We offer programs for players from 18 months to 18 years of age. Our Dribblers program for players up to 4 and our Academy program from 4 to 14 years. We also have our elite Premier 6 to 14 years and Adastra, 14 to 18 years programs which is by invite only.
We offer a girls only Academy program from 4 to 14 years. We also have our elite Girls Adastra program, 14 to 18 years which is by invite only.
We offer after school coaching programs which run for the duration of a school term. We therefore request all parents to commit their children to attend a full coaching term at IFA. It is important that the participants attend 100% of the sessions to receive the full benefit of the coaching programs.
You can register and pay online through our website or app. There will be a one of registration fee for which you will receive a full IFA kit and a term fee which will vary depending on the number of weeks in a term. All payments must be made in advance and be for the full term or the remaining part of the term if you are registering midterm. (IFA members shall be offered first refusal on each course before we promote the spaces to the wider community).
We accept payments by credit card. Credit card details are not stored in our database or server and are processed through a secure SSL environment.
Please send your child in their IFA football uniform and Trainers or football boots (depending on the surface) - Watches / ear rings / bracelets / necklaces should not be worn. Please ensure that your child brings plenty of water and during the summer months wears sun screen and a hat.
Please arrive to the IFA sessions no later than 5 minutes prior to the start time. If your child is late they may be asked to sit at the side of the session until the coach/group has finished their current practice. Please ensure an IFA coach is present at the venue before leaving your child.
Can I attend the session.
All parents are welcome to watch their child during a session. However, please ensure you do not enter the field of play at any time during the session. This also applies to younger siblings. Please keep to a safe distance away from the playing area. If you have any questions for the coach please wait until the session has ended.
All players should be collected from the playing area no later than 15 minutes after the session has ended. If you wish for your child to be collected by a different parent/person, please inform the IFA staff of who that person shall be.
Refund's shall not be given if a session is cancelled outside of IFA's control - e.g. Inclement weather or school cancellations. Refunds shall not be given to those people who simply do not attend the session or choose to go on holiday during school term time. If a refund request is considered valid due to injury or ill health then IFA will offer an alternative or make up session. In exceptional circumstances if monies are to be refunded then this will be by cheque within a maximum of 5 working days.
If your child is ill and cannot attend a session please notify the IFA office 24 hours prior to the session. You can make up this session at any one of our other venues / days or at catch up sessions. Please note the catch up sessions may be at another venue. If you require help with this matter please email or telephone us. Regrettably, we are unable to arrange make up sessions if you inform us after the session has taken place.


Cytomegalovirus (CMV) is a common viral infection that is easily acquired in the community setting and is usually mild and self-limiting, although it can potentially have serious consequences for pregnant women, babies and some immunosuppressed patient groups. CMV can also be transmitted through a blood transfusion.
All Australian cellular blood products (except granulocytes) are leucodepleted (removal of white cells).
In January 2014, JBC approved the establishment of a JBC working group to oversee the development of options to produce a national statement on indications and prioritisation for apheresis and whole blood platelets and CMV seronegative blood products.
In April 2016, JBC endorsed the Clinical Indications for Apheresis and Whole Blood Platelets – A National Statement  and agreed to the JBC working group producing a statement on the Clinical Use of CMV Seronegative Blood Products as there were multiple sources of guidance published already based on the available evidence and differing expert opinion. The working group reviewed international practice, current literature and local guidance documents with the intent of developing a national approach to the clinical use of CMV seronegative products.
The position of the working group endorsed by JBC, and based on the Expert Opinion Points in the Patient Blood Management Guidelines, is that only laboratories that provide blood products to paediatric or pregnancy and birth services should hold CMV seronegative inventory.
The NBA will work in collaboration with key stakeholders to implement the recommendations, including education and training on the risks of CMV transmission via transfusion versus community acquired infection, and the development of audits for health services to understand where CMV seronegative blood products are used. Further information will be made available when completed.


Remember when earth day meant something other than a date on the calendar? Me too.
I have been thinking a lot about our planet and what our responsibility is to her. We are grateful are we not? I think we owe her mindfulness. Consciousness of what we consume, how it is consumed and how it goes back to her. Can we agree to think about our consumption? This is the root of what we impose on our planet. Is it not our responsibility to take care of her?
We are still in recovery mode here in CT. If you are a tree lover (and I am) these are sad days. The recent premature snowfall (snowmageddon) left our trees shattered. It is like Edward Scissorhands ran through every neighborhood. Piles of branches sit curbside at every home. What is not down is in need of attention. Everywhere you turn there are trees that will need to come down as they have been seriously damaged. So sad!
I could complain about all the inconveniences that this brought into our lives with 9 days of no power, no phone, no internet. Instead I would like to say how lucky we were that family and neighbors were with us through this ordeal. People opened their doors and offered what they could. As we get ready for Thanksgiving let's remember how much we take for granted and be truly grateful that we rarely go without. Let's be thankful.
My life has hit so many speed bumps lately I feel like I am on a ride at the amusement park. I usually love grocery shopping but when time after time you can't get what you came for, the romance is over.
