text:
Tag Archives: Twins
VAGINAL BIRTH AFTER CESAREAN SECTION (VBAC): ALL YOU NEED TO KNOW BEFORE MAKING YOUR EDUCATED CHOICE
Posted in Health	by woman2womenblog
"Once a Cesarean, always a Cesarean" has been the standard recommendation for many years. But the increasingly high cesarean section (C-section) rates around the world have led doctors to reassess the risks of a cesarean section versus delivering vaginally after having a previous C-section.
Repeat C-section or VBAC? The answer is not straightforward. Both options do come with some risks, and those risks vary depending on the woman and the specific pregnancy.
Here's what you need to know about a vaginal birth after cesarean section and what you should discuss with your doctor if you want to try delivering your next baby vaginally.
1) What is a vaginal birth after cesarean delivery (VBAC)?
If you're pregnant again and your last baby was born via cesarean section, this time you have two choices about how to give birth:
an elective repeat caesarean section (ERCS), or
a VBAC. "VBAC" stands for "vaginal birth after cesarean" and refers to giving birth through the vagina after a woman has already had a C-section. Vaginal birth also includes deliveries assisted by forceps or ventouse.
Planning for a vaginal birth after caesarean (VBAC) or choosing an ERCS have different benefits and risks (see below).
A TOLAC (trial of labor after cesarean delivery) is the attempt to have a VBAC. If it is successful, TOLAC results in a vaginal birth. If it is not successful, you will need another cesarean delivery.
2) What are my chances of giving birth vaginally after having a C-section?
As long as you are an appropriate candidate for a VBAC, there are good chances to succeed: about 60 to 80% of women who attempt a VBAC will deliver vaginally.
There are certain factors which affect the chances of success, both related to the mother and the baby (see below). Nevertheless, it's impossible to predict with certainty who will be able to have a vaginal delivery and who will end up with a repeat c-section.
A previous vaginal delivery, particularly previous VBAC, is the single best predictor of successful VBAC and is associated with a VBAC success rate of 85–90%.
3) Am I a good candidate for a VBAC?
Planned VBAC is appropriate for the majority of women who:
are pregnant with one fetus (as opposed to twins/multiples),
their baby is positioned head down (cephalic presentation),
have a pregnancy at term (37+0 weeks or beyond),
have had one previous lower segment caesarean delivery.
4) When is VBAC contraindicated?
Planned VBAC is strongly discouraged in the following cases:
Three or more previous caesarean deliveries. See below in case you have two previous C-sections.
The uterus has ruptured during a previous labor, as this increases considerably your risk (7 times higher) of a recurrent uterine rupture with the next pregnancy.
The previous caesarean section was "classical". In the vast majority of women, the uterus is cut horizontally, in its lower segment. This is called a low-transverse uterine incision. Rarely, a vertical incision in the upper uterus is required, this is known as a "classical" incision. Occasionally, a J- or T-shaped cut is performed. In both cases of vertical and J/T-shaped incision there is higher risk for uterine rupture. Therefore, it is very important to know which incision was performed in your previous C-section. You should note that the type of scar on your skin does not necessarily match the one on your uterus.
A previous uterine surgery, such as fibroid removal (myomectomy), as this increases the risk of uterine rupture.
There is other pregnancy complications that requires a C-section.There are certain absolute contraindications to vaginal birth that apply irrespective of the presence or absence of a scar (e.g. placenta previa)
Breech presentation (the baby comes with buttocks and/or feet first) or other abnormal presentations.
Multiple pregnancies (twins or more).
5) What factors reduce my changes of having a successful VBAC?
In general, the chances of success are lower in the following situations:
The reason for the previous c-section is likely to be problem this time around. Let's say that a woman who already had a vaginal delivery and then had a c-section because her baby was breech (buttocks or feet first) is much more likely to have a successful VBAC than one who had a previous c-section after achieving full dilation and pushing for three hours, which may signal a narrow basin.
Labor is induced (did not start spontaneously).
You are older than 40 years old.
You are overweight.
The baby is big (over 4,000 grams estimated weight, or 8.8 pounds).
Advanced gestational age at delivery (more than 40 weeks).
Having a short time between pregnancies (less than 19 months).
You have preeclampsia (high blood pressure) at the time of delivery.
You should discuss with your practitioner about your individual chance of success and carefully weigh the benefits and the risks.
6) What are the benefits of a VBAC?
C-section is a major abdominal surgery, and as such is associated with certain increased risks as opposed to a vaginal birth. Therefore, a successful VBAC entails:
Shorter recovery period
Less post-partum pain.
Lower risk of infection.
Less blood loss, reduced need for a blood transfusion.
Less chances of needing an emergency hysterectomy (uterine removal).
Lower likelihood of damaging other organs (bladder and bowel).
Lower risk of developing a blood clot (thrombosis) in the legs (deep vein thrombosis) or lungs (pulmonary embolism).
Reduced risk of pelvic adhesions (internal scar tissue that forms between the organs, which may be responsible for chronic pain, infertility or intestinal obstruction).
Decreased chances of breathing problems for your baby. About 4-5% of babies born by planned C-section have breathing problems, compared with 2-3% following VBAC; the risk is slightly higher if you have a planned caesarean section earlier than 39 weeks. In fact, breathing problems are quite common after caesarean delivery, but usually do not last long.
Many women would like to have the experience of vaginal birth, and when successful, VBAC allows this to happen.
If you plan to have more children, VBAC may help you avoid certain health problems linked to multiple cesarean deliveries. In fact, C-section complications, such as haemorrhage, emergency hysterectomy, bowel or bladder injury, adhesion formations are all higher with the increased number of cesarean deliveries. Moreover, every C-section you have raises your risk in future pregnancies of placenta complications, such as placenta previa (the placenta lyes low and covers the cervix) and placenta accreta (the placenta implants too deeply and doesn't separate properly at delivery). Both conditions can result in life-threatening bleeding and a hysterectomy. If you know that you want more children, this may figure into your decision.
7) What are the risks of a VBAC?
One of the most feared complications of a VBAC is the possibility of uterine rupture, that is, the scar of the uterus tears or separates. Even if you're a good candidate for a VBAC, there is a 0.7% risk (that is, 7 out of 1000 woman undergoing a VBAC) that your uterus will rupture at the site of your C-section incision. If this happens, it may result in severe blood loss for you, eventually life-threatening, and possibly oxygen deprivation for your baby, which may result in brain damage (in 8 out of 10,000 cases) or even death (in 2-3 out of 10,000 cases). While this risk is very small overall, it is higher as compared to a scheduled C-section.
Regardless of uterine rupture, VBAC carries in increased risk of long-term neurological damage or even death. Again, the risk is very small, but is higher in women who undergo an unsuccessful VBAC than in women who have a successful vaginal delivery or a scheduled C-section.
If you end up being unable to deliver vaginally, you could endure hours of labor only to have an unplanned C-section. This may be very frustrating for certain women, as their expectations for a vaginal birth are not fulfilled.
You may need an assisted vaginal birth using ventouse or forceps, which may lead to increased risk of having a tear involving the muscle that controls the anus or rectum (third or fourth degree tear).
You may need to have an emergency C-section during labour. This happens in 25% of women. An emergency cesarean carries more risks than a planned C-section. The most common reasons for an emergency caesarean section are if your labour slows or if there is a concern for the wellbeing of your baby.
You should note that while a successful VBAC is less risky than a scheduled repeat C-section, an unsuccessful VBAC requiring a C-section after the onset of labor carries more risk than a scheduled C-section. And the risk of complications is even higher if you end up needing an emergency cesarean.
8) Can I have a VBAC if I have two prior C-sections?
According to the American (ACOG) and British (RCOG) guidelines, women who have had two prior lower segment caesarean deliveries may be offered VBAC after careful counselling. Nonetheless, they should be aware that the risk of uterine rupture is increased up to 5 times (0,9 to 3,7%).
VBAC after 2 previous C-sections is highly controversial, and may not be acceptable for certain physicians or institutions.
9) What to expect during a VBAC
VBAC should take place in a hospital or maternity that can manage situations that threaten the life of the woman or her fetus, and should NOT be attempted at home.
You should meet all the criteria, and have none of the contraindications for VBAC above-mentioned.
Factors that may reduce or increase the likelihood of success will be thoroughly discussed, and are different for each woman and each pregnancy.
Best candidates for VBAC are those women whose labor starts spontaneously, as induced labor (started with drugs or other methods) reduces the chances of a successful vaginal delivery and carries 3 times higher risk of complications.
You will be advised to present yourself at the hospital at the earliest sign of labour for careful assessment.
Your baby's heartbeat will be monitored continuously during labour; this is to ensure your baby's wellbeing, since changes in the heartbeat pattern can be an early sign of problems with your previous caesarean scar.
An intravenous (IV) line is indispensable in order to promptly manage any eventual complication.
You'll have to refrain from eating anything during labor in case you require an emergency c-section later.
You can choose various options for pain relief, including an epidural.
The following signs may be indicators of uterine rupture, and warrant an emergency C-section:
Persistent fetal bradycardia (the baby's heart rate drops; this is the commonest sign of uterine rupture).
Vaginal bleeding.
Uterine scar tenderness.
Pain between contractions.
Cessation of contractions.
Pain "breaking through" the epidural analgesia, or excessive epidural requirements.
Palpation of fetal parts outside the uterus.
Haematuria (blood in the urine).
It is important that you understand that uterine scar rupture may be silent, and that even an emergency C-section may not prevent serious complications, both for you and your baby.
Successful VBAC has the fewest complications.
The greatest risk of adverse outcomes associated with VBAC occurs when a VBAC results in an emergency caesarean section.
It is often impossible to predict who will be able to have a successful VBAC and who require a repeat C-section.
Spontaneous (not induced) VBAC has a 1:150 risk of uterine rupture.
Uterine rupture is a rare but potentially life-threatening condition, both for the mother and her baby.
Even an immediate emergency C-section may not prevent serious complications, both for the mother and her baby.
The absolute risk of severe fetal problems and death associated with VBAC are very low, but higher than for planned C-section.
Babies born via planned C-section have increased risk of neonatal respiratory problems, which are usually short-lived.
Planned C-section is associated with an increased risk of placenta praevia/accreta complicating any future pregnancies; other complications such as pelvic adhesions are higher as the number of C-sections increases.
VBACs are controversial, and it may be challenging to decide whether is the best choice for you. Find a practitioner willing to support VBAC, discuss with him/her your options. Give yourself plenty of time to inform yourself and consider carefully the pros and cons of each option.
The American College of Obstetricians and Gynecologists (ACOG) – Vaginal Birth After Cesarean Delivery FAQ 070, December 2017 (For patients)
ACOG Practice Bulletin Number 184 – Vaginal Birth After Cesarean Delivery, November 2017
Royal College of Obstetricians & Gynaecologists (RCOG) – Birth options after previous caesarean section – July 2016 (For patients)
Royal College of Obstetricians & Gynaecologists (RCOG) – Birth After Previous Caesarean Birth – Green-top Guideline No. 45, October 2015
National Health System (NHS) UK – Clinical Guideline for: The Management of Vaginal Birth After Caesarean (VBAC). July 2016
1.Parents.com; 2.EvolutionaryParenting.com; 3.goldengateobgyn.org; 4.Healthymummy.com; 5.YouTube.com; 6.Scarymummy.com; 7.geoscripts.meredith.services
abnormal fetal presentations, ACOG, advanced gestational age, assisted delivery, baby, benefits, birth, Birth options after previous caesarean section, bladder injury, blood clot, blood in the urine, blood loss, blood transfusion, bowel injury, brain damage, breech presentation, C-section, candidate forVBAC, cephalic presentation, cephalo-pelvic disproportion, Cesarean, cesarean section, cessation of contractions, changes in the heartbeat pattern, chronic pain, classical caesarean section, death, deep vein thrombosis, delivery, elective repeat caesarean section, emergency C-section, epidural, epidural analgesia, ERCS, FAQ, fibroid removal, forceps, fourth degree vaginal tear, Green-top Guideline, guidelines, haematuria, health, high blood pressure, home birth, hospital, hysterectomy, infection, infertility, intestinal obstruction, intravenous line, IV line, J- or T-shaped cut, labor, labor induction, large baby, life-threatening bleeding, low transverse uterine incision, lower segment caesarean delivery, major abdominal surgery, maternity, monitoring, multiple cesarean deliveries, Multiple Pregnancy, multiples, myomectomy, National Health System UK, natural delivery, neonatal breathing problems, neurological damage, NHS, older mother, overweight, oxygen deprivation, pain, pain between contractions, pain relief, palpation of fetal parts outside the uterus, patients, pelvic adhesions, persistent fetal bradycardia, placenta, placenta accreta, placenta previa, planned caesarean section, planned VBAC, post-partum pain, preeclampsia, Pregnancy, previous C-section, previous uterine surgery, previous vaginal delivery, pulmonary embolism, RCOG, recovery period, risks of a cesarean section, Royal College of Obstetricians & Gynaecologists, short time between pregnancies, spontaneous VBAC, successful VBAC, term pregnancy, The American College of Obstetricians and Gynecologists, third degree vaginal tear, three or more previous caesarean deliveries, thrombosis, TOLAC, trial of labor after cesarean delivery, Twins, two prior C-sections, uterine removal, uterine rupture, uterine scar, uterine scar tenderness, vagina, vaginal birth after cesarean section, vaginal bleeding, vaginal delivery Repeat C-section, VBAC, VBAC contraindications, VBAC success rates, ventouse, vertical incision	Leave a comment
EGG DONATION IN GREECE: ALL YOU NEED TO KNOW
Assisted reproduction techniques help thousands of couples with infertility to circumvent their problem and become parents. Nevertheless, when it is not possible for a woman to conceive due to poor egg quality or from having no eggs at all, she may still become pregnant by using eggs from a donor.
