text:
Local toy company provides culturally appropriate toys for children
in Arts & Culture, Business, Sports, Youth
by Curlan Campbell, NOW Grenada
Tamboulay to supply toys reflecting Grenadian heritage and sporting prowess
Kevin Dolland creates toys and children's literature for the Grenadian market
A fascination with toys at a very young age has propelled Kevin Dolland to start his company, Tamboulay, which supplies toys reflecting Grenadian heritage and sporting prowess. "I love toys. As a child, I had over a hundred of them; the majority were action figures. From wrestlers to superheroes, playing with those toys took up the majority of my time in my childhood, and I absolutely loved them."
The 34-year-old was inspired by two defining moments: the birth of his 2 children, and the experience he garnered working with his father's company, Spice Basket – experiences, he said, that formed the catalyst which triggered this bold move. He stands proudly behind his artistic creation of action figures inspired by real-life local sporting icons, including former West Indies cricketer Junior Murray, and Olympic gold medallist Kirani James.
Trinidad and Grenada football action figures
Dolland told NOW Grenada that just like in his childhood, his daughter's toy collection grew quickly, and it was then that he noticed that it was hard to find toys that reflected her background. "It isn't enough to have a toy that is black; I felt like another step was needed and the toys should represent her far beyond just race."
And with his children being his prime motivation, Dolland pursued his dreams by designing toys and children's literature for the Grenadian market. These products include Grenadian, Trinidadian, Jamaican and Barbadian football and cricket action figures.
Dolland said, "During the design process, it felt like the 8-year-old me took over, and I began designing based on the passion for toys I had when I was a child. I wanted to create toys that children can easily identify with and a quality that is consistent with any toy they may already have in their toy box."
Alongside these action figures are 2 children's books. "Carey and Cassie's Olympic Dreams" is about Olympians representing Grenada inspiring siblings to dream about taking part in non-traditional Olympic events, like rhythmic gymnastics, sailing, and tennis. The book "Junior Murray's Camp Wicket" teaches the value of team sport. Both books come with stuffed toys.
Cricket action figures
Dolland has also introduced a cyborg police officer named "The Corporal," a superhero named "Lion Paw" which is based on the Rastafarian culture and "Ajay," the African inspired Grenadian drummer. Each action figure – some with accessories for added fun – is produced in the People's Republic of China and comes neatly packaged.
The origin of his company? "When I decided to actively pursue the concept of developing a company that produces cartoons, toys, and children books that are reflective of different passions and cultures, I wanted a name that gave that same energy of passion and culture. Eventually, I came across the word Canboulay, which has historic roots to carnival and the origins of calypso. So, Canboulay inspired the name Tamboulay."
Dolland is enjoying every moment of his journey as he realises his dreams of becoming an entrepreneur, but he admits that there are hurdles to be overcome in the process. "What gets me through all of them is the passion of creating content that I believe in and the commitment to follow through on what I have started. The main thing I got from my family is to be dedicated to the job that I am undertaking and knowing that there are no shortcuts to success. Whatever challenge comes my way, I need to embrace it and deal with it with a positive mindset."
Lion Paw action figure
Dolland believes his creative direction is in keeping with Caribbean sporting tradition, with the storyline of each character formulated. "Playing cricket is the only activity that the Caribbean comes together under one banner to compete with the rest of the world. Every other activity, the islands compete as individuals, so I felt it important to create a Caribbean cricket toy that children across the region can play with. Superheroes and mythology are popular toy categories, so I wanted to create superheroes that are inspired and based on Caribbean culture."
The expansion of the company will see the introduction of series of toys for girls which is currently in development as well as animation and other forms of productions that will seek to share Grenada's culture around the world. "Already the company has received the endorsement of Junior Murray who is expected to partner with the company on this venture throughout the various schools around the island," Dolland said.
The toys are available online at Amazon and will be introduced into many stores across the Caribbean within the coming months. Anyone interested in making a purchase can visit the company's website tamboulay.com, or on instagram.com/Tamboulay, facebook.com/tamboulaystudios and via founder's email kdolland@gmail.com.
Tags: action figurecurlan campbelljunior murraykevin dollandkirani jamesspice basketstuffed toystamboulay
Ann-Marie Mitchell says:
I would love more info. Or to subscribe,that is so impressive .


From the story of the ten lepers (Luke 17:11-19), we learn that stewardship is not simply about money. Stewardship is both a principle and a practice, a lifelong attitude and activity that has many aspects. It is a realization of who God is and what he has done – how he has provided for us….


This amazing 3x2 + Theatre dream house and land package has just been put together. Would you like to make the most of your weekends enjoying great food and wine in the company of great family and friends? Well this is the perfect package, close to West Swan road and Great Northern High way which both offer some great options!


2013 Master Directing Retreat. Actors Kelley Curran (L) and Ariel Shafir in a scene from Tennessee Williams A Streetcar Named Desire, directed by Fellow Elizabeth Carlson. Photo credit: Kalina Wagenstein.
Founded in 1984, The New York Directing Fellowships bring extraordinary emerging stage directors into an extended program of creative advancement, industry-focused development, professional assistantships, and an opportunity to present their work to the field as part of the Off-Broadway festival DirectorFest, the nation's preeminent festival highlighting rising directorial talent. The Fellowships nurture artistry, open doors, and usher in a maturation of skills and talent, preparing a director to work professionally at the highest levels the field can offer.
July 28-August 1, 2019: Fellows will participate in the Regathering Weekend and the Master Directing Retreat, an extended directing workshop under the guidance of a master director and teachers. Regathering Weekend will focus on practical skill acquisition, while the Master Directing Retreat will be held at a retreat center. Professional actors will join the directors for an immersive exploration of a specific text or playwright.
The New York Directing Fellows will assist on productions at major regional and/or New York theaters with leading theater artists. Each Fellow completes one or two assisting assignments depending on length and availability. These are designed for each director's needs and curated by Drama League staff.
January 2020: The New York Directing Fellows stage one-act productions as part of DirectorFest, The Drama League's annual festival dedicated to the art of professional directing in the United States. The festival takes place in New York City for an audience that includes artistic directors, producers, interested industry professionals, and others. DirectorFest is fully produced using professional casting directors, designers and production personnel. Post-production, the directors meet with theater professionals for an in-depth discussion of their work.
The stipend amount will be determined in April 2019. For the 2017 cycle, the Stipend was $7,225 for the 17 active weeks of the fellowship (between late May and late January), paid in equal installments. The amount of the Stipend will be disclosed prior to acceptance.
Fellows are provided with housing in New York (if needed) during Professionals Week, Regathering Weekend, DirectorFest and the Master Directing Retreat; round-trip transportation to, and housing for, their assistantship assignments (if needed).
The Drama League DirectorFest production of Out At Sea by Slawomir Mrozek, translation by Nicholas Bethell, directed by 2016 Directors Project Fall Fellow Sarah Elizabeth Wansley. Photo: Richard Termine.
"The Drama League took a risk and gave me an opportunity no one else would - they produced a play I directed in the heart of New York City and invited everyone to see it. Every professional opportunity I've had since is the resulte of that chance they took on someone unknown and untested. I will always be eternally grateful to The Drama League for their belief in me and for the continued nurturing that has endured over the years."


Consumers looking for a better way to easily store and share photos and videos can turn to Sony's new Personal Content Station. This wireless home device gives users centralized control over their data, even if it was captured and resides on several devices.
The rise in smartphones and tablets with advanced cameras and imaging capabilities is creating a content storage and management issue for consumers. According to recent industry research, 80% of smartphone users admit to keeping photos on their device, rather than deal with the hassle of transferring them to a PC.
The Personal Content Station addresses this need simply and effectively. It connects wirelessly to a home network to store, view and share photos and videos from a consumer's different devices including smartphones, tablets, cameras and camcorders.
The Personal Content Station supports data transfer through a Wi-Fi connection from smartphones or tablets, a USB connection or memory card.
Using near field communications (NFC) technology, with just one touch, users can automatically begin transferring the most recent photos and videos taken from a phone to the Personal Content Station. This "One-touch backup" is managed by the "PCS Manager" App (available for download through Google Play or the iTunes App Store). All users need to do is bring their device close to the "N" marked area on the Personal Content Station. For non-NFC devices, users can simply start the transfer process by following the instructions on the PCS Manager App.
The PCS has a contoured top design well-suited for placing smartphones or digital cameras while transferring content and its stylish look blends easily into home environments.
A key feature of the PCS device is a built-in video transcoder that automatically converts high-definition AVCHD videos to the MP4 format for playback on smartphones or tablets. The original files remain on the Personal Content Station untouched and at their original quality and resolution. Its HDMI interface lets users view photos and videos on large-screen TVs in full HD (up to 1080/60p) quality.
Users can manage and post photos and videos stored on the device to cloud network services or social media sites such as Facebook and Twitter from their smartphone or tablet.
The Sony Personal Content Station, model LLS-201, is planned to be available in June 2013, at a suggested retail price of $299. For more information please visit http://www.sony.net/Products/ws/en_us/pcsintro/index.html.


Set in the underworld of Fortune Valley, you and your crew are reunited by a search for vengeance against The House, a nefarious cartel that rules the city's casinos, criminals, and cops. In this corrupt gambler's paradise, the stakes are high and The House always wins. Play a variety of events as Tyler, Mac, and Jess. Earn the respect of the Valley's underground and compete in the ultimate race to finally take down The House.
A natural-born racer, Ty possesses killer racing instincts and an unwavering will to win that make him a formidable opponent whether in a street race or on the drag strip.
Jess is a runner, a driver for hire to the rich and infamous who can get you out of trouble no matter how volatile the situation.
Mac is the crew's drift and off-road specialist, a happy-go-lucky driver with a flashy, unpredictable style. He loves getting down and dirty on the trail, or executing that flawless line around a tight corner.
Put your foot to the floor and never hold back. Bring home the win, speed is everything.
Perform high-risk, high-reward jobs, just keep a look out for the cops.
Head off-road and kick up the sand and dust, don't let the tarmac contain you.
Rav is the crew's mechanical genius. Although he rarely steps out of his workshop, he lets the crew use his garage out in the desert and helps them tune up their rides.
Lina Navarro is the House's representative on the street racing scene. Although she's one of Fortune Valley's top technical racers, she prefers to rely on her street smarts to get ahead.
Marcus Weir is the apex predator of the Silver Rock casino scene. A relentless risk-taker with a taste for long shots and impossible odds, he has risen through the Fortune Valley scene through wits and guts alone.
The street leagues of Fortune Valley stand between you and the Outlaw's Rush. Take on the races and face each league's boss.
Tyler and the rest of the crew set out to steal a super car from under the nose of the Gambler.
The crew have learned that The House are transporting a car equipped with new technology.
Take on blockbuster missions and take down The House.


