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The main threats to human health from heavy metals are associated with exposure to lead, cadmium, mercury and arsenic. These metals have been extensively studied and their effects on human health regularly reviewed by international bodies such as the WHO. Heavy metals have been used by humans for thousands of years. Although several adverse health effects of heavy metals have been known for a long time, exposure to heavy metals continues, and is even increasing in some parts of the world, in particular in less developed countries, though emissions have declined in most developed countries over the last 100 years. Cadmium compounds are currently mainly used in re-chargeable nickel–cadmium batteries. Cadmium emissions have increased dramatically during the 20th century, one reason being that cadmium-containing products are rarely re-cycled, but often dumped together with household waste. Cigarette smoking is a major source of cadmium exposure. In non-smokers, food is the most important source of cadmium exposure. Recent data indicate that adverse health effects of cadmium exposure may occur at lower exposure levels than previously anticipated, primarily in the form of kidney damage but possibly also bone effects and fractures. Many individuals in Europe already exceed these exposure levels and the margin is very narrow for large groups. Therefore, measures should be taken to reduce cadmium exposure in the general population in order to minimize the risk of adverse health effects. The general population is primarily exposed to mercury via food, fish being a major source of methyl mercury exposure, and dental amalgam. The general population does not face a significant health risk from methyl mercury, although certain groups with high fish consumption may attain blood levels associated with a low risk of neurological damage to adults. Since there is a risk to the fetus in particular, pregnant women should avoid a high intake of certain fish, such as shark, swordfish and tuna; fish (such as pike, walleye and bass) taken from polluted fresh waters should especially be avoided. There has been a debate on the safety of dental amalgams and claims have been made that mercury from amalgam may cause a variety of diseases. However, there are no studies so far that have been able to show any associations between amalgam fillings and ill health. The general population is exposed to lead from air and food in roughly equal proportions. During the last century, lead emissions to ambient air have caused considerable pollution, mainly due to lead emissions from petrol. Children are particularly susceptible to lead exposure due to high gastrointestinal uptake and the permeable blood–brain barrier. Blood levels in children should be reduced below the levels so far considered acceptable, recent data indicating that there may be neurotoxic effects of lead at lower levels of exposure than previously anticipated. Although lead in petrol has dramatically decreased over the last decades, thereby reducing environmental exposure, phasing out any remaining uses of lead additives in motor fuels should be encouraged. The use of lead-based paints should be abandoned, and lead should not be used in food containers. In particular, the public should be aware of glazed food containers, which may leach lead into food. Exposure to arsenic is mainly via intake of food and drinking water, food being the most important source in most populations. Long-term exposure to arsenic in drinking-water is mainly related to increased risks of skin cancer, but also some other cancers, as well as other skin lesions such as hyperkeratosis and pigmentation changes. Occupational exposure to arsenic, primarily by inhalation, is causally associated with lung cancer. Clear exposure–response relationships and high risks have been observed.
Although there is no clear definition of what a heavy metal is, density is in most cases taken to be the defining factor. Heavy metals are thus commonly defined as those having a specific density of more than 5 g/cm3. The main threats to human health from heavy metals are associated with exposure to lead, cadmium, mercury and arsenic (arsenic is a metalloid, but is usually classified as a heavy metal).
Heavy metals have been used in many different areas for thousands of years. Lead has been used for at least 5000 years, early applications including building materials, pigments for glazing ceramics, and pipes for transporting water. In ancient Rome, lead acetate was used to sweeten old wine, and some Romans might have consumed as much as a gram of lead a day. Mercury was allegedly used by the Romans as a salve to alleviate teething pain in infants, and was later (from the 1300s to the late 1800s) employed as a remedy for syphilis. Claude Monet used cadmium pigments extensively in the mid 1800s, but the scarcity of the metal limited the use in artists’ materials until the early 1900s.
Although adverse health effects of heavy metals have been known for a long time, exposure to heavy metals continues and is even increasing in some areas. For example, mercury is still used in gold mining in many parts of Latin America. Arsenic is still common in wood preservatives, and tetraethyl lead remains a common additive to petrol, although this use has decreased dramatically in the developed countries. Since the middle of the 19th century, production of heavy metals increased steeply for more than 100 years, with concomitant emissions to the environment (Fig. 1).
At the end of the 20th century, however, emissions of heavy metals started to decrease in developed countries: in the UK, emissions of heavy metals fell by over 50% between 1990 and 20001.
Emissions of heavy metals to the environment occur via a wide range of processes and pathways, including to the air (e.g. during combustion, extraction and processing), to surface waters (via runoff and releases from storage and transport) and to the soil (and hence into groundwaters and crops) (see Chapter 1). Atmospheric emissions tend to be of greatest concern in terms of human health, both because of the quantities involved and the widespread dispersion and potential for exposure that often ensues. The spatial distributions of cadmium, lead and mercury emissions to the atmosphere in Europe can be found in the Meteorological Synthesizing Centre-East (MSC-E) website (http://www.msceast.org/hms/emission.html#Spatial). Lead emissions are mainly related to road transport and thus most uniformly distributed over space. Cadmium emissions are primarily associated with non-ferrous metallurgy and fuel combustion, whereas the spatial distribution of anthropogenic mercury emissions reflects mainly the level of coal consumption in different regions.
People may be exposed to potentially harmful chemical, physical and biological agents in air, food, water or soil. However, exposure does not result only from the presence of a harmful agent in the environment. The key word in the definition of exposure is contact2. There must be contact between the agent and the outer boundary of the human body, such as the airways, the skin or the mouth. Exposure is often defined as a function of concentration and time: “an event that occurs when there is contact at a boundary between a human and the environment with a contaminant of a specific concentration for an interval of time”3. For exposure to happen, therefore, co-existence of heavy metals and people has to occur (see Chapter 1).
Occurrence, exposure and dose
Cadmium occurs naturally in ores together with zinc, lead and copper. Cadmium compounds are used as stabilizers in PVC products, colour pigment, several alloys and, now most commonly, in re-chargeable nickel–cadmium batteries. Metallic cadmium has mostly been used as an anticorrosion agent (cadmiation). Cadmium is also present as a pollutant in phosphate fertilizers. EU cadmium usage has decreased considerably during the 1990s, mainly due to the gradual phase-out of cadmium products other than Ni-Cd batteries and the implementation of more stringent EU environmental legislation (Directive 91/338/ECC). Notwithstanding these reductions in Europe, however, cadmium production, consumption and emissions to the environment worldwide have increased dramatically during the 20th century. Cadmium containing products are rarely re-cycled, but frequently dumped together with household waste, thereby contaminating the environment, especially if the waste is incinerated.
Natural as well as anthropogenic sources of cadmium, including industrial emissions and the application of fertilizer and sewage sludge to farm land, may lead to contamination of soils, and to increased cadmium uptake by crops and vegetables, grown for human consumption. The uptake process of soil cadmium by plants is enhanced at low pH4.
Cigarette smoking is a major source of cadmium exposure. Biological monitoring of cadmium in the general population has shown that cigarette smoking may cause significant increases in blood cadmium (B-Cd) levels, the concentrations in smokers being on average 4–5 times higher than those in non-smokers4. Despite evidence of exposure from environmental tobacco smoke5, however, this is probably contributing little to total cadmium body burden.
Food is the most important source of cadmium exposure in the general non-smoking population in most countries6. Cadmium is present in most foodstuffs, but concentrations vary greatly, and individual intake also varies considerably due to differences in dietary habits4. Women usually have lower daily cadmium intakes, because of lower energy consumption than men. Gastrointestinal absorption of cadmium may be influenced by nutritional factors, such as iron status7.
B-Cd generally reflects current exposure, but partly also lifetime body burden8. The cadmium concentration in urine (U-Cd) is mainly influenced by the body burden, U-Cd being proportional to the kidney concentration. Smokers and people living in contaminated areas have higher urinary cadmium concentrations, smokers having about twice as high concentrations as non-smokers4.
Inhalation of cadmium fumes or particles can be life threatening, and although acute pulmonary effects and deaths are uncommon, sporadic cases still occur9,10. Cadmium exposure may cause kidney damage. The first sign of the renal lesion is usually a tubular dysfunction, evidenced by an increased excretion of low molecular weight proteins [such as β2-microglobulin and α1-microglobulin (protein HC)] or enzymes [such as N-Acetyl-β-D-glucosaminidase (NAG)]4,6. It has been suggested that the tubular damage is reversible11, but there is overwhelming evidence that the cadmium induced tubular damage is indeed irreversible4.
WHO6 estimated that a urinary excretion of 10 nmol/mmol creatinine (corresponding to circa 200 mg Cd/kg kidney cortex) would constitute a ‘critical limit’ below which kidney damage would not occur. However, WHO calculated that circa 10% of individuals with this kidney concentration would be affected by tubular damage. Several reports have since shown that kidney damage and/or bone effects are likely to occur at lower kidney cadmium levels. European studies have shown signs of cadmium induced kidney damage in the general population at urinary cadmium levels around 2–3 μg Cd/g creatinine12,13.
The initial tubular damage may progress to more severe kidney damage, and already in 1950 it was reported that some cadmium exposed workers had developed decreased glomerular filtration rate (GFR)14. This has been confirmed in later studies of occupationally exposed workers15,16. An excess risk of kidney stones, possibly related to an increased excretion of calcium in urine following the tubular damage, has been shown in several studies4.
Recently, an association between cadmium exposure and chronic renal failure [end stage renal disease (ESRD)] was shown17. Using a registry of patients, who had been treated for uraemia, the investigators found a double risk of ESRD in persons living close to (<2 km) industrial cadmium emitting plants as well as in occupationally exposed workers.
Long-term high cadmium exposure may cause skeletal damage, first reported from Japan, where the itai-itai (ouch-ouch) disease (a combination of osteomalacia and osteoporosis) was discovered in the 1950s. The exposure was caused by cadmium-contaminated water used for irrigation of local rice fields. A few studies outside Japan have reported similar findings4. During recent years, new data have emerged suggesting that also relatively low cadmium exposure may give rise to skeletal damage, evidenced by low bone mineral density (osteoporosis) and fractures18–20.
Animal experiments have suggested that cadmium may be a risk factor for cardiovascular disease, but studies of humans have not been able to confirm this4. However, a Japanese study showed an excess risk of cardiovascular mortality in cadmium-exposed persons with signs of tubular kidney damage compared to individuals without kidney damage21.
The IARC has classified cadmium as a human carcinogen (group I) on the basis of sufficient evidence in both humans and experimental animals22. IARC, however, noted that the assessment was based on few studies of lung cancer in occupationally exposed populations, often with imperfect exposure data, and without the capability to consider possible confounding by smoking and other associated exposures (such as nickel and arsenic). Cadmium has been associated with prostate cancer, but both positive and negative studies have been published. Early data indicated an association between cadmium exposure and kidney cancer23. Later studies have not been able clearly to confirm this, but a large multi-centre study showed a (borderline) significant over-all excess risk of renal-cell cancer, although a negative dose–response relationship did not support a causal relation24. Furthermore, a population-based multicentre-study of renal cell carcinoma found an excess risk in occupationally exposed persons25. In summary, the evidence for cadmium as a human carcinogen is rather weak, in particular after oral exposure. Therefore, a classification of cadmium as ‘probably carcinogenic to humans’ (IARC group 2A) would be more appropriate. This conclusion also complies with the EC classification of some cadmium compounds (Carcinogen Category 2; Annex 1 to the directive 67/548/EEC).
Occurrence, exposure and dose
The mercury compound cinnabar (HgS), was used in pre-historic cave paintings for red colours, and metallic mercury was known in ancient Greece where it (as well as white lead) was used as a cosmetic to lighten the skin. In medicine, apart from the previously mentioned use of mercury as a cure for syphilis, mercury compounds have also been used as diuretics [calomel (Hg2Cl2)], and mercury amalgam is still used for filling teeth in many countries26.
Metallic mercury is used in thermometers, barometers and instruments for measuring blood pressure. A major use of mercury is in the chlor-alkali industry, in the electrochemical process of manufacturing chlorine, where mercury is used as an electrode.
The largest occupational group exposed to mercury is dental care staff. During the 1970s, air concentrations in some dental surgeries reached 20 μg/m3, but since then levels have generally fallen to about one-tenth of those concentrations.
Inorganic mercury is converted to organic compounds, such as methyl mercury, which is very stable and accumulates in the food chain. Until the 1970s, methyl mercury was commonly used for control of fungi on seed grain.
The general population is primarily exposed to mercury via food, fish being a major source of methyl mercury exposure27, and dental amalgam. Several experimental studies have shown that mercury vapour is released from amalgam fillings, and that the release rate may increase by chewing28.