The first pregnancy with egg donation was reported in 1983, and ever since, more and more women are choosing this procedure to achieve their dream of having children. The main reason for this trend is that women are increasingly postponing childbearing until later on in life, when their fertility is often reduced; another reason is that over the years, the process has become highly successful due to recent technologies advances and improved freezing techniques.
What is egg donation?
Egg donation is a form of assisted reproduction by which a woman donates her ova to enable another woman to conceive. These oocytes are fertilized by the recipient's husband sperm, or alternatively by a donor sperm.
The resulting embryos are transferred into the recipient uterus, which has been adequately prepared to receive them. The difference with routine in vitro fertilization (IVF) is that the egg donor is not the recipient; that is, they are two different women.
If pregnancy occurs, the recipient will have a biological but not a genetic relationship to the child, and her partner (if he provided the sperm) will be both biologically and genetically related.
What are the indications for egg donation?
Egg donation may be considered in the following situations:
Premature ovarian insufficiency: a condition in which menopause begins earlier than usual, usually before the age of 40 years old. In most cases the cause is unknown, but it may be the result of certain diseases, chemotherapy, radiotherapy or surgical removal of the ovaries. Egg donation is also suitable for women who were born without ovaries.
Low ovarian reserve: when there is a decrease in the number of eggs, resulting in reduced chances of pregnancy. Generally, this is due to advanced reproductive age, as the number of oocytes -and therefore fertility- decreases rapidly after the age of 35-40 years old.
Genetically transmitted diseases: women affected by, or carriers of a significant genetic disease who would prefer not to pass this disease on to their child.
Previous history of failure with IVF: especially when egg quality seems to be the problem.
Who are the egg donors?
1) Anonymous, voluntary donors: According to the Greek law, candidate egg donors are covered by anonymity and are required to sign a specific consent for the donation of their genetic material. In order to accept a woman into an egg donation program she should meet the following requirements:
Age between 18 and 35 years old.
She should be healthy, non-smoker, with no personal or family history of genetic diseases.
By law, the donor receives financial compensation only for the loss of working days, travel and other expenses incurred during the treatment cycle in which she participates. In any case, egg donation is an altruistic, anonymous and voluntary act.
2) Egg sharing: Women undergoing IVF may agree to donate their surplus oocytes to other women with infertility.
3) Known donor: a person who is known to the recipient, usually a close relative of friend. According to the Greek law, oocyte donation is an anonymous procedure, that is, the donor has no access to the child born, nor the recipient to the donor. Therefore, in Greece the donation of ova to known persons is forbidden by law.
Evaluation of the egg donor
Each candidate donor, after being fully informed about the egg donation program, completes a thorough questionnaire on her family, medical and psychological history. In addition, she is the subject of a series of exams to determine whether her health is in good condition and she can respond properly to the hormonal therapy.
The evaluation involves a comprehensive physical and gynecological examination, as well as the assessment of her psychological and mental status, her genetic material and reproductive system.
In addition, donors undergo the following laboratory testing:
Blood type and Rhesus
Hepatitis B & C
HIV 1 & 2
Hemoglobin electrophoresis
Sickle cell trait testing
Cystic fibrosis (CF) mutation
Fragile X testing
Conventional karyotype. It is also possible to a perform a molecular karyotype, upon request of the recipient couple.
A donor is ineligible if either the questionnaire or the screening tests indicate the presence of risk factors, or clinical evidence of an infectious or genetic disease.
Evaluation of the recipient couple
Adequate screening and preparation of the recipient couple are essential for the success of an egg donation program.
According to the Greek law, a woman is considered suitable to receive oocytes when her uterus has normal morphology and functionality and has not exceeded the age of 50 years.
The evaluation of the recipient couple is similar to that of couples undergoing routine IVF. First, the physician obtains a thorough medical history from both partners.
The assessment of the woman includes an in-depth physical and gynecological examination, a detailed pelvic ultrasound and laboratory testing. Briefly, the ovarian function, her blood group, and exposure to certain infections are examined. In addition, a Pap smear test and cultures for certain microbes (Neisseria gonorrhoeae, Chlamydia trachomatis, etc) are obtained.
In some cases, the uterine cavity is evaluated with hysterosalpingography (HSG), sonohysterography or hysteroscopy. If the woman is over 45 years old, a more thorough assessment of her cardiac function, pregnancy-induced hypertension and gestational diabetes risk are recommended. The effect of advanced maternal age on pregnancy will be discussed extensively, as well as any medical conditions that may affect pregnancy.
An embryo transfer trial before the actual procedure ("mock" embryo transfer) is strongly recommended. It allows to determine the best way to place the embryos into the uterus, and ensures that there are no unexpected obstacles along the way. Sometimes the cervix is very narrow and hinders the transfer of the embryos into the uterus; this may result in significantly reduced chances of pregnancy. In case of a narrow or distorted cervical canal, a cervical dilation may be recommended.
A treatment trial in a previous cycle with the same medications used for the endometrial preparations is proposed when possible, in order to assess the uterine response to hormone therapy.
The male assessment includes a semen analysis, blood group and genetic testing, among other exams.
According to the Greek law, the recipient couple should be tested for syphilis, hepatitis B and C, HIV-1 and HIV-2 within the six months preceding the treatment cycle.
Preparation of the donor for egg retrieval
The donor follows the procedure of a standard IVF. Initially, she undergoes ovarian stimulation, that is, she receives a combination of hormonal medications in order to achieve the development of a sufficient number of oocytes within the ovaries; egg development is monitored by ultrasound and blood exams at regular intervals. When the oocytes are at the appropriate size, ovulation is triggered by an injection of human chorionic gonadotropin (hCG). Oocyte retrieval, scheduled approximately 34-36 hours after hCG administration, entails the use of a needle which is inserted through the vagina into the ovaries, whereby the eggs are aspirated under ultrasound guidance. The procedure is carried out under a mild sedation.
The ova obtained are evaluated for their maturity and then fertilized with the partner's sperm, which has been processed in the laboratory. Donor sperm may be also utilized when indicated.
The male partner should provide the semen sample the day of the donor's egg retrieval. Alternatively, if the presence of the partner is not possible on that day, the semen can be cryopreserved (frozen) at an earlier time.
Preparation of the recipient for embryo transfer
In order for the embryos to implant into the recipient's uterus, the endometrium (uterine lining) must be prepared and synchronized with the donor cycle.
There are numerous protocols for endometrial preparation. Briefly, women who still have menstrual period may receive an injectable medication for temporary suppression of the ovarian function. When the donor starts ovarian stimulation, the recipient receives a hormone called estradiol to achieve endometrial growth. Estradiol can be administered orally or through a transdermal patch. Ultrasound assessment of endometrial thickness -and occasionally blood tests- are performed during this period. On the day after the donor receives hCG, the recipient begins treatment with progesterone. Progesterone causes endometrial maturational changes that allow the embryo to implant. Progesterone can be administered by intramuscular injection, vaginally or orally. Besides estradiol and progesterone, other medications may be prescribed if required.
The embryos are transferred into the recipient's uterus, usually within three to five days after fertilization of the eggs in the laboratory. Embryo transfer is done using a thin catheter inserted through the cervix into the uterus. If the recipient couple has extra embryos, they will be cryopreserved (frozen). Thus, it is possible to transfer these embryos at a later time without the need for another egg donation.
Hormonal therapy with estradiol and progesterone continues until the recipient takes a blood pregnancy test (β hCG). If the test is positive, the hormones are continued during the first trimester of pregnancy.
Success rates with egg donation
Since egg donors are young and healthy women, success rates are higher than those obtained with conventional IVF. The age of the recipient does not seem to affect the success of the procedure. According to data from the National Agency of Medically Assisted Reproduction, the pregnancy rate with egg donation in Greece is 54%.
Nevertheless, the greater the number of attempts with donor-egg IVF, the higher the odds of success. Thus, it is estimated that the success rates after the third attempt reach almost 90% in most cases.
Many factors play an important role in the success of the procedure: adequate evaluation and preparation of both donors and recipients, optimal synchronization between them, high laboratory standards and well-trained scientific staff, will all have a positive impact on pregnancy rates in an egg donation program.
Risks of egg donation
1) For the donor:
Egg donation is a very safe procedure. Nevertheless, it is not entirely risk-free. Medicines taken to stimulate the ovaries, oocyte retrieval and the anesthesia required are all possible sources of complications. Briefly, the side effects of medications are usually mild, as one of the most feared complications in assisted reproduction, ovarian hyperstimulation syndrome is very rare in these cases. The remaining risks are estimated as follows: anesthesia risks: 1 / 10,000; risk of severe bleeding from oocyte retrieval: 1 / 2,500; risk of infection: less than 1/500.
It should be noted that the fertility of women who become egg donors is in no way affected. In fact, the eggs donated would have been otherwise discarded by their bodies.
2) For the recipient:
The possibility a donor transmits an infectious disease to the recipient is virtually non-existent, provided that proper evaluation of the egg donor has been performed, as dictated by the Greek law.
The most common risk for the recipient is the occurrence of a multiple pregnancy (twins) if more than one embryo is transferred. In any case, in egg donation cycles, the transfer of more than two embryos is strictly forbidden by the Greek law. If the couple is opposed to the possibility of a twin pregnancy, then only one embryo may be transferred (single embryo transfer, SET).
Pregnancy complication risk in recipiens with advanced age should be assessed individually for each case.
3) For the child:
To date, thousands of children have been born with this procedure, and the available data is reassuring, and equivalent to that of conventional IVF: the rate of birth defects is the same as the general population.
THE LEGISLATION IN GREECE
On Egg Donation
Egg donation is an altruistic act, voluntary and with no financial benefit. Donors are compensated only for the working days they lose as part of the donation process and their travel expenses.
Donation of ova and sperm is allowed in Greece provided donor anonymity is ensured.
Egg donation is not allowed to women over 50 years old.
Donors must sign an oocyte concession consent.
Recipients sign a document stating that they are married and accept to undergo in vitro fertilization with egg donation. If they are not married, they should sign a notary act stating that they wish to undego IVF using the egg donation method.
On Assisted Reproduction
On January 27 2005, the law 3305/2005 on the application of assisted reproduction techniques was reported.
The Greek law on medically assisted reproduction is one of Europe's most flexible. It safeguards the couple who wants to have a child based on medical, biological and bioethical principles. Its main purpose is, ultimately, the protection of the child to be born.
Basic principles of the current legislation
Some of the key points of the in-force law are the following:
1) Assisted reproduction methods are legal and allowed for women up to the age of 50 years, as this is considered the limit for natural conception.
2) The donation of ova and sperm is permitted, but the consent of the spouse or partner is also required.
3) Pre-implantation genetic diagnosis is allowed with the purpose of diagnosing whether the resulting embryos are carriers of genetic diseases. Consent of the concerned individuals is required.
4) Sex selection is prohibited unless a serious sex-related hereditary disease is avoided.
5) Cloning for reproductive purposes is prohibited.
6) Cryopreservation of genetic material or fertilized eggs is permitted.
7) The use of a gestational carrier (surrogacy) is allowed. A surrogate is a woman who carries a pregnancy for another couple or woman, who wishes to have a child but is unable to get pregnant for medical reasons. The surrogate woman must undergo medical and psychological examination. There should be no financial transaction other than the costs resulting from pregnancy exams, loss of work, etc. The procedure requires a special permit from a judge.
8) Assisted Reproduction Units are established and operate with the permission of the competent Authority, which shall give its agreement and verify that the legal requirements are met. For any violation, it sets administrative and criminal penalties.
9) The law sets age limits for sperm donors (younger than 40 years old) and egg donors (younger than 35 years).
10) Single women are allowed to conceive with assisted reproduction.
11) Donors must undergo clinical and laboratory testing and are not admitted to donation programs if they suffer from hereditary, genetic or infectious diseases. The use of fresh semen from donor is not permitted; only frozen semen may be used.
More info at gofertile.eu
advanced maternal age, advanced reproductive age, altruistic, anesthesia, anonymous donors, assisted reproduction, assisted reproduction units, birth defects, bleeding, chemotherapy, cloning, congenital malformation, couples, cryopreservation, delayed childbearing, delayed motherhood, donor, egg donation, egg quality, egg sharing, embryo, embryo freezing, embryo transfer, endometrial preparation, estradiol, fertility, frozen semen, genetic abnormalities, genetic material, genetically transmitted diseases, gestational carrier, Greece, Greek legislation, health, hereditary disease, hormonal drugs, hormones, husband's sperm, in vitro fertilization, in vitro fertilization failure, infection, infertility, IVF, karyotype, known donor, Law 3305/2005, laws in Greece, legislature in Greece, live birth rates, low ovarian reserve, mock embryo transfer, Multiple Pregnancy, National Agency for Medically Assisted Reproduction, oocyte donation, oocyte retrieval, oocytes, ova, ovarian ablation, Ovarian Hyperstimulation Syndrome, ovarian stimulation, ovulation induction, Pregnancy, pregnancy rates, preimplantation genetic diagnosis, premature menopause, premature ovarian failure, progesterone, radiotherapy, recipient, reproductive potential, risk, Safety, sex selection, single embryo transfer, sperm donor, success rates, surplus eggs, surrogate motherhood, Twins, Uterus, voluntary donors, women born without ovaries	2 Comments


