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SAMJ: South African Medical Journal
SAMJ, S. Afr. med. j. vol.98 n.6 Cape Town Jun. 2008
Prevention of mother-to-child transmission of HIV programme: Low vertical transmission in KwaZulu-Natal, South Africa
Rosemary GeddesI; Stephen KnightII; Sandy ReidIII; Janet GiddyIV; Tonya EsterhuizenV; Candice RobertsVI
IMB ChB. Department of Public Health, School of Family and Public Health Medicine, University of KwaZulu-Natal
IIMB BCh, FCPHM (SA). Department of Public Health, School of Family and Public Health Medicine, University of KwaZulu-Natal
IIIMSc. Department of Public Health, School of Family and Public Health Medicine, University of KwaZulu-Natal
IVRN. McCord Hospital, Durban
VMB ChB, Dip PHC Ed, MFamMed. McCord Hospital, Durban
VIMB ChB, FCOG (SA). McCord Hospital, Durban
OBJECTIVE: To describe the operational effectiveness of the prevention of mother-to-child transmission (PMTCT) of HIV programme at McCord Hospital during the period 1 March 2004 - 31 August 2005.
DESIGN: Observational cohort study.
SETTING: McCord Hospital, Durban, South Africa.
SUBJECTS: Antenatal patients attending the PMTCT clinic.
MEASUREMENTS AND RESULTS: During the 18 months all 2 624 women (100%) attending the antenatal clinic received HIV counselling, resulting in 91% (2 388) being tested for HIV. The prevalence of HIV in the total cohort was 13% (95% confidence interval (CI) 11.6 - 14.2).
Of the HIV-positive mothers 302 (89%) completed their pregnancy at the hospital, and in this group there were 3 intrauterine deaths, 1 miscarriage, 1 maternal death (with the baby in utero) and 297 live births with 1 early neonatal death.
Only 11% (36 out of 338) were lost to follow-up. A quarter (668) of the partners of all women attending the antenatal clinic were tested for HIV.
Delivery in 70% (209) of live births was by caesarean section. Nevirapine was administered to 98% (290) of live babies and 75% (224) received zidovudine (AZT) as well.
The 6-week polymerase chain reaction (PCR) baby test uptake was 81% (239 out of 296 live babies). Of those tested, 2.9% (95% CI 1.3 - 6.2) tested HIV positive.
CONCLUSION: Despite challenges faced by PMTCT providers in a resource-constrained setting, this state-aided hospital provides a comprehensive and integrated service and has achieved outcomes that compare favourably with those in the developed world.
At the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in 2001, member states committed themselves to the goal of reducing the proportion of infants infected with HIV by 20% by 2005 and by 50% by 2010.1 During 2005 an estimated 700 000 children were newly infected with HIV, the vast majority in sub-Saharan Africa through mother-to-child transmission (MTCT).2 In South Africa, a country with an antenatal HIV seroprevalence of 30.2%,3 the prevention of mother-to-child transmission (PMTCT) programme covers less than one-third of the country and to date 'dual therapy' (zidovudine (AZT) during pregnancy and nevirapine at delivery) is still not available in the public sector.4
The efficacy of single-dose nevirapine in PMTCT of HIV in the HIVNET012 trial was 11.9% (95% confidence interval (CI) 8.2 - 15.7).5 The generalisability of trial results to the general population can be difficult.6-8 The challenges with extended prophylactic regimens, when PMTCT is integrated into existing health systems and monitoring to evaluate whether they have the desired effect, are even greater.
The operational effectiveness of PMTCT programmes in South Africa is described in three studies,6,9,10 only one reporting on a site where prophylactic regimens contain more than just single-dose nevirapine.10 The 2002 evaluation of South Africa's PMTCT of HIV at 18 sites reported that 56% of antenatal attendees were tested. The prevalence of HIV infection was 30% and only 55% of these women received nevirapine, while 99% of HIV-exposed newborns received nevirapine. Half of infants born to HIV-infected mothers were followed up and 18% tested positive for HIV.6 A lower vertical transmission rate of 8.7% at 6 weeks was reported from Coronation Women and Children's Hospital in Johannesburg in 2002.9 The MTCT rate reported from Khayelitsha in Cape Town in 2003 was 8.8% (95% CI 6.2 - 10.9) when women were given AZT from 34 weeks' gestation.10
A study in KwaZulu-Natal (KZN) used dry blood spot testing at immunisation clinics to estimate the prevalence of HIV.7 Despite the availability of nevirapine the vertical transmission rate of HIV was estimated at 20.8% (CI 18.2 -23.6) in 6-week-old infants. In 2005 the HIV prevalence among antenatal clinic attendees in KZN was estimated at 39.1%, the highest in the country.3 Here, more than almost anywhere else, effective PMTCT programmes are needed in order to achieve UNGASS goals.
Owing to poor monitoring in PMTCT programmes, operational research in areas of high HIV prevalence is necessary to determine outcomes and provide answers to service delivery problems. This study reports on the outcomes achieved in a PMTCT programme in KZN where extended PMTCT regimens have been introduced.
McCord Hospital is a state-aided hospital in Durban, South Africa, serving patients from a wide catchment area. It offers patients an affordable alternative to overcrowded public services and expensive private medicine. Funding for the hospital comes from the KZN Department of Health (43%), patient fees and grants. In 2004 McCord received funding from the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) to expand and improve the PMTCT programme.
PMTCT programme
The PMTCT programme is integrated into general antenatal services. Staff comprise one medical officer, two nurses, two counsellors, four midwives, one administrative assistant and an obstetrician. Four first-visit midwives are trained as counsellors to reduce the number of steps in the care pathway. Most staff have other duties and are not dedicated to PMTCT only. Since 2004 the programme has been part of the KZN provincial PMTCT programme.
Counselling and testing
Voluntary counselling and testing (VCT) is conducted on an individual basis. Since February 2005, pre- and post-test counselling and testing have been done by the same midwife to improve integration. A rapid HIV test (Abbott Determine) is used and positive results are confirmed with a second rapid test (Smart Check). The test results are given as part of the initial visit. HIV-negative women are offered a repeat test after 3 months.
Partner testing
All pregnant women are encouraged to bring their partners to the antenatal clinic. Partners are also offered testing and, if HIV positive, are referred to Sinikithemba, the HIV clinic at McCord Hospital. Disclosure is encouraged. Psychology services are available for couples experiencing serious relationship difficulties due to discordancy.
Laboratory monitoring and follow-up
Early in the study period CD4 counts and viral loads were not being done on all women, but this improved and now all HIV-positive women have a routine CD4 count after post-test counselling. A goal of the PMTCT programme is to identify women who need highly active antiretroviral treatment (HAART) (CD4 <200 cells/µl) for their own health and to fast-track them onto treatment. Women with a CD4 count above 200 cells/ul have their viral load measured to determine the most suitable PMTCT prophylaxis. Furthermore, all HIV-positive women have their viral load measured at 36 weeks' gestation to determine the most appropriate mode of delivery.
CD4 lymphocyte counts are performed by flow cytometry (Becton Dickinson) and viral load is measured by means of the Amplicor HIV-1 Monitor PCR test (Roche), with a lower limit of detection of <50 copies of HIV RNA/ml. A private laboratory service is utilised for these tests. A polymerase chain reaction (PCR) test is done on HIV-exposed babies whose mothers return for the 6-week postnatal check. The PCR results are given 1 week later when the mother returns for a further appointment. The paediatrician is immediately informed of HIV-positive babies so they can be enrolled in the Sinikithemba children's programme.
Over the 18-month period the McCord PMTCT guidelines were based on evidence from international studies.11,12 If the CD4 count was below 200 cells/µl, women were started on HAART. If it was >200 cells/ul, women received either HAART, AZT antenatally and nevirapine at onset of labour, or nevirapine alone at onset of labour. The decision was based on viral load, gestational age at presentation and patient finances. After June 2005, when more funding became available, women with a CD4 of >200 cells/ul received either AZT antenatally and single-dose nevirapine at the onset of labour (if viral load <1 500 copies/ml) or prophylactic HAART during pregnancy (if viral load >1 500 copies/ml).
HIV-infected pregnant women were counselled about infant feeding options and assisted in deciding whether formula feeding would be acceptable, feasible, affordable, sustainable and safe for them. If not, exclusive breastfeeding for 6 months was recommended.
Study design and population
An observational cohort design was utilised. Data were collected retrospectively and prospectively since the study began in June 2005 and continued till all the women had delivered. The study population was all pregnant women attending McCord Hospital for their first antenatal visit from the beginning of March 2004 till the end of August 2005.
Quantitative and qualitative data were collected from antenatal clinic charts, electronic records, review of routine monthly PMTCT data, record and document review, individual key informant interviews with staff members and participant observation.
Data were captured and analysed using SPSS 13 (SPSS Inc., Chicago, Ill). EpiCalc 200013 was used to calculate bivariate relative risks and 95% confidence intervals.
The study was approved by the University of KwaZulu-Natal Biomedical Research Ethics Committee (reference number H055/05) and the McCord Hospital ethics committee. No individual patient consent was deemed necessary as it was an anonymous record review.
Testing, seroprevalence and follow-up
During the 18 months all 2 624 women (100%) attending the antenatal clinic received counselling, and 91% (2 388) of them were tested for HIV. Sixty-nine per cent (1 811) were tested at McCord Hospital, 577 (22%) were tested elsewhere and 236 (9%) were not tested. Of women attending the clinic, 338 (13%) were HIV positive (95% CI 11.6 - 14.2). Of these 338 women, 89% (302) completed their antenatal care at McCord and 36 (11%) were lost to follow-up.
Demographics and partner testing
The mean age of the HIV-infected cohort was 28 years (range 18 - 40 years) and 24% were married. Twenty-five per cent of partners (668) were tested for HIV. The HIV status of 113 (37%) partners of the 302 HIV-positive women who completed their care at McCord was disclosed to the service. It was found that there were 42 (37%) discordant couples.
CD4 counts and viral loads
The mean gestation at first visit was 30 weeks (range 14 - 41 weeks). CD4 counts were done on 262 women, with 67 (26%) having a CD4 count of <200 cells/µl and 195 (74%) >200 cells/ µl; the median CD4 count was 293 (interquartile range (IQR) 195 - 451). Initial viral loads were done on 166 women but 36-week viral loads were only done on 121 women. The median viral load at first presentation was 3.9 logs (IQR 3.1 - 4.6) or 7 787 copies/ml (IQR 1 403 - 39 856). At 36 weeks' gestation the median viral load was <50 copies/ml (IQR <50 - 558) or 1.7 logs (IQR 1.7 - 2.7).
Prophylaxis regimens