Mercury in urine is primarily related to (relatively recent) exposure to inorganic compounds, whereas blood mercury may be used to identify exposure to methyl mercury. A number of studies have correlated the number of dental amalgam fillings or amalgam surfaces with the mercury content in tissues from human autopsy, as well as in samples of blood, urine and plasma26. Mercury in hair may be used to estimate long-term exposure, but potential contamination may make interpretation difficult.
Acute mercury exposure may give rise to lung damage. Chronic poisoning is characterized by neurological and psychological symptoms, such as tremor, changes in personality, restlessness, anxiety, sleep disturbance and depression. The symptoms are reversible after cessation of exposure. Because of the blood–brain barrier there is no central nervous involvement related to inorganic mercury exposure. Metallic mercury may cause kidney damage, which is reversible after exposure has stopped. It has also been possible to detect proteinuria at relatively low levels of occupational exposure.
Metallic mercury is an allergen, which may cause contact eczema, and mercury from amalgam fillings may give rise to oral lichen. It has been feared that mercury in amalgam may cause a variety of symptoms. This so-called ‘amalgam disease’ is, however, controversial, and although some authors claim proof of symptom relief after removal of dental amalgam fillings29, there is no scientific evidence of this30.
Methyl mercury poisoning has a latency of 1 month or longer after acute exposure, and the main symptoms relate to nervous system damage31. The earliest symptoms are parestesias and numbness in the hands and feet. Later, coordination difficulties and concentric constriction of the visual field may develop as well as auditory symptoms. High doses may lead to death, usually 2–4 weeks after onset of symptoms. The Minamata catastrophe in Japan in the 1950s was caused by methyl mercury poisoning from fish contaminated by mercury discharges to the surrounding sea. In the early 1970s, more than 10,000 persons in Iraq were poisoned by eating bread baked from mercury-polluted grain, and several thousand people died as a consequence of the poisoning. However, the general population does not face significant health risks from methyl mercury exposure with the exception of certain groups with high fish consumption.
A high dietary intake of mercury from consumption of fish has been hypothesized to increase the risk of coronary heart disease32. In a recent case-control study, the joint association of mercury levels in toenail clippings and docosahexaenoic acid levels in adipose tissue with the risk of a first myocardial infarction in men was evaluated33. Mercury levels in the patients were 15% higher than those in controls (95% CI, 5–25%), and the adjusted odds ratio for myocardial infarction associated with the highest compared with the lowest quintile of mercury was 2.16 (95% CI, 1.09–4.29; P for trend = 0.006).
Another recent case-control study investigated the association between mercury levels in toenails and the risk of coronary heart disease among male health professionals with no previous history of cardiovascular disease. Mercury levels were significantly correlated with fish consumption, and the mean mercury level was higher in dentists than in non-dentists. When other risk factors for coronary heart disease had been controlled for, mercury levels were not significantly associated with the risk of coronary heart disease34.
These intriguing contradictory findings need to be followed up by more studies of other similarly exposed populations.
Occurrence, exposure and dose
The general population is exposed to lead from air and food in roughly equal proportions. Earlier, lead in foodstuff originated from pots used for cooking and storage, and lead acetate was previously used to sweeten port wine. During the last century, lead emissions to ambient air have further polluted our environment, over 50% of lead emissions originating from petrol. Over the last few decades, however, lead emissions in developed countries have decreased markedly due to the introduction of unleaded petrol. Subsequently blood lead levels in the general population have decreased (Fig. 2).
Occupational exposure to inorganic lead occurs in mines and smelters as well as welding of lead painted metal, and in battery plants. Low or moderate exposure may take place in the glass industry. High levels of air emissions may pollute areas near lead mines and smelters. Airborne lead can be deposited on soil and water, thus reaching humans via the food chain.
Up to 50% of inhaled inorganic lead may be absorbed in the lungs. Adults take up 10–15% of lead in food, whereas children may absorb up to 50% via the gastrointestinal tract. Lead in blood is bound to erythrocytes, and elimination is slow and principally via urine. Lead is accumulated in the skeleton, and is only slowly released from this body compartment. Half-life of lead in blood is about 1 month and in the skeleton 20–30 years35.
In adults, inorganic lead does not penetrate the blood–brain barrier, whereas this barrier is less developed in children. The high gastrointestinal uptake and the permeable blood–brain barrier make children especially susceptible to lead exposure and subsequent brain damage. Organic lead compounds penetrate body and cell membranes. Tetramethyl lead and tetraethyl lead penetrate the skin easily. These compounds may also cross the blood–brain barrier in adults, and thus adults may suffer from lead encephalopathy related to acute poisoning by organic lead compounds.
The symptoms of acute lead poisoning are headache, irritability, abdominal pain and various symptoms related to the nervous system. Lead encephalopathy is characterized by sleeplessness and restlessness. Children may be affected by behavioural disturbances, learning and concentration difficulties. In severe cases of lead encephalopathy, the affected person may suffer from acute psychosis, confusion and reduced consciousness. People who have been exposed to lead for a long time may suffer from memory deterioration, prolonged reaction time and reduced ability to understand. Individuals with average blood lead levels under 3 μmol/l may show signs of peripheral nerve symptoms with reduced nerve conduction velocity and reduced dermal sensibility. If the neuropathy is severe the lesion may be permanent. The classical picture includes a dark blue lead sulphide line at the gingival margin. In less serious cases, the most obvious sign of lead poisoning is disturbance of haemoglobin synthesis, and long-term lead exposure may lead to anaemia.
Recent research has shown that long-term low-level lead exposure in children may also lead to diminished intellectual capacity. Figure 3 shows a meta-analysis of four prospective studies using mean blood lead level over a number of years. The combined evidence suggests a weighted mean decrease in IQ of 2 points for a 0.48 μmol/l (10 μg/dl) increase in blood lead level (95% confidence interval from −0.3 points to −3.6 points)35.
Acute exposure to lead is known to cause proximal renal tubular damage35. Long-term lead exposure may also give rise to kidney damage and, in a recent study of Egyptian policemen, urinary excretion of NAG was positively correlated with duration of exposure to lead from automobile exhaust, blood lead and nail lead36.
Despite intensive efforts to define the relationship between body burden of lead and blood pressure or other effects on the cardiovascular system, no causal relationship has been demonstrated in humans35.
Using routinely collected data on mortality (1981–96), hospital episode statistics data 1992–1995 and statutory returns to the Health and Safety Executive (RIDDOR), one death and 83 hospital cases were identified37. The authors found that mortality and hospital admission ascribed to lead poisoning in England were rare, but that cases continue to occur and that some seem to be associated with considerable morbidity.
Blood lead levels in children below 10 μmg/dl have so far been considered acceptable, but recent data indicate that there may be toxicological effects of lead at lower levels of exposure than previously anticipated. There is also evidence that certain genetic and environmental factors can increase the detrimental effects of lead on neural development, thereby rendering certain children more vulnerable to lead neurotoxicity38.
IARC classified lead as a ‘possible human carcinogen’ based on sufficient animal data and insufficient human data in 1987. Since then a few studies have been published, the overall evidence for lead as a carcinogen being only weak, the most likely candidates are lung cancer, stomach cancer and gliomas39.
Occurrence, exposure and dose
Arsenic is a widely distributed metalloid, occurring in rock, soil, water and air. Inorganic arsenic is present in groundwater used for drinking in several countries all over the world (e.g. Bangladesh, Chile and China), whereas organic arsenic compounds (such as arsenobetaine) are primarily found in fish, which thus may give rise to human exposure40.
Smelting of non-ferrous metals and the production of energy from fossil fuel are the two major industrial processes that lead to arsenic contamination of air, water and soil, smelting activities being the largest single anthropogenic source of atmospheric pollution41. Other sources of contamination are the manufacture and use of arsenical pesticides and wood preservatives.
The working group of the EU DG Environment concluded that there were large reductions in the emissions of arsenic to air in several member countries of the European Union in the 1980s. In 1990, the total emissions of arsenic to the air in the member states were estimated to be 575 tonnes. In 1996, the estimated total releases of arsenic to the air in the UK were 50 tonnes42.
Concentrations in air in rural areas range from <1 to 4 ng/m3, whereas concentrations in cities may be as high as 200 ng/m3. Much higher concentrations (>1000 ng/m3) have been measured near industrial sources. Water concentrations are usually <10 μg/l, although higher concentrations may occur near anthropogenic sources. Levels in soils usually range from 1 to 40 mg/kg, but pesticide application and waste disposal can result in much higher concentrations40.
General population exposure to arsenic is mainly via intake of food and drinking water. Food is the most important source, but in some areas, arsenic in drinking water is a significant source of exposure to inorganic arsenic. Contaminated soils such as mine-tailings are also a potential source of arsenic exposure40.
Absorption of arsenic in inhaled airborne particles is highly dependent on the solubility and the size of particles. Soluble arsenic compounds are easily absorbed from the gastrointestinal tract. However, inorganic arsenic is extensively methylated in humans and the metabolites are excreted in the urine40.
Arsenic (or metabolites) concentrations in blood, hair, nails and urine have been used as biomarkers of exposure. Arsenic in hair and nails can be useful indicators of past arsenic exposure, if care is taken to avoid external arsenic contamination of the samples. Speciated metabolites in urine expressed as either inorganic arsenic or the sum of metabolites (inorganic arsenic + MMA + DMA) is generally the best estimate of recent arsenic dose. However, consumption of certain seafood may confound estimation of inorganic arsenic exposure, and should thus be avoided before urine sampling40.
Inorganic arsenic is acutely toxic and intake of large quantities leads to gastrointestinal symptoms, severe disturbances of the cardiovascular and central nervous systems, and eventually death. In survivors, bone marrow depression, haemolysis, hepatomegaly, melanosis, polyneuropathy and encephalopathy may be observed. Ingestion of inorganic arsenic may induce peripheral vascular disease, which in its extreme form leads to gangrenous changes (black foot disease, only reported in Taiwan).
Populations exposed to arsenic via drinking water show excess risk of mortality from lung, bladder and kidney cancer, the risk increasing with increasing exposure. There is also an increased risk of skin cancer and other skin lesions, such as hyperkeratosis and pigmentation changes.
Studies on various populations exposed to arsenic by inhalation, such as smelter workers, pesticide manufacturers and miners in many different countries consistently demonstrate an excess lung cancer. Although all these groups are exposed to other chemicals in addition to arsenic, there is no other common factor that could explain the findings. The lung cancer risk increases with increasing arsenic exposure in all relevant studies, and confounding by smoking does not explain the findings.
The latest WHO evaluation40 concludes that arsenic exposure via drinking water is causally related to cancer in the lungs, kidney, bladder and skin, the last of which is preceded by directly observable precancerous lesions. Uncertainties in the estimation of past exposures are important when assessing the exposure–response relationships, but it would seem that drinking water arsenic concentrations of approximately 100 μg/l have led to cancer at these sites, and that precursors of skin cancer have been associated with levels of 50–100 μg/l.
The relationships between arsenic exposure and other health effects are less clear. There is relatively strong evidence for hypertension and cardiovascular disease, but the evidence is only suggestive for diabetes and reproductive effects and weak for cerebrovascular disease, long-term neurological effects, and cancer at sites other than lung, bladder, kidney and skin40.
Recent data indicate that adverse health effects of cadmium exposure, primarily in the form of renal tubular damage but possibly also effects on bone and fractures, may occur at lower exposure levels than previously anticipated. Many individuals in Europe already exceed these exposure levels and the margin is very narrow for large groups. Therefore, measures should be taken to reduce cadmium exposure in the general population in order to minimize the risk of adverse health effects.
The general population does not face a significant health risk from methylmercury, although certain groups with high fish consumption may attain blood levels associated with a low risk of neurological damage to adults. Since there is a risk to the fetus in particular, pregnant women should avoid a high intake of certain fish, such as shark, swordfish and tuna. Fish, such as pike, walleye and bass, taken from polluted fresh waters should especially be avoided.
There has been a debate on the safety of dental amalgams and claims have been made that mercury from amalgam may cause a variety of diseases, but to date no studies have been able to show any associations between amalgam fillings and ill health.
Children are particularly vulnerable to lead exposure. Blood levels in children should be reduced below the levels so far considered acceptable, recent data indicating that there may be neurotoxic effects of lead at lower levels of exposure than previously anticipated. Although lead in petrol has dramatically declined over the last decades, thereby reducing environmental exposure, there is a need to phase out any remaining uses of lead additives in motor fuels. The use of lead-based paints should also be abandoned, and lead should not be used in food containers. In particular, the public should be aware of glazed food containers, which may leach lead into food.
Long-term exposure to arsenic in drinking water is mainly related to increased risks of skin cancer, but also some other cancers, and other skin lesions such as hyperkeratosis and pigmentation changes. Occupational exposure to arsenic, primarily by inhalation, is causally associated with lung cancer. Clear exposure–response relationships and high risks have been observed.
- neurotoxicity syndromes
- blood-brain barrier
- cadmium compounds
- dental amalgam
- developed countries
- developing countries
- environmental exposure
- fresh water
- lead poisoning
- metals, heavy
- occupational exposure
- trauma, nervous system
- world health organization
- lung cancer
- skin lesion
- skin cancer
- fish intake
- potable water

