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PHOENIXVILLE — By unanimous vote of the borough council Tuesday night, Trappe Ambulance will take over emergency medical services from West End Fire Company.
Once everything is finalized, Trappe could take over as early as April 1, according to Councilman David Gautreau, liaison to the fire department.
“We weren’t happy with (West End’s) management and we gave them opportunities to make changes but we were dissatisfied with their service,” Gautreau explained following Tuesday’s council meeting.
Trappe Ambulance will enter into a three-year contract with Phoenixville.
“It means a lot,” said Clint Tichnell, Trappe Ambulance’s chief. “It’s going to mean some expansion. We look forward to working with a municipality and a new area.”
About a dozen Trappe Ambulance workers were in attendance at the meeting when the vote took place. When Gautreau announced that the police and personnel committee, which he sits on and is headed by Councilman Mike Speck, recommended Trappe Ambulance, one of the members audibly exhaled in relief just before the 7-0 vote.
Councilwoman Jen Mayo, who had her first baby last week, did not attend the meeting.
Gautreau said the decision came down to the quality of service Trappe provided.
“They take a tender-love-and-care approach,” Gautreau said.
According to Gautreau, Trappe gets to know patients in the area. For example, he said, patients they know of that require oxygen would be checked on in situations like a power outage or a storm to make sure they were alright.
With this addition of coverage area, Trappe Ambulance will likely take on a larger staff.
“Well be adding some full-time positions,” Tichnell said.
He expected the service to expand by roughly 50 percent.
Tichnell said a unit of the company will move into the borough but which building and where they’ll occupy is, as yet, “to be determined.”
According to a press release from Captain Paul Giannini, an “aggressive” search is commencing for a “suitable location” to house Trappe’s first foray into Chester County.
When it came down to it, Gautreau said Uwchlan and Trappe Ambulance were the finalists interviewed.
A few Uwchlan Ambulance employees were in the audience for Tuesday’s meeting.
“It was hard,” Gautreau said. “If it had gone down to Uwchlan getting it, it was fine. We just chose Trappe.”
In the process, Gautreau said he was impressed with the professionalism in the companies he encountered through the search.
As for West End, Gautreau said they might continue serving other municipalities but would not be serving Phoenixville anymore.
In October, West End introduced a new ambulance coordinator, Ron Sigismonti Jr., a 22-year veteran in the paramedic business, at a borough council meeting. However, it seemed too little too late, with council voting the same night to shop for new emergency medical service providers.


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- 1 Construction Injury Introduction for Assonet, Massachusetts
- 2 Building Accidents prevail
- 3 Construction Mishaps can be Complex – Important Information for Assonet, MA 02702
- 4 OSHA Security Laws
- 5 Getting Help with a Construction Mishap Injury in Assonet,Massachusetts
- 6 Get a Initial Claim Review of Your Building and construction Injury
Construction Injury Introduction for Assonet, Massachusetts
Whether on a small project for a private property owner or for a major business advancement, building and construction work can rather unsafe. Undoubtedly, daily building workers need to deal with a few of the most harmful working conditions dealt with by employees in any industry. As a result, serious job-related injuries at building sites occur with a regrettable frequency. Regulations, specifications, examination requirements, and task security programs all look for to prevent building and construction website accidents and promote security awareness on the part of all parties involved in a building project.
Building Accidents prevail
Regardless of these crucial efforts to deal with the difficulty of building website security, accidents happen and will certainly continue to take place, due to both the nature of the work itself and the variety of threats faced by building employees. These dangers can consist of falls from scaffolds and other elevations, being struck by moving or falling equipment, electrocution, health hazards arising from direct exposure to asbestos and chemicals, injuries triggered by malfunctioning or unreasonably hazardous devices, and lifting and carpal tunnel syndrome.
Construction Mishaps can be Complex – Important Information for Assonet, MA 02702
If you or a loved one has been injured as a result of a building and construction accident, the first step in your legal healing is to consult with a competent building lawyer to talk about the scenario. Concerns in your possible case, including compliance with occupational and site safety standards and regulations, engineering problems, and liability and indemnity determinations, all need that your claim be managed by an attorney who is experienced in the area of building and construction accident liability.
OSHA Security Laws
Safety policies under the Occupational Security and Health Act of 1970 have actually been embraced by most states in some type, and these regulations apply to work done at construction websites. The concern of who is responsible for guaranteeing compliance with OSHA guidelines (i.e. basic professional or sub-contractor) frequently switches on who was in control of the job website or job activity when the injured worker was hurt. The legal effect of an infraction of OSHA regulations will vary, depending upon the state in which the building and construction injury took place. In certain jurisdictions, if it can be revealed that an OSHA regulation was breached and an injury resulted, nothing more need be proven to establish that the liable party was negligent.
OSHA policies are not the only legal requirements to which a homeowner, basic specialist, or sub-contractor might be held in determining liability for a building and construction mishap. Typically the homeowner or basic professional will have his or her own set of safety rules, either generally relevant or specific to the building task at hand, created to secure those carrying out deal with the task. Violations of these guidelines might serve to support a claim for a building and construction accident. See OSHA Frequently asked questions to learn more.
Getting Help with a Construction Mishap Injury in Assonet,Massachusetts
If you have actually been hurt as a result of an accident at a building site, there are a variety of things you can do to safeguard yourself and your legal rights:
- Get medical attention for your injuries.
- Report the injury to your company and/or building website manager, and note the name and position of the person alerted.
- Get the names and contact information of anyone who may have seen the mishap.
- If possible, attempt to preserve any proof related to your injury, by taking photographs of the location where you were hurt (and the injuries themselves), or keeping the devices or tool that was involved in your injury.
Get a Initial Claim Review of Your Building and construction Injury
Your next factor to consider should be to discover a lawyer to assist you evaluate your potential claim. More often than not, your case can be won or lost based upon the work done prior to it ever goes to trial, depending upon the results of the examination and fact-finding that your attorney will carry out on your behalf. Thankfully, you can have a preliminary claim evaluation by a certified lawyer free of charge.

domain: law


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Waka Kotahi NZ Transport Agency advises that State Highway 25 between Hikuai and Opoutere will open to one lane this evening to allow light vehicle access over the weekend, after an underslip took out part of the road earlier in the week.
A blessing ceremony led by Dr Wayne Ngata (Te Aitanga a Hauiti, Ngati Ira and Ngati Porou) with support from Mark Kopua and Iwiata Williams this morning has paved the way for construction of a temporary Bailey bridge to replace the Hikuwai #1 bridge, which was destroyed during Cyclone Gabrielle, to get underway from Monday.
Waka Kotahi is working closely with Civil Defence and other central and local government partners to minimise the impact of the closure of State Highway 2 between Tangoio and Tūtira to residents and emergency services.
Two ‘gateway’ sculptures – formally opened today at each end of Ōtaki as part of the State Highway 1 Peka Peka to Ōtaki Expressway (PP2Ō) project north of Wellington – will attract attention to the township and encourage people to exit the new expressway to visit.
State highway links in several areas of the North Island are re-opening as floodwaters recede and slip debris is cleared, but Waka Kotahi is urging people only to travel where and when necessary, and asking those who are travelling to use caution and allow extra time for journeys with restrictions still in place in many areas.
Last night Waka Kotahi NZ Transport Agency restored access to areas of the Coromandel when State Highway 25 reopened from Thames to Matarangi around the east coast, but this is for essential travel only and extreme caution is advised.

