not have been recently acquired. Persons newly diagnosed with HIV might be at any stage of infection. Therefore, health-care providers should be alert for symptoms or signs that suggest advanced HIV infection (e.g., fever, weight loss, diarrhea, cough, shortness of breath, and oral candidiasis). The presence of any of these symptoms should prompt urgent referral for specialty medical care. Similarly, providers should be alert for signs of psychologic distress and be prepared to refer patients accordingly. Diagnosis of HIV infection reinforces the need to counsel patients regarding high-risk behaviors because the consequences of such behaviors include the risk for acquiring additional STDs and for transmitting HIV (and other STDs) to other persons. Such attention to behaviors in HIV-infected persons is consistent with national strategies for HIV prevention (55). Providers should refer patients for prevention counseling and risk-reduction support concerning high-risk behaviors (e.g., substance abuse and high-risk sexual behaviors). In multiple recent studies, researchers have developed successful prevention interventions for different HIV-infected populations that can be adapted to individuals (56,57). Persons with newly diagnosed HIV infection who receive care in the STD treatment setting should be educated concerning what to expect as they enter medical care for HIV infection (51). In nonemergent situations, the initial evaluation of HIV-positive patients usually includes the following: a detailed medical history, including sexual and substance abuse history; vaccination history; previous STDs; and specific HIV-related symptoms or diagnoses; a physical examination, including a gynecologic examination for women; testing for N. gonorrhoeae and C. trachomatis (and for women, a Pap test and wet mount examination of vaginal secretions); complete blood and platelet counts and blood chemistry profile; toxoplasma antibody test; tests for antibodies to HCV; testing for previous or present HAV or HBV infection is recommended if determined to be cost-effective before considering vaccination (see Hepatitis A and Hepatitis B); a CD4 T-lymphocyte analysis and determination of HIV plasma viral load; a tuberculin skin test (sometimes referred to as a purified protein derivative); a urinalysis; and a chest radiograph. Some specialists recommend type-specific testing for HSV-2 if herpes infection status is unknown. A first dose of hepatitis A and/or hepatitis B vaccination for previously unvaccinated persons for whom vaccine is recommended (see Hepatitis A and Hepatitis B) should be administered at this first visit. In subsequent visits, when the results of laboratory and skin tests are available, antiretroviral therapy may be offered, if indicated, after initial antiretroviral resistance testing is performed (53) and specific prophylactic medications are administered to reduce the incidence of opportunistic infections (e.g., Pneumocystis jiroveci pneumonia, TE, disseminated MAC infection, and TB) (50). The vaccination series for hepatitis A and/or B should be offered for those in whom vaccination is recommended. Influenza vaccination should be offered annually, and pneumococcal vaccination should be given if it has not been administered in the previous 5 years (50,51). Providers should be alert to the possibility of new or recurrent STDs and should treat such conditions aggressively. The occurrence of an STD in an HIV-infected person is an indication of high-risk behavior and should prompt referral for counseling. Because many STDs are asymptomatic, routine screening for curable STDs (e.g., syphilis, gonorrhea, and chlamydia) should be performed at least yearly for sexually active persons. Women should be screened for cervical cancer precursor lesions by annual Pap smears. More frequent STD screening might be appropriate depending on individual risk behaviors, the local epidemiology of STDs, and whether incident STDs are detected by screening or by the presence of symptoms. Newly diagnosed HIV-infected persons should receive or be referred for a thorough psychosocial evaluation, including ascertainment of behavioral factors indicating risk for transmitting HIV. Patients might require referral for specific behavioral intervention (e.g., a substance abuse program), mental health disorders (e.g., depression), or emotional distress. They might require assistance with securing and maintaining employment and housing. Women should be counseled or appropriately referred regarding reproductive choices and contraceptive options. Patients with multiple psychosocial problems might be candidates for comprehensive risk-reduction counseling and services (8). The following are specific recommendations for HIV counseling and referral: Persons who test positive for HIV antibody should be counseled, either on site or through referral, concerning the behavioral, psychosocial, and medical implications of HIV infection. Health-care providers should be alert for medical or psychosocial conditions that require immediate attention. Providers should assess newly diagnosed persons' need for immediate medical care or support and should link them to services in which health-care personnel are experienced in providing care for HIV-infected persons. Such persons might need medical care or services for substance abuse, mental health disorders, emotional distress, reproductive counseling, risk-reduction counseling, and case management. Providers should follow-up to ensure that patients have received the needed services. Patients should be educated regarding what to expect in follow-up medical care. Several innovative interventions for HIV prevention have been developed for diverse at-risk populations, and these can be locally replicated or adapted (11,12). Involvement of nongovernment organizations and community-based organizations might complement such efforts in the clinical setting. Management of Sex Partners and Injecting-Drug Partners Clinicians evaluating HIV-infected persons should collect information to determine whether any partners should be notified concerning possible exposure to HIV (6). When referring to persons who are infected with HIV, the term "partner" includes not only sex partners but also IDUs who share syringes or other injection equipment. The rationale for partner notification is that the early diagnosis and treatment of HIV infection in these partners might reduce morbidity and provides the opportunity to encourage risk-reducing behaviors. Partner notification for HIV infection should be confidential and depends on the voluntary cooperation of the patient. Specific guidance regarding spousal notification may vary by jurisdiction. Two complementary notification processes, patient referral and provider referral, can be used to identify partners. With patient referral, patients directly inform their partners of their exposure to HIV infection. With provider referral, trained health department personnel locate partners on the basis of the names, descriptions, and addresses provided by the patient. During the notification process, the confidentiality of patients is protected; their names are not revealed to partners who are notified. Many state and local health departments provide these services. The following are specific recommendations for implementing partner-notification procedures: HIV-infected patients should be encouraged to notify their partners and to refer them for counseling and testing. If requested by the patient, health-care providers should assist in this process, either directly or by referral to health department partner-notification programs. If patients are unwilling to notify their partners or if they cannot ensure that their partners will seek counseling, physicians or health department personnel should use confidential partner notification procedures. Partners who are contacted within 72 hours of a high-risk sexual or injecting-drug exposure to an HIV-infected partner, which involves exposure to genital secretions and/or blood, should be offered PEP with combination antiretroviral therapy to complete a 28-day course (58). Pregnancy. All pregnant women in the United States should be tested for HIV infection as early during pregnancy as possible. Testing should occur after the patient is notified that she will be tested for HIV as part of the routine panel of prenatal tests, unless she declines (i.e., opt-out screening) (30--32). For women who decline, providers should continue to strongly encourage testing and address concerns that pose obstacles to testing. Women who decline testing because they have had a previous negative HIV test should be informed of the importance of retesting during each pregnancy. Testing pregnant women is particularly important, not only to maintain the health of the patient, but also because interventions (i.e., antiretroviral and obstetrical) can reduce the risk of perinatal transmission of HIV. After pregnant women have been identified as being HIV-infected, they should be educated about the risk of perinatal infection. Evidence indicates that, in the absence of antiretroviral and other interventions, 15%--25% of infants born to HIV-infected mothers will become infected with HIV; such evidence also indicates that an additional 12%--14% will become infected during breastfeeding where HIV-infected women breastfeed their infants into the second year of life (59,60). The risk of perinatal HIV transmission can be reduced substantially to <2% through the use of antiretroviral regimens and obstetrical interventions (i.e., zidovudine or nevirapine and elective cesarean section at 38 weeks of pregnancy) and by avoiding breastfeeding (61). Pregnant women who are HIV infected should be counseled concerning their options (either on-site or by referral), given appropriate antenatal treatment, and advised not to breastfeed their infants (for women living in the United States, where infant formula is readily available and can be safely prepared). HIV Infection Among Infants and Children. Diagnosis of HIV infection in a pregnant woman indicates the need to consider whether other children of the woman might be infected. Infants and young children with HIV infection differ from adults and adolescents with respect to the diagnosis, clinical presentation, and management of HIV disease. For example, because maternal HIV antibody passes through the placenta, antibody tests for HIV are expected to be positive in the sera of both infected and uninfected infants born to seropositive mothers. A definitive determination of HIV infection for an infant aged <18 months is usually based on HIV nucleic acid testing. Management of infants, children, and adolescents who are known or suspected to be infected with HIV requires referral to physicians familiar with the manifestations and treatment of pediatric HIV infection (50,51,62). Diseases Characterized by Genital Ulcers Management of Patients Who Have Genital Ulcers In the United States, the majority of young, sexually active patients who have genital ulcers have either genital herpes, syphilis, or chancroid. The frequency of each condition differs by geographic area and patient population; however, genital herpes is the most prevalent of these diseases. More than one of these diseases can be present in a patient who has genital ulcers. All three of these diseases has been associated with an increased risk for HIV infection. Not all genital ulcers are caused by sexually transmitted infections. A diagnosis based only on the patient's medical history and physical examination frequently is inaccurate. Therefore, all patients who have genital ulcers should be evaluated with a serologic test for syphilis and a diagnostic evaluation for genital herpes; in settings where chancroid is prevalent, a test for Haemophilus ducreyi should also be performed. Specific tests for evaluation of genital ulcers include 1) syphilis serology and either darkfield examination or direct immunofluorescence test for T. pallidum; 2) culture or antigen test for HSV; and 3) culture for H. ducreyi. No FDA-cleared PCR test for these organisms is available in the United States; however, such testing can be performed by clinical laboratories that have developed their own tests and conducted a Clinical Laboratory Improvement Amendment (CLIA) verification study. Type-specific serology for HSV-2 might be helpful in identifying persons with genital herpes (see Genital Herpes, Type-Specific Serologic Tests). Biopsy of genital ulcers might be helpful in identifying the cause of ulcers that are unusual or that do not respond to initial therapy. HIV testing should be performed on all patients who have genital ulcers caused by T. pallidum or H. ducreyi, and should be strongly considered for those who have genital ulcers caused by HSV (see Diagnostic Considerations, sections, Syphilis, Chancroid, and Genital Herpes Simplex Virus). Health-care providers frequently must treat patients before test results are available because early treatment decreases the possibility of ongoing transmission and because successful treatment of genital herpes depends on prompt initiation of therapy. The clinician should treat for the diagnosis considered most likely, on the basis of clinical presentation and epidemiologic circumstances. In some instances, treatment must be initiated for additional conditions because of diagnostic uncertainty. Even after complete diagnostic evaluation, at least 25% of patients who have genital ulcers have no laboratory-confirmed diagnosis. In the United States, chancroid usually occurs in discrete outbreaks, although the disease is endemic in some areas. Chancroid is a cofactor for HIV transmission, as are genital herpes and syphilis; high rates of HIV infection among patients who have chancroid occur in the United States and other countries. Approximately 10% of persons who have chancroid that was acquired in the United States are coinfected with T. pallidum or HSV; this percentage is higher in persons who have acquired chancroid outside the United States. A definitive diagnosis of chancroid requires the identification of H. ducreyi on special culture media that is not widely available from commercial sources; even when these media are used, sensitivity is <80%. No FDA-cleared PCR test for H. ducreyi is available in the United States, but such testing can be performed by clinical laboratories that have developed their own PCR test and conducted a CLIA verification study. The combination of a painful genital ulcer and tender suppurative inguinal adenopathy suggests the diagnosis of chancroid. A probable diagnosis of chancroid, for both clinical and surveillance purposes, can be made if all of the following criteria are met: 1) the patient has one or more painful genital ulcers; 2) the patient has no evidence of T. pallidum infection by darkfield examination of ulcer exudate or by a serologic test for syphilis performed at least 7 days after onset of ulcers; 3) the clinical presentation, appearance of genital ulcers and, if present, regional lymphadenopathy are typical for chancroid; and 4) a test for HSV performed on the ulcer exudate is negative. Successful treatment for chancroid cures the infection, resolves the clinical symptoms, and prevents transmission to others. In advanced cases, scarring can result, despite successful therapy. Recommended Regimens* Azithromycin 1 g orally in a single dose Ceftriaxone 250 mg intramuscularly (IM) in a single dose Ciprofloxacin 500 mg orally twice a day for 3 days Erythromycin base 500 mg orally three times a day for 7 days * Ciprofloxacin is contraindicated for pregnant and lactating women. Azithromycin and ceftriaxone offer the advantage of single-dose therapy. Worldwide, several isolates with intermediate resistance to either ciprofloxacin or erythromycin have been reported. Other Management Considerations Male patients who are uncircumcised and patients with HIV infection do not respond as well to treatment as those who are circumcised or HIV negative. Patients should be tested for HIV infection at the time chancroid is diagnosed. Patients should be retested for syphilis and HIV 3 months after the diagnosis of chancroid, if the initial test results were negative. Patients should be reexamined 3--7 days after initiation of therapy. If treatment is successful, ulcers usually improve symptomatically within 3 days and objectively within 7 days after therapy. If no clinical improvement is evident, the clinician must consider whether 1) the diagnosis is correct, 2) the patient is coinfected with another STD, 3) the patient is infected with HIV, 4) the treatment was not used as instructed, or 5) the H. ducreyi strain causing the infection is resistant to the prescribed antimicrobial. The time required for complete healing depends on the size of the ulcer; large ulcers might require >2 weeks. In addition, healing is slower for some uncircumcised men who have ulcers under the foreskin. Clinical resolution of fluctuant lymphadenopathy is slower than resolution for ulcers and might require needle aspiration or incision and drainage. Although needle aspiration of chancroid buboes is a simple procedure, incision and drainage might be preferred because of a reduced need for repeat drainage procedures. Management of Sex Partners Sex partners of patients who have chancroid should be examined and treated, regardless of whether symptoms of the disease are present, if they had sexual contact with the patient during the 10 days preceding the patient's onset of symptoms. The safety and efficacy of azithromycin for pregnant and lactating women have not been established. Ciprofloxacin is contraindicated during pregnancy and lactation. No adverse effects of chancroid on pregnancy outcome have been reported. HIV-infected patients who have chancroid should be monitored closely because, as a group, these patients are more likely to experience treatment failure and to have ulcers that heal more slowly. HIV-infected patients might require longer courses of therapy than those recommended for HIV-negative patients, and treatment failures can occur with any regimen. Because evidence is limited concerning the therapeutic efficacy of the recommended ceftriaxone and azithromycin regimens in HIV-infected patients, these regimens should be used for such patients only if follow-up can be ensured. Some specialists prefer the erythromycin 7-day regimen for treating HIV-infected persons. Genital HSV Infections Genital herpes is a chronic, life-long viral infection. Two types of HSV have been identified, HSV-1 and HSV-2. The majority of cases of recurrent genital herpes are caused by HSV-2 although HSV-1 might become more common as a cause of first episode genital herpes. At least 50 million persons in the United States have genital HSV infection. The majority of persons infected with HSV-2 have not been diagnosed with genital herpes. Many such persons have mild or unrecognized infections but shed virus intermittently in the genital tract. The majority of genital herpes infections are transmitted by persons unaware that they have the infection or who are asymptomatic when transmission occurs. Diagnosis of HSV Infection The clinical diagnosis of genital herpes is both insensitive and nonspecific. The classical painful multiple vesicular or ulcerative lesions are absent in many infected persons. Up to 50% of first-episode cases of genital herpes are caused by HSV-1 (63), but recurrences and subclinical shedding are much less frequent for genital HSV-1 infection than genital HSV-2 infection (64,65). Therefore, whether genital herpes is caused by HSV-1 or HSV-2 influences prognosis and counseling. Therefore, the clinical diagnosis of genital herpes should be confirmed by laboratory testing (66). Both virologic and type-specific serologic tests for HSV should be available in clinical settings that provide care for patients with STDs or those at risk for STDs. Virologic Tests Isolation of HSV in cell culture is the preferred virologic test for patients who seek medical treatment for genital ulcers or other mucocutaneous lesions. However, the sensitivity of culture is low, especially for recurrent lesions, and declines rapidly as lesions begin to heal. PCR assays for HSV DNA are more sensitive and have been used instead of viral culture (67,68); however, PCR tests are not FDA-cleared for testing of genital specimens. PCR is the test of choice for detecting HSV in spinal fluid for diagnosis of HSV infection of the central nervous system (CNS). Viral culture isolates should be typed to determine if HSV-1 or HSV-2 is the cause of the infection. Lack of HSV detection (i.e., culture or PCR) does not indicate a lack of HSV infection, as viral shedding is intermittent. The use of cytologic detection of cellular changes of HSV infection is an insensitive and nonspecific method of diagnosis, both for genital lesions (i.e., Tzanck preparation) and for cervical Pap smears and should not be relied upon. Type-Specific Serologic Tests Both type-specific and nontype-specific antibodies to HSV develop during the first several weeks after infection and persist indefinitely. Accurate type-specific HSV serologic assays are based on the HSV-specific glycoprotein G2 (HSV-2) and glycoprotein G1 (HSV-1). Such assays first became commercially available in 1999, but older assays that do not accurately distinguish HSV-1 from HSV-2 antibody (despite claims to the contrary) remain on the market. Therefore, the serologic type-specific glycoprotein G (gG)-based assays should be specifically requested when serology is performed (69--71). The FDA-cleared glycoprotein G-based type-specific assays include the laboratory-based assays HerpeSelect™-1 enzyme-linked immunosorbent assay (ELISA) immunoglobulin G (IgG) or HerpeSelect™-2 ELISA IgG and HerpeSelect™ 1 and 2 Immunoblot IgG (Focus Technology, Inc., Herndon, Virginia), and HSV-2 ELISA (Trinity Biotech USA, Berkeley Heights, New Jersey). Two other assays, Biokit HSV-2 and SureVue HSV-2 (Biokit USA, Lexington, Massachusetts, and Fisher Scientific, Pittsburgh, Pennsylvania, respectively), are point-of-care tests that provide results for HSV-2 antibodies from capillary blood or serum during a clinic visit. The sensitivities of these glycoprotein G type-specific tests for the detection of HSV-2 antibody vary from 80%--98%, and false-negative results might be more frequent at early stages of infection. The specificities of these assays are >96%. False-positive results can occur, especially in patients with a low likelihood of HSV infection. Repeat or confirmatory testing might be indicated in some settings, especially if recent acquisition of genital herpes is suspected. Because nearly all HSV-2 infections are sexually acquired, the presence of type-specific HSV-2 antibody implies anogenital infection and education and counseling appropriate for persons with genital herpes should be provided. The presence of HSV-1 antibody alone is more difficult to interpret. The majority of persons with HSV-1 antibody have oral HSV infection acquired during childhood, which might be asymptomatic. However, acquisition of genital HSV-1 appears to be increasing, and genital HSV-1 also might be asymptomatic. Lack of symptoms in an HSV-1 seropositive person does not distinguish anogenital from orolabial or cutaneous infection. Persons with HSV-1 infection, regardless of site of infection, remain at risk for HSV-2 acquisition. Type-specific HSV serologic assays might be useful in the following scenarios: 1) recurrent genital symptoms or atypical symptoms with negative HSV cultures; 2) a clinical diagnosis of genital herpes without laboratory confirmation; and 3) a partner with genital herpes. Some specialists believe that HSV serologic testing should be included in a comprehensive evaluation for STDs among persons with multiple sex partners, HIV infection, and among MSM at increased risk for HIV acquisition. Screening for HSV-1 or HSV-2 in the general population is not indicated. Principles of Management of Genital Herpes Antiviral chemotherapy offers clinical benefits to the majority of symptomatic patients and is the mainstay of management. Counseling regarding the natural history of genital herpes, sexual and perinatal transmission, and methods to reduce transmission is integral to clinical management. Systemic antiviral drugs can partially control the signs and symptoms of herpes episodes when used to treat first clinical and recurrent episodes, or when used as daily suppressive therapy. However, these drugs neither eradicate latent virus nor affect the risk, frequency, or severity of recurrences after the drug is discontinued. Randomized trials have indicated that three antiviral medications provide clinical benefit for genital herpes: acyclovir, valacyclovir, and famciclovir (72--80). Valacyclovir is the valine ester of acyclovir and has enhanced absorption after oral administration. Famciclovir also has high oral bioavailability. Topical therapy with antiviral drugs offers minimal clinical benefit, and its use is discouraged. First Clinical Episode of Genital Herpes Many persons with first-episode herpes have mild clinical manifestations but later develop severe or prolonged symptoms. Therefore, patients with initial genital herpes should receive antiviral therapy. Acyclovir 400 mg orally three times a day for 7--10 days Acyclovir 200 mg orally five times a day for 7--10 days Famciclovir 250 mg orally three times a day for 7--10 days Valacyclovir 1 g orally twice a day for 7--10 days * Treatment might be extended if healing is incomplete after 10 days of therapy. Established HSV-2 infection The majority of patients with symptomatic, first-episode genital HSV-2 infection subsequently experience recurrent episodes of genital lesions; recurrences are less frequent after initial genital HSV-1 infection. Intermittent asymptomatic shedding occurs in persons with genital HSV-2 infection, even in those with longstanding or clinically silent infection. Antiviral therapy for recurrent genital herpes can be administered either episodically to ameliorate or shorten the duration of lesions or continuously as suppressive therapy to reduce the frequency of recurrences. Many persons, including those with mild or infrequent recurrent outbreaks, benefit from antiviral therapy; therefore, options for treatment should be discussed. Some persons might prefer suppressive therapy, which has the additional advantage of decreasing the risk of genital HSV-2 transmission to susceptible partners (81). Suppressive Therapy for Recurrent Genital Herpes Suppressive therapy reduces the frequency of genital herpes recurrences by 70%--80% in patients who have frequent recurrences (i.e., >6 recurrences per year), and many patients report no symptomatic outbreaks. Treatment also is effective in patients with less frequent recurrences. Safety and efficacy have been documented among patients receiving daily therapy with acyclovir for as long as 6 years and with valacyclovir or famciclovir for 1 year. Quality of life frequently is improved in patients with frequent recurrences who receive suppressive therapy, compared with episodic treatment. The frequency of recurrent genital herpes outbreaks diminishes over time in many patients, and the patient's psychological adjustment to the disease might change. Therefore, periodically during suppressive treatment (e.g., once a year), providers should discuss the need to continue therapy with the patient. Daily treatment with valacyclovir 500 mg daily decreases the rate of HSV-2 transmission in discordant, heterosexual couples in which the source partner has a history of genital HSV-2 infection (82). Such couples should be encouraged to consider suppressive antiviral therapy as part of a strategy to prevent transmission, in addition to consistent condom use and avoidance of sexual activity during recurrences. Suppressive antiviral therapy probably reduces transmission when used by persons who have multiple partners (including MSM) and by those who are HSV-2 seropositive without a history of genital herpes. Recommended Regimens Acyclovir 400 mg orally twice a day Famiciclovir 250 mg orally twice a day Valacyclovir 500 mg orally once a day Valacyclovir 1.0 g orally once a day Valacyclovir 500 mg once a day might be less effective than other valacyclovir or acyclovir dosing regimens in patients who have very frequent recurrences (i.e., >10 episodes per year). Several studies have compared valacyclovir or famciclovir with acyclovir. The results of these studies suggest that valacyclovir and famciclovir are comparable to acyclovir in clinical outcome (74,78,79,83). Ease of administration and cost also are important considerations for prolonged treatment. Episodic Therapy for Recurrent Genital Herpes Effective episodic treatment of recurrent herpes requires initiation of therapy within 1 day of lesion onset or during the prodrome that precedes some outbreaks. The patient should be provided with a supply of drug or a prescription for the medication with instructions to initiate treatment immediately when symptoms begin. Acyclovir 400 mg orally three times a day for 5 days Acyclovir 800 mg orally twice a day for 5 days Famciclovir 125 mg orally twice daily for 5 days Famciclovir 1000 mg orally twice daily for 1 day Valacyclovir 500 mg orally twice a day for 3 days Valacyclovir 1.0 g orally once a day for 5 days Intravenous (IV) acyclovir therapy should be provided for patients who have severe HSV disease or complications that necessitate hospitalization (e.g., disseminated infection, pneumonitis, or hepatitis) or CNS complications (e.g., meningitis or encephalitis). The recommended regimen is acyclovir 5--10 mg/kg body weight IV every 8 hours for 2--7 days or until clinical improvement is observed, followed by oral antiviral therapy to complete at least 10 days of total therapy. Counseling of infected persons and their sex partners is critical to the management of genital herpes. The goal of counseling is to 1) help patients cope with the infection and 2) prevent sexual and perinatal transmission (8). Although initial counseling can be provided at the first visit, many patients benefit from learning about the chronic aspects of the disease after the acute illness subsides. Multiple resources, including websites (http://www.ashastd.org and http://www.ihmf.org) and printed materials are available to assist patients, their partners, and clinicians in counseling. HSV-infected persons might express anxiety concerning genital herpes that does not reflect the actual clinical severity of their disease; the psychological effect of HSV infection frequently is substantial. Common concerns regarding genital herpes include the severity of initial clinical manifestations, recurrent episodes, sexual relationships and transmission to sex partners, and ability to bear healthy children. The misconception that HSV causes cancer should be dispelled. The psychological effect of a serologic diagnosis of HSV-2 infection in a person with asymptomatic or unrecognized genital herpes appears small and transient (84). The following recommendations apply to counseling of persons with HSV infection: Persons who have genital herpes should be educated concerning the natural history of the disease, with emphasis on the potential for recurrent episodes, asymptomatic viral shedding, and the attendant risks of sexual transmission. Persons experiencing a first episode of genital herpes should be advised that suppressive therapy is available and is effective in preventing symptomatic recurrent episodes and that episodic therapy sometimes is useful in shortening the duration of recurrent episodes. All persons with genital HSV infection should be encouraged to inform their current sex partners that they have genital herpes and to inform future partners before initiating a sexual relationship. Sexual transmission of HSV can occur during asymptomatic periods. Asymptomatic viral shedding is more frequent in genital HSV-2 infection than genital HSV-1 infection and is most frequent during the first 12 months after acquiring HSV-2. All persons with genital herpes should remain abstinent from sexual activity with uninfected partners when lesions or prodromal symptoms are present. The risk of HSV-2 sexual transmission can be decreased by the daily use of valacyclovir by the infected person. Recent studies indicate that latex condoms, when used consistently and correctly, might reduce the risk for genital herpes transmission (15,16). Sex partners of infected persons should be advised that they might be infected even if they have no symptoms. Type-specific serologic testing of asymptomatic partners of persons with genital herpes is recommended to determine whether risk for HSV acquisition exists. The risk for neonatal HSV infection should be explained to all persons, including men. Pregnant women and women of childbearing age who have genital herpes should inform their providers who care for them during pregnancy and those who will care for their newborn infant. Pregnant women who are not infected with HSV-2 should be advised to avoid intercourse during the third trimester with men who have genital herpes. Similarly, pregnant women who are not infected with HSV-1 should be counseled to avoid genital exposure to HSV-1 during the third trimester (e.g., oral sex with a partner with oral herpes and vaginal intercourse with a partner with genital HSV-1 infection). Asymptomatic persons diagnosed with HSV-2 infection by type-specific serologic testing should receive the same counseling messages as persons with symptomatic infection. In addition, such persons should be taught about the clinical manifestations of genital herpes. The sex partners of patients who have genital herpes can benefit from evaluation and counseling. Symptomatic sex partners should be evaluated and treated in the same manner as patients who have genital lesions. Asymptomatic sex partners of patients who have genital herpes should be questioned concerning histories of genital lesions and offered type-specific serologic testing for HSV infection. Allergy, Intolerance, and Adverse Reactions Allergic and other adverse reactions to acyclovir, valacyclovir, and famciclovir are rare. Desensitization to acyclovir has been described (85). Immunocompromised patients might have prolonged or severe episodes of genital, perianal, or oral herpes. Lesions caused by HSV are common among HIV-infected patients and might be severe, painful, and atypical. HSV shedding is increased in HIV-infected persons. Whereas antiretroviral therapy reduces the severity and frequency of symptomatic genital herpes, frequent subclinical shedding still occurs (86). Suppressive or episodic therapy with oral antiviral agents is effective in decreasing the clinical manifestations of HSV among HIV-positive persons (87--89). HIV-infected persons are likely to be more contagious for HSV; the extent to which suppressive antiviral therapy will decrease HSV transmission from this population is unknown. Some specialists suggest that HSV type-specific serologies be offered to HIV-positive persons during their initial evaluation, and that suppressive antiviral therapy be considered in those who have HSV-2 infection. Recommended Regimens for Daily Suppressive Therapy in Persons Infected with HIV Acyclovir 400--800 mg orally twice to three times a day Famciclovir 500 mg orally twice a day Valacyclovir 500 mg orally twice a day Recommended Regimens for Episodic Infection in Persons Infected with HIV Famiciclovir 500 mg orally twice a day for 5--10 days Valacyclovir 1.0 grams orally twice a day for 5--10 days Acyclovir, valacyclovir, and famciclovir are safe for use in immunocompromised patients in the doses recommended for treatment of genital herpes. For severe HSV disease, initiating therapy with acyclovir 5--10 mg/kg body weight IV every 8 hours might be necessary. If lesions persist or recur in a patient receiving antiviral treatment, HSV resistance should be suspected and a viral isolate should be obtained for sensitivity testing (90). Such patients should be managed in consultation with an HIV specialist, and alternate therapy should be administered. All acyclovir-resistant strains are resistant to valacyclovir, and the majority are resistant to famciclovir. Foscarnet, 40 mg/kg body weight IV every 8 hours until clinical resolution is attained, is frequently effective for treatment of acyclovir-resistant genital herpes. Topical cidofovir gel 1% applied to the lesions once daily for 5 consecutive days also might be effective. This preparation is not commercially available and must be compounded at a pharmacy. Genital Herpes in Pregnancy The majority of mothers of infants who acquire neonatal herpes lack histories of clinically evident genital herpes. The risk for transmission to the neonate from an infected mother is high (30%--50%) among women who acquire genital herpes near the time of delivery and is low (<1%) among women with histories of recurrent herpes at term or who acquire genital HSV during the first half of pregnancy. However, because recurrent genital herpes is much more common than initial HSV infection during pregnancy, the proportion of neonatal HSV infections acquired from mothers with recurrent herpes is substantial. Prevention of neonatal herpes depends both on preventing acquisition of genital HSV infection during late pregnancy and avoiding exposure of the infant to herpetic lesions during delivery. Women without known genital herpes should be counseled to avoid intercourse during the third trimester with partners known or suspected of having genital herpes. In addition, pregnant women without known orolabial herpes should be advised to avoid receptive oral sex during the third trimester with partners known or suspected to have orolabial herpes. Some specialists believe that type-specific serologic tests are useful to identify pregnant women at risk for HSV infection and to guide counseling regarding the risk for acquiring genital herpes during pregnancy. Such testing should be offered to women without genital herpes whose sex partner has HSV infection. The effectiveness of antiviral therapy to decrease the risk for HSV transmission to pregnant women has not been studied. All pregnant women should be asked whether they have a history of genital herpes. At the onset of labor, all women should be questioned carefully about symptoms of genital herpes, including prodromal symptoms, and all women should be examined carefully for herpetic lesions. Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally. The majority of specialists recommend that women with recurrent genital herpetic lesions at the onset of labor deliver by cesarean section to prevent neonatal herpes. However, cesarean section does not completely eliminate the risk for HSV transmission to the infant. The safety of systemic acyclovir, valacyclovir, and famciclovir therapy in pregnant women has not been definitively established. Available data do not indicate an increased risk for major birth defects compared with the general population in women treated with acyclovir during the first trimester (91). These findings provide some assurance to women who have had prenatal exposure to acyclovir. The experience with prenatal exposure to valacyclovir and famciclovir is too limited to provide useful information on pregnancy outcomes. Acyclovir may be administered orally to pregnant women with first episode genital herpes or severe recurrent herpes and should be administered IV to pregnant women with severe HSV infection. Acyclovir treatment late in pregnancy reduces the frequency of cesarean sections among women who have recurrent genital herpes by diminishing the frequency of recurrences at term, and many specialists recommend such treatment (92--94). No data support the use of antiviral therapy among HSV seropositive women without a history of genital herpes. The risk for herpes is high in infants of women who acquire genital HSV during late pregnancy; such women should be managed in consultation with an infectious diseases specialist. Some specialists recommend acyclovir therapy in this circumstance, some recommend routine cesarean section to reduce the risk for neonatal herpes, and others recommend both. Neonatal Herpes Infants exposed to HSV during birth, as documented by maternal virologic testing or presumed by observation of maternal lesions, should be followed carefully in consultation with a specialist. Some specialists recommend that such infants undergo surveillance cultures of mucosal surfaces to detect HSV infection before development of clinical signs of neonatal herpes. In addition, some specialists recommend the use of acyclovir for infants born to women who acquired HSV near term because the risk for neonatal herpes is high for these infants. All infants who have neonatal herpes should be promptly evaluated and treated with systemic acyclovir. The recommended regimen for infants treated for known or suspected neonatal herpes is acyclovir 20 mg/kg body weight IV every 8 hours for 21 days for disseminated and CNS disease or for 14 days for disease limited to the skin and mucous membranes. Granuloma Inguinale (Donovanosis) Granuloma inguinale is a genital ulcerative disease caused by the intracellular gram-negative bacterium Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis). The disease occurs rarely in the United States, although it is endemic in some tropical and developing areas, including India; Papua, New Guinea; central Australia; and southern Africa. Clinically, the disease is commonly characterized as painless, progressive ulcerative lesions without regional lymphadenopathy. The lesions are highly vascular (i.e., beefy red appearance) and bleed easily on contact. However, the clinical presentation also can include hypertrophic, necrotic, or sclerotic variants. The causative organism is difficult to culture, and diagnosis requires visualization of dark-staining Donovan bodies on tissue crush preparation or biopsy. No FDA-cleared PCR tests for the detection of K. granulomatis DNA exist, but such an assay might be useful if a CLIA verification study has been conducted. The lesions might develop secondary bacterial infection or can coexist with other sexually transmitted pathogens. A limited number of studies on Donovanosis treatment have been published. Treatment halts progression of lesions, although prolonged therapy is usually required to permit granulation and reepithelialization of the ulcers. Healing typically proceeds inward from the ulcer margins. Relapse can occur 6--18 months after apparently effective therapy. Several antimicrobial regimens have been effective, but a limited number of controlled trials have been published (95). Doxycycline 100 mg orally twice a day for at least 3 weeks and until all lesions have completely healed Alternative Regimens Azithromycin 1 g orally once per week for at least 3 weeks and until all lesions have completely healed Ciprofloxacin 750 mg orally twice a day for at least 3 weeks and until all lesions have completely healed Erythromycin base 500 mg orally four times a day for at least 3 weeks and until all lesions have completely healed Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally twice a day for at least 3 weeks and until all lesions have completely healed Therapy should be continued at least 3 weeks and until all lesions have completely healed. Some specialists recommend the addition of an aminoglycoside (e.g., gentamicin 1 mg/kg IV every 8 hours) to these regimens if improvement is not evident within the first few days of therapy. Patients should be followed clinically until signs and symptoms have resolved. Persons who have had sexual contact with a patient who has granuloma inguinale within the 60 days before onset of the patient's symptoms should be examined and offered therapy. However, the value of empiric therapy in the absence of clinical signs and symptoms has not been established. Pregnancy is a relative contraindication to the use of sulfonamides. Pregnant and lactating women should be treated with the erythromycin regimen, and consideration should be given to the addition of a parenteral aminoglycoside (e.g., gentamicin). Azithromycin might prove useful for treating granuloma inguinale during pregnancy, but published data are lacking. Doxycycline and ciprofloxacin are contraindicated in pregnant women. Persons with both granuloma inguinale and HIV infection should receive the same regimens as those who are HIV negative. Consideration should be given to the addition of a parenteral aminoglycoside (e.g., gentamicin). Lymphogranuloma Venereum Lymphogranuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3 (96). The most common clinical manifestation of LGV among heterosexuals is tender inguinal and/or femoral lymphadenopathy that is typically unilateral. A self-limited genital ulcer or papule sometimes occurs at the site of inoculation. However, by the time patients seek care, the lesions might have disappeared. Rectal exposure in women or MSM might result in proctocolitis (including mucoid and/or hemorrhagic rectal discharge, anal pain, constipation, fever, and/or tenesmus). LGV is an invasive, systemic infection, and if it is not treated early, LGV proctocolitis might lead to chronic, colorectal fistulas and strictures. Genital and colorectal LGV lesions might also develop secondary bacterial infection or might be coinfected with other sexually and nonsexually transmitted pathogens. Diagnosis is based on clinical suspicion, epidemiologic information, and the exclusion of other etiologies (of proctocolitis, inguinal lymphadenopathy, or genital or rectal ulcers), along with C. trachomatis testing, if available. Genital and lymph node specimens (i.e., lesion swab or bubo aspirate) may be tested for C. trachomatis by culture, direct immunofluorescence, or nucleic acid detection. Nucleic acid amplification tests (NAAT) for C. trachomatis are not FDA-cleared for testing rectal specimens. Additional procedures (e.g., genotyping) are required for differentiating LGV from non-LGV C. trachomatis but are not widely available. Chlamydia serology (complement fixation titers >1:64) can support the diagnosis in the appropriate clinical context. Comparative data between types of serologic tests are lacking, and the diagnostic utility of serologic methods other than complement fixation and some microimmunofluorescence procedures has not been established. Serologic test interpretation for LGV is not standardized, tests have not been validated for clinical proctitis presentations, and C. trachomatis serovar-specific serologic tests are not widely available. In the absence of specific LGV diagnostic testing, patients with a clinical syndrome consistent with LGV, including proctocolitis or genital ulcer disease with lymphadenopathy, should be treated for LGV as described in this report. Treatment cures infection and prevents ongoing tissue damage, although tissue reaction to the injection can result in scarring. Buboes might require aspiration through intact skin or incision and drainage to prevent the formation of inguinal/femoral ulcerations. Doxycycline is the preferred treatment. Doxycycline 100 mg orally twice a day for 21 days Alternative Regimen Erythromycin base 500 mg orally four times a day for 21 days Some STD specialists believe that azithromycin 1.0 g orally once weekly for 3 weeks is probably effective, although clinical data are lacking. Persons who have had sexual contact with a patient who has LGV within the 60 days before onset of the patient's symptoms should be examined, tested for urethral or cervical chlamydial infection, and treated with a standard chlamydia regimen (azithromycin 1 gm orally x 1 or doxycycline 100 mg orally twice a day for 7 days). The optimum contact interval is unknown; some specialists use longer contact intervals. Pregnant and lactating women should be treated with erythromycin. Azithromycin might prove useful for treatment of LGV in pregnancy, but no published data are available regarding its safety and efficacy. Doxycycline is contraindicated in pregnant women. Persons with both LGV and HIV infection should receive the same regimens as those who are HIV negative. Prolonged therapy might be required, and delay in resolution of symptoms might occur. Syphilis is a systemic disease caused by T. pallidum. Patients who have syphilis might seek treatment for signs or symptoms of primary infection (i.e., ulcer or chancre at the infection site), secondary infection (i.e., manifestations that include, but are not limited to, skin rash, mucocutaneous lesions, and lymphadenopathy), or tertiary infection (e.g., cardiac or ophthalmic manifestations, auditory abnormalities, or gummatous lesions). Latent infections (i.e., those lacking clinical manifestations) are detected by serologic testing. Latent syphilis acquired within the preceding year is referred to as early latent syphilis; all other cases of latent syphilis are either late latent syphilis or latent syphilis of unknown duration. Treatment for both late latent syphilis and tertiary syphilis theoretically might require a longer duration of therapy because organisms are dividing more slowly; however, the validity of this concept has not been assessed. Diagnostic Considerations and Use of Serologic Tests Darkfield examinations and direct fluorescent antibody (DFA) tests of lesion exudate or tissue are the definitive methods for diagnosing early syphilis. A presumptive diagnosis is possible with the use of two types of serologic tests: 1) nontreponemal tests (e.g., Venereal Disease Research Laboratory [VDRL] and RPR) and 2) treponemal tests (e.g., fluorescent treponemal antibody absorbed [FTA-ABS] and T. pallidum particle agglutination [TP-PA]). The use of only one type of serologic test is insufficient for diagnosis because false-positive nontreponemal test results are sometimes associated with various medical conditions unrelated to syphilis. Nontreponemal test antibody titers usually correlate with disease activity, and results should be reported quantitatively. A fourfold change in titer, equivalent to a change of two dilutions (e.g., from 1:16--1:4 or from 1:8--1:32), is considered necessary to demonstrate a clinically significant difference between two nontreponemal test results that were obtained using the same serologic test. Sequential serologic tests in individual patients should be performed by using the same testing method (e.g., VDRL or RPR), preferably by the same laboratory. The VDRL and RPR are equally valid assays, but quantitative results from the two tests cannot be compared directly because RPR titers frequently are slightly higher than VDRL titers. Nontreponemal tests usually become nonreactive with time after treatment; however, in some patients, nontreponemal antibodies can persist at a low titer for a long period of time, sometimes for the life of the patient. This response is referred to as the serofast reaction. The majority of patients who have reactive treponemal tests will have reactive tests for the remainder of their lives, regardless of treatment or disease activity. However, 15%--25% of patients treated during the primary stage revert to being serologically nonreactive after 2--3 years (97). Treponemal test antibody titers do not correlate with disease activity and should not be used to assess treatment response. Some clinical laboratories and blood banks have begun to screen samples using treponemal EIA tests (98). This strategy will identify both persons with previous treatment and persons with untreated or incompletely treated syphilis. False-positive results can occur, particularly among populations with a low prevalence of syphilis. Persons with a positive treponemal screening test should have a standard nontreponemal test with titer to guide patient management decisions. If the nontreponemal test is negative, then a different treponemal test should be performed to confirm the results of the initial test. If a second trepomenal test is positive, treatment decisions should be discussed in consultation with a specialist. Some HIV-infected patients can have atypical serologic test results (i.e., unusually high, unusually low, or fluctuating titers). For such patients, when serologic tests do not correspond with clinical syndromes suggestive of early syphilis, use of other tests (e.g., biopsy and direct microscopy) should be considered. However, for the majority of HIV-infected patients, serologic tests are accurate and reliable for the diagnosis of syphilis and for following the response to treatment. No single test can be used to diagnose neurosyphilis. The VDRL-cerebrospinal fluid (CSF) is highly specific, but it is insensitive. The majority of other tests are both insensitive and nonspecific and must be interpreted in relation to other test results and the clinical assessment. Therefore, the diagnosis of neurosyphilis usually depends on various combinations of reactive serologic test results, CSF cell count or protein, or a reactive VDRL-CSF with or without clinical manifestations. The CSF leukocyte count usually is elevated (>5 white blood cell count [WBC]/mm3) in patients with neurosyphilis; this count also is a sensitive measure of the effectiveness of therapy. The VDRL-CSF is the standard serologic test for CSF, and when reactive in the absence of substantial contamination of CSF with blood, it is considered diagnostic of neurosyphilis. However, the VDRL-CSF might be nonreactive even when neurosyphilis is present. Some specialists recommend performing an FTA-ABS test on CSF. The CSF FTA-ABS is less specific (i.e., yields more false-positive results) for neurosyphilis than the VDRL-CSF, but the test is highly sensitive. Therefore, some specialists believe that a negative CSF FTA-ABS test excludes neurosyphilis. Penicillin G, administered parenterally, is the preferred drug for treatment of all stages of syphilis. The preparation(s) used (i.e., benzathine, aqueous procaine, or aqueous crystalline), the dosage, and the length of treatment depend on the stage and clinical manifestations of the disease. However, neither combinations of benzathine penicillin and procaine penicillin nor oral penicillin preparations are considered appropriate for the treatment of syphilis. Reports have indicated that inappropriate use of combination benzathine-procaine penicillin (Bicillin C-R®) instead of the standard benzathine penicillin product widely used in the United States (Bicillin L-A®) has occurred. Practitioners, pharmacists, and purchasing agents should be aware of the similar names of these two products and avoid use of the inappropriate combination therapy agent for treating syphilis (99). The efficacy of penicillin for the treatment of syphilis was well established through clinical experience even before the value of randomized controlled clinical trials was recognized. Therefore, nearly all the recommendations for the treatment of syphilis are based on the opinions of persons knowledgeable about STDs and are reinforced by case series, clinical trials, and 50 years of clinical experience. Parenteral penicillin G is the only therapy with documented efficacy for syphilis during pregnancy. Pregnant women with syphilis in any stage who report penicillin allergy should be desensitized and treated with penicillin. Skin testing for penicillin allergy might be useful in pregnant women; such testing also is useful in other patients (see Management of Patients Who Have a History of Penicillin Allergy). The Jarisch-Herxheimer reaction is an acute febrile reaction frequently accompanied by headache, myalgia, and other symptoms that usually occur within the first 24 hours after any therapy for syphilis. Patients should be informed about this possible adverse reaction. The Jarisch-Herxheimer reaction occurs most frequently among patients who have early syphilis. Antipyretics may be used, but they have not been proven to prevent this reaction. The Jarisch-Herxheimer reaction might induce early labor or cause fetal distress in pregnant women, but this should not prevent or delay therapy (see Syphilis During Pregnancy). Sexual transmission of T. pallidum occurs only when mucocutaneous syphilitic lesions are present; such manifestations are uncommon after the first year of infection. However, persons exposed sexually to a patient who has syphilis in any stage should be evaluated clinically and serologically and treated with a recommended regimen, according to the following recommendations: Persons who were exposed within the 90 days preceding the diagnosis of primary, secondary, or early latent syphilis in a sex partner might be infected even if seronegative; therefore, such persons should be treated presumptively. Persons who were exposed >90 days before the diagnosis of primary, secondary, or early latent syphilis in a sex partner should be treated presumptively if serologic test results are not available immediately and the opportunity for follow-up is uncertain. For purposes of partner notification and presumptive treatment of exposed sex partners, patients with syphilis of unknown duration who have high nontreponemal serologic test titers (i.e., >1:32) can be assumed to have early syphilis. However, serologic titers should not be used to differentiate early from late latent syphilis for the purpose of determining treatment (see Latent Syphilis, Treatment). Long-term sex partners of patients who have latent syphilis should be evaluated clinically and serologically for syphilis and treated on the basis of the evaluation findings. For identification of at-risk sexual partners, the periods before treatment are 1) 3 months plus duration of symptoms for primary syphilis, 2) 6 months plus duration of symptoms for secondary syphilis, and 3) 1 year for early latent syphilis. Primary and Secondary Syphilis Parenteral penicillin G has been used effectively for more than 50 years to achieve clinical resolution (i.e., healing of lesions and prevention of sexual transmission) and to prevent late sequelae. However, no comparative trials have been adequately conducted to guide the selection of an optimal penicillin regimen (i.e., the dose, duration, and preparation). Substantially fewer data are available for nonpenicillin regimens. Recommended Regimen for Adults* Benzathine penicillin G 2.4 million units IM in a single dose * Recommendations for treating HIV-infected persons and pregnant women for syphilis have been discussed in this report (see Syphilis, Special considerations and Syphilis in Pregnancy). Recommended Regimen for Children After the newborn period (aged >1 month), children with syphilis should have a CSF examination to detect asymptomatic neurosyphilis, and birth and maternal medical records should be reviewed to assess whether such children have congenital or acquired syphilis (see Congenital Syphilis). Children with acquired primary or secondary syphilis should be evaluated (e.g., through consultation with child-protection services) (see Sexual Assault or Abuse of Children) and treated by using the following pediatric regimen. Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose All patients who have syphilis should be tested for HIV infection. In geographic areas in which the prevalence of HIV is high, patients who have primary syphilis should be retested for HIV after 3 months if the first HIV test result was negative. Patients who have syphilis and symptoms or signs suggesting neurologic disease (e.g., meningitis) or ophthalmic disease (e.g., uveitis, iritis, neuroretinitis, or optic neuritis) should have an evaluation that includes CSF analysis and ocular slit-lamp examination. Treatment should be guided by the results of this evaluation. Invasion of CSF by T. pallidum accompanied by CSF abnormalities is common among adults who have primary or secondary syphilis. However, neurosyphilis develops in only a limited number of patients after treatment with the penicillin regimens recommended for primary and secondary syphilis. Therefore, unless clinical signs or symptoms of neurologic or ophthalmic involvement are present, CSF analysis is not recommended for routine evaluation of patients who have primary or secondary syphilis. Treatment failure can occur with any regimen. However, assessing response to treatment frequently is difficult, and definitive criteria for cure or failure have not been established. Nontreponemal test titers might decline more slowly for persons who previously had syphilis. Patients should be reexamined clinically and serologically 6 months and 12 months after treatment; more frequent evaluation might be prudent if follow-up is uncertain. Patients who have signs or symptoms that persist or recur or who have a sustained fourfold increase in nontreponemal test titer (i.e., compared with the maximum or baseline titer at the time of treatment) probably failed treatment or were reinfected. These patients should be retreated and reevaluated for HIV infection. Because treatment failure usually cannot be reliably distinguished from reinfection with T. pallidum, a CSF analysis also should be performed. Clinical trial data have demonstrated that 15% of patients with early syphilis treated with the recommended therapy will not achieve a two dilution decline in nontreponemal titer used to define response at 1 year after treatment (100). Failure of nontreponemal test titers to decline fourfold within 6 months after therapy for primary or secondary syphilis might be indicative of probable treatment failure. Persons for whom titers remain serofast should be reevaluated for HIV infection. Optimal management of such patients is unclear. At a minimum, these patients should receive additional clinical and serologic follow-up. HIV-infected patients should be evaluated more frequently (i.e., at 3-month intervals instead of 6-month intervals). If additional follow-up cannot be ensured, re-treatment is recommended. Because treatment failure might be the result of unrecognized CNS infection, many specialists recommend CSF examination in such situations. For retreatment, the majority of STD specialists recommend administering weekly injections of benzathine penicillin G 2.4 million units IM for 3 weeks, unless CSF examination indicates that neurosyphilis is present. In rare instances, serologic titers do not decline despite a negative CSF examination and a repeated course of therapy. Additional therapy or repeated CSF examinations are not warranted in these circumstances. See General Principles, Management of Sex Partners. Penicillin Allergy. Data to support the use of alternatives to penicillin in the treatment of early syphilis are limited. However, several therapies might be effective in nonpregnant, penicillin-allergic patients who have primary or secondary syphilis. Doxycycline (100 mg orally twice daily for 14 days) and tetracycline (500 mg four times daily for 14 days) are regimens that have been used for many years. Compliance is likely to be better with doxycycline than tetracycline because tetracycline can cause gastrointestinal side effects. Although limited clinical studies, along with biologic and pharmacologic evidence, suggest that ceftriaxone is effective for treating early syphilis, the optimal dose and duration of ceftriaxone therapy have not been defined. Some specialists recommend 1 g daily either IM or IV for 8--10 days. Some patients who are allergic to penicillin also might be allergic to ceftriaxone; in these circumstances, use of an alternative agent might be required. Preliminary data suggest that azithromycin might be effective as a single oral dose of 2 g (101,102). However, several cases of azithromycin treatment failure have been reported, and resistance to azithromycin has been documented in several geographic areas (103). Close follow-up of persons receiving alternative therapies is essential. The use of any of these therapies in HIV-infected persons has not been well-studied; therefore, the use of doxycycline, ceftriaxone, and azithromycin among such persons must be undertaken with caution. Patients with penicillin allergy whose compliance with therapy or follow-up cannot be ensured should be desensitized and treated with benzathine penicillin. Skin testing for penicillin allergy might be useful in some circumstances in which the reagents and expertise are available to perform the test adequately (see Management of Patients Who Have a History of Penicillin Allergy). Pregnancy. Pregnant patients who are allergic to penicillin should be desensitized and treated with penicillin (see Management of Patients Who Have a History of Penicillin Allergy and Syphilis During Pregnancy). HIV Infection. See Syphilis Among HIV-Infected Persons. Latent Syphilis Latent syphilis is defined as syphilis characterized by seroreactivity without other evidence of disease. Patients who have latent syphilis and who acquired syphilis within the preceding year are classified as having early latent syphilis. Patients' conditions can be diagnosed as early latent syphilis if, within the year preceding the evaluation, they had 1) a documented seroconversion or fourfold or greater increase in titer of a nontreponemal test; 2) unequivocal symptoms of primary or secondary syphilis; 3) a sex partner documented to have primary, secondary, or early latent syphilis; or 4) reactive nontreponemal and treponemal tests from a person whose only possible exposure occurred within the previous 12 months. Nontreponemal serologic titers usually are higher during early latent syphilis than late latent syphilis. However, early latent syphilis cannot be reliably distinguished from late latent syphilis solely on the basis of nontreponemal titers. All patients with latent syphilis should have careful examination of all accessible mucosal surfaces (i.e., the oral cavity, the perineum in women, and perianal area, underneath the foreskin in uncircumcised men) to evaluate for internal mucosal lesions. All patients who have syphilis should be tested for HIV infection. Treatment of latent syphilis usually does not affect transmission and is intended to prevent late complications. Although clinical experience supports the effectiveness of penicillin in achieving this goal, limited evidence is available for guidance in choosing specific regimens. The following regimens are recommended for penicillin nonallergic patients who have normal CSF examinations (if performed). Recommended Regimens for Adults Early Latent Syphilis Late Latent Syphilis or Latent Syphilis of Unknown Duration Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals After the newborn period, children with syphilis should have a CSF examination to exclude neurosyphilis. In addition, birth and maternal medical records should be reviewed to assess whether children have congenital or acquired syphilis (see Congenital Syphilis). Older children with acquired latent syphilis should be evaluated as described for adults and treated using the following pediatric regimens (see Sexual Assault or Abuse of Children). These regimens are for penicillin nonallergic children who have acquired syphilis and who have normal CSF examination results. Recommended Regimens for Children Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units, administered as 3 doses at 1-week intervals (total 150,000 units/kg up to the adult total dose of 7.2 million units) All persons who have latent syphilis should be evaluated clinically for evidence of tertiary disease (e.g., aortitis and gumma) and syphilitic ocular disease (e.g., iritis and uveitis). Patients who have syphilis and who demonstrate any of the following criteria should have a prompt CSF examination: neurologic or ophthalmic signs or symptoms, evidence of active tertiary syphilis (e.g., aortitis and gumma), treatment failure, or HIV infection with late latent syphilis or syphilis of unknown duration. If dictated by circumstances and patient preferences, a CSF examination may be performed for patients who do not meet these criteria. Some specialists recommend performing a CSF examination on all patients who have latent syphilis and a nontreponemal serologic test of >1:32 or if the patient is HIV-infected with a serum CD4 count <350 (104). However, the likelihood of neurosyphilis in this circumstance is unknown. If a CSF examination is performed and the results indicate abnormalities consistent with neurosyphilis, the patient should be treated for neurosyphilis (see Neurosyphilis). If a patient misses a dose of penicillin in a course of weekly therapy for late syphilis, the appropriate course of action is unclear. Pharmacologic considerations suggest that an interval of 10--14 days between doses of benzathine penicillin for late syphilis or latent syphilis of unknown duration might be acceptable before restarting the sequence of injections. Missed doses are not acceptable for pregnant patients receiving therapy for late latent syphilis; pregnant women who miss any dose of therapy must repeat the full course of therapy. Follow-Up. Quantitative nontreponemal serologic tests should be repeated at 6, 12, and 24 months. Patients with a normal CSF examination should be re-treated for latent syphilis if 1) titers increase fourfold, 2) an initially high titer (>1:32) fails to decline at least fourfold (i.e., two dilutions) within 12--24 months of therapy, or 3) signs or symptoms attributable to syphilis develop. In rare instances, despite a negative CSF examination and a repeated course of therapy, serologic titers might still not decline. In these circumstances, the need for additional therapy or repeated CSF examinations is unclear. Management of Sex Partners. See General Principles, Management of Sex Partners. Penicillin Allergy. The effectiveness of alternatives to penicillin in the treatment of latent syphilis has not been well-documented. Nonpregnant patients allergic to penicillin who have clearly defined early latent syphilis should respond to therapies recommended as alternatives to penicillin for the treatment of primary and secondary syphilis (see Primary and Secondary Syphilis, Treatment). The only acceptable alternatives for the treatment of late latent syphilis or latent syphilis of unknown duration are doxycycline (100 mg orally twice daily) or tetracycline (500 mg orally four times daily), both for 28 days. These therapies should be used only in conjunction with close serologic and clinical follow-up. Limited clinical studies, along with biologic and pharmacologic evidence, suggest that ceftriaxone might be effective for treating late latent syphilis or syphilis of unknown duration (105). However, the optimal dose and duration of ceftriaxone therapy have not been defined, and treatment decisions should be discussed in consultation with a specialist. Some patients who are allergic to penicillin also might be allergic to ceftriaxone; in these circumstances, use of an alternative agent might be required. The efficacy of these alternative regimens in HIV-infected persons has not been well-studied and, therefore, must be considered with caution. Tertiary Syphilis Tertiary syphilis refers to gumma and cardiovascular syphilis but not to all neurosyphilis. Patients who are not allergic to penicillin and have no evidence of neurosyphilis should be treated with the following regimen. Patients who have symptomatic late syphilis should be given a CSF examination before therapy is initiated. Some providers treat all patients who have cardiovascular syphilis with a neurosyphilis regimen. The complete management of patients who have cardiovascular or gummatous syphilis is beyond the scope of these guidelines. These patients should be managed in consultation with an infectious diseases specialist. Follow-Up. Limited information is available concerning clinical response and follow-up of patients who have tertiary syphilis. Penicillin Allergy. Patients allergic to penicillin should be treated according to treatment regimens recommended for late latent syphilis. Pregnancy. Pregnant patients who are allergic to penicillin should be desensitized, if necessary, and treated with penicillin (see Management of Patients Who Have a History of Penicillin Allergy and Syphilis During Pregnancy). CNS involvement can occur during any stage of syphilis. A patient who has clinical evidence of neurologic involvement with syphilis (e.g., cognitive dysfunction, motor or sensory deficits, ophthalmic or auditory symptoms, cranial nerve palsies, and symptoms or signs of meningitis) should have a CSF examination. Syphilitic uveitis or other ocular manifestations frequently are associated with neurosyphilis; patients with these symptoms should be treated according to the recommendations for patients with neurosyphilis. A CSF examination should be performed for all such patients to identify those with abnormalities that require follow-up CSF examinations to assess treatment response. Patients who have neurosyphilis or syphilitic eye disease (e.g., uveitis, neuroretinitis, and optic neuritis) should be treated with the following regimen. Aqueous crystalline penicillin G 18--24 million units per day, administered as 3--4 million units IV every 4 hours or continuous infusion, for 10--14 days If compliance with therapy can be ensured, patients may be treated with the following alternative regimen. Procaine penicillin 2.4 million units IM once daily Probenecid 500 mg orally four times a day, both for 10--14 days The durations of the recommended and alternative regimens for neurosyphilis are shorter than that of the regimen used for late syphilis in the absence of neurosyphilis. Therefore, some specialists administer benzathine penicillin, 2.4 million units IM once per week for up to 3 weeks after completion of these neurosyphilis treatment regimens to provide a comparable total duration of therapy. Other considerations in the management of patients who have neurosyphilis are as follows: All patients who have syphilis should be tested for HIV. Many specialists recommend treating patients who have evidence of auditory disease caused by syphilis in the same manner as patients who have neurosyphilis, regardless of CSF examination results. Although systemic steroids are used frequently as adjunctive therapy for otologic syphilis, such drugs have not been proven beneficial. Follow-Up. If CSF pleocytosis was present initially, a CSF examination should be repeated every 6 months until the cell count is normal. Follow-up CSF examinations also can be used to evaluate changes in the VDRL-CSF or CSF protein after therapy; however, changes in these two parameters occur more slowly than cell counts, and persistent abnormalities might be less important. If the cell count has not decreased after 6 months or if the CSF is not normal after 2 years, re-treatment should be considered. Recent data on HIV-infected persons with neurosyphilis suggest that CSF abnormalities might persist for extended periods in these persons, and close clinical follow-up is warranted (105,106). Penicillin Allergy. Ceftriaxone can be used as an alternative treatment for patients with neurosyphilis, although the possibility of cross-reactivity between this agent and penicillin exists. Some specialists recommend ceftriaxone 2 g daily either IM or IV for 10--14 days. Other regimens have not been adequately evaluated for treatment of neurosyphilis. Therefore, if concern exists regarding the safety of ceftriaxone for a patient with neurosyphilis, the patient should obtain skin testing to confirm penicillin allergy and, if necessary, be desensitized and managed in consultation with a specialist. Pregnancy. Pregnant patients who are allergic to penicillin should be desensitized, if necessary, and treated with penicillin (see Syphilis During Pregnancy). HIV Infection. See Syphilis Among HIV-Infected Patients. Syphilis Among HIV-Infected Persons Diagnostic Considerations Unusual serologic responses have been observed among HIV-infected persons who have syphilis. The majority of reports have involved serologic titers that were higher than expected, but false-negative serologic test results and delayed appearance of seroreactivity also have been reported. However, unusual serologic responses are uncommon, and the majority of specialists believe that both treponemal and nontreponemal serologic tests for syphilis can be interpreted in the usual manner for the majority of patients who are coinfected with T. pallidum and HIV. When clinical findings are suggestive of syphilis but serologic tests are nonreactive or their interpretation is unclear, alternative tests (e.g., biopsy of a lesion, darkfield examination, or DFA staining of lesion material) might be useful for diagnosis. Neurosyphilis should be considered in the differential diagnosis of neurologic disease in HIV-infected persons. Compared with HIV-negative patients, HIV-positive patients who have early syphilis might be at increased risk for neurologic complications and might have higher rates of treatment failure with currently recommended regimens. The magnitude of these risks is not defined precisely but is likely minimal. No treatment regimens for syphilis have been demonstrated to be more effective in preventing neurosyphilis in HIV-infected patients than the syphilis regimens recommended for HIV-negative patients (100). Careful follow-up after therapy is essential. Primary and Secondary Syphilis Among HIV-Infected Persons Treatment with benzathine penicillin G, 2.4 million units IM in a single dose is recommended. Some specialists recommend additional treatments (e.g., benzathine penicillin G administered at 1-week intervals for 3 weeks, as recommended for late syphilis) in addition to benzathine penicillin G 2.4 million units IM. Because CSF abnormalities (e.g., mononuclear pleocytosis and elevated protein levels) are common in patients with early syphilis and in persons with HIV infection, the clinical and prognostic significance of such CSF abnormalities in HIV- infected persons with primary or secondary syphilis is unknown. Although the majority of HIV-infected persons respond appropriately to standard benzathine penicillin therapy, some specialists recommend intensified therapy when CNS syphilis is suspected in these persons. Therefore, some specialists recommend CSF examination before treatment of HIV-infected persons with early syphilis, with follow-up CSF examination conducted after treatment in persons with initial abnormalities. Follow-Up. HIV-infected persons should be evaluated clinically and serologically for treatment failure at 3, 6, 9, 12, and 24 months after therapy. Although of unproven benefit, some specialists recommend a CSF examination 6 months after therapy. HIV-infected persons who meet the criteria for treatment failure (i.e., signs or symptoms that persist or recur or persons who have fourfold increase in nontreponemal test titer) should be managed in the same manner as HIV-negative patients (i.e., a CSF examination and re-treatment). CSF examination and re-treatment also should be strongly considered for persons whose nontreponemal test titers do not decrease fourfold within 6--12 months of therapy. The majority of specialists would re-treat patients with benzathine penicillin G administered as 3 doses of 2.4 million units IM each at weekly intervals, if CSF examinations are normal. Penicillin Allergy. Penicillin-allergic patients who have primary or secondary syphilis and HIV infection should be managed according to the recommendations for penicillin-allergic, HIV-negative patients. The use of alternatives to penicillin has not been well studied in HIV-infected patients. Latent Syphilis Among HIV-Infected Persons HIV-infected patients who have early latent syphilis should be managed and treated according to the recommendations for HIV-negative patients who have primary and secondary syphilis. HIV-infected patients who have either late latent syphilis or syphilis of unknown duration should have a CSF examination before treatment. Patients with late latent syphilis or syphilis of unknown duration and a normal CSF examination can be treated with benzathine penicillin G, at weekly doses of 2.4 million units for 3 weeks. Patients who have CSF consistent with neurosyphilis should be treated and managed as patients who have neurosyphilis (see Neurosyphilis). Follow-Up. Patients should be evaluated clinically and serologically at 6, 12, 18, and 24 months after therapy. If, at any time, clinical symptoms develop or nontreponemal titers rise fourfold, a repeat CSF examination should be performed and treatment administered accordingly. If during 12--24 months the nontreponemal titer does not decline fourfold, the CSF examination should be repeated and treatment administered accordingly. Penicillin Allergy. The efficacy of alternative nonpenicillin regimens in HIV-infected persons has not been well studied. Patients with penicillin allergy whose compliance with therapy or follow-up cannot be ensured should be desensitized and treated with penicillin (see Management of Patients Who Have a History of Penicillin Allergy). These therapies should be used only in conjunction with close serologic and clinical follow-up. Limited clinical studies, along with biologic and pharmacologic evidence, suggest that ceftriaxone might be effective (105). However, optimal dose and duration of ceftriaxone therapy have not been defined. Syphilis During Pregnancy All women should be screened serologically for syphilis during the early stages of pregnancy. The majority of states mandate screening at the first prenatal visit for all women. Antepartum screening by nontreponemal antibody testing is typical, but in some settings, treponemal antibody testing is being used. Pregnant women with reactive treponemal screening tests should have confirmatory testing with nontreponemal tests with titers. In populations in which use of prenatal care is not optimal, RPR-card test screening and treatment (i.e., if the RPR-card test is reactive) should be performed at the time a pregnancy is diagnosed. For communities and populations in which the prevalence of syphilis is high or for patients at high risk, serologic testing should be performed twice during the third trimester, at 28 to 32 weeks' gestation and at delivery. Any woman who delivers a stillborn infant after 20 weeks' gestation should be tested for syphilis. No infant should leave the hospital without the maternal serologic status having been determined at least once during pregnancy. Seropositive pregnant women should be considered infected unless an adequate treatment history is documented clearly in the medical records and sequential serologic antibody titers have declined. Serofast low antibody titers might not require treatment; however, persistent higher titer antibody tests might indicate reinfection and require treatment. Penicillin is effective for preventing maternal transmission to the fetus and for treating fetal infection. Evidence is insufficient to determine specific, recommended penicillin regimens that are optimal (107). Treatment during pregnancy should be the penicillin regimen appropriate for the stage of syphilis. Some specialists recommend additional therapy for pregnant women in some settings (e.g., a second dose of benzathine penicillin 2.4 million units IM administered 1 week after the initial dose for women who have primary, secondary, or early latent syphilis). During the second half of pregnancy, syphilis management may be facilitated by a sonographic fetal evaluation for congenital syphilis, but this evaluation should not delay therapy. Sonographic signs of fetal or placental syphilis (i.e., hepatomegaly, ascites, hydrops, or a thickened placenta) indicate a greater risk for fetal treatment failure (108); such cases should be managed in consultation with obstetric specialists. Evidence is insufficient to recommend specific regimens for these situations. Women treated for syphilis during the second half of pregnancy are at risk for premature labor and/or fetal distress, if the treatment precipitates the Jarisch-Herxheimer reaction. These women should be advised to seek obstetric attention after treatment, if they notice any contractions or decrease in fetal movements. Stillbirth is a rare complication of treatment, but concern for this complication should not delay necessary treatment. All patients who have syphilis should be offered testing for HIV infection. Follow-Up. Coordinated prenatal care and treatment follow-up are vital. Serologic titers should be repeated at 28--32 weeks' gestation, at delivery, and following the recommendations for the stage of disease. Serologic titers can be checked monthly in women at high risk for reinfection or in geographic areas in which the prevalence of syphilis is high. The clinical and antibody response should be appropriate for the stage of disease. The majority of women will deliver before their serologic response to treatment can be assessed definitively. Inadequate maternal treatment is likely if delivery occurs within 30 days of therapy, if clinical signs of infection are present at delivery, or if the maternal antibody titer is fourfold higher than the pretreatment titer. Penicillin Allergy. For treatment of syphilis during pregnancy, no proven alternatives to penicillin exist. Pregnant women who have a history of penicillin allergy should be desensitized and treated with penicillin. Skin testing might be helpful (see Management of Patients Who Have a History of Penicillin Allergy). Tetracycline and doxycycline usually are not used during pregnancy. Erythromycin should not be used because it does not reliably cure an infected fetus. Data are insufficient to recommend azithromycin or ceftriaxone for treatment of maternal infection and prevention of congenital syphilis. HIV Infection. Placental inflammation from congenital infection might increase the risk for perinatal transmission of HIV. All HIV-infected women should be evaluated for infectious syphilis and treated. Data are insufficient to recommend a specific regimen (see Syphilis Among HIV-Infected Patients). Congenital Syphilis Effective prevention and detection of congenital syphilis depends on the identification of syphilis in pregnant women and, therefore, on the routine serologic screening of pregnant women during the first prenatal visit. In communities and populations in which the risk for congenital syphilis is high, serologic testing and a sexual history also should be obtained at 28 weeks' gestation and at delivery. Moreover, as part of the management of pregnant women who have syphilis, information concerning treatment of sex partners should be obtained to assess the risk for reinfection. All pregnant women who have syphilis should be tested for HIV infection. Routine screening of newborn sera or umbilical cord blood is not recommended. Serologic testing of the mother's serum is preferred rather than testing of the infant's serum because the serologic tests performed on infant serum can be nonreactive if the mother's serologic test result is of low titer or was infected late in pregnancy (see Diagnostic Considerations and Use of Serologic Tests). No infant or mother should leave the hospital unless the maternal serologic status has been documented at least once during pregnancy, and at delivery in communities and populations in which the risk for congenital syphilis is high. Evaluation and Treatment of Infants During the First Month of Life The diagnosis of congenital syphilis is complicated by the transplacental transfer of maternal nontreponemal and treponemal IgG antibodies to the fetus. This transfer of antibodies makes the interpretation of reactive serologic tests for syphilis in infants difficult. Treatment decisions frequently must be made on the basis of 1) identification of syphilis in the mother; 2) adequacy of maternal treatment; 3) presence of clinical, laboratory, or radiographic evidence of syphilis in the infant; and 4) comparison of maternal (at delivery) and infant nontreponemal serologic titers by using the same test and preferably the same laboratory. All infants born to mothers who have reactive nontreponemal and treponemal test results should be evaluated with a quantitative nontreponemal serologic test (RPR or VDRL) performed on infant serum because umbilical cord blood can become contaminated with maternal blood and could yield a false-positive result. Conducting a treponemal test (i.e., TP-PA or FTA-ABS) on a newborn's serum is not necessary. No commercially available immunoglobulin (IgM) test can be recommended. All infants born to women who have reactive serologic tests for syphilis should be examined thoroughly for evidence of congenital syphilis (e.g., nonimmune hydrops, jaundice, hepatosplenomegaly, rhinitis, skin rash, and/or pseudoparalysis of an extremity). Pathologic examination of the placenta or umbilical cord by using specific fluorescent antitreponemal antibody staining is suggested. Darkfield microscopic examination or DFA staining of suspicious lesions or body fluids (e.g., nasal discharge) also should be performed. The following scenarios describe the evaluation and treatment of infants for congenital syphilis: Scenario 1. Infants with proven or highly probable disease and an abnormal physical examination that is consistent with congenital syphilis, a serum quantitative nontreponemal serologic titer that is fourfold higher than the mother's titer,§ or a positive darkfield or fluorescent antibody test of body fluid(s). Recommended Evaluation CSF analysis for VDRL, cell count, and protein¶ Complete blood count (CBC) and differential and platelet count Other tests as clinically indicated (e.g., long-bone radiographs, chest radiograph, liver-function tests, cranial ultrasound, ophthalmologic examination, and auditory brainstem response) Aqueous crystalline penicillin G 100,000--150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days If >1 day of therapy is missed, the entire course should be restarted. Data are insufficient regarding the use of other antimicrobial agents (e.g., ampicillin). When possible, a full 10-day course of penicillin is preferred, even if ampicillin was initially provided for possible sepsis. The use of agents other than penicillin requires close serologic follow-up to assess adequacy of therapy. In all other situations, the maternal history of infection with T. pallidum and treatment for syphilis must be considered when evaluating and treating the infant. Scenario 2. Infants who have a normal physical examination and a serum quantitive nontreponemal serologic titer the same or less than fourfold the maternal titer and the mother was not treated, inadequately treated, or has no documentation of having received treatment; mother was treated with erythromycin or other nonpenicillin regimen;** or mother received treatment <4 weeks before delivery. CSF analysis for VDRL, cell count, and protein CBC and differential and platelet count Long-bone radiographs A complete evaluation is not necessary if 10 days of parenteral therapy is administered. However, such evaluations might be useful; a lumbar puncture might document CSF abnormalities that would prompt close follow-up. Other tests (e.g., CBC, platelet count, and bone radiographs) may be performed to further support a diagnosis of congenital syphilis. If a single dose of benzathine penicillin G is used, then the infant must be fully evaluated (i.e., through CSF examination, long-bone radiographs, and CBC with platelets), the full evaluation must be normal, and follow-up must be certain. If any part of the infant's evaluation is abnormal or not performed or if the CSF analysis is rendered uninterpretable because of contamination with blood, then a 10-day course of penicillin is required.†† Benzathine penicillin G 50,000 units/kg/dose IM in a single dose Some specialists prefer the 10 days of parenteral therapy if the mother has untreated early syphilis at delivery. Scenario 3. Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the mother was treated during pregnancy, treatment was appropriate for the stage of infection, and treatment was administered >4 weeks before delivery; and mother has no evidence of reinfection or relapse. No evaluation is required. Benzathine penicillin G 50,000 units/kg/dose IM in a single dose§§ mother's treatment was adequate before pregnancy, and mother's nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL <1:2; RPR <1:4). No treatment is required; however, some specialists would treat with benzathine penicillin G 50,000 units/kg as a single IM injection, particularly if follow-up is uncertain. Evaluation and Treatment of Older Infants and Children Children who are identified as having reactive serologic tests for syphilis after the neonatal period (i.e., aged >1 month) should have maternal serology and records reviewed to assess whether the child has congenital or acquired syphilis (see Primary and Secondary Syphilis and Latent Syphilis, Sexual Assault or Abuse of Children). Any child at risk for congenital syphilis should receive a full evaluation and testing for HIV infection. CBC, differential, and platelet count Other tests as clinically indicated (e.g., long-bone radiographs, chest radiograph, liver function tests, abdominal ultrasound, ophthalmologic examination, and auditory brain stem response) Aqueous crystalline penicillin G 200,000--300,000 units/kg/day IV, administered as 50,000 units/kg every 4--6 hours for 10 days If the child has no clinical manifestations of disease, the CSF examination is normal, and the CSF VDRL test result is negative, some specialists would treat with up to 3 weekly doses of benzathine penicillin G, 50,000 U/kg IM. Any child who is suspected of having congenital syphilis or who has neurologic involvement should be treated with aqueous penicillin G. Some specialists also suggest giving these patients a single dose of benzathine penicillin G, 50,000 units/kg IM after the 10-day course of IV aqueous penicillin. This treatment also would be adequate for children who might have other treponemal infections. All seroreactive infants (or infants whose mothers were seroreactive at delivery) should receive careful follow-up examinations and serologic testing (i.e., a nontreponemal test) every 2--3 months until the test becomes nonreactive or the titer has decreased fourfold. Nontreponemal antibody titers should decline by age 3 months and should be nonreactive by age 6 months if the infant was not infected (i.e., if the reactive test result was caused by passive transfer of maternal IgG antibody) or was infected but adequately treated. The serologic response after therapy might be slower for infants treated after the neonatal period. If these titers are stable or increase after age 6--12 months, the child should be evaluated (e.g., given a CSF examination) and treated with a 10-day course of parenteral penicillin G. Treponemal tests should not be used to evaluate treatment response because the results for an infected child can remain positive despite effective therapy. Passively transferred maternal treponemal antibodies can be present in an infant until age 15 months. A reactive treponemal test after age 18 months is diagnostic of congenital syphilis. If the nontreponemal test is nonreactive at this time, no further evaluation or treatment is necessary. If the nontreponemal test is reactive at age 18 months, the infant should be fully (re)evaluated and treated for congenital syphilis. Infants whose initial CSF evaluations are abnormal should undergo a repeat lumbar puncture approximately every 6 months until the results are normal. A reactive CSF VDRL test or abnormal CSF indices that cannot be attributed to other ongoing illness requires re-treatment for possible neurosyphilis. Follow-up of children treated for congenital syphilis after the newborn period should be conducted as is recommended for neonates. Penicillin Allergy Infants and children who require treatment for syphilis but who have a history of penicillin allergy or develop an allergic reaction presumed secondary to penicillin should be desensitized, if necessary, and then treated with penicillin (see Management of Patients With a History of Penicillin Allergy). Data are insufficient regarding the use of other antimicrobial agents (e.g., ceftriaxone); if a nonpenicillin agent is used, close serologic and CSF follow-up are indicated. Evidence is insufficient to determine whether infants who have congenital syphilis and whose mothers are coinfected with HIV require different evaluation, therapy, or follow-up for syphilis than is recommended for all infants. Penicillin Shortage During periods when the availability of penicillin is compromised, the following is recommended (see http://www.cdc.gov/nchstp/dstd/penicillinG.htm): 1. For infants with clinical evidence of congenital syphilis (Scenario 1), check local sources for aqueous crystalline penicillin G (potassium or sodium). If IV penicillin G is limited, substitute some or all daily doses with procaine penicillin G (50,000 U/kg/dose IM a day in a single daily dose for 10 days). If aqueous or procaine penicillin G is not available, ceftriaxone (in doses according to age and weight) may be considered with careful clinical and serologic follow-up. Ceftriaxone must be used with caution in infants with jaundice. For infants aged >30 days, use 75 mg/kg IV/IM a day in a single daily dose for 10--14 days; however, dose adjustment might be necessary based on birthweight. For older infants, the dose should be 100 mg/kg a day in a single daily dose. Studies that strongly support ceftriaxone for the treatment of congenital syphilis have not been conducted. Therefore, ceftriaxone should be used in consultation with a specialist in the treatment of infants with congenital syphilis. Management may include a repeat CSF examination at age 6 months if the initial examination was abnormal. 2. For infants at risk for congenital syphilis without any clinical evidence of infection (Scenarios 2 and 3), use a. procaine penicillin G, 50,000 U/kg/dose IM a day in a single dose for 10 days; b. benzathine penicillin G, 50,000 U/kg IM as a single dose. If any part of the evaluation for congenital syphilis is abnormal, CSF examination is not interpretable, CSF examination was not performed, or follow-up is uncertain, Procaine penicillin G is recommended. A single dose of ceftriaxone is inadequate therapy. 3. For premature infants at risk for congenital syphilis but who have no other clinical evidence of infection (Scenarios 2 and 3) and who might not tolerate IM injections because of decreased muscle mass, IV ceftriaxone may be considered with careful clinical and serologic follow-up (see Penicillin Shortage, Number 1). Ceftriaxone dosing must be adjusted to age and birthweight. Management of Patients Who Have a History of Penicillin Allergy No proven alternatives to penicillin are available for treating neurosyphilis, congenital syphilis, or syphilis in pregnant women. Penicillin also is recommended for use, whenever possible, in HIV-infected patients. Of the adult U.S. population, 3%--10% have experienced an immunoglobulin E (IgE) mediated allergic response to penicillin such as urticaria, angioedema, or anaphylaxis (i.e., upper airway obstruction, bronchospasm, or hypotension). Re-administration of penicillin to these patients can cause severe, immediate reactions. Because anaphylactic reactions to penicillin can be fatal, every effort should be made to avoid administering penicillin to penicillin-allergic patients, unless they undergo acute desensitization to eliminate anaphylactic sensitivity. An estimated 10% of persons who report a history of severe allergic reactions to penicillin remain allergic. With the passage of time, the majority of persons who have had a severe reaction to penicillin stop expressing penicillin-specific IgE. These persons can be treated safely with penicillin. The results of many investigations indicate that skin testing with the major and minor determinants of penicillin can reliably identify persons at high risk for penicillin reactions. Although these reagents are easily generated and have been available for >30 years, only benzylpenicilloyl poly-L-lysine (Pre-Pen® [i.e., the major determinant]) and penicillin G have been available commercially. Testing with only the major determinant and penicillin G identifies an estimated 90%--97% of the currently allergic patients. However, because skin testing without the minor determinants would still miss 3%--10% of allergic patients and because serious or fatal reactions can occur among these minor-determinant--positive patients, specialists suggest exercising caution when the full battery of skin-test reagents is not available (Box 1). An additional challenge has occurred with the recent unavailability of Pre-Pen®; however, plans for future availability of this product have been made, as well as a companion minor determinant mixture. If the full battery of skin-test reagents is available, including the major and minor determinants (see Penicillin Allergy Skin Testing), patients who report a history of penicillin reaction and who are skin-test negative can receive conventional penicillin therapy. Skin-test--positive patients should be desensitized. If the full battery of skin-test reagents, including the minor determinants, is not available, the patient should be skin tested using benzylpenicilloyl poly-L-lysine (i.e., the major determinant) and penicillin G. Patients who have positive test results should be desensitized. Some specialists suggest that persons who have negative test results should be regarded as probably allergic and should be desensitized. Others suggest that those with negative skin-test results can be test-dosed gradually with oral penicillin in a monitored setting in which treatment for anaphylactic reaction can be provided. If the major determinant (Pre-Pen®) is not available for skin testing, all patients with a history suggesting IgE mediated reactions (anaphylaxis, angioedema, bronchospasm, or urticaria) to penicillin should be desensitized in a hospital setting. In patients with reactions not likely to be IgE mediated, outpatient oral desensitization or monitored test doses may be considered. Penicillin Allergy Skin Testing Patients at high risk for anaphylaxis, including those who 1) have a history of penicillin-related anaphylaxis, asthma, or other diseases that would make anaphylaxis more dangerous or 2) are being treated with beta-adrenergic blocking agents should be tested with 100-fold dilutions of the full-strength skin-test reagents before being tested with full-strength reagents. In these situations, patients should be tested in a monitored setting in which treatment for an anaphylactic reaction is available. If possible, the patient should not have taken antihistamines recently (e.g., chlorpheniramine maleate or terfenadine during the preceding 24 hours, diphenhydramine HCl or hydroxyzine during the preceding 4 days, or astemizole during the preceding 3 weeks). Dilute the antigens either 1) 100-fold for preliminary testing if the patient has had a life-threatening reaction to penicillin or 2) 10-fold if the patient has had another type of immediate, generalized reaction to penicillin within the preceding year. Epicutaneous (Prick) Tests Duplicate drops of skin-test reagent are placed on the volar surface of the forearm. The underlying epidermis is pierced with a 26-gauge needle without drawing blood. An epicutaneous test is positive if the average wheal diameter after 15 minutes is 4 mm larger than that of negative controls; otherwise, the test is negative. The histamine controls should be positive to ensure that results are not falsely negative because of the effect of antihistaminic drugs. Intradermal Test If epicutaneous tests are negative, duplicate 0.02-mL intradermal injections of negative control and antigen solutions are made into the volar surface of the forearm by using a 26- or 27-gauge needle on a syringe. The diameters of the wheals induced by the injections should be recorded. An intradermal test is positive if the average wheal diameter 15 minutes after injection is >2 mm larger than the initial wheal size and also is >2 mm larger than the negative controls. Otherwise, the tests are negative. Patients who have a positive skin test to one of the penicillin determinants can be desensitized (Table 1). This is a straightforward, relatively safe procedure that can be performed orally or IV. Although the two approaches have not been compared, oral desensitization is regarded as safer and easier to perform. Patients should be desensitized in a hospital setting because serious IgE-mediated allergic reactions can occur. Desensitization usually can be completed in approximately 4 hours, after which the first dose of penicillin is administered. After desensitization, patients must be maintained on penicillin continuously for the duration of the course of therapy. Diseases Characterized by Urethritis and Cervicitis Management of Male Patients Who Have Urethritis Urethritis, as characterized by urethral inflammation, can result from infectious and noninfectious conditions. Symptoms, if present, include discharge of mucopurulent or purulent material, dysuria, or urethral pruritus. Asymptomatic infections are common. N. gonorrhoeae and C. trachomatis are clinically important infectious causes of urethritis. If clinic-based diagnostic tools (Gram stain microscopy) are not available, patients should be treated for both gonorrhea and chlamydia. Further testing to determine the specific etiology is recommended because both chlamydia and gonorrhea are reportable to state health departments, and a specific diagnosis might enhance partner notification and improve compliance with treatment, especially in exposed partners. Culture, nucleic acid hybridization tests, and nucleic acid amplification tests are available for the detection of both N. gonorrhoeae and C. trachomatis. Culture and hybridization tests require urethral swab specimens, whereas amplification tests can be performed on urine specimens. Because of their higher sensitivity, amplification tests are preferred for the detection of C. trachomatis. Several organisms can cause infectious urethritis. The presence of Gram-negative intracellular diplococci (GNID) on urethral smear is indicative of gonorrhea infection, which is frequently accompanied by chlamydial infection. Nongonoccocal urethritis (NGU) is diagnosed when microscopy indicates inflammation without GNID. C. trachomatis is a frequent cause of NGU (i.e., 15%--55% of cases); however, the prevalence varies by age group, with lower prevalence among older men. The proportion of NGU cases caused by chlamydia has been declining gradually. Complications of NGU among men infected with C. trachomatis include epididymitis, prostatitis, and Reiter's syndrome. Documentation of chlamydia infection is essential because of the need for partner referral for evaluation and treatment. The etiology of the majority of cases of nonchlamydial NGU is unknown. Ureaplasma urealyticum and Mycoplasma genitalium have been implicated as etiologic agents of NGU in some studies; however, detection of these organisms is frequently difficult (109--111). T. vaginalis, HSV, and adenovirus might also cause NGU (112--114). Diagnostic and treatment procedures for these organisms are reserved for situations in which these infections are suspected (e.g., contact with trichomoniasis and genital lesions or severe dysuria and meatitis, which might suggest genital herpes) or when NGU is not responsive to therapy. Enteric bacteria have been identified as an uncommon cause of NGU and might be associated with insertive anal sex. Confirmed Urethritis Clinicians should document that urethritis is present. Urethritis can be documented on the basis of any of the following signs or laboratory tests: Mucopurulent or purulent discharge. Gram stain of urethral secretions demonstrating >5 WBC per oil immersion field. The Gram stain is the preferred rapid diagnostic test for evaluating urethritis. It is highly sensitive and specific for documenting both urethritis and the presence or absence of gonococcal infection. Gonococcal infection is established by documenting the presence of WBC containing GNID, or Positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine sediment demonstrating >10 WBC per high power field. If none of these criteria are present, treatment should be deferred, and the patient should be tested for N. gonorrhoeae and C. trachomatis and followed closely if test results are negative. If the results demonstrate infection with either N. gonorrhoeae or C. trachomatis, the appropriate treatment should be given and sex partners referred for evaluation and treatment. Empiric treatment of symptoms without documentation of urethritis is recommended only for patients at high risk for infection who are unlikely to return for a follow-up evaluation. Such patients should be treated for gonorrhea and chlamydia. Partners of patients treated empirically should be evaluated and treated. Management of Patients Who Have Nongonococcal Urethritis All patients who have confirmed or suspected urethritis should be tested for gonorrhea and chlamydia. Testing for chlamydia is strongly recommended because of the increased utility and availability of highly sensitive and specific testing methods and because a specific diagnosis might enhance partner notification and improve compliance with treatment, especially in the exposed partner. Treatment should be initiated as soon as possible after diagnosis. Azithromycin and doxycycline are highly effective for chlamydial urethritis; however, infections with M. genitalium may respond better to azithromycin (115). Single-dose regimens have the advantage of improved compliance and directly observed treatment. To improve compliance, ideally the medication should be provided in the clinic or health-care provider's office. Doxycycline 100 mg orally twice a day for 7 days Erythromycin base 500 mg orally four times a day for 7 days Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days Ofloxacin 300 mg orally twice a day for 7 days Levofloxacin 500 mg orally once daily for 7 days Follow-Up for Patients Who Have Urethritis Patients should be instructed to return for evaluation if symptoms persist or recur after completion of therapy. Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not a sufficient basis for re-treatment. Patients should be instructed to abstain from sexual intercourse until 7 days after therapy is initiated, provided their symptoms have resolved and their sex partners have been adequately treated. Persistence of pain, discomfort, and irritative voiding symptoms beyond 3 months should alert the clinician to the possibility of chronic prostatitis/chronic pelvic pain syndrome in men. Persons whose conditions have been diagnosed as a new STD should receive testing for other STDs, including syphilis and HIV. Persons with NGU should refer for evaluation and treatment all sex partners within the preceding 60 days. Because a specific diagnosis might facilitate partner referral, testing for gonorrhea and chlamydia is encouraged. Recurrent and Persistent Urethritis Objective signs of urethritis should be present before initiation of antimicrobial therapy. In persons who have persistent symptoms after treatment without objective signs of urethritis, the value of extending the duration of antimicrobials has not been demonstrated. Persons who have persistent or recurrent urethritis can be re-treated with the initial regimen if they did not comply with the treatment regimen or if they were reexposed to an untreated sex partner. Otherwise, a T. vaginalis culture should be performed using an intraurethral swab or a first-void urine specimen (112). Some cases of recurrent urethritis after doxycycline treatment might be caused by tetracycline-resistant U. urealyticum. Urologic examinations usually do not reveal a specific etiology. Approximately 50% of men with chronic nonbacterial prostatitis/chronic pelvic pain syndrome have evidence of urethral inflammation without any identifiable microbial pathogens. If the patient was compliant with the initial regimen and reexposure can be excluded, the following regimen is recommended. Metronidazole 2 g orally in a single dose Tinidazole 2 g orally in a single dose Azithromycin 1 g orally in a single dose (if not used for initial episode) Gonococcal urethritis, chlamydial urethritis, and nongonococcal, nonchlamydial urethritis might facilitate HIV transmission. Patients who have NGU and also are infected with HIV should receive the same treatment regimen as those who are HIV negative. Management of Patients Who Have Cervicitis Two major diagnostic signs characterize cervicitis: 1) a purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen (commonly referred to as "mucopurulent cervicitis" or cervicitis), and 2) sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. Either or both signs might be present. Cervicitis frequently is asymptomatic, but some women complain of an abnormal vaginal discharge and intermenstrual vaginal bleeding (e.g., after sexual intercourse). A finding of leukorrhea (>10 WBC per high power field on microscopic examination of vaginal fluid) has been associated with chlamydial and gonococcal infection of the cervix. In the absence of inflammatory vaginitis, leukorrhea might be a sensitive indicator of cervical inflammation with a high negative predictive value (116). Although some specialists consider an increased number of polymorphonuclear leukocytes on endocervical Gram stain as being useful in the diagnosis of cervicitis, this criterion has not been standardized. In addition, it has a low positive-predictive value (PPV) for infection with C. trachomatis and N. gonorrhoeae and is not available in the majority of clinical settings. Finally, although the presence of GNID on Gram stain of endocervical fluid is specific for the diagnosis of gonococcal cervical infection, it is insensitive because it is observed in only 50% of women with this infection. When an etiologic organism is isolated in the setting of cervicitis, it is typically C. trachomatis or N. gonorrhoeae. Cervicitis also can accompany trichomoniasis and genital herpes (especially primary HSV-2 infection). However, in the majority of cases of cervicitis, no organism is isolated, especially in women at relatively low risk for recent acquisition of these STDs (for example, women aged >30 years). Limited data indicate that infection with M. genitalium and BV as well as frequent douching might cause cervicitis (117--119). For reasons that are unclear, cervicitis can persist despite repeated courses of antimicrobial therapy. Because the majority of persistent cases of cervicitis are not caused by relapse or reinfection with C. trachomatis or N. gonorrhoeae, other determinants (e.g., persistent abnormality of vaginal flora, douching or exposure to chemical irritants, or idiopathic inflammation in the zone of ectopy) might be involved. Because cervicitis might be a sign of upper genital tract infection (endometritis), women who seek medical treatment for a new episode of cervicitis should be assessed for signs of PID and should be tested for C. trachomatis and for N. gonorrhoeae with the most sensitive and specific test available, NAAT. Women with cervicitis also should be evaluated for the presence of BV and trichomoniasis, and these conditions should be treated, if present. Because the sensitivity of microscopy to detect T. vaginalis is relatively low (approximately 50%), symptomatic women with cervicitis and negative microscopy for trichomonads should receive further testing (i.e., culture or antigen-based detection). Although HSV-2 infection has been associated with cervicitis, the utility of specific testing (i.e., culture or serologic testing) for HSV-2 in this setting is unclear. Standardized diagnostic tests for M. genitalium are not commercially available. NAAT for C. trachomatis and N. gonorrhoeae are preferred for the diagnostic evaluation of cervicitis and can be performed on either cervical or urine samples. A finding of >10 WBC in vaginal fluid, in the absence of trichomoniasis, might indicate endocervical inflammation caused specifically by C. trachomatis or N. gonorrhoeae (116,120,121). Several factors should affect the decision to provide presumptive therapy for cervicitis or to await the results of diagnostic tests. Treatment with antibiotics for C. trachomatis should be provided in women at increased risk for this common STD (age <25 years, new or multiple sex partners, and unprotected sex), especially if follow-up cannot be ensured and if a relatively insensitive diagnostic test (not a NAAT) is used. Concurrent therapy for N. gonorrhoeae is indicated if the prevalence of this infection is high (>5%) in the patient population (young age and facility prevalence). Concomitant trichomoniasis or symptomatic BV should also be treated if detected. For women in whom any component of (or all) presumptive therapy is deferred, the results of sensitive tests for C. trachomatis and N. gonorrhoeae (e.g., nucleic acid amplification tests) should determine the need for treatment subsequent to the initial evaluation. Recommended Regimens for Presumptive Treatment* * Consider concurrent treatment for gonococcal infection if prevalence of gonorrhea is high in the patient population under assessment. Recurrent and Persistent Cervicitis Women with persistent cervicitis should be reevaluated for possible reexposure to an STD, and her vaginal flora should be reassessed. If relapse and/or reinfection with a specific STD has been excluded, BV is not present, and sex partners have been evaluated and treated, management options for persistent cervicitis are undefined. For such women, the value of repeated or prolonged administration of antibiotic therapy for persistent symptomatic cervicitis is unknown. Women who receive such a course should return after treatment so that a determination can be made regarding whether cervicitis has resolved. In women with persistent symptoms that are clearly attributable to cervicitis, ablative therapy may be considered by a gynecologic specialist. Follow-up should be conducted as recommended for the infections for which a woman is treated. If symptoms persist, women should be instructed to return for reevaluation. Management of sex partners of women treated for cervicitis should be appropriate for the identified or suspected STD. Partners should be notified and examined if chlamydia, gonorrhea, or trichomoniasis was identified or suspected in the index patient and treated for the STDs for which the index patient received treatment. To avoid re-infection, patients and their sex partners should abstain from sexual intercourse until therapy is completed (i.e., 7 days after a single-dose regimen or after completion of a 7-day regimen). Patients who have cervicitis and also are infected with HIV should receive the same treatment regimen as those who are HIV negative. Treatment of cervicitis in HIV-infected women is vital because cervicitis increases cervical HIV shedding. Treatment of cervicitis in HIV-infected women reduces HIV shedding from the cervix and might reduce HIV transmission to susceptible sex partners (122). Chlamydial Infections Chlamydial Infections in Adolescents and Adults In the United States, chlamydial genital infection is the most frequently reported infectious disease, and the prevalence is highest in persons aged <25 years (123). Several important sequelae can result from C. trachomatis infection in women; the most serious of these include PID, ectopic pregnancy, and infertility. Some women who have uncomplicated cervical infection