The regimens of 293 women (97% of the 302) were documented (Fig. 1). Of the 130 women (44%) who received HAART during pregnancy, 121 (93%) were started before or at 36 weeks' gestation. Seven were started after 36 weeks and in 2 cases the gestation was not documented. Sixty per cent (77) of the women who received HAART had CD4 counts >200 cells/µl.
In 14 cases in which two antiretroviral drugs had been given during pregnancy, these were started by private doctors before the patient came to McCord Hospital.
Baby outcomes
In the group of 302 HIV-positive mothers there were 3 intrauterine deaths, 1 miscarriage, 1 maternal death (with baby in utero) and 297 live births. One baby died shortly after birth. Of the live births 70% (209) were by caesarean section. Of the live babies, 290 (98%) received nevirapine after birth and 76% (224) also received AZT. In 6 cases (2%) there was no record of the baby receiving any antiretroviral therapy.
The 6-week PCR baby test uptake was 81% (239 of 296 live babies). Of those tested, 2.9% (95% CI 1.29 - 6.19) (7 babies) were HIV positive. Of the 296 mothers questioned after delivery, 93% planned to formula feed.
Risk of MTCT of HIV
Although the sample size was low and the study was not powered for it, bivariate analysis was performed to determine risk factors for transmission. The only significant (p<0.05) risk factors were found to be a first antenatal booking later than 36 weeks' gestation, a CD4 count in the mother less than 200 cells/µl, and the baby receiving nevirapine only as opposed to nevirapine and AZT (Table I). As expected, the lowest prevalence of MTCT of HIV was in mothers on HAART (1.8%; 95% CI 0.3 - 6.8) and the highest in mothers who received single-dose nevirapine only (8.2%; 95% CI 3.1 - 18.8). The incidence risk ratio of a baby being infected with HIV was 5.9 (95% CI 1.1 - 31.1) if the mother's CD4 count was less than 200 cells/µl compared with more than 200. If the baby received nevirapine only as opposed to nevirapine and AZT, the incidence risk ratio was 5.3 (95% CI 1.2 - 22.7).
The McCord Hospital PMTCT programme has achieved a number of positive outcomes in its first 18 months. As in many sites, the number of antenatal clients counselled is very high. In addition, in this programme 91% of antenatal clients' HIV status is known through testing at McCord or elsewhere, which compares favourably with results in the developing world.14-16
The McCord PMTCT programme follow-up of mothers is good, with almost 90% completing their care at the service. In scaling up a nevirapine-based programme in Lusaka, Zambia, patient attrition and non-adherence were major sources of inefficiency.17
Unpublished data from a situational analysis of PMTCT done in KwaZulu-Natal showed that 84% of health care workers agreed that men should be involved in the maternal health of their partners. A study in Uganda showed that at a routine antenatal service only 1.8% of partners tested for HIV.18 At McCord Hospital just over a quarter of partners are testing and discordant couples are being identified and counselled.
A very high percentage (97%) of mothers received prophylaxis, the most common being HAART, and 98% of babies received prophylaxis. This is a higher proportion than in most developing countries where studies have been done. In the Dominican Republic 89% of mothers and 98% of children received ARV prophylaxis.19 In the Ukraine 91% of HIV-positive women received ARV prophylaxis for PMTCT.14 In Cameroon, the prevalence of maternal prophylactic treatment increased from 46% in 2004 to 86% in 2005.15 In the scale-up in Lusaka, Zambia, in 2002 nevirapine had been taken by 57% of mothers and 40% of babies. In South Africa as a whole 61% of HIV-infected women and 47% of exposed babies receive nevirapine prophylaxis.16
Follow-up of infants is a problem. At Coronation Hospital more than one-third of infants were never brought back for follow-up and more than 70% were lost to follow-up by 4 months of age.9 In KZN problems have been experienced with PCR testing of babies. An Integrated Management of Childhood Illnesses (IMCI) review (unpublished data) in 2005 revealed that only 47 of 209 clinic managers were able to report on the percentage of babies PCR tested. Many clinics had stopped PCR testing because of the long turnaround time. The 6-week follow-up for PCR testing of babies at McCord is just over 80%. The 1-week turnaround of the PCR test is achieved because the midwife who is responsible for monitoring obtains all the results in time for the mothers' return visits.
The low transmission rate to babies compares with rates achieved in sites in developed countries. The fact that 44% received HAART contributed to this, and the group cannot be compared with sites providing nevirapine only. The need to educate mothers to attend for their first antenatal booking before 36 weeks' gestation is highlighted by the results of this study, as are the advantages of a higher CD4 count.
Selection bias
This study may have been subject to selection bias, since 11% of the HIV-infected women were lost to follow-up and may have been systematically different in some way to those studied. Furthermore, since McCord Hospital charges a user fee, patients attending may be socio-economically and educationally better off than those attending public facilities. This may influence health and compliance and the results may therefore not be generalisable to the general antenatal population of South Africa.
Information bias
This study relied on data collected for routine monitoring. There may have been errors in written and electronic records.
Confounding
The rate of transmission was very low; with only 7 babies who tested positive, low power was therefore achieved in analysis to determine risk factors for transmission, making multivariate analysis impossible. The risk ratios and transmission risks are therefore from crude bivariate analysis only and could be subject to confounding that could not be controlled for in the study.
Conclusion and recommendations
This programme has done remarkably well at implementing PMTCT of HIV in a developing country with limited resources. It has managed to maintain its success despite changing and extended regimens. The service offered is comprehensive and integrated. It has achieved reduction of the rate of transmission to babies to 2.9% during the first 18 months while the programme was still evolving.
Despite the successes, areas of the McCord PMTCT programme need attention. The low breastfeeding rate is of concern. Over 90% of women choose to formula feed; however, these babies are not specifically followed up to assess mortality or illness, particularly due to diarrhoeal disease. This is important to determine how accurate the infant feeding counselling is in flagging women who are not appropriate for formula feeding.
Although they are referred on to the adult HIV clinic, it is unclear how many mothers who need HAART continue with these services. The incentive for HIV-positive mothers to obtain care and treatment is great during pregnancy but possibly wanes once the baby is born and found to be HIV negative. More should be done to monitor this and keep these women engaging with the services. Women who received short-course HAART during pregnancy for PMTCT prophylaxis (60% of those on HAART) should be monitored in order to start them on ARV therapy when their CD4 counts reach the treatment threshold.
Finally, not only the HIV-positive but also the negative babies need to be monitored over time. In this way the medium- and longer-term effects of PMTCT interventions can be evaluated and the safety of strategies improved.
We are grateful to Candace Westgate, Hiliary Plioplys, Kristie Nixon and Chantelle Young for their assistance with data collection, Professor Quarraisha Abdool Karim and Professor Myra Taylor for commenting on the manuscript, and the McCord Hospital manager, Helga Holst, for advice and support.
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2. Joint United Nations Programme on HIV/AIDS. AIDS Epidemic Update 2005. Geneva: World Health Organisation and UNAIDS, 2005. http://www.unicef.org/protection/files/HIV-AIDS.pdf (accessed 17 October 2006). [ Links ]
3. Department of Health. National HIV and Syphilis Antenatal Sero-prevalence Survey in South Africa 2005. Pretoria: Department of Health, 2005. [ Links ]
4. Bateman C. Low PMTCT coverage/lack of dual therapy 'disgraceful'. S Afr Med J 2007; 97: 906-910. [ Links ]
5. Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet 1999; 354: 795-802. [ Links ]
6. Doherty TM, McCoy D, Donohue S. Health systems constraints to the optimal coverage of the prevention of mother-to-child HIV transmission programme in South Africa: lessons from the implementation of the national pilot programme. Afr Health Sci 2005; 5(3): 213-218. [ Links ]
7. Rollins N, Mzolo S, Little K, Horwood C, Newell ML. HIV prevalence rates amongst 6 week old infants in South Africa: the case for universal screening at immunization clinics. Oral presentation. XVI International AIDS Conference, Toronto, 2006. Abstract No. THAC0104. [ Links ]
8. Quaghebeur A, Mutungu L, Mwanyumba F, Mandaliya K, Verhofstede C, Temmerman M. Low efficacy of nevirapine (HIVNET012) in preventing perinatal HIV-1 transmission in a real-life situation. AIDS 2004; 18(13): 1854-1856. [ Links ]
9. Sherman GG, Jones SA, Coovadia AH, Urban MF, Bolton KD. PMTCT from research to reality - results from a routine service. S Afr Med J 2004; 94(4): 289-292. [ Links ]
10. Coetzee D, Hilderbrand K, Boulle A, Draper B, Abdullah F, Goemaere E. Effectiveness of the first district-wide programme for the prevention of mother-to-child transmission of HIV in South Africa. Bull World Health Organ 2005; 83(7): 489-494. [ Links ]
11. Wade NA, Birkhead GS, Warren BL, et al. Abbreviated regimens of zidovudine prophylaxis and perinatal transmission of the human immunodeficiency virus. N Engl J Med 1998; 339: 1409-1414. [ Links ]
12. Lallemant M, Jourdain G, Le Coeur S, et al. Single-dose perinatal Nevirapine plus standard Zidovudine to prevent mother-to-child transmission of HIV-1 in Thailand. N Engl J Med 2004; 351: 217-228. [ Links ]
13. Brixton Health. EpiCalc 2000. Version 1.02 [computerised program]. [ Links ] Brixton, UK: Brixton Books, 2000.
14. Malyuta R, Newell ML, Ostergren M, Thorne C, Zhilka N. Prevention of mother-to-child transmission of HIV infection: Ukraine experience to date. Eur J Public Health 2006; 16(2):123-127. [ Links ]
15. Welty TK, Bulterys M, Welty ER, et al. Integrating prevention of mother-to-child HIV transmission into routine antenatal care: the key to program expansion in Cameroon. J Acquir Immune Defic Syndr 2005; 40(4): 486-493. [ Links ]
16. Barron P, Day C, Monticelli F, et al. The District Health Barometer 2005/2006. Durban: Health Systems Trust, 2006. [ Links ]
17. Stringer EM, Sinkala M, Stringer JS, et al. Prevention of mother-to-child transmission of HIV in Africa: successes and challenges in scaling-up a nevirapine-based program in Lusaka, Zambia. AIDS 2003; 17: 1377-1382. [ Links ]
18. Kizito D, Woodburn PW, Kesande B, et al. Uptake of HIV and syphilis testing of pregnant women and their male partners in a programme for prevention of mother-to-child HIV transmission in Uganda. Troop Med Int Health 2008; Mar 10 [Epub ahead of print]. [ Links ]
19. Perez-Then E, Pena R, Tavarez-Rojas M, et al. Preventing mother-to-child HIV transmission in a developing country: the Dominican Republic experience. J Acquir Immune Defic Syndr 2003; 34: 506-511. [ Links ]
R Geddes
(murose@saol.com)
Accepted 22 February 2008.
Health and Medical Publishing Group
South African Medial Journal, 28 Main Road, Rondebosch,
Cape Town, Western Cape Province, ZA, 7700,
publishing@hmpg.co.za