domain: travel


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Hello everybody, welcome to my recipe page, if you’re looking for Coconut Pecan Candy or Frosting recipe, look no further! We provide you only the best Coconut Pecan Candy or Frosting recipe here. We also have wide variety of recipes to try.
Before you jump to Coconut Pecan Candy or Frosting recipe, you may want to read this short interesting healthy tips about Techniques To Live Green And Spend less Money In The Kitchen.
Remember when the only men and women who cared about the environment were tree huggers along with hippies? Those days are over, and it looks like we all recognize our role in stopping and conceivably reversing the damage being done to our planet. The experts are agreed that we are unable to transform things for the better without everyone’s active contribution. Each and every family ought to start creating changes that are environmentally friendly and they have to do this soon. Here are a few tips that can help you save energy, for the most part by making your cooking area more green.
Perhaps the food just isn’t quite as good when cooked in the microwave, nevertheless it will save you money to use it over your oven. If you find out it will take 75% more energy to cook in the oven, you could possibly look for more ways to use the microwave. Compared with your stove, you can make boiled water or steamed vegetables faster, and use considerably less energy, by using countertop appliances. Many individuals incorrectly believe that doing the dishes by hand uses less energy than a dishwasher. You get the highest energy savings by fully loading the dishwasher just before commencing a wash cycle. Save even more money by air drying as well as cool drying your dishes rather than heat drying them.
From the above it should be apparent that just in the kitchen, by itself, there are many little opportunities for saving energy and money. It is pretty uncomplicated to live green, after all. Mostly, all it requires is a bit of common sense.
We hope you got benefit from reading it, now let’s go back to coconut pecan candy or frosting recipe. You can cook coconut pecan candy or frosting using 10 ingredients and 10 steps. Here is how you achieve it.
The ingredients needed to cook Coconut Pecan Candy or Frosting:
- Provide of For Candy:.
- Take 2 1/2 cups of granulated sugar.
- Get 1/2 cup of evaporated milk.
- Use 1/2 cup of corn syrup.
- Use 1 stick of real butter.
- Prepare 2 cups of shredded coconut.
- You need 1-2 cups of pecans. Put as little or many as you like.
- You need 1 teaspoon of vanilla extract.
- Use of Notes:.
- You need of You can drop like a cookie or pour into pan and cut into squares.
Instructions to make Coconut Pecan Candy or Frosting:
- Line a baking sheet or pan with wax or parchment paper. Set aside..
- In a heavy bottom saucepan, mix sugar, evaporated milk, corn syrup and butter..
- On medium high heat, stir until mixture comes to a rolling boil..
- Without stirring, let mixture boil 5 minutes or to 235 on a thermometer. Soft ball stage..
- After time is up, remove from heat and add vanilla..
- Stir then add coconut and pecans..
- Stir off heat about 5 minutes until mixture starts to thicken some..
- Drop by spoonfuls onto wax paper lined baking sheets. Or you can pour mixture into pan and cut..
- When completely cool, store in layers with wax paper between to keep from sticking..
- If using for frosting, let cool stirring occasionally until it thickens and is spreadable. Put in between layers of cake or frost 9×13 cake..
Coconut Macadamia Bites are candies made with toasted coconut and macadamia nuts, caramelized sweetened condensed milk & salt drizzled. Easy Candied Pecans are the perfect sweet and salty snack, gift, or salad topper! They're quick to make and the perfect garnish for sweet and savory dishes! Glazed or candied nuts of any sort are really easy to make. I have a fantastic Glazed Macadamia Nut Recipe here on my site that is.
If you find this Coconut Pecan Candy or Frosting recipe helpful please share it to your friends or family, thank you and good luck.

domain: food


How can I bluetooth my old printer?
May 7, 2005 3:19 PM Subscribe
I've got an old laser printer (with parallel and USB ports) which still works really well. But it's big and ugly and I'd like to move it into a cupboard, and print wirelessly. I thought this would be really easy to do, but there doesn't seem to be many options on the market? Has anyone done this?
posted by ascullion to Computers & Internet (5 answers total)
By the way, there's no bluetooth on the printer, but there is on my main PC and my laptop.


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The tuxedo ... the corsage ... the King and Queen and their court ... the alcohol test ...
Wait, scratch that last one from the prom memory bank. Students and their guests attending Saturday's prom in Perham will not be subjected to a breath test, after all.
The Perham Focus reports organizers of the high school prom have changed their minds about their plan to ensure the sobriety of prom attendees. The decision came after a talk with the school district attorney inspired by a letter from the American Civil Liberties Union of Minnesota.
Word spread quickly last week that the school in Otter Tail County planned breath tests as a way to detect any underage drinking by those attending the prom.
This week the ACLU argued that subjecting students to such testing implied that they were guilty until proven innocent. The organization sent a letter to the superintendent of the Perham-Dent school district, Mitch Anderson, reminding him that the U.S. and Minnesota Constitutions protect Americans from searches unless there is reasonable suspicion that a law was violated. Anderson tells the Focus prom organizers decided soon after receiving the ACLU's letter to skip the alcohol test and rely on chaperones and security guards to spot any students who've been drinking.
Anderson says the plan never involved having students breathe into a device. Instead, prom guests would have filed past a sensor that can detect alcohol in the air.
Forum News Service checked with school districts in the Fargo-Moorhead area and found that use of such passive screening devices – and in some cases Breathalyzers – is not uncommon at high school events.
The legal director of the ACLU-MN told the news service the group is pleased that the Perham district reconsidered its plan to test students.

domain: news


Rosemount 2160 Wireless Level Switch - Joe Willson
Joe Willson introduces the Rosemount 2160 wireless level switch and explains how the proven advantages of the Rosemount vibrating fork switches has been combined with Emerson’s wireless expertise.
Getting to Know Emerson’s Engineered Solutions Provider Program
Original Equipment Manufacturers (OEMs) committed to staying ahead of the technology curve and optimizing their operations through automation and instrumentation have questions. Emerson’s Engineered Solutions Provider program has answers.
Spurring Innovation – Rocket Lemonade
Product Updates: DeltaV™ DCS Cybersecurity Enhancements
DeltaV™ v14 gives you a new level of confidence and protection from cybersecurity threats by being one of the only systems to have a top-to-bottom cybersecurity certification. DeltaV™ v14 will be certified ISASecure SSA Level 1 and IEC 62443 com..
Emerson Exchange 2018 Highlights
Fortschrittliche Diagnose von Durchflussmessungen für ein ruhiges Gewissen
German version of the Rosemount(tm) video showcasing the 8700 Magnetic Flow Meter Portfolio and ATEX and NAMUR certification.
Rosemount™ X-well™ Technology: How It Works
You'll get 65% reduction in engineering design time, 70% reduction of installation time and fast, efficient commissioning. Rosemount™ X-well™ Technology is an accurate, non-intrusive way to quickly add temperature measurement points to your proce


Betonex partners with Metso for Algeria quarry facility
Betonex is an aggregates company that maintains three concrete plants producing slabs and blocks, as well as ready-mix products. The crushing and screening technology from Metso that will outfit their new plant is expected to reduce dust and build processing capacity.
"Aggregates production is the epicenter of our business, and a large part of the aggregates we produce is used by the sister companies of Benseba Group,” Karim Benesba, associate manager for Betonex, said. “This is our main reason for investing in a new Metso installation, but we also want to become a major supplier to the construction industry in the region. Housing construction programs, the Hauts Plateaux highway, and the new expressway between Anhif and Bejaia reflect the will of the government to make this a priority. We compared the production performance of our first crushing station, investment and operating costs. We expect the same quality aggregates that are produced in Europe while maintaining affordable prices for the local markets. We want to be a reference for our clients. Metso's process design with this new crushing and screening installation will supply not just a quarry, but a real aggregates production center.”
The plant will have three tiers and be capable of processing 500 tons per hour, and many of the components being installed are firsts for any Algerian facilitiy, such as Metso's Nordberg C120 jaw crusher and a PREMIER ES horizontal screen.
Benesba said the facility will help the company address demand for aggregate products in a country where building and development projects continue to outpace the production of supplies.