already have subclinical upper reproductive tract infection. Asymptomatic infection is common among both men and women, and to detect chlamydial infections health-care providers frequently rely on screening tests. Annual screening of all sexually active women aged <25 years is recommended (124), as is screening of older women with risk factors (e.g., those who have a new sex partner or multiple sex partners). The benefits of C. trachomatis screening in women have been demonstrated in areas where screening programs have reduced both the prevalence of infection and rates of PID (125,126). Evidence is insufficient to recommend routine screening for C. trachomatis in sexually active young men, based on feasibility, efficacy, and cost-effectiveness. However, screening of sexually active young men should be considered in clinical settings with a high prevalence of chlamydia (e.g., adolescent clinics, correctional facilities, and STD clinics). An appropriate sexual risk assessment should be conducted for all persons and might indicate more frequent screening for some women or certain men. C. trachomatis urogenital infection in women can be diagnosed by testing urine or swab specimens collected from the endocervix or vagina. Diagnosis of C. trachomatis urethral infection in men can be made by testing a urethral swab or urine specimen. Rectal C. trachomatis infections in persons that engage in receptive anal intercourse can be diagnosed by testing a rectal swab specimen. Culture, direct immunofluorescence, EIA, nucleic acid hybridization tests, and NAATs are available for the detection of C. trachomatis on endocervical and male urethral swab specimens (127). NAATs are the most sensitive tests for these specimens and are FDA-cleared for use with urine, and some tests are cleared for use with vaginal swab specimens. The majority of tests, including NAAT and nucleic acid hybridization tests, are not FDA-cleared for use with rectal swab specimens, and chlamydia culture is not widely available for this purpose. Some noncommercial laboratories have initiated NAAT of rectal swab specimens after establishing the performance of the test to meet CLIA requirements. Patients' whose condition has been diagnosed as chlamydia also should be tested for other STDs. Treating infected patients prevents transmission to sex partners. In addition, treating pregnant women usually prevents transmission of C. trachomatis to infants during birth. Treatment of sex partners helps to prevent reinfection of the index patient and infection of other partners. Coinfection with C. trachomatis frequently occurs among patients who have gonococcal infection; therefore, presumptive treatment of such patients for chlamydia is appropriate (see Gonococcal Infection, Dual Therapy for Gonococcal and Chlamydial Infections). The following recommended treatment regimens and alternative regimens cure infection and usually relieve symptoms. A recent meta-analysis of 12 randomized clinical trials of azithromycin versus doxycycline for the treatment of genital chlamydial infection demonstrated that the treatments were equally efficacious, with microbial cure rates of 97% and 98%, respectively (128). These studies were conducted primarily in populations in which follow-up was encouraged, adherence to a 7-day regimen was effective, and culture or EIA (rather than the more sensitive NAAT was used for determining microbiological outcome. Azithromycin should always be available to treat patients for whom compliance with multiday dosing is in question. In populations that have erratic health-care--seeking behavior, poor treatment compliance, or unpredictable follow-up, azithromycin might be more cost-effective because it enables the provision of a single-dose of directly observed therapy. However, doxycycline costs less than azithromycin and has no higher risk for adverse events (128). Erythromycin might be less efficacious than either azithromycin or doxycycline, mainly because of the frequent occurrence of gastrointestinal side effects that discourage compliance. Ofloxacin and levofloxacin are effective treatment alternatives but are more expensive and offer no advantage in the dosage regimen. Other quinolones either are not reliably effective against chlamydial infection or have not been evaluated adequately. To maximize compliance with recommended therapies, medications for chlamydial infections should be dispensed on site, and the first dose should be directly observed. To minimize transmission, persons treated for chlamydia should be instructed to abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen. To minimize the risk for reinfection, patients also should be instructed to abstain from sexual intercourse until all of their sex partners are treated. Except in pregnant women, test-of-cure (repeat testing 3--4 weeks after completing therapy) is not recommended for persons treated with the recommended or alterative regimens, unless therapeutic compliance is in question, symptoms persist, or reinfection is suspected. Moreover, the validity of chlamydial diagnostic testing at <3 weeks after completion of therapy (to identify patients who did not respond to therapy) has not been established. False-negative results might occur because of persistent infections involving limited numbers of chlamydial organisms. In addition, NAAT conducted at <3 weeks after completion of therapy in persons who were treated successfully could yield false-positive results because of the continued presence of dead organisms. A high prevalence of C. trachomatis infection is observed in women who were treated for chlamydial infection in the preceding several months (129,130). The majority of posttreatment infections result from reinfection, frequently occurring because the patient's sex partners were not treated or because the patient resumed sex with a new partner infected with C. trachomatis. Repeat infections confer an elevated risk for PID and other complications when compared with the initial infection. Therefore, recently infected women are a major priority for repeat testing for C. trachomatis. Clinicians and health-care agencies should consider advising all women with chlamydial infection to be retested approximately 3 months after treatment. Providers also are strongly encouraged to retest all women treated for chlamydial infection whenever they next seek medical care within the following 3--12 months, regardless of whether the patient believes that her sex partners were treated. Recognizing that retesting is distinct from a test-of-cure, as discussed in this report, is vital. Limited evidence is available on the benefit of retesting for chlamydia in men previously infected; however, some specialists suggest retesting men approximately 3 months after treatment. Patients should be instructed to refer their sex partners for evaluation, testing, and treatment. The following recommendations on exposure intervals are based on limited evaluation. Sex partners should be evaluated, tested, and treated if they had sexual contact with the patient during the 60 days preceding onset of symptoms in the patient or diagnosis of chlamydia. The most recent sex partner should be evaluated and treated, even if the time of the last sexual contact was >60 days before symptom onset or diagnosis. If concerns exist that sex partners will not seek evaluation and treatment, or if other management strategies are impractical or unsuccessful, then delivery of antibiotic therapy (either a prescription or medication) by heterosexual male or female patients to their partners might be an option (see Partner Management). Limited studies to date have demonstrated a trend toward a decrease in rates of persistent or recurrent chlamydia with this approach compared with standard partner referral (25,27). Male patients must inform female partners of their infection and be given accompanying written materials about the importance of seeking evaluation for PID (especially if symptomatic). Patient-delivered partner therapy is not routinely recommended for MSM because of a high risk for coexisting infections, especially undiagnosed HIV infection, in their partners. Patients should be instructed to abstain from sexual intercourse until they and their sex partners have completed treatment. Abstinence should be continued until 7 days after a single-dose regimen or after completion of a 7-day regimen. Timely treatment of sex partners is essential for decreasing the risk for reinfecting the index patient. Pregnancy. Doxycycline, ofloxacin, and levofloxacin are contraindicated in pregnant women. However, clinical experience and studies suggest that azithromycin is safe and effective (131--133). Repeat testing (preferably by NAAT) 3 weeks after completion of therapy with the following regimens is recommended for all pregnant women to ensure therapeutic cure, considering the sequelae that might occur in the mother and neonate if the infection persists. The frequent gastrointestinal side effects associated with erythromycin might discourage patient compliance with the alternative regimens. Amoxicillin 500 mg orally three times a day for 7 days Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days Erythromycin estolate is contraindicated during pregnancy because of drug-related hepatotoxicity. The lower dose 14-day erythromycin regimens may be considered if gastrointestinal tolerance is a concern. HIV Infection. Patients who have chlamydial infection and also are infected with HIV should receive the same treatment regimen as those who are HIV negative. Chlamydial Infections Among Infants Prenatal screening of pregnant women can prevent chlamydial infection among neonates. Pregnant women aged <25 years are at high risk for infection. Local or regional prevalence surveys of chlamydial infection can be conducted to confirm the utility of using these recommendations in particular settings. C. trachomatis infection of neonates results from perinatal exposure to the mother's infected cervix. Neonatal ocular prophylaxis with silver nitrate solution or antibiotic ointments does not prevent perinatal transmission of C. trachomatis from mother to infant. However, ocular prophylaxis with those agents does prevent gonococcal ophthalmia and, therefore, should be continued (see Ophthalmia Neonatorum Prophylaxis). Initial C. trachomatis perinatal infection involves the mucous membranes of the eye, oropharynx, urogenital tract, and rectum and might be asymptomatic in these locations. C. trachomatis infection in neonates is most frequently recognized by conjunctivitis that develops 5--12 days after birth. C. trachomatis also can cause a subacute, afebrile pneumonia with onset at ages 1--3 months. C. trachomatis has been the most frequent identifiable infectious cause of ophthalmia neonatorum, but perinatal chlamydial infections, including opthalmia and pneumonia, are detected less frequently because of the institution of widespread prenatal screening and treatment of pregnant women. Ophthalmia Neonatorum Caused by C. trachomatis A chlamydial etiology should be considered for all infants aged <30 days who have conjunctivitis, especially if the mother has a history of untreated chlamydia infection. Sensitive and specific methods used to diagnose chlamydial ophthalmia in the neonate include both tissue culture and nonculture tests (e.g., DFA tests, EIA, and NAAT). The majority of nonculture tests are not FDA-cleared for the detection of chlamydia from conjunctival swabs, and clinical laboratories must verify the procedure according to CLIA regulations. Specimens must contain conjunctival cells, not exudate alone. Specimens for culture isolation and nonculture tests should be obtained from the everted eyelid using a dacron-tipped swab or the swab specified by the manufacturer's test kit. A specific diagnosis of C. trachomatis infection confirms the need for treatment not only for the neonate but also for the mother and her sex partner(s). Ocular exudate from infants being evaluated for chlamydial conjunctivitis also should be tested for N. gonorrhoeae. Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days¶¶,*** Topical antibiotic therapy alone is inadequate for treatment of chlamydial infection and is unnecessary when systemic treatment is administered. The efficacy of erythromycin treatment is approximately 80%; a second course of therapy might be required and, therefore, follow-up of infants is recommended to determine whether initial treatment was effective. The possibility of concomitant chlamydial pneumonia should be considered. Management of Mothers and Their Sex Partners The mothers of infants who have chlamydial infection and the sex partners of these women should be evaluated and treated (see Chlamydial Infection in Adolescents and Adults). Infant Pneumonia Caused by C. trachomatis Characteristic signs of chlamydial pneumonia in infants include 1) a repetitive staccato cough with tachypnea and 2) hyperinflation and bilateral diffuse infiltrates on a chest radiograph. Wheezing is rare, and infants are typically afebrile. Peripheral eosinophilia (>400 cells/mm3) occurs frequently. Because clinical presentations differ, initial treatment and diagnostic tests should include C. trachomatis for all infants aged 1--3 months who possibly have pneumonia (especially with untreated maternal chlamydial infection). Specimens for chlamydial testing should be collected from the nasopharynx. Tissue culture is the definitive standard for chlamydial pneumonia. Nonculture tests (e.g., EIA, DFA, and NAAT) can be used, although nonculture tests of nasopharyngeal specimens have a lower sensitivity and specificity than nonculture tests of ocular specimens. DFA is the only FDA-cleared test for the detection of C. trachomatis from nasopharyngeal specimens. Tracheal aspirates and lung biopsy specimens, if collected, should be tested for C. trachomatis. Because of the delay in obtaining test results for chlamydia, the decision to provide treatment for C. trachomatis pneumonia must frequently be based on clinical and radiologic findings. The results of tests for chlamydial infection assist in the management of an infant's illness and determine the need for treating the mother and her sex partner(s). Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days The effectiveness of erythromycin in treating pneumonia caused by C. trachomatis is approximately 80%; a second course of therapy might be required. Follow-up of infants is recommended to determine whether the pneumonia has resolved. Some infants with chlamydial pneumonia have abnormal pulmonary function tests later in childhood. Mothers of infants who have chlamydia pneumonia and the sex partners of these women should be evaluated and treated according to the recommended treatment of adults for chlamydial infections (see Chlamydial Infection in Adolescents and Adults). Infants Born to Mothers Who Have Chlamydial Infection Infants born to mothers who have untreated chlamydia are at high risk for infection; however, prophylatic antibiotic treatment is not indicated, and the efficacy of such treatment is unknown. Infants should be monitored to ensure appropriate treatment if symptoms develop. Chlamydial Infections Among Children Sexual abuse must be considered a cause of chlamydial infection in preadolescent children, although perinatally transmitted C. trachomatis infection of the nasopharynx, urogenital tract, and rectum might persist for >1 year (see Sexual Assault or Abuse of Children). Nonculture, nonamplified probe tests for chlamydia (EIA, DFA) should not be used because of the possibility of false-positive test results. With respiratory tract specimens, false-positive results can occur because of cross-reaction of test reagents with C. pneumoniae; with genital and anal specimens, false-positive results might occur because of cross-reaction with fecal flora. Recommended Regimens for Children Who Weigh <45 kg Recommended Regimen for Children Who Weigh >45 kg but Who Are Aged <8 Years Recommended Regimens for Children Aged >8 years See Sexual Assault or Abuse of Children. Follow-Up. Follow-up cultures are necessary to ensure that treatment has been effective. Gonococcal Infections Gonococcal Infections in Adolescents and Adults In the United States, an estimated 600,000 new N. gonorrhoeae infections occur each year (123). Gonorrhea is the second most commonly reported bacterial STD. The majority of urethral infections caused by N. gonorrhoeae among men produce symptoms that cause them to seek curative treatment soon enough to prevent serious sequelae, but treatment might not be soon enough to prevent transmission to others. Among women, several infections do not produce recognizable symptoms until complications (e.g., PID) have occurred. Both symptomatic and asymptomatic cases of PID can result in tubal scarring that can lead to infertility or ectopic pregnancy. Because gonococcal infections among women frequently are asymptomatic, an essential component of gonorrhea control in the United States continues to be the screening of women at high risk for STDs. The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk. Women aged <25 years are at highest risk for gonorrhea infection. Other risk factors for gonorrhea include a previous gonorrhea infection, other sexually transmitted infections, new or multiple sex partners, inconsistent condom use, commercial sex work, and drug use. The prevalence of gonorrhea infection varies widely among communities and patient populations. The USPSTF does not recommend screening for gonorrhea in men and women who are at low risk for infection (134). Because of high specificity (>99%) and sensitivity (>95%), a Gram stain of a male urethral specimen that demonstrates polymorphonuclear leukocytes with intracellular Gram-negative diplococci can be considered diagnostic for infection with N. gonorrhoeae in symptomatic men. However, because of lower sensitivity, a negative Gram stain should not be considered sufficient for ruling out infection in asymptomatic men. In addition, Gram stain of endocervical specimens, pharyngeal, or rectal specimens also are not sufficient to detect infection and, therefore, are not recommended. Specific testing for N. gonorrhoeae is recommended because of the increased utility and availability of highly sensitive and specific testing methods and because a specific diagnosis might enhance partner notification. Specific diagnosis of infection with N. gonorrhoeae may be performed by testing endocervical, vaginal, male urethral, or urine specimens. Culture, nucleic acid hybridization tests, and NAAT are available for the detection of genitourinary infection with N. gonorrhoeae (127). Culture and nucleic acid hybridization tests require female endocervical or male urethral swab specimens. NAAT offer the widest range of testing specimen types because they are FDA-cleared for use with endocervical swabs, vaginal swabs, male urethral swabs, and female and male urine. However, product inserts for each NAAT vendor must be carefully examined to assess current indications because FDA-cleared specimen types might vary. In general, culture is the most widely available option for the diagnosis of infection with N. gonorrhoeae in nongenital sites (e.g., rectum and pharynx). Nonculture tests are not FDA-cleared for use in the rectum and pharynx. Some NAATs have the potential to cross-react with nongonococcal Neisseria and related organisms that are commonly found in the throat. Some noncommercial laboratories have initiated NAAT of rectal and pharyngeal swab specimens after establishing the performance of the test to meet CLIA requirements. Because nonculture tests cannot provide antimicrobial susceptibility results, in cases of persistent gonococcal infection after treatment, clinicians should perform both culture and antimicrobial susceptibility testing. All patients tested for gonorrhea should be tested for other STDs, including chlamydia, syphilis, and HIV. Dual Therapy for Gonococcal and Chlamydial Infections Patients infected with N. gonorrhoeae frequently are coinfected with C. trachomatis; this finding has led to the recommendation that patients treated for gonococcal infection also be treated routinely with a regimen that is effective against uncomplicated genital C. trachomatis infection (135). Because the majority of gonococci in the United States are susceptible to doxycycline and azithromycin, routine cotreatment might also hinder the development of antimicrobial-resistant N. gonorrhoeae. Because of the high sensitivity of NAATs for chlamydial infection, patients with a negative chlamydial NAAT result at the time of treatment for gonorrhea do not need to be treated for chlamydia as well. However, if chlamydial test results are not available or if a non-NAAT was negative for chlamydia, patients should be treated for both gonorrhea and chlamydia. Quinolone-Resistant N. gonorrhoeae (QRNG) QRNG continues to spread, making the treatment of gonorrhea with quinolones such as ciprofloxacin inadvisable in many areas and populations (136). Resistance to ciprofloxacin usually indicates resistance to other quinolones as well. QRNG is common in parts of Europe, the Middle East, Asia, and the Pacific. In the United States, QRNG is becoming increasingly common. Previously, CDC had advised that quinolones not be used in California and Hawaii because of the high prevalence of QRNG in these areas (137). The prevalence of QRNG has increased in other areas of the United States, which has resulted in changes in recommended treatment regimens by other states and local areas. QRNG prevalence will continue to increase, and quinolones will eventually not be advisable for the treatment of gonorrhea. The CDC website (http://www.cdc.gov/std/gisp) or state health departments can provide the most current information. In 2004, of 6,322 isolates collected by CDC's Gonococcal Isolate Surveillance Project (GISP), 6.8% were resistant to ciprofloxacin (minimum inhibitory concentrations [MICs] >1.0 µg/mL). Excluding isolates from California and Hawaii, 3.6% of isolates were QRNG. QRNG was more common among MSM than among heterosexual men (23.9% versus 2.9%). In 2004, QRNG among heterosexual men outside of California and Hawaii was 1.4% (138). Quinolones should not be used for the treatment of gonorrhea among MSM (139) or in areas with increased QRNG prevalence in the United States (e.g., California and Hawaii) or for infections acquired while traveling abroad. Because oral alternatives to quinolones are limited, quinolones may continue to be used for heterosexual men and women in areas and populations not known to have elevated levels of resistance. Clinicians should obtain information on the sexual behavior and recent travel history (including histories from sex partners) of persons to be treated for gonorrhea to ensure appropriate antibiotic therapy. Resistance of N. gonorrhoeae to fluoroquinolones and other antimicrobials is expected to continue to spread; therefore, state and local surveillance for antimicrobial resistance is crucial for guiding local therapy recommendations. GISP, which samples approximately 3% of all U.S. men who have gonococcal infections, is a mainstay of surveillance. However, surveillance by clinicians also is critical. Clinicians who have diagnosed N. gonorrhoeae infection in a person who was previously treated with a recommended regimen and who probably has not been reexposed should perform culture and susceptibility testing of relevant clinical specimens and report the case to the local health department. Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum Ceftriaxone 125 mg IM in a single dose Cefixime 400 mg orally in a single dose Ciprofloxacin 500 mg orally in a single dose* Ofloxacin 400 mg orally in a single dose* Levofloxacin 250 mg orally in a single dose* TREATMENT FOR CHLAMYDIA IF CHLAMYDIAL INFECTION IS NOT RULED OUT * Quinolones should not be used for infections in MSM or in those with a history of recent foreign travel or partners' travel, infections acquired in California or Hawaii, or infections acquired in other areas with increased QRNG prevalence. Recommended Regimens for MSM or Heterosexuals with a History of Recent Travel* To maximize compliance with recommended therapies, medications for gonococcal infections should be dispensed on site. Ceftriaxone in a single injection of 125 mg provides sustained, high bactericidal levels in the blood. Extensive clinical experience indicates that ceftriaxone is safe and effective for the treatment of uncomplicated gonorrhea at all anatomic sites, curing 98.9% of uncomplicated urogenital and anorectal infections in published clinical trials (140). Cefixime has an antimicrobial spectrum similar to that of ceftriaxone, but the 400 mg oral dose does not provide as high, nor as sustained, a bactericidal level as that provided by the 125 mg dose of ceftriaxone. In published clinical trials, the 400 mg dose cured 97.4% of uncomplicated urogenital and anorectal gonococcal infections (140). The advantage of cefixime is that it can be administered orally. Updates on the availability of cefixime are available from CDC or state health departments. Ciprofloxacin is no longer universally effective against N. gonorrhoeae in the United States (138). However, ciprofloxacin is safe, inexpensive, and can be administered orally. In published clinical trials of uncomplicated urogenital and anorectal infections in the absence of QRNG, a dose of 500 mg of ciprofloxacin provides sustained bactericidal levels with cure rates of 99.8% (140). If QRNG is suspected, ceftriaxone IM or cefixime PO (by mouth) should be used. If neither of these regimens are feasible options, then one of the alternative nonquinolone regimens in this report should be considered. Similar to ciprofloxacin, ofloxacin is no longer universally effective against N. gonorrhoeae in the United States. The 400 mg oral dose of ofloxacin has been effective for treatment of uncomplicated urogenital and anorectal infections; in clinical trials, 98.6% of infections were cured (140). Levofloxacin, the active l-isomer of ofloxacin, can be used in place of ofloxacin as a single dose of 250 mg. Spectinomycin 2 g in a single IM dose Single-dose cephalosporin regimens Single-dose quinolone regimens Several other antimicrobials are active against N. gonorrhoeae, but none have substantial advantages over the recommended regimens. Spectinomycin is expensive and must be injected; however, it has been effective in published clinical trials, curing 98.2% of uncomplicated urogenital and anorectal gonococcal infections (140). Spectinomycin is useful for the treatment of patients who cannot tolerate cephalosporins and quinolones. Single-dose cephalosporin regimens (other than ceftriaxone 125 mg IM and cefixime 400 mg orally) that are safe and highly effective against uncomplicated urogenital and anorectal gonococcal infections include ceftizoxime (500 mg, administered IM), cefoxitin (2 g, administered IM with probenecid 1 g orally), and cefotaxime (500 mg, administered IM). None of the injectable cephalosporins offer any advantage over ceftriaxone. Single-dose quinolone regimens include gatifloxacin 400 mg orally, norfloxacin 800 mg orally, and lomefloxacin 400 mg orally. These regimens appear to be safe and effective for the treatment of uncomplicated gonorrhea, but data regarding their use are limited. None of the regimens appear to offer any advantage over ciprofloxacin, ofloxacin, or levofloxacin, and they are not effective against QRNG. Some evidence suggests that cefpodoxime and cefuroxime axetil 1 g orally might be additional oral alternatives in the treatment of uncomplicated urogenital gonorrhea; additional information on alternative oral regimens are available at http://www.cdc.gov/std. Cefpodoxime proxetil 200 mg PO is less active against N. gonorrhoeae than cefixime and also does not quite meet the minimum efficacy criteria (demonstrated efficacy with lower 95% confidence interval [CI] of >95% in summed clinical trials) with cure rates, 96.5% (CI = 94.8%--98.9%) for urogenital and rectal infection; efficacy in treating pharyngeal infection is unsatisfactory, 78.9% (CI = 54.5%--94%). Clinical studies are being conducted to assess whether cefpodoxime 400 mg PO is an acceptable oral alternative. Treatment with cefuroxime axetil 1 g PO does not quite meet the minimum efficacy criteria for urogenital and rectal infection (95.9%; CI = 94.5%--97.3%) and, its efficacy in treating pharyngeal infection is unacceptable (56.9%; CI = 42.2%--70.7%). Azithromycin 2 g orally is effective against uncomplicated gonococcal infection but is expensive and causes gastrointestinal distress and is not recommended for treatment of gonorrhea. Although azithromycin 1 g theoretically meets alternative regimen criteria, it is not recommended because of concerns regarding the possible rapid emergence of antimicrobial resistance. N. gonorrhoeae in the United States is not adequately susceptible to penicillins, tetracyclines, and macrolides (e.g., erythromycin) for these antimicrobials to be recommended. Uncomplicated Gonococcal Infections of the Pharynx Gonococcal infections of the pharynx are more difficult to eradicate than infections at urogenital and anorectal sites. Few antimicrobial regimens can reliably cure >90% of gonococcal pharyngeal infections. Although chlamydial coinfection of the pharynx is unusual, coinfection at genital sites sometimes occurs. Therefore, treatment for both gonorrhea and chlamydia is recommended. Ciprofloxacin 500 mg orally in a single dose Recommended Regimens for MSM or Heterosexuals with a History of Recent Travel TREATMENT FOR CHLAMYDIA IN CHLAMYDIAL INFECTION IS NOT RULED OUT Patients who have uncomplicated gonorrhea and who are treated with any of the recommended or alternative regimens do not need a test of cure. Patients who have symptoms that persist after treatment should be evaluated by culture for N. gonorrhoeae, and any gonococci isolated should be tested for antimicrobial susceptibility. Persistent urethritis, cervicitis, or proctitis also might be caused by C. trachomatis or other organisms. A high prevalence of N. gonorrhoeae infection is observed in patients who have had gonorrhea in the preceding several months (141,142). The majority of infections identified after treatment with one of the recommended regimens result from reinfection rather than treatment failure, indicating a need for improved patient education and referral of sex partners. Clinicians should consider advising all patients with gonorrhea to be retested 3 months after treatment. If patients do not seek medical care for retesting in 3 months, providers are encouraged to test these patients whenever they next seek medical care within the following 12 months, regardless of whether the patient believes that their sex partners were treated. Retesting is distinct from test of cure to detect therapeutic failure, which is not recommended. Effective clinical management of patients with treatable STDs requires treatment of the patients' recent sex partners to prevent reinfection and curtail further transmission. Patients should be instructed to refer their sex partners for evaluation and treatment. Sex partners of patients with N. gonorrhoeae infection whose last sexual contact with the patient was within 60 days before onset of symptoms or diagnosis of infection in the patient should be evaluated and treated for N. gonorrhoeae and C. trachomatis infections. If a patient's last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient's most recent sex partner should be treated. Patients should be instructed to avoid sexual intercourse until therapy is completed and until they and their sex partners no longer have symptoms. For patients with gonorrhea whose partners' treatment cannot be ensured or is unlikely, delivery of antibiotic therapy (i.e., either a prescription or medication) by heterosexual male or female patients to their partners is an option (see Partner Management). Use of this approach (25,27) should always be accompanied by efforts to educate partners about symptoms and to encourage partners to seek clinical evaluation. Male patients must inform female partners of their infection and be given accompanying materials about the importance of seeking medical evaluation for PID (especially if symptomatic). Possible undertreatment of PID in female partners and possible missed opportunities to diagnose other STDs are of concern and have not been evaluated in comparisons with patient-delivered therapy and partner referral. Patient-delivered therapy for patients with gonorrhea should routinely include treatment for chlamydia. This approach should not be considered a routine partner management strategy in MSM because of the high risk of coexisting undiagnosed STDs or HIV infection. Persons who cannot tolerate cephalosporins or quinolones should be treated with spectinomycin. Because spectinomycin is unreliable (52% effective) against pharyngeal infections, patients who have suspected or known pharyngeal infection should have a pharyngeal culture 3--5 days after treatment to verify eradication of infection. Pregnant women should not be treated with quinolones or tetracyclines. Those infected with N. gonorrhoeae should be treated with a recommended or alternate cephalosporin. Women who cannot tolerate a cephalosporin should be administered a single 2-g dose of spectinomycin IM. Either azithromycin or amoxicillin is recommended for treatment of presumptive or diagnosed C. trachomatis infection during pregnancy (see Chlamydial Infections). Administration of Quinolones to Adolescents Fluoroquinolones have not been recommended for persons aged <18 years because studies have indicated that they can damage articular cartilage in some young animals. However, no joint damage attributable to quinolone therapy has been observed in children treated with prolonged ciprofloxacin regimens (143). Therefore, children who weigh >45 kg can be treated with any regimen recommended for adults (See Gonococcal Infections). Patients who have gonococcal infection and also are infected with HIV should receive the same treatment regimen as those who are HIV negative. Gonococcal Conjunctivitis In the only published study of the treatment of gonococcal conjunctivitis among U.S. adults, all 12 study participants responded to a single 1-g IM injection of ceftriaxone (144). The following recommendation reflects the opinions of consultants knowledgeable in the field of STDs. Ceftriaxone 1 g IM in a single dose Consider lavage of the infected eye with saline solution once. Patients should be instructed to refer their sex partners for evaluation and treatment (see Gonococcal Infections, Management of Sex Partners). Disseminated Gonococcal Infection (DGI) DGI results from gonococcal bacteremia. DGI frequently results in petechial or pustular acral skin lesions, asymmetrical arthralgia, tenosynovitis, or septic arthritis. The infection is complicated occasionally by perihepatitis and rarely by endocarditis or meningitis. Some strains of N. gonorrhoeae that cause DGI may cause minimal genital inflammation. No studies on the treatment of DGI among adults have been published since publication of the last CDC STD treatment guidelines publication. DGI treatment recommendations reflect the opinions of consultants. No treatment failures have been reported with the recommended regimens. Hospitalization is recommended for initial therapy, especially for patients who might not comply with treatment, for those in whom diagnosis is uncertain, and for those who have purulent synovial effusions or other complications. Patients should be examined for clinical evidence of endocarditis and meningitis. Patients treated for DGI should be treated presumptively for concurrent C. trachomatis infection, unless appropriate testing excludes this infection. Ceftriaxone 1 g IM or IV every 24 hours Cefotaxime 1 g IV every 8 hours Ceftizoxime 1 g IV every 8 hours Ciprofloxacin 400 mg IV every 12 hours* Ofloxacin 400 mg IV every 12 hours* Levofloxacin 250 mg IV daily* Spectinomycin 2 g IM every 12 hours All of the preceding regimens should be continued for 24--48 hours after improvement begins, at which time therapy may be switched to one of the following regimens to complete at least 1 week of antimicrobial therapy. Cefixime 400 mg orally twice daily Ciprofloxacin 500 mg orally twice daily* Ofloxacin 400 mg orally twice daily* Levofloxacin 500 mg orally once daily* Gonococcal infection frequently is asymptomatic in sex partners of patients who have DGI. As with uncomplicated gonococcal infections, patients should be instructed to refer their sex partners for evaluation and treatment (see Gonococcal Infection, Management of Sex Partners). Gonococcal Meningitis and Endocarditis Ceftriaxone 1--2 g IV every 12 hours Therapy for meningitis should be continued for 10--14 days; therapy for endocarditis should be continued for at least 4 weeks. Treatment of complicated DGI should be undertaken in consultation with a specialist. Patients should be instructed to refer their sex partners for evaluation and treatment (see Gonococcal Infection, Management of Sex Partners). Gonococcal Infections Among Infants Gonococcal infection among infants usually results from exposure to infected cervical exudate at birth. It is usually an acute illness that manifests 2--5 days after birth. The prevalence of infection among infants depends on the prevalence of infection among pregnant women, whether pregnant women are screened for gonorrhea, and whether newborns receive ophthalmia prophylaxis. The most severe manifestations of N. gonorrhoeae infection in newborns are ophthalmia neonatorum and sepsis, which can include arthritis and meningitis. Less severe manifestations include rhinitis, vaginitis, urethritis, and reinfection at sites of fetal monitoring. Ophthalmia Neonatorum Caused by N. gonorrhoeae In the United States, although N. gonorrhoeae causes ophthalmia neonatorum less frequently than C. trachomatis and nonsexually transmitted agents, identifying and treating this infection is especially important because ophthalmia neonatorum can result in perforation of the globe of the eye and blindness. Infants at increased risk for gonococcal ophthalmia are those who do not receive ophthalmia prophylaxis and those whose mothers have had no prenatal care or whose mothers have a history of STDs or substance abuse. Gonococcal ophthalmia is strongly suspected when intracellular gram-negative diplococci are identified in conjunctival exudate, justifying presumptive treatment for gonorrhea after appropriate cultures for N. gonorrhoeae are obtained. Appropriate chlamydial testing should be done simultaneously. Presumptive treatment for N. gonorrhoeae might be indicated for newborns who are at increased risk for gonococcal ophthalmia and who have conjunctivitis but do not have gonococci in a Gram-stained smear of conjunctival exudate. In all cases of neonatal conjunctivitis, conjunctival exudates should be cultured for N. gonorrhoeae and tested for antibiotic susceptibility before a definitive diagnosis is made. A definitive diagnosis is vital because of the public health and social consequences of a diagnosis of gonorrhea. Nongonococcal causes of neonatal ophthalmia include Moraxella catarrhalis and other Neisseria species that are indistinguishable from N. gonorrhoeae on Gram-stained smear but can be differentiated in the microbiology laboratory. Ceftriaxone 25--50 mg/kg IV or IM in a single dose, not to exceed 125 mg Topical antibiotic therapy alone is inadequate and is unnecessary if systemic treatment is administered. Simultaneous infection with C. trachomatis should be considered when a patient does not improve after treatment. Both mother and infant should be tested for chlamydial infection at the same time that gonorrhea testing is conducted (see Ophthalmia Neonatorum Caused by C. trachomatis). Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely. Infants who have gonococcal ophthalmia should be hospitalized and evaluated for signs of disseminated infection (e.g., sepsis, arthritis, and meningitis). One dose of ceftriaxone is adequate therapy for gonococcal conjunctivitis. The mothers of infants who have gonococcal infection and the mothers' sex partners should be evaluated and treated according to the recommendations for treating gonococcal infections in adults (see Gonococcal Infections in Adolescents and Adults). DGI and Gonococcal Scalp Abscesses in Newborns Sepsis, arthritis, and meningitis (or any combination of these conditions) are rare complications of neonatal gonococcal infection. Localized gonococcal infection of the scalp can result from fetal monitoring through scalp electrodes. Detection of gonococcal infection in neonates who have sepsis, arthritis, meningitis, or scalp abscesses requires cultures of blood, CSF, and joint aspirate on chocolate agar. Specimens obtained from the conjunctiva, vagina, oropharynx, and rectum that are cultured on gonococcal selective medium are useful for identifying the primary site(s) of infection, especially if inflammation is present. Positive Gram-stained smears of exudate, CSF, or joint aspirate provide a presumptive basis for initiating treatment for N. gonorrhoeae. Diagnoses based on Gram-stained smears or presumptive identification of cultures should be confirmed with definitive tests on culture isolates. Ceftriaxone 25--50 mg/kg/day IV or IM in a single daily dose for 7 days, with a duration of 10--14 days, if meningitis is documented Cefotaxime 25 mg/kg IV or IM every 12 hours for 7 days, with a duration of 10--14 days, if meningitis is documented Prophylactic Treatment for Infants Whose Mothers Have Gonococcal Infection Infants born to mothers who have untreated gonorrhea are at high risk for infection. Recommended Regimen in the Absence of Signs of Gonococcal Infection Ceftriaxone 25--50 mg/kg IV or IM, not to exceed 125 mg, in a single dose Both mother and infant should be tested for chlamydial infection. Follow-up examination is not required. The mothers of infants who have gonococcal infection and the mothers' sex partners should be evaluated and treated according to the recommendations for treatment of gonococcal infections in adults (see Gonococcal Infections). Gonococcal Infections Among Children Sexual abuse is the most frequent cause of gonococcal infection in pre-adolescent children (see Sexual Assault or Abuse of Children). Vaginitis is the most common manifestation of gonococcal infection in preadolescent girls. PID after vaginal infection is probably less common in children than among adults. Among sexually abused children, anorectal and pharyngeal infections with N. gonorrhoeae are common and frequently asymptomatic. Because of the legal implications of a diagnosis of N. gonorrhoeae infection in a child, only standard culture procedures for the isolation of N. gonorrhoeae should be used for children. Nonculture gonococcal tests for gonococci (e.g., Gram-stained smear, nucleic acid hybridization tests, EIA, and NAAT) should not be used without standard culture; none of these tests have been approved by FDA for use with specimens obtained from the oropharynx, rectum, or genital tract of children. Specimens from the vagina, urethra, pharynx, or rectum should be streaked onto selective media for isolation of N. gonorrhoeae, and all presumptive isolates of N. gonorrhoeae should be identified definitively by at least two tests that involve different principles (e.g., biochemical, enzyme substrate, or serologic). Isolates should be preserved to enable additional or repeated testing. Recommended Regimens for Children Who Weigh >45 kg Treat with one of the regimens recommended for adults (see Gonococcal Infections) Fluoroquinolones have not been recommended for persons aged <18 years because they have damaged articular cartilage in young animals. However, no such joint damage clearly attributable to quinolone therapy has been observed in children, even in those receiving multiple-dose regimens. Recommended Regimens for Children Who Weigh <45 kg and Who Have Uncomplicated Gonococcal Vulvovaginitis, Cervicitis, Urethritis, Pharyngitis, or Proctitis Spectinomycin 40 mg/kg (maximum dose: 2 g) IM in a single dose may be used, but this therapy is unreliable for treatment of pharyngeal infections. Some specialists use cefixime to treat gonococcal infections in children because it can be administered orally; however, no reports have been published concerning the safety or effectiveness of cefixime used for this purpose. Recommended Regimen for Children Who Weigh <45 kg and Who Have Bacteremia or Arthritis Ceftriaxone 50 mg/kg (maximum dose: 1 g) IM or IV in a single dose daily for 7 days Recommended Regimen for Children Who Weigh >45 kg and Who Have Bacteremia or Arthritis Ceftriaxone 50 mg/kg IM or IV in a single dose daily for 7 days Follow-up cultures are unnecessary if ceftriaxone is used. If spectinomycin is used to treat pharyngitis, a follow-up culture is necessary to ensure that treatment was effective. Only parenteral cephalosporins are recommended for use in children. Ceftriaxone is approved for all gonococcal infections in children; cefotaxime is approved for gonococcal ophthalmia only. Oral cephalosporins used for treatment of gonococcal infections in children have not been adequately evaluated. All children who have gonococcal infections should be evaluated for coinfection with syphilis and C. trachomatis. (For a discussion of concerns regarding sexual assault, refer to Sexual Assault or Abuse of Children). Ophthalmia Neonatorum Prophylaxis To prevent gonococcal ophthalmia neonatorum, a prophylactic agent should be instilled into the eyes of all newborn infants; this procedure is required by law in the majority of states. All of the recommended prophylactic regimens in this section prevent gonococcal ophthalmia. However, the efficacy of these preparations in preventing chlamydial ophthalmia is less clear, and they do not eliminate nasopharyngeal colonization by C. trachomatis. The diagnosis and treatment of gonococcal and chlamydial infections in pregnant women is the best method for preventing neonatal gonococcal and chlamydial disease. Not all women, however, receive prenatal care. Ocular prophylaxis is warranted because it can prevent sight-threatening gonococcal ophthalmia and because it is safe, easy to administer, and inexpensive. Erythromycin (0.5%) ophthalmic ointment in a single application Tetracycline ophthalmic ointment (1%) in a single application One of these recommended preparations should be instilled into both eyes of every neonate as soon as possible after delivery. If prophylaxis is delayed (i.e., not administered in the delivery room), a monitoring system should be established to ensure that all infants receive prophylaxis. All infants should be administered ocular prophylaxis, regardless of whether they are delivered vaginally or by cesarean section. Single-use tubes or ampules are preferable to multiple-use tubes. Bacitracin is not effective. Use of povidone iodine has not been studied adequately. Diseases Characterized by Vaginal Discharge Management of Patients Who Have Vaginal Infections Vaginitis is usually characterized by a vaginal discharge and/or vulvar itching and irritation, and a vaginal odor might be present. The three diseases most frequently associated with vaginal discharge are BV (replacement of the normal vaginal flora by an overgrowth of anaerobic microorganisms, mycoplasmas, and Gardnerella vaginalis), trichomoniasis (T. vaginalis), and candidiasis (usually caused by Candida albicans). Cervicitis can sometimes cause a vaginal discharge. Although vulvovaginal candidiasis (VVC) usually is not transmitted sexually, it is included in this section because it is frequently diagnosed in women being evaluated for STDs. Various diagnostic methods are available to identify the etiology of an abnormal vaginal discharge. Laboratory testing fails to identify the cause of vaginitis in a minority of women. The cause of vaginal symptoms usually can be determined by pH and microscopic examination of fresh samples of the discharge. The pH of the vaginal secretions can be determined by narrow-range pH paper; an elevated pH (i.e., >4.5) is common with BV or trichomoniasis but might not be highly specific. Discharge can be further examined by diluting one sample in one to two drops of 0.9% normal saline solution on one slide and a second sample in 10% potassium hydroxide (KOH) solution. An amine odor detected immediately after applying KOH suggests BV. Cover slips are placed on the slides, and they are examined under a microscope at low- and high-dry power. Motile T. vaginalis or clue cells (epithelial cells with borders obscured by small bacteria), which are characteristic of BV, usually are identified easily in the saline specimen. WBCs without evidence of trichomonads or yeast are usually suggestive of cervicitis (see Cervicitis). The yeast or pseudohyphae of Candida species are more easily identified in the KOH specimen. However, the absence of trichomonads or pseudohyphae does not rule out these infections because several studies have demonstrated the presence of these pathogens by culture or PCR after a negative microscopic examination. The presence of objective signs of vulvar inflammation in the absence of vaginal pathogens, along with a minimal amount of discharge, suggests the possibility of mechanical, chemical, allergic, or other noninfectious irritation of the vulva. Culture for T. vaginalis is more sensitive than microscopic examination. In settings where microscopy is not available, alternative point-of-care tests may be used to diagnose vaginitis. BV is a polymicrobial clinical syndrome resulting from replacement of the normal H2O2--producing Lactobacillus sp. in the vagina with high concentrations of anaerobic bacteria (e.g., Prevotella sp. and Mobiluncus sp.), G. vaginalis, and Mycoplasma hominis. BV is the most prevalent cause of vaginal discharge or malodor; however, more than 50% of women with BV are asymptomatic. The cause of the microbial alteration is not fully understood. BV is associated with having multiple sex partners, a new sex partner, douching, and lack of vaginal lactobacilli; whether BV results from acquisition of a sexually transmitted pathogen is unclear. Women who have never been sexually active are rarely affected. Treatment of male sex partners has not been beneficial in preventing the recurrence of BV. BV can be diagnosed by the use of clinical criteria or Gram stain. Clinical criteria require three of the following symptoms or signs: homogeneous, thin, white discharge that smoothly coats the vaginal walls; presence of clue cells on microscopic examination; pH of vaginal fluid >4.5; and a fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test). When a Gram stain is used, determining the relative concentration of lactobacilli (long Gram-positive rods), Gram-negative and Gram-variable rods and cocci (i.e., G. vaginalis, Prevotella, Porphyromonas, and peptostreptococci), and curved Gram-negative rods (Mobiluncus) characteristic of BV is considered the gold standard laboratory method for diagnosing BV. Culture of G. vaginalis is not recommended as a diagnostic tool because it is not specific. However, a DNA probe-based test for high concentrations of G. vaginalis (AffirmTM VP III, Becton Dickinson, Sparks, Maryland) might have clinical utility. Cervical Pap tests have no clinical utility for the diagnosis of BV because of low sensitivity. Other commercially available tests that might be useful for the diagnosis of BV include a card test for the detection of elevated pH and trimethylamine (QuickVue Advance Quidel, San Diego, California) and prolineaminopeptidase (Pip Activity TestCardTM, Quidel, San Diego, California). The established benefits of therapy for BV in nonpregnant women are to 1) relieve vaginal symptoms and signs of infection and 2) reduce the risk for infectious complications after abortion or hysterectomy. Other potential benefits might include a reduction in risk for other infections (e.g., HIV and other STDs). All women who have symptomatic disease require treatment. BV during pregnancy is associated with adverse pregnancy outcomes, including premature rupture of the membranes, preterm labor, preterm birth, intraamniotic infection, and postpartum endometritis. The established benefit of therapy for BV in pregnant women is to relieve vaginal symptoms and signs of infection. Additional potential benefits of therapy include 1) reducing the risk for infectious complications associated with BV during pregnancy and 2) reducing the risk for other infections (e.g., other STDs or HIV). The results of several investigations indicate that treatment of pregnant women with BV who are at high risk for preterm delivery (i.e., those who previously delivered a premature infant) might reduce the risk for prematurity (145--147). Therefore, clinicians should consider evaluation and treatment of high-risk pregnant women with asymptomatic BV. The bacterial flora that characterizes BV have been recovered from the endometria and salpinges of women who have PID. BV has been associated with endometritis, PID, and vaginal cuff cellulitis after invasive procedures, including endometrial biopsy, hysterectomy, hysterosalpingography, placement of an IUD, cesarean section, and uterine curettage. The results of two randomized controlled trials have indicated that treatment of BV with metronidazole substantially reduced postabortion PID (148,149). Three trials that evaluated the use of anaerobic antimicrobial coverage (i.e., metronidazole) for routine operative prophylaxis before abortion and seven trials that evaluated this additional coverage for women undergoing hysterectomy demonstrated a substantial reduction in postoperative infectious complications (148--156). Because of the increased risk for postoperative infectious complications associated with BV, some specialists suggest that before performing surgical abortion or hysterectomy, providers should screen for and treat women with BV in addition to providing routine prophylaxis. However, more information is needed before recommending treatment of asymptomatic BV before other invasive procedures. Metronidazole 500 mg orally twice a day for 7 days Metronidazole gel, 0.75%, one full applicator (5g) intravaginally, once a day for 5 days Clindamycin cream, 2%, one full applicator (5g) intravaginally at bedtime for 7 days Patients should be advised to avoid consuming alcohol during treatment with metronidazole and for 24 hours thereafter. Clindamycin cream is oil-based and might weaken latex condoms and diaphragms for 5 days after use. Refer to clindamycin product labeling for additional information. Topical clindamycin preparations should not be used in the second half of pregnancy. The recommended metronidazole regimens are equally efficacious. One randomized trial evaluated the clinical equivalency of intravaginal metronidazole gel 0.75% once daily versus twice daily and demonstrated similar cure rates 1 month after therapy (157). Clindamycin 300 mg orally twice a day for 7 days Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days Metronidazole 2 g single-dose therapy has the lowest efficacy for BV and is no longer a recommended or alternative regimen. FDA has cleared metronidazole 750 mg extended release tablets once daily for 7 days and a single dose of clindamycin intravaginal cream. Limited data have been published that compares the clinical or microbiologic equivalencies of these regimens with other regimens. Cure rates do not differ between intravaginal clindamycin cream and ovules (158). Several studies have evaluated the clinical and microbiologic efficacy of using lactobacillus intravaginal suppositories to restore normal flora and treat BV. However, no currently available lactobacillus suppository was determined to be better than placebo 1 month after therapy for either clinical or microbiologic cure. No data support the use of douching for treatment or relief of symptoms. Follow-up visits are unnecessary if symptoms resolve. Because recurrence of BV is not unusual, women should be advised to return for additional therapy if symptoms recur. A treatment regimen different from the original regimen may be used to treat recurrent disease. However, women with multiple recurrences should be managed in consultation with a specialist. One randomized trial for persistent BV indicated that metronidazole gel 0.75% twice per week for 6 months after completion of a recommended regimen was effective in maintaining a clinical cure for 6 months (159). The results of clinical trials indicate that a woman's response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner(s). Therefore, routine treatment of sex partners is not recommended. Allergy or Intolerance to the Recommended Therapy Intravaginal clindamycin cream is preferred in case of allergy or intolerance to metronidazole. Intravaginal metronidazole gel can be considered for patients who do not tolerate systemic metronidazole, but patients allergic to oral metronidazole should not be administered intravaginal metronidazole. All pregnant women who have symptomatic disease require treatment. BV has been associated with adverse pregnancy outcomes (e.g., premature rupture of the membranes, chorioamnionitis, preterm labor, preterm birth, intraamniotic infection, postpartum endometritis, and postcesarean wound infection). Some specialists prefer using systemic therapy to treat possible subclinical upper genital tract infections. Treatment of BV in asymptomatic pregnant women at high risk for preterm delivery (i.e., those who have previously delivered a premature infant) with a recommended oral regimen has reduced preterm delivery in three of four randomized controlled trials (145,146,160,161); some specialists recommend screening and oral treatment of these women. However, the optimal treatment regimens have not been established. Screening (if conducted) and treatment should be performed during the first prenatal visit. Two trials that evaluated the efficacy of metronidazole during pregnancy used the 250-mg regimen (145,146). However, some specialists suggest using a regimen of 500 mg twice daily in pregnant women. One small trial demonstrated that treatment with oral metronidazole 500 mg twice daily was equally effective as metronidazole gel, with cure rates of 70% (162). These regimens were not effective in reducing preterm birth in any group of women. Multiple studies and meta-analyses have not demonstrated an association between metronidazole use during pregnancy and teratogenic or mutagenic effects in newborns (164--166). Recommended Regimens for Pregnant Women Metronidazole 250 mg orally three times a day for 7 days Whether treatment of asymptomatic pregnant women with BV who are at low risk for preterm delivery reduces adverse outcomes of pregnancy is unclear. One trial in which oral clindamycin was used demonstrated a reduction in spontaneous preterm birth (147). Several trials have evaluated the use of intravaginal clindamycin during pregnancy to reduce preterm birth and treat asymptomatic BV. One trial in which women were treated before 20 weeks' gestation demonstrated a reduction in preterm birth (166). In three other trials, intravaginal clindamycin cream was administered at 16--32 weeks' gestation, and an increase in adverse events (e.g., low birthweight and neonatal infections) was observed in newborns (167--169). Therefore, intravaginal clindamycin cream should only be used during the first half of pregnancy. Follow-Up of Pregnant Women Treatment of BV in asymptomatic pregnant women who are at high risk for preterm delivery might prevent adverse pregnancy outcomes. Therefore, a follow-up evaluation 1 month after completion of treatment should