The experienced technicians at Green Pest Solutions have built a solid reputation in the Chalfont area because of our eco-friendly methods and premium customer service. We have an unwavering commitment to keeping your home and business safe from filthy bugs and rodents.
Great company, great employees, always helpful and educated about their service.
Right on time and just what we needed!
My expectations were met with Jermaine's timeliness, friendliness, and knowledge.
Excellent service, very competitive price.
Very happy with service. Would have liked to have an appointment sooner. I called Monday at 9 am and couldn't get an appointment until Wed 11-1. One of the technicians who was here a month ago said he was available earlier and asked when I called.


Please check your own postcard collections and if your are able to add to the content of the 'Guy' list below then we would like to hear from you. You can do this very simply by using the 'Contribute' form provided at the end of the list. Fill in all the relevant details about your postcard/s and upload an image (if you choose to) by using the facility provided. Our preference is for 600 dpi .jpg images (file size of less than 5MB).


Once Andrew Pierce and Ashley Hudson met at their church in Hamburg, they knew there was no going back. Ashley was only 17 and had never had a boyfriend, so the two took things really slow. But it was truly love at first sight.
On New Year's Eve, right before the start of 2016, Andrew asked God to bless him with one last thing that year… that Ashley would say "yes" and marry him.
Ashley really wanted a woodsy, folk-themed wedding that truly represented her and Andrew. They combined a little bit of everything they loved for the big day.
The venue chosen was on the back 40 acres of the land Ashley grew up on. From the trail they walked down, to the field the couple said "I do" in, Ashley had explored and played on all of it.
On top of that, Andrew and Ashley had walked the area many times when they first started dating.
Since almost everything was DIY by the bride and groom, personalization was important. Ashley painted and made a lot of the decorations, and Andrew and Ashley's dad made the seating and ceremony arch.
Rental Company Dansby's Taylor Rental Center of Monroe, La.