Description CARFAX One-Owner. Clean CARFAX. Certified. Iridium Silver Metallic 2016 Mercedes-Benz C-Class C 300 4MATIC® 4MATIC® 7G-TRONIC PLUS 7-Speed Automatic 2.0L I4 Turbocharged *MERCEDES-BENZ CERTIFIED, *ONE OWNER CLEAN CARFAX REPORT, *POWER TILT/ SLIDING PANORAMA SUNROOF, Blind Spot Assist, Burmester Premium Sound, COMAND Navigation & Voice Control, Heated Steering Wheel, KEYLESS GO®, Multimedia Package, Navigation Map Updates Included For 3 Years, Premium 2 Package, Rear-View Camera, SiriusXM Satellite Radio, SiriusXM Traffic and Weather Services, Surround Light Mirror Mounted Entry Lamps.
Please feel free to call or text Mike DiPrimeo, our Pre-Owned Sales Manager, directly at 855-372-6356 to schedule an appointment. You can visit our virtual showroom at www.yourmercedes.com to view pictures and our entire inventory!


The article, "Genome wide association analysis in a mouse advanced intercross line," was written by Dr. Natalia Gonzales, Dr. Abraham Palmer, and other co-authors. It was just accepted for publication in Nature Communications.
Read the article here! Congratulations, Natalia!


text:
Module contains logic from [cca](https://www.npmjs.org/package/cca) that is
shared with the [Chrome App Developer Tool](https://github.com/MobileChromeApps/chrome-app-developer-tool/).

## Using from cca

Nothing must be done when developing locally, but the version must be bumped
and published when publishing cca.

## Using from chrome-app-developer-tool

When developing changes, npm link cca-manifest-logic, install CADT and then run `gulp`
whenever files change. When happy with change, publish a new version to npm so that
chrome-app-deleloper-tool always works without needing to `npm link` in this module.

redpajama_set_name: RedPajamaGithub


Last January a new platform for young nature photographers was born thanks to 4 people who are deeply connect to photography and nature: Mónica Busquets, Jon A. Juarez, Sergio MarijuánandAdelina Sánchez.
This platform aims to promote respect and love for our environment, but also discovering and showing all its treasures and biodiversity through the photos taken by the upcoming photographers.
Youngnaturephotographers seeks a virtual space via an online community, as well as a platform to facilitate connections and meetings among all members. We want to support the discovery of new environments and the development of creativity and artistic sensibility without forgetting all environmental and conservationist values.
Some of the most active members are: Paloma Lario, Lluc Semis, Marc and Laura Albiac, David Guisande, Sabin Infante, Victor Ortega (Spain), Laurent Dumas (France), Toby Pickard (UK), Ashleigh Scully, Carolina Fraser (USA), Ingo Zahlheimer (Germany), Sara Skidell (Sweden), ... among the almost 700 members.
Besides the daily posts, there are ruffles backed by our partners. To participate one has to be 25 or younger and label their photos with our hashtag. All the photos posted from our members are shown also on Facebook, a very interesting platform full of shared articles and news:www.facebook.com/youngnaturephotographers.
Right on top of our ToDo list there is a new website for our community and a first international meeting planned for this autumn in Berlin (Germany).
Younger than 25 or not we are gonna be happy if you follow us!
We are very proud to welcome the Association of Slovenian Nature Photographers to our IFWP!!!
The Association was founded on April 5, 2017 in Ljubljana, where is based.
The Association of Nature Photographers of Slovenia encourage the photographers to improve nature photography and take care of nature conservation.
The purpose of the association is to promote and popularize author nature photography and to create a positive attitude to it, with pictures of nature in society organizing photo contests, exhibitions, screenings and conferences among photographers, to increase interest and make this style of photography more popular and, at the same time, increasing the formation of the members of the association and the community in general.
We hope you will develop your projects with us and do not hesitate to suggest us any initiative for makig our Federation stronger.