be considered to evaluate whether therapy was effective. Patients who have BV and also are infected with HIV should receive the same treatment regimen as those who are HIV negative. BV appears to be more persistent in HIV-positive women. Trichomoniasis is caused by the protozoan T. vaginalis. Some men who are infected with T. vaginalis might not have symptoms; others have NGU. Many infected women have symptoms characterized by a diffuse, malodorous, yellow-green vaginal discharge with vulvar irritation. However, some women have minimal or no symptoms. Diagnosis of vaginal trichomoniasis is usually performed by microscopy of vaginal secretions, but this method has a sensitivity of only approximately 60%--70% and requires immediate evaluation of wet preparation slide for optimal results. Other FDA-cleared tests for trichomoniasis in women include OSOM Trichomonas Rapid Test (Genzyme Diagnostics, Cambridge, Massachusetts), an immunochromatographic capillary flow dipstick technology, and the Affirm™ VP III (Becton Dickenson, San Jose, California), a nucleic acid probe test that evaluates for T. vaginalis, G. vaginalis, and C. albicans. These tests are both performed on vaginal secretions and have a sensitivity >83% and a specificity >97%. Both tests are point-of-care diagnostics. The results of the OSOM Trichomonas Rapid Test are available in approximately 10 minutes, and results of the Affirm™ VP III are available within 45 minutes. Although these tests tend to be more sensitive than vaginal wet preparation, false positives might occur especially in low prevalence populations. Culture is the most sensitive and specific commercially available method of diagnosis. In women in whom trichomoniasis is suspected but not confirmed by microscopy, vaginal secretions should be cultured for T. vaginalis. In men, wet preparation is insensitive, and culture testing of urethral swab, urine, and semen is required for optimal sensitivity. No FDA-cleared PCR test for T. vaginalis is available in the United States, but such testing might be available from commercial laboratories that have developed their own PCR tests. Patients should be advised to avoid consuming alcohol during treatment with metronidazole or tinidazole. Abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole. The nitroimidazoles comprise the only class of drugs useful for the oral or parenteral therapy of trichomoniasis. Of these drugs, metronidazole and tinidazole are available in the United States and are cleared by the FDA for the treatment of trichomoniasis. In randomized clinical trials, the recommended metronidazole regimens have resulted in cure rates of approximately 90%--95%, and the recommended tinidazole regimen has resulted in cure rates of approximately 86%--100%. The appropriate treatment of sex partners might increase these reported rates. Randomized controlled trials comparing single 2 g doses of metronidazole and tinidazole suggest that tinidazole is equivalent to, or superior to, metronidazole in achieving parasitologic cure and resolution of symptoms (170). Treatment of patients and sex partners results in relief of symptoms, microbiologic cure, and reduction of transmission. Metronidazole gel is considerably less efficacious for the treatment of trichomoniasis (<50%) than oral preparations of metronidazole. Topically applied antimicrobials (e.g., metronidazole gel) are unlikely to achieve therapeutic levels in the urethra or perivaginal glands; therefore, use of the gel is not recommended. Several other topically applied antimicrobials occasionally have been used for treatment of trichomoniasis; however, these preparations probably do not have greater efficacy than metronidazole gel. Follow-up is unnecessary for men and women who become asymptomatic after treatment or who are initially asymptomatic. Some strains of T. vaginalis can have diminished susceptibility to metronidazole; however, infections caused by the majority of these organisms respond to tinidazole or higher doses of metronidazole. Low-level metronidazole resistance has been identified in 2%--5% of cases of vaginal trichomoniasis. High-level resistance is rare. Tinidazole has a longer serum half-life and reaches higher levels in genitourinary tissues than metronidazole. In addition, many T. vaginalis isolates have lower minimum inhibitory concentrations (MICs) to tinidazole than metronidazole. If treatment failure occurs with metronidazole 2 g single dose and reinfection is excluded, the patient can be treated with metronidazole 500 mg orally twice daily for 7 days or tinidazole 2 g single dose. For patients failing either of these regimens, clinicians should consider treatment with tinidazole or metronidazole at 2 g orally for 5 days. If these therapies are not effective, further management should be discussed with a specialist. The consultation should ideally include determination of the susceptibility of T. vaginalis to metronidazole and tinidazole. Consultation and T. vaginalis susceptibility testing is available from CDC (telephone: 770-488-4115; website: http://www.cdc.gov/std). Sex partners of patients with T. vaginalis should be treated. Patients should be instructed to avoid sex until they and their sex partners are cured (i.e., when therapy has been completed and patient and partner(s) are asymptomatic). Metronidazole and tinidazole are both nitroimidazoles. Patients with an immediate-type allergy to a nitroimidazole can be managed by metronidazole desensitization in consultation with a specialist (171,172). Topical therapy with drugs other than nitroimidazoles can be attempted, but cure rates are low (<50%). Vaginal trichomoniasis has been associated with adverse pregnancy outcomes, particularly premature rupture of membranes, preterm delivery, and low birthweight. However, data do not suggest that metronidazole treatment results in a reduction in perinatal morbidity. Although some trials suggest the possibility of increased prematurity or low birthweight after metronidazole treatment, limitations of the studies prevent definitive conclusions regarding risks of treatment (173,174). Treatment of T. vaginalis might relieve symptoms of vaginal discharge in pregnant women and might prevent respiratory or genital infection of the newborn and further sexual transmission. Clinicians should counsel patients regarding the potential risks and benefits of treatment. Some specialists would defer therapy in asymptomatic pregnant women until after 37 weeks' gestation. In addition, these pregnant women should be provided careful counseling regarding condom use and the continued risk of sexual transmission. Women may be treated with 2 g of metronidazole in a single dose. Metronidazole is pregnancy category B (animal studies have revealed no evidence of harm to the fetus, but no adequate, well-controlled studies among pregnant women have been conducted). Multiple studies and meta-analyses have not demonstrated a consistent association between metronidazole use during pregnancy and teratogenic or mutagenic effects in infants (163--165). Tinidazole is pregnancy category C (animal studies have demonstrated an adverse event, and no adequate, well-controlled studies in pregnant women have been conducted), and its safety in pregnant women has not been well-evaluated. In lactating women who are administered metronidazole, withholding breastfeeding during treatment and for 12--24 hours after the last dose will reduce the exposure of metronidazole to the infant. While using tinidazole, interruption of breastfeeding is recommended during treatment and for 3 days after the last dose. Patients who have trichomoniasis and also are infected with HIV should receive the same treatment regimen as those who are HIV negative. The incidence, persistence, and recurrence of trichomoniasis in HIV-infected women are not correlated with immune status. Vulvovaginal Candidiasis VVC usually is caused by C. albicans but occasionally is caused by other Candida sp. or yeasts. Typical symptoms of VVC include pruritus, vaginal soreness, dyspareunia, external dysuria, and abnormal vaginal discharge. None of these symptoms is specific for VVC. An estimated 75% of women will have at least one episode of VVC, and 40%--45% will have two or more episodes. On the basis of clinical presentation, microbiology, host factors, and response to therapy, VVC can be classified as either uncomplicated or complicated (Box 2). Approximately 10%--20% of women will have complicated VVC, suggesting diagnostic and therapeutic considerations. Uncomplicated VVC Diagnostic Considerations in Uncomplicated VVC A diagnosis of Candida vaginitis is suggested clinically by the presence of external dysuria and vulvar pruritus, pain, swelling, and redness. Signs include vulvar edema, fissures, excoriations, or thick curdy vaginal discharge. The diagnosis can be made in a woman who has signs and symptoms of vaginitis when either 1) a wet preparation (saline, 10% KOH) or Gram stain of vaginal discharge demonstrates yeasts or pseudohyphae or 2) a culture or other test yields a positive result for a yeast species. Candida vaginitis is associated with a normal vaginal pH (<4.5). Use of 10% KOH in wet preparations improves the visualization of yeast and mycelia by disrupting cellular material that might obscure the yeast or pseudohyphae. Examination of a wet mount with KOH preparation should be performed for all women with symptoms or signs of VVC, and women with a positive result should receive treatment. For those with negative wet mounts, vaginal cultures for Candida should be considered for those with any sign or multiple symptoms. If Candida cultures cannot be done, empiric treatment can be considered for symptomatic women with any sign of VVC on examination when the wet mount is negative. Identifying Candida by culture in the absence of symptoms or signs is not an indication for treatment because approximately 10%--20% of women harbor Candida sp. and other yeasts in the vagina. VVC can occur concomitantly with STDs. The majority of healthy women with uncomplicated VVC have no identifiable precipitating factors. Short-course topical formulations (i.e., single dose and regimens of 1--3 days) effectively treat uncomplicated VVC. The topically applied azole drugs are more effective than nystatin. Treatment with azoles results in relief of symptoms and negative cultures in 80%--90% of patients who complete therapy. Intravaginal Agents: Butoconazole 2% cream 5 g intravaginally for 3 days* Butoconazole 2% cream 5 g (Butaconazole1-sustained release), single intravaginal application Clotrimazole 1% cream 5 g intravaginally for 7--14 days* Clotrimazole 100 mg vaginal tablet for 7 days Clotrimazole 100 mg vaginal tablet, two tablets for 3 days Miconazole 2% cream 5 g intravaginally for 7 days* Miconazole 100 mg vaginal suppository, one suppository for 7 days* Miconazole 1,200 mg vaginal suppository, one suppository for 1 day* Nystatin 100,000-unit vaginal tablet, one tablet for 14 days Tioconazole 6.5% ointment 5 g intravaginally in a single application* Terconazole 0.4% cream 5 g intravaginally for 7 days Terconazole 80 mg vaginal suppository, one suppository for 3 days Oral Agent: Fluconazole 150 mg oral tablet, one tablet in single dose * Over-the-counter preparations. The creams and suppositories in this regimen are oil-based and might weaken latex condoms and diaphragms. Refer to condom product labeling for further information. Intravaginal preparations of butaconazole, clotrimazole, miconazole, and tioconazole are available over-the-counter (OTC). Women whose condition has previously been diagnosed with VVC are not necessarily more likely to be able to diagnose themselves; therefore, any woman whose symptoms persist after using an OTC preparation, or who has a recurrence of symptoms within 2 months, should be evaluated with office-based testing. Unnecessary or inappropriate use of OTC preparations is common and can lead to a delay in the treatment of other vulvovaginitis etiologies, which can result in adverse clinical outcomes. Patients should be instructed to return for follow-up visits only if symptoms persist or recur within 2 months of onset of initial symptoms. VVC is not usually acquired through sexual intercourse; treatment of sex partners is not recommended but may be considered in women who have recurrent infection. A minority of male sex partners might have balanitis, which is characterized by erythematous areas on the glans of the penis in conjunction with pruritus or irritation. These men benefit from treatment with topical antifungal agents to relieve symptoms. Topical agents usually cause no systemic side effects, although local burning or irritation might occur. Oral agents occasionally cause nausea, abdominal pain, and headache. Therapy with the oral azoles has been associated rarely with abnormal elevations of liver enzymes. Clinically important interactions can occur when these oral agents are administered with other drugs, including astemizole, calcium channel antagonists, cisapride, coumadin, cyclosporin A, oral hypoglycemic agents, phenytoin, protease inhibitors, tacrolimus, terfenadine, theophylline, trimetrexate, and rifampin. Complicated VVC Recurrent Vulvovaginal Candidiasis (RVVC) RVVC, usually defined as four or more episodes of symptomatic VVC in 1 year, affects a small percentage of women (<5%). The pathogenesis of RVVC is poorly understood, and the majority of women with RVVC have no apparent predisposing or underlying conditions. Vaginal cultures should be obtained from patients with RVVC to confirm the clinical diagnosis and to identify unusual species, including nonalbicans species, particularly Candida glabrata (C. glabrata does not form pseudohyphae or hyphae and is not easily recognized on microscopy). C. glabrata and other nonalbicans Candidia species are observed in 10%--20% of patients with RVVC. Conventional antimycotic therapies are not as effective against these species as against C. albicans. Each individual episode of RVVC caused by C. albicans responds well to short duration oral or topical azole therapy. However, to maintain clinical and mycologic control, some specialists recommend a longer duration of initial therapy (e.g., 7--14 days of topical therapy or a 100 mg, 150 mg, or 200 mg oral dose of fluconazole every third day for a total of 3 doses (day 1, 4, and 7) to attempt mycologic remission before initiating a maintenance antifungal regimen. Maintenance Regimens Oral fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose) weekly for 6 months is the first line of treatment. If this regimen is not feasible, some specialists recommend topical clotrimazole 200 mg twice a week, clotrimazole (500-mg dose vaginal suppositories once weekly), or other topical treatments used intermittently. Suppressive maintenance antifungal therapies are effective in reducing RVVC. However, 30%--50% of women will have recurrent disease after maintenance therapy is discontinued. Routine treatment of sex partners is controversial. C. albicans azole resistance is rare in vaginal isolates, and susceptibility testing is usually not warranted for individual treatment guidance. Severe VVC Severe vulvovaginitis (i.e., extensive vulvar erythema, edema, excoriation, and fissure formation) is associated with lower clinical response rates in patients treated with short courses of topical or oral therapy. Either 7--14 days of topical azole or 150 mg of fluconazole in two sequential doses (second dose 72 hours after initial dose) is recommended. Nonalbicans VVC The optimal treatment of nonalbicans VVC remains unknown. Options include longer duration of therapy (7--14 days) with a nonfluconazole azole drug (oral or topical) as first-line therapy. If recurrence occurs, 600 mg of boric acid in a gelatin capsule is recommended, administered vaginally once daily for 2 weeks. This regimen has clinical and mycologic eradication rates of approximately 70% (175). If symptoms recur, referral to a specialist is advised. Compromised Host Women with underlying debilitating medical conditions (e.g., those with uncontrolled diabetes or those receiving corticosteroid treatment) do not respond as well to short-term therapies. Efforts to correct modifiable conditions should be made, and more prolonged (i.e., 7--14 days) conventional antimycotic treatment is necessary. VVC frequently occurs during pregnancy. Only topical azole therapies, applied for 7 days, are recommended for use among pregnant women. The incidence of VVC in HIV-infected women is unknown. Vaginal Candida colonization rates among HIV-infected women are higher than among those for seronegative women with similar demographic characteristics and high-risk behaviors, and the colonization rates correlate with increasing severity of immunosuppression. Symptomatic VVC is more frequent in seropositive women and similarly correlates with severity of immunodeficiency. In addition, among HIV-infected women, systemic azole exposure is associated with the isolation of nonalbicans Candida species from the vagina. Based on available data, therapy for VVC in HIV-infected women should not differ from that for seronegative women. Although long-term prophylactic therapy with fluconazole at a dose of 200 mg weekly has been effective in reducing C. albicans colonization and symptomatic VVC (176), this regimen is not recommended for routine primary prophylaxis in HIV-infected women in the absence of recurrent VVC (50). Given the frequency at which RVVC occurs in the immmunocompetent healthy population, the occurrence of RVVC should not be considered an indication for HIV testing. PID comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually transmitted organisms, especially N. gonorrhoeae and C. trachomatis, are implicated in many cases; however, microorganisms that comprise the vaginal flora (e.g., anaerobes, G. vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) also have been associated with PID. In addition, cytomegalovirus (CMV), M. hominis, U. urealyticum, and M. genitalium might be associated with some cases of PID. All women who are diagnosed with acute PID should be tested for N. gonorrhoeae and C. trachomatis and should be screened for HIV infection. Acute PID is difficult to diagnose because of the wide variation in the symptoms and signs. Many women with PID have subtle or mild symptoms. Delay in diagnosis and treatment probably contributes to inflammatory sequelae in the upper reproductive tract. Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and a more complete bacteriologic diagnosis. However, this diagnostic tool frequently is not readily available, and its use is not easy to justify when symptoms are mild or vague. Moreover, laparoscopy will not detect endometritis and might not detect subtle inflammation of the fallopian tubes. Consequently, a diagnosis of PID usually is based on clinical findings. The clinical diagnosis of acute PID is imprecise (177,178). Data indicate that a clinical diagnosis of symptomatic PID has a positive predictive value (PPV) for salpingitis of 65%--90% compared with laparoscopy. The PPV of a clinical diagnosis of acute PID depends on the epidemiologic characteristics of the population, with higher PPVs among sexually active young women (particularly adolescents), among patients attending STD clinics, or in other settings where the rates of gonorrhea or chlamydia are high. In all settings, however, no single historical, physical, or laboratory finding is both sensitive and specific for the diagnosis of acute PID (i.e., can be used both to detect all cases of PID and to exclude all women without PID). Combinations of diagnostic findings that improve either sensitivity (i.e., detect more women who have PID) or specificity (i.e., exclude more women who do not have PID) do so only at the expense of the other. For example, requiring two or more findings excludes more women who do not have PID but also reduces the number of women with PID who are identified. Many episodes of PID go unrecognized. Although some cases are asymptomatic, others are not diagnosed because the patient or the health-care provider fails to recognize the implications of mild or nonspecific symptoms or signs (e.g., abnormal bleeding, dyspareunia, and vaginal discharge). Because of the difficulty of diagnosis and the potential for damage to the reproductive health of women, even by apparently mild or subclinical PID, health-care providers should maintain a low threshold for the diagnosis of PID. The optimal treatment regimen and long-term outcome of early treatment of women with asymptomatic or subclinical PID are unknown. The following recommendations for diagnosing PID are intended to help health-care providers recognize when PID should be suspected and when they need to obtain additional information to increase diagnostic certainty. Diagnosis and management of other common causes of lower abdominal pain (e.g., ectopic pregnancy, acute appendicitis, and functional pain) are unlikely to be impaired by initiating empiric antimicrobial therapy for PID. Empiric treatment of PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination: cervical motion tenderness OR uterine tenderness OR adnexal tenderness. The requirement that all three minimum criteria be present before the initiation of empiric treatment could result in insufficient sensitivity for the diagnosis of PID. The presence of signs of lower genital tract inflammation, in addition to one of the three minimum criteria, increases the specificity of diagnosis. In deciding upon the initiation of empiric treatment, clinicians should also consider the risk profile of the patient for STDs. More elaborate diagnostic evaluation frequently is needed because incorrect diagnosis and management might cause unnecessary morbidity. These additional criteria may be used to enhance the specificity of the minimum criteria. The following additional criteria can be used to enhance the specificity of the minimum criteria and support a diagnosis of PID: oral temperature >101°F (>38.3°C), abnormal cervical or vaginal mucopurulent discharge, presence of abundant numbers of WBC on saline microscopy of vaginal secretions, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis. The majority of women with PID have either mucopurulent cervical discharge or evidence of WBC on a microscopic evaluation of a saline preparation of vaginal fluid. If the cervical discharge appears normal and no WBCs are observed on the wet prep of vaginal fluid, the diagnosis of PID is unlikely, and alternative causes of pain should be investigated. A wet prep of vaginal fluid offers the ability to detect the presence of concomitant infections (e.g., bacterial vaginosis and trichomoniasis). The most specific criteria for diagnosing PID include the following: endometrial biopsy with histopathologic evidence of endometritis; transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or doppler studies suggesting pelvic infection (e.g., tubal hyperemia); and laparoscopic abnormalities consistent with PID. A diagnostic evaluation that includes some of these more extensive studies might be warranted in some cases. Endometrial biopsy is warranted in women undergoing laparoscopy who do not have visual evidence of salpingitis, as some women with PID have endometritis alone. PID treatment regimens must provide empiric, broad spectrum coverage of likely pathogens. Several antimicrobial regimens have been effective in achieving clinical and microbiologic cure in randomized clinical trials with short-term follow-up. However, only a limited number of investigations have assessed and compared these regimens with regard to elimination of infection in the endometrium and fallopian tubes or determined the incidence of long-term complications (e.g., tubal infertility and ectopic pregnancy) after antimicrobial regimens (179,180). All treatment regimens should be effective against N. gonorrhoeae and C. trachomatis because negative endocervical screening for these organisms does not rule out upper reproductive tract infection. The need to eradicate anaerobes from women who have PID has not been determined definitively. Anaerobic bacteria have been isolated from the upper reproductive tract of women who have PID, and data from in vitro studies have revealed that some anaerobes (e.g., Bacteroides fragilis) can cause tubal and epithelial destruction. In addition, BV also is present in many women who have PID (181).Until treatment regimens that do not adequately cover these microbes have been demonstrated to prevent long-term sequelae (e.g., infertility and ectopic pregnancy) as successfully as the regimens that are effective against these microbes, the use of regimens with anaerobic activity should be considered. Treatment should be initiated as soon as the presumptive diagnosis has been made because prevention of long-term sequelae is dependent on immediate administration of appropriate antibiotics. When selecting a treatment regimen, health-care providers should consider availability, cost, patient acceptance, and antimicrobial susceptibility. Some specialists have recommended that all patients with PID be hospitalized so that bed rest and supervised treatment with parenteral antibiotics can be initiated. However, in women with PID of mild or moderate clinical severity, outpatient therapy can provide short- and long-term clinical outcomes similar to inpatient therapy. Limited data support the use of outpatient therapy in women with more severe clinical presentations. The decision of whether hospitalization is necessary should be based on the discretion of the health-care provider. The following criteria for hospitalization are suggested: surgical emergencies (e.g., appendicitis) cannot be excluded; the patient is pregnant; the patient does not respond clinically to oral antimicrobial therapy; the patient is unable to follow or tolerate an outpatient oral regimen; the patient has severe illness, nausea and vomiting, or high fever; and the patient has a tubo-ovarian abscess. Many practitioners have preferred to hospitalize adolescent women whose condition is diagnosed as acute PID. No evidence is available suggesting that adolescents benefit from hospitalization for treatment of PID. Younger women with mild-to-moderate acute PID have similar outcomes with either outpatient therapy or inpatient therapy. Further, clinical response to outpatient treatment is similar among younger and older women. The decision to hospitalize adolescents with acute PID should be based on the same criteria used for older women. Whether women in their later reproductive years benefit from hospitalization for treatment of PID also is unclear, although women aged >35 years who are hospitalized with PID are more likely than younger women to have a complicated clinical course. Parenteral Treatment For women with PID of mild or moderate severity, parenteral and oral therapy appears to have similar clinical efficacy. Many randomized trials have demonstrated the efficacy of both parenteral and oral regimens (180,182,183). In the majority of clinical trials, parenteral treatment for at least 48 hours has been used after the patient has demonstrated substantial clinical improvement. Clinical experience should guide decisions regarding transition to oral therapy, which usually can be initiated within 24 hours of clinical improvement. The majority of clinicians recommend at least 24 hours of direct inpatient observation for patients who have tubo-ovarian abscesses. Recommended Parenteral Regimen A Cefotetan 2 g IV every 12 hours Cefoxitin 2 g IV every 6 hours Doxycycline 100 mg orally or IV every 12 hours Because of the pain associated with infusion, doxycycline should be administered orally when possible, even when the patient is hospitalized. Oral and IV administration of doxycycline provide similar bioavailability. Parenteral therapy may be discontinued 24 hours after a patient improves clinically, and oral therapy with doxycycline (100 mg twice a day) should continue to complete 14 days of therapy. When tubo-ovarian abscess is present, many health-care providers use clindamycin or metronidazole with doxycycline for continued therapy, rather than doxycycline alone, because it provides more effective anaerobic coverage. Clinical data are limited regarding the use of other second- or third-generation cephalosporins (e.g., ceftizoxime, cefotaxime, and ceftriaxone), which also might be effective therapy for PID and may replace cefotetan or cefoxitin. However, these cephalosporins are less active than cefotetan or cefoxitin against anaerobic bacteria. Recommmended Parenteral Regimen B Clindamycin 900 mg IV every 8 hours Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing may be substituted. Although use of a single daily dose of gentamicin has not been evaluated for the treatment of PID, it is efficacious in analogous situations. Parenteral therapy can be discontinued 24 hours after a patient improves clinically; continuing oral therapy should consist of doxycycline 100 mg orally twice a day or clindamycin 450 mg orally four times a day to complete a total of 14 days of therapy. When tubo-ovarian abscess is present, many health-care providers use clindamycin for continued therapy, rather than doxycycline, because clindamycin provides more effective anaerobic coverage. Alternative Parenteral Regimens Limited data support the use of other parenteral regimens, but the following three regimens have been investigated in at least one clinical trial, and they have broad spectrum coverage. Levofloxacin 500 mg IV once daily* Metronidazole 500 mg IV every 8 hours Ampicillin/Sulbactam 3 g IV every 6 hours * Quinolones should not be used in persons with a history of recent foreign travel or partners' travel, infections acquired in California or Hawaii, or infections acquired in other areas with increased QRNG prevalence. IV ofloxacin has been investigated as a single agent; however, because of concerns regarding its spectum, metronidazole may be included in the regimen. Levofloxacin is as effective as ofloxacin and may be substituted; its single daily dosing makes it advantageous from a compliance perspective. One trial demonstrated high short-term clinical cure rates with azithromycin, either alone for 1 week (at least one IV dose followed by oral therapy) or with a 12-day course of metronidazole (184). Ampicillin/sulbactam plus doxycycline is effective coverage against C. trachomatis, N. gonorrhoeae, and anaerobes and for patients who have tubo-ovarian abscess. Oral therapy can be considered for women with mild-to-moderately severe acute PID, as the clinical outcomes among women treated with oral therapy are similar to those treated with parenteral therapy. The following regimens provide coverage against the frequent etiologic agents of PID. Patients who do not respond to oral therapy within 72 hours should be reevaluated to confirm the diagnosis and should be administered parenteral therapy on either an outpatient or inpatient basis. Recommended Regimen A Levofloxacin 500 mg orally once daily for 14 days* Ofloxacin 400 mg orally twice daily for 14 days* Metronidazole 500 mg orally twice a day for 14 days Oral ofloxacin has been investigated as a single agent in two clinical trials, and it is effective against both N. gonorrhoeae and C. trachomatis (185,186). Despite the results of these trials, lack of anaerobic coverage with ofloxacin is a concern; the addition of metronidazole to the treatment regimen provides this coverage. Levofloxacin is as effective as ofloxacin and may be substituted. Azithromycin has been demonstrated in one randomized trial to be an effective regimen for acute PID (184). The addition of metronidazole should be considered, as anaerobic organisms are suspected in the etiology of the majority of PID cases. Metronidazole will also treat BV, which frequently is associated with PID. Regimen B Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) The optimal choice of a cephalosporin for Regimen B is unclear; although cefoxitin has better anaerobic coverage, ceftriaxone has better coverage against N. gonorrhoeae. Clinical trials have demonstrated that a single dose of cefoxitin is effective in obtaining short-term clinical response in women who have PID. However, the theoretical limitations in cefoxitin's coverage of anaerobes might require the addition of metronidazole to the treatment regimen (182). Metronidazole also will effectively treat BV, which is frequently associated with PID. No data have been published regarding the use of oral cephalosporins for the treatment of PID. Limited data suggest that the combination of oral metronidazole and doxycycline after primary parenteral therapy is safe and effective (187). Alternative Oral Regimens Although information regarding other outpatient regimens is limited, one other regimen has undergone at least one clinical trial and has broad spectrum coverage. Amoxicillin/clavulanic acid and doxycycline was effective in obtaining short-term clinical response in a single clinical trial; however, gastrointestinal symptoms might limit compliance with this regimen. Patients should demonstrate substantial clinical improvement (e.g., defervescence; reduction in direct or rebound abdominal tenderness; and reduction in uterine, adnexal, and cervical motion tenderness) within 3 days after initiation of therapy. Patients who do not improve within this period usually require hospitalization, additional diagnostic tests, and surgical intervention. If no clinical improvement has occurred within 72 hours after outpatient oral or parenteral therapy (using the criteria for clinical improvement described previously), an examination should be performed. Subsequent hospitalization, parenteral therapy, and diagnostic evaluation, including the consideration of diagnostic laparoscopy for alternative diagnoses, are recommended in women without clinical improvement. Some specialists also recommend rescreening for C. trachomatis and N. gonorrhoeae 4--6 weeks after therapy is completed in women with documented infection with these pathogens. All women diagnosed with acute PID should be offered HIV testing. Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the 60 days preceding the patient's onset of symptoms. Evaluation and treatment are imperative because of the risk for reinfection of the patient and the strong likelihood of urethral gonococcal or chlamydial infection in the sex partner. Male partners of women who have PID caused by C. trachomatis and/or N. gonorrhoeae frequently are asymptomatic. Sex partners should be treated empirically with regimens effective against both of these infections, regardless of the etiology of PID or pathogens isolated from the infected woman. Even in clinical settings in which only women are treated, arrangements should be made to provide care for male sex partners of women who have PID. When providing care for male sex partners is not feasible, health-care providers should ensure that sex partners are referred for appropriate treatment. Prevention of chlamydial infection by screening and treating high-risk women reduces the incidence of PID (125). Theoretically, the majority of cases of PID can be prevented by screening all women or those determined to be at high risk (based on age or other factors) by using DNA amplification on cervical specimens (in women receiving pelvic examinations) and on urine specimens (in women not undergoing examinations). Although BV is associated with PID, whether the incidence of PID can be reduced by identifying and treating women with BV is unclear (181). Pregnancy. Because of the high risk for maternal morbidity and preterm delivery, pregnant women who have suspected PID should be hospitalized and treated with parenteral antibiotics. HIV Infection. Differences in the clinical manifestations of PID between HIV-infected women and HIV-negative women have not been well-delineated. In previous observational studies, HIV-infected women with PID were more likely to require surgical intervention. More comprehensive observational and controlled studies (published since the 2002 STD Treatment Guidelines) have demonstrated that HIV-infected women with PID had similar symptoms when compared with uninfected controls (125,188--190). They were more likely to have a tubo-ovarian abscess but responded equally well to standard parenteral and oral antibiotic regimens when compared with HIV-negative women. The microbiologic findings for HIV- positive and HIV-negative women were similar, except HIV-infected women had higher rates of concomitant M. hominis, candida, streptococcal, and HPV infections and HPV-related cytologic abnormalities. Whether the management of immunodeficient HIV-infected women with PID requires more aggressive interventions (e.g., hospitalization or parenteral antimicrobial regimens) has not been determined. IUD. Intrauterine contraceptive devices are becoming a popular contraceptive choice for women. Both levonorgestrel- and copper-containing devices are marketed in the United States. The risk of PID associated with IUD use is primarily confined to the first 3 weeks after insertion and is uncommon thereafter (191). Given the popularity of IUDs, practitioners might encounter PID in IUD users. No evidence suggests that IUDs should be removed in women diagnosed with acute PID. However, caution should be exercised if the IUD remains in place, and close clinical follow-up is mandatory. The rate of treatment failure and recurrent PID in women continuing to use an IUD is unknown. No data exist on antibiotic selection and treatment outcomes according to type of IUD (e.g., copper or levonorgestrel). Acute epididymitis is a clinical syndrome consisting of pain, swelling, and inflammation of the epididymis of <6 weeks. Chronic epididymitis is characterized by a 3-month or longer history of symptoms of discomfort and/or pain in the scrotum, testicle, or epididymis that is localized on clinical examination. Chronic epididymitis has been subcategorized into inflammatory chronic epididymitis, obstructive chronic epididymitis, and chronic epididymalgia (192). Among sexually active men aged <35 years, acute epididymitis is most frequently caused by C. trachomatis or N. gonorrhoeae. Acute epididymitis caused by sexually transmitted enteric organisms (e.g., Escherichia coli) also occurs among men who are the insertive partner during anal intercourse. Sexually transmitted acute epididymitis usually is accompanied by urethritis, which frequently is asymptomatic and is usually never accompanied by bacteriuria. In men aged >35 years, sexually transmitted epididymitis is uncommon. However, bacteriuria secondary to obstructive urinary disease is relatively common. In this group, nonsexually transmitted epididymitis is associated with urinary-tract instrumentation or surgery, systemic disease, or immunosuppression. Although the majority of patients can be treated on an outpatient basis, hospitalization should be considered when severe pain suggests other diagnoses (e.g., torsion, testicular infarction, or abscess) or when patients are febrile or might be noncompliant with an antimicrobial regimen. Men who have acute epididymitis typically have unilateral testicular pain and tenderness; hydrocele and palpable swelling of the epididymis usually are present. Although the inflammation and swelling usually begin in the tail of the epididymis, they can spread to involve the rest of the epididymis and testicle. The spermatic cord is usually tender and swollen.Testicular torsion, a surgical emergency, should be considered in all cases, but it occurs more frequently among adolescents and in men without evidence of inflammation or infection. Emergency testing for torsion might be indicated when the onset of pain is sudden, pain is severe, or the test results available during the initial examination do not support a diagnosis of urethritis or urinary-tract infection. If the diagnosis is questionable, a specialist should be consulted immediately because testicular viability might be compromised. Radionuclide scanning of the scrotum is the most accurate radiologic method of diagnosis, although it is not routinely available. Color duplex doppler ultrasonography has a sensitivity of 70% and a specificity of 88% in diagnosing acute epididymitis. The evaluation of men for epididymitis should include one of the following: Gram stain of urethral secretions demonstrating >5 WBC per oil immersion field. The Gram stain is the preferred rapid diagnostic test for evaluating urethritis. It is highly sensitive and specific for documenting both urethritis and the presence or absence of gonococcal infection. Gonococcal infection is established by documenting the presence of WBC containing intracellular Gram-negative diplococci on urethral Gram stain. Culture, nucleic acid hybridization tests, and nucleic acid amplification tests are available for the detection of both N. gonorrhoeae and C. trachomatis. Culture and nucleic acid hybridization tests require urethral swab specimens, whereas amplification tests can be performed on urine specimens. Because of their higher sensitivity, amplification tests are preferred for the detection of C. trachomatis. Depending on the risk, patients whose conditions have been diagnosed as a new STD should receive testing for other STDs. Empiric therapy is indicated before laboratory test results are available. The goals of treatment of acute epididymitis caused by C. trachomatis or N. gonorrhoeae are 1) microbiologic cure of infection, 2) improvement of signs and symptoms, 3) prevention of transmission to others, and 4) a decrease in potential complications (e.g., infertility or chronic pain). As an adjunct to therapy, bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation have subsided. For acute epididymitis most likely caused by gonococcal or chlamydial infection: For acute epididymitis most likely caused by enteric organisms or for patients allergic to cephalosporins and/or tetracyclines: Ofloxacin 300 mg orally twice a day for 10 days Levofloxacin 500 mg orally once daily for 10 days Failure to improve within 3 days of the initiation of treatment requires reevaluation of both the diagnosis and therapy. Swelling and tenderness that persist after completion of antimicrobial therapy should be evaluated comprehensively. The differential diagnosis includes tumor, abscess, infarction, testicular cancer, TB, and fungal epididymitis. Patients who have acute epididymitis, confirmed or suspected to be caused by N. gonorrhoeae or C. trachomatis, should be instructed to refer sex partners for evaluation and treatment if their contact with the index patient was within the 60 days preceding onset of the patient's symptoms. Patients should be instructed to avoid sexual intercourse until they and their sex partners are cured (i.e., until therapy is completed and patient and partners no longer have symptoms). Patients who have uncomplicated acute epididymitis and also are infected with HIV should receive the same treatment regimen as those who are HIV negative. Fungi and mycobacteria, however, are more likely to cause acute epididymitis in immunosuppressed patients than in immunocompetent patients. HPV Infection More than 100 types of HPV exist; more than 30 types can infect the genital area. The majority of HPV infections are asymptomatic, unrecognized, or subclinical. Genital HPV infection is common and usually self-limited. Genital HPV infection occurs more frequently than visible genital warts among both men and women and cervical cell changes among women. Genital HPV infection can cause genital warts, usually associated with HPV types 6 or 11. Other HPV types that infect the anogenital region (e.g., high-risk HPV types 16, 18, 31, 33, and 35) are strongly associated with cervical neoplasia. Persistent infection with high-risk types of HPV is the most important risk factor for cervical neoplasia. HPV Tests A definitive diagnosis of HPV infection is based on detection of viral nucleic acid (i.e., DNA or RNA) or capsid protein. Tests that detect several types of HPV DNA in cells scraped from the cervix are available and might be useful in the triage of women with atypical squamous cells of undetermined significance (ASC-US) or in screening women aged >30 years in conjunction with the Pap test (see Cervical Cancer Screening for Women Who Attend STD Clinics or Have a History of of STDs). Women determined to have HPV infection on such testing should be counseled that HPV infection is common, infection is frequently transmitted between partners, and that infection usually goes away on its own. If any Pap test or biopsy abnormalities have been observed, further evaluation is recommended. Screening women or men with the HPV test, outside of the above recommendations for use of the test with cervical cancer screening, is not recommended. In the absence of genital warts or cervical SIL, treatment is not recommended for subclinical genital HPV infection, whether it is diagnosed by colposcopy, biopsy, acetic acid application, or through the detection of HPV by laboratory tests. Genital HPV infection frequently goes away on its own, and no therapy has been identified that can eradicate infection. In the presence of coexistent SIL, management should be based on histopathologic findings. HPV types 6 or 11 are commonly found before, or at the time of, detection of genital warts; however, the use of HPV testing for genital wart diagnosis is not recommended. Genital warts are usually flat, papular, or pedunculated growths on the genital mucosa. Diagnosis of genital warts is made by visual inspection and may be confirmed by biopsy, although biopsy is needed only under certain circumstances (e.g., if the diagnosis is uncertain; the lesions do not respond to standard therapy; the disease worsens during therapy; the patient is immunocompromised; or warts are pigmented, indurated, fixed, bleeding, or ulcerated). No data support the use of HPV nucleic acid tests in the routine diagnosis or management of visible genital warts. The application of 3%--5% acetic acid usually turns HPV-infected genital mucosal tissue to a whitish color. However, acetic acid application is not a specific test for HPV infection, and the specificity and sensitivity of this procedure for screening have not been defined. Therefore, the routine use of this procedure for screening to detect HPV infection is not recommended. However, some clinicians, who are experienced in the management of genital warts, have determined that this test is useful for identifying flat genital warts. In addition to the external genitalia (i.e., penis, vulva, scrotum, perineum, and perianal skin), genital warts can occur on the uterine cervix and in the vagina, urethra, anus, and mouth. Intra-anal warts are observed predominantly in patients who have had receptive anal intercourse; these warts are distinct from perianal warts, which can occur in men and women who do not have a history of anal sex. In addition to the genital area, HPV types 6 and 11 have been associated with conjunctival, nasal, oral, and laryngeal warts. Genital warts are usually asymptomatic, but depending on the size and anatomic location, genital warts can be painful, friable, or pruritic. HPV types 16, 18, 31, 33, and 35 are found occasionally in visible genital warts and have been associated with external genital (i.e., vulvar, penile, and anal) squamous intraepithelial neoplasia (i.e., squamous cell carcinoma in situ, bowenoid papulosis, Erythroplasia of Queyrat, or Bowen's disease of the genitalia). These HPV types also have been associated with vaginal, anal, and CIN and anogenital and some head and neck squamous cell carcinomas. Patients who have visible genital warts are frequently infected simultaneously with multiple HPV types. The primary goal of treating visible genital warts is the removal of the warts. In the majority of patients, treatment can induce wart-free periods. If left untreated, visible genital warts might resolve on their own, remain unchanged, or increase in size or number. Treatment possibly reduces, but does not eliminate, HPV infection. Existing data indicate that currently available therapies for genital warts might reduce, but probably do not eradicate, HPV infectivity. Whether the reduction in HPV viral DNA, resulting from treatment, impacts future transmission remains unclear. No evidence indicates that the presence of genital warts or their treatment is associated with the development of cervical cancer. Treatment of genital warts should be guided by the preference of the patient, the available resources, and the experience of the health-care provider. No definitive evidence suggests that any of the available treatments are superior to any other and no single treatment is ideal for all patients or all warts. The use of locally developed and monitored treatment algorithms has been associated with improved clinical outcomes and should be encouraged. Because of uncertainty regarding the effect of treatment on future transmission of HPV and the possibility of spontaneous resolution, an acceptable alternative for some persons is to forego treatment and wait for spontaneous resolution. The majority of patients have <10 genital warts, with a total wart area of 0.5--1.0 cm2. These warts respond to various treatment modalities. Factors that might influence selection of treatment include wart size, wart number, anatomic site of wart, wart morphology, patient preference, cost of treatment, convenience, adverse effects, and provider experience. Factors that might affect response to therapy include the presence of immunosuppression and compliance with therapy. The majority of patients require a course of therapy rather than a single treatment. In general, warts located on moist surfaces or in intertriginous areas respond better to topical treatment than do warts on drier surfaces. The treatment modality should be changed if a patient has not improved substantially. The majority of genital warts respond within 3 months of therapy. The response to treatment and its side effects should be evaluated throughout the course of therapy. Complications occur rarely if treatments for warts are employed properly. Patients should be warned that persistent hypopigmentation or hyperpigmentation occurs commonly with ablative modalities. Depressed or hypertrophic scars are uncommon but can occur, especially if the patient has had insufficient time to heal between treatments. Rarely, treatment can result in disabling chronic pain syndromes (e.g., vulvodynia or analdynia, and hyperesthesia of the treatment site) or, in the case of rectal warts, painful defecation or fistulas. A limited number of case reports of severe systemic effects from podophyllin resin and interferon have been documented. Treatment regimens are classified into patient-applied and provider-applied modalities. Patient-applied modalities are preferred by some patients because they can be administered in the privacy of the patient's home. To use patient-applied modalities effectively, compliance with the treatment regimen is important along with the ability to identify and reach all genital warts. Recommended Regimens for External Genital Warts Patient-Applied: Podofilox 0.5% solution or gel. Patients should apply podofilox solution with a cotton swab, or podofilox gel with a finger, to visible genital warts twice a day for 3 days, followed by 4 days of no therapy. This cycle may be repeated, as necessary, for up to four cycles. The total wart area treated should not exceed 10 cm2, and the total volume of podofilox should be limited to 0.5 mL per day. If possible, the health-care provider should apply the initial treatment to demonstrate the proper application technique and identify which warts should be treated. The safety of podofilox during pregnancy has not been established. Imiquimod 5% cream. Patients should apply imiquimod cream once daily at bedtime, three times a week for up to 16 weeks. The treatment area should be washed with soap and water 6--10 hours after the application. The safety of imiquimod during pregnancy has not been established. Provider-Administered: Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every 1--2 weeks. Podophyllin resin 10%--25% in a compound tincture of benzoin. A small amount should be applied to each wart and allowed to air dry. The treatment can be repeated weekly, if necessary. To avoid the possibility of complications associated with systemic absorption and toxicity, two important guidelines should be followed: 1) application should be limited to <0.5 mL of podophyllin or an area of <10 cm2 of warts per session, and 2) no open lesions or wounds should exist in the area to which treatment is administered. Some specialists suggest that the preparation should be thoroughly washed off 1--4 hours after application to reduce local irritation. The safety of podophyllin during pregnancy has not been established. Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%--90%. A small amount should be applied only to the warts and allowed to dry, at which time a white "frosting" develops. If an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate (i.e., baking soda), or liquid soap preparations to remove unreacted acid. This treatment can be repeated weekly, if necessary. Surgical removal either by tangential scissor excision, tangential shave excision, curettage, or electrosurgery Intralesional interferon Podofilox 0.5% solution or gel, an antimitotic drug that destroys warts, is relatively inexpensive, easy to use, safe, and self-applied by patients. The majority of patients experience mild-to-moderate pain or local irritation after treatment. Imiquimod is a topically active immune enhancer that stimulates production of interferon and other cytokines. Local inflammatory reactions are common with the use of imiquimod; these reactions include redness and irritation and are usually mild to moderate. Traditionally, follow-up visits are not required for patients using self-administered therapy. However, follow-up might be useful several weeks into therapy to determine the appropriateness of medication use and the response to treatment. Cryotherapy destroys warts by thermal-induced cytolysis. Health-care providers must be trained on the proper use of this therapy because over- and undertreatment might result in complications or low efficacy. Pain after application of the liquid nitrogen, followed by necrosis and sometimes blistering, is common. Local anesthesia (topical or injected) might facilitate therapy if warts are present in many areas or if the area of warts is large. Podophyllin resin, which contains several compounds, including antimitotic podophyllin lignans, is another treatment option. The resin is most frequently compounded at 10%--25% in a tincture of benzoin. However, podophyllin resin preparations differ in the concentration of active components and contaminants. The shelf life and stability of podophyllin preparations are unknown. A thin layer of podophyllin resin must be applied to the warts and allowed to air dry before the treated area comes into contact with clothing; overapplication or failure to air dry can result in local irritation caused by spread of the compound to adjacent areas. Both TCA and BCA are caustic agents that destroy warts by chemical coagulation of proteins. Although these preparations are widely used, they have not been investigated thoroughly. TCA solutions have a low viscosity comparable with that of water and can spread rapidly if applied excessively; therefore, they can damage adjacent tissues. Both TCA and BCA should be applied sparingly and allowed to dry before the patient sits or stands. If pain is intense, the acid can be neutralized with soap or sodium bicarbonate. Surgical therapy has the advantage of usually eliminating warts at a single visit. However, such therapy requires substantial clinical training, additional equipment, and a longer office visit. After local anesthesia is applied, the visible genital warts can be physically destroyed by electrocautery, in which case no additional hemostasis is required. Care must be taken to control the depth of electrocautery to prevent scarring. Alternatively, the warts can be removed either by tangential excision with a pair of fine scissors or a scalpel or by curettage. Because the majority of warts are exophytic, this procedure can be accomplished with a resulting wound that only extends into the upper dermis. Hemostasis can be achieved with an electrocautery unit or a chemical styptic (e.g., an aluminum chloride solution). Suturing is neither required nor indicated in the majority of cases if surgical removal is performed properly. Surgical therapy is most beneficial for patients who have a large number or area of genital warts. Carbon dioxide laser and surgery might be useful in the management of extensive warts or intraurethral warts, particularly for those patients who have not responded to other treatments. Interferons, both natural or recombinant, have been used for the treatment of genital warts. They have been administered systemically (i.e., subcutaneously at a distant site or IM) and intralesionally (i.e., injected into the warts). Systemic interferon is not effective. The efficacy and recurrence rates of intralesional interferon are comparable to other treatment modalities. Administration of intralesional interferon is associated with stinging, burning, and pain at the injection site. Interferon is probably effective because of its antiviral and/or immunostimulating effects. Interferon therapy is not recommended as a primary modality because of inconvenient routes of administration, frequent office visits, and the association between its use and a high frequency of systemic adverse effects. Because of the shortcomings associated with all available treatments, some clinics employ combination therapy (i.e., the simultaneous use of two or more modalities on the same wart at the same time). No data support the use of more than one therapy at a time to improve efficacy of treatment, and some specialists believe that combining modalities might increase complications. Recommended Regimens for Cervical Warts For women who have exophytic cervical warts, high-grade SIL must be excluded before treatment is initiated. Management of exophytic cervical warts should include consultation with a specialist. Recommended Regimens for Vaginal Warts Cryotherapy with liquid nitrogen. The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation. TCA or BCA 80%--90% applied to warts. A small amount should be applied only to warts and allowed to dry, at which time a white "frosting" develops. If an excess amount of acid is applied, the treated area should be powdered with talc, sodium bicarbonate, or liquid soap preparations to remove unreacted acid. This treatment can be repeated weekly, if necessary. Recommended Regimens for Urethral Meatus Warts Cryotherapy with liquid nitrogen Podophyllin 10%--25% in compound tincture of benzoin. The treatment area must be dry before contact with normal mucosa. This treatment can be repeated weekly, if necessary. The safety of podophyllin during pregnancy has not been established. Although data evaluating the use of podofilox and imiquimod for the treatment of distal meatal warts are limited, some specialists recommend their use in some patients. Recommended Regimens for Anal Warts Warts on the rectal mucosa should be managed in consultation with a specialist. Many persons with warts on the anal mucosa also have warts on the rectal mucosa, so persons with anal warts can benefit from an inspection of the rectal mucosa by digital examination or anoscopy. Education and counseling are vital aspects of managing patients with genital warts. Patients can be educated through patient education materials, including pamphlets, hotlines, and websites (http://www.ashastd.org or http://www.cdc.gov/std/hpv). Attempts should be made to convey the following key messages: Genital HPV infection is common among sexually active adults. The majority of sexually active adults will have it at some point in their lives, although the majority of them will never know because the infection usually has no symptoms and clears on its own. Genital HPV infection is usually sexually transmitted. The incubation period (i.e., the interval between initial exposure and established infection or disease) is variable, and determining the timing and source of infection is frequently difficult. Within ongoing sexual relationships, sex partners usually are infected by the time of the patient's diagnosis, although they might have no symptoms or signs of infection. No recommended uses of the HPV test to diagnose HPV infection in sex partners have been established. HPV infection is commonly transmitted to partners but usually goes away on its own. Genital warts are caused by specific types of HPV infection. The types that cause genital warts are different from the types that cause cervical and other anogenital cancers. Persons can possibly have infection with the types of HPV that cause genital warts but never develop symptoms. Why some persons with genital HPV infection develop warts and others do not is unclear. Immunity probably plays a key role. The natural history of genital warts is usually benign, but recurrence of genital warts within the first several months after treatment is common. Treatment for genital warts can reduce HPV infection, but whether the treatment results in a reduction in risk for transmission of HPV to sex partners is unclear. The duration of infectivity after wart treatment is unknown. Condoms might reduce the risk for HPV-associated diseases (e.g., genital warts and cervical cancer). Consistent condom use also may reduce the risk for genital HPV (18). HPV infection can occur in areas that are not covered or protected by a condom (e.g., scrotum, vulva, or perianus). The presence of genital warts is not an indication for HPV testing, a change in the frequency of Pap tests, or cervical colposcopy. HPV testing is not indicated for partners of persons with genital warts. After visible genital warts have cleared, a follow-up evaluation might be helpful. Patients should be cautioned to watch for recurrences, which occur most frequently during the first 3 months. External genital warts can be difficult to identify, so it might be useful for patients to have a follow-up evaluation 3 months after treatment. Earlier follow-up visits also might be useful for some patients to document the absence of warts, to monitor for or treat complications of therapy, and to provide an additional opportunity for patient education and counseling. Women should be counseled to undergo regular Pap screening as recommended for women without genital warts. Examination of sex partners is not necessary for the management of genital warts because no data indicate that reinfection plays a role in recurrences. In addition, providing treatment for genital warts solely for the purpose of preventing future transmission cannot be recommended because the value of treatment in reducing infectivity is unknown. However, sex partners of patients who have genital warts might benefit from counseling and examination to assess the presence of genital warts and other STDs. The counseling of sex partners provides an opportunity for these partners to 1) learn that HPV infection is common and probably shared between partners and 2) receive STD evaluation and screening and Pap screening if they are female. Female sex partners of patients who have genital warts should be reminded that cytologic screening for cervical cancer is recommended for all sexually active women. Imiquimod, podophyllin, and podofilox should not be used during pregnancy. However, because genital warts can proliferate and become friable during pregnancy, many specialists advocate their removal during pregnancy. HPV types 6 and 11 can cause respiratory papillomatosis in infants and children. The route of transmission (i.e., transplacental, perinatal, or postnatal) is not completely understood. Whether cesarean section prevents respiratory papillomatosis in infants and children is unclear; therefore, cesarean delivery should not be performed solely to prevent transmission of HPV infection to the newborn. Cesarean delivery might be indicated for women with genital warts if the pelvic outlet is obstructed or if vaginal delivery would result in excessive bleeding. Pregnant women with genital warts should be counseled concerning the low risk for warts on the larynx (recurrent respiratory papillomatosis) in their infants or children (193). No controlled studies have suggested that cesarean section prevents this condition. No data suggest that treatment modalities for external genital warts should be different in the setting of HIV-infection. However, persons who are immunosuppressed because of HIV or other reasons might have larger or more numerous warts, might not respond as well as immunocompetent persons to therapy for genital warts, and might have more frequent recurrences after treatment (194,195). Squamous cell carcinomas arising in or resembling genital warts might occur more frequently among immunosuppressed persons, therefore, requiring biopsy for confirmation of diagnosis. Because of the increased incidence of anal cancer in HIV-infected homosexual men, screening for anal SIL by cytology in this population is recommended by some specialists. However, evidence is limited concerning the natural history of anal intraepithelial neoplasias, the reliability of screening methods, the safety and response to treatments, and the programmatic considerations that would support this screening approach. Until additional data are generated on screening for anal SIL, this screening approach cannot be recommended. Squamous Cell Carcinoma in Situ Patients in whom squamous cell carcinoma in situ of the genitalia is diagnosed should be referred to a specialist for treatment. Ablative modalities usually are effective, but careful follow-up is essential. The risk for these lesions leading to invasive squamous cell carcinoma of the external genitalia in immunocompetent patients is unknown but is probably low. Female partners of male patients who have squamous cell carcinoma in situ are at high risk for cervical abnormalities. Cervical Cancer Screening for Women Who Attend STD Clinics or Have a History of STDs Women with a history of STDs might be at increased risk for cervical cancer, and women attending STD clinics might have other risk factors that place them at even greater risk. Prevalence studies indicate that precursor lesions for cervical cancer occur approximately five times more frequently among women attending STD clinics than among women attending family planning clinics (196). Cervical cancer screening using the Pap test is an effective, low-cost screening test for preventing invasive cervical cancer. Recommendations for cervical cancer screening intervals vary in the United States, but the American Cancer Society and American College of Obstetricians and Gynecologists guidelines recommend annual screening for women aged 21--30 years and then every 2--3 years for women aged >30 years if three consecutive annual Pap tests are negative (197,198). During the appointment in which a pelvic examination for STD screening is performed, the health-care provider should inquire about the result of the patient's most recent Pap test and discuss the following information with the patient: the purpose and importance of a Pap test; the need for regularly scheduled Pap tests between aged 21--65 years; whether a Pap test will be obtained during this clinic visit; and if a Pap test will NOT be obtained during this examination, the names of local providers or referral clinics that can perform Pap tests and adequately follow up results if indicated. If a woman has not had a Pap test during the previous 12 months, a Pap test may be obtained as part of the routine pelvic examination. Health-care providers should be aware that many women frequently equate having a pelvic examination with having a Pap test; they believe that a Pap test was taken when they actually received only a pelvic examination. They might, therefore, over report having had a recent Pap test. Therefore, in STD clinics, having a protocol for conducting cervical cancer screening should be highly encouraged and obtaining a Pap test strongly considered during the routine clinical evaluation of women who do not have clinical-record documentation of a normal Pap test within the preceding 12 months. A woman might benefit from receiving printed information concerning Pap tests and a report containing a statement that a Pap test was obtained during her clinic visit. If possible, a copy of the Pap test result should be provided to the patient for her records when it becomes available. STD clinics offering cervical cancer screening are encouraged to use cytopathology laboratories that report results by using the Bethesda System of classification (199).††† If the results of the Pap test are abnormal, follow-up care should be provided according to the ASCCP Consensus Guidelines for Management of Abnormal Cervical Cytology (198), or information regarding follow-up care is available at http//www.asccp.org. If resources in STD clinics do not allow follow-up of abnormal results, protocols for referral of women needing follow-up and case management should be in place. Pap tests indicating low- or high-grade SIL should always include referral to a clinician who can perform a colposcopic examination of the lower genital tract and, if indicated, colposcopically directed biopsy. For patients with an equivocal Pap test report indicating ASC-US, three options are available for follow-up management: 1) immediate colposcopy, 2) repeat Pap tests at 6-month intervals for 3 intervals, or 3) an HPV DNA test. Women with ASC-US may be considered for immediate colposcopy if concerns for patient adherence with recommended follow-up or for other clinical indications are a factor. The presence of high grade histological changes after ASC-US Pap test reports usually is <10%. If repeat Pap tests are used to follow ASC-US results, a test should be performed every 6 months until 3 negative results are noted before the women returns to cervical cancer screening at a normal interval for age. If subsequent Pap tests demonstrate progression to SIL, follow-up should be conducted according to ASCCP Consensus Guidelines (i.e., frequent colposcopy and directed cervical biopsy). If specific infections other than HPV are identified, the patient might need to have a repeat Pap test after appropriate treatment for those infections. In the majority of instances, even in the presence of some severe infections, Pap tests will be reported as satisfactory for evaluation, so they may be read and final reports produced without the necessity to treat and repeat the Pap test. When repeating the Pap test is necessary because of an unsatisfactory for interpretation report, the repeat test must be interpreted by the laboratory as satisfactory and also be negative before returning the woman to Pap tests at regularly scheduled intervals. A third strategy for managing patients with ASC-US Pap test results involves testing for HPV DNA. Whereas conducting HPV testing in some STD clinics might not be possible or appropriate because of inadequate resources, such testing might be appropriate in other public health clinic settings. Only one FDA-cleared test exists, the Digene Hybrid Capture II. The HPV DNA test may be performed by 1) co-collecting a specimen; 2) using a supplied swab at the time of the Pap test, if conventional cytology is used; 3) reflex testing, if liquid-based cytology is used and enough residual material is available in the cytology test vial; or 4) scheduling a separate follow-up appointment when the Pap test report results are known. If the high-risk HPV DNA test is positive, women are referred immediately for colposcopy, and if indicated, directed cervical biopsy. Because many public health clinics, including the majority of STD clinics, cannot provide clinical follow-up of abnormal Pap tests, women with Pap tests demonstrating low or high grade SIL or ASC-US usually need a referral to other local health-care providers or clinics for colposcopy and biopsy. Clinics and health-care providers who offer Pap test screening services but cannot provide appropriate colposcopic follow-up of abnormal Pap tests should arrange referral to health-care facilities in which 1) a patient will be promptly evaluated and treated and 2) the results of the evaluation will be reported to the referring clinic or health-care provider. Clinics and health-care providers should develop protocols that identify women who miss follow-up appointments so that these women can be located and scheduled for needed studies and management, and they should reevaluate such protocols routinely. Pap test results, type and location of follow-up appointments, and results of follow-up appointments should be clearly documented in the clinic record. The establishment of colposcopy and biopsy services in local health departments, especially in circumstances in which referrals are difficult and follow-up is unlikely, should be considered if resources are available. Other considerations in performing Pap tests include the following: The Pap test should not be considered a screening test for STDs. All women, regardless of sexual orientation (heterosexual women and those who identify themselves as lesbian or bisexual), should be considered for cervical cancer screening in an STD clinic setting. If a woman is menstruating, a Pap test should be postponed, and the woman should be advised to have a Pap test at the earliest opportunity. The presence of a mucopurulent discharge should not delay the Pap test. The test can be performed after careful removal of the discharge with a saline-soaked cotton swab. Women who have external genital warts do not need Pap tests more frequently than women who do not have warts, unless otherwise indicated. The sequence of Pap testing in relation to collection of other cervicovaginal specimens does not appear to influence Pap test results or their interpretation. Therefore, when other cultures or specimens are collected for STD diagnoses, the Pap test can be obtained last. Women who have had a total hysterectomy do not require a routine Pap test unless the hysterectomy was performed because of cervical cancer or its precursor lesions. In these situations, women should be advised to continue follow-up with the physician(s) who provided health care at the time of the hysterectomy, if possible. If the cervix remains after a hysterectomy, a woman should receive regularly scheduled Pap tests. Health-care providers who receive basic retraining on Pap test collection and clinics that use simple quality assurance measures obtain fewer unsatisfactory tests. The use of cytobrushes and brooms also improves the number of satisfactory Pap tests. Whereas evidence supports the option of HPV testing for the triage of women with ASC-US Pap test reports, this option might not be appropriate in an STD clinic because of limited resources. Studies to define the cost-effectiveness of HPV testing for the triage of women with ASC-US Pap tests are ongoing. The HPV test strategy that might be most cost-effective is the collection of a cervical swab placed in liquid media (i.e., liquid-based cytology or collection of a separate swab stored in HPV DNA transport media) during the initial visit when a Pap test is collected. When the Pap test report is available, an HPV DNA test can be performed on the residual material, if indicated, without the patient needing another clinic visit. Liquid-based cytology is an alternative to conventional Pap tests; it has a higher sensitivity for detection of SIL and can facilitate HPV testing in women with ASC-US. However, liquid-based cytology has a lower specificity, resulting in more false-positive tests and, therefore, more administrative and patient-related costs, which could reduce the cost-effectiveness of cervical cancer screening and increase the risk of patient harm because of unnecessary follow-up tests. Pregnant women should have a Pap test as part of routine prenatal care. A cytobrush and an Ayers spatula might be used for obtaining Pap tests in pregnant women. Several studies have documented an increased prevalence of SIL in HIV-infected women (200,201). The following recommendations for Pap test screening among HIV-infected women are consistent with other guidelines published by the U.S. Department of Health and Human Services (50) and are based partially on the opinions of professionals knowledgeable about the care and management of cervical cancer and HIV infection in women. After obtaining a complete history of previous cervical disease, HIV-infected women should be provided a comprehensive gynecologic examination, including a pelvic examination and Pap test, as part of their initial evaluation. A Pap test should be obtained twice in the first year after diagnosis of HIV infection and, if the results are normal, annually thereafter. If the results of the Pap test are abnormal, care should be provided according to the ASCCP Consensus Guidelines for Management of Abnormal Cervical Cytology (198). Women with cytological reports of ASC-US, low or high-grade SIL or squamous cell carcinoma, regardless of CD4+ count or antiretroviral treatment status, should undergo colposcopy and directed biopsy. Colposcopy and biopsy are not indicated in HIV-positive women with negative Pap test reports. Vaccine Preventable STDs Some STDs can be effectively prevented through preexposure vaccination. Vaccines are under development or are undergoing clinical trials for certain STDs, including HIV and HSV. However, the only vaccines currently available are for prevention of HAV, HBV, and HPV infection. Vaccination efforts focus largely on integrating the use of these available vaccines into STD prevention and treatment activities. Every person being evaluated or treated for an STD, who is not already vaccinated, should receive hepatitis B vaccination. In addition, some persons (e.g., MSM and illegal-drug users) should receive hepatitis A vaccination. Hepatitis A, caused by infection with HAV, has an incubation period of approximately 28 days (range: 15--50 days). HAV replicates in the liver and is shed in high concentrations in feces from 2 weeks before to 1 week after the onset of clinical illness. HAV infection produces a self-limited disease that does not result in chronic infection or chronic liver disease. However, 10%--15% of patients might experience a relapse of symptoms during the 6 months after acute illness. Acute liver failure from hepatitis A is rare (overall case-fatality rate: 0.5%). The risk for symptomatic infection is directly related to age, with >80% of adults having symptoms compatible with acute viral hepatitis and the majority of children having either asymptomatic or unrecognized infection. Antibody produced in response to HAV infection persists for life and confers protection against reinfection. HAV infection is primarily transmitted by the fecal-oral route, by either person-to-person contact, or through consumption of contaminated food or water. Although viremia occurs early in infection and can persist for several weeks after onset of symptoms, bloodborne transmission of HAV is uncommon. HAV occasionally might be detected in saliva in experimentally infected animals, but transmission by saliva has not been demonstrated. In the United States, nearly half of all reported hepatitis A cases have no specific risk factor identified. Among adults with identified risk factors, the majority of cases are among MSM, persons who use illegal drugs, and international travelers (202). Because transmission of HAV during sexual activity probably occurs because of fecal-oral contact, measures typically used to prevent the transmission of other STDs (e.g., use of condoms) do not prevent HAV transmission. In addition, efforts to promote good personal hygiene have not been successful in interrupting outbreaks of hepatitis A. Vaccination is the most effective means of preventing HAV transmission among persons at risk for infection, many of whom might seek services in STD clinics. The diagnosis of hepatitis A cannot be made on clinical grounds alone and requires serologic testing. The presence of IgM antibody to HAV is diagnostic of acute HAV infection. A positive test for total anti-HAV indicates immunity to HAV infection but does not differentiate current from previous HAV infection. Although usually not sensitive enough to detect the low level of protective antibody after vaccination, anti-HAV tests might be positive after hepatitis A vaccination. Patients with acute hepatitis A usually require only supportive care, with no restrictions in diet or activity. Hospitalization might be necessary for patients who become dehydrated because of nausea and vomiting and is critical for patients with signs or symptoms of acute liver failure. Medications that might cause liver damage or are metabolized by the liver should be used with caution among persons with hepatitis A. Two products are available for the prevention of HAV infection: hepatitis A vaccine (Table 2) and immune globulin (Ig) for IM administration. Hepatitis A vaccines are prepared from formalin-inactivated, cell-culture--derived HAV and have been available in the United States since 1995, initially for persons aged >2 years. In 2005, the vaccines were approved by FDA for persons aged >12 months. Administered IM in a 2-dose series, these vaccines induce protective antibody levels in virtually all adults. By 1 month after the first dose, 94%--100% of adults have protective antibody levels; 100% of adults develop protective antibody after a second dose. In randomized controlled trials, the equivalent of 1 dose of hepatitis A vaccine administered before exposure has been 94%--100% effective in preventing clinical hepatitis A (3). Kinetic models of antibody decline indicate that protective levels of antibody persist for at least 20 years. A combined hepatitis A and hepatitis B vaccine have been developed and licensed for use as a 3-dose series in adults aged >18 years (see Table 3, Hepatitis B). When administered IM on a 0-, 1-, and 6-month schedule, the vaccine has equivalent immunogenicity to that of the monovalent vaccines. Hepatitis A vaccine is available for eligible children and adolescents aged <19 years through the Vaccines for Children program (telephone: 800-232-2522). Ig is a sterile solution of concentrated immunoglobulins prepared from pooled human plasma processed by cold ethanol fractionation. In the United States, Ig is produced only from plasma that has tested negative for hepatitis B surface antigen, antibodies to HIV and HCV, and HCV RNA. In addition, the process used to manufacture Ig inactivates viruses (e.g., HBV, HCV, and HIV). When administered IM before or within 2 weeks after exposure to HAV, Ig is >85% effective in preventing HAV infections. Preexposure Immunization Persons in the following groups who are likely to be treated in STD clinic settings should be offered hepatitis A vaccine: 1) all MSM; 2) illegal drug users (both injecting and noninjecting drugs); and 3) persons with CLD, including persons with chronic HBV and HCV infection who have evidence of CLD. Prevaccination Serologic Testing for Susceptibility Approximately one third of the U.S. population has serologic evidence of previous HAV infection, which increases directly with age and reaches 75% among persons aged >70 years. Screening for HAV infection might be cost-effective in populations where the prevalence of infection is likely to be high (e.g., persons aged >40 years and persons born in areas of high HAV endemicity). The potential cost-savings of testing should be weighed against the cost and the likelihood that testing will interfere with initiating vaccination. Vaccination of a person who is already immune is not harmful. Postvaccination Serologic Testing Postvaccination serologic testing is not indicated because the majority of persons respond to the vaccine. In addition, the commercially available serologic test is not sensitive enough to detect the low, but protective, levels of antibody produced by vaccination. Postexposure Prophylaxis Previously unvaccinated persons exposed to HAV (e.g., through household or sexual contact or by sharing illegal drugs with a person who has hepatitis A) should be administered a single IM dose of Ig (0.02 mL/kg) as soon as possible but not >2 weeks after exposure. Persons who have had 1 dose of hepatitis A vaccine at least 1 month before exposure to HAV do not need Ig. If hepatitis A vaccine is recommended for a person receiving Ig, it can be administered simultaneously at a separate anatomic injection site. The use of hepatitis A vaccine alone is not recommended for PEP. Limited data indicate that vaccination of persons with CLD and of HIV-infected persons results in lower seroprotection rates and antibody concentrations (50). In HIV-infected persons, antibody response might be directly related to CD4+ levels. Hepatitis B is caused by infection with HBV. The incubation period from the time of exposure to onset of symptoms is 6 weeks to 6 months. HBV is found in highest concentrations in blood and in lower concentrations in other body fluids (e.g., semen, vaginal secretions, and wound exudates). HBV infection can be self-limited or chronic. In adults, only approximately half of newly acquired HBV infections are symptomatic, and approximately 1% of reported cases result in acute liver failure and death. Risk for chronic infection is inversely related to age at infection: approximately 90% of infected infants and 30% of infected children aged <5 years become chronically infected, compared with 2%--6% of adults. Among persons with chronic HBV infection, the risk for premature death from cirrhosis or hepatocellular carcinoma (HCC) is 15%--25%. HBV is efficiently transmitted by percutaneous or mucous membrane exposure to infectious blood or body fluids that contain blood. The primary risk factors that have been associated with infection among adolescents and adults are unprotected sex with an infected partner, unprotected sex with more than one partner, MSM, history of other STDs, and illegal injecting-drug use. CDC's national strategy to eliminate transmission of HBV infection includes 1) prevention of perinatal infection through routine screening of all pregnant women for HBsAg and immunoprophylaxis of infants born to HBsAg-positive mothers and infants born to mothers with unknown HBsAg status, 2) routine infant vaccination, 3) vaccination of previously unvaccinated children and adolescents through age 18 years, and 4) vaccination of previously unvaccinated adults at increased risk for infection (2,4). High vaccination coverage rates, with subsequent declines in acute hepatitis B incidence, have been achieved among infants and adolescents (2,203,204). In contrast, vaccination coverage among the majority of high-risk adult groups (e.g., persons with more than one sex partner in the previous 6 months, MSM, and IDUs) have remained low, and the majority of new infections occur in these high-risk groups (4,205--207). STD clinics and other settings that provide services targeted to high-risk adults are ideal sites in which to provide hepatitis B vaccination to adults at risk for HBV infection. All unvaccinated adults seeking services in these settings should be assumed to be at risk for hepatitis B and should receive hepatitis B vaccination. Diagnosis of acute or chronic HBV infection requires serologic testing (Table 4). HBsAg is present in both acute and chronic infection. The presence of IgM antibody to hepatitis B core antigen (IgM anti-HBc) is diagnostic of acute or recently acquired HBV infection. Antibody to HBsAg (anti-HBs) is produced after a resolved infection and is the only HBV antibody marker present after immunization. The presence of HBsAg and total anti-HBc, with a negative test for IgM anti-HBc, indicates chronic HBV infection. The presence of anti-HBc alone might indicate a false-positive result or acute, resolved, or chronic infection. No specific therapy is available for persons with acute hepatitis B; treatment is supportive. Persons with chronic HBV infection should be referred for evaluation to a physician experienced in the management of CLD. Therapeutic agents approved by FDA for treatment of chronic hepatitis B can achieve sustained suppression of HBV replication and remission of liver disease in some persons. In addition, patients with chronic hepatitis B might benefit from screening to detect HCC at an early stage. Two products have been approved for hepatitis B prevention: hepatitis B immune globulin (HBIG) and hepatitis B vaccine. HBIG provides temporary (i.e., 3--6 months) protection from HBV infection and is typically used as PEP either as an adjunct to hepatitis B vaccination in previously unvaccinated persons or alone in persons who have not responded to vaccination. HBIG is prepared from plasma known to contain high concentrations of anti-HBs. The recommended dose of HBIG is 0.06 mL/kg. Hepatitis B vaccine contains HBsAg produced in yeast by recombinant DNA technology and provides protection from HBV infection when used for both preexposure immunization and PEP. The two available monovalent hepatitis B vaccines for use in adolescents and adults are Recombivax HB® (Merck and Co., Inc., Whitehouse Station, New Jersey) and Engerix- B® (GlaxoSmithKline Biologicals, Pittsburgh, Pennsylvania). A combination vaccine (hepatitis A and hepatitis B) for use in adults, Twinrix® (GlaxoSmithKline Biologicals, Pittsburgh, Pennsylvania), also is available. The recommended HBV dose varies by product and age of recipient (Table 3). When selecting a hepatitis B vaccination schedule, the health-care provider should consider the need to achieve completion of the vaccine series. Approved adolescent and adult schedules for both monovalent hepatitis B vaccine (i.e., Engerix-B® and Recombivax HB®) include the following: 0, 1, and 6 months; 0, 1, and 4 months; and 0, 2, and 4 months. A 4-dose schedule of Engerix-B® at 0, 1, 2, and 12 months is licensed for all age groups. A 2-dose schedule of Recombivax HB® adult formulation (10 µg) is licensed for adolescents aged 11--15 years. When scheduled to receive the second dose, adolescents aged >15 years should be switched to a 3-dose series, with doses 2 and 3 consisting of the pediatric formulation (5 µg) administered on an appropriate schedule. Twinrix® may be administered to persons aged >18 years at risk for both HAV and HBV infections at 0, 1, and 6 months. Hepatitis B vaccine should be administered IM in the deltoid muscle and may be administered simultaneously with other vaccines. For adolescents and adults, the needle length should be 1--2 inches, depending on the recipient's weight (1 inch for females weighing <70 kg), 1.5 inches for males weighing <120 kg; and 2 inches for males weighing >120 kg and females >100 kg). A 22- to 25-gauge needle is recommended. If the vaccine series is interrupted after the first or second dose of vaccine, the missed dose should be administered as soon as possible. The series does not need to be restarted after a missed dose. In adolescents and healthy adults aged <40 years, approximately 30%--55% acquire a protective antibody response (anti-HBs >10 mIU/mL) after the first vaccine dose, 75% after the second, and >90% after the third. Vaccine-induced immune memory has been demonstrated to persist for at least 15--20 years. Periodic testing to determine antibody levels in immunocompetent persons is not necessary, and booster doses of vaccine are not recommended. Hepatitis B vaccination is generally well-tolerated by the majority of recipients. Pain at the injection site and low-grade fever are reported by a minority of recipients. Evidence for a causal association between receipt of hepatitis B vaccination and anaphylaxis exists, which is estimated to occur in 1 of 1.1 million doses of vaccine administered among children and adolescents; no deaths have been reported after anaphylaxis. Vaccine is contraindicated in persons with a history of anaphylaxis after a previous dose of hepatitis B vaccine and in persons with a known anaphylactic reaction to any vaccine component. No evidence for a causal association has been demonstrated for other adverse events reported after administration of hepatitis B vaccine. Hepatitis B vaccination is recommended for all unvaccinated adolescents, all unvaccinated adults at risk for HBV infection, and all adults seeking protection from HBV infection. For adults, acknowledgement of a specific risk factor is not a requirement for vaccination. Hepatitis B vaccine should be routinely offered to all unvaccinated persons attending STD clinics and to all unvaccinated persons seeking treatment for STDs in other settings. Other settings where all unvaccinated adults should be assumed to be at risk for hepatitis B and should receive hepatitis B vaccination include correctional facilities, facilities providing drug abuse treatment and prevention services, health-care settings serving MSM, and HIV testing and treatment facilities. All persons who receive clinical services in these settings should be offered hepatitis B vaccine, unless they have a reliable vaccination history (i.e., a written, dated record of each dose of a complete series). In all settings, vaccination should be initiated even though completion of the vaccine series might not be ensured. Prevaccination Antibody Screening Prevaccination serologic testing for susceptibility may be considered to reduce the cost of vaccinating adult populations that have an expected high prevalence of HBV infection (i.e., >20%--30%) (e.g., IDUs and MSM [especially in older age groups]). In addition, prevaccination testing for susceptibility is recommended for unvaccinated household, sexual, and needle-sharing contacts of HBsAg-positive persons. Anti-HBc is the test of choice for prevaccination testing; persons who are anti-HBc--positive should be tested for HBsAg. If persons are determined to be HBsAg negative, no further action is required. If persons are determined to be HBsAg positive, the person should be referred for medical follow-up, including counseling and evaluation for antiviral treatment (see Management of HBsAg-Positive Persons). In addition, all household members, sex partners, and needle-sharing partners of HBsAg-positive persons should be vaccinated. Serologic testing should not be a barrier to vaccination of susceptible persons, especially in populations that are difficult to access. In the majority of situations, the first vaccine dose should be administered immediately after collection of the blood sample for serologic testing. Vaccination of persons who are immune to HBV infection because of current or previous infection or vaccination does not increase the risk for adverse events. Postvaccination Testing for Serologic Response Serologic testing for immunity is not necessary after routine vaccination of adolescents or adults. Testing after vaccination is recommended for persons whose subsequent clinical management depends on knowledge of their immune status (e.g., health-care workers or public safety workers at high risk for continued percutaneous or mucosal exposure to blood or body fluids). In addition, testing is recommended for 1) HIV-infected persons and other immunocompromised persons to determine the need for revaccination and the type of follow-up testing; and 2) sex and needle-sharing partners of HBsAg-positive persons to determine the need for revaccination and for other methods to protect themselves from HBV infection. If indicated, testing should be performed 1--2 months after administration of the last dose of the vaccine series by using a method that allows determination of a protective level of anti-HBs (>10 mIU/mL). Persons determined to have anti-HBs levels of <10 mIU/mL after the primary vaccine series should be revaccinated with a 3-dose series, followed by anti-HBs testing 1--2 months after the third dose. Persons who do not respond to revaccination should be tested for HBsAg. If HBsAg positive, the person should receive appropriate management (see Management of HBsAg-Positive Persons); if HBsAg negative, the person should be considered susceptible to HBV infection and counseled concerning precautions to prevent HBV infection and the need for HBIG PEP for any known exposure (see PEP). Both passive-active PEP with HBIG and hepatitis B vaccination and active PEP with hepatitis B vaccination alone have been demonstrated to be highly effective in preventing transmission after exposure to HBV (2). HBIG alone also has been demonstrated to be effective in preventing HBV transmission, but with the availability of hepatitis B vaccine, HBIG typically is used as an adjunct to vaccination. Exposure to HBsAg-Positive Source. Unvaccinated persons or persons known not to have responded to a complete hepatitis B vaccine series should receive both HBIG and hepatitis vaccine as soon as possible (preferably <24 hours) after a discrete, identifiable exposure to blood or body fluids that contain blood from an HBsAg-positive source (Table 5). Hepatitis B vaccine should be administered simultaneously with HBIG in a separate injection site, and the vaccine series should be completed by using the age-appropriate vaccine dose and schedule (Table 3). Exposed persons who are in the process of being vaccinated but who have not completed the vaccine series should receive the appropriate dose of HBIG (i.e., 0.06 mL/kg) and should complete the vaccine series. Exposed persons who are known to have responded to vaccination are considered protected and need no further vaccine doses. Persons who have written documentation of a complete hepatitis B vaccine series and who did not receive postvaccination testing should receive a single vaccine booster dose. Alternatively, these persons can be managed according to guidelines for management of persons with occupational exposure to blood or body fluids that contain blood (207). Exposure to Source with Unknown HBsAg Status. Unvaccinated persons who have a discrete, identifiable exposure to blood or body fluids containing blood from a source with unknown HBsAg status should receive the hepatitis B vaccine series, with the first dose initiated as soon as possible after exposure (preferably within 24 hours) and the series completed by using the age-appropriate dose and schedule. Exposed persons who are not fully vaccinated should complete the vaccine series. Exposed persons with written documentation of a complete hepatitis B vaccine series require no further treatment. Pregnancy. All pregnant women receiving STD services should be tested for HBsAg, regardless of whether they have been previously tested or vaccinated. All HBsAg-positive pregnant women should be reported to state and local perinatal hepatitis B prevention programs. HBsAg-negative pregnant women seeking STD treatment who have not been previously vaccinated should receive hepatitis B vaccination. Additional information regarding management of HBsAg-positive pregnant women and their infants is available at http://www.cdc.gov/mmwr/PDF/rr/rr5416.pdf. HIV Infection. HIV infection can impair the response to hepatitis B vaccination. HIV-infected persons should be tested for anti-HBs 1--2 months after the third vaccine dose (see Postvaccination Testing for Serologic Response). Modified dosing regimens, including a doubling of the standard antigen dose and administration of additional doses, might increase the response rate. Management of HBsAg-Positive Persons This section provides recommendations for management of all HBsAg-positive persons. Additional recommendations for management of HBsAg-positive persons who are coinfected with HIV are available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5315a1.htm. All persons with HBsAg-positive laboratory results should be reported to the state or local health department. To verify the presence of chronic HBV infection, HBsAg-positive persons should be retested. The absence of IgM anti-HBc or the persistence of HBsAg for 6 months indicates chronic HBV infection. Persons with chronic HBV infection should be referred for evaluation to a physician experienced in the management of CLD. Some patients with chronic hepatitis B will benefit from early intervention with antiviral treatment or screening to detect HCC at an early stage. Household, sexual, and needle-sharing contacts of chronically infected persons should be identified. Unvaccinated sex partners and household and needle-sharing contacts should be tested for susceptibility to HBV infection (see Prevaccination Antibody Screening) and should receive the first dose of hepatitis B vaccine immediately after collection of the blood sample for serologic testing. Susceptible persons should complete the vaccine series by using an age-appropriate vaccine dose and schedule. Persons who are fully vaccinated should complete the vaccine series. Sex partners of HBsAg-positive persons should be counseled to use methods (e.g., condoms) to protect themselves from sexual exposure to infectious body fluids (e.g., semen and vaginal secretions), unless they have been demonstrated to be immune after vaccination (anti-HBs >10 mIU/mL) or previously infected (anti-HBc positive). To prevent or reduce the risk for transmission to others, HBsAg-positive persons should be advised concerning the risk for transmission to household, sexual, and needle-sharing contacts and the need for such contacts to receive hepatitis B vaccination. HBsAg-positive persons also should be advised to --- use methods (e.g., condoms) to protect nonimmune sex partners from acquiring HBV infection from sexual activity until the partner can be vaccinated and immunity documented; --- cover cuts and skin lesions to prevent the spread of infectious secretions or blood; --- refrain from donating blood, plasma, body organs, other tissue, or semen; and --- refrain from sharing household articles (e.g., toothbrushes, razors, or personal injection equipment) that could become contaminated with blood. To protect the liver from further harm, HBsAg-positive persons should be advised to --- avoid or limit alcohol consumption because of the effects of alcohol on the liver; --- refrain from starting any new medicines, including OTC and herbal medicines, without checking with their health-care provider; and --- obtain vaccination against hepatitis A if liver disease is determined to be present. When seeking medical or dental care, HBsAg-positive persons should be advised to inform those responsible for their care of their HBsAg status so that they can be appropriately evaluated and managed. Information regarding HBsAg-positive women who are pregnant is available in this report (see Special Populations, Pregnant Women). Other counseling messages also should be considered. --- HBV is not spread by hugging, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact. --- Persons should not be excluded from work, school, play, child care, or other settings because they are infected with HBV. --- Involvement with a support group might help patients cope with chronic HBV infection. Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States; approximately 2.7 million persons are chronically infected (204). Although HCV is not efficiently transmitted sexually, persons at risk for infection through injection-drug use might seek care in STD treatment facilities, HIV counseling and testing facilities, correctional facilities, drug treatment facilities, and other public health settings where STD and HIV prevention and control services are available. Persons newly infected with HCV typically are either asymptomatic or have a mild clinical illness. HCV RNA can be detected in blood within 1--3 weeks after exposure. The average time from exposure to antibody to HCV (anti-HCV) seroconversion is 8--9 weeks, and anti-HCV can be detected in >97% of persons by 6 months after exposure. Chronic HCV infection develops in 60%--85% of HCV-infected persons; 60%--70% of chronically infected persons have evidence of active liver disease. The majority of infected persons might not be aware of their infection because they are not clinically ill. However, infected persons serve as a source of transmission to others and are at risk for CLD or other HCV-related chronic diseases for decades after infection. HCV is most efficiently transmitted through large or repeated percutaneous exposure to infected blood (e.g., through transfusion of blood from unscreened donors or through use of injecting drugs), although less efficient, occupational, perinatal, and sexual exposures also can result in transmission of HCV. The role of sexual activity in the transmission of HCV has been controversial. Case-control studies have reported an association between acquiring HCV infection and exposure to a sex contact with HCV infection or exposure to multiple sex partners. Surveillance data also indicate that 15%--20% of persons reported with acute HCV infection have a history of sexual exposure in the absence of other risk factors (204,208). Case reports of acute HCV infection among HIV-positive MSM who deny injecting-drug use have indicated that this occurrence is frequently associated with other STDs (e.g., syphilis) (209,210). In contrast, a low prevalence (average: 1.5%) of HCV infection has been demonstrated in studies of long-term spouses of patients with chronic HCV infection who had no other risk factors for infection, and multiple published studies have demonstrated the prevalence of HCV infection among MSM who have not reported a history of injecting-drug use to be no higher than that of heterosexuals (211--213). Because sexual transmission of bloodborne viruses is more efficient among homosexual men compared with heterosexual men and women, the reason that HCV infection rates are not substantially higher among MSM compared with heterosexuals is unclear. Overall, these findings indicate that sexual transmission of HCV is possible but inefficient. Additional data are needed to determine whether sexual transmission of HCV might be increased in the context of HIV infection or other STDs. Anti-HCV testing is recommended for routine screening of asymptomatic persons based on their risk for infection or based on a recognized exposure (see Hepatitis C, Prevention). For such persons, testing for HCV infection should include the use of an FDA-cleared test for antibody to HCV (i.e., immunoassay, EIA, or enhanced chemiluminescence assay and, if recommended, a supplemental antibody test) (214). Persons counseled and tested for HCV infection and determined to be anti-HCV positive should be evaluated (by referral or consultation, if appropriate) for presence of active infection, presence or development of CLD, and for possible treatment. Reverse transcriptase polymerase chain reaction to detect HCV RNA may be used to confirm the diagnosis of current HCV infection, and an elevated alanine aminotransferase (ALT) level is biochemical evidence of CLD. Combination therapy with pegylated interferon and ribavirin is the treatment of choice for patients with chronic hepatitis C. Because of advances in the field of antiviral therapy for acute and chronic hepatitis C, clinicians should consult with specialists knowledgeable about management of hepatitis C infection. No vaccine for hepatitis C is available, and prophylaxis with immune globulin is not effective in preventing HCV infection after exposure. Reducing the burden of HCV infection and disease in the United States requires implementation of both primary and secondary prevention activities (208). Primary prevention reduces or eliminates HCV transmission; secondary prevention activities reduce liver and other chronic diseases in HCV-infected persons by identifying them and providing appropriate medical management and antiviral therapy, if appropriate. Persons seeking care in STD clinics or other primary-care settings should be screened to identify those who should be offered HCV counseling and testing. In STD clinics and other settings that serve large numbers of persons at high risk for bloodborne infections (e.g., correctional settings), the major risk factor for which to screen for HCV infection is injection of illegal drugs. In addition, for clinical management issues, all persons with HIV infection should also be offered HCV counseling and testing. Other risk factors for which routine HCV testing is recommended include persons who had a blood transfusion or solid organ transplant before July 1992, who received clotting factor concentrates produced before 1987, who have been on long-term dialysis, and those with signs and symptoms of liver disease (e.g., abnormal ALT). Persons who test positive for anti-HCV (see Diagnosis and Treatment) should be provided information regarding 1) how to protect their liver from further harm, 2) how to prevent transmission to others, and 3) the need for medical evaluation for CLD and possible treatment. To protect their liver from further harm, HCV-positive persons should be advised to avoid alcohol and taking any new medicines (including OTC and herbals) without checking with their doctor. To reduce the risk for transmission to others, HCV-positive persons should be advised to 1) not donate blood, body organs, other tissue, or semen; 2) not share any personal items that might have blood on them (e.g., toothbrushes and razors); and 3) cover cuts and sores on the skin to keep from spreading infectious blood or secretions. HCV-positive persons with one long-term, steady sex partner do not need to change their sexual practices. They should discuss the low but present risk for transmission with their partner and discuss the need for counseling and testing. HCV-positive women do not need to avoid pregnancy or breastfeeding. HCV-positive persons should be evaluated (by referral or consultation, if appropriate) for presence of development of CLD, including assessment of liver function tests, assessment for severity of liver disease and possible treatment, and determination of the need for hepatitis A and B vaccination. Persons who test negative for anti-HCV who had an exposure previously should be reassured that they are not infected. Regardless of test results, persons who use or inject illegal drugs should be counseled to stop using and injecting drugs; enter and complete substance abuse treatment, including relapse prevention; take the following steps to reduce personal and public health risks, if they continue to inject drugs: --- never reuse or share syringes, water, or drug preparation equipment; --- use only syringes obtained from a reliable source (e.g., pharmacies); --- use a new, sterile syringe to prepare and inject drugs; --- if possible, use sterile water to prepare drugs; otherwise, use clean water from a reliable source (e.g., fresh tap water); --- use a new or disinfected container ("cooker") and a new filter ("cotton") to prepare drugs; --- clean the injection site before injection with a new alcohol swab; --- safely dispose of syringes after one use; and --- get vaccinated for hepatitis A and B. Postexposure Follow-Up No PEP has been demonstrated to be effective against HCV. Testing to determine whether HCV infection has developed is recommended for health-care workers after percutaneous or permucosal exposures to HCV-positive blood and for children born to HCV-positive women. Routine testing for HCV infection is not recommended for all pregnant women. Pregnant women with a known risk factor for HCV infection should be offered counseling and testing. Patients should be advised that approximately five of every 100 infants born to HCV-infected woman become infected. This infection occurs predominantly during or near delivery, and no treatment or delivery method is known to decrease this risk. The risk is increased by the presence of maternal HCV viremia at delivery and also is greater (2--3 times) if the woman is coinfected with HIV. Breastfeeding does not appear to transmit HCV, although HCV-positive mothers should consider abstaining from breastfeeding if their nipples are cracked or bleeding. Infants born to HCV-positive mothers should be tested for HCV infection and, if positive, evaluated for the presence of CLD. Because of the high prevalence of HIV/HCV coinfection and because of critical clinical management issues for coinfected persons, all HIV-infected persons should be tested for HCV. Because a small percentage of coinfected persons fail to acquire HCV antibodies, HCV RNA should be tested in HIV-positive persons with unexplained liver disease who are anti-HCV negative. The course of liver disease is more rapid in HIV/HCV coinfected persons, and the risk for cirrhosis is nearly twice that in persons with HCV infection alone. Treatment of HCV in coinfected persons might improve tolerance to highly active antiretroviral therapy (HAART) for HIV infection because of the increased risk for hepatotoxicity from HAART with HCV infection. However, anti-HCV treatment in coinfected persons is still investigational, and based on ongoing clinical trials, more data are needed to determine the best regimens. Proctitis, Proctocolitis, and Enteritis Sexually transmitted gastrointestinal syndromes include proctitis, proctocolitis, and enteritis. Evaluation for these syndromes should include appropriate diagnostic procedures (e.g., anoscopy or sigmoidoscopy, stool examination, and culture). Proctitis is inflammation of the rectum (i.e., the distal 10--12 cm) that might be associated with anorectal pain, tenesmus, or rectal discharge. N. gonorrhoeae, C. trachomatis (including LGV serovars), T. pallidum, and HSV are the most common sexually transmitted pathogens involved. In patients coinfected with HIV, herpes proctitis might be especially severe. Proctitis occurs predominantly among persons who participate in receptive anal intercourse. Proctocolitis is associated with symptoms of proctitis and diarrhea or abdominal cramps and inflammation of the colonic mucosa, extending to 12 cm above the anus. Fecal leukocytes might be detected on stool examination, depending on the pathogen. Pathogenic organisms include Campylobacter sp., Shigella sp., Entamoeba histolytica, and, rarely, LGV serovars of C. trachomatis. CMV or other opportunistic agents might be involved in immunosuppressed HIV-infected patients. Proctocolitis can be acquired by the oral route or by oral-anal contact, depending on the pathogen. Enteritis usually results in diarrhea and abdominal cramping without signs of proctitis or proctocolitis; it occurs among persons whose sexual practices include oral-anal contact. In otherwise healthy persons, Giardia lamblia is most frequently implicated. When outbreaks of gastrointestinal illness occur among social or sexual networks of MSM, clinicians should consider sexual transmission as a mode of spread and provide counseling accordingly. Among HIV-infected patients, gastrointestinal illness can be caused by other infections that usually are not sexually transmitted, including CMV, Mycobacterium avium-intracellulare, Salmonella sp., Campylobacter sp., Shigella sp., Cryptosporidium, Microsporidium, and Isospora. Multiple stool examinations might be necessary to detect Giardia, and special stool preparations are required to diagnose cryptosporidiosis and microsporidiosis. In addition, enteritis might be directly caused by HIV infection. When laboratory diagnostic capabilities are available, treatment decisions should be based on the specific diagnosis. Diagnostic and treatment recommendations for all enteric infections are beyond the scope of these guidelines. Acute proctitis of recent onset among persons who have recently practiced receptive anal intercourse is usually sexually acquired (215,216). Such patients should be examined by anoscopy and should be evaluated for infection with HSV, N. gonorrhoeae, C. trachomatis, and T. pallidum. If an anorectal exudate is detected on examination or if polymorphonuclear leukocytes are detected on a Gram-stained smear of anorectal secretions, the following therapy may be prescribed while awaiting additional laboratory tests. Ceftriaxone 125 mg IM (or another agent effective against rectal and genital gonorrhea) Patients with suspected or documented herpes proctitis should be managed in the same manner as those with genital herpes (see Genital HSV Infections). If painful perianal ulcers are present or mucosal ulcers are detected on anoscopy, presumptive therapy should include a regimen for treating genital herpes. In addition, LGV proctitis and proctocolitis also should be considered. Appropriate diagnostic testing for LGV should be conducted in accordance with state or federal guidelines, and doxycycline therapy should be administered 100 mg orally twice daily for 3 weeks. Follow-up should be based on specific etiology and severity of clinical symptoms. Reinfection might be difficult to distinguish from treatment failure. Partners of patients with sexually transmitted enteric infections should be evaluated for any diseases diagnosed in the index patient. Ectoparasitic Infections Pediculosis Pubis Patients who have pediculosis pubis (i.e., pubic lice) usually seek medical attention because of pruritus or because they notice lice or nits on their pubic hair. Pediculosis pubis is usually transmitted by sexual contact. Permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes Pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 minutes Malathion 0.5% lotion applied for 8--12 hours and washed off Ivermectin 250 ug/kg repeated in 2 weeks Reported resistance to pediculcides has been increasing and is widespread. Malathion may be used when treatment failure is believed to have occurred because of resistance (217). The odor and long duration of application for malathion make it a less attractive alternative than the recommended pediculcides. Ivermectin has been successfully used to treat lice but has only been evaluated in small studies. Lindane is not recommended as first-line therapy because of toxicity. It should only be used as an alternative because of inability to tolerate other therapies or if other therapies have failed. Lindane toxicity, as indicated by seizure and aplastic anemia, has not been reported when treatment was limited to the recommended 4-minute period. Permethrin has less potential for toxicity than lindane. The recommended regimens should not be applied to the eyes. Pediculosis of the eyelashes should be treated by applying occlusive ophthalmic ointment to the eyelid margins twice a day for 10 days. Bedding and clothing should be decontaminated (i.e., machine-washed, machine-dried using the heat cycle, or dry cleaned) or removed from body contact for at least 72 hours. Fumigation of living areas is not necessary. Patients with pediculosis pubis should be evaluated for other STDs. Patients should be evaluated after 1 week if symptoms persist. Re-treatment might be necessary if lice are found or if eggs are observed at the hair-skin junction. Patients who do not respond to one of the recommended regimens should be re-treated with an alternative regimen. Sex partners within the previous month should be treated. Patients should avoid sexual contact with their sex partner(s) until patients and partners have been treated and reevaluated to rule out persistent disease. Pregnant and lactating women should be treated with either permethrin or pyrethrins with piperonyl butoxide; lindane is contraindicated in