A ruffled Floral Kimona is a must have in every girls closet. We love the versitility of our Kimona's. Thow on over a bathing suit or over a dress. This sheer, colorful, floral, draped pattern goes with just about anything!


text:
Veterans Mental Health
DVA Health Cards
Memorial Dedication Ceremony
Royal Commission into Defence and Veteran Suicide to open in Brisbane
Royal Commission into Defence and Veteran Suicide to open in Brisbane We are pleased to announce the commencement of the Royal Commission into Defence and Veteran Suicide hearings and other updates regarding the work of the Commission.
Hearings The Royal Commission into Defence and Veteran Suicide will hold its first public hearing at the Brisbane Convention Centre on Friday November 26. More details will be announced in the coming weeks. The hearing will explain how the Commissioners will conduct the inquiry. The first block of public hearings where participants will give evidence begins in Brisbane on Monday November 29, 2021.
The ceremonial hearing will be open to the public if COVID restrictions allow. It will also be webcast.
Private sessions People are being invited to share their experiences and register for a private session. This is an opportunity to meet a Commissioner as they consider any changes that are needed to help veterans and their supporters. These sessions will begin in November and continue for the duration of the Royal Commission.
Submissions Anyone wishing to make a submission to the Commission can do so on the Commission's website. The Commission will accept submissions until at least the end of March 2022. The closing date will be confirmed later this year.
Sharing your experiences will help the Commission understand:
• Systemic issues among Defence and veteran deaths by suicide
• Risk factors, and
• The availability of support services
The Royal Commission cannot decide or resolve individual cases or award compensation.
Minister's Announcement Last week the Federal Minister for Veterans' Affairs and Defence Personnel announced the appointment of consultants McKinsey & Company to take action to improve the claims system for supporting veterans, administered by the Department of Veterans' Affairs. The Minister is reported to have said that McKinsey & Co would be consulting with bereaved families of veterans who have died by suicide.
The Royal Commission looks forward to learning more about the scope and nature of the actions McKinsey & Co will be taking, and to working with the Department to ensure the interests and wellbeing of bereaved families are protected.
The Commission Chair Nick Kaldas said: "We are mindful that with both organisations seeking to work closely with Defence members, veterans and their families, our processes should support those involved and avoid being duplicative, conflicting or otherwise overwhelming."
Support The Royal Commission acknowledges that coming forward to share your experience is a big step. We want to make it as easy as possible. Please tell us about any support you need. For more information, visit the Royal Commission website.
From the Commissioners
Hearing from people touched by the tragedy of suicide and suicide behaviour is critical for Australia to learn and improve the lives of veterans and their families.
Your story can help others. We're encouraging anyone who wants to share their experiences to come forward.
The experiences of veterans, families, support people, organisations and the broader community will help us understand the problem and make recommendations that may reduce the number of deaths by suicide.
© Royal Commission into Defence and Veteran Suicide
www.defenceveteransuicide.royalcommission.gov.au | Email : dvsrc.enquiries@royalcommission.gov.au |
Veteran's Support Group QLD ®
We have created this privacy statement in order to demonstrate our firm and continuing commitment to the privacy of personal information provided by those visiting and interacting with this web site.
Queensland Branches
Queensland Branch
Brisbane & Gold Coast Branch
DVA - Department of Veterans Affairs
CLIK - Consolidated Library of Information and Knowledge
RMA - Statement of Principles
Disability Pension Rates
Military Academic Pathway Program
© Copyright 2017-2023 - Veteran's Support Group, Inc. All rights reserved.

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: How to force text and figures to be on the same page when minipage, samepage, nopagebreak do not work I'm trying to get four figures (centered on a page in a 2x2 grid) to show up on the same page as the section heading ("Appendix").
The following puts the word "Appendix" on one page (all by itself) and then the four figures on their own page.
I've messed with \nopagebreak, \begin{samepage}...\end{samepage}, \begin{minipage}...\end{minipage} with no luck.
\bibliographystyle{plain}
\bibliography{sid}
\vfill\eject
\appendix
\label{sec:ads}
\begin{figure*}
\centering
\subfigure[]{
  \includegraphics[height=150pt]{./figs/jjj.png}
  \label{fig:jjj}
} \quad
\subfigure[]{
  \includegraphics[height=150pt]{./figs/xxx.png}
  \label{fig:xxx}
} \quad
\subfigure[]{
  \includegraphics[height=150pt]{./figs/nnn.png}
  \label{fig:nnn}
} \quad
\subfigure[]{
  \includegraphics[height=150pt]{./figs/aaaa.png}
  \label{fig:aaa}
} \quad
\caption{blah  }
\label{fig:aaaa}
\end{figure*}

The \vfill\eject business is to get the word "Appendix" to appear at the top of a new page, not right after the bibliography. BTW, \appendix has this entry in the cls file:
 \def\appendix{\par
 \section*{APPENDIX}
 \setcounter{section}{0}
 \setcounter{subsection}{0}
 \def\thesection{\Alph{section}} }

A: Obviously, in this case, you don't want your figures to float, so the natural approach would be not to use float environments. You can use minipages to properly align your subfigures, and using the \captionof command provided by the caption and subcaption packages you can give a caption to your subfigures and to your figure, allowing corresponding labels for cross-references. Here's a little example:
\documentclass{book}
\usepackage{caption}
\usepackage{subcaption}
\usepackage[demo]{graphicx}

\begin{document}

\appendix
\chapter{Test Appendix}\label{sec:ads}

\noindent\begin{minipage}{\textwidth}
\begin{minipage}{.5\textwidth}
  \centering
  \includegraphics[height=150pt]{./figs/jjj.png}
  \captionof{subfigure}{First subfigure.}
  \label{fig:jjj}
\end{minipage}%
\begin{minipage}{.5\textwidth}
  \centering
  \includegraphics[height=150pt]{./figs/xxx.png}
  \captionof{subfigure}{Second subfigure.}
  \label{fig:xxx}
\end{minipage}\\
\begin{minipage}{.5\textwidth}
  \centering
  \includegraphics[height=150pt]{./figs/nnn.png}
  \captionof{subfigure}{Third subfigure.}
  \label{fig:nnn}
\end{minipage}%
\begin{minipage}{.5\textwidth}
  \centering
  \includegraphics[height=150pt]{./figs/aaaa.png}
  \captionof{subfigure}{Fourth subfigure.}
  \label{fig:aaa}
\end{minipage}
\captionof{figure}{A figure with four subfigures.}
\label{fig:aaaa}
\end{minipage}

\end{document}

I added the demo option to the graphicx package in order to make my example compilable for everyone; do not use that option in your actual code.
As a side note, you seem to be using the subfigure package; this package is obsolete and shouldn't be used anymore; you can use the subcaption package instead.

A: I think this has something to do with the fact that you are using figure*. Normally
you can use the [H] option provided by the float package.
\begin{figure}[H]
...
\end{figure}

will force the figure to exactly where it appears in the input file. However, starred figures can only appear at the top of a page, or on their own page.

redpajama_set_name: RedPajamaStackExchange


Thanks for catching that, I added it in.
"A preliminary investigation shows that the postal truck did not come to a complete stop before entering the intersection, Esparza said. The cyclist had the right of way, he said.
And unlike the case from a couple days ago near the Panhandle, we know the driver was in the wrong. And yet again, SFPD refuses to cite.
Combined with increasing oil use in China, India and most oil-exporting countries, we can expect America's oil consumption to continue its forced decline. Whether it happens in two years or five, hauling around our own 3000 lbs of metal with us wherever we go will soon become the privilege of an elite few. If Americans really understood what lies ahead for us, there would be less clamoring for free parking and free roads and frantic urgency for public transit and safe bicycling instead.
Damnit this irritates me so much. I would love to corner a city official on this issue in private and get them to explain this mentality to me. I'm pretty sure I could convince any reasonable person that this is not acceptable behavior. We need to keep pushing for this discussion at the societal level and raising awareness of how much bias our society has against non-motorists.
Today's motorists are kinda of like the landed gentry of feudal Europe who are the only ones who wield any real power. They are also kind of like the founding fathers of the US who said one thing ("everybody" is equal …) so they could feel noble about themselves and claim that they were better than those they were trying to overthrow, but actually meant another ( … unless you are black, a woman, or non-Christian). Today's city governments say they espouse the idea that all road users are equal, yet their actions show that they are heavily biased towards motorists.
@jd_x:disqus Yes, I agree. We need to stop tolerating collateral damage from the almighty automobile and treat this as what it is: vehicular assault.


