text:
A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with low back pain: study methods and rationale
Julie M Fritz1,2,
Anne Thackeray1,2,
John D Childs3 &
Gerard P Brennan1
BMC Musculoskeletal Disorders volume 11, Article number: 81 (2010) Cite this article
Patients with signs of nerve root irritation represent a sub-group of those with low back pain who are at increased risk of persistent symptoms and progression to costly and invasive management strategies including surgery. A period of non-surgical management is recommended for most patients, but there is little evidence to guide non-surgical decision-making. We conducted a preliminary study examining the effectiveness of a treatment protocol of mechanical traction with extension-oriented activities for patients with low back pain and signs of nerve root irritation. The results suggested this approach may be effective, particularly in a more specific sub-group of patients. The aim of this study will be to examine the effectiveness of treatment that includes traction for patients with low back pain and signs of nerve root irritation, and within the pre-defined sub-group.
Methods/Design
The study will recruit 120 patients with low back pain and signs of nerve root irritation. Patients will be randomized to receive an extension-oriented treatment approach, with or without the addition of mechanical traction. Randomization will be stratified based on the presence of the pre-defined sub-grouping criteria. All patients will receive 12 physical therapy treatment sessions over 6 weeks. Follow-up assessments will occur after 6 weeks, 6 months, and 1 year. The primary outcome will be disability measured with a modified Oswestry questionnaire. Secondary outcomes will include self-reports of low back and leg pain intensity, quality of life, global rating of improvement, additional healthcare utilization, and work absence. Statistical analysis will be based on intention to treat principles and will use linear mixed model analysis to compare treatment groups, and examine the interaction between treatment and sub-grouping status.
This trial will provide a methodologically rigorous evaluation of the effectiveness of using traction for patients with low back pain and signs of nerve root irritation, and will examine the validity of a pre-defined sub-grouping hypothesis. The results will provide evidence to inform non-surgical decision-making for these patients.
This trial has been registered with http://ClinicalTrials.gov: NCT00942227
The Problem of Low Back Pain with Nerve Root Involvement
Low back pain is a common condition that is estimated to affect approximately 40% of the adult population within a 1-month time frame [1]. A majority of cases of LBP are considered "non-specific", with no clearly evident pathoanatomic cause [2]. Among the most common specific causes of LBP are disorders of the lumbar intervertebral disks resulting in irritation of the lumbar nerve roots. It is estimated that nerve root involvement accompanies approximately 10% of episodes of LBP [3], with lifetime prevalence estimates ranging from 12% - 43% [4, 5]. Although LBP accompanied by nerve root involvement accounts for a relatively small percentage of all cases of LBP, the presence of nerve root involvement has been associated with an increased severity of symptoms, heightened risk of chronicity and work absence, and higher health care costs [3, 6–8].
Although surgery may offer benefits for some patients with LBP and nerve root involvement [9], non-surgical management is recommended as an initial strategy in most cases [10]. However, there appears to be a wide range of non-surgical management strategies undertaken for these patients, with little standardization or evidence to inform decision-making [11]. Many patients with LBP and nerve root involvement receive physical therapy [12], yet there is currently little research examining the potential benefits of physical therapy relative to other non-surgical options. A recent study suggests there may be some benefit to receiving physical therapy compared to management by a general practitioner alone [13], however the benefits of physical therapy were not consistent across all outcomes in the study, and the results did not support the overall cost-effectiveness of physical therapy [14]. Physical therapists use a wide variety of treatments for patients with LBP and nerve root involvement [15], and sub-optimal outcomes may be at least partly attributable to the relatively sparse evidence on the specific treatment options that are most effective for these patients [16, 17]. It is also unclear if there is meaningful heterogeneity in the response to different physical therapy treatment options, which would indicate a potential benefit in identifying more homogeneous sub-groups within the larger group of patients with LBP and nerve root involvement.
Mechanical Traction as a Treatment for Low Back Pain with Nerve Root Involvement
Axial traction has been used for centuries as a treatment for LBP and was popularized by Cyriax as an intervention for patients with nerve root involvement due to lumbar intervertebral disk herniation [18]. Evidence-based guidelines and systematic reviews have generally not supported the use of traction for patients with LBP [19–21]. Despite the lack of research support, surveys indicate continued use of traction, in various forms and delivered by various providers, for patients with LBP [22–25]. The rationale offered by those who advocate the use of traction despite the lack of supporting evidence is the low methodological quality and questionable external validity of the majority of the research examining traction [26]. External validity concerns have centered on divergences between the delivery of traction in research and clinical practice, including questions about dosage parameters (traction force and duration), the use of concomitant interventions, and patient selection [27]. Specifically, traction has generally been researched as a stand-alone treatment, whereas clinicians often deliver traction in conjunction with other treatments, most often exercise interventions [28]. Clinicians also report using traction for selected sub-groups of patients with LBP, whereas research has often included more heterogeneous patient samples. The most common sub-group of patients cited by clinicians as appropriate for traction are those with LBP accompanied by signs of nerve root irritation [27, 28], however the accuracy of this clinical perception has not been adequately researched.
Preliminary Research to Identify a Sub-Group of Patients Likely to Benefit from Traction
As an initial step towards investigating if a more clinically-relevant traction protocol would result in larger treatment effects, and to explore if a specific sub-group of patients with LBP exists for whom evidence would support the use of traction, we conducted a randomized clinical trial [29]. The inclusion criteria for this trial were designed to provide a more homogeneous sample that reflected clinicians' perceptions of the appropriate sub-group of patients most likely to benefit from traction. The trial required patients to have symptoms distal to the buttock accompanied by clinical signs of nerve root irritation. Because we hypothesized that clinically important heterogeneity may exist even within this more narrowly-defined sample of patients, we secondarily examined additional baseline variables, nominated based on expert opinion and observations, for their potential to further define a traction sub-group. The trial randomized patients to one of two treatment groups, both of which received 6 weeks of treatment involving an extension-oriented treatment approach (EOTA) comprised of repeated end-range extension exercises and supplemented with manual therapy and education designed to facilitate centralization of the patient's symptoms. One group also received mechanical traction during the first two weeks of treatment, in addition to this extension-oriented approach (EOTA+traction). The traction protocol was designed to reflect common clinical practice [28] and was informed by expert clinical input [30]. The protocol used a high dosage of traction, with a sustained traction force ranging between 40%-60% of a patient's body weight, delivered for a maximum of 12 minutes during a treatment session. The delivery of traction was combined with concomitant use of the EOTA interventions designed to enhance centralization of symptoms. We provided this high-dose traction during the initial 2 weeks of traction to reflect the clinical perception that traction is most effective when delivered early in the course of treatment, followed by transition to exercise or other patient-directed activities [30].
Analysis of the overall randomized trial results found a significant time x treatment interaction after 2 weeks, but not at the 6 week follow-up for the outcome of disability (Modified Oswestry questionnaire) (figure 1). The group receiving EOTA+traction experienced greater change after 2 weeks on the Oswestry questionnaire, however the magnitude of the treatment effect was at the margins of clinical significance [31] (mean difference = 7.2 points (95% CI: 0.13, 14.3)), and was no longer significant after 6 weeks. Our secondary analysis identified two baseline variables that significantly interacted with the treatment provided: the presence of peripheralization of symptoms with extension movement, and a positive crossed straight leg raise test. Analysis of the results using the presence of either of these two factors to preliminarily define a sub-group of likely traction responders (table 1) demonstrated a significant time x treatment x sub-group status, 3-way interaction at both the 2- and 6-week follow-up (figure 2). The nature of this interaction indicated that patients who met the preliminary sub-grouping criteria and received traction experienced greater change in disability across time than those who did not meet the sub-grouping criteria and received traction, or those who met the criteria but did not receive traction (figure 2). The presence of this interaction suggests the sub-grouping criteria identified in this preliminary study may represent an effect modifier specific to the use of lumbar traction (i.e., the response to lumbar traction is expected to differ based on sub-grouping status) [32]. Additional research in different patient samples is needed to validate or refute this preliminary finding [33].
Table 1 Definition of preliminary criteria to define a sub-group of patients likely to benefit from traction.