domain: medical


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WWE and FOX Reportedly Have A 'Strained' Relationship
Posted By: Ben Jordan Kerin on Sep 24, 2021
We reported recently that Dave Meltzer noted that FOX wasn’t happy about WWE not pushing harder to sign CM Punk with FOX even offering to step in to help negotiations.
In a further update, Fightful is reporting that WWE's relationship is further strained with FOX as the network is disappointed with WWE’s viewership compared to what they had hoped when they first signed them to a billion-dollar broadcasting deal.
FOX at the time of signing their deal was hoping SmackDown on Friday night could pull in around 3.3 million viewers on average, but apart from their debut episode on the network which scored 3.9 million viewers they generally average around 2 million viewers.
In addition to viewership, FOX is not "over the moon" that WWE advertises other streaming services during SmackDown such as Peacock which is owned by their rival NBCUniversal. WWE does this as they need to advertise their pay-per-view events since the WWE Network shut down in the United States. WWE feels if FOX really didn't want them to advertise other streaming services they should have made a play to secure the rights to their PPVs as NBCUniversal did.
The report goes on to note that FOX owner Rupert Murdoch is going to be portrayed in a less-than-flattering way in the upcoming scripted Vince McMahon series (The United States of America vs. Vince McMahon). The move is being described as a "childish move" by WWE, although it does note that Vince McMahon had one call with Rupert recently and the subjected wasn't discussed, and the Murdoch family has "great respect" for the McMahon family and vice versa.
In more positive news, FOX is happy with how WWE has made a real effort to stack the roster since fans have returned to live events.
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Oct 17 - During the latest DC FanDome, a trailer was released for The Suicide Squad: Kill The Justice League video game. In the trailer, Samoa Joe can be heard as the voice of King Shark. The official IMDb pa[...]


THE completion of a £3 million project to extend and improve Cookley Sebright Primary School has been officially celebrated.
Gwen Palmer, 101, a former pupil and Phoebe-Rose Harvey, 4, the school’s youngest current student, unveiled a commemorative plaque last Friday, while a fruit tree was planted and a time capsule was also buried to mark the occasion.
The development included building eight new classrooms, refurbishing the existing Victorian building and demolishing outdated parts of the site.
Martin de Vine, headteacher at Cookley Sebright Primary School, said: “ Everyone is delighted that this important project is now complete.
“Children are at the heart of all we do and the modern facilities that are now available to us will enhance the dynamic learning environment that makes our school community so special.”
The project was funded by Worcestershire County Council, alongside a large contribution from the school.
Conservative councillor John Campion, Worcestershire County Council cabinet member for transformation and commissioning, said: “The county council has a well-deserved track record in providing sustainable public buildings and our schools are no exception.
“It is always exciting to see what positive changes this will make for future generations.”
Worcestershire County Council cabinet member for children and families, Conservative councillor Liz Eyre, added: “The new and updated facilities are a fantastic addition, which will benefit many local children and families for years to come.”
Quattro Architects of Gloucester designed the development while Kier Construction carried out the building work.