text:
Immunological response to nitroglycerin-loaded shear-responsive liposomes in vitro and in vivo
Buscema, Marzia Biomaterials Science Center, Department of Biomedical Engineering, University of Basel, Switzerland
Matviykiv, Sofiya Biomaterials Science Center, Department of Biomedical Engineering, University of Basel, Switzerland
Mészáros, Tamás Nanomedicine Research and Education Center, Institute of Pathophysiology, Semmelweis University Budapest, Hungary - SeroScience Ltd., Budapest, Hungary
Gerganova, Gabriela Biomaterials Science Center, Department of Biomedical Engineering, University of Basel, Switzerland
Weinberger, Andreas Department of Chemistry, University of Fribourg, Switzerland
Mettal, Ute Department of Chemistry, University of Fribourg, Switzerland
Mueller, Dennis Department of Chemistry, University of Fribourg, Switzerland
Neuhaus, Frederik Department of Chemistry, University of Fribourg, Switzerland
Stalder, Etienne Department of Chemistry, University of Fribourg, Switzerland
Ishikawa, Takashi Paul Scherrer Institute (PSI), Villigen, Switzerland
Urbanics, Rudolf SeroScience Ltd., Budapest, Hungary
Saxer, Till Cardiology Division, University Hospital of Geneva, Switzerland
Pfohl, Thomas Biomaterials Science Center, Department of Biomedical Engineering, University of Basel, Switzerland
Szebeni, János Nanomedicine Research and Education Center, Institute of Pathophysiology, Semmelweis University Budapest, Hungary - SeroScience Ltd., Budapest, Hungary - Department of Nanobiotechnology and Regenerative Medicine, Faculty of Health, Miskolc University, Hungary
Zumbuehl, Andreas Department of Chemistry, University of Fribourg, Switzerland
Müller, Bert Biomaterials Science Center, Department of Biomedical Engineering, University of Basel, Switzerland
Journal of Controlled Release. - 2017, vol. 264, no. Supplement C, p. 14–23
English Liposomes formulated from the 1,3-diamidophospholipid Pad-PC-Pad are shear- responsive and thus promising nano-containers to specifically release a vasodilator at stenotic arteries. The recommended preclinical safety tests for therapeutic liposomes of nanometer size include the in vitro assessment of complement activation and the evaluation of the associated risk of complement activation-related pseudo-allergy (CARPA) in vivo. For this reason, we measured complement activation by Pad-PC- Pad formulations in human and porcine sera, along with the nanopharmaceutical- mediated cardiopulmonary responses in pigs. The evaluated formulations comprised of Pad-PC-Pad liposomes, with and without polyethylene glycol on the surface of the liposomes, and nitroglycerin as a model vasodilator. The nitroglycerin incorporation efficiency ranged from 25% to 50%. In human sera, liposome formulations with 20 mg/mL phospholipid gave rise to complement activation, mainly via the alternative pathway, as reflected by the rises in SC5b-9 and Bb protein complex concentrations. Formulations having a factor of ten lower phospholipid content did not result in measurable complement activation. The weak complement activation induced by Pad- PC-Pad liposomal formulations was confirmed by the results obtained by performing an in vivo study in a porcine model, where hemodynamic parameters were monitored continuously. Our study suggests that, compared to FDA-approved liposomal drugs, Pad-PC-Pad exhibits less or similar risks of CARPA.
DOI 10.1016/j.jconrel.2017.08.010
zue_irn.pdf: 2
zue_irn_sm.pdf: 2


text:
Integrative Mental Health for You
Adding Spirituality to Mental Health Practices
The New Integrative Psychiatry
Effective Alternatives to Psychiatric Medication
Spiritual Emergence Phenomena Explained
Spiritual Emergence Coach® Directory
Work with Emma Bragdon
About IMHU
Expert Faculty
Guest Presenters
Aligned Orgs
What is the Difference Between Spiritism and Spiritualism?
It's in the Original Mission
Both Spiritism and Spiritualism believe that the spirit world exists and spirits have an impact on human beings. The impact may be positive or negative, informative or deceptive. Both Spiritism and Spiritualism agree that we continue to live on after physical death in "Spirit World". Both believe in psychic, or paranormal abilities, like clairvoyance, that make it possible for gifted "psychics" to see what is invisible to most people. Both Spiritism and Spiritualism believe that spiritual healing has many forms and can have a very positive impact on physical health.
Spiritualism existed before Spiritism. Thus, Spiritism can be considered an offshoot of Spiritualism but with a different mission. Spiritism is oriented towards supporting spiritual evolution in concrete ways. Spiritism has a coherent philosophy and cogent principles about how to live together to achieve spiritual growth. Spiritualism, in its origins, was oriented towards exploring the unusual phenomena of spirit contact. It has no cohesive philosophy or principles for living in its origins.
Today, most Spiritualists embrace the ideal of spiritual evolution. However, they still don't follow one philosophy. There are many psychics who have written books and displayed their clairvoyant and healing gifts in presentations and private consultations who are the figureheads of Spiritualists. Edgar Cayce is one. Cayce's clients included a number of famous people such as Woodrow Wilson, Thomas Edison, Irving Berlin, and George Gershwin (1).
Spiritism Today
An academic Frenchman, Allan Kardec, birthed Spiritism in the 1850s in France. He asked 1001 questions to psychic mediums about basic existential questions and then collated the answers in 5 foundational books. Questions answered were things like: "What is the purpose of life? What happens at death? Do disembodied spirits interact with embodied human beings?" He published the answers that were similar from qualified mediums who channeled information from highly evolved spirits.
In a nutshell Kardec's books reflect: The purpose of life is spiritual growth, i.e. to become more compassionate and wise. We keep coming back (reincarnating) through successive lifetimes to get closer to the goal. Karma reigns; the Universe is run by cause and effect. Jesus Christ is an excellent example of one person who reached the goal. Some say Spiritism is a path of practical Christianity. Kardec clarified that not all spirits have positive intent so we must be very careful if we open ourselves to spirit contact.
Spiritist Community Centers evolved to give support to those who want to evolve spiritually. These Centers are in many countries, but most are located in the Phillipines and in Brazil. They offer spiritual healing (e.g. laying on of hands), classes, training of healers, inspiring talks, and fellowship. People of all faiths are welcome. Spiritism is not a religion; it is a path of life with a philosophy that resonates with many. Over 20-40 million Brazilians use the Spiritist Community Centers when they need help with physical illness or psychological issues. There are 50 Spiritist Psychiatric Hospitals in Brazil that combine spiritual healing with conventional psychiatry.
Spiritualism Today
Spiritualism was birthed in 1848 in the USA with two girls, the Fox sisters, who reported hearing rapping inside the walls of their home unrelated to anyone's physical actions. Through their psychic abilities, they received a spirit communication explaining the rapping. The message was: a skeleton was buried in the basement of their home. They located the skeleton of the man who had been murdered and buried there. Town officials corroborated their story, as they had been looking for this man's body after he had been reported missing. Thus the Fox sisters psychic attunement to the sounds, and their interpretation of them, proved valid.
The public became intensely fascinated with phenomena that come from spirits interacting with human beings as a result of the Fox sisters. Large dramatic exhibitions where people like the Fox sisters were on display for a fee became popular. The drama and suspense around psychic phenomena increased when some wanted to prove that contact with spirits could not exist and devised ways to make a mockery of the Fox sisters and other mediums. However, the fascination with getting discrete information from spirits grew. Explorations went on in living rooms with séances, where small groups would open themselves to communication with spirits. Even President Lincoln attended some séances in Washington, DC. They gave him useful information in his Presidency related to the Civil War (2).
President Lincoln holding down a piano at a Spiritualist meeting
The Ouija Board is a contemporary offshoot of séances that is sold as a "game". A person following the instructions can open themselves to communication with spirits. There are 60+ choices of Ouija Boards on Amazon.com.
In the USA there is a National Spiritualist Association of Churches (NSAC), The National Spiritual Alliance (TNSA), and the United Spiritualist Church Association (USCA), but many spiritualist organizations are independent with no national affiliation. The church services include prayer and a demonstration by a visiting psychic medium. The churches also provide education of Spiritualist history and thought outside of the services. In the 19th century some Spiritualist Camps were set up for families for summer recreation and Spiritualist study. Among the best-known of the Spiritualist camps that still exist are Lily Dale Assembly in Lily Dale, New York, and Camp Cassadaga in Cassadaga, Florida(3). Approximately 0.1% of the populations of USA, UK, AU and Canada are Spiritualist, or about 220,000 people.
Emma Bragdon, PhD is the Executive Director of Integrative Mental Health for You, IMHU.org. It offers online and live presentations giving choices for effectively optimizing mental health. Once a year Emma takes a small group of healthcare providers to Brazil for a transformative weeklong seminar on Spiritist treatments used in Spiritist Psychiatric Hospitals and Community Centers. See YouTube videos here.
(1) Kirkpatrick, S. (2000) Edgar Cayce: an American prophet. Riverhead Books
(2) Maynard, N. C. (2009) Séances in Washington: Abraham Lincoln and Spiritualism during the Civil War. Ancient Wisdom Publishing.
(3) Wicker, C. (2003). Lily Dale: the True Story of the Town that Talks to the Dead. Harper San Francisco.
Emma Bragdon
mediumship, psychics, Spiritism, Spiritist Community Centers, Spiritist Psychiatric Hospitals, spiritual healing, spiritualism, spirituality
in Life After Death, Mental Health, Paranormal, Psychic Experiences, Spiritism, Spiritualism, Uncategorized
An Alternative to Hospitalization: Inner Fire
Effective Choices in Treating Depression Using Integrative Mental Health
Eli Richardson says:
I found it interesting when you talked about the differences between spiritism and spiritualism. Recently, I started to become interested in learning about different religions and beliefs. I'm not much of a believer, but I'd like to know more about them and how they've helped people. I appreciate your information on how both of them are focused on how the spirit world exists.
RH Trowbridge says:
Thanks for the helpful distinction between spiritism and spiritualism! It is in line with the little I know and taught me some new things. Alan Kardec asked 1019 questions to mediums throughout Europe. Quite an interesting man. It does seem Spiritism is an offshoot of Spiritualism. It followed so soon after the Fox sisters' experience! It must have taken off very quickly across the ocean when news didn't travel that fast ordinarily. Or did it. So glad you didn't disparage the Fox sisters. Theirs is a rather convoluted story, and they had a difficult life. It must have been difficult for them NOT to suffer negative effects, coming forth at that time. And so interesting that these spiritual paths (and others) arose during such a flowering of materialistic science. The spirit flows where it will, and we feel it, but know not where it is going – and certainly cannot prevent it. Thanks again. Many good regards.
Filter by Categories Select CategoryAlternatives to Psych Meds (53) Energy Work (5) Healing Touch (1) Ibogaine (2) MDMA (1) Micronutrients (7) Nutrition (4) Peers (3) Plant Medicine (1) Psychedelics (5) Psychotherapy (2) Residential Care (1) Spiritual Healing (12) John of God (5)Anomalous Experience (30) Kundalini (1) Life After Death (5) Mediums (2) Mysticism (2) NDE (1) Non-Ordinary States of Consciousness (3) Paranormal (5) Psychic Experiences (4) Self-Realization (7) Yogananda (4) Soul (2) Spirit (6) Spiritually Transformative Experiences (11)Children (11) Mercury (1) Vaccines (5)Health (17)Integrative Mental Health (60)Karma (2)Medical marijuana (1)Meditation (20) Mindfulness (4)Mental Health (54)Mental Illness (57) ADD (4) Addiction (1) ADHD (3) Anxiety (11) Autism (8) Bipolar (3) Depression (18) Diagnosis (8) Drugs (17) DSM (1) Hallucinations (2) Medication (17) Anti-Depressants (7) Psychiatry (19) Psychosis (4) Suicide (7)Relationship (2) Sex (1)Research (9)Shamanism (1)Spiritism (6) Spiritualism (3)Spiritual Crisis (2)Spiritual Emergence (12)Spiritual Emergency (19) Spiritual Crisis (2)Spirituality (12)Uncategorized (7)
Get in the Loop!
Sign up for the IMHU newsletter and get info on newest courses, blogs and more!
8 Clough Ave • Windsor, VT 05089 USA
For Health Seekers
© 2021 All Rights Reserved. Terms of Use | Sitemap | Privacy Policy