Comparison of patients receiving an Extension-Oriented Treatment Approach (EOTA) with or without traction in the preliminary randomized trial [29]. A significant treatment effect favoring traction was evident after 2 weeks, but not after 6 weeks.
Comparison of patients receiving an Extension-Oriented Treatment Approach (EOTA) with or without traction based on status on the sub-grouping (SG) criteria for traction in the preliminary randomized trial [29]. A significant 3-way interaction between treatment, sub-grouping status, and time was evident after 2 and 6 weeks.
Overview of research design
The study will be a randomized controlled trial comparing an extension-oriented treatment approach (EOTA) with or without the addition of mechanical traction. The study will include patients with signs and symptoms consistent with lumbar nerve root irritation. Randomization will be stratified based on the preliminary sub-grouping criteria (table 1). The study design and subject flow are outlined in figure 3. Subjects in each treatment group will receive 12 individual treatment sessions with a physical therapist delivered over a 6-week period. Patients randomized to the traction group will receive traction combined with the EOTA throughout the 6-week treatment period. Outcomes will be assessed at the conclusion of treatment (6 weeks), and after 6 months and 1 year. The study has been approved by the Institutional Review Boards at the University of Utah, Intermountain Healthcare, Inc., and Wilford Hall Medical Center.
Participant flow through the study.
The treatment group receiving traction in addition to an EOTA intervention will have better outcomes than the treatment group receiving the EOTA intervention without traction after 6 weeks.
The treatment group receiving traction in addition to an EOTA intervention will have better outcomes than the treatment group receiving the EOTA intervention without traction after 6 months and 1 year.
Patients who are positive on the preliminary traction sub-grouping criteria and receive traction in addition to an EOTA intervention will have better outcomes at all time points than:
a. patients who are negative on the preliminary traction sub-grouping criteria and receive traction in addition to an EOTA intervention
patients who are positive on the preliminary traction sub-grouping criteria and do not receive traction in addition to an EOTA intervention.
Subject Recruitment
A total of 120 subjects will be recruited for participation. Subjects will be recruited from physician (general practice, physiatry, orthopedic surgery) and physical therapist (outpatient orthopedic) practices in Salt Lake City, Utah and San Antonio, Texas in the United States. Interested individuals from these practices will be screened for eligibility based on the inclusion/exclusion criteria. Subjects must meet each of the study's inclusion criteria, and not have any of the exclusion criteria in order to be eligible for enrollment in this study (table 2). These criteria are designed to recruit a sample of subjects with signs and symptoms of nerve root irritation without contraindications to the study treatments. Subjects over age 60, and those reporting an absence of symptoms when seated, are excluded to reduce to likelihood of including subjects whose LBP is attributable to lumbar spinal stenosis, for whom extension exercises may be contra-indicated. All potential subjects screened for eligibility will be recorded as well as the reason for ineligibility of potential subjects who are not enrolled in the study.
Table 2 Inclusion and exclusion criteria for participation in the study.
The baseline evaluation of the subject will be conducted following confirmation of eligibility and the provision of informed consent. Demographic characteristics will be collected including the subject's age, gender, employment status, LBP history, prior treatments for LBP, and treatment expectations. Subjects' fear-avoidance beliefs regarding physical activity and work will be assessed using the Fear-Avoidance Belief Questionnaire [34], and pain catastrophizing will be evaluated with the Pain Catastrophizing Scale [35]. Measures of treatment outcome will be collected at the baseline evaluation and repeated after 6 weeks, 6 months, and 1 year.
The primary outcome measure for determining treatment effectiveness will be LBP-related disability measured using a Modified version of the Oswestry disability index (OSW) [31]. The OSW consists of 10 items assessing different aspects of pain and function related to LBP. Each item is scored from 0-5 with higher scores representing greater disability. The OSW is a recommended and widely-used measure of outcome in clinical trials evaluating treatments for patients with LBP [36], with demonstrated responsiveness to change in individuals with LBP, including those with LBP accompanied by leg pain [37, 38]. Secondary outcome measures will include average low back and leg pain intensity over the past 24 hours measured using numeric rating scales [39]. Subject's will be asked to rate their current level of pain as well as the best and worst levels of pain over the past 24 hours on 11-point scales ranging from 0 "no pain" to 10 "worst imaginable pain". The mean of the three ratings will represent the average pain intensity. Separate ratings will be collected for LBP and leg pain. Additional secondary outcome measures will be the subject's global rating of change from initiation of treatment to present using a 15-level scale [40], and health-related quality of life assessed using the Euroqol (EQ-5D) [41].
Subjects' utilization of healthcare resources and associated direct healthcare costs, as well as work absence due to LBP will be recorded during the year following enrollment in the trial. The subject will be contacted by phone or e-mail on a monthly basis following enrollment. At each contact the subject will asked to report any visits to healthcare providers for the management of LBP, any diagnostic (e.g., MRI, radiographs, etc.) or interventional procedures (e.g., injection, surgery, etc.), and any prescription medication purchased for LBP. The subject will also be asked to report the number of days absent from work related to LBP. Direct healthcare costs will be computed by assigning a standardized cost to each healthcare service received based on average procedure cost data from Intermountain Healthcare's health plan.
Randomization
Assignment of subjects to treatment groups will be performed by a research assistant following completion of all baseline evaluation procedures. Randomization will be stratified based on the presence (or absence) of the preliminary traction sub-grouping criteria. The preliminary sub-grouping criteria will be judged positive (SG+) if either of the two sub-grouping variables is identified during the baseline physical examination (table 1). The preliminary sub-grouping criteria will be judged to be absent (SG-) if both of the sub-grouping variables are absent during the baseline physical examination. Our preliminary study found 32 out of 64 subjects to be SG+ (50%), and we anticipate a similar proportion in this study. After completion of all baseline evaluation activities, the research assistant will select and open the next sealed opaque envelope appropriate to the subject's sub-grouping status. Allocation sequences will be generated in permuted block sizes of 6, 8, or 10 by study personnel prior to beginning the trial using a web-based randomization generator http://www.randomization.com. Separate sequences will be generated for each recruitment site.
Subjects will be randomized to one of two treatment groups. One group will receive only the EOTA intervention, the other group will receive the EOTA intervention with the addition of mechanical lumbar traction. Subjects in both treatment groups will receive a total of 12 individual physical therapy treatment sessions delivered over a 6-week treatment period. Three sessions will occur during weeks 1 and 2 of the treatment period, two sessions in weeks 3 and 4, and one session during weeks 5 and 6.
Extension-Oriented Treatment Approach (EOTA) Group
The EOTA intervention involves three components. The goals of each component are to promote centralization of symptoms and extension range of motion of the lumbar spine. The first component will be a series of active extension-oriented exercises (table 3). These exercises will consist of sustained and repeated extension movements performed with the subject prone or standing. The exercises may be performed with a lateral component (i.e., shifting of the pelvis in the frontal plane) if this facilitates centralization. Exercises will be progressed at the treating physical therapist's discretion, guided by the principles of maximizing centralization of symptoms and increasing extension range of motion. Not all exercises will be used for every subject, only those which promote centralization or extension range of motion. Exercise progression will be accomplished by increasing the exercise time (up to 5 minutes for sustained exercises) or repetitions (up to 30 repetitions per session), increasing the range of motion towards greater lumbar extension, and adding over-pressure once the end-range of extension range of motion is obtained. Subjects will be instructed to perform all assigned exercise activities at home, every 4-5 hours throughout the day, on days when they do not have a treatment session. Subjects will be provided a copy of an exercise instruction booklet with detailed written descriptions and pictures of the proper performance, frequency, and progression of each exercise. Subject compliance with their home exercise program will be recorded by the treating physical therapist at each treatment session.
Table 3 Exercise progression within the extension-oriented treatment approach.
The second component of the EOTA will be subject education. Subjects will be educated to maintain the natural lordosis of the lumbar spine while sitting, and will be instructed to avoid prolonged sitting for greater than 20-30 minutes whenever possible. Additionally, subjects will be educated on the principles of symptom centralization/peripheralization, and will be given general instructions to discontinue any activities and avoid positions that cause symptoms to peripheralize, and to encourage activities or spinal positions that centralize or improve symptoms.
The third component of the EOTA will be mobilization of the lumbar spine to promote lumbar extension. The mobilization component will consist of a series of up to 20 graded oscillatory mobilizations performed with the subject prone. The physical therapist will apply a posterior-to-anterior mobilization force directed over the spinous process, or laterally over the transverse process, using a grade I - IV mobilization force as described by Maitland [42]. The therapist will select the specific grade(s) and spinal level(s) for mobilization during each treatment session based on the consideration of promoting centralization and lumbar extension range of motion.