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Always read the label and follow the directions for use. Read the warnings before purchase.
NutriVital Natural Vitamin E 500IU is an antioxidant which helps protect cells, membranes and tissues from free radical damage. Also supports immune system health and maintains wound healing.
Adults: Take one capsule a day with water or as directed by your healthcare professional.
Each capsule contains:
equivalent to natural vitamin E 500IU
Contains sulfites and phenylalanine.
Dairy, gluten, fish, crustaceans, tree nuts, peanuts, eggs, sugars, artificial colours, flavours, sweeteners and preservatives.
Vitamins and minerals can only be of assistance if dietary intake is inadequate.
If symptoms persist, talk to your healthcare professional.
Always read the label. Follow the directions for use.
Phenlyketonurics - this product contains phenylalanine.

domain: medical


Fifty-five years have past since the United Nations set forth the specific framework for resolving the Palestinian refugee case. On December 11, 1948, the UN
adopted resolution 194, affirming their right to return to their homes of origin, property restitution and compensation for losses and damages. Palestinian refugees should be free to seek their right to repatriation, regardless of what negotiators acquiesces to. Rifat Odeh Kassis comments.


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Diana Fernández vs. Lourdes ‘Lulú’ Juárez
Josué Neri Santos Municipal Auditorium, Ciudad Juárez, Chihuahua, Mexico – 16/7/21
Number one ranked of the World Boxing Council in the super flyweight division, Diana ‘La Bonita’ Fernández, is metallized in conquering the world super flyweight title
She fights the champion Lourdes ‘Lulú’ Juárez on July 16 and it will be broadcast throughout Latin America through ‘ESPN Knockout’.
She is assured and bolstered by her extraordinary physical shape and how much her boxing has evolved in her last fights;
Fernández has fully dedicated herself to total training because she knew that the opportunity to contest the title would come soon.
She’s ready to face the world champion at the Josué Neri Santos Municipal Auditorium in Ciudad Juárez, Chihuahua, Mexico.
“This time I receive the opportunity in my division, which is super flyweight, at the best moment of my professional career and above all with the support of my people; I am going to be world champion,” she vowed..
“I have a great champion in front of me, a boxer that I already know but who has also grown a lot since the last time we faced each other.
“A great fight between the two best in the world today and it will be an honor to fight in my city and win the championship.”
The card is presented by Promociones del Pueblo in association with BXSTRS Promotions.
(by Kristian von Sponneck)
Subscribe to our new YouTube Channel starting soon with the latest boxing news and results, gossip and information from around the world. Just click the image link below:
For the list of boxing events we will cover live with and with unofficial scorecard (main event), click the following link > Live Boxing Results & Events<

domain: sports


text: Square wooden seat bar stool high chair kitchen counter metal rustic intended for stools decor. Yaheetech x vintage rustic kitchen pub bar stools set with black intended for metal idea. Metal breakfast bar stools industrial kitchen stool intended for idea. Bar stools metal and wood stool modern kitchen intended for plans. Metal kitchen bar stools with regard to design.

domain: design


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In Waikato Hospital, a newborn baby attacked by a dog in a Hamilton household has died.
In the incident at around 7 p.m. on Sunday in the Hamilton suburb of Enderley, the child, understood to be just a day old, sustained serious injury.
The baby was rushed by St John Ambulance to Waikato Hospital and was in critical condition on Monday evening in the Neonatal Intensive Care Unit of the hospital.
The identity of the infant and the breed of the dog are undisclosed.
Hamilton City Council animal care officer Susan Stanford said in a statement on Monday that her employees had been contacted by the police shortly after the incident.
“Staff collected the dog and it is now secured at the council’s animal control facility,” she said.
“Further decisions regarding the animal will be informed by the ongoing police investigation.
“This is a traumatic time for all involved and our thoughts are with the families and individuals involved.”
The death was referred to the coroner.


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SPRINGFIELD, MO — Back by popular demand, the Evangel University Auxiliary will once again be holding its Colossal Garage Sale on May 15-18, 2019, in the Mabee Student Fitness Center on the northwest side of the campus.
Clothing, small appliances, jewelry, books and office items, toys, furniture and other household goods will be among the items for sale.
“A very nice bedroom set and mattress were given to us for the sale,” said Marilyn Quigley, one of the retired faculty members volunteering this year.
Evangel’s library also donated VCRs, cameras, tape recorders and other hard-to-find electronic devices.
The event will help raise funds for academic projects funded by the Auxiliary.
The sale will last four days:
• Wednesday, May 15 — 8 a.m. – 5 p.m.
• Thursday, May 16 — 8 a.m. – 5 p.m.
• Friday, May 17 — 8 a.m. – 5 p.m. — 1/2-PRICE DAY
• Saturday, May 18 — 8 a.m. – noon — $5-A-BAG DAY
Saturday is BAG SALE day, where shoppers will be able to fill a provided bag for $5!
For additional information, call Jeanine Bartels at 417-631-7052.
“Since the beginning of Evangel in 1955, the ladies of the Evangel Auxiliary have been a constant support by volunteering time and talents,” said Dr. Michael Kolstad, vice president for university advancement.
“Their earliest efforts provided curtains and furniture in the dorms for our very first group of students.”
The Ladies’ Auxiliary has been holding an annual fundraising sale since 1964. In 1980, they held the first all-college sale in the gym with clothing and things donated or left behind by the students.
Major projects funded by the EUA have included the Heritage Room in Riggs Hall, the massive Schantz Pipe Organ in the chapel, the second and third floor lobbies of Trask Hall, lighting and stage curtains for the Barnett Fine Arts Theatre and uniforms for Evangel’s marching band.
The Colossal Garage Sale went on hiatus after the 2014 event, and was revived in 2019, with an influx of younger members of the Auxiliary.
Evangel University, which includes Assemblies of God Theological Seminary, is a comprehensive Christian university committed to excellence in educating and equipping students to serve the church and society globally. Evangel serves more than 2,100 students from all 50 states and numerous foreign countries, offering 65 undergraduate majors and 19 master’s and doctoral degrees.