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J&K tourism department to come up with safety guidelines for adventure tourism
In order to promote adventure tourism in Jammu and Kashmir, the state government is working towards devising new guidelines for adventure activities being undertaken by different business concerns in the state.
According to news reports, these guidelines would include registration of tour operators, giving due permission to them for undertaking adventure activities as well as setting up a standard of the bare minimum requirements for equipment to be used, safety rules and the rulebook for any adventure tourism agency to perform the activities in J&K.
Tourism secretary, Rigzian Sampheal, reportedly said that the state has an enormous prospect to grow as an adventure tourism state. Already, there are tourists visiting the destination for the sake of adventure activities such as skiing and trekking. However, the state never had adventure tourism guidelines in place the way other Indian states have.
Reportedly, Rigzin Sampheal told the press that the government intends to come up with guidelines on the basis of Gol norms. He also opined that the state wants to set high benchmarks for executing adventure sports activities for drawing on the huge scope of adventure tourism that is yet to be duly utilised, due to the absence of standard regulatory and safety guidelines.
All these reasons, according to Rigzin Sampheal, make it all the more crucial for the adventure tourism industry in Jammu & Kashmir to have proper guidelines in place. Prior to the approval of this draft of safety guidelines, the department is seeking feedback from agencies connected with adventure tourism and the members of public, in order to have an exhaustive rule book for adventure activities in the state.
News has it that the tourism department would officially circulate the guidelines after receiving the feedback and duly scrutinising it for implementation

domain: news


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I saw a lot of different variations of this Garden Black Bean Salsa floating around over 4th of July weekend, & everyone was asking how it’s made. It’s such a simple delicious dish to whip up for any occasion, and it appeals to many as it’s Gluten Free & Vegetarian.
I think this version is not only the tastiest, but the simplest as well!
What You Need:
15 oz Can Of Black Beans
1 Cup of Golden Corn (uncooked, I used from can)
1 Small/Medium Orange Bell Pepper
1/3 Cup Of Diced Red Onion
3-4 Roma Tomatoes
1 Medium/Large Avocado
1/3 Cup Cilantro Leaves
1. For the black beans, place in strainer and rinse with water and then place in large bowl
2. Drain the corn and add to bowl
3. Chop bell pepper, onion, tomato, & avocado into small pieces and add to bowl
4. Add cilantro leaves to bowl
Next We Add Some Sweetness
5. Take 1/2 an orange and squeeze it over your mixture. Don’t wring the orange dry, but squeeze a decent amount
6. Take lime juice and give one little squirt from bottle, or use 1/2 of a real lime & do the same as the orange above
7. Add a dash of cumin & a dash of salt
8. Stir with spoon
Serve with tortilla chips & enjoy!

domain: food


|Wedgie is seriously on the rocks now, apparently the new radar doesn't look like it wants to work. Why Defence can't learn our lesson that we just aren't big enough to pull off major bleeding edge technology projects without unacceptable risks to our defence capability and budget is beyond me. What would have been wrong with sticking the latest version of the E-2's radar on top of a 767 airframe, or some other similar COT/MOTS solution?
PROJECT Wedgetail, the RAAF's $3.8 billion hi-tech airborne surveillance and early warning system, is in deep trouble and may never achieve the performance levels expected by the air force.
So fundamental are the problems surrounding Wedgetail that Defence has had to commission a top US laboratory to conduct an independent design and performance review of the aircraft's radar developed by US defence giant, Northrop Grumman.
The Massachusetts Institute of Technology's Lincoln Laboratory is undertaking the review, assisted by a small team from Australia's Defence Science and Technology Organisation.
Australia is the leading customer for the Wedgetail airborne early warning system that will see six modified Boeing 737-700 aircraft, mounted with a specially developed phased array radar, delivered to the RAAF under a contract originally signed in 1997.
The worry for the Government is that, if the Wedgetail system can't meet the RAAF's requirements, it will become a procurement nightmare far worse than the $1billion Seasprite helicopter debacle finally cancelled last year.
The Defence Materiel Organisation urgently sought an independent review by Lincoln Laboratory after the prime contractor, Boeing, had further significant problems integrating Wedgetail's multi-role electronically scanned array radar with other systems on the aircraft.
Already running at least 38 months late, Project Wedgetail is designed to be the nerve centre of Australia's air defence system over the next generation.
The Wedgetail's radar is designed to track hundreds of targets in the air and at sea simultaneously, including cruise missiles at a range of more than 400km.
Senior defence sources say the problems with the radar go beyond simple target identification and software integration issues to the basic performance and geometry of the system, which sits on top of the 737's fuselage.
The Lincoln Laboratory assessment is due to be completed by the end of March and will be followed by flight testing over northern Australia in May.
Lincoln is a US government-funded research and development lab that works on cutting edge defence technologies, such as ballistic missile defence.
Subject to further tests later this year, Boeing expects to deliver an initial 737 aircraft to the RAAF for training tasks in November with the first two planes achieving full capability by March next year.
Parliamentary secretary for defence procurement Greg Combet said last night there was still a "long way to go and many hurdles to overcome" with Wedgetail's radar and integrated system performance.
"The Wedgetail early warning and control aircraft are, by their very nature, extremely complex, given the range of cutting-edge radar technology and sensors that will be incorporated into each aircraft," Mr Combet told The Weekend Australian.
Mr Combet said Boeing had not sought, nor had the commonwealth agreed to, any change in the Wedgetail contract prior to the completion of the review by Lincoln Laboratory and the operational evaluation.
He said a "high-level summit" involving the commonwealth, Boeing and Northrop Grumman to determine the way ahead for the program was planned for later this year.
Boeing and Northrop Grumman remain confident the performance of the Wedgetail system will easily exceed any existing airborne warning system.


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Modi using nationalism to promote RuPay, hurting business: Mastercard complains to US authorities
More than half of India’s 1 billion debit and credit cards now go through the RuPay payment system
A step closer to cashless economy : BHIM-UPI hits a record high of 1 crore transactions in a day
The Modi government has given unprecedented push towards cashless economy
When a common user’s suggestion for BHIM app was adopted by NPCI
I have been using BHIM app since beginning, and I decided to write to top executives with a suggestion.


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Today I am reviewing something a little more offbeat than the games I usually write about. I had heard of Aviary Attorney: Definitive Edition through another review site, and I discovered that I wanted to see what it was all about. I am a fan of both good writing and comedies, so I decided to give this game a go.
Aviary Attorney is sort of a spoof of the Ace Attorney games. In this game, you follow the character Jayjay Falcon and his sidekick Sparrowson on a handful of legal cases and detective work that concludes in a trial. The game takes place in mid-19th century France. It should be noted that all the characters are anthropomorphic animals based on the illustrations of J. J. Grandville. The game also features music by Camille Saint-Saëns.
Aviary Attorney is more story than game, and could be classified as a visual novel. Most of the gameplay comes from dialogue choices and searching for clues. That being said, this game is smartly written, and features a lot of corny bird based puns. Even better, the story weaves in enough inconsistencies that help you unravel lies and find out the truth to help the player solve the crimes placed before them. You do have to pay attention to find all the evidence and solve each case, but the fun of this sort of detective work is to try and figure these things out yourself.
Early on, the game gripped me with its humorous puns, but the characters and sharp writing kept me invested as the story took some darker turns. The music was so well integrated to the characters or action on screen that I only grew more intrigued as the suspense was building to each case’s climax. The game also features three endings (I only found one, so far), so you can keep playing to try and find them all. You can even enjoy a few false leads for some dialogue you might have missed.
Aviary Attorney is a short game, but the quick and often funny writing is clever enough to keep you reading until the end of the story. If you like to read, particularly detective novels, and don’t mind some clever wordplay, this game is for you. If you are looking for something more gameplay based, Aviary Attorney might not be up your alley. I found it a quick and fun experience, and any avid reader should give it a look.
- Read everything carefully when you have plenty of time to follow each case.
- Try to take in as much dialogue as possible, there are some real gems here.
- If not satisfied with the ending, try to find another one when you feel up for it.
- I recommend playing an entire act in one sitting. Taking too many breaks mid act could mean forgetting vital information.
- Playing too long could make you lose track of what is going on too, so take a break after each act.
- Smart and funny writing.
- Music meshes well with the action and visuals.
- Gripping story with great use of suspense.
- Might be worth seeing multiple endings.
- Very short game.
- Features more story than gameplay (possible con based on personal preferences).
8.2/10 A great visual novel
I feel based on a player’s preference of gameplay to story ratio, this game is anywhere from a 7-8.6. Those looking for more gameplay may rate this game on the lower end, while those who prefer good writing could rate this game more highly.
Well that wraps up my review of Aviary Attorney: Definitive Edition. Did you like this game? Did you experience all the endings? Are all the endings worth it? What did you make of the price of this game? Let me know in the comments below! If you enjoyed this review, be sure to click that like button. Remember to share this article on social media, and if you want to keep up with That’s All Games you can subscribe via email or through WordPress if you use that platform. Until next time, have fun gaming!
2 thoughts on “Review: Aviary Attorney: Definitive Edition (Switch)”
Great post 🙂

domain: hobby


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PMMA General purpose - ALTUGLASTM acrylic resins
These clear thermoplastic materials (92% LT / 0.5% haze) offer
- Outstanding resistance to mechanical damage and discoloration by ultraviolet rays; years outdoor exposure have no visible effect on ALTUGLASTM PMMA
- Unsurpassed surface hardness (Rockwell M-Scale) and hence scratch resistance ensuring a lasting premium look
- Higher heat resistance than impact-modified grades (Vicat B50 up to 108°C)
- Good stiffness
- Ease of colouring (PMMA based MB required for non opaque colours to avoid optical defects)
General purpose grades - ALTUGLASTM acrylic resins
ALTUGLASTM V 046
Extrusion resin with high heat resistance.
ALTUGLASTM V 825T
Both injection and extrusion resin with good flow and high heat resistance.
ALTUGLASTM V 920T / V 920
Injection molding resin with high flow and heat resistance.
Injection molding resin offering very high flow but slightly lower heat resistance.
Lubricated version of ALTUGLASTM VM grade intended for injection of complex parts with easier demolding.