Our Whole Foods market opened in 2005. As a cook and a food lover I was ecstatic. Finally, a grocery store with quality ingredients, a range of organic foods, local ingredients. Dan and I were quickly hooked. In the past 6 years we have found wonderful people and food at WFM. Yes I shopped at other stores but certain ingredients were better at WFM. Based on these convictions I persuaded friends and family to shop there.
"You know this meat has so much flavor" my Mom told me.
"I know!" I replied. We were all so happy.
Today I went to get some cans of beans. Cannellini was my first choice. The shelf was bare. Black beans or chick peas perhaps? No and no. Yes, they did have the pricier organic chick peas but in addition to the extra 30¢ per can they were not sodium free. Ok, we will have hamburgers. No 85% ground beef. Not in the prepackaged case, nor in the butcher's case. No American cheese. What about that rice mix I like? No, that was out too. This unfortunately has become the norm for Whole Foods Market. And that was just Wednesday at 3:30 pm. Can you imagine what 5 pm on Saturday is like?
My quick dash through the market did spy price increases all over the store. If they had the 85% ground beef it would be $1 more per lb than last year. And my favorite chocolate? 40¢ a bar more than last year.
Sigh. It was so much better than this once upon a time.
ahhh, the end of summer. Delicious!
Ruth lived across the street and up the hill from the first house I ever lived in. She also attended the same church as my family. She was tiny, maybe 5 feet tall. She worked downtown, took the bus and enjoyed UConn basketball games and Whalers hockey. She never let meager means or ailing health hold her back.
Long ago at a church tag sale I purchased some 1940's pink glasses from Ruth. When Dan and I bought our house a year or so later, Ruth had run across the matching pitcher and gave it to us as a gift. It was so thoughtful. I still only bring the set out for special occasions. To thank Ruth I clipped a bouquet of these roses, placed them in an odd glass that I had and left them for her with a thank you note. She said it was the prettiest bouquet she had ever received.
Ruth has been gone for several years now. The roses were in bloom the other day and looking quite beautiful. Something so simple that made her smile. She never would presume to be remembered but I remember. I remember dear Ruth and her generous heart each time these roses are in bloom. Thank you Ruth!


text:
Justia › US Law › Case Law › California Case Law › Cal. App. 2d › Volume 259 › Mack v. Superior Court
Mack v. Superior Court
[Civ. No. 24998. First Dist., Div. Four. Feb. 14, 1968.]
FRANK P. MACK et al., Petitioners, v. THE SUPERIOR COURT OF SACRAMENTO COUNTY, Respondent; THE STATE OF CALIFORNIA ex rel. STATE PUBLIC WORKS BOARD, Real Party in Interest.
Desmond, Miller, Desmond & West and John R. Lewis, Jr., for Petitioners.
Thomas C. Lynch, Attorney General, Willard A. Shank, Assistant Attorney General, and William A. Mayhew, Deputy Attorney General, for Real Party in Interest. [259 Cal. App. 2d 9]
CHRISTIAN, J.
Petitioners, landowner-defendants in an eminent domain proceeding, seek a writ of prohibition to restrain respondent court from enforcing an order requiring petitioners to disclose, in answer to interrogatories, the following information about a real estate appraisal obtained by petitioners' former attorney: (1) the appraiser's name and address; (2) the date he was hired; (3) whether he rendered an opinion of the fair market value of the property sought to be condemned; and (4) the appraiser's opinion of the fair market value of the property. In opposition to real party in interest State of California's motion in the superior court to compel answers to these interrogatories, petitioners filed their joint declaration, under penalty of perjury, asserting that their former attorney did hire a real estate appraiser to assist him in forming an opinion about the case. The declaration continued:
"[A]ll of the information obtained by the said appraiser was obtained solely and exclusively for the information and eyes of our said attorney; and was at all times treated as confidential ... that the information developed by said appraiser was not for the purposes of obtaining testimony for trial but solely and exclusively for the information of the [attorney], and declarants do not plan to call said appraiser as a witness in the trial of this action."
Nevertheless the superior court ordered petitioners to answer.
Petitioners claim the protection of the statutory privilege covering an attorney's work product. See McCoy, California Civil Discovery Work Product of Attorneys (1966) 18 Stan.L.Rev. 783 for a review of the context of case law in which the Legislature in 1963 (Stats. 1963, ch. 1744) expressly sanctioned the nondiscoverability of an attorney's work product. By that enactment Code of Civil Procedure section 2016 was amended to include a provision that "The work product of an attorney shall not be discoverable unless the court determines that denial of discovery will unfairly prejudice the party seeking discovery in preparing his claim or defense or will result in an injustice, and any writing that reflects an attorney's impressions, conclusions, opinions, or legal research or theories shall not be discoverable under any circumstances." The same amendment added subdivision (g):
"It is the policy of this State (i) to preserve the rights of attorneys to prepare cases for trial with that degree of privacy necessary to encourage them to prepare their cases [259 Cal. App. 2d 10] thoroughly and to investigate not only the favorable but the unfavorable aspects of such cases and (ii) to prevent an attorney from taking undue advantage of his adversary's industry or efforts."