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You are now entering the Caldwell & Orkin – Gator Capital Long/Short Fund website.
If you do not want to continue, click “Cancel”. Otherwise, click “Proceed”.
Thank you for your investment in our fund(s). Please click on the fund(s) you are invested in to view your private investor portal.
We’ve owned Voya Financial since its IPO in 2013 and believe it represents an extraordinary opportunity at current prices around $31. Voya Financial is the old U.S. subsidiary of ING, the Dutch insurance company. ING needed a bailout from the Dutch government during the financial crisis. One of the conditions of the bailout was ING had to divest its US operations. So, after renaming the subsidiary Voya, ING sold a stake through an IPO in 2013 and sold off the rest of its stake through a series of secondary offerings in 2013-2015. ING no longer owns shares in Voya.
Voya has been undergoing a transformation for the last several years and management has already made significant progress. Rod Martin joined Voya in 2012 from AIG. At AIG, he ran the life insurance operation and helped to exit several lines of business to improve returns. His mission at Voya has been similar, and he has made significant progress. He has refocused Voya on higher return businesses. He has raised return thresholds in capital intensive businesses. He has also showed a commitment to returning capital to shareholders instead of expanding low return insurance businesses such as term life.
Management has focused on improving returns by reducing capital intensity and cutting costs. At the company’s IPO, management set the goal of improving the company’s return on equity (ROE) from 8.3% in 2012 to 12% to 13% by 2016. One of the main tools Voya’s management has used to improve returns is to change the company’s focus from top-line growth and market share ranking towards measuring risk-adjusted returns, growth in distributable earnings, and sales with above target returns.
Management was able to hit their 2016 ROE goal two years early by posting a 12.1% ROE in 2014. At the company’s 2015 Analyst Meeting, management raised the bar by setting a 2018 ROE target of 13.5% to 14.5%. To hit the 2018 ROE target, management has begun focusing on reducing costs by reducing the complexity of Voya’s operations. We believe this improvement in ROE is important for driving the company’s stock price and valuation higher.
Voya’s valuation is very cheap. If you look at the graph below, you can see Voya currently trades at just under 0.6x book value. For the majority of the time since its IPO, Voya’s stock has traded 80% to 90% of book value. Voya would have to increase 40% just to get back to this valuation range. Voya has steadily increased its book value since coming public through retained earnings and repurchasing stock at a discount to book value. The large step up in book value at the end of 2014 was due to reversing the valuation allowance for its deferred tax asset. In the graph, we see that Voya’s stock price peaked last summer but its book value per share continues to grow.
Source: Company reports, Bloomberg.
As mentioned, Voya management has had a strong commitment to returning capital to shareholders. In less than 3 years since its IPO, Voya‘s management has repurchased 20% of the company’s shares. For example in 2015, the company spent almost $1.5 billion to repurchase 12% of shares. We expect the company to repurchase a similar dollar amount in 2016. With the stock at its current discount to book value, we expect the repurchases this year to help drive book value higher.
We believe as Voya reports increasing returns on capital, continues to run-off of the closed block of variable annuity policies, and continues to repurchase shares that Voya’s stock price will approach its $58 book value.
Disclaimer: The discussion of any security is meant solely as an illustration of our investment and thought process and should NOT be considered as a recommendation or suggestion to buy or sell any securities. Before you make any investment, do your own research and talk to your own financial adviser. Information in this report is received from external sources. Therefore, we can make no guarantee as to the completeness or accuracy of the information provided.

domain: finance


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"Two of the most outstanding services I can supply to your overall business picture are clarification and direction, without which your business will not succeed."
"I use clear, concise, compelling language and images to communicate the benefits of your products and services."
"A website must be designed from the point of view of your client and the emotional experience they garner from it. Every point of contact with the site must fulfill this requirement. "
"Hi, my name is Gerard. Isn't it time your business made an impact on the web? I can help. Let's chat."
A SEASONED PROFESSIONAL
(207) 233 - 4837
From smoky pool halls to award-winning writer and designer, Renaissance Man, Gerard Bianco combines his artistic talents and business savvy to conjure creative impact for his clients. He is founder of Storyteller Marketing, a full-service marketing firm, specializing in website design and copywriting.
His many talents included: jewelry designer, graphic designer, illustrator for firms such as Merrill Lynch and entertainment illustration. He’s also painted portraits for the U.S. Navy. His published books - a mystery/thriller, a full-length play, and a collection of short stories can be seen and purchased on Amazon.
30+ years of business savvy and design expertise, coupled with an author's mastery of words, make Gerard Bianco your number-one choice for marketing, website design, and copywriting strategies that work.
Here is his 4-Phase Marketing Strategy:
Fist Step is DISCOVERY - Offers clarification
Second Step is PLANNING - Offers direction
Third Step is IMPLEMENTATION - Compelling Website Design combined with persuasive copywriting result in creative impact that will motivate people to look at, think about, and purchase your products and services.
Fourth Step is ANALYSIS - Allows you to see how your marketing is working, allowing for adjustments to garner maximum results

domain: artistic


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Matthew Vella from Capsule Computers wrote :
The most amazing thing about The Amazing Spider-Man by Gameloft is how surprised I am. It should be referred to as The Surprising Spider-Man from now on. Movie tie-ins are generally considered to be really average or sucky games, and on mobile devices they tend to be some of the worst crap you could ever possibly play. But Gameloft have lived up to their reputation of providing high-quality hardcore games for mobile devices, and delivered a solid title reminiscent of the classic Spider-Man 2 web-heads fell in love with back in 2004. What’s even more surprising is that while this is the 2nd Spider-Man title by Gameloft, they actually went back to the drawing board and pretty much reinvented the gameplay all together resulting in a very, very different type of game. While it isn’t perfect, The Amazing Spider-Man is easily one of if not the best movie-based mobile game I’ve played and is definitely worth picking up if your a Spider-fan!

domain: entertainment


Photographs by Seitu Oronde
On Monday, February 15th, 2021 at 10 am, thousand’s of mourners pay respects to Cicely Tyson in Harlem, NY.
Admirers lined up outside the famous Abyssinian Baptist Church at public viewing on a wintry New York morning.
Thousand’s of mourners lined a New York City block in Harlem on Monday, to pay their respects to Cicely Tyson at a public viewing.
On a wintry New York morning, admirers of the pioneering Black actor lined up outside the famous Abyssinian Baptist Church. Some said they had come from as far as Atlanta or Los Angeles.
Many in the multigenerational crowd held photos of Tyson, who died on 28 January, aged 96. Her family said masks and social distancing would be required at the viewing.
Tyson was the first Black woman to have a recurring role in a dramatic television series, the 1963 drama East Side, West Side.
Her performance as a sharecropper’s wife in the 1972 movie Sounder earned an Oscar nomination.
She went on to win two Emmy awards for playing a 110-year-old former slave in the 1974 television drama The Autobiography of Miss Jane Pittman and another 20 years later for Oldest Living Confederate Widow Tells All.
At the age of 88, Tyson won a Tony award for a revival of Horton Foote’s The Trip to Bountiful in 2013.
In 2016, President Barack Obama awarded her the medal of freedom.
Click here to find more about Seitu’s World.
We want to hear what you think about this article. Submit a comment below or write to firstname.lastname@example.org.


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The app requires a GScore of around 600 to unlock the 10000 credit limit to unlock the feature. You just have to keep on using the cash-in feature to increase your score.
How can I use my GCash credit balance?
Pay Bills. Pay Online. Pay QR. Purchase in GLife. Backup Payment Option for Google Playstore and Apple Store purchases.
How do I know if I am eligible for GCredit?
You are 21 to 65 years old. You are a Filipino citizen. You have fully-verified your GCash account. Visit How do I get Fully Verified? to learn how to fully verify your GCash account.
What is available credit in GCash?
GCredit is a revolving mobile credit line available on the GCash app which may be used as another payment option for your purchases. Once eligible, you will be given a credit limit that you may consume and replenish every time you pay off your balance with the corresponding interest. GCredit.
What is the GScore for 10000 GCredit Related Questions
What is the highest credit limit in GCredit?
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text: Mt. St. Helens is in Washington State (about 90 miles from where I am typing this) and is part of the Cascade range. The Cascade Mountains are young in geologic terms, and growing. They were created by a giant subduction zone where the Juan de Fuca plate is subducted (forced under) the North American continental plate, which is forced upward. The resultant heat and magma that is generated is pushed and formed along vents, and Mt. St. Helens was built over time from a long series of these lava producing eruptions. So in other words, it is constructive forces that made the mountain.