domain: chemistry


text:
Celtic Rose or Eternal Knot
05/21/2013 correction of grammatical mistakes
The tutorial describes the basics of the Celtic Eternal knot and shows four different designs on the basis of this knot. It also includes instructions of making coiled wire. The tutorial consist of four main steps, but each main step is divided in the sub-steps referring to the design. There will be in total 8 steps for the Celtic Eternal Knot Earrings and 12 steps for the Rose pendant. The tutorial describes on detail how to make Celtic Eternal knot by using a rope, and it shows the main steps for making it from the coiled wire. Making the knot from wire demands more experience, because it is more difficult to make any corrections.
Number of steps: 12
File size: 1430.83 KB
Page count: 13
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domain: library


When you are buying any equipment, you will make sure to check whether they are all energy efficient or not. Nowadays the trend has changed completely and people are trying to make sure that even their house is also energy efficient. They are all having the knowledge that the resources available are limited and hence they will have to make right use them and make sure that they are able to save some for their next generations as well. One of the important things to consider when you are going for making your home energy efficient and that is spray insulation Toronto. Yes, insulation to the house will make it energy efficient and for that you will need companies like http://foamworks.ca/.
When you have winter, you will start using the heating systems at home and when it is summer, you wil go for cooling systems. So, that means, you are using one or the other temperature regulizer at home depending on the climate and the country in which you live. But when there are any leaks or cracks in the walls or roofs of the house, then the room temperature will not remain stable because there is air passing in and out of the room. That will not make the temperature stable. So, in order to overcome this kind of problem, you will need the spray foam contractors in Toronto.
How does this insulation work?
When you are going for an insulation, you may have a doubt on how does this actually work. The walls and the roof of the house are sealed with the help of the spray foam insulation material. That means, all the cracks will be sealed. When they are all sealed, then you will not have passage of air, in and out of the house. That way, you will be able to get the best out of the insulation process.
Measure the good insulator
When you are going for insulation process, then you should understand that you are always opting for a good insulator. That means, you will have to check the R factor of the insulation material that is being used and that way you can decide on which one is good and which is bad. Spray foam insulation comes with a rating between 6.7 to 7.0 and that is the good one to consider.
So, always pay a little attention and time, when you are ready to pay so much money for it. When you are finding the right contractor for spray foam insulation for your house, then your money will not be waste. It is definitely worth the money that you are spending as long as you are spending it on the right company. You need not worry about the quality when you have the top services for you.


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2 bedroom townhouse in Woodhaven This 2 bedrooms townhouse is in a good location. An ideal property for a small family. It's a perfect startup for a growing family. It has a beautiful view. Bathroom, toilet and kitchen needs some attention.
Burlington Heights , Crossmoor , Glen Park , Mariann Heights , Mariann Ridge , Mariannhill , Mariannhill Park , Moseley , Moseley Park , Nazareth , Nirvana Hills , Northdene , Paradise Valley , Savanna Park , Shallcross , Southcliff , St Wendolins Ridge , Caversham Glen , Queensmead Industrial , Mariann Industrial Park , Dawncliffe , Escombe , Hillary , Malvern - DBN , Memorial Park , Mount Vernon , Queensburgh , Bonela , Cato Manor , Chesterville , Coedmore , Ridgeview , Seaview , Umkumbaan , Wiggins , Yellowwood Park , Bellair - DBN , Mayville (KZN)
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domain: geography