redpajama_set_name: RedPajamaCommonCrawl


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iPhone 12 coming October during rough year for Apple
Lizzie Weer, Staff Reporter
Recently, Apple has been hard at work creating their new iPhone while struggling with the tough times brought on by COVID-19. Many Apple stores across the world have temporarily closed down due to COVID-19 which has restricted the company to sell their products primarily online. Despite these challenges, Apple has faced over the past year, the iPhone 12 is likely to reach stores around October 13.
iPhone 12 was originally supposed to be displayed in Apple's September 2020 launch event, but the pandemic has pushed the release back. The Apple Watch Series 6, iPad Air 4, 10.2 inch iPad, and the Apple Watch service bundle became the focus of the event instead.
The iPhone 12 is said to come in four sizes including the Mini, Max, Pro, and Pro Max, but the names are subject to change. The new phone is also rumored to come in silver, space gray, and navy blue and will most likely have a starting price of $649.
But just how many people are interested in buying the iPhone 12? According to Pisgah students, only 31.4% of those who were surveyed were interested in an upgrade, while 39.5% said no and finally, 29.1% said they were unsure. Unfortunately, there is no way of getting everyone's opinion of the phone, however if the student body survey is indicative of how most people feel about the new phone,that more people don't want to buy it than those that do, Apple should be concerned.
Many people who are interested in Apple's new product may not even be able to test it out beforehand due to the lack of open stores. This issue is might drive away some potential customers because they won't be able to see exactly what they are buying. This could be disastrous for Apple, as fewer in-store customers would likely cause the company to struggle even more.
While Apple may loose a lot of its in-store customers, they are bound to have more online shoppers looking for new products. Although most consumers won't be able to see the features of Apple's recent additions, they can easily find out about them with a quick search online.
Despite Apple's recent decline in sales, it appears that company might not have as hard a time getting back to its fit as other businesses amidst the disaster of COVID-19.


Great news for Blender users! We now have native animation support for .blend files. This means you can upload your .blend file directly, there is no need to convert to an fbx file anymore. You can also use our native Blender exporter, which now adds a cool 'uploaded with Blender' icon to your model.
We always welcome your feedback, so if you come across any issues, please let us know in this forum thread, and feel free to check the Help Center for tips.
Remember to tag your uploads with 'Blender' so it shows up in the gallery and BlenderNation can find them to feature each week! You can also embed directly on Blender Artists and Blender Market.
Looking forward to seeing your Blender animations!
How to animate object transparency? Or had to scale it really quick.
I cannot use the exporter addon with Blender 2.8 and the blend file for the version of Blender 2.8 cannot be upload to the sketchfab website.


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Q: Obter valores das checkboxes selecionadas e seus respectivos preços
Bom, estou desenvolvendo um sistema de pedidos online, inicialmente só para fins de aprendizado, só que me deparei com algo que não faço a mínima ideia de como fazer e apreciaria imensamente qualquer tipo de ajuda.
Na página produtos.php eu estabeleço duas conexões com o DB e busco os produtos presentes na tabela produtos por categoria e os acréscimos existentes na tabela acrescimos:
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                while ($row = $stmt2->fetch(PDO::FETCH_ASSOC))
                {
                    extract($row);
                    $preco_acrescimo_reajustado = number_format($preco_acrescimo, 2, ",", ".");
                    echo "
                    <input type='checkbox' name='{$nome_acrescimo}' value='{$nome_acrescimo}'/>{$nome_acrescimo} - R${$preco_acrescimo_reajustado} <input type='number' name='quantidade_acr[]' value='1' min='1' max='5'/>

                    ";
                }
                echo "	";
            }
            echo "
                <form class='adicionar'>
                    <button type='submit'>Adicionar</button>
                </form>

";
    }
    echo "
";
}

Como puderam ver com este código, se o ID da categoria correspondente for igual a 1, outra coluna será criada na table. A coluna Acréscimos. E é aí que se encontra o meu maior problema. Se analisaram bem o código, puderam ver que meu output será algo como:

Notaram as checkboxes presentes na coluna Acréscimos? Então, o que estou tentando fazer (sem sucesso) é, no ato do click no botão Adicionar, obter os valores das checkboxes selecionadas de acordo com seus nomes e preços existentes na tabela acrescimos. Mas como fazer isso?
Eu preciso obter esses valores e armazená-los em variáveis para posteriormente inseri-los dentro da SESSION e exibi-los junto com os outros no carrinho do usuário. No produtos.php eu tenho uma função de jQuery que armazena os dados da linha selecionada em variáveis para depois serem inseridos em suas determinadas variáveis na SESSION:
$(document).ready(function()
{
    $('.adicionar').on('submit', function()
    {
        var id_produto = $(this).closest('tr').find('.id-produto').text();
        var nome_produto = $(this).closest('tr').find('.nome-produto').text();
        var quantidade = $(this).closest('tr').find('input').val();
        window.location.href = "adicionar.php?id_produto=" + id_produto + "&nome_produto=" + nome_produto + "&quantidade=" + quantidade;
        return false;
    });
});