domain: geography


text:
The rapper maintains his innocence as part of the special plea, which cannot be used against him in a civil lawsuit.
The plea was entered by West's attorney and the Grammy-winning artist was not in court for the hearing.
Judge Alan Rubin sentenced West to 24 months on informal probation and 250 hours of community service.
He has also been ordered to attend 24 anger management sessions.
West was charged with battery and attempted theft over the altercation with photographer Daniel Ramos at Los Angeles International Airport last July.
Mr Ramos claimed West punched him in an unprovoked attack and wrestled him to the ground.
After the alleged incident, Mr Ramos received hospital treatment for an injured hip.
Prosecutors declined to file felony charges against West, but city prosecutors decided to pursue misdemeanour charges.
Each count carried a penalty of up to six months in jail or a $1,000 (£600) fine.


text:
Robinson Cano is the most dangerous hitter on the Yankees these days, and as we discussed before the season began, Cano has the makings of the next great Yankee: He can hit for power and for average, he’s finished in the top six of the MVP voting in each of the last six years, and at 29 years old, he’s in the prime-iest part of his prime.
Cano has taken on a more prominent role in the Yankees’ lineup this year (more than three-quarters of his at bats this year have come from the No. 3 or No. 4 spot in the lineup), and the results, over the past month especially, have been impressive.
Cano’s numbers through the end of May this year were strong, if not necessarily the best of his career: a .291/.346/.508 slash line with eight home runs in 50 games. But his June was superb: In 27 games, Cano batted .340, hit eleven homers, and posted an OPS of 1.146. This kind of thing isn’t an exact science, of course, but if it’s true that baseball players really do tend to peak around age 29 or 30 (as the Baseball Prospectus article linked above found that they do), then the next few months (and really, the next couple of seasons) should be a lot of fun to watch.
Cano’s July is off to a pretty great start, too, by the way: Yesterday, in a win over the White Sox, Cano went 2-for-4, including a two-run homer in the third inning that gave the Yankees a 4-2 lead. (They’d go on to win by that 4-2 score.) Meanwhile, he was announced as the starting second baseman for the American League All-Star team, the fourth time he’s been selected for the team. He’s on pace to crack 30 home runs for the first time this year. For that matter, he’s also on pace to crack 40 homers for the first time.
Perhaps it’s unwise to make grand proclamations about a player in the middle of such a scorching hot stretch, just like one shouldn’t evaluate a team during a winning streak and expect that such a level of play can continue indefinitely. But it’s reasonable to expect Cano to play some of the best baseball of his career this season, and over the last month, he’s done just that.


text:
by Amy Hautman Bates
Three pieces from my recent series are hanging in the entryway at Southwestern College this week. Sometimes Art Therapists will tell you the therapy is in the process, not in the finished painting. For me, it is in both.
When I paint, I rarely consciously plan anything. The canvas comes out, a certain brush feels right and paint gets carefully mixed until it is the perfect color for loading my brush and smearing on the canvas. Very little analytical thinking is happening. When painting is working for me, it flows easily. It feels like pure, raw, unadulterated soul. I have no sense of time or place. It just happens… like magic.
I usually go back later to reevaluate and rework some things. Sometimes a painting is done in one session, but often I restudy a piece for years. I try to make improvements and quite frequently, I drive the whole thing into the ground and ruin it. But that’s okay.
I recently visited my ninety year old artist mother. We painted together and I saw that now that she is less steady with a brush she preferred smudging the paint around with her fingers instead.
When I got home, I wanted to try that. I added sand to my oil paint for texture and then smooshed and smeared it around until I liked the composition. Then I went in with a scraping tool, a brush and finally oil pastel sticks. The tactile experience was nearly as exciting as the visual one.
After I had a series of oil paintings that felt like a complete set, I studied the work to find its meaning. I had no preconceived ideas about what these paintings would convey. I look for the messages afterwards. On different days, I see them different ways. Today, they mean this, to me.
Here is a 3 minute video of my paintings tracking the exploration of myself as peacekeeper and what parts of myself I suppress in order to maintain peace.


Ferris Sports Update 2.16.22
In this episode of Ferris Sports Update, host Rob Bentley speaks with Men's Basketball Head Coach Andy Bronkema about the team's recent game against Lake Superior State University. Then, Bentley talks to Women's Basketball Head Coach Kurt Westendorp about their win against Lake Superior State University. Finally, a conversation with Senior Hockey Defenseman Brendon Michaelian about the two recent hockey games also against Lake Superior State University.
Tune in every week for new episodes!


text:
Peanut Butter Rice Krispy Squares
FROM BECKY TURNER '16/G'18, DIGITAL/SOCIAL MEDIA SPECIALIST
These squares are made in my house only for the Super Bowl as part of our day of amazing snacks. What I like best about these squares is not only the peanut butter, chocolate chips, and sprinkles, but that you can customize the squares to your liking—I mean, there's no such thing as too many sprinkles.
What You'll Need:
- 6 tablespoons unsalted butter
- 16 ounces mini marshmallows
- 1/2 teaspoon kosher salt
- 6 tablespoons peanut butter
- 2 teaspoons vanilla extract
- 6 1/2 cups crispy rice cereal
- 2 1/2 cups coarsely crushed graham crackers (about 9 rectangles)
- 1 cup milk chocolate chips
- 1/4 cup rainbow sprinkles, plus more for decorating
Line an 8-inch square baking dish with parchment paper, allowing 1-inch wings to hang over the edges; set aside.
In a large pot over medium heat, melt the butter. Add the marshmallows and salt and cook, stirring, until the marshmallows are melted and smooth. Remove from the heat and stir in the peanut butter and vanilla (the peanut butter can still be swirly).
Add the cereal, crushed graham crackers, chocolate chips and sprinkles and fold with a large rubber spatula to combine.
Pour the mixture into the prepared baking dish, using the spatula to spread it out evenly. Place a piece of parchment on top and then use your hands to press the mixture down very firmly. Top with additional sprinkles as desired.
Let the mixture firm up in the refrigerator for 1 hour, then cut into squares.


text:
Fillings can be whatever happens to be knocking about in the fridge* – as long as they're cooked: nothing will have time to cook through. Two tips: always add a little water to the eggs while beating them, and never add any salt until they start to set in the pan. For a good crust and a melting interior, make sure the butter in the pan is nut-brown before introducing the eggs, and have your filling and garnishes ready to go.
extra virgin olive oil
40g unsalted butter
4 slices quality smoked ham (check gluten free if required)
80g freshly grated gruyere
freshly ground black pepper
1 tbsp chopped flat-leaf parsley
40g freshly grated parmesan
1. Gently beat together the eggs and 2 tablespoons of water with a fork. Heat a non-stick 22cm frying pan on the stove. When hot, add a dash of olive oil and the butter.
2. When the butter is bubbling and just turning a nut-brown colour, add the egg and stir from the outside inwards with a rubber spatula. Keeping the heat high, cook until the inside of the omelette is still a little undercooked, then add the ham. Sprinkle the gruyere, sea salt, ground pepper and parsley over the middle third of the omelette.
3. Scatter about two-thirds of the parmesan over the whole omelette. Fold one-third of the omelette into the centre, then the second, encasing the ham and cheese. Allow the omelette to cook for a further minute before removing from the heat.
4. Transfer the omelette to a chopping board, cut in half and place each half on a plate – brown side up. Sprinkle over the remaining parmesan, add more pepper and drizzle with olive oil. Serve immediately.
*Use smoked salmon instead of ham, any greens like zucchini or asparagus, mushrooms (of course!) and cheese (absolutely!) – the list is endless.
Find more of Neil Perry's recipes in the Good Food New Classics cookbook.