Clinical research has recently demonstrated that vitamin D deficiency (VDD) is highly prevalent in the pediatric intensive care unit (PICU) and associated with worse clinical course. Multiple adult ICU trials have suggested that optimization of vitamin D status through high-dose supplementation may reduce mortality and improve other clinically relevant outcomes; however, there have been no trials of rapid normalization in the PICU setting. The objective of this study is to evaluate the safety and efficacy of an enteral weight-based cholecalciferol loading dose regimen in critically ill children with VDD.
The VITdAL-PICU pilot study is designed as a multicenter placebo-controlled phase II dose evaluation pilot randomized controlled trial. We aim to randomize 67 VDD critically ill children using a 2:1 randomization schema to receive loading dose enteral cholecalciferol (10,000 IU/kg, maximum of 400,000 IU) or a placebo solution. Participants, caregivers and outcome assessors will be blinded to allocation. Eligibility criteria include ICU patient, aged 37 weeks to 18 years, expected ICU length of stay more than 48 h, anticipated access to bloodwork at 7 days, and VDD (blood total 25 hydroxyvitamin D < 50 nmol/L). The primary objective is to determine whether the dosing protocol normalizes vitamin D status, defined as a blood total 25(OH)D concentration above 75 nmol/L. Secondary objectives include an examination of the safety of the dosing regimen (e.g. hypercalcemia, hypercalciuria, nephrocalcinosis), measures of vitamin D axis function (e.g. calcitriol levels, immune function), and protocol feasibility (eligibility criteria, protocol deviations, blinding).
Despite significant observational literature suggesting VDD to be a modifiable risk factor in the PICU setting, there is no robust clinical trial evidence evaluating the benefits of rapid normalization. This phase II clinical trial will evaluate an innovative weight-based dosing regimen intended to rapidly and safely normalize vitamin D levels in critically ill children. Study findings will be used to inform the design of a multicenter phase III trial evaluating the clinical and economic benefits to rapid normalization. Recruitment for this trial was initiated in January 2016 and is expected to continue until November 30, 2017.
Numerous observational studies have demonstrated that vitamin D deficiency (VDD) is highly prevalent in pediatric intensive care units (PICU) around the globe, with rates ranging from 30 to 80% [1–7]. These observations are concerning as vitamin D is accepted as a pleiotropic hormone important for the proper functioning of organ systems central to the progression of critical illness. VDD has been implicated in the health and stress response of the cardiovascular, immune, respiratory, and neurological systems. The biological mechanisms through which VDD may contribute to primary or secondary ICU pathophysiology have been discussed in detail elsewhere [8–10]. Multiple observational studies have established an association between lower vitamin D levels and worse clinical outcomes in critically ill children [1, 3, 4, 7, 11]. These same findings are well established in the adult intensive care unit (ICU) setting, with cumulative results on tens of thousands of critically ill adults reporting associations between hormone level and organ dysfunction, health resource utilization, and mortality [12–18]. In 2014, two systematic reviews and meta-analyses of adult ICU observational data independently concluded that a total 25 hydroxyvitamin D level, 25(OH)D, below 50 nmol/L was associated with an almost twofold increased risk of mortality [19, 20]. However, as the findings are based on data from observational studies, it is important not to draw conclusions on causality as the relationship may be driven by confounding factors.
Multiple adult and pediatric critical care research groups have hypothesized that optimization of vitamin D status could improve clinical outcomes and save health care costs [21, 22]. This optimization will require a significant change in the current approach to vitamin D supplementation. Presently, usual care involves the enteral or parenteral administration of between 200 and 1000 IU/day of cholecalciferol. Although widespread, this approach may only minimally benefit patients. Substantial literature from ambulatory populations suggests that administration of low-dose daily supplementation can require months to rebuild body stores and may not be sufficient in some patients. Moreover, emerging evidence from hospitalized and ICU patients suggest that levels often remain constant and may even decline during the first few weeks in the ICU with usual care [18, 23]. The Institute of Medicine Tolerable Upper Intake Level supports the use of higher daily doses which are age-based and range from 1000 to 4000 IU . Although this would be an improvement, a recent systematic review by our group identified that these doses still require at least a month to normalize vitamin D status in those who are VDD . This timeframe would be reasonable in the outpatient settings, but may not be optimal in critical illness where prolonged periods of VDD could contribute to secondary pathology, protracted recovery, and may influence long-term quality of life. Consequently, alternative approaches to vitamin D supplementation will be required to rapidly optimize vitamin D status in the ICU setting. The high VDD rates in critically ill patients, while concerning, could also present a unique opportunity to improve outcomes following the critical stages of illness once an ICU-specific approach to vitamin D supplementation is identified.
Recognizing that vitamin D is a safe, simple, and inexpensive intervention, multiple adult ICU research groups have proceeded to randomized controlled trials (RCT) [26–33]. Of these, two RCTs have been especially important in demonstrating the benefit of vitamin D supplementation in ICU. Both trials sought to rapidly normalize vitamin D status in ICU, over 2 to 5 days, using enteral loading dose cholecalciferol therapy. VITdAL-ICU, the only phase III trial to date, reported that administration of a single enteral cholecalciferol loading dose (540,000 IU) to VDD critically ill adults reduced mortality in those with severe deficiency and improved long-term functional outcomes in those with more moderate deficiency . Second, the RCT by Han and colleagues comparing 250,000 and 500,000 IU enteral cholecalciferol (divided over 5 days) with placebo in critically ill ventilated adults reported a statistically significant reduction in length of stay . Two adult systematic reviews with meta-analyses published in late 2016 suggested that high-dose vitamin D has the potential to reduce ICU mortality and length of stay [15, 16].
Although encouraging, the findings from adult trials are not directly transferrable to the PICU setting and clinical trials will be required to address the unique characteristics of children. Primary among the issues to be resolved include establishing a dosing regimen that safely allows for rapid normalization of vitamin D status across a broad range of pediatric ages and conditions. We recently performed a systematic review and meta-regression of pediatric high-dose vitamin D trials to help inform the dosing regimen for a rapid normalization RCT in the PICU setting . This analysis identified weight-based enteral loading therapy of 10,000 IU/kg, up to a maximum of 400,000 IU, as the dosing regimen most likely to rapidly and safely normalize levels (in unwell VDD children). Although not commonly used in North America, intermittent or loading dose cholecalciferol is well studied for the prevention and treatment of rickets in many countries and is included in reviews and positions statements [34, 35]. That said, as concern persists about the safety of high-dose vitamin D, we completed a meta-analysis of clinical trial data which failed to identify evidence of toxicity until doses generated group average 25(OH)D level above 200 nmol/L (consistent with dosing above 400,000 IU). The dosing regimen identified in our meta-analysis should avoid the supraphysiological concentrations (> 200 nmol/L) associated with toxicity in the majority of patients. While data from this extensive review support the efficacy and safety of this dose, rigorous clinical trials are required before it can become part of standard care in PICU.
In collaboration with the Canadian Critical Care Trials Group (CCCTG), we propose a placebo-controlled phase II dose evaluation pilot trial of a weight-based enteral loading dose of cholecalciferol in critically ill children with vitamin D deficiency. The primary objective of the VITdAL-PICU pilot study is to determine whether the dosing regimen can rapidly normalize vitamin D levels in critically ill children with VDD. Secondary objectives are to evaluate the safety of the dosing regimen (e.g., hypercalcemia and hypocalcemia), improved vitamin D axis functioning (e.g., active hormone levels and calcium metabolism), and differences in blood measures of inflammation and innate immunity (e.g., C-reactive protein and procalcitonin) compared to placebo. Tertiary feasibility objectives are to assess adherence to the treatment protocol (including blinding), assess the appropriateness of our eligibility criteria for the full trial, and estimate the rate of patient recruitment while understanding barriers to recruitment.
This study was designed as a placebo-controlled dose evaluation pilot RCT. Although the placebo group is not directly relevant to our primary objective of dose evaluation, this study design is essential to allow us to address our secondary and tertiary objectives. The inclusion of a placebo group will allow us to describe blood or urine calcium levels (i.e., surrogates of vitamin D toxicity) for children who are and are not exposed to the rapid restoration dose. Further, the placebo arm is required to properly evaluate recruitment and our ability to achieve blinding. The study protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist (see checklist, Additional file 1). A summary of the protocol is provided in Table 1.
The VITdAL-PICU pilot study was initially designed to recruit patients from the pediatric and neonatal ICUs at a single academic center in Ottawa, Canada (Children's Hospital of Eastern Ontario (CHEO)). To increase feasibility and further evaluate the study protocol, two additional study sites were added: Graz, Austria (Medical University of Graz) and Concepción, Chile (Hospital Guillermo Grant Benavente).
Study staff will screen pediatric ICUs (and neonatal ICU at Ottawa site) from Monday to Friday for patients meeting eligibility criteria. Eligibility criteria include patient admitted to the ICU, corrected gestational age > 37 weeks to age < 18 years, expected ICU admission in excess of 48 h and likely to have access for bloodwork at day 7, and blood 25(OH)D level of < 50 nmol/L (regardless of prior approach to supplementation). The inclusion and exclusion criteria, and justification for each criterion, are presented in detail in Table 2. If a patient meets all eligibility criteria, with the exception of 25(OH)D level, the study team will approach the legal guardian for informed consent. If consent is obtained, the patient's vitamin D status will be determined, and the patient randomized into the study if they meet the 25(OH)D criteria.
Admitted to the pediatric or neonatal ICU. The neonatal ICU was included to improve recruitment and to increase the number of participants aged < 30 days. At randomization, patients are stratified by recruitment site (PICU vs NICU) to account for site-specific practice variation.
Pediatric study (< 18 years). Very premature infants are at significantly increased risk for nephrocalcinosis [40, 41]; children < 37 weeks corrected gestational age are excluded to reduce the risk of enrolling patients with an increased chance of adverse outcome.
This inclusion criterion was selected to (i) include an ICU population with a higher illness severity and (ii) to increase the likelihood of obtaining a blood sample at day 7 for measurement of the primary outcome.
Although thresholds and terminology can vary, vitamin D deficiency is generally accepted as < 50 nmol/L (severe deficiency as < 30 nmol/L) [42–45]. Multiple observational ICU studies have shown an association with poorer outcome once vitamin D levels fall below 50 nmol/L [19, 20]. Some evidence exists that shows the benefit of supplementation (as defined by mortality) may be limited to ICU patients with severe deficiency (< 30 nmol/L) [2, 27]. In those with more moderate deficiency (30–50 nmol/L) benefits were observed in repeated infections and quality of life [2, 27]. To evaluate this in PICU, we will compare changes in biochemistry and clinical measures separately for the groups with starting 25(OH)D above and below 30 nmol/L.
At present, there is no intravenous form of cholecalciferol, preventing the inclusion of ICU patients who cannot receive enteral drugs.
Patients presenting with hypercalcemia may be at increased risk for toxicity or adverse outcome with a significant abrupt increase in vitamin D level.
Patient with William's syndrome have a genetic susceptibility to hypercalcemia, and current guidelines recommend against any vitamin D supplementation [46, 47].
Patients presenting with nephrolithiasis or nephrocalcinosis would be at increased risk for an adverse outcome.
If a patient will be transferred or have care withdrawn imminently, we would be unlikely to obtain either day 3 or day 7 blood and urine sample (25OHD, hypercalcemia, hypercalciuria).
Patients who previously participated in the VITdAL-PICU study will be excluded to avoid confounding.
Excess active vitamin D hormone has been observed in patients with granulomatous diseases (tuberculosis/sarcoidosis) and can potentially lead to hypercalcemia or hypercalciuria through increased intestinal absorption of calcium .
The liver plays an essential role in vitamin D metabolism. Patients with severe liver dysfunction/failure have a minimized capacity to convert vitamin D to its active form. To allow for a study population with a more homogenous ability to metabolize and benefit from vitamin D supplementation, patients with severe liver dysfunction/failure will be excluded.
There is an increased risk of hypercalcemia if vitamin D is co-administered with both thiazide diuretics and calcium (as per product monograph).
Maternal hypercalcemia, possibly caused by excessive vitamin D intake during pregnancy, has been associated with hypercalcemia in neonates, which may lead to adverse effects (as per product monograph).
Vitamin D should be used with caution in patients on digoxin. Hypercalcemia (which may result with vitamin D use) may precipitate cardiac arrhythmias (as per product monograph).
As clinical testing and reporting of blood 25(OH)D concentration frequently requires 10 to 14 days at CHEO, rapid determination of vitamin D levels will be performed using a FDA and Health Canada approved device (FastPak®, Qualigen, Inc.). Prior to the initiation of recruitment, the FastPak® was validated, and a proficiency certificate was obtained from the Vitamin D External Quality Assessment Scheme (DEQAS) group for meeting the performance targets set by their advisory panel for 25(OH)D assays (Additional file 2). The laboratories in Austria and Chile are capable of rapid measurement of vitamin D (< 24 h); therefore, the screening sample will be analyzed by the laboratory using a validated assay.
Patients will be randomized 2:1 and stratified by (i) patient age (above or below 30 days of age) and (ii) recruitment location (CHEO NICU, CHEO PICU, Austria, or Chile). A 2:1 randomization (high dose: placebo) schema was employed because the control group is not directly pertinent for our primary objective of dose evaluation but required to assess our secondary objectives. The secondary objectives can be properly assessed with a smaller control group. Therefore, in order to avoid enrolling more participants than necessary, and to improve the feasibility of this dose evaluation study by minimizing costs, the decision was made to use 2:1 randomization. We have decided to stratify by age as neonates can respond uniquely to medications due to different water/fat content, hepatic, and renal functioning. Further, calcium homeostasis and the definition of abnormal for both hypercalcemia and hypercalciuria are different for neonates. Stratification by neonatal status will ensure that these differences are equally distributed between the two groups.
The Methods Centre at the Ottawa Hospital Research Institute will prepare a computer-generated randomization list. Randomized allocation will be achieved as follows: At enrolment, study staff will record the next available study ID number within the correct stratification group on the study drug order form. The pharmacist will match the study ID number assigned to the hard-copy randomization list to determine treatment allocation and will dispense the appropriate study drug and dose.
Blinding during this pilot study is necessary to allow us to evaluate the feasibility of a phase III trial designed to evaluate clinically relevant outcomes that are subjective in nature. Study personnel (study coordinator, research assistants, principal investigator, co-investigators, site investigators, data management personnel, and statisticians), members of the health care team (treating physicians, bedside nurses, and clinical pharmacists), and patients/families will be blinded to the study group assignment. It is possible that the study safety officer (PG) will become aware of study group allocation. The safety officer, who does not contribute to the medical care of the patients, will review each study participant's vitamin D level from the day 7 blood sample to identify participants at potential risk for vitamin D toxicity (25(OH)D > 200 nmol/L) in real-time. Since it is expected that the vitamin D level of patients in the control group will not increase significantly from the time when they met eligibility criteria (25(OH)D < 50 nmol/L), the safety officer will likely be able to determine which patients were allocated to the vitamin D treatment arm if their discharge vitamin D level is substantially higher than 50 nmol/L. Otherwise, the assigned intervention will not be revealed until all patients have been discharged from hospital (censored at 90 days), determination of research-related biochemical testing is complete, and the research database has been finalized. To maintain blinding, the randomization lists will only be accessible to the Data Management Services of The Methods Centre at the Ottawa Hospital Research Institute and to the research pharmacist(s). Further, the active drug and placebo will be identical in appearance, consistency, volume, taste, and smell.
In the event of an unexpected serious adverse event that is believed to be related to vitamin D administration, blinding can be broken at the request of clinical service. The randomization code and list of randomized participants will be stored at the pharmacy. Clinical service will notify the principal investigator, who will then contact the pharmacy to unblind the participant. In the event that a participant's day 7 25(OH)D level is > 200 nmol/L, the safety officer will refer the patient to endocrinology. The patient will be managed clinically as determined by endocrinology, who may elect to unblind the participant.
Participants randomized to the experimental arm (see protocol flow diagram, Fig. 1) will receive an enteral cholecalciferol load (vitamin D3 (cholecalciferol) oral solution 50,000 IU/mL, Euro-Pharm International Canada Inc.) at a dose of 10,000 IU/kg (maximum 400,000 IU). This dose was chosen based on our systematic review of all pediatric trials reporting on the administration of high-dose vitamin D . This review comprehensively evaluated the ability of different dosing regimens to rapidly normalize vitamin D levels and concluded that a weight-based enteral loading therapy of approximately 10,000 IU/kg was the suitable dosing regimen to rapidly normalize vitamin D status.
Participants randomized to the control group will receive a placebo solution equivalent in volume to the appropriate dose of cholecalciferol. The placebo will be provided by Euro-Pharm International Canada Inc. and contains caramel color, cherry flavor, citric acid (anhydrous), glycerin, polysorbate 80, propylene glycol, purified water, and sucralose. The control product will be identical in smell, taste, and appearance to the study drug. Sites in Austria and Chile will use vitamin D and placebo from Fresenius Kabi (Oleovit D3) and Laboratorios Andromaco SA (D'Vidamax 50,000 IU Oral Solution), respectively.
At the discretion of the health care team, study participants in either arm can receive routine or standard of care daily vitamin D administration. If the health care team chooses to prescribe vitamin D as part of clinical care, the study team will recommend a dose of 400–800 IU/day. However, the health care team will be free to prescribe doses outside of this range, and it will not be documented as a protocol violation. If a patient presents with symptoms of severe vitamin D deficiency and the treating physician intends to administer a large dose of vitamin D, or if standard treatment includes administration of high-dose vitamin D (i.e., patient admitted with severe burns) the patient will not be enrolled in the study (excluded due to physician refusal). Additional vitamin D administration will be documented on the case report form. With the exception of study drug administration, there will be no other changes to clinical management. Co-interventions will not be protocolized as the study is blinded, and any differences should relate to either random chance or effects from the study drug. Major co-interventions will be captured on the case report form during data collection.