[1a] Real party in interest first contends that the declaration presented to respondent court by petitioners is hearsay and that since petitioners' former attorney did not file a declaration in support of their contention there is no competent evidence to show that the work product privilege applies. [2] It is true that an affidavit which sets forth only hearsay and conclusionary material is incompetent. (Wilson v. Superior Court (1964) 226 Cal. App. 2d 715 [38 Cal. Rptr. 255].) It is stated that " 'The true test of the sufficiency of an affidavit is whether it has been drawn in such a manner that perjury could be charged thereon if any material allegation contained therein is false.' " (People v. Thompson (1935) 5 Cal. App. 2d 655, 664 [43 P.2d 600].) [1b] There is nothing in petitioners' declaration to indicate that the essential assertions are based upon hearsay.petitioners have been in a position to have personal knowledge of the facts asserted and the declaration, with the exception of one immaterial sentence, takes the form of direct statements of fact. We find neither reason nor authority to support the state's contention that the declaration should have been signed by petitioner's former attorney. [3] The work product privilege was created for the protection of the client as well as the attorney and there is no reason why a party's declaration, asserting facts apparently within personal knowledge, should not be as effective as a declaration by the attorney.
[4] The state next contends that as a matter of law appraisal information cannot be protected from discovery as an attorney's work product. The 1963 amendments to Code of Civil Procedure section 2016 contain no definition of "work product" and we must therefore resort to the cases and to the policy declared in Code of Civil Procedure section 2016, subdivision (g), in determining whether work product is involved here. Information regarding events provable at trial, or the identity and location of physical evidence, cannot be brought within the work product privilege simply by transmitting it to the attorney. But the cases indicate generally that material of a derivative character, such as diagrams prepared for trial, audit reports, appraisals, and other expert opinions, developed as a result of the initiative of counsel in preparing for trial, are to be protected as work product. In [259 Cal. App. 2d 11] San Diego Professional Assn. v. Superior Court (1962) 58 Cal. 2d 194, 204 [23 Cal. Rptr. 384, 373 P.2d 448, 97 A.L.R.2d 761], the Supreme Court held that an engineering evaluation commissioned by an attorney for his guidance in preparing for trial was work product. Similarly, in Brown v. Superior Court (1963) 218 Cal. App. 2d 430 [32 Cal. Rptr. 527], the opinions of medical members of a committee formed to consult with defense counsel in a medical malpractice action were privileged as work product. (Also see Kenney v. Superior Court (1967) 255 Cal. App. 2d 106 [63 Cal. Rptr. 84].) In Scotsman Mfg. Co. v. Superior Court (1966) 242 Cal. App. 2d 527 [51 Cal. Rptr. 511], the report of a scientific consultant as to the cause of the explosion of a butane lamp was held to be privileged as work product. [5] It appears from these cases, and from the provision of Code of Civil Procedure section 2016, subdivision (g), that an attorney should be allowed to prepare his case thoroughly and "to investigate not only the favorable but the unfavorable aspects of such cases ...," that even clearly relevant evidence such as the unfavorable opinion of value formed by an appraiser consulted by counsel may be privileged; but the privilege must give way before a showing that "denial of discovery will unfairly prejudice the party seeking discovery in preparing his claim or defense or will result in an injustice, ..." The privilege is also subject to the court's power to require reciprocal disclosure of data regarding appraisals intended to be used in evidence. (Cf. Code Civ. Proc., § 1272.01 et seq.; Swartzman v. Superior Court (1964) 231 Cal. App. 2d 195 [41 Cal. Rptr. 721].)
[6] We may surmise that petitioners' former attorney, by consulting the appraiser, developed an "unfavorable aspect" of the case in the form of a low valuation opinion. But petitioners' declaration asserted facts which would qualify the valuation data as work product. The state made no showing, through affidavits or other evidence, either contradicting petitioners' declaration or indicating that unfair prejudice would result from denial of discovery regarding that opinion. If we assume that the appraiser was properly qualified and that his opinion would be relevant and admissible, the fact remains that there is nothing unique and irreplaceable about his opinion. The state will have no difficulty in obtaining the opinions of other appraisers; thus there is no showing that any injustice will result if the privilege is upheld. [259 Cal. App. 2d 12]
A peremptory writ of prohibition will issue restraining enforcement of respondent court's order.
Devine, P. J., and Rattigan, J., concurred.
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redpajama_set_name: RedPajamaCommonCrawl


On 27 and 28 July 2017 the German Marshall Fund of the United States (GMF) organised and event entitled "Mission Critical: Inclusive Leadership for the Security Sector" in Washington D.C. in which EUROMIL President Emmanuel Jacob participated.
At the July 2017 event, inclusive leadership at large was discussed. "As our security personnel at all levels of leadership – engaged to ensure peace and freedom for all in our democratic societies – grow to fully reflect the diverse populations they are sworn to serve, we will become best equipped to inspire new generations to engage in public service. Vital conversations with constituents and stakeholders outside of the security services can richly inform decision making." Dr. Karen Donfried, President of the GMF stated when opening the conference on 27 July. Lieutenant General Stayce Harris, Assistant Vice Chief of Staff and Director at the Air Staff Headquarters within the Pentagon, made clear that D&I are critical for security forces especially because of the growing impact of refugees and migration.