EOTA + Traction Group
Subjects in the EOTA + traction group will include the EOTA components described above. Mechanical lumbar traction will be applied using a 3D ActiveTrac traction table (Chattanooga Group, Hixson, TN), a motorized, split-table, traction device with a surface that can be adjusted in 3 dimensions (flexion/extension, rotation, and side bending). Subjects will be positioned prone with the table in a neutral position in all planes. If this position causes peripheralization or an intolerable increase in symptoms, the table will be adjusted using flexion or side-bending to promote centralization of symptoms and subject comfort as needed.
Static traction will be applied for a maximum of 12 minutes total, which consists of 10 minutes at the desired intensity, plus 1-minute ramp-up and ramp-down times. The intensity of the pull will be 40-60% of the subject's body weight, adjusted based on the subject's tolerance and symptom response. After 3 minutes of traction, if the table was initially positioned in flexion or side bending, the table will be repositioned as tolerated to achieve a neutral lumbar posture. "Tolerance" will be defined as the ability to achieve a neutral posture (or as close as possible) without peripheralization of symptoms or significant increase in LBP. If the table was initially positioned using both flexion and side-bending, the table will be repositioned first to correct the side-bending accommodation, and then to correct the flexion accommodation. It may not be possible to achieve the goal of a neutral posture during each session, but the goal will be to be as close to neutral posture as tolerated by the subject each session.
At the end of traction treatment, the subject will lie still for 2 minutes prone. For subjects who end their traction treatment in a flat (neutral) position, additional extension positioning will be attempted as follows: the table will be positioned in up to 10 (of extension as tolerated, and the patients will lie still in this position for an additional 2 minutes. For patients who did not end the traction treatment in a flat (neutral) position, no extension positioning will be attempted. At the conclusion of the traction treatment, the subject will be assisted to stand and walk. Flexion, side bending, and sitting positions are to be minimized as much as possible following the traction treatment. If tolerated, the subject will be instructed to perform the same home program of extension-oriented exercises as described in the EOTA group. The mobilization component of the EOTA will be added in the 3rd week for patients in the EOTA plus traction group.
A questionnaire for reporting any side effects the subject perceives to be related to treatment procedures will be completed by the subject at the 6-week follow-up. The questionnaire is based on a questionnaire used previously to examine subjects with LBP receiving spinal manipulation [43]. Subjects are asked if they experienced any commonly-reported side effects following treatment including stiffness, muscle spasm, fatigue, or increased radiating symptoms. Subjects will also be able to report side effects not specifically named. For each side effect reported, the subject is asked to report the time of onset relative to the precipitating treatment session (≤24 hours or >24 hours), the duration of the side effect symptoms (≤24 hours or >24 hours), and severity of symptoms (categorized from 1 "light" to 4 "severe").
Physical Therapist Training and Compliance
All physical therapists will be trained by the study investigators in the treatment protocols used in this study. One training session of approximately 90 minutes will be used to review all treatment procedures. Each of the participating physical therapy clinics will be equipped with the 3D Active Trac traction table prior to initiation of the study, and physical therapists will have experience with this equipment. Each participating physical therapist will also have prior experience using an EOTA intervention. Participating physical therapists will be trained to provide treatment for subjects in either group in this study. The assignment of a study subject to a participating physical therapist will be done on a pragmatic basis (location of clinic, availability of appointment, etc.) A study treatment folder will be provided to the treating physical therapist each time he or she is assigned a new study subject. The study treatment folder will include a written protocol outline specific to the subject's group assignment, and treatment forms for each physical therapy session to allow the physical therapist to record the specific activities performed during the session and the exercises assigned to the subject for home performance. In addition, each treatment session form will require the physical therapist to record the subject's reported home exercise compliance since the last treatment session. The physical therapist's compliance with the treatment protocols will be recorded and reviewed periodically. The use of any off-protocol co-interventions will be recorded. The subject's compliance with performing the assigned home exercises will be recorded from the physical therapist's treatment forms.
The integrity of the data collected throughout the trial will be monitored by regular review of the data collection forms for missing responses, errors, or out of range values.
Intention-to-treat principles will be applied to all analyses, with all subjects analyzed with the group to which they were randomized regardless of compliance with treatment. Hypotheses 1 and 2 relate to determining the overall effectiveness of adding traction to an EOTA intervention. Linear mixed models with repeated measures will be used to analyze overall treatment effectiveness. The treating physical therapist and physical therapy clinic will be modeled as random effects. Covariates, treatment group, and treatment group by time interaction will modeled as fixed effects. The treatment group by time interaction effect will be used to examine hypotheses 1 and 2 related to the effectiveness of adding traction to an EOTA intervention. Treatment effect sizes with 95% confidence intervals will be calculated for each follow-up time point. The third hypothesis, examining effectiveness of adding traction to an EOTA intervention based on subjects' status on the preliminary sub-grouping criteria, will be examined with similar procedures with the inclusion of a 3-way, time by group by sub-grouping status interaction term. Statistical significance will be based on an alpha level of 0.05 for all analyses.
Sample Size and Power
The sample size calculation is based on examining the differences between treatment groups after 6 weeks on the primary outcome measure (OSW), while preserving adequate power for detecting the sub-grouping effect in hypothesis 3. In our preliminary study [29] we found a treatment effect following the traction intervention of 0.47, based on a mean between group difference of 6.4 points on the OSW with a sd of 13.7, and a correlation between baseline and follow-up OSW scores of r = 0.57. We believe our modification of the traction protocol in the present may improve the treatment effect. A sample size of 128 subjects would provide 80% to detect a slightly larger effect size (0.50). Adjustment for the baseline OSW score will improve power versus an unadjusted comparison of means [44]. Presuming a correlation between baseline and post-treatment OSW scores of 0.57, a sample size of 86 subjects would provide 80% power for the same treatment effect [44]. To preserve adequate power to examine the interaction effect related to the sub-grouping status in hypothesis 3, we inflated the sample size based on the size of the anticipated interaction effect relative to the overall treatment effect [45]. In our preliminary study, the magnitude the interaction effect was 1.07 sd between subjects receiving traction who were SG+ compared with subjects receiving EOTA only who were SG+, and was 0.71 sd between subjects receiving traction who were SG+ and those receiving traction who were SG-. If the sub-group effect size is presumed to be at least 1.0, no further sample size inflation would be required to maintain the same power as for the overall treatment effect, while a sub-group effect size of 0.71 would require an inflation of approximately 1.5 [45]. Inflating the sample size by 1.2 results in a sample size of 104 subjects. Recruiting 120 subjects (60 per group) allows for a drop-out rate of approximately 13%. Our sample size estimate would be under-powered if a large clustering effect due to subjects within clinical sites were present [46]. We are presuming that our use of standardized protocols will make any clustering effects negligible. If this presumption proves incorrect the study could be under-powered. Conversely, our sample size calculation accounts for adjustment for baseline OSW values. We will adjust for additional baseline co-variates which may increase power. A sample size of 120 subjects provides 80% power to detect a between-group difference in low back or leg pain rating of 1.0 points presuming a sd of 2.0, and a difference in the percentage of successful patients of 25% based on dichotomization of the global rating of change scale.
This study will examine the effectiveness of adding a standardized protocol of lumbar mechanical traction to an extension-oriented treatment approach for individuals with LBP and nerve root irritation who are receiving non-surgical care. The study will further examine if the addition of the traction protocol is particularly beneficial in a sub-group of subjects defined by the presence of clinical examination factors identified in preliminary research. The study will examine the overall effect of the treatment received, and the interaction between treatment received and the sub-group status. This is the recommended strategy for determining if treatment effects differ across sub-groups [47]. The sample size has been adjusted to preserve adequate power for the analysis of the sub-grouping interaction effect [45]. There is currently a lack of evidence to inform clinical decision-making for the non-surgical management of LBP and nerve root irritation, even though a period of non-surgical management is recommended for most patients. The overall goal of this study is to provide evidence that can improve decision-making for these patients.