Blood samples will be collected at the time of clinically indicated venipuncture or through arterial or central venous line access. When possible, blood will be collected at enrolment, and on days 1, 2, 3, 7, 30, 60, and 90 and at hospital discharge. Urine samples will be collected at enrolment, on days 3 and 7 and at hospital discharge. Blood samples at each time point will be analyzed for 25(OH)D levels. Ionized calcium will be measured on days 3, 7, 30, 60, and 90, unless ionized calcium has been measured through clinical bloodwork in the preceding 24 h, or a clinical calcium sample is planned for that day. Urine samples at each time point will be analyzed for calcium:creatinine ratios.
Our primary outcome is the proportion of critically ill children who achieve blood 25(OH)D concentration above 75 nmol/L by day 7 (normalization of vitamin D status). 25(OH)D is widely regarded as the best indicator of vitamin D status . If bloodwork cannot be obtained on day 7 ± 48 h (e.g., no access to bloodwork, patient discharged), the patient's 25(OH)D level from day 3 will be used for the primary outcome. Results from an adult ICU RCT evaluating a single 540,000 IU enteral load demonstrated no difference in 25(OH)D levels at day 3 versus day 7 . Secondary and tertiary outcome measures are summarized in Table 3 and include an examination of the safety of the vitamin D dosing regimen, vitamin D axis function, immune function, feasibility, and identification of phase III trial outcomes.
• Hypercalcemia—defined as an ionized calcium level above 1.40 mmol/L (children under 8 weeks as > 1.45 mmol/L).
We will also evaluate for, and report on, the occurrence of serious adverse events that could potentially be related to vitamin D.
Evaluated through an analysis of blood calcium, parathyroid hormone, and 1,25(OH)2D.
Protocol non-adherence: protocol adherence will be considered successful if (a) major protocol deviations occur with regard to study drug administration or safety procedures in < 20% of enrolled patients.
Study drop out: a study dropout rate of < 10% will be considered acceptable.
Evaluation of the proposed eligibility criteria: defined as our ability to predict ICU stay longer than 48 h and bloodwork access at 7 days.
Patient accrual rate: defined as the number of patients enrolled over a 2-year period. We will consider the patient accrual rate acceptable if we are able to successfully enroll 67 patients within 2 years.
Ability to maintain blinding: ability to maintain blinding will be considered successful if the frequency of unblinding requests from the clinical care team and from the pharmacy is < 10%.
Specific criteria must be met to establish the feasibility of proceeding to a phase III trial. Protocol adherence will be considered successful if major protocol deviations with regard to study drug administration (e.g., patient randomized but drug not administered, drug administered late) or safety procedures (e.g., referral not given for patient who met safety criteria for referral to nephrology/endocrinology) occur in < 20% of enrolled patients. In our sample size calculation, we estimated a dropout rate of 5%; however, we will consider a study dropout rate of up to 10% as acceptable. Recruitment rate will be defined as the number of patients enrolled over a 2-year period. We will consider the patient accrual rate successful if we are able to enroll 67 patients within 2 years (average 2.5 patients/month). We will consider our ability to maintain blinding successful if the clinical care team or pharmacy request unblinding in < 10% of enrolled patients. Finally, we will also evaluate the proposed eligibility criteria, specifically, out of ability to predict ICU stay longer than 48 h and bloodwork access at 7 days. The purpose of these criteria is to ensure we are able to collect a blood sample for the primary outcome. We will consider these criteria acceptable if we are able to obtain a blood sample in 95% of enrolled patients.
Adverse events will be monitored and reported according to regulatory and local ethics board requirements. Specifically, three serious adverse events (SAEs) have been identified that would be considered both unexpected and potentially related to study drug and would require reporting Health Canada, European Medical Association and local research ethics boards. They are (i) gastrointestinal bleeding (requiring blood transfusion) and perforation (requiring surgery) within 48 h of study drug administration; (ii) persistent hypercalcemia (> 24 h in the absence of parenteral calcium administration) with renal failure requiring dialysis, nephrocalcinosis, hemodynamically significant arrhythmia, and cardiorespiratory arrest or death; and (iii) new or worsening hypercalciuria with nephrolithiasis, renal failure leading to dialysis or death. Ionized calcium levels and urine calcium:creatinine ratios from study samples will be monitored in real time by the site investigator for hypercalcemia and hypercalciuria (see Table 4 for established thresholds). Additionally, the 25(OH)D level at day 7 will be reviewed by the study nephrologist (PG). Safety procedures have been protocolized, and patients with abnormal research samples will be referred to nephrology or endocrinology as outlined in Table 4.
The goal of our weight-based loading protocol is to achieve target 25(OH)D concentrations above 75 nmol/L in 75% of the participants who receive loading dose vitamin D. Further, the minimal acceptable proportion achieving target where we would consider proceeding with a phase III trial is 50%. This minimal acceptable proportion is based on results from the VITdAL-ICU phase II study in adult ICU that suggested a 7% absolute risk reduction in mortality with only 52% of enrolled patients achieving a 25(OH)D level > 75 nmol/L . Assuming that the true proportion achieving target is 75%, a random sampling of 36 patients has ~ 90% power to return an estimate in excess of 66%––two thirds of participants achieving target 25(OH)D. Given an estimate in excess of 66% and a sample size of 36, the lower 95% confidence interval will exclude 50%. To account for 5% dropout or missing samples, we will recruit up to 40 patients into the high-dose arm, and 20 in the placebo arm, for a total sample size of 60 patients.
The assumption that 75% of patients who receive the loading dose will achieve target levels is based on our systematic review and meta-regression . We anticipate that 10,000 IU/kg will raise the vitamin D level by 70 nmol/l. Assuming a group average value of 40 nmol/L in the intervention arm, this will result in a post-load group 25(OH)D level of approximately ~ 110 nmol/L. Given a standard deviation of no more than 35 nmol/L, we would anticipate that 16% of the group will not achieve a post-load value of 75 nmol/L (z score of − 1). However, given that some of the older children (weight above 40 kg) will receive less than 10,000 IU/kg, we have reduced our estimate of proportion achieving target to 25%.
Based on (i) the annual ICU admission rate at participating sites, (ii) our experience with vitamin D RCTs and published work on factors affecting consent rate in PICU studies in Canada (anticipated consent rate ~ 50%) , (iii) discussions with the CCCTG, and (iv) the anticipated frequency of VDD in PICU, we have planned for up to 2 years as a feasible timeframe for recruitment into this dose evaluation study.
Follow-up for the VITdAL-PICU pilot study ends at 90 days, hospital discharge, or death. Consequently, loss to follow-up will primarily relate to participant withdrawal or dropout and is anticipated to be negligible (< 5%). As most critically ill ICU patients have regular blood work, we anticipate that in the absence of death, there will be research blood and urine collected for 25(OH)D and calcium determination on the vast majority (> 95%) of patients on day 7 (or day 3). For our recently completed RCT of pre-operative supplementation in children with congenital heart disease (NCT01838447), post-operative collection of research blood for the primary outcome, collected at the time of PICU admission following surgery, was 100% .
Data for each study patient will be entered by site study staff directly into the web-based case report form (eCRF), using only the study ID number to identify the record. The case report form has been developed and managed using an electronic data capture tool, Research Electronic Data Capture (REDCap) , which will be hosted at the CHEO Clinical Research Unit. REDCap is a secure, web-based application designed to support data collection for research studies. Pre-defined ranges for all data values will be set up in this application to allow data entry personnel to validate data as soon as they are entered and send data queries immediately. Missing data will be similarly managed.
The following information will be collected: demographic information, fluid and inotrope administration, surgical procedures, progression and resolution of organ dysfunction (e.g., PEdiatric Logistic Organ Dysfunction-2 score), occurrence of adverse events, length of mechanical ventilation, length of ICU and hospital stay, survival status, renal function, gastrointestinal bleeding, quality of life scores (e.g., PedsQL™ Pediatric Quality of Life Inventory™), and laboratory results. Additional information will be collected for patients who are discharged from hospital before 90 days including hospital readmission rate and frequency of illness.
Participant-related information including eCRFs and laboratory specimens will be kept strictly confidential. All records will be kept in a secure, locked location, and only research staff will have access to the records. The REDCap study database is securely protected and encrypted. All computerized databases will identify subjects by numeric codes only.
Analyses will be performed using SAS® software (Cary, NC, USA), and a p value less than 0.05 will be considered statistically significant. Additionally, both treatment arms will be described using descriptive statistics: (i) means with standard deviations or medians with inter-quartile range values for continuous variables or (ii) frequencies with percentages for categorical variables.
The primary analysis for the study will be the proportion of participants in the treatment arm achieving 25(OH)D levels above 75 nmol/L on day 7 (with its 95% confidence interval). We expect 0% of the control arm to achieve the target 25(OH)D level of 75 nmol/L. This assumption is based on the fact that the control arm will receive no vitamin D treatment, or usual care vitamin D (if prescribed by the care team) which our meta-analysis demonstrated would not be able to move vitamin D levels from < 50 nmol/L to ≥ 75 nmol/L within 7 days . Further, vitamin D levels of hospitalized children have been shown to stay the same or even fall over time with usual care [18, 23]. The analysis will evaluate the data using both intention to treat (primary) and per protocol (secondary) approaches. In addition, we will also report on (i) the distribution of 25(OH)D levels on day 7 using means/medians with the appropriate measure of distribution (standard deviation, IQR) and (ii) the number of study participants who developed 25(OH)D levels in excess of 200 nmol/L.
Analyses of secondary outcomes will focus on confidence interval generation. Secondary outcomes will be described by group as means with standard deviations or medians with inter-quartile range values for continuous variables, or as frequencies with percentages for categorical variables (e.g., hypercalciuria, hypercalcemia, nephrocalcinosis). We will also conduct some exploratory evaluations between groups based on data type. Outcome measures that are continuous will be evaluated using the t test or Mann-Whitney (where appropriate). Binary secondary outcome measures will be compared between the two treatment groups using Fisher's exact or chi-square test. If randomization does not lead to equal distribution of important variables (e.g., weight), the above analysis will be expanded to regression modeling to allow for adjustment. Results of between group analyses will be considered hypothesis generating.
We will describe 25(OH)D and other biochemical outcomes within three different subgroups. First, we will describe 25(OH)D response in the group of patients under and over 40 kg. Second, we will describe changes in biochemistry and clinical measures separately for the groups with an enrolment 25(OH)D level above and below 30 nmol/L. Third, we will describe 25(OH)D response and clinical measures separately for newborns (age < 30 days) versus older children (age > 30 days).
The Data Safety Monitoring Board (DSMB) will be comprised of two clinical experts (critical care, nephrology) and a biostatistician and will function independently from the study investigators and the steering committee. The DSMB will review safety data, blinded in aggregate and by study group, after 30 and 53 patients have completed day 7. Specifically, the DSMB will review the occurrence of hypervitaminosis D (25(OH)D > 200 nmol/L), vitamin D-related adverse events (hypercalciuria, hypercalcemia), and serious adverse events potentially related to study drug. The DSMB chair will also receive immediate notification and reports of serious adverse events determined to be related to the study drug. In addition, the DSMB chair will receive a report for all deaths and all requirements for renal replacement therapy, regardless of whether they are thought to be related to the VITdAL-PICU pilot study. There would be concern regarding the dosing protocol if more than 10% of participants achieved 25(OH)D levels above 250 nmol/L (even in the absence of clinical sequelae). If this criterion was met, a downward adjustment of the loading dose would be considered.
Study monitoring at CHEO will be conducted by qualified peer-to-peer monitors. The monitoring review will occur approximately every 3 months or as needed based on enrollment. The principal investigator and the study coordinator will review the study regularly and assess evaluations of patients' eligibility, study data, and adverse events in the study database. Study monitoring of sites in Austria and Chile will be performed remotely by the study coordinator and principal investigator.
Research ethics board approval will be obtained before initiation of recruitment. Protocol amendments will be communicated as necessary to those involved in the study. In Canada, the study protocol was approved by the Children's Hospital of Eastern Ontario Research Ethics Board (REB reference number 15/18E), and regulatory approval was obtained from Health Canada (control number 184825). In Austria, the study protocol was approved by the Medical University of Graz Ethics Committee (REB reference 28-619 ex 15/16) and regulatory approval was obtained from European Medical Association (EudraCT number 2016-002459-38). The Chilean site obtained approval from the Ethical Scientific Committee of the Concepción Health Service (REB reference 16-03-10). Regulatory approval was not required in Chile. The study was first posted on Clinicaltrials.gov on 05/152/2015 (NCT02452762).
At study close out, study data, source documentation, and regulatory files will be securely stored for 25 years. The study drug will be destroyed and reconciled at each site according to site standard operating procedures and regulatory requirements. Study data will only be accessible to the principal investigator, research coordinator, or delegate.
The principal investigator will write up the results of the study for publication in a peer-review journal. Interim and final results will be presented at national and international scientific meetings. In addition, the CCCTG will be updated on the project and progress biannually at their scientific meetings, and other team members sharing the results at their professional meetings, outside of the critical care discipline. A summary of the study results will be prepared in lay terms and sent by mail to study participants. If funding allows, other knowledge translation methods will be explored, including a decision aid to help families make informed choices around testing vitamin D levels and the options for clinical management of the results, and media tools, pamphlets and posters directed at the general public, ICU patients and families, and physicians.
Data analysis will occur at CHEO RI/OHRI. Participant level trial data will not be sent to other sites or researchers. Co-authors may suggest sub-studies and will be given the opportunity to take the lead on manuscript preparation. Data analysis will take place at CHEO RI/OHRI and aggregate data corresponding to what is standard for a manuscript will be provided to the co-author. If participant level data is required, then a data sharing agreement will be obtained between institutions.
High-prevalence rates of VDD in pediatric ICUs worldwide and the recognized importance of vitamin D to the health of multiple organ systems suggest that rapid normalization could represent a simple, inexpensive, and safe means of improving outcomes and reducing health care spending. An important step towards determining the potential benefit of rapidly normalizing vitamin D status in PICU is the establishment of an evidence-based dosing protocol. This phase II dose evaluation study aims to determine the effectiveness and safety of a weight-based enteral rapid restoration dose of vitamin D in deficient critically ill children and is the first step towards a definitive phase III clinical trial to evaluate both the clinical and economic benefits of rapid normalization in this population.
To facilitate the success of completing this pilot RCT and the subsequent phase III trial, ongoing review, problem identification, with adjustments are imperative. Since initiating recruitment, the authors have implemented a number of modifications to the protocol aimed at increasing feasibility. Although the majority have been minor, a significant change was made to the dosing regimen after 5 months of recruitment (12% of target sample size given two doses). The original protocol included a second loading dose of cholecalciferol on day 3 (if the 25(OH)D level measured on day 3 was not above 75 nmol/L). The second dose was initially included due to concerns that some critically ill children might not achieve target 25(OH)D levels with a single dose, as observed in the similar adult VITdAL-ICU trial. The decision to drop the second dose was based on several factors, including (i) a literature update suggesting that the second load may not be necessary, and evidence suggesting clinical benefit with a single enteral load [26, 27]; (ii) concern from other sites suggesting it may prevent their participation; (iii) cost of additional drug and measuring 25(OH)D status on day 3 to determine dosing level; (iv) feedback from participants and potential participants that the study protocol, specifically the day 3 dose, was complicated and difficult to understand which the authors felt may have a negative impact on recruitment rate; and (v) although procedures were put in place to maintain blinding during measurement of 25(OH)D at day 3, the second dose increased the chances of accidental unblinding. Additional, more minor changes, to the protocol are presented and discussed in Additional file 3.
Recruitment for the VITdAL-PICU pilot study started at the Children's Hospital of Eastern Ontario in January 2016. Although initially started as a single center RCT in the PICU, recruitment was expanded to sites in Chile and Austria on May 1, 2017. At the time of manuscript acceptance, approximately 95% (n = 64) of the target sample size has been enrolled. Recruitment is anticipated to continue until November 30, 2017.
This work was supported by bridge funding from the Canadian Institutes of Health Research through the Project Scheme Grant and the AHSC AFP Innovation Fund 2014–2015 at the Children's Hospital of Eastern Ontario. The authors wish to thank Euro-Pharm International Canada Inc. for providing the study drug in-kind, and Qualigen Inc. for providing the FastPak® Vitamin D Immunoassay kits in-kind. The authors also wish to thank the Canadian Critical Care Trials Group members and the Grant and Manuscript Review Committee member (Karen Choong) for their indispensable involvement and input. Finally, the authors are grateful to the research assistants, pharmacy, laboratory, and ICU staff at each participating site.
This study was funded by the AHSC AFP Innovation Fund 2014–2015 at the Children's Hospital of Eastern Ontario and Canadian Institutes of Health Research (CIHR), Project Scheme (bridge funding), Ottawa, Ontario, Canada.
DM conceived of the study. DM, KM, DF, LM, and KA led the steering committee in the trial design and coordination of the study, as well as drafted the manuscript. Subspecialty expertise and valuable insight during trial design and during the conduct of the trial are as follows: critical care (DM, KM, KA, LM, SR), pediatric nephrology (PG), pediatric endocrinology (ML), laboratory methodology (MH, AK), vitamin D (AK, HW), and clinical trial methodology (DF). KO drafted the manuscript, figures, and supporting documentation. All authors read and approved the final manuscript, and will be involved in the communication and publication of trial results.
The VITdAL-PICU pilot study protocol and consent form were approved by the Children's Hospital of Eastern Ontario Research Ethics Board (protocol no. 15/18E) on 16-Oct-2015 and was initiated on 11-Jan-2016. The first participant was enrolled on 29-Jan-2016. The current version of the protocol (version no. 8, version date 04-Oct-2017) was approved on 25-May-2017. The protocol was approved by the Medical University of Graz Ethics Committee (REB reference 28-619 ex 15/16) on 19-Jan-2017 and the Ethical Scientific Committee of the Concepción Health Service (REB reference 16-03-10) on 24-May-2016. Recruitment at both sites was initiated on 01-May-2017. Written informed consent will be obtained for each participant by the site investigator or trained delegate prior to any study-related procedures. Where applicable, assent will also be obtained.
Dr. Khamessan is employed by Euro-Pharm International Canada Inc. Dr. Khamessan and Euro-Pharm International Canada Inc., at the request of the investigative team, developed and prepared the concentrated vitamin D solution used in the study.
McNally JD, Amrein K. Vitamin D deficiency in pediatric critical care. J Pediatr Intensive Care. 2016;05(04):142–153. doi:10.1055/s-0036-1583285.