No arquivo adicionar.php eu busco no DB o ID e nome do produto selecionado para então obter o preço do mesmo. Se meu retorno for true, o script prossegue adicionando os dados na SESSION:
if (isset($_GET['id_produto']) && $_GET['id_produto'] != "")
{
    if(isset($_SESSION['carrinho']))
    {
        $contar = count($_SESSION['carrinho']);
        $id_produto_sessao = $contar++;
    }
    else
    {
        $id_produto_sessao = 0;
    }
    $id_produto = isset($_GET['id_produto']) ? $_GET['id_produto'] : "";
    $nome_produto = isset($_GET['nome_produto']) ? $_GET['nome_produto'] : "";
    $quantidade = isset($_GET['quantidade']) ? $_GET['quantidade'] : "";

    $sql = "SELECT * FROM produtos WHERE id_produto LIKE '{$id_produto}' AND nome_produto LIKE '{$nome_produto}' LIMIT 1";
    $stmt = $conexao->prepare($sql);
    $stmt->execute();

    $num = $stmt->rowCount();

    if($num == 1)
    {
        if($quantidade <= 0 || $quantidade > 20)
        {
            header('Location: produtos.php?acao=quantidadeinvalida&nome_produto=' . $nome_produto);
        }
        else if(!isset($_SESSION['carrinho']))
        {
            $_SESSION['carrinho'] = array();
        }
        if(isset($_SESSION['carrinho']))
        {
            while ($row = $stmt->fetch(PDO::FETCH_ASSOC))
            {
                extract($row);
                $colunas = array
                (
                    'id_produto_sessao' => $id_produto_sessao,
                    'id_produto' => $id_produto,
                    'nome_produto' => $nome_produto,
                    'preco_produto' => $preco_produto,
                    'quantidade' => $quantidade
                );
            }
            $_SESSION['carrinho'][$id_produto_sessao] = $colunas;
            header('Location: produtos.php?acao=adicionado&nome_produto=' . $nome_produto);
        }
    }
    else
    {
        redirecionar_para("produtos.php");
    }
}

Notem que a quantidade informada é obtida com o jQuery e passada para a SESSION. Creio que terei que fazer algo parecido para obter os dados referentes às checkboxes selecionadas, mas não faço ideia de como fazer isso. Iria colocar também o código que consta no arquivo carrinho.php e que tem como finalidade exibir os dados presentes na SESSION carrinho, mas isso vai deixar a pergunta extensa demais. Acho que primeiro devo conseguir armazenar os dados dessas checkboxes. A tarefa de exibi-los depois não deve ser tão difícil. Mas voltando ao problema em pauta, como obter os valores de cada uma das checkboxes selecionadas anteriormente e também inseri-los nessa SESSION? Como implementar isso no meu sistema?

A: Se mudares o HTML um pouco facilitas as coisas. Muda:

    <input type='checkbox' name='acr[0]' value='Queijo'/>Queijo - R$2,00 <input type='number' name='quantidade_acr[0]' value='1' min='1' max='5'/>

    <input type='checkbox' name='acr[1]' value='Alho'/>Alho - R$0,50 <input type='number' name='quantidade_acr[1]' value='1' min='1' max='5'/>

    <input type='checkbox' name='acr[2]' value='Oregano'/>Orégano - R$0,50 <input type='number' name='quantidade_acr[2]' value='1' min='1' max='5'/>

para:

   <input type='checkbox' name='acr[]' value='{"tipo": "Queijo", "preco": 2.0}'/>Queijo - R$2,00 <input type='number' name='quantidade_acr[0]' value='1' min='1' max='5'/>

   etc...

Assim no valor dessas checkboxes já tens o preço e tens uma classe com essa td.
Depois podes fazer assim para passar isso para um JavaScript:
var dados = $('.acr input[type=checkbox]:checked').map(function (i) {
    var data = JSON.parse(this.value);
    var qtd = this.checked ? parseInt($(this).next('input').val(), 10) : 0;
    var preco = data.preco;
    var toString = {
        tipo: data.tipo,
        preco: data.preco,
        qdt: qtd,
        total: qtd * data.preco
    };
    var obj = {};
    obj['acr_' + i] = encodeURIComponent(JSON.stringify(toString));
    return obj;
});

var queryString = dados.map(function () {
    return $.param(this, true)
}).get().join('&');

Isso vai criar uma array dados com objetos com tipo, preco, qtd e total. Depois converte essa informação toda numa _query string_, que vejo que usas no teu código. Assim podes juntar o que está nessa variável queryString ao GET que fazes quando tens window.location.href =  ... lembra-te de juntar & entre cada parte desse url.
Se fizeres com AJAX podes fazer assim, dentro da função que inicia o envio para o servidor:
var obj = {};
var dados = $('.acr input[type=checkbox]:checked').each(function (i) {
    var data = JSON.parse(this.value);
    var qtd = this.checked ? parseInt($(this).next('input').val(), 10) : 0;
    var preco = data.preco;
    var dados = {
        tipo: data.tipo,
        preco: data.preco,
        qdt: qtd,
        total: qtd * data.preco
    };
    obj['acr_' + i] = dados;
});
$.post(url, obj, function (res) {
    console.log(res);
});

Se tiveres problemas a recuperar isso no PHP coloca outra pergunta que podemos ajudar mais.
jsFiddle: https://jsfiddle.net/Lubvpnz5/

A: Você pode fazer o seguinte, no seu formulário, coloque o atributo data-(o parâmetro que quer capturar):
<input type='checkbox' name='acr[0]' data-id="1" data-valor="2.00" value='Queijo'/>Queijo - R$2,00 <input type='number' name='quantidade_acr[0]' value='1' step="1" min='1' max='5'/>

                <input type='checkbox' data-id="2" data-valor="0.50" name='acr[1]' value='Alho'/>Alho - R$0,50 <input type='number' name='quantidade_acr[1]' value='1' step="1" min='1' max='5'/>

                <input type='checkbox' data-id="3" data-valor="0.50" name='acr[2]' value='Oregano'/>Orégano - R$0,50 <input type='number' name='quantidade_acr[2]' value='1'step="1" min='1' max='5'/>

<button id="salvar">Salva</button>

Depois crie o método em jquery para salvar os dados:
$(document).ready(function(){
    $('#salvar').on('click', function() {
        var list = [];
         $('[name*="acr"]:checked').each(function(key) {

             var qtde = $('[name*="quantidade_acr['+key+']"]').val();
             var produto = $(this).val();
             var id = $(this).data('id');
             var valor = $(this).data('valor');
             var total = qtde * valor;
            list[key] = {
                          produto: produto,
                          quantidade: qtde,
                          id: id,
                          valor: valor,
                          total_valor: total
                         };

           });
          /* aqui eu dei uma saída em HTML
             do JSON apenas para exibir, o
             ideal é que você envie esse
             array para o seu método post. */
           alert(JSON.stringify(list));

    });
});

Aqui está o exemplo:
https://jsfiddle.net/ivanferrer/kumyaj8g/
Aqui um exemplo mais complexo:
http://jsfiddle.net/ivanferrer/nq9Lts0f/1/

redpajama_set_name: RedPajamaStackExchange


Lakeland's Board of Education is comprised of nine school district residents who are elected by voters to three-year terms in the annual election each spring. Terms are staggered so that three members are elected each year. Board members serve without compensation. Board members attend at least two public meetings each month along with committee meetings and various school-related activities. At the annual organizational meeting in July, the Board elects a president and vice-president.
The Board of Education is the official policy-making body of the school district.