Deyo RA, Mirza SK, Martin BI: Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine. 2006, 31: 2724-2727. 10.1097/01.brs.0000244618.06877.cd.
Abenhaim L, Rossignol M, Gobeille D, Bonvalot Y, Fines P, Scott S: The prognostic consequences in the making of the initial medical diagnosis of work-related back injuries. Spine. 1995, 20: 791-795. 10.1097/00007632-199504000-00010.
Tubach F, Beaute J, Leclerc A: Natural history and prognostic indicators of sciatica. J Clin Epidemiol. 2004, 57: 174-179. 10.1016/S0895-4356(03)00257-9.
Stafford MA, Peng P, Hill DA: Sciatica: a review of history, epidemiology, pathogenesis and the role of epidural steroid injection in management. Br J Anaesth. 2007, 99: 461-473. 10.1093/bja/aem238.
Konstantinou K, Dunn KM: Sciatica: review of epidemiological studies and prevalence estimates. Spine. 2008, 33: 2464-2472. 10.1097/BRS.0b013e318183a4a2.
Balague F, Nordin M, Sheikhzadeh A, Echegoyen AC, Brisby H, Hoogewoud HM, Fredman P, Skovron ML: Recovery of severe sciatica. Spine. 1999, 24: 2516-2524. 10.1097/00007632-199912010-00014.
Selim AJ, Ren XS, Fincke G, Deyo RA, Rogers W, Miller D, Linzer M, Kazis L: The importance of radiating leg pain in assessing health outcomes among patients with low back pain. Results from the Veteran Health Study. Spine. 1998, 23: 470-474. 10.1097/00007632-199802150-00013.
Engel CC, von Korff M, Katon WJ: Back pain in primary care: predictors of high health-care costs. Pain. 1996, 65: 197-204. 10.1016/0304-3959(95)00164-6.
Peul WC, Hout van den WB, Brand R, Thomeer RT, Koes BW: Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ. 2008, 336: 1355-1358. 10.1136/bmj.a143.
Andersson GB, Brown MD, Dvorak J, Herzog RJ, Kambin P, Malter A, McCulloch JA, Saal JA, Spratt KF, Weinstein JN: Consensus summary of the diagnosis and treatment of lumbar disc herniation. Spine. 1996, 21 (suppl): s75-s78.
Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE: Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the Maine lumbar spine study. Spine. 2005, 30: 927-934. 10.1097/01.brs.0000158954.68522.2a.
Cummins J, Lurie JD, Tosteson TD, Hanscom B, Abdu WA, Birkmeyer NJ, Herkowitz H, Weinstein J: Descriptive epidemiology and prior healthcare utilization of patients in the Spine Patient Outcomes Research Trial's (SPORT) three observational cohorts: disc herniation spinal stenosis and degenerative spondylolisthesis. Spine. 2006, 31: 806-814. 10.1097/01.brs.0000207473.09030.0d.
Luijsterburg PA, Verhagen AP, Ostelo RW, Hoogen van den HJ, Peul WC, Avezaat CJ, Koes BW: Physical therapy plus general practitioners' care versus general practitioners' care alone for sciatica: a randomised clinical trial with a 12-month follow-up. Eur Spine J. 2008, 17: 509-517. 10.1007/s00586-007-0569-6.
Luijsterburg PA, Lamers LM, Verhagen AP, Ostelo RW, Hoogen van den HJ, Peul WC, Avezaat CJ, Koes BW: Cost-effectiveness of physical therapy and general practitioner care for sciatica. Spine. 2007, 32: 1942-1948. 10.1097/BRS.0b013e31813162f9.
Jewell DV, Riddle DL: Interventions that increase or decrease the likelihood of a meaningful improvement in physical health in patients with sciatica. Phys Ther. 2005, 85: 1139-1150.
Luijsterburg PA, Verhagen AP, Ostelo RW, van Os TA, Peul WC, Koes BW: Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Eur Spine J. 2007, 16: 881-899. 10.1007/s00586-007-0367-1.
Vroomen PCAJ, de Krom MC, Slofstra PD, Knottnerus JA: Conservative treatment of sciatica: a systematic review. J Spinal Dis. 2000, 13: 463-469. 10.1097/00002517-200012000-00001.
Crisp EJ, Cyriax JH, Christie BG: Discussion on the treatment of backache by traction. Proc R Soc Med. 1955, 48: 805-814.
Chou R, Huffman LH: Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007, 147: 492-504.
Clarke J, van Tulder M, Blomberg S, de Vet H, Heijden van der G, Bronfort G: Traction for low back pain with or without sciatica: an updated systematic review within the framework of the Cochrane collaboration. Spine. 2006, 31: 1591-1599. 10.1097/01.brs.0000222043.09835.72.
van Tulder MW, Koes BW, Seitsalo S, Malmivaara A: Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review. Eur Spine J. 2006, 15 (suppl): S82-S92. 10.1007/s00586-005-1049-5.
Foster NE, Thompson KA, Baxter GD, Allen JM: Management of nonspecific low back pain by physiotherapists in Britain and Ireland. A descriptive questionnaire of current clinical practice. Spine. 1999, 24: 1332-1342. 10.1097/00007632-199907010-00011.
Gracey JH, McDonough SM, Baxter GD: Physiotherapy management of low back pain. Spine. 2002, 27: 406-411. 10.1097/00007632-200202150-00017.
Mikhail C, Korner-Bitensky N, Rossignoi M, Dumas JP: Physical therapists' use of interventions with high evidence of effectiveness in the management of a hypothetical typical patient with acute low back pain. Phys Ther. 2005, 85: 1151-1167.
Poitras S, Blais R, Swaine B, Rossignol M: Management of work-related low back pain: a population-based survey of physical therapists. Phys Ther. 2005, 85: 1168-1181.
Gay RE, Brault JS: Evidence-based management of chronic low back pain with traction therapy. Spine J. 2008, 8: 234-242. 10.1016/j.spinee.2007.10.025.
Krause M, Refshauge KM, Dessen M, Boland R: Lumbar spine traction: evaluation of effects and recommended application for treatment. Man Ther. 2000, 5: 72-81. 10.1054/math.2000.0235.
Harte AA, Gracey JH, Baxter GD: Current use of lumbar traction in the management of low back pain: results of a survey of physiotherapists in the United Kingdom. Arch Phys Med Rehabil. 2005, 86: 1164-1169. 10.1016/j.apmr.2004.11.040.
Fritz JM, Lindsay W, Matheson JW, Brennan GP, Hunter SJ, Moffitt SD, Swalberg A, Rodriquez B: Is there a subgroup of patients with low back pain likely to benefit from mechanical traction?: Results of a randomized clinical trial and subgrouping analysis. Spine. 2007, 32: E793-E800. 10.1097/BRS.0b013e31815d001a.
Saunders HD, Ryan RS: Spinal traction. Evaluation Treatment and Prevention of Musculoskeletal Disorders. 2004, Chaska, MN: The Saunders Group, Inc., 1: 301-325.
Fritz JM, Irrgang JJ: A comparison of a modified Oswestry disability questionnaire and the Quebec back pain disability scale. Phys Ther. 2001, 81: 776-788.
Hancock MJ, Herbert RD, Maher CG: A guide to interpretation of studies investgating subgroups of responders to physical therapy interventions. Phys Ther. 2009, 89: 698-704. 10.2522/ptj.20080351.
Laupacis A, Sekar N, Stiell IG: Clinical prediction rules: a review and suggested modifications of methodological standards. JAMA. 1997, 277 (6): 488-494. 10.1001/jama.277.6.488.
Waddell G, Newton M, Henderson I, Somerville D, Main CJ: A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993, 52: 157-168. 10.1016/0304-3959(93)90127-B.
Sullivan MJ, Bishop SR, Pivik J: The pain catastrophizing scale: development and validation. Psychol Assess. 1995, 7: 524-532. 10.1037/1040-3590.7.4.524.
Bombardier C: Outcome assessment in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine. 2000, 25 (24): 3100-3103. 10.1097/00007632-200012150-00003.
Frost H, Lamb SE, Stewart-Brown S: Responsiveness of a patient specific outcome measure compared With the Oswestry disability index v2.1 and Roland and Morris disability questionnaire for patients with subacute and chronic low back pain. Spine. 2008, 33: 2450-2457. 10.1097/BRS.0b013e31818916fd.
Walsh TL, Hanscom B, Lurie JD, Weinstein JN: Is a condition-specific instrument for patients with low back pain/leg symptoms really necessary? The responsiveness of the Oswestry Disability Index, MODEMS and the SF-36. Spine. 2003, 28: 607-615. 10.1097/00007632-200303150-00017.
Childs JD, Piva SR, Fritz JM: Responsiveness of the numeric pain rating scale in patients with low back pain. Spine. 2005, 30: 1331-1335. 10.1097/01.brs.0000164099.92112.29.
Jaeschke R, Singer J, Guyatt GH: Measurement of health status: ascertaining the minimal clinically important difference. Control Clin Trials. 1989, 10: 407-415. 10.1016/0197-2456(89)90005-6.
EuroQol Group: EuroQol-A new facility for the measurement of health-related quality of life. Health Policy. 1990, 16: 199-208. 10.1016/0168-8510(90)90421-9.
Maitland GD, Hengeveld E, Banks K: Vertebral Manipulation. 2000, Oxford: Butterworth Heinemann, 6
Caigne B, Vinck E, Beernaert A: How common are side effects of spinal manipulation and can these side effects be predicted?. Man Ther. 2004, 9: 151-156. 10.1016/j.math.2004.03.001.
Borm GF, Fransen J, Lemmens WAJG: A simple sample size formula for analysis of covariance in randomized clinical trials. J Clin Epidemiol. 2007, 60: 1234-1238. 10.1016/j.jclinepi.2007.02.006.
Brookes ST, Whitely E, Egger M, Smith GD, Mulheran PA, Peters TJ: Subgroup analyses in randomised trials: risks of subgroup specific analyses; power and sample size for the interaction test. J Clin Epidemiol. 2004, 57: 229-236. 10.1016/j.jclinepi.2003.08.009.
Lee KJ, Thompson SG: Clustering by health professional in individually randomised trials. BMJ. 2005, 330: 142-144. 10.1136/bmj.330.7483.142.
Oxman AD, Guyatt GH: A consumer's guide to subgroup analyses. Ann Intern Med. 1992, 116: 78-84.
Fritz JM, Delitto A, Vignovic M, Busse RG: Inter-rater reliability of judgments of the centralization phenomenon and status change during movement testing in patients with low back pain. Arch Phys Med Rehabil. 2000, 81: 57-61.
Hudgins WR: The crossed straight leg raising test: a diagnostic sign of herniated disc. J Occup Med. 1979, 21: 407-408.
Rehabilitation Agency, Intermountain Healthcare, Salt Lake City, Utah, USA
Julie M Fritz, Anne Thackeray & Gerard P Brennan
Department of Physical Therapy, The University of Utah, Salt Lake City, Utah, USA
Julie M Fritz & Anne Thackeray
U.S. Army-Baylor University, Fort Sam Houston, Texas, USA
John D Childs
Julie M Fritz
Anne Thackeray
Gerard P Brennan
Correspondence to Julie M Fritz.
We acknowledge a potential competing interest in the funding of this study, which is provided by DJO incorporated, Vista, California, USA. DJO is the parent company of Chattanooga, Inc., the manufacturer of the 3D ActiveTrac traction table used in this study.
JF and JC conceived of this study and participated in its design. AT and GB contributed to the design of this study. AT will serve as the study coordinator. All authors have read and approved the final manuscript.
Fritz, J.M., Thackeray, A., Childs, J.D. et al. A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with low back pain: study methods and rationale. BMC Musculoskelet Disord 11, 81 (2010). https://doi.org/10.1186/1471-2474-11-81
Nerve Root
Lumbar Intervertebral Disk
Lumbar Nerve Root
Submission enquiries: bmcmusculoskeletaldisorders@biomedcentral.com