pregnancy. Patients who have pediculosis pubis and also are infected with HIV should receive the same treatment regimen as those who are HIV negative. The predominant symptom of scabies is pruritus. Sensitization to Sarcoptes scabiei occurs before pruritus begins. The first time a person is infested with S. scabiei, sensitization takes up to several weeks to develop. However, pruritus might occur within 24 hours after a subsequent reinfestation. Scabies in adults frequently is sexually acquired, although scabies in children usually is not. Permethrin cream (5%) applied to all areas of the body from the neck down and washed off after 8--14 hours Ivermectin 200ug/kg orally, repeated in 2 weeks Lindane (1%) 1 oz. of lotion or 30 g of cream applied in a thin layer to all areas of the body from the neck down and thoroughly washed off after 8 hours Lindane is not recommended as first-line therapy because of toxicity. It should only be used as an alternative if the patient cannot tolerate other therapies or if other therapies have failed. Lindane should not be used immediately after a bath or shower, and it should not be used by persons who have extensive dermatitis, women who are pregnant or lactating, or children aged <2 years. Lindane resistance has been reported in some areas of the world, including parts of the United States. Seizures have occurred when lindane was applied after a bath or used by patients who had extensive dermatitis. Aplastic anemia after lindane use also has been reported. Permethrin is effective and safe and less expensive than ivermectin. One study demonstrated increased mortality among elderly, debilitated persons who received ivermectin, but this observation has not been confirmed in subsequent reports (218). Bedding and clothing should be decontaminated (i.e., either machine-washed, machine-dried using the hot cycle, or dry cleaned) or removed from body contact for at least 72 hours. Fumigation of living areas is unnecessary. Crusted Scabies Crusted scabies (i.e., Norwegian scabies) is an aggressive infestation that usually occurs in immunodeficient, debilitated, or malnourished persons. Patients who are receiving systemic or potent topical glucocorticoids, organ transplant recipients, mentally retarded or physically incapacitated persons, HIV-infected or human T-lymphotrophic virus-1-infected persons, and persons with various hematologic malignancies are at risk for developing crusted scabies. Crusted scabies is associated with greater transmissibility than scabies. No controlled therapeutic studies for crusted scabies have been conducted, and the appropriate treatment remains unclear. Substantial treatment failure might occur with a single topical scabicide or with oral ivermectin treatment. Some specialists recommend combined treatment with a topical scabicide and oral ivermectin or repeated treatments with ivermectin 200 ug/kg on days 1, 15, and 29. Lindane should be avoided because of the risks for neurotoxicity with heavy applications or denuded skin. Patient's fingernails should be closely trimmed to reduce injury from excessive scratching. Patients should be informed that the rash and pruritus of scabies might persist for up to 2 weeks after treatment. Symptoms or signs that persist for >2 weeks can be attributed to several factors. Treatment failure might be caused by resistance to medication or by faulty application of topical scabicides. Patients with crusted scabies might have poor penetration into thick scaly skin and harbor mites in these difficult-to-penetrate layers. Particular attention must be given to the fingernails of these patients. Reinfection from family members or fomites might occur in the absence of appropriate contact treatment and washing of bedding and clothing. Even when treatment is successful and reinfection is avoided, symptoms can persist or worsen as a result of allergic dermatitis. Finally, household mites can cause symptoms to persist as a result of crossreactivity between antigens. Some specialists recommend re-treatment after 1--2 weeks for patients who are still symptomatic; others recommend re-treatment only if live mites are observed. Patients who do not respond to the recommended treatment should be re-treated with an alternative regimen. Management of Sex Partners and Household Contacts Both sexual and close personal or household contacts within the preceding month should be examined and treated. Management of Outbreaks in Communities, Nursing Homes, and Other Institutional Settings Scabies epidemics frequently occur in nursing homes, hospitals, residential facilities, and other communities. Control of an epidemic can only be achieved by treatment of the entire population at risk. Ivermectin can be considered in this setting, especially if treatment with topical scabicides fails. Epidemics should be managed in consultation with a specialist. Infants, Young Children, and Pregnant or Lactating Women Infants, young children, and pregnant or lactating women should not be treated with lindane. They can be treated with permethrin. Ivermectin is not recommended for pregnant or lactating patients. The safety of ivermectin in children who weigh <15 kg has not been determined. Patients who have uncomplicated scabies and also are infected with HIV should receive the same treatment regimens as those who are HIV negative. HIV-infected patients and others who are immunosuppressed are at increased risk for crusted scabies. Ivermectin has been reported to be useful in small, noncontrolled studies. Such patients should be managed in consultation with a specialist. Sexual Assault and STDs Adults and Adolescents The recommendations in this report are limited to the identification, prophylaxis, and treatment of sexually transmitted infections and conditions commonly identified in the management of such infections. The documentation of findings, collection of nonmicrobiologic specimens for forensic purposes, and the management of potential pregnancy or physical and psychological trauma are beyond the scope of this report. Examinations of survivors of sexual assault should be conducted by an experienced clinician in a way that minimizes further trauma to the survivor. The decision to obtain genital or other specimens for STD diagnosis should be made on an individual basis. Care systems for survivors should be designed to ensure continuity (including timely review of test results), support adherence, and monitor for adverse reactions to any therapeutic or prophylactic regimens prescribed at initial examination. Laws in all 50 states strictly limit the evidentiary use of a survivor's previous sexual history, including evidence of previously acquired STDs, as part of an effort to undermine the credibility of the survivor's testimony. Evidentiary privilege against revealing any aspect of the examination or treatment is enforced in the majority of states. In unanticipated, exceptional situations, STD diagnoses may later be accessed, and the survivor and clinician may opt to defer testing for this reason. However, collection of specimens at initial examination for laboratory STD diagnosis gives the survivor and clinician the option to defer empiric prophylactic antimicrobial treatment. Among sexually active adults, the identification of sexually transmitted infection after an assault might be more important for the psychological and medical management of the patient than for legal purposes because the infection could have been acquired before the assault. Trichomoniasis, BV, gonorrhea, and chlamydial infection are the most frequently diagnosed infections among women who have been sexually assaulted. Because the prevalence of these infections is high among sexually active women, their presence after an assault does not necessarily signify acquisition during the assault. A postassault examination is, however, an opportunity to identify or prevent sexually transmitted infections, regardless of whether they were acquired during an assault. Chlamydial and gonococcal infections in women are of particular concern because of the possibility of ascending infection. In addition, HBV infection might be prevented by postexposure administration of hepatitis B vaccine. Reproductive-aged female survivors should be evaluated for pregnancy, if appropriate. Evaluation for Sexually Transmitted Infections Initial Examination An initial examination should include the following procedures: Testing for N. gonorrhoeae and C. trachomatis from specimens collected from any sites of penetration or attempted penetration. Culture or FDA-cleared nucleic acid amplification tests for either N. gonorrhoeae or C. trachomatis. NAAT offer the advantage of increased sensitivity in detection of C. trachomatis. Wet mount and culture of a vaginal swab specimen for T. vaginalis infection. If vaginal discharge, malodor, or itching is evident, the wet mount also should be examined for evidence of BV and candidiasis. Collection of a serum sample for immediate evaluation for HIV, hepatitis B, and syphilis (see Sexual Assault and STDs, sections Prophylaxis, Risk for Acquiring HIV Infection, and Follow-Up Examination After Assault). Follow-Up Examinations After the initial postassault examination, follow-up examinations provide an opportunity to 1) detect new infections acquired during or after the assault; 2) complete hepatitis B immunization, if indicated; 3) complete counseling and treatment for other STDs; and 4) monitor side effects and adherence to postexposure prophylactic medication, if prescribed. Examination for STDs should be repeated within 1--2 weeks of the assault. Because infectious agents acquired through assault might not have produced sufficient concentrations of organisms to result in positive test results at the initial examination, testing should be repeated during the follow-up visit, unless prophylactic treatment was provided. If treatment was provided, testing should be conducted only if the survivor reports having symptoms. If treatment was not provided, follow-up examination should be conducted within 1 week to ensure that results of positive tests can be discussed promptly with the survivor and that treatment is provided. Serologic tests for syphilis and HIV infection should be repeated 6 weeks, 3 months, and 6 months after the assault if initial test results were negative and infection in the assailant could not be ruled out (see Sexual Assaults, Risk for Acquiring HIV Infection). Many specialists recommend routine preventive therapy after a sexual assault because follow-up of survivors of sexual assault can be difficult. The following prophylactic regimen is suggested as preventive therapy: Postexposure hepatitis B vaccination, without HBIG, should adequately protect against HBV infection. Hepatitis B vaccination should be administered to sexual assault victims at the time of the initial examination if they have not been previously vaccinated. Follow-up doses of vaccine should be administered 1--2 and 4--6 months after the first dose. An empiric antimicrobial regimen for chlamydia, gonorrhea, trichomonas, and BV. EC should be offered if the postassault could result in pregnancy in the survivor. For patients requiring alternative treatments, refer to the sections in this report relevant to the specific agent. The efficacy of these regimens in preventing infections after sexual assault has not been evaluated. Clinicians should counsel patients regarding the possible benefits and toxicities associated with these treatment regimens; gastrointestinal side effects can occur with this combination. Providers might also consider anti-emetic medications, particularly if EC also is provided. At the initial examination and, if indicated, at follow-up examinations, patients should be counseled regarding 1) symptoms of STDs and the need for immediate examination if symptoms occur and 2) abstinence from sexual intercourse until STD prophylactic treatment is completed. Risk for Acquiring HIV Infection HIV seroconversion has occurred in persons whose only known risk factor was sexual assault or sexual abuse, but the frequency of this occurrence is probably low. In consensual sex, the risk for HIV transmission from vaginal intercourse is 0.1%--0.2% and for receptive rectal intercourse, 0.5%--3% (219). The risk for HIV transmission from oral sex is substantially lower. Specific circumstances of an assault might increase risk for HIV transmission (e.g., trauma, including bleeding) with vaginal, anal, or oral penetration; site of exposure to ejaculate; viral load in ejaculate; and the presence of an STD or genital lesions in the assailant or survivor. Children might be at higher risk for transmission because child sexual abuse is frequently associated with multiple episodes of assault and might result in mucosal trauma (see Sexual Assault or Abuse of Children). Postexposure therapy with zidovudine was associated with a reduced risk for acquiring HIV in a study of health-care workers who had percutaneous exposures to HIV-infected blood (220). On the basis of these results and the results of animal studies, PEP has been recommended for health-care workers who have occupational exposures to HIV (207). These findings have been extrapolated to other types of HIV exposure, including sexual assault (58). If HIV exposure has occurred, initiation of PEP as soon as possible after the exposure likely increases benefit. Although a definitive statement of benefit cannot be made regarding PEP after sexual assault, the possibility of HIV exposure from the assault should be assessed at the time of the postassault examination. The possible benefit of PEP in preventing HIV infection also should be discussed with the assault survivor if risk exists for HIV exposure from the assault. The likelihood of the assailant having HIV, any exposure characteristics that might increase the risk for HIV transmission, the time elapsed after the event, as well as potential benefits and risks the PEP are all factors that will impact the medical recommendation for PEP and impact the assault survivor's acceptance of that recommendation (58). Determination of assailant's HIV status at the time of the assault examination will usually be impossible. Therefore, the health-care provider should assess any available information concerning HIV-risk behaviors of the assailant(s) (e.g., a man who has sex with other men and injecting-drug or crack cocaine use), local epidemiology of HIV/AIDS, and exposure characteristics of the assault. When an assailant's HIV status is unknown, factors that should be considered in determining whether an increased risk for HIV transmission exists include 1) whether vaginal or anal penetration occurred; 2) whether ejaculation occurred on mucous membranes; 3) whether multiple assailants were involved; 4) whether mucosal lesions are present in the assailant or survivor; and 5) other characteristics of the assault, survivor, or assailant that might increase risk for HIV transmission. If PEP is offered, the following information should be discussed with the patient: 1) the unproven benefit and known toxicities of antiretrovirals; 2) the close follow-up that will be necessary; 3) the benefit of adherence to recommended dosing; and 4) the necessity of early initiation of PEP to optimize potential benefits (as soon as possible after and up to 72 hours after the assault). Providers should emphasize that PEP appears to be well-tolerated in both adults and children and that severe adverse effects are rare. Clinical management of the survivor should be implemented according to the following guidelines (58). Specialist consultation on PEP regimens is recommended if HIV exposure during the assault was possible and if PEP is being considered. The sooner PEP is initiated after the exposure, the higher the likelihood that it will prevent HIV transmission, if HIV exposure occurred; however, distress after an assault also might prevent the survivor from accurately weighing exposure risks and benefits of PEP and making an informed decision to start PEP. If use of PEP is judged to be warranted, the survivor should be offered a 3--5-day supply of PEP with a follow-up visit scheduled for additional counseling after several days. Recommendations for Postexposure Assessment of Adolescent and Adult Survivors Within 72 hours of Sexual Assault§§§ Assess risk for HIV infection in the assailant. Evaluate characteristics of the assault event that might increase risk for HIV transmission. Consult with a specialist in HIV treatment, if PEP is being considered. If the survivor appears to be at risk for HIV transmission from the assault, discuss antiretroviral prophylaxis, including toxicity and lack of proven benefit. If the survivor chooses to start antiretroviral PEP (58), provide enough medication to last until the next return visit; reevaluate the survivor 3--7 days after initial assessment and assess tolerance of medications. If PEP is started, perform CBC and serum chemistry at baseline (initiation of PEP should not be delayed, pending results). Perform HIV antibody test at original assessment; repeat at 6 weeks, 3 months, and 6 months. Sexual Assault or Abuse of Children Recommendations in this report are limited to the identification and treatment of STDs. Management of the psychosocial aspects of the sexual assault or abuse of children is beyond the scope of these recommendations. The identification of sexually transmissible agents in children beyond the neonatal period suggests sexual abuse. The significance of the identification of a sexually transmitted agent in such children as evidence of possible child sexual abuse varies by pathogen. Postnatally acquired gonorrhea; syphilis; and nontransfusion, nonperinatally acquired HIV are usually diagnostic of sexual abuse. Sexual abuse should be suspected when genital herpes is diagnosed. The investigation of sexual abuse among children who possibly have an infection that might have been sexually transmitted should be conducted in compliance with recommendations by clinicians who have experience and training in all elements of the evaluation of child abuse, neglect, and assault. The social importance of infection that might have been acquired sexually and the recommended action regarding reporting of suspected child sexual abuse varies by the specific organism (Table 6). In all cases in which a sexually transmitted infection has been diagnosed in a child, efforts should be made to detect evidence of sexual abuse, including conducting diagnostic testing for other commonly occurring sexually transmitted infections (221). The general rule that sexually transmissible infections beyond the neonatal period are evidence of sexual abuse has exceptions. For example, rectal or genital infection with C. trachomatis among young children might be the result of perinatally acquired infection and has, in some cases, persisted for as long as 2--3 years. Genital warts have been diagnosed in children who have been sexually abused, but also in children who have no other evidence of sexual abuse. BV has been diagnosed in children who have been abused, but its presence alone does not prove sexual abuse. The majority of HBV infections in children result from household exposure to persons who have chronic HBV infection. The possibility of sexual abuse should be strongly considered if no conclusive explanation for nonsexual transmission of a sexually transmitted infection can be identified. When the only evidence of sexual abuse is the isolation of an organism or the detection of antibodies to a sexually transmissible agent, findings should be confirmed and the implications considered carefully. Examinations of children for sexual assault or abuse should be conducted in a manner designed to minimize pain and trauma to the child. Collection of vaginal specimens in prepubertal children can be very uncomfortable and should be performed by an experienced clinician to avoid psychological and physical trauma to the child. The decision to obtain genital or other specimens from a child to conduct an STD evaluation must be made on an individual basis. The following situations involve a high risk for STDs and constitute a strong indication for testing: The child has or has had symptoms or signs of an STD or of an infection that can be sexually transmitted, even in the absence of suspicion of sexual abuse. Among the signs that are associated with a confirmed STD diagnosis are vaginal discharge or pain, genital itching or odor, urinary symptoms, and genital ulcers or lesions. A suspected assailant is known to have an STD or to be at high risk for STDs (e.g., has multiple sex partners or a history of STDs). A sibling or another child or adult in the household or child's immediate environment has an STD. The patient or parent requests testing. Evidence of genital, oral, or anal penetration or ejaculation is present. If a child has symptoms, signs, or evidence of an infection that might be sexually transmitted, the child should be tested for other common STDs before the initiation of any treatment that could interfere with the diagnosis of those other STDs. Because of the legal and psychosocial consequences of a false-positive diagnosis, only tests with high specificities should be used. The potential benefit to the child of a reliable diagnosis of an STD justifies deferring presumptive treatment until specimens for highly specific tests are obtained by providers with experience in the evaluation of sexually abused and assaulted children. The scheduling of an examination should depend on the history of assault or abuse. If the initial exposure was recent, the infectious agents acquired through the exposure might not have produced sufficient concentrations of organisms to result in positive test results. A follow-up visit approximately 2 weeks after the most recent sexual exposure may include a repeat physical examination and collection of additional specimens. To allow sufficient time for antibodies to develop, another follow-up visit approximately 12 weeks after the most recent sexual exposure might be necessary to collect sera. A single examination might be sufficient if the child was abused for an extended period and if the last suspected episode of abuse occurred substantially before the child received medical evaluation. The following recommendations for scheduling examinations serve as a general guide. The exact timing and nature of follow-up examinations should be determined on an individual basis and should be performed to minimize the possibility for psychological trauma and social stigma. Compliance with follow-up appointments might be improved when law enforcement personnel or child protective services are involved. Initial and 2-Week Follow-Up Examinations During the initial examination and 2-week follow-up examination (if indicated), the following should be performed: Visual inspection of the genital, perianal, and oral areas for genital discharge, odor, bleeding, irritation, warts, and ulcerative lesions. The clinical manifestations of some STDs are different in children than in adults. For example, typical vesicular lesions might not be present in the presence of HSV infection. Because this infection is suspicious for sexual abuse, specimens should be obtained from all vesicular or ulcerative genital or perianal lesions compatible with genital herpes and then sent for viral culture. Specimen collection for culture for N. gonorrhoeae from the pharynx and anus in both boys and girls, the vagina in girls, and the urethra in boys. Cervical specimens are not recommended for prepubertal girls. For boys with a urethral discharge, a meatal specimen discharge is an adequate substitute for an intraurethral swab specimen. Only standard culture systems for the isolation of N. gonorrhoeae should be used. All presumptive isolates of N. gonorrhoeae should be confirmed by at least two tests that involve different principles (i.e., biochemical, enzyme substrate, serologic, or nucleic acid hybridization test methods). Isolates and specimens should be retained or preserved in case additional or repeated testing is needed. Gram stains are inadequate to evaluate prepubertal children for gonorrhea and should not be used to diagnose or exclude gonorrhea. Cultures for C. trachomatis from specimens collected from the anus in both boys and girls and from the vagina in girls. Some data suggest that the likelihood of recovering C. trachomatis from the urethra of prepubertal boys is too low to justify the trauma involved in obtaining an intraurethral specimen. However, a meatal specimen should be obtained if urethral discharge is present. Pharyngeal specimens for C. trachomatis are not recommended for children of either sex because the yield is low, perinatally acquired infection might persist beyond infancy, and culture systems in some laboratories do not distinguish between C. trachomatis and C. pneumoniae. Only standard culture systems for the isolation of C. trachomatis should be used. The isolation of C. trachomatis should be confirmed by microscopic identification of inclusions by staining with fluorescein-conjugated monoclonal antibody specific for C. trachomatis; EIAs are not acceptable confirmatory methods. Isolates should be preserved. Nonculture tests for chlamydia (e.g., nonamplified probes, EIAs, and DFA) are not sufficiently specific for use in circumstances involving possible child abuse or assault. Data are insufficient to adequately assess the utility of nucleic acid amplification tests in the evaluation of children who might have been sexually abused, but these tests might be an alternative if confirmation is available and culture systems for C. trachomatis are unavailable. Confirmation tests should consist of a second FDA-cleared nucleic acid amplification test that targets a different sequence from the initial test. Culture and wet mount of a vaginal swab specimen for T. vaginalis infection and BV. Collection of serum samples to be evaluated immediately, preserved for subsequent analysis, and used as a baseline for comparison with follow-up serologic tests. Sera should be tested immediately for antibodies to sexually transmitted agents. Agents for which suitable tests are available include T. pallidum, HIV, and HBV. Decisions regarding which agents to use for serologic tests should be made on a case-by-case basis (see Sexual Assault, Examination 12 Weeks after Assault). HIV infection has been reported in children whose only known risk factor was sexual abuse. Serologic testing for HIV infection should be considered for abused children. The decision to test for HIV infection should be made on a case-by-case basis, depending on the likelihood of infection among assailant(s). Data are insufficient concerning the efficacy and safety of PEP among both children and adults. However, antiretroviral treatment is well-tolerated by infants and children with and without HIV infection. In addition, children who receive such treatment have a minimal risk for serious adverse reactions because of the short period recommended for prophylaxis (58,62). In considering whether to offer antiretroviral PEP, health-care providers should consider whether the child can be treated soon after the sexual exposure (i.e., within 72 hours), the likelihood that the assailant is at risk for HIV infection, and the likelihood of high compliance with the prophylactic regimen. The potential benefit of treating a sexually abused child should be weighed against the risk for adverse reactions. If antiretroviral PEP is being considered, a professional specializing in HIV-infected children should be consulted. Recommendations for HIV-Related Postexposure Assessment of Children within 72 Hours of Sexual Assault Review HIV/AIDS local epidemiology and assess risk for HIV infection in the assailant. Evaluate circumstances of assault that might affect risk for HIV transmission. Consult with a specialist in treating HIV-infected children if PEP is considered. If the child appears to be at risk for HIV transmission from the assault, discuss PEP with the caregiver(s), including its toxicity and unknown efficacy. If caregivers choose for the child to receive antiretroviral PEP (58,62,222), provide enough medication to last until the return visit at 3--7 days after the initial assessment, at which time the child should be reevaluated and tolerance of medication should be assessed; dosages should not exceed those for adults. Perform HIV antibody test at original assessment, 6 weeks, 3 months, and 6 months. Follow-Up Examination After Assault In circumstances in which transmission of syphilis, HIV, or hepatitis B is a concern but baseline tests are negative, an examination approximately 6 weeks, 3 months, and 6 months after the last suspected sexual exposure is recommended to allow time for antibodies to infectious agents to develop. 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Single dose metronidazole prophylaxis in gynaecological surgery. NZ Med J 1979;89:243--5. Luton and Dunstable Hospital Study Group. Metronidazole in the prevention and treatment of bacteroides infections in gynaecological patients. Lancet 1974;304:1543. Larsson PG, Platz-Christensen JJ, Forsum U, Pahlson C. Clue cells in predicting infections after abdominal hysterectomy. Obstet Gynecol 1991;77:450--2. Newton ER, Prihoda TJ, Gibbs RS. A clinical and microbiologic analysis of risk factors for puerperal endometritis. Obstet Gynecol 1990;75:402--6. Soper DE, Bump RC, Hurt WG. Bacterial vaginosis and trichomoniasis vaginitis are risk factors for cuff cellulitis after abdominal hysterectomy. Am J Obstet Gynecol 1990;163:1016--21. Watts DH, Krohn MA, Hillier SL, Eschenbach DA. Bacterial vaginosis as a risk factor for post-cesarean endometritis. Obstet Gynecol 1990;75:52--8. Silver HM, Sperling RS, St. Clair PJ, Gibbs RS. Evidence relating bacterial vaginosis to intraamniotic infection. Am J Obstet Gynecol 1989;161:808--12. Hamark B, Forssam L. Postabortal endometritis in chlamydia-negative women--- association with preoperative clinical signs of infection. Gynecol Obstet Invest 1991;31:102--5. Hillier SL, Martius J, Krohn M, Kiviat N, Holmes KK, Eschenback DA. A case-control study of chorioamnionic infection and histologic chorioamnionitis in prematurity. N Engl J Med 1988;319:972--8. Livengood CH III, Soper DE, Sheehan KL, et al. Comparison of once-daily and twice-daily dosing of 0.75% metronidazole gel in the treatment of bacterial vaginosis. Sex Transmit Dis 1999;26:137--42. Sobel J, Peipert JF, McGregor JA, et al. Efficacy of clindamycin vaginal ovule (3-day treatment) vs. clindamycin vaginal cream (7-day treatment) in bacterial vaginosis. Infect Dis Obstet Gynecol 2001;9:9--15. Sobel JD, Ferris D, Schwebke J, et al. Suppressive antibacterial therapy with 0.75% metronidazole vaginal gel to prevent recurrent bacterial vaginosis. Am J Obstet Gynecol 2006;194:1283--9. McDonald HM, O'Loughlin JA, Vigneswaran R, Jolley PT, Harvey JA, Bof A. Impact of metronidazole therapy on preterm birth in women with bacterial vaginosis flora (Gardnerella vaginalis): a randomised, placebo controlled trial. Br J of Obstet Gynaecol 1997;104:1391--7. Carey JC, Klebanoff MA, Hauth JC, et al. Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis. N Engl J Med 2000;342:534--40. Yudin MH, Landers DV, Meyn L, Hillier SL. Clinical and cervical cytokine response to treatment with oral or vaginal metronidazole for bacterial vaginosis during pregnancy: a randomized trial. Obstet Gynecol 2003;102:527--34. Caro-Paton T, Carvajal A, Martin de Diego I, Martin-Arias LH, Reguero A, Rodríguez PE. Is metronidazole teratogenic? A meta-analysis. Br J Clin Pharmacol 1997;44:179--82. Burtin P, Taddio A, Ariburnu O, Einarson TR, Koren G. Safety of metronidazole in pregnancy: a meta-analysis. Obstet Gynecol 1995;172:525--9. Piper JM, Mitchel EF, Ray WA. Prenatal use of metronidazole and birth defects: no association. Obstet Gynecol 1993;82:348--52. Lamont RF, Duncan SLB, Mandal D, Bassett P. Intravaginal clindamycin to reduce preterm birth in women with abnormal genital tract flora. Obstet Gynecol 2003;101:516--22. McGregor JA, French JI, Jones W, et al. Bacterial vaginosis is associated with prematurity and vaginal fluid mucinase and sialidase: results of a controlled trial of topical clindamycin cream. Am J Obstet Gynecol 1994;170:1048--59. Joesoef MR, Hillier SL, Wiknjosastro G, et al. Intravaginal clindamycin treatment for bacterial vaginosis: effects on preterm delivery and low birth weight. Am J Obstet Gynecol. 1995;173:1527--31. Vermeulen GM, Bruinse HW. Prophylactic administration of clindamycin 2% vaginal cream to reduce the incidence of spontaneous preterm birth in women with an increased recurrence risk: a randomised placebo-controlled double-blind trial. Br J of Obstet Gynaecol. 1999;106:652--7. Forna F, Gulmezoglu AM. Interventions for treating trichomoniasis in women. Cochrane Database Syst Rev 2003;2:CD000218. Pearlman MD, Yashar C, Ernst S, Solomon W. An incremental dosing protocol for women with severe vaginal trichomoniasis and adverse reactions to metronidazole. Am J Obstet Gynecol 1996;174:934--6. Kurohara ML, Kwong FK, Lebherz TB, Klaustermeyer WB. Metronidazole hypersensitivity and oral desensitization. J Allergy Clin Immunol 1991;88:279--80. Klebanoff MA, Carey JC, Hauth JC, et al. Failure of metronidazole to prevent preterm delivery among pregnant women with asymptomatic Trichomonas vaginalis infection. N Engl J Med 2001;345:487--93. Kigozi GG, Brahmbhatt H, Wabwire-Mangen F, et al. Treatment of Trichomonas in pregnancy and adverse outcomes of pregnancy: a subanalysis of a randomized trial in Rakai, Uganda. Am J Obstet Gynecol 2003;189:1398--400. Sobel JD, Chaim W, Nagappan V, Leaman D. Treatment of vaginitis caused by Candida glabrata: use of topical boric acid and flucytosine. Am J Obstet Gynecol 2003;189:1297--300. Vazquez JA, Peng G, Sobel JD, et al. Evolution of antifungal susceptibility among Candida species isolates recovered from human immunodeficiency virus-infected women receiving fluconazole prophylaxis. Clin Infect Dis 2001;33:1069--75. Peipert JF, Ness RB, Blume J, et al. Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease. Am J Obstet Gynecol 2001;184:856--64. Gaitán H, Angel E, Diaz R, Parada A, Sanchez L, Vargas C. Accuracy of five different diagnostic techniques in mild-to-moderate pelvic inflammatory disease. Infect Dis Obstet Gynecol 2002;10:171--80. Haggerty CL, Ness RB, Amortegui A, et al. Endometritis does not predict reproductive morbidity after pelvic inflammatory disease. Am J Obstet Gynecol 2003;188:141--8. Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929--37. Ness RB, Hillier SL, Kip KE, et al. Bacterial vaginosis and risk of pelvic inflammatory disease. Obstet Gynecol 2004;104:761--9. Walker CK, Workowski KA, Washington AE, Soper D, Sweet RL. Anaerobes in pelvic inflammatory disease: implications for the Centers for Disease Control and Prevention's guidelines for treatment of sexually transmitted diseases. Clin Infect Dis 1999;28(Supp 1):S29--S36. Walker CK, Kahn JG, Washington AE, Peterson HB, Sweet RL. Pelvic inflammatory disease: metaanalysis of antimicrobial regimen efficacy. J Infect Dis 1993;168:969--78. Bevan CD, Ridgway GL, Rothermel CD. Efficacy and safety of azithromycin as monotherapy or combined with metronidazole compared with two standard multidrug regimens for the treatment of acute pelvic inflammatory disease. J Int Med Res 2003;31:45--54. Martens MG, Gordon S, Yarborough DR, Faro S, Binder D, Berkeley A. Multicenter randomized trial of ofloxacin versus cefoxitin and doxycycline in outpatient treatment of pelvic inflammatory disease: Ambulatory PID Research Group. South Med J 1993;86:604--10. Peipert JF, Sweet RL, Walker CL, Kahn J, Rielly-Gauvin K. Evaluation of ofloxacin in the treatment of laparoscopically documented acute pelvic inflammatory disease (salpingitis). Infect Dis Obstet Gynecol 1999;7:138--44. Witte EH, Peters AA, Smit IB, et al. A comparison of pefloxacin/metronidazole and doxycycline/metronidazole in the treatment of laparoscopically confirmed acute pelvic inflammatory disease. Eur J Obstet Gynecol Reprod Biol 1993;50:153--8. Bukusi EA, Cohen CR, Stevens CE, et al. Effects of human immunodeficiency virus 1 infection on microbial origins of pelvic inflammatory disease and on efficacy of ambulatory oral therapy. Am J Obstet Gynecol 1999;181:1374--81. Irwin KL, Moorman AC, O'Sullivan M, et al. Influence of human immunodeficiency virus infection on pelvic inflammatory disease. Obstet Gynecol 2000;95:525--34. Cohen CR, Sinei S, Reilly M, et al. Effect of human immunodeficiency virus type 1 infection upon acute salpingitis: a laparoscopic study. J Infect Dis 1998;178:1352--8. Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet 2000;356:1013--9. Nickel JC, Siemens DR, Nickel KR, Downey J. The patient with chronic epididymitis: characterization of an enigmatic syndrome. J Urol 2002;167:1701--4. Silverberg MJ, Thorsen P, Lindeberg H, Grant LA, Shah KV. Condyloma in pregnancy is strongly predictive of juvenile-onset recurrent respiratory papillomatosis. Obstet Gynecol 2003;101:645--52. De Panfilis G, Melzani G, Mori G, Ghidini A, Graifenberghi S. Relapses after treatment of external genital warts are more frequent in HIV-positive patients than in HIV-negative controls. Sex Transmit Dis 2002;29:121--5. Silverberg MJ, Ahdieh L, Munoz A, et al. The impact of HIV infection and immunodeficiency on human papillomavirus type 6 or 11 infection and on genital warts. Sex Transmit Dis 2002;29:427--35. Kamb ML. Cervical cancer screening of women attending sexually transmitted disease clinics. Clin Infect Dis 1995;20(Suppl 1):S98--S103. Saslow D, Runowicz CD, Solomon D, et al. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin 2002;52:342--62. Wright TC Jr, Cox JT, Massad LS, Twiggs LB, Wilkinson EJ. 2001 Consensus guidelines for the management of women with cervical cytological abnormalities. JAMA 2002;287:2120--9. Solomon D, Davey D, Kurman R, et al. The 2001 Bethesda System: terminology for reporting results of cervical cytology. JAMA 2002;287:2114--9. Conley LJ, Ellenbrock TV, Bush TJ, Chiasson MA, Sawo D, Wright TC. HIV-1 infection and risk of vulvovaginal and perianal condylomata acuminata and intraepithelial neoplasia: a prospective cohort study. Lancet 2002;359:108--13. Delmas M-C, Larsen C, van Benthem B, et al. Cervical squamous intraepithelial lesions in HIV-infected women: prevalence, incidence and regression. AIDS 2000;14:1775--84. Diamond C, Thiede H, Perdue T, et al. Viral hepatitis among young men who have sex with men: prevalence of infection, risk behaviors and vaccination. Sex Transmit Dis 2003;30:425--32. CDC. National, state, and urban area vaccination coverage among children aged 19--35 months---United States, 2004. MMWR 2005;54:717--21. CDC. Hepatitis Surveillance Report no. 60. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC; 2005. CDC. Hepatitis B vaccination among high-risk adolescents and adults---San Diego, California, 1998--2001. MMWR 2002;51:618--21. MacKellar DA, Valleroy LA, Secura GM, et al. Two decades after vaccine license: hepatitis B immunization and infection among young men who have sex with men. Am J Public Health 2001;91:965--71. CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 2001;50(No. RR-11). CDC. Recommendations for prevention and control of hepatitis C Virus (HCV) infection and HCV-related chronic diseases. MMWR 1998;47(No. RR-19). Ghosn J, Pierre-François S, Thibault V, et al. Acute hepatitis C in HIV-infected men who have sex with men. HIV Medicine 2004;5:303--6. Browne R, Asboe D, Gilleece Y, et al. Increased numbers of acute hepatitis C infections in HIV positive homosexual men; is sexual transmission feeding the increase? Sex Transmit Infect 2004;80:326--7. Hammer GP, Kellogg TA, McFarland WC, et al. Low incidence and prevalence of hepatitis C virus infection among sexually active nonintravenous drug-using adults, San Francisco, 1997--2000. Sex Transmit Dis 2003;30:919--24. Alary M, Joly JR, Vincelette J, Lavoie R, Turmel B, Remis RS. Lack of evidence of sexual transmission of Hepatitis C virus in a prospective cohort study of men who have sex with men. Am J Public Health 2005;95:502--505. Roy KM, Goldberg DJ, Hutchinson S, Cameron SO, Wilson K, MacDonald L. Hepatitis C virus among self declared non-injecting sexual partners of injecting drug users. J Med Virol 2004;74:62--6. CDC. Guidelines for laboratory testing and result reporting of antibody to hepatitis C virus. MMWR 2003;52(No. RR-3). Klausner JD, Kohn R, Kent C. Etiology of clinical proctitis among men who have sex with men. Clin Infect Dis 2004;38:300--2. Rompalo AM. Diagnosis and treatment of sexually acquired proctocolitis and proctocolitis: an update. Clin Infect Dis 1999;28(Suppl 1):S84--S90. Chosidow O. Scabies and pediculosis. Lancet 2000;355:819--26. Barkwell R, Shields S. Deaths associated with ivermectin treatment of scabies. Lancet 1997;349:1144--5. Varghese B, Maher JE, Peterman TA, Branson BM, Steketee RW. Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use. Sex Transmit Dis 2002;29:38--43. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. N Engl J Med 1997;337:1485--90. Kellogg N, Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics 2005;116:506--12. Havens PL, Committee on Pediatric AIDS. Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus. Pediatrics 2003;111:1475--89. * Regardless of history of condom use during exposure. † Providers should use a culture or test that has been cleared by the FDA or locally verified in accordance with applicable statutes. § The absence of a fourfold or greater titer for an infant does not exclude congenital syphilis. ¶ CSF test results obtained during the neonatal period can be difficult to interpret; normal values differ by gestational age and are higher in preterm infants. Values as high as 25 white blood cells (WBCs)/mm3 and/or protein of 150 mg/dL might occur among normal neonates; some specialists, however, recommend that lower values (i.e., 5 WBCs/mm3 and protein of 40 mg/dL) be considered the upper limits of normal. Other causes of elevated values should be considered when an infant is being evaluated for congenital syphilis. A woman treated with a regimen other than those recommended in these guidelines for treatment should be considered untreated. †† If the infant's nontreponemal test is nonreactive and the likelihood of the infant being infected is low, certain specialists recommend no evaluation but treatment of the infant with a single IM dose of benzathine penicillin G 50,000 units/kg for possible incubating syphilis, after which the infant should receive close serologic follow-up. §§ Some specialists would not treat the infant but would provide close serologic follow-up in those whose mother's nontreponemal titers decreased fourfold after appropriate therapy for early syphilis or remained stable or low for late syphilis. ¶¶ An association between oral erythromycin and infantile hypertrophic pyloric stenosis has been reported in infants aged <6 weeks who were treated with this drug. Infants treated with erythromycin should be followed for signs and symptoms of idiopathic hypertrophic pyloric stenosis (IHPS). * Data on use of other macrolides (e.g., azithromycin and clarithromycin) for the treatment of neonatal chlamydia infection are limited. The results of one study involving a limited number of patients suggest that a short course of azithromycin, 20 mg/kg/day orally, 1 dose daily for 3 days, may be effective. ††† The Bethesda System for Reporting Cervical/Vaginal Cytologic Results uses the terms "low-grade SIL" and "high-grade SIL" for abnormal results (199). Low-grade SIL encompasses cytological changes associated with HPV and mild dysplasia. High-grade SIL includes cytological changes associated with moderate dysplasia, severe dysplasia, and carcinoma in situ. Cytological results should be distinguished from histological results obtained from biopsy specimens. §§§ Assistance with postexposure prophylaxis decisions can be obtained by calling the National Clinician's Post-Exposure Prophylaxis Hotline (PEPLine), telephone: 888-448-4911. Terms and Abbreviations Used in This Report AIDS Acquired immunodeficiency syndrome IgE Immunoglobulin E ALT Alanine aminotransferase Ig Immune globulin anti-HBc Antibody to hepatitis B core antigen IgG Immunoglobulin G anti-HCV Hepatitis C antibodies IgM Immunoglobulin M ASC-US Atypical squamous cells of undetermined significance IM Intramuscularly BCA Bichloroacetic acid IUD Intrauterine device BV Bacterial vaginosis IV Intravenous or intravenously CBC Complete blood count KOH Potassium hydroxide CI Confidence interval LGV Lymphogranuloma venereum CIN Cervical intraepithelial neoplasia MAC Mycobacterium avium complex CLIA Clinical Laboratory Improvement Amendments MIC Minimum inhibitory concentration CNS Central nervous system MSM Men who have sex with men CSF Cerebrospinal fluid N-9 Nonoxynol-9 DFA Direct fluorescent antibody NAAT Nucleic acid amplification test DGI Disseminated gonococcal infection NGU Nongonococcal urethritis dL Deciliter Pap Papanicolaou DNA Deoxyribonucleic acid PCR Polymerase chain reaction EC Emergency contraception PEP Postexposure prophylaxis EIA Enzyme immunoassay PID Pelvic inflammatory disease ELISA Enzyme-linked immunosorbent assay PO By mouth EPT Expedited partner therapy PPV Positive predictive value FDA Food and Drug Administration QRNG Quinolone resistant Neisseria gonorrhoeae FTA-ABS Fluorescent treponemal antibody absorbed RNA Ribonucleic acid gG Glycoprotein G RPR Rapid plasma reagin GNID Gram-negative intracellular diplococci RT-PCR Reverse transcriptase polymerase chain reaction HAART Highly active antiretroviral therapy RVVC Recurrent vulvovaginal candidiasis HAV Hepatitis A virus SIL Squamous intraepithelial lesion HBIG Hepatitis B immune globulin STD Sexually transmitted disease HBsAg Hepatitis B surface antigen TCA Trichloroacetic acid HBV Hepatitis B virus TE Toxoplasmic encephalitis HCC hepatocellular carcinoma TP-PA Treponema pallidum particle agglutation HCV Hepatitis C virus VDRL Venereal Disease Research Laboratory HIV Human immunodeficiency virus VVC Vulvovaginal candidiasis HPV Human papillomavirus WB Western blot HSV Herpes simplex virus WBC White blood count IFA Immunofluorescence assay WSW Women who have sex with women Chairpersons: David Atkins, MD, Agency for Healthcare Research and Quality, Rockville, Maryland; Kimberly A. Workowski, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, and Emory University, Atlanta, Georgia. Presenters: Heidi Bauer, MD, California Sexually Transmitted Disease Control Branch, Oakland, California; Emily J. Erbelding, MD, Johns Hopkins University School of Medicine, Baltimore, Maryland; William M. Geisler, MD, Department of Medicine, University of Alabama, Birmingham, Alabama; Margaret Hammerschlag, MD, State University of New York, Downstate Medical Center, Brooklyn, New York; Peter Leone, MD, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Jeanne Marrazzo, MD, University of Washington, Harborview Medical Center, Seattle, Washington; Kenneth Hugh Mayer, MD, Brown University Medical School, Providence, Rhode Island; Pablo Sanchez, MD, University of Texas Southwestern Medical Center, Dallas, Texas; Bradley Stoner, MD, PhD, Washington University, St. Louis, Missouri; Anna Wald, MD, University of Washington, Harborview Medical Center, Seattle, Washington; George Wendel, MD, University of Texas Southwestern Medical School, Dallas, Texas; Karen Wendel, MD, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma; Harold C. Wiesenfeld, MD, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Moderators: Willard Cates, Jr., MD, Family Health International, Durham, North Carolina; King K. Holmes, MD, PhD, University of Washington, Harborview Medical Center, Seattle, Washington; David Martin, MD, Louisiana State University Medical Center, New Orleans, Louisiana. Rapporteurs: Hunter Handsfield, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, Atlanta, Georgia, University of Washington, Seattle, Washington; William McCormack, MD, State University of New York Health Science Center, Brooklyn, New York; Anne Rompalo, MD, Johns Hopkins School of Medicine, Baltimore, Maryland. Consultants: Michael Augenbraun, MD, State University of New York Health Science Center, Brooklyn, New York; Gail Bolan, MD, California Department of Health, Oakland, California; Carolyn Deal, PhD, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland; Kenneth H. Fife, MD, PhD, Indiana University School of Medicine, Indianapolis, Indiana; J. Dennis Fortenberry, MD, Indiana University School of Medicine, Indianapolis, Indiana; Edward Hook, III, MD, Department of Medicine, University of Alabama, Birmingham, Alabama; Franklyn Judson, MD, University of Colorado Department of Medicine and Preventive Medicine, Denver, Colorado; Alice A. Kraman, PharmD; Emory Healthcare, Atlanta, Georgia; Roberta B. Ness, MD, University of Pittsburgh Department of Medicine, Pittsburgh, Pennsylvania; Paul Nyirjesy, MD, Drexel University College of Medicine, Philadelphia, Pennsylvania; Jeffrey Peipert, MD, Women and Infants Hospital, Providence, Rhode Island; Jane R. Schwebke, MD, Department of Medicine, University of Alabama, Birmingham, Alabama; Mary Ann Shafer, MD, University of California, San Francisco Department of Medicine, San Francisco, California; David Soper, MD, Medical University of South Carolina, Charleston, South Carolina; Lawrence Stanberry, MD, PhD, University of Texas Medical Branch, Galveston, Texas; Heather Watts, MD, National Institute of Child Health and Development, National Institutes of Health, Bethesda, Maryland; Jonathan M. Zenilman, MD, Johns Hopkins Bayview Medical Center, Baltimore, Maryland. Liaison Participants: Joanne Armstrong, MD, Women's Health, Aetna, Sugar Land, Texas; James R. Allen, MD, American Social Health Association, Durham, North Carolina; Margaret J. Blythe, MD, American Academy of Pediatrics, Indianapolis, Indiana; Sherry R. Crump, MD, American College of Preventive Medicine, Atlanta, Georgia; Carolyn D. Deal, PhD, National Institutes of Health, Bethesda, Maryland; Jordon Dimitrakov, MD, PhD, American Urological Association, Boston, Massachusetts; Mark FitzGerald, MD, British Association for Sexual Health and HIV, Southampton, United Kingdom; Edward Harrison, National Commission on Correctional Health Care, Chicago, Illinois; Edward W. Hook, III, MD, Infectious Disease Society of America, Birmingham, Alabama; Michel Janier, MD, PhD, International Union Against Sexually Transmitted Infections Europe, Paris, France; Abe Macher, MD, HIV/AIDS Bureau, Rockville, Maryland; Francis J. Ndowa, MD, World Health Organization, Geneva, Switzerland; Jeffrey F. Peipert, MD, American College of Obstetricians and Gynecologists, Providence, Rhode Island; Kees A. Rietmeijer, MD, PhD, Denver Public Health Department, Denver, Colorado; Richard Rothman, MD, American College of Emergency Physicians, Baltimore, Maryland; David Soper, MD, Infectious Diseases Society for Obstetrics and Gynecology, Charleston, South Carolina; Litjen Tan, PhD, American Medical Association, Chicago, Illinois; Bruce Trigg, MD, National Coalition for Sexually Transmitted Disease Directors, Albuquerque, New Mexico; Julia Valderrama, MD, Pan American Health Organization, Washington, DC; Tom Wong, MD, Public Health Agency of Canada, Ottawa, Ontario, Canada; Miriam Zieman, MD, Association of Reproductive Health Professionals, Atlanta, Georgia. CDC, Division of Sexually Transmitted Disease Prevention Treatment Guidelines 2006 Project. Coordinator: Kimberly A. Workowski, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, and Emory University, Atlanta, Georgia. Project Managers: Donald F. Dowda, ORISE, Oakridge, Tennessee; Richard Voigt, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, Atlanta, Georgia. CDC Presenters: Joanna Buffington, MD, National Center for Infectious Diseases; Eileen Dunne, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, Atlanta, Georgia; Matthew Hogben, PhD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, Atlanta, Georgia; Emily Koumans, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, Atlanta, Georgia; Hershel Lawson, MD, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia; Catherine McLean, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), Atlanta, Georgia; Juliette Morgan, MD, National Center for Infectious Diseases, CDC, Atlanta, Georgia; Lori Newman, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, Atlanta, Georgia; Madeline Sutton, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, Atlanta, Georgia. CDC Consultants: Sevgi O. Aral, PhD, Stuart M. Berman, MD, John Douglas, MD, Susan J. DeLisle, Kathleen Ethier, PhD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, Atlanta, Georgia; Kevin Fenton, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, Atlanta, Georgia; John Moran, MD, National Immunization Program, CDC, Atlanta, Georgia; Julia Schillinger, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, Atlanta, Georgia. Support Staff: Valerie Barner, Winda Graves, Garrett Mallory, Deborah McElroy, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), CDC, Atlanta, Georgia; Eboney Walker, NAI Personnel, Washington, DC. Disclaimer All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices. Date last reviewed: 10/24/2006 HOME \| ABOUT MMWR \| MMWR SEARCH \| DOWNLOADS \| RSS \| CONTACT POLICY \| DISCLAIMER \| ACCESSIBILITY Morbidity and Mortality Weekly Report 1600 Clifton Rd, MailStop E-90, Atlanta, GA 30333, U.S.A and Human Services	cc/2021-04/en_middle_0068.json.gz/line1666