Being grown up is a nebulous concept. You can be a functioning adult at age 18 but in many ways not feel, or even be, 'grown up' at all.
I have it on good authority that this feeling can last for many more years.
But I took an important step towards grown-upness when I received my first paycheck a few months ago. The feeling of joy at seeing the money I had earned was soon replaced with the fear that I am now undeniably an adult – one who has to pay taxes and must be responsible with their money (thrilling isn't it).
But where to start? Like most teenagers, I used to find the jargon around personal finance pretty impenetrable. People of all ages do.
But I chose to take a gap year after doing my A-Levels, to give me more time to think about what I really want to do. Working as a trainee at an investment company, sitting alongside financial experts, is giving me a different perspective on money.
I'm thinking about stuff that I know others my age aren't because of where I work.
I'm in a good position to learn about the journey to financial independence (as boring and serious as that might sound). So that's what I've done and here's what I've learned.
Like many people, I like eating out, going for drinks with friends and the occasional new outfit. However, I've also got rent to pay and groceries to buy. Learning to budget properly and sustainably is going to be a key part of my mission. How else will I know what I can afford and what's worth my money?
Someone recommended the book In Love Is Not Enough: A Smart Woman's Guide to Money to me and that's been very useful.
Financial journalist Merryn Somerset Webb suggests a good way of making smart purchases is calculating the number of hours of work that goes into each item.
If you're a school-leaver, you could well be earning the National Minimum Wage of £6.50 (for 18-20 year olds). In which case, that £30 dress in the sales will cost you nearly five hours of work. Do you really like it and how much will you wear it.
My plan: With the help of my colleague Claire, who is a financial adviser, I came up with a plan to spend money more mindfully by tracking my spending digitally and working out my monthly levels of disposable income. I am going to use this as a baseline for what I can and cannot afford.
A quarter of British adults have no savings, according to a study by Skipton Building Society. It also found one in ten typically spend more than they earn.
I might feel like I've got a way to go when it comes to understanding finances, but I do know that having money put aside means security – and freedom.
When I go to university next year, I will want to travel and to have a social life. I'm putting money aside now to fund all those non-essentials.
If your money is sitting in a current account where it is gaining no interest, the effect of inflation means it is likely you are actually losing money.
Let's say you have £100 in a current account that pays little or no interest. After a year, you will still have £100 in your account. But if the rate of inflation is running at 2%, you would need £102 to have the same purchasing power that you started with.
My plan: I am going to look at different savings accounts, and shop around for the best interest rates on offer. Then I can work out how much I can afford to put aside and start building my savings for emergencies.
Warren Buffett, the world's best-known investor, once said: 'Successful investing takes time, discipline and patience.' I'm a teenager, so I guess I have time - but discipline and patience? Well, let's say I'm working on it.
Claire said: 'It is a bit like exercise. When you start it feels like hard work, but once you get used to it, it becomes second nature. You might even enjoy it. But the real reward is the results.
My plan: Once I have savings for emergencies, I will research and compare the different investment Isa platforms. I plan to start putting small amounts of money towards investing each month so I can get to grips with it, and not invest more than I am prepared to lose.
The journey to financial adulthood might seem long and arduous – but it's much easier if you have some order to it. The really good news is it turns out I'm an investor already, because I have a pension. Tick. Not so arduous after all.
The views are those of the author. We cannot provide investment or pension advice; please speak to an independent adviser should you be uncertain what is appropriate for you.
Alexandra is a communications trainee on the Investment 2020 scheme, an initiative to offer young people from different backgrounds a first job in the City. New to the world of work, she's charting her journey into adulthood and financial independence. She loves fashion and economics and is studying Mandarin.


The Philippines is a country that is progressing and expanding and the standards are being raised in every department of the business sector to reflect this growth. Indeed, 2015 saw many changes in the accounting industry that indicate that the Board of Accountancy (BoA) is determined to do everything it can in order to increase the quality of service in this field.
It revised the syllabus for the Certified Public Accountant (CPA) exams by overhauling the subjects in order to ensure that they meet global standards and that they are more current and relevant. There was a reduction in the number of examination subjects from seven to six by amalgamating some of the previous subjects and then adding a new one entitled the Regulatory Framework for Business Transactions, and there will be a shift towards an outcome-based education with a focus on effective communication.
It has also implemented new rules on accreditation, as well as in the preparation of financial statements, by tightening up the procedures and enforcing stricter guidelines. It will also soon put in place changes in the Continuing Professional Development (CPD) which are aimed at improving the quality of certified accountants in the country. While certain rules may prove costly and burdensome to some, they are necessary in order to improve the quality control in the industry.
The major changes include the increase, year-on-year, in the number of CPD units that have to be completed, from the current number of 60 to 80 for the end of 2016, then 100 for 2017 and 120 for 2018; the establishment of clearer rules on how to secure CPD credits for self-directed learning activities, while also encouraging more online courses to be made available; a more efficient and restructured monitoring of the CPD units by using the BoA's IT tracking system, and the firm shift of the categories studied in order to align them with the International Education Standards.
There are also a few other less important changes, and it all goes to show the willingness and single-mindedness of the BoA to take whatever steps are necessary in order to improve the standards within the industry and the quality of CPAs. What should be noted, though, is that, while this is a good thing, there may be a downside in that it may make it very difficult for sole practitioners to continue working independently due to the costly requirements, leaving the field open only to the big firms.
However, the end result should be that there will be a better regulation of the accountancy profession, which will bring about more trust from the general public, as well as the international business community at large.


The post-crisis financial landscape may be confusing to investors, but it offers more banking models to choose from—including one that seems poised for long-term growth.
If you were designing a bank now, from scratch, for growth and maximum profits, what kind of bank would you build?
Bank earnings this year—from the biggest and most aggressive investment banks such as Goldman Sachs (NYSE: GS) to the do-everything behemoths such as JPMorgan Chase (NYSE: JPM), to the lending-oriented banks such as U.S. Bancorp (NYSE: USB), to the specialist banks—don't give a single definitive answer. It's hard to tell whether the old models are in need of serious overhaul or just taking a breather, and there are serious doubts about the future profitability of many classic banking activities.
And I think that's healthy—even if it makes life hard for investors. The clear consensus on what a bank should be if it wanted to maximize growth and profits was, it turns out, one of the great weaknesses of the banking system before the financial crisis. Too many banks had decided to be the same kind of bank. And that left the industry exceedingly vulnerable to disruption and failure.
For the moment, at least, investors are free again to look for the best bank among many styles of banks, rather than investigating which bank matches up best with a single model for success.
Here's how the landscape looks to me right now and the names of some interesting banks, of different models.
Before the financial crisis, bank CEOs thought they had a clear answer to what the best bank would be like. They wouldn't worry too much about building a big base of depositors; it was easy to raise all the money a bank needed to finance its lending and other activities in the financial markets. They'd build trading desks that traded for clients, of course, but that also put the bank's own capital at risk in proprietary trades. And they'd work to build up investment banking activities ranging from underwriting stock and bond offerings to selling packages of securitized mortgages, credit card receipts, and car loans. They would also engage in complex derivatives that let clients bet on the direction of financial markets or let them hedge the risk of complicated trading strategies.
The bank these CEOs had in mind was about as far from Frank Capra's Bailey Building & Loan as possible.
But the financial crisis took some of the edge off that model.
For one thing, it demonstrated that the banks built on that model had put everything in one basket. They needed functioning financial markets, not just to raise capital, but also to roll over the existing debt that provided current capital. Gains from trading for a bank's own account were dependent on being able to figure out the direction of the markets, and revenue from trading for clients' accounts were dependent on the willingness of those clients to be in the markets at all.
The model left banks with strikingly few alternatives in a crisis. At the end of "It's a Wonderful Life," the building and loan's depositors ride to George Bailey's rescue. In the recent crisis, banks built around the pre-crash model had no one to turn to but governments and reluctant taxpayers.
Here's a quick rundown of the various banking models and their prospects.
It's not clear how damaged this model is. In the first quarter of 2010, it looked like it was back on top: Trading and investment banking revenue soared while commercial and consumer lenders were still drowning in a sea of bad loans. In the just-completed second quarter, trading and investment banking revenue fell. The infallible traders of the first quarter turned out to be no better than the average investor at making a profit in a volatile and unpredictable market. Even the banks, such as Morgan Stanley (NYSE: MS), that had looked like they'd had successful trading quarters, wound up making a good part of their trading revenue out of accounting gimmicks based on the price of their own debt.
But the biggest long-term threat to the trading and investment banking model as adopted by US banks comes from the shift in global finance toward the world's developing financial markets. The largest stock offerings of 2010, for example, haven't been in New York or London, but in São Paulo, Hong Kong, and Shanghai. The big US-based pre-crisis powers such as Morgan Stanley haven't been shut out of these deals, but they've had to share them with "local" banks such as HSBC (NYSE: HBC) in Hong Kong and Itaú Unibanco (NYSE: ITUB) in São Paulo. In one example of growing heft, Itaú climbed past Goldman Sachs in 2009 to become the fourth-largest underwriter of overseas bond sales for Brazilian companies.
Second, many of the US banks built on the investment banking/trading model now can't match the deposit-gathering power of either big (Banco Santander (NYSE: STD) and HSBC) or smaller (India's HDFC (NYSE: HDB)) overseas banks.
Once the banks built on the investment bank/trading model have their bounce—and some of them clearly have—investors need to recognize that the US banks that adopted this model face some of the toughest challenges in the banking sector. Indeed, my favorite banks built on this model are not US banks. I much prefer overseas banks such as Itaú Unibanco, HSBC, and Banco Santander.
You could see that in the regional bank earnings announced July 22 and in the earnings announced the day before by US Bancorp, which has emerged as the fourth-largest US bank during the crisis.
These banks lagged the investment banks in 2009 and in the first quarter of 2010 because the latter saw a recovery in revenue from investment and trading well before the lending-oriented banks saw any improvement in either bad loans or loan volume.
Now it looks like the roles are reversed: Trading revenue has faltered just as loan portfolios have started to improve.
PNC Financial Services (NYSE: PNC), for example, reported earnings per share of $1.47 for the second quarter. That was 19 cents a share above the Wall Street consensus projection. Revenue climbed almost 3% from the second quarter of 2009. That beat the projection of $3.78 billion by 3.4%.
The big story was the stabilization in the bank's loan portfolios. Non-performing assets fell by $465 million in the quarter. There's still quite a way to go, though: The bank finished the quarter with $6.1 billion in non-performing assets.
Change the names and the story remains the same at Fifth Third Bancorp (Nasdaq: FITB) and KeyCorp (NYSE: KEY). Fifth Third reported its first profit since the fourth quarter of 2007 as non-performing loans fell by 8% from the first quarter. Keycorp reported its first profit in more than two years; non-performing loans fell by $362 million in the quarter.
My two favorite banks in this part of the industry are US Bancorp, which reported earnings July 21 (for the details, see this post on my Web site), and Wilmington Trust (NYSE: WL). Wilmington is still very risky—its recovery seems to be lagging some similarly constructed banks—but the bank's July 23 earnings report definitely showed signs that it was catching up.
So why do I like US Bancorp and Wilmington Trust among the banks that still follow a traditional mix of lending and deposit gathering? Because they've built up big fee-based wealth management businesses, and, as the country ages, that's a piece of the banking industry that will become increasingly profitable.
But if you really want exposure to this revenue and profit stream, you need to look at smaller banks, where wealth management is a bigger part of revenue.
Bank of Marin Bancorp (Nasdaq: BMRC), for example, reported second quarter earnings of $3.3 million, up 6.5% from the second quarter of 2009. But non-interest income—what the bank earns on its for-fee businesses—did somewhat better than the bank as a whole. Non-interest income grew 18.2% from the second quarter of 2009, to a total of $1.5 million, and equaled 45% of the bank's income for the quarter. The biggest contributors to that growth came from higher merchant interchange income and higher wealth management service fees, the bank said in its earnings announcement.
If that kind of banking model tickles your investing bone, take a look at Bryn Mawr Bank (Nasdaq: BMTC). Assets under management on June 30, 2010, in the bank's wealth management division were up $3.1 billion, or 37%, from a year earlier. Revenue from that division had climbed almost 8% from the second quarter of 2009.
You can invest in any of these three models or concentrate in just one of them. I think that the stocks of the traditional lending/deposit-gathering banks are the most timely, that the stocks of the big investment banking/trading are the most volatile, and that the stocks of the wealth management specialty banks are the least risky in the long run.
At the time of publication, Jim Jubak owned shares of the following company mentioned in this column: Bank of Marin Bancorp.