It is a long cord worn around the waist used for fastening apparels. It is hemmed with fringe that hang from the waist. Priests wear black, bishops wear purple, cardinals wear red, and the pope wears white. There are two types of cinctures: one is a rope-like narrow girdle and the other type is a broad ribbon of cloth that runs around the waist is called as "band cincture"


text:
Police Headquarters release 2-Special lines for Crime Reporting, As IGP Gives Directive To AIGs
ABUJA-The Inspector-General of Police, IGP Usman Alkali Baba, has charged members of the public, who are strategic partners in security and policing of the country, to report all forms of cybercrimes – identity theft, child sexual exploitation, cyber-stalking, cyber-bullying, credit card fraud, internet fraud and other forms of cybercrimes online through the Nigeria Police... Read More
Just-in: Resignation surfaces in INEC over intimidation by security agencies, narrates how elections were rigged
ABUJA-The Inspector-General of Police, IGP Usman Alkali Baba, has charged members of the public, who are strategic partners in security and policing of the country, to report all forms of cybercrimes – identity theft, child sexual exploitation, cyber-stalking, cyber-bullying, credit card fraud, internet fraud and other forms of cybercrimes online through the Nigeria Police Force Cybercrime Reporting Portal – https://incb.npf.gov.ng, interpolnigeria@npf.gov.ng, via WhatsApp on 07043797900, and via call/SMS on 08094557845.
PORTAL PAGE
The IG further stated that Cybercrime Reporting Portal domiciled at the INTERPOL National Central Bureau (NCB) Abuja, avails the Force with access to intelligence and data sharing between the 195 member countries of the INTERPOL. The portal also has various other resources to be enjoyed by visitors to the website such as abridged cybercrime awareness material, online safety tips, the 2015 Cybercrime Act and Africa's First Storified Cybersecurity Handbook – "no go fall maga", in portable document format.
However, in a press statement from the Force headquarters, Baba in same vein,bid for the expansion of the intelligence gathering capability of the Nigeria Police Force, ordering that the immediate completion of a new office complex opposite the Louis Edet House for the Force Intelligence Bureau. The new complex will be fitted with ICT-based state-of-the-art gadgets which will be in tune with contemporary intelligence gathering realities. He also charged various units of effective policing via intelligence gathering, while admonishing Assistant Inspector-General of Police Force Intelligence Bureau (AIG-FIB), on the effective deployment of human and materials assets for effective gathering of active intelligence. Baba equally tasked the AIG-FIB to commence immediate training for its officers and men on the use of the new office complex, and deployment of the new gadgets.
For breaking News, please call +2348028592006: Email us @: afrikanwatch122@gmail.com, for your interview on national issues, or article, commentary or event coverage. View our services and profile by clicking about Afrikanwatch Network and Service.
YABATECH N50 Billion Endowment And What the Future Holds
US Forces Will Defend Taiwan If China Invades-Pres. Biden


We are committed to protecting your privacy. We will only use information that we collect about you lawfully (in accordance with the Data Protection Act 1998). We collect information about you for two reasons: firstly, to process your order and second, to provide you with the best possible service. We will not email you unless you have given us your consent. We will give you the chance to refuse any marketing email from us or from another trader in the future.


text:
Sulfonylurea-Induced Hypoglycemia: The Case Against Glyburide
Maegan Rogers, PharmD
, Christopher Sands, MD
Christopher Sands, MD
Since it came onto the market in 1983, glyburide has been one of the most popular sulfonylureas. The American Diabetes Association (ADA) recommends the use of these agents as part of a stepwise approach to treating type 2 diabetes mellitus.
Since it came onto the market in 1983, glyburide has been one of the most popular sulfonylureas. The American Diabetes Association (ADA) recommends the use of these agents as part of a stepwise approach to treating type 2 diabetes mellitus. According to the ADA algorithm, all patients should start with therapeutic lifestyle modifications and metformin-if no contraindications are present. Next, depending on the hemoglobin A1c (HbA1c) level, patients should receive either a sulfonylurea or insulin.1
Sulfonylureas were among the first oral antihyperglycemic agents developed, and they are still commonly used today because they are inexpensive and well tolerated.2 They produce an antihyperglycemic effect by stimulating insulin secretion from the pancreas; it therefore follows that hypoglycemia is the chief adverse effect associated with their use.3
Glyburide, a second-generation sulfonylurea, is associated with hypoglycemia more often than most other sulfonylureas.4 Currently, glyburide is not recommended for patients with renal impairment (creatinine clearance of less than 50 mL/min) or severe hepatic impairment because of the risk of hypoglycemia. It should be used with caution in elderly patients because they are also at increased risk for hypoglycemia.
Here we will examine the evidence to address the question of whether glyburide should still be prescribed when other equally inexpensive second-generation sulfonylureas that pose less risk of hypoglycemia, such as glipizide and glimepiride, are available.
HYPOGLYCEMIA WITH SULFONYLUREAS
Studies have been conducted to determine which sulfonylureas are the safest and most effective. Because hypoglycemia is the chief adverse effect of sulfonylurea use, many studies have looked specifically at this phenomenon. Table 1 summarizes the results of some of these trials.
van Staa and associates5 theorized that hypoglycemia risk varies among individual sulfonylureas. They conducted an epidemiological study to evaluate the risk of hypoglycemia in patients with type 2 diabetes mellitus who were receiving chlorpropamide; tolbutamide; glyburide; glipizide; or gliclazide, which is not available in the United States. This study revealed that the risk of hypoglycemia was higher in patients who used glyburide than in those who used other sulfonylureas. Table 2 shows the relative risk of hypoglycemia associated with the available sulfonylureas. van Staa and associates5 also found that patients older than 65 years were at higher risk for hypoglycemia than their younger counterparts.
A number of factors predispose elderly patients to hypoglycemia, including polypharmacy, intercurrent illness, and declining renal and hepatic function.6 This predisposition makes the use of glyburide even more hazardous in elderly patients. Shorr and colleagues6 conducted a retrospective cohort study to assess the risk of sulfonylurea-associated hypoglycemia specifically in the elderly population. The medications reviewed included first-generation agents chlorpropamide, tolazamide, tolbutamide, and acetohexamide, and second-generation agents glyburide and glipizide. This study showed that the lowest risk of hypoglycemia was observed with glipizide, tolbutamide, and tolazamide and the highest risk was seen with chlorpropamide and glyburide.6 A comparison of the rates of hypoglycemia associated with second-generation sulfonylureas revealed that hypoglycemia occurred twice as frequently in patients receiving glyburide as in those receiving glipizide.6
In a 2007 meta-analysis, glyburide was compared with other anti-diabetic medications, including insulin, to determine whether it was associated with a higher risk of hypoglycemia.4 The meta-analysis, which included 21 studies, revealed a 52% higher risk of hypoglycemia in patients receiving glyburide compared with those taking other insulin secretagogues. In addition, glyburide posed an 83% higher risk of hypoglycemia compared with other sulfonylureas.
Of note, HbA1c values were not significantly different between patients receiving glyburide and those receiving other sulfonylureas.4 This finding indicates that the higher risk of hypoglycemia seen with glyburide is not associated with lower HbA1c values.
DOES GLYBURIDE HAVE A NICHE?
With numerous studies pointing to an increased risk of adverse effects with the use of glyburide, we are left with the question of whether the medication should be removed from the market. Arguments could be made for such an action; however, glyburide has been suggested as a therapeutic option for one set of patients typically treated only with insulin: women with gestational diabetes mellitus. Glyburide is recommended for women with gestational diabetes mellitus who may not necessarily require insulin but who are unable to reach their blood glucose goals with medical nutrition therapy.7,8 These recommendations are based largely on a randomized unblinded trial that compared the use of glyburide with that of insulin in women with gestational diabetes mellitus. This study found no difference in rates of glycemic control between the two treatment groups.9
Although glyburide has been used in women with gestational diabetes mellitus, it does not have FDA approval for this indication and larger studies are needed to confirm its efficacy and safety in this population.8 It would also be prudent to conduct studies evaluating the use of other second-generation sulfonylureas, such as glipizide or glimepiride, in women with gestational diabetes mellitus.
GLYBURIDE: NOT RECOMMENDED
The ADA includes a footnote to their treatment algorithm recommending the use of any sulfonylurea other than glyburide or chlorpropamide.1 Glyburide, glipizide, and glimepiride are inexpensive and readily available as generics on most $4 prescription programs. These second-generation sulfonylureas all have similar durations of action; however, they have markedly different relative risks of hypoglycemia.6,10 This could be explained by glyburide's increased effect on hepatic insulin sensitivity through high affinity for the -cell sulfonylurea receptor, accumulation of active metabolites, and general accumulation in the islet -cell, which causes insulin release even after the medication is stopped.4,6,10
It follows that patients who are receiving glyburide, excluding women with gestational diabetes mellitus, should be switched to an equivalent dose of glipizide or glimepiride. In light of evidence that suggests glyburide is associated with at least a 50% higher risk of hypoglycemia than other sulfonylureas, it may be wise to avoid glyburide in all patients who have diabetes.4
REFERENCES:1. Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2008;31:1-11.
2. Burge M, Schmitz-Fiorentino K, Fischette C, et al. A prospective trial of risk factors for sulfonylurea-induced hypoglycemia in type 2 diabetes mellitus. JAMA. 1998;279:137-143.
3. Scheen AJ, Lefébvre PJ. Oral antidiabetic agents. A guide to selection. Drugs. 1998;55:225-236.
4. Gangji AS, Cukierman T, Gerstein HC, et al. A systematic review and meta-analysis of hypoglycemia and cardiovascular events: a comparison of glyburide with other secretagogues and with insulin. Diabetes Care. 2007;30:389-394.
5. van Staa T, Abenhaim L, Monette J. Rates of hypoglycemia in users of sulfonylureas. J Clin Epidemiol. 1997;50:735-741.
6. Shorr RI, Ray WA, Daugherty JR, Griffen MR. Individual sulfonylureas and serious hypoglycemia in older people. J Am Geriatr Soc. 1996;44:751-755.
7. American Diabetes Association. Gestational diabetes mellitus. Diabetes Care. 2004;27(suppl 1):S88-S90.
8. Cheung NW. The management of gestational diabetes. Vasc Health Risk Manag. 2009;5:153-164.
9. Langer O, Conway DL, Berkus MD, et al. A comparison of glyburide and insulin in women with gestational diabetes mellitus. N Engl J Med. 2000;343:1134-1138.
10. Szoke E, Gosmanov NR, Sinkin JC, et al. Effects of glimepiride and glyburide on glucose counterregulation and recovery from hypoglycemia. Metabolism. 2006;55:78-83.
11. Baba S, Nakagawa S, Takebe K, et al. Comparison of gliclazide and glibenclamide treatment in non-insulin-dependent diabetes. Tohoku J Exp Med. 1983;141(suppl):693-706.
12. Dills DG, Schneider J. Clinical evaluation of glimepiride versus glyburide in NIDDM in a double-blind comparative study. Glimepiride/Glyburide Research Group. Horm Metab Res. 1996;28:426-429.
13. Draeger KE, Wernicke-Panten K, Lomp HJ, et al. Long-term treatment of type 2 diabetic patients with the new oral antidiabetic agent glimepiride (Amaryl): a double-blind comparison with glibenclamide. Horm Metab Res. 1996;28:419-425.
14. Haider Z, Obaidullah S, Fayyaz UD. Comparative study of glibenclamide and chlorpropamide in newly diagnosed maturity onset diabetics. J Pak Med Assoc. 1976;26:23-26.
15. Hamblin JJ, Ismay G, Good MS, et al. A comparative study of glibenclamide and chlorpropamide. (Preliminary report). Postgrad Med J. 1970;(suppl):92-94.
16. Harrower AD. Comparison of efficacy secondary failure rate, and complications of sulfonylureas. J Diabetes Complications. 1994;8:201-203.
17. Landgraf R, Bilo HJ, Müller PG. A comparison of repaglinide and glibenclamide in the treatment of type 2 diabetic patients previously treated with sulphonylureas. Eur J Clin Pharmacol. 1999;55:165-171.
18. Mafauzy M. Repaglinide versus glibenclamide treatment of type 2 diabetes during Ramadan fasting. Diabetes Res Clin Pract. 2002;58:45-53.
19. Marbury T, Huang WC, Strange P, Lebovitz H. Repaglinide versus glyburide: a one-year comparison trial. Diabetes Res Clin Pract. 1999;43:155-166.
20. Rosenstock J, Carrao PJ, Goldberg RB, Kilo C. Diabetes control in the elderly: a randomized, comparative study of glyburide versus glipizide in non-insulin-dependent diabetes mellitus. Clin Ther. 1993;15:1031-1040.
21. United Kingdom Prospective Diabetes Study (UKPDS). 13: relative efficacy of randomly allocated diet, sulphonylurea, insulin, or metformin in patients with newly diagnosed non-insulin dependent diabetes followed for three years. BMJ. 1995;310:83-88.
22. Wolffenbuttel BH, Landgraf R. A 1-year multicenter randomized double-blind comparison of repaglinide and glyburide for the treatment of type 2 diabetes. Dutch and German Repaglinide Study Group. Diabetes Care. 1999;22:463-467.