text:
Supplementary Materialsanimals-10-01098-s001. the development overall performance, serum immunity, and cecal bacterial microbiota of broilers fed a diet in which soybean meal (SBM) was partially replaced with fermented soybean meal (FSBM) for 36 days. A total of 180 one-day-old male Cobb 500 broilers were randomly divided into three diet organizations (six Hydralazine hydrochloride replicates per group): corn-SBM diet (CC); 25% SBM replaced by FSBM (SC); 50% SBM replaced by FSBM (TC). The average daily gain (ADG) and feed conversion rates (FCR) were higher in SC than CC and TC organizations ( 0.05) during the growth (d 22C36) and whole (d 1C36) phases. No significant difference was observed in ADG and common daily feed intake (ADFI) between CC and TC organizations during any phases. Dietary treatments improved serum IgA, IgG, and IgM, Chao 1, noticed types, and the plethora from the phylum but reduced the percentage of ( 0.05). Eating treatments elevated the plethora from the genera but reduced the plethora of and ( 0.05). Spearmans correlations demonstrated which the plethora of was correlated with ADG and serum immunity favorably, as well as the abundance of was positively with IgM strongly. Thus, changing 25% of SBM with FSBM increases the development functionality and serum immunity of broilers, because of altered Hydralazine hydrochloride cecal microbial structure possibly. [5,6,7]. Zhang Hydralazine hydrochloride et al.  demonstrated that 92.36% of glycinin and 88.44% of -conglycinin was removed from SBM, and the quantity of trichloroacetic acid-soluble protein (TCA-SP) was increased 4.6-fold following the solid-state fermentation of SBM with BS12 for 24 h. A prior study reported which the solid-state fermentation of SBM with for 48 h degraded soybean macro-molecular protein to significantly less than 25 kDa and totally decomposed raffinose and stachyose in SBM . Many research have got showed that total or incomplete replacing of SBM with FSBM increases the development functionality, digestive enzyme activity, and gut morphology of broilers [8,9,10]. Nourishing broilers made by blended strains FSBM, including from d 1 to 24. Oddly enough, Kim et al.  discovered that nourishing broilers 3% FSBM fermented by by itself or in conjunction with a fungus byproduct in the initial seven days post-hatching considerably increased typical daily gain (ADG) and reduced FCR through the entire entire development phase. On the other hand, a diet filled with 10% FSBM with comprehensive reduction of glycinin and -conglycinin didn’t improve the development functionality of broilers but do increase average give food Hydralazine hydrochloride to intake (ADFI) during d 1 to 21 . As a result, further research of the effects of FSBM produced by different kinds of microorganisms, fermentation instances, and processing methods on the growth overall performance of broilers is necessary. The intestinal microbiota of pets plays a significant role in preserving intestinal homeostasis and pet wellness by modulating nutritional digestion, avoiding enteric pathogens, improving intestinal immunity, and executing other physiological features . It had been reported that nutritional absorption, give food to digestibility, and energy harvest are from the gut microbiota and highly, therefore, pet productivity is normally influenced by microbial diversity and composition. Furthermore, the gut microbial variety and structure could be modulated by diet plan, including feed elements and feed chemicals . FSBM fermented by microorganisms not merely increases the dietary quality of SBM but also provides prebiotics, probiotics, and their metabolites to pets, exerting growth-promoting results  thereby. A prior research in weaning piglets showed that eating supplementation with FSBM modulated the microbial structure from the digestive tract and feces and elevated the plethora from the possibly beneficial bacterias and . Xie et al.  also discovered that nourishing piglets 15% clean FSBM changed intestinal bacterial community framework and elevated the relative plethora of butyrate-producing bacterias. A recent research utilizing a traditional culture-based strategy reported that FSBM supplementation of broiler diet plans increased the amount of lactic acidity bacteria, reduced the real variety of in the ileum and cecum . Nevertheless, the broiler gut microbiota contains a huge Mouse monoclonal to 4E-BP1 selection of bacterial types, which is tough to cultivate and research the composition, variety, and framework of intestinal microbiota using traditional culture-based strategies . Lately, 16s rDNA gene amplicon deep sequencing continues to be widely used in a variety of studies to research microbial structure and variety and their romantic relationship to the development functionality [17,18] and immunity of pets [15,19,20]. Presently, to the very best of our understanding, there.
Food intake takes on a pivotal part in human development, constituting 45% from the global overall economy and wellbeing generally
Food intake takes on a pivotal part in human development, constituting 45% from the global overall economy and wellbeing generally. have already been the concentrate of research, though diet can be of paramount importance sometimes. Hence, in this specific article, we review the corollary organizations with the intake of varied foods as well as the role these play in KSD within an Indian framework. 0.001) . To intricate upon this paradigm further, reports have depicted aptly, inside a Canadian framework, that despite the fact that the current presence of dent disease and hypophosphatemic rickets with hypercalciuria continues to be observed, there’s a strong relationship with ancestry and genetic patterns  still. Furthermore, to summarize this hypothesis, they need to counteract several hereditary analysis approaches, specifically, encoding supplement D receptor (VDR), calcium-sensing receptor (CaSR), 25(OH)D 1-hydroxylase, osteocalcin, uromodulin, and osteopontin amongst others . Alternatively, research portraying gender and age group as the rule parameters have exposed that Iran and USA will SPN be the maximum KSD locations for folks aged 40C49 years, as the biggest prevalence among people aged 50C59 years is certainly proven in Japanese females . The info illustrated an identical design in USA and Japan for the male group within the 40C49 generation, and Iran implemented, using a different craze . This preliminary investigation qualified prospects us to summarize that it’s significantly unscientific to extrapolate KSD patterns predicated on age group and sex in various geographic locations. As a result, the researchers had been challenged to make a set of brand-new variables to fine-tune even more reasonable solutions in the world of KSD and its own prevalence. Diet plan can be an essential section of renal deposition and purification hence, which impacts the Piperonyl butoxide Piperonyl butoxide absorption and physical homeostasis of renal rock incident [14,15]. The epidemiology differs relative to different physical regions and cultural constructs. In this framework, meals habits have already been proposed among the main risk elements in renal rock formation, as a kind of epidemiology for urine structure [16,17]. Meals patterns are one of the main elements for renal rock formation, and rock material deposition could be maintained by regulating diet. In the framework from Piperonyl butoxide the Indian diet plan, there’s a assortment of many tastes and likes, through the color-rich food of Rajasthan, to the spicy food of Punjab, and from your slightly nice, oil-based food of Gujarat, to the southern, slightly sour seafood. All of these foods are found in this land of paradise. Several communities in the country are vegetarian, although there is still a large range of rich non-vegetarian quality recipes. Increases in urinary calcium excretion are strongly related to the consumption of animal proteins, with a consequent reduction in urinary pH and citrate excretion, which are the basis of stone formation. Due to this food pattern in Indian culture, we believe that it is of paramount interest to describe the nutritional factors causing renal stone formation and the immediate effects thereof. 2. Diverse Food Habits in India The era of quick globalization and packaged market products has shifted the equilibrium of nutrition in India. Urban areas in India have embraced more packaged foods, which have led to increased body mass and premature obesity. In this realm, Indian cooking displays thousands of years of history, leading to the diversity of flavors and the innumerable regional dishes found in the country . Diversified food habits range in different parts of India, with different geographical areas spanning from your Rajasthan desert to the Madhya Pradesh forest, or in the Maharashtra seashore towards the Kashmir and Jammu Mountains . For the simple description, Indian food preparation is Piperonyl butoxide normally categorized in to the North Indian principally, East Indian, Western world Indian, and South Indian food, in line with the differences and similarity in the type of the cuisines. North Indian cuisines are recognized by their large usage of dairy products as well as the prevalence of flatbreads, such as for example paratha and roti, cooked in clay ovens, over grain meals. Though elements of Traditional western India Also, such as for example Rajasthan and Gujarat, are vegetarian predominantly, the rest of the cuisines possess their fair talk about of meats or pet proteins, due to their organizations using the Muslim incursion into India. South India can boast a bewildering selection of local cuisines. As a result, with cuisines which range from the wealthy northern design Mughlai cooking.
PURPOSE The overall survival (OS) results in patients with rearrangement. for inhibitor, crizotinib, has demonstrated significant benefit in progression-free survival, objective response rate, and patient-reported outcomes compared with standard platinum-based chemotherapy in European and Asian patients with metastatic NSCLC who had the gene rearrangement.5,6 Although crizotinib has shown significant improvement in progression-free survival in phase III studies,5-7 there are fewer data on overall survival (OS) and patient outcomes when using crizotinib in real-world clinical practice. The aim of this study was to examine treatment patterns and outcomes of crizotinib compared with chemotherapy in patients with NSCLC from Russian community oncology practices. PATIENTS AND METHODS Study Design The current observational study used a prospective-retrospective cohort design on the basis of a review of medical records or prospective recruitment of patients with rearrangement via diagnostic procedures (fluorescence in situ hybridization, immunohistochemistry, or polymerase chain reaction) used in the molecular testing RUSSCO national program and to be age 18 years or older at the time of diagnosis. Patients were included if treatment with crizotinib or the investigators choice of platinum-based chemotherapy have been initiated as first-line or afterwards therapy for metastatic exams and 2 exams, as suitable, with corresponding beliefs reported. All statistical analyses had been performed using IBM SPSS Figures Bottom v22.0 (SPSS, Chicago, IL). Outcomes Patient Features We screened 1,817 sufferers with rearrangement (Desk 1). Ninety-six sufferers (64%) had been contained in the research group and received crizotinib regarding to process. Fifty-three sufferers (36%) had been contained in the control group and received chemotherapy. Chemotherapy included mixture regimens with either carboplatin or cisplatin plus paclitaxel, pemetrexed, etoposide, or gemcitabine. The most frequent reason for not really assigning crizotinib was insufficient usage of the medication. TABLE 1 Individual and Treatment Features Open in another window Mean variety of enrolled sufferers in one area was 6.5 sufferers (range, someone to 13 sufferers). Most patients (greater than 60%) were recorded as having by no means smoked. Mean age at diagnosis of older than age Rabbit Polyclonal to NT5E 55 years), sex (male female), or histology (adenocarcinoma other subtypes) between the study and control groups were found (all .1). Among the 96 patients for whom crizotinib initiation was documented, 16 patients (17%) had human brain metastases. No sufferers in the chemotherapy group acquired human brain metastasis at or before treatment initiation. Over fifty percent of sufferers received no prior adjuvant therapy (69%) or rays (89%), and chemotherapy was the most frequent cancer-directed TC-E 5003 treatment modality utilized before crizotinib initiation. Sixty-eight sufferers (71%) had been treated with crizotinib as first-line therapy, and 28 sufferers (29%) had been treated with crizotinib as second-line therapy. In the control group, all sufferers received chemotherapy as first-line treatment. Disease development after initial scientific response was the most frequent cause (71% of sufferers) for crizotinib discontinuation. Treatment-related toxicities or undesireable effects had been cited as the explanation for last crizotinib discontinuation in 3% of sufferers. Clinical Final results Median follow-up was 15.0 months (range, 11 to two years). TC-E 5003 At the proper period of the final follow-up, 79 of 149 sufferers contained in the evaluation had died, whereas 70 sufferers had been alive still. Median OS period right away of treatment was 31 a few months (95% CI, 28.5 to 33.5 months) in the crizotinib group and 15.0 months (95% CI, 9.0 to 21.0 months) in the chemotherapy group ( .001). Success curves are proven in Amount 1. OS period was very similar in sufferers initiating crizotinib as initial- and TC-E 5003 second-line therapy (= .381; Fig 2). The 1-calendar year OS rates had been 85.4% and 64% in the analysis and control groupings, respectively. Open up in another screen FIG 1 Kaplan-Meier curves for overall survival (OS). Open in a separate windows FIG 2 Kaplan-Meier curves for overall survival (OS) from crizotinib as 1st- TC-E 5003 and second-line therapy. Disease progression on crizotinib was recorded in 13 individuals (15%). The objective response rate was 34% (30 of 88 sufferers). Partial replies had been seen in 27 sufferers, whereas complete replies had been seen in three sufferers (3.4%). The median time for you to response was 4.1 months (range, 2 to 1 . 5 years). In the entire research sample, the condition control price was 85%. Eight sufferers were not qualified to receive evaluation of response. Among sufferers with human brain TC-E 5003 metastasis, one comprehensive response (6%) and five incomplete responses (31%) had been achieved. Nine sufferers (56%) had steady disease. Quality 3 adverse occasions had been seen in three sufferers (3%). No treatment-related quality.

domain: biology


text:
Introduction: Prenatal care is recommended during pregnancy to improve neonatal and maternal outcomes. Women of lower socioeconomic status (SES) are less compliant to recommended prenatal care and suffer a higher risk of adverse perinatal outcomes. Several attempts to encourage optimal pregnancy follow-up have shown controversial results, particularly in high-income countries. Few studies have assessed financial incentives to encourage prenatal care, and none reported materno-fetal events as the primary outcome. Our study aims to determine whether financial incentives could improve pregnancy outcomes in women with low SES in a high-income country.
Methods and analysis: This pragmatic cluster-randomised clinical trial includes pregnant women with the following criteria: (1) age above 18 years, (2) first pregnancy visit before 26 weeks of gestation and (3) belonging to a socioeconomically disadvantaged group. The intervention consists in offering financial incentives conditional on attending scheduled pregnancy follow-up consultations. Clusters are 2-month periods with random turnover across centres. A composite outcome of maternal and neonatal morbidity and mortality is the primary endpoint. Secondary endpoints include maternal or neonatal outcomes assessed separately, qualitative assessment of the perception of the intervention and cost-effectiveness analysis for which children will be followed to the end of their first year through the French health insurance database. The study started in June 2016, and based on an expected decrease in the primary endpoint from 18% to 14% in the intervention group, we plan to include 2000 women in each group.
Ethics and dissemination: Ethics approval was first gained on 28 September 2014. An independent data security and monitoring committee has been established. Results of the main trial and each of the secondary analyses will be submitted for publication in a peer-reviewed journal.
Trial registration number: NCT02402855; pre-results.
Keywords: clinical governance; maternal medicine; organisation of health services.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.