Hypohidrotic ectodermal dysplasia (HED) is the most correct term for this inherited condition. Other synonyms include anhidrotic ectodermal dysplasia, but this is a misnomer, as affected individuals are typically able to sweat to some degree.
Sweating is greatly diminished. An infantile history of unexplained fevers is usually reported. Often affected toddlers lay on the floor in an attempt to cool themselves.
Overheating can manifest with symptoms of irritability, erythema of the ears, headache, dizziness, weakness, fatigue, nausea, vomiting and muscle cramps.
Diagnosis is most often made with the eruption of conical teeth which may be delayed beyond 15 months of age. Hypodontia is also appreciated on imaging at this age (Figure 1).
Affected newborns may be born with diffuse, scaling, erythematous skin similar to a collodian membrane. Classic facial features include frontal bossing, prominent supraorbital ridge, small chin, low, depressed nasal bridge, and prominent lips (Figure 2). Periorbital and perioral wrinkling and hyperpigmentation are obvious features . White facial papules described as sebaceous hyperplasia can also be seen as can hypotrichosis with thin, light, slow-growing hair on the scalp and also thin, sparse eyebrows and eyelashes. (Figure 3).
Secondary sexual hair is typically normal. Nails are most often normal but can be thin or spoon shaped. The skin may be thin, smooth and dry.
The differential diagnosis includes ichthyosis; the neonatal finding of diffuse scaly erythema can be mistaken for an inherited ichthyosis. Ichthyotic disorders present with a true collodian membrane while hypohidrotic ectodermal dysplasia may mimic this finding with a pseudo-collodian membrane.
Hypohidrotic ectodermal dysplasia with immune deficiency caused by mutations in the NEMO gene presents with similar but more subtle clinical findings but can be distinguished by the multiple severe infections that develop due to the underlying immunodeficiency.
The prevalence of HED is 1:10,000.It does not appear to have a racial or ethnic predilection.
Ninety-five percent of hypohidrotic ectodermal dysplasia cases are inherited as an X-linked recessive disorder. Therefore, the disease is only fully manifest in affected males and female carriers are more mildly affected. All daughters born to an affected male will be a carrier. None of the sons of an affected male will be affected. Each child of a carrier female has a 50% possibility of inheriting the mutation.
Equal incidence in males and females is noted in the rare autosomal dominant or autosomal recessive cases reported.
Hypohidrotic ectodermal dysplasia is a genetically inherited disorder. Mutations in the causative gene are typically inherited from an affected parent but a spontaneous mutation can also occur.
Mutations in the causative gene are responsible for the manifestations of the disorder. Mutations in the ectodysplasin signaling pathway are seen in those affected with hypohidrotic ectodermal dysplasia. X-linked cases are due to a mutation in the gene encoding ectodysplasin (EDA1) on chromosome Xq12-13.1.
Autosomal dominant and autosomal recessive cases are due to mutations in the gene for ectodysplasin receptor (EDAR) on chromosome 2q11-q13 or EDAR-associated death domain (EDAR-ADD) on chromosome 1q42.4-q43. The NEMO gene is implicated for HED-ID.
The inability to perspire can cause hyperthermia, which may lead to febrile seizures and neurologic damage. Decreased secretions can also lead to xerostomia, xerophthalmia, thick nasal secretions, excessive cerumen, hoarse voice, respiratory infections, and dysphagia.
Feeding issues, weight deficits and failure to thrive can be seen in affected infants and children. An increased incidence of atopy is also noted in affected individuals, including eczema, wheezing, asthma, food allergy and abnormal immunoglobulin production, in particular elevated IgE levels related to atopic diathesis and also a decreased delayed hypersensitivity to DNCB.
Mortality in the first three years of life is as high as 13% due to complications of hyperthermia, failure to thrive, and respiratory infections. Otherwise, life expectancy is normal.
Cooling techniques to reduce elevated body temperature are key. Avoiding or appropriately managing situations with intense physical activity (ie sports) or when exposed to high ambient temperatures is important, especially in infancy, childhood and in the elderly.
Specific cooling techniques include seeking shade, using umbrellas, carrying damp washclothes or towels in a small cooler with ice, use of moistened bandanas around the head, neck or wrists, wearing dampened clothing, application of chilled emollients, misting water bottles, battery powered handheld fans, consuming cool drinks, use of cooling vests and air conditioned environments.
There is no currently available therapy that leads to cure of hypohidrotic ectodermal dysplasia.
Promising animal models in mice and dogs with gestational and postnatal administration of a synthetic recombinant EDA-A1 protein led to phenotypic rescue, including normalization of hair, teeth, lacrimation and improved sweating as well as decreased respiratory infections. EDI200 is currently being developed with the hope of human trials in XLHED in the near future.
Symptomatic treatment is warranted for the skin findings and co-morbid diseases. Dental referral is warranted in all cases. Other specialty consultations are warranted based on individual symptoms.
Atopic dermatitis can be appropriately managed with topical steroids, topical immunomodulators and antihistamines by a dermatologist. Potential increased risk of melanoma has been reported, so an annual full body skin examination is also advised.
Early dental evaluation and treatment is important and helps with language development, mastication, and cosmesis. Dentures in childhood and orthodontia or dental implants are options for treatment in older individuals.
Dry eyes and thick nasal secretions can be treated with saline sprays. Consultation with ophthalmology and otolaryngology may be warranted.
Asthma and recurrent respiratory infections should be treated appropriately and referral to a pulmonologist may be warranted.
Weight deficits can be managed by high caloric diets. Gastroenterology or nutrition consultation may be indicated in cases of failure to thrive.
Genetics evaluation can be helpful in coordination of care, genetic counseling and molecular testing.
Education of the patient and family regarding the condition is necessary. Patients should be instructed regarding the signs of overheating. They should be encouraged to modify their activities when necessary and to be aware of their body's limitations when at risk for hyperthermia.
Cooling techniques should also be discussed and readily implemented by the patients and families when warranted.
The importance of recognizing and promptly treating hyperthermia, failure to thrive and respiratory infections in affected infants and toddlers should be stressed as these issues can lead to mortality. Multidisciplinary care is important in this condition and follow-up with multiple specialists may be required.
Affected individuals should be encouraged to lead full lives with lifestyle modifications required only as necessary. Affected children and adolescents should be encouraged to participate in water-based sports as an ideal option but can also fully participate in all sports with precautions. Letters from the physician may need to be written to schools, teachers, and coaches to educate them about the need and importance of activity modifications, signs of overheating and cooling techniques.
Ability to sweat is reported by some affected adults to improve with age. Common medical conditions and illnesses also occur in affected individuals and not every symptom will be associated with or explained by the patient's ectodermal dysplasia.
Thick secretions can lead to impressive nasal casts.
There is no optimal treatment for the periorbital/perioral wrinkling and long-term use of topical steroids to manage this condition should be avoided. Topical immunomodulators, topical keratolytics and topical vitamin D analogues are also uniformly ineffective for treatment.