text:
01.12.2011 CULTURAL AND SOCIAL HISTORY, MODERN HISTORY
Wives and mothers in Tudor age
A Tudor marriage was usually a carefully orchestrated affair, be it for monarch or commoner – a business arrangement to safeguard family fortunes, enhance wealth and property and advance social status. The bride was expected to provide an appropriately large dowry. Love matches and Romeo and Juliet scenarios were strictly for the stage.
The traditional Catholic Church considered marriage a necessary evil for those women too weak to remain virgins, whereas the Protestant church regarded marriage as perfectly acceptable – providing the wife remained obedient.
Premarital sex was illegal, which is possibly why Shakespeare was so quick to marry Anne Hathaway after she became pregnant. One Tudor method of birth control involved drinking honeysuckle juice for 37 consecutive days. Adultery was also unlawful, as was abortion – a woman faced execution if unable to prove her has died of natural causes. Conversely, barren women were advised to touch the hand of a hanged man in order to improve their chances of becoming pregnant.
Motherhood remained a hazardous affair. Many women, including Jane Seymour and Catherine Parr (two of Henry VIII's wives), died in childbirth through inadequate medical procedures and poor hygiene at the time of delivery. The traditional regard for the midwife's abilities declined in the Tudor era due to the growing importance of male physicians, and the midwfe's skill even became confused with witchcraft. As there was still no satisfactory substitute for breast-feeding, however, the wet-nurse remained an essential part of a newborn baby's welfare.
Infant mortality was high – one third of all 16th century children died in their first five years. It would seem that being either a mother or an infant in the Tudor age was fraught with difficulty.
The baby who provoked a revolu...
marriage, Tudors, woman


If you only have one day in Wanaka then this is what you must do! This guided nature encounter includes a boat cruise on Lake Wanaka, a guided island nature walk & a leisurely high country 4WD tour.
Begin your day with a cruise on the pristine waters of Lake Wanaka to Mou Waho Island Nature Reserve. A guided walk to the spectacular summit reveals the island's secret – a lake on top of an island!
Enjoy 'high tea' up close and personal with rare native birds, including weka, wood pigeon and bellbird. Plant a tree as part of this unique eco experience.
After lunch in one of Wanaka's many fine cafés (own expense), discover the secrets of Wanaka's highcountry with a leisurely 4WD tour of a local sheep station.
An extremely well worthwhile & most enjoyable adventure.


If you click on a link to a third party site you will leave our site and go to the site you selected. Because we cannot control the activities of third parties, we cannot accept responsibility for any use of your personally identifiable information by such third parties, and we cannot guarantee that they will adhere to the same privacy practices as us. We encourage you to review the privacy statements of any other service provider from whom you request services.


Check out our 2 Thunder Valley Casino Resort coupons including 2 sales.
The best way to save at Thunder Valley Casino Resort is to book your stay under one of the featured promotions in their Promotions section of the website. You can also sign up for the Thunder Valley Casino Resort email list to have special offers and coupon codes sent to your inbox as they become available. Other Thunder Valley Casino Resort promotions and coupons can be found on their social media pages and at Coupons.com.


text:
Q: Low Resolution KML GroundOverlay I have a problem that has been driving me crazy for two days.
We have a Google Maps app that pulls in a KML file to display historical maps as image overlays. Around last week, our app started showing very blurry images that were pulled from googleusercontent servers not our own. What's even more puzzling is that the images in Google's cache are not the same size as the ones on my server -- they're three times smaller.
I'm not having any luck forcing Google to not use the version of the file in their cache. When I change the file's name or directory, I'll get a 404 error from the googleusercontent url, but it will not load the actual link that is being referenced.
Here is an example KML file (exported from Google Earth). The image is in the same directory as the KML file.
<?xml version="1.0" encoding="UTF-8"?>
<kml xmlns="http://www.opengis.net/kml/2.2"  xmlns:gx="http://www.google.com/kml/ext/2.2" xmlns:kml="http://www.opengis.net/kml/2.2" xmlns:atom="http://www.w3.org/2005/Atom">
<GroundOverlay>
    <name>panel1</name>
    <Icon>
            <href>panel1.png</href>
            <viewBoundScale>0.75</viewBoundScale>
    </Icon>
    <LatLonBox>
            <north>37.5422476694301</north>
            <south>37.53370251727466</south>
            <east>-77.43246990568036</east>
            <west>-77.44384562932868</west>
    </LatLonBox>
</GroundOverlay>
</kml>

Here is the call that I am making to load the KMLOverlay on my map.
this.GOOGLE_MAP = new google.maps.Map(document.getElementById('richmond_map'),{
        center: new google.maps.LatLng(<lat_value>, <lng_value>),
        zoom:16,
        streetView: new google.maps.StreetViewPanorama($('#street')[0],{disableDefaultUI: true})
    });

    var d = new Date();
    this.OVERLAY = new google.maps.KmlLayer({url: <url_to_KML_file>, clickable: false, map: this.GOOGLE_MAP, preserveViewport: true, zIndex:2 });

A: This problem should be fixed now - see Google Maps API issue for a working example.