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Ascent to Magnolia Hill-Private Drive on 2014-02-28
|Other People:||Solo Ascent|
|Date:||Friday, February 28, 2014|
|Ascent Type:||Unsuccessful - Turned Back|
| Motorized Transport to Trailhead:||Start at Home|
|Point Reached:||Magnolia Hill - Private Drive|
| Elevation:||377 ft / 114 m|
| Remaining Elevation:||13 ft / 4 m (2% left to go)|
Ascent Trip ReportSecond of two bumps on my "Seattle bump collecting" bicycle ride from home today.
I was off work early since it is Friday and the weather was spectacular - sunny and 50. Not bad for February in Seattle. I put on my bike shorts, jersey, and shoes and I was off on my road bike. First up was Queen Anne Hill. I live at exactly the 50 meter contour line on this urban gem. I took 2nd Ave N up to Ward where I encountered stairs to continue upward. Not wanting to do the stairs with the bike, I actually rode down to 5th Ave and then up that to Highland just below Bhy Kracke Park (not to be confused with Buy Crack Park in Everett). I cranked up Highland to 3rd Ave then Galer, passing a school along the way. The high point is at the fire station on Warren & Lee. I rode all over this area on my bike to cover the high ground, touching my toe down on candidates, midwest CoHP style. There are tennis courts here, which I took note of as I have a tennis racket at home that never gets used and a work friend who plays tennis.
I then decided that this sub-10 minute ride was not a workout, so I decided to head for Magnolia Hill across the way. On the way up Magnolia Hill I ran into a bike problem with my smallest front gear. It had somehow bent causing the chain to derail twice, which was quite dangerous as I was clipped in, next to traffic, and lost all pedal power. I managed to fall to the right to avoid being run over by a SUV-driving soccer mom and somehow unclipped my right foot as I fell so I prevented myself from eating shit on the pavement. I moved over to the sidewalk to see what the problem was. I used my multi-tool to hammer the gear back as flat as it can go - probably exactly the use a bicycle multi-tool is designed for... I tested it out on an intersecting flat street before I again geared down to crank up the hill. This time I didn't pop the chain off on the steepest part next to a car - sweet. I explored the top of Magnolia Hill thoroughly. There is a large water tower that I walked next to while a utility guy gave me a weird look. Then I explored the new suburban sprawl on Briarcliff Lane. The rest of the neighborhood is very nice with houses that all look different and have trees. Briarcliff Lane is suburban blight at its worst - damn Californians moving here to Seattle! So, the actual highpoint is on a private drive. In my normal P2k/CoHP pursuits, I disregard all private property signs since they are usually massive ranches in central CA owned by people who hate hikers. In this case, it was a decent looking house in a nice neighborhood on a pointless bump, and it was not gated off like they are some kind of royalty. It was wide open and I could have walked right up to the high point on their front yard. I declined to do so as it seemed unnecessarily intrusive and was signed as private. It is just some normal person's house and deserves some respect. I am cool with that. So, should I log it as successful - I guess not. Eh, whatever....
I returned via the Elliot Bay bike trail to the new bike ramp that leads right into my neighborhood near the space needle. Seattle is definitely a bike friendly city as my numerous road bike rides last year can attest to.
Naturally, I forgot to turn on the tracking on my GPS, so I have no track, which I planned on uploading to get a laugh...
Pictures? You bet! I actually didn't take a "summit" shot on Queen Anne Hill. I guess it's that impressive...
1h 11m moving time
28.8 mph max
10mph moving avg
|Summary Total Data|
| Total Elevation Gain:||590 ft / 179 m|
| Total Elevation Loss:||262 ft / 79 m|
| Gear Used:||Bicycle|
| Gain on way in:||590 ft / 179 m|
| Gain Breakdown:||Net: 328 ft / 100 m; Extra: 262 ft / 79m|
| Loss on way in:||262 ft / 79 m|
| Route:||Quiet residential roads|
| Start Trailhead:||49 ft / 14 m|
This page has been served 603 times since 2005-01-15.


text:
Every year, as the season draws to a close and transfer stories hit the web, a steadily decreasing portion of the Arsenal fan base begins to dream.
Most fans have their fantasy list of transfer targets; players that would make Arsenal compete again after another season of mediocrity, masked by a conveniently timed surge of form.
Every year also, an increasing number of fans become disillusioned with Arsenal's long-term transfer policy, understandably frustrated at the seemingly inexplicable lack of spending. And every year without fail, some fans, at least secretly, think this year will be different.
Arsenal fans reading this will be familiar with the ridicule that comes as a result of airing this view, usually from smug Chelsea and Manchester United fans that take great pleasure in reminding everyone that Gunners say the same thing every year, but this year really is different.
No one apart from people inside the club can know exactly what is being planned on the transfer front, but there's enough information in the public domain to suggest that this summer could actually spell change in the way Arsenal conduct their dealings.
Sceptics will undoubtedly disagree, and there are plenty of them, but consider first the long list of factors which have come together this year, which will undoubtedly have an effect on transfer policy.
The biggest reason why Arsenal are more likely to spend big this year than in any other year, is the huge financial strength that the club now has for a variety of reasons.
Arsenal have long been a profit making club, even last summer various unconfirmed figures were being touted as being available to the manager to spend.
Since then, much has happened to strengthen the north London club's financial position further; beginning with the profit made in last summer's transfer window. Alex Song and Robin van Persie were sold, generating more income than the combined costs of Cazorla, Podolski and Giroud.
In addition, this season was the announcement of two big sponsorship deals for the club: Fly Emirates renewed their shirt sponsorship deal in an agreement reportedly worth £150 million over the course of five years, while Puma were announced as Arsenal’s kit supplier for the 2014-15 season in the most lucrative kit deal in British football, again worth £150 million over five years.
The Premier League is also seemingly entering a golden age from a financial perspective, with a massive increase in prize money due next season as a result of foreign and domestic TV rights rising in value. This would see Arsenal in a great position to pay off any debt they may acquire this summer, providing a safety net for extravagant spending.
The second major factor which may see Arsenal surprise a lot of people with their summer spending is the unprecedented pressure on the manager. Arsene Wenger has long held one of the safest seats in football management, but for the first time this season a significant section of the Arsenal support displayed displeasure with the Frenchman. A man of high intelligence and professional pride, Wenger will be hurting and hungry to prove his critics wrong in emphatic fashion.
The best way to do that will be through boosting his squad through entering the market for players of a high calibre. The voices of the supporters have been reinforced by those of Arsenal legends, who have also called for the manager to spend big this summer, as the pressure escalates on a manager who risks throwing away a legacy second only to Ferguson in English football.
Considering all of that, it's hard to imagine the under-fire Arsene Wenger, armed with mountains of money from commercial deals, not being provoked into action in the transfer market in an attempt to cement his legacy once and for all.
This summer will be long, and as always will see Arsenal linked to every footballer under the sun, but there is new hope this time around. This year will be different.
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domain: economics


text:
Spanish olives and mediterranean herbs naan
- 20 pc (60 g) Sliced black OLIVES FROM SPAIN
- 10 g Dry Mediterranean herbs mixture (oregano, basil, thyme)
- 300 g Refined flour
- 1.5 tsp yeast
- 1 tsp sugar
- 10 g Salt
- 3 tbsp Butter
- 3 tbsp Curd
- 2 tbsp warm water
Preparation time:20 minutes
Level of difficulty:Easy
- Mix 2 tablespoon warm water, sugar, and yeast in a small bowl. Cover and keep in a warm place for 10 minutes or so till the mixture rises.
- Sieve wheat flour and salt together. Add curd, the mixture of yeast and combine. Knead into smooth, elastic dough and no longer sticky.
- Keep the dough in a large bowl covered with a lid in a warm place for 2 hours or more till the dough rises and doubles in size.
- Punch the dough and then knead on a floured surface for 5 mins until smooth and elastic.
- Tip the dough onto a floured surface, divide into 6-8, then use a rolling pin to roll each into a 20 cm circle.
- Scatter the olives and herbs in the centre of the dough circles. Brush a little water around the edges, then roll again to seal in the filling and make a tear shaped bread.
- Melt the butter and brush on both sides of the naan. Cook on a hot oven at 220ºC or in a tandoor until golden and puffy.
- Smear butter, cut and serve as an appetizer or with curry.