Several plenary sessions with experts from amongst others DELL, Shell US, Boeing, the Center for Strategic and International Studies (CSIS), were organised. We need to "take things from a good idea to something institutionalised" Fred Whipple, Vice President of Diversity, Community & Workforce of Shell US, said, emphasizing that manager might leave or change but ideas and projects should stay in place. At several occasions, the question of how to change the culture of an organisation was discussed.
During eleven "International Cross Talk" the participants had the chance to discuss important issues in depth and work on topical cases. One of these sessions was facilitated by Nadia Firozvi, Project Manager at the Democracy Fund and Emmanuel Jacob, President of EUROMIL. The session dealt with civil and human rights in the security context. Emmanuel Jacob briefly presented EUROMIL as well as the OSCE-DCAF Handbook on Human Rights and Fundamental Freedoms of Armed Forces Personnel and the Council of Europe Committee of Ministers Recommendation (2010)4 on Human Rights of members of the Armed Forces. Several aspects such as EUROMIL's basic principle of "Citizen in Uniform" and the recent developments on European defence were especially interesting for the non-European participants from the U.S., Canada and Australia. During the session, one gender related and one transgender related case were discussed by the participants. It was coincidence that US President Trump announced the ban on transgender people in the US military only a day before the GMF event, but was nevertheless debated in the course of the session.
Much appreciated was a visit at Capitol Hill on invitation of US Senator Ben Cardin of Maryland and US Representative Alcee Hastings of Florida. Both addressed the participants on "Inclusive Security: View from Capitol Hill" and gave an interesting overview of the current political situation. Both politicians are dedicated supporters of military personnel's rights and made it clear that they will not accept the latest decision of President Trump on military transgender personnel: "It is not about how one looks, how one thinks, what your religion or sexual orientation is, … but about if one can perform the military tasks he or she is engaged for!" In this context, they also referred to the refugee discussion making clear that "the US needs immigrants and refugees, today and even more in the future".
With some imagination, one can see in Cardin and Hastings defenders of the US version of the "Citizen in Uniform" principle!


Spontaneous abortion (SA) affects 11.2% of recognized pregnancies in Korea. Many studies have focused on the increased risk of SA in obese populations, but there are few studies that have focused on underweight (Body mass index (BMI) <18.5 kg/m2) women, especially in relation to pre-pregnancy BMI. The aim of this study was to examine the role of pre-pregnancy BMI at age 18–20 in later SA.
Among the women who were ever pregnant in the Health Examinees Study (HEXA), which was one of the cohorts studied in the KoGES (Korean Genome and Epidemiology Study) from 2004 to 2012 (N = 80,447), the likelihood of SA based on pre-pregnancy BMI, classified by the criteria for Asians (Underweight: <18.5 kg/m2; Normal range: 18.5-22.9 kg/m2; Overweight at risk: 23–24.9 kg/m2; Obese I: 25–29.9 kg/m2; Obese II: ≥30 kg/m2), was presented as odds ratios (ORs) and 95% confidence intervals (95% CIs) using logistic regression models.
Being underweight or obese relative to the normal weight range was associated with a higher likelihood of SA (OR = 1.10 [95% CI = 1.05–1.15] in underweight women and OR = 1.06 [95% CI = 0.96–1.16] in obese women), and this effect was much greater in women who experienced recurrent SAs (for three or more SAs: OR = 1.29 [95% CI 1.14–1.46] in underweight women and OR = 1.39 [95% CI 1.09–1.78] in obese women). Obesity was associated with an increased likelihood of SA at a younger age (≤25 years), whereas underweight was associated with an increased OR of SA at an older age (≥26 years).
As this study was conducted with baseline data of original cohort which focused on other chronic diseases, recall for previous pregnancy-related information might be less accurate. However, this study shows strength in its large size and prospective potential.
Pre-pregnancy BMI at ages 18–20 years revealed a U-shaped association with SA, and underweight and obese women showed increased likelihood for SA during different age periods.
Spontaneous abortion (SA), or miscarriage, is defined as a clinically observed pregnancy that is lost or that ends before the 20th week of gestation . According to the Korean national survey on Fertility, Family Health & Welfare 2012, SA affects 11.2% of recognized pregnancies, which can be viewed as a rather frequent medical phenomenon .
Maternal overweight and obesity are related to increased risk of stillbirth, neonatal and infant death, large for gestational age (LGA), fetal malformations, maternal diabetes, pregnancy-induced hypertension, pre-eclampsia and a high frequency of Caesarean section [3–6]. In obese women, folliculogenesis, ovulation and conception are more likely to be impaired, and pregnancy complications frequently occur .
In accordance with the known mechanism linking obesity and SA, there are multiple epidemiologic studies reporting the association between these two factors [8, 9]. Many studies focusing on obese or overweight mothers and their adverse outcomes related to pregnancy have been published [4–6], but studies on underweight mothers are rare . Likewise, an association between pre-pregnancy body mass index (BMI) and adverse pregnancy outcomes has been assessed in several studies [11, 12], but similar studies are uncommon in Asian populations.