__label__wiki	0.551442	0.551442	Tania Sachdev Biography, Age, Height, Weight, Family, Caste, Wiki & More Updated On : August 19, 2017 Tania Sachdev Chess Player #78 \| Most Popular #39 \| Like 20 August, 1986 (Wednesday) in Pounds- 141.1 lbs Tania Sachdev Popularity on Social Media Tania Sachdev was born on 20th August 1986 in Delhi, India. She is an ace Indian Chess Player. Chess Grandmaster Tania Sachdev Wiki Link Tania Sachdev Complete Bio & Career Tania Sachdev won her first international title when she was just eight years old. Subsequently, she went on to win Woman Grandmaster title in 2005 and International Master Title in 2008. Tania’s Father Pammi Sachdev is a businessman while Mother Anju was a former Badminton player. Tania has two siblings, one elder sister Amrita Sachdev and one elder brother who is a professional Golfer. She fell in love with chess at the tender age of 6 when her elder brother gifted her a chess board. She was introduced to chess by her mother. First and foremost she won the World and Asian junior titles. Then she stood third in World under 12. Then came her biggest victory then, when she grabbed the gold medal in under 14 Commonwealth games. The biggest title that she has won thus far is Woman Grandmaster title which she won in 2005 and the International Master in the year 2008. She was conferred Arjuna Award for her contribution to Sports in India, in 2009. She is the eighth Indian Women Grandmaster joining the elite list which is full of the South Indian Players. RECEIPT YEAR RECEIPT FIELD Arjuna Award National Sports Award 2009 Chess Life's Important Dates Of Tania Sachdev Tania Sachdev Age, Birthday Facts and Birthday Countdown 34 years, 4 months, 28 days old age Tania Sachdev will turn 35 on 20 August, 2021. Only 7 months, 2 days, 3 hours, 21 minutes has left for her next birthday. Tania Sachdev Born On Wednesday Day of the Next Birthday Friday Tania Sachdev has celebrated the total number of 34 birthdays till date. See the analysis by days count and bar graph.	cc/2021-04/en_middle_0068.json.gz/line1667
__label__cc	0.568327	0.431673	Team Discmania’s Kyle Klein wins 2019 NextGen Championships Tour / Promotions Kyle Klein entered 2019 with a focused mind and his eyes set winning some notable disc golf tournaments. After taking down the 2019 US Amateur Disc Golf Championship in June, Klein looked for redemption at the Next Generation Tour Championships. In 2018, Klein finished in second behind Team Discmania’s Silas Schultz. As the NextGen Championships moved from Arizona to Austin, Texas, Klein was certainly one of the favorites going into the event. Klein shook off a slow start in the first round and soon took firm control of the tournament en route to the championship finish. After shaking off the first round, Klein really hit a groove in round two. “It was one of those rounds where everything was clicking and going right,” Klein says about his second round. “I just had to line it up and hit it. I didn’t have to try very hard to get it to do what I wanted it to do. It was just happening.” The highlight of the round was an ace for Klein that helped with the positive momentum. Klein says the ace was his first ever tournament ace, “In the first round, I hit the cage on that hole. I thought same disc, same shot and this one went in. I was having a good round up until that point and that made it even greater.” With the USADGC and NextGen titles to his name, Klein believes this is his best year in disc golf yet. He says it acme down to execution. He put in the work off the course and knows he had the skills to make it happen. Looking to next year, Klein says he wants to hit as many Disc Golf Pro Tour events as possible, make it to PDGA Pro Worlds, and return to the USDGC. Go-To Discs for Klein Throughout the tournament, Klein says he was reaching for the Swirly S-Line CD3, “It goes nearly as far as my DD3s but more controllable and straighter. The DD3 Cloud Breaker, of course, C-Line PD2s, and the new run of the Swirly S-Line FD. Klein actually used two different putters in the tournament. In the first three rounds, the cooler weather caused him to use the D-Line P2. Once things warmed up a bit, he switched to the Swirly P-Line P2 Imperial Eagle III.	cc/2021-04/en_middle_0068.json.gz/line1676
__label__wiki	0.680299	0.680299	> Auctions > Ancient, British and World Coins, Tokens, Jetons,... (2 & 3 April 2014) Ancient, British and World Coins, Tokens, Jetons, Medals and Books Live Online Auction with room bidding available at: Washington Mayfair Hotel W1J 5HE 2 April 2014, starting at 10:00 Browse Sale Free Digital Catalogue Jamaica, Authority of November 1758, Doubloon (valued at Five Po... Sold for £25,000 Italy, VENICE, Paolo Renier, gold Osella of 6 Zecchini, 1787, yr... South Africa, Thomas Burgers, Pattern Pond, 1874, by L.C. Wyon,... Australia, Victoria, Sovereign, 1886m, shield rev. (M 67; S 3854... Stephen (1135-1154), Penny, East Midlands variant, Tutbury, Walc... Greek Coinages, PTOLEMAIC KINGS OF EGYPT, Ptolemy II (285-246),... Greek Coinages, PTOLEMAIC KINGS OF EGYPT, Ptolemy III (246-221),... William and Mary (1688-1694), Five Guineas, 1691, elephant and c... Elizabeth I (1558-1603), Sixth issue, Pound, mm. key (over woolp... Charles II (1660-1685), Guinea, 1664, second bust, elephant belo... Charles I (1625-1649), Oxford mint, Unite, 1643, mm. plume with... Charles I (1625-1649), Pattern Broad or Halfcrown, 1630, by N. B... Victoria (1837-1901), Proof Crown, 1839, edge plain, 28.23g/12h... United States of America, Dollar, 1798 (Bowers/Borckhardt 122; B... Kings of East Anglia, Æthelweard (c. 845-c. 855), Penny, Dudda,... Charles I (1625-1649), Oxford mint, Half-Pound, 1642, mm. Oxford... Charles I and Henrietta Maria, an oval cast silver-gilt Royalist... Australia, Victoria, Sovereign, 1855, Sydney (M 360; KM. 2; F 9)... Oliver Cromwell, Crown, 1658/7 (ESC 10; S 3226). Early strike wi... Edward VII (1901-1910), Proof set, 1902, comprising Half-Soverei... George V (1910-1936), Crown, 1934 (ESC 374; S 4036). Extremely f... William IV (1830-1837), Sovereign, 1832, first bust (M 17; S 382... Victoria (1837-1901), Crown, 1847, edge undecimo (ESC 288; S 388... Named Collections James Francis Sazama James Sazama, known to all his friends and associates in numismatics as Jim, passed away at his home in Southern Pines, North Carolina, on 18 February 2011 after a courageous battle with cancer. He was 64 years old. One of nine children, Jim was born on 30 October 1946 in San Francisco. He graduated... The Late Jim Sazama Collection of Medieval Coins (Part XI) Allan Vayle Ever since I visited a boyhood friend in August 1960, whose kitchen table was littered with Lincoln head pennies, I have had an interest in numismatics. It was one thing to collect U.S. coinage and fill the Whitman folders, it was quite another to study the esoteric tokens that have been issued sinc... World Tokens from the Collection formed by Allan Vayle (Part II) Arthur Lainchbury British Coins from the Collection Originally formed by the late Arthur Lainchbury George Berry George Berry was born in Oldham, Lancashire on 18 October 1928, the younger of two sons of George Ingham Berry, a Congregational church minister who had seen service in the trenches in World War I, and his wife Ethel, nee Gill, a schoolteacher. In 1933 the family moved to the Liverpool suburb of Sea... Further Jetons from the Collection formed by the late George Berry Michael Ewing British Historical Medals from the collection formed by the late Michael Ewing Neil Beaton Countermarked Tokens from the Collection of Neil Beaton Raymond Brandon Coins, Tokens and Medals of the Caribbean from the late Raymond Brandon Collection Railroad Tallies of the USA from the late Raymond Brandon Collection Catalogue Status We are no longer accepting consignments for this auction. Please consult our auction calendar to find out about forthcoming Coins auctions. Lot Schedule Day 1: Lots 1 to 860 Day 2: Lots 861 to 1719 Saleroom Notices There are currently 12 saleroom notices for this auction. View Saleroom Notices	cc/2021-04/en_middle_0068.json.gz/line1679
__label__cc	0.734376	0.265624	选择您的网站个人银行服务个人银行星展丰盛理财中小企业银行企业及机构银行星展集团关于星展银行个人网银企业网银IDEAL 关于星展中国企业公民 DBS third-quarter net profit rises to SGD 1.41 billion, total income up 10% to record SGD 3.38 billion Print-frendly version Nine-month earnings increase 36% to SGD 4.31 billion SINGAPORE,HONG KONG,CHINA,INDIA,INDONESIA,TAIWAN,05 November 2018 - DBS Group delivered another healthy performance in third-quarter 2018 as loan growth, fee income trends and net interest margin progression were sustained. The business momentum propelled total income to a record SGD 3.38 billion, up 5% from the previous quarter and 10% from a year ago. It exceeded the earlier high in first-quarter 2018, when exceptionally buoyant markets and a property disposal gain had boosted non-interest income. The income growth drove net profit to SGD 1.41 billion, a 3% increase from the previous quarter. Net profit was 72% higher than a year ago, when accelerated allowances had been taken for weak oil and gas support service exposures. For the nine months, net profit increased 36% to SGD 4.31 billion. Total income grew 12% to SGD 9.94 billion, led by a 16% increase in net interest income and 8% rise in fee income. Specific allowances were one-fifth of a year ago as new non-performing asset formation declined. Return on equity improved from 9.4% to 12.4% due to a higher net interest margin, a normalisation of allowances and a more efficient capital base. Third-quarter total income up 10% from year ago Compared to a year ago, third-quarter net interest income grew 15% to SGD 2.27 billion from an increase in loan volumes and net interest margin. Loans expanded 8% to SGD 340 billion, led by consumer and non-trade corporate loans. Net interest margin rose 13 basis points to 1.86% in line with higher interest rates in Singapore and Hong Kong. Net fee income rose 1% to SGD 695 million as increases in a wide range of activities were offset by a two-thirds decline in investment banking fees. Card fees increased 33% to SGD 185 million from higher customer transactions and the consolidation of the retail and wealth management business of ANZ. Wealth management fees grew 7% to SGD 292 million as higher bancassurance income was moderated by lower investment sales income. Transaction service fees increased 5% to SGD 162 million from a 12% rise in cash management fees. Other non-interest income was 2% higher at SGD 407 million. Net trading income rose 34% to SGD 354 million as Treasury Markets trading gains improved from a low base; treasury customer income was also higher. The increase was offset by a 60% decline in net gains from investment securities to SGD 48 million. Expenses increased 18% to SGD 1.48 billion. Excluding a fiftieth-anniversary staff bonus and other non-recurring items, underlying expenses rose 15% and the cost-income ratio was 43%, in line with first-half 2018. ANZ accounted for six percentage points of the increase in expenses. Third-quarter total income up 5% from previous quarter Compared to the previous quarter, third-quarter net profit was 3% higher. A 5% increase in total income was partially offset by higher total allowances as there had been a specific allowance write-back in the previous quarter. Net interest income rose 2%. Non-trade corporate and consumer loans grew 2%, sustaining the momentum of previous quarters, while trade loans fell 6% as maturing exposures were not replaced due to unattractive pricing. As a result, overall loans increased 1% during the quarter. Net interest margin rose one basis point. While higher interest rates in Singapore and Hong Kong boosted net interest margin by four basis points, the impact was moderated by a lower net interest margin from Treasury Markets activities and by the full-period impact of Tier-2 capital issuances in the previous quarter. Fee income fell 2% as an increase in loan-related fees was offset by lower investment banking and wealth management fees. Other non-interest income was 49% higher as trading income increased 56% from the previous quarter’s weak performance. Underlying expenses rose 3%, below the 5% increase in total income. Profit before allowances rose 6%. Nine-month total income up 12% For the nine months, total income grew 12% to a new high of SGD 9.94 billion. With the cost-income ratio remaining stable, profit before allowances was 11% higher. Net interest income rose 16% to SGD 6.63 billion. Net interest margin increased 11 basis points to 1.85% in line with higher interest rates. Loans expanded 8%. Fee income increased 8% to SGD 2.15 billion as higher wealth management and card fees were moderated by lower investment banking fees. Other non-interest income fell 2% to SGD 1.17 billion as a 68% decline in net gains on investment securities was offset by a 14% increase in trading income and by a property disposal gain. By business unit, Consumer Banking / Wealth Management income rose 21% to SGD 4.20 billion from increases in all product categories led by deposits, investment products and cards. Institutional Banking income grew 8% to SGD 4.26 billion as income from cash management and treasury customer flows rose. Treasury Markets trading income declined 12% to SGD 580 million. Expenses increased 14% to SGD 4.30 billion. Excluding ANZ, they were 8% higher. The cost-income ratio was at 43%, in line with a year ago. Profit before allowances rose 11% to SGD 5.64 billion. Balance sheet remains strong Non-performing assets were stable at SGD 5.90 billion and the NPL rate was unchanged at 1.6% from the previous quarter. Total allowances of SGD 236 million for the third quarter brought the nine-month amount to SGD 505 million, with specific allowances at 18 basis points of loans. Allowance coverage was at 93% and at 174% after taking collateral into account. Deposits were 7% higher than a year ago and stable over the quarter at SGD 388 billion. The liquidity coverage ratio of 132% and the net stable funding ratio of 109% were both above the regulatory requirements of 100%. The Common Equity Tier-1 ratio declined 0.3% points from the previous quarter to 13.3% due to the interim dividend payout. The leverage ratio of 7.1% was more than twice the regulatory requirement of 3%. DBS CEO Piyush Gupta said, “Third-quarter business momentum was sustained amidst heightened geopolitical and economic headwinds. Year-to-date earnings per share is the highest in our history while return on equity is the best in more than a decade. As we celebrate our fiftieth anniversary, we are pleased to be named Best Bank in the World by Global Finance and World’s Best Digital Bank by Euromoney. We are well positioned to continue capitalising on Asia’s long-term prospects while navigating short-term uncertainties.” DBS is a leading financial services group in Asia, with over 280 branches across 18 markets. Headquartered and listed in Singapore, DBS has a growing presence in the three key Asian axes of growth: Greater China, Southeast Asia and South Asia. The bank's "AA-" and "Aa1" credit ratings are among the highest in the world. Recognised for its global leadership, DBS has been named “Best Bank in the World” by Global Finance. The bank is at the forefront of leveraging digital technology to shape the future of banking, having been named “World’s Best Digital Bank” by Euromoney. In addition, DBS has been accorded the “Safest Bank in Asia” award by Global Finance for ten consecutive years from 2009 to 2018. 所有新加坡台湾中国印度印尼香港区域性 DBS Annual Report Click here to read DBS' 2018 Annual Report - Best Bank in the World. View our previous Annual Reports 关于星展个人银行服务费表个人帐户章则及条款星展银行（中国）有限公司对公业务标准费率表咨询星展专家将有工作人员与您联系查找最近的一家分行	cc/2021-04/en_middle_0068.json.gz/line1680
__label__wiki	0.986867	0.986867	Northbound I-95 was closed near Newark for about two hours late Friday into Saturday after a trailer hauling a race car caught fire. The fire was reported at 10:34 p.m., near the railroad tracks just north of Del. 896, emergency dispatch officials told The News Journal. The race car was engulfed in the fire, fed by the race car's fuel. Crews from Aetna Hose Hook & Ladder Company of Newark and Christiana Fire Company responded, along with the Delaware National Guard's foam unit, emergency response officials said. Delaware State Police assisted with traffic, Master Cpl. Gary E. Fournier said. No information was available about the race car, its hauler or where they were headed at the time of the fire. The roadway opened up at about 12:30 a.m. after heavy delays stretching back to the state line. Contact robin brown at (302) 324-2856 or rbrown@delawareonline.com . Find her on Facebook and follow her on Tw itter @rbrowndelaware. Jobs Cars Homes Classifieds Education 10Best Reviewed Reach Local © 2021 www.delawareonline.com. All rights reserved.	cc/2021-04/en_middle_0068.json.gz/line1688
__label__wiki	0.855208	0.855208	Digital Europe Foreign and security policy Institutions and democracy Podcast "EU to go" Vacancies and Stipends Newsletter and Mailinglist Visiting the Centre Go to the Hertie School Policy areas Show subnavigation Back Close navigation About Show subnavigation News Show subnavigation Six questions to… #ArmchairEurope People Show subnavigation Prof. Dr. Christine Reh Dean of Graduate Programmes and Professor of European Politics Email: reh[at]hertie-school[dot]org Mirjam Schlechter Assistant to the Dean of Graduate Programmes Phone: +49 (0)30 259 219 -152 Email: schlechter[at]hertie-school[dot]org Contact our press office Email: pressoffice[at]hertie-school[dot]org Christine Reh is Dean of Graduate Programmes and Professor of European Politics at the Hertie School. Her work focuses on the European Union’s institutions, politics and legitimacy, with a particular interest in decision-making processes, informal governance and politicisation. Her current research explores the impact of national (electoral) politics on supranational actors and law-making. She previously held academic positions at the College of Europe in Bruges (Belgium) and at University College London, where she maintains an affiliation with the Department of Political Science. She is also an editorial board member of the Journal of European Public Policy. Reh received her PhD from the European University Institute in Florence (Italy) in 2007. Google Scholar Monday, 4:00 - 5:00 pm (Room 2.50) Please make an apointment with Mirjam Schlechter. Latest news and media appearances Hertie School announces new Master of Data Science for Public Policy programme Academic year 2020/21: A message from the leadership University life at the Hertie School during COVID-19 Events and executive training 07-11-19 \| 6:15 pm - 7:30 pm Adrienne Héritier - 2019 Michael Endres Prize recipient: Quo vadis, Europa? 25-04-19 \| 2:00 pm - 3:00 pm Webinar for prospective students: Moving to Berlin 27-10-18 Trust and the public good: Strengthening the confidence in governments, experts and policy makers When Politics Prevails: Parties, Elections And Loyalty In The European Parliament EU Actors under pressure: politicisation and depoliticisation as strategic responses Influencing Brussels: The “European Green Deal” in real time \| GRAD The European Union, globalisation and the state \| E1298 Jacques Delors Centre \| Hertie School Phone +49 (0)30 259219-107 info[at]delorscentre[dot]eu	cc/2021-04/en_middle_0068.json.gz/line1689
__label__wiki	0.816568	0.816568	Colorado sees drop in new COVID-19 cases after… Colorado sees drop in new COVID-19 cases after 6 weeks of increases State also seeing decline in hospitalizations and rate at which coronavirus tests come back positive By Jessica Seaman \| jseaman@denverpost.com \| The Denver Post PUBLISHED: August 3, 2020 at 6:54 p.m. \| UPDATED: August 4, 2020 at 7:42 a.m. The number of new coronavirus cases in Colorado dropped 18% last week, marking the first week-over-week decline since confirmed infections began increasing in the state a month-and-a-half ago. The state health department recorded 3,243 new COVID-19 cases between July 27 and Sunday, down from 3,961 cases the prior week. The drop in new cases comes after Colorado saw infections rise for six consecutive weeks following a long decline, as more residents left their homes while the state reopened, which can increase the chances of exposure to the novel coronavirus. Colorado also is seeing a decline in hospitalizations and the rate at which COVID-19 tests come back positive. The former is an indicator of the severity of the pandemic, while the latter provides insight into the transmission of the disease within the community. Despite the decline in confirmed cases, last week’s total remains elevated and is on the same level as the week of July 13, when there were 3,299 newly confirmed cases. Before COVID-19 infections started increasing again, the state recorded just 1,135 new cases the week of June 8, according to data from the Colorado Department of Public Health and Environment. Gov. Jared Polis last week said he thinks Colorado is starting to see the effects of the statewide order requiring individuals to wear masks when in public indoor spaces, along with his directives to close bars again and set the last call for alcohol at 10 p.m. for restaurants and other establishments that can stay open because they also serve food. “We can certainly say we’re no longer seeing that same rate of increase that we saw several weeks ago,” the governor said during a briefing. “And we’re very hopeful that in the days ahead that these extra measures that Coloradans are taking to stay safe will pay off in terms of making all of our lives a little bit safer and allowing for more robust economic recovery.” Hospitalizations, which increased in late June and in July, also continue their two-week decline. On Monday, the state’s hospitals were treating 209 people with COVID-19, which was down from 221 the previous day, according to the Colorado Hospital Association. Following a long decline that started in late April, Colorado’s daily coronavirus hospitalizations began inching upward from a low of 126 in late June, peaking at 275 in late July — never approaching the mid-April high of 888. The positivity rate for Colorado’s COVID-19 tests, which began climbing again in early June and slid slightly above 5% in mid-July, also has dropped since that summer peak. As of the week of July 26, the number of tests coming back positive was 4.04%, according to the state health department. Parents struggle as schools reopen amid coronavirus surge How did we get back here? Colorado’s COVID-19 cases near peak levels, though deaths remain low COVID-19 cases hit new weekly high in Colorado, but virus’ trajectory unclear The World Health Organization advises the rate of coronavirus tests coming back positive, which indicates how much the virus is spreading in a community, should be 5% or lower for at least two weeks before governments proceed with reopenings. Nineteen more people were confirmed Monday to have died recently from COVID-19, bringing the number of people killed by the virus in Colorado to 1,710. Since March, a total of 1,844 people have died with the disease in their system, though not necessarily directly due to the virus, according to state health department. Subscribe to bi-weekly newsletter to get health news sent straight to your inbox. Colorado Department of Public Health and Environment coronavirus in Colorado Governor Jared Polis Jared Polis Jessica Seaman \| Health reporter Jessica joined the Denver Post as a health reporter in 2018. She covers various topics, including mental health, hospitals and health care costs. She also writes The Post's health newsletter Checkup Denver. jseaman@denverpost.com Follow Jessica Seaman @jessicaseaman On Edge: Veteran paramedic grapples with post-COVID toll on his lungs and his sense of self 39,000 Denver students attend schools that lack adequate mental health staff, study finds “This is not a game”: Global COVID-19 death toll hits 2 million	cc/2021-04/en_middle_0068.json.gz/line1690
__label__wiki	0.70754	0.70754	Adam Fitch: Analyzing the esports winners at The Game Awards 2020 Published: 11/Dec/2020 19:12 Updated: 6/Jan/2021 11:56 by Adam Fitch Colin Young-Wolff/Riot Games The Game Awards is an annual awards show, celebration, and launchpad for the entirety of the gaming industry — an entertainment sector that is larger than the common person may realise. With celebrities in attendance, new games being announced, and everything in between, it’s fair to say that the night is a big deal. Now, esports is a niche of gaming. As a result, naturally, it’s smaller. In fact, in most cases, esports is simply just a marketing activity for many games developers. Valve don’t have any meaningful input with CS:GO beyond the two annual Majors, for example, whereas Riot Games have gone all-in on esports as a means of promoting League of Legends and ensuring it stays in the conversation year-round. At this year’s iteration of The Game Awards, esports decently represented in terms of the categories it was involved in; five of almost-30 awards that were handed out on November 10 — albeit virtually — were focused on competitive gaming. So, as we tend to do in esports, it’s time to reflect on how we’re being represented and received by those outside of our ever-growing industry. Were the right winners chosen? Let’s take a look. The Game Awards still went ahead this year, only virtually. Also, if you want to see the entire list of categories and subsequent winners from this year’s awards, you can find them here. Best Esports Game League of Legends (Riot Games) – WINNER It’s hard to argue against League of Legends in this category, truthfully. Not only is it the biggest esport in terms of viewership, but it also has the most comprehensive global structure and a player count that’s always impressive. Almost everything is in place for the MOBA to thrive. Specifically in 2020, I feel there was a somewhat unfair advantage in Riot’s corner. With events and travel restricted on a global basis for much of the year, only one of the major tentpole events was carried out in-person: the League of Legends World Championship. Not only is the event an absolute behemoth in any normal circumstance, it stood out from the crowd more than ever due to the circumstances. However, this is down to Riot’s determination and immense planning to make it happen so they can’t be discredited on that front. They took a chance and it paid off tenfold. Valorant is too new, having only just had its first set of major events in First Strike, Modern Warfare wasn’t one of the good Call of Duty instalments by any means, CS:GO is facing plenty of obstacles and has been for a little while, and Fortnite hasn’t done anything particularly noteworthy in 2020. This is a deserved win for League of Legends esports. Best Esports Athlete Ian ‘Crimsix’ Porter / Call of Duty Heo ‘Showmaker’ Su / League of Legends – WINNER Kim ‘Canyon’ Geon-bu / League of Legends Anthony ‘Shotzzy’ Cuevas-Castro / Call of Duty Matthieu ‘ZywOo’ Herbaut / CS:GO Brush off your controllers & stretch those fingers, the Best Esports Player is Showmaker!! 🏆 #TheGameAwards pic.twitter.com/b7etVtWBMh — The Game Awards (@thegameawards) December 11, 2020 I’m not going to pretend as if I’m entirely neutral here, I’m an FPS man at heart. Nonetheless, it’s undeniable that both Showmaker and Canyon had a great 2020 — finishing the calendar year off nicely with a win at LoL Worlds as teammates in DAMWON Gaming. However, as rife with MVP picks at tournaments, we tend to (often-wrongly) believe that a player who won the tournament has to be up for the honour. I don’t think that should always the case. They both placed fifth in the LCK Spring regular season and fourth in the Spring playoffs before going on to LCK Summer and Worlds. That has to be taken into account, by my money. Neither Shotzzy or Crimsix of the Dallas Empire went on a dominant run throughout the entirety of the inaugural Call of Duty League season, to be fair, and ZywOo continued to prove himself as a contender for the title of ‘Best player in CS:GO’ despite having a string of underwhelming event results himself with Team Vitality. I think this is a hard category to call, you’d have to compare the impact of the players to truly judge them against each other, and we only see what happens in-game. Read More: Crimsix clarifies comment on Dallas Empire being his “best team ever” I would choose Crimsix, the player with the most event wins in Call of Duty history, because he proved on multiple occasions that he isn’t slowing down — all whilst mentoring two less-experienced players. After being a large part of dynasties with both Complexity Gaming and OpTic Gaming, he’s on the way to affirming that he has what it takes to forge a third. Best Esports Team G2 Esports / League of Legends – WINNER Team Secret / Dota 2 Dallas Empire don’t deserve the award, G2 Esports dominated in Europe but fell short internationally, San Francisco Shock won when it mattered but didn’t dominate as much as they could have, and DAMWON Gaming started off rough but got going as 2020 progressed. Team Secret went on an unreal run in Dota 2, claiming eight consecutive trophies over the course of four months, and they’re my pick because of just how convincing they were for such a large portion of the calendar. I know G2 are lovable and full to the brim of personality whether they win or lose, but it’s not all about that. Nonetheless, they provide European League of Legends fans with hope, this likely worked in their favour and I understand it. We've got a whole lotta Esports wins here on #TheGameAwards! Congratulations to everyone! 🎉 pic.twitter.com/rbtiIoNdR7 Best Esports Event BLAST Premier: Spring 2020 European Finals (CS:GO) League of Legends World Championship 2020 – WINNER As I mentioned earlier, Riot Games’ risk paid off with the bubble for Worlds. They even managed to have a crowd for the grand finals and this is an aspect of live events that cannot be understated. BLAST have done a great job introducing new features while teams were playing online this year, but I simply don’t see how any of the events can compare to the grand finale of League of Legends esports’ 2020 season. It’s always a spectacle, but it really got a boost from being one of the rare offline events since restrictions were placed. Read More: DAMWON players reveal which League champions they want Worlds skins for Best Esports Host Eefje ‘Sjokz’ Depoortere – WINNER Alex ‘Machine’ Richardson Alex ‘Goldenboy’ Mendez James ‘Dash’ Patterson Jorien ‘Sheever’ van der Heijden Last but not least by any means is Best Esports Host. This role is pivotable in any broadcast — somewhat managing the flow of the event, building up storylines to make matches even better, and setting up their analyst colleagues. All five of the finalists here are great and most of them should have been in with a shout to receive the trophy, but I think The Game Awards made the right choice. Being able to competently host events in four different languages, always managing to put on a good show, and even proving herself once again in CS:GO at the top of the year, Sjokz is the full package when it comes to hosting. Machine, Goldenboy, Dash, and Sheever have all done commendable work throughout 2020, that’s for sure, but I cannot argue with this particular choice by any means. Fitz responds to backlash for using a “slur” on Minecraft stream Epic Games sues Apple & Google in UK over Fortnite removals Published: 16/Jan/2021 1:28 by Theo Salaun Epic Games / Pexels, @Ekaterina Following litigation over Fortnite’s app store removals by Apple and Google in the United States of America, Epic Games have officially mounted lawsuits against both tech companies in the United Kingdom, as well. In August 2020, Epic Games added their own payment process to Fortnite’s mobile offerings so that Apple and Google’s cellphone and tablet users could purchase in-game items at a discounted price. This discount was specifically enabled by the new process, which bypassed each company’s transaction fees. Unsurprisingly, as the payment method was in direct violation of both the App Store and Play Store’s Terms of Services, each company subsequently removed Fornite from their offerings. And, expecting this, Epic Games responded by launching lawsuits against the companies in the U.S. and Australia. Now, the makers behind the world’s most popular third-person battle royale have tripled down and mounted legal action against both tech giants in the U.K. Citing violations of competition laws, Epic Games’ legal case in the U.K. is very similar to the ones already made in other countries. And, immediately contested, Apple and Google’s responses have proved similar, as well. Fortnite’s Crew subscription service means even more payments for Epic Games. As discussed by BBC News, Epic have officially submitted documents to the Competition Appeal Tribunal in the UK. The allegations suggest a monopolistic abuse of power by each company that centers around competitive restrictions to app store and payment processing options, as well as unfair payment fees. Read more: Epic Games tease more content coming for Fortnite Crew Typically, those fees come at about 30 percent of all purchases, although exact figures differ depending on company and app. Fortnite is obviously one of the biggest games in the entire world, so almost one-third of their sales on mobile means hefty earnings. But, like their other lawsuits, Epic allege that this is about more than their own profits. The company demands that Apple and Google begin allowing software developers to institute their own payment-processing systems and options to be downloaded outside of the App and Play stores. Fortnite has always delighted its fanbase with purchasable cosmetics. So far, Apple and Google have both replied similarly in the U.K. situation, claiming that they are open to reintroducing Fortnite to their mobile stores but that they deny any violation of competitiveness. Read more: Dangerous Fortnite Season 5 jetpack exploit lets you float forever Dexerto will continue to monitor the legal cases in each country, providing updates whenever these prolonged legal disputes begin reaching their conclusions.	cc/2021-04/en_middle_0068.json.gz/line1693
__label__wiki	0.611314	0.611314	What are community mental health block grants? What are they designed to accomplish? Why do rehabs offer these grants - or accept them? How can they help you find the recovery that you need? What Are Community Mental Health Block Grants? Community mental health block grants refer to the funding that is provided to ensure that members of the community and the general public can access the mental health treatments and rehabilitation services that they require but might have been able to pay for without these grants. A number of federal, state, local, and jurisdictional bodies provide these grants to ensure that more people can access treatment for psychological disorders like post-traumatic stress disorder, anxiety, depression, and other mental health issues - whether they are linked to ongoing substance abuse or not. Additionally, these community mental health block grants are designed to support a variety of public psychiatric health services while encouraging the learning of and development of more cost effective and creative systems of care at the community level. By so doing, they effectively ensure that more people with a serious mental health disorder can get treatment. Why Rehab Offer Community Mental Health Block Grants Community mental health block grants are dedicated to ensure that the public health care system involved in the treatment of poor mental health all across the country are improved. To this end, the purpose of these grants is to support and build public psychological health systems at the community level to help both SEDs (children with severe emotional disturbances) and SMIs (adults with serious mental illnesses) overcome their mental health conditions. Rehabs also work with governmental and non-governmental donors to ensure that these grants are used for the right purposes - to help those who might otherwise not have received the mental health care they need. Who Would Benefit From Community Mental Health Block Grants? community mental health block grants targets people with have mental health disorders and issues that affect their health and wellness, performance, and day to day functioning - as well as those who have co-occurring substance use disorders. Drug and Alcohol Treatment Programs That Offer Community Mental Health Block Grants By State: Other Drug and Alcohol Rehab Services: Drug and Alcohol Hospital Services Inpatient Hospital Programs Hospital Inpatient Detoxification Programs General Hospital (including VA Hospitals) Partial Hospitalization/Day Treatment Programs Drug and Alcohol Counseling Services Rehab Programs That Offer Group Counseling Treatment Programs That Offer Individual Counseling Rehab Centers That Offer Family Counseling Treatment Centers That Offer Marital/Couples Counseling Rehab Facilities That Offer Substance Abuse Counseling approach Treatment Facilities That Offer Trauma-related Counseling Drug and Alcohol Rehabs That Offer Diet and Exercise Counseling Drug and Alcohol Programs By Treatment Of Specific Drugs Alcohol Rehab Facilities Heroin Rehab Centers Cocaine Treatment Programs OxyContin Rehab Centers Meth Rehab Facilities Crack Treatment Facilities Adderall Rehabilitation Centers Benzodiazepines Treatment Programs Xanax Rehab Centers Prescription Drug Rehab Facilities Codeine Treatment Programs Fentanyl Rehab Facilities Hydrocodone Treatment Centers Percocet Rehab Programs Vicodin Treatment Facilities Ecstasy Treatment Programs Valium Rehab Centers Ritalin Treatment Centers Morphine Rehab Centers Roxycodone Treatment Centers Ambien Treatment Facilities Opioid Rehab Programs	cc/2021-04/en_middle_0068.json.gz/line1698
__label__wiki	0.804409	0.804409	Home » Prevalence of Alcohol, Tobacco, and Other Drug Use Among Youth, England Prevalence of Alcohol, Tobacco, and Other Drug Use Among Youth, England "The survey sample represents an estimated population of around 3.0 million young people aged between 11 and 15 in England. Findings from this survey indicate that in England in 2011 around 140,000 young people aged between 11 and 15 were regular smokers, around 360,000 drank alcohol in the last week, and around 180,000 had taken drugs (including glue, gas and other volatile substances) in the last month. "Pupils aged 11 to 15 were more likely to have drunk alcohol at least once (45%) than to have tried smoking (25%) or taking drugs (17%). The proportion of pupils who had done at least one of these increased with age from 20% of 11 year olds to 80% of 15 year olds. "Less than half of pupils who had tried smoking, drinking or drug use had done so recently. 12% of 11 to 15 year olds had drunk alcohol in the last week, 8% had smoked in the last week and 6% had taken drugs in the last month. "Several factors were strongly associated with smoking, drinking and drug use. If a pupil had done one of these, he or she had an increased likelihood of having done one or both of the others. All three became increasingly prevalent with age. Other characteristics, such as sex and ethnicity, were not consistent predictors of whether pupils were more likely to smoke, drink or take drugs." Fuller, Elizabeth (Ed.), "Smoking, drinking and drug use among young people in England in 2011" (London, England: NHS Health and Social Care Information Centre, July 26, 2012), p. 11. http://www.hscic.gov.uk/catalo... Addiction and Dependence Capital Punishment for Drug Offenses Cocaine, Crack, and Coca Crime, Arrests & Law Enforcement Dark Net Drug Markets & Cryptomarkets Demand Reduction Diversion of Drugs Driving and Drugs Drug Courts Drug Testing (Employment) Drug Testing (Schools) Drug Testing Overview Drug Use Estimates: Prevalence and Trends Drugs & the Correctional System Entheogens & Psychedelics Gateway Hypothesis Heroin Assisted Treatment Injection Drug Use and HIV Injection Drug Use, Race, and HIV Mandatory Minimums Marijuana Policies & Policy Reform Mental Health Medications (Psychotropics) Mental Health, Co-Occurring Disorders and Dual Diagnosis Mushrooms (Psilocybin) Netherlands vs US Opioid Overdose Crisis Opioid Substitution Treatment Pregnancy and Substance Use Prescription Drug Monitoring Programs Prevalence of Substance Use Prisons & Race Prisons and Drugs Prisons and Jails Overview Psilocybin (Magic Mushrooms) Race & Prisons Race and Injection Drug Use Recovery and Social Reintegration Supervised Consumption Facilities and Overdose Prevention Sites Supply Reduction Syringe Service and Needle Exchange Programs Testing for Alcohol and Other Drugs Tobacco & Nicotine Treatment for Substance Use Disorders Women & The Drug War Young People and Drugs Regions Outside the US Central Asia and Eastern Europe Copyright © 2021, Common Sense for Drug Policy	cc/2021-04/en_middle_0068.json.gz/line1699
__label__wiki	0.978975	0.978975	West Virginia Seizes Control Of Its Third School District By Bess Keller — June 21, 2000 3 min read The West Virginia board of education took control of a local school system early this month, declaring that the Lincoln County district had made insufficient progress toward correcting major problems cited in a report last October. The June 8 takeover marks the third time the state has intervened in the operation of local district. West Virginia officials said that financial and hiring practices, curriculum and instruction, and facilities in the rural, 4,100-student district remained deficient, despite improvements made in the past seven months after a state agency report triggered help from education department consultants. Lincoln’s per-capita income is the fourth-lowest among the state’s 55 counties, and one of the 100 lowest in the nation. “It is always difficult to make this decision to intervene in the operation of a school system,” state board President Cleo P. Matthews said in a written statement. “But we believe this is necessary to bring high standards and quality education to the system.” Under the state’s takeover law, the board removed all major decisions from the hands of the five-member local school board. State Superintendent David Stewart also ousted district Superintendent Peggy Adkins and named as her replacement William K. Grizzell, the superintendent of West Virginia’s Nicholas County district, effective July 1. Ms. Adkins was reassigned to her former position as the principal of one of Lincoln County’s four high schools. Rate of Improvement District officials defended their work last week, citing improvements in student test scores, a drop in the number of teacher grievances, and a new facilities plan. “We made great progress under [Ms. Adkins’] superintendency, but we couldn’t do it quick enough” for the state, said Charles McCann, a 36-year veteran of the system who has also served as its superintendent. Mr. McCann oversaw hiring for the system, an area that came in for heavy criticism in the October report and again in the follow-up report. “We found a lot of issues with personnel selection, assessment, and the use of interim positions—what appeared to us as a subversion of the personnel laws of the state,” said Kenna Seal, the executive director of the state’s Education Performance Audits Office. Officials of the 2-year-old office, which conducts school districts’ accreditation audits, visited Lincoln County before its normally scheduled time at the direction of the state school board, which had received many complaints about the system, Mr. Seal said. He added that the May visit revealed additional sloppy bookkeeping practices, while problems with curriculum, such as the lack of Advanced Placement courses, had not been corrected. Educators and education advocates generally welcomed the takeover. “When I heard the takeover had happened, I cried with relief,” said Anita Mitter, who represents Lincoln County teachers for the West Virginia Education Association, the state’s largest teachers’ union and a National Education Association affiliate. “The main thing we have to do is get the politics out of the school system.” Linda Martin, the education coordinator of Challenge West Virginia, a statewide group that supports small, community schools, agreed. “We’re hopeful because it couldn’t have gotten worse,” she said. “Lincoln County has been the pits for years.” The 1982 school finance ruling by state Judge Arthur M. Recht that has prompted almost two decades of efforts to improve West Virginia schools arose from a case filed on behalf of Lincoln County students. Daniel F. Hedges, a lawyer for the students who is continuing to push for an elimination of state funding disparities, agreed with Ms. Martin. But he added that the state was to blame for many of the troubles. For example, the state has balked at the district’s proposals to keep any of its four small high schools open, refusing to pay for renovations and instead offering money only for a single new school, Mr. Hedges said. In the meantime, he added, operating the four, increasingly run-down schools has proved to be a costly and wasteful proposition. “Everybody has the right to complain about what was delivered out there ... but the district does have the worst facility configuration in the state,” he said. Hoping in part to stave off the takeover, the district board adopted a plan calling for a single high school on June 5. The state board last intervened in a district’s operation in 1998, when it took control of most functions in Mingo County, to the south of Lincoln on the Kentucky border. The board also forced a takeover in adjacent Logan County in 1992, but returned full control there in 1996. Bess Keller Senior Contributing Editor, Education Week Bess Keller is a senior contributing editor for the opinion section of Education Week. Takeovers West Virginia A version of this article appeared in the June 21, 2000 edition of Education Week as West Virginia Seizes Control Of Its Third School District Maria Casinos/iStock/Getty School & District Management Student Mental Health and Learning Loss Continue to Worry Principals Denisa R. Superville, January 15, 2021 School & District Management Opinion A Road Map for Education Research in a Crisis Here are five basic principles for a responsible and timely research agenda during the COVID-19 pandemic. Robin J. Lake J.R. Bee for Education Week School & District Management 1,000 Students, No Social Distancing, and a Fight to Keep the Virus Out A principal describes the "nightmare" job of keeping more than 1,000 people safe in the fast-moving pandemic. Denisa R. Superville Dixie Rae Garrison, principal of West Jordan Middle School in West Jordan, Utah, would have preferred a hybrid schedule and other social distancing measures. Courtesy of Dixie Rae Garrison School & District Management A School Leader Who Calls Her Own Shots on Battling the Coronavirus A charter school founder uses her autonomy to move swiftly on everything from classroom shutdowns to remote schooling. Nigena Livingston, founder and head of school at the URBAN ACT Academy in Indianapolis, makes swift decisions in responding to the threat of COVID-19 in her school community. Courtesy of Nigena Livingston School & District Management A COVID-19 Lull Gives Way to ‘Borderline Insanity’ When the number of cases started to rise steeply, a school community hammered out a routine. Then a basketball player tested positive. Andy McGill, K-12 assistant principal at West Liberty-Salem Local School District in Ohio, includes coronavirus response among his administrative duties. Courtesy of Andy McGill	cc/2021-04/en_middle_0068.json.gz/line1703
__label__cc	0.74089	0.25911	Where To Eat In Ambleside Ambleside is bursting with great places to eat and drink: the town has become something of a destination for foodies over the past few years, and is a vibrant hub of restaurants, bars, pubs and cafes. From cosy daytime eateries, to sophisticated fine dining, here are our top eleven places to eat in Ambleside. Lake Road Kitchen An award winning, fine dining restaurant in the heart of Ambleside, a visit to Lake Road Kitchen makes for a truly memorable experience. After a stint on MasterChef in 2005, the restaurant’s chef and owner James Cross worked in some of the world’s finest kitchens before settling in the Lake District to open Lake Road Kitchen in 2014. The result is an intimate space in which the food takes centre stage: the focus is very much on quality ingredients and local produce, as well as flavours from Northern Europe. The menu is constantly changing and evolving; as a result, there are no sample menus online. Instead, guests are invited to experience a five, eight or twelve course tasting menu which changes as regularly as every day. It’s a truly special dining experience which you won’t forget in a hurry. A definition of Wabi Sabi I found is “finding beauty in uncertain times” and I think we could all benefit from some of that right now. Wabi Sabi is a fantastic Japanese restaurant on Compston Road. They also have a little shop selling handmade Gyoza, sushi, ramen kits, sake cocktails and Japanese inspired cakes. Great food, great ambiance – what’s not to like! They are open for lunch and dinner – booking is essential. Thinking about a winter break? Check rooms and availability The Priest Hole Restaurant & Tea Rooms The Priest Hole Restaurant and Tea Rooms are part of Kelsick Old Hall, one of the oldest buildings in the beautiful village of Ambleside with many original features and a lovely atmosphere. There is also a delightful outside terrace for alfresco meals on those warmer days, or just to sit and have a coffee and watch the world go by. They serve fresh home-made traditional Cumbrian/British food, all sourced locally, and accompanied by a good selection of drinks. Lunch is served from 12noon to 4pm and dinner from 4pm to 9pm. The Priest Hole The Flying Fleece The Flying Fleece has just opened in July 2020, in a 15th century fulling mill. The historic mill building has recently been refurbished and the interiors have been designed to create a relaxing and cosy atmosphere that retains that recognisable traditional British pub feel. Food is served all day, while the atmosphere is casual and relaxed: diners can even enjoy their meal while admiring the working weir, millrace and wheel which still stand inside the building. The Old Stamp House Opened in 2014, The Old Stamp House is an award winning, fine dining restaurant headed up by Cumbrian chef Ryan Blackburn. Local produce such as Herdwick sheep and fish sourced from Barrow and Whitehaven can be found on the menu, which also features locally foraged herbs, mushrooms and game. Dishes are inspired by Cumbria, and the restaurant is located in what was once the office of William Wordsworth himself. Open for lunch and dinner, a la carte and tasting menus are both available to guests. Zefffirelis & Fellinis For vegetarian dining in Ambleside, look no further than Zeffirelis and Fellinis (even enthusiastic meat eaters will find something to enjoy here!). Offering a contemporary, award winning dining experience, these two friendly restaurants are local institutions. Zeffirelis focuses on Italian cuisine, with pasta and home baked pizzas on the menu; while Fellinis offers more of a fine dining experience, with creative vegetarian dishes inspired by the flavours of the Mediterranean. Both restaurants are housed in the same buildings as cinemas, showing a combination of the latest releases as well as art house movies, and cinema/dining deals are available. Zeffirelis also features a popular jazz bar for a great night out in Ambleside. Zeffirelis & Fellinis With a well deserved reputation as one of the best Thai restaurants around, Doi Intanon aims to bring a flavour of Asia to the heart of the Lakes. Owned by Chris and Busara since 2000, this welcoming Thai eatery in the centre of Ambleside is popular with both locals and visitors thanks to its authentic cuisine and delicious, freshly prepared dishes. Find classics such as Pad Thai and Thai Green Curry on the menu, alongside some Thai specialties you may not have heard of before! Dodd’s A popular restaurant found in the heart of Ambleside, Dodd’s is open from noon ‘til late and welcomes guests for lunch, coffee and dinner in a relaxed environment. Known for its freshly prepared Mediterranean cuisine and friendly welcome, it’s a great place to enjoy a meal in Ambleside. Dishes are prepared using fresh local produce, while an open kitchen adds to the vibrant atmosphere. It’s also worth noting that Dodd’s doesn’t take bookings, however there is a small bar where diners can enjoy a pre dinner drink while waiting for a table. Dodd’s Restaurant The Copper Pot This popular little cafe, nestled on a side street in the heart of town, is a great place to relax and recharge while exploring all Ambleside has to offer. Slate walls and soothing tones provide the perfect backdrop to enjoy a freshly ground coffee made using Mr Duffin’s Coffee, locally roasted in nearby Staveley. Open for breakfast and lunch, as well as coffee and home baked cakes, there’s plenty of indoor seating as well as a small garden in which to enjoy those sunny Lake District days. Ra ttle Ghyll Hearty, homemade vegetarian cooking, served up in a cosy cafe by friendly staff: that’s exactly what you’ll find at the popular Rattle Ghyll cafe. Located next to the beck which winds its way through Ambleside, Rattle Ghyll is the perfect place to get away from the hustle and bustle of town. Take a seat and peruse the daily papers with coffee and cake, or enjoy lunch while the beck babbles quietly in the background. The menu focuses on fresh food and decent portions, while the cake selection changes on a daily basis. For the discerning (or the indecisive!), a ‘Cake Platter’ featuring five smaller slices of cake allows for a little taste of a few different bakes. Rattle Ghyll Cafe Fancy coming to stay in Ambleside for a weekend? The Apple Pie An incredibly popular, well established family business, The Apple Pie Cafe and Bakery is known for its baked goods, which are made on site and served up to take away or enjoy in the cosy on site cafe. Scones, cakes and (of course!) apple pie are all on the menu, alongside locally roasted coffees, house blended hot chocolates, Farrer’s teas and a wide selection of cold drinks. For lunch, enjoy homemade soups, sandwiches, salads, pies and more. Kysty The casual dining sister of The Old Stamp House, Kysty is a bistro which offers something a little different. Its name means ‘discerning about one’s food’ in Cumbrian, and the focus is certainly on providing well prepared, creative and delicious fare inspired by Cumbria, made using local produce. A relaxed, welcoming atmosphere awaits visitors, serving an early evening menu between 5 and 6pm(Tues – Fri), followed by dinner from 6pm to 9pm(Tues-Sat). They also serve lunch from 12am to 2pm on Saturdays.	cc/2021-04/en_middle_0068.json.gz/line1708
__label__cc	0.677523	0.322477	« Embracing GHOSTS Man Booker Shortlist, 2016 » THE NIX To TV The glittering era of cinematic TV adaptations continues with the news that movie star maven Meryl Streep and Star Wars director J.J. Abrams are teaming up to produce a small screen limited series of The Nix by Nathan Hill (PRH/Knopf; RH Audio/BOT; OverDrive Sample). Deadline Hollywood reports the deal is with Warner Bros Television which will be able to auction the finished project to the highest bidder. New York Magazine has already called the debut novel “One of This Fall’s Buzziest.” As we noted, it racked up accolades when it hit the shelves with People magazine making it a pick for the week, calling it “as good as the best Michael Chabon or Jonathan Franzen.” Entertainment Weekly was also impressed, giving it an A- and calling it “a big fat cinder block of a book brainy enough to wipe away the last SPF-smeared vestiges of a lazy summer but so immediately engaging, too, that it makes the transition feel like a reward.” Early days yet and no word on who will star opposite Streep in the role of her on-screen son, Samuel Andresen-Anderson. This entry was posted on Monday, September 12th, 2016 at 2:26 pm and is filed under 2016 - Fall, Fiction, Literary. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.	cc/2021-04/en_middle_0068.json.gz/line1711
__label__wiki	0.951927	0.951927	New Motion City Soundtrack album is out; stream it here! Yes, Tuesday is the day that Motion City Soundtracks new album "I Am The Movie" will be available everywhere! This band was dubbed "The best unsigned band in America" until we got a hold of them, and now we have a killer record to share with you all. The word "catchy" doesn't even begin to describe this album. Songs like "Cambridge," "Boombox Generation" and "The Future Freaks Me Out" are intense, driven, melodic as all hell and just straight-up fun to listen to! But don't our word for it...hit the link below and listen for yourself! href='http://www.epitaph.com/goodies/ecard.php?id=241'>Motion City Soundtrack - "I Am The Movie" E-Player Off With Their Heads Announce New Album 'Be Good' Architects Announce New Album 'For Those That Wish To Exist' Joyce Manor Announce 'Songs From Northern Torrance'	cc/2021-04/en_middle_0068.json.gz/line1719
__label__cc	0.693692	0.306308	Redskins \| Adrian Peterson eyeing 6 more seasons Washington Redskins RB Adrian Peterson said Thursday, Dec. 26, he wants to keep playing. ‘I can see myself playing to 40,’ the 34-year-old running back said. ‘People look at that and say ‘oh my god, that’s crazy,’ but they’ve been doing that for the past two years and — surprise, surprise — I’m still able to do it at a high level.’ NFL Network - Jane Slater	cc/2021-04/en_middle_0068.json.gz/line1722
__label__wiki	0.631568	0.631568	Inbox Shame Is Real: How I Wound Up With 70,000 Unread Emails My inbox resembled Grey Gardens, a once-stately institution overgrown with weeds and cat poop and dying dreams. By Anna Breslaw You know those friends who will just grab your phone out of your hand if you mention a crazy email you got the other day, rather than just letting you read it out loud? They obviously don't understand that seeing someone's Gmail inbox is like looking into their bedroom. You don't just barge in uninvited, and if you do, you withhold judgment, whether it's spotless or there's a few socks on the floor. Or 13,000 socks. Or 13,000 unread emails. Or—as I had about six months ago—70,000 unread emails. For a few years (like once I hit 20k until I topped out at 70k) my inbox resembled Grey Gardens, a once-stately institution overgrown with weeds and cat poop and dying dreams. I didn't do it on purpose, I just didn't delete the unread emails because there always seemed like something more urgent to do. The bulk of it was spam. Not necessarily the "penis enlargement" or "Nigerian prince" variety (although I got those, too), but endless amounts of work spam ("Working on an article about Jennifer Aniston's hands?!?! Talk to our plastic surgeon who had nothing to do with that!" or "Hi Anna! Check out Swiss Cheese Incorporated's new single, 'Light Fixtures'" See above re. dying dreams). And the rest were email blasts from clothing or beauty stores like J.Crew, Net-a-Porter, Gilt, Rue La La, Sephora — basically anywhere I'd purchased at least one thing, at least one time. (Ann Taylor's were my favorite.) Once they start building up, defeatism takes over. How can one woman compete against thousands of unsolicited emails? As they accumulated, I briefly considered hiring an undergraduate to come over just to hit "Select unread" and "Delete" from sunup to sundown. But I didn't want them seeing my inbox, so I didn't go through with it. You can't blame me, considering it's such a mark of shame that there are tutorials online on how to delete the "Unread Email" number on your iPhone. But eventually, to be honest, it was… kind of fun? I had created an Internet-age monster, and it was alive, and (mostly) a secret. I even bought more space for my wild email greenhouse to continue thriving, because I was too overwhelmed to do anything else about it. Earlier this month, a meme called "There are two kinds of people in this world" went viral. It posits that there are "the 0 unread emails people," and "the 13,000 unread emails people." Like many other memes about how there are "two kinds of people in this world," it's popular because it suggests that the world can all be boiled down to Divergent but with more boring categories (in this case, an unread-emails caste system) and lets one half of us look down on the other half. This implies, obviously, that the 13k people are disorganized, forgetful, and easily overwhelmed. It encourages the "0 unread" set to equate their efficient email management with some Olympian feat like swimming the English Channel or climbing Mount Everest. Or maybe they just have the time-management ability, the reasonable workload, or even the available emotional bandwidth to face the unread-email grind—alas, not all of us can keep a sparkling inbox all the time. "I'll have a few days of back to back meetings, or a few days of work travel… and my inbox is the stuff of nightmares in no time," says Leah, 29. "I'm not one of those people who files to archive or puts everything in folders. I never will be." That said, she's made inbox management work for her: "I get a few spare hours one day on the weekend to plow through it and mass delete." With inboxes becoming ever-increasingly linked to our social, professional, and private lives, it's easy to become overwhelmed—whether your inbox is pristine or a mess. "I delete emails really methodically/obsessively, but that's like a coping mechanism for me," says Carrie, a 26-year-old writer. "I do it when I'm procrastinating reading/dealing with legitimate emails from friends or bosses or editors. I have a lot of anxiety over email. I let a ton of important stuff go unread for hours or days at a time because I'm not ready to confront it. I get paralyzed." Of course, there's also the fear of the Email that Got Away: What if you carelessly delete something important, or cool, or an email that would have changed your life, or whatever? Edith Zimmerman, former editor of the Hairpin, recalls: "I think I ended up opening pretty much all of my emails, even for just a second, in case there was something cool in there. Reading a random promotional newsletter gave me the idea for [viral Hairpin post] Women Laughing Alone With Salad, so you never know." Ultimately, the turning point in my inbox arrived with my boyfriend. He was mercilessly organized with everything, including email. I thought I might be off the hook when I saw what a maverick he was with tabs — he had 50 open at any given time, and left them open. One time I closed them all (ironically, I hate browser clutter) and he was more incensed than I'd ever seen him. But he winced every time I checked my email in front of him. He asked me if I needed any of the unread emails; I said no. He said, "OK. Do you want me to get rid of them?" I mentally said goodbye to my 70,000 unread PR emails. I thanked them for their constant, stable presence in my life, even when everything else was in a state of flux. And then I nodded. He sat down in front of my laptop and did something (he just followed this weird YouTube tutorial) and they were gone. Sans any of my own effort—like, say, I'd been airlifted to the top of Mount Everest—I had 0 unread emails. I actually felt physically lighter, as if I'd finally set down a pair of 15 lb. kettlebells. Now that my inbox was cleaned out, I felt obligated to keep it that way, and ever since, I have. With unread emails. Not read ones, because I'm not a psycho. I won't lie: It's surprisingly gratifying to step back and watch your email become a post-modern art project, if you can deal with the inconvenience, not lose any of your business correspondences, and gracefully handle the inevitable judgment. But it's nice to wake up to a clean inbox. Incidentally, I have yet to unsubscribe from any of the listservs and will probably never unsubscribe from Ann Taylor's. Anna Breslaw Writer. No Mask, No Girlfriend 45 Gifts That Won't Freak Out Your New Boyfriend How Three Couples Are Navigating the 2020 Election My Parents Grieved When I Came Out. Now I See Why. How Women Are Rethinking Motherhood This Year I Got Married in the Sims Quarantine Sucks. Why Not Get Engaged? They Found Love in a Hopeless Place (Quarantine) How to Find Love During a Pandemic The Best Sex Toys for Couples Who Vibe Together And Then…I Got Age Shamed New Study Confirms Work Email Is Ruining Your Life Bride Fires Bridesmaid in Painfully Awkward Email Wentworth Miller Responds to Body-Shaming Meme, Opens Up About Suicide Struggle The Rise of the Mom-Shaming Resistance News: Harvey Nicks' Walk of Shame	cc/2021-04/en_middle_0068.json.gz/line1723
__label__cc	0.695801	0.304199	Why Marketers Are Wrong to Be Hung Up on Mobile Measurement Craig Palli Fiksu Marketers continue to grapple with questions and concerns about mobile measurement. Yet some of those concerns stem from misconceptions about mobile measurement capabilities and data availability. Craig Palli, chief strategy officer at mobile marketing technology provider Fiksu, spoke with eMarketer’s Cathy Boyle about where marketers are getting things wrong with mobile and why several common misconceptions about mobile advertising persist. eMarketer: What are the top misconceptions with mobile advertising? Craig Palli: The biggest misconceptions are around data. When you market in apps, you can’t collect good data on results. However, the reality is the measurement capabilities on mobile are at least as good as the measurement capabilities on desktop. eMarketer: If the capabilities are as good as desktop, why do misconceptions still exist? Palli: In the desktop world, everything is based on the cookie, and the cookie is not transferable in and out of the app store. Marketers are saying, “I can’t drop a cookie, therefore I can’t measure.” The reality is it’s just as easy, if not easier, to measure in mobile apps, because Apple and Google have given us advertising identifiers. But most of the digital measurement infrastructures are not built around those mobile advertising IDs. eMarketer: If mobile is highly measurable, are marketers getting stuck on measurement because it’s difficult to benchmark mobile results against desktop results? Palli: Many brands don’t yet know what to measure mobile against. The reality is they have to look at different metrics. In the desktop world, you’re looking at things like how many total impressions did I get? How many unique visitors went to the website? And how much time was spent on the site? “Many brands don’t yet know what to measure mobile against. The reality is they have to look at different metrics.” In mobile, you’re going to replace those metrics with things like, how many downloads do I have? How many unique consumers do I have interacting with my applications? How much time do they spend in the app? How many actions did they take in the app? There’s a paradigm in mobile that is similar to desktop, but you just have to tweak the metrics slightly to be more mobile-friendly. When you do that, things line up quite nicely. eMarketer: But there are distinct differences as well, aren’t there? Palli: Yes, you get a lot more value in mobile because it’s a multievent marketing experience. If I’m Procter & Gamble and I want to show an ad for one of my apps, I might register millions of impressions, many clicks, and those clicks direct people to an app store—so far, so good. But as a brand marketer, they’re also getting a consumer to land on their app store page where they can be fully immersed in language that pertains to the brand. Then, if the consumer downloads that branded app, the brand has a persistent presence on the consumer’s phone. And once that person starts launching the app, they’re engaging with that brand over and over again. There’s a ton of value in all of those things from a brand marketing perspective. In fact, the advantages related to apps are so far superior to what you’d get on the desktop. It’s all incredibly measurable. eMarketer: While we’re on the subject of apps, do you have plans to track the download volumes for the Apple Watch apps, like you do for iPhone and iPad? Palli: Of course. We’re fully compatible with Apple Watch, we know all these in-app actions that are taking place on it. In general we see Apple Watch usage growing, but it is still slow. Watch users are still just a small percentage of all app users—it’s currently just 5%. However, that figure has been increasing a percentage point every two weeks so far. eMarketer: Back on the mobile marketing or advertising front, what hurdle do marketers or the industry have yet to overcome? Palli: The hurdle relates back to the data. Let’s assume the average marketer is bought in to mobile advertising and understands they have to work with Apple advertising identifiers and Android advertising identifiers. The next thing they’re going to say is, “I don’t have the data available to buy audiences, and some third-party data providers don’t have enough information for me to work with.” The reality is there is a lot of mobile data out there. Marketers just have to be smart enough to say, “OK, what are the good data sources for me to build audiences on?” and then recognize that once they’ve built those audiences, they can reach those audiences in all the best places they’d go to on desktop. Marketers need to seek out different partners than the ones they’ve been working with on desktop. Why buy an eMarketer corporate subscription? Learn more about eMarketer data and insights »	cc/2021-04/en_middle_0068.json.gz/line1724
__label__wiki	0.932215	0.932215	New Aphex Twin documentary available through BBC radio 4! Richard David James, better know as Aphex Twin just releases a documentary surrounding the mysteries around his career as well as the creation and development his sound. The documentary, titled “The Cult of the Aphex Twin”, was hosted by Quietus’ journalist John Doran. ‘The Cult of the Aphex Twin’ features interviews from fans including Vic Reeves and friends such as musicians Tom Middleton, Leila, David Toop and Scanner and much more. Go give the radio doc a listen here. Go listen to Aphex Twin's selected Ambient works below. Electronic music group The Orb shares latest album... New Aphex Twin documentary available through BBC r...	cc/2021-04/en_middle_0068.json.gz/line1727
__label__wiki	0.725185	0.725185	Worldwide Medical Insurance News: French administration 'problematic' March 28, 2011 by Expatriate Healthcare Expatriate health insurance could be particularly important for people living in France due to the country's problematic administrative processes. A recent article in the Telegraph noted that it can take years to acquire the necessary documentation to gain access to the country's healthcare system. Expatriate Cathy Boylan explained that she retained her native UK health insurance when she first moved to France due to her excessive travel plans. But when she registered as self-employed in the country and decided to apply for the medical insurance card, known as a Carte Vitale, she encountered difficulties. The card, which was due to arrive "in a few weeks", didn't come and Mr Boylan faced years of difficulties chasing her way through the famously-bureaucratic French system. Expatriates could avoid these problems by registering themselves for international health insurance cover. Expatriate Healthcare specialise in providing international health insurance. Make sure you're protected. © Expatriate Healthcare The Best Christmas Markets Around the World How to Cope with Expat Homesickness What You Should Know About Retiring to Spain Expat Safety Tips: What to Do During a Volcanic Eruption Things to consider when being offered a relocation package	cc/2021-04/en_middle_0068.json.gz/line1728
__label__wiki	0.554441	0.554441	The conservancy Mission & GoalsProjectsOur StoryThe TeamContact Us OverviewEPISODESHOW-TOTRAILCAMS Wildlife NEWSTell Your StoryStock Footage We Can Save Alberta's High Country Kevin Van Tighem Author & Conservationist Grizzly bears are a threatened species in Alberta - John E. Marriott We can save Alberta's scenic high country. In a confidential meeting with the Calgary Chamber of Commerce during the last Alberta provincial election campaign, Jason Kenney described his strategy for implementing a far-right exploitation agenda. He said the plan was to overwhelm any opposition by bringing in massive policy changes as fast as possible. And that is exactly what he has done. The power of that approach is that it both confuses people and makes them feel overwhelmed and helpless. So they retreat into despair, and those who profit from extracting value from the public purse, the work of others and the environment win. But it’s a tactic based on overwhelming our senses, not on real power. In a democracy like ours, real power is distributed across many levels of government and many groups of people. And we can still tap into it to defend our province from those who would suck it dry and then discard it. The coal mining assault on the Eastern Slopes is a case in point. We are meant to feel that there is nothing we can do to stop strip mines from opening, one after another, from Crowsnest Pass to Grande Cache, in the scenic headwaters of our prairie rivers. We’re supposed to go down without a fight as the habitats of native trout and the homes of bighorn sheep, alpine forget me nots and golden eagles get reduced to rubble in order to send coal to be burnt in foreign steel mills. But we have the power to keep our mountains free of coal strip-mines. I and others have been encouraging concerned Albertans to write to the Premier and our so-called Minister of Environment and Parks with their objections. That’s still a good idea, because it does ensure that they know that their voters actually care about our home place enough to protest bad policy. But we need to be realistic: this is a government with a far-right ideology. They truly believe in what they are doing. We are not going to convince them to change course. On the other hand, they have done almost everything they can to alienate the federal government and to let the ruling Liberals know that there's little hope of winning seats in Alberta. Ironically, this could help Albertans who care deeply about our Eastern Slopes to persuade Ottawa to stand on guard for us and the places we love. A Varied Thrush in the Alberta Rockies - John E. Marriott Provincial and federal governments alike have a duty, under our Constitution, to consult with First Nations whose rights are affected by major changes to land use policy. When Alberta arbitrarily revoked its Coal Policy — one that was originally put in place by Peter Lougheed’s Progressive Conservative government after extensive consultation — they consulted only with the coal industry. They are in breach of their Constitutional duty to respectfully consult Indigenous people. The federal government has a direct interest in that. Almost all the current coal mining proposals affect the breeding habitat of species protected by law under the federal Species At Risk Act. These include Westslope Cutthroat Trout, Limber and Whitebark Pines, and Grizzly Bear. The province has submitted draft recovery plans for cutthroat trout and grizzly that are clearly substandard and they expect the federal government to rubber stamp those plans — even while instituting a policy that is intended to facilitate strip-mining of critical habitats. The federal government has a duty to protect those species. The Government of Canada and Alberta are subject to international agreements to reduce greenhouse gases. This is an urgent priority in the face of our ongoing climate crisis. Burning coal releases stored carbon into the atmosphere as carbon dioxide. Coal mined in Alberta might be burned in China, Japan or India, but there is only one atmosphere: we don’t get to play Pontius Pilate on this. The federal government has a duty to consider the impact of major new initiatives on our ability to meet our greenhouse gas reduction targets. Ram River in the Alberta Rockies - John E. Marriott The Eastern Slopes of the Rocky Mountains provide more than 80% of all the river water in the arable regions of prairie Canada. Water security is a critical strategic issue for this country, given the importance of irrigation agriculture and prairie towns and cities, and the costs of flood-relief and drought-relief programs. Coal strip mining destroys the surface hydrology of headwater basins and releases soluble toxins like selenium into ground and surface water. Existing coal mines in BC and near Hinton have failed to find a way to keep those toxins out of rivers and in fact more than 90% of the threatened west slope cutthroat trout population recently died in the Fording River because of coal mine pollution. Water security is a federal concern. So the Federal government has jurisdictional responsibilities that are affected both by individual coal mine proposals and by the Alberta government’s decision to open up formerly protected Coal Policy zone 2 lands to new strip mining. The Federal government has both the responsibility and the power to intervene — and no political reason to avoid intervening. We need to tell them this. And we need to ask them to impose a solution. The simplest solution? Federal legislation dictating that ANY new coal mine proposals in Canada, including expansion proposals for existing coal mines, will henceforth be subject to a formal review under the federal Impact Assessment Act. With no exceptions. Bighorn sheep lambs and ewes in the Alberta Rockies - John E. Marriott This would ensure full scrutiny of all environmental impacts, including greenhouse gas emissions, and full consideration of government duty to consult with affected Indigenous communities. It would mean that species at risk don’t get swept under the rug. And it would guarantee all Canadians an open, transparent and accessible process for citizens to intervene against bad decisions. No less important: it would scare away a lot of investors, because they would be dealing with the kind of investment risks — i.e. full-cost accounting — that the Kenney government is trying to help them avoid. Mining investors prefer to deal with desperate third-world governments than with ones that hold investors fully accountable, because they don’t want to pay to clean up their messes or live with the damage they cause. We CAN save our Eastern Slopes. This is one fight we can win, but citizens need to convince our federal Cabinet to step up to the plate. If you have visited the places that are now at risk, or even if you just think water security and endangered species matter, it should be pretty clear that this is one fight we have to win. So here are some key Cabinet Ministers to whom you should send your thoughts and suggestions. Please feel free to borrow from any of the points raised above: Prime Minister. Rt. Hon. Justin Trudeau - justin.trudeau@parl.gc.ca Intergovernmental Affairs Minister and Deputy Prime Minister. Hon. Chrystia Freeland - chrystia.freeland@parl.gc.ca Environment and Climate Change Minister. Hon. Jonathan Wilkinson - jonathan.wilkinson@parl.gc.ca Crown-Indigenous Relations Minister. Hon. Carolyn Bennet - carolyn.bennet@parl.gc.ca Finance Minister. Hon. Bill Morneau - bill.morneau@parl.gc.ca Agriculture and Agri-food Minister. Hon. Marie-Claude Bibeau - marie-claude.bibeau@parl.gc.ca Infrastructure and Communities Minister. Hon. Catherine McKenna - catherine.mckenna@parl.gc.ca Minister of Health. Hon. Patty Hajdu - patty.hajdu@parl.gc.ca Minister of Natural Resources. Hon. Seamus O’Regan - seamus.o’regan@parl.gc.ca Minister of Indigenous Services. Hon. Marc Miller - marc.miller@parl.gc.ca Back to Wildlife News OverviewEpisodesHow-ToTrail Cam Wildlife NewsTell Your StoryStock FootageFAQ Insider ProgramDonateSponsorShopShipping YouTubeFacebookInstagramTwitter Our StoryThe TeamMission & GoalsProjectsContact Us By subscribing you agree that you accept our privacy policy and consent to receive emails from EXPOSED Wildlife Conservancy. We will not sell your personal information and you can unsubscribe at any time. © Copyright 2020 Exposed Wildlife Conservancy. All Photography © John E. Marriott	cc/2021-04/en_middle_0068.json.gz/line1729
__label__wiki	0.656389	0.656389	Microsoft Unveils Dual-Screen ‘Surface Neo’ Tablet and ‘Surface Duo’ Android Phone By Ryan Whitwam on October 2, 2019 at 3:02 pm In 2008, the iPhone was still the hot new gadget, and the iPad was just a twinkle in Steve Jobs’ eye. That year, the Microsoft Courier dual-screen tablet concept leaked all over the internet. It was a fascinating idea that never came to fruition, but Microsoft is going all-in with dual-screen devices in 2020. The company has announced a pair of dual-screen devices at its latest Surface event: the Surface Neo computer and the Surface Duo Android phone. The Surface Neo straddles the tablet and notebook categories. It folds, but it’s not a “foldable” like the Galaxy Fold which has a single flexible panel. Instead, the Neo has dual 9-inch displays. Each side of the device is 5.6mm thick, and the whole thing weighs 655g (1.44 pounds). It has a 360-degree hinge, so you can fold the screens inward to close it or position it like a traditional laptop (there’s an optional keyboard cover). You can also fold the displays outward to prop it up like a tent or use just one of the two LCDs. Unlike the new Surface Pro X, this is not an ARM-powered device. Microsoft says it runs a custom Intel Lakefield processor with 11th Gen graphics powering both displays. There’s also support for the Surface Pen, which attached magnetically to the back. It runs Windows 10X, which appears to be a tweaked build of the full operating system for dual-screen devices. Microsoft engineer Carmen Zlateff confirms Windows 10X can run all existing Windows apps. The Neo would have been the clear headliner if it wasn’t for Microsoft’s other dual-screen announcement. The Surface Duo is Microsoft’s first Android phone, and it looks like a shrunken-down version of the Neo. It has similar hinges, allowing you to use it in various configurations. For example, you can fold it all the way open to access just one of the 5.6-inch displays or flatten the device out to use both screens side-by-side. Still, the ergonomics of this design are highly suspect. While the Neo doesn’t have the expansive flexible OLED like the Galaxy Fold, it’s probably going to be more durable — flexible OLEDs are plastic, but the Surface Duo can use glass like every other phone. Microsoft is also working closely with one-time mobile competitor Google to make this distinctive design play nicely with Android. We don’t know much about the internals, but the Duo is currently running a Snapdragon 855. That could change by the time it launches, which won’t be soon. According to Microsoft, it’s showing off the new dual-screen devices early so developers can get ready. It plans to launch the Surface Neo and Duo in time for the 2020 holiday shopping season. It didn’t touch on pricing, but we’d wager it’ll be high. Now read: Microsoft’s OneDrive ‘Personal Vault’ Rolls Out Globally Microsoft Says AI-Powered Windows Updates Have Reduced Crashes Microsoft Files Another Patent for a Dual-Screen Device surface neo Post a Comment Comment	cc/2021-04/en_middle_0068.json.gz/line1730
__label__cc	0.719801	0.280199	Welcome to EY Iraq (EN) You are visiting now EY Iraq (EN) 5 minute read 4 Sep 2019 How agility becomes critical in the face of rapid market shifts Randall Miller By Randall Miller EY Global Advanced Manufacturing & Mobility Leader Passionate about manufacturing, mobility and disruption. Champion for women and diversity & inclusiveness in the Advanced Manufacturing & Mobility industries. Kris Ringland, John Simlett, Sven Dharmani Related topics Transportation Supply chain Mobility Automotive 1Q19 Mobility Quarterly (pdf) New regulations, economic conditions and changing customer preferences are forcing vehicle manufacturers and their suppliers become more agile. Leaders of 17 automotive and transportation (A&T) companies, during public earnings calls with analysts, have revealed that they are being forced to improve their agility amid shifts in demand patterns. They are trying to balance the management of their operating costs while adequately supporting the development of new technologies. Download: Mobility Quarterly Final The top 10 themes from the quarterly earnings calls: Geographic developments Evolution of mobility Operating costs Restructuring initiatives Inorganic growth (M&A, JV and partnerships) Manufacturing and supply chain management Product evolution Working capital and cash flow management Geopolitical issues Top three themes that stood out in 1Q19 Regional demand, evolution of mobility and operating costs remain the top three themes for 1Q19 just as they were for 4Q18. The fact that their positions have not shifted in this quarter indicate that local demands, technological advancements and macroeconomic conditions continue to play key roles in the growth strategies of A&T companies. These themes are discussed below: Geographic developments: Holding the first position in the top 10 list for 1Q19 and 4Q18, the theme of regional demand indicates that A&T companies are responding to changing demands across Asia, Europe and North America. Although Asia is witnessing a slowdown in growth across several major vehicle segments, its overall economic growth rate is still higher than average. While manufacturers in Europe are facing new challenges due to new emissions regulations, there is evidence of an increasing interest in sport utility vehicles (SUVs), light trucks and crossovers across the US. Evolution of mobility: Technological advancements remained at the second position both in 1Q19 and 4Q18, indicating that data and content management are becoming more integral to A&T companies. As the evolution of autonomous vehicle (AV) technology and electric vehicle (EV) technology continues to transform the market, companies are seeking new ways to improve their services and strengthen customer relations. This is also eventually affecting the demand for advanced driver-assistance systems, which is growing faster than estimated. Supporting these innovations is requiring manufacturers to look for acquisitions, JVs and in-house incubators that provide access to such technologies. Operating costs: Operations teams in A&T companies are finding new challenges as macroeconomic conditions keep shifting. The major areas of concern are related to raw materials, foreign exchange (forex), technology, logistics and talent, with forex volatility remaining the top concern. These uncertainties and the higher costs associated with evolution of mobility are expected to continue in the next quarter. However, despite the increase in operating costs, analyses of the earnings calls indicate that costs related to technological developments are expected to support top-line growth in the long term. How EY can help Mobility innovation-as-a-service We can help you innovate, commercialize and scale by bringing together proprietary forecasting tools, a focus on outcomes and a series of key innovation principles — driving confidence and accelerated speed-to-market in a disruptive era. New themes for 1Q19 Initiatives at the firm level and product evolution are the two new themes that have made entry to the list. While the former considers operational streamlining, business function reorganization and divestments, the latter looks at the shift in demand of vehicle types, increasing the advent of R&D and product innovation: Restructuring initiatives: A&T companies are focusing on ways to improve structural efficiency while also ensuring reduction in operational costs. Some think hiring a digital-ready workforce would help them achieve this. There are also advocates of restructuring, which is becoming a “normal” aspect of business culture. Product evolution: More A&T companies are seeking to introduce new initiatives to improve customer experience. New architectures, improved fuel efficiency and new infotainment features, along with renewed focus on meeting emission standards, continue to be the key focuses of new launches. EY OpsChain Tesseract: Blockchain integrated mobility platform EY OpsChain Tesseract is a blockchain-powered platform supporting new mobility businesses built around fractional ownership of vehicles and new investment models. Scope, limitations and methodology This analysis reviews the top themes discussed by leaders of 17 A&T companies (including passenger vehicle, commercial vehicle and automotive suppliers) during public earnings calls with analysts. The report tracks the movement of these themes from quarter to quarter to provide a perspective on shifts in the sector landscape. {{ user.name }} @{{ user.screen_name }} {{ created_at }} Follow Automotive companies, including passenger vehicle, commercial vehicle and automotive suppliers, are being forced to become more agile than ever due to shifts in local economic conditions, operating costs associated with technological advancements and changing customer preferences.	cc/2021-04/en_middle_0068.json.gz/line1731
__label__wiki	0.500282	0.500282	By ThatCery - United Kingdom Today, I rang my dad to tell him and my half-sister that I'm finally engaged. I then asked my half-sister to tell my stepmother. Still on speaker, I heard her run upstairs and pass the good news on. My stepmother responded with 'Cery who?', followed by 'So what? I can't stand her'. I'm Cery. FML Serious times By The captain - Canada Today, I found out what it's like to get brain-freeze while recovering from a head injury. FML By inpain - United States - San Francisco Today, in my self-defense class, we did an attack simulation. As I began to hit my attacker, my fist hit the top of his helmet, dislocating my shoulder. I then spent the next hour in the ER sobbing until it was popped back in. I need to learn to defend myself against myself. FML By FuckfaceSteve - United Kingdom - Chester-le-street Today, the girl I like finally replied to a text I sent a week ago. Her reply was: "Don't ever text me again, fuckface." FML By ChrissySoltys - Canada Today, I realized that the black leggings I wear quite often become see-through when I bend over. I have been showing the world my ass as well as my thong for over a month now. FML recoils in horror Today, I am violently allergic to my boyfriend's new hand cream. I know this because after last night's quickie on the sofa, I now have a rash all over my skin and weeping sores inside my vagina and around my bum hole. FML By Coley - Canada Today, I went to the doctor to talk about my depression and low self-esteem. He told me that I shouldn't think of myself as a fat pig for being overweight. I don't think that and I'm NOT overweight. FML By Loveless - United States Today, during foreplay, I was trying to be sexy. But instead I fell off the bed, landed in the laundry basket, and was attacked by the dog. FML By Anonymous - United States - Salt Lake City Today, I found out I'm allergic to mosquito repellent. I fly out on a two month trip to India on Saturday. FML By coloradoman - United States Today, while flying on American Airlines back from visiting family, a new born puked its breakfast all over my HP mini, knocked my orange juice ino my lap, and than coughed up another layer on top of it all. I couldn't change my pants because of we were about to experience turbulance. FML By tinaburrito - France Today, I found out my bank account was in the negative because my work gave me a check that didn't clear. I went to my bank to get a statement of charges so my job could reimburse me. They told me requesting a statement costs 8 dollars, which I don't have because my account is in the negative. FML By gottacatchemall - United States Today, I tried to lose my virginity to my boyfriend of a year. We're almost twenty. In the end, we both chickened out and played Pokémon instead. FML By time to lawyer up - United States - Forney Today, I saw a photo on my mother-in-law's Facebook, proudly showing off the horrible job she'd done of painting her car. I sarcastically commented that I wouldn't inflict that on my worst enemy's ride. An hour later, she came by and emptied a bucket of paint over my windshield. FML By Anonymous - United States - Seattle Today, my 4-year-old twin boys are fighting because they both want to watch the SAME show on Netflix. They don't want the other one to choose, because somehow that invalidates their own choice, even though they both get to watch what they want, which is "Barbie, life in the dream house". FML By ELparano - Canada Today, I was driving without my seatbelt on, when I noticed a police car approaching. I panicked and desperately fumbled around for my seatbelt, only for them to pass by with just a funny look. Then it hit me that I was riding my motorcycle. FML By Brandon - United States Today, my girlfriend called me from her parents' house where she is visiting. They were BBQing outside when out of the blue her childhood friend Adam showed up at the door for the BBQ. She asked her parents why he was there, and her dad replied that he "wants her to know that she has options." FML Today, I was moving. While packing, I found an old photo that had been laying face down in the bottom of a drawer for some time, and some of the ink transfered to the drawer lining. There is now an image of my ex-girlfriend's face permanently burned into the bottom of my nightstand drawer. FML By shadowsorel - United States - Chicago Today, I have a cold, and was stuck sleeping in bed. My roommate decided to wake me up by sticking headphones in my ears and playing heavy metal on full volume. This is the third time this week. FML By arsenic660 - United States Today, I went into my part-time job at a drugstore. We always have one item we try and sell to every customer. For the next week I have to ask every person if they would like to try my nuts. FML By highschoolsucks - United States Today, I let out a monstrous fart at the gym. They said it didn't even sound human. FML By Anonymous - 28/1/2020 14:00 - United States - Oakland Today, I finally got up early enough to get to work on time. I arrived 15 minutes early only to realize that I'd left my work laptop at home. Ended up being 30 minutes late. FML By troublewithbleach - United States Today, I was cleaning my bathroom, and accidentally spilled bleach, ruining my shower curtain, rugs, and towels. While attempting to wipe up the bleach, I knocked over a bottle of shower cleaner. It read, "WARNING: DO NOT MIX WITH BLEACH." I still can't go in the house. FML By storrent - United States - Houston Today, I discovered that my band section had misspelled my name as "Joke" on our section poster. On purpose. It's supposed to be Jake. FML By Anonymous - France Today, I was so bored, I sewed my name into my underwear. FML By MERRY FUCKMYARSEMASS - United Kingdom Today, my car broke down on the highway, and I had to call for a tow truck. It finally showed up, only to break down too less than a mile later. Cue nearly freezing to death while we waited for help to arrive for the both of us. FML By i fuckin love habaneros - United States - Charlottesville Today, I'm so deprived of female attention that I got a hard-on when a nurse told me I have beautiful veins. FML By Sheggie - Australia Today, I found a wallet belonging to some guy, it had $355 inside. Because he had his address written inside, I decided to return it hoping for a reward. I drove for 40 mins and finally got to his house during peak hour. All he did was say "oh cool". FML By burb - Germany - Berlin Today, I invited my new girlfriend over for the first time. My roommate thought it would be funny to go on a porn site on my computer and leave it up. She saw it, freaked out, slapped me, and left. FML By fledermausi - Hungary - Budapest Today, I came home to my boyfriend emptying his bowels into my aquarium. FML By Umwhat Today, my boss wanted to talk to me. Nervous, I went to her office. Turns out that my coworkers talk about me behind my back, and my boss is worried about me. Apparently, I lie about my bad knees, and me wearing black leggings is horrible. Most of them wear sweatpants on a daily basis. FML Today, I offered to let my niece and brother stay at my apartment, as my brother was going through a rough divorce and had lost his job. After coming home from work, I found my niece had snapped all of my pencils and had ruined over ten years worth of artwork. FML Today, I was prescribed medicine for anxiety. Without it, my stomach churns all day. With it, I shake uncontrollably and my eyes twitch. Now I have to choose between diarrhea and rude stares from people in public. FML By 404: Sanity Not Found - United Kingdom Today, my girlfriend made a patronising post on Facebook, "to all you guys out there" saying how having sex with a drunk person is straight-up, 100% rape. I pointed out that she's had sex with me several times after I've come home drunk. That pissed her off. Now I'm single. FML By alikat - United States Today, I found out that the noise I thought was a mouse in my room was a water bottle shaking when my refrigerator turned on. I stayed up till 4am looking for a mouse that didn't exist. FML By Anonymous - Japan - Tokyo Today, I found out via Instagram that my boyfriend didn't actually go to the Bahamas with his dad as he claimed. Not unless his dad lost weight, grew tits and long hair, and likes to make out with his son. They have no cellphone service, so I can't even call to break up with him. FML By Rosie Today, I discovered that you can vomit hard enough to break a rib and tear a ligament. Why was I barfing so violently? The stray cat I'm feeding has given me worms. I found one during "down there cleanup" time. I got laughed at by EMS, nurses, doctors, and my family. FML By Anonymous - United States - Perris Today, I realized the reason my 20-year-old daughter has been so moody and aggressive is because she missed the promotional My Little Pony toys at McDonald's. FML By Soverytired - Australia Today, I received a gift certificate from my grandmother for a local bookshop. Considering how broke I am, this would be a fantastic gift. If the bookshop in question wasn't a right-wing evangelical Christian Bookshop, and I wasn't Jewish. FML Today, my parents and I were looking through old photos. My dad comments, "Wow you were chubby back then. But that's ok, it was baby fat." Then he turns to me and asks, "What's your excuse now?" FML By Anonymous - United States - San Diego Today, I caught my parents having sex. It wouldn't have been as mortifying if they weren't doing it in my room. FML By ThatGirl - United States Today, an idiot decided it would be fun to light up a firecracker in front of our house. It ended with firetrucks, a black yard, and yet somehow the weeds survived. FML By McCannCanTriple \| 0 #778199 - Saturday 16 January 2010 19:49 What a bitch. By MegMM \| 0 what a bitch!!! don't invite her to the wedding!!! z620 \| 0 #927352 - Tuesday 9 March 2010 3:48 that's a strange name... anyway that sucks loveanthony645 \| 5 #3690143 - Tuesday 6 December 2011 5:39 Cinderella, eh? By AnimaBella \| 0 at least your dad will know she's a bitch surescope \| 0 #1024629 - Wednesday 9 June 2010 5:55 you should invite her it would be hilarious pinkpeach222 \| 0 #3152994 - Sunday 21 August 2011 15:26 in what way would that be hilarious? lionkat456 \| 28 #5545483 - Friday 21 June 2013 17:43 hilarious as in watching her toast to your wedding, walk up to hug her, then whisper a death threat in her ear XD By jessxoxo28 \| 5 what a bitch, i gotta step mom to, so i no how things could be. dont tell her anything anymore. sooner or later she'll hate being left out By Loveya448 \| 0 Your dad married a bitch. Ketchup_Castle \| 30 #3237283 - Monday 5 September 2011 4:13 By perdix \| 29 So what did you do to her? There's one grandma you can't count on for babysitting. That's a HUGE benefit of grandmas. You should try to patch things up before you have kids. Elesiel \| 0 Why would you want someone like that watching your kids? perdix \| 29 So you can have a little grown-up time every now and then. Even if the stepmom still doesn't like Cery then, she most likely would have the common decency not to bad-mouth her to the child. If she doesn't, well, then she's a psycho and Cery shouldn't let her babysit. #778619 - Sunday 17 January 2010 0:40 Sure, mostly from getting old, but some of it, I just make up! ;) Moemoemoe_fml \| 0 Dude, it's not her grandkids. If she hates Cery and has no blood relation with her, what makes you think she'll be up to babysitting Cery's kids??? The Dad might be up for it, it's his grandkids, but certainly not her. arcadiaware \| 0 #779890 - Sunday 17 January 2010 16:37 You realize people use the kids to get back at someone they dislike all the time, right? Psycho or not, if she really dislikes Cery that much, the kids will eventually come home thinking mommy is an alcoholic or something. By Nic_hole \| 0 aww that's some bullshit right there!! don't invite her, damn bitch By GodsLittlePain \| 0 #6: Sometimes stepmothers just hate their step kids in general. No use patching if theres nothing to patch. FML: Well, Guess you know who to NOT invite, Huh? Hope she enjoys feeling rejected and not knowing whats going on when you finally have a little brat of yer own. You may be right, but I just want Cery to confirm this before we all take her side. Other times, stepmoms bend over backwards to win the affection of the stepkids, and it is the kids who ruin it out of some loyalty to their birth moms. girlygirl666 \| 0 Or it could be that she didn't do anything to her step- mother at all. Maybe the step-mom is jealous of Cery's relationship with her father. Maybe she looks like her mom, and she's feeling salty about that for any number of reasons. Maybe Cery is prettier than her own daughter, and she's jealous for her daughter's sake. It could even be that she suspects her husband favors her over her half-sister. Who knows? It could be worth talking it out to get to the real issue. If she honestly just dislikes you, OP, then say "screw her" and move on. You've got a wedding to plan! By fudrick \| 0 FYL for having the name Cery. Seriously that must suck. By Elesiel \| 0 That sucks. At least it sounds like you don't live there with them. Time to cut her out of your life.	cc/2021-04/en_middle_0068.json.gz/line1733
__label__cc	0.68094	0.31906	Home Truths: An Anthropology of House and Home CategoriesWindowTagged anthropology, house, truths Tour homes, condos, cottages, flats, townhomes and more in this inspiring playlist. You’ll find renovation ideas and tricks for both massive and small spaces. Interior Design: How To Mix Traditional And Modern Decor – Durasi: three menit, forty nine detik. The end result’s all the time the exceptional fulfillment of your imaginative and prescient. House & Home has constructed a reputation for constructing the highest quality custom properties. In 1977, OK/Hyperama opened its first branch in Johannesburg with House & Home as the flagship brand in the Furniture Division. The chain now boasts with nearly 50 large-sized shops trading on locations starting from m². Every week there are new leaflets with the best offers, which are available in South Africa. There are also brochures for the international locations around South Africa, by which the corporate has stores. To apply for a House and Home account, simply visit the corporate web site and observe the steps or visit a store for assistance. House and Home deliver nationwide and prospects can even go forward and utilise the online shopping feature for added comfort. View the House and Home catalogue for all the newest specials on beds, furnishings, appliances, computer systems and extra. The studio at Eames House, designed by Charles and Ray Eames, in the Pacific Palisades neighborhood of Los Angeles. Image via Wikimedia Commons.The Eames House and Eames Studio grew to become the placement for a lot of the Eames’ work output throughout the 1950s, 60s, and 70s. Houston House & Home is contemporary, entertaining, helpful, and better of all, written particularly for the Houston homeowner. House & Home focuses on a wide range of practical articles on residence enchancment, remodeling, renovation and interior design, as well as a variety of house repair-up projects. Meldon House & Home is a superbly curated assortment of upcycled, revived, pre-loved and in addition contemporary furniture and homewares, personally sourced and chosen by its owner, Judie Sherriff. HOUSEBOUND with Lynda Reeves Putar semua It’s raining heavily once more in Atlanta, and the soothing sound of heavy drops hitting against the roof and home windows brings to mind the language of house and home. Both the phrases “house” and “home” found their method into trendy English from the Proto-Germanic. Khusan, for “home” was become hus with Old English, and stems from the verb “to hide.” Both phrases indicate shelter, which explains the use of the time period “disguise” to imply animal skin. While many animals are at residence of their skin, throughout our evolution, humans have developed places that transcend shelter; we now have made houses. The whole football staff came to visit and ate poor Sally out of home and residential. Vinyl Fence, Deck & Railing by Country Estate: Home Download iCloud for Windows Tavira House and Home	cc/2021-04/en_middle_0068.json.gz/line1734
__label__cc	0.678173	0.321827	800.394.3301 info@fiberplusinc.com Premise/Outside Plant Air Blown Fiber Central Station UL 2050 Cellular Signal Enhancement The Basics of Sound Masking Sound masking is a technology that offers comfort in workplaces and privacy where it’s needed. Whether you were aware of it or not, you have likely experienced sound masking before. It’s a basic concept: additional background noises are piped into a space to help cover up unwanted outside noises or human speech. In spaces where confidentiality and privacy are critical, it’s a technique often used to establish an atmosphere where you don’t need to worry about whether or not information is being overheard by parties who shouldn’t be privy to such knowledge. On the other end of the spectrum, sound masking is sometimes used to make for a more relaxing work environment as well. Read on to find out the many benefits of sound masking technology and why it has become so widely used. At its core, sound masking is about normalizing sound levels. This can be used in workspaces to make otherwise distracting noises, like people typing on keyboards or having conversations, much less noticeable. It isn’t exclusively used for this purpose however. It’s also an effective means of establishing privacy. If you’re having conversations that contain the kind of knowledge that shouldn’t be overheard by any eavesdroppers, sound masking can be a fantastic way of preventing anyone from hearing what is being said. What Approaches Work Best? There are all kinds of approaches to sound masking, from using nature sounds to trying something a bit more concealed and unassuming. While something like instrumental background music or even just regular old HVAC sounds could work in some instances, sound masking is often most effective when people don’t even realize it’s happening. If you’re looking for an unobtrusive sound masking solution, FiberPlus can help. When Should It Be Used? Everything from offices, hospitals, and public spaces can benefit from sound masking technologies. In an open office, this can be critical in boosting employee productivity, whereas patients in a hospital may feel more at ease discussing their personal information if it’s more difficult for others to overhear it all (think HIPPA). This same idea also applies to waiting rooms or banks where some people may not feel comfortable discussing their sensitive information. Lastly, sound masking is utilized in specialty situations like SCIFs to create an extra barrier of protection. Get in Touch with FiberPlus FiberPlus has been providing data communication solutions for over 25 years in the Mid Atlantic Region for a number of different markets. What began as a cable installation company for Local Area Networks has grown into a leading provider of innovative technology solutions improving the way our customers communicate and keeping them secure. Our solutions now include: Structured Cabling (Fiberoptic, Copper and Coax for inside and outside plant) Electronic Security Systems (Access Control & CCTV Solutions) Wireless Access Point installations Public Safety DAS Audio/Video Services (Intercoms and Display Monitors) Design/Build Services FiberPlus promises the communities in which we serve that we will continue to expand and evolve as new technology is introduced within the telecommunications industry. Have any questions? Interested in one of our services? Call FiberPlus today 800-394-3301, email us at info@fiberplusinc.com, or visit our contact page. Our offices are located in the Washington, DC metro area, Richmond, VA, and Columbus, OH. In Pennsylvania, please call Pennsylvania Networks, Inc. at 814-259-3999. Do you enjoy clicking “Like” and “Follow?” Be sure to click on our official Google+, Pinterest, Facebook, Twitter, and LinkedIn pages today! Categories: Systems Offered \| Tags: services offered, sound, sound masking, and systems offered This entry was posted on Friday, September 28th, 2018 at 1:20 pm . You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed. Why Labeling Network Cables is Essential for Structured Cabling When to Upgrade Your Access Control System Technology How a Messy Server Room Can Cost You How Fast Internet Can Boost Your Security The Benefits of Switching from Analog to Digital Security Cameras Fiber Plus News Systems Offered Premise/ Outside Plant Maryland Headquarters 9515 Gerwig Lane Suite 105/106 8201 Hermitage Road 21334 Croghan Pike, Ste 2 Orbisonia, PA 17243 Copyright © 2021 FiberPlus, Inc. All Rights Reserved.	cc/2021-04/en_middle_0068.json.gz/line1735
__label__wiki	0.519968	0.519968	These ranking sets have been generated by a recent version of the software, using recent data and will not match previously published issues of the rankings, especially since a majority of these generated sets are for dates much earlier than the site’s inception. Rankings will list until the next relatively standard increment (Top 5, 10, 15, etc.) after the last fighter at 20 points is found, to a maximum amount (found in the current rankings). At a bare minimum, a fighter needs at least 15 points to be displayed. Gathering data for the “unknown division lists” are crucial in building these sets, so if you want to help us research, please review these lists and inform us in the forum. Some of the older divisional lists are very small, or even blank, due to limited fights and/or limited data. Once deemed as retired or assumed as such (no fights scheduled, no fights in past 900 days from last update or manually marked as retired/deceased/etc), fighters are removed from any ranking pages more recent than their last fight. This is the one major difference between these sets and the current rankings. Note: Fighter records within these historical rankings represent their records at the date of the rankings. <<< Ranked Fighters: 76-100 >>> << Previous Issue Next Issue >> Issue 01/01/202110/01/202007/01/202004/01/202001/01/202010/01/201907/01/201904/01/201901/01/201910/01/201807/01/201804/01/201801/01/201810/01/201707/01/201704/01/201701/01/201710/01/201607/01/201604/01/201601/01/201610/01/201507/01/201504/01/201501/01/201510/01/201407/01/201404/01/201401/01/201410/01/201307/01/201304/01/201301/01/201310/01/201207/01/201204/01/201201/01/201210/01/201107/01/201104/01/201101/01/201110/01/201007/01/201004/01/201001/01/201010/01/200907/01/200904/01/200901/01/200910/01/200807/01/200804/01/200801/01/200810/01/200707/01/200704/01/200701/01/200710/01/200607/01/200604/01/200601/01/200610/01/200507/01/200504/01/200501/01/200510/01/200407/01/200404/01/200401/01/200410/01/200307/01/200304/01/200301/01/200310/01/200207/01/200204/01/200201/01/200210/01/200107/01/200104/01/200101/01/200110/01/200007/01/200004/01/200001/01/200010/01/199907/01/199904/01/199901/01/199910/01/199807/01/199804/01/199801/01/199810/01/199707/01/199704/01/199701/01/199710/01/199607/01/199604/01/199601/01/199610/01/199507/01/199504/01/199501/01/199510/01/199407/01/199404/01/199401/01/199410/01/199307/01/199304/01/199301/01/199310/01/199207/01/199204/01/199201/01/199210/01/199107/01/199104/01/199101/01/199110/01/199007/01/199004/01/199001/01/1990 Division Pound-for-PoundDivision Dominance ListHeavyweightLightHeavyweightMiddleweightWelterweightLightweightFeatherweightBantamweightFlyweightStrawweightWomen - Pound-for-PoundWomen - Division DominanceWomen - Featherweight+Women - BantamweightWomen - FlyweightWomen - StrawweightWomen - Atomweight Note: Rankings include fights on selected date. Last Generated on 12/14/2020 Rank ↑ ↓ Fighter Record Points 76 NR Akhmed Sagidguseinov 12-4-0 77 2 Assuerio Silva 4-2-0 78 -26 Marcus Silveira 5-3-0 79 32 Ian Freeman 8-1-0 80 -25 Heath Herring 14-5-0 81 NR Andrei Arlovski 3-1-0 82 Vepcho Bardanashvili 5-1-0 83 -14 Andrei Kopylov 5-6-0 84 -1 Nobuhiko Takada 2-4-0 85 -5 Borislav Jeliazkov 4-4-0 86 -8 Tra Telligman 6-3-1 87 -1 Alexander Otsuka 1-5-0 88 NR Dave Beneteau 5-4-1 89 -1 Kavkaz Sultanmagomedov 6-2-0 90 -19 Jason Godsey 11-12-0 91 -1 Danielius Razmus 7-3-0 92 11 Alistair Overeem 4-3-0 93 -19 Lee Hasdell 7-10-1 94 NR Achmed Labasanov 5-1-0 95 21 Ron Waterman 5-1-1 96 -36 Remco Pardoel 7-4-0 97 -2 Justin McCully 4-2-2 98 1 Alexei Sitnikov 6-1-0 99 -2 Katsuomi Inagaki 18-21-3 100 4 Gary Goodridge 10-11-0	cc/2021-04/en_middle_0068.json.gz/line1736
__label__wiki	0.596657	0.596657	Caine, Hall: The Woman Thou Gavest Me by Hall Caine, Fiction, Literary, Classics - Paperback [ED: Taschenbuch], [PU: Aegypan], This is the sprawling, richly detailed story of a Irish woman whose life and love are hemmed in on all sides by social prejudice and religious intolerance. Mary O'Neill is born to an already too-large family, disliked and then hated by her father. As she grows up, she clashes again and again with her family and church: for release from a marriage gone bad, for a chance at marrying the man she does love, for the legitimacy of the child she has with him. At last she finds some terms of peace, and whether they mark defeat or triumph is in the eye of the beholder. Versandfertig in 6-10 Tagen, DE, [SC: 0.00], Neuware, gewerbliches Angebot, Offene Rechnung (Vorkasse vorbehalten) Shipping costs:Versandkostenfrei, Versand nach Deutschland. (EUR 0.00) Hall Caine: The Woman Thou Gavest Me - Paperback [SR: 8249847], Paperback, [EAN: 9781603122146], Aegypan, Aegypan, Book, [PU: Aegypan], 2007-05-01, Aegypan, 590756, Contemporary Fiction, 62, Fiction, 1025612, Subjects, 266239, Books, 590912, Classics, 62, Fiction, 1025612, Subjects, 266239, Books, 275054, Religious & Inspirational, 426312031, Christian, 277403, Historical, 426311031, Jewish, 277404, Mystery, 277833, Romance, 275059, Science Fiction & Fantasy, 62, Fiction, 1025612, Subjects, 266239, Books, 590934, Literary Fiction, 62, Fiction, 1025612, Subjects, 266239, Books, 277400, Spiritual Literature & Fiction, 16269491, Devotional Calendars, 277403, Historical, 277404, Mystery, 58, Religion & Spirituality, 1025612, Subjects, 266239, Books , New item Shipping costs:Europe zone 1: GBP 5,48 / item.. Usually dispatched within 2 to 3 weeks (EUR 6.75) Paperback, [PU: AEGYPAN], This is the sprawling, richly detailed story of a Irish woman whose life and love are hemmed in on all sides by social prejudice and religious intolerance., Religious & Spiritual Fiction Shipping costs:Versandkostenfrei. (EUR 0.00) The Woman Thou Gavest Me by Hall Caine, Fiction, Literary, Classics - new book Kartoniert / Broschiert FICTION / Religious, Bezug zu religiösen Gruppen, Adultery; Divorce; domestic violence, mit Schutzumschlag neu, [PU:Aegypan] MARZIES.de Buch- und Medienhandel, 14621 Schönwalde-Glien Shipping costs:Versandkostenfrei innerhalb der BRD. (EUR 0.00) at booklooker.de [ED: Taschenbuch], [PU: Aegypan], This is the sprawling, richly detailed story of a Irish woman whose life and love are hemmed in on all sides by social prejudice and religious intoleranc… More... [ED: Taschenbuch], [PU: Aegypan], This is the sprawling, richly detailed story of a Irish woman whose life and love are hemmed in on all sides by social prejudice and religious intolerance. Mary O'Neill is born to an already too-large family, disliked and then hated by her father. As she grows up, she clashes again and again with her family and church: for release from a marriage gone bad, for a chance at marrying the man she does love, for the legitimacy of the child she has with him. At last she finds some terms of peace, and whether they mark defeat or triumph is in the eye of the beholder. Versandfertig in 6-10 Tagen, DE, [SC: 0.00], Neuware, gewerbliches Angebot, Offene Rechnung (Vorkasse vorbehalten)< [SR: 8249847], Paperback, [EAN: 9781603122146], Aegypan, Aegypan, Book, [PU: Aegypan], 2007-05-01, Aegypan, 590756, Contemporary Fiction, 62, Fiction, 1025612, Subjects, 266239, Books, 59… More... [SR: 8249847], Paperback, [EAN: 9781603122146], Aegypan, Aegypan, Book, [PU: Aegypan], 2007-05-01, Aegypan, 590756, Contemporary Fiction, 62, Fiction, 1025612, Subjects, 266239, Books, 590912, Classics, 62, Fiction, 1025612, Subjects, 266239, Books, 275054, Religious & Inspirational, 426312031, Christian, 277403, Historical, 426311031, Jewish, 277404, Mystery, 277833, Romance, 275059, Science Fiction & Fantasy, 62, Fiction, 1025612, Subjects, 266239, Books, 590934, Literary Fiction, 62, Fiction, 1025612, Subjects, 266239, Books, 277400, Spiritual Literature & Fiction, 16269491, Devotional Calendars, 277403, Historical, 277404, Mystery, 58, Religion & Spirituality, 1025612, Subjects, 266239, Books< - Amazon.co.uk at BookDepository.com Paperback, [PU: AEGYPAN], This is the sprawling, richly detailed story of a Irish woman whose life and love are hemmed in on all sides by social prejudice and religious intolerance., Reli… More... Paperback, [PU: AEGYPAN], This is the sprawling, richly detailed story of a Irish woman whose life and love are hemmed in on all sides by social prejudice and religious intolerance., Religious & Spiritual Fiction< at Achtung-Buecher.de - MARZIES.de Buch- und Medienhandel, 14621 Schönwalde-Glien Caine, Hall The Woman Thou Gavest Me This is the sprawling, richly detailed story of a Irish woman whose life and love are hemmed in on all sides by social prejudice and religious intolerance. Mary O'Neill is born to an already too-large family, disliked and then hated by her father. As she grows up, she clashes again and again with her family and church: for release from a marriage gone bad, for a chance at marrying the man she does love, for the legitimacy of the child she has with him. At last she finds some terms of peace, and whether they mark defeat or triumph is in the eye of the beholder. Details of the book - The Woman Thou Gavest Me Publisher: AEGYPAN 1-60312-214-1, 978-1-60312-214-6	cc/2021-04/en_middle_0068.json.gz/line1738
__label__wiki	0.683055	0.683055	USGS State Geologic Map Compilation Added to the Living Atlas Portions of the Bighorn Mountains in Northern Wyoming are nearly 3 billion years old. The rocks that form the mountains are among the oldest in North America. The US Geologic Survey’s (USGS) State Geologic Map Compilation is now available as a ready-to-use webmap and a set of three feature layers in the Living Atlas. These map and layers can be used as part of your GIS project in ArcGIS Online and in ArcGIS Pro. The State Geologic Map Compilation provides a seamless spatial data set that combines state geologic maps for the 48 conterminous United States. The layer’s attributes have been standardized among states to facilitate analyses of lithology, age, and stratigraphy at a national scale. Esri built these maps using feature services hosted by the USGS through the ScienceBase catalog which include more than 2,500 ArcGIS map layers. The ScienceBase catalog provides open access to a wide array of data produced for publications by USGS and partnering agencies engaged in scientific endeavors. It covers topics from sea otter tracking in California, to fish populations in headwater streams of the Adirondack Mountains, to this beautiful geology map compilation. In addition to lithology the State Geologic Map Compilation includes line features that document faulting on land and in near-shore areas. This screen shot of Marin County, California shows the complex geology and associated faulting found in the Point Reyes region. petroleum and pipeline living atlas of the world nauman	cc/2021-04/en_middle_0068.json.gz/line1741
__label__wiki	0.697451	0.697451	'Don't be fooled': ETU NSW Construction staunch against bosses' misinformation campaign Problem with ‘multi-enterprise bargaining’ laid bare in NSW construction battle. You could call it a conspiracy. In a stark indication of how badly our industrial rules are broken, several large construction companies have grouped together in an effort to undercut the ETU and its members. Seven electrical contracting companies – Star, Stowe, Heyday, FIP, NCI, Goldline and Fredon – have been working together to undermine the ETU’s efforts to bargain in good faith in a largely untested process known as “multi-enterprise bargaining”. This allows the bosses to come together and push for the same goal in a way that workers are not allowed to. Some bosses sent letters to their workers, misrepresenting ACTU Secretary Sally McManus and incorrectly comparing multi-enterprise bargaining to sector-wide industry bargaining that unions are calling for as part of the Change the Rules campaign. ETU National Legal Counsel Alana Heffernan said multi-enterprise bargaining was being sold as something akin to industry bargaining. https://www.youtube.com/watch?v=QZXFivg99Ik “When you hear the words ‘multi-enterprise bargaining’, it sounds like the type of industry bargaining that union movement is fighting for in its Change the Rules campaign. It’s not even close,” she said. “Multi-enterprise bargaining, once it commences, locks workers out from protected industrial action and stops the union from being able to enforce companies’ good faith bargaining obligations. “The Fair Work Commission can’t even intervene if the companies aren’t negotiating in good faith. READ MORE: A call to action for the ETU's Sydney Construction crew READ MORE: Rallies for a Pay Rise wrap up after month-long protest READ MORE: A tale of two solar cities “But ‘multi-enterprise bargaining’ is a system that gives workers no power or leverage at the negotiating table, which could result in you being locked in to a bad deal for years.” Heffernan said that with our current broken industrial system the best way for unions to get what’s best for members is through the direct EBAs. “Until the rules are changed, the union will continue to negotiate single-enterprise agreements, which is the best we have in a broken system, and which the union has used year on year to achieve fair conditions for its members,” she said. ETU National Secretary Allen Hicks was quick to jump on the misinformation campaign that was spreading through the NSW construction industry like wildfire. “Do not be fooled by what the company is telling you,” he warned workers. “The Fair Work system is broken. It does not provide genuine or fair industry bargaining. “The companies are promoting a system that gives workers no power or leverage at the negotiating table, which could result in you being locked in to a bad deal for years.” Hicks said the union was seeking to engage the companies one-on-one and called for them to “cease circulating misleading and inappropriate material”. This was the same message ACTU Secretary Sally McManus shared with ETU NSW members to correct some misinformation and inform them their bosses might be colluding against them. “It has come to my attention that a number of employers in the electrical contracting industry in NSW may have been misrepresenting my views, those of the ACTU and the Australian union movement, in their attempt to railroad electrical workers into an unfair and un-balanced negotiation process,” she wrote. In the letter levelled at the large construction firms’ antics, McManus ripped into the laws that allow bosses to abandon good-faith bargaining – a position that, if pursed, even locks out the Fair Work Commission. “When business owners exploit the loopholes in our current laws to force people into unfair negotiations like those proposed by these five companies, we lose our rights,” the ACTU Secretary wrote. CLICK HERE TO READ THE LETTER IN FULL “These include the right to ensure the employers bargain in good faith and the right to withdraw our labour as a last resort during the bargaining period. Not even the Fair Work Commission can intervene if employers fail to bargain in good faith under our current laws. “Under these current laws big business has too much power and working people have too little. “We need to change the rules so working people have the tools we need to sit down and have a fair negotiation to win fair pay rises and secure jobs.” The union will continue to campaign against unjust laws and fight to give our members the best possible opportunities through the bargaining process. Construction Industry featured NSW	cc/2021-04/en_middle_0068.json.gz/line1743

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