Winter Nights: FARGO
The Indianapolis Museum of Art held a special winter movie night for the first time ever Friday.
Guests were invited to bring folding chairs and blankets to sit outside in the Alliance Sculpture Court for a screening of “Fargo.” The man behind the idea is the museum’s director who is from Minnesota. He said along with the “Fargo” theme, you are encouraged to dress like a Minnesotan to embrace the cold. “We are going to have a Minnesota accent contest, somewhat kind of related to the film. We are having a Minnesota dress contest so people can interpret that however they like. We are also having a Minnesota trivia contest,” said Scott Stulen, IMA curator of Audience Experiences and Performance. Any audience member who can provide documented proof that they lived in Minnesota will receive priority seating and VIP service for the screening.


text:
Emerging topics in FXTAS
Journal of Neurodevelopmental Disorders volume 6, Article number: 31 (2014)
This paper summarizes key emerging issues in fragile X-associated tremor/ataxia syndrome (FXTAS) as presented at the First International Conference on the FMR1 Premutation: Basic Mechanisms & Clinical Involvement in 2013.
It has been over a decade since the fragile X-associated tremor/ataxia syndrome (FXTAS) was discovered. The clinical description of this new condition placed the disorder into the family of movement disorders. Movement disorders are neurological syndromes in which there is either an excess of movement (referred to as hyperkinesias, dyskinesia, or abnormal involuntary movements) or a paucity of voluntary and automatic movements (hypokinesia). Movement disorders are classified by their motor phenomenology. While many movement disorders have predominantly one type of abnormal movement, several diseases characteristically manifest a combination of abnormal movements. Because of the variety of motor phenomenology in FXTAS, patients with this condition are considered within the combinational movement disorders. In FXTAS, Parkinsonian and cerebellar features were initially described, but continued research suggests the disorder also includes non motor features, such as autonomic features, peripheral neuropathy, and neuropsychiatric manifestations.
The current definition of FXTAS is that it is caused by a premutation size expansion (55 to 199 CGG repeats) in the fragile X mental retardation 1 (FMR1) gene. Full expansions of more than 200 CGG repeats in FMR1 results in methylation and transcriptional silencing of the gene. Full mutation carriers have fragile X syndrome, which is characterized by intellectual disability, seizures, and autism with onset in childhood.
Unlike many other genetic disorders, the genetic abnormality that causes FXTAS was described and characterized before the discovery of the movement disorder. This has enhanced the ability of clinicians who identify children with fragile X syndrome (FXS) to rapidly identify parents and grandparents who may have FXTAS. It has also catalyzed the research in this disease. This paper is a summary of progress that has been made more recently in FXTAS and encompasses definitional changes, findings in women, classification of the cognitive disorders, measurement of clinical features, and report of data from the first clinical trial in the disorder.
Expanding the FXTAS phenotype
The initial description of FXTAS consisted of a neurodegenerative disorder in premutation carriers, mostly in men over age 50, characterized by intention tremor, cerebellar gait ataxia, and parkinsonism, as well as brain atrophy and often middle cerebellar peduncle hyperintensities (the ‘MCP sign’) on magnetic resonance imaging (MRI) scans [1–4]. Diagnostic criteria , as shown in Table 1, were proposed based on this, with the addition of the neuropathological hallmark, intranuclear inclusion bodies , soon after. These diagnostic criteria have been helpful in clinical practice and research to identify affected persons [6, 7].
Since then there has been an enormous amount of literature suggesting that the disorder has additional features, as shown in Table 2. Further, some evidence suggests that REM sleep behavior disorder  and small fiber painful neuropathy  also occur in FXTAS. Thus, the original diagnostic criteria may be inadequate to best identify affected persons and need to be updated [4, 9, 10]. Indeed, given the accumulating literature, illness associated with the FMR1 premutation includes a spectrum of disorders, depending on stage of life . FXTAS, with core signs of action tremor and cerebellar gait ataxia, is a degenerative syndrome that occurs in late life and is the most severe end of this spectrum.
Several additional clinical features may also occur in non-FXTAS carriers, do not presage the disease, and are not specific for FXTAS, such as chronic muscle pain, hypertension, and anxiety. However, these nonspecific signs often occur in early stages, and typical signs of FXTAS may be absent until more advanced stages. Of note, the expanded FXTAS clinical phenotype includes women, who tend to present differently than men as discussed in the next section.
Two major new findings in persons with FXTAS have been reported. A peripheral neuropathy has been known to be associated with FXTAS since the first cases. Apartis et al., found that a non-length dependent neuropathy is found in 56% of premutation carriers with FXTAS. Thus, neuropathy is common enough to be a minor clinical diagnostic criterion, but too non-specific and common in the aging population to be classified as a major criterion. The same group  found that MRI T2 hyperintensities in the splenium of the corpus callosum splenium (CCS) were as frequent as MCP hyperintensities, and were useful in identifying patients who had no MCP sign (Figure 1). Therefore, CCS hyperintensities should be an additional major MRI criterion for the diagnosis of FXTAS.
FXTAS was initially described in FMR1 premutation carriers. Recent reports, however, have shown that individuals carrying a gray zone [32, 33] or full mutation without methylation  have developed a classic FXTAS picture, and thus would meet diagnostic criteria except that they were not premutation carriers. The pathologic mechanism that is proposed to underlie FXTAS is FMR1 mRNA mediated neurotoxicity due to elevated levels of expanded repeat mRNA in the premutation range. Studies have shown that increased levels of mRNA levels begin in the gray zone [35, 36]; this likely accounts for FXTAS occurring in individuals with these smaller alleles. Likewise, the occurrence of FXTAS in association with a full mutation was seen in a patient with an unmethylated allele ; and FMR1 mRNA is significantly elevated in carriers of unmethylated full mutation alleles . Given these findings, the diagnostic criteria for FXTAS need to be amended to allow for the diagnosis in individuals carrying gray zone or unmethylated full mutation alleles.
The current estimation of the prevalence of the tremor/ataxia phenotype in premutation carriers older than 50 years is 40% in men and 16% in women, recruited through families with known fragile X syndrome probands [19, 38, 39]. With recognition of the expanded phenotype and revision of the diagnostic criteria, identification of FXTAS will be increased. This allows earlier diagnosis and management of patients and their relatives, and is important because family members can be educated regarding their genetic and medical risks.
FXTAS in women
The first carrier women of a FMR1 premutation with FXTAS were reported in 2004 . More women with FXTAS have since been described and FXTAS is now estimated to occur in 8 to 16% of premutation carrier women older than 50 years [6, 19, 39]. However, penetrance appears to be higher when there is a family history of FXTAS or other premutation problems such as immune mediated disorders [40, 41]. As in men, the penetrance of FXTAS may increase with age in women, but this is less well documented . Reduced penetrance in women is likely due to the protective effect of their normal allele on the second X-chromosome.
Women with FXTAS may be as severely affected as males, but in most women symptoms may vary in several respects from the original diagnostic criteria . Women with FXTAS tend to have less tremor, ataxia, white matter disease and brain atrophy on MRI. In only 13% of females affected with FXTAS was the MCP sign observed . In a small group of women affected with FXTAS (without a family history of FXS), the MCP sign was lacking in all patients and hyperintensities in the pons were less frequently observed . In half of the women, hyperintensities of CCS were present. Some of the affected women presented with prominent parkinsonism .
Less dementia in late stage FXTAS has been reported in women [13, 42], but a recent study suggests that dementia could be more common than initially described . In this study, neuropathological findings in most premutation carrier women with dementia included cortical amyloid plaques and neurofibrillary tangles, making Alzheimer disease (AD) a possible cause of their dementia. The authors suggested that a synergistic effect could cause the disease progression in some FXTAS cases.