A 2019 Electronic Season ticket grants you access to the remaining three regular season home games. Super fans can get a laminated season pass and lanyard to wear for access to each home game! 2019 Home Game Schedule: 3/30/2019 -- Keystone Assault - Woodrow Wilson HS 4/6/2019 -- DMV Knights - Woodrow Wilson HS 5/4/2019 -- Fayetteville Fierce - Dunbar HS 6/15/2019 -- Keystone Assault - Dunbar HS All games kickoff at 7pm. Gates open at 6pm. Purchasing a ticket to support a player? Enter her name in the designated field.


When a beauty product starts running into six figures, would you call it makeup or jewellery? And what if it contains 267 carats of black diamonds? Luxe enough for you?
Billed as the most expensive nail polish in the world (a title previously held by Models Own's $130,000 bottle that features a 24-carat gold and diamond lid), this outrageously sparkly black polish contains 267 carats of real bling – in one bottle. And there is just one extremely limited edition bottle on offer!
For those of us who think that a quarter million dollars might be a tad bit too high for a manicure, Azature has also created an economy version, which contains a single black diamond and retails for $25. Oh! Don't be sad… at least it's glittery, jet black and even comes in a diamond-shaped bottle 😉 Now, I have been known to have my princessy moments but seriously, I would prefer those two Bentleys for this money (or maybe a Van Cleef & Arpels necklace), thank you very much! What would you buy for 250,000 dollars?
what would i buy for $250,000? Honestly? i'd pay off my loans from undergrad, then pay all the expenses for my upcoming master's education. with whatever is left, i'd travel, publish my novel(s), and/or get a small plae in the greater NYC area, so i could be available to interview for jobs in the city.