text:
Q: Adding cusotm boxes inside my community site that link to to other sharepoint pages , and also link to external systems I have created new community site inside my SP 2013 server, and on the Category page , each category is displayed inside a box. now i need to add some Boxes to my home page that link to external systems, and to some SharePoint pages. so it there a way to insert custome Boxes inside SharePoint pages ? such as :-

A: Those boxes are called "Tiles" and it's super easy to spin up your own.
Go to the settings dropdown in top right > add an app > Promoted Links > fill in list data, drop on page, and presto
http://alinimer.com/2013/02/09/oob-creating-your-own-custom-tiles-in-sharepoint-2013/

redpajama_set_name: RedPajamaStackExchange


Christian is a Christian year when Christians have mentioned the death and resurrection of Jesus Christ. They believe that the Christians, whom they accepted, were God's child, passed away for every mischief and later three days later he returned to life after his death and anger. On this occasion, you believe that on this occasion you always live in heaven.
There is no 100% special where we get the English word 'Easter'! Practically every second European language, for Easter's celebration is derived from a minor leave from the word "Passo" (chapters in Hebrew phisher or Πάσχα in Greek).
Most Christians told Easter as "Heavenly Week" for the first week – it includes the time of Easter Tydecom, including Mandi with Friday, the market and the last speaker and good Friday, Death penalty and honor of Jesus. In Western Christianity, Easter-tee or Easter season starts at Eight Sunday and runs for seven weeks, Pentecost Sunday is happening for fifteen days. Prediction predictions in Eastern Christianity start on and on the fourth day, with the invitation of the Assessment.
Easter and opportunities from which they are identified are strangers that do not fall on a permanent date in Georgia or Julin book books that take just after sun's cycle; rather, its history is a lunisolar schedule like Hebrew Is resolved on timetable. Nicole's first council (325) established the freedom of two directions, Jewish historical books and overall stability, which included Easter's main principles, which were clearly defined on Friday.
Some fine elements were indicated for accounting; They used to communicate effectively, a procedure that took hundreds of years and produced various discussions. After March 21 or soon, the Foreign Minister has become the main festival after the moon however flurry in figuring s.
Easter is associated with a little bit of her reflection of the Jewish Passover, and in addition to her situation in the book book. In most European languages, the name of Easter in English is named in Bolivia, in terminology and more established English forms of Bible, which was used to terminate terminology of terminology.Easter traditions make a Christian change in the world and helping to cut the church while welcoming the pasture and designing Easter eggs.
Easter Lily an image of the Hour Usually this day increase worship places and Easter-tide remedies. Additional traditions that have developed Easter-related and two Christians and some non-Christians are involved in egg-chasing, Easter Bano, and Easter-feet.Similarly, there are various traditional Easter foods that move provincially.
For the most part, Easter's word is born from Yigang Senson month 'Asturamunath', which we call on the season when the Christian celebration was held. This month is known as a German Goddess 'Eastery' or 'Asta'. In any case, the basic reference to this name is from the earliest ancient bed in 725. In addition, we are not 100% of any doubt they were right! However, that is located in the celebration celebrated after the month is fine.
(You can also observe some sources that it may be named as 'Start' named Anwar Devi. In any case, it is usually shown that neither the rhyme nor the That is why! Stator was a Goddess in the Middle East's extraordinary ancient religions, about 5,000 years ago.
He lost the minimum of 1500 years before being Christian, so separated from the name separated from some Easter Looks like he does not have any connection with Jewish celebration of the Jewish Passover or the Christian celebration.
His name was first associated with Easter in 1853 when a gym The ordinance was served, which were very unusual view of bamboo things, wrote a booklet that was not valid according to the real from any source.
The Passover Festival was presented about 4,000 years ago when Jehovah remembers that God saved them from the slavery of Egypt. Jesus Christ was the one who prayed for the Passover. The Passover occurs in the month of Jehovah's month (14-15 in the long run of Nissan). The Jewish schedule is scheduled after the moon cycle, so history changes somewhat permanently.
The basic Jewish Christians included Christian festivals on the occasion of the Passover celebration, and the fact that Jesus was once again resurrected on Sunday, Christian day turned to the Principal Sunday after the Passover.
Worthy of Christmas, when the introduction of the world of Jesus is appreciated (despite the fact that we do not realize what Christian thought was!), Easter appreciated similar Christian He has been sentenced to death. According to Jesus, the bucket was killed in the celebration of Jehovah's Passover Festival.
In many years, the Christian celebration has been shifted to the extent to the extent of the Jewish Passover, so they do not have the same date yet, but for a while they are close! Similarly, Christian history takes place for Easter after the moon, so it changes every year more frequently. To make things more significantly, Orthodox Christians observe Catholic and Western Christians Easter like Christmas on an alternate day!
For the Christians, full Easter time frame continued for a long time. Easter Wednesday 46 days ago Easter Wednesday's event begins officially. The lender operates for 40 days but you do not cool on Sunday! After 39 days of Easter Day while observing the luxury day of Christians when they remember Jesus back to heaven Let's go and promise to come back to the ground one day.
The end of the end of the Easter closes for the end of 49 days, with the Christian day of Pentecost or White House, when Christians tell that God sent their holy spirit to help Christians. So Easter for Christians is an extraordinary difficult time.


Missing teeth can be a major problem from a number of different perspectives. From an aesthetic point of view, a smile that's missing some teeth just doesn't look all that attractive. It may leave you feeling self-conscious about smiling. Many people with missing teeth tend to cover their mouths then they talk or laugh, even around people that they know and care about. From a dental health standpoint, there are plenty of dental problems to consider that people may not be aware you're your bite strength and ability to chew can be severely affected by missing teeth. Bone loss is common in the spot where the tooth is missing, as is gum recession. Over time, the teeth surrounding the tooth gap can slowly shift out of place and become misaligned since there is no adjacent tooth or teeth to maintain proper alignment.
It's for this reason that many patients come to visit a Brooklyn Heights cosmetic dentist at our practice. Dr. Eugene D. Stanislaus and his entire team of dental professionals is committed to providing every patient with the best possible care. In some cases, patients who are missing multiple teeth will best benefit from getting dental bridges, which are a great treatment option. Yet, while dental bridges are a fine solution for missing teeth, there are other options to consider as well. We'd like to look at the alternatives to getting dental bridges right now so you have some idea of what to expect from dental care treatment.
If you are missing many teeth, it may be a better option to get dentures rather than dental bridges. Dental bridges rely on the adjacent teeth to help lend support and keep the bridges fixed in place. Dentures, by contrast, will use the bone and gum structures of the mouth to be held in place. The hold is generally good, and denture creams may be used to help maintain the position of the denture in the mouth.
One of the best options to consider for missing teeth, however, is dental implants. Dental implants are not dental restorations in themselves but are rather a means of securing dental restorations in place as firmly and securely as natural tooth roots. Brooklyn Heights dental implants are essentially artificial tooth roots that are integrated into the bone and soft tissue structures of the mouth through oral surgery. Once the dental implants are in place, they can be used to support a single dental crown, dental bridges, or even full dentures. Both bite strength and appearance will be enhanced when the dental implants are in place.
It should be noted that while dental implants are a fine solution for missing teeth, not everyone is a good candidate for implant dentistry. Issues with bone density or gum recession can prevent people from getting dental implants, though special grafting procedures for bone and gum tissue may help make a person eligible for dental implants. In order to find out if dentures, dental implants, or dental bridges are best for you, you need to visit Brooklyn Heights Dental.
To schedule an appointment with a member of our team or to learn more about your treatment options for missing teeth and other dental problems, contact our Brooklyn Heights cosmetic and family dentistry practice today.


text:
Andrew Yang says he is 'breaking up' with Democratic Party and becoming an independent
John Locher/AP
Democratic presidential candidate and entrepreneur Andrew Yang speaks at a campaign event Tuesday, April 23, 2019, in Las Vegas. (AP Photo/John Locher)
Andrew Yang, who ran for the Democratic presidential nomination, said he is leaving the party.
In a blog post, Yang said partisan gridlock was a driving factor behind his decision to become an independent.
"Many of the people I know are doing all of the good they can – but their impact is constrained," Yang said. "Now that I'm not a member of one party or another, I feel like I can be even more honest about both the system and the people in it."
Yang, who has been a registered Democrat for more than 20 years, said changing his party affiliation was an emotional experience. However, he said he knew it was the right move immediately after he changed affiliations.
"Breaking up with the Democratic Party feels like the right thing to do because I believe I can have a greater impact this way," Yang said.
Despite becoming an independent, Yang discouraged people from changing their party affiliation.
"Doing so could disenfranchise you if you live in the 83% of the country that is very blue or very red," Yang said.
Going forward, Yang said he wants to work on trying to "fix the system." He claims rank choice voting and open primaries will give voters more power.