Comments: Nav System, Heated Seats, BLUE JEANS METALLIC, 110V/400W OUTLET, ENGINE: 5.0L V8, XLT CHROME APPEARANCE PACKAGE, TWO-TONE PAINT, Smart Device Integration. XLT trim, Blue Jeans Metallic exterior and Dark Earth Gray interior. SEE MORE!


After searching all over the world for an XML-RPC or similar interface (there is one on the RedHat version of bugzilla apparently) I found bugzilla-submit right there on the official bugzilla download page.
So I'll just have to write an XSLT transform to put my analysis into action (well, let's make this planning instead, the action will come right after).
This entry was posted on Tuesday, June 15th, 2004 at 10:39 am and is filed under tools.	You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.


A forum "Making Ends Meet - What Should We Do To Support Working Families?" will be held on Wednesday, February 21 on the second floor of the Calhoun County Library. The event will begin with lunch at 11:30 a.m. and the forum will start at 2:30 p.m., according to Sue Jones, local WVU Extension Agent.
The forum is one of several being held across West Virginia out of concern for struggling families, such as lay-offs, low wage jobs, unemployment, lack of health insurance or loss of public benefits.
The event, jointly sponsored by the Calhoun County Family Resource Network and WVU Extension Service, will bring people together to explore the problems faced by working families.
The goals of the forum are to think about what we can do about the problem in Calhoun County, according to Jones, including informing our policy makers.
"We need input from people from various agencies and from all walks of life. We hope people will come and participate," she said. You can call 354-6332 to register.


Drake and Kentucky: In 2012, Kentucky won their first national championship under head coach John Calipari and ironically enough, Drake proved to be a big fan of Big Blue. So much so that in 2014, Drake appeared at Midnight Madness in Lexington … and then shot an airball in a layup line. The year after Kentucky won it all, they missed the tournament. Since then? They've lost in the National Championship Game (2014), lost in the National Semifinal (2015), lost in the second round (2016), lost in the Elite Eight (2017) and just this past season lost in the Sweet Sixten.
In other words, Kentucky hasn't won a title since Drake dropped Nothing Was The Same.
Drake and the Raptors: Since the Raptors switched to OVO branding on their jerseys and literally everything else, Drake's been courtside to root the Raptors on. Only problem is, they've fallen short every single year. They've never made an NBA Finals (blame LeBron James for that) and they've only been to the Eastern Conference Finals once. Well, at least they have clean jerseys?
Drake and Conor McGregor: Well, Conor got choked out after talking big noise and Drake still rode for the man. Let's just say, Drake really isn't good at this whole picking teams thing.
So, let it be said here and now – do not let Drake pick your team or your squad when it comes to anything going forward. If you're a Cowboys or Saints fan, don't wish for Drake to don a Zeke Elliott or Drew Brees jersey. If you're the Rockets, well you already know about that. And so on!


Writers looking for writing inspiration?
Do you have writers burnout?
Need a little writing help with a plot or character?
Check out these great generators to kick-start your writing.
Need to generate everything but the kitchen sink to get your story started.
Characters, First Line, Theme, Names, Dialog and more generators to get you started.
Generate an entire short story?
A romantic/fantasy blurb? This generator over at Plot Generator might be for you. There you can find inspiration for Pen Names, Letter writing and much more.
Over at the Writers Plot Idea Generator you might like the Blank Page Eliminator, Plot Twist Generator or the Fun stuff.
After surviving the A to Z Challenge left me with a bit of writers burnout and I needed to recharge. Scouring Amazon for something to read I found a short book and after reading it for free on Kindle Unlimited, I bought it for my library.
Now as a disclaimer, I haven't yet put into practice Mr. Windsor's technique, but there are some really good tips in this book. I hope you enjoy the websites and book as much as I did.


Alan travels a lot for work, which can present challenges for eating plant-based and healthy. When he's at home, he eats old-fashioned oats, which he loves. For years, he's traveled with packets of instant oatmeal to have for breakfasts and meals in a pinch. They are convenient, but not all instant oatmeal packets are vegan, a lot have milk powder, and artificial colorings and flavors, not to mention a lot of added sugar. In addition, we're picky about our oats, preferring non-GMO, organic oats to reduce our exposure to glyphosphate (the herbicide Roundup). The Environmental Working Group has found levels of glyphopate in the majority non-organic oatmeal products they tested to be higher than what they consider safe, posing an increased cancer risk. You can check their studies out at https://www.ewg.org/childrenshealth/glyphosateincereal/ and https://www.ewg.org/release/roundup-breakfast-part-2-new-tests-weed-killer-found-all-kids-cereals-sampled. And, instant oatmeal packets generate a lot of trash, which we are actively working to reduce. One would think they are just a paper bag and therefore would be recyclable, but no, they are lined with some sort of plastic (check out this hack about cooking your oatmeal right in the baggie https://lifehacker.com/5879863/cook-instant-oatmeal-in-the-packet-when-you-dont-have-a-bowl), which we certainly don't to expose to our food. So, given all of these things, coming up with a better alternative for Alan's instant oats was high on the list to find a solution for.
The hardest part of change was not in making the instant oatmeal mix, which I'll share in a moment, but in the packaging. Alan needs something durable but lightweight and small, something that will easily fit in his computer bag or carry-on for the airplane. A glass jar is too bulky and we aren't using plastic storage bags anymore. I'd considered sewing up one of my vegan wax wraps, but we didn't want wax inside of his computer bag or carry-on in case it got warm on the airplane or in the trunk of a rental car. I finally discovered the silicone resealable Stasher bags and decided to give them a try. They come in different sizes and the snack bag size seemed perfect! And it was—it fit perfectly in Alan's carry-on with no spillage.
sample bags that I thought would go through security better than unmarked baggies of white powder! Finally, I put in a little coconut sugar, but you can use other dry sweetener of choice or omit, and cinnamon.
Alan loves this instant oatmeal, in fact, he likes it better than the packaged stuff we used to get at the store. It's fresher and tastier than what we used to buy. We hope you love it too!
Mix all together and store in a sealed container. To use, add 1/3 cup of oatmeal mix to a cup or bowl and add 3/4 cup of boiling water. Stir and let stand 2 minutes before eating.
Those bags look really cool! Reusable replacements for plastic bags have been on my list of things to buy when I have the money for a while now.
The Stasher Bags are great! They've worked great and haven't opened up at all during any of Alan's air travel. We were really concerned about that.


Home fashion fashion essentials Reebok Welcome Back The Nano Denim!
Welcome Back The Nano Denim!
DENIM IS BACK! The OG Denim Nano makes a comeback in 2019 and it's ready for anything.
Since 2010, Reebok has forged the Nano through sweat, testing, re-designing and re-testing to create the most versatile and dependable CrossFit shoe in the box. The Nano 8 was developed with insight from the CrossFit community, and has been engineered for maximum comfort. The re-engineered Flexweave upper provides breathability, stability, and durability, and the added cushioning in the forefoot help keep you comfortable. The CrossFit-specific outsole gives you grip in the box so you can hit your PRs.


text:
FSB research shows lack of preparedness for end of Brexit transition period
December 24, 2020 @ 7:30 by Richard Dawson
A new study of more than 1500 small firms has found that just 18 per cent of those which believe they will be negatively impacted by the end of the Brexit transition period have prepared for the changes coming on January 1.
The Federation of Small Businesses (FSB) research explains how uncertainty around future trade arrangements COVID-19 disruption is hampering efforts to prepare.
68 per cent of firms surveyed said the uncertainty around the future relationship with the EU was the biggest barrier to preparedness, while 22 per cent said a lack of time and resources due to COVID-19 was to blame.
Among those that have managed to make some preparations, more than a quarter (27 per cent) say the cost of doing so has been in excess of £2000. One in ten (10 per cent) say the cost has exceeded £5000.
For those that trade in goods, more than half (58 per cent) do not have experience of completing certificates of origin. Under any deal, small firms will have to meet rules of origin obligations to unlock preferential zero tariffs from January 1.
One in five (23 per cent) of those fearing the end of transition are stockpiling, exacerbating a squeeze on capacity at UK ports in the run-up to Christmas.
FSB national chairman Mike Cherry said: "With only two weeks to go, small firms don't have the time, money or clarity they need to prepare for the end of the transition period even if they want or need to.
"More than four years on from the referendum, and after such a torrid 2020, we urgently need to see negotiators strike a pro-enterprise free trade agreement in the days ahead, one that includes an ambitious small business chapter.
"Fundamentally, if the Government wants firms to make additional preparations over the coming days and into the New Year, it needs to put its money where its mouth is.
"Transition vouchers – £3000 grants that firms can use to buy the tech, training and advice needed to navigate a new trading relationship – would make a massive difference.
"The clock is ticking more loudly than ever before. It's time for negotiators on both sides to get a free trade deal done."
Chamber QES highlights tough conditions for firms at the close of 2020


In memory of these artists who gave us years of enjoyment and great entertainment. If there is a Rock and Roll heaven, you guys make one hell of a band. We miss you.
Danny Mackenize passed away on Saturday, March 26th, 2016 Danny played in many bands some of which include: Sam, Reckless, Hour Glass, Windjammers, and Good Cheer.


View our Council Meeting Minutes section for Council and Committee Meeting minutes.
Please note that RSVP is required for community Council meeting dinner attendance by the Wednesday prior to the meeting. Community Council meeting dates are marked **. Please email council.reports@mornpen.vic.gov.au or telephone 5950 1439.