Birth in a birthing center caters to the healthy, low-risk mother. Some risk factors do not prohibit you from giving birth at the center, and some risk factors must be closely monitored by your midwife and/or by her consulting physicians. You are probably eligible for a birth center birth if you are healthy and without any chronic medical conditions. Your midwife will carefully screen you before admittance to the birth center and continuously evaluate you throughout your pregnancy to promote a safe and satisfying birth experience.
We offer preconception appointments if you are interested in talking with a midwife about eligibility, conceiving and overall health for pregnancy.


Three generations of the Fletcher-Brewer family have developed Porth Tocyn for over 70 years to become one of Wales' foremost country hotels.
Sitting on the headland beyond the sailing village of Abersoch, with stunning views across Cardigan Bay and out to Snowdonia, the hotel is furnished with country antiques. It exudes a warm & friendly atmosphere which draws guests back time after time.
We are ideally situated just a mile from Abersoch Golf Club.
Porth Tocyn has 17 individually designed bedrooms most boast super king sized beds & captivating sea views with the dramatic backdrop of the Welsh mountains. Some bedrooms are interconnecting which is ideal for families. All our room's are furnished with country antiques, water colours & prints. Books abound. All have flat screen TVs. Beds are made up with lovely Egyptian cotton sheets & quality blankets or duvets. Complementing these are fresh modern tiled bathrooms with thick Egyptian cotton towels. All bathrooms have power showers over their baths.
Food is at the very heart of the Porth Tocyn experience & always has been. Recognised continuously in the pages of the Good Food Guide since 1957, & with two AA rosettes under its belt, dining here is a great and enjoyable experience.
Porth Tocyn has been recognised as one of Britain's top family friendly hotels by the Good Hotel Guide for more than 30 years.
We strongly recommend that you read more about what we offer families & discuss your needs with us over the telephone!
Porth Tocyn lends itself to exclusive family gatherings & get aways for friends & parties who want that catered country house atmosphere. We offer bespoke packages at the fringes of our season.


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Cops: Subway Worker Didn't Drug Officer
Tests showed no drugs in drink, officer's system
By Arden Dier, Newser Staff
Posted Oct 12, 2016 7:00 AM CDT
Tanis Ukena speaks at his attorney's office in Clearfield, Utah. (AP Photo/Rick Bowmer)
(Newser) – An 18-year-old Subway employee has been cleared of charges two months after he was accused of drugging a police officer's drink. Tanis Ukena was arrested Aug. 8 in Layton, Utah, after a uniformed police officer who'd consumed part of a Subway drink and sandwich reported feeling intoxicated. Ukena tells KSL he "went into shock" when officers arrested him after he'd helped them search the Subway location "for an hour or two." Authorities at the time claimed an ion scanner test showed the officer's drink was laced with THC and methamphetamine and surveillance footage showed the crime unfold. However, Utah State Crime Lab tests were "unable to confirm that contaminates [sic] were in the officer's drink," police say.
Urine and blood tests showed no drugs in the officer's system and "extensive medical testing" offered no clues to his condition, reports the Standard-Examiner. Ukena's lawyer says police initially used a "cheap" drug test, noting, "The officer's symptoms did not correlate with the drugs, and that should have raised some red flags." He adds surveillance video shows Ukena only holding the officer's drink. Ukena—who's considering legal action, per the Standard-Examiner—says he's still "pro-police," but he fears "this is going to affect me for years to come." Since his arrest, he says he's received death threats and finds it "scary to go out in public." An apology would be nice, he adds. In a statement, police noted their "appreciation" for his "patience." (Read more Utah stories.)
Next on Newser: Clinton Campaign Chair Blames Russia for Email Hack
Susannellis
Google is paying 97$ per hour! Work for few hours and have longer with friends & family! !mj211d: On tuesday I got a great new Land Rover Range Rover from having earned $8752 this last four weeks.. Its the most-financialy rewarding I've had.. It sounds unbelievable but you wont forgive yourself if you don't check it !mj211d: ?? ??;?? http://GoogleFinancialJobsCash211TopApps\GetPay$97\Hour... ?????????????????????????????????????????????????????::::::!mj211d:....,....,..
Bundy714
Those same cheapo drug tests have ruined many lives, and put a lot of people in prison. But it's ok, some of them were actually guilty, and the rest were poor, which is almost just as bad as being guilty to some people. You know the type, they post here all the time.
TwoSheds
Notice they put this kid's name and picture all over the public space, but not the criminal accuser.

redpajama_set_name: RedPajamaCommonCrawl


Armistice Day, November 11th 1918, was to mark the end of the war that was to end all wars. History very quickly showed that this was not to be. As the prophet Isaiah had predicted and warned, the way to peace is not known.
There is an obstacle that always gets in the way of lasting peace. That obstacle is our human nature, or at least, what our human nature has become.
When God made mankind he declared them very good (Genesis 1:31). But something terrible happened to them. They fell from that exalted position by rebelling against the instruction of God, being led astray by their lust and vanity and a desire to be in control. In the vanity of their minds they thought they could decide for themselves how they ought to live. This experiment very quickly turned sour and led to the first murder, and then to all the wickedness that afflicts us today. Our nature has become so corrupted it is beyond us to find our way back.
Hebrews 4:15 tells us, "For we do not have a High Priest who cannot sympathise with our weaknesses, but was in all points tempted as we are, yet without sin." We find our release from our nature in Jesus. He grants us his nature, and his nature is one of peace. No wonder Isaiah calls him the prince of peace (Isaiah 9:6). At last peace will be the order of the day and will fill the earth.
Father in Heaven, forgive us for the sickness of our nature, and thank you for the redemption of that nature which you have made available for us in Jesus.


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You are at:Home»News»Global News»Michelle Gomez's Missy is returning to Doctor Who
Credit: BBC
Michelle Gomez's Missy is returning to Doctor Who
By James Barker	on	 October 17, 2016 Global News, News
She's the baddest, maddest Time Lady in Doctor Who right now – and the good news as Michelle Gomez's villainous Missy is back for Series 10 of the show.
'Missy' is the current incarnation of the Doctor's oldest foe, the Master, who first appeared back in Series 8. She was last seen in Series 9's two-part opener, causing trouble on Skaro. Since then, she's been notably absent from the life of her best friend/archnemesis – has she been away forming a new way to cause hell to rain down?
In an interview with The Music magazine, Michelle Gomez confirmed that Missy is back in some capacity for Series 10. "Weirdly, this is crunch week where I get to find out what I'm going to be doing next – I can officially say that I will be starting back on Doctor Who soon." Good news for the big Missy fans out there, but equally bad news for those Whovians who dislike the character, and Steven Moffat's decision to turn the traditionally male character female in her latest regeneration.
It's likely Missy won't be back until past the halfway mark of next year's season, as it has been filming now for several months. Series 10 is Peter Capaldi's third as the Twelfth Doctor, and he is joined by new companion Bill, played by Pearl Mackie. Before that he will appear in a Christmas Special with Matt Lucas' Nardole (groan), and will make a guest appearance in the debut of Who-spinoff Class this Saturday!
Series 10 of Doctor Who will kick off in Spring 2017 – the first Who series to start in that slot since Series 6. How heavily Michelle Gomez and Missy will be involved is still unknown.
James Barker
Editor of The Edge 2017-18. Culture Editor before that. Sporadic writer for the Wessex Scene, DJ on Surge, known photobomber of SUSUtv's videos. Bad habits include Netflix, not doing my work and drinking too much tea.