text:
Malaysia wants to cut out third parties in foreign worker recruitment
The Malaysian government has advised the employers not to make any payment through intermediaries or third parties for the speeding up the application process as its cabinet recently approved the entry of foreign workers for all employment sectors.
"This is to prevent fraud by irresponsible parties," said Malaysian minister for human resources M Saravanan in a media statement on recruitment and employment of foreign workers.
The Malaysian minister also reminded employers who want to employ foreign workers to submit their own applications and based on the actual needs for foreign workers.
Employers who use the services of private employment agencies must also ensure that the agency is registered and has a license certified by the Department of Manpower Peninsular Malaysia under the Private Employment Agencies Act 1981, according to the statement.
The entry of foreign workers for all employment sectors was approved by the Malaysian cabinet meeting on 10 December last year.
This entry will open to all sectors allowed for the employment of foreign workers namely agriculture, manufacturing, services, mining and quarrying, construction and domestic servants.
Previously, approval was given for the entry of 32,000 foreign workers for the plantation sector with special exemptions.
All these admissions must comply with the Standing Operating Procedure (SOP) for the admission of foreign workers which was approved by the Covid-19 Ministerial Quartet Meeting on 14 December 2021, according to the media statement.
This SOP includes four phases namely pre-release, on arrival, post-arrival i.e. quarantine and post-quarantine period.
Accordingly, the minister will make an announcement in the near future on the date of applications that can be submitted by employers online for the process of hiring foreign workers for each sector of employment allowed from the Source Country.
Read more from Bangladesh
Expatriate Workers


text:
WP NewsPaper
'Shocked, disheartened, devastated': Restaurant and hotel workers reel as layoffs soar again
[email protected] January 13, 2021 No Comments
"It's been 10 months but I'm still shocked, disheartened, devastated," Slater mentioned. "I've gone through my savings, I've gone through my resources — all of that is depleted now. The bills are piling up and my kids are looking to me for answers I can't provide."
The coronavirus pandemic has ravaged the hospitality, journey and retail industries since its outset in March, when shutdowns and restrictions meant to include the virus value extra than 520,000 U.S. service workers their jobs.
This workforce is below renewed strain amid a resurgence in coronavirus circumstances: 498,000 leisure and hospitality jobs disappeared final month, the Labor Department reported Friday. Restaurant and bar workers comprised the majority of these losses, roughly 3 in 4, an onslaught that disproportionately affected women and workers of shade. Overall employment within the sector has fallen 23 p.c in the course of the pandemic, outpacing each different business, federal information reveals.
With new rounds of state-mandated restaurant and bar restrictions, and winter climate limiting outside eating, meals companies accounted for 372,000 job losses in December. That backslide obliterated important hiring features in industries like skilled companies, retail and development, and the United States recorded a internet lack of 140,000 jobs in December — its first adverse displaying since April.
"A lot of these places were only just holding on, and a lot of people were crossing their fingers and hoping for the best," mentioned Martha Gimbel, a labor economist and senior supervisor of financial research at Schmidt Futures. "But December was an important reminder that there are industries that will not be recovering until this public health crisis is over."
The $900 billion pandemic aid bundle Congress accepted in December restarts the Paycheck Protection Program (PPP), giving loans to small companies, with worker retention incentives and mortgage forgiveness for small eating places. Nonetheless, many business specialists say eating places, bars, resorts and tourism companies stay susceptible to everlasting closure.
Some 110,000 eating places and bars — greater than 1 in 6 throughout the nation — have gone below since March.
Incoming Senate Majority Leader Charles E. Schumer has pushed bipartisan laws identified as the Restaurants Act, which would offer $120 billion to eateries nationwide. President-elect Joe Biden additionally has advocated for direct aid to eating places.
"We need to do much more for restaurants," Schumer (D-N.Y.) told the Senate in December.
For half 1,000,000 restaurant and hospitality workers, support could come too late. They have been unemployed, reemployed and unemployed again. They have cobbled collectively piecemeal work and toggled between serving solely to-go prospects, at 50 p.c capability, then to 25 p.c capability and then again to no indoor eating, guidelines usually various from city to city.
"We've pivoted so many times we've made a circle," mentioned Eric Cook, chef-owner of Gris-Gris in New Orleans. "We're like a million termites on a bridge holding hands."
'It's been tough'
Malcolm Garrett, a line cook dinner at a on line casino steakhouse in New Orleans, misplaced his job the day earlier than Thanksgiving.
Garrett, who had been furloughed early within the pandemic, went again to work at Harrah's New Orleans Hotel & Casino in June. But with occupancy capped at 25 p.c and locals nonetheless skittish about venturing out, enterprise fell drastically. He fired up about 80 steaks on the busiest nights, down from 230 earlier than the pandemic.
"It's been rough," mentioned Garrett, who purchased a home along with his girlfriend in August. "Now it's been over a month and I'm still looking for a job."
Garrett filed for unemployment advantages in November however continues to be ready on cash to reach. In the meantime, he's been interviewing for jobs however says it's been onerous as a result of many chains are quickly closing places.
"I hope my unemployment comes through before I get really desperate," he mentioned. "This pandemic is really thinning out the amount of work I can find."
Nearly 4 million leisure and hospitality jobs have been misplaced since February, a staggering blow to an business that after had 15 million workers, economists mentioned.
"Workers have already gone through this incredibly unstable 2020 experience — even if they kept their jobs or got their jobs back, they may have just lost them again," mentioned Gimbel, the economist. "It's incredibly destabilizing."
The hemorrhaging of service-sector jobs, she added, has additionally had ripple results for unemployed workers from all sectors who may need in any other case taken jobs at eating places, bars or leisure venues to make ends meet. The variety of leisure and hospitality job openings has additionally fallen markedly — down 17 p.c in November from a 12 months earlier — based on information launched Tuesday by the Labor Department. "All of these industries are interconnected," she mentioned.
After a good friend died of covid-19 early within the pandemic, Timothy Carl made himself a promise: He was going to dwell his greatest life. He left Rochester, N.Y., for Southern California and took a job as an assistant innkeeper and chef on the Palm Springs Rendezvous, an 11-room bed-and-breakfast identified for its retro aptitude.
He made $15 an hour and good ideas cooking three-course breakfasts for a gentle stream of company earlier than enterprise dried up. He misplaced his job on Dec. 1, days earlier than Gov. Gavin Newsom (D) issued a stay-at-home order that prohibited hotel bookings for tourism and different nonessential causes. The property is now up on the market.
"I've gone through my savings and I am as broke as a joke," mentioned Carl, who's greater than $3,000 behind on hire. "The whole month of December felt like the darkest time of my life. I haven't made money in a month and, to be honest, I don't know when I will again."
Beast was the type of restaurant Portland, Ore., was well-known for: culinarily bold however nonetheless informal and inviting. Bambi Stenberg, 44, served a six-course tasting menu 4 nights every week to diners alongside two communal tables.
When the pandemic hit, her James Beard award-winning boss, Naomi Pomeroy, was decisive, closing the restaurant a day earlier than the governor mandated it in March. Stenberg received on unemployment straight away, every test about half of what she would have made on the restaurant. It lasted till September, then partial unemployment after that ran out in December.
"At first, me and my team from Beast did Zoom calls, but those tapered off," she mentioned. "I thought I would have read a huge stack of books by now, but the level of stress prevalent for a year has prevented me from focusing."
Having labored in high-end eating places for the previous 15 years, she worries what the eating panorama will appear like when that is throughout: "So many exciting restaurant groups have shuttered entirely." Beast is completely closed, with Pomeroy turning to a brand new retail takeout meal idea.
"Restaurants need a relief bill, some kind of influx of support to keep the lights on," Stenberg mentioned, "otherwise the Portland food scene will disappear."
For cities such as Las Vegas, Orlando and New Orleans, tourism and hospitality are financial drivers that gasoline your entire state.
"In New Orleans we only have food, music, culture. It's what keeps this city alive, and what feeds the state," mentioned Cook of Gris-Gris. His restaurant closed for months, reopened for takeout, closed again and has operated as a non-public social gathering house.
"This past year we gave up our lives and we're now right back where we were," he says, pointing to strong vacation air journey and the unrestricted reopening of different kinds of companies in latest months that led to an explosion in coronavirus an infection numbers. New Orleans returned to "modified Phase 1" restrictions on Friday, with eating places again to 25 p.c capability.
"It's a sin tax; we're being punished," he mentioned. "We haven't done anything wrong and we're still the target. It's the biggest misdirection of blame I've ever seen in my life."
'Like a ghost town'
In Tampa, Michelle Cooper breathed a sigh of aid when Disney World known as her again to work within the reservations division in late May, after greater than two months on furlough. She labored from dwelling by early October, then was laid off from the $15-an-hour place.
Since then, the 51-year-old says, it's been tough to search out distant work in a state that depends closely on tourism. Cooper, whose bronchial asthma makes her extra weak to the coronavirus, says she worries about taking an workplace or retail job that might put her in shut contact with others. For now, she has sufficient in financial savings to maintain her household afloat however worries about what would possibly occur in one other month or two. Florida unemployment advantages max out at $275 every week, which she says received't cowl her month-to-month hire.
"I've never made a ton of money anyway, but it's definitely more difficult now," mentioned Cooper, whose 20-year-old son not too long ago moved again in along with her after shedding his job at Busch Gardens. "We're buying less food because we have to be careful about what we spend."
After months of uncertainty, some service workers say they're contemplating leaving the business altogether. Michael Matsuse-Panzo, who was furloughed in April from his front-desk job at a hotel on Oahu, says he's been considering transferring to the East Coast or in search of a brand new line of labor if tourism doesn't return to the island quickly.
"We're so used to seeing the hustle and bustle of tourists, but now it's like a ghost town," the 31-year-old Hawaii native mentioned. "You go to Waikiki [Beach] and there are no cars, no people. It's almost frightening."
Matsuse-Panzo's unemployment advantages lapsed a couple of days after Christmas. He obtained his $600 stimulus test quickly after, which he used to purchase groceries and pay down bank card payments.
"I'm going to ride it out the next few months and see what happens," he mentioned. "But a lot of places still have a hiring freeze. There's no way to get your foot in the door. When you've worked in the hospitality industry for 10 years, it's hard to move on to the unknown of something different."
Nothing however lifeless ends
For many Americans, restaurant and hospitality work presents first-job, entry-level employment for younger adults, college students and these nonetheless "figuring things out." But for others, it's a lifelong profession path, says Matt Duggan, who in November misplaced his place as common supervisor for the high-end Lucques Group in Los Angeles. It's a path that, after 31 years within the enterprise, now seems like nothing however lifeless ends.
His restaurant group had three eating places initially of the pandemic, as effectively as the contract for meals service on the Hollywood Bowl. In the spring, the corporate closed two of the eating places, leaving one empty and promoting the constructing of the opposite, and protecting A.O.C. as its final stand. Their workforce shriveled from 500 to a half-dozen, Duggan amongst them.
"We kept thinking, 'Just a little bit more,' but that light at the end of the tunnel hasn't gotten any closer," he mentioned. The group put cash into constructing outside eating house, then outside eating received shut down again. He misplaced his job simply earlier than Thanksgiving.
Extended unemployment advantages had been set to run out on the finish of the 12 months. The most up-to-date aid bundle extends the applications, however by lower than three months. That's not a lot time to search out new work within the business, particularly if working restrictions persist.
"Things are financially pretty grim for me right now," Duggan mentioned. "Is there any other job where I could take my restaurant skills? Do I take a chance and move to another state where I can do restaurant work? The overall impact and duration of the crisis means that even places that haven't had as many restrictions are going out of business."
Duggan is doing tai chi on the home, making an attempt to reconnect with household and associates. This Christmas, he and his spouse put up each vacation ornament they personal. They haven't taken them down. Every evening, they mild each mild.
#Shocked #disheartened #devastated #Restaurant #hotel #workers #reel #layoffs #soar
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Discovery: Wikinews do (non-cryptic) crosswords.
My only new year resolution for 2005 has been to do a cryptic crossword. I started by reverse engineering the Hindu's cryptic crosswords.
Can anyone recommend a good dictionary site? I hate dictionary.com and MW is just as bad. I should just write my own Web app with a nice clean fast interface to my dict server.