redpajama_set_name: RedPajamaCommonCrawl


text:
7 Singapore Government Agencies You Must Know As a Business Owner
7 Singapore Government Agencies You…
The company registration procedure for any business can be intimidating and confusing, especially for individuals who are registering their company for the first time or who are unfamiliar with Singapore's local incorporation process.
If you're a foreigner looking to start a business in Singapore, there are many resources available to assist you. It's not uncommon in Singapore for you to be required to show many documents to various Singaporean government agencies before you can progress with your business registration.
It's also important to familiarise yourself with the many types of government-funded support, both monetary and non-monetary, that can help you speed up the process and get your company on board.
This article delves into the seven most important Singapore government offices you may need to contact while registering your business in the country for assistance.
7 Must-Know Singapore Government Agencies
Enterprise Singapore (ESG)
Inland Revenue Authority Singapore (IRAS)
Singapore Ministry of Manpower (MOM)
Accounting and Corporate Regulatory Authority (ACRA)
SkillsFuture Singapore
Singapore Economic Development Board (EDB)
Central Provident Fund Board (CPF Board)
Enterprise Singapore (ESG) is a statutory board that reports to Singapore's Ministry of Trade and Industry. It was established on April 1, 2018, to assist Singapore's small and medium enterprises (SMEs) in growing, upgrading their capabilities, innovating, transforming, and internationalising.
It also continues to be the national standards and accreditation body, supporting Singapore's growth as a trading and startup hub.
The merger of International Enterprise Singapore (IE) and SPRING Singapore resulted in Enterprise Singapore. The agency is attracting global commodity traders to set up shop in Singapore as their global or Asian headquarters.
Enterprise Singapore is in charge of Singapore's national standards. Entrepreneurs of all sizes and stages of development, including startups, SMEs, and large corporations, are supported by Enterprise Singapore.
Through a variety of programs managed by Startup SG, it collaborates with incubators, angel investors, and government agencies to develop the startup ecosystem in Singapore.
It offers SMEs grants and programs to help them improve their business capabilities, as well as access to technology and research institutes. It also allows SMEs to expand internationally by providing tax breaks, grant funds, the Plug and Play Network, and over 22 FTAs.
Enterprise Singapore assists large corporations in expanding their global market reach and identifying new opportunities. They also lead smaller companies in joint projects through initiatives like the PACT program.
The Inland Revenue Authority of Singapore (IRAS) is a statutory board that collects taxes under the Ministry of Finance of the Singapore government.
IRAS was established as a statutory board under the Ministry of Finance on September 1, 1992. The Inland Revenue Authority of Singapore Act was enacted to incorporate IRAS to take over the functions previously performed by the Inland Revenue Department.
The goal of the conversion was to give IRAS more autonomy and flexibility in managing its personnel and finances.
IRAS collects Income Tax, Goods and Services Tax (GST), Property Tax, Estate Duty, Betting and Sweepstakes Duties, Stamp Duties, and Casino taxes on behalf of the Singapore government.
The Ministry of Manpower (MOM) is a Singapore government ministry in charge of formulating and enforcing labour policies affecting the workforce. It was established on 7th April 1955. Until 1998, the Ministry was known as the Ministry of Labor.
The Central Provident Fund Board, the Singapore Labour Foundation, and Workforce Singapore are all statutory boards the Ministry oversees. The Ministry of Manpower is led by the Minister for Manpower, a member of Singapore's Cabinet.
The goal of this ministry is to create a productive workforce and forward-thinking workplaces. In addition, its intent is to provide all Singaporeans with better jobs and secure retirement.
The Ministry intends to build a strong core for growth in the country by enabling businesses to provide excellent jobs. To achieve the best possible results, the foreign workforce is meant to supplement the local workforce.
When applying for a Singapore work visa, such as an Employment Pass, EntrePass, S Pass, or Personalised Employment Pass, you must contact MOM.
The Accounting and Corporate Regulatory Authority (ACRA) is a statutory board that reports to Singapore's Ministry of Finance. Business registration, financial reporting, public accountants, and corporate service providers are all regulated by ACRA.
ACRA also catalyses the growth of business entities and the public accounting profession.
The Accounting and Corporate Regulatory Act, which merged the Registry of Companies and Businesses (RCB) and the Public Accountants' Board on April 1, 2004, gave birth to ACRA (PAB).
The purpose of the merger was to combine the monitoring of companies' compliance with disclosure requirements with the regulation of public accountants who perform statutory audits.
The Singapore government established SkillsFuture – SSG, an agency that provides and assists lifelong learning, training, and development programs for local employees, in response to the abundance and adaptability of the Singapore workforce.
Business owners must use SSG to register for the SkillsFuture Development Levy when hiring any local employee. SDL funds are transferred to the Skills Development Fund to aid labour resource improvement programs.
Employers can also apply for grants from SDL funds to send their employees to certified training courses in various fields.
Businesses with training and development branches in Singapore can also register with SSG to become certified SkillsFuture Training Providers, giving local workers more opportunities to network with new companies.
SkillsFuture provides new businesses with the opportunity to organise practical internship and training programs for university and college students.
The Economic Development Board (EDB) is a statutory board under Singapore's Ministry of Trade and Industry that develops and implements strategies to keep Singapore a leading global business and investment hub.
It was established in August 1961 to assist you with business research or provide you with all the required information to continue with your business.
EDB collaborates with other international businesses to identify growth opportunities in various regions across the country for multiple industries. In addition, it works to establish and strengthen the country's numerous strategic activities.
It also offers the Global Investor Programme (GIP) to foreign investors who wish to relocate to Singapore, which allows them to apply for and obtain permanent residency in Singapore.
The Central Provident Fund (CPF) is a mandatory comprehensive savings and pension plan for working Singaporeans and permanent residents. It is primarily to fund their retirement, healthcare, and housing needs in Singapore. It was established on 1st July 1955.
The CPF is an employer-sponsored savings plan in which both employers and employees contribute a set amount to the fund for certain benefits.
The CPF Board, a statutory board under the Ministry of Manpower, administers the fund and investing contributions.
It is critical for individuals or businesses wishing to start a business in Singapore to understand and identify the functions of Singapore government agencies. However, without prior experience working directly with these government bodies, it is impossible to do so, which may make it tough to start a business in Singapore.
As a result, relying on business consultants with a thorough understanding of Singapore agencies and their operations procedures is a sensible and required alternative.
Contact us to find out more about how we can help you with your company today. Our wide range of professional services serves as a one-stop solution for your business. We offer the most affordable price for services like
Check out our services, covering all aspects of your business needs:
Company Secretarial Services
Bookkeeping, Accounting & Taxation
Setting up and managing your Xero accounts
Category: Business Guide January 18, 2022
PreviousPrevious post:How Can Foreign Startups Open a Corporate Account in Singapore?NextNext post:All You Need to Know About Productivity Solutions Grant (PSG)
How to Check and Verify if a Company is Registered in Singapore?
6 Ways to Use Social Media to Grow Your Business
Trying to Raise Series A Funding? Here are 5 Effective Tips for Entrepreneurs
3 Financial Elements Your Business Needs To Get Right
What to Do When a Shareholder Dies in Singapore
10 Small Businesses You Can Start from Home


text:
Early transcriptional changes in rabies virus-infected neurons and their impact on neuronal functions
S. Kim, F. Larrous, H. Varet, R. Legendre, L. Feige, G. Dumas, R. Matsas, G. Kouroupi, R. Grailhe, H. Bourhy
Frontiers in Microbiology
Rabies is a zoonotic disease caused by rabies virus (RABV). As rabies advances, patients develop a variety of severe neurological symptoms that inevitably lead to coma and death. Unlike other neurotropic viruses that can induce symptoms of a similar range, RABV-infected post-mortem brains do not show significant signs of inflammation nor the structural damages on neurons. This suggests that the observed neurological symptoms possibly originate from dysfunctions of neurons. However, many aspects of neuronal dysfunctions in the context of RABV infection are only partially understood, and therefore require further investigation. In this study, we used differentiated neurons to characterize the RABV-induced transcriptomic changes at the early time-points of infection. We found that the genes modulated in response to the infection are particularly involved in cell cycle, gene expression, immune response, and neuronal function-associated processes. Comparing a wild-type RABV to a mutant virus harboring altered matrix proteins, we found that the RABV matrix protein plays an important role in the early down-regulation of host genes, of which a significant number is involved in neuronal functions. The kinetics of differentially expressed genes (DEGs) are also different between the wild type and mutant virus datasets. The number of modulated genes remained constant upon wild-type RABV infection up to 24 h post-infection, but dramatically increased in the mutant condition. This result suggests that the intact viral matrix protein is important to control the size of host gene modulation. We then examined the signaling pathways previously studied in relation to the innate immune responses against RABV, and found that these pathways contribute to the changes in neuronal function-associated processes. We further examined a set of regulated genes that could impact neuronal functions collectively, and demonstrated in calcium imaging that indeed the spontaneous activity of neurons is influenced by RABV infection. Overall, our findings suggest that neuronal function-associated genes are modulated by RABV early on, potentially through the viral matrix protein-interacting signaling molecules and their downstream pathways.


There's a movement in progress to keep Donald Trump from hosting SNL on November 7.
Some on the left want to once again abandon any right to free speech if that speech includes conservative thought. They say that the program will embarrass NBC because of Trump's views. In order to reinforce their biased viewpoint, they are spreading the word that it will alienate NBC's Latino and pro-immigrant viewers by showing how little the corporation cares. Unlike any of the comedic skits skewering conservatives, the claim is that Trump spews hateful rhetoric that cannot be reconciled in comedy.
Whoa! He doesn't say what I believe and inherently know, so shut him down. This is typical of the tolerant, inclusive and diversity driven left. If you feel as I do, you're welcome and we can have a discussion. If you have a different viewpoint, you are wrong and therefore a bigot.
I quit watching Hannity some years ago because he tends to overtalk and shut down liberals as they attempt to make their points known. I say let them speak their own words so the world can find out just how factually bereft they really are. Offer a counterpoint when he or she has made a complete fool of themself, but let the world see just how self contradictory liberalism can truly be.
And I say the same for NBC and SNL. Allow the station and program an opportunity to showcase what might be the progressive's premier exposure to Donald Trump. After all, there possibly isn't a liberal who has ever listened to what he has to say. Most liberals, because they hate to hear opposing viewpoints, generally get their news about conservatives through filtered and distorted news sources such as the former Daily Show and the totally partisan MSNBC, NPR, etc. while occasionally tuning in to CNN (Clinton News Network).
Hey liberals, let the Donald make a complete fool of himself right in front of you and millions of others. You'll have even more to misrepresent for the coming weeks or months.
But then, he could make a salient point for the liberal world to hear. That would infuriate you and cause you to find ways to pervert it before fellow liberals realize they agree with him. Could that possibility be what's really behind your protest?