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MAFS
9Honey
Liam Gallagher lashes out after Melbourne concert is 'cut off' due to noise curfew
By Karina Recchi| 2 years ago
Former Oasis frontman Liam Gallagher has lashed out online after his concert at Margaret Court, Melbourne, was cut short due to noise restrictions.
The rocker was moments away from finishing his set at 11pm on Wednesday December 11 when the sound disappeared half-way through performing Supersonic, prompting boos from the crowd.
Gallagher has since revealed it was a "$250,000 fine if we played over the curfew".
"I mean those tunes are biblical and I'm the f---ing biblical brother, but c'mon, that's a f---ing piss take," he wrote online, adding, "Whoever made that rule needs to stop smoking spice."
Despite being irritated, Gallagher's laughed off the incident, calling it "a load of w---".
"We weren't that bad," he insisted. "I've heard worse! Anyways, them the rules… You still smashed it Melbourne biblical. Stay young. Stay safe."
Fans, however, haven't been as forgiving.
After realising the music was cut off, they continued to sing along with the rocker, allowing him to finish his hit, before going home to brand the rule as a "joke" online.
"This is so un-Melbourian and Un-Victorian, as a Patriot to my true home state, I am ashamed we did this to the great man at his gig," a fan wrote on Twitter, with another posting footage, labelled, "The moment a crime was committed".
After one follower suggested that if this had happened back in the UK, Gallagher had a one-word response.
"Exactly."
Celebrity throwback photos: Guess who!
Property News: Music promoter Michael Coppel sells Toorak home for more than $30 million - domain.com.au
French actor dies in skiing accident, aged 37
Prince Andrew's social media accounts deactivated and horse race renamed
Duchess of Cambridge wears $3.80 earrings for first royal engagement of 2022


text:
ExxonMobil Petroleum Contract
CGX Energy Petroleum Contract
Ratio Energy Ltd. Contract
Tullow/Eco Petroleum Contract
Low Carbon Development Strategy
NewsPaperLatest News and Information from the Oil and Gas sector in Guyana
OilNOWLatest News and Information from the Oil and Gas sector in Guyana
Guyana must balance extraction of natural resources with protection of environment – Bharrat
By OilNOW
NewsOilNOW - January 27, 2023
Exxon announces public meetings in Guyana to discuss Whiptail impact study
Uaru subsurface installations will be "twice as big as Yellowtail" – Hess
NewsShikema Dey - January 27, 2023
Liquidation of CGX subsidiary, ON Energy, to have no impact on Guyana operations
OilNOW
OilNOW is an online-based Information and Resource Centre
On World Environment Day, Minister of Natural Resources, Vickram Bharrat stressed the importance of Guyana balancing the extraction of its natural resources with the protection of the environment.
The need for this approach was iterated by Mr. Bharrat at a ceremony held on Saturday at the Promenade Gardens in Georgetown to commemorate World Environment Day.
Bharrat said that the government is in a difficult position because it has a mandate to rapidly develop the country using Guyana's oil resources. By the same token, he said this cannot happen without some amount of sacrifice. In this regard, he cited the removal of mangroves at Versailles in May, to facilitate a shorebase project as an example. There was a public outcry, as mangroves play a critical role in carbon sequestration. Even then, Mr. Bharrat said the Government would not simply allow such a removal without seeking to restore the loss.
"We are working on a system where we can offset, [where] we can put a mechanism in place [to] have offsets elsewhere," he stated.
Mr. Bharrat said the Government will continue a mangrove restoration project which was started under a previous PPP/C administration. He said 36.5km of mangroves have already been planted under this initiative. The Government, according to Vice President Dr. Bharrat Jagdeo, also intends to reforest 6,000 acres of mined out lands.
Furthermore, Mr. Bharrat noted that Guyana has already done a lot to contribute to the global effort.
"In Guyana, there is this old saying that a small axe can cut down a big tree," he said. "We consider ourselves, as a very small country, but we have been doing wonders in terms of protecting the environment, in terms of being a carbon sink, in terms of keeping our forests intact, in terms of having sustainable mining, and in terms of our energy mixes."
Dr. Jagdeo had similarly said, in an OilNOW exclusive, that Guyana pays more than its fair share to keep its emissions low and to prevent the over warming of the earth.
"As a government, you would have seen that our direction and our vision is to ensure that we move from strength to strength with regards to protecting our environment and maintaining our carbon sink status. Mr. Jagdeo said. "That is something that we pride ourselves on."
Mr. Bharrat reminded too that this small country contributes significantly to the oxygen that the world breathes. "And we will continue to do so… 87% of our landmass is covered by forests, and if I may also say that in Guyana, we boast one of the best and one of the most sustainable forest management systems, if not in this hemisphere, in the world."
The natural resources minister recalled that the PPP/C Government is operationalising an ambitious energy mix programme that will largely substitute Guyana's current diesel and heavy fuel oil with cleaner natural gas from the Liza Phase 1 Development project. He said that mix will be supported by hydro, wind and solar projects across the country, which will further cement Guyana's status as a carbon sink.
Vickram Bharrat
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Animals MagazineLatest News and Information from the Oil and Gas sector in Guyana
OilNOW is a Resource Center founded and owned by Guyanese. OilNOW is an apolitical, non-partisan, privately owned agency that strives to ensure the highest degree of accuracy and balance.


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Choose and configure your bowstring now.


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'To Die For' killer Pamela Smart denied hearing that could have led to release from prison
By David Boroff
Pamela Smart, seen here in 2010, is serving a life sentence. (WMUR Television via AP, File)
The "To Die For" killer likely will die in prison.
Pamela Smart was denied a chance for freedom nearly 30 years after conspiring with a student to murder her husband in New Hampshire.
A state council voted Wednesday to forego a hearing for the 51-year-old Smart, who has now exhausted all of her appeal options.
Smart was sentenced to life in prison without parole in connection with the 1990 slaying of husband Greggory Smart. Student William Flynn, who served nearly 25 years in prison, and three other youths cooperated with prosecutors.
The council voted 4-0 to deny Smart a hearing, with one member abstaining. The council had denied a similar request 14 years ago.
Smart was convicted of conspiracy to commit murder and other crimes after a sensationalized trial that was widely televised. The murder plot was the inspiration for the 1995 Nicole Kidman film "To Die For."
Pamela Smart's spokeswoman Eleanor Pam said the vote "avoided and voided fairness, objectivity and compassion." Smart has always maintained her innocence.
"Political cowardice is on full display in this state as usual by politicians primarily concerned about retaining or advancing their political careers," she said.
Dan Le Batard defies ESPN's 'no politics' policy by slamming Trump's racism
Smart has earned two master's degrees at the Bedford Hills Correctional Facility, which is located about 50 miles north of New York City. She has also tutored fellow inmates and works as an AIDS educator. Many letters of support, including from activist Gloria Steinem, are included in her application.
Smart's mother called the council's decision "cruel."
"On Aug. 1 she will have spent 29 years in prison for a crime committed by others," Linda Wojas told reporters. "She has been in prison longer than she has been free."
The attorney general's office in New Hampshire opposed the request for a hearing. Associate Attorney General Jeffery Strelzin said Smart "has never accepted full responsibility" for the slaying.
[More News] Area 51 raid warning, new breed of deadly ticks and 'manhole' renamed in California: Daily News Weekly »
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EXCLUSIVE: Palin — Bombs Away on Obamacare; Cruz Is over the Target
Americans who are fed up with Obamacare won a victory yesterday. The House voted to defund Obamacare while still funding the federal government to avoid a "devastating" shutdown. (I shall not digress, but it's beyond distressing to hear liberals try to convince Americans that any government slowdown is comparable to "terrorism.")
Now the battle goes to the Senate, and we'll find out if Harry Reid is so committed to the horrendous "Un-affordable Care Act" that he'll be the one to shut down the government to fund the unworkable Obamacare.
Let's be clear. Republicans in Congress aren't advocating a government shutdown. That's why they voted in the House to fully fund our bureaucracy while defunding Obamacare. The conservatives in Congress are listening to the majority of Americans who do not want Obamacare.
Following the will of the people is apparently a novel idea in D.C. these days. Just ask Senator Ted Cruz and his liberty-loving posse on Capitol Hill who have led the charge to defund Obama's train wreck.
Those of us who hang in there supporting a major political party with our energy, time, and contributions would like to believe that that party would praise principled conservatives like Ted Cruz and Mike Lee for following through on campaign promises. We'd like to believe that the GOP establishment would applaud the way these bold leaders have rallied the grassroots to their cause. But, no, such praise would require a commensurate level of guts and leadership, and the permanent political class in D.C. is nothing if not gutless and rudderless.
We're now, once again, subjected to the "anonymous sources" backstabbing game. The Capitol Hill cowards are rushing to anonymously denounce Senator Cruz to any reporter with a pad and pen.
Welcome to our world, Ted. The same people have been denouncing conservatives like me for years (right after they ask for help fundraising for themselves or endorsing the latest candidate they've suckered into paying their exorbitant consulting fees). We can compare shiv marks next time we meet, my friend.
If the Senate doesn't get behind Ted Cruz's efforts to defund Obamacare, it won't be because of any failure on Ted's part. It'll be because there weren't enough principled leaders to stand with him, and that would be a tragic loss, not for Ted, but for America.
More and more Americans are waking up to the nightmare of Obamacare as its rollout continues. Hardworking families are losing their employer-provided health care coverage. Businesses are cutting back their employees' hours to skirt Obamacare's mandates. Americans barely scrapping by are discovering that Obamacare has made health care completely unaffordable. Those who aren't part of a protected special interest group have been left in the cold.
When you're living on a fixed income, having to pay hundreds of dollars more each month for health care will cut into your ability to pay for basic necessities like food, electricity, or gas (which has increased 90% under Obama). Open your eyes, America. When the full reality of Obamacare strikes home, we'll thank God that principled leaders like Ted Cruz and Mike Lee took a stand to stop it in its tracks.
But the permanent political class is handwringing and howling that if there's a government shutdown the media will blame Republicans for it. Here's a little newsflash, GOP establishment: Whenever anything bad happens, the media blames Republicans for it. That's not an excuse to roll over and play dead. It's a call to follow the advice I give my daughters: Woman up, stand your ground, and fight like a girl!
I want no pity. I need no empathy. But use me as a barometer. Over the years, the leftwing media has falsely and irrationally accused me of everything from faking a pregnancy to abetting murder. They lie. Deal with it.
Republicans in Congress support funding the government. If the Democrats block these funding measures, a government shutdown is on them. In the meantime, stop the ridiculous hysterics. Heck, about the most significant thing that happened during the last government shutdown was Clinton hooked up with Monica.
As I said in my speech at CPAC this year, it's time for the Senate to put itself on Cruz Control.
Ignore the peanut gallery pundits. They've written my political obituary so many times, I'm practically Lazarus. Now they're trying to destroy Ted Cruz. Good luck with that, you weasels. Texans are just as tough as Alaskans. Smaller, but just as tough.
But here's the important thing that none of these establishment backstabbers understand. It's not the messenger that matters. It's the message. You can try to take out someone like Ted Cruz, but that won't stop the message from catching fire. The message is liberty, and it's been resounding ever since a band of patriots dumped tea in Boston harbor.
The message only grows stronger. The grassroots is bigger than any one person. We the People will rise up, and we will make our voices heard. Right now, Ted Cruz is speaking for us in this Obamacare fight. God bless him for it.
Hang in there, Ted and Mike. You have millions of supporters among ordinary hardworking Americans. We support you because you don't shy away from the fray. May your colleagues in the Senate gain the wisdom to support your excellent efforts so that you can see that the view is better from inside the bus than under it.
Oh, and a little reminder to Republican senators up for re-election in 2014: Moose season ends soon, allowing more time on one's hands. So, we'll be watching your votes very carefully this week.
PoliticsCongressSenateTed Cruz