In contrast to premutation carrier men, medical co-morbidities are more common in women both with and without FXTAS. A higher incidence of hypothyroidism and fibromyalgia is reported in women with FXTAS than in men with FXTAS and age-matched controls [24, 35]. Peripheral neuropathy, seizures and hypertension are also reported to be present more often in females with FXTAS than in controls [18, 19]. Presence of FXTAS and other (neurological) disorders such as multiple sclerosis have been described in some carrier women [44, 45]. Interestingly, although approximately 20% of carrier women have primary ovarian failure , one study reports that it is not associated with later onset of FXTAS .
Emerging issues in clinical classification of cognitive disorders in FXTAS
Over 50% of patients with FXTAS show cognitive and behavioral changes, including impairment in executive function, processing speed and mood dysregulation, and increased risk for mood and anxiety disorders [8, 13, 15, 16, 31, 47–49]. Additional features of apathy, disinhibition, and impairments in behavioral regulation suggest widespread dysfunction of the prefrontal lobe and its connections [12, 16, 50]. Collectively these features are consistent with the fronto-subcortical involvement that is commonly seen in association with other movement disorders including Parkinson disease (PD) and progressive supranuclear palsy [13, 16].
Retrospective reports suggest that cognitive dysfunction emerges later than tremor and ataxia, [8, 13] but many experience memory and executive dysfunction earlier than tremor or ataxia . Cognitive dysfunction may be partly determined by disease duration or age. However, there is also evidence that cognitive dysfunction may be moderated by the FMR1 gene. Larger CGG repeat expansions have been associated with increased relative risk for cognitive impairment  and specific impairments on measures of general intelligence [12, 52, 53], response inhibition and verbal fluency [54, 55]. Moreover, volume loss and reduced activation in brain regions associated with working memory have been linked to larger CGG repeats and increased FMR1 mRNA respectively [48, 56].
The classification of the cognitive disorder associated with FXTAS has important research and clinical implications. A threshold for determining the presence of a cognitive disorder associated with FXTAS has not been established. The fifth edition of the Diagnostic and Statistical Manual (DSM-5)  introduces a new framework for classifying Mild or Major Neurocognitive Disorder (NCD) due to a variety of etiologies. This can be adopted for use in FXTAS. Cognitive impairment can be described as fulfilling criteria for Mild or Major NCD due to FXTAS, depending on the impact of cognitive symptoms on activities of daily living. Unlike its predecessor, DSM-5 does not require impairment in memory for a diagnosis of Mild or Major NCD, making the criteria more suitable for fronto-subcortical syndromes such as FXTAS.
The clinical classification of cognitive disorders in FXTAS can be challenging, especially in the elderly where multiple pathologies are more likely to co-exist. A number of post-mortem case studies examining brain tissue from patients with FXTAS have revealed evidence of co-morbid pathologies including multiple sclerosis, AD and dementia with Lewy bodies [44, 45, 58] in addition to FXTAS inclusions. Atypical cognitive phenotypes or atypical progression of symptoms may suggest the presence of co-morbid neurodegenerative conditions. Consideration of co-morbid degenerative syndromes has implications for clinical course and treatment. As postural instability and gait disturbance are associated with increased rates of cognitive decline in other motor disorders (for example, PD ), ataxia should be further evaluated as a possible association with cognitive decline in FXTAS. In fact, a study of 50 men with FXTAS suggested that cognitive impairment was positively associated with longer duration of ataxia .
The FXTAS Rating Scale was created to capture the motor abnormalities, specifically tremor, ataxia and parkinsonism, in patients with FXTAS . The scale was composed of items from the Clinical Rating Scale for Tremor , the International Cooperative Ataxia Rating Scale  and the Unified Parkinson’s Disease Rating Scale  with a tandem gait test added. The scale is designed to be administered by a neurologist trained to use the scale on either a live patient or a videotape of a patient, which captures the items to be rated. The items are all rated from a neurological exam and there is no patient-report or historical items. Clinimetric qualities of the scale have been evaluated by using scores from movement disorder neurologists blinded to gene status rating videotapes of premutation carriers using a structured videotape protocol. Four hundred and twenty-one individual ratings represented the gamut of FXTAS severity. Internal consistency, or the general agreement between items and the total score of the FXTAS Rating Scale was acceptable (Cronbach’s alpha = 0.93). However, some items had a less than ideal item to total score correlation, suggesting limited utility of these items for assessing overall FXTAS severity. The structure of the scale, when examined using exploratory factor analysis, encompasses ten domains or factors. These ten factors included measures of bradykinesia, ataxic signs, action tremor, rigidity, dysarthria, upper limb dystonia, rest tremor, lower limb dystonia, abnormal eye signs, and head tremor with dystonic voice. Although these ten factors were identified, many of the individual items were associated with multiple factors, suggesting a lack of domain specificity for those items. To determine the responsivity of the scale, retrospectively collected FXTAS Rating Scale scores of premutation carriers between 2001 and 2012 were utilized. Mean follow up time of the subjects (n = 67) was 38.5 months and mean change in score from baseline to follow up was +4.32 points (SD = 13.46). This was calculated to be an average yearly change of +2.55 points (95% CI was −12.44 to +17.53). The studies show that FXTAS Rating Scale has good internal consistency, but specific items need to be altered or eliminated to complete development of the scale.
Falls and balance issues are clearly a major aspect of FXTAS and the FXTAS Motor Rating Scale may not be sensitive enough to detect early balance dysfunction in the disease. Highly sensitive early markers of disease onset are critically needed to characterize the subtle balance deficits that may not be identifiable on the neurological exam in early FXTAS or in premutation carriers without FXTAS. Computerized Dynamic Posturography (CDP) with a Neurocom® Balance Master has been used in a small series of premutation carriers with and without a definitive diagnosis of FXTAS  to investigate balance in this population compared with normative data from a group of healthy controls provided by the Neurocom® manufacturer.
CDP testing, in premutation carriers over age sixty (n = 8 between 60 and 69 years of age and n = 6 greater than 70 years of age), demonstrated abnormally low scores on conditions of the Sensory Organization Test (SOT) that reflect vestibular system balance deficits (See Figure 2; P = 0.02 to < 0.001). In the SOT, the relative somatosensory, visual and vestibular contributions to balance control are tested by evaluating balance in six different conditions in which somatosensory and/or visual inputs in various combinations are eliminated or made unreliable for maintenance of balance. On the CDP motor control test, which measures latency of automatic postural responses to balance disruption, response latencies to medium and large forward and backward translations were significantly longer in older premutation carriers (0.002 > P < 0.0001). The CDP limits of stability test, which measures maximum distance one can displace their center of gravity without stepping or falling, showed significantly reduction for maximum excursion to targets and directional control while moving toward a target, in the premutation carrier group at all ages tested (0.05 ≥ P < 0.0001). Scores on vestibular conditions of the SOT were reduced not only in carriers with evidence of FXTAS on exam and on the FXTAS Rating Scale, but also in a subset of carriers with normal neurological exams and normal scores on the FXTAS Rating Scale. A ‘Balance subscale’ score of the FXTAS Rating Scale scores correlated with severity of the deficit on vestibular SOT conditions (r = 0.56; P = 0.02). These analyses suggest that CDP may be a more sensitive balance ‘marker’ than the FXTAS Rating Scale in detecting preclinical disease and for risk prediction. Larger longitudinal studies are needed to fully validate and develop this and other such measures.
Memantine for FXTAS