text:
Leaffooted bugs are medium to large sized insects that are about 0.75 to 1 inch in length. All three species of Leaffooted bugs are very similar in appearance. They are brown with a white band across their back with a narrow body. They are often seen on pomegranates, but their mouthparts cannot pierce through the skin of this fruit. Only once the fruit has opened, can this insect suck the juice. In general, they do relatively little damage to plants. Although these medium to large size insects feed on fruits, vegetables, nuts, and other plants, they are generally in few numbers and do little damage. Leaffooted bugs pierce with their mouthparts that let them suck out fluids and even seeds. Leaffooted bugs are named as such because of small leaf-like enlargements found on the hind leg. They are closely related to other sucking insects, such as stink bugs (family Pentatomidae) that can also suck juices from plants.
In California, there are three native and common species of leaffooted bugs. These are Leptoglossus zonatus, L. clypealis, and L. occidentalis. Adults of all three species are about 0.75 to 1 inch long and have a narrow brown body. Adults of all three species are similar in appearance, except that:
L. zonatus has two yellow spots just behind the head (on the pronotum).
L. clypealis has a thorn-like projection called a clypeus that extends forward from the tip of the head.
L. occidentalis has neither of these features.
All three species have a white zigzag pattern across the wings: this pattern is prominent in L. zonatus and L. clypealis and is relatively faint in L. occidentalis.
The brown, cylindrical eggs of all three species are laid end-to-end in a string-like strand on the host plant, often along a stem or leaf midrib. Most egg masses have 10-15 eggs, though more than 50 have been reported. Eggs hatch into small nymphs that have dark heads and dark legs on bodies that range in color from orange to reddish-brown. Small Leaffooted bugs can be confused with nymphs of the assassin bug (Zelus renardii). Nymphs of this beneficial insect have light-colored legs and antennae and hatch from barrel-shaped eggs that are grouped together with a white cone top. As Leaffooted bug nymphs become larger, they can easily be recognized by the development of the leaf-like projection on the hind legs.
Leaffooted bugs overwinter as adults, typically in aggregations located in protected areas, such as in woodpiles, barns or other buildings, palm fronds, citrus or juniper trees, under peeling bark, and in tree cracks.These aggregations occur in areas where the group can best collect heat from the sun during peak solar periods. Cold winters kill many adults, and major outbreaks often occur after mild winters. Overwintered adults live from September/October until late spring. When the weather gets warm, typically in March in the San Joaquin Valley and April in the Sacramento Valley, adults disperse to find food sources. Adults are strong flyers that may feed initially on the seeds of winter weeds and later move into gardens, landscapes, and farms in search of early-season fruit and a place to lay eggs.
Overwintering Leaffooted bugs can lay over 200 eggs during a two-month period in the spring. Nymphs emerge from the eggs about 1 week after being deposited, after which they develop into adults in 5 to 8 weeks. Adults are long-lived and can lay eggs over an extended period, so the population can consist of all life stages by late June. At this time, overwintering adults are still alive as the first generation of their offspring develop into adults. During the spring and summer, there are typically two to three generations of leaffooted bugs. In the fall, all bugs develop until they become adults that overwinter in aggregations.
Population levels change from year to year depending on weather and parasitism of eggs. Populations are typically highest after mild winters that allow high survival of overwintering adults. Seasonal fluctuations in the number of bugs can also be related to rainfall, food availability, and the prevalence of natural enemies.
In the spring, Leaffooted bugs often feed on thistles and other weeds. Adults migrate from weedy areas into gardens and landscapes, particularly when fruits have started to ripen. L. zonatus is the most destructive of the Leaffooted bug species. It feeds on many types of plants and is most commonly reported by gardeners as a pest of tomatoes and pomegranates; farmers primarily report it as a pest of almonds, pistachios, and pomegranates. Other important hosts in California include young citrus fruit, cotton bolls, watermelons, and several ornamental trees and shrubs. L. clypealisalso has a wide host range within gardens, landscapes, and farms and is the predominant species found on desert plants like palm trees, Joshua trees, and yucca. L. occidentalis, also known as the western conifer seed bug, is primarily found in association with conifer trees.
Leaffooted bugs have piercing-sucking mouthparts that extend more than half of the length of their narrow body. They use this mouthpart to probe into leaves, shoots, and fruits to suck out plant juices. The depth of the probing depends on the size of the bug: small nymphs feed shallowly on superficial plant juices, whereas adult bugs probe deep into fruit in search of seeds. If a hard seed is found, such as an almond kernel or juniper berry, the bug excretes digestive enzymes from its mouthparts to liquefy a small part of the seed so that it can be ingested. Leaffooted bug mouthparts are also known to carry a fungal yeast, Eremothecium coryli (formerly known as Nematospora). When Leaffooted bugs feed, this yeast can be introduced into fruit causing a variety of symptoms usually related to discoloration. However, the yeast causes no damage that would limit the ability of the fruit to be harvested and consumed. This infection is most predominant when rains are abundant.
For most ornamental and many garden plants, feeding on the leaves and shoots causes no visual damage and is of little concern. The most destructive damage occurs when bugs feed on fruit. Early-season feeding on nuts like almonds and pistachios can cause the kernel to abort and die, and mid- to late-season feeding on nuts causes a black stain on the kernel. On pomegranates, late-season feeding as the fruit ripens generally causes no external damage but can cause aryls (seed-like structures) to darken and wither, especially if fungal spores gain entry into the fruit through the feeding wound. Large aggregations of leaffooted bugs can also leave excrement on the surface of the fruit that can reduce its aesthetic appeal. Feeding on small fruit (e.g., tomatoes) can cause the fruit to abort, while feeding on medium-sized fruit can result in depressions or discoloration at the feeding site as the fruit expands and ripens. Feeding on mature tomatoes can cause slight discoloration to the surface of the fruit that should be of no concern to backyard gardeners.
During most years, Leaffooted bug populations are low enough that damage to gardens is tolerable and damage to landscape plants is negligible. When outbreaks occur, a variety of methods will likely be needed to manage this pest, which may include removing overwintering sites or the use of weed host removal, row covers, physical removal, natural enemies, and insecticides. Achieving good control will likely require some combination of these methods.
Remove Overwintering Sites
Adult bugs overwinter in woodpiles, under the bark of eucalyptus, juniper, or cypress, and in outbuildings. Large numbers may pass the winter in culls of fruit such as pomegranates. Remove these overwintering sites where possible or inspect them for Leaffooted bugs.
Weedy areas serve as a food source for Leaffooted bugs during winter and spring, when fruits are not available. Try to eliminate such areas near your garden or keep weedy areas closely mowed.
Row Covers
Covering plants with a row cover material can prevent feeding by leaffooted bugs. A row cover is a light, permeable material, usually made of polypropylene or polyester. Row covers are sometimes used to extend the harvest season past the first few frosts but are also valuable for preventing damage by a wide range of pests. Covers must be applied early, before bugs arrive and lay eggs on plants; otherwise, bugs will be trapped inside. Unfortunately, row covers will prevent pollinators and beneficial insects from reaching plants. Some garden plants like tomatoes are self-pollinating, but whiteflies or aphids may build up if beneficial insects are excluded.
Physical Removal
Thoroughly examine plants for all stages of the pest, daily to several times per week. The bugs may be hidden inside dense foliage layers or fruit clusters, and they may hide or fly when startled. Handpick and crush the bugs or brush them off plants into soapy water. Wear gloves because of the odor they will emit when handled. A handheld vacuum dedicated to catching the bugs can be effective at reducing numbers, if used regularly. It is especially important to remove the bugs as early in the season as possible, when the very young nymphs are tightly clustered together, and morning is best to reduce movement and flight. Be sure to also destroy the egg masses found on the underside of leaves.
For late-season infestations in pomegranate trees, prune trees so that there is a space between tree limbs and the ground. Leaffooted bug nymphs can easily be knocked out of the tree using a stick, by physically shaking the tree limbs, or using water from a pressure nozzle on a garden hose. Once bugs fall on the ground, they can be smashed. This method is effective against nymphs but will not dislodge eggs. It is less effective against adults, which are able to fly away. For this reason, this method should be repeated once every 1 to 2 weeks as necessary, until the majority of the bugs have disappeared. Laying a white ground cover beneath the plant can aid in seeing the insects when using this control method.
Native egg parasites, such as the tiny wasp, Gryon pennsylvanicum, if not disrupted, may reduce leaffooted bug populations by killing the eggs before they hatch. Adult leaffooted bugs may be parasitized by certain tachinid flies, such as Trichopoda pennipes, which lays its eggs on the sides of large nymphs or adults of several species of true bugs. Leaffooted bug predators include birds, spiders, and assassin bugs. Although they may control only a small number of the bugs, natural enemies are important to preserve because they control other pests as well. Avoiding use of persistent broad-spectrum insecticides and assuring pollen and nectar sources for adult beneficials are important ways to protect natural enemies.
Insecticides are rarely needed and are usually a last resort for Leaffooted bug control. The reason being that small blemishes on fruit in gardening situations is tolerable and landscape plants have very little to no damage. Also, because they are primarily seed feeders, Leaffooted bugs are most common on garden plants near harvest, when the application of pesticides to fruits that are going to be consumed is undesirable. In addition, most insecticides available to homeowners only have temporary effects on the leaffooted bug.
If needed, insecticides will be most effective against small nymphs. Therefore, monitor infested plants for egg masses and try to make insecticide applications when small nymphs are present. The most effective insecticides against leaffooted bug are broad-spectrum, pyrethroid-based insecticides, such as permethrin. However, these products are quite toxic to bees and beneficial insects. Insecticidal soap or botanicals, such as neem oil or pyrethrin, may provide some control of young nymphs only. If insecticides are used close to harvest, make sure to observe the days-to-harvest period indicated on the insecticide label; and wash the fruit before eating.
Leptoglossus zonatus adult.
Leptoglossus clypealis adult showing sharply pointed clypeus.
Leptoglossus occidentalis adult.
Leaf footed bug eggs are laid end to end in strands.
Leaffooted bug nymph.
An adult parasitoid lays its eggs inside of the eggs of leaffooted bug
Fig beetle
Snails and Slug control and management information


Full title reads: "FINALS DAY AT HENLEY - Brilliant weather has made this up-river festival exceptionally enjoyable."
Several shots of the crowds along the river bank. Several fashionable ladies are seen eating lunch.
The end of Diamond sculls race - the winner, H. Buhtz of the Berliner Club, rows vigorously towards finish.
Start of the principal race of the day - Grand Challenge Cup. Contestants are Leander (Great Britain) and Princeton University (USA). Several shots of the race and the crowds. Leander's crew resting after winning the race.
Winners receiving cups from a fashionable lady.
Stanley Baldwin is amongst crowds who attends Henley Regatta's last day of rowing races.
On the third day of Henley Royal Regatta, July 1, Oxford University made sure that the Grand Challenge Cup will stay in England for the first time in seven years.
The last day of the Henley Regatta opened in blazing sunshine with a win for Lady Margaret, head of the river at Cambridge, in the Ladies' Plate.
EAST GERMAN CREWS, COMPETING AT THE HENLEY ROYAL REGATTA FOR THE FIRST TIME, CARRIED ALL BEFORE THEN IN TODAY'S FINALS - WINNING FIVE OF THE NINE TROPHIES OPEN TO FOREIGN CREWS TO SET AN ALL TIME RECORD.
THE CRACK WEST GERMAN CREW, RATZEBURGER, TODAY (SATURDAY) AVENGED THEIR DEFEAT IN LAST YEAR'S OLYMPIC GAMES BY DEFEATING THE AMERICAN EIGHT, VESPER, IN THE FINAL OF THE GRAND CHALLENGE CUP FOR EIGHTS AT ROYAL ROWING REGATTA, AT HENLEY.