It is known that bodyweight in early life is associated with morbidity in adult life . In the Nurses' Health Study (NHS), women with a BMI greater than 25 kg/m2 at age 18 had an increased risk of premature death, and this association was only partially explained by adult obesity . Likewise, there are studies suggesting a crucial effect of early life BMI on later parity [15, 16]. Another study from NHS with 17 years of follow-up also revealed that BMI at age 18 was associated with anovulatory infertility . As BMI in the early years of life seems to affect maternal health, in this study, we aim to evaluate the association between underweight, as well as obesity, at age 18–20 and the risk of SA in the Korean population.
The eligible population was selected from the Health Examinees Study (HEXA). The HEXA comprises a large-scale genomic community-based prospective cohort of 170,094 participants and biological samples between 2004 and 2012. The HEXA was specifically conducted to evaluate epidemiologic characteristics and genomic risk factors focusing on major chronic diseases, including cancer, in the Korean population. It is a component of the Korean Genome and Epidemiology Study (KoGES). Participating centers were chosen after strict evaluation of the selection criteria and community representativeness of participating hospitals. Recruited subjects were drawn from the community's adult population, ages 40 to 69 years. Information on general lifestyle, including smoking and drinking habits, physical activity, past medical history, family medical history, drug use (including health supplements), health check-ups, psychological factors, diet and reproductive factors, was obtained by trained interviewers with a structured questionnaire. This questionnaire was developed from an extensive literature review of other questionnaires, including the Korea National Health and Nutrition Examination Survey (KNHANES) , which is a representative epidemiologic study of Korea funded by the Korean Center for Disease Control (KCDC). The questionnaire was validated using back translation with English, and a pilot study was conducted to evaluate its efficacy and feasibility . Furthermore, anthropometric measures were performed by trained interviewers, and laboratory tests for blood and urine were conducted by central laboratory. More details about the HEXA can be found elsewhere .
Of the total participants, 111,600 participants were women. Among them, 8,605 women were excluded because they had an age other than 40–69 years, no experience of pregnancy, or no information on their parity. Additionally, we excluded the 20,729 women who had missing information on weight or height at ages 18–20 years. A total of 1,244 women with a first pregnancy before age 18 or 20 or with unknown age of first pregnancy and 316 women with missing data on spontaneous abortion were also excluded. Finally, a total of 80,447 women were included in the final analysis.
The participants were asked about their general characteristics, including occupations, lifestyle factors, socio-psychological factors, past medical history, family history for medical diseases, surgical history, list of medications and dietary habits. Additionally, the participants were asked about factors associated with obstetrics and gynecology. Women were also asked whether they had ever had a SA; if the answer was 'yes', then they were asked at what age the SA had occurred. Additionally, participants were asked about other factors, such as age at menarche, age at first pregnancy, gestational hypertension and gestational diabetes.
Women were asked to recall their weight at age 20 years (surveys from 2004 to 2006) or at age 18 years (surveys from 2007 to 2012). From 2004 to 2006, women had to report their weight at 20 years, but a corresponding question changed to asking the weight at age 18 instead. Therefore, women who participated in the surveys between 2007 and 2012 reported their recalled weight at age 18 only. BMI at age 18 or 20 years was calculated using the measured height at the baseline and dividing the weight by the height squared (kg/m2).
We modified the BMI criteria of the Steering Committee of the Regional Office for the Western Pacific Region of the World Health Organization (WHO-WPRO), which the International Association for the Study of Obesity and the International Obesity Task Force had suggested to be the proper categorization of obesity in Asians. The criteria defines 'underweight', 'normal range', 'overweight at risk', 'obese I', and 'obese II' as a BMI under 18.5 kg/m2, between 18.5–22.9 kg/m2, between 23–24.9 kg/m2, between 25–29.9 kg/m2, and 30 kg/m2 or higher, respectively . According to these criteria, people who were either 'obese I' or 'obese II' comprised only 3% of the study population. For this reason, women who were in either the 'obese I' or 'obese II' group were placed into one group ('obese'). For the reference group, the 'normal range' group was selected.
Multivariable logistic regression was applied to compute odds ratios (ORs) and 95% confidence intervals (95% CI) of the association between BMI at ages 18–20 years and SA. Possible confounders, such as participants' age at the survey, income, education, comorbid diseases, exercise, cigarette smoking, alcohol drinking, gestational hypertension and gestational diabetes, were selected based on a literature review. Covariates that altered the odds ratio (OR) for at least one SA in the underweight population by 10% compared to the original model were selected.
Initially, the outcome variable was SA; then, we further defined multiple SAs as variables for those who had more than one SA. First, we analyzed the association between pre-pregnancy BMI and women who ever had an SA. Consequently, women who experienced a SA more than twice were classified as the 'event group', compared to those who never had a SA or experienced a SA only once. Similarly, those who had a SA at least three times were defined as the 'event group' in a later analysis. Additionally, we classified these cases by age at first SA to evaluate the effects of BMI across distinct age groups. Women who experienced SA were divided into 3 groups (≤25 years, 26–28 years, and >28 years) by tertile distribution of age at first SA. Additionally, as both BMI and spontaneous abortion showed associations with gestational diabetes [21–23] and gestational hypertension [22, 24], we performed a stratification analysis on the association between BMI and spontaneous abortions according to these two comorbidities to assess a potential effect modifications.