Tytuł artykułuGait Variations in Human Micro-Doppler
Tytuł czasopismaInternational Journal of Electronics and Telecommunications
Wydział PANNauki Techniczne
International Journal of Electronics and Telecommunications (IJET, eISSN 2300-1933, untill 2013 also print ISSN 2081-8491) is a periodical of Electronics and Telecommunications Committee of Polish Academy of Sciences and it is published by Warsaw Science Publishers of PAS. It continues tradition of the Electronics and Telecommunications Quarterly (ISSN 0867-6747) established in 1955 as the Rozprawy Elektrotechniczne. The IJET is a scientific periodical where papers present the results of original, theoretical, experimental and reviewed works. They consider widely recognized aspects of modern electronics, telecommunications, microelectronics, optoelectronics, radioelectronics and medical electronics.
The authors are outstanding scientists, well‐known experienced specialists as well as young researchers – mainly candidates for a doctor's degree. The papers present original approaches to problems, interesting research results, critical estimation of theories and methods, discuss current state or progress in a given branch of technology and describe development prospects. All the papers published in IJET are reviewed by international specialists who ensure that the publications are recognized as author's scientific output.
The printed periodical is distributed among all those who deal with electronics and telecommunications in national scientific centers as well as in numeral foreign institutions, and it is subscribed by many specialists and libraries. Its electronic version is available at http://ijet.pl.
The papers received are published within half a year if the cooperation between author and the editorial staff is efficient. The papers may be submitted to the editorial office by the journal web page http://ijet.pl.
WydawcaPolish Academy of Sciences Committee of Electronics and Telecommunications
IdentyfikatoreISSN 2300-1933 (since 2013) ; ISSN 2081-8491 (until 2012)
ReferencjeCohen L. (1995), Time-Frequency Analysis. ; Chen V. (2002), Time-Frequency Transforms for Radar Imaging and Signal Analysis. ; Gürbüz S. (2007), Detection and Identification of Human Targets in Radar Data, Proceedings of the SPIE, 6567, doi.org/10.1117/12.718974 ; Greneker G. (2005), Very Low Cost Stand-Off Suicide Bomber Detection System Using Human Gait Analysis to Screen Potential Bomb Carrying Individuals, Proceedings of the SPIE, 5788, doi.org/10.1117/12.600603 ; Geisheimer J. (2001), A Continuous-Wave (CW) Radar for Gait Analysis, Conference Record of the Thirty-Fifth Asilomar Conference on Signals, Systems and Computers, 1, 834, doi.org/10.1109/ACSSC.2001.987041 ; Tahmoush D. (2009), Target Discrimination with a Radar Unattended Ground Sensor, null. ; Boulic R. (1990), A Global Human Walking Model with Real-time Kinematic Personification, The Visual Computer, 6, 6, 344, doi.org/10.1007/BF01901021 ; Bruderlin A. (1993), Interactive Animation of Personalized Human Locomotion, null, 17. ; Ko H. (1996), VRLOCO: Real-time Human Locomotion from Positional Input Streams, Presence, 5, 4, 367, doi.org/10.1162/pres.1922.214.171.1247 ; Laszlo J. (1996), Limit Cycle Control and Its Application to the Animation of Balancing and Walking, null, 155. ; McKenna M. (1990), Dynamic Simulation of Autonomous Legged Locomotion, null, 29. ; Rose C. (1998), Verbs and Adverbs: Multidimensional Motion Interpolation, IEEE Computer Graphics and Applications, 18, 5, 32, doi.org/10.1109/38.708559 ; Tsutsuguchi K. (2000), Human Walking Animation Based on Foot Reaction Force in the Three-dimensional Virtual World, Journal of Visualization and Computer Animation, 11, 1, 3, doi.org/10.1002/(SICI)1099-1778(200002)11:1<3::AID-VIS212>3.0.CO;2-5 ; Troje N. (2002), Decomposing Biological Motion: A Framework for Analysis and Synthesis of Human Gait Patterns, Journal of Vision, 2, 5, 371, doi.org/10.1167/2.5.2 ; T. Dogaru, C. Le, and G. Kirose, "Time-Frequency Analysis of a Moving Human Doppler Signature," February 2009, aRL-TR-4728. ; Geisheimer J. (2002), A High-resolution Doppler Model of Human Gait, Radar Sensor Technology and Data Visualization Proceedings of SPIE, 4744, 8, doi.org/10.1117/12.488286 ; P. van Dorp (2005), Human Walking Etimation with Radar, IEE Proceedings on Radar, Sonar and Navigation, 150, 4237. ; Tahmoush D. (2009), Radar MicroDoppler for Security Applications: Modeling Men Versus Women, null, 1. ; Tahmoush D. (2009), A Compact Persistent Surveillance Radar with Micro-Doppler Capabilities, null. ; Wellman R. (2009), Design of a Compact, Low-Power Radar for Unattended Ground Sensor Applications, null. ; Tahmoush D. (2009), Dismount Threat Detection via Radar Doppler, null. ; Tahmoush D. (2009), Angle, Elevation, PRF, and Illumination in Radar MicroDoppler for Security Applications, null. ; Tahmoush D. (2009), Radar Micro-Doppler for Long Range Front-View Gait Recognition, null.


text:
Added to shopping list. Go to shopping list.
Ingredients8 h 15 m servings 445
Original recipe yields 16 servings
- Mix egg yolks, 2 cups sugar, rum, and nutmeg together in a large bowl. Cover with plastic wrap and refrigerate 8 hours to overnight to "cure."
- Beat egg whites and remaining 1 cup sugar in a bowl using an electric mixer until firm peaks form. Fold in heavy cream. Fold in the egg yolk mixture. Beat in half-and-half until well combined. Pour into lidded jars or containers, refrigerate, and shake before serving.
- Cook's Note:
- Make sure you use a big bowl that will hold a gallon for mixing.
- Editor's Note:
- This recipe contains raw egg. We recommend that pregnant women, young children, the elderly, and the infirm do not consume raw egg. Learn more about egg safety from our article, Making Your Eggs Safe.
Per Serving: 445 calories; 21.7 41.3 7.1 203 89 Full nutrition
ReviewsRead all reviews 1


text:
The U.S. Supreme Court will hear arguments Monday in two cases with potentially broad implications to technology users, one reviewing whether consumers can resell copyright-protected products they have purchased and the second challenging an electron...
A proposed amendment to the controversial copyright enforcement bill, the Stop Online Piracy Act, has not swayed many opponents to the legislation.
An upcoming version of U.S. legislation designed to combat copyright infringement on the Web may include provisions that hold online services such as Twitter, Facebook and YouTube legally responsible for infringing material posted by users, according...
Several tech trade groups have voiced opposition to new legislation in the U.S. Congress that would require Web-based retailers to collect sales tax from customers.
New U.S. legislation intended to shut down foreign websites that infringe copyrights would cause major headaches because it would allow copyright holders to target legitimate Web services with "thousands" of court orders, an e-commerce trade group sa...
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domain: law


One woman died and another was critically injured in a house fire early Sunday morning in Philadelphia, Pennsylvania.
The fire broke out about 7:30 a.m. in a two-story home, according to the Philadelphia Daily News.
When firefighters arrived, they found one woman, 76, near the home’s front door, the report said. The woman was hospitalized in critical condition. Her husband was able to escape uninjured from the building’s basement.
According to the report, after the fire was controlled, firefighters found a 45-year-old woman in a bedroom on the second floor.
There was only one smoke detector inside the home, a unit in the basement that wasn’t working, the report said.
Read more about this incident at http://www.philly.com/philly/news/20150614_NE_Philly_house_fire_kills_woman__injures_mother.html.


text:
Some of the best palates from across Asia have gathered in Hong Kong to judge more than 3,000 wines in the Decanter Asia Wine Awards 2017.
More than 50 wine experts, including top sommeliers and Masters of Wine, began judging at this year’s Decanter Asia Wine Awards (DAWA 2017) in Hong Kong this morning (5 September).
DAWA 2017 will see 3,235 wines tasted by judges, the most since the competition launched five years ago.
The wines will be tasted blind according to region and style and rated against their peers, in a judging process set to last for four days.
After competing for bronze, silver, and gold medals, the gold medalists compete for the highest award in the competition on Friday 8 September – the platinum best in show.
This year’s judging panel includes experts from 11 countries, including Mainland China, Hong Kong, Macau, Japan, Singapore, India, Indonesia, Korea, and Taiwan.
Most judges work in top establishments in the Asia region and the DAWA 2017 chairs include professor Li Demei, a world authority on Chinese wine and DecanterChina columnist.
He is joined by Japan’s Shinya Tasaki, previously named the world’s best sommelier and now president of the international sommeliers’ association; Gerard Basset MS MW, Ch’ng Poh Tiong, Andrew Jefford, Michael Hill Smith and Steven Spurrier.
Joining this year’s line-up is Sonal Holland, India’s first Master of Wine. Holland founded SOHO wine club and her namesake institute offers WSET-accredited wine training; Tan Ying Hsien, Singapore’s first Master of Wine; and Adrian Zhang, Director of Wine at the Park Hyatt Shanghai.
Italy is the best-represented country at DAWA 2017 with a record-breaking 719 entries, followed by Australia with 591 and France with 391 wines.
The DAWA has seen a sustained interest from China, with 124 entries from eight wine-producing regions – including 50 wines from Ningxia, 33 from Xinjiang and 15 from Shandong province.
Christelle Guibert, Decanter’s tastings director, said, ‘We are so thrilled to start the 6th edition of the Decanter Asia Wine Awards, our biggest year to date. We have gathered some of the best and most influential wine experts across Asia to join our judging panel. During the four-day judging, they will work closely with our seven chairs and taste, discuss and award medals to the 3,235 wines received.’
Asian consumers will have the chance to try the wines at numerous promotions this Autumn.
This will include the Decanter Shanghai Fine Wine Encounter on 18 November and a tasting in Seoul on 3 December.
The DAWA 2017 is kindly sponsored by Riedel glasses and Acqua Panna and San Pellegrino water.
Stay tuned for more information promotions, and for the latest details from DAWA 2017 judging week.
Translated by Sylvia Wu / 吴嘉溦
All rights reserved by Future plc. No part of this publication may be reproduced, distributed or transmitted in any form or by any means without the prior written permission of Decanter.
Only Official Media Partners (see About us) of DecanterChina.com may republish part of the content from the site without prior permission under strict Terms & Conditions. Contact firstname.lastname@example.org to learn about how to become an Official Media Partner of DecanterChina.com.


text: Welcome! I am Dr. Amanda Weston, licensed mental health counselor working out of Tampa, Florida. I offer a compassionate, non-judgmental, trauma-informed, and holistic approach in treatment. I approach each individual as unique and tailor treatment to their specific needs. My specialty areas include: OCD and related disorders, anxiety, PTSD/trauma, Depression and Mood Disorders, LGBTQ+ issues, and problematic gaming behaviors/Gaming Disorder for adolescents and adults. I use evidence-based methods and specialize in treatment modalities that focus on Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, and Exposure Therapy to provide you with the skills needed to manage the stressors of your life.