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Britain must do more to deter Russian aggression – diplomacy and sanctions are not enough
By Bernard Jenkin MP
Global Britain has a responsibility to act as conflict and climate change push displacement to a record high
By Lord Alton
06 Jan Foreign affairs
We should ban organ tourism to combat China's forced organ harvesting
By Lord Hunt
04 Jan Health
The right kind of investment for Africa must be a collaborative effort
By Lord St John
23 Dec 2021 Education
Anniversary brings meeting of minds over veterans affairs
By Veterans Aid
Rail Industry welcomes signing of Australia-UK Free Trade Agreement
The UK must develop and fund a plan for Afghan education at G20
By Harriett Baldwin MP
AFGHANISTAN: Save the Children resumes life-saving services for children in Kandahar
By Save the Children
UK slashes direct aid to countries fending off climate crisis
3 min read 31 March 2021 Partner content
Save the Children has issued a statement on UK aid cuts to countries considered among the most vulnerable to climate change.
LONDON, March 31, 2021 – As it prepares to host a critical climate and development summit the UK is slashing direct aid to countries that are home to millions of children on the front-line of the climate emergency.
Around £691m will be cut from the direct aid budgets of countries considered among the most vulnerable to climate change. They include Yemen, Bangladesh, Afghanistan and the Democratic Republic of the Congo (DRC). Between them, they will lose around £463 million.
These are countries where extreme climate events fuelled by global warming are destroying harvests, homes and livelihoods, leaving children facing hunger and poverty.
Save the Children UK CEO Kevin Watkins said: "The UK's broken promises on aid make a mockery of the government's claim to leadership ahead of the climate summit. No other G7 country is cutting aid. The UK should be stepping up to protect children facing the disastrous impacts of climate change. Instead, it is stepping down and turning its back on children who will be among the worst affected by the climate crisis and for whom we should do be doing more, not less."
Other countries at risk of deep aid cuts are: Somalia, Sudan, Zimbabwe, and Liberia.
While UK aid given directly to these eight countries, plus Malawi and Uganda, dropped by around 10% last year – it will be approximately £126 million lower than in 2019 – it's expected to drop by £691 million this year. Only Malawi and Uganda buck the trend in 2021.
Last year, UK direct aid to Uganda is estimated to have been slashed by 50% - falling from £119.7 million to £57.8 million - and for Afghanistan, DRC and Liberia it's estimated to have been cut by more than a quarter – that's a total of £120 million across all three countries.
Also, over the last two years, the UK supported what are considered to be primarily climate adaptation or mitigation projects in only three of these 10 highlighted countries. Those countries were Zimbabwe, Uganda, and Malawi.
Save the Children Somalia Country Office Director, Mohamud Mohamed Hassan, said: "A devastating climate crisis is growing at a rapid rate in Somalia, fuelling severe food and water shortages, displacing families and reducing the capacity of schools to provide classes. The economic impacts of COVID-19 and prolonged conflict are further pushing families to their limits.
"Children are the most vulnerable during a hunger crisis. Without enough food and the right nutrition, they can become malnourished, which can lead to illness, infections, stunting and death. In Somalia this year, approximately 839,000 children under five are likely to become acutely malnourished and 143,000 children are likely to be severely malnourished – the most life-threatening form of extreme hunger requiring urgent medical treatment to survive.
"For Somali children who will have nothing to eat, these cuts could be a death sentence. The UK should be standing up for the children who are facing hunger, school closures, displacement and exploitation in Somalia, not abandoning them in their hour of greatest need."
The UK has increased its funding this year for the global Green Climate Fund. However, only Bangladesh – among these 10 countries - has been a significant recipient of the $7.2 billion allocated, to date. Yemen and Somalia have yet to receive any project funding.
Malawi (with a 34% increase - £19.5 million) and Uganda (a 2% increase - £1 million) are the only countries set to experience an increase in UK direct aid funding this year, although in both cases this has followed significant cuts in 2020.
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Government Accused Of "Lack Of Confidence" In Priti Patel With Small Boats Task Force
24 Nov 2021 Communities


Many women experience back pain during pregnancy. The ligaments in the body are softened preparing for delivery and the body's posture and biomechanics are drastically altered during pregnancy. The growing baby moves more weight forward into the abdomen increasing the curvature of the spine and changing the distribution of weight among the joints, muscles and discs. This altered biomechanics causes most women to experience pain during pregnancy.
Chiropractic works with the body's biomechanics to improve the range of motion and alleviate some of the increased stresses placed on the spine during pregnancy. In a review of the published medical literature (33 different studies), Chiropractic care was shown to be safe and effective during pregnancy1.
Nasa Chiropractic has a great relationship with many M.D.s and midwifes in our area and we have a lot of experience working with patients during pregnancy. Additionally, Dr. Case Ricks is certified in the Webster Technique which is a specialty certification requiring additional post graduate training in pregnancy adjusting techniques. "The Webster technique is a specific chiropractic analysis and diversified adjustment. The goal of the adjustment is to reduce the effects of sacral subluxation/ SI joint dysfunction. In so doing neuro-biomechanical function in the pelvis is improved.2"


text:
<?php

/**
 * Git Stream Wrapper for PHP
 *
 * @category   TQ
 * @package    TQ_VCS
 * @subpackage VCS
 * @copyright  Copyright (C) 2014 by TEQneers GmbH & Co. KG
 */

namespace TQ\Vcs\StreamWrapper;
use TQ\Vcs\Repository\RepositoryInterface;

/**
 * Represents a given stream wrapper path
 *
 * @author     Stefan Gehrig <gehrigteqneers.de>
 * @category   TQ
 * @package    TQ_VCS
 * @subpackage VCS
 * @copyright  Copyright (C) 2014 by TEQneers GmbH & Co. KG
 */
interface PathInformationInterface
{
    /**
     * The host name used for global paths
     */
    const GLOBAL_PATH_HOST  = '__global__';

    /**
     * Returns the URL
     *
     * @return  string
     */
    public function getUrl();

    /**
     * Returns the repository instance
     *
     * @return  RepositoryInterface
     */
    public function getRepository();

    /**
     * Returns the absolute repository path
     *
     * @return  string
     */
    public function getRepositoryPath();

    /**
     * Returns the absolute path to the resource
     *
     * @return  string
     */
    public function getFullPath();

    /**
     * Returns the relative path to the resource based on the repository path
     *
     * @return  string
     */
    public function getLocalPath();

    /**
     * Returns the version ref
     *
     * @return  string
     */
    public function getRef();

    /**
     * Returns the additional arguments given
     *
     * @return  array
     */
    public function getArguments();

    /**
     * Checks if the given argument exists
     *
     * @param   string  $argument   The argument name
     * @return  boolean
     */
    public function hasArgument($argument);

    /**
     * Returns the given argument from the argument collection
     *
     * @param   string  $argument   The argument name
     * @return  string|null         The argument value or NULL if the argument does not exist
     */
    public function getArgument($argument);
}


This sterling silver candelabra is a unique and stunning piece by Bier Judaica. The balls step upwards as they go, each one of the six is another candle holder. This is a one of kind artistic piece that will be sure to show off your unique and modern taste. As a part of our sterling silver gift items collection this is a gorgeous piece to give or receive. Stands at 10.5 inches tall.