For statistical analysis, SAS version 9.3 (SAS Institute Inc., Cary, NC, USA) was used. We set P-values less than 0.05 to indicate significance.
Written consent was provided by all subjects who agreed to participate in the HEXA. The statistical analysis of publicly available data was approved by the Institutional Review Board of the Seoul National University Hospital in Seoul, Korea (IRB No.1408-087-604).
Women who experienced SA were more likely to have more than a high-school education compared to women without an SA experience (25.2% vs. 23.3%) and had an older age at first pregnancy (≥27 years) than women without SA experience (31.9% vs. 29.3%). The proportion of women who had gestational diabetes (GDM) or gestational hypertension (GHT) also differed between SA and non-SA groups (GDM: 1.18% with SA vs. 0.91% without SA; GHT: 6.0% with SA vs. 4.7% without SA). The proportion of women with babies over 4.0 kg (macrosomia) or under 2.5 kg (microsomia) also differed between the two groups (macrosomia: 8.2% with SA vs. 7.0% without SA; microsomia: 5.6% with SA vs. 3.8% without SA) (Table 1).
In the adjusted logistic regression model, a significantly increased likelihood was observed in women who had a BMI lower than 18.5 kg/m2 (OR 1.10, 95% CI 1.05–1.15); conversely, a significantly reduced likelihood of SA was observed in women who had a BMI between 23–24.9 kg/m2 (OR 0.94, 95% CI 0.88–0.99) compared to the reference group with a BMI between 18.5–22.9 kg/m2. The association between BMI and total SAs showed a U-shape pattern when considering all three SA categories. When we defined multiple SA as women who had at least 3 SA, the likelihood significantly increased in both those who had a BMI less than 18.5 kg/m2 and those who had a BMI of 25 kg/m2 or higher at ages 18–20 years (OR 1.29, 95% CI 1.14–1.46 and OR 1.39, 95% CI 1.09–1.78, respectively, for three or more SAs) (Table 2).
Different patterns were observed in groups with different ages of onset of SA. In women who had their first SA at the age of 25 years or younger, only those with a BMI of 25 kg/m2 or higher at ages 18–20 years showed a significantly increased likelihood (OR 1.22, 95% CI 1.02–1.45) of SA. In contrast, the likelihood of SA at ages 26 to 28 years decreased in women with a BMI of 25 kg/m2 or higher (OR 0.82, 95% CI 0.66–1.01). In regard to the likelihood of an SA after the age of 28 years, only women with a BMI less than 18.5 kg/m2 at ages 18–20 years showed a marginally significant increased likelihood (OR 1.11, 95% CI 1.02–1.21) (Table 3).
In the stratification analysis of smoking status before first pregnancy, there were similar patterns in the likelihood of SA according to smoking status with various degrees of ORs, compared to the reference group (BMI 18.5–23 kg/m2). In women who did not smoke before pregnancy, the likelihood significantly increased for those who had a BMI less than 18.5 kg/m2 (OR 1.09, 95% CI 1.05–1.15) and decreased with marginal significance for those who had BMIs between 23–24.9 kg/m2 (OR 0.95, 95% CI 0.89–1.00). In women who smoked before the first pregnancy, those who were 'underweight' at ages 18–20 years had an increased odds ratio (OR 1.31, 95% CI 0.70–2.44), whereas the odds ratio in those who had a BMI of 25 kg/m2 or over was decreased (OR 0.74, 95% CI 0.15–3.59), although they were not significant (Table 4).
An additional stratification analysis was conducted with gestational diabetes and gestational hypertension. In women with gestational hypertension, only women with BMIs less than 18.5 kg/m2 were associated with a higher likelihood of SA (OR 1.22, 95% CI 1.01–1.49). In those with gestational diabetes, no significantly increased OR was observed in the groups, compared with the reference group. Among women with no gestational diabetes and gestational hypertension, both underweight and obesity were associated with a higher likelihood of SA, and women who were in the overweight range showed significantly decreased likelihoods of SA, which were similar to the patterns observed for the entire population (Additional file 1: Table S1 and Additional file 2: Table S2).
The goal of this study was to evaluate the effect of pre-pregnancy BMI on SA as an independent risk factor in a large Korean population. In the analysis of approximately 80,000 women, both high and low BMIs showed increased likelihoods of SA, resulting in a U-shaped association. In contrast to the expected result, being overweight (BMI 23–24.9 kg/m2) showed the lowest OR of SA. Our results also showed a similar pattern to the results of a study conducted on more than 1 million Asians, in which a harmful effect due to being underweight and a positive effect due to being overweight (22.6–25.0 kg/ m2) on mortality was suggested .
Considering the age at the first SA, it appears that a high BMI or being 'obese' at ages 18–20 years seems to affect SA at an earlier age, such as 25 years or younger. In contrast, lower BMI at ages 18–20 years or being 'underweight' influenced SA at a later age (i.e., more than 25 years). If women had gestational hypertension, those with a BMI under 18.5 kg/m2 tended to have more SAs.