M&M Records Recording Artist Diane Marino has recorded five critically acclaimed CD's- all of which have been on the National JazzWeek charts. She has recorded and shared the stage with jazz legends Houston Person, Joe Henderson, Wycliffe Gordon, Harry Allen, Pete Escovedo, Tania Maria, Kirk Whalum, Ralph Lalama, to name a few.
New York City native Diane Marino performs traditional jazz, Latin and Brazilian jazz and puts her own stamp on classic American standards. Diane has performed to captivated audiences in jazz venues, performing arts centers and festivals such as Birdland - NYC, Blues Alley - D.C., Twins Jazz-D.C.,Vitello's Jazz Club - L.A., Nighttown-Cleveland, Trumpets Jazz Club -NJ, The Metropolitan Room-NYC, Bethesda Blues & Jazz - D.C, Town Point Jazz Festival, and many more.
With vocals and tracks all completed, Diane Marino's next CD release is expected to be released in the summer 2017. This CD is a collaboration with Brad Cole (Musical director for Phil Collins) who has arranged and produced the project. Tracks vary in instrumentation from a classic Jazz trio accompaniment to fully orchestrated treatments.


text:
Q: Selecting a given row in a table here is a simple problem. I have a table of 500 rows and what to be able to select a given row number n. This is what I am doing:
    select *
    from table
    where table.arg1 ='A'
    and time_stamp=to_date('1/8/2010','MM/DD/YYYY')
    and rownum = n

But it would only work for the row 1, for the rest it doesn't return anything. Any idea?

A: The reason why where rownum = 3 returns an empty rowset is that the condition is not true for the first row.  For the second row, there is still no first row in the resultset, and rownum is still 1.  So the condition fails again.  See this page for a more detailed explanation.
You can use row_number() in a subquery:
select *
from (
    select row_number() over (order by col1) as rn, yt.*
    from YourTable yt
) sub
where rn = 3

Or even simpler, but perhaps more confusing, using rownum itself:
select *
from (
    select rownum as rn, yt.*
    from YourTable yt
) sub
where rn = 3


Regenerative Medicine is the exciting and ever dynamic branch of medicine with the purpose of replacing, repairing, renewing or engineering human cells, tissues, organs or their building blocks, utilizing the body's innate cellular pathways for the purposes of restoring function and homeostasis in the body. Regenerative cellular biomedical therapies are powerful adjuncts to the natural healing mechanisms of the human body to reduce, relieve, or manage painful and certain chronic conditions and improve function.
The goal of both Regenerative and Anti-Aging Medicine is to optimize both longevity and to enhance the quality of life. It is based on the premise that aging, in the traditional sense, and tissue degeneration and accompanying pain and inflammation, is a condition or state of "disease" rather than a natural progression of human longevity potential.
Perinatal tissue is primarily used as Allograft sourcing. Umbilical Cord tissue and Amniotic cells have Growth Factors and Cytokins and a viable concentration of cells but can be easily attained and used for Regenerative Medicine with more ease than bone marrow and adipose aspirate without the increased cost, time, inconvenience, and pain to the patient.
Flowable Amnion tissue and Amniotic fluid is obtained from Placental products from healthy live birthed babies. Amniotic tissue flowables promote healing with viable cellular material and have anti-inflammatory properties (Cytokins & Growth Factors, Secretosomes, Exosomes and microRNA). Amniotic Fluid alone has similar properties with fewer viable cells. These cytokines and growth factors can impact collagen and other tissue production.
Umbilical Cord Blood Stem Cells are derived from the umbilical cord and the placenta and are donated by mothers of normal healthy live birthed babies. This cord blood contains mostly HSCs with some MSCs. The current FDA guidelines mandate that Cord Blood is to only be used on first and second degree relatives of therived Cord Blood.
Flowable Umbilical Cord Tissue is considered by thought leaders in biomedical research to hold the promise of innovation in regenerative medicine. These sources contain extracellular matrix (structural healing) components, Stem Cells (MSCs) and growth factors for the efficient repair and healing of injured or degenerated tissue through the replacement of cells which are identical to the original tissue. The cells in the Wharton's Jelly of the cord genetically code for Adult Stem Cell (MSC) production. The extracellular components contained accelerate Collagen production. Due to Wharton's Jelly, the MSCs rate of growth, immune-privilege status, non- tumor-making property and lack of ethical concerns, cord tissue is an ideal MSC source.