Memantine, an antagonist of N-methyl-D-aspartate (NMDA) glutamate receptor approved for the treatment of moderate to severe AD, has been suggested to be of therapeutic benefit in a number of neurological disorders associated with over-activation of glutamate receptors, including AD, PD, and Huntington’s disease . Anecdotal reports have suggested that memantine could be helpful in the treatment of FXTAS . There is evidence of down-regulation of GABA pathways causing  excessive glutamate to remain at the synapse leading to possible glutamate toxicity . Based on this mechanism, a randomized, double-blind, placebo-controlled trial of memantine in individuals with FXTAS ages 34 to 80 years was carried out . Ninety-four participants were randomized to either memantine or placebo and were treated for one year. There was no improvement over placebo in the primary outcome measures of intention tremor severity as measured by the CATSYS (memantine versus placebo: 1.01 ± 0.75 versus 1.76 ± 2.13, P = 0.0785) or executive function as measured by the Behavior Dyscontrol Scale (16.12 ± 5.43 versus 15.72 ± 3.93, P = 0.7268) in an intention-to-treat analysis. More mild adverse events (AEs) were observed in the placebo group and more moderate AEs occurred in the memantine group (P = 0.007). This study suggests that memantine is not helpful for the primary problems of FXTAS, specifically tremor and executive function.
A sub-study using event related potentials (ERP) in a word repetition paradigm was performed in order to elicit N400 repetition effects with congruous and incongruous words. There were 21 patients in the memantine group and 20 in the placebo group who underwent successful ERP studies before and after one year of treatment. The memantine group exhibited larger improvements on the cued recall test for targeted words compared to the placebo group (P = 0.050). The placebo group displayed statistically significant reduction of the N400 repetition effect after one year, while the treated group showed preservation of the N400 repetition effect, with a significant trend for larger N400 repetition effect amplitude after one year of treatment with memantine . Correlational tests revealed that increased N400 repetition effect amplitudes were associated with improved cued-recall scores for the congruous target words (one year to baseline) across all subjects (r = 0.36, P = 0.02), and in the memantine group (r = 0.46, P = 0.038), but not within the placebo group (r = 0.17, P = 0.46). This sub-study suggests that the ERP paradigm may be a sensitive measure to document some limited benefit from memantine in individuals with FXTAS.
While the prevalence of the FXTAS is estimated to be similar to that of other neurodegenerative disorders , FXTAS is under-recognized and frequently misdiagnosed . While neurologists are becoming more aware of FXTAS, approximately half of affected persons are seen and managed by primary care physicians . Improved education of physicians and more accurate, broader diagnostic criteria, as in Table 3, would improve diagnosis. Health care professionals especially need to be educated about the expanded female phenotype, as these carriers have serious genetic and medical risks. Keeping in mind that a family history should be checked, but also that the family history may be negative for clear FMR1 related disorders, health care professionals should consider gene testing if a patient over age 50 has unexplained cerebellar gait ataxia, unexplained action tremor and dementia, or the MCP or CCS hyperintensity on MRI and some FXTAS signs, as in Table 2.
Many important avenues of research need attention. The female FXTAS phenotype requires further study to accurately define medical risks, especially regarding endocrine dysfunction and chronic pain. Genetic, epigenetic and environmental factors that predispose carriers to develop FXTAS need identification. Further, to date only one randomized, controlled trial to study modification of progression of FXTAS has been conducted. The tools for these studies, for example, the FXTAS Rating Scale and other motor measures such as the Neurocom®, need refinement, and the molecular science behind such trials needs to be established.
Computerized dynamic posturography
Central nervous system
Event related potential
- FMR1 Fragile X mental retardation 1 :
Fragile X syndrome
Fragile X-associated tremor/ataxia syndrome
Middle Cerebellar Peduncle
Magnetic resonance imaging
Rapid eye movement.
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The writing of this manuscript was partially supported by NINDS NS082416 (DAH), NICHD HD 036071 (RJH) and AG032115 (RJH).
EBK: EBK has received clinical trial funding and consulting fees from Novartis, Roche and Seaside Therapeutics and has received funding to develop standards for FMR1 testing from Asuragen, Inc. She is also on advisory boards for Genentech, Roche and Novartis regarding treatment of FXS.
RJH has received funding from Novartis, Roche, Seaside Therapeutics, Forest and Curemark for clinical trials in FXS or autism. She is also on advisory boards for Genentech, Roche and Novartis regarding treatment of FXS. The Kennedy Center, Denmark has received clinical trial funding from Novartis. All the other authors have no competing interest to declare.
DH: manuscript planning, drafting of initial manuscript, final manuscript editing and submission. EBK: drafting of initial manuscript, final manuscript editing. RH: drafting of initial and final manuscript editing. RB: drafting of initial manuscript, final manuscript editing. JNT: drafting of initial manuscript, final manuscript editing. ML: manuscript planning, drafting of initial manuscript, final manuscript editing. MA: drafting of the manuscript, critical revision of the manuscript. AEJ: drafting of initial manuscript, final manuscript editing. EP: drafting of initial manuscript, final manuscript editing. GS: final manuscript editing. All authors read and approved the final manuscript.
An erratum to this article is available at http://dx.doi.org/10.1186/s11689-015-9108-7.
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Hall, D.A., Birch, R.C., Anheim, M. et al. Emerging topics in FXTAS. J Neurodevelop Disord 6, 31 (2014). https://doi.org/10.1186/1866-1955-6-31
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(AP Photo/Matt York)
After years of complaints from immigration rights groups about the administration’s deportation policy—which is expected to toss 400,000 immigrants from the country this year—the White House announced a significant policy shift this morning. The Department of Homeland Security said that young people (between 16 and 30) who have no criminal histories will be issued work visas allowing them to find work and stay in the country.
Despite the stark-naked political motivations—to win over Latino voters and box out Congressional Republicans, who have been talking about introducing legislation with similar intent—the policy change is still meaningful. (And it shouldn’t really be a surprise that politicians do things for political reasons, though I think undocumented young people could legitimately wonder why this wasn’t enacted two years ago, when it was clear the DREAM Act was dead in Congress).
Under the new policy, as many as 800,000 young undocumented immigrants could stay in the country indefinitely if they are between 16 and 30, have no criminal histories, have been in the country for at least five continuous years, and graduated from high school (or obtained a GED, or served in the military). Under those qualifications, they can obtain a two-year visa with no limits on how often it can be renewed.
This is doubtless a huge relief to many people who came to the country without documentation when they were young and have known no other home, and have been trying to build a life while under constant fear of deportation.
Unlike previous easements of deportation policy, like last summer’s announcement that only people with criminal histories would be targeted, this shift is important because the government will issue work visas conferring legitimate legal status on people instead of just granting an understanding that they won’t be deported. Also, the policy is affirmative, meaning one can approach DHS and apply for the visa instead of waiting to be caught by authorities.
But there are several important caveats. Since this is an executive action, it could (and likely would) be reversed by President Romney in six months. Granted, the administration had no choice to go this route, since House Republicans have already declared the DREAM Act dead, but undocumented young people still know they are walking on shaky ground even with the new policy.
Previous administration efforts to ease deportations also create reasons to be skeptical. Though the administration claimed it would exercise discretion and deport only those with violent criminal histories, deportations only dropped an almost imperceptible two percent.
Without question, the new policy isn’t enough and the undocumented need a comprehensive immigration strategy to be enshrined through legislation. But with Republicans like Rubio already saying the new policy is “welcome news,” the administration may be pulling the debate to the left and making a comprehensive solution more likely.