As many studies have focused only on the harm of being obese before pregnancy, the possible association between underweight and reproduction has not received much attention. However, our results suggest that underweight women at pre-pregnancy ages are at higher risk for SA compared to normal weight women.
According to the literature review, there is evidence that an increase in BMI raises the risk of SA in the general population , as well as in women who have undergone infertility treatment . However, the relationship between lower BMI and SA is far from conclusive, especially in Asians. In a Danish National Birth Cohort (DNBC), 23,000 women were analyzed, and women with a pre-pregnancy BMI under 18.5 kg/m2 or higher than 25 kg/m2 had an increased hazard ratio (HR) of SA (HR 1.24, 95% CI 0.95–1.63; HR 1.14 95% CI 0.98–1.31, respectively) . In comparison, our results show significantly increased ORs in both 'underweight' and 'obese' populations, demonstrating a U-shaped pattern.
In regard to the association between BMI and multiple recurrent SA, women with a higher BMI were considered to have a greater likelihood of SA. A study conducted in the Guangzhou Chinese population reported significantly increased likelihoods of recurrent SA in participants with a BMI of 24 kg/m2 or higher (OR 1.54; 95% CI 1.28–3.49) compared to their counterparts . Because this study only compared those with a BMI of 24 kg/m2 or higher to those with a BMI under 24 kg/m2, it was impossible to evaluate the effect of lower BMIs on SA. Another study conducted in the U.K. analyzed 844 pregnancies of 491 women with recurrent SA. In this study, women with a BMI under 19 kg/m2 or over 30 kg/m2 had increased ORs, but neither group was significant .
Given the number of studies regarding the effect of smoking on SA, studies comparing the effect of BMI on both smokers and non-smokers are scarce. Most studies evaluate the effect of smoking and BMI on SA separately . A study conducted in Sweden reported that the interaction among age, BMI and smoking was not statistically significant . However, as seen in our results, the likelihood of SA increases in both 'underweight' and 'obese' women, and this association is not linear. Additionally, it is well known that as BMI increases, the risk of hypertensive disorders also increases . Interestingly, in women who had gestational hypertension, we observed significantly increased ORs only in the 'underweight' population.
There is abundant evidence supporting the biological plausibility of the extended risk of higher BMIs and the risk of SA. Adolescent or early adult obesity is related to increased overall mortality and especially and an increased risk of diabetes and cardiovascular diseases in adult life . The association between obesity in youth and inflammation leads to vascular damage over time. Chronic inflammation may have a key role in SA by damaging the vessels, which support the utero-feto-placental complex .
In contrast, there are also studies supporting the mechanism of SA in low BMI women. It has been reported that women with low weights have an increased risk of fetal growth retardation , which can be explained by an increased rate of vasoconstriction and decreased serum glucose levels due to poor diet and decreased blood pressure, provoking reduced placental perfusion . Additionally, it has been proposed that leptin, a hormone secreted by adipose cells, may play a role in this association. Underweight women usually have low levels of this hormone, which can block ovulation . Similarly, maternal underweight caused by a shortage of food or eating disorders, such as anorexia or bulimia, is associated with SA [36, 37].
There are several limitations to this study. First, as the original HEXA was designed to mainly focus on other chronic diseases, the recall of retrospective, pregnancy-related information might be less accurate. However, as participants were not aware of the main purpose of this study, there is less chance for recall bias. Additionally, the mean age at enrollment was 52.0 years, and the women were asked to recall their weight nearly 30 years prior. The results of the Nurses' Health Study (NHS) indicate that participants were able to recall their weight at the age of 18 years, and the correlation coefficient between recalled and objective measurements for weight was approximately 0.9 . Although women in the NHS were aged 25 to 42 years were therefore younger than our participants, there is evidence that self-reported height and weight data are adequate for assessing associations in epidemiological studies . In the stratification analysis of cigarette smoking before pregnancy, we had an insufficient number of samples to explore the effect of the association of first age of smoking and BMI at ages 18–20 years and SA.
This study's strength is its large size and prospective potential. To the best of our knowledge, it is currently the largest study that has addressed pre-pregnancy BMI and SA. Additionally, although this study used baseline cohort data with cross-sectional analysis, temporal characteristics are included in the analysis, as women with BMIs at ages 18–20 years were analyzed. Reverse causation is the most important problem, in which the loss of weight resulting from particular diseases can falsify the association between lower BMI and health outcomes. To clarify this problem, we excluded women who had pregnancies before the ages of 18–20 years. Furthermore, to provide reliable estimated values for the total effect of BMI on the likelihood of SA in a large Korean population, this study also evaluated the relationship between low BMI and the likelihood of SA in a more discrete way. This particular outcome could not be appropriately demonstrated in most of the earlier studies conducted in European populations.
This study revealed that pre-pregnancy BMI at ages 18–20 years was associated with a higher likelihood of SA in underweight or obese women, using the Asian BMI classification. This U-shaped association was much stronger for recurrent, consequent SA or in women who had ever smoked cigarettes before pregnancy. Age at SA and gestational hypertension modified the association of pre-pregnancy BMI with SA. Obese women had a higher likelihood of SA at earlier maternal ages, whereas underweight women had a higher likelihood of SA at typical or later ages or with gestational hypertension. Further studies are needed to evaluate the exact cause of the difference in age trends and BMI ranges.