On January 15, 2019, Dr. Boris Saavedra gave the presentation "Cybersecurity: Data, Algorithms and Policy" at the Graduate School of Higher Strategic Studies (Escuela de Graduados de Altos Estudios Estratégicos - EGAEE), inaugurating the first cybersecurity course offered by EGAEE. Over 100 participants comprised of cybersecurity students, Ministry of Defense officials and Perry Center graduates attended. Vice Minister of Defense, Rear Admiral Miguel Peña Acosta, in representation of Minister of Defense, Lieutenant General Rubén Darío Paulino presided at the opening of the event.
Dr. Saavedra spoke of the importance of creating a cybersecurity ecosystem and strategic focus to develop clear policy that includes both private and public entities. This policy must define the role of the military in responding to cyber security threats to national infrastructure that affect the whole of society. At the conclusion of the presentation, EGAEE director and Perry Center alumnus Coronel Nelton Baralt Blanco hosted an alumni event for the Perry Center alumni in attendance which included graduates of resident courses from 2002 to present.


1.OA.A.1 Task Cards - 1st Grade Addition and Subtraction Word Problems!
Here are 20 task cards and a recording sheet for 1.OA.A.1, addition and subtraction word problems.These could be used for math centers, projected on the board to discuss as a class, or posted throughout the classroom for a carousel activity.
Would you like an assessment for this standard as well?


Does anyone here grow Ceraria and if so can you tell me something about them and where I might go to buy one or two.
I had never heard of it, but since no one responded, I did look it up. Very interesting little plant, actually in the same family with moss roses.
I can see why you are having trouble finding it. I found it on a list of rare and unusual succulents.
http://www.aridlands.com/catalog/produc ... f8ueovjhk2 "arid lands greenhouses"


In August 1814, the USA military was once defeated simply outdoor Washington, D.C., via the world's maximum army strength. President James Madison and his spouse had barely enough time to escape the White residence prior to the British invaders entered. British troops stopped to dinner party at the meal nonetheless sitting at the Madisons' dining-room desk ahead of surroundings the White apartment on fireplace. the level of the destruction used to be large; accomplished in wooden instead of marble, every little thing contained in the mansion used to be flamable. simply the outer stone partitions might face up to the fire.
The tide of the conflict of 1812 could speedy flip, in spite of the fact that. under a month later, American troops may stand positive on the conflict of citadel McHenry. Poet Francis Scott Key, struck via the sight of the yank flag waving over fortress McHenry, jotted down the beginnings of a poem that will be set to track and develop into the U.S. nationwide anthem, "The superstar Spangled Banner."
In his compelling narrative variety, Peter Snow recounts the fast-changing fortunes of that summer's amazing confrontations. Drawing from a wealth of fabric, together with eyewitness bills, Snow describes the colourful personalities on either side of these excellent occasions: together with the beleaguered President James Madison and primary girl Dolley, American heroes akin to Joshua Barney and Sam Smith, and mistaken army leaders like military leader William Winder and struggle Secretary John Armstrong. at the British aspect, Snow re-creates the fiery Admiral George Cockburn, the wary yet immensely renowned significant normal Robert Ross, and sharp-eyed diarists James Scott and George Gleig.
When Britain Burned the White House highlights this unprecedented second in British and American historical past, the brave, winning protection of castle McHenry and the yank triumph that might persist with, and America's and Britain's selection to by no means back struggle each one other.
From the "preeminent historian of Reconstruction" (New York occasions ebook Review), a newly up to date abridged version of the prize-winning vintage paintings at the post-Civil conflict interval which formed smooth the USA. during this up-to-date variation of the abridged Reconstruction, Eric Foner redefines how the post-Civil struggle interval was once seen.
A different account of the main profitable slave uprising in American history, now up-to-date with a brand new epilogue—from the award-winning writer of The Slave ShipIn this robust and hugely unique account, Marcus Rediker reclaims the Amistad rebellion for its actual proponents: the enslaved Africans who risked demise to stake a declare for freedom.
"A shiny, soaking up account of a brief interval in historical past that also resounds this present day. " —Kirkus ReviewsBeautifully written and brilliantly argued, whilst the U.S. Spoke French bargains a clean standpoint at the tumultuous years of the United States as a tender country, whilst the Atlantic world's first republican experiments have been placed to the attempt.
The paperback version of the hot York instances Bestseller. this is often the little-known tale of ways a newly self sustaining kingdom was once challenged through 4 Muslim powers and what occurred whilst America's 3rd president determined to face as much as intimidation. When Thomas Jefferson turned president in 1801, the United States used to be deeply in debt and wanted its economic system to develop speedy, yet its service provider ships have been lower than assault.
M. as deliberate, Brooke may possibly nonetheless continue along with his scheduled assault. yet, hear even though they did, the British on their ships may perhaps pay attention no sound of firing from Brooke's military. both his assault were postponed or anything had long past mistaken. 21 You move on at your peril thirteen September TWENTY-FOUR HOURS prior Arthur Brooke had long gone to mattress understanding that tomorrow, Tuesday thirteen September, he might face the best problem of his profession. Ross's loss of life had given him the opportunity to steer a British military to a old victory. The Royal military could start its bombardment of Baltimore's coastal forts the next morning. in the event that they may be suppressed, the town will be uncovered to attack from the ocean on one aspect and from his military from the opposite. And if his forces may well holiday via as that they had at Bladensburg and North aspect, town will be at his mercy. An encouraging message reached Brooke at the night of the twelfth from the British Commander in leader, Vice Admiral Sir Alexander Cochrane. He used to be all able to provide his bomb ships the order to open hearth once the sunshine got here up day after today. Cochrane instructed Brooke that he had checked out the fortifications the americans had thrown up in entrance of Baltimore, and 'It struck me that this entrenched camp could be grew to become. ' Brooke wrote again to claim that 'in the morning we are hoping to continue at approximately twelve or one to paintings our destruction…' and he further: 'your hearth I may still imagine in town will be of limitless carrier to us'. He ended by way of expressing 'my wish for our mutual success'. It was once one other rainy evening. The rain used to be so heavy that infantrymen struggled to maintain their guns dry. The fortunate ones had leather-based circumstances which gave their muskets a few security; others did their top to safeguard their weapons lower than their hands. within the morning the troops have been ordered to lighten their a lot by way of dumping their blankets, so much of which have been sodden with the rain. Gleig received up, 'absolutely heavy with the weight of moisture which hung approximately me … My very dermis was once perforated – i used to be rainy to the bones and marrow. ' the military moved off and shortly there has been the welcome sound of the aiding British naval bombardment over to their left. Gleig led a patrol to maintain a watch at the army's flank, and it wasn't lengthy prior to he stumbled on americans as he struggled via a few undergrowth. 'Holding a cocked pistol in my hand, I ran in the direction of them and commanded them on ache of dying to give up. ' Gleig needed to knock a rifle out of the hand of 1 of them, who rapidly burst into tears. He stated he didn't brain what Gleig did to him so long as he might spare the lifetime of his father, who used to be mendacity badly wounded at the flooring. Gleig took one examine the daddy and observed that he was once truly useless. 'God forbid that I should still do harm both to a father or a son lower than such circumstances,' he acknowledged and moved on, leaving the younger guy to deal with his father's corpse. After trudging via woods and clambering over a few bushes the american citizens had scale back of their direction, Brooke and his military without warning broke out into even more open kingdom which fell away prior to them after which rose to a ridge that hid town of Baltimore at once in the back of it.


text:
WORLD Fresh Ebola cases reported in DRC: WHO
Fresh Ebola cases reported in DRC: WHO
(Photo: VCG)
The Democratic Republic of Congo (DRC) has confirmed new Ebola cases, just days after declaring the end of an outbreak in the country's far western region, the World Health Organization (WHO) said on Wednesday.
The DRC government announced Wednesday that preliminary laboratory results indicate a cluster of cases of Ebola virus in the province of North Kivu, which came little more than a week after the Ministry of Health declared the end of an outbreak in Equateur Province in the far western part of the country, some 2500km from North Kivu.
Local health authorities said four out of six samples tested positive for Ebola virus at the Institut National de Recherche Biomedicale (INRB) in Kinshasa. Further testing is on-going.
The majority of the cases are in the Mangina health area, which is 30km from the northeastern city of Beni. "This new cluster is occurring in an environment which is very different from where we were operating in the northwest," said WHO Deputy Director-General Dr. Peter Salama. "This is an active conflict zone. The major barrier will be safely accessing the affected population."
"Ebola is a constant threat in the DRC," said WHO Dr. Tedros Adhanom Ghebreyesus. "What adds to our confidence in the country's ability to respond is the transparency they have displayed once again. Working closely with the Ministry of Health and partners, we will fight this one as we did the last."
The DRC government was quick to provide public updates, with press releases on Tuesday and Wednesday.
"Since we are coming out of another Ebola outbreak, we have kept staff and equipment in place," said Dr. Matshidiso Moeti, WHO regional director for Africa. "This allows us to have a head start in response to this cluster."
North Kivu hosts over one million displaced people and shares borders with Rwanda and Uganda with a great deal of cross-border movement due to the trade activities. The WHO is now working with neighboring countries to ensure health authorities are alerted and prepared to respond.
13 Ebola cases confirmed in eastern DR Congo
Thirteen Ebola cases have been confirmed, including three deaths, in North-Kivu province in the Democratic Republic of the Congo (DRC), according to a statement released overnight by the ministry of health.
Four more dead from Ebola in DR Congo
The Congolese health ministry on August 1 said the country was facing its tenth outbreak of Ebola since 1976 (Photo: AFP)Four more people have died from Ebola in eastern Democratic Republic of Congo, two weeks after another outbreak that killed 33 people in the northwest was declared over, the Congolese health ministry has said.Four new deaths from people who tested
Ebola outbreak in DR Congo believed to have killed 33: health ministry
A new outbreak of the Ebola virus in the Democratic Republic of Congo is believed to have killed 33 people in the east of the country, the health ministry said Saturday.