This work was supported by Basic Research Fellowship Program from Seoul National University College of Medicine and grant from Seoul National University Hospital (2015).
We thank BK21 plus program through the National Research Foundation (NRF) funded by the Ministry ofEducation of Korea for financial support.
Sun Jae Jung (SJJ), Sue Kyung Park (SKP) and Daehee Kang (DK) set conception and design of the study. Keun-Young Yoo (KYY), Jong-Koo Lee (JKL) and DK helped the acquisition of data. SJJ, SKP and Aesun Shin (AS) made the draft of the manuscript. Sang-Ah Lee (SAL), Ji-yeob Choi (JYC), and Yun-chul Hong (YCH) reviewed the manuscript and revised critical point with SJJ, and AS. All authors read and approved the final manuscript.


This data is used by many people in the course of their work.
At Trust Board level, we have appointed a Senior Information Risk Owner who is accountable for the management of all information assets and any associated risks and incidents, and a Caldicott Guardian* who is responsible for the management of patient information and patient confidentiality.
* Caldicott Guardians are experts on confidentiality issues and access to patient records. Dame Fiona Caldicott recommended such posts in her 1997 report into how patient information was used (and should be protected) in the health service, and in its increasingly complex information systems: "A senior person, preferably a health professional, should be nominated in each health organisation to act as a guardian, responsible for safeguarding the confidentiality of patient information."


My last post about setting up a Virtual Machine to use as your local webserver was quite the success (hits increased from about 30 to nearly 1000 within 2 days…and dropped back to somewhere slightly above the old value by now) and I promised I would write some more tutorials on how to install some useful libs, so here we go and start with SVN in combination with TortoiseSVN a SVN client for Windows.
Apache Subversion (often abbreviated SVN, after the command name svn) is a software versioning and a revision control system founded and sponsored in 2000 by CollabNet Inc. Developers use Subversion to maintain current and historical versions of files such as source code, web pages, and documentation.
And here are some terms you'll run into.
Repository: SVN creates a repository for each project and it's basically the place where all the files and their history is stored. It's located on the server that runs SVN, in your case propably the VM from my last tutorial.
Checkout: It's your local copy of the repository where you make your changes to the files. It's usually located on your local machine in your webserver root where you work and edit files. In your case that's propably not the case and it would be in the /var/www on your VM because that's where you work via shared folders.
Commit: It's a command that sends all the changes you made to the files in your checkout folder to the repository. Each commit creates a new revision with it's own number that let's you revert your files to an older version that you commited before.
Update: Compares your local copy to the repository and updates your local files to mirror any changes commited by other users since your last checkout/update.
Installing SVN is actually pretty easy, like most of the libs. Configuration is where it might get tricky, but we'll come to that in a bit.
This will prompt you to enter a password for the user. You can choose whatever user name and password you want. These credentials will be used to access your repositories. I chose user name "root" with my root password out of habit, but it's entirely up to you. Now that we are all set we can setup our first project.
This will tell Apache that our repository can be found under http://ip-address-of-my-vm/svn/<project name> and allows us to use a client like TortoiseSVN to connect to our repository.
First we need to download and install TortoiseSVN from their website. Choose the version matching your system (32 or 64bit) and install it using the pre-selected options after the download is done. I use the 64bit version but there shouldn't be any differences to the 32bit version. If you are asked to reboot, then please do so and afterwards go to the shared folder from your VM where you usually work in.
and the second one defaults to the <project name> but you can choose whatever folder you want as long as it's empty (it doesn't have to exist yet, TortoiseSVN will create it if needed). Leave the other options as they are and click "OK". You should see a new window that says "Completed At revision: 0" or something like that.
Now you can navigate to the new folder and start working on your project. If you've done some changes, e.g. created a new file or whatever and want to commit them to the repository, then simply right-click the project folder and select "SVN Commit". You'll see a text input at the top and a list of all new/deleted/changed files below that. In the text are you are supposed to enter a "message" or rather a comment which describes what has changed and below you should select all files that are related to these changes/de-select all files that are not related. After clicking "OK" your changes will be tranferred to the repository and new revision will be created.
Small tip: If you want to enhance existing projects of yours with some SVN powered version control, then you can simply create a new project like I describe above, copy your files from their old project folder to the new one and commit your changes.
If you are not the only one working on the repository, e.g. because you are using the VM in the local network of your company, you'll need to run "SVN Update" now and then (each time you start working propably) to make sure you have the latest versions of the files and don't work on old copies that have already been changed by someone else.
SVN offers some more options but I guess you can figure them out yourself by playing around with TortoiseSVN, at least that's how got to know it ;) Feel free to leave a comment if you want me to elaborate on some of the options.
That's it. You've successfully setup SVN+TortoiseSVN and can start working in a safer environment where you can keep track of all your changes.
I hope you like this tutorial as much as you liked my last one and I'm looking